Consensus Guideline for the Management of Malignant Gastrointestinal Obstruction in Patients with Peritoneal Surface Malignancies

BackgroundMalignant gastrointestinal obstruction (MGIO), a frequent complication of peritoneal surface malignancies (PSM), often portends a poor prognosis. The lack of high-quality evidence on optimal management strategies necessitated a national consensus to address this clinical problem. MethodsA clinical management pathway was designed through a Delphi consensus process with national experts in peritoneal disease. Two rounds of voting were conducted to assess agreement levels with pathway blocks. Supporting evidence regarding procedural interventions for MGIO underwent evaluation via a rapid literature review. ResultsOf 111 participants responding in the first round, 90 (81%) responded in the second round. Over 90% consensus was achieved in 4/6 and 6/6 pathway blocks during rounds I and II, respectively. Encouraging a multidisciplinary approach, the pathway emphasized early palliative care assessments and iterative goals of care evaluation throughout treatment. Management was delineated based on obstruction acuity, and selection criteria for palliative-intent surgical interventions and stenting were elucidated. Studies demonstrated limited benefits for such interventions in patients with multifocal obstructions, poor performance status, and high-grade and/or high-burden PSMs. In these cases, a recommendation for supportive care or upper GI decompression tube placement was favored. The overall level of evidence was generally low-moderate in existing literature. ConclusionGiven limited evidence, the consensus-driven pathway provides crucial clinical guidance for practitioners dealing with MGIO in PSM patients. There is a need for high-quality prospective evidence in this domain.