Parenteral nutrition and venting gastrostomy in the management of malignant bowel obstruction

Patterson, Michael John

Abstract

Background: Malignant bowel obstruction (MBO) is a distressing complication of gastrointestinal, gynaecological and other cancers causing severe pain, intractable nausea and vomiting, anorexia, and death. There are no agreed best approaches for symptom control, or to improve survival.
Aim: I aimed to evaluate the current practice of percutaneous venting gastrostomy (PVG) and parenteral nutrition (PN) in inoperable malignant bowel obstruction (MBO) relating to benefits and harms and the views and experiences of patients, their family carers and clinicians.
Methods: In this multiple-methods thesis I used a i) mixed-methods systematic review and narrative synthesis of published literature aimed to investigate how PVG and PN in MBO affect clinical and quality-of-life (QoL) outcomes and, ii) two-site mixed-methods study; a retrospective consecutive cohort study using clinical record data (opt-out consent) to observe management and clinical outcomes of inpatients with MBO, including those making the clinical decisions; qualitative in-depth interviews of those involved in caring for people with MBO to explore the views, experiences and decision-making of MBO in health care professionals (HCPs). Mixed-methods findings were synthesised using a modified critical interpretative synthesis and then integrated with the systematic review results.
Findings: Review findings from 47 included studies highlighted the lack of high-quality evidence that PN improves survival in those MBO. PN and VPG allow people valuable time at home. PN appears to improve QoL but with PN-associated burdens. PVG provides immediate and effective symptom relief and improves QoL for most. Most patients trusted their clinical team and felt they had little choice but to agree with a decision already made, often presented as ‘do or die’ or with conflicting information.
Mixed-methods data (total cohort n = 143; interviews n = 14) show surgery and home PN are associated with better survival but this finding is confounded by performance status. Better performance status is associated with better clinical outcomes; HCPs use performance status to determine the interventions offered. Only a third of patients are referred to palliative care services despite severe symptoms and a very poor prognosis. Despite good symptomatic resolution with nasogastric tubes and PVG, lack of familiarity with and resources contribute to poor self-fulfilling availability. HCPs know the evidence for managing MBO is poor, and variable clinical practice is driven by local clinical culture and consensus.
Conclusion: MBO is challenging for patients, carers, and HCPs, with little clinical guidance to aid them. Gut decompression appears to provide excellent symptom relief but has barriers to its use, including clinical uptake. PN is beneficial in selected MBO patients.

Citation

Patterson, M. J. (2024). Parenteral nutrition and venting gastrostomy in the management of malignant bowel obstruction. (Thesis). Hull York Medical School. https://hull-repository.worktribe.com/output/4711450

• Thesis Type: Thesis
• Deposit Date: Jun 18, 2024
• Publicly Available Date: Jun 2, 2026
• Keywords: Medicine
• Public URL: https://hull-repository.worktribe.com/output/4711450
• Additional Information: Hull York Medical School; The University of Hull and the University of York
• Award Date: May 27, 2024