Advances in the management of cancer-related incomplete intestinal obstruction: Therapeutic strategies and emerging interventions

Abstract

Cancer-related incomplete intestinal obstruction (CRIO) presents a significant challenge in patients with advanced malignancies, affecting quality of life and complicating treatment regimens. This editorial explores the multifaceted approaches to managing CRIO, emphasizing recent advancements in diagnostic techniques, pharmacological treatments, minimally invasive procedures, and surgical interventions. The pathophysiology of CRIO is complex, involving tumor invasion, fibrosis, and peritoneal dissemination, which result in partial bowel obstruction and impaired motility. Traditional management has focused on supportive care and palliative measures; however, new interventions, such as endoscopic stenting and laparoscopic surgery, have demonstrated improved outcomes with fewer complications. In addition, the integration of systemic therapies like immunotherapy and targeted agents offers promising results in reducing tumor burden and alleviating obstruction. The editorial also discusses the critical role of nutritional support and fluid management in managing CRIO symptoms and improving patient recovery. Despite these advancements, the complexity of CRIO, with its varied causes and patient-specific factors, necessitates individualized, multidisciplinary care strategies. This editorial aims to provide an updated, comprehensive framework for clinicians managing CRIO, highlighting current practices and future directions for research and therapeutic development.

Key Words: Cancer-related incomplete intestinal obstruction; Minimally invasive intervention; Targeted therapy; Multidisciplinary management; Precision treatment

Core Tip: Cancer-related incomplete intestinal obstruction represents a multifactorial clinical challenge in patients with advanced malignancies, combining mechanical, inflammatory, and functional components. This editorial systematically summarizes recent progress in the diagnosis and management of cancer-related incomplete intestinal obstruction, including advances in imaging, pharmacological therapy, nutritional optimization, minimally invasive intervention, and surgical strategies. It emphasizes the integration of multidisciplinary care and emerging targeted therapies, highlighting the shift toward individualized, patient-centered management aimed at improving prognosis and quality of life.

INTRODUCTION

Cancer-related incomplete intestinal obstruction (CRIO) is a complex clinical condition characterized by partial blockage of the intestinal lumen caused by malignant tumors or their associated complications. Unlike complete obstruction, CRIO involves a degree of residual intestinal patency, yet it significantly impairs intestinal transit and function. Epidemiologically, CRIO occurs in approximately 3%-15% of patients with advanced gastrointestinal malignancies, particularly colorectal and ovarian cancers, and is more frequent among elderly and malnourished populations. This condition frequently occurs in patients with advanced gastrointestinal malignancies, including colorectal, small intestinal, and anal cancers, and is associated with considerable morbidity and mortality[1-3]. The pathophysiology of CRIO is multifactorial, involving direct tumor infiltration, external compression by tumor masses or metastatic lesions, radiation-induced fibrosis, and postoperative adhesions. These factors contribute to luminal narrowing and dysmotility, resulting in symptoms such as abdominal pain, distension, nausea, vomiting, and altered bowel habits, which collectively deteriorate patients’ nutritional status and quality of life[3-5].

The clinical significance of CRIO extends beyond symptom burden. It complicates the administration of systemic anticancer therapies by limiting oral intake and absorption, increasing the risk of treatment interruptions and dose reductions. Moreover, CRIO often heralds disease progression and portends a poor prognosis. For instance, patients with small intestinal metastases or multifocal tumor involvement causing obstruction have limited survival despite surgical or chemotherapeutic interventions[6-8]. The management of CRIO is therefore challenging, requiring a multidisciplinary approach that balances symptom control, maintenance of intestinal function, and oncological treatment goals.

Historically, conventional management of intestinal obstruction in cancer patients has relied on supportive care measures, including nasogastric decompression, fluid and electrolyte correction, and bowel rest. Surgical interventions, such as tumor resection, stoma creation, or bypass procedures, have been the mainstay for patients with operable disease and acceptable performance status. However, these approaches are often limited by high perioperative morbidity and mortality, especially in elderly or frail patients with advanced malignancies[9-11]. Furthermore, surgery may not be feasible in cases of multifocal disease or extensive peritoneal carcinomatosis.

In recent years, advances in minimally invasive techniques and interventional therapies have transformed the therapeutic landscape for CRIO. Laparoscopic surgery has demonstrated advantages over open procedures, including reduced operative trauma, faster recovery, and lower complication rates, without compromising oncological outcomes[12,13]. Endoscopic stenting has emerged as a valuable palliative option, effectively relieving obstruction and enabling subsequent elective surgery or systemic therapy, with lower morbidity compared to emergency surgery[13,14]. Additionally, novel radiotherapeutic and chemotherapeutic strategies, including neoadjuvant immunotherapy, have shown promise in downstaging tumors causing obstruction and improving resectability[15]. The role of precise diagnostic modalities, such as computed tomography (CT), magnetic resonance imaging (MRI), and endoscopy, is critical in characterizing the extent and etiology of obstruction, guiding treatment planning, and monitoring response[16,17]. Moreover, understanding the pathophysiological mechanisms underlying CRIO, including radiation-induced enteritis and tumor-associated fibrosis, informs the development of targeted therapies and supportive care measures.

Despite these advances, challenges remain in optimizing management strategies for CRIO. The heterogeneity of tumor types, patient comorbidities, and obstruction severity necessitates individualized treatment plans. Furthermore, complications such as postoperative sepsis, intestinal ischemia, and recurrent obstruction require vigilant perioperative care and risk stratification[18,19]. Emerging research on the role of the intestinal microbiota and immune responses in intestinal motility disorders offers potential avenues for novel therapeutic interventions[20].

In summary, CRIO is a multifaceted clinical problem with significant impact on patient outcomes. The evolution of surgical, endoscopic, and systemic therapies has improved the management of CRIO, yet further research is essential to refine treatment algorithms, enhance symptom control, and prolong survival. This editorial aims to provide a comprehensive overview of the current understanding and recent advances in the diagnosis and treatment of CRIO, highlighting future directions for research and clinical practice (Figure 1, Table 1).

Figure 1 Mechanistic basis and multidisciplinary management strategies for cancer-related incomplete intestinal obstruction. CT: Computed tomography; MRI: Magnetic resonance imaging; ERAS: Enhanced recovery after surgery.

Table 1 Diagnostic and therapeutic evidence for cancer-related incomplete intestinal obstruction.

Category	Main intervention or finding	Key outcomes/clinical implications
Diagnostic imaging	Contrast-enhanced CT for surgical timing in acute intestinal obstruction	Identifies ischemia and perforation risk; guides operative decision-making
MRI evaluation	MRI for assessing tumor invasion depth and peritoneal spread	Provides superior soft-tissue contrast and avoids radiation; suitable for serial follow-up
Endoscopic evaluation	Capsule and double-balloon endoscopy for lesion localization and biopsy	Enables direct visualization and limited therapy; use with caution in suspected obstruction due to capsule-retention risk
Biomarker exploration	Cytokines (interleukin-6, tumor necrosis factor-α) and intestinal-barrier markers	Potential adjuncts for diagnosis and monitoring, though clinical use remains investigational
Pharmacologic therapy (integrative)	Dahuang Fuzi decoction modulates phosphoinositide-3 kinase-protein kinase B and hypoxia-inducible factor-1 pathways	Demonstrates anti-inflammatory and pro-motility effects in pre-clinical models
Immunotherapy/targeted therapy	Neoadjuvant tislelizumab in MMR-deficient colorectal cancer with incomplete obstruction	Achieved pathological complete response; reduced obstruction severity and improved resectability
Nutritional and fluid management	Pre-operative nutritional optimization in chronic radiation enteropathy	Decreases postoperative complications; supports individualized nutrition plans
Interventional stenting	Combined intestinal stent + laparoscopic surgery in malignant obstruction	Higher short-term success and lower morbidity than emergency surgery
Minimally invasive surgery	Laparoscopic vs open colectomy for obstruction due to colon cancer	Laparoscopy shortens recovery and hospital stay without compromising oncologic safety
Multidisciplinary management	Integrated palliative-oncologic care for incurable cancer	Enhances quality of life and symptom control through team-based coordination

CT: Computed tomography; MRI: Magnetic resonance imaging; MMR: Mismatch repair.

PATHOPHYSIOLOGICAL MECHANISMS AND DIAGNOSTIC ADVANCES

Pathological mechanisms analysis

CRIO arises from multifactorial pathological mechanisms involving both direct and indirect tumor effects on the intestinal tract. Primarily, tumor cells can directly invade the intestinal wall or protrude into the lumen, causing mechanical partial obstruction. For example, colorectal cancers can grow intraluminally or infiltrate the bowel wall, leading to luminal narrowing and impaired passage of intestinal contents, which manifests clinically as incomplete obstruction[21,22]. Beyond direct tumor invasion, the peritumoral microenvironment contributes significantly to obstruction progression. Tumor-induced inflammation in the surrounding intestinal tissues triggers a cascade of immune responses, leading to fibrosis and scarring around the bowel, which exacerbates luminal narrowing and rigidity[21]. This inflammatory-fibrotic reaction is a key factor in the chronicity and worsening of obstruction symptoms.

Additionally, alterations in intestinal motility and neural dysregulation play crucial roles in the pathogenesis of CRIO. Tumor infiltration or paraneoplastic processes can disrupt the enteric nervous system, leading to dysmotility and impaired peristalsis, which further contribute to functional obstruction beyond the mechanical component[23]. Moreover, tumor-related peritoneal dissemination and malignant ascites can cause secondary intestinal obstruction by external compression or tethering of the bowel loops. Peritoneal metastases often induce adhesions and localized inflammation, compounding the obstruction[24,25]. In some cases, malignant ascites increases intra-abdominal pressure and impair bowel motility, aggravating incomplete obstruction.

Emerging biomarker studies have provided further insight into these mechanisms. Elevated inflammatory cytokines such as interleukin-6 and tumor necrosis factor-α correlate with the degree of intestinal inflammation and fibrosis, and may serve as indicators of disease activity and systemic response[26]. Meanwhile, fecal calprotectin, a marker of neutrophil activation, has shown potential utility in assessing mucosal inflammation and monitoring the therapeutic response in malignancy-associated intestinal dysfunction[27]. Integration of these biomarkers into clinical evaluation may enhance diagnostic precision and guide individualized management strategies. Collectively, these mechanisms, tumor invasion, peritumoral inflammation and fibrosis, neural dysfunction, and peritoneal metastasis, interact to produce the complex pathophysiology of CRIO. Understanding these intertwined processes is critical for developing targeted diagnostic and therapeutic strategies to manage CRIO effectively.

Advances in diagnostic techniques

Recent advances in diagnostic modalities have significantly improved the detection, localization, and characterization of CRIO, facilitating earlier intervention and personalized treatment planning. Imaging techniques remain the cornerstone of diagnosis, with CT and MRI playing pivotal roles. Contrast-enhanced CT scans provide high-resolution cross-sectional images that delineate the site and extent of obstruction, tumor size, and involvement of adjacent structures. Enhanced CT can also detect complications such as perforation or ischemia, which are critical for surgical decision-making[21,28]. MRI, particularly with contrast enhancement, offers superior soft tissue contrast and is valuable in assessing tumor invasion depth and peritoneal metastasis without radiation exposure, making it suitable for repeated evaluations[22]. Endoscopic technologies have evolved to complement imaging by enabling direct visualization and biopsy of obstructive lesions. Capsule endoscopy allows non-invasive examination of the small intestine, identifying mucosal abnormalities and strictures that may not be apparent on imaging[24]. However, capsule endoscopy carries a potential risk of capsule retention in patients with suspected or known obstruction; therefore, its application should be preceded by patency capsule testing or radiological evaluation to exclude complete blockage. Double-balloon enteroscopy extends this capability by permitting therapeutic interventions such as stent placement or dilation in selected cases. These endoscopic advances enhance diagnostic accuracy and facilitate minimally invasive management. In addition to imaging and endoscopy, research into tumor-associated biomarkers has opened new avenues for early diagnosis and monitoring. Inflammatory cytokines and markers of intestinal barrier function are being explored for their potential to reflect tumor activity and intestinal dysfunction in CRIO, although clinical application remains under investigation[23]. Importantly, the integration of multimodal diagnostic strategies, combining imaging, endoscopy, and biomarker analysis, has improved the sensitivity and specificity of CRIO detection. Multidisciplinary approaches leveraging these complementary tools enable earlier recognition of obstruction severity and underlying pathology, guiding optimal therapeutic choices and improving patient outcomes[29,30]. In summary, advances in imaging, endoscopic techniques, and biomarker research have collectively enhanced the diagnostic landscape of CRIO, enabling more precise and timely clinical management.

PROGRESS IN CONSERVATIVE MANAGEMENT

New strategies in pharmacological treatment

Recent advances in the pharmacological management of CRIO emphasize a multimodal approach integrating anti-inflammatory agents, prokinetic drugs, targeted therapies, and optimized symptom control. The combined application of anti-inflammatory drugs and intestinal motility agents aims to restore bowel function by reducing local inflammation and enhancing peristalsis. Dahuang Fuzi decoction, a traditional Chinese herbal formula consisting mainly of Aconitum carmichaelii, Rheum palmatum, and Asarum sieboldii, has been traditionally used to alleviate intestinal obstruction symptoms by promoting peristalsis and reducing inflammation. It has been investigated through network pharmacology and molecular docking, revealing active ingredients such as kaempferol and deltoin that regulate key inflammatory pathways including phosphoinositide-3 kinase-protein kinase B and hypoxia-inducible factor-1, thereby reducing pro-inflammatory cytokines such as tumor necrosis factor-α and interleukin-6, which are implicated in intestinal obstruction pathophysiology[31]. This integrative approach may mitigate intestinal edema and improve motility, addressing the functional component of obstruction.

In addition, molecularly targeted and immune-based therapies have emerged as promising adjunctive options in the broader context of malignancy-associated bowel obstruction. These agents do not directly treat CRIO itself, but rather act on the underlying malignancy that causes the obstruction. For instance, immune checkpoint inhibitors, such as tislelizumab, have demonstrated efficacy in locally advanced mismatch repair-deficient colorectal cancer complicated by incomplete obstruction, achieving pathological complete response and thereby indirectly relieving the obstructive symptoms through tumor downstaging[15]. These agents may offer neoadjuvant benefits, improving obstruction symptoms and surgical outcomes.

Furthermore, symptom control with analgesics and antiemetics remains critical. Optimizing pain management through multimodal analgesia, including patient-controlled analgesia, has been shown to effectively alleviate refractory cancer pain associated with obstruction, while minimizing adverse effects[32]. Antiemetic regimens incorporating antidopaminergic agents such as haloperidol and metoclopramide are recommended for nausea control in malignant intestinal obstruction, improving patient comfort and tolerance of nutritional support[33].

Given the complexity of pharmacological management in patients with CRIO, it is crucial to consider potential drug interactions and side effects, especially in those receiving multiple therapies for advanced cancer. Prokinetic agents, commonly used to enhance intestinal motility, can interact with opioids, often prescribed for cancer-related pain, by exacerbating constipation or impairing gut motility further. Moreover, chemotherapeutic agents, such as 5-fluorouracil and irinotecan, may cause gastrointestinal side effects like diarrhea, nausea, and vomiting, which can be worsened by concomitant use of antiemetics or other gastrointestinal agents. A comprehensive, multidisciplinary medication review is essential to balance efficacy with safety, minimizing adverse reactions and optimizing therapeutic outcomes. Collectively, these pharmacological strategies reflect an evolving paradigm that addresses both the underlying tumor pathology and the symptomatic burden of CRIO, aiming to improve intestinal function and patient quality of life.

Advances in nutritional support and fluid management

Nutritional support and fluid management constitute cornerstone conservative therapies for CRIO, with recent progress focusing on individualized enteral nutrition protocols, judicious use of parenteral nutrition, and precise fluid balance control to prevent complications such as intestinal edema and electrolyte disturbances. Tailored enteral nutrition plans emphasize minimizing intestinal workload while promoting mucosal repair and maintaining gut integrity. For example, in patients with intestinal stenosis or partial obstruction, small-dose laxatives combined with oral antibiotics have been employed preoperatively to optimize bowel preparation without exacerbating obstruction, reflecting an evidence-based stratified approach[30]. Moreover, exclusive enteral nutrition has demonstrated efficacy in inflammatory bowel disease and may have analogous benefits in cancer patients by providing easily absorbable nutrients that reduce mechanical stress on the bowel[34]. In cases where enteral feeding is contraindicated or insufficient, parenteral nutrition is indicated; however, its use requires careful monitoring to mitigate risks such as catheter-related infections and liver dysfunction. Studies in chronic radiation intestinal injury highlight the importance of preoperative nutritional optimization, including parenteral support, to reduce postoperative complications and enhance recovery[35]. Fluid management strategies aim to maintain euvolemia and electrolyte homeostasis to prevent intestinal wall edema, which can worsen obstruction. This involves careful intravenous fluid administration and electrolyte monitoring, particularly in patients with compromised absorption or high-output fistulas[34]. Overall, advances in nutritional and fluid management underscore the need for individualized, multidisciplinary care plans that balance nutritional adequacy with the pathophysiological constraints imposed by incomplete obstruction, thereby promoting intestinal healing and improving clinical outcomes.

Non-pharmacological conservative measures

Non-pharmacological interventions play a vital role in the conservative management of CRIO by alleviating symptoms, enhancing intestinal function, and improving patient quality of life. Abdominal decompression techniques, including nasogastric or nasojejunal tube placement, facilitate the relief of intraluminal pressure and reduce nausea and vomiting, thereby mitigating obstruction symptoms and preventing progression to complete obstruction[36]. Positional adjustments, such as elevating the head of the bed or adopting specific postures, may aid in promoting intestinal transit and reducing discomfort. Physical therapy and rehabilitation programs have been shown to support recovery of bowel motility by enhancing overall muscular function and reducing deconditioning, which is particularly important in cancer patients with prolonged immobility[33]. Psychological support is increasingly recognized as essential in managing the complex symptom burden of CRIO. Anxiety and depression can exacerbate gastrointestinal symptoms and reduce treatment adherence; thus, integrating psychological counseling and cognitive behavioral therapy can improve coping mechanisms and overall well-being[33]. Furthermore, comprehensive pain management strategies that incorporate both pharmacologic and non-pharmacologic modalities, including relaxation techniques and patient education, contribute to better symptom control and quality of life[33]. Collectively, these non-drug conservative measures complement pharmacological and nutritional therapies, forming an integrated approach that addresses the multifaceted needs of patients with CRIO.

INTERVENTIONAL AND SURGICAL TREATMENT ADVANCES

Minimally invasive interventional techniques

Percutaneous intestinal decompression tube placement represents a pivotal minimally invasive intervention for patients with cancer-related incomplete bowel obstruction, especially when surgical risks are prohibitive. This technique involves the insertion of a decompression catheter under imaging guidance to relieve intestinal distension and alleviate obstructive symptoms. Indications include patients with mechanical obstruction due to tumor infiltration or extrinsic compression, who are either unfit for surgery or require symptom palliation. Technical considerations emphasize precise catheter placement beyond the obstruction site to ensure effective decompression while minimizing complications such as perforation or infection.

Intestinal stenting has emerged as a complementary or alternative modality, particularly for mechanical obstructions. Self-expandable metal stents can be endoscopically or radiologically deployed to restore luminal patency, offering rapid symptom relief and improving quality of life. Clinical outcomes demonstrate high technical success rates and favorable short-term efficacy, though stent patency duration and risk of re-obstruction remain challenges. The combination of interventional radiology techniques with local tumor therapies, such as interventional radiotherapy and tumor ablation, has shown promising synergistic effects. For instance, transcatheter arterial chemoembolization or radiofrequency ablation can be integrated with stenting to control tumor burden while maintaining intestinal patency. Recent advances in targeted delivery systems, including the use of nanoplatforms and natural polysaccharide-based carriers, enhance the precision and efficacy of local therapies, potentially reducing systemic toxicity. These innovations reflect a trend toward personalized interventional oncology, leveraging tumor biology and immune microenvironment insights to optimize therapeutic outcomes. Overall, minimally invasive interventional techniques provide effective symptom control and bridge to further systemic or surgical treatments, marking a significant advancement in managing cancer-associated intestinal obstruction[37-41].

Optimization of surgical treatment strategies

Surgical management of cancer-related intestinal obstruction has evolved with the advent of minimally invasive techniques such as laparoscopy and robot-assisted surgery. These approaches offer distinct advantages including reduced operative trauma, faster recovery, and decreased postoperative complications compared to traditional open surgery. Recent studies have reported that laparoscopic surgery offers shorter recovery times and lower morbidity rates, particularly in patients with non-complex tumors, while open surgery remains the preferred option for extensive or multifocal disease[42]. Laparoscopic surgery has demonstrated efficacy in small bowel obstruction management, with studies reporting shorter return of bowel function and hospital stays, without compromising safety or oncologic outcomes. Robot-assisted surgery further enhances precision, dexterity, and visualization, facilitating complex resections and reconstructions even in challenging anatomical locations. Careful patient selection based on comprehensive preoperative assessment is critical to optimize surgical outcomes. This includes evaluating tumor extent, patient performance status, nutritional condition, and comorbidities. Perioperative management strategies, such as enhanced recovery after surgery protocols, have been increasingly adopted to mitigate surgical stress, reduce complications, and expedite rehabilitation. Enhanced recovery after surgery components encompass multimodal analgesia, early mobilization, optimized fluid management, and nutritional support. Additionally, meticulous surgical technique aimed at achieving R0 resection margins is paramount for oncologic control and improved survival, especially in advanced malignancies involving the gastrointestinal tract. Postoperative complication prevention involves vigilant monitoring for anastomotic leaks, infections, and bowel dysfunction, with prompt intervention as needed. Emerging evidence supports the integration of minimally invasive surgery with multidisciplinary care pathways, contributing to improved functional and oncologic outcomes in patients with cancer-related bowel obstruction[43-47].

Multidisciplinary comprehensive treatment model

The complexity of cancer-related incomplete bowel obstruction necessitates a multidisciplinary approach involving oncologists, surgeons, interventional radiologists, nutritionists, pain specialists, and palliative care teams. Collaborative decision-making ensures individualized treatment plans tailored to tumor biology, patient comorbidities, and goals of care. Nutritional support plays a vital role in optimizing patient condition pre- and post-intervention, addressing malnutrition and enhancing tolerance to therapies. Pain management, incorporating pharmacologic and interventional modalities, improves symptom control and quality of life. Psychological support and mental health interventions are integral components of multidisciplinary management, as anxiety and depression commonly exacerbate symptom burden and impair treatment adherence in CRIO patients. Dynamic adjustment of treatment strategies based on clinical response and disease progression is essential, with regular multidisciplinary evaluations facilitating timely modifications. Integration of systemic therapies, such as chemotherapy or targeted agents, with local interventions can prolong survival and maintain functional status. Evidence indicates that comprehensive multidisciplinary care extends survival and improves quality of life in patients with advanced gastrointestinal malignancies complicated by bowel obstruction. This holistic model underscores the importance of coordinated care pathways and patient-centered outcomes in the management of this challenging clinical scenario[33,37,48].

CONCLUSION

In conclusion, cancer-related incomplete bowel obstruction remains a multifaceted challenge that requires individualized, multidisciplinary management[49]. Advances in diagnostic imaging, pharmacologic therapy, nutritional support, and minimally invasive interventions have significantly improved symptom control, functional recovery, and patient survival. Integrating these modalities within a coordinated treatment framework enables tailored strategies that balance palliation and oncologic outcomes. The shift toward precision medicine and patient-centered care emphasizes the importance of combining technological innovation with clinical judgment. Future efforts should focus on developing molecularly targeted therapies, refining perioperative protocols, and strengthening multidisciplinary collaboration to optimize outcomes. Overall, a comprehensive, mechanism-driven approach grounded in early diagnosis and minimally invasive treatment represents the future direction for managing CRIO.