Re: Recommendations for Bowel Obstruction With Peritoneal Carcinomatosis by Laval et al.

Laval et al. are to be commended for their comprehensive review article on management of malignant bowel obstruction (MBO) in patients with peritoneal carcinomatosis. They address an issue, however, which I would like to comment on from a palliative care perspective. Current evidence does not support their statement that “rehydration is needed for virtually every patient.” An earlier observational study on patients with MBO reported intravenous volume depletion with signs of fluid retention, regardless of artificial hydration (AH) administration. According to a large survey conducted by the same group, health care professionals witnessed volume-dependent adverse effects of AH on patients with terminal cancer. The lack of benefit of AH on dry mouth and thirst in MBO, a correlation of large AH volumes with an increase of bowel secretions, but also possible preventive effects of AH on metabolic symptoms, have to be considered. Moreover, focusing on the last week of life in cancer patients, a systematic review found conflicting evidence of AH effects: Although some studies reported improved nausea and dehydration symptoms, others found increases of ascitic fluid and gastrointestinal secretions. Finally, a recent randomized placebo-controlled trial was not able to demonstrate any benefit of AH in terms of symptom control, quality of life, and survival. Being aware that these studies include conditions other than MBO, most of the observed patients share common features, such as dehydration, edema, abdominal symptoms, low serum albumin levels, and a very poor prognosis. Thus, an individual risk-adapted approach that carefully balances harms and benefits of AH seems more appropriate than a global recommendation in favor of this intervention.