Management of malignant bowel obstruction in sub-Saharan Africa: A structured narrative review of evidence, contextual challenges and clinical practice gaps

Malignant bowel obstruction (MBO) is a known, devastating complication of advanced intra-abdominal malignancy. International management guidelines are derived from high-income settings and rely on resources: computed tomography, self-expanding metal stents, total parenteral nutrition, specialist palliative care, that are inconsistently available in low- and middle-income countries (LMICs). Clinicians in LMICs therefore manage MBO within a fundamentally different diagnostic and therapeutic landscape, usually without context-specific guidance. Surgery dominates management but carries high morbidity and mortality, particularly in patients with ECOG performance status ≥3, serum albumin <30 g/L, ascites and peritoneal carcinomatosis. Emerging LMIC-based data confirm these patterns: a prospective Kenyan series reported 30-day postoperative mortality of 10.8% for malignant obstruction, while a South African review of 510 obstructed colorectal cancer patients found stomas were used twice as frequently as stents, the reverse of high-income country practice. No prognostic tool has been validated in LMIC populations. MBO care in LMICs demands a recalibration of international evidence to local realities. Our proposed context-adapted decision framework offers a structured, evidence-informed approach to rational surgical decision-making that can be applied immediately, even in settings lacking advanced imaging or endoscopic services.