Current perioperative outcomes for patients with disseminated cancer

Abstract

Background Surgical morbidity and mortality (M&M) for patients with disseminated malignancy (DMa) is high, and some have questioned the role of surgery. Therefore, we sought to characterize temporal trends in M&M among DMa patients, hypothesizing that surgical intervention would remain prevalent. Methods We queried the American College of Surgeons National Surgical Quality Improvement Program from 2006 to 2010. Excluding patients undergoing a primary hepatic operation, we identified 21,755 patients with DMa. Parametric/non-parametric statistics and logistic regression were used to evaluate temporal trends and predictors of M&M. Results The prevalence of surgical intervention for DMa declined slightly over the time period, from 1.9% to 1.6% of all procedures (p<0.01). Among DMa patients, the most frequent operations performed were bowel resection, other gastrointestinal procedures, and multivisceral resections, these all showed small statistically significant decreases over time (p<0.01). The rate of emergency operations also decreased (p<0.01). In contrast, the rate of preoperative independent functional status rose, while the rate of preoperative weight loss and sepsis decreased (p<0.01). Rates of 30-day morbidity (33.7 vs 26.6%), serious morbidity (19.8 vs 14.2%), and mortality (10.4 vs 9.3%) all decreased over the study period (p<0.05). Multivariate analysis identified standard predictors (e.g. impaired functional status, pre-operative weight loss pre-operative sepsis, and hypoalbuminemia) of worse 30-day M&M. Conclusion 30-day morbidity, serious morbidity, and mortality have decreased incrementally for patients with DMa undergoing surgical intervention, but surgical intervention remains prevalent. These data further highlight the importance of careful patient selection and goal-directed therapy in patients with incurable malignancy.

Increased Rates of Prolonged Length of Stay, Readmissions, and Discharge to Care Facilities among Postoperative Patients with Disseminated Malignancy: Implications for Clinical Practice

“…[6, 21] Although malignant bowel obstruction may be successfully managed by non-operative approaches, bowel obstruction is still considered a surgical condition, as in some cases the consequences of a delay in indicated surgical treatment may be severe. [21–24] However, our results emphasize not only the significant risks of acute morbidity and mortality associated with performing surgery, which others have also observed,[10, 11, 22, 23] but also the increased risks of prolonged hospital stays, hospital readmissions, and discharge to facilities. For example, in our analysis, DMa patients who underwent bowel resections, a common surgery performed for obstruction, were more likely to experience prolonged length of stay and disposition to a facility other than home.…”

“…[8–11] However, most importantly, we observed that DMa patients undergoing surgery had significantly higher rates of prolonged length of hospital stay, readmissions, and disposition to facilities other than home compared to non-DMa matched controls. These data highlight the dilemma that physicians and surgeons commonly face when presented with patients with DMa who are diagnosed with an acute surgical condition and/or condition that potentially may benefit from surgical palliation.…”

“…[11] ACS-NSQIP defines DMa as “patients who have cancer that: (1) has spread to one or more sites in addition to the primary site and (2) in whom the presence of multiple metastases indicates the cancer is widespread, fulminant or near terminal.”[13] Patients undergoing primary hepatic operation (N = 2,543) were excluded, as prior research has shown that hepatic operations are potentially curative in selected patients. [14–16]…”

“…These characteristics were specifically chosen as they have previously been shown to be independent predictors of postoperative morbidity and mortality for DMa patients. [10, 11] Standard ACS-NSQIP definitions were used to define these variables. [13] After matching, 123 DMa patients were excluded due to missing data from ≥1 of the matched variables, with a final cohort of 17,972 matched pairs.…”

“…[8, 9] However, we and others have shown that surgical intervention in this population is associated with high 30-day morbidity and mortality, with rates ranging from 27–44% and 9–11% respectively. [8–11] It is unclear to what extent this elevated post-surgical morbidity impacts other metrics of surgical outcomes among patients with disseminated malignancy (DMa) such as prolonged postoperative length of hospital stay, hospital readmission following the index surgical procedure, and disposition to facilities such as nursing homes.…”