Management of Bowel Obstruction in Patients with Stage IV Cancer: Predictors of Outcome After Surgery

Abstract

Introduction Patients with Stage IV cancer and bowel obstruction (BO) present a complicated management problem. We sought to determine if specific parameters could predict outcome after surgery. Methods Records of patients with Stage IV cancer and BO treated from 1991–2008 were reviewed. For surgical patients, 30-day morbidity and 90-day mortality were assessed using exact multivariable Logistic regression methods. Results Of 198 patients, 132 (66.7%) underwent surgery, 66 medical treatment alone, and demographics were similar. 41 (20.7%) patients were diagnosed with Stage IV cancer and BO synchronously, all treated surgically; the remaining presented metachronously. Medically managed patients were more likely to have received chemotherapy in the 30 days prior to BO [45/66 (68.2%) vs 40/132 (30.3%), p <0.01]. In the surgical group, 30-day morbidity was 35.6%, while 90-day mortality was 42.3%. Median overall survival for synchronous patients was 14.1 months (95 % CI 7.6, 23.2), and 3.7 months (95 % CI 2.5, 5.2) and 3.6 months (95 % CI 1.5, 5.2) for metachronous patients treated surgically and medically, respectively. A multivariate model for 90-day surgical mortality identified low serum albumin, metachronous presentation, and ECOG > 1 as predictors of death (p<0.05). A model for 30-day surgical morbidity yielded low hematocrit as a predictive factor (p<0.05). Conclusions This cohort identifies characteristics indicative of morbidity and mortality in Stage IV cancer and BO. Low serum albumin, ECOG > 1, and metachronous presentation predicted for 90-day surgical mortality. These data suggest factors that can be used to frame treatment discussion plans with patients.

Current perioperative outcomes for patients with disseminated cancer

“…These findings are consistent with prior research. [4, 6, 17] For example, the incidence of malignant bowel obstruction has been estimated to be 5 – 51% in ovarian malignancies and 10 – 28% in gastrointestinal cancers, and rates of operations performed on stage IV cancer patients with bowel obstructions have consistently ranged from 57 – 67% [1, 3, 7, 18]. …”

“…This decision-making process should include an assessment of the risks of the procedure based on patient and procedural characteristics as well as probability of symptom resolution, the effect of overall quality of life, pain control, cost-effectiveness, and individual patient goals [3, 22]. Important patient characteristics to consider include patient functional status, as we and others have observed this factor to be a significant predictor of the risks of morbidity and mortality [4, 18]. …”

Palliative Care Version 1.2016

“…Risk factors for poor surgical outcome include ascites, carcinomatosis, palpable intra-abdominal masses, multiple bowel obstructions, previous abdominal radiation, advanced disease, and poor overall clinical status. 123 In these patients, medical management can include pharmacologic measures, parenteral fluids, endoscopic management, and enteral tube drainage (silicone tubing may offer superior comfort over vinyl).…”

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.…”