Palliative Surgery for Malignant Bowel Obstruction From Carcinomatosis

Olson, Terrah J. Paul; Pinkerton, Carolyn; Brasel, Karen J.; Schwarze, Margaret L.

doi:10.1001/jamasurg.2013.4059

Cited by 169 publications

(97 citation statements)

References 59 publications

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“…However, a substantial number die soon after surgery, and many others experience postoperative complications, reoperations, stays in nursing facilities, and readmissions. These postoperative events have previously been shown to adversely affect patients' quality of life (17, 18). In addition, the mortality rates found in our patient population are higher than previously reported emergency laparotomy rates in the general population of around 17% (19).…”

Section: Discussionmentioning

confidence: 99%

Outcomes after emergency abdominal surgery in patients with advanced cancer

Cauley

Panizales

Reznor

et al. 2015

Journal of Trauma and Acute Care Surgery

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Background There is increasing emphasis on the appropriateness and quality of acute surgical care for patients with serious illness, and at the end-of-life. However, there is a lack of evidence regarding outcomes after emergent major abdominal surgery among patients with advanced cancer to guide treatment decisions. This analysis seeks to characterize adverse outcomes (mortality, complications, institutional discharge) and to identify factors independently associated with 30-day mortality among patients with disseminated cancer who undergo emergent abdominal surgery for intestinal obstruction or perforation. Methods This is a retrospective cohort study of 875 disseminated cancer patients undergoing emergency surgery for perforation (n=499) or obstruction (n=376) at hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) from 2005-2012. Predictors of 30 day mortality were identified using multivariate logistic regression. Results Among patients who underwent surgery for perforation, 30-day mortality was 34%, 67% had complications and 52% were discharged to an institution. Renal failure, septic shock, ascites, dyspnea at rest, and dependent functional status were independent preoperative predictors of death at 30 days. When complications were considered, postoperative respiratory complications and age (75-84 years) were also predictors of mortality. Patients who had surgery for obstruction had a 30-day mortality rate of 18% (n=68), 41% had complications, and 60% were discharged to an institution. Dependent functional status and ascites were independent predictors of death at 30 days. In addition to these predictors, postoperative predictors of mortality included respiratory and cardiac complications. Few patients (4%) had DNR orders prior to surgery. Conclusions Emergency abdominal operations in patients with disseminated cancer are highly morbid and many patients die soon after surgery. High rates of complications, and low rates of pre-existing DNR orders highlight the need for targeted interventions to reduce complications and integrate palliative approaches into the care of these patients. Level of Evidence III Study Type Prognostic

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Section: Discussionmentioning

confidence: 99%

Outcomes after emergency abdominal surgery in patients with advanced cancer

Cauley

Panizales

Reznor

et al. 2015

Journal of Trauma and Acute Care Surgery

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“…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]. …”

Section: Discussionmentioning

confidence: 99%

“…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].…”

Section: Discussionmentioning

confidence: 99%

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Current perioperative outcomes for patients with disseminated cancer

Bateni

Meyers

Bold

et al. 2015

Journal of Surgical Research

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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.

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“…High-risk surgery can have other unintended consequences including postoperative suffering, conflict about additional aggressive treatments and receipt of unwanted interventions. 4,5 Thus, much is at stake for patients in the decision to proceed.…”

Section: Introductionmentioning

confidence: 99%

Engaging Patients, Health Care Professionals, and Community Members to Improve Preoperative Decision Making for Older Adults Facing High-Risk Surgery

et al. 2016

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Importance Older patients are at greater risk for postoperative complications yet they are less likely than younger patients to ask questions about surgery. Objective To design an intervention to improve preoperative decision making and manage postoperative expectations. Design We created a Patient and Family Advisory Council (PFAC) to help identify preoperative decisional needs. We met monthly for one year to examine findings from a prior qualitative study and to integrate themes with PFAC members’ lived experience. PFAC members and other stakeholders evaluated 118 publically available questions and selected 12 corresponding to identified needs to generate a question prompt list. To refine this intervention, we conducted focus groups and a clinical pilot. Setting The local library and one outpatient surgical clinic in Madison and three community centers in Madison and Milwaukee, Wisconsin. Participants Four men and women who had previous experience with high-risk surgery as either older patients or family members participated in our PFAC. Three focus groups included 31 community members from diverse backgrounds. We pilot tested the intervention with 42 patients considering surgery. Exposure(s) None Main Outcome and Measure(s) Generation of an intervention to address patients’ preoperative informational and decisional needs. Results Through exploration of qualitative data the PFAC noted three critical problems; patients and family members believed surgery “had to be done,” were surprised that postoperative recovery was difficult and lacked knowledge about the use of advance directives perioperatively. The PFAC identified a need for more information and decisional support during preoperative conversations including clarification of treatment options, setting postoperative expectations and advance care planning. Three question prompt categories arose: “Should I have surgery?”, “What should I expect if everything goes well?”, and “What happens if things go wrong?” The final list includes 11 questions within these domains, was understandable in English and Spanish, and was acceptable to patients in clinic. Conclusions and Relevance Through direct engagement of stakeholders, we created a question prompt list to address core decisional and informational needs of surgical patients. Future testing will evaluate whether this list can be used to improve patient engagement and reduce postoperative regret and conflict about postoperative treatments.

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Palliative Surgery for Malignant Bowel Obstruction From Carcinomatosis

Cited by 169 publications

References 59 publications

Outcomes after emergency abdominal surgery in patients with advanced cancer

Outcomes after emergency abdominal surgery in patients with advanced cancer

Current perioperative outcomes for patients with disseminated cancer

Engaging Patients, Health Care Professionals, and Community Members to Improve Preoperative Decision Making for Older Adults Facing High-Risk Surgery

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