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Palliative Surgery for Malignant Bowel Obstruction: a Systematic Review
Terrah J. Paul Olson*1, Carolyn Pinkerton2, Karen J. Brasel2, Margaret L. Schwarze3
1General Surgery, University of Wisconsin Hospital and Clinics, Madison, WI; 2Surgery, Medical College of Wisconsin, Milwaukee, WI; 3Division of Vascular Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
Objectives: Malignant bowel obstruction (MBO) from peritoneal metastasis has a grim prognosis regardless of the primary cancer. Patients presenting with MBO have a life expectancy of weeks to months. When conservative treatments such as medications and gastric drainage are inadequate, palliative surgery may provide symptomatic relief. Morbidity and mortality after surgery for MBO is high, and effects of palliative surgery on patients' quality of life are not well characterized. We performed a systematic review to better characterize palliative surgery outcomes for patients with MBO to guide decision making about the value of surgery and associated postoperative interventions in the setting of incurable cancer.
Materials and Methods: We searched PubMed, EMBASE, CINAHL Plus, Cochrane Library, Web of Knowledge, and Google Scholar from inception through August 2012 for all available literature in all languages. We included studies reporting outcomes after open or laparoscopic surgery for bowel obstruction from peritoneal metastases from any primary malignancy. Outcomes of interest included survival, postoperative mortality, postoperative complications, ability to tolerate a diet or resolution of obstructive symptoms (successful treatment), rates of re-obstruction, hospital length of stay, and quality of life. We excluded case studies with fewer than 5 patients, studies of operations with curative rather than palliative intent, studies of percutaneous procedures, and studies where outcomes of benign obstruction could not be separated from malignant.
Results: We screened 2347 titles and selected 109 articles for review. Fifteen studies fit our inclusion and exclusion criteria. Survival and post-operative outcomes are summarized in the table. Median postoperative survival was low (range 36 days-7.9 months) while postoperative mortality was high (range 6-32%). Complications included wound dehiscence, enterocutaneous fistulae, sepsis, pulmonary emboli, and cardiopulmonary complications. Median lengths of stay ranged from 13-25 days. Rates of re-obstruction varied widely (range 6-47%). No studies reported quality of life postoperatively.
Discussion: This review highlights postoperative outcomes that can be used preoperatively to inform surgical decision making for MBO. Given the high mortality and substantial length of stay relative to overall survival, a thorough discussion of the patient's values and goals is advisable. Patients should be apprised of the modest chance of resuming a diet or relieving symptoms. Because 30-40% of these terminally ill patients will experience serious complications, patients should discuss whether aggressive management of postoperative complications is in line with their goals. Additionally, this study highlights a profound lack of attention to patient-centered outcomes for palliative surgical therapy.
Table. Outcomes after palliative surgery for malignant bowel obstruction.
| Study | N | Malignancy | Survival | Post-operative Mortality | Post-operative Complications | Successful Treatment | | Abbas 2006, 2007 | 79 | CRC*, GYN†, other | Median 5 months | 10% (8/79) | 35% (28/79) | Not reported | | Blair 2001 | 63 | CRC, non-GYN other | Median 3 months | 21% (13/63) | 44% (28/63) | 45% (29/63) | | Lau 1993 | 30 | CRC | Not reported | 17% (5/30) | 27% (8/30) | Not reported | | Mäkelä 1991 | 85 | CRC, GYN, other | Median 3 months (range 0-144 months) | 22% (19/85) | 42% (36/85) | 55% (47/85) | | Turnbull 1989 | 89 | CRC, non-GYN other | Median 98 days (range 1 day-2.5 years) | 13% (12/89) | 44% (39/89) | 74% (66/89) | | Van Ooijen 1993 | 20 | GYN, CRC, other | Median 36 days (range 3-151 days | Not reported | 5% (1/20) | Not reported | | Wong 2009 | 27 | CRC, GYN, other | Not reported | 15% (4/27) | Not reported | 85% (23/27) | | Bais 1995 | 19 | Ovarian | Median 109 days (range 15-775 days) | 11% (2/19) | 32% (6/19) | 68% (13/19) | | Kim 2009 | 23 | Ovarian | Not reported | Not reported | 13% (3/23) | 48% (11/23) | | Kolomainen 2012 | 90 | Ovarian | Median 90.5 days (range <1 day-6 years) | 18% (16/90) | 27% (24/90) | 66% (59/90) | | Lund 1989 | 25 | Ovarian | Median 68 days (range 7-919 days) | 32% (8/25) | 32% (8/25) | 20% (5/25) | | Mangili 2005 | 27 | Ovarian | Not reported | 22% (6/27) | 33% (9/27) | 59% (16/27) | | Piver 1982 | 60 | Ovarian | Median 2.5 months (range <1-27 months) | 17% (10/60) | 31% (19/60) | Not reported | | Pothuri 2003 | 64 | Ovarian | Median 7.9 months | 6% (4/64) | 23% (15/64) | 58% (37/64) | | Rubin 1989 | 52 | Ovarian | Median 5.8 months (range 0.02-37 months) | 17% (9/52) | 15% (8/52) | 65% (34/52) |
*Colorectal cancer †Gynecologic malignancies including ovarian, cervical, uterine, and endometrial cancers
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