Frequent and early death limits quality of life assessment in patients with advanced malignancies evaluated for palliative surgical intervention

Palliative Surgery for Patients with Gastroesophageal Junction or Gastric Cancer: A Report on Clinical Observational Outcomes

BACKGROUND

Few studies have focused on palliative surgery in patients with advanced gastroesophageal junction (GEJ) or gastric cancer. We sought to evaluate clinical observational outcomes following palliative surgery in this population.

PATIENTS AND METHODS

Patients with GEJ or gastric cancer who underwent palliative surgery (1/2010-11/2022) were identified. The primary outcomes were symptom improvement, ability to tolerate an oral diet, discharge to home, 30 "good days" without hospitalization, and receipt of systemic treatment. Postoperative outcomes and survival were secondarily evaluated.

RESULTS

Among 93 patients, the median age was 59 (IQR 47-68) years, and the median Eastern Cooperative Oncology Group Performance Status (ECOG-PS) was 1 (range 0-3). The most frequent indication for palliative surgery was primary tumor obstruction [75 (81%) patients]. The most common procedures were feeding tube placement in 60 (65%) and intestinal bypass in 15 (16%) patients. A total of 75 (81%) patients experienced symptom improvement. Of these, 19 (25%) developed recurrent and 49 (65%) developed new symptoms. ECOG-PS was significantly associated with symptom-free time. Among those who underwent a bypass, resection, or ostomy creation for malignant obstruction, 16 (80%) tolerated an oral diet. Postoperatively, 87 (94%) were discharged home, 72 (77%) had 30 good days, and 64 (69%) received systemic treatment. Postoperative complications occurred in 35 (38%) patients, and 7 (8%) died within 30 days. The median survival time was 7.7 (95% CI 6.4-10.40) months.

CONCLUSIONS

Patients with incurable GEJ or gastric cancer can benefit from palliative surgery. Prognosis and performance status should inform goals-of-care discussions and patient selection for surgical palliation.

Palliative surgery: state of the science and future directions

Palliative surgical procedures are operations that aim to alleviate symptoms in a patient with serious, life-limiting illness. They are common, particularly within the field of surgical oncology. However, few high-quality studies have attempted to measure the durability of improvements in symptoms and quality of life after palliative surgery. Furthermore, many of the studies that do exist are outdated and employ highly inconsistent definitions of palliative surgery. Consequently, the paucity of robust and reliable evidence on the benefits, risks, and trade-offs of palliative surgery hampers clinical decision-making for patients and their surgeons. The evidence for palliative surgery suggests that, with effective communication about goals of care and careful patient selection, palliative surgery can provide symptomatic relief and reduce healthcare burdens for certain seriously ill patients.

The First Cold Atmospheric Plasma Phase I Clinical Trial for the Treatment of Advanced Solid Tumors: A Novel Treatment Arm for Cancer

Local regional recurrence (LRR) remains the primary cause of treatment failure in solid tumors despite advancements in cancer therapies. Canady Helios Cold Plasma (CHCP) is a novel Cold Atmospheric Plasma device that generates an Electromagnetic Field and Reactive Oxygen and Nitrogen Species to induce cancer cell death. In the first FDA-approved Phase I trial (March 2020-April 2021), 20 patients with stage IV or recurrent solid tumors underwent surgical resection combined with intra-operative CHCP treatment. Safety was the primary endpoint; secondary endpoints were non-LRR, survival, cancer cell death, and the preservation of surrounding healthy tissue. CHCP did not impact intraoperative physiological data (p > 0.05) or cause any related adverse events. Overall response rates at 26 months for R0 and R0 with microscopic positive margin (R0-MPM) patients were 69% (95% CI, 19-40%) and 100% (95% CI, 100-100.0%), respectively. Survival rates for R0 (n = 7), R0-MPM (n = 5), R1 (n = 6), and R2 (n = 2) patients at 28 months were 86%, 40%, 67%, and 0%, respectively. The cumulative overall survival rate was 24% at 31 months (n = 20, 95% CI, 5.3-100.0). CHCP treatment combined with surgery is safe, selective towards cancer, and demonstrates exceptional LRR control in R0 and R0-MPM patients. (Clinical Trials identifier: NCT04267575).

Symptom Burden in Patients with Malignant Bowel Obstruction Treated With or Without Surgery

BACKGROUND

Gastrointestinal obstruction is the most common indication for palliative surgical consultation. We sought to assess patient-reported outcomes and survival after surgical and nonsurgical treatment of malignant bowel obstruction.

STUDY DESIGN

This was a prospective observational study enrolling patients with advanced malignancy who underwent surgical consultation at a tertiary cancer center. Patient-reported outcomes were evaluated using a previously validated inventory, the MD Anderson Symptom Inventory-Gastrointestinal Obstruction (MDASI-GIO), administered at enrollment and 7 other time points for up to 90 days.

RESULTS

We enrolled 125 patients, of whom 37 underwent surgery and 88 did not. Patients treated nonsurgically were more likely to have carcinomatosis on imaging (71% vs 49%, p = 0.02). Pain medicine, palliative care, and chaplaincy consultations occurred in 17%, 30%, and 15% of patients within the first month of enrollment. Higher mean symptom scores were noted by surgical patients, although the only single scores with effect sizes 0.5 or greater were symptom interference with general activity and work. The composite score for interference in work, activity, and walking had the largest effect size at -0.37, indicating greater interference in patients undergoing surgery. Patients selected for surgery had extended overall survival (median 15 vs 3 months, p < 0.01). Carcinomatosis, palliative care evaluation, and venting gastrostomy tube were associated with increased risk of death, and ability to receive subsequent chemotherapy and surgical management were positive prognostic indicators.

CONCLUSIONS

In this first study evaluating patient-reported outcomes after treatment for malignant bowel obstruction, we found that selection for surgical treatment was associated with improved survival, but also more symptom interference in general activities and work. These results may be useful in palliative surgical decision-making and informing patients during consultation for malignant bowel obstruction.

Trajectories of Patient-Reported Outcomes After Palliative Gastrointestinal Surgery in Advanced Cancer: Is Good Quality of Life Sustainable?

To evaluate the trajectories and sustainability of health-related quality of life (HRQoL) outcomes after palliative gastrointestinal (GI) surgery and perioperative factors associated with HRQoL improvement postsurgery.

Background

Palliative patients face a wide range of physical, emotional, social, and functional challenges. In evaluating the efficacy of palliative surgical interventions, a major pitfall of traditional surgical outcome measures is that they fall short of measuring outcomes that are meaningful to patients during end-of-life. HRQoL tools may provide a more comprehensive assessment of the true value and impact of palliative surgery.

Methods

We prospectively recruit advanced cancer patients undergoing palliative GI surgery. The Functional Assessment of Cancer Therapy-General (FACT-G) questionnaire was administered before and at regular intervals after surgery. HRQoL improvement was defined as ≥4-points increment in FACT-G total score over baseline. Duration of sustained HRQoL improvement above this threshold and factors associated with varying extents of HRQoL change were evaluated.

Results

Of the 65 patients, intestinal obstruction was the most common indication for surgery (70.8%). The mean baseline FACT-G total score was 70.7 (95% CI: 66.3-75.1). Forty-six (70.8%) patients experienced HRQoL improvement after surgery. This HRQoL improvement was sustained over a median duration of 3.5 months and was driven mainly by improvements in patients' physical and emotional well-being. Albumin was significantly associated with the extent of HRQoL improvements (P = 0.043).

Conclusion

A clinically significant and sustained improvement in HRQoL was observed after palliative GI surgery. Patients with higher preoperative albumin levels were more likely to experience HRQoL improvements.

Identifying Core Principles of Palliative Care Consultation in Surgical Patients and Potential Knowledge Gaps for Surgeons

BACKGROUND

Palliative medicine is an important component of care for patients with advanced cancer. Previous studies demonstrated that surgeons tend to underuse palliative care in comparison with medical services. In addition, little is known about the specific use of palliative care services among surgical oncology practices. Therefore, we designed and performed this study to evaluate the use of palliative care in medical and surgical oncology patients.

STUDY DESIGN

A single-institution retrospective review of consecutive palliative care consultations within a large National Cancer Institute-designated comprehensive cancer center in 2016 to 2017 was conducted.

RESULTS

We analyzed 120 patients (60 surgical and 60 medical). Patient demographics in the 2 groups were similar. The surgical oncology patients were more likely to undergo consultation for advanced care planning (32% vs 13%; p = 0.02). Medical oncology patients were more likely to undergo consultation for pain management (97% vs 62%; p < 0.001). Symptom assessment scores for medical patients more frequently demonstrated dyspnea and malignancy-related pain than in surgical patients. Also, palliative care recommendations and interventions for surgical patients more frequently included end-of-life discussions and transfer to the inpatient palliative care unit. For medical oncology patients, recommendations more often included changes in pain and bowel regimen medication. In addition, despite more frequent consults for advanced care planning in the surgical patients, code status was changed to DNR more frequently in the medical patient cohort.

CONCLUSIONS

Surgical patients were less likely to undergo palliative care consultation for assistance with symptom management and more likely to undergo consultation for assistance with end-of-life discussions than were medical oncology patients. Advanced care planning and end-of-life discussions should be an area of focus in palliative care education for surgeons.

Needle in a Haystack: Natural Language Processing to Identify Serious Illness

BACKGROUND

Alone, administrative data poorly identifies patients with palliative care needs.

OBJECTIVE

To identify patients with uncommon, yet devastating, illnesses using a combination of administrative data and natural language processing (NLP).

DESIGN/SETTING

Retrospective cohort study using the electronic medical records of a healthcare network totaling over 2500 hospital beds. We sought to identify patient populations with two unique disease processes associated with a poor prognosis: pneumoperitoneum and leptomeningeal metastases from breast cancer.

MEASUREMENTS

Patients with pneumoperitoneum or leptomeningeal metastasis from breast cancer were identified through administrative codes and NLP.

RESULTS

Administrative codes alone resulted in identification of 6438 patients with possible pneumoperitoneum and 557 patients with possible leptomeningeal metastasis. Adding NLP to this analysis reduced the number of patients to 869 with pneumoperitoneum and 187 with leptomeningeal metastasis secondary to breast cancer. Administrative codes alone yielded a 13% positive predictive value (PPV) for pneumoperitoneum and 25% PPV for leptomeningeal metastasis. The combination of administrative codes and NLP achieved a PPV of 100%. The entire process was completed within hours.

CONCLUSIONS

Adding NLP to the use of administrative codes allows for rapid identification of seriously ill patients with otherwise difficult to detect disease processes and eliminates costly, tedious, and time-intensive manual chart review. This method enables studies to evaluate the effectiveness of treatment, including palliative interventions, for unique populations of seriously ill patients who cannot be identified by administrative codes alone.

Feasibility and Pilot Studies in Palliative Care Research: A Systematic Review

CONTEXT

Feasibility and pilot study designs are common in palliative care research. Finding standard guidelines on the structure and reporting of these study types is difficult.

OBJECTIVES

In feasibility and pilot studies in palliative care research, to determine 1) how commonly a priori feasibility are criteria reported and whether results are subsequently reported against these criteria? and 2) how commonly are participants' views on acceptability of burden of the study protocol assessed?

METHODS

Four databases (OVID Medline, EMBASE, CINAHL, and PubMed via caresearch.com.au.) were searched. Search terms included palliative care, terminal care, advance care planning, hospice, pilot, feasibility, with a publication date between January 1, 2012 and December 31, 2013. Articles were selected and appraised by two independent reviewers.

RESULTS

Fifty-six feasibility and/or pilot studies were included in this review. Only three studies had clear a priori criteria to measure success. Sixteen studies reported participant acceptability or burden with measures. Forty-eight studies concluded feasibility.

CONCLUSION

The terms "feasibility" and "pilot" are used synonymously in palliative care research when describing studies that test for feasibility. Few studies in palliative care research outline clear criteria for success. The assessment of participant acceptability and burden is uncommon. A gold standard for feasibility study design in palliative care research that includes both clear criteria for success and testing of the study protocol for participant acceptability and burden is needed. Such a standard would assist with consistency in the design, conduct and reporting of feasibility and pilot studies.

Cost-effectiveness of palliative surgery versus nonsurgical procedures in gastrointestinal cancer patients

Palliative care is an essential component to multidisciplinary cancer care. Improved symptom control, quality of life (QOL), and survival have resulted from its utilization. Cost-effectiveness and utility analyses are significant variables that should be considered in comparing benefits and costs of medical interventions to determine if certain treatments are economically justified. This is a review on the cost-effectiveness of palliative surgery compared to other nonsurgical palliative procedures in patients with unresectable gastrointestinal cancers. J. Surg. Oncol. 2016;114:316-322. © 2016 Wiley Periodicals, Inc.

Abdominal surgical emergencies in patients with advanced cancer

Abdominal emergency in an advanced oncologic setting is defined as an acute life-threatening abdominal pathology in a patient with incurable cancer. These include bowel obstruction, infections and, more rarely, hemorrhage. To benefit the patient, surgery should both increase the survival and improve the quality of life. These two goals are of equal importance and must be achieved together. This is difficult because these patients are frail, often malnourished and have a poor performance status. They also have a high risk of post-operative morbidity and mortality, a major risk of symptom recurrence and a limited life expectancy. For patients near the end-of-life, a therapeutic decision for surgical intervention must respect ethical and legal standards. This review reports the surgical outcomes and median survival of these patients, specifies rules that must be known and respected, and presents non-operative interventional alternatives.

Cancer Pain Management

Safe, effective, and evidence-based management of cancer-related pain is a cornerstone of comprehensive cancer care. Despite increasing interest in and efforts to improve its management, pain remains poorly controlled in nearly half of all patients with cancer, with little change in the past 20 years. Limited training in pain assessment and management, overestimation of providers' own skills to treat pain, and failure to refer patients to pain specialists can result in suboptimal pain management with devastating effects on quality of life, physical functioning, and increased psychological distress. From a thorough assessment of cancer-related pain to appropriate treatments that may include opiates, adjuvant medications, nerve blocks, and nondrug interventions, this article is intended as a brief overview of the mechanisms and types of pain as well as a review of current, new, and promising approaches to its management.

Palliative surgery: incidence and outcomes

OBJECTIVES

To describe the goals of treatment, decision-making, incidence, and outcomes of surgical palliation in advanced cancer.

DATA SOURCES

Journal articles, research reports, state of the science papers, and clinical guidelines.

CONCLUSION

Surgical palliation is common in advanced cancer settings, and is indicated primarily in settings where the goals of treatment are focused on quality of life, symptom control, and symptom prevention. More research is needed to guide evidence-based best practices in palliative surgery.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses practicing in clinical and research settings have a responsibility to arm themselves with knowledge related to the indications and options of palliative procedures, and the impact of surgery on quality of life for patients and families facing advanced cancer.

Long-term survival in patients with metastatic gastric and gastroesophageal cancer treated with surgery

BACKGROUND

The purpose of this study was to determine the survival of patients with metastatic gastric cancer treated with surgery.

METHODS

We reviewed the medical records of 7,404 patients with gastric or gastroesophageal cancer seen from January 1995 to August 2012 at MD Anderson Cancer Center and identified patients with stage IV disease treated with surgery. Kaplan-Meier curves were created to compare overall survival (OS) between groups.

RESULTS

Of the 82 patients who met inclusion criteria, sites of metastatic disease included peritoneum (N = 34, 42%), positive cytology only (N = 17, 21%), distant lymph nodes (N = 12, 15%), and distant organs (N = 19, 23%). The median time from initial cancer diagnosis to surgery for metastatic disease was 10 months (range, 0-70). Surgery included exploratory surgery only (N = 16, 20%), primary tumor resection with or without resection of distant disease (N = 50, 61%), and distant disease resection only (N = 16, 20%). Median follow-up for living patients was 3 years (range, 0.1-14). Median survival for all patients was 1.5 years (range, 0.1-14). Five year OS for patients with peritoneal metastases, positive cytology only, distant lymph nodes, and distant organ involvement was 13, 42, 20, and 34%, respectively.

CONCLUSIONS

Surgery in the setting of metastatic disease is an uncommon clinical scenario and has a considerable risk of exploration without resection, although long-term survival is possible.

Current perioperative outcomes for patients with disseminated cancer

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 2006-2010. Excluding patients undergoing a primary hepatic operation, we identified 21,755 patients with DMa. Parametric and/or nonparametric 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%-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, whereas the rate of preoperative weight loss and sepsis decreased (P < 0.01). Rates of 30-d morbidity (33.7 versus 26.6%), serious morbidity (19.8 versus 14.2%), and mortality (10.4 versus 9.3%) all decreased over the study period (P < 0.05). Multivariate analysis identified standard predictors (e.g., impaired functional status, preoperative weight loss, preoperative sepsis, and hypoalbuminemia) of worse 30-d M&M.

CONCLUSIONS

Thirty-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.

Palliative surgery for malignant bowel obstruction from carcinomatosis: a systematic review

IMPORTANCE

Care of patients with malignant bowel obstruction caused by peritoneal metastases may present an ethical dilemma for surgeons when nonoperative management fails.

OBJECTIVE

To characterize outcomes of palliative surgery for malignant bowel obstruction from peritoneal carcinomatosis to guide decision making about surgery and postoperative interventions for patients with terminal illness.

EVIDENCE REVIEW

We searched PubMed, EMBASE, Cochrane Library, Web of Knowledge, Cumulative Index to Nursing and Allied Health Literature Plus, and Google Scholar and performed manual searches of selected journals from inception to August 30, 2012, with no filters, limits, or language restrictions. We used database-specific combinations of the terms intestinal obstruction, malignant, surgery or surgical, and palliat*. We included studies reporting outcomes after palliative surgery for malignant bowel obstruction from peritoneal carcinomatosis from any primary malignant neoplasm and excluded case studies, curative surgery, isolated percutaneous procedures, stenting for intraluminal lesions, and studies in which benign and malignant obstructions could not be distinguished. We assessed quality with the Newcastle-Ottawa Scale.

FINDINGS

We screened 2347 unique articles, selected 108 articles for full-text review, and included 17 studies. Surgery was able to palliate obstructive symptoms for 32% to 100% of patients, enable resumption of a diet for 45% to 75% of patients, and facilitate discharge to home in 34% to 87% of patients. Mortality was high (6%-32%), and serious complications were common (7%-44%). Frequent reobstructions (6%-47%), readmissions (38%-74%), and reoperations (2%-15%) occurred. Survival was limited (median, 26-273 days), and hospitalization for surgery consumed a substantial portion of the patient's remaining life (11%-61%).

CONCLUSIONS AND RELEVANCE

Although palliative surgery can benefit patients, it comes at the cost of high mortality and substantial hospitalization relative to the patient's remaining survival time. Preoperatively, surgeons should present realistic goals and limitations of surgery. For patients choosing surgery, clarifying preferences for aggressive postoperative interventions preoperatively is critical given the high complication rate and limited survival after surgery for malignant bowel obstruction.

Outcome measures other than morbidity and mortality for patients with incurable cancer and gastrointestinal obstruction

OBJECTIVE

To prospectively evaluate outcome measures of patients undergoing palliative surgical evaluation for gastrointestinal obstruction.

METHODS

Patients with an incurable malignancy undergoing consultation for gastrointestinal obstruction were prospectively enrolled from November 2009 to July 2012. We evaluated two patient-reported outcome measures of quality of life (Functional Assessment of Cancer Therapy-General [FACT-G]) and treatment satisfaction (Functional Assessment of Chronic Illness Therapy-Treatment Satisfaction-General Version 1 [FACIT-TS-G]) and five observational outcome measures (symptom improvement, 30 "good days," ability to tolerate diet at discharge, discharge home, and death within 90 days).

RESULTS

Of 53 patients enrolled, 13 had gastric outlet obstruction, 22 had small bowel obstruction, and 18 had large bowel obstruction. Patient-reported measures could not be analyzed because only 19 patients (36%) completed the FACT-G and FACIT-TS-G survey at 1-month follow-up. However, we were able to obtain results for the 5 clinical observational outcomes in all patients. Symptom improvement was obtained in 41 (77%) patients, 30 "good days" in 40 (75%), ability to tolerate diet at discharge in 45 (85%), discharge to home in 46 (87%), and 18 (34%) of patients died within 90 days of evaluation. Large bowel obstruction was associated with symptom improvement, and noncolorectal cancer histology and carcinomatosis were negatively associated with having 30 "good days." The ability to tolerate oral intake at discharge was associated with Eastern Cooperative Oncology Group performance status and no recent chemotherapy administration. Death within 90 days was independently associated with noncolorectal cancer histology, ascites, and nonsurgical treatment.

CONCLUSIONS

Observational outcome measures can provide follow-up data and the identification of variables associated with outcome for patients who are unable to respond to outpatient surveys.

Can patient reported outcomes help identify the optimal outcome in palliative surgery?

BACKGROUND

The purpose of this pilot study was to determine whether an open-ended questionnaire captures severe symptoms in cancer patients undergoing palliative surgical consultation that a structured, validated quality-of-life assessment does not capture.

METHODS

We prospectively used the Functional Assessment of Cancer Therapy-General (FACT-G) and an open-ended questionnaire to assess the symptoms of patients with incurable malignancies who underwent palliative surgical consultation at our institution between January 2011 and September 2012.

RESULTS

Of the 69 patients enrolled, the most common indications for consultation were bowel obstruction (54%), jaundice (13%), wound problems (10%), and gastrointestinal bleeding (7%). Of the severe symptoms patients reported, 76% were identified with the FACT-G alone, 22% were identified with the open-ended questionnaire alone, and 2% were duplicate responses captured with both the FACT-G and open-ended questionnaire. The open-ended questionnaire captured 68 instances of severe symptoms in 47 patients that the FACT-G did not capture; of these symptoms, 52 were considered to be highly relevant to surgery and potential outcome measures.

CONCLUSIONS

An open-ended questionnaire can identify severe symptoms that a global quality of life survey cannot capture and could be used in conjunction with a global survey to reassess symptoms after palliative surgical consultation.

Comprehensive geriatric assessment of risk factors associated with adverse outcomes and resource utilization in cancer patients undergoing abdominal surgery

BACKGROUND

The purpose of this prospective study was to identify risk factors for adverse outcomes or increased resource utilization after abdominal cancer surgery in geriatric patients.

METHODS

Baseline clinical and geriatric assessment variables including functional status, nutritional status, comorbidity index, mental status, depression scale score, fatigue inventory scale, and polypharmacy scale were prospectively recorded for patients age ≥65 undergoing intra-abdominal oncologic surgery. Outcome variables included morbidity, mortality, discharge to nursing facility, prolonged hospital stay, and readmission.

RESULTS

Of 111 patients, surgery type was colorectal in 40%, hepatopancreatobiliary in 30%, and gastric/duodenal in 14%. Variables associated with discharge to a nursing facility on multivariate analysis included weight loss ≥10% (OR 6.52 [95% CI: 1.43-29.76], P = 0.02), ASA score ≥2 (OR 5.08 [1.13-22.77], P = 0.03), and ECOG score ≥2 (OR 4.51 [1.03-19.71], P = 0.04). Variables independently associated with prolonged hospital stay included weight loss ≥10% (OR 4.03 [1.13-14.43], P = 0.03), the presence of polypharmacy (OR 2.45 [1.09-5.48], P = 0.03), and distant disease (OR 0.37 [0.15-0.91], P = 0.03). No variables were associated with morbidity or readmission.

CONCLUSIONS

Pre-operative clinical and geriatric assessment tools can help predict the need for discharge to a nursing facility or increased length of stay. Future studies will be required to identify patients suitable for interventions to decrease hospital and post-discharge resource utilization.

Indicators of symptom improvement and survival in inpatients with advanced cancer undergoing palliative surgical consultation

BACKGROUND

The purpose of this study was to prospectively identify the presentation, treatment, and outcomes of inpatients with advanced malignancy undergoing palliative surgical consultation.

METHODS

Inpatients undergoing palliative surgical consultation were prospectively identified from November 2008 to May 2011. Medical records were retrospectively reviewed to obtain clinical data and outcome.

RESULTS

Of 202 consultations, the diagnoses were wound problems (N = 39, 19%), bowel obstruction (N = 75, 37%), intra-abdominal inflammatory conditions (N = 36, 18%), abdominal pain of unclear etiology (N = 13, 6%), gastrointestinal hemorrhage (N = 15, 7%), malnutrition/feeding tube request (N = 14, 7%), and biliary obstruction (N = 10, 5%). Management included non-operative/non-procedural treatment in 81 (40%), procedures in 35 (17%), and surgery in 86 (43%). Patients treated with non-operative/non-procedural, procedural, and surgical treatment demonstrated symptom improvement rates of 60% (49/81), 69% (24/35), and 78% (67/86), respectively. Surgical treatment was associated with symptom improvement (OR 2.3 [95% CI 1.2-4.5]) compared to non-operative/non-procedural management. Symptom improvement was associated with improved survival (HR 0.27 [95% CI 0.19-0.38]) on multivariate analysis.

CONCLUSIONS

Symptom improvement was obtained in the majority of patients regardless of treatment strategy. Although patients selected for surgery demonstrated an association with symptom improvement, future prospective studies are needed to determine additional variables important in treatment selection.