Palliative surgery for malignant bowel obstruction from carcinomatosis a systematic review

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

Research output: Contribution to journalArticle

51 Citations (Scopus)

Abstract

IMPORTANCE Care of patients with malignant bowel obstruction caused by peritoneal metastasesmay 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.

Original languageEnglish (US)
Pages (from-to)383-392
Number of pages10
JournalJAMA Surgery
Volume149
Issue number4
DOIs
StatePublished - 2014
Externally publishedYes

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Palliative Care
Carcinoma
Hospitalization
Survival
Mortality
Patient Discharge
Intestinal Obstruction
Ambulatory Surgical Procedures
Reoperation
PubMed
Libraries
Decision Making
Patient Care
Nursing
Language
Survival Rate
Outcome Assessment (Health Care)
Databases
Diet
Health

ASJC Scopus subject areas

  • Surgery

Cite this

Palliative surgery for malignant bowel obstruction from carcinomatosis a systematic review. / Olson, Terrah J Paul; Pinkerton, Carolyn; Brasel, Karen; Schwarze, Margaret L.

In: JAMA Surgery, Vol. 149, No. 4, 2014, p. 383-392.

Research output: Contribution to journalArticle

Olson, Terrah J Paul ; Pinkerton, Carolyn ; Brasel, Karen ; Schwarze, Margaret L. / Palliative surgery for malignant bowel obstruction from carcinomatosis a systematic review. In: JAMA Surgery. 2014 ; Vol. 149, No. 4. pp. 383-392.
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abstract = "IMPORTANCE Care of patients with malignant bowel obstruction caused by peritoneal metastasesmay 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.",
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