The palliative triangle: improved patient selection and outcomes associated with palliative operations

Abstract

Objectives: To examine the outcomes of patients managed with the palliative triangle method and to evaluate factors associated with effective patient selection.

Design: Patients receiving a procedure to palliate symptoms of advanced cancer were identified prospectively from all surgical palliative care consultations and observed for at least 90 days or until death.

Setting: Academic surgical oncology service.

Patients: A total of 227 patients symptomatic from advanced incurable cancer.

Intervention: The palliative triangle technique was used to select patients for palliative operations.

Main outcome measures: Symptom resolution, overall survival, and complications.

Results: We evaluated 227 patients from July 1, 2004, through June 30, 2009. Reasons cited for not selecting 121 patients (53.3%) for a palliative procedure were low symptom severity (23.9%), decision for nonoperative palliation (19.0%), patient preference (19.8%), concerns about complications (15.7%), and other (21.6%). A palliative operation was performed in 106 patients (46.7%) for complaints of gastrointestinal obstruction (35.8%), local control of tumor-related symptoms (25.5%), jaundice (10.4%), and other (28.3%). Of these 106 patients, 5 required procedures for recurrent symptoms and 6 for additional symptoms; of the 121 patients originally not selected, 12 required procedures for progressive symptoms, for a total of 129 procedures. Patient-reported symptom resolution or improvement was noted in 117 of 129 procedures (90.7%). Palliative procedures were associated with 30-day postoperative morbidity (20.1%) and mortality (3.9%). Median survival was 212 days.

Conclusion: Palliative operations performed in these carefully selected patients were associated with significantly better symptom resolution and fewer postoperative complications compared with previously published results.