Outcomes after emergency abdominal surgery in patients with advanced cancer: Opportunities to reduce complications and improve palliative care

Abstract

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 sought 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 from 2005 to 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 do-not-resuscitate orders before surgery.

Conclusion: 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 preexisting do-not-resuscitate orders highlight the need for targeted interventions to reduce complications and integrate palliative approaches into the care of these patients.

Level of evidence: Prognostic study, level III; therapeutic study, level IV.

Figure 1

Predictors of 30-Day mortality for patients undergoing emergent operations for perforation. All predictors were statistically significant with p<0.05. Model including preoperative variables alone: AUC 0.7754 (95% CI: 0.7563-0.7946) Model including pre- and postoperative variables: AUC 0.8111 (95% CI: 0.7934-0.8289) * Indicates variables from the model including postoperative predictors.

Figure 2

Predictors of 30-Day mortality for patients undergoing emergent operations for obstruction. All predictors were statistically significant with p<0.05. Model including preoperative variables alone: AUC 0.7998 (95% CI: 0.7737-0.8258) Model including pre- and postoperative variables: AUC 0.7789 (95% CI: 0.7520-0.8058) * Indicates variables from the model including postoperative predictors.