S. B. Bateni1, F. J. Meyers2, R. J. Bold1, A. R. Kirane1, D. J. Canter3, R. J. Canter1 1University Of California – Davis,Surgical Oncology,Sacramento, CA, USA 2University Of California – Davis,Hematology/Oncology,Sacramento, CA, USA 3Ochsner Clinic,Urology,New Orleans, LOUSIANA, USA
Introduction: Patients with disseminated malignancy (DMa) frequently present with acute surgical conditions. Bowel obstructions are especially common, with rates as high as 28-51% for gastrointestinal and gynecologic cancers. However, surgical intervention performed on this at-risk population is associated with increased rates of morbidity and mortality as high as 44% and 11% respectively. Our objective was to determine the effect of frailty on predicting the risk of acute morbidity and mortality in DMa patients undergoing surgical management of bowel obstruction.
Methods: Patients with DMa and primary diagnosis of bowel obstruction were identified from the 2007 to 2012 American College of Surgeons National Surgical Quality Improvement Program with corresponding ICD-9 codes. The previously validated modified frailty index (mFI) score was calculated for each patient. Univariate and multivariate standard parametric and nonparametric statistical analyses including χ² and logistic regression were utilized to identify predictors of 30-day overall morbidity, Clavien IV/V morbidity and mortality.
Results: We identified 1,928 DMa patients with bowel obstruction who underwent small bowel resection (22.0%, n=424), large bowel resection (20.5%, n=395), celiotomy or lysis of adhesions (22.8%, n=440), gastric (3.7%, n=71) or other abdominal operation (31.0%, n=598). 11.9% (n=181) were identified as frail with mFI≥0.27. Emergency operations were common at 34.6% (n=668). Preoperative impaired functional status and diagnoses of systemic inflammatory response syndrome (SIRS) and sepsis/septic shock were also frequent at 21% (n=404), 17.8% (n=341) and 6.6% (n=127) respectively. Rates of 30-day overall morbidity, ClavienIV/V morbidity, and mortality were 35.8% (n=690), 12.2% (n=235), and 14.8% (n=285) respectively. Predictors of overall and Clavien IV/V morbidity identified on multivariate analysis included impaired functional status, low albumin, SIRS, sepsis and septic shock, and emergency operations. Frailty was significant on univariate, but not multivariate analyses, for overall and Clavien IV/V morbidity (p>0.05). Frailty was identified as a significant predictor for 30-day mortality on univariate (OR=3.56, 95%CI 2.59-5.15) and multivariate analysis (OR=1.73, 95CI 1.09-2.75) in addition to low albumin, SIRS, and ASA 4/5.
Conclusion: Frailty is a predictor of acute mortality after surgery for bowel obstruction among DMa patients. In patients with a terminal malignancy, the goals of surgical therapy for symptom palliation need to be balanced against adverse outcomes, particularly mortality. Risk assessment is essential. The mFI, therefore, may be used as an additional tool by surgeons to determine risk of acute mortality for DMa patients with bowel obstruction. It is important to recognize that the mFI was not a predictor of acute morbidity and, consequently, further research is needed to optimize decision making for this at-risk population.