C. E. Cauley1,3, M. T. Panizales5, G. Reznor2,4, A. B. Haynes1,3, J. M. Havens2,4, Z. Cooper1,2,4 1Ariadne Labs,Boston, MA, USA 2Brigham And Women’s Hospital,Department Of Surgery,Boston, MA, USA 3Massachusetts General Hospital,Department Of Surgery,Boston, MA, USA 4Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 5Partners Healthcare International,Boston, MA, USA
Introduction: Surgical intervention in patients with serious preexisting illness is an important area of inquiry due to a lack of clarity about the impact of such interventions on quality of life and overall disease course. Identifying patients with the highest mortality risk prior to surgery would help guide clinical decisions, increase family understanding, and avoid non-beneficial operations. The outcomes after emergency surgery for patients with disseminated cancer have not been well described. We sought to characterize the 30-day postoperative mortality of patients with disseminated cancer who underwent surgery for intestinal perforations, and to identify preoperative factors and patient characteristics associated with worse survival.
Methods: We performed a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2005-2012 to identify patients with disseminated cancer who underwent emergency operations for intestinal perforation. Patient demographics and clinical data such as age, gender, race, comorbidities, American Society of Anesthesiology (ASA) Class, preoperative lab results, and survival were included. We conducted univariate analysis using Chi square and Wilcoxon Sum to determine differences between survivors and non-survivors. We used stepwise multivariate logistic regression including variables significant at p <0.10 level to determine patient factors predicting death at 30 days. We used the multiple imputation chained equations (MICE) method to account for missing data. Analysis was performed using SAS 9.3.
Results: Among 499 patients in our cohort, 30-day postoperative mortality was 34% (n=170). Patients who died were more likely to have ascites (43% vs. 41%, P<0.001), dyspnea at rest (25% vs. 8%, P<0.001), renal failure (11% vs. 3%, P<0.001), septic shock (39% vs. 12%, P<0.001), ASA Class >3 (69% vs. 51%, P<0.001), and preoperative do not resuscitate orders (10% vs. 2%, P<0.001), than survivors; they were less like to have body mass index (BMI) >25 (45% vs. 53%, P=0.067). Renal failure, septic shock, ascites, dyspnea at rest, and dependent functional status were independent predictors of death at 30 days (See table). BMI > 25 was protective with an odds ratio of 0.5 (0.28-0.75).
Conclusion: More than one in three patients with disseminated cancer who has surgery for gastrointestinal perforation dies within thirty days. Preoperative factors can help identify patients at highest risk of postoperative mortality and frame expectations for patients, clinicians and caregivers. Further studies are needed to examine longer-term survival and quality of life for advanced cancer patients undergoing these procedures.
