EJSO 2001; 27: 364–367 doi:10.1053/ejso.2001.1120, available online at http://www.idealibrary.com on
Survival and quality of life after palliative surgery for neoplastic gastrointestinal obstruction H. Legendre∗, F. Vanhuyse∗, F.-X. Caroli-Bosc† and J.-C. Pector∗ Departments of ∗Surgery and †Gastroenterology, Jules Bordet Institute, U.L.B., Brussels, Belgium
Objective: The aim was to identify the prognostic factors which relate to the results, in terms of survival and quality of life, of palliative surgery in cancer patients presenting with an occlusion. Methods: The files of 109 patients with a neoplasm who were operated on for occlusion between 1990 and 2000 have been re-examined. The prognostic factors studied were age, sex, the location of the primary tumour, the extension of the cancer at the time of the operation, and the surgical procedure carried out. The impact on the quality of life was assessed by the resumption of transit and the return home. Results: The median survival was 64 days and the peroperative mortality was 21%. The quality of life of patients has been improved in 65% of cases. The only factors clearly correlating to survival and the success of the operation are the aetiological diagnosis of the occlusion (local recurrence better than carcinomatosis) and the type of procedure it was possible to carry out (resection better than bypass). Conclusion: Palliative surgery can, in a certain number of cases, improve the quality of life of patients, but it has not been possible for us to demonstrate prognostic factors which would allow the selection of patients who could benefit the most from such surgery. 2001 Harcourt Publishers Ltd Key words: neoplasm; quality of life; intestinal obstruction.
PATIENTS AND METHOD
During the evolution of their neoplastic illness a certain number of patients will present with a digestive occlusion which can justify a surgical procedure. The intervention itself, in patients who are often in a poor general state, has a high morbidity and mortality rate. Moreover, the prospect of an operation carries a heavy psychological burden for the patients and their families. Finally, the palliative procedure, which aims to eliminate the symptoms and may enable the patient to benefit from a later treatment, only achieves its goal in a limited number of patients. Improved identification of the factors which allow us to assess the surgical risk and the progress of these patients would enable us to make better informed recommendations for palliative surgery. It is to this end that we have carried out a retrospective review of the files of patients operated on a palliative basis for intestinal occlusion at the Institute Bordet between January 1990 and January 2000.
Between January 1990 and January 2000, 109 patients have been operated on a palliative basis at the Institute Bordet for a digestive occlusion. There were 78 women and 31 men of a median age of 62 (between 32 and 88 years). The primary cancer was of colorectal origin in 34 cases, ovarian in 26 cases, gastric in 12 cases, uterine in 11 cases, mammary in nine cases and from other sites in 17 cases. In 98 cases the cause of the occlusion was pathological development of the neoplasm in the abdomen, but in 11 cases the origin of the occlusion was benign (Fig. 1). In 62 cases surgical intervention consisted of a bypass, either in the form of a colostomy or an entero-digestive bypass, in 22 cases a digestive resection with or without restoration of continuity and in three cases an adhesiolysis. Finally, in 22 cases, either no effective procedure could be carried out, or a discharge gastrostomy was the only feasible procedure. Surgical mortality was defined as being the death rate in the 30 days following the operation. The quality of life was not measured by using assessment tools, but its improvement has been defined as being whether the patients could return home with their digestive transit restored. The data analysed were the age and sex of the patients,
Correspondence to: Hugues Legendre, Department of Surgery, Jules Bordet, 1 Rue He´ger-Bordet, B-1000 – Brussels, Belgium. Tel: +32 (0)2 541 31 52; Fax: +32 (02) 541 31 41; E-mail: [email protected]
bordet.be 0748–7983/01/040364+04 $35.00/0
2001 Harcourt Publishers Ltd
NEOPLASTIC GASTROINTESTINAL OBSTRUCTION AND QUALITY OF LIFE Post-radiation enteritis 4% Adhesion 6% Ogilvie's syndrome 1% Local recurrence 22%
Table 1 Analysis of survival
Peritoneal carcinosis 67%
Figure 1 Aetiologies of the occlusions.
M F Primary Colorectal Ovary Gastric Mammary Uterus Various Procedure Bypass Resection Laparotomy Peroperative Carcinomatosis diagnosis Local recurrence
Median survival (days)
57 69 96 84 55 108 63 47 64 102 35 58
Respiratory failure 4%
Multiple organ failure 4% Pneumonia 9%
Neoplastic evolution 53%
Figure 2 Cause of post-operative deaths.
the location of the primary tumour and its various treatments, the extension of the cancer at the time of the intervention, the surgical procedure carried out, post-operative mortality, median post-operative survival and, finally, improvement in the quality of life. The estimated parameters are survival of 100 days with a confidence interval (CI) of 95% as well as median survival with a CI of 95%. Survival distributions are estimated by the Kaplan–Meier method and compared by log-rank tests. The impact of patient characteristics on the success rate has been evaluated with the aid of chi-squared tests with, if need be, a correction in continuity.
RESULTS Overall median survival is 64 days with extremes going from 2 to 1531 days (CI 95%: 58–98). Survival for 100 days is 40% (CI 95%: 31–49%). Operative mortality is 21% (23 deaths). Of these 23 deaths, 11 can be attributed to neoplastic progression, whilst the other 12 (52%) are secondary to post-operative complications (Fig. 2). For 71 patients (65%) an improvement in the quality of life was obtained (CI 95%: 56–72). Improvement in the quality of life was obtained in 77%
of the patients in case of resection, in 69% if bypass was carried out and in 36% if only laparotomy was performed (P<0.01). Improvement was significantly higher in cases of local recurrence than in cases of carcinomatosis: 75% vs 61% (P<0.01); the origin of the primary cancer did not make any difference. Table 1 shows that only the peroperative diagnosis and the type of operation carried out have a significant influence on the duration of post-operative survival. The age of the patients, their sex and the primary tumour are not associated with significant differences in survival.
DISCUSSION The indication of palliative surgery for neoplastic occlusion remains controversial, as reported by SchnollSussman et al.1 and Feuer et al. in a recent meta-analysis.2 It actually carries a high mortality rate, but this mortality must be compared with that of surgery for all types of cancers which is 13%.3 In the study by Meguid et al.3 it seems that systemic (infectious or cardiopulmonary) complications occurring after palliative surgery are no more frequent than after curative surgery. However, this same study reports a higher rate of digestive complications (fistulas, acute digestive haemorrhages, formation of intra-abdominal abscesses and prolonged ileus) after palliative surgery.3 In our series, post-operative mortality is 21%, a rate comparable to those found in different studies which vary from 9% to 46% (Table 2). The median survival is low (2.1 months) but this should not obscure the fact that certain patients enjoy long survival times. Moreover, although the calculation of survival and post-operative mortality are two important variables to be taken into consideration in the evaluation of a surgical procedure, in the case
H. LEGENDRE ET AL.
Table 2 Results of palliative surgery for occlusion Series
130 64 43 23 49 98 90 60 11 36 40 26 32 41 10 34 89 25
Undifferentiated Gynecological Ovarian Ovarian Ovarian Ovarian Ovarian Ovarian Ovarian Undifferentiated Undifferentiated Undifferentiated Undifferentiated Undifferentiated Undifferentiated Undifferentiated Undifferentiated Ovarian
Bordet Soo5 Rubin6 Castaldo7 Clarke-Pearson8 Krebs9 Tunca10 Piver11 Beattie12 Walsh13 Aranha14 Aranha14 Osteen15 Aabo16 Chan17 Annest18 Turnbull19 Lund20
Table 3 Benign occlusions Author Bordet Soo5 ClarkePearson8 Tunca10 Gallick24 Osteen15 Spears25 Aabo16 Annest18
109 64 49
Undifferentiated Gynecological Ovarian
10% 34% 6.1%
127 50 66 62 41 34
Ovarian Undifferentiated Undifferentiated Colorectal Undifferentiated Undifferentiated
9.4% 26% 31.8% 48% 12% 3%
of palliative operations in patients with a progressive neoplastic pathology and, with limited life expectancy, it is also very important to try to offer these patients, at the very least, the best possible post-operative quality of life. In the absence of quantitative criteria to evaluate this quality of life, we have defined it as giving the patient the chance to return home with restored digestive transit and survival of more than 30 days. This result has been achieved in 65% of cases (51% in the series by Jong et al.,21 58% in the series by Tang et al.22). This success rate encourages us to continue proposing a surgical treatment to patients presenting with a digestive obstruction, particularly as we have not been able to show a factor which is predictive of success. Furthermore, it should not be forgotten that in a certain number of cases, the causes of the symptoms are benign and easily curable.2,23 In our study the rate for benign occlusion is 10% and varies between 3% and 48% depending on the author (Table 3). However, in our series, the postoperative evolution of patients was not significantly
21% 11% 9% 13% 14% 12% 14% 16.5% 9% 19% 27.5% 46% 24.4% 40% 18% 13% 32%
Morbidity rate 33% 15.5% 11.5% 43% 49% 12% 31% 9% 22.5% 15%
80% 44% 44% 32%
Survival 2.1 months median 2.5 months median 2.0 months median 6.8 months average 17% at 1 year 4.5 months median 3.1 months median 7.0 months average 2.5 months median 7.0 months average 11 months median 7.0 months average 4.5 months average 3 months median 4.5 months median 2 months median 4.0 months average 2.0 months median
different in terms of overall survival and impact on the quality of life whether the aetiology of the occlusion was benign or malignant (data not shown). This is probably due to pre-existing metastatic dissemination of the illness in both situations. Finally, the only factor with any clear significant association with the success of the operation is the type of procedure that it was possible to carry out. Even if the resection of the occlusive tumour is only palliative the success rate is better (77%) than for a bypass (69%), or if no useful procedure was possible (36%). However, the type of operation carried out is dictated by observations made during surgery and we have not been able to identify a predictive variable for it.
CONCLUSION It is clear that surgery can alleviate symptoms in a certain number of patients presenting with neoplastic occlusion. However, this operation carries a high mortality rate and if there is no urgency, which is often the case, this procedure should only be recommended after discussion with the patient and the family. They should be as fully informed as possible, about both the benefits and limitations of the operation.
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Accepted for publication 7 February 2001