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Palliative Surgery for Malignant Bowel Obstruction From Carcinomatosis:  A Systematic Review

Terrah J. Paul Olson, MD1; Carolyn Pinkerton, MD2; Karen J. Brasel, MD, MPH2; Margaret L. Schwarze, MD, MPP3
[+] Author Affiliations
1Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
2Department of Surgery, Medical College of Wisconsin, Milwaukee
3Division of Vascular Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
JAMA Surg. 2014;149(4):383-392. doi:10.1001/jamasurg.2013.4059.
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Importance  Care of patients with malignant bowel obstruction caused by peritoneal metastases may present an ethical dilemma for surgeons when nonoperative management fails.

Objective  To characterize outcomes of palliative surgery for malignant bowel obstruction from peritoneal carcinomatosis to guide decision making about surgery and postoperative interventions for patients with terminal illness.

Evidence Review  We searched PubMed, EMBASE, Cochrane Library, Web of Knowledge, Cumulative Index to Nursing and Allied Health Literature Plus, and Google Scholar and performed manual searches of selected journals from inception to August 30, 2012, with no filters, limits, or language restrictions. We used database-specific combinations of the terms intestinal obstruction, malignant, surgery or surgical, and palliat*. We included studies reporting outcomes after palliative surgery for malignant bowel obstruction from peritoneal carcinomatosis from any primary malignant neoplasm and excluded case studies, curative surgery, isolated percutaneous procedures, stenting for intraluminal lesions, and studies in which benign and malignant obstructions could not be distinguished. We assessed quality with the Newcastle-Ottawa Scale.

Findings  We screened 2347 unique articles, selected 108 articles for full-text review, and included 17 studies. Surgery was able to palliate obstructive symptoms for 32% to 100% of patients, enable resumption of a diet for 45% to 75% of patients, and facilitate discharge to home in 34% to 87% of patients. Mortality was high (6%-32%), and serious complications were common (7%-44%). Frequent reobstructions (6%-47%), readmissions (38%-74%), and reoperations (2%-15%) occurred. Survival was limited (median, 26-273 days), and hospitalization for surgery consumed a substantial portion of the patient’s remaining life (11%-61%).

Conclusions and Relevance  Although palliative surgery can benefit patients, it comes at the cost of high mortality and substantial hospitalization relative to the patient’s remaining survival time. Preoperatively, surgeons should present realistic goals and limitations of surgery. For patients choosing surgery, clarifying preferences for aggressive postoperative interventions preoperatively is critical given the high complication rate and limited survival after surgery for malignant bowel obstruction.

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Figure.
Flowchart of Literature Search Strategy

aThe total number of exclusions does not equal 90 because all reasons that articles could be excluded are listed, and some articles fit multiple exclusion criteria. CINAHL indicates Cumulative Index to Nursing and Allied Health Literature; MBO, malignant bowel obstruction.

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