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Review |

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

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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Published online

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.

Figures in this Article

Malignant bowel obstruction (MBO) is a common preterminal event for patients with advanced cancer, with an incidence as high as 28% in gastrointestinal cancer and 51% in ovarian cancer.1,2 Patients with MBO are unable to eat, experience severe pain, and develop intractable nausea and vomiting—symptoms that incite considerable distress for patients and their families.3,4 Treatment options include supportive care with nasogastric drainage, pain control, antiemetics, antisecretory medications, and corticosteroids; endoscopically placed stents; percutaneous endoscopic gastrostomy tubes; or palliative surgery to relieve symptoms.5 Palliative operations can be successful for patients with MBO due to intraluminal or localized tumors but are less effective for patients with MBO associated with carcinomatosis.57 However, patients with MBO from peritoneal metastases can develop distressing symptoms despite maximal medical treatment and present the surgeon with an ethical dilemma.

Surgical decision making in this setting is particularly difficult; an operation may provide relief of intolerable symptoms for a patient, but patients with MBO due to peritoneal metastases may have only weeks or months to live2,8 and are often poor surgical candidates because of malnutrition and underlying disease.5,6 Patients with terminal illness may prefer to avoid burdensome treatments near the end of life.911 Additionally, frail patients may agree to an initial operation to alleviate severe symptoms but then choose to forgo aggressive treatments in the postoperative period.12 Surgical decision making for MBO is further complicated by a lack of high-quality data. Information regarding palliative outcomes, including quality of life, functional outcomes, or patient distress, is sparse.

We performed a systematic review of the literature to determine the effects of palliative surgery for MBO associated with peritoneal metastases on quality of life, successful palliation, postoperative mortality, complications, and survival to help surgeons and patients make decisions about surgery that are in line with the patient’s goals and values. This information may have particular value for surgeons and for patients who choose to have surgery because it can facilitate preoperative discussion about the patient’s preferences for aggressive postoperative treatments.

We performed a systematic review according to guidelines outlined in the Cochrane Collaboration handbook.13 Before starting our literature search and data collection, we designed a protocol based on the Preferred Reporting Items for Systematic reviews and Meta-analyses statement14 and the Meta-analysis of Observational Studies in Epidemiology guideline.15

Data Sources and Search Strategy

We searched PubMed, EMBASE, the Cochrane Library, Web of Knowledge, Cumulative Index to Nursing and Allied Health Literature Plus, and Google Scholar from inception to August 30, 2012. We used database-specific combinations of the following index terms and text words: intestinal obstruction, malignant, surgery or surgical, and palliat*. To avoid studies focused on endoscopic stenting of obstructive intraluminal lesions, we designed our search to omit articles with the terms stent or stenting in the title. We used an English-only filter for our search of Google Scholar to obtain a manageable collection of results, but we did not use any filters or limits for the remaining databases. Details of the search strategy for each database are described in the Supplement (eTable). In addition, we performed a hand search of the tables of contents of Annals of Surgical Oncology, Palliative Medicine, Journal of Pain and Symptom Management, and Gynecologic Oncology from inception of each journal through August 30, 2012. These searches were supplemented with a manual review of references from review articles retrieved from the primary database search. We used EndNote X5 and EndNote Web (Thomson Reuters) to organize references.

Inclusion and Exclusion Criteria

According to our protocol, we included original research describing outcomes of open or laparoscopic surgery for bowel obstruction from peritoneal carcinomatosis while excluding treatment of intraluminal lesions. Outcomes of interest included survival; postoperative mortality; postoperative complications (specifically, rates of wound infection, wound dehiscence, enterocutaneous fistula, anastomotic leak, deep vein thrombosis/pulmonary embolus, bleeding complications, gastrointestinal bleeding, myocardial infarction, sepsis, or other complications); hospital length of stay; intensive care unit length of stay; postoperative use of life-supporting interventions, such as mechanical ventilation or cardiopulmonary resuscitation; additional procedures or operations; conversations about goals of care; pain control; control of nausea and vomiting; ability to tolerate a diet; freedom from nasogastric tube drainage; discharge disposition, including hospice; incidence of reobstruction; and patient-reported quality-of-life measures using validated instruments.

We excluded articles that did not report baseline characteristics of the study group, studies that did not separate surgical outcomes for benign obstructions from those for malignant obstructions, reports including operations with curative rather than palliative intent, series that reported only obstructions amenable to stenting (ie, large bowel or gastroduodenal obstructions) or reported only percutaneous procedures, and case studies that included fewer than 5 patients. We also excluded reviews, editorials, conference proceedings, and articles that were not peer reviewed.

Study Selection and Data Extraction

One reviewer (T.J.P.O.) evaluated the titles and abstracts of all identified articles to develop a subset for full-text review. We obtained translations of articles in French and Chinese that were identified by their English-language abstracts as potentially relevant for full-text review. Two independent reviewers (T.J.P.O. and C.P.) applied the inclusion and exclusion criteria from our protocol to the full-text articles to identify articles for review. We adjudicated discrepancies between the reviewers’ assessments through collaborative discussion. Because included studies covered a broad time span, we did not contact study authors to obtain additional data. One reviewer (T.J.P.O.) extracted data from included studies according to the criteria defined in the protocol.

Data Synthesis

Fifteen of 17 studies included in the present review were of low methodologic quality with significant risk of bias and heterogeneity. As such, we were unable to perform statistical meta-analysis on the extracted data. Instead, we performed descriptive synthesis of the outcomes reported for studies that met our inclusion criteria.

Quality Assessment

We used the Newcastle-Ottawa Scale for cohort studies16 to assess the quality of studies included in this review. None to 9 stars are awarded for the methodologic quality of case selection, comparability of cohorts, and measurement of outcomes. An award of 6 or more stars is considered high methodologic quality.16,17 We also assessed confounding factors and risks of bias that were not addressed by study design or data analysis using the Cochrane Collaboration handbook classification of bias.13

We identified 3115 articles through database retrieval and located an additional 33 titles by hand for a total of 3148 articles. Of these, 801 were duplicates, leaving 2347 unique articles. After screening titles and abstracts, we excluded 2239 articles that did not fit our inclusion criteria. We reviewed the full-text versions of the remaining 108 articles and excluded an additional 90 articles. Two articles reported the results of a single study, so we extracted data from these articles as if they were one study. Our final cohort contained 18 articles describing 17 studies (Figure).

Place holder to copy figure label and caption
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.

Graphic Jump Location
Study and Patient Characteristics

We found 17 studies published between 1982 and 2012,1835 including 11 retrospective single-institution case series,1820,2226,30,31,34,35 3 retrospective single-institution cohort studies,21,28,29 2 retrospective multicenter cohort studies,27,32 and 1 prospective single-institution cohort study33 (Table 1). Of the 6 cohort studies, 1 compared 2 distinct operative interventions (exploratory laparotomy alone compared with major intestinal surgery),28 3 compared surgical patients with patients whose care was managed by gastric drainage,21,27,29 1 compared surgical patients with patients who received octreotide,32 and 1 compared surgical patients with those whose care was managed with either percutaneous endoscopic gastrostomy tubes or colonic stents for extrinsic intestinal obstruction from intra-abdominal tumor.33

Table Graphic Jump LocationTable 1.  Outcomes After Palliative Surgery for MBO From Peritoneal Carcinomatosis

The 17 studies included a total of 868 patients, of whom 77% were female. Median reported age was 52 to 63 years (range, 19-90). Several types of surgical interventions were performed, including creation of an ostomy (colostomy, ileostomy, or jejunostomy), intestinal resection and/or bypass (enteroenterostomy, enterocolostomy, or colocolostomy), lysis of malignant adhesions, open or percutaneous placement of gastrostomy tube or long jejunal tube, and exploratory laparotomy without additional intervention for cases in which carcinomatosis was too extensive. No study used a prespecified protocol for operative intervention; the operations performed were determined by intraoperative findings.1835

Patients had a variety of primary malignant neoplasms, including colorectal, gastric, gynecologic (ovarian, cervical, uterine, endometrial, and unspecified gynecologic malignant neoplasms), melanoma, breast, pancreaticobiliary, gallbladder, small bowel, gastrointestinal stromal tumor, kidney, bladder, lung, prostate, esophageal, duodenal, periampullary, carcinoid, adrenal, extremity sarcoma, other nongynecologic visceral malignancies, tumors of unknown gastrointestinal origin, and unknown primary malignant neoplasms. Ten studies described only patients with ovarian cancer.2635

Outcomes of Palliative Surgery

Studies demonstrated benefits from palliative surgery for MBO, including relief of obstructive symptoms, ability to tolerate a diet, and discharge to home. Obstructive symptoms were relieved or diet was resumed after surgery in 32% to 100% of patients.1821,27,30,32,33 Patients were able to tolerate a diet postoperatively in 45% to 75% of the cases,18,19,22,23,28,29,31,32,34,35 and 34% to 87% of patients were discharged to home.20,21,23,28,30 Other measures of palliation, such as validated quality-of-life metrics or measures of patient distress, were not reported by any studies. Furthermore, markers of quality end-of-life care, such as goals-of-care meetings or discussions of do-not-resuscitate status, were not reported in any studies.

Thirty-day postoperative mortality was high, with rates ranging from 6% to 32%.1820,22,2432,35 The incidence of serious complications was 7% to 44%. These complications included enterocutaneous fistula, wound infection, wound dehiscence, early obstruction, high-output ostomy, myocardial infarction/cardiovascular failure, deep vein thrombosis/pulmonary embolus, pulmonary infection/pneumonia, anastomotic leak, and infection.1820,22,2429,3135

Reobstruction occurred in 6% to 47% of the patients,1921,27,2931,33,35 and the duration of symptom relief after palliative surgery was short, with only 32% to 71% of patients remaining symptom free or tolerating a diet 60 days postoperatively.27,2931,3335 One study reported a 74% all-cause readmission rate,22 and others reported readmission rates of 38% to 47% for recurrent bowel obstruction.19,20 Few patients (2%-15%) underwent additional operations to address complications or reobstruction.19,20,28,29,31,35 However, one study19 reported that only 46% of patients who underwent a second surgical procedure were able to return home postoperatively, and complications and mortality were frequent in this group (46% and 23%, respectively).

Median survival time after diagnosis of MBO was 26 to 273 days1927,2931,33,35 and was related to prognostic features. Two studies compared survival for patients with favorable indicators (no ascites or palpable masses, return of bowel function postoperatively) with patients who had poor prognostic features (ascites, palpable masses, or continued obstruction postoperatively). Median survival was 154 to 192 days with favorable prognostic features, whereas patients with poor prognostic features survived only 26 to 36 days.20,21

Mean hospital length of stay for initial treatment of MBO, including a preoperative trial of conservative management, was 12.5 to 31 days and ranged from 1 to 94 days.19,21,29,31,33 Time spent in the hospital relative to remaining life was considerable. Two studies19,29 reported that approximately one-fourth (22%-26%) of the patient’s remaining life was spent in the hospital, and another reported 11%.31 For patients with poor prognostic features (ascites and/or palpable masses) reported by van Ooijen and colleagues,21 61% of the patients’ remaining life was spent in the hospital. Patients who were readmitted also spent significant time in the hospital, with median length of stay ranging from 22 to 41 days.19,22

Comparative Studies

Five studies compared outcomes between palliative surgery and nonsurgical treatments for MBO (Table 2).21,27,29,32,33 Nonoperative alternatives included gastrostomy tube (either open or percutaneous),21,33 endoscopically placed intraluminal stents for extrinsic compression of the bowel from intra-abdominal metastases,33 nasogastric drainage,27,29 and octreotide.32 In 4 of 5 studies,27,29,32,33 surgery more effectively relieved obstructive symptoms or enabled patients to tolerate a diet, with rates of palliation ranging from 32% to 100% in the surgical groups and 0% to 75% in the groups with nonoperative treatment. van Ooijen et al21 compared 3 groups: surgical patients with favorable prognostic features (no ascites or palpable masses), surgical patients with poor prognostic features (ascites and/or palpable masses), and patients with poor prognostic features who were not operative candidates and received only gastrostomy tubes. They found high rates of palliation in patients with favorable prognostic features who had surgery and in patients with poor prognostic features who received gastrostomy tubes (85% and 90%, respectively). However, only 43% of patients with poor prognostic features who underwent surgery achieved palliation.

Table Graphic Jump LocationTable 2.  Comparison of Outcomes After Palliative Surgery or Nonoperative Treatment for Malignant Bowel Obstruction From Peritoneal Carcinomatosis

Four of 5 studies reported improved survival with surgery compared with nonoperative treatment.21,29,32,33 Median survival after surgery ranged from 109 to 191 days vs 33 to 78 days for nonoperative treatments.21,29,33 van Ooijen et al21reported that patients with poor prognostic features who underwent surgery had a median survival comparable to that of patients with similar features who received only gastrostomy tubes (36 and 33 days, respectively). In contrast, surgical patients with favorable prognostic features had a median survival of 154 days.

Quality of Included Studies and Risk of Bias

The methodologic quality of the included studies is summarized in Table 3. Twelve studies1826,30,31,34,35 received 2 to 3 stars, indicating low methodologic quality, and 5 studies2729,32,33 received 5 to 6 stars, indicating moderate to high methodologic quality.

Table Graphic Jump LocationTable 3.  Quality of Included Studies as Assessed by Newcastle-Ottawa Scale and Type of Bias Identified

We identified multiple sources of bias. Selection bias, in which the baseline characteristics of groups are systematically different, was common. Most studies did not report or define the selection strategy for surgical intervention. Five studies20,27,29,31,32 described criteria for surgery and selected healthier patients for operative intervention. Additionally, 3 studies19,20,35 included a mix of patients who had urgent or elective surgery for MBO, but 2 of these studies19,20 did not adjust for this significant covariate.3639

Patients received treatment with several oncologic interventions before and after treatment of MBO, introducing a risk of performance bias. Additionally, 6 of 15 studies21,22,26,32,34,35 did not report length of follow-up, had very short follow-up, or lost a high percentage of patients to follow-up, raising the concern for attrition bias. Finally, considerable variation in the reported outcomes (a source of detection bias) complicates comparison of the effect of surgery between studies.

Palliative surgery for MBO from peritoneal carcinomatosis can provide relief from obstructive symptoms and enable patients to resume eating as well as return home. However, these benefits come at a cost; mortality and complication rates are high, and reobstruction requiring readmission and additional procedures is common. Survival is short, and a substantial proportion of the patient’s remaining life may be spent in the hospital recovering from surgery and associated complications. This information can help surgeons and patients navigate the preference-sensitive and value-laden decisions surrounding palliative surgery.

For surgeons, these data can be used to facilitate frank discussion about whether palliative surgery is in line with patient preferences and goals of care. First, surgeons can inform patients about the probability of real symptomatic relief with surgery for at least a short time. However, these potential benefits should be presented along with the high probability of serious complications, including the high rate of reobstruction and the substantial duration of hospitalization associated with surgery. Additionally, although palliation might be achieved for a short time, the effects of surgery on quality of life are not well understood.4044 Second, surgeons routinely treat postoperative complications aggressively with burdensome treatments12,4547 that patients with terminal illness are unlikely to want.911 Because surgery for MBO has substantial morbidity, surgeons should preoperatively explore patients’ preferences for limiting aggressive treatments in the event of a postoperative complication. Surgeons often struggle when shifting focus from cure to comfort postoperatively,4749 but in the setting of palliative surgery, comfort is the primary goal. As such, preoperative clarification of desired rescue interventions can be used to inform difficult treatment decisions for patients, families, and surgeons if complications occur.

For patients, these data illustrate what palliative surgery can realistically accomplish in the setting of MBO. Surgery entails substantial risks for short-lived benefits, and survival is limited. Patients with incurable cancer often hope for considerable benefit and even cure from palliative interventions.5052 Data on the likelihood of such benefits can direct patients to anticipate more realistic postoperative outcomes. Patients also should be informed that, although palliative surgery can provide symptomatic relief, this benefit comes at the cost of spending a substantial proportion of their remaining life in the hospital recovering from surgery, even if the postoperative course is uncomplicated. As such, surgery may conflict with the patient’s goal of spending as much of his/her remaining life as possible at home with loved ones.53

For policy makers, palliative operations contribute to a high proportion of overall mortality5456 and, as such, a metric that values the use of palliative surgery without penalizing surgeons for associated mortality is required. With increasing focus on outcomes profiling, surgeons and institutions risk penalties for their mortality rates, which can be affected by palliative operations. For example, at Memorial Sloan-Kettering Cancer Center, palliative operations (6% of total cases) represent 36% of the institution’s 30-day operative mortality.55 Quality assessment programs, such as the American College of Surgeons’ National Surgical Quality Improvement Program, adjust for underlying patient comorbidity but do not have strategies to identify operations performed with palliative intent or capture the palliative benefits offered by surgery aimed at comfort care. Identification of palliative operations and application of standard quality metrics for palliative care is needed to ensure that patients receive the care they desire and avoid aggressive postoperative interventions that conflict with their goals.44,5759 Informed patients should be able to choose palliative surgery to control intolerable symptoms, but they should not be subjected to undesired postoperative treatments. This should not be scored as a failure to attempt rescue12 but rather as a success in eliciting and honoring patient preferences for end-of-life care.

Our study has some limitations. The patients included in this review received treatment between 1977 and 2008. Significant changes in cancer treatment and palliative care occurred over this span of 31 years, including the evolution of effective medical management for MBO in 1985.60 In addition, patients described in these studies had a mix of primary malignant neoplasms. Different cancers have divergent behavior and variable response to treatment that can affect outcomes, such as survival and rates of reobstruction. However, all patients included in the present review had reached the common end point of MBO from peritoneal involvement and underwent palliative intervention. Additionally, it may not be possible to determine with certainty the cause of a bowel obstruction in patients with advanced cancer, particularly if they have had prior operations. This uncertainty can limit the usefulness of these data for a particular patient. This review is also limited by the poor reporting of palliative outcomes after surgery. Quality-of-life assessments after palliative surgery were rarely initiated, and studies that included quality-of-life measures were limited by a lack of pertinent assessment tools.41,42 Research to adapt metrics of palliative care quality61 and quality-of-life assessment57 for surgical patients is needed to inform surgical decision making and surgical treatment for patients with terminal illness.

The information presented in this review can help surgeons and patients with difficult decisions for patients with terminal cancer. Palliative surgery for MBO can provide benefits, but patients risk serious complications, high rates of reobstruction, and long hospitalizations. Surgeons can use these data to guide decisions about the role of surgery in the setting of incurable cancer and to advance preoperative discussions by determining patient preferences about burdensome postoperative treatments with unclear benefits. Palliative surgery can be valuable to patients; however, surgeons who provide this treatment should not be penalized for providing comfort for the terminally ill.

Accepted for Publication: July 23, 2013.

Corresponding Author: Margaret L. Schwarze, MD, MPP, Division of Vascular Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, G5/315 CSC, 600 Highland Ave, Madison, WI 53792 (schwarze@surgery.wisc.edu).

Published Online: January 29, 2014. doi:10.1001/jamasurg.2013.4059.

Author Contributions: Drs Paul Olson and Schwarze had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Paul Olson, Brasel, Schwarze.

Acquisition of data: Paul Olson, Pinkerton.

Analysis and interpretation of data: All authors.

Drafting of the manuscript: Paul Olson, Schwarze.

Critical revision of the manuscript for important intellectual content: Pinkerton, Brasel, Schwarze.

Statistical analysis: Paul Olson.

Study supervision: Brasel, Schwarze.

Conflict of Interest Disclosures: None reported.

Funding/Support: Dr Paul Olson is supported by the National Institutes of Health training grant T32 CA090217. Dr Schwarze is supported by the Clinical and Translational Science Award program, previously through National Center for Research Resources grant 1UL1RR025011, and now by National Center for Advancing Translational Sciences grant 9U54TR000021.

Role of the Sponsor: The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Previous Presentation: Portions of this project were presented as a poster at Digestive Diseases Week; May 20, 2013; Orlando, Florida.

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Chi  DS, Phaëton  R, Miner  TJ,  et al.  A prospective outcomes analysis of palliative procedures performed for malignant intestinal obstruction due to recurrent ovarian cancer. Oncologist. 2009;14(8):835-839.
PubMed
Kim  K, Kang  SB, Kim  MJ,  et al.  Factors associated with successful palliation and improved survival in patients with malignant bowel obstruction caused by ovarian cancer. J Women's Med. 2009;2(2):54-58.
Kolomainen  DF, Daponte  A, Barton  DPJ,  et al.  Outcomes of surgical management of bowel obstruction in relapsed epithelial ovarian cancer (EOC). Gynecol Oncol. 2012;125(1):31-36.
PubMed   |  Link to Article
Diggs  JC, Xu  F, Diaz  M, Cooper  GS, Koroukian  SM.  Failure to screen: predictors and burden of emergency colorectal cancer resection. Am J Manag Care. 2007;13(3):157-164.
PubMed
McArdle  CS, Hole  DJ.  Emergency presentation of colorectal cancer is associated with poor 5-year survival. Br J Surg. 2004;91(5):605-609.
PubMed   |  Link to Article
Patel  SS, Patel  MS, Goldfarb  M,  et al.  Elective versus emergency surgery for ulcerative colitis: a National Surgical Quality Improvement Program analysis. Am J Surg. 2013;205(3):333-338.
PubMed   |  Link to Article
Tekkis  PP, Kinsman  R, Thompson  MR, Stamatakis  JD; Association of Coloproctology of Great Britain, Ireland.  The Association of Coloproctology of Great Britain and Ireland study of large bowel obstruction caused by colorectal cancer. Ann Surg. 2004;240(1):76-81.
PubMed   |  Link to Article
Miner  TJ, Jaques  DP, Shriver  CD.  A prospective evaluation of patients undergoing surgery for the palliation of an advanced malignancy. Ann Surg Oncol. 2002;9(7):696-703.
PubMed   |  Link to Article
Badgwell  B, Krouse  R, Cormier  J, Guevara  C, Klimberg  VS, Ferrell  B.  Frequent and early death limits quality of life assessment in patients with advanced malignancies evaluated for palliative surgical intervention. Ann Surg Oncol. 2012;19(12):3651-3658.
PubMed   |  Link to Article
Selby  D, Wright  F, Stilos  K,  et al.  Room for improvement? a quality-of-life assessment in patients with malignant bowel obstruction. Palliat Med. 2010;24(1):38-45.
PubMed   |  Link to Article
Podnos  YD, Juarez  G, Pameijer  C, Uman  G, Ferrell  BR, Wagman  LD.  Surgical palliation of advanced gastrointestinal tumors. J Palliat Med. 2007;10(4):871-876.
PubMed   |  Link to Article
Podnos  YD, Juarez  G, Pameijer  C, Choi  K, Ferrell  BR, Wagman  LD.  Impact of surgical palliation on quality of life in patients with advanced malignancy: results of the Decisions and Outcomes in Palliative Surgery (DOPS) trial. Ann Surg Oncol. 2007;14(2):922-928.
PubMed   |  Link to Article
Schwarze  ML, Bradley  CT, Brasel  KJ.  Surgical “buy-in”: the contractual relationship between surgeons and patients that influences decisions regarding life-supporting therapy. Crit Care Med. 2010;38(3):843-848.
PubMed   |  Link to Article
Schwarze  ML, Redmann  AJ, Alexander  GC, Brasel  KJ.  Surgeons expect patients to buy-in to postoperative life support preoperatively: results of a national survey. Crit Care Med. 2013;41(1):1-8.
PubMed   |  Link to Article
Cassell  J, Buchman  TG, Streat  S, Stewart  RM.  Surgeons, intensivists, and the covenant of care: administrative models and values affecting care at the end of life—updated. Crit Care Med. 2003;31(5):1551-1559.
PubMed   |  Link to Article
Schwarze  ML, Redmann  AJ, Brasel  KJ, Alexander  GC.  The role of surgeon error in withdrawal of postoperative life support. Ann Surg. 2012;256(1):10-15.
PubMed   |  Link to Article
Penkoske  PA, Buchman  TG.  The relationship between the surgeon and the intensivist in the surgical intensive care unit. Surg Clin North Am. 2006;86(6):1351-1357.
PubMed   |  Link to Article
Ferrell  BR, Chu  DZJ, Wagman  L,  et al.  Patient and surgeon decision making regarding surgery for advanced cancer. Oncol Nurs Forum. 2003;30(6):E106-E114.doi:10.3923/ijcr.2006.42.46.
PubMed   |  Link to Article
Krouse  RS, McCahill  LE, Easson  AM, Dunn  GP.  When the sun can set on an unoperated bowel obstruction: management of malignant bowel obstruction. J Am Coll Surg. 2002;195(1):117-128.
PubMed   |  Link to Article
Weeks  JC, Catalano  PJ, Cronin  A,  et al.  Patients’ expectations about effects of chemotherapy for advanced cancer. N Engl J Med. 2012;367(17):1616-1625.
PubMed   |  Link to Article
Higginson  IJ, Sen-Gupta  GJ.  Place of care in advanced cancer: a qualitative systematic literature review of patient preferences. J Palliat Med. 2000;3(3):287-300.
PubMed   |  Link to Article
Krouse  RS, Nelson  RA, Farrell  BR,  et al.  Surgical palliation at a cancer center: incidence and outcomes. Arch Surg. 2001;136(7):773-778.
PubMed   |  Link to Article
Miner  TJ, Brennan  MF, Jaques  DP.  A prospective, symptom related, outcomes analysis of 1022 palliative procedures for advanced cancer. Ann Surg. 2004;240(4):719-727.
PubMed
McCahill  LE, Krouse  RS, Chu  DZJ,  et al.  Indications and use of palliative surgery—results of Society of Surgical Oncology survey. Ann Surg Oncol. 2002;9(1):104-112.
PubMed   |  Link to Article
McCahill  LE, Smith  DD, Borneman  T,  et al.  A prospective evaluation of palliative outcomes for surgery of advanced malignancies. Ann Surg Oncol. 2003;10(6):654-663.
PubMed   |  Link to Article
McCahill  LE, Krouse  RS, Chu  DZJ,  et al.  Decision making in palliative surgery. J Am Coll Surg. 2002;195(3):411-423.
PubMed   |  Link to Article
Miner  TJ, Jaques  DP, Tavaf-Motamen  H, Shriver  CD.  Decision making on surgical palliation based on patient outcome data. Am J Surg. 1999;177(2):150-154.
PubMed   |  Link to Article
Baines  M, Oliver  DJ, Carter  RL.  Medical management of intestinal obstruction in patients with advanced malignant disease: a clinical and pathological study. Lancet. 1985;2(8462):990-993.
PubMed   |  Link to Article
Pasman  HR, Brandt  HE, Deliens  L, Francke  AL.  Quality indicators for palliative care: a systematic review. J Pain Symptom Manage. 2009;38(1):145-156.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
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.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1.  Outcomes After Palliative Surgery for MBO From Peritoneal Carcinomatosis
Table Graphic Jump LocationTable 2.  Comparison of Outcomes After Palliative Surgery or Nonoperative Treatment for Malignant Bowel Obstruction From Peritoneal Carcinomatosis
Table Graphic Jump LocationTable 3.  Quality of Included Studies as Assessed by Newcastle-Ottawa Scale and Type of Bias Identified

References

Feuer  DJ, Broadley  KE, Shepherd  JH, Barton  DP.  Surgery for the resolution of symptoms in malignant bowel obstruction in advanced gynaecological and gastrointestinal cancer. Cochrane Database Syst Rev. 2000;3(4):CD002764.
PubMed
Chakraborty  A, Selby  D, Gardiner  K, Myers  J, Moravan  V, Wright  F.  Malignant bowel obstruction: natural history of a heterogeneous patient population followed prospectively over two years. J Pain Symptom Manage. 2011;41(2):412-420.
PubMed   |  Link to Article
Gwilliam  B, Bailey  C.  The nature of terminal malignant bowel obstruction and its impact on patients with advanced cancer. Int J Palliat Nurs. 2001;7(10):474-481.
PubMed
Borneman  T, Chu  DZJ, Wagman  L,  et al.  Concerns of family caregivers of patients with cancer facing palliative surgery for advanced malignancies. Onc Nurs Forum. 2003;30(6):997-1005.
PubMed   |  Link to Article
Ripamonti  CI, Easson  AM, Gerdes  H.  Management of malignant bowel obstruction. Eur J Cancer. 2008;44(8):1105-1115.
PubMed   |  Link to Article
Helyer  L, Easson  AM.  Surgical approaches to malignant bowel obstruction. J Support Oncol. 2008;6(3):105-113.
PubMed
Ripamonti  CI, Twycross  R, Baines  M,  et al; Working Group of the European Association for Palliative Care.  Clinical-practice recommendations for the management of bowel obstruction in patients with end-stage cancer. Support Care Cancer. 2001;9(4):223-233.
PubMed   |  Link to Article
Soriano  A, Davis  MP.  Malignant bowel obstruction: individualized treatment near the end of life. Cleve Clin J Med. 2011;78(3):197-206.
PubMed   |  Link to Article
Weeks  JC, Cook  EF, O’Day  SJ,  et al.  Relationship between cancer patients’ predictions of prognosis and their treatment preferences. JAMA. 1998;279(21):1709-1714.
PubMed   |  Link to Article
Teno  JM, Fisher  ES, Hamel  MB, Coppola  K, Dawson  NV.  Medical care inconsistent with patients’ treatment goals: association with 1-year Medicare resource use and survival. J Am Geriatr Soc. 2002;50(3):496-500.
PubMed   |  Link to Article
Fried  TR, Bradley  EH, Towle  VR, Allore  H.  Understanding the treatment preferences of seriously ill patients. N Engl J Med. 2002;346(14):1061-1066.
PubMed   |  Link to Article
Scarborough  JE, Pappas  TN, Bennett  KM, Lagoo-Deenadayalan  S.  Failure-to-pursue rescue: explaining excess mortality in elderly emergency general surgical patients with preexisting “do-not-resuscitate” orders. Ann Surg. 2012;256(3):453-461.
PubMed   |  Link to Article
Higgins  JPT, Green  S, eds. Cochrane Handbook for Systematic Reviews of Interventions. Oxford, England: Cochrane Collaboration; 2011.
Liberati  A, Altman  DG, Tetzlaff  J,  et al.  The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. Ann Intern Med. 2009;151(4):W65-W94.
PubMed   |  Link to Article
Stroup  DF, Berlin  JA, Morton  SC,  et al; Meta-analysis of Observational Studies in Epidemiology (MOOSE) group.  Meta-analysis of observational studies in epidemiology: a proposal for reporting. JAMA. 2000;283(15):2008-2012.
PubMed   |  Link to Article
Wells GA, Shea B, O'Connell D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analyses. http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. Accessed December 10, 2012.
Shabanzadeh  DM, Sørensen  LT.  Laparoscopic surgery compared with open surgery decreases surgical site infection in obese patients: a systematic review and meta-analysis. Ann Surg. 2012;256(6):934-945.
PubMed   |  Link to Article
McCarthy  JD.  A strategy for intestinal obstruction of peritoneal carcinomatosis. Arch Surg. 1986;121(9):1081-1082.
PubMed   |  Link to Article
Turnbull  AD, Guerra  J, Starnes  HF.  Results of surgery for obstructing carcinomatosis of gastrointestinal, pancreatic, or biliary origin. J Clin Oncol. 1989;7(3):381-386.
PubMed
Lau  PW, Lorentz  TG.  Results of surgery for malignant bowel obstruction in advanced, unresectable, recurrent colorectal cancer. Dis Colon Rectum. 1993;36(1):61-64.
PubMed   |  Link to Article
van Ooijen  B, van der Burg  MEL, Planting  AS, Siersema  PD, Wiggers  T.  Surgical treatment or gastric drainage only for intestinal obstruction in patients with carcinoma of the ovary or peritoneal carcinomatosis of other origin. Surg Gynecol Obstet. 1993;176(5):469-474.
PubMed
Blair  SL, Chu  DZJ, Schwarz  RE.  Outcome of palliative operations for malignant bowel obstruction in patients with peritoneal carcinomatosis from nongynecological cancer. Ann Surg Oncol. 2001;8(8):632-637.
PubMed   |  Link to Article
Legendre  H, Vanhuyse  F, Caroli-Bosc  F-X, Pector  JC.  Survival and quality of life after palliative surgery for neoplastic gastrointestinal obstruction. Eur J Surg Oncol. 2001;27(4):364-367.
PubMed   |  Link to Article
Abbas  SM, Merrie  AE.  Palliative small bowel surgery in patients with history of malignancy. Int J Cancer Res. 2006;2(1):42-46. doi:10.3923/ijcr.2006.42.46.
Link to Article
Abbas  SM, Merrie  AE.  Resection of peritoneal metastases causing malignant small bowel obstruction. World J Surg Oncol. 2007;5(1):122-125.
PubMed   |  Link to Article
Piver  MS, Barlow  JJ, Lele  SB, Frank  A.  Survival after ovarian cancer induced intestinal obstruction. Gynecol Oncol. 1982;13(1):44-49.
PubMed   |  Link to Article
Lund  B, Hansen  M, Lundvall  F, Nielsen  NC, Sørensen  BL, Hansen  HH.  Intestinal obstruction in patients with advanced carcinoma of the ovaries treated with combination chemotherapy. Surg Gynecol Obstet. 1989;169(3):213-218.
PubMed
Rubin  SC, Hoskins  WJ, Benjamin  I, Lewis  JL  Jr.  Palliative surgery for intestinal obstruction in advanced ovarian cancer. Gynecol Oncol. 1989;34(1):16-19.
PubMed   |  Link to Article
Bais  JMJ, Schilthuis  MS, Slors  JFM, Lammes  FB.  Intestinal obstruction in patients with advanced ovarian cancer. Int J Gynecol Cancer. 1995;5(5):346-350.
PubMed   |  Link to Article
Jong  P, Sturgeon  J, Jamieson  CG.  Benefit of palliative surgery for bowel obstruction in advanced ovarian cancer. Can J Surg. 1995;38(5):454-457.
PubMed
Pothuri  B, Vaidya  A, Aghajanian  C, Venkatraman  E, Barakat  RR, Chi  DS.  Palliative surgery for bowel obstruction in recurrent ovarian cancer: an updated series. Gynecol Oncol. 2003;89(2):306-313.
PubMed   |  Link to Article
Mangili  G, Aletti  G, Frigerio  L,  et al.  Palliative care for intestinal obstruction in recurrent ovarian cancer: a multivariate analysis. Int J Gynecol Cancer. 2005;15(5):830-835.
PubMed   |  Link to Article
Chi  DS, Phaëton  R, Miner  TJ,  et al.  A prospective outcomes analysis of palliative procedures performed for malignant intestinal obstruction due to recurrent ovarian cancer. Oncologist. 2009;14(8):835-839.
PubMed
Kim  K, Kang  SB, Kim  MJ,  et al.  Factors associated with successful palliation and improved survival in patients with malignant bowel obstruction caused by ovarian cancer. J Women's Med. 2009;2(2):54-58.
Kolomainen  DF, Daponte  A, Barton  DPJ,  et al.  Outcomes of surgical management of bowel obstruction in relapsed epithelial ovarian cancer (EOC). Gynecol Oncol. 2012;125(1):31-36.
PubMed   |  Link to Article
Diggs  JC, Xu  F, Diaz  M, Cooper  GS, Koroukian  SM.  Failure to screen: predictors and burden of emergency colorectal cancer resection. Am J Manag Care. 2007;13(3):157-164.
PubMed
McArdle  CS, Hole  DJ.  Emergency presentation of colorectal cancer is associated with poor 5-year survival. Br J Surg. 2004;91(5):605-609.
PubMed   |  Link to Article
Patel  SS, Patel  MS, Goldfarb  M,  et al.  Elective versus emergency surgery for ulcerative colitis: a National Surgical Quality Improvement Program analysis. Am J Surg. 2013;205(3):333-338.
PubMed   |  Link to Article
Tekkis  PP, Kinsman  R, Thompson  MR, Stamatakis  JD; Association of Coloproctology of Great Britain, Ireland.  The Association of Coloproctology of Great Britain and Ireland study of large bowel obstruction caused by colorectal cancer. Ann Surg. 2004;240(1):76-81.
PubMed   |  Link to Article
Miner  TJ, Jaques  DP, Shriver  CD.  A prospective evaluation of patients undergoing surgery for the palliation of an advanced malignancy. Ann Surg Oncol. 2002;9(7):696-703.
PubMed   |  Link to Article
Badgwell  B, Krouse  R, Cormier  J, Guevara  C, Klimberg  VS, Ferrell  B.  Frequent and early death limits quality of life assessment in patients with advanced malignancies evaluated for palliative surgical intervention. Ann Surg Oncol. 2012;19(12):3651-3658.
PubMed   |  Link to Article
Selby  D, Wright  F, Stilos  K,  et al.  Room for improvement? a quality-of-life assessment in patients with malignant bowel obstruction. Palliat Med. 2010;24(1):38-45.
PubMed   |  Link to Article
Podnos  YD, Juarez  G, Pameijer  C, Uman  G, Ferrell  BR, Wagman  LD.  Surgical palliation of advanced gastrointestinal tumors. J Palliat Med. 2007;10(4):871-876.
PubMed   |  Link to Article
Podnos  YD, Juarez  G, Pameijer  C, Choi  K, Ferrell  BR, Wagman  LD.  Impact of surgical palliation on quality of life in patients with advanced malignancy: results of the Decisions and Outcomes in Palliative Surgery (DOPS) trial. Ann Surg Oncol. 2007;14(2):922-928.
PubMed   |  Link to Article
Schwarze  ML, Bradley  CT, Brasel  KJ.  Surgical “buy-in”: the contractual relationship between surgeons and patients that influences decisions regarding life-supporting therapy. Crit Care Med. 2010;38(3):843-848.
PubMed   |  Link to Article
Schwarze  ML, Redmann  AJ, Alexander  GC, Brasel  KJ.  Surgeons expect patients to buy-in to postoperative life support preoperatively: results of a national survey. Crit Care Med. 2013;41(1):1-8.
PubMed   |  Link to Article
Cassell  J, Buchman  TG, Streat  S, Stewart  RM.  Surgeons, intensivists, and the covenant of care: administrative models and values affecting care at the end of life—updated. Crit Care Med. 2003;31(5):1551-1559.
PubMed   |  Link to Article
Schwarze  ML, Redmann  AJ, Brasel  KJ, Alexander  GC.  The role of surgeon error in withdrawal of postoperative life support. Ann Surg. 2012;256(1):10-15.
PubMed   |  Link to Article
Penkoske  PA, Buchman  TG.  The relationship between the surgeon and the intensivist in the surgical intensive care unit. Surg Clin North Am. 2006;86(6):1351-1357.
PubMed   |  Link to Article
Ferrell  BR, Chu  DZJ, Wagman  L,  et al.  Patient and surgeon decision making regarding surgery for advanced cancer. Oncol Nurs Forum. 2003;30(6):E106-E114.doi:10.3923/ijcr.2006.42.46.
PubMed   |  Link to Article
Krouse  RS, McCahill  LE, Easson  AM, Dunn  GP.  When the sun can set on an unoperated bowel obstruction: management of malignant bowel obstruction. J Am Coll Surg. 2002;195(1):117-128.
PubMed   |  Link to Article
Weeks  JC, Catalano  PJ, Cronin  A,  et al.  Patients’ expectations about effects of chemotherapy for advanced cancer. N Engl J Med. 2012;367(17):1616-1625.
PubMed   |  Link to Article
Higginson  IJ, Sen-Gupta  GJ.  Place of care in advanced cancer: a qualitative systematic literature review of patient preferences. J Palliat Med. 2000;3(3):287-300.
PubMed   |  Link to Article
Krouse  RS, Nelson  RA, Farrell  BR,  et al.  Surgical palliation at a cancer center: incidence and outcomes. Arch Surg. 2001;136(7):773-778.
PubMed   |  Link to Article
Miner  TJ, Brennan  MF, Jaques  DP.  A prospective, symptom related, outcomes analysis of 1022 palliative procedures for advanced cancer. Ann Surg. 2004;240(4):719-727.
PubMed
McCahill  LE, Krouse  RS, Chu  DZJ,  et al.  Indications and use of palliative surgery—results of Society of Surgical Oncology survey. Ann Surg Oncol. 2002;9(1):104-112.
PubMed   |  Link to Article
McCahill  LE, Smith  DD, Borneman  T,  et al.  A prospective evaluation of palliative outcomes for surgery of advanced malignancies. Ann Surg Oncol. 2003;10(6):654-663.
PubMed   |  Link to Article
McCahill  LE, Krouse  RS, Chu  DZJ,  et al.  Decision making in palliative surgery. J Am Coll Surg. 2002;195(3):411-423.
PubMed   |  Link to Article
Miner  TJ, Jaques  DP, Tavaf-Motamen  H, Shriver  CD.  Decision making on surgical palliation based on patient outcome data. Am J Surg. 1999;177(2):150-154.
PubMed   |  Link to Article
Baines  M, Oliver  DJ, Carter  RL.  Medical management of intestinal obstruction in patients with advanced malignant disease: a clinical and pathological study. Lancet. 1985;2(8462):990-993.
PubMed   |  Link to Article
Pasman  HR, Brandt  HE, Deliens  L, Francke  AL.  Quality indicators for palliative care: a systematic review. J Pain Symptom Manage. 2009;38(1):145-156.
PubMed   |  Link to Article

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