F. F. Yang1, E. Serrano1, K. S. Bilodeau1, C. J. Silvestri2, M. Weykamp1, B. Gitonga1, C. Galet3, A. C. Bull3, L. J. Garcia3, B. Lin4, S. L. Schaefer5, N. Olbrich5, P. K. Park5, S. Sanchez4, D. Skeete3, K. N. Fischkoff2, D. R. Flum1 1University Of Washington, Surgery, Seattle, WA, USA 2Columbia University College Of Physicians And Surgeons, Surgery, New York, NY, USA 3University Of Iowa, Surgery, Iowa City, IA, USA 4Boston University, Surgery, Boston, MA, USA 5University Of Michigan, Surgery, Ann Arbor, MI, USA
Introduction: mSBO is common in patients with advanced abdomino-pelvic cancers. Management goals include controlling symptoms to maintain quality of life and avoiding surgical intervention when possible. Use of dexamethasone to restore bowel function was demonstrated in several randomized-trials and is recommended in 2020 National Comprehensive Cancer Network (NCCN) palliative guidelines. However, the extent of dexamethasone use and outcomes for mSBO in non-research settings has not been studied.
Methods: Retrospective chart review including unique admissions for mSBO at 5 centers (Boston Medical Center, Columbia University, University of Iowa, University of Michigan, University of Washington) from 1/1/2019-12/31/21. Sociodemographic and clinical factors, dexamethasone use, and management outcomes were summarized with descriptive statistics and multiple logistic regression.
Results: 403 patients had 521 unique admissions for mSBO (67% female, mean age 63 years, 84% with history of previous abdominal surgery). 53 patients were ineligible for dexamethasone, including 40 who underwent immediate surgical intervention and 13 who did not tolerate it previously, were in sepsis at presentation, or transitioned to comfort-care immediately at presentation. Among 468 admissions that were eligible and initially non-operative, 124 (26%, 95%CI 23-31%) received dexamethasone treatment (69% female, mean age 63 years, 89% with history of surgery). Of these, 16 (13%, 95%CI 8-20%) subsequently required urgent surgery exclusive of planned gastrostomy during the same admission, mean length of stay (LOS) was 11d (95%CI 9.4-12.6), and 4 dexamethasone-related safety events were reported. Amongst 344 eligible admissions where dexamethasone was not used (69% female, mean age 63 years, 83% with history of abdominal surgery), 58 (17%, 95%CI 13-21%) subsequently required urgent surgery and mean LOS was 8.7d (95%CI 7.4-9.6).
Overall, the unadjusted odds ratio (OR) of non-operative management in admissions with dexamethasone use compared to without its use is 1.4 (95%CI 0.8-2.6) and was similar at each site (Table). Using multiple logistic regression, the adjusted OR after accounting for site is 1.6 (95%CI 0.9-3.1).
Conclusions: Dexamethasone was used in about 1 in 4 eligible mSBO admissions with some evidence of lower rates of operative intervention. Based on these findings, the sample size for a randomized control trial (RCT) to confirm the effect size of dexamethasone use on operative management is estimated to be at least n=4300. While an RCT of this size may not be feasible, this multicenter retrospective cohort study suggests that more consistent use of dexamethasone for mSBO may represent an opportunity for quality improvement.
