P. J. Chung1, M. C. Smith1, H. Talus3, V. Roudnitsky2, A. Alfonso1, G. Sugiyama1 1State University Of New York Downstate Medical Center,Surgery,Brooklyn, NY, USA 2Kings County Hospital Center,Acute Care Surgery/Trauma,Brooklyn, NY, USA 3Kings County Hospital Center,Surgery,Brooklyn, NY, USA
Introduction:
Colorectal cancer is the fourth most common malignancy in the United States, with over 134,000 new cases expected in 2016. Though many of these cases are early-stage and identified on screening colonoscopy, a subset of patients are detected because they present with large bowel obstruction (LBO). These patients are likely to require urgent or emergent operative therapy. Using a large national database we sought to investigate the outcomes of patients who present with LBO as there are several options for managing this condition.
Methods:
Data was collected from the Nationwide Inpatient Sample (NIS) 2010 – 2012. We included patients with a diagnosis of LBO (560.89, 560.9), with a confirmed diagnosis of colorectal cancer (153 – 154). To identify patients with average risk we excluded patients with familial syndromes (e.g. Familial Adenomatous Polyposis), concurrent neoplasms, age <60 years, and missing race data. We calculated the Elixhauser-Van Walraven score to assess comorbidity status. We identified patients that underwent non-surgical therapy (non-invasive or invasive diagnostic modalities, with resuscitation and/or percutaneous drainage, with or without subsequent chemotherapy), diversion alone, diversion followed by either open or laparoscopic resection, colonic stenting alone, or stenting followed by either open or laparoscopic resection, and either open or laparoscopic resection alone. Multiple imputation was performed. Using inpatient mortality as the outcome variable we performed multivariable logistic regression using age, gender, race, insurance status, income status, elective procedure status, hospital size, urban vs rural hospital setting, geographic region, type of procedure performed, tumor location, presence of perforation, and Elixhauser-Van Walraven score as risk variables.
Results:
6,308 patients met the inclusion criteria of which 473 (7.50%) died. The median age was 74.0 years and 80.23% underwent an emergent procedure. After adjusting for all risk variables, age (OR 1.67 [1.39 – 2.00], p<0.0001), perforation (OR 2.85 [1.97 – 4.11], p<0.0001), Elixhauser-Van Walraven score (OR 1.97 [1.71 – 2.27], p<0.0001), and non-surgical management compared to open resection alone (OR 2.06 [1.60 – 2.65], p<0.0001) were predictive of mortality. However laparoscopic resection compared to open was associated with decreased risk of mortality (OR 0.33 [0.17 – 0.67], p<0.0001).
Conclusion:
In this large observational study of patients presenting with LBO due to colorectal cancer, we found that age, perforation, increasing comorbidities, and non-surgical management were associated with a significantly increased risk of mortality, while undergoing a laparoscopic compared to open resection was associated with decreased risk of mortality. Further prospective studies are warranted to study longer term outcomes and better inform operative planning, particularly as less invasive options become more widely available.