S. Bateni1, F. J. Meyers3, R. J. Bold2, R. J. Canter2 1University Of California – Davis,General Surgery,Sacramento, CA, USA 2University Of California – Davis,Surgical Oncology,Sacramento, CA, USA 3University Of California – Davis,School Of Medicine,Sacramento, CA, USA
Introduction: There is substantial risk of acute morbidity and mortality following surgical intervention for patients with disseminated malignancy. However, concerns also exist regarding the risks of untreated surgical disease among these patients. We sought to characterize temporal trends in morbidity and mortality among disseminated malignancy patients, hypothesizing that surgical intervention would remain a prevalent modality among these patients.
Methods: We queried the American College of Surgeons National Surgical Quality Improvement Program from 2006 to 2010 for patients with disseminated malignancy. Excluding patients undergoing a primary hepatic operation, we identified 21,755 patients. Parametric and non-parametric statistics were used to evaluate the association of patient characteristics and surgical interventions to 30-day morbidity and mortality outcomes. Logistic regression analysis was performed to identify independent predictors of 30-day morbidity and mortality.
Results: The prevalence of surgical intervention for disseminated malignancy was stable at 1.9 – 2.2% of all NSQIP procedures per year. Among disseminated malignancy patients, the most frequent operations performed were bowel resections (24.7%), varied gastrointestinal procedures (22.0%), and multivisceral resections (13.7%). The rates of bowel resection, celiotomy/lysis of adhesions and appendectomy/cholecystectomy, showed small, but statistically significant, decreases over time (26.1 vs 22.6%, 8.4 vs 5.8%, 6.6 vs 2.9% respectively, p<0.001). The rate of emergency operations also decreased over the study period (17.4 vs 15.0%, p<0.005). In contrast, the rate of preoperative independent functional status rose (82.3 vs 86.1%, p<0.001), while the rate of preoperative weight loss (14.4 vs 12.8%) and sepsis (20.6 vs 15.7%) decreased (p<0.005). Rates of 30-day morbidity (30.1 vs 23.5%), serious morbidity (16.1 vs 10.6%), and mortality (10.4 vs 9.3%) all decreased over the study period (p<0.05). On multivariate analysis, male sex, BMI, age, impaired functional status, weight loss, pre-operative sepsis, leukocytosis, elevated creatinine, anemia, and hypoalbuminemia all predicted worse 30-day morbidity and mortality. A lack of DNR status was associated with greater morbidity, while a present DNR status was associated with higher mortality.
Conclusion: Although 30-day morbidity, serious morbidity, and mortality have decreased for patients with disseminated malignancy undergoing surgical intervention, they remain elevated, and surgical intervention remains prevalent in patients with incurable malignancy. These data highlight the importance of careful patient selection and an evaluation of the goals of therapy among this patient population.
