Surgical management of malignant bowel obstruction: at what price palliation?

Several options exist to palliate malignant obstruction (MBO), none of which have established consensus among surgeons. The purpose of this study was to establish outcomes of diverting stoma (DS), internal bypass (IB), and palliative resection (PR) for a tertiary academic referral surgical oncology service. All patients presenting to a surgical oncology service with malignant bowel obstruction over a 3-year period were identified. Records were reviewed to determine success of diversion, bypass, or resection and associated cost, length of stay (LOS), morbidity, and mortality. Forty-three patients undergoing palliative surgery were identified. The success of each approach was 80, 78, and 63 per cent for diversion, bypass, and resection, respectively. Major morbidity (63%), mortality (16%), and LOS (26 days) were greatest in those undergoing PR, but so was survival (8.4 months). DS and IB had comparable morbidity (40 and 33%), mortality (10 and 0%), and LOS (25 and 21 days), but survival was shorter for DS (5.3 vs 6.5 months). Cost of PR was significantly greater ($79,000) than both DS ($36,000) and IB ($51,000). Escalation in complexity of palliative measures for MBO results in improved survival but at significant cost both economically and physiologically. Quality of life should be discussed with patients when deciding how best to palliate their symptoms.