Surgery for the palliation of intestinal perforation from secondary metastases in advanced malignancies

This study aims to review patient and disease factors that predict survival after palliative surgery for intestinal perforation from metastases in advanced malignancies, with a goal to help decision-making in this clinical scenario. Secondary aims include validation of the UC Davis Cancer Centre nomogram to predict risk of 30-day morbidity and mortality for patients with disseminated malignancy undergoing surgical intervention.

The following factors were examined: age, preoperative albumin, total white blood cell count, creatinine, site of metastases, presence of ascites, presence of sepsis, steroid use, presence of dyspnea, presence of significant weight loss, preoperative chemotherapy, preoperative radiotherapy, type of operative procedure performed, Eastern Cooperative Oncology Group (ECOG) status, length of surgery, duration of inhospitalization and mortality. For univariate analysis, independent t-test and Fisher's exact test were used to analyze the association of continuous and categorical variables, respectively. For multivariate analysis, logistic regression using likelihood ratios was used. The nomogram was validated by assessing its extent of discrimination (c-index).

Twenty palliative operations for intestinal perforation were performed during this period. On univariate analysis, presence of dyspnea, decreased preoperative levels of albumin and high ECOG status were significant predictors of increased mortality. On multivariate analysis, high ECOG status and decreased preoperative albumin were statistically significant. The concordance index in our data set was 0.64.

Preoperative levels of albumin (>20 g/L) and low ECOG status (≤1) were independently associated with favorable postoperative outcomes. In patients with favorable prognostic factors such as absence of dyspnea, high preoperative levels of albumin and low ECOG status, surgical management should be considered. Conversely, in patients with unfavorable prognostic factors, medical management should be considered to avoid unnecessary surgery.