緩和ケアと医学

抽象的な

Impact of Resuming Oral Intake after Palliative Surgery in Patients with Malignant Bowel Obstruction

Yoon-Hye Kwon, Han-Ki Lim, Min Jung Kim, Ji Won Park, Seung-Bum Ryoo, Seung-Yong Jeong, Kyu Joo Park

Objective: Malignant bowel obstruction (MBO) is serious problem in patients with advanced cancer, often results in poor quality of life and prolonged hospitalization at the end of life. The important role of surgical treatment in these patients is symptom palliation and restoration of the ability to eat rather than cure. The purpose of this study was to evaluate the postoperative outcomes of patients with MBO and to assess the benefit of palliative operation.

Methods: Medical records of patients with stage IV cancer with bowel obstruction underwent laparotomy by a single experienced surgeon at Seoul National University Hospital between 1998 and 2012 were collected retrospectively. A total of 747 patients underwent laparotomy for MBO was identified and 517 patients who underwent curative intent operation were excluded. Overall survival and tolerable feeding duration was evaluated using the Kaplan-Meier method and log-rank test. The primary outcome was defined as the restoration of ability to intake oral feeding.

Results: Two-hundred thirty patients underwent palliative operation. The origin of malignancies was colorectal in 114 patients, gynaecological in 37, gastric in 35 and other sites in 44 patients. 171 patients had large bowel obstruction and 59 had small bowel obstruction. 110 patients underwent palliative primary tumour resection, 103 had only stoma formation or bypass surgery. Mean length of stay after operation was 17.1 days. The complication rate was 26.5% and postoperative 30-day mortality was 7.8%. 205 patients (89.1%) were able to restore oral feeding and it lasted for median duration of 5.7 months. The median overall survival was 7.1 months. Palliative primary tumour resection showed superior overall survival to stoma formation or bypass surgery (p<0.001). Resume oral intake, length of oral nutrition, wound complication, re-operation for obstruction and postoperative chemotherapy were associated with overall survival on multivariate analysis.

Conclusions: Palliative resection of primary cancer in patients with MBO had survival benefit. Especially resume oral intake is a good predictor of survival outcome for most patients. Patients with advanced cancer with MBO need a highly individualized approach and aggressive procedure for restoration of oral feeding could be one of important goal of care.