Management of Malignant Small Bowel Obstruction: Is Intestinal Bypass Effective Palliation?

BACKGROUND/PURPOSE: Malignant small bowel obstruction (mSBO) is a common consequence of advanced malignancies. Surgical consultation is common, however data on the outcomes following an operation are lacking. We investigated a specific operative approach-intestinal bypass-to determine the outcomes associated with this intervention. METHODS: Patients with a preoperative diagnosis of mSBO who underwent intestinal bypass between 2015 and 2021 were included. Isolated colonic obstruction was excluded as was gastric outlet obstruction. Perioperative and postoperative outcomes were measured, including complications, overall survival, return to oral intake, and return to intended oncologic therapy. Patients were additionally grouped as to whether the operation was performed as elective or as inpatient. RESULTS: Overall, 55 patients were identified, with a mean age of 61.2 ± 14 years. The most common primary malignancy was colorectal cancer (65.5%) and 80% of patients had a preoperative diagnosis of metastatic disease. Small bowel to colon was the most common bypass procedure (51%). Severe complications occurred in 25.5% of patients with three in-hospital mortalities (5.5%). Survival rates at 30, 90, and 180 days were 91%, 80%, and 62%, respectively. The majority of patients were discharged to home (85.5%) and were tolerating an oral diet (74.6%). Twenty-seven patients (49.1%) returned to some form of oncologic treatment. CONCLUSIONS: Patients with mSBO face a potentially terminal condition. In this study, approximately 75% of patients who underwent intestinal bypass were able to regain the ability to eat, and 49% returned to oncologic therapy. Although retrospective, these data suggest the approach is efficacious for palliation of this difficult sequela of advanced cancer.

Combined use of advanced practice providers and care pathways reduces the duration of stay after surgery for gastrointestinal malignancies.

BACKGROUND: The gastrointestinal surgical oncology service at our comprehensive cancer center sought to improve the quality of postsurgical inpatient care while increasing discharge efficiency. METHODS: A stakeholder team established standard postsurgical care pathways and dedicated inpatient advanced practice provider positions. We compared postsurgical length of stay before (July 2017 to April 2018) and after (May 2018 to April 2019) the interventions using Wilcoxon rank-sum tests. We benchmarked length of stay to National Surgical Quality Improvement Project and Centers for Medicare and Medicaid Services geometric mean length of stay. We also compared readmission rates and surgeon-specific Hospital Consumer Assessment of Health Care Provider and Systems and Press-Ganey scores. RESULTS: There were 462 cases before and 563 after the interventions. Postintervention, median length of stay decreased from 6.50 to 6.00 days (P = .017). There was a ≥1-day reduction for 10 of 14 case types with significant length of stay decreases for robotic esophagectomy (P = .001), liver resection (P = .023), and cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (P = .030). More case types met or exceeded Centers for Medicare and Medicaid Services and National Surgical Quality Improvement Project benchmarks after the interventions. Readmission rates were stable (preintervention 9.3%, postintervention 10.3%, P = .585). Press-Ganey and HCAHPS measures were stable or improved in all evaluated domains. CONCLUSION: Incorporating advanced practice providers and care pathways into gastrointestinal surgical oncology inpatient care was associated with reduced length of stay without declination in readmission rates or patient experience measures.