Palliative Gastrointestinal Surgery: Preoperative evaluation and postoperative outcomes

Palliative care is a patient-centered care aimed at improving quality of life by alleviating symptoms and giving psychosocial support in patients suffering from incurable diseases. Palliative surgery involves surgical interventions to achieve the same goals when curative treatment is not feasible. According to World Health Organization (WHO) reports, up to 56 million people are in need of palliative care worldwide and although only a small minority requires palliative surgery, palliative surgery affects tens of thousands of people yearly. While the importance of highquality palliative surgery is well recognized, it remains a little studied field.

The aim of this thesis is to examine the surgical outcomes of palliative gastrointestinal surgical patients and to explore ways to enhance preoperative risk assessment including multidisciplinary assessments for the palliative patient group. The study moreover investigates the treatment of duodenal obstruction using either endoscopic or surgical techniques.

The data of this thesis consists of the retrospectively analyzed outcomes of patients undergoing palliative surgery at a single tertiary care center. Preoperative data, surgical outcomes, and follow-up information were collected from medical records. We evaluated the correlation between variables measured before surgery and their connection to surgical outcomes.

Study I included 93 patients, of whom 63% died within 90 days of surgery. Patient age, ASA classification, and ACS NSQIP were associated with higher mortality, but no statistically significant correlation was found with morbidity. Postoperative activities of daily living were significantly impaired compared to preoperative functional capacity. The results of Study II show a trend that the palliative consultation team’s involvement in the patient’s care before surgery could reduce inhospital mortality and readmissions, although these results were not statistically significant. In Study III, duodenal bypass surgery proved to be preferable to endoscopic duodenal stenting in terms of long-term outcomes. Stented patients had shorter hospital stays and were able to eat sooner, but they experienced more severe complications, had shorter life expectancy, and a higher number of repeat visits for procedures and hospital readmissions. The results of Study IV showed no correlation between sarcopenia and surgical outcomes in the palliative patient group. Sarcopenia was measured by surface area of the psoas muscle. Secondary outcomes indicated that preoperative elevated infection parameters (CRP and leukocytes) and low albumin levels correlated with 30- and 90-day mortality.

Surgical treatment for palliative gastrointestinal patients is associated with considerable mortality. Laboratory results, ASA classification, ACS NSQIP scoring, and multidisciplinary assessments are valuable tools for clinicians in predicting surgical outcomes for this patient group. More high-quality research is needed on palliative gastrointestinal surgical patients. Educating surgeons and increasing awareness of palliative care will be important in the future for improving the care of palliative surgical patients.