Received: 22 June 2017
Accepted: 1 September 2017
Comparison of common risk stratification indices to predict
outcomes among stage IV cancer patients with bowel
obstruction undergoing surgery
Sarah B. Bateni MD
Richard J. Bold MD
Frederick J. Meyers MD
Daniel J. Canter MD
Robert J. Canter MD
Divison of Surgical Oncology, Department of
Surgery, University of California, Davis
Medical Center, Sacramento, California
Division of Hematology/Oncology,
Department of Internal Medicine, University
of California, Davis Medical Center,
Department of Urology, Ochsner Clinic, New
Robert J. Canter, MD, Division of Surgical
Oncology, Department of Surgery, University
of California, Davis Medical Center, Suite
3010, UC Davis Cancer Center, 4501 X
Street, Sacramento 95817, CA.
National Center for Advancing Translational
Sciences, Grant number: UL1TR001860;
Agency for Health Care Research and Quality,
Grant number: T32HS022236
Background and Objectives: Among patients with disseminated malignancy (DMa),
bowel obstruction is common with high operative morbidity. Since preoperative risk
stratification is critical, we sought to compare three standard risk indices, the American
Society of Anesthesiology (ASA) classification, Charlson comorbidity index (CCI), and
modified frailty index (mFI).
Methods: We identified 1928 DMa patients with bowel obstruction who underwent
an abdominal operation from 2007 to 2012 American College of Surgeons National
Surgical Quality Improvement Program. Multivariate analyses assessed predictors of
prolonged length of stay (LOS), 30-day serious morbidity and mortality. Receiver
operating characteristics’ areas under the curves (AUCs) for risk indices scores and
30-day mortality were assessed.
Results: Serious morbidity and mortality rates were 20.4% and 14.8%. ASA and CCI did
not predict serious morbidity or prolonged LOS, but were predictors of mortality. The
mFI did not predict prolonged LOS, but did predict serious morbidity and mortality.
Subgroup analyses showed similar results. There were no significant differences
between ASA, CCI, and mFI AUCs for mortality.
Conclusions: ASA, CCI, and mFI are limited in their ability to predict postoperative
adverse events among DMa patients undergoing surgery for bowel obstruction.
These data suggest that a more tailored preoperative risk stratification tool would
improve treatment planning.
disseminated malignancy, malignant bowel obstruction, NSQIP, palliative surgery, risk
Malignant bowel obstruction is common among patients with
advanced malignancy with incidence rates of 28-51% for gastrointes-
tinal and gynecological cancers.
This condition may signify a terminal
event with an associated median life expectancy of 4 months.
Therefore, goals of care for this high-risk population are palliative
requiring careful consideration of patient quality of life through either
medical or surgical treatment approaches. Despite the potential
palliative benefits of surgery for patients with malignant bowel
obstruction, surgery is associated with rates of serious complications
as high as 44%.
Furthermore, these patients are at risk for prolonged
hospitalization which may consume a considerable percentage of their
limited life expectancy. Therefore, careful surgical risk stratification is
J Surg Oncol. 2018;117:479–487. wileyonlinelibrary.com/journal/jso © 2017 Wiley Periodicals, Inc.