title: Optimal indications of surgical palliation for incurable advanced gastric cancer presenting with malignant gastrointestinal obstruction.
abstract: BACKGROUND
  Decision-making for surgical palliation remains one of the most challenging clinical scenarios. We investigated the optimal indications for surgical palliation in advanced gastric cancer (AGC) patients presenting with gastrointestinal (GI) obstruction.
  
  
  METHODS
  A retrospective analysis was performed on 53 consecutive patients who underwent surgical palliation for GI obstruction caused by AGC between 2000 and 2007 at Osaka National Hospital. The clinical course of each patient was followed until death. Postoperative improvement of oral intake, achievement of hospital discharge, and implementation of chemotherapy in each patient were documented and used as a triad to assess the quality of life (QOL). Prognostic factors for overall survival were investigated by univariate and multivariate analyses. In addition, postoperative morbidity and mortality rates were recorded.
  
  
  RESULTS
  Of the entire patient cohort, 64% demonstrated a QOL improvement by having achieved the triad. Performance status (PS) of 1 or less was the only significant predictive factor for QOL improvement. The median survival time (MST) of the whole patient cohort following surgical palliation was 161 days, while the MSTs of patients fulfilling the triad and of those failing to achieve the triad were 253 and 60 days, respectively, with a significant difference between them (P < 0.0001). PS of 1 or less (hazard ratio 0.265, P = 0.0008) and recurrent disease (hazard ratio 0.394, P = 0.043) were identified as significant independent prognostic factors for longer survival on multivariate analysis. Overall morbidity and 30-day postoperative mortality rates were 24.5% (13 patients) and 7.5% (4 patients) respectively.
  
  
  CONCLUSIONS
  In AGC patients presenting with GI obstruction, surgical palliation was beneficial in patients with PS of 0-1 and those with recurrent disease, in terms of improved QOL and prolonged survival, with acceptable operative morbidity and mortality rates.
authors.affiliation: Department of Surgery, Osaka National Hospital, 2-1-14 Hoenzaka, Chuo-ku, Osaka, Japan. fujitani@onh.go.jp
authors.forename: Kazumasa
authors.initials: K
authors.lastname: Fujitani
authors.forename: Manami
authors.initials: M
authors.lastname: Yamada
authors.forename: Motohiro
authors.initials: M
authors.lastname: Hirao
authors.forename: Yukinori
authors.initials: Y
authors.lastname: Kurokawa
authors.forename: Toshimasa
authors.initials: T
authors.lastname: Tsujinaka
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D017219:Gastric Outlet Obstruction / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D006801:Humans; D007415:Intestinal Obstruction / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D010166:Palliative Care / Q000379:methods*; D011184:Postoperative Period; D011379:Prognosis; D011788:Quality of Life; D012189:Retrospective Studies; D013274:Stomach Neoplasms / Q000150:complications / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D016019:Survival Analysis