Early operative management versus nonoperative care for cancer-associated small bowel obstruction in patients with recent peritoneal metastasis: A real-world propensity-matched analysis.

Abstract

e15574 Background: Cancer-associated small bowel obstruction (SBO) is a morbid complication of advanced malignancy; malignant bowel obstruction occurs in 3–15% of cancer patients, and untreated cases have a mean survival of only 4–5 weeks. Guidelines emphasize conservative management because comparative evidence for palliative surgery remains limited. Consequently, clinicians often favor nonoperative or hospice-directed care. We evaluated the association between early operative management and short-term survival and palliative care utilization in this population. Methods: We performed a retrospective cohort study using the TriNetX global federated electronic health record network. Adults (≥18 years) with SBO and active peritoneal metastasis within 1 year before to 1 day after SBO were included; hematologic malignancies were excluded. Exposure was bowel surgery within 30 days of SBO diagnosis. Outcomes were all-cause mortality and palliative care encounter at 1, 3, and 6 months. Cohort 1 consisted of 24,076 patients who had nonoperative management. Cohort 2 consisted of 2,173 patients who had early palliative surgery. Within each time horizon, cohorts were propensity-score matched 1:1 using demographics, comorbidities, baseline laboratory values, and documented do-not-resuscitate status. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated. Results: After 1:1 propensity-score matching, each cohort included 2,063 patients. Compared with early surgery, nonoperative management was associated with higher mortality at 1 month (OR 2.24; 95% CI 1.87–2.67; p < 0.001), 3 months (OR 2.45; 95% CI 2.12–2.84; p < 0.001), and 6 months (OR 2.05; 95% CI 1.80–2.35; p < 0.001). Nonoperative management was also associated with higher palliative encounters at 1 month (OR 2.18; 95% CI 1.86–2.56; p < 0.001), 3 months (OR 1.81; 95% CI 1.57–2.09; p < 0.001), and 6 months (OR 1.86; 95% CI 1.61–2.14; p < 0.001). Conclusions: Among patients with cancer-associated SBO and recent peritoneal metastasis, early operative management was associated with improved short-term survival and fewer transitions to palliative care through 6 months. These real-world, risk-adjusted estimates suggest that peritoneal metastasis alone should not preclude surgical consideration and support individualized, multidisciplinary decision-making rather than default nonoperative or hospice-directed pathways.