Trauma/Critical Care| Volume 158, ISSUE 3, P636-645, September 2015

Should we operate for an intra-abdominal emergency in the setting of disseminated cancer?


      Patients with advanced cancer and an abdominal surgical emergency pose a dilemma, because rescue surgery may be futile. This study defines morbidity and mortality rates and identifies preoperative risk factors that may predict outcome.


      The National Surgical Quality Improvement Program database was queried for patients with disseminated cancer undergoing emergent abdominal surgery (2005–2012). Preoperative variables were used for prediction models for 30-day major morbidity and mortality. A tree model and logistic regression were used to find factors associated with outcomes. A training dataset was analyzed and then model performance was evaluated on a validation dataset.


      Study patients had an overall 30-day major morbidity and mortality rate of 48.8% and 26%, respectively. The classification tree model for prediction for a morbidity involved the following variables: sepsis, albumin, functional status, and transfusion (misclassification rate, 36%). The tree model for mortality showed that an American Society of Anesthesiologists (ASA) score of 4 or 5 with a dependent functional status to be predictive of mortality (misclassification rate, 24%). There was agreement between models for predictive variables.


      The decision to operate for an abdominal emergency in the setting of disseminated cancer is difficult. Our study confirms the high risk for morbidity and mortality in this population. Preoperative factors including sepsis, increased ASA class, low serum albumin level, and patient functional dependence all predict poor outcomes.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Ingraham A.M.
        • Cohen M.E.
        • Bilimoria K.Y.
        • Raval M.V.
        • Ko C.Y.
        • Nathens A.B.
        • et al.
        Comparison of 30-day outcomes after emergency general surgery procedures; potential for targeted improvement.
        Surgery. 2010; 148: 217-238
        • Bilimoria K.Y.
        • Liu Y.
        • Paruch J.L.
        • Zhou L.
        • Kmiecik T.E.
        • Ko C.Y.
        • et al.
        Development and evaluation of the universal ACS NSQIP surgical risk calculator: a decision aide and informed consent tool for patients and surgeons.
        J Am Coll Surg. 2013; 217: 833-842
        • Cohen M.E.
        • Bilimoria K.Y.
        • Ko C.Y.
        • Hall B.L.
        Development of an American College of Surgeons National Surgery Quality Improvement Program: morbidity and mortality risk calculator for colorectal surgery.
        J Am Coll Surg. 2009; 208: 1009-1016
        • Ballian N.
        • Rajamanickam V.
        • Harms B.
        • Foley E.F.
        • Heise C.P.
        • Greenberg C.C.
        • et al.
        Predictors of mortality after emergent surgery for acute colonic diverticulitis: analysis of National Surgical Quality Improvement Project data.
        J Trauma Acute Care Surg. 2013; 74: 611-616
        • Vaid S.
        • Bell T.
        • Grim R.
        • Ahuja V.
        Predicting risk of death in general surgery patients on the basis of preoperative variables using American College of Surgeons National Surgical Quality Improvement Program data.
        Perm J. 2012; 4: 10-17
        • Al-Temimi M.H.
        • Griffee M.
        • Enniss T.M.
        • Preston R.
        • Vargo D.
        • Overton S.
        • et al.
        When is death inevitable after emergency laparotomy? Analysis of the America College of Surgeons national Surgical Quality Improvement Program database.
        J Am Coll Surg. 2012; 215: 503-511
        • Khuri S.F.
        • Henderson W.G.
        • Daley J.
        • Jonasson O.
        • Jones S.
        • Campbell D.A.
        • et al.
        Successful implementation of the Department of Veterans Affairs’ National Surgical Quality Improvement Program in the private sector: the patient safety in surgery study.
        Ann Surg. 2008; 248: 329-336
        • Itani K.M.
        Fifteen years of the National Surgical Quality Improvement Program in review.
        Am J Surg. 2009; 198: S9-18
      1. American College of Surgeons National Surgical Quality Improvement website. Available from: Accessed March, 2013.

        • American College of Surgeons
        American College of Surgeons National Quality Surgical Improvement Program operations manual.
        American College of Surgeons, Chicago2012
      2. 18th ed. Harrison’s principles of internal medicine. Vol. II. McGraw-Hill, San Francisco2012
      3. World Health Organization. Global database on body mass index. Available from: Accessed December 16, 2013.

        • Breiman L.
        • Friedman J.H.
        • Olshen R.A.
        • Stone C.J.
        Classification and regression trees.
        Wadsworth International Group, Belmont, CA1984
        • Fair B.A.
        • Kubasiak J.C.
        • Janssen I.
        • Myers J.A.
        • Millikan K.W.
        • Deziel D.J.
        • et al.
        The impact of operative timing on outcomes of appendicitis: a National Surgical Quality Improvement Project analysis.
        Am J Surg. 2015; 209: 498-502
        • Zafar S.N.
        • Obirieze A.
        • Adesibikan B.
        • Cornwell E.E.
        • Fullum T.M.
        • Tran D.D.
        Optimal time for early laparoscopic cholecystectomy for acute cholecystitis.
        JAMA Surg. 2015; 150: 129-136
        • Gurusamy K.S.
        • Davidson C.
        • Gluud C.
        • Davidson B.R.
        Early versus delayed laparoscopic cholecystectomy for people with acute cholecystitis.
        Cochrane Database Syst Rev. 2013; : CD005440
        • Gawande A.A.
        • Kwaan M.R.
        • Regenbogen S.E.
        • Lipsitz S.A.
        • Zinner M.J.
        An APGAR score for surgery.
        J Am Coll Surg. 2007; 204: 201-208
        • Glance L.G.
        • Lustik S.J.
        • Hannan E.L.
        • Osler T.M.
        • Mukamel D.B.
        • Qian F.
        • et al.
        The surgical mortality probability model.
        Ann Surg. 2012; 255: 696-702