Palliative Procedure For Patients Research Articles

Scalp Reconstruction With Free Tissue Transfer as a Palliative Surgical Intervention in a High-Risk Population.

Microvascular reconstruction of the scalp is frequently indicated in patients with locally advanced tumors, among other etiologies, in a relatively high-risk, older patient population that often has multiple medical comorbidities. A retrospective analysis was performed on patients undergoing microvascular scalp reconstruction at Emory University Hospital and Grady Memorial Hospital between 2011 and 2021. Patient demographics, wound characteristics, operative details, and complications were recorded. Statistical analysis using univariate and multivariate models was performed. Forty-two patients underwent 45 microvascular scalp reconstructive procedures during the study period. The median age was 63 years. Wounds were predominantly oncologic (n=38, 84.4%) and frequently involved deeper structures [calvarium (n=38, 84.4%), dura (n=17, 37.8%)]. At a median follow-up of 350 days, 33 patients (73.3%) had healed flaps, 9 (20.0%) had wound healing issues but ultimately successful reconstruction, and 3 (6.7%) experienced flap failure. Most patients (n=33, 80.9%) were discharged home or to a rehabilitation facility, while the remaining 8 patients (19.1%) were discharged to hospice or died. The 30-day mortality was 4 patients (8.9%) and the 6-month mortality was 8 patients (20.5%). There was a statistically significant difference in 30-day mortality (P=0.0001) on univariate analysis and 6-month mortality (P=0.003) on both univariate and multivariate analysis for patients >70 years. While age >70 years is a risk factor for mortality in patients undergoing microvascular scalp reconstruction, mortality was commonly related to underlying disease processes rather than complication of surgery. Microvascular reconstruction for scalp defects has a high success rate and can be offered as a palliative procedure for patients with locally advanced cancers, advanced age, and multiple comorbidities.

Successful Pregnancy in A Patient with Fontan Surgery: A Case Report

The Fontan operation is a palliative procedure for patients with several forms of congenital heart disease unsuitable for biventricular circulation, especially tricuspid valve atresia. In this procedure, the vena cava flow is directed to the pulmonary arteries bypassing the ventricle. Pregnant patients with Fontan surgery in their post-surgical history have more maternal risks. We should counsel patients with saturations <85%, depressed ventricular function, refractory arrhythmia, or protein-losing enteropathy against pregnancy (mWHO; IV). In this study, we review a pregnant case that has successful pregnancy and Fontan palliation and lv systolic heart failure (LVEF: 35%) in her past medical history.

Retrospective study of preoperative sildenafil in prolonged pleural effusion after Fontan.

By rerouting the systemic venous return into the pulmonary circulation, the Fontan operation is perhaps the most effective palliative procedure in patients with complex congenital heart disease. The Fontan, however, still comes with several significant complications and morbidities, one of them being postoperative prolonged pleural effusion. In our center from 2017 to 2021, 10% of all our patients who underwent Fontan operation developed prolonged pleural effusion. With this study, we aimed to analyze the preoperative use of sildenafil for 6 months and its role in prolonged pleural effusion after the Fontan operation. In total, 158 patients were included in the analysis. The cohort was divided into patients who developed prolonged pleural effusion after Fontan surgery (n = 17) and those who did not (n = 141). We analyzed several risk factors and the history of sildenafil use in each group in the cohort. We found that patients who used sildenafil for at least 6 months prior to Fontan surgery versus those who did not use (n = 112 vs. n = 46) were found to be at lower risk of developing prolonged pleural effusion (odds ratio [OR]: 0.32 [confidence interval 95%: 0.11-0.88], P = 0.027). Preoperative administration of sildenafil for at least 6 months before Fontan might reduce the risk of postoperative prolonged pleural effusion.

Databases for Gastrointestinal Clinical and Public Health Research: Have Database, Will Research

Databases for Gastrointestinal Clinical and Public Health Research: Have Database, Will Research

Ten-year trends of utilizing palliative care and palliative procedures in patients with gastric Cancer in the United States from 2009 to 2018 - a nationwide database study

ObjectivesLittle is known about the current status and the changing trends of hospitalization and palliative care consultation of patients with gastric cancer in the United States. The aim of this study was to evaluate the changing trend in the number of hospitalization, palliative care consultation, and palliative procedures in the US during a recent 10-year period using a nationwide database.MethodsThis was a retrospective study that analyzed the National Inpatient Sample (NIS) database of 2009–2018. Patients aged more than 18 years who were diagnosed with a gastric cancer using International Classification of Diseases (ICD)-9 and 10 codes were included. Palliative care consultation included palliative care (ICD-9, V66.7; ICD-10, Z51.5) and advanced care planning (ICD-9, V69.89; ICD-10, Z71.89). Palliative procedures included percutaneous or endoscopic bypass, gastrostomy or enterostomy, dilation, drainage, nutrition, and irrigation for palliative purpose.Results and discussionA total of 86,430 patients were selected and analyzed in this study. Using a compound annual growth rate (CAGR) approach, the annual number of hospitalizations of gastric cancer patients was found to be decreased during 2009–2018 (CAGR: -0.8%, P = 0.0084), while utilization rates of palliative care and palliative procedures increased (CAGR: 9.3 and 1.6%, respectively; P < 0.0001). Multivariable regression analysis revealed that palliative care consultation was associated with reduced total hospital charges (−$34,188, P < 0.0001).ConclusionUtilization of palliative care consultation to patients with gastric cancer may reduce use of medical resources and hospital costs.

Semi-Automatic Planning and Three-Dimensional Electrospinning of Patient-Specific Grafts for Fontan Surgery.

This paper proposes a semi-automatic Fontan surgery planning method for designing and manufacturing hemodynamically optimized patient-specific grafts. Fontan surgery is a palliative procedure for patients with a single ventricle heart defect by creating a new path using a vascular graft for the deoxygenated blood to be directed to the lungs, bypassing the heart. However, designing patient-specific grafts with optimized hemodynamic performance is a complex task due to the variety of patient-specific anatomies, confined surgical planning space, and the requirement of simultaneously considering multiple design criteria for vascular graft optimization. To address these challenges, we used parameterized Fontan pathways to explore patient-specific vascular graft design spaces and search for optimal solutions by formulating a nonlinear constrained optimization problem, which minimizes indexed power loss (iPL) of the Fontan model by constraining hepatic flow distribution (HFD), percentage of abnormal wall shear stress (%WSS) and geometric interference between Fontan pathways and the heart models (InDep) within clinically acceptable thresholds. Gaussian process regression was employed to build surrogate models of the hemodynamic parameters as well as InDep and [Formula: see text] (conduit model smoothness indicator) for optimization by pattern search. We tested the proposed method on two patient-specific models (n=2). The results showed the automatically optimized (AutoOpt) Fontan models hemodynamically outperformed or at least are comparable to manually optimized Fontan models with significantly reduced surgical planning time (15 hours versus over 2 weeks). We also demonstrated feasibility of manufacturing the AutoOpt Fontan conduits by using electrospun nanofibers.

Newer Stents for Unresectable Malignant Distal Biliary Obstruction: Striving for Perfection!

AbstractEndoscopic biliary stenting is one of the most commonly used palliative procedure in patients with unresectable malignant distal biliary obstruction. Biliary stenting can be performed with either plastic or metallic stents. Stent occlusion and migration are important limitations of currently available stents. Variety of newer stents with varying designs and stent materials like stents with antimigratory properties, antireflux stents, drug-eluting stents, radioactive stents, and bioabsorbable stents are being developed to overcome the limitations of currently available stents. In this article, we are discussing two articles on the newer stent designs (plastic and metal stents) for biliary drainage in patients with unresectable malignant distal biliary obstruction.

Comparative analysis of different palliative procedures in patients with pulmonary atresia and ventricular septal defect

Comparative analysis of different palliative procedures in patients with pulmonary atresia and ventricular septal defect

Deficits in the Palliative Care Process Measures in Patients with Advanced Pancreatic Cancer Undergoing Operative and Invasive Nonoperative Palliative Procedures.

Given survival measured in months, metrics, such as 30-day mortality, are poorly suited to measure the quality of palliative procedures for patients with advanced cancer. Nationally endorsed process measures associated with high-quality PC include code-status clarification, goals-of-care discussions, palliative-care referral, and hospice assessment. The impact of the performance of these process measures on subsequent healthcare utilization is unknown. Administrative data and manual review were used to identify hospital admissions with performance of palliative procedures for advanced pancreatic cancer at two tertiary care hospitals from 2011 to 2016. Natural language processing, a form of computer-assisted abstraction, identified process measures in associated free-text notes. Healthcare utilization was compared using a Cox proportional hazard model. We identified 823 hospital admissions with performance of a palliative procedure. PC process measures were identified in 68% of admissions. Patients with documented process measures were older (66 vs. 63; p = 0.04) and had a longer length of stay (9 vs. 6days; p < 0.001). In multivariate analysis, patients treated by surgeons were less likely to have PC process measures performed (odds ratio 0.19; 95% confidence interval 0.10-0.37). Performance of PC process measures was associated with decreased healthcare utilization in a Cox proportional hazard model. PC process measures were not performed in almost one-third of hospital admissions for palliative procedures in patients with advanced pancreatic cancer. Performance of established high-quality process measures for seriously ill patients undergoing palliative procedures may help patients to avoid burdensome, high-intensity care at the end-of-life.

Four successful pregnancies in a patient with Fontan palliation and congenital heart disease: a case report

BackgroundFontan is a palliative procedure in patients with single ventricle. Single ventricle supports systemic cardiac output and pulmonary blood flow is passively directed to the right pulmonary artery. Women with Fontan palliation are reported to have increased maternal risk during pregnancy. There are few reports of successful pregnancies in such cases. However data on these pregnancies is lacking, we consider this to be the first reported from kingdom of Saudi Arabia.Case presentationWe present a 35-year-old woman from the Kingdom of Saudi Arabia who had Fontan surgery and who had four successful pregnancies and multiple miscarriages. She delivered live, low birth weight neonates.ConclusionThis report provides an anecdotal evidence that pregnancy can be tolerated in an adequate Fontan patient with successful outcomes.

The use of Macitentan in Fontan circulation: a case report

BackgroundThe Fontan circulation, a result of a palliative procedure in patients with single systemic ventricles, is defined by chronically elevated pulmonary vascular resistance. When traditional heart failure therapies fail, pharmacological agents that reduce pulmonary artery pressures may be used. These include endothelial-receptor antagonists, prostanoids and phosphodiesterase type 5 inhibitors. We report the first use of macitentan, an endothelin-receptor antagonist, in a patient with a Fontan circulation.Case presentationWe describe the case of a 50 year old female with tricuspid atresia and transposition of the great arteries. Following complex surgery as a child, she subsequently underwent a fenestrated modified atrial pulmonary Fontan operation which was later converted to a total cavopulmonary anastomosis Fontan circulation. Due to failure of various medications to relieve her worsening symptoms, she was commenced on macitentan in April 2016. Few months later, she demonstrated a significant symptomatic improvement and associated increase in her incremental shuttle walking test distance.ConclusionsMacitentan has slower receptor dissociation kinetics compared to other endothelin-receptor antagonists, leading to enhanced pharmacological activity with promising effects in patients with pulmonary arterial hypertension. The patient we report has shown considerable improvement in exercise capacity following introduction of this medication and thus we suggest further randomised trials to establish the role of different endothelin-receptor antagonists in the management of the Fontan circulation.

Stenting of the ductus arteriosus in infants with functionally univentricular heart disease and ductal-dependent pulmonary blood flow: A single-center experience.

To determine the short- and medium-term outcomes of ductal stenting (DS) in patients with functionally univentricular hearts (FUHs) and ductal-dependent pulmonary blood flow. Several studies have evaluated the outcomes of DS in a limited number of patients with FUHs. Nonetheless, there is still no consensus regarding the indications for this procedure, and no appropriate patient selection criteria have been devised. From 2005 to 2015, cardiac catheterization for DS was performed in 68 patients with FUHs. Of these patients, 49 had single source pulmonary blood flow from ductus arteriosus. Procedural and follow-up data were evaluated. The median weight of the patients was 3.6 kg (2.3-6.8 kg), and the median age was 26 days (3 days-8 months). The technical success rate of the procedure was 95% (65 of 68 patients). Mean oxygen saturation increased from 70% ± 7.6% to 87% ± 4.6% (P < 0.0001). Among patients in whom DS was successful, 55 (84.6%) were bridged to a Glenn procedure after a median of 9.1 months (6.4-14 months), and 41 (63%) were successfully bridged to a Glenn procedure without additional interventions. Of the 16 patients with preexisting mild pulmonary artery stenosis, five required a surgical shunt due to progressive branch pulmonary artery stenosis, while nine were bridged to a Glenn operation without shunt placement. Five (7.3%) patients died, including patients who were sent to surgery. DS is a reasonable and effective alternative to surgical shunt placement as a first-stage palliative procedure in patients with FUHs. © 2016 Wiley Periodicals, Inc.

Prevalence and characterization of fibrosis in surveillance liver biopsies of patients with Fontan circulation

The Fontan operation is a widely used palliative procedure in patients with single-ventricle anatomy that results in liver injury. As timely identification of liver fibrosis may result in management changes to Fontan patients, the aim of our study was to identify clinically meaningful semi quantitative/quantitative pathologic parameters for biopsy assessment. We performed a retrospective review of 74 liver needle biopsies from Fontan patients. Fibrosis was assessed using quantitative % collagen deposition by Sirius red image analysis, METAVIR, congestive hepatic fibrosis score, sinusoidal fibrosis score, and sinusoidal dilation score. Contemporaneous laboratory, hemodynamic, and ultrasound data were collected. Centrilobular and peri sinusoidal fibrosis was observed in all cases, with 39.2% high grade. Portal fibrosis was observed in 93.2%, with 36.2% high-grade (METAVIR F3-F4). Cirrhosis was observed in 5.4%. % Collagen deposition was increased over control tissue (P < .001) and correlated with time from Fontan (r = 0.3, P = .009) and prothrombin time (r = 0.25, P = .034). Mildly elevated prothrombin time/international normalized ratio was the only measure of liver function consistently associated with multiple high-grade fibrosis scores (METAVIR P = .046, sinusoidal fibrosis P = .018). Abnormal liver echotexture on ultrasound was associated with high-grade congestive hepatic fibrosis score (P = .03). Pathologic gradings and %CD correlated with each other (r = 0.48-0.8, P < .001). Hepatic fibrosis in Fontan patients in our study is universally present, appears to be time dependent, and correlates with few laboratory measurements of liver function. Careful assessment of needle liver biopsies lends a more meaningful measure of liver fibrosis in the Fontan patient than clinical and laboratory data, allowing for appropriate changes to patient management.

Effects of Balloon Pulmonary Valvuloplasty as Preoperative Palliation for Tetralogy of Fallot.

We investigated the effect of balloon pulmonary valvuloplasty (BPV) as a palliative procedure for patients with tetralogy of Fallot (TOF). This was a retrospective single-center study conducted between 2008 and 2014. We classified patients into three groups according to palliation: treatment with BPV (group I), with a Blalock-Taussig shunt (group II), and with infundibulectomy (group III). The growth of the pulmonary valve (PV) annulus and need for transannular patching (TAP) during total correction were compared between groups. Forty-eight patients were enrolled: 31, 10, and 7 in groups I, II, and III, respectively. The mean ages at palliation were 26.3 ± 23.6, 21.5 ± 16.4, and 15.2 ± 4.2 days in groups I, II, and III, respectively (P = .867). The success rate of BPV was 90.3%. The initial PV z-score before palliation did not differ between groups I, II, and III (-3.14 ± 1.44, -3.84 ± 1.47, and -3.71 ± 1.68; P = .494); the preoperative PV z-score before total correction was larger in group I than in group II (-1.19 ± 1.14 and -3.05 ± 1.19; P = .001), and also larger in group III than in group II (group III: -1.10 ± 0.90; P = .003). The change in pulse oxygen saturation differed significantly between the three groups (P = .031), particularly between groups I and II (P = .010), and the change in PV z-score was greater in groups I and III than in group II (P < .001). TAP during total correction was performed in 29.0%, 90.0%, and 16.7% of groups I, II, and III, respectively (P = .001; group I vs. II, P = .001; group II vs. III, P = .008). BPV was an effective and safe palliation that increased pulmonary blood flow and promoted growth of the PV annulus in selected symptomatic newborns with TOF.

PTH-011 Novel Endoscopic Ultrasound-Guided Interventional Techniques for The Palliative Management of Malignant Biliary Tract Obstruction: A Single UK Centre Experience

Introduction Endoscopic retrograde cholangiopancreatography (ERCP) is used as the first-line modality for biliary drainage in patients with obstructive jaundice. However, anatomical or technical factors may preclude conventional trans-papillary biliary access in less than 10% of cases. Endoscopic ultrasound-guided biliary drainage (EUS-BD) has recently emerged as an alternative method to percutaneous transhepatic biliary drainage (PTBD) or surgical biliary bypass after unsuccessful ERCP in patients with inoperable pancreatobiliary malignancies. We present initial experience of EUS-BD in our unit. Methods A prospectively collected database, of consecutive patients undergoing EUS-BD in our unit, was analysed. Data was retrieved from electronic, clinical and endoscopy records. All EUS-BD procedures were undertaken in the endoscopy department, under conscious sedation, using Pentax echoendoscopes and Hitachi ultrasound workstations. In all cases, conventional diagnostic EUS procedure was performed followed by trans-luminal EUS-guided placement of metal stents. One of three endoscopists (KO/MN/MD) performed the procedures. The primary outcome measurements were technical success, clinical success and adverse events. Results 4 EUS-BD procedures were performed in 4 patients – ¾ were female (75%) with median age 70 years (range 51–79). The primary indication in all patients was malignant biliary obstruction, which was not amenable to either PTBD or surgery. One patient had symptomatic cystic duct obstruction with gallbladder empyema. 1 patient received a Hot AXIOS™ covered lumen apposing metal stent (cLAMS), 1 had a Wallflex™ biliary fully covered self-expanding metal stent (fcSEMS) and the others had NAGI™ covered self-expanding metal stents (cSEMS) inserted. Technical and clinical success was 100% across all procedures with symptomatic improvement noted in all patients. Serum bilirubin measurements decremented post EUS-BD by median 89% (range 85–98%). No procedure related complications were seen. During follow up, 3/4 patients have died (median 7 months (range 3–8) from date of EUS-BD) of end-stage disease (unrelated to the EUS-BD procedure). The 4th patient remains clinically stable on follow-up (2 months after EUS-BD) with no evidence of further biliary symptoms. Conclusion Our early experience of EUS-BD confirms that it is a safe and effective palliative procedure in patients with malignant biliary tract obstruction, in whom surgery and/or PTBD are less favourable. We recommend that EUS-BD is performed after multidisciplinary team discussion and by experienced therapeutic endosonographers. Disclosure of Interest None Declared

Cost-effectiveness of palliative surgery versus nonsurgical procedures in gastrointestinal cancer patients.

Palliative care is an essential component to multidisciplinary cancer care. Improved symptom control, quality of life (QOL), and survival have resulted from its utilization. Cost-effectiveness and utility analyses are significant variables that should be considered in comparing benefits and costs of medical interventions to determine if certain treatments are economically justified. This is a review on the cost-effectiveness of palliative surgery compared to other nonsurgical palliative procedures in patients with unresectable gastrointestinal cancers. J. Surg. Oncol. 2016;114:316-322. © 2016 Wiley Periodicals, Inc.

Vagus Nerve Stimulation for Epilepsy: An Evidence-Based Approach.

Medical treatment of seizures yields a satisfactory response in 75-80% of the patients; resective epilepsy surgery is a therapeutic option for those patients who are refractory to drug therapy, but there is still a considerable portion (20-30%) of patients who are ineligible for surgery or failed surgery. Vagus nerve stimulation (VNS) might be an option for these very refractory patients. We carried out an evidence-based search to identify the best evidence presently available related to the use of VNS. We used multiple searchable databases (primary: PubMed-MEDLINE, EMBASE, LILACS, and SciELO; secondary: Cochrane Library) and a standard structured approach know as the PICO scheme: P (patient), I (intervention), C (comparison), and O (outcome). Publications were selected based on study design, PICO components, language, and availability of full text. For study design, we included papers designed as 'randomized controlled trials'; these trials were evaluated according to the Jadad score; the type II error was not used while selecting studies to avoid further limitations. Twenty-eight papers were selected, all from PubMed-MEDLINE. The search results showed that patients older than 12 years with refractory partial seizures (with or without generalization) may benefit from VNS. Children might also benefit, but might need different stimulation parameters. We also noted that higher stimulation settings are associated with increased occurrence of hoarseness, throat pain, cough, and dyspnea. The available randomized controlled trials and cohorts made it clear that VNS is a useful palliative procedure in adult patients with partial epilepsy, and a 50-60% reduction in seizure frequency might be expected in at least 50% of the patients. VNS is a useful palliative procedure in patients with refractory epilepsy. As our practical experience and understanding of the mechanism of action of VNS increase, more homogeneous patient populations that might respond better to VNS are being recognized, such as children with secondary generalized epilepsy and some types of reflex epilepsy.

Prognostic Factors of 30-Day Mortality After Palliative Procedures in Patients with Malignant Pleural Effusion.

The aim of this study was to identify predictors of 30-day mortality in patients with malignant pleural effusion (MPE) who need pleural palliative procedures. Data was prospectively collected from our database, between January 2013 and July 2014 on 86 patients with MPE and complete follow-up 30 days after the procedure. The sample was divided into two groups. The first group (G1) included patients who had died up to 30 days after the palliative procedure, and the second group (G2) included patients who survived for more than 30 days after the palliative procedure. The identification of prognostic factors occurred through univariate analysis using Fisher exact test for analysis of categorical variables and the t test for quantitative variables. Subsequently, all variables were used in the multivariate logistic regression analysis. The cutoff values for any significant continuous variables were determined by receiver operating characteristics analysis. There were 24 patients in G1 and 62 patients in G2. Univariate analysis of factors affecting postprocedural survival disclosed nine factors that were associated with significantly reduced postoperative survival. At the multivariate analysis, high levels of white blood cells, (p = .013), low levels of red blood cells (p < .0001) and protein in pleural fluid (p = .001), and primary lung and gastrointestinal sites (p = .0076) were identified as independent predictors of mortality. We identified four factors that are easily recognized in daily practice and can help select patients with low life expectancy. Therefore, invasive procedures and hospitalizations for this subgroup of patients can be prevented.

TCT-166 Stenting the Right Ventricular Outflow Tract as a Palliative Procedure in Patients with Tetralogy of Fallot

Neonates and infants with Tetralogy of Fallot (TOF) may occasionally need a BTT shunt to treat hypoxemia. However it may distort the anatomy of the pulmonary arteries (PAs). We report the outcomes after stenting the right ventricular outflow tract (RVOT) as an alternative procedure to temporarily

Bridging Patients Using Balloon Valvuloplasty in Patients With Acutely Decompensated Heart Failure: A Single Center Experience

Balloon aortic valvuloplasty (BAV),once considered a palliative procedure for patients who were deemed too high risk for conventional aortic valve replacement, may be an effective bridging strategy for patients presenting in acutely decompensated heart failure from severe aortic stenosis.