Role Of Palliative Surgery Research Articles

The Role of Palliative Surgery in the Management of Acute Intestinal Obstruction Secondary to Peritoneal Carcinomatosis.

Introduction: Acute intestinal obstruction secondary to extensive peritoneal carcinomatosis is an end stage event. The role of palliative surgery in these patients is debatable in view of the anticipated severe complications and its doubtful role in achieving adequate palliation. The primary objective of our study was to evaluate the feasibility and ability of patients to resume oral nutrition after palliative surgery for acute intestinal obstruction due to peritoneal carcinomatosis. Patients and Methods: It is an observational study in which we retrospectively reviewed the data from a prospectively maintained clinical database of 40 patients. The predefined pre- and intraoperative variables were obtained. The immediate outcome variables like postoperative complications, length of hospital stay, and mortality were analyzed. The short-term outcomes at 3 months in the form of survival, ability to resume enteral nutrition were analyzed. Results: Among the 40 patients 18 were males and 22 females. Ovarian cancer was the most common primary (27.5%) in the study. Twelve patients had acute intestinal obstruction as their first presentation without any past events and 25 (62.5%) patients had been operated on previously or received adjuvant systemic treatment. The palliative surgical option was technically feasible in 37 (93.5%) patients. The median length of hospitalization for the patients who were discharged was 10 days with a range of 6-18 days. Six (15%) patients died in the postoperative period. Severe post-operative complications were seen in 9 (26.4%) patients. Among the patients (n=34) discharged 26 (76.4%) were alive at 3 months. In those who were alive, 21 (80.7%) of them were on some form of oral nutrition at 3 months. Conclusion: Palliative surgery in patients with acute intestinal obstruction secondary to peritoneal carcinomatosis is feasible with acceptable morbidity and mortality. The enteral nutrition can be restored in the majority of these patients.

The Role of Surgery in the Palliative Care of Cancer: A Retrospective Analysis of 22 years

Aim: Surgical procedures in palliative care are common, however the indications, risks and outcomes are not well described. We present a retrospective review of the management of cancer patients. Material and Methods: During the period 2000-2022, 11.700 of cancer cases (abdominal, gynecological, urological and breast) were recorded in our registries and are analyzed. Group A: All 6000 patients (51,3%) included in this group had a therapeutic intent in their management which include surgical procedures ± neoadjuvant and systemic chemotherapy and radiotherapy. Group B: Palliative approach was applied in 2650 cases (22,6%) with both surgical and medical management being performed. Medical management consists of systemic chemotherapy and radiotherapy. Surgical procedures for palliation, include resections, reconstructions, ostomies, functional repairs, tube drainage and biopsies. Group C: Best supportive care was applied in 3050 cases (26,1%) which includes nutritional management with home parenteral or enteral nutrition, pain management, physical and respiratory physiotherapy, and fistulas or ulcers management. Primary end points include survival advantages while Quality of Life (QOL) was set as a secondary benefit. The risk of morbidity and treatment related mortality are also calculated between the different groups. Results: A median follow up of 80 months was observed. The median O.S. for group A was 44,4 ± 16,3 months and for palliative care group (B) was 26,3+11,7 m (p<0,01). On the other hand, the median O.S. for the group C (Best supportive care) was 8,7 ± 5,2 m. More specifically the group of patients with peritoneal metastasis which include 5200 patients (44,5%) of the total cancer patients was subdivided in 4 subgroups. The role of palliative surgery with or without systemic or neoadjuvant chemotherapy, offer a better O.S. when compared with only systemic chemotherapy (13,4 ± 7,5 m vs 71 ± 4,3 m) with acceptable morbidity and mortality rates. Conclusion: In conclusion, the need for holistic palliative care in cases of incurable malignancy is not entirely clear how it is best to integrate into palliative surgical principles. The essential roles of surgical palliation are, initial evaluation of the disease, local control, control of discharge or hemorrhage, control of pain and reconstruction and rehabilitation

Malignant Bowel Obstruction in Ovarian Cancer Recurrence: The Role of Palliative Surgery in a Decision-Making Process

Background: Malignant bowel obstruction (MBO) is often the latest stage in ovarian cancer (OC). The therapy of this condition ranges from medical waiting to surgery. The objective of this pilot study is to compare the two strategies so that we can provide a path forward for future studies. Methods: From 700 women diagnosed with OC in the database of the Division of Gynecologic Oncology we crossed the names of those admitted by the emergency services of the IRCSS Azienda Ospedaliero Universitaria of Bologna, Italy. We selected MBO patients with a history of OC as the only neoplastic condition and compared the results between medical conduct and surgery to restore intestinal transit. Results: Of the 700 women in our database, 36 were eligible for study according to the inclusion and exclusion criteria: 9 in surgery group and 27 in medical group. Surgical conduct (tumor biopsy and stoma) appears to be resolutory for the obstruction and have a better result than medical therapy regarding recurrence of MBO, despite the development of greater complications. Relapses of MBOs occurred in 11% of surgical patients and 44% of medical patients (p = 0.0714). Furthermore, after surgical treatment, five patients (55%) experienced postoperative complications; in four cases, severe anemia requiring blood transfusion, while one patient developed post-surgical sepsis, which evolved into multiple organ failure and death. Of the 9 patients treated surgically, 2 (22%) were given surgery as a first choice. In most cases (78%), surgery was decided upon when medical treatment failed. The only discriminative factor appears to be age. The length of hospitalization increased with the patient’s age (p = 0.0181) as statistically significant factors for a worse outcome in surgery. Conclusions: MBO requires complex and multidisciplinary management where different factors need to be considered before initiating surgical therapy. Future studies are needed to deal with this complex problem.

The Role of Palliative Surgery in Stage IV Gastric Cancer: A Retrospective Study.

Background: Palliative chemotherapy is the mainstay of treatment for metastatic gastric adenocarcinoma but in some patients, surgically correctable factors such as obstruction lead to intolerance of further systemic treatment. The aim of this study was to evaluate the role of selective palliative surgery in incurable gastric cancer. Methods: All patients with stage IV and locally advanced unresectable gastric adenocarcinoma treated at a single centre from March 2006 to January 2019 were included. Data were retrieved from a prospectively maintained database. Patients were categorized into palliative surgery (PS) and no surgery (NS). Results: Of 666 patients with gastric cancer treated over the study period, 146 patients had stage IV gastric adenocarcinoma and 121 patients met inclusion criteria. Sites of metastases were peritoneum (55; 46%), non-regional lymph nodes (10; 8%), solid organ (17, 14%), adjacent organ invasion (4, 3.3%) and a combination of factors (32, 26%). Forty-six (38%) patients underwent palliative surgery which included anatomical gastrectomy (total, subtotal, distal or proximal, 78%) gastro-jejunal bypass and feeding jejunostomy (12%). Thirty-day post-operative complications occurred in 24 patients (52%) with one mortality (2.1%). Following surgery, 52% received systemic chemotherapy. For the PS and NS groups respectively, median overall survival was 9.1 versus 9.4 months (p = 0.6) and median progression-free survival was 7.1 versus 6.7 months (p = 0.2) after a follow up period of 7.3 (4.7-13.1) versus 7.8 (2.6-13.4) months (p = 0.46). Conclusion: Targeted surgical intervention for incurable gastric cancer can be used to palliate symptoms and facilitate continuation of systemic therapy with acceptable risks and post-operative outcomes.

Palliative surgery and the surgeon's role in the palliative care team: a review.

This review focuses on the role of palliative surgery in the care of the palliative care patient, and the appropriate role of the surgeon. The surgeon has much to bring to the palliative care team. The surgeon's role goes beyond the technical requirements of the palliative procedure, which itself must be strictly defined, and has recognized utility for improving quality of life in selected patients. These benefits may be substantial, but come at significant risk; requiring careful balancing of risks and benefits that is most completely understood by the surgeon. The surgeon's judgement can help determine which procedure best meets a patient's goals. The complex dialogue involved in the decision to undergo a palliative operation requires excellent communication between the palliative care team, the patient, and their family. Integrating the surgeon into the palliative care team could help with earlier initiation of those palliative discussions, and assist deliberation of palliative surgery. Surgeons also understand the importance of communication around palliative surgical interventions and have adapted several teaching models to the specifics of this crucial communication. A palliative team combining both surgeons and palliative care physicians may promote goal-concordant decision-making and remove barriers to communication and team engagement. The future of palliative surgery research will involve measures of success that go beyond physiology or mortality, to include more evaluations of communication and patient goals.

Cholangiocarcinoma in Pregnancy: Literature Review and Case Report

Introduction: Hepatobiliary malignancies during pregnancy are extremely rare, with probably around 11 published cases of cholangiocarcinoma (CCA) in pregnant woman. Case report: A 35 years-old pregnant woman, 34 weeks pregnant, with 2 weeks of cholestasis. Exams reveals total bilirubin of 7.08 mg/dL, AST 97 U/L, ALT 131 U/L, CA 19-9 7724 U/mL and CEA 11 ng/ml. MRI showed a 4.0x3.5 cm mass in hepatic confluence, suspicion of CCA, with right portal and hepatic artery invasion. One week later, bilirubin raised to 13 mg/dL, and cesarean was permorfed. Percutaneous biopsy was performed and moderately differentiated CCA was confirmed. Multidisciplinary team decided for bilateral external transhepatic biliary catheter placement and right portal vein embolization before the surgery. Exploratory laparoscopy demonstrated a small and unique peritoneal implant in the hepatorenal area. Was decided to continuous with the surgery, and a right hepatic trisegmentectomy with Roux-en-Y biliary anastomosis was performed. After six weeks, she has started chemotherapy. The total survival was 2,4 years. Discussion/ conclusion: Cholangiocarcinoma is a rare malignancy encountered even more rarely during pregnancy. Termination of pregnancy and rapid initiation of chemotherapy may be an option in patients in the third semester of pregnancy. The role of palliative surgery in this setting is not determined in literature, but we know that many CCA patients die of cholangitis. Cancer in pregnancy marks an emotional and devastating diagnosis that requires a multidisciplinary approach to management. Each case needs to be considered individually and there are no consensus guidelines and few cases reports.

Jejunal limb obstruction by a tumor thrombus from pancreatic metastasis of renal cell carcinoma: a case report

BackgroundRenal cell carcinoma (RCC) is a primary tumor with the highest frequency of pancreatic metastasis. Although surgical resection can improve the prognosis of some patients with pancreatic metastasis of RCC (PM-RCC), the role of palliative surgery remains unclear. Herein, we described a case of jejunal limb occlusion caused by a tumor thrombus arising from a PM-RCC which was treated by surgical resection.Case presentationA 75-year-old, male patient with metastatic RCC was admitted to our hospital with new-onset dysphagia and weight loss. Twenty years earlier he underwent a right nephrectomy with an adrenalectomy for the first surgical resection of RCC, and 12 years ago he underwent a left partial nephrectomy for metachronous primary RCC. Nine years later, multiple pancreatic metastases were detected. After discontinuing interferon therapy, he was followed up at his request without anticancer treatment. Multiple, pulmonary metastases developed 3 years ago, and resection of a brain metastasis was performed 6 months ago. He had also undergone a total gastrectomy with Roux-en Y reconstruction and splenectomy for gastric cancer 23 years ago. Computed tomography revealed a metastatic lesion in the pancreatic tail extending into the jejunal limb, which was obstructed by a tumor thrombus. Jejunal limb resection was performed concomitantly with a distal pancreatectomy as palliative surgery. The jejunal limb remnant was approximately 30 cm long and was re-anastomosed to the esophagus using a circular stapler. Blood perfusion at the anastomotic site was confirmed by indocyanine green fluorescence imaging. He was discharged on postoperative day 24 and was followed in the outpatient clinic. He achieved sufficient oral intake at 8 months postoperatively.ConclusionsPM-RCC can invade the gastrointestinal tract and cause tumor thrombus formation resulting in bowel occlusion requiring surgical intervention.

Role of Palliative Surgery and Whole Pelvic Radiotherapy on Symptom Palliation and Quality of Life in Advanced Rectal Cancer: a Prospective Observational Study

Introduction: Patients with metastatic / advanced inoperable rectal cancer usually complain of symptoms like per rectal bleeding, local pain and irregular bowel habits. The main objective of care in these patients is to improve overall survival (OS) while palliating the symptoms and maintaining the Health Related Quality of Life (HRQoL). This may be achieved by either palliative surgery or radiotherapy along with systemic chemotherapy and we aimed to investigate these two modalities for symptom palliation, HRQoL and OS. Material and methods: The advanced rectal cancer (AJCC Stage group IV) patients with pelvic symptoms (rectal bleeding, pain or obstructive features) aged 18 – 75 years with ECOG PS 0 – 3 were included in this prospective non randomized observational study. Choice of palliative surgery or radiotherapy was done by MDT discussion. Symptoms and HRQoL (using FACT-G) were assessed at baseline, after intervention and every three months thereafter till one year. Results: Between February 2017 to June 2020, 102 patients of advanced rectal cancer were accrued. Eighty six patients were ultimately evaluated. Change in bowel habit (76%), pain (62%) rectal bleeding (37%) were the most common symptoms. Sixty seven patients received pelvic radiotherapy and nineteen underwent palliative surgery. Overall response rate at 3rd month after completion of treatment was 59%. Symptom control rates and time to symptom progression were comparable. The mean score of HRQoL were higher in the Radiotherapy arm. There were no grade III-IV toxicity. Median OS was eight and ten months in the surgery and radiotherapy arms, respectively. Conclusion: Morbid surgical procedure renders no advantage over palliative radiotherapy in metastatic rectal cancer with respect to palliation of pelvic symptoms and maintenance of HRQoL.

Palliative surgery in gastrointestinal malignancy: experience from a regional cancer centre

Background: With so much burden of advanced incurable disease, the role of palliative surgery is paramount for gastrointestinal malignancies improving quality of life. Aim of the study was to study the indications, risks and outcome of palliative surgeries in gastrointestinal malignancies, the burden of disease requiring palliative surgery, and to describe strategies to improve end of life care.Methods: All the patients diagnosed with gastrointestinal malignancy and who underwent palliative surgery between January 2017 and December 2017 were analysed.Results: A total of 186 cases underwent palliative surgery. The most common age group affected was between 50-60 years and the mean age was 54.55 years. Stomach was the most common primary consisting of 58.60% followed by colorectal (23.66%), small intestine (9.68%), hepato-pacreatico-billiary (4.30%), and oesophageal (3.76%) primary. Major complications were seen in 4.84% of cases. Average symptomatic relief was observed for 5.5 months in cases of stomach and 7 months in case of colorectal malignancies. 35.48% cases were alive at the end of one year.Conclusions: Present study concludes that palliative surgery improves quality of life of the patient, provides them with time to accept death and live rest of the life in a dignified manner.

Acute malignant obstruction in patients with peritoneal carcinomatosis: The role of palliative surgery

IntroductionPatients with peritoneal carcinomatosis who do not have curative treatment options often develop acute obstructive symptoms and when conservative management fails, surgical treatment is the remaining option. However, palliative surgery is associated with high morbidity and mortality and the chance of success is unclear. The aim of this study was to evaluate outcomes of palliative surgery and to provide guidance for surgeons, medical oncologists and patients in their decision-making. MethodsAll consecutive patients who underwent palliative surgery for acute obstruction caused by peritoneal carcinomatosis between January 2005 and October 2017 where identified. ResultsIn total 148 patients underwent surgery. Primary malignancy was colorectal cancer (28.4%), neuroendocrine tumor (20.3%), ovarian cancer (14.2%) or ‘other’ (37.2%). Median length of postoperative hospital stay was 16 days (IQR 9–24). More than half (58.1%) of the patients developed postoperative complications, 29.1% developed ≥2 complications. In-hospital mortality was 8.8%. Readmission (56.1%) and re-obstruction (35.0%) were common. Median overall survival was 119 days (IQR 48–420). Patients with a neuroendocrine tumor had a significantly better overall survival compared to other primary malignancies (p < 0.001). Patients who developed an obstruction during or within 6 months after treatment with chemotherapy had a worse overall survival (p < 0.001), compared to patients treated with chemotherapy longer than 6 months ago, or patients not treated with chemotherapy. ConclusionPalliative surgery is associated with high rates of complications and readmission and re-obstruction are common. Comfort care is often a better option than surgery, especially in patients with disease progression under recent treatment with chemotherapy.

Advanced gastrointestinal stromal tumor patients benefit from palliative surgery after tyrosine kinase inhibitors therapy.

The role of palliative surgery is controversial in advanced gastrointestinal stromal tumors (GIST) after tyrosine kinase inhibitors (TKIs) therapy.We evaluated safety and clinical outcomes in a single institution series of advanced GIST patients from January 2002 to December 2008.One hundred and fifty-six patients had been recruited, including 87 patients underwent surgical resection and 69 patients kept on TKIs treatment. Four patients had major surgical complications. Median follow-up was 38.3 months, the overall survival (OS) and progression-free survival (PFS) of the patients in surgical group were longer than the nonsurgical group, PFS: 46.1 versus 33.8 months (P < .01), OS: 54.8 versus 40.4 months. In the subgroup analysis for the patients received surgery, the median PFS for patients with progression disease, stable disease, and partial response was 33.3, 51.5, and 83.0 months, respectively (P < .01). Median OS was 68.0 months in those with only liver or peritoneal metastases, and 45.3 months in those with both metastases. Median PFS of patients underwent R0/R1 resection was 73.6 months compared with 35.8 months in R2 resection patients (P < .01).Patients with advanced GISTs have prolonged OS after debulking procedures. Surgery for patients who have responsive disease after TKIs treatment should be considered.

Is gall bladder cancer a bad cancer per se?

Gall bladder cancer (GBC) has one of the poorest outcomes of all cancers. Early GBC is difficult to diagnose on even computed tomography. GB has no submucosa and the cancer infiltrates directly into the muscularis propria. GB wall is thin and important adjacent organs viz. liver, duodenum and pancreas get easily infiltrated. Tumor in the GB neck often needs extended right hepatectomy. Infiltration of duodenum/pancreas may necessitate pancreato-duodenectomy or even hepato-pancreato-duodenectomy. Mortality of surgical procedures, when performed for GBC, is higher than when performed for other cancers. Survival in GBC, even after R0 resection, is poor. There is no proven role of neo-adjuvant or adjuvant therapy for loco-regionally advanced GBC. There is no role of palliative surgery in metastatic GBC. Early GBC is diagnosed incidentally after cholecystectomy for stones and requires reoperation for completion extended cholecystectomy but unfortunately, most surgeons are not aware of this. GBC has a peculiar epidemiology and is uncommon in the West and has, therefore, not received much attention. Preventive cholecystectomy for asymptomatic stones is not recommended and there is no serum marker for screening. With all factors pitched against it, it does appear that GBC is a bad cancer per se!

350. The role of palliative surgery in unresectable pancreas cancer: Retrospective study

350. The role of palliative surgery in unresectable pancreas cancer: Retrospective study

The role of palliative surgery in castration-resistant prostate cancer.

Androgen deprivation therapy with luteinising hormone releasing hormone (LHRH) analogues or antagonists represents the treatment of choice in men metastatic prostate cancer (PCA). Depending on the serum concentration of the prostate-specific antigen (PSA) nadir, the survival might vary between 11 and 78 months. About one-third of all patients without local treatment of the primary will develop significant complications of the lower and upper urinary tract because of local progression of PCA. It is the purpose of the review to inform the treating physician about palliative surgical options in men with castration-resistant prostate cancer (CRPC). In men with CRPC and lower urinary tract symptoms, palliative transurethral resection of the prostate (TUR-P) can be performed with a 60-70% success rate. Infiltration of the pelvic floor, the bladder neck and trigone and the external urethral sphincter can make palliative radical surgery necessary. Bladder neck closure with continent vesicostomy, radical cystoprostatectomy with an incontinent urinary diversion, and anterior and posterior exenteration are individual therapeutic options in men with a good performance status and a considerable life expectancy. Symptomatic involvement of the upper urinary tract can be managed by placement of endoluminal stents or a percutaneous nephrostomy in men with a poor performance. In men with a good response to androgen deprivation therapy (ADT) and a good performance status reconstructive ureteral surgery might be considered and the options of ureteral reimplantation, ureter ileal replacement and a subcutaneous pyelovesical bypass have to be discussed. There are various palliative surgical treatment options in the management of men with CRPC and symptomatic deterioration of the lower or the upper urinary tract, which should be considered in well selected patients. The indication to perform one of the above-mentioned surgical approaches needs to be discussed in a multidisciplinary tumour board.

The Role of Palliative Surgery in Gynecologic Cancer Cases

The decision to undergo major palliative surgery in end-stage gynecologic cancer is made when severe disease symptoms significantly hinder quality of life. Malignant bowel obstruction, unremitting pelvic pain, fistula formation, tumor necrosis, pelvic sepsis, and chronic hemorrhage are among the reasons patients undergo palliative surgeries. This review discusses and summarizes the literature on surgical management of malignant bowel obstruction and palliative pelvic exenteration in gynecologic oncology.

Current surgical aspects of palliative treatment for unresectable pancreatic cancer.

Despite all improvements in both surgical and other conservative therapies, pancreatic cancer is steadily associated with a poor overall prognosis and remains a major cause of cancer mortality. Radical surgical resection has been established as the best chance these patients have for long-term survival. However, in most cases the disease has reached an incurable state at the time of diagnosis, mainly due to the silent clinical course at its early stages. The role of palliative surgery in locally advanced pancreatic cancer mainly involves patients who are found unresectable during open surgical exploration and consists of combined biliary and duodenal bypass procedures. Chemical splanchnicectomy is another modality that should also be applied intraoperatively with good results. There are no randomized controlled trials evaluating the outcomes of palliative pancreatic resection. Nevertheless, data from retrospective reports suggest that this practice, compared with bypass procedures, may lead to improved survival without increasing perioperative morbidity and mortality. All efforts at developing a more effective treatment for unresectable pancreatic cancer have been directed towards neoadjuvant and targeted therapies. The scenario of downstaging tumors in anticipation of a future oncological surgical resection has been advocated by trials combining gemcitabine with radiation therapy or with the tyrosine kinase inhibitor erlotinib, with promising early results.

Perioperative DNR Orders, Palliative Surgery, and Ethics

Do-not-resuscitate (DNR) orders and implementation vary among institutions. Without clear documentation and communication, DNR orders may be a source of misunderstanding among health care team members. A DNR order must be clearly defined so that patients, family members, and the health care team understand patient wishes if a life-threatening event occurs. A DNR order does not mean that patients are giving up or refusing treatment to make their life more comfortable or improve their quality of life. A DNR order identifies the decision of a patient and care team regarding cardiopulmonary resuscitation during a life-ending event. Often patients who have a DNR order may require palliative surgical intervention; this may present a challenge for nurses caring for a patient. This article discusses the ethical issues and methods of respecting DNR work orders for patients undergoing surgery and the role of palliative surgery in addressing quality of life and care issues.

An Evidence‐Based Approach to the Treatment of Thyroid Lymphoma

Primary thyroid lymphoma is a rare tumor that makes up 1-5% of thyroid malignancies and less than 2% of extranodal lymphomas. The treatment and prognosis of thyroid lymphomas can be divided into two distinct clinicopathologic entities: pure mucosa-associated lymphoid tissue (MALT) lymphomas and diffuse large B-cell or mixed subtypes. An evidence-based review was performed to determine the role of fine-needle aspiration (FNA) biopsy and adjuncts as the first diagnostic test for thyroid lymphoma, the role of open surgical biopsy, the role of palliative surgery as well as the best treatment (combined chemoradiation versus single modality surgery or radiation) for thyroid lymphoma. The ideal treatment of thyroid lymphoma was further assessed for both diffuse B-cell and MALT histologic subtypes. Although an evidence-based review was challenging primarily due to a lack of high-level evidence, several recommendations are possible and presented regarding the optimal diagnostic methods and treatment of thyroid lymphoma. FNA and adjuncts are recommended as the first test to diagnose thyroid lymphoma, but open surgical biopsy may still be required in many cases. Combined chemoradiation therapy is recommended for all diffuse B-cell or mixed lymphomas. Single modality therapy with surgery or radiation alone may be considered for early-stage (IE) intrathyroidal MALT lymphomas. No recommendations could be made regarding the role of palliative surgery. Evidence-based recommendations can be applied to the individual patient with thyroid lymphoma with the involvement of an experienced multidisciplinary team consisting of an endocrine/oncology surgeon, radiation oncologist, and medical oncologist.

Role of palliative surgery in advanced gastric carcinoma

Role of palliative surgery in advanced gastric carcinoma

The role of palliative surgery in hospice care

The role of palliative surgery in hospice care