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Oncology- Palliative Surgery
I. Core Principles of Palliative Surgery
A. Bowel Obstruction
III. Key Terms
I. Core Principles of Palliative Surgery
- Timing is Crucial: The decision to operate is paramount. The adage "Good surgeons know how to operate; better ones when to operate; the best when not to operate" highlights the importance of considering a patient's life expectancy and overall condition. Multidisciplinary team discussions are essential.
- Individualized Approach: The optimal procedure varies widely depending on the patient's specific circumstances and tumor characteristics.
A. Bowel Obstruction
- Causes: Most commonly arises from colon cancer, due to resectable tumors or advanced pelvic masses. Ovarian cancer can also cause obstruction.
- Management:
- Resectable tumors: Surgical resection is ideal.
- Inoperable tumors:
- Colostomy/Ileostomy: Decompresses the bowel.
- Endoscopic stent placement (left-sided tumors): A less invasive option, but carries a 4% perforation and 12% migration risk.
- Ovarian cancer: Debulking surgery (often combined with chemotherapy) may provide good long-term palliation in suitable patients.
- Multiple obstruction sites: Often difficult to manage surgically; internal bypass or proximal stoma may be options, but surgery isn't always feasible.
- Causes: Direct tumor invasion or post-radiotherapy complications (especially with pelvic tumors).
- Types: Rectovaginal, enterovaginal, colovesical, vesicovaginal, enteroenteric, enterocutaneous.
- Management: Preoperative assessment is crucial. If definitive surgery isn't possible, a proximal end stoma is the preferred treatment to minimize distress. Endoscopic covered stents can be used for colovesical fistulae.
- Management:
- Endoscopic Stenting (ERCP): Primary method for periampullary lesions. Percutaneous transhepatic cholangiography (PTC) may be necessary for hilar cholangiocarcinomas, sometimes in conjunction with ERCP. Metallic stents are preferred for survival >3 months.
- Operative Options (Hepatojejunostomy/Choledochojejunostomy): Less common due to endoscopic stenting, but regaining popularity via laparoscopic techniques due to shorter hospital stays and reduced morbidity compared to endoscopic stenting. Segment III biliary enteric bypass for selected inoperable hilar tumors. Requires hepato-pancreato-biliary (HPB) MDT discussion.
- Management: Sodium restriction, diuresis, serial paracentesis are first-line treatments.
- Refractory Cases: Peritoneal drain or a peritoneal-venous shunt (Le Veen or Denver) may provide relief, particularly for ovarian or breast cancer. Less effective for GI malignancies. Assess for loculated ascites and mucinous tumors (risk of rapid shunt occlusion).
- Management: Requires collaboration with palliative care. Surgical options include:
- Debulking: For large, slow-growing tumors in fit patients.
- Fracture Stabilization: Prophylactic pinning for bone metastases affecting >50% of the cortex.
- Neurosurgical Approaches (rare): Cordotomy is rarely used now due to advancements in analgesia.
- Thoracoscopic Splanchnectomy (rare): For intractable pancreatic cancer pain, largely replaced by EUS-guided coeliac plexus blocks.
- Management: Endoscopic and radiological techniques (injection sclerotherapy, laser coagulation, arteriographic embolization) are initial treatments. Surgery is considered only if other methods fail and life expectancy is ≥3 months.
- Partial resection: Appropriate when complete removal of disease is not possible, particularly in ovarian cancer, to improve outcomes with subsequent chemotherapy.
- Breast Cancer: Resection may improve quality of life (QoL) by preventing fungation or uncontrolled axillary metastases, especially in patients with bone metastases (median survival >2 years).
- Gastric Cancer: Considered for outlet obstruction or persistent anemia despite transfusions.
- Colorectal Cancer: May be considered even with inoperable liver metastases to reduce bleeding, perforation, or obstruction risk.
III. Key Terms
- Palliation: Relieving symptoms and improving quality of life without aiming for a cure.
- Debulking: Surgical removal of as much of a tumor as possible.
- ERCP (Endoscopic Retrograde Cholangiopancreatography): Endoscopic procedure to visualize and treat biliary and pancreatic ducts.
- PTC (Percutaneous Transhepatic Cholangiography): A procedure to visualize the biliary system via a needle inserted through the skin and liver.
- MDT (Multidisciplinary Team): A team of specialists (surgeons, oncologists, radiologists, etc.) working together to plan patient care.
- Co-morbidities: The presence of one or more additional diseases or conditions in a patient.
- QoL (Quality of Life): A subjective assessment of a patient’s overall well-being.
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