General Surgery and Palliative Care

Question 1

Goals of palliative surgery

Answer 1

• QOL
• physical symptoms
• social symptoms
• maintenance of hope
• ability to eat and drink normally
• survival, morbidity secondary outcomes

Question 2

When would pre-emptive palliative surgery be considered?

Answer 2

• biliary obstruction with bypass
• gastric bypass may be considered to alleviate possible risk of GOO

Question 3

List possible morbidities/complications of surgery for palliation

Answer 3

• pna
• dvt
• ileus
• chf
• pain
• wound complications
• infection
• seroma
• QOL impacts (ie stoma)

Question 4

Maligant bowel obstruction : indications for and goals of surgical intervention

Answer 4

• indications
  
  • persistent obstruction despite conservative tx
  • evidence of complete obstruction
  • patient is not actively dying
• goals
  
  • relief of n/vx
  • imrpoved po intake
  • pain relief
  • patient able to return to preferred setting

Question 5

List surgical options for MBO

Answer 5

• adhesiolysis
• bowel resection
• bypass
• venting peg

Question 6

Contraindications for surgery for MBO

Answer 6

• Ascites > 3L
• recurrent rapid ascites
• carcinomatosis
• mutiple obstructions
• palpale intra abdo mass
• poor PPS

Question 7

Gastric Outlet Obstruction : treatment options

Answer 7

• Indications:
  
  • symptoms
  • evidence of duodenal obstruction on imaging

Treatment Options”

• Stent
  
  • 90% success, rare complications
  • can re-stent
• Gastric bypass (gastrojejunosty)
  
  • if stenting fails
• Resection (antrectomy, pancreaticoduodenectomy
• Percutaneous gastrostomy (PEG)

Question 8

Surgical wound care

Answer 8

• prevention best
• debridement
• Incision and drainage
• goal is pain control / odour control

Question 9

Surgical care for fistulas

Answer 9

• poor treatment options surgically
• rarely cured
• non surgical options preferred (stoma bags, drains, wound care)

Question 10

Biliary obstruction : surgical options

Answer 10

• obstruction of extra hepatic bile duct at ampulla of Vater
• hyperbilirubinemia

Treatment

1. ERCP
   * preferred, but higher risk of recurrence
2. Transhepatic percutaneous drain
   * if surgery not realistic
3. Surgical bypass

• cholecystojejunostomy, Whipples, choledochojejunostomy
• if unstentable
• longer prognosis
• morbidity 20%

Question 11

Surgical interventions for tumours

Answer 11

• resection
• usually only considered after conservative approaches fail to control sx (radiation, ambolization, endoscopy, etc)

Question 12

Surgery and Ascites

Answer 12

1. Intraperitoneal drainage catheters
2. Peritovenous shunt

• ascites drained into venous circulation
• significant complications (DIC, CHF, PE, sepsis)

3. Debulking and intraperitoneal chemo

• HIPEC
• carcinomatosis

Question 13

Splenomegaly

Answer 13

• early satiety, hydronephrosis, traumatic risk to spleen
• Splenectomy indications:
  
  • trauma
  • symptomatic splenomegaly if prognosis > 6 months

Question 14

Surgical management of hormally active tumours

Answer 14

• insulinoma, GIST, gastrinoma, VIPoma
• goal to limit endocrine symptoms or medications patient needs
• Radiofrequency ablation
• Debulking