14.4 (12.4) The role of general surgery in the palliative care of patients with cancer

Question 1

List 3 common medical indications for surgery in a cancer patient to improve QOL

Answer 1

Pain

Obstructions (bowel, biliary)

Wound/fistula management

Bleeding or other local complications of tumors

Malignant ascites

FS: similar to rads - WP BOS

Question 2

List 5 complications a patient may experience if undergoing palliative surgery

Answer 2

Pain related to procedure

Wound complications - seroma, infection, lymphatic leak, non healing wound

Death

Complications unrelated to the surgical site (e.g. pneumonia, DVT, ileus, and heart failure)

Longer admission to hospital

Disfigurement /lifestyle change

Question 3

What two types of tumor are most commonly associated with MBO

Answer 3

Ovarian and colorectal cancer

Question 4

List two indications for surgery in MBO

Answer 4

(1) Persistent obstructions in the face of conservative therapy (NG, IVF and bowel rest)

(2) Complete MBO

Question 5

List three etiologies of MBO

Answer 5

MBO may be related to:

1) tumour
2) complication of tumor treatment (e.g. radiation enteritis)
3) benign aetiologies (e.g. adhesions or internal hernia)

Question 6

List 4 procedural interventions for MBO

Answer 6

Adhesiolysis (lysis of adhesions)

Bowel resection *
Bowel bypass *

Cytoreductive procedures (resection of intraperitoneal tumour)

Bowel stenting * (endoscopy)

Venting gastrostomy tube*

Question 7

List 3 medical issues (beside poor condition) which may become contraindications for bowel resection surgery

Answer 7

Ascites*
Peritoneal carcinomatosis*
Palpable intra-abdominal masses
Multiple bowel obstructions*

Question 8

Where can stents be put?

List three risks for stent placement for MBO

Answer 8

Gastric outlet, duodenal, jejunal, colorectal areas

perforation (0–15%), stent migration (0–40%), re-occlusion (0–33%)

Question 9

List two findings to suggest GOO (gastric outlet obstruction) that may need surgical intervention

Answer 9

1. Persistent nausea/vomiting, eructation (belching), and early satiety
2. Evidence of duodenal compression on radiographic or endoscopic evaluations

Question 10

List four possible procedural/surgical interventions for GOO

What is the preferred procedure?

Answer 10

stent (very successful, preferable procedure)

gastrojejunostomy (bypass)

resection

percutaneous venting gastrostomy

Question 11

Are most wounds in setting of advance cancer surgical?

What are the 3 main types of surgical intervention for wounds?

What is the best management for wounds?

Answer 11

Not surgical

(1) Incision and drainage
(2) Debridement
(3) Reconstruction (e.g. skin grafts, free flaps)
(FS: RID)

Best management for wounds is good wound care/prevention

Question 12

What is the evidence for fistula management?

What to do for rectovaginal and colovesicular fistula?

Answer 12

Little evidence specific to EOL patient, non-surgical techniques are optimal (e.g. stoma bags, drains, wound care)

Diverting colostomy

Question 13

Biliary obstruction occurs most commonly due to malignant obstruction of what anatomical structure?

What are three major interventions for biliary obstruction?

What is whipple surgery?

Answer 13

Tumours causing obstruction of the extrahepatic bile duct may also occur all along the biliary tree, most likely at the ampulla of Vatar

(1) Stenting via ERCP (GI)
(2) PTC (percutaneous transhepatic cholangiography) drain (IR)
(3) Whipple (pancreaticoduodenectomy), cholecystojejunostomy, choledochojejunostomy, or choledochoduodenostomy (Surgery)

Whipple = remove head of the pancreas, duodenum, gallbladder and the bile duct.

Question 14

Surgical intervention for GI bleeding is infrequently required - most often involves?

Answer 14

Bowel resection

Question 15

When is a surgical intervention for malignant ascites considered? Name 2 reasons

Answer 15

• if diuretics no longer are helping
• percutaneous aspirations are becoming painful and frequent

Question 16

List three surgical options for chronic malignant ascites

Answer 16

• insertion of permanent intraperitoneal drainage catheter
• peritoneovenous shunt (Leveen, Dever) - diverting ascites from peritoneal cavity into venous circulation (rarely performed due to catastrophic complications)
• Hyperthermic intraperitoneal chemotherapy (HIPEC) with or without debulking - high morbidity procedure

Question 17

List three complications of a permanent intraperitoneal catheter

Answer 17

Leakage, blockage, infection

Question 18

In management of splenomegally, when to choose surgical splenectomy vs splenic XRT?

(Not in 6th edition)

Answer 18

Depends on anticipated survival and the estimated operative risks.

• If survival at least 3–6 months, an operation is usually the best alternative as the recurrence rate related to radiation for haematological disorders is quite high
• If survival is <3 months, it is reasonable to attempt radiation therapy.

Question 19

List 1 surgical intervention for hormonally active hepatic neuroendocrine tumors

(Not in 6th edition)

Answer 19

Surgical debulking

radiofrequency ablation

liver or multivisceral transplantation

Question 20

Patients, families, and care teams must understand what two elements of palliative surgery before surgery takes place?

Answer 20

Benefits (QOL, symptom control, symptom prevention)

Risks

Question 21

List three indicators for poor intraoperative risk in cancer patient

Answer 21

current nutritional functional status (e.g. Karnofsky < 50%)

co-morbidities (e.g. cardiac and pulmonary function)

amount and location of metastatic disease