Palliative General Surgical Procedures

The outcomes of palliative surgical treatment in a context of rising incidence of gastro intestinal cancers in Burkina Faso, Africa

BACKGROUND AND OBJECTIVES

Digestive cancers are frequent and of late diagnosis in Africa. Palliative surgery therefore plays an important role. Our objective is to describe its indications, techniques and results in primary digestive cancers.

METHODS

Retrospective, bicentric, descriptive study of palliative surgery for primary digestive cancer, performed in Ouagadougou over the last twelve years. The results were assessed according to the degree of improvement in the patients' quality of life. We divided the patients into four groups according to the improvement of the quality of life after the operation. The results were considered very satisfactory when the symptoms disappeared completely. They were considered satisfactory when the symptoms decreased in intensity. They were unsatisfactory when the symptoms kept the same intensity. They were considered poor when the symptoms persisted with greater intensity.

RESULTS

Six hundred and thirty-nine palliative digestive cancer surgeries were performed. All patients had clinical symptoms deteriorating their quality of life (56.7%) or even a surgical emergency (43.3%). Biliodigestive diversion, gastroentero-anastomosis and colostomy were the palliative procedures performed respectively in 26.6%, 16.9%, and 34.1%. Complications were noted in 11.7%. These were digestive fistulas in 9 cases, retraction and stomal prolapse in 11 cases. The improvement of the quality of life was very satisfactory in 76%.

CONCLUSIONS

Palliative surgery is widely practiced in digestive cancers. It improves the quality of life. African surgeons should be aware and well-educated to safely perform surgical palliative procedures.

TruView Video Laryngoscope for Lateral Position Intubation in a Patient With Giant Presacral Neurofibroma

BACKGROUND

Most airway management is done in the supine position, but some situations may require airway management in the lateral position. Most emergency physicians and anesthesiologists are not comfortable with intubation in the lateral position.

CASE REPORT

We present a patient with giant presacral neurofibroma and the use of video laryngoscope for airway management in the lateral position. To the best of our knowledge, we are the first to utilize a video laryngoscope for lateral intubation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: An emergency physician is the first contact for many patients when immediate airway management is mandatory. Lateral position for airway management is not popular among anesthesiologists and emergency physicians, but the patient's condition and pathology may demand this approach. Airway management in the lateral position can be considered part of airway management training.

Breast cancer: presentation and intervention in women with gastrointestinal metastasis and carcinomatosis

BACKGROUND

Breast cancer metastatic to the gastrointestinal tract or peritoneum is rare. We reviewed the natural history of ductal and lobular carcinoma in women with breast cancer metastatic to the gastrointestinal tract, peritoneum, or both.

METHODS

We performed a retrospective review of all patients (1985-2000) with a pathologic diagnosis of breast cancer metastatic to the gastrointestinal tract or peritoneum. Patients were categorized into three groups: those with gastrointestinal metastasis, carcinomatosis, or both.

RESULTS

Of 73 patients, 23 (32%) had gastrointestinal metastasis only, 32 (44%) had carcinomatosis only, and 18 (25%) had both. The median age at initial breast cancer diagnosis was 55 years. The mean interval between the primary diagnosis and metastatic presentation was 7 years. Sites of gastrointestinal metastases included the esophagus (8%), stomach (28%), small intestine (19%), and colon and rectum (45%). Infiltrating lobular carcinoma represented 34 (64%) of the 53 gastrointestinal metastases. The median overall survival after diagnosis was 28 months. Palliative surgical intervention in 47 patients (64%) did not affect overall survival. Some survival benefit may have accrued to select patients with gastrointestinal metastasis who underwent surgical palliation (44 vs. 9 months). Advanced age at diagnosis and gastric metastases had a negative effect on survival, whereas treatment with systemic chemotherapy or tamoxifen had a positive effect on survival.

CONCLUSIONS

Gastrointestinal metastasis occurred more often in patients with invasive lobular carcinoma. Surgical intervention did not significantly extend overall survival but may be considered in a select group of patients.

Ethics of palliative surgery in patients with cancer

BACKGROUND

Surgery is an important palliative method for patients with advanced malignant disease. In addition to concerns related to clinical decision making, various moral challenges are encountered in palliative surgery. Some of these relate to the patients and their illness, others to the surgeons, their attitudes, skills and knowledge base.

METHOD AND RESULTS

Pertinent moral challenges are addressed and analysed with respect to prevailing perspectives in normative ethics. The vulnerability of patients with non-curable cancer calls for moral awareness. Demands regarding sensibility and precaution in this clinical setting represent substantial challenges with regard to the 'duty to help', benevolence, respect of autonomy and proper patient information. Moreover, variations in definition of palliative surgery as well as limited scientific evidence with respect to efficacy, effectiveness and efficiency pose methodological and moral problems. Therefore, a definition of palliative surgery that addresses these issues is provided.

CONCLUSION

Both surgical skill and much moral sensibility are required to improve palliative care in surgical oncology. This should be taken into account not only in clinical practice but also in education and research.

Surgical palliative care

Surgery has always played a pivotal role in care of the patient with cancer, independent of treatment intent. Recent advances have expanded that role, not only in terms of modalities available, but more broadly in terms of the expectations of the surgeon as physician involved in the interdisciplinary care of the patient with symptomatic, incurable disease.

Decompressive Tube Esophagostomy: A Forgotten Palliative Procedure?

Many patients with complete, irreversible upper gastrointestinal (GI) tract obstruction will require decompression for relief of intractable nausea and vomiting. Nasogastric (NG) tubes are associated with patient discomfort and risk. Gastrostomy tubes may not be technically feasible in a small subset of patients with advanced upper GI tract malignancy. Decompressive tube esophagostomy is an underutilized, minimally invasive alternative in such patients. We present a case report, a description of the procedure, and a review of the literature for this palliative procedure.

A prospective evaluation of palliative outcomes for surgery of advanced malignancies

BACKGROUND

We prospectively evaluated the effectiveness of major surgery in treating symptoms of advanced malignancies.

METHODS

Fifty-nine patients were evaluated for major symptoms of intent to treat and were followed up until death or last clinical evaluation. Surgeons identified planned operations before surgery as either curative or palliative and estimated patient survival time. An independent observer assessed symptom relief. A palliative surgery outcome score was determined for each symptomatic patient.

RESULTS

Surgeons identified 22 operations (37%) as palliative intent and 37 (63%) as curative intent. The median overall survival time was 14.9 months and did not differ between curative and palliative operations. Surgical morbidity was high but did not differ between palliative (41%) and curative (44%) operations. Thirty-three patients (56%) were symptomatic before surgery, and major symptom resolution was achieved after surgery in 26 (79%) of 33. Good to excellent palliation, defined as a palliative surgery outcome score >70, was achieved in 64% of symptomatic patients.

CONCLUSIONS

Most symptomatic patients with advanced malignancies undergoing major operations attained good to excellent symptom relief. Outcome measurements other than survival are feasible and can better define the role of surgery in multimodality palliative care. A new outcome measure to evaluate major palliative operations is proposed.

Surgical palliation in advanced disease: recent developments

Despite many valuable technical innovations for the relief of suffering in advanced disease over the past few years, only recently have surgical oncologists attempted to more clearly define palliation. Previous definitions have been misleading, creating confusion about the merits of surgery in many situations and difficulty in posing questions for future prospective clinical trials. This report outlines recent progress in identifying and refining a philosophy of palliative surgery that would align it with the consensus of nonsurgical opinion summarized by the 1990 World Health Organization definition of palliative care and the emerging consensus among the medical specialties in the United States concerning principles of care at the end of life. Selected controversies and recent innovations, as well as guidelines for palliative surgery, are discussed.