Palliation and General Surgery Flashcards
1
Q
Goals of surgery in palliative care surgery
A
- QOL, with survival, morbidity, and physiologic response as secondary outcomes
- For most patients, studies show the primary decision-making factor is the physical impact of uncontrolled symptoms, followed by social impact of symptoms and maintenance of hope.
- Ability to eat and drink normally and physician’s recommendations are also key
2
Q
Pre-emptive surgical palliation
A
- Surgery may be indicated for prevention of symptoms in the palliative settings
- E.g. biliary obstruction with surgical bypass, gastric bypass may also be considered to alleviate risk of GOO prior to death
3
Q
Surgical morbidity
A
- Pneumonia
- DVT
- Ileus
- CHF
- Pain
- Wound complications
- Seromas
- Infections
- Impaired healing (especially in the setting of cancer)
- Immediate QOL impacts (e.g. with stoma)
4
Q
Malignant bowel obstruction (definition)
A
- Clinical evidence of bowel obstruction via history, physical exam, radiographic examination
- Bowel obstruction beyond the ligament of Treitz
- Intra abdominal primary cancer with incurable disease
- Non-intra abdominal primary cancer with clear intraperitoneal disease
5
Q
Indications and Goals for surgical intervention for MBO
A
Indications:
- Persistent obstruction despite conservative tx (NG decompression, hydration, bowel rest) OR Evidence of complete obstruction
- Patient is not actively dying
Goals
- Relief of N/V
- Improved PO intake
- Alleviating pain
- Patient able to return to preferred setting
Outcomes in real life are variable, but may improve survival
6
Q
Surgical options for MBO
A
- Approach typically unknown until patient is in the OR and the abdomen can be explored
- Generally, quickest, safest, and most efficacious
May include: - Adhesiolysis
- Bowel resection
- Bypass
- Venting gastrostomy tube (especially in cases of carcinomatosis)
7
Q
Contraindications for MBO
A
Relative Contrandications:
- Ascites > 3L
- Rapidly re accumulating ascites after drainage
- Carcinomatosis
- Multiple obstructions
- Palpable intra abdo mass
- Poor PS (bad prognostic marker but not a contraindication per se)
8
Q
Endoscopic approaches for MBO (Indications, approaches)
A
Indications
- Poor operative candidates
- Patients who decline operative procedure
Techniques
- PEG tube placement (‘venting’)
- Stenting
9
Q
Gastric outlet obstruction - presentation, indications for surgery
A
Presentation
- Nausea
- Vomiting
- Burping
- Early satiety
- Evidence of duodenal obstruction on radiographic/endoscopic eval
Indications for surgery
- Symptomatic (though typically poorer outcome if vomiting)
- Evidence of duodenal compression by imaging
10
Q
Surgical options for GOO
A
- Stent
- Typically 90% success rate, rare complications
- Most commonly used
- If stent fails, another can be placed
- Limitation is clinicians with training to do this procedure - Gastric bypass (gastrojejunostomy)
- May be done concurrently with biliary bypass (preemptive), especially if patient has good PS
- Typically indicated if stenting fails or is unavailable - Resection (Antrectomy or pancreaticoduodenectomy)
- Percutaneous gastrostomy
- For patients with advanced malignancy
11
Q
Surgical Wound Care
A
- Most wounds are best prevented rather than treated (e.g. early excision of nodal or soft tissue mets to avoid complications)
Debridement/incision and drainage
- Some wounds (e.g. related to radiation or in very malnourished patients) may not heal, and goal is for control of pain/odour rather than mess
12
Q
Surgical care for fistulas
A
- In general, treatment options do not differ from the general population
- Controlling rather than curing may be important
- Non surgical options typically preferred
- E.g. stoma bags, drains, or active wound care for cutaneous fistula
Internal fistula
- Typically requires assessment of the anatomy of the communication to determine if surgical intervention will be beneficial
13
Q
Biliary obstruction: Presentation and surgical options
A
Presentation
- Hyperbilirubinemia (pruritis, bleeding diathesis, liver failure)
- Typically due to obstruction of the extra hepatic bile duct at the ampulla of Vatar
Options
- ERCP stenting
- Generally preferred, as similar success rates to surgery but with less morbidity
- Higher risk of recurrence (may consider surgical bypass for patients with longer prognosis)
- Metal stents may have improved patency compared to plastic - Transhepatic/percutaneous drain
- Can be used if there is imminient risk of cholangitis and urgent surgery is not realistic - Surgical bypass (cholecystojejunostomy, Whipple’s, choledochojejunostomy, choldedochoduodenostomy)
- If unstentable by ERCP or patient has a longer life span
- If patient is found to be incurable at the time of surgical exploration
- Morbidity of 20%
14
Q
Surgical interventions for tumours
A
- May be appropriate for surgical intervention if resection is possible (e.g. colon tumours)
- Typically only considered after more conservative approaches (e.g. radiation, arterial embolization, endoscopic/bronchoscopic techniques)
15
Q
Surgical interventions for ascites
A
- Intraperitoneal drainage catheters
- Serial drainage of fluid
- Higher risk of infection and obstruction (17%)
- Generally successful
- Low morbidity and mortality - Peritonovenous shunt
- Ascitic fluid drained from peritoneal cacity into the venous circulation
- Significant complications (DIC, CHF, PE, Sepsis) and not commonly performed - Debulking and intraperitoneal chemo in patients with carcinomatosis
- Can improve survival and dramatically improve symptoms
- May be intraperitoneal chemo only without Debulking
