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ROLE OF ONCOLOGICAL SURGERY IN PALLIATIVE THERAPY D. KHALED HILAL ALKHALEDI KCCC

ROLE OF ONCOLOGICAL SURGERY IN PALLIATIVE THERAPY D. KHALED HILAL ALKHALEDI KCCC. The WHO defines palliative care as the active total care of patients whose disease is not responsive to curative treatment

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ROLE OF ONCOLOGICAL SURGERY IN PALLIATIVE THERAPY D. KHALED HILAL ALKHALEDI KCCC

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  1. ROLE OF ONCOLOGICAL SURGERY IN PALLIATIVE THERAPYD. KHALED HILAL ALKHALEDIKCCC

  2. The WHO defines palliative care as the active total care of patients whose disease is not responsive to curative treatment This includes the control of pain and other distressing symptoms and of psychological, social and spiritual problems

  3. Surgery has its roots in palliation of both symptoms and disease and, until the 20th century, the vast majority of medical and surgical procedures were palliative in nature Procedures for palliation of symptoms of bowel obstruction, control of bleeding, for drainage of abscesses and for removal of tumors were common

  4. Pain Pain is common in patients withcancer, occurring in upto 75% of patients and effective painmanagement iscrucial.

  5. Bowel obstruction • Malignant bowel obstruction most frequently seen inbowel and pelvic carcinoma, occurs in 3–15% of advancedcancers • It can occur anywhere in thegastrointestinaltract. • CAUSES: • the cancer itself • Druginduced (e.g. opioids, antimuscarinics) related to constipation • previous treatment (e.g. surgery, radiation)

  6. Obstruction can cause considerable distress to the patient and is often accompanied by nausea, vomiting and abdominal pain and distension

  7. Surgery for obstruction is often indicated where a procedure is technically feasible, it carries clear benefits and the patient is sufficiently fit, • but is often not possible, • especially in cases of diffuse intra-abdominal disease, rapidly • recurring ascites, or where there has been previous radiotherapy or extensive surgery.

  8. 40–70% of patients will have relief of their obstruction following surgery, although perioperative mortality can be high Medical or conservative management of bowel obstruction includes the use of a nasogastric tube and intravenous fluid Gut motility can be improved using a prokineticdrugs such as metoclopramide, possibly with dexamethasone to reduce bowel edema

  9. Pancreatic cancer Patients with unresectable or recurrent pancreatic cancer frequently require palliative treatment for biliary obstruction, gastric outlet obstruction and pain Historically, palliation for these patients was undertaken at laparotomy after a tumor was deemed unresectable Operative biliary bypass, gastric bypass, and splanchnicectomy are effective methods of palliation

  10. with current improved diagnostic techniques, unresectability should be determined before laparotomy. Biliary diversion can then be achieved either endoscopically or percutaneously. Gastric outlet obstruction occurs in only 10% to 15% of patients and is often a preterminal event, and so does not mandate surgical correction

  11. CT-guided alcohol splanchnicectomy is an effective option for the palliation of pain in the occasional patient unresponsive to narcotics

  12. Therefore, the surgeon can avoid laparotomy in most patients who have a limited life expectancy

  13. Anorexia and cachexia Management is complex and multidisciplinary While artificial nutrition, for example via enteral tube feeding is possible, it is not always beneficial or appropriate in patients with advanced cancer, the enteral route is preferred over the parenteral route. Enteral feeding is simple, physiologic, inexpensive and well tolerated by most patients. Enteral feeding maintains the GI tract cytoarchitecture and mucosal integrity ,absorptive function, and normal microbial flora. This results in less bacterial translocation and endotoxin release from the intestinal lumen into the bloodstream

  14. Enteral feedings indicated for patients who have a functional GI tract but are unable to sustain an adequate oral diet Enteral feedings may be contraindicated in patients with an intestinal obstruction, ileus, GI bleeding, severe diarrhea, vomiting, enterocolitis, or a high-output enterocutaneousfistula Choice of appropriate feeding site, administration technique, formula, and equipment may circumvent these problems.

  15. Feeding tubes Nasogastric, nasojejunal tube (e.g., Dobhoff), gastrostomy and jejunostomyare available for the administration of enteral feeds Percutaneous gastrostomy tubes can be placed endoscopically or under fluoroscopy.

  16. Risk • PEG tube malfunction • Aspiration—accidental sucking into the airways of fluid, food, or any foreign material • Damage to other organs • Inflammation of the lining of the abdomen • Infection • Bloating • Nausea • Diarrhea • Irritation of skin near the tube • Death • Factors that may increase the risk of complications include: • Obesity or diabetes • Smoking • Alcohol abuse • Prior abdominal surgeries • Advanced age

  17. Palliative care need not to be synonymouswith end-of-life care Major componentsof the palliative care approach are symptom controland psychological support, both of which are applicablein most clinical situations

  18. Suffering has four components: physical, psychological, social and spiritual. When defined this way, palliative care isapplicable across the spectrum of cancer care and not merely at the end of life

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