Palliative Surgical Procedures

Palliative Surgery - Comfort & Care

• Goal: Alleviate symptoms, improve Quality of Life (QoL), not curative. Manages complications of advanced cancer.
• Focus: Symptom control (pain, obstruction, bleeding, fungation).
• Indications:
  • Unresectable tumors causing severe symptoms.
  • Metastatic disease with localized problems.
  • Impending complications (e.g., pathological fracture).
• Key Considerations:
  • Patient's overall condition & life expectancy (typically > 2-3 months).
  • Patient wishes & realistic goals.
  • Minimally invasive options preferred when possible.
• Common Procedures:
  • GI Obstruction: Stenting, bypass, diverting stoma.
  • Bleeding: Ligation, embolization, palliative resection.
  • Pain: Debulking, neurolysis.
  • Fungating Wounds: Toilet mastectomy, debridement.
  • Pathological Fractures: Internal fixation.

⭐ Palliative surgery aims to improve the patient's remaining life, focusing on symptom relief even when cure is not possible. The "benefit vs. burden" ratio is crucial.

Symptom Management - Surgical Toolkit

• Pain Management:
  • Neuroablative: Celiac plexus block (pancreatic ca), cordotomy (unilateral pain).
  • Debulking: For nerve compression.
  • Bone Stabilization: Vertebroplasty/Kyphoplasty (vertebral mets); prophylactic fixation.
• Obstruction Relief:
  • Gastrointestinal (GI):
    • Stenting: Self-expanding metallic stents (SEMS) (esophageal, gastroduodenal, colonic).
    • Bypass: Gastrojejunostomy (GOO), enteroenterostomy (SBO).
    • Stoma: Colostomy/ileostomy (distal obstruction).
    • Tubes: Percutaneous Endoscopic Gastrostomy (PEG)/Jejunostomy (venting/feeding).
  • Biliary Tract:
    • Stenting: ERCP/PTC (plastic/metallic) for jaundice.
    • Drainage: Percutaneous Transhepatic Biliary Drainage (PTBD) (external/internal-external).
    • Bypass: Choledochojejunostomy (if stenting fails).
  • Genitourinary (GU):
    • Stenting: JJ stent (ureteric).
    • Drainage: Percutaneous nephrostomy (PCN) (supravesical obstruction).
• Bleeding Control:
  • Endoscopic: Argon plasma coagulation (APC), clips, injection (GI bleed).
  • Angioembolization: For visceral/tumor bleed.
  • Surgical: Palliative resection/ligation.
• Fungating Wounds:
  • Debridement: Necrotic tissue, odor, infection control.
  • Palliative excision: Localized, distressing lesions (e.g., toilet mastectomy).
• Pathological Fractures:
  • Internal Fixation: ORIF (plates, nails).
  • Joint Replacement: Hemiarthroplasty (e.g., hip).
  • Cementoplasty: Polymethylmethacrylate (PMMA) injection.
• Malignant Effusions/Ascites:
  • Drainage: Paracentesis, thoracentesis.
  • Indwelling Catheters: PleurX, Aspira (self-drainage).
  • Pleurodesis: Talc/doxycycline (pleural).
  • Pericardial Window: For recurrent pericardial effusion.

⭐ For malignant gastric outlet obstruction, endoscopic stenting offers faster relief and shorter hospital stay vs. surgical gastrojejunostomy in palliative settings.

Special Cases & Support - Holistic View

• Malignant Bowel Obstruction (MBO):
  • Surgical: Stenting, bypass, colostomy/ileostomy, venting gastrostomy.
  • Medical: Octreotide, antiemetics, analgesics.
• Pathological Fractures:
  • Prophylactic fixation if Mirels' score >8.
  • Surgical options: Internal fixation, arthroplasty, cementoplasty.
• Spinal Cord Compression:
  • Emergency: High-dose steroids (e.g., Dexamethasone 16mg IV), urgent radiotherapy, surgical decompression.
• Bleeding/Fungating Tumors:
  • Control bleeding: Radiotherapy, embolization, topical agents, surgical ligation/debulking.
• Malignant Effusions (Pleural, Ascites):
  • Drainage (thoracentesis, paracentesis), pleurodesis, indwelling catheters, shunts.
• Holistic Care:
  • Multidisciplinary Team (MDT) essential: Surgeons, oncologists, palliative care specialists.
  • Comprehensive symptom control: Pain (WHO ladder), nausea, dyspnea.
  • Nutritional, psychosocial, spiritual support.
  • Advance care planning.

⭐ Mirels' scoring system (assessing site, pain, lesion type, size) predicts pathological fracture risk; a score >8 often indicates need for prophylactic fixation.

High‑Yield Points - ⚡ Biggest Takeaways

• Palliative surgery aims for symptom relief (e.g., pain, obstruction) and QoL improvement, not cure.
• Patient selection is critical: assess performance status, life expectancy, and patient wishes.
• Common interventions: Symptomatic debulking, bypass procedures, stenting, pleurodesis, fracture fixation.
• Prefer minimally invasive surgery (MIS) to reduce morbidity and shorten recovery.
• A multidisciplinary team (MDT) approach is essential for comprehensive care.
• Ethical considerations and shared decision-making are paramount.
• Early palliative interventions can significantly improve patient comfort and function.