A 53-year-old woman comes to the emergency department because of weakness and abdominal pain for 24 hours. She has had three bowel movements with dark stool during this period. She has not had vomiting and has never had such episodes in the past. She underwent a tubal ligation 15 years ago. She has chronic lower extremity lymphedema, osteoarthritis, and type 2 diabetes mellitus. Her father died of colon cancer at the age of 72 years. Current medications include metformin, naproxen, and calcium with vitamin D3. She had a screening colonoscopy at 50 years of age which was normal. She appears pale and diaphoretic. Her temperature is 36°C (96.8°F), pulse is 110/min, respirations are 20/min, and blood pressure is 90/50 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 98%. The abdomen is soft and nondistended with mild epigastric tenderness. Rectal exam shows tarry stool. Two large bore IV lines are placed and fluid resuscitation with normal saline is initiated. Which of the following is the most appropriate next step in management?

CT scan of the abdomen with contrast

A 19-year-old woman is diagnosed with metastatic Ewing sarcoma. She has undergone multiple treatments without improvement. She decides to stop treatment and pursue only palliative care. She is of sound mind and has weighed the benefits and risks of this decision. The patient’s mother objects and insists that treatments be continued. What should be done?

Halt treatments and begin palliative care.

Try to seek additional experimental treatments that are promising.

Follow the wishes of the patient’s mother as she has decision making power for the patient.

Continue treatments until the patient has a psychiatric evaluation.

Continue treatment because otherwise, the patient will die.

One week after admission to the hospital for an extensive left middle cerebral artery stroke, a 91-year-old woman is unable to communicate, walk, or safely swallow food. She has been without nutrition for the duration of her hospitalization. The patient's sister requests placement of a percutaneous endoscopic gastrostomy tube for nutrition. The patient's husband declines the intervention. There is no living will. Which of the following is the most appropriate course of action by the physician?

Initiate total parenteral nutrition

Consult the hospital ethics committee

Transfer to a physician specialized in hospice care

A previously healthy 37-year-old man comes to the physician for the evaluation of an 8-week history of intermittent burning epigastric pain. During this period, he has also felt bloated and uncomfortable after meals. He has not had weight loss or a change in bowel habits. He has no personal or family history of serious illness. He takes no medications. He does not smoke. He drinks 1–3 beers per week. Vital signs are within normal limits. Abdominal examination shows mild epigastric tenderness on palpation without guarding or rebound tenderness. Bowel sounds are normal. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in management?

Helicobacter pylori eradication therapy

Upper gastrointestinal endoscopy

A 68-year-old man comes to the emergency department because of sudden onset abdominal pain for 6 hours. On a 10-point scale, he rates the pain as a 8 to 9. The abdominal pain is worst in the right upper quadrant. He has atrial fibrillation and hyperlipidemia. His temperature is 38.7° C (101.7°F), pulse is 110/min, and blood pressure is 146/86 mm Hg. The patient appears acutely ill. Physical examination shows a distended abdomen and tenderness to palpation in all quadrants with guarding, but no rebound. Murphy's sign is positive. Right upper quadrant ultrasound shows thickening of the gallbladder wall, sludging in the gallbladder, and pericolic fat stranding. He is admitted for acute cholecystitis and grants permission for cholecystectomy. His wife is his healthcare power of attorney (POA), but she is out of town on a business trip. He is accompanied today by his brother. After induction and anesthesia, the surgeon removes the gallbladder but also finds a portion of the small intestine is necrotic due to a large thromboembolism occluding a branch of the superior mesenteric artery. The treatment is additional surgery with small bowel resection and thromboendarterectomy. Which of the following is the most appropriate next step in management?

Proceed with additional surgery without obtaining consent

Decrease the patient's sedation until he is able to give consent

Contact the patient's healthcare POA to consent

Ask the patient's brother in the waiting room to consent

Close the patient and obtain re-consent for a second operation

A 66-year-old man comes to the physician because of yellowish discoloration of his eyes and skin, abdominal discomfort, and generalized fatigue for the past 2 weeks. He has had dark urine and pale stools during this period. He has had a 10-kg (22-lb) weight loss since his last visit 6 months ago. He has hypertension. He has smoked one pack of cigarettes daily for 34 years. He drinks three to four beers over the weekends. His only medication is amlodipine. His temperature is 37.3°C (99.1°F), pulse is 89/min, respirations are 14/min, and blood pressure is 114/74 mm Hg. Examination shows jaundice of the sclera and skin and excoriation marks on his trunk and extremities. The lungs are clear to auscultation. The abdomen is soft and nontender. The remainder of the examination shows no abnormalities. Laboratory studies show: Hemoglobin 12 g/dL Leukocyte count 5,000/mm3 Platelet count 400,000/mm3 Serum Urea nitrogen 28 mg/dL Creatinine 1.2 mg/dL Bilirubin Total 7.0 mg/dL Direct 5.5 mg/dL Alkaline phosphatase 615 U/L Aspartate aminotransferase (AST, GOT) 170 U/L Alanine aminotransferase (ALT, GPT) 310 U/L γ-Glutamyltransferase (GGT) 592 U/L (N = 5–50 U/L) An ultrasound shows extrahepatic biliary dilation. A CT scan of the abdomen shows a 2.5-cm (1-in) mass in the head of the pancreas with no abdominal lymphadenopathy. The patient undergoes biliary stenting. Which of the following is the most appropriate next step in the management of this patient?

Gemcitabine and 5-fluorouracil therapy

A 63-year-old female with known breast cancer presents with progressive motor weakness in bilateral lower extremities and difficulty ambulating. Physical exam shows 4 of 5 motor strength in her legs and hyper-reflexia in her patellar tendons. Neurologic examination 2 weeks prior was normal. Imaging studies, including an MRI, show significant spinal cord compression by the metastatic lesion and complete erosion of the T12 vertebrae. She has no metastatic disease to the visceral organs and her oncologist reports her life expectancy to be greater than one year. What is the most appropriate treatment?

Surgical decompression and postoperative radiotherapy

Palliative pain management consultation

High-dose corticosteroids and clinical observation

Fourteen days after a laparoscopic cholecystectomy for cholelithiasis, a 45-year-old woman comes to the emergency department because of persistent episodic epigastric pain for 3 days. The pain radiates to her back, occurs randomly throughout the day, and is associated with nausea and vomiting. Each episode lasts 30 minutes to one hour. Antacids do not improve her symptoms. She has hypertension and fibromyalgia. She has smoked 1–2 packs of cigarettes daily for the past 10 years and drinks 4 cans of beer every week. She takes lisinopril and pregabalin. She appears uncomfortable. Her temperature is 37°C (98.6° F), pulse is 84/min, respirations are 14/min, and blood pressure is 127/85 mm Hg. Abdominal examination shows tenderness to palpation in the upper quadrants without rebound or guarding. Bowel sounds are normal. The incisions are clean, dry, and intact. Serum studies show: AST 80 U/L ALT 95 U/L Alkaline phosphatase 213 U/L Bilirubin, total 1.3 mg/dL Direct 0.7 mg/dL Amylase 52 U/L Abdominal ultrasonography shows dilation of the common bile duct and no gallstones. Which of the following is the most appropriate next step in management?

Endoscopic retrograde cholangiopancreatography

Counseling on alcohol cessation

Reassurance and follow-up in 4 weeks

Palliative surgical procedures for USMLE Step 2 CK: High-Yield Surgery Lessons

🕊️ Core Concept - Beyond the Cure

Palliative surgery aims to alleviate symptoms and improve Quality of Life (QoL) in patients with incurable, advanced cancer. It is not intended to be curative.

Key Prerequisite: Patient's expected survival should significantly exceed the surgical recovery period (e.g., > 2-3 months).
Decision Framework:

Common Indications & Procedures:
- Obstruction: GI/biliary stenting, bypass (e.g., gastrojejunostomy), diverting colostomy.
- Bleeding: Resection, ligation, embolization.
- Pain: Debulking of a painful mass, neurolysis.
- Pathologic Fracture: Prophylactic fixation.

⭐ The primary endpoint for success in palliative surgery is symptom control and improved QoL, not overall survival.

📖 Management - The Palliative Playbook

Palliative surgery aims to relieve symptoms and improve Quality of Life (QoL) in incurable disease, not to cure. The core principle is balancing surgical morbidity against expected survival and potential benefit.

Common Indications & Procedures:

Obstruction:
- GI: Bypass (gastrojejunostomy), diverting stoma (colostomy), or endoscopic stenting.
- Biliary: Stenting via ERCP/PTC or surgical bypass (choledochojejunostomy).
- Urinary: Percutaneous nephrostomy tubes or ureteral stents.
Bleeding: Resection, angiographic embolization, or direct ligation of a bleeding tumor.
Pain: Debulking of a painful mass, stabilization of pathologic fractures (internal fixation).
Fistula/Perforation: Surgical diversion or repair.

⭐ High-Yield: Patient selection is paramount. A good candidate typically has an expected survival > 2-3 months and a reasonable performance status (e.g., ECOG ≤ 2).

Decision-Making Flow:

Bowel Obstruction due to Cancer

🎯 Clinical Manifestations - Symptom Relief Targets

Obstruction: Most common indication for palliative surgery.
- GI Tract: Malignant bowel obstruction (MBO), gastric outlet obstruction (GOO), esophageal dysphagia.
  - Procedures: Endoscopic stenting, surgical bypass (e.g., gastrojejunostomy), diverting stoma (colostomy/ileostomy), palliative resection/debulking.
- Biliary Tree: Obstructive jaundice, pruritus, cholangitis.
  - Procedures: ERCP with stenting, percutaneous transhepatic cholangiography (PTC) with drainage.
- Urinary Tract: Ureteral obstruction causing hydronephrosis, renal failure.
  - Procedures: Ureteral stenting, percutaneous nephrostomy tube.
Bleeding: From ulcerated tumors (e.g., GI, lung).
- Procedures: Palliative resection, vessel ligation, angiographic embolization.
Pain:
- From nerve invasion, spinal cord compression, or pathological fractures.
- Procedures: Debulking, neurolysis (celiac plexus block), orthopedic stabilization (e.g., vertebroplasty).
Fistula / Perforation / Infection:
- Procedures: Abscess drainage, resection, diversion (stoma).

⭐ In malignant gastric outlet/duodenal obstruction, endoscopic stenting is preferred for patients with life expectancy < 2-3 months due to faster recovery, while surgical bypass (gastrojejunostomy) is considered for those expected to live longer (> 3-6 months) due to better long-term patency.

⚖️ Complications - Balancing Risks & Rewards

Core Principle: Benefit (↑ Quality of Life) must significantly outweigh surgical risk and recovery burden.
Key Risks: Standard surgical risks (bleeding, infection, VTE) are amplified by malignancy, malnutrition, and chemotherapy effects.
Specific Concerns: Poor wound healing, anastomotic leaks, prolonged ileus.

⭐ A patient's pre-operative performance status (e.g., ECOG, Karnofsky) is a primary predictor of post-operative morbidity and mortality in palliative surgery.

⚡ Biggest Takeaways

Palliative surgery's goal is symptom relief and improved quality of life (QoL), not cure.

Common indications: malignant bowel/biliary obstruction, hemorrhage, or intractable pain.

Crucial patient selection: must have adequate performance status and life expectancy (typically > 3 months) for benefits to outweigh surgical risks.

Procedures aim for minimal morbidity: examples include stenting, bypass, diversion (colostomy), and debulking.

Shared decision-making regarding goals of care is essential.

Prophylactic fixation of impending pathologic fractures preserves function.

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