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Surgical palliation in advanced disease: Recent developments

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Abstract

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.

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References

  1. Whalen GF and Ferrans CE. Quality of life as an outcome in clinical trials and cancer care: a primer for surgeons. J Surg Oncol 2001, 77:270–276.

    Article  PubMed  CAS  Google Scholar 

  2. Velanovich V: The quality of life studies in general surgical journals. J Am Coll Surg 2001, 193:288–295. This article demonstrates the current lack of consistency in quality-oflife studies in surgical literature. This area will need to improve to complement the maturation of surgical palliative care.

    Article  PubMed  CAS  Google Scholar 

  3. Udekwu P, Gurkin B, Oller D, et al.: Quality of life and functional level in elderly patients surviving surgical intensive care. J Am Coll Surg 2001, 193:245–249.

    Article  PubMed  CAS  Google Scholar 

  4. Dunn GP: The surgeon and palliative care. Surg Oncol Clin North Am 2001, 10:1–242. This journal issue, written for all surgeons, is meant to bring the worlds of palliative medicine and surgery closer together. It is based on the premise that surgeons must acknowledge their own fears and accomplishments in the war against human suffering as well as learning from the experience of others to be more supportive of patients with advanced, incurable disease.

    Google Scholar 

  5. Cady B: The changing role of the surgical oncologist. In Multidisciplinary Approach to Cancer. Edited by Rossi R, Cady B, Martin RF. Surg Clin North Am 2000, 80:459–469. This insightful article concerns the most difficult subject to write about: change. Cady identifies the changes in presentation of disease and newer insights into the biology of disease as the stimulus for redefining the role of the surgical oncologist, a role that should be more interdisciplinary and sustained.

  6. Nuland S: A surgeon’s reflections on the care of the dying. In The Surgeon and Palliative Care. Edited by Dunn GP. Surg Clin North Am 2001, 10:1:1–5.

  7. Lopez MJ: Multivisceral resections for colorectal cancer. J Surg Oncol 2001, 76:1–5.

    Article  PubMed  CAS  Google Scholar 

  8. Hermanek P: Impact of surgeon’s technique on outcome after treatment of rectal carcinoma. Dis Colon Rectum 1999, 42:559–562.

    Article  PubMed  CAS  Google Scholar 

  9. Finlayson CA, Eisenberg BL: Pelvic exenteration: patient selection and results. Oncology 1996, 10:479–484.

    PubMed  CAS  Google Scholar 

  10. Easson A, Asch M, Swallow CJ: Palliative general surgical procedures. In The Surgeon and Palliative Care. Edited by Dunn GP. Surg Clin North Am 2001, 10:161–184.

  11. Miner TJ, Jaques DP, Shriver C: Decision making on surgical palliation based on patient outcome data. Am J Surg 1999, 177:150–154.

    Article  PubMed  CAS  Google Scholar 

  12. Porter GA, Skibber JM: Outcomes research in surgical oncology. Ann Surg Oncol 2000, 7:367–375.

    Article  PubMed  CAS  Google Scholar 

  13. Sugarbaker PH, Barofsky I, Rosenberg SA, Gianola FJ: Quality of life assessment of patients in extremity sarcoma clinical trials. Surgery 1982, 92:17–23.

    Google Scholar 

  14. McCahill LE, Krouse RS, Chu DZJ, et al.: Indications and utilization of palliative surgery: results of Society of Surgical Oncology survey. Ann Surg Oncol 2002, in press. This article identifies the prevalence of palliative procedures in surgical oncology practice and the wide discrepancies of surgeons’ definitions of palliation. These varied definitions make interpretation of surgical outcome data about palliation difficult. A clearer consensus on the definition of palliation on the part of surgeons is needed for future clinical study design.

  15. McCahill LE, Krouse RS, Chu DZJ, et al.: Decision making in palliative surgery. Paper presented at the 87th Clinical Congress of the American College of Surgeons. Washington, DC. October 9, 2001.

  16. Krouse RS, Nelson RA, Farrell BR, et al.: Surgical palliation at a cancer center. Arch Surg 2001, 136:773–778.

    Article  PubMed  CAS  Google Scholar 

  17. Fernandez-Del Castillo C, Rattner DW, Warshaw AL: Further experience with laparoscopy and peritoneal cytology in the staging of pancreatic cancer. Br J Surg 1995, 82:1127–1129.

    Article  PubMed  CAS  Google Scholar 

  18. Merchant NP, Conlon KC, Saigo P, Brennan MF: Positive peritoneal cytology predicts unresectability of pancreatic adenocarcinoma. J Am Coll Surg 1999, 188:421–426. The findings of these investigators have important implications for staging that would eliminate the need for numerous laparotomies, some of which would have no palliative benefit.

    Article  PubMed  CAS  Google Scholar 

  19. Minnard E, Conlon KC, Hoos A, et al.: Laparoscopic ultrasound enhances standard laparoscopy in the staging of pancreatic cancer. Ann Surg 1998, 228:182–187.

    Article  PubMed  CAS  Google Scholar 

  20. Espat NJ, Brennan MF, Conlon KC: Patients with laparoscopically staged unresectable pancreatic adenocarcinoma do not require subsequent surgical biliary or gastric bypass. J Am Coll Surg 1999, 188:649–657. An important article challenging the notion of prophylactic gastrojejunostomy for unresectable periampullary cancer. This paper represents one of the positions in the debate concerning laparoscopy-versus laparotomy-staged pancreatic cancer, a debate with significant implications for palliative treatment.

    Article  PubMed  CAS  Google Scholar 

  21. Hemming AW, Nagy AG, Scudamore CH, Edelmann K: Laparoscopic staging of intra-abdominal malignancy. Surg Endosc 1995, 9:325–328.

    Article  PubMed  CAS  Google Scholar 

  22. Salky B, Bauer J, Gelernt I, Kreel I: Laparoscopy for gastrointestinal diseases. Mt. Sinai J Med 1985, 52:228–232.

    PubMed  CAS  Google Scholar 

  23. Lowy AM, Mansfield PF, Leach SD: Laparoscopic staging for gastric cancer. Surgery 1996, 119:611–614.

    Article  PubMed  CAS  Google Scholar 

  24. Rothlin MA, Schob O, Weber M: Laparoscopic gastro- and hepaticojejunostomy for palliation of pancreatic cancer: a case controlled study. Surg Endosc 1999, 13:1065–1069.

    Article  PubMed  CAS  Google Scholar 

  25. Roser JC Jr, Rodas EB, Blancaflor J, et al.: A simplied technique for laparoscopic jejunostomy and gastrostomy tube placement. Am J Surg 1999, 177:61–65.

    Article  Google Scholar 

  26. Milsom JW, Kim SH, Hammerhofer KA, Fazio VW: Laparoscopic colorectal cancer surgery for palliation. Dis Colon Rectum 2000, 43:1512–1516.

    Article  PubMed  CAS  Google Scholar 

  27. Giraudo G, Kazemier G, Van Eijck CH, Bonjer HJ: Endoscopic palliative treatment of pancreatic cancer: thoracoscopic splanchnicectomy and laparoscopic gastrojejunostomy. Ann Oncol 1999, 10(suppl 4):278–280.

    Article  PubMed  Google Scholar 

  28. Goh PM, Khan AZ, So JB, et al.: Early experience with laparascopic radical gastrectomy for advanced cancer. Surg Laparosc 2001, 11:83–87.

    Article  CAS  Google Scholar 

  29. Watson DI, Davies N, Jamieson GG: Totally endoscopic Ivor-Lewis esophagectomy. Surg Endosc 1999, 13:293–297.

    Article  PubMed  CAS  Google Scholar 

  30. Walsh RM, Heniford BT, Brody F, Ponsky J: The ascendance of laparoscopic splenectomy. Am Surg 2001, 67:48–53.

    PubMed  CAS  Google Scholar 

  31. Heniford BT, Park A, Walsh RM, et al.: Laparoscopic splenectomy in patients with normal sized spleens versus splenomegaly: does size matter? Am Surg 2001, 67:854–858.

    PubMed  CAS  Google Scholar 

  32. Akpek G, McAneny, Weintraub L: Risks and benefits of splenectomy in myelofibrosis with myeloid metaplasia: a retrospective analysis of 26 cases. J Surg Oncol 2001, 77:42–48.

    Article  PubMed  CAS  Google Scholar 

  33. Kubba AK, Krasner N: An update in the palliative management of malignant dysphagia. Eur J Surg Oncol 2000, 26:116–129.

    Article  PubMed  CAS  Google Scholar 

  34. Mauro MA, Koehler RE, Baron TH: Advances in gastrointestinal intervention: the treatment of gastroduodenal and colorectal obstructions with metallic stents. Radiology 2000, 215:659–669.

    PubMed  CAS  Google Scholar 

  35. Singer SB, Asch M: Metallic stents in the treatment of duodenal obstruction: technical issues and results. Can Assoc Radiol J 2000, 51:121–129.

    PubMed  CAS  Google Scholar 

  36. Yim HB, Jacobson BC, Saltzman JR, et al.: Clinical outcome of the use of enteral stents for palliation of patients with malignant upper GI obstruction. Gastrointest Endosc 2001, 53:329–332.

    PubMed  CAS  Google Scholar 

  37. Mainar A, De Gregorio Ariza MA, Tejero E, et al.: Acute colorectal obstruction: treatment with self-expandable metallic stents before scheduled surgery—results of a multi-center study. Radiology 1999, 210:65–69.

    PubMed  CAS  Google Scholar 

  38. Camunez F, Echenagusia A, Simo G, et al.: Malignant colorectal obstruction treated by means of self-expanding metallic stents: effectiveness before surgery and palliation. Radiology 2000, 216:492–497.

    PubMed  CAS  Google Scholar 

  39. Smith AC, Dowsett JF, Russell RC, et al.: Randomized trial of endoscopic stenting versus surgical bypass in malignant low bile duct obstruction. Lancet 1994, 344:1655–1660.

    Article  PubMed  CAS  Google Scholar 

  40. Cooperman AM, Subhash K, Snady H, et al.: Current surgical therapy for carcinoma of the pancreas. J Clin Gastroenterol 2000, 31:107–113.

    Article  PubMed  CAS  Google Scholar 

  41. Schwarz A, Beger HG: Biliary and gastric bypass or stenting in nonresctable periampullary cancer: analysis on the basis of controlled trials. Int J Pancreatol 2000, 27:51–58.

    PubMed  CAS  Google Scholar 

  42. Lillemoe KD, Cameron JL, Hardacre JM, et al.: Is prophylactic gastrojejunostomy indicated for unresectable periampullary cancer? A prospective randomized trial. Ann Surg 1999, 230:322–330.

    Article  PubMed  CAS  Google Scholar 

  43. Tamai H, Igaki K, Kyo E, et al.: Initial and 6-month results of biodegradable poly-1-lactic acid coronary stents in humans. Circulation 2000, 102:399–404.

    PubMed  CAS  Google Scholar 

  44. Barron TH: Current concepts: expandable metal stents for the treatment of cancerous obstruction of the gastrointestinal tract. N Engl J Med 2001, 344:1681–1687. Excellent review from an institution with extensive experience.

    Article  Google Scholar 

  45. Rafanan AL and Mehta AC: Stenting of the tracheobronchial tree. Radiol Clin North Am 2000, 38:395–400.

    Article  PubMed  CAS  Google Scholar 

  46. Lyburn I, Blazeby JM, Barham P, Loveday E: Palliation of malignant gastric outlet obstruction after oesophagectomy by percutaneous transthoracic placement of an expanding metal stent. Clin Radiol 2001, 56:82–83.

    Article  PubMed  CAS  Google Scholar 

  47. Cady B: The importance of tumor biology and surgical experience. Presented as part of panel discussion, Major Oncologic Resections as Palliative Procedures: Is it Justifiable? At the Society of Surgical Oncology 54th Annual Cancer Symposium. Washington, DC. March 15, 2001. This lecture given by a preeminent surgical oncologist provides a philosophy and strategy not only for palliative resections but for all palliative procedures.

  48. Link J: Gastrectomy confirmed to prolong survival: report from 2001 Canadian Surgery Forum. Gen Surg News 2001, 281:1–9.

    Google Scholar 

  49. Hanazaki K, Sodeyama H, Mochizuki Y, et al.: Palliative gastrectomy for advanced gastric cancer. Hepatogastroenterology 2001, 48:285–289.

    PubMed  CAS  Google Scholar 

  50. Doglietto GB, Pacelli F, Caprino P, et al.: Palliative surgery for far-advanced gastric cancer: a retrospective study on 305 consecutive patients. Am Surg 1999, 65:352–355. Extensive review of one of the prototypes of surgical palliative treatment, resection of symptomatic and incurable gastric cancer.

    PubMed  CAS  Google Scholar 

  51. Trede M, Schwall G, Saeger HD: Survival after pancreaticoduodenectomy: 118 consecutive resections without an operative mortality. Ann Surg 1990, 211:447–458.

    Article  PubMed  CAS  Google Scholar 

  52. Whipple AO: Present day surgery of the pancreas. N Engl J Med 1942, 226:515.

    Article  Google Scholar 

  53. Gouma DJ, van Dijkum EJ, van Geenen RC, et al.: Are there indications for palliative resection in pancreatic cancer? World J Surgery 1999, 23:954–959.

    Article  CAS  Google Scholar 

  54. Kymionis GD, Konstadoulakis MM, Leandros E, et al.: Effects of curative versus palliative treatment for stage III pancreatic cancer patients. J R Coll Edin 1999, 44:231–235.

    CAS  Google Scholar 

  55. McLeod RS: Quality of life, nutritional status and gastrointestinal hormone profile following Whipple procedure. Ann Oncol 1999, 4(suppl):281–285.

    Article  Google Scholar 

  56. Farnadez-del Castillo CF, Rattner DW, Warshaw AL: Standards for pancreatic resection in the 1990s. Arch Surg 1995, 130:295–300.

    Google Scholar 

  57. Yeo CJ, Cameron JL, Sohn TA, et al.: Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes. Ann Surg 1997, 226:248–260.

    Article  PubMed  CAS  Google Scholar 

  58. Pietrabissa A, Vistoli F, Carrobi A, et al.: Thoracoscopic splanchnicectomy for pain relief in unresectable pancreatic cancer. Arch Surg 2000, 135:332–350.

    Article  PubMed  CAS  Google Scholar 

  59. Molinari M, Helton WS, Espat NJ: Palliative strategies for locally advance unresectable and metastatic pancreatic cancer. In The Pancreas Revisited II: Benign and Malignant Tumors: An Interdisciplinary Approach. Edited by Cooperman AM, Chamberlain RS. Surgl Clin North Am 2001, 81:651–665. This is an example of surgical palliative care at its best—interdisciplinary in spirit, mindful of the availability of pain management consultants and hospice, and offering solid arguments for a number of strategies for the salient symptoms of pancreatic cancer.

  60. Lo C, Lam K, Wan K: Anaplastic carcinoma of the thyroid. Am J Surg 1999, 177:337–339.

    Article  PubMed  CAS  Google Scholar 

  61. Nilsson O, Lindeberg J, Zedenius J, et al.: Anaplastic giant cell carcinoma of the thyroid gland: treatment and survival over a 25-year period. World J Surg 1998, 22:725–730.

    Article  PubMed  CAS  Google Scholar 

  62. Loggie B, Fleming RA, McQuellon RP, et al.: Cytoreductive surgery with intraperitoneal hyperthermic chemotherapy for disseminated peritoneal cancer of gastrointestinal origin. Am Surg 2000, 66:561–568. Despite the aggressiveness of the approach, the attention given to the relief of ascites offers promise for future multimodality treatment incorporating surgery for symptom relief whether or not survival is prolonged.

    PubMed  CAS  Google Scholar 

  63. McQuellon RP, Loggie BW, Fleming RA, et al.: Quality of life after intraperitoneal hyperthermic chemotherapy (IHPC) for peritoneal carcinomatosis. Eur J Surg Oncol 2001, 27:65–73.

    Article  PubMed  CAS  Google Scholar 

  64. Temple WJ, Saettler EB: Locally recurrent rectal cancer: role of composite resection of extensive pelvic tumors with strategies for minimizing risk of recurrence. J Surg Oncol 2000, 73:47–58.

    Article  PubMed  CAS  Google Scholar 

  65. Legendre H, Vanhuyse F, Caroli-Bosc F-X, Pector J-C: Survival and quality of life after palliative surgery for neoplastic gastrointestinal obstruction. Eur J Surg Oncol 2001, 27:364–367. A good example of the type of inquiry necessary to provide the groundwork for future prospective clinical trials reflecting a more comprehensive philosophy of surgical palliative care.

    Article  PubMed  CAS  Google Scholar 

  66. Agrawal S, Yao TJ, Coit DG: Surgery for melanoma metastatic to the gastrointestinal tract. Ann Surg Oncol 1999, 6:336–344.

    Article  PubMed  CAS  Google Scholar 

  67. Dunn GP: Selected surgical approaches. In Cancer Pain Management: A Comprehensive Approach. Edited by Simpson KH, Budd K. Oxford: Oxford University Press; 2000:168–187.

    Google Scholar 

  68. Dotzenrath C, Goretzki PE, Sarbia M, et al.: Parathyroid carcinoma: problems in diagnosis and the need for radical surgery even in recurrent disease. Eur J Surg Oncol 2001, 27:383–389.

    Article  PubMed  CAS  Google Scholar 

  69. Wittig JC, Bickels J, Kollender Y, et al.: Palliative forequarter amputation for metastatic carcinoma to the shoulder girdle region: indications, preoperative evaluation, surgical technique, and results. J Surg Oncol 2001, 77:105–113. Despite the highly aggressive approach, this is an excellent example of interdisciplinary cooperation effectively palliating an extremely difficult problem, justifying the means.

    Article  PubMed  CAS  Google Scholar 

  70. Beitler AL, Virgo KS, Johnson FE, et al.: Current follow-up strategies after potentially curative resection of extremity sarcomas. Cancer 2000, 88:777–785.

    Article  PubMed  CAS  Google Scholar 

  71. American College of Surgeons: Principles of care at the end of life. Bull Am Coll Surg 1998, 83:46.

    Google Scholar 

  72. Cassel C, Foley K: Principles for care of patients at end of life: an emerging consensus among the specialties of medicine. Report sponsored by the Milbank Memorial Fund. December, 1999. Accessible at http://www.milbank.org.

  73. American Board of Surgery: Booklet of Information: July 2001-June 2002. Philadelphia: American Board of Surgery; 2001.

    Google Scholar 

  74. Dunn GP: Palliative care by the surgeon: how to do it. Presented as part of General Symposium, 87th Clinical Congress of the American College of Surgeons held on October 10, 2001. J Am Coll Surg 2002, in press.

  75. Dunn GP, Milch RA: Introduction and historical background of palliative care: where does the surgeon fit in? J Am Coll Surg 2001, 193:325–327. This article was written to introduce a wide audience of surgeons of all specialties to the historical and philosophical background of palliative care. The authors point out the rich precedents in surgical experience for development of a palliative philosophy specifically for surgeons. This was the lead article of a series about palliative care by surgeons written by surgeons.

    PubMed  CAS  Google Scholar 

  76. Milch RA, Dunn GP: Communication: part of the surgical armamentarium. J Am Coll Surg 2001, 193:449–451.

    Article  PubMed  CAS  Google Scholar 

  77. Dunn GP: Patient assessment in palliative care: how to see the ‘big picture’ and what to do when ‘there is no more we can do’. J Am Coll Surg 2001, 193:565–573.

    Article  PubMed  CAS  Google Scholar 

  78. Lee FK, Ray JB, Dunn GP: Chronic pain management. J Am Coll Surg 2001, 193:689–702.

    Article  PubMed  CAS  Google Scholar 

  79. World Health Organization: Cancer Pain Relief and Palliative Care. Technical report, series 804. Geneva: WHO; 1990.

    Google Scholar 

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Dunn, G.P. Surgical palliation in advanced disease: Recent developments. Curr Oncol Rep 4, 233–241 (2002). https://doi.org/10.1007/s11912-002-0021-3

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