Palliative Care Surgical Updates

1
Palliative Care Surgical Updates

• Robert S. Krouse, MD
• Staff, General and Oncologic Surgery, Southern
  Arizona Veterans Affairs Health Care System
• Professor of Surgery, University of Arizona

2
Objectives

• Appreciate the importance of palliative surgery
  in the practice of surgical oncology.
• Understand the various roles of the surgeon for
  patients with advanced cancers.
• Become aware of the various techniques available
  for palliative procedures.
• Consider the role of the surgeon as a partner of
  the palliative care team.

3
How common is palliative surgery?
4
Retrospective Review of Palliative Surgeries
Krouse, Archives of Surgery, 2000.
5
Society of Surgical Oncology Survey Palliative
Surgeries per Year
0-10
21-30
41-50
Number of Respondents
McCahill, JACS, 2002.
6
What is a measure of success?

• Improved Quality of Life
• Based on patient/family goals
• Low morbidity
• Low procedure-related mortality

7
Surgical palliative care problems for the cancer
patient

• Hormonal control
• Wounds/Fistulae
• Biliary obstruction
• Gastric outlet obstruction (GOO)
• Bleeding
• Malignant ascites
• Splenomegaly
• Malignant Bowel Obstruction (MBO)

Krouse, Oxford Textbook of Palliative Medicine,
Jan 2010.
8
Hormonal control

• Carcinoid Syndrome
• Malignant Gastinoma

9
Clinical approaches

• Surgical approaches- Resection/debulking
• Liver transplantation
• Surgical ablation- RFA/cryotherapy
• Interventional Radiology- chemoembolization/RFA/cr
  yotherapy
• Hormonal treatment
• Chemotherapy
• Medical Symptom Management

10
Treatment goals

• Decrease symptoms
• Improve response to medical therapies
• Improve survival

11
Carcinoid Syndrome- Medical Symptom Control

• Somatostatin analogues- 72-74 symptomatic
  responses
• BID injections
• Bi weekly
• Monthly depot form
• Interferon-alpha- 68 symptomatic responses
• Chemotherapy (streptozocin, cyclophosphamide,
  5-flourouracil)- 9 symptomatic responses

12
Metastatic Gastrinoma- Medical Symptom
Control

• Proton pump inhibitors- can be increased
• Somatostatin analogues
• Chemotherapy/biotherapy (?)

13
Neuroendocrine tumors-Invasive approaches

• Symptom improvement variable but likely 100 if
  can completely resect
• RFA alone symptom relief 69 (12 morbidity)
  (Gilliams, A, Abd Imag, 2005)
• Hepatic artery embolization (HAE) responses can
  be quite high (65-95)
• HAE morbidity (12) mortality (6) can be
  significant
• HAE better for carcinoid than islet cell tumors

14
Metastatic neuroendocrine tumors-Surgical
Recommendation

• Due to slow growth, consider aggressive
  approaches
• Symptom relief may lead to longer survival
• Utilize RFA with resection or alone
• Consider a combination/serial approaches

15
Wound problems

• Tumor-related
• Skin cancers
• Sarcoma
• Breast Cancer
• Radiation-related
• Surgery-related
• Pressure ulcers

16
Clinical goals

• Function
• Pain control
• Odor
• Cosmesis
• Ease burden of care
• Minimize recurrence
• Keep out of the hospital
• Improve survival (?)

17
Clinical approaches

• Aggressive surgical resection
• Reconstruction
• Flaps
• Skin grafts
• Wound care
• Radiation
• Primary
• Adjuvant
• Chemotherapy for breast cancers

18

• 71 yo man with history of hairy cell leukemia and
  rapidly growing tumor of left preauricular area
• Persistent neutropenia
• Operation Wide Local Excision with STSG
• Margins Negative

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Things dont always go the way you want them to.
20
Follow-up

• Tumor recurred through radiation treatment
• Committed suicide 2.5 months from operation

21
Outcomes for chest wall resections for breast
cancer
Study Closure Recurrence Local Wound
Technique Morbidity Flook, 1989. Myocut
flap 12/42 (29) 12/42 (29) Sweetland,
1995. Myocut flap 7/35 (20) 15/35 (43) Cheung,
1997. Omental flap 8/11 (73) 3/11 (27) Downey,
2000. Marlex/flap 14/38 (37) 6/38
(9) Henderson, 2001. Omental flap 32/61
(52) 35/61 (57)
22
Pressure ulcers

• Avoidance
• But Surgeon usually consulted late
• Usual wound care
• Debridement
• Dressing changes
• Unlikely for major reconstruction

23
Tumor-related odor

• Wound Care Nurse
• Topical antibiotics
• Kitty litter or activated charcoal under
  patients bed
• Charcoal-impregnated dressings
• Deodorants

24
Biliary Obstruction Treatment options

• Transhepatic biliary stent
• Endoscopic biliary stent
• Open bypass
• Cholecystjejunostomy
• Choledochoenteric bypass
• Laparoscopic bypass
• Cholecystjejunostomy
• Choledochoenteric bypass

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Outcomes for biliary bypass
Study Stent Surgical Stent Surgical
(Stent/OR) Success Success Recur Recur Bor
nman, 1986 84 76 38 15 (25/25) Shepard,
1988 82 92 30 0 (23/25) Anderson, 1989
96 88 0 0 (25/25) Dowsett, 1989
94 94 17 3 (65/62) Smith, 1994
92 92 36 2 (100/102)
26
Late duodenal obstruction for biliary
decompression alone
Study N Tumor Procedure Late GOO Parks,
1997 61 Peripancreatic Bypass 8 Coene,
1994 581 Pancreas Endoscopic 9 Coene,
1994 81 Ampullary Endoscopic
23 Holbrook, 1990 128 Peripancreatic Bypass
10 Huguier, 1993 636 Pancreas Bypass
16
27
Treatment optionsGastric outlet obstruction
(GOO)

• NG
• PEG
• Stent
• Bypass
• Resection

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Outcomes for GOO
Study Procedure Morbidity Positive Recur. R
esults Kim, 2001 Stent 0 26/29
(89.7) 2/27 Kaw, 2003 Stent 0 29/33
(91) 4/29 Born, 1996 Open/Lap 0 16/16
(100) 0/16 Lucas, 1990 Antrect 0 19/19 (100)
NR
29
Should one do a gastrojejunostomy in the setting
of pancreatic cancer?
Pre-OR Status (n81) Poor outcome Patent
duodenum (45) 40 Duodenal narrowing
(36) 70 Emesis (21) 90 No emesis (60) 40
Inability to retain a reasonable amount of
food and death within 30 days
Weaver, Surgery, 1987.
30
Unresectable peripancreatic tumors-Recommendation
s

• If endoscopic expertise available, stenting is
  preferable for both biliary and gastric
  obstructions
• If endoscopic stenting fails or is unavailable,
  open or laparoscopic bypass is warranted
• If explore through laparoscope and unresectable,
  reasonable to close
• If explore open and unresectable, reasonable to
  bypass (GI, biliary, or both)

31
Bleeding

• Etiology
• Wounds
• GI
• Gynecologic
• Treatment options
• Radiation therapy
• Interventional radiology
• Endoscopy
• Resection

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Indications for Surgical Intervention

• Failure of other modalities
• Facility of operation vs. other modalities
• Urgency of intervention
• Potential for cure

33
Case Example

• Patient is a 65 yo man with a history of
  intermittent massive upper GI bleed
• EGD displays a large, ulcerating, partially
  obstructing mass in the 3rd portion of the
  duodenum Biopsy inflammatory tissue
• Exploration reveals metastatic disease in the
  liver Biopsy GIST vs. neuroendocrine tumor

34
Bleeding duodenal tumor
35
Duodenojejunostomy
36
Malignant ascites Treatment options

• Medical management
• Diuretics- help in 1/3 patients
• Serial paracentesis- 90 relief (temporary)
• External drains Dialysis catheter, fenestrated
  port, Foley catheter, Pleurex catheter, pig-tail
  catheter
• Intraperitoneal sclerosis
• Peritoneal-venous shunts Leveen, Denver
• Resection
• Debulking alone
• Hyperthermic chemotherapy

37
CT- Ascites and tumor caking
38
Outcomes for ascites
Study Procedure Functional Until
Complication Death () (Range-days)
() ONeill, 2001 Pig-tail 23/24 (96)
(7-98) 4/24 (17) Barnett, 2002 Tenckhoff 27/29
(93) (9-218) 5/29 (17) Smith,
1989 Denver/Leveen 31/50 (62) (0-104) 16/50
(32) Bieligk, 2000 Denver shunt Not reported
26/51 (51) Zanon, 2002 Denver 24/25 (96)
(17 A) 6/44 (14) Loggie, 2000 CR/IP Chemo
31/39 (79) (7.6 mo med) NR
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Major surgical complications

• Drainage procedures
• Infection
• Occlusion
• Leak
• Peritoneal-venous shunts
• DIC
• CHF
• Occlusion (25)
• Infection

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Malignant ascites-Recommendations

• Intermittent drainage and diuretics is reasonable
  to try first or if nearing death
• External drains are reasonable procedures to
  treat malignant ascites with minimal major
  morbidity
• Peritoneal-venous shunts can have excellent
  long-term results but major complications are
  possible
• Debulking with/without hyperthermic chemotherapy
  can have dramatic results but necessitate
  expertise and may have high morbidly

41
Splenomegaly

• Etiology- hematologic malignancies
• Symptoms
• Pain
• Bloating
• Early satiety
• Treatment options
• Radiationtherapy
• Interventional radiolgy
• Splenectomy
• Open
• Laparoscopic

42
Splenic Irradiation for Hematologic Malignancies
Disorder Size Pain Duration Response Respon
se of Response (mean months) Chronic
Lymphocytic 50-82 80-100 7-18 Leukemia Hairy
Cell 3-16 Leukemia Myeloproliferative 50-95
66-100 7-10 Disorders
Weinmann M. Radiother Oncol, 2001.
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Indications for Splenectomy

• Lifespan gt6 months
• Trauma

44
Malignant Bowel Obstruction (MBO) Invasive
options

• Endoscopic
• Laser
• Stent
• PEG
• Surgery
• Bypass
• Enteroenterostomy
• Intestinal stoma
• Resection
• Gastrostomy

45
Malignant Bowel Obstruction-Medical Symptom
Control

• Opioids
• Anti-emetics (haloperidol, odansatron
  prochlorperazine, etc.)- 30 complete relief of
  emesis
• Somatostatin analogue (Octreotide- 75-100
  response rate)
• Anti-cholinergics (Scopolamine)
• Steroids
• Hydration
• Gastric decompression
• TPN

46
Malignant Bowel Obstruction- Surgical
Considerations

• 6-50 inoperable
• Contraindications to surgery ascites,
  carcinomatosis, multiple bowel obstructions,
  palpable intraabdominal mass, overwhelming
  disease, poor clinical status
• 3-48 benign

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MBO and Surgery- Beliefs and Reality

• Belief
• Probable best modality if patient has
  reasonable expected survival
• May spend shorter time in hospital
• May relieve possible ischemia/infarction of bowel
• May improve survival

• Reality
• Explorations alone- 3-18
• 10-50 chance of recurrence
• Morbidity 42
• May spend longer time in hospital
• Mortality 5-32
• QOL improvement variable (42-85)

48
Malignant bowel obstruction-Recommendations

• Patient selection is crucial when considering
  operative interventions
• MBO is rarely an emergency
• Non-operative approaches should be considered

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Palliative Surgery- Conclusions

• Palliative procedures are an important part of
  the practice for surgeons
• It is imperative to focus on Quality of Life
  outcomes for patients with advanced cancer
• Surgeons have a lot to offer the cancer patient
  facing the end of life and the medical/palliative
  care team
• As long as realistic goals of the patient and
  their family are identified, all treatment
  modalities should be considered