Palliation

Surgical intervention is sometimes required in the patient with unresectable advanced cancer for palliative indications. The common indications for palliation in this setting are pain, bleeding, obstruction, malnutrition, or infection. The surgeon needs to consider several factors regarding each situation as to whether the surgical intervention will add significantly to the quality of life of the patient. These factors include the expected survival of the individual, the potential morbidity of the procedure, the likelihood that the procedure will palliate the patient, and whether there are alternative nonsurgical methods of palliation.

The acute onset of pain, bleeding, or obstruction represents a potential oncologic emergency. This topic is covered in more detail in Chapter 74 (Surgical Emergencies). Probably the most common oncologic emergency that the surgeon con fronts is the obstruction of a hollow viscus, which can give rise to an acute abdomen, perforation of the viscus, and possibly bleeding. The hollow viscus could be the bowel, biliary tree, endobronchial tree, ureters, or bladder. There are surgical interventions that can be employed to address these problems, and in certain instances, nonsurgical approaches with stents that are effective.

Malnutrition is a common problem in the cancer patient, especially one with advanced, unresectable disease. Nutrition can be supplemented or replaced by intravenous hyperali-mentation or enteral feedings via a gastrostomy or jejunos-tomy tube. Commonly, the surgeon is involved in placement of vascular access for hyperalimentation. If the gastrointestinal tract is functional, the surgeon may be called upon to place a feeding tube for enteral nutrition. The nutritional support of the cancer patient as well as aspects of vascular access are reviewed in more detail in Chapters 82 and 85.

Occasionally, the surgeon is involved in palliating pain caused by a metastatic lesion compressing an organ or adjacent nerves. Examples include cutaneous or subcutaneous melanoma metastases, a large ulcerating breast cancer, or a recurrent intraabdominal sarcoma mass. As indicated previously, the surgeon needs to assess the relative risk-to-benefit ratio in resecting a symptomatic mass, knowing that it will not affect the overall survival of the patient. If the quality of life of the individual can be improved at an acceptable operative risk, then the surgical intervention is warranted.

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