Surgical palliation in advanced disease: Recent developments

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.

Use of Palliative Care and Hospice Among Surgical and Medical Specialties in the Veterans Health Administration

“…In our study, all surgical patients had at least 1 major surgery prior to either hospice or palliative consultation, with only a small group undergoing a major surgical procedure following initiation of palliative care and hospice. Some studies found that procedures performed with palliative intent can improve quality of life and increase longevity, 26 but our study cannot speak to this.…”

Repair of a complex incisional hernia in the setting of palliative care

“…Surgery in palliative care is invariably complicated by the underlying disease of the patient, and usually focused on complications caused directly or indirectly by the cancer. There has been an increased focus on the role of the surgeon in end of life care in the literature, with a shift from mortality and morbidity related outcomes to quality-of-life based outcomes [4] .…”

Ethics of palliative surgery in patients with cancer

“…Research on palliative surgery has suffered from inconsistent definitions23–25 and so the results of various studies can hardly be meaningfully compared; the core evidence from these studies has been difficult to find. Consequently, the value of achieved knowledge from many of these research efforts can barely be appreciated because of methodological concerns.…”

“…If palliative surgery is defined by postoperative status, for example ‘resection with microscopic or gross residual tumour left in situ at the end of the procedure’ or ‘resection for recurrent or persistent disease after primary treatment failure’23, 26, it is defined by its result. This can be convenient in situations where a particular procedure can be regarded as either curative or palliative before operation, because the treatment goal cannot be defined accurately in advance.…”