👰 👩🏽‍🤝‍👨🏿 🌜 Palliative surgery in oncology: how a surgeon can prolong and improve a patient’s life even without radical surgery 🛁 🔓 👩🏾

Bet you won’t guess what it is? This is a stent in the lumen of the esophagus.

Not everyone who coughs in the spring of 2020 is ill with COVID-19. There are patients who are even worse: they are suffocating, and they will not be helped for 2 weeks in the infectious diseases hospital. They have cancer. Cancer of the lungs, or breast, or ovary, or possibly lymphoma.

With many tumors, a frequent complication is fluid accumulation in the pleural cavity (around the lungs). It happens a lot, up to several liters (!) - and it compresses the lungs, preventing them from working. This is called hydrothorax.

In this case, only the surgeon can return the person the ability to breathe. He performs an operation called "thoracocentesis" - punctures the pleural cavity with a thick needle and removes the accumulated fluid through it. The lungs straighten, the patient breathes normally again.

Note, the surgeon allows a person to live on, although it does not affect the main cause of the disaster: a malignant tumor. This is one example of palliative surgery.

Palliative surgery- this is one that does not eliminate the main problem - a cancerous tumor, does not cure a person completely. But a palliative operation is likely to prolong his life and significantly improve its quality: he will retain the ability to self-care and social adequacy, he will be able to move around, eat or go to the toilet, will stop suffering from pain.

But such improvements for our patients in "Medicine 24/7" are especially needed. More than half of them are people with stage III and IV cancer.

Many came to us after they were told in the regional oncology dispensary: "It’s too late to cut." But we are cutting - focusing on new international protocols and the experience of Western colleagues. And the patient even in the last stages receives an increase in the quality of life, and often - and its duration.

Today we’ll tell you how operations that do not remove the tumor help with cancer, and why it is worth operating “hopeless” patients.

Why is it impossible to just excise a tumor?

Surgical treatment in oncology, many consider only radical: when all the lesions can simply be excised. Otherwise, after all, why bother with traumatic interventions and generally wave the scalpel for nothing? This is a common stereotype.

The fact is that cancer in Russia in almost 40% of cases is detected in the later stages. At this point, the malignant process is often generalized - spread throughout the body. And “just cutting out the tumor and all metastases” becomes a task incompatible with the patient’s life.

If, for example, in addition to a tumor in the woman’s mammary gland, metastases in the liver, lungs and spine are necessary, too many tissues will have to be removed from different organs at once, and the risk of dying from such an operation will be higher than from the progression of the disease.

Organs, where breast cancer most often metastases.

But this does not mean that there is nothing to help such people! Palliative care can significantly alleviate the patient’s condition and improve his quality of life, and sometimes prolong it - without resorting to radical treatment.

Palliative medicine most often uses chemotherapy and radiation therapy. Unfortunately, this was too tight in the minds of many Russian doctors: they are not ready to use surgery when they realize in advance that they will leave the tumor or part of it inside the patient. Although in oncology departments around the world, up to 20% of all operations are palliative.

And there are more of them. Indications for surgical treatment at any stage of cancer - even with a common process - are expanding. New minimally invasive methods of intervention appear - they reduce the risks for the patient and after them it is easier to recover.

Palliative surgery is becoming part of a comprehensive treatment. Well-established interdisciplinary interaction helps us a lot. When a surgeon, oncologist, chemotherapist, radiation therapy doctor, and resuscitator get together, they do not pull the blanket over themselves (as you might think), but find the optimal treatment tactics to rid the patient of painful symptoms as safely and as long as possible.

The successes are today. Using palliative surgery, you can:

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Cytoreductive - literally translates as "those that reduce the number of cells." Cancer cells in the body. That is - removal of a fully or partially primary tumor, removal of the maximum possible number of metastases. This is necessary in order to:

a) extend the patient's life,

b) remove painful symptoms,

c) prevent life-threatening conditions.

Often, tumor foci cannot be removed entirely. For example, a tumor is too large - along with it, a vital organ or a very large area of it would have to be removed. Or too many body systems are affected - multiple distant metastases. Or the foci of metastasis are small, up to a microscopic size, but there are a thousand of them - as with peritoneal carcinomatosis.

Such patients are often called "inoperable", and they are left with only symptomatic treatment and chemotherapy, which does not always give a good result.

Although in such cases it is often possible to remove not all, but the maximum possible part of the tumor. This will reduce severe symptoms caused by the activity of cancer cells. And most importantly, it will not stop, but it will slow down the spread of the malignant process, allow the patient to gain time, give more chances that chemotherapy and radiation therapy will work - they work the more efficiently, the smaller the volume of tumor tissue in the body.

Cytoreductive surgery becomes part of a comprehensive treatment. We already talked about HIPEC , a hyperthermic intraperitoneal therapy that helps patients in the last stagescancer of the ovaries, stomach, various parts of the intestine, liver. Cytoreductive surgery takes first place in the HIPEC procedure: first, the surgeon will remove all the foci that can be found, and then the patient’s abdominal cavity will be treated with a hot chemotherapy. After such an operation, people can live for years instead of months, and in some cases, achieve remission.

In this video you can see how the cytoreductive surgery is performed for peritoneal carcinomatosis. Be careful if you do not like to look people too deep inside!

One of our patients, who had ovarian adenocarcinoma removed , performs cytoreductive surgery in combination with HIPEC for the fifth time in a row - and this is 5 years of life.

In addition to ovarian cancer, cytoreductive surgery, as one of the stages of treatment, shows an improvement in survival rates for colorectal cancer, stomach cancer, appendix adenocarcinoma, soft tissue sarcomas - even at those stages when the tumor has already begun to metastasize.

Cytoreductive surgery is often a way to avoid the worst in a situation where the patient is threatened by serious, dangerous complications. For example, such an intervention helps prevent intestinal perforation or heavy bleeding due to tumor decay.

These measures, although palliative, do not allow the patient to die prematurely.

Therefore, we always try to find the maximum possible treatment options and monitor progression, even when it is impossible to perform a radical intervention or the tumor does not respond well to chemotherapy.

We can’t remove the cause - we cut the consequences. Symptomatic operations

Symptomatic palliative surgical interventions do not affect the tumor at all, unlike cytoreductive surgeries, but struggle with the dangerous consequences for the patient that cause the growth of the malignant neoplasm.

For example, we described thoracocentesis with fluid accumulation in the chest at the very beginning of the article. But at least there is an accumulation of fluid in the abdominal cavity - ascites. This is a common complication in cancer of the stomach, ovaries, colorectal cancer, etc.

With ascites (accumulation of fluid in the abdominal cavity), the volume of fluid can reach 10 or more liters. The patient feels very bad: shortness of breath, a violation in the digestive tract and internal organs. To alleviate this condition, laparocentesis is performed .- a puncture in the wall of the abdominal cavity to remove fluid. If the fluid accumulates quickly, install drainage - it removes excess continuously.

However, most often symptomatic operations are needed so that the body, in fact, continues to make an exchange with the environment, which is familiar to us all and is taken by healthy people for granted.

To ensure the functioning of the digestive system

Anastomosis.Artificially created communication between vessels, organs or cavities. In oncology, this is most often necessary for cancer of the digestive tract. Most inoperable patients with cancer of the esophagus, stomach, colon and rectum sooner or later have to form bypass anastomoses, turn off the tumor from the esophagus, because it creates obstruction (obstruction.) For this, part of the organ affected by the cancer is removed, and the remaining parts are sutured. “As if it was”, most likely, no one will succeed, but we always try to keep the patient a continuous gastrointestinal tract that performs its basic functions - so that it can eat normally.

Removal of a part of the colon and the formation of an anastomosis

However, it is not always possible to apply an anastomosis: for example, the esophagus or intestines may be too badly damaged by the tumor. There are a number of situations when it becomes necessary to create a direct communication between the cavity of any organ and the environment.

In this case, there are stomas - openings surgically formed on the skin, to which the edges of the desired cavity are sutured, depending on the location of the inoperable tumor that closes the lumen.

For example, a gastrostomy - if it is not possible to use the esophagus for nutrition: the stomach is sutured to the wall of the abdominal cavity and a hole is formed on the skin through which semi-liquid food is introduced.

The device of the gastrostomy

Colostomy and ileostomy.If the previous hole was intended to supply the patient, then this is the opposite. With a colostomy, a hole is removed from the colon to the skin of the abdomen, with an ileum during an ileostomy. The vital products leave through a colostomy or ileostomy in a special bag-kalopriemnik.

Colon resection with colostomy removal.

Ensuring respiratory function of the

tracheostomy. For tumors of the larynx, in order to prevent suffocation, a tracheostomy is performed - a hole is removed from the trachea on the skin through which a person can breathe.

Tracheostomy and tracheostomy procedure

Providing urination

Nephrostoma- a special hollow tube that performs the function of drainage in case of violations of the outflow of urine. It is installed in the renal pelvis through a puncture on the skin under the supervision of an ultrasound scan.

Nephrostoma

When possible - do not cut, but use an endoscope

When a tumor grows and involves any hollow organ (esophagus, stomach, bile duct, ureter, etc.), this can lead to compression of the walls of the organ, narrowing of the lumen and complete obstruction.

Often in such cases it is possible to install a stent - a metal or polymer mesh cylinder expander, which automatically straightens inside the body cavity and creates a frame to maintain sufficient clearance and patency.

Biliary stent (for bile duct)

Stents can be installed endoscopically. For this, you do not need to make large cuts, rather small punctures. A miniature video camera and instruments are introduced through a thin tube-endoscope into them: the doctor uses this camera to see all the manipulations on the screen and performs the operation “live”, under the additional control of an x-ray or ultrasound. Such a minimally invasive method allows you to perform serious operations without resorting to "big surgery". After such an operation, an order of magnitude less complications and faster rehabilitation.

And there’s no need, perhaps, to explain why stenting is better for any patient compared to applying, for example, a gastrostomy: we maintain a normal human life for a person, without having to eat “through a tube”.

With the help of stenting, we manage to maintain the physiological functions of many organs even in the late stages of the tumor process.

Normal removal of bile and treatment of obstructive jaundice. Stenting of the bile duct restores the unobstructed outflow of bile from the liver to the duodenum. Firstly, the patient will get rid of a dangerous condition: obstructive jaundice. It is caused by a violation of the outflow of bile, provokes an increase in the level of bilirubin in the blood and a toxic effect on the central nervous system. Secondly, the patient does not have to go with outward drains. Thirdly, the natural flow of bile will maintain normal bowel function. So one minimally invasive operation does a lot to maintain the quality of life.

Bile duct stenting with an endoscope

Providing the work of the esophagus and the ability to eat independently. We can stent the esophagus and stomach in cases when the tumor is located in the organ itself, or grows, squeezing it from the outside, or narrowing of the lumen was the result of earlier interventions or other injuries (scars from a chemical burn, for example).

The operation of the stent in the esophagus, squeezed by the tumor. The

installation of the stent literally “works wonders” from the point of view of patients.

Judge for yourself: the patient was brought on an intensive care unit with obstructive jaundice and stenosis of the esophagus, and was discharged after 10 days in a state where he can independently take food by mouth and digest it normally.

Remove everything and restore beauty. Remediation and reconstruction

When the tumor has not been operated on, and not very successfully treated with other methods, it continues to grow, and then begins to disintegrate. This tumor tissue can become infected, cause massive bleeding, necrosis, have a toxic effect on the patient's body, and greatly worsens his condition.

To prevent this, remove as much of the infected tumor tissue as possible. Such palliative operations in oncology are called rehabilitation. They are performed, for example, in breast cancer. The need for such operations occurs in 30-40% of women at stages III-IV. Also, such operations are carried out with the threat of decay and suppuration of tumors of other organs: for example, the liver, colon.

Often after volumetric surgical interventions with complete removal of the affected organ, subsequent reconstruction is required . For example, the mammary gland, parts of the face or parts of the intestines, bladder - to restore the body's vital functions.

This is extremely important for the patient’s psycho-emotional mood - so that he again feels like a normal person, with symmetrical mammary glands and the ability to go to the toilet without drains and urinals. To a large extent, it depends on whether a person will find joy in life and motivation to continue treatment.

With this article, we want, firstly, to remind you at this troubled time of how happy those of us whose body does not need the support of surgeons to eat or breathe.

And secondly, to show: even in advanced and severe cases, there are still quite a lot of opportunities to help the cancer patient, prolong life, remove or alleviate painful symptoms. Even if, according to forecasts, there is very little life left - there is a very big difference in how to live it. In quality, and not just in quantity. Palliative medicine - and palliative surgery in particular, today can do a lot for quality.

Be healthy!

Palliative surgery in oncology: how a surgeon can prolong and improve a patient’s life even without radical surgery

Why is it impossible to just excise a tumor?

– .

We can’t remove the cause - we cut the consequences. Symptomatic operations

When possible - do not cut, but use an endoscope

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