Stoma-related considerations in palliative patients

In the community there are about 200 000 people with a stoma. Some of these may have been performed as a palliative procedure to relieve a bowel obstruction, for example. Alternatively, the condition of the patient may have altered. A person with a stoma may, for many reasons, be approaching the end of life. There are a number of stoma-related issues that can occur at the end of life as a result of cancer treatment, such as skin around the stoma being damaged as a result of chemotherapy or changes in weight. In the palliative setting, patients may no longer be able to independently care for their stoma and may require assistance from the community nurse. Input from the community nurse may include information on changing stool consistency, as a result of disease progression or cancer treatment. Alternatively, nursing input might be necessary to train carers to perform stoma care. Community nurses can also provide knowledge to patients to improve understanding and decrease anxiety at the end of life.

TP6.2.13 A PEG insertion pathway for Motor Neurone Disease patients improves efficiency and patient outcomes

Aims Patients with Motor Neurone Disease (MND) often require a Percutaneous Endoscopic Gastrostomy (PEG) as a palliative procedure during the later stages of their illness, due to swallowing difficulties. More recently these are being inserted earlier before the inevitable decrease in nutritional intake and subsequent fall in albumin levels. This allows patients to eat food they enjoy rather than concentrating on maintaining intake. Insertion has traditionally been done with local anaesthetic and OGD, which can be difficult and traumatic. We propose a method of insertion using TIVA (Totally Intravenous Anaesthetic) in theatre with no intubation, performed by the surgical team, with a pathway including pre-operative anaesthetic assessment. Methods Data was collected from all PEG insertions performed in theatre from 1/1/2011 to 1/9/2019. MND patients following our pathway were compared to all other indications for PEG insertions. Length of stay (LOS), 30-day re-admission rates, 30-day, 90-day and 1-year mortality were analysed. Results 98 patients were identified. Median LOS was 3 days (mean 12.2) with a 3% 30-day mortality, 12.2% 90-day mortality and 34.7% 1-year mortality. In the MND group there were 27 patients. Median LOS was 2 days (mean 8.6) with a 7.4% (2 patients) 30-day mortality, which remained 7.4% at 90 days. There were 13 re-admissions (13.3%) overall compared to 0% in the MND group (p = 0.04 (Chi-squared test)). Conclusions PEG insertion under TIVA for MND patients is safe. A set pathway for admission and pre/post-insertion care increases efficiency with reduced length of stay and improves patient outcomes with no re-admissions.

Case report laparoscopy-assisted pre-pubic urethrostomy as a palliative procedure for resection of distal urethral tumor in a female dog

Background This paper presents the first described case of laparoscopy-assisted prepubic urethrostomy and laparoscopic resection of a tumor of the distal part of the urethra in a female dog as a palliative treatment. Case presentation An intact, 11 -year-old, mixed breed female dog, weighing 15 kg, was admitted with signs of urinary obstruction and difficulty with catheterization. Vaginal, rectal, and endoscopic examinations revealed a firm mass in the pelvic cavity at the level of the pelvic urethra. Ultrasound and computed tomography examination showed enlargement of the urethral wall (5.5 cm width and 3 cm thick), which was significantly restricting the patency of the urethra. The lesion affected only the distal part of the urethra without the presence of local or distant metastatic changes. The affected portion of the urethra was laparoscopically removed while performing pre-pubic urethrostomy with laparoscopy. The patient regained full consciousness immediately after the end of anesthesia, without signs of urinary incontinence. Histopathological examination of the removed urethra revealed an oncological margin only from the side of the bladder. In the period of 2.5 months after the procedure, the owner did not notice any symptoms that could indicate a postoperative recurrence, which was diagnosed three months after the procedure. Conclusions Pre-pubic urethrostomy can be successfully performed with the assistance of laparoscopy. The use of minimally invasive surgery will allow, in selected cases, removal of the urethral tumor, and in inoperable cases, to perform a minimally invasive palliative pre-pubic urethrostomy.

870 Surgical Outcomes of Primary and Two-Stage Atrioventricular Septal Defect (AVSD) Repair: A Single Institution Experience

Objective To examine the surgical outcomes of primary and two-stage repair of complete atrioventricular septal defect(AVSD). Method This retrospective study included 74 patients who underwent operation for balanced complete AVSD between January 2015 and December 2018 in National Heart Centre Kuala Lumpur. Patient demographics, types of procedure, post-op complications and follow-up atrioventricular (AV) valve function were analysed. Results Twenty-one patients (median age: 3 months(2.28-4.32months)), weight: 3.10kg( 2.7-3.82kg)) had Pulmonary Artery Banding (PAB) prior to complete AVSD repair. The post-banding weight of patients rose from 3.1kg to 6.4kg prior to complete repair. The rate of ventilator dependence decreased from 19.8 to 4.8%. There was no worsening of post-banding left AV valve insufficiency (5%) before the complete repair. There was no statistically significant difference in the outcomes after complete AVSD repair in both groups (mortality p = 0.133, morbidities p = 0.471). There was a trend towards higher left AV valve insufficiency in the PAB group over time (at discharge, 10 vs 12%; at 3-months, 12 vs 6%; at 1-year, 14 vs 11%). Similarly, the PAB group also demonstrated a trend towards higher rates of major post- operative complications (33 vs 21%) and in-hospital mortality (9.5 vs 1.9%). Conclusions PAB remained as an effective palliative procedure for patients who are not suitable for primary AVSD repair at the time of presentation. However, it is associated with a higher incidence of left AV valve insufficiency at follow up.

Balloon atrial septostomy through azygos vein in two cases of D-TGA with left atrial isomerism

Balloon atrial septostomy is a palliative procedure that is performed in D-transposition of great arteries when surgery is not immediately available. Although D-TGA and left isomerism association are rare, it is an important condition as the BAS procedure approach is unique. In this case report, we present two cases of D-TGA with left isomerism where BAS was performed due to restrictive atrial septal defect and lack of immediate availability of the paediatric cardiac surgeon.

COVID-19 Pandemic: Challenges, Impacts and Dilemmas in Surgical Oncology (Descriptive Longitudinal Study)

Background: The oncologic surgery patients constitute a highly susceptible group during COVID-19 pandemic. Aim: To determine how the COVID-19 pandemic affected the cases of surgical oncology, their frequency with reference to the pre-pandemic era and the challenges faced in general and in their management during the pandemic. Methodology: we conducted a descriptive longitudinal study, using consecutive non-probability sampling technique, estimating the number of cancer cases in our center, their management protocols keeping in view the local and international guidelines, resource availability and how the pandemic affected the dynamics of cancer surgery. Results: we received a total of 63 cancer cases from 1st march-31st august 2020, between age groups 29-70 years. 40 patients out of those 63 presented with complications and received early definitive surgery, where surgery could not be deferred due to the course of disease or complications. Rest of the 20 patients received either neoadjuvant chemotherapy, a palliative procedure or chemoradiotherapy, 2 patients tested COVID-19 positive, 1 non-cancer related mortality. We received 63 patients during our 6 months study time, compared with a total of 156 cancer cases received during the pre-pandemic 6 months period, showing significant decrease in frequency of cancer cases. Conclusion: Cancer cases with a chance of upgradation of disease stage due to delay or those complicated with obstruction or bleeding could not be deferred. Mandatory PCR COVID-19 testing of every admitted patient with a repeat test 48-72 hours before surgery. Early referral to corona care center if patient tests positive. Discussion of every case in MDM prior to decision making. Operating every case with complete SOPs. Keywords: COVID-19, surgical oncology, pandemic

Risk factors for the development of arrhythmias after the fontan surgery

Funding Acknowledgements Type of funding sources: None. Introduction Fontan surgery or total cavopulmonary connection is a palliative procedure for complex congenital heart disease with univentricular physiology, without the possibility of biventricular surgical correction. This surgery has a high mortality rate (70%), with heart failure and arrhythmias being the main causes of death. Objective Identify the pre, intra and post-surgical factors that may predispose to arrhythmias in patients undergoing to Fontan surgery. Methods We conducted a retrospective review of the patients who underwent a total cavopulmonary connection from January 2003 to December 2018. We performed an analysis employing the Chi-square test to determine which variables were associated with the development of arrhythmias. Results During the mentioned period, 115 patients underwent to Fontan surgery, of which 51.3% were women, the average age at the time of surgery was 8 years. The most frequent diagnosis was tricuspid atresia in 44 patients (38.2%), followed by pulmonary atresia in 18 patients (15.7%) and double outlet right ventricle in 14 patients (12.2%). Regarding the type of the procedures performed, 93.9% (n = 108) were total extracardiac cavopulmonary connection and 6.1% (n = 7) were intracardiac. Also, 8.6% (n = 10) were taken to fenestration, the mean size of the fenestration was 7 mm (7 ± 3 mm) After Fontan surgery, there was a high incidence of arrhythmias which was 38% (n = 44). 22 patients (50%) presented them in the late postoperative period, being this, the most frequent time for the appearance of arrhythmias. We found that the intracardiac surgery presented an OR of 4.423 (95% CI 0.819 - 23.879, p> 0.05), being not statistically significant. Instead, the bidirectional cavopulmonary shunt previous to the Fontan surgery presented an OR of 0.255 (95% CI 0.081 - 0.806, p <0.05) and on the other hand the QRS duration > 120 ms was significantly associated with the appearance of arrythmias with an OR 2.99 (95% CI 1.2-4.2, p <0.05). Conclusions In patients undergoing to Fontan surgery, the previous bidirectional cavopulmonary bypass is a protective factor for the development of arrhythmias. And an QRS duration > 120 ms is a parameter that predicts the apparence of arrhythmias. Abstract Figure. QRS INTERVAL POST FONTAN SURGERY

Outcome of loop cholecystojejunostomy as a palliative procedure in unresectable distal malignant biliary obstruction

Background: Up to 70-80% of patients with malignant biliary obstruction seek medical attention only at unresectable stage. Though R0 resection is the therapeutic modality, surgical palliation has a definite role for securing biliary bypass. Hepatico (choledocho) jejunostomy and cholecystojejunostomy are the procedures of choice. As loop CCJ is technically simple to perform as well as having less operating time and blood loss;anappealing choice. Aim of the current study was to assess the outcome of loop CCJ as a palliative procedure in unresectable distal malignant biliary obstruction.Methods: 25 patients who underwent loop CCJ for radiologically and histopathologically proven unresectable distal malignant biliary obstruction in GMC, Thiruvananthapuram, were studied for a period from 1st January 2015 to 31st December 2016. Each patient was followed up for 6 months post operatively for the occurrence of cholangitis, relief from pruritus, number of hospitalization, duration of hospital stay, postoperative 30 day mortality and life span. Pre and postoperative serum bilirubin were studied using paired t test. Palliative surgery outcome score was calculated to assess the outcome.Results: Serum bilirubin levels were significantly reduced postoperatively. Mean pre and post-operative total bilirubin values were 15.10±1.65 (mg/dl) and 4.30±3.04 (mg/dl) respectively with p<0.001. 80% had relief of pruritus and 96% were free of cholangitis 76% had a PSOS more than 0.7.Conclusions: Loop CCJ has acceptable outcome as a palliative option for surgical bypass to relieve jaundice, pruritus in patients with unresectable distal malignant biliary obstruction with a good PSOS. This procedure is technically simpler and having fewer incidences of post-operative cholangitis, pruritus, post-operative hospital stays as well as 30 day mortality.

Birth and Growth of Neuroimaging and Vascular Intervention at Sree Chitra Tirunal Institute for Medical Sciences & Technology, Thiruvananthapuram—Part II

This is the second part of the two-part paper on the history of development of neuroradiology at the Sree Chitra Tirunal Institute of Medical Sciences and Technology, Thiruvananthapuram. In this part, the authors describe the evolution of interventional procedures at their institute from the initial techniques of free-flow embolization as a palliative procedure for large arteriovenous malformations (AVMs) to the more refined techniques of selective embolization using microcatheters, calibrated leak balloons and liquid polymerizing embolic agents. The authors acknowledge the immense encouragement and support provided to them by the French neurointervention pioneers Prof. Luc Picard and Prof. Jacques Moret in this endeavor.

Patient-reported assessment of outcome after surgery for bone metastases

Regardless of prognosis, surgery is often considered in metastatic bone disease (MBD) as a palliative procedure to improve function and quality of life. Traditional focus on objective outcomes such as mortality is inappropriate in this group, and there is a drive to assess outcomes via patient-reported outcome measures (PROMs). This is an overview of current understanding of MBD outcomes and how this should influence future decision-making and research. The objectives of this review were to identify difficulties in measuring PROMs in the MBD patient population and explore alternatives to patientreported outcomes. We also provide an overview of current understanding of outcomes in MBD and how this should influence decision-making and direct research.