REVIEWPalliation of colorectal cancer
Introduction
Palliative care is defined by the World Health Organization (WHO) as ‘‘the active total care of patients whose disease is not responsive to curative treatment. Control of pain, other symptoms, and psychological, social, and spiritual problems is paramount. The goal of palliative care is achievement of the best quality of life for patients and their families’’ [1]. Palliation of advanced cancer requires the highest level of surgical judgment. In the traditional curative model of cancer therapy, prolongation of life is the ultimate primary goal. Towards that intent, treatment complications including patient discomfort, toxicity and even death are “acceptable” risks. In contrast, the primary objectives of palliative cancer treatment include control of symptoms, improvement or maintenance of quality of life, and cost effectiveness [2].
Colorectal cancer (CRC) is the second leading cause of cancer-related mortality in the United States, with 147,000 new cases and 57,000 deaths occurring each year. Approximately 20% of CRC patients will present with unresectable locally advanced or metastatic disease [3], [4], [5]. Moreover, approximately one-half of patients who underwent “curative” resection for localized disease will eventually die of metastatic disease [6].
The median survival for patients with stage IV CRC is between 6 and 9 months from the time of diagnosis [7]. During that time, patients may present with a variety of disease-related to psychological and physical symptoms such as obstruction, bleeding, perforation, pain, weight loss, and fatigue, all affecting and diminishing quality of life.
The goal of palliative intervention is directed at alleviating disease-related symptoms and improving the patient's quality of life. However, the indications for the appropriate use of these palliative interventions are not clearly defined. While symptom palliation may result in increased survival for some patients, it is not always appropriate to choose a palliative procedure based upon improved duration of survival alone. When considering the “best” palliative procedure, surgeons face a broad range of multidisciplinary treatment options. Reports of recent advances in systemic chemotherapy for CRC have demonstrated an almost 2 year median survival for patients with Stage IV [8]. Noncurative surgery may delay systemic chemotherapy that could otherwise result in regression of both the primary tumor and metastatic foci. The determination of the most effective palliative strategy in these patients is a compound decision that will significantly affect the patient and his family [9].
In an analysis of surgeons’ treatment selection for patients with advanced malignancies, McCahill et al. [10] found that patient age and comorbidities, aggressiveness of tumor biology including response to chemotherapy, local extent of disease, and severity of patient symptoms are the main factors that influence treatment plan decisions. As a key member of a multidisciplinary team, the surgeon's role in palliation of CRC may include local, segmental, or extensive surgical resection, fecal diversion, and endoscopic procedures. This review aims at presenting the current surgical palliative modalities that are available for patients with advanced CRC.
Section snippets
Patient evaluation
The goals of the evaluation of the patient with CRC are to make and/or confirm an accurate diagnosis, to stage the disease, to identify candidates for curative resection, and to plan palliative treatment for the ones who deemed unresectable for cure. Once the diagnosis of disseminated stage IV disease has been made, additional studies will likely add little to patient care, add to treatment costs and may worsen discomfort. In this setting, diagnostic studies should be minimized and performed
Surgical resection
Despite increasing public awareness, and wider promotion and acceptance of screening initiatives, 20% of patients with CRC will present with stage IV CRC [24], with a reported 8% 5-year survival [25]. About 75–90% of these patients will present with unresectable disease [26]. While there is consensus regarding noncurative resection for palliation of symptoms such as bleeding, perforation, and obstruction [27], the approach to asymptomatic patients or patients who present with symptoms that may
Fecal diversion
Approximately one-third of the patients with CRC presents with near or complete bowel obstruction [56]. Patients with bowel obstruction tend to have more advanced disease [57], and bowel obstruction per se is a poor prognostic sign [58]. At laparotomy 30% of patients who present with malignant bowel obstruction will be deemed unresectable due to extensive local or systemic disease, and/or associated comorbidities [59]. When patients present with acute malignant large bowel obstruction, an
Laparoscopic palliation
The advantages of laparoscopic surgery over open surgery include less incisional pain, faster recovery, and shorter hospital stay. Laparoscopic surgery is also thought to be less immunologically stressful due to attenuation of the perioperative operative stress response and its associated sequelae [72]. Laparoscopic assisted colon resection for CRC has been performed since the early 1990s [73]. Controversy mounted over the use of minimally invasive surgery for curative resection after a report
Endoscopic palliation
Patients with stage IV incurable CRC who are not candidates for surgery may benefit from endoscopic palliation including laser therapy and self-expanding metallic stents. Endoscopic laser therapy using the neodymium-doped yttrium aluminum garnet (Nd:YAG) laser has been used to palliate symptomatic colorectal lesions since the early 1980s. Laser treatment can successfully provide symptom relief for patients with bleeding, mucus discharge, or tenesmus and can effectively maintain luminal patency
Laser therapy
Patients with CRC who deem inoperable due to advanced disease or patients with potentially curable disease in whom surgery is precluded because of concomitant high-risk medical problems, may benefit from palliative endoscopic laser therapy [83]. Furthermore, endoscopic laser therapy has been used successfully to decompress obstructed left-sided colonic tumors as a bridge to surgical resection [84]. Nd:YAG laser ablation therapy was primarily introduced for obstructing esophageal lesions and was
Colonic self-expending metal stents
Despite improvement in colorectal screening programs up to 30% of patients with CRC will present with total or partially obstructing lesions [91], and malignant colonic obstruction is the primary cause for emergency large bowel surgery [92]. Most patients who present with malignant obstruction will have advanced disease [93] and will often be dehydrated with associated electrolyte disturbances and renal impairment. Surgical resection in the face of an acute malignant obstruction is associated
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Malignant bowel obstruction
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