Download PDF
Clin Colon Rectal Surg
DOI: 10.1055/s-0045-1807756
Review Article

Palliation for Inoperable Infectious and Neoplastic Long-Term Surgical Complications

Peter A. Bryant
1   Department of Surgery, Vanderbilt University Medical Center, Medical Center North, Nashville, Tennessee
,
Myrick C. Shinall Jr.
2   Department of Surgery, Vanderbilt University Medical Center, Geriatrics Research, Education, and Clinical Center, VA Tennessee Valley Healthcare System, Medical Center North, Nashville, Tennessee
› Author Affiliations
› Further Information
Also available at
    Permissions and Reprints

Abstract

Inoperable complications from pelvic surgery or the progression of unresectable colorectal neoplasms may create a situation requiring a focus on quality of life over cure within a palliative care framework. This review outlines management strategies for some common, incurable, long-term sequelae patients of colorectal surgeons may experience, including advanced cancer-causing obstruction, bleeding, and pain; chronic anastomotic leak after pelvic surgery, including salvage techniques; and chronic pelvic pain after surgery. Strategies include palliative operations, endoscopic and minimally invasive techniques, and unique approaches to pain control and symptom management. The paper also reviews evidence on the benefit of palliative care specialists, when such specialists may be beneficial, as well as how the colorectal surgeon may facilitate decision-making in treatment decisions of incurable disease.

Keywords

colorectal cancer - palliative care - complications - anastomotic leak


Publication History

Article published online:
21 April 2025

© 2025. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Turner PS, Burke D, Finan PJ. Nonresectional management of colorectal cancer: multidisciplinary factors that influence treatment strategy. Colorectal Dis 2013; 15 (10) e569-e575
    PubMedSearch in Google Scholar
  • 2 Rothenberger DA. Palliative therapy of rectal cancer. Overview: epidemiology, indications, goals, extent, and nature of work-up. J Gastrointest Surg 2004; 8 (03) 259-261
    PubMedSearch in Google Scholar
  • 3 Rosen SA, Buell JF, Yoshida A. et al. Initial presentation with stage IV colorectal cancer: how aggressive should we be?. Arch Surg 2000; 135 (05) 530-534 , discussion 534–535
    CrossrefPubMedSearch in Google Scholar
  • 4 Esnaola NF, Cantor SB, Johnson ML. et al. Pain and quality of life after treatment in patients with locally recurrent rectal cancer. J Clin Oncol 2002; 20 (21) 4361-4367
    PubMedSearch in Google Scholar
  • 5 Ronnekleiv-Kelly SM, Kennedy GD. Management of stage IV rectal cancer: palliative options. World J Gastroenterol 2011; 17 (07) 835-847
    PubMedSearch in Google Scholar
  • 6 Wasserberg N, Kaufman HS. Palliation of colorectal cancer. Surg Oncol 2007; 16 (04) 299-310
    PubMedSearch in Google Scholar
  • 7 Quyn AJ, Solomon MJ, Lee PM, Badgery-Parker T, Masya LM, Young JM. Palliative pelvic exenteration: clinical outcomes and quality of life. Dis Colon Rectum 2016; 59 (11) 1005-1010
    CrossrefPubMedSearch in Google Scholar
  • 8 Cirocchi R, Trastulli S, Abraha I. et al. Non-resection versus resection for an asymptomatic primary tumour in patients with unresectable stage IV colorectal cancer. Cochrane Database Syst Rev 2012; 2012 (08) CD008997
    PubMedSearch in Google Scholar
  • 9 National Comprehensive Cancer Network. Colon Cancer (Version 5). 2024 . Accessed September 2, 2024 at: https://www.nccn.org/professionals/physician_gls/pdf/colon.pdf
    PubMedSearch in Google Scholar
  • 10 Muratore A, Zorzi D, Bouzari H. et al. Asymptomatic colorectal cancer with un-resectable liver metastases: immediate colorectal resection or up-front systemic chemotherapy?. Ann Surg Oncol 2007; 14 (02) 766-770
    CrossrefPubMedSearch in Google Scholar
  • 11 Law WL, Chan WF, Lee YM, Chu KW. Non-curative surgery for colorectal cancer: critical appraisal of outcomes. Int J Colorectal Dis 2004; 19 (03) 197-202
    PubMedSearch in Google Scholar
  • 12 Devlin JW, Skrobik Y, Gélinas C. et al. Clinical Practice Guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med 2018; 46 (09) e825-e873
    CrossrefPubMedSearch in Google Scholar
  • 13 Liang TW, Sun Y, Wei YC, Yang DX. Palliative treatment of malignant colorectal obstruction caused by advanced malignancy: a self-expanding metallic stent or surgery? A system review and meta-analysis. Surg Today 2014; 44 (01) 22-33
    PubMedSearch in Google Scholar
  • 14 Fiori E, Lamazza A, Schillaci A. et al. Palliative management for patients with subacute obstruction and stage IV unresectable rectosigmoid cancer: colostomy versus endoscopic stenting: final results of a prospective randomized trial. Am J Surg 2012; 204 (03) 321-326
    PubMedSearch in Google Scholar
  • 15 Ribeiro IB, Bernardo WM, Martins BDC. et al. Colonic stent versus emergency surgery as treatment of malignant colonic obstruction in the palliative setting: a systematic review and meta-analysis. Endosc Int Open 2018; 6 (05) E558-E567
    PubMedSearch in Google Scholar
  • 16 Al-Jundi W, Kadam S, Giagtzidis I. et al. Self-expanding metal stenting for malignant colonic tumours: a prospective study. Surg Sci 2011; 2 (03) 151-154
    PubMedSearch in Google Scholar
  • 17 Ripamonti C, Panzeri C, Groff L, Galeazzi G, Boffi R. The role of somatostatin and octreotide in bowel obstruction: pre-clinical and clinical results. Tumori 2001; 87 (01) 1-9
    PubMedSearch in Google Scholar
  • 18 Teriaky A, Gregor J, Chande N. Percutaneous endoscopic gastrostomy tube placement for end-stage palliation of malignant gastrointestinal obstructions. Saudi J Gastroenterol 2012; 18 (02) 95-98
    CrossrefPubMedSearch in Google Scholar
  • 19 Costi R, Leonardi F, Zanoni D, Violi V, Roncoroni L. Palliative care and end-stage colorectal cancer management: the surgeon meets the oncologist. World J Gastroenterol 2014; 20 (24) 7602-7621
    PubMedSearch in Google Scholar
  • 20 Bae SH, Park W, Choi DH. et al. Palliative radiotherapy in patients with a symptomatic pelvic mass of metastatic colorectal cancer. Radiat Oncol 2011; 6: 52
    PubMedSearch in Google Scholar
  • 21 Mueller K, Karimuddin AA, Metcalf C, Woo A, Lefresne S. Management of malignant rectal pain and tenesmus: a systematic review. J Palliat Med 2020; 23 (07) 964-971
    PubMedSearch in Google Scholar
  • 22 Rigor Sr BM. Pelvic cancer pain. J Surg Oncol 2000; 75 (04) 280-300
    PubMedSearch in Google Scholar
  • 23 Ventafridda V, Saita L, Ripamonti C, De Conno F. WHO guidelines for the use of analgesics in cancer pain. Int J Tissue React 1985; 7 (01) 93-96
    PubMedSearch in Google Scholar
  • 24 Ní Laoire Á, Fettes L, Murtagh FE. A systematic review of the effectiveness of palliative interventions to treat rectal tenesmus in cancer. Palliat Med 2017; 31 (10) 975-981
    PubMedSearch in Google Scholar
  • 25 Caulfield H, Hyman NH. Anastomotic leak after low anterior resection: a spectrum of clinical entities. JAMA Surg 2013; 148 (02) 177-182
    CrossrefPubMedSearch in Google Scholar
  • 26 Borstlap WAA, Westerduin E, Aukema TS, Bemelman WA, Tanis PJ. Dutch Snapshot Research Group. Anastomotic leakage and chronic presacral sinus formation after low anterior resection: results from a large cross-sectional study. Ann Surg 2017; 266 (05) 870-877
    CrossrefPubMedSearch in Google Scholar
  • 27 Bhama AR, Maykel JA. Diagnosis and management of chronic anastomotic leak. Clin Colon Rectal Surg 2021; 34 (06) 406-411
    Thieme ConnectPubMedSearch in Google Scholar
  • 28 Sharabiany S, Joosten JJ, Musters GD. et al. Management of acute and chronic pelvic sepsis after total mesorectal excision for rectal cancer-a 10-year experience of a national referral centre. Colorectal Dis 2024; 26 (04) 650-659
    PubMedSearch in Google Scholar
  • 29 Fraccalvieri D, Biondo S, Saez J. et al. Management of colorectal anastomotic leakage: differences between salvage and anastomotic takedown. Am J Surg 2012; 204 (05) 671-676
    PubMedSearch in Google Scholar
  • 30 Strangio G, Zullo A, Ferrara EC. et al. Endo-sponge therapy for management of anastomotic leakages after colorectal surgery: A case series and review of literature. Dig Liver Dis 2015; 47 (06) 465-469
    PubMedSearch in Google Scholar
  • 31 Mahendran B, Rossi B, Coleman M, Smolarek S. The use of Endo-SPONGE® in rectal anastomotic leaks: a systematic review. Tech Coloproctol 2020; 24 (07) 685-694
    PubMedSearch in Google Scholar
  • 32 Weidenhagen R, Gruetzner KU, Wiecken T, Spelsberg F, Jauch KW. Endoscopic vacuum-assisted closure of anastomotic leakage following anterior resection of the rectum: a new method. Surg Endosc 2008; 22 (08) 1818-1825
    CrossrefPubMedSearch in Google Scholar
  • 33 Robertson C, Savioli F, Shalli K. A novel endoscopic treatment for anastomotic leakage post anterior resection: Padlock over the scope clip. Int J Colorectal Dis 2018; 33 (01) 91-93
    PubMedSearch in Google Scholar
  • 34 Arezzo A, Verra M, Reddavid R, Cravero F, Bonino MA, Morino M. Efficacy of the over-the-scope clip (OTSC) for treatment of colorectal postsurgical leaks and fistulas. Surg Endosc 2012; 26 (11) 3330-3333
    PubMedSearch in Google Scholar
  • 35 Alsanea N, Alabbad S. Use of the endostapler for the treatment of non-healing sinus secondary to a dehisced colorectal anastomosis. Tech Coloproctol 2010; 14 (03) 249-251
    PubMedSearch in Google Scholar
  • 36 Feddern ML, Jensen TS, Laurberg S. Chronic pain in the pelvic area or lower extremities after rectal cancer treatment and its impact on quality of life: a population-based cross-sectional study. Pain 2015; 156 (09) 1765-1771
    PubMedSearch in Google Scholar
  • 37 Giglia MD, Stein SL. Overlooked long-term complications of colorectal surgery. Clin Colon Rectal Surg 2019; 32 (03) 204-211
    Thieme ConnectPubMedSearch in Google Scholar
  • 38 Christensen P, Im Baeten C, Espín-Basany E. et al.; MANUEL Project Working Group. Management guidelines for low anterior resection syndrome - the MANUEL project. Colorectal Dis 2021; 23 (02) 461-475
    CrossrefPubMedSearch in Google Scholar
  • 39 Chiarioni G, Asteria C, Whitehead WE. Chronic proctalgia and chronic pelvic pain syndromes: new etiologic insights and treatment options. World J Gastroenterol 2011; 17 (40) 4447-4455
    PubMedSearch in Google Scholar
  • 40 Hunter CW, Stovall B, Chen G, Carlson J, Levy R. Anatomy, pathophysiology and interventional therapies for chronic pelvic pain: a review. Pain Physician 2018; 21 (02) 147-167
    PubMedSearch in Google Scholar
  • 41 Quinn KL, Shurrab M, Gitau K. et al. Association of receipt of palliative care interventions with health care use, quality of life, and symptom burden among adults with chronic noncancer illness: a systematic review and meta-analysis. JAMA 2020; 324 (14) 1439-1450
    PubMedSearch in Google Scholar
  • 42 Ferrell BR, Temel JS, Temin S. et al. Integration of palliative care into standard oncology care: American Society of Clinical Oncology Clinical Practice Guideline update. J Clin Oncol 2017; 35 (01) 96-112
    CrossrefPubMedSearch in Google Scholar
  • 43 Morita T, Akechi T, Ikenaga M. et al. Late referrals to specialized palliative care service in Japan. J Clin Oncol 2005; 23 (12) 2637-2644
    PubMedSearch in Google Scholar
  • 44 Müller S, Fink M, Hense J. et al. Palliative care outpatients in a German comprehensive cancer center-identifying indicators for early and late referral. BMC Palliat Care 2022; 21 (01) 221
    PubMedSearch in Google Scholar
  • 45 Temel JS, Greer JA, Muzikansky A. et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010; 363 (08) 733-742
    CrossrefPubMedSearch in Google Scholar
  • 46 Yefimova M, Aslakson RA, Yang L. et al. Palliative care and end-of-life outcomes following high-risk surgery. JAMA Surg 2020; 155 (02) 138-146
    CrossrefPubMedSearch in Google Scholar
  • 47 Kavalieratos D, Corbelli J, Zhang D. et al. Association between palliative care and patient and caregiver outcomes: a systematic review and meta-analysis. JAMA 2016; 316 (20) 2104-2114
    CrossrefPubMedSearch in Google Scholar
  • 48 Bakitas M, Lyons KD, Hegel MT. et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial. JAMA 2009; 302 (07) 741-749
    CrossrefPubMedSearch in Google Scholar
  • 49 Zimmermann C, Swami N, Krzyzanowska M. et al. Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. Lancet 2014; 383 (9930) 1721-1730
    CrossrefPubMedSearch in Google Scholar
  • 50 Heller DR, Jean RA, Chiu AS. et al. Regional differences in palliative care utilization among geriatric colorectal cancer patients needing emergent surgery. J Gastrointest Surg 2019; 23 (01) 153-162
    CrossrefPubMedSearch in Google Scholar
  • 51 Kruser JM, Nabozny MJ, Steffens NM. et al. “Best Case/Worst Case”: Qualitative evaluation of a novel communication tool for difficult in-the-moment surgical decisions. J Am Geriatr Soc 2015; 63 (09) 1805-1811
    CrossrefPubMedSearch in Google Scholar
  • 52 Shinall Jr MC, Martin SF, Karlekar M. et al. Effects of specialist palliative care for patients undergoing major abdominal surgery for cancer: a randomized clinical trial. JAMA Surg 2023; 158 (07) 747-755
    PubMedSearch in Google Scholar
  • 53 Aslakson RA, Rickerson E, Fahy B. et al. Effect of perioperative palliative care on health-related quality of life among patients undergoing surgery for cancer: a randomized clinical trial. JAMA Netw Open 2023; 6 (05) e2314660
    PubMedSearch in Google Scholar