The role of palliative surgery in gynecologic cancer cases

Abstract

The decision to undergo major palliative surgery in end-stage gynecologic cancer is made when severe disease symptoms significantly hinder quality of life. Malignant bowel obstruction, unremitting pelvic pain, fistula formation, tumor necrosis, pelvic sepsis, and chronic hemorrhage are among the reasons patients undergo palliative surgeries. This review discusses and summarizes the literature on surgical management of malignant bowel obstruction and palliative pelvic exenteration in gynecologic oncology.

Figure 1.

Intraoperative images of malignant bowel obstruction. Dilated, engorged, and hyperemic loops of small (A) and large (B) intestine typically found proximal to the site of obstruction.

Figure 2.

Diagnostic imaging for bowel obstruction. (A): Gastrointestinal obstruction series includes a supine (top) and upright (bottom) image showing dilated bowel, air-fluid levels, and lack of air in rectum. (B): Computed tomography scan depicted massively dilated bowel juxtaposed with collapsed loops. (C): Gastrografin (diatrizoic acid) enema demonstrated the transition point in a large bowel obstruction.

Figure 3.

Management algorithm for small and large bowel obstructions in women with gynecologic malignancies. Unresolved indicates no relief of nausea, vomiting, or abdominal pain within 7 days of nasogastric tube placement. Resolved indicates relief of nausea, vomiting, or abdominal pain within 7 days of nasogastric tube placement. Abbreviations: AXR, abdominal x-ray; IVF, intravenous fluids; LBO, large bowel obstruction; NGT, nasogastric food; NPO, nil per os (nothing by mouth); PEG, percutaneous endoscopic gastrostomy; SB, small bowel; SBO, small bowel obstruction.

Figure 4.

Operative options for malignant bowel obstruction. (A): Resection of tumor mass with anastomosis of healthy proximal and distal bowel. (B): Bypass of tumor mass without resection. (C): Bypass of tumor mass by creation of ostomy using bowel proximal to the malignant obstruction.

Figure 5.

Palliative total pelvic exenteration. (A): Outline of perineal incision encompassing vulvar lesion. (B): Perineum after removal of pelvic structures. (C): Perineum after reconstruction with ventral rectus abdominus myocutaneous flap. (D): External view of specimen including vulva, vagina, perineal body, and anus. (E): Internal view of specimen including bladder, uterus, and rectum removed en masse. (F): Abdomen after creation of ileal conduit and diverting end colostomy.