PURPOSE: Single-port laparoscopic techniques can be optimized with confined incisions. This approach has an intraoperative advantage of excellent visualization of the correct intestinal segment for exteriorization, along with direct visual control of the extraction to avoid twisting. However, only a few studies have verified the efficacy of the technique. Thus, this study assessed the results of single-port laparoscopic stoma creation for fecal diversion, specifically focusing on feasibility, safety, and efficacy.
METHODS: Patients who underwent single-incision enterostomy performed by a single surgeon were included. Data on demographics, indications for and chosen procedure, and operation results were retrospectively collected and analyzed.
RESULTS: Between April 2015 and January 2018, a total of 13 patients (8 males, 5 females) with a mean age of 57.7 years (range, 41-83 years) underwent single-port ileostomy creation. The most common reason for diversion was palliative ileostomy for colon obstruction or fistula from peritoneal malignancy (n = 12), followed by colonic fistula with necrotizing pancreatitis (n = 1). There were no cases of conversion to open or multiport laparoscopic surgery. The mean operative time was 54 minutes (range, 37-118 minutes), and the median length of hospital stay was 8 days (range, 2-211 days). A postoperative complication, aspiration pneumonia, was documented in 1 patient and treated conservatively. The mean duration of bowel movement was 0.7 days (range, 0-4 days). All stomas had good function, and there was no 30-day mortality.
CONCLUSION: Single-port laparoscopic ileostomy in patients with a palliative setting could be a safe and feasible option for fecal diversion.
BACKGROUND: Gastrointestinal symptoms, including nausea, vomiting, bowel obstruction, ascites, constipation, and anorexia, are common and often refractory in advanced cancer patients. The palliation of gastrointestinal symptoms is important in improving the quality of life of cancer patients, as well as that of their families and caregivers. Currently published clinical guidelines for the management of gastrointestinal symptoms in cancer patients do not comprehensively cover the topics or are not based on a formal process for the development of clinical guidelines.
METHODS: The Japanese Society for Palliative Medicine (JSPM) developed comprehensive clinical guidelines for the management of gastrointestinal symptoms in cancer patients after a formal guideline development process.
RESULTS: This article summarizes the recommendations along with their rationale and a short summary of the development process of the JSPM gastrointestinal symptom management guidelines. We established 31 recommendations, all of which are based on the best available evidence and agreement of expert taskforce members.
DISCUSSION: Future clinical studies and continuous guideline updates are required to improve gastrointestinal symptom management in cancer patients.
BACKGROUND: Specialty palliative care (PC) is underutilized for patients with end-stage liver disease (ESLD). We sought to examine hepatologists' and gastroenterologists' attitudes about PC for patients with ESLD.
METHODS: We conducted a cross-sectional survey of hepatologists' and gastroenterologists' who provide care to patients with ESLD recruited from the American Association for the Study of Liver Diseases membership directory. Using a questionnaire adapted from prior studies, we examined physicians' attitudes about PC and whether these attitudes varied based on patients' candidacy for liver transplantation. We identified predictors of physicians' attitudes about PC using linear regression.
RESULTS: Approximately one-third of eligible physicians (396/1236, 32%) completed the survey. Most (95%) believed that centers providing care to patients with ESLD should have PC services, and 86% trusted PC clinicians to care for their patients. Only a minority reported collaborating frequently with inpatient (32%) or outpatient (11%) PC services. Most believed that when patients hear the term PC, they feel scared (94%) and anxious (87%). Most (83%) believed that patients would think nothing more could be done for their underlying disease if a PC referral was suggested. Physicians who believed that ESLD is a terminal condition (B=1.09, p = 0.006) reported more positive attitudes about PC. Conversely, physicians with negative perceptions of PC for transplant candidates (B = -0.22, SE = 0.05, p < 0.001) reported more negative attitudes toward PC.
CONCLUSION: Although most hepatologists' and gastroenterologists' believe that patients with ESLD should have access to PC, they reported rarely collaborating with PC and had substantial concerns about patients' perceptions of PC. Interventions are needed to overcome misperceptions of PC and promote collaboration with PC clinicians for patients with ESLD.
BACKGROUND & AIMS: Despite evidence for the benefits of palliative care (PC) referrals and early advance care planning (ACP) discussions for patients with chronic diseases, patients with end-stage liver disease (ESLD) often do not receive such care. We sought to examine physicians' perceptions of the barriers to PC and timely ACP discussions for patients with ESLD.
METHODS: We conducted a cross-sectional survey of hepatologists and gastroenterologists who provide care to adult patients with ESLD, recruited from the American Association for the Study of Liver Diseases 2018 membership registry. Using a questionnaire adapted from prior studies, we assessed physicians' perceptions of barriers to PC use and timely ACP discussions; 396 of 1236 eligible physicians (32%) completed the questionnaire.
RESULTS: The most commonly cited barriers to PC use were cultural factors that affect perception of PC (by 95% of respondents), unrealistic expectations from patients about their prognosis (by 93% of respondents), and competing demands for clinicians' time (by 91% of respondents). Most respondents (81%) thought that ACP discussions with patients who have ESLD typically occur too late in the course of illness. The most commonly cited barriers to timely ACP discussions were insufficient communication between clinicians and families about goals of care (by 84% of respondents) and insufficient cultural competency training about end-of-life care (81%).
CONCLUSION: There are substantial barriers to use of PC and timely discussions about ACP-most hepatologists and gastroenterologists believe that ACP occurs too late for patients with ESLD. Strategies are needed to overcome barriers and increase delivery of high-quality palliative and end-of-life care to patients with ESLD.
OBJECTIVE: Delays in specialized palliative care (PC) consultation in end-stage liver disease (ESLD) patients may be explained by clinician attitudes toward PC. Our aim is to assess the attitudes of hepatology and liver transplant (HLT) and PC clinicians toward PC consultation and consultant roles in ESLD patient care.
METHODS: Clinician members of HLT and PC professional societies were surveyed. Using a five-point Likert scale, they rated their comfort level toward various PC consultant roles and their agreement with triggers for and reasons to defer PC consultation. Change in attitudes toward PC consultation resulting from liver transplant (LT) eligibility was evaluated.
RESULTS: A total of 311 HLT (6.2%) and 379 PC (8.1%) clinicians completed the survey. The vast majority of HLT clinicians (>80%) were comfortable if PC consultants palliate symptoms, provide support, or facilitate advance care planning in LT-ineligible patients. LT eligibility reduced HLT clinician comfort toward all PC consultant roles, except supportive care. A vast majority of PC clinicians (>90%) were comfortable assuming all PC roles, except pain management without opioids (43-51%). About 80% of HLT clinicians agree with PC consultation in LT-ineligible patients with decompensated cirrhosis or hepatocellular carcinoma (HCC), compared to 20-30% if LT ineligible. Common justifications for deferring PC consultation included mild disease, LT eligibility, unavailability of PC specialists, and lack of addressable palliative issues.
CONCLUSIONS: Barriers to specialized PC consultation in ESLD include HLT clinician discomfort with PC consultant roles, patients' LT eligibility, perception that PC is end-of-life care, unclear triggers for PC consultation, and concern about opioid-based pain palliation.
BACKGROUND: Liver disease represents the third commonest cause of death in adults of working age and is associated with an extensive illness burden towards the end of life. Despite this, patients rarely receive palliative care and are unlikely to be involved in advance care planning discussions. Evidence addressing how existing services meet end-of-life needs, and exploring attitudes of patients and carers towards palliative care, is lacking.
AIM: To explore the needs of patients and carers with liver disease towards the end of life, evaluate how existing services meet need, and examine patient and carer attitudes towards palliative care.
DESIGN: Qualitative study - semi-structured interviews analysed using thematic analysis. Settings/participants: A total of 17 participants (12 patients, 5 bereaved carers) recruited from University Hospitals Bristol.
RESULTS: Participants described escalating physical, psychological and social needs as liver disease progressed, including disabling symptoms, emotional distress and uncertainty, addiction, financial hardship and social isolation. End-of-life needs were incompatible with the healthcare services available to address them; these were heavily centred in secondary care, focussed on disease modification at the expense of symptom control and provided limited support after curative options were exhausted. Attitudes towards palliative care were mixed, however, participants valued opportunities to express future care preferences (particularly relating to avoidance of hospital admission towards the end of life) and an increased focus on symptomatic and logistical aspects of care.
CONCLUSION: The needs of patients with liver disease and their carers are frequently incompatible with the healthcare services available to them towards the end of life. Novel strategies, which recognise the life-limiting nature of liver disease explicitly and improve coordination with community services, are required if end-of-life care is to improve.
BACKGROUND: When patients with dementia develop acute surgical abdomen, patients, surrogates, and surgeons need accurate prognostic information to facilitate goal-concordant decision making. Palliative care can assist with communication, symptom management, and family and caregiver support in this population. We aimed to characterize outcomes and patterns of palliative care utilization among patients with dementia, presenting with abdominal surgical emergency.
METHOD: We retrospectively queried the National Inpatient Sample for patients aged >50 years with dementia and acute abdominal emergency who were admitted nonelectively 2009-2013, utilizing ICD-9-CM codes for dementia and surgical indication. We characterized outcomes and identified predictors of palliative care utilization.
RESULTS: Among 15,209 patients, in-hospital mortality was 10.2%, the nonroutine discharge rate was 67.2%, and 7.5% received palliative care. Patients treated operatively were less likely to receive palliative care than those who did not undergo operation (adjusted OR = 0.50; 95% CI 0.41–0.62). Only 6.4% of patients discharged nonroutinely received palliative care.
CONCLUSION: Patients with dementia and acute abdominal emergency have considerable in-hospital mortality, a high frequency of nonroutine discharge, and low palliative care utilization. In this group, we discovered a large gap in palliative care utilization, particularly among those treated operatively and those who are discharged nonroutinely.
Cet article présente le cas d'une femme âgée de 78 ans atteinte d'un cancer de l'oesophage. Il montre comment l'admission en soins palliatifs peut soulager les symptômes ressentis, notamment les nausées et les vomissements.
Cet ouvrage, écrit par un médecin de St Christopher, décrit le soutien et les soins qui peuvent être apportés aux patients en fin de vie mais aussi à leurs familles. Les traitements médicaux sont abordés dans les chapitres sur le contrôle de la douleur, sur les problèmes respiratoires, sur les problèmes intestinaux. Le traitement de la souffrance psychique est abordé dans les chapitres sur le psycho-social, sur la spiritualité et sur la souffrance. Une dernière partie est consacrée à l'évolution des soins palliatifs, à l'équipe de soins palliatifs et à l'évaluation des services de soins palliatifs.