Journal of Palliative Care & Medicine
Open Access

Surgery is detrimental because it harms the human body by its very nature. The ideal surgical patient is one whose general health has undergone extensive review and been approved for operational intervention. The patient receives the most benefit while limiting any possible morbidity and death from the operational care of the condition. Attaining the aforementioned objective is particularly challenging when the patient has an advanced, terminal illness. The practitioner must be considerably more aware of the fine line between benefit and damage while caring for this patient population. Therefore, symptomatic alleviation must be the goal of palliative surgery or therapies rather than a cure. The ultimate objective of such operations should be the improvement of symptoms and general quality of life, in addition to being relatively low risk and easy to carry out. This article's goal is to cover the various palliative surgical treatments for symptom reduction in thoracic surgery, as well as their objectives and the circumstances under which they should be used. The report also examines each patient's data and, when applicable, conducts an evidence-based assessment of palliative thoracic surgery.

Unresectable esophageal cancer: Two-thirds of patients with the approximately 17,000 newly diagnosed instances of esophageal cancer each year in the United States are not candidates for an esophagogastrectomy because their illness was well advanced when they received their diagnosis. In the past, some people with terminal illnesses underwent surgical intervention. The main goal of these "bypass" surgeries was to treat patients' dysphagia. It is not unexpected that results were dismal, with median survival only being five months and in-hospital death ranging from 11% to 41.5% [1-3]. Contrarily, combination chemotherapy and radiation treatments for cancer that cannot be surgically treated are well tolerated and produce survival rates that are higher than those anticipated from these surgeries [4,5]. Present endoscopic technology has made instruments for palliation more accessible than surgical bypass, which is mostly of historical importance in the modern period. Among other things, current palliative measures are made to deal with dysphagia, tracheoesophageal fistulas, and bleeding. Esophageal stenting is very helpful for individuals who have severe dysphagia from the mass of the tumour. Self-Expanding Metal Stents (SEMS) and plastic stents are available as stent choices (SEPS). Early research on SEMS showed that the vast majority of patients experienced relief from dysphagia, with growth or overgrowth being the most frequent side effect [6]. Conio et al. [7] found an improvement in dysphagia symptoms utilising both SEMS and SEPS in a randomised controlled study of 100 patients with unresectable esophageal cancer. Final results showed that 100% of the SEPS group and 94% of the SEMS group had dysphagia that had improved by at least one grade. However, the SEPS group saw more issues, notably late stent migration.

Obstruction can occasionally result from an endoluminal tumour. Neodymium-doped yttrium aluminium garnet (Nd:YAG) laser debridement and photodynamic therapy are more widely used methods for removing blockage in these circumstances than stenting, which is a less effective modality for palliation (PDT). While the latter uses a chemical sensitizer that builds up in the tumour and is triggered by light to eliminate the tumour via a photochemical action, the former uses thermal ablation to do so. In a multicenter randomised study, 236 patients with unresectable esophageal cancer were randomly assigned to receive either PDT or Nd: YAG therapy for their blockage. The two treatment options provided similar alleviation from dysphagia, but the PDT group's objective tumour response at one month was noticeably better than the other two. Significantly more individuals in the PDT group encountered an unfavourable event in terms of consequences. It should be noted that patients receiving PDT therapy could exhibit skin hypersensitivity for one to two months following therapy and might get sunburns if they spend too much time in the sun. Overall, the researchers came to the conclusion that PDT was less invasive than laser debridement and had less side effects than Nd: YAG therapy while providing similar dysphagia alleviation [8]. For controlling bleeding from an unresectable esophageal tumour, the Nd: YAG laser and PDT are additional useful treatments [9,10]. Homs and colleagues randomised 209 patients with inoperable esophageal cancer to metal stent insertion vs single dose brachytherapy in a significant trial that aimed to examine gains in quality of life beyond merely relieving dysphagia. They then used a general and disease-specific questionnaire to rate the quality of life for each patient. The diseasespecific questionnaire showed that while patients receiving a single dose of brachytherapy saw a decline in their capacity to eat and relieve dysphagia over time, this decline was less pronounced than in the cohort who received stenting. Additionally, the general questionnaire's findings showed that brachytherapy outperformed other treatments in terms of enhancing patients' emotional, social, cognitive, and role functioning. Future research will undoubtedly continue to evaluate the diverse benefits of these several different technologies on quality of life beyond straightforward enhancements in dysphagia alleviation [11].

Chest wall tumors: Tumors on the chest wall can be either original lesions or metastatic in origin. These tumours can be very crippling owing to pain, bleeding, ulceration, and infection, regardless of their histology. For these reasons, individuals who are carefully chosen are given a major surgical resection. People should have their dietary needs addressed, stop smoking, and have pulmonary function tests that show they are physically healthy enough to undertake such procedures. These treatments should ideally not only be palliative but also, in most situations, result in the patient becoming disease-free. A large excision with 2 to 4 cm of circumferential substantially normal tissue is frequently necessary to achieve both of these objectives, followed by chest wall rebuilding. A plastic and reconstructive surgeon can help you achieve free or advanced flaps for soft tissue covering. Of course, before beginning such palliative procedures, each applicant must be carefully assessed. A dialogue with the patient and other medical professionals about the advantages of surgical resection vs palliative radiotherapy for pain complaints should start if preoperative PET/CT is beneficial for identifying the existence of distant metastatic illness [12]. Palliative radiation therapy is a viable alternative to surgery for patients with chest wall lesions who are physically unfit for surgery or who have oligometastatic illness, albeit it is outside the focus of this chapter.

Conclusion

Over the past 20 years, there have been significant advancements in the alternatives for the palliative therapy of thoracic illness. For many patients, the popularity and widespread use of esophageal and tracheobronchial stents have significantly reduced their symptoms. Additionally, knowledge of laser and photodynamic treatment has given management of blockage in both organ systems still another choice. As a consequence of randomised trials, evidence-based methods for the management of malignant pleural effusions have been developed. Despite these developments, it is nevertheless crucial for the thoracic surgeon to constantly be aware of the occasionally precarious clinical situation of these patients. Always start by taking the patient's preferences and level of tolerance into account before choosing the best method for symptom relief. Secondarily, one must think about what is most sensible from a cost-effectiveness perspective in the current healthcare environment. In a perfect scenario, the patient would receive the most clinically and economically advantageous palliation with the least amount of morbidity.

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