Dear Dr:Paul,
Kindly provide answer for the following question-
You havejust performed a laparotomy on a 60 year old woman and found an inoperable adenocarcinoma of right ovary. justify your subsequent management.
Thanking you,
Dr: Tajunnisa
Posted by Sivapriya S.
The inoperability should be confirmed with the lead consultant . Being inoperable, adequate biopsy should be taken. the midline incision is closed in a mass closure to prevent postoperative wound dehiscence.The findings and the decision should be recorded in the notes.
Postoperative care should include measures to prevent DVT and pulmonary embolism because of the increased risk associated with the combination of old age, malignancy and prolonged hospitalisation. This should include good hydration, TED stockings and fractionated or unfractionated heparin in prophylactic dosage (e.g. 20-40 mg clexane once daily or 5000-10000 unfractionated heparin SC bid ). Any associated medical condition such as hypertension, ischaemic heart disease or DM should be carefully monitored with the help of the anaesthetist and a specialist physician. Adequate analgesia should be ensured.
The concern here is, palliative care , which is the active total care of patient whose disease is not responsive to curative treatment . The Multidisciplinary team( involving the gynaecologist, GP, social services, Macmillan nurses / Hospice and the woman?s family), involved in the care of the women at the cancer centre should take the decision to abandon curative treatment and give palliative care.The women and her family should be explained about the inoperability, advanced stage and 5 year survival (~25%) and that the treatment decisions should be centred around the woman?s perception of ?quality of life? .
Pain control is achieved using the WHO ladder approach.Initially, oral drugs,should be given round-the-clock basis.Mild ? moderate pain could be managed with Non-opioid analgesic (Aspirin, NSAIDs, acetaminophen) plus adjuvant drug.If pain persists or increases, Weak opioid analgesic (codeine, hydrocodone, oxycodone) plus non opioid drug plus adjuvant drug are used. For persistant pain, Strong opioid analgesic (morphine, dihydromorphone,oxycodone, Trans-dermal therapeutic system ? Fentanyl patch) plus non-opioid analgesic plus adjuvant drugs are used. Non pharmacological method like TENS should be considered for pain relief. Cognitive techniques help patients think differently about their pain while behavioural techniques help her develop skills to cope with pain.
Vomiting is managed be with antiemetics and corticosteroids. Corticosteroids can be used to enhance analgesia and elevate mood and have anti-inflammatory, anti-emetic activity and stimulate appetite.
In the event of bowel obstruction, surgery (including per-cutaneous gastrostomy) may be effective . Otherwise the aim should be to eliminate nausea and colic and reduce vomiting to 1-2 episodes per day. Hyoscine has anti-emetic effects and reduces GI secretions. Intestinal secretions and colic may also be reduced using octreotide.
Ascites is managed with paracentesis but becomes progressively difficult and would be required at more frequent intervals. Other treatments are diuretics (spironolactone / frusemide), corticosteroids or peritoneovenous shunting.
It is essential to ensure the location of treatment in discussion with the woman and her family , Whether care at home / hospice is preferred to hospital care . The family or carers should be involved in the decision making in circumstances where the woman is unable to express herself , and regarding decisions on resuscitation status . Psycho-social support should be given to the woman and the carers.
