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Palliative Surgery for Cancer in Southwest Nigeria

Babatunde Ayoade, Abimbola Oyelekan, Oluwabunmi Fatungase, Chigbundu Nwokoro, Babatunde Salami, Adeleke Adekoya

Department of Surgery, Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria

Correspondence to: Dr Babatunde Ayoade, PO Box 17, Sagamu, Ogun, Nigeria; email: teruayoade@yahoo.co.uk

Abstract

Background: Most patients with cancer in the low-income environment present late, when the chances of cure are remote. Palliative care which includes surgery is needed to improve quality of life and minimize suffering and emotional disturbances associated with end of life. Methodology: Retrospective study of palliative surgery cases over five years. Data extracted included demographic features, diagnosis, procedure carried out, clinical status at 30 days postoperative, and survival. Results: 1,581 patients were operated over the study period. 227 patients were operated for malignancies; of these 91 patients (40%) had palliative procedures. The diagnoses in palliative surgery cases: prostate cancer 50 patients (54.9%), breast cancer 14.3%, stomach cancer 9.9%, and others. Indications for surgery were: urinary bladder outlet obstruction 46.1%, pleural effusion 14.3 %, obstructive jaundice 13.2%, and others. Bilateral total orchidectomy was performed in 50.5%, tube thoracostomy in 14.3%, laparotomy and biopsy in 11%. Thirteen patients (14.3%) died postoperatively; 57 patients (62.6%) were alive and well at 30 days after surgery. Survival period was <1 to 53 months with a mean of 8 months. Conclusion: Palliative surgery is useful in some patients with cancer. Facilities for less invasive procedures should be improved.

Key words: Palliative surgery, Cancer, Outcome

Ann Afr Surg. 2019; 16(2):55–58

DOI: http://dx.doi.org/10.4314/aas.v16i2.3

Conflicts of Interest: None

Funding: None

© 2019 Author. This work is licensed under the Creative Commons Attribution 4.0 International License.

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Introduction

Cancer is a major cause of mortality worldwide and was responsible for 9.6 million deaths in 2018 (1). About 53% of cancer mortality and 44% of cancer cases occur in countries with a low or medium human development index (HDI) (2). In Africa, cancer is an emerging public health concern. The International Agency for Research on Cancer (IARC) estimated that slightly over 1.05 million new cases and about 700,000 cancer deaths occurred in Africa in 2018; it is projected that 2.12 million cases and 1.43 million cancer deaths will occur by 2040 (3). Cancer care in low-income countries is bedevilled by many problems including late presentation, poor health facilities, ignorance, poor socio -economic status, adverse religious and cultural factors, with overall poor outcome (4–6). Most cancers in the low -income environment present late when chances of cure are remote even if the best treatment is available. Palliative care is needed to improve quality of life and minimize the suffering and emotional disturbances associated with end of life. Palliative care as defined by the World Health Organization is “an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual” (7).Palliative care involves measures to improve quality of life and minimize suffering but not necessarily to prolong life (7). Palliative surgery is generally defined as procedures that are carried out to control symptoms and improve quality of life without consideration for overall survival (8). Common troublesome symptoms in cancer patients include pain, haemorrhage, vomiting, obstruction of hollow viscus (bowel, biliary tract, urinary tract) and inability to move. In high HDI countries, varieties of surgical techniques are available for symptom control and improvement of quality of life in patients with advanced cancers. These include minimal-access techniques such as endoscopy, laparoscopy, interventional radiology and open surgery. Most of these techniques are not available in resource-limited environments of low HDI countries like Nigeria. Most reports on surgical oncology worldwide focus on curative procedures with little mention of outcome of palliative surgery (9). Despite the above, cancer patients in need of palliative surgery in low HDI countries still have surgical procedures done, but reports of these efforts are few. This work reports on the spectrum of palliative surgical procedures carried out on cancer patients managed by the Surgery Department of Olabisi Onabanjo University Teaching Hospital Sagamu, Nigeria, and their outcomes.

 

Methods

Olabisi Onabanjo University Teaching Hospital, Sagamu, is a 290-bed tertiary care facility located halfway between the densely populated cities of Lagos and Ibadan in southwest Nigeria. The hospital receives patients from the two cities  and surrounding communities. The hospital has a surgical oncology unit, a well-established histopathology service, radio-diagnostic services equipped with CT scan, ultrasonography, mammography machines, digital x-ray machines with facilities for screening, and well-equipped hematology and chemical pathology laboratories. The hospital offers diagnostic and therapeutic services—ablative surgery and chemotherapy for solid and hematological malignancies, but a radiotherapy or separate facility for palliative care is lacking. This was a retrospective study of all patients who had palliative surgery from 1 January 2013 to 31 December 2017, on account of cancer confirmed by histopathology. Palliative surgery was defined as procedures carried out for symptom control and improvement in quality of life without consideration for overall survival (8).Using this definition, one of the authors identified the cases; cases whose planned procedure at surgery was modified were included. The theatre register was used to identify cases, and case notes were retrieved from the Health Information Management