Palliation

Many factors were involved in getting to our current standard of application for laparoscopy. Over the past 12 years, there have been significant technologic advances not only in the laparoscopic field but also in competing fields such as radiology and endoscopy. In many cases, procedures that previously required an operation can now be performed via radio-logically guided percutaneous procedures or endoscopic techniques. For example, a patient with an obstructing lesion of the upper rectum would previously have been treated with a diverting colostomy. Traditionally this was an open surgical procedure; in the mid-1990s, this procedure was frequently performed with a laparoscopic-assisted technique. However, it is now often possible to palliate the obstruction without having to use general anesthesia, using endoscopically placed stents or laser ablation of the tumor mass to prevent complete obstruction. Another procedure that has become less commonly performed laparoscopically is biliary bypass. Again, initially it was believed that a laparoscopic cholecystojejunostomy would be a desirable alternative to an open surgical bypass. However, the development of endoscopically placed biliary stents has made the former procedure nearly obsolete.

Because of these nonoperative alternative techniques, we have seen a decrease in enthusiasm for some of the initial laparoscopic applications of palliative procedures, and several palliative techniques for which there was initially great enthusiasm for laparoscopic applications are now only rarely used in our practice.

Despite this change, laparoscopy remains a significant treatment option for patients with gastrointestinal malignancies who are not candidates for percutaneous procedures. In other cases, however, it has clearly become our preference to perform percutaneous procedures as the primary treatment option whenever available in the palliative setting. This avoids the need for a general anesthetic and frequently allows these procedures to be performed on an outpatient basis, minimizing the disruption of the normal daily routine for patients with advanced disease. Additionally, it allows patients to proceed to their next phase of treatment in a more expeditious manner. Just as the recovery from laparoscopic procedures has been quicker and less stressful for the patient than the recovery from open surgical procedures, percutaneous procedures that avoid general anesthesia result in even less trauma to the patient and thus an even shorter recovery period. Furthermore, although many colonic obstructions can be treated with endoscopic techniques, many malignant intestinal obstructions still are not amenable to endoscopic palliation. For these patients, laparoscopic colostomies and bypasses are still frequently employed in our practice.

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