 Our keynote for this afternoon's surgery session is by Dr. Larry Gottlieb. Dr. Gottlieb is an internationally known plastic surgeon and professor of surgery at the University of Chicago. His clinical and research interests are in reconstructive microsurgery, the care of patients with burn injuries, difficult wounds. Dr. Gottlieb obtained his surgery training at Yale, went on to plastic and reconstructive surgery residency at the University of Southern California. And Dr. Gottlieb has been here for many years and is the most innovative surgeon that I know and is also faculty of the McLean Center and graduate of the McLean Fellowship. Now, as a small disclaimer, for those of you who may have weak stomachs, you may want to avert your eyes at certain points during this presentation. Dr. Gottlieb. Thank you, Peter. They specifically put me after lunch. Peter's talk on innovation is really important. I rarely do the same thing twice. Gretchen's talk was just great. I really loved it. I think those both will intertwine somewhat in this talk. And I didn't know exactly where to start and what the baseline of the balance of the audience would be, so I have some basic stuff and then somewhat thoughtful stuff. I have no financial conflicts of interest. I have nothing to disclose except most of you that know me know that I'm the ultimate optimist and frequently accused of wearing rose-colored glasses. So what is reconstructive surgery? It's not bound by an anatomic location, an organ system, or a tissue type, or an age of patient. Frequently we work with multidisciplinary teams. We close wounds and reconstruct parts. Most importantly, we problem-solve. And frequently problem-solving requires innovation. In its broadest sense, it's surgery to restore form and function. Everybody knows this. I felt compelled to put it in, in an ethics lecture, though we have our economy on justice of beneficence and a nominal feasence. And we need all these things to be ethical. An approach to the failure patient is the same. Simplistically, does the patient have enough information to make the best decision? Do the benefits, improve the quality of life, justify the cost, and is equally distributed to the difficult thing to decide? Will surgery alleviate the pain, restore function and appearance, and is it feasible and safe? Failure to surgery is usually defined as surgery done on a patient that has a terminal disease to improve the quality of life, and to help the patient live as comfortably as possible. Failure to surgery is not intended to cure people or even for a long life. It sounds very similar to what we do every day in reconstructive surgery, that is perform surgery to improve the quality of life. The key difference is performing the surgery on a dying or terminally ill patient, or perhaps on somebody that has metastatic disease. Some of the limitations that we have, and Peter talked about this a little bit, I think, because it's so complex and so highly technical, and there's a lot of emotions in this whole deal of a very sick patient, it's really hard to know if the patient is really gonna give informed consent. I haven't spent a lot of time with my patients before him, and I usually, although the nurses don't like it, right on the consent form, that Dr. Gottlieb's allowed to use his judgment and do what he thinks is right, which is different than the explicit things that we need to do, usually from a medical legal point of view of what we write down. But frequently we don't always know what we're gonna do, and if we do, it is so technical that the average person patient is not gonna understand it and be able to make an informed consent. And basically, I ask them to trust me. The other limitations and conflicts is the unrealistic expectations, which were somewhat mentioned before, but even in the non-palliative case, we have somebody with a bad scar, somebody with some sort of deformity that we are trying to fix. And we bend over backwards, tell them, this is not gonna get you to where you were. We're trying to improve upon it, but so many patients tell me the night before, and during it when they go to sleep during surgery, what they imagine and what they dream is that they're gonna come out perfect, even though they can intellectualize and say, I know that's not true, what they really want and what they dream about is coming out perfect. And this magical thinking goes both for the surgeon sometimes with unrealistic expectations of what they can do as well as to the patient as what they can get. Willingness is important. We've heard about willingness to the patient. The problem with palliative surgery frequently is willingness of the surgeon. And there are many surgeons that will not do palliative surgery, especially palliative reconstructive surgery. They say, you know, this patient should just die, should do comfort care, should do all these other things, and why should I put them through all this just for a month or two months or a day or whatever it may be. And then of course is being able to give the alternatives, whether it be interventional reality doing something rather than we doing it, or whether it be comfort care or a whole host of things. And these things are not really well defined, I'll declare it. In the past, palliative surgery terminology was used in a lot of different ways. If you resected the tumor and there was microscopic tumor left behind, you said, oh, it was palliative surgery, so to remember to respect. Or resection for a persistent tumor that was a treatment failure and you know that this is not gonna really be definitive curative, you say that was palliative surgery. But for the purpose of this presentation and the way we really should think is that this is more appropriately called non-curative surgery. And technically to be palliative surgery, it should address the symptom. So we have palliative surgery, which is improving quality of life, relieving symptoms. We have non-curative surgery, which is a curative intent, the asymptomatic patient that you're not able to really get to that, because you have positive margins. There's a third category that I am adding that is not described in any place that I know of. It's called even F. And the even F is the category of a really non-curative patient that even if it was palliative, you knew upfront you're not gonna cure him, you would do the same vibration. Most of the descriptions of palliative surgery and literature related to general surgery in the past. And it was diverting bowel obstruction or putting a gastrostomy or a pegged tube in or leaving pain with pancreatic cancer and diverting the bile or whatever it may be. And this is not a new concept. Bullrock, who's one of the fathers of surgery, said, I hope we have taken another good step towards securing unfortunate people with it to regard it as uncurable or if there should be recurrences of cancer at least alleviating their suffering for a time. This is in 1881. And Whipple, the father of pancreatic surgery. The considerable risk, i.e. operative mortality of over 30% is justified if they the patients can be made comfortable for a year or two in 1942. Each specialty has their common scenarios wherein palliative surgery is considered. Thoracic surgery is common scenarios of chest tubes for malignancy, resection for symptomatic mastastases, foul wounds, pain, bleeding, what we call tumor faction where tumors are fully apart. Orthopedic surgery, common scenarios of pathologic fractures, unstable spines, also the wounds, pain and bleeding, which is common in most surgical practices. GYN, very similar, painful bleeding, pelvic masses, tumor-poked debulking they will do, as well as bad wounds. Urologists have hydronephrosis from obstruction, venerary retention, and bad fungating wounds. Neurosurgery is a lot of literature on whether or not you operate on single brain metastases or not as a palliative operation. Unstable spines, of course, somebody could be a critical deal, but if they're gonna be paraplegic or quadriplegic in a day or two and they don't live for a week or two, doesn't make a difference. Foul wound, pain, bleeding, tumors as well. ENT, it had neck surgeons, Alan's a little bit, I don't know if he's specifically talking about ENT, has problems of mechanical airway obstruction, parotid rupture, bad wounds, and again, if the tumors go into the spine, possible quadriplegia. John Gaseford, Jack Gaseford, who's a plastic surgeon who does head and neck surgery, says palliative surgery procedures can be of greater magnitude than curative operations, so that to palliate, if there's more than you would do, if you would just do it a standard operation to take out a thyroid. The head and neck cancer surgeon must be ready, willing and able, but mostly willing. And that has been our biggest issue, I think, in many, many cases of having somebody that's willing. There is in the last analysis no absolute rule. The surgeon who accepts patients with cancer for their initial care is obligated to care for them throughout the course of their disease. The complication rate for palliative surgery intervention is high and not limited to major procedures. There's not a lot of literature about this, but at one major cancer center, 36% of the total annual 30-day operative mortality was from post-operative complications. And if you had one complication, you reduced the probability of symptom resolution to 17%, which is very, very scary. And the complications occurred with comparable frequency, regardless of the surgical specialty in this survey. There is currently no validated instrument of measuring quality of outcome for palliative surgical procedures. There's almost nothing in the literature that discusses palliative reconstructive surgery or palliative reconstructive microsurgery. We, S.E.Kabrua, just so walked in the room a little while ago, did a research project that's still in the works, who looked at a year of Alex and mine microsurgery for head and neck cancer. We had a very limited number of patients, but actually our morbidity was not greater. We had a hard time finding out what their quality of life was and whether or not we really will ever have a good sense of that without a multidisciplinary or multi-institutional prospective study, it's hard to tell. Frequently, as reconstructive surgeons and reconstructive microsurgeons will call to close the wound or reconstruct the part after an excavative surgical colleagues performed a palliative surgery to control pain, infection, or impending carotid rupture or asphyxiation. And we'll call right on the spot to try to fix it. Ideally, we would work as part of a multidisciplinary team to input prior to this so you can have this discussion of the surgery preoperatively. And the multidisciplinary teams ideally has a blade of surgeon, which sometimes is the plastic reconstructive surgeon, and then the reconstructive person who sometimes is the blade of surgeon, the medical oncologist, radiation oncologist, pain management teams, palliative care teams, and social work. How do we decide who should be operated on? That's a little typo and who we should not operate on. Use the four box method as described by Dr. Siegler when everybody in this room should know about, although in his description of the medical ethics is above the line. In palliative care, of course, it's angled where we have shared decision making with the most important thing is quality of life, safety, and patient preference. There are three main determinants for deciding if an operative candidate is good for a procedure or not. The patient's symptoms and personal goals, the expected impact of the procedure on the quality of life, the function and or prognosis, and the prognosis of the underlying disease or the tumor biology, which we frequently may, may not have a handle on at that time. There are four general patient groups that we see. There's elective immediate reconstruction after extirpation. There's elective delayed reconstruction. There's emergent immediate reconstruction like a crowded blowout. There's surgery for disease or injury, which is independent from their cancer. So some other thing came on but they have this ongoing metastatic disease, perhaps. Give some examples. 56 year old lady with metastatic laryngeal cancer had a pharyngeal cutaneous fistula, fist in her neck, in a scarred radiative field. Patient wants to be able to swallow before she dies. She's planning on hospice care. Referred by the ENT surgeon who said, if you can or will rebuild her pharyngeal suffocates, I'll excise it. Excise the fistula. The question is, what do we do? So we ask, what are symptoms and personal goals? Not able to swallow, or a goal is to swallow. Very simple. What's the impact, ability to swallow? One of the risks is pretty major surgery with somewhat of moderate risk if we can do it without too much hassle. And what is the prognosis for the underlying disease? And it's poor. The time for function of decline is months. But that doesn't make a difference. She just wants to be able to swallow before she dies. So what do we do? We took it to the OR. We used some local flaps to get some lining and we used a little flap from a chest, pedicle, internal mammary artery peripheral flap to close the skin on the outside. It all healed and sealed. Here she has 10 days post-op. She was hospitalized for three days. She was drinking water at one week. She was happy as can be. And she was getting nutritional supplements still by two feet. She wasn't eating Big Macs. But she was able to have the emotional benefits of having something by now. The Medisac disease progressed and she went to hospice one month post-op, very happy. When we have the elective immediate reconstruction of the death of the patient, there's an old catechid male with a painful draining chest wall metastasis. He was unable to get adequate pain control despite our best pain doctors. He was about to enter hospice as well. He was referred by the thoracic surgeon. He said, if you can, it will close it. I'll excise it. Again, asking the same questions. The goal is to relieve pain while the improvements of quality of life is to decrease the pain and the odor and have under reasonable risks. Prognosis is poor and the time to function with the client we really don't know. But we do similar operation. They cut it out, left him behind. We closed it. Pain was actually totally relieved. It was amazing. I really didn't think it was gonna happen, but it did. And he had an uncomplicated post-op course and went on. This is a 65 year old with metastatic thyroid cancer. Two were extended to the margins of bleeding the pleura and the lungs. The wound is tender but not painful. What do you do? Well, it doesn't have any pain unless it was closed wound and perhaps a psychological benefit. The advantage of closing the wound is avoiding dressing changes and nothing else would change. It is major surgery at very high risk that may not even be able to be accomplished safely. And the prognosis is really, don't know. I did a wound biopsy for a path of the culture to prevent the diagnosis and make sure we had no bacteria. I told him and his family that the only reason to operate was to avoid dressing changes and considering that the risk was too big to undergo surgery for no symptoms and I recommend that you continue to do dressing changes and refuse to do surgery on him. We have the relatively young woman who had a mastectomy. Ghost medicine, static disease. She's about to enter hospice. She says, doctor, I don't wanna die without a breast. What do you do? She wants psychological benefits of a breast. Improved body image. It's major surgery, reasonable risk. Especially autologous reconstruction. Prognosis is poor. Time to function with the decline, we don't know. Does she have enough information to make the best decision? I think so. Will the surgery alleviate her pain, which is not pain, but to restore her function and appearance and her quality of life? Yes. Is it feasible and safe? Yes. Is it justifiable? That's a big question. Your electrosurgical schedule is delayed for delayed breast reconstruction book for three to six months. You schedule for immediate ones of book for two to four months, for two to four weeks. Do you make her wait three to six months? Wish you would deteriorate and preclude surgery. Do you put a hire on the list? Do you make other patients wait? Do you refer to another less busy surgeon? What do you do if the other surgeon is not willing to perform palliative breast reconstruction? To make a long story short, she also ran with delayed otolarygist breast reconstruction. Then she said, doctor, I don't want to die without an apple. That was easy because it was an outpatient procedure. I'm gonna keep moving. So this is a person who I had reconstructed his esophagus also for cancer. He has metastatic disease in his lung and he presented with a new primary, which was a squamous cell customer of his head, of his scalp, his forehead. Dinsburg English, he's brought him by the daughter. And his symptoms were really, he was very embarrassed by the lesion and he was bleeding and he didn't want to go out. And the impact would be improved his body image and his sociability. His moderate risk of moderate surgery. And prognosis was poor, it's not a function of decline, we don't know. What do we do? So we excised with frozen section control, which is important because I didn't want it to recur because I didn't know how long it was gonna live. And my resident too was with me, said let's just put a skin graft on that. The simplest thing to do, all we wanna do is get out of the room. I said, well, if we put a skin graft on that, it's gonna look terrible. The skin grafts never look good. It's gonna be redacted, it's gonna be baked color, it's just not gonna look good, it's not gonna be any happier than with this tumor. But since he's gonna die from his other tumor anyway, why give him something that's gonna not look any better than he has now? So we basically did a small rotation, they'll kick local flap, which gave him, there's still a scar, but a much better aesthetic result, which he now feels pretty good about. What's the outcome? Two years later, it was then with new skin cancer of his ear, which I also took care of because you can't predict how people with metastatic disease, of which they kept increasing on his lungs, but it wasn't killing him, and he was living day to day and doing well. We talked about these definitions. And there's this last definition, which I think is, again, something that's really important, is even if, and it's operations which you would hope is curative in the symptomatic patient. But even if it was palliative, and you knew that up front, you would do the same operation. This is a gentleman who came into our ER, this is not from a third world country, with a neglected cancer of his cheek, his pathologic fracture, his tremendous pain, and mal-odorant infection, his surgery, chemotherapy, radiation, likely to cure him, not likely, but we're all gonna try. But even if we knew that all the surgery would fail, for sure, that the surgery would be palliative, I would do the same thing. And this is where I differed in many of my colleagues. He's malnourished, it was infected, and we had to do something. Everybody would agree we should do something. And you can cut it out and just slap on a piece of meat or take a piece of tissue and stuff like that and get it closed, and it would look terrible, even for the period of time that he's gonna live, or you can try to give him a semblance of a face. So after a week of two feedings, topical antimicrobial, systemic antibiotics, we're brought up to the operating room to take off the bad stuff. And what was our goals? Safe, reliable, swung closure, so indeed he can get chemo-radiation two weeks later, but also to give him a semblance of a face. So he can interact with his family, he can interact with the nursing care. And what I have found is that patients that are severely mal-deformed from things like this and big tumors, nurses don't really interact very well. And the hospital personnel don't interact very well. And if somebody looks more human and less deformed, they will. So after a very long complex operation with bone and soft tissue, we're able to give him this. We had reconstructed part of his mandible and his soft tissue. And if we went from there to there, and here he is at 10 days. Despite post-op chemotherapy and radiation, the tumor progressed, and two months later, he went on to hospice. But even if I knew that before, I would have done the same operation. What did surgery accomplish? We closed the wound, controlled the pain, made him look human, which facilitated interactions and care by the family, by the nurses, and the healthcare professor personnel. The American College of Surgeons talks about the tradition of heritage of surgery, emphasizing the control of suffering, is equal importance to the cure of disease. Almost at a time, so I'm gonna skip these two. And they have 10 statements of principles of palliative care, most important being out of the right of the competent patient for a surrogate to choose among treatments, including those that may or may not for a long life, identify the primary goals of care from the patient's perspective, and address how the surgeon's care can achieve the patient's objectives, and strive to alleviate pain and other burdens through physical and non-physical symptoms. Palliation is not the opposite of cure. It has its own distinct indications and goals that should be evaluated independently. Asymptomatic patients cannot be palliated. Patient or surrogate must acknowledge the personal relevance of the symptom to be treated. Goals must be clearly and honestly defined to the patient, family, and all members of the healthcare team. You must respect the patient's right to refuse treatment, and recognize the physician's responsibility to forego treatments that are futile. Meaningful survival expectations should exist before offering surgical palliation, but I'm not sure what that means. Does that mean a day? Does that mean a month? Six months, as most people talk about, but I think that's really up to discussion. Dr. Blake, Katie, is a great surgeon who writes a lot about palliation and is a moderate, very manate number of panels on it. And he talks about biology as king, patient sex, selection as queen, and technical maneuvers of the prince and princesses. In the case of the prince and princess, tries to usurp the throne, they almost always fail to overcome the powerful forces of the king, the biology, and the queen, patient selection. Thank you very much. Judge, of course, Tom Krizik, a great mentor and friend, and also I honor this lecture and his name as he passed away this year, and all the residents at the University of Chicago, who I can't do anything without. Thank you. Yeah, Larry, great talk. So the patient with the breast reconstruction, I think you did a tremendous kindness for her. I'm surprised insurance paid for that procedure, and it made me wonder, have you encountered that issue at all in these procedures regarding insurance willingness to pay for any kind of procedure on a patient who is terminally ill? You know, I agree totally with full disclosure and discussion with the patients that Gretchen was talking about. I don't necessarily believe that with insurance companies, although I never lie. I think there are ways to describe what you need to do, what the patient needs that if they ask, you tell them. But I've never had insurance companies say is this curative, it's not curative. I mean, you have a diagnosis of breast cancer or previous mastectomy, insurance companies will pay for reconstruction. If they asked me the question, I would tell them it in a truthful but somewhat different way that would tell the patient. Thanks for a really, really good talk. I guess I was really struck again by thinking again of Peter Uble's point this morning about language, because in the very last sort of set of principles that you outlined, which I think were very good and very relevant, you did not include the phrase that you had included a whole lot in your talk, which I find kind of troubling. And that's quality of life. Because who defines it? By what criteria? What it actually means, I'm never entirely sure of. So can you tell me more about what it means as different from just patient autonomy or relief of pain? I mean, those we can identify pretty specifically, right? Or promoting a better appearance as in some of your cases. To me, that's a kind of a nebulous term. I think you're absolutely right. And I think it also ties into Gretchen's talk. When patients can or cannot do what they wanna do, basically in life. My parents, they got at 93 years old and healthy still. But they told me many, many times, if they cannot have the quality of life they have now, they don't wanna keep going. And the question is having that discussion and spending the time with the family, with the patient to say every realistic about what you're gonna have at the end. I think it's the real thing. And you're absolutely right. I mean, it's really hard to talk to, like you said, but you're- For example, the quality of life is what they are going to define. They're defining it, absolutely. The word itself doesn't say that. But sometimes you have patients for whom you don't have any input like that. And then you're defined. Then we have to, exactly. And I think we do that all the time. And I think if we don't have a patient, a patient is intubator is not able to be able to talk to us about or confused, then we have, and there's no surrogate. And we have to make that decision. That's absolutely right. But if not, we all, I think, try to figure out what the patient really wants, not just in a procedure, but in a quality. Thanks, thanks.