**2.2 Bleeding**

Bleeding can be a life-threatening complication in pediatric oncology patients, necessitating rapid blood transfusions and/or definitive hemorrhage control (by surgery, embolization, or devascularization) [48]. Bleeding was recorded in 12.7% of the investigated population (particularly in hematological patients) in the UK Children's Cancer Study Group/Pediatric Oncology Nurses Forum Survey of 2006 [49], but only a handful of them required surgical operations. Selective arterial embolization (SAE) may be a safer and more successful method of treating acute hemorrhages in children with cancer than surgery, which can be too intrusive and carry a high risk of morbidity and mortality in patients with severe illnesses [50].

### **2.3 Bowel obstruction**

In oncological children, bowel blockage normally progresses over time, although it can also be abrupt. Symptoms are connected to irregular intestinal transit (abdominal distension, bilious/fecaloid vomiting, and dehydration) and can quickly affect the patient's clinical state and the quality of life [51]. Bowel obstruction can be caused by a variety of factors, including tumor growth compressing the gut, intra-luminally blocking masses, radiotherapy side effects, past surgery complications, or harsh medical treatment creating intestinal stenosis or occlusion. The goal of treatment should be to relieve abdominal distention, clear the blockage (restore bowel continuity and/or bypass the "obstacle"), and avoid consequences (dyselectrolytemia, bacterial overgrowth, and perforation) as well as respiratory distress (caused by increase of intra-abdominal pressure) [52]. Even while an intestinal stoma can be a source of additional trauma for oncological children and their parents, it can also help to improve the quality of life by providing a viable option for nutritional needs (through gastrostomy), bolus or continuous enteral feedings. Although most patients tolerate bolus feeding, intolerance can manifest itself in the form of vomiting, severe abdominal distension, excessive gastric residuals, or diarrhea. If this is the case, continual feedings are required, especially in patients who are at high risk of aspiration or have poor absorption [53].

#### **2.4 Urinary obstruction**

Urinary obstruction occurs in nearly 10% of adults with advanced primary or metastatic intra-abdominal cancer, according to recent literature; no data on this issue has been documented in the pediatric population. Pelvic neuroblastoma, vesical or prostatic rhabdomyosarcoma, abdominal Burkitt lymphoma, non-Hodgkin lymphoma, retroperitoneal germ cell tumors, diffuse desmoplastic tumor, and peritoneal metastatic disease are the most common cancers that can cause urinary obstruction in children. Furthermore, periureteral fibrosis, a long-term side effect of chemo and radiation therapy, may exacerbate the situation. Urinary blockage can be influenced by a variety of factors, including: tumor development caused by recurrent, metachronous, or metastatic disease; tumor blockage caused by extraluminal carcinomatosis or

bulk; tumor intramural growth; tumor direct adhesion or kinking. Urinary blockage symptoms include abdominal pain, oliguria/anuria, ascites increasing hydronephrosis, and a high serum creatinine level. It denotes a situation that necessitates immediate urine relief or diversion (depending on the degree of obstruction) using:

*Open urinary diversion*: Surgical alternatives include laparotomy for tumor debulking and/or urinary tract resection with anastomosis or stoma and suprapubic cystostomy for individuals with a favorable prognosis, good performance level, and a single site of obstruction.

*Retrograde ureteral stent*: In individuals with a short life expectancy, a percutaneous nephrostomy tube, such as an internal double J nephro-ureteric stent (double J) or an internal/external nephroureteral stent (NUS), is advised [54].

*Nephrostomy tube*: In patients who are not candidates for surgery, a percutaneous nephrostomy should considered.

There are currently few data on the true occurrence of this complication in intra-abdominal malignancies, resulting in a lack of therapy guidelines [55, 56]. Even in these circumstances, a multidisciplinary team of specialists is needed, including pediatric surgeons, urologists, radiologists, interventionists, and medical oncologists.

#### **2.5 Malnutrition**

Malnutrition is an unfavorable side effect of cancer treatment. Weight loss happens in 41.3% of children with cancer, and nutritional supplementation is required in some cases. In many circumstances, nutritional needs are met by administering total parenteral nutrition (TPN) through central venous catheters; in other cases, enteral feeding via a nasogastric/orogastric tube or gastrostomy/jejunostomy is an option [57, 58].

#### **2.6 Vascular access**

Vascular access is a major concern in the treatment of children with cancer [59–62]. Vascular access can be divided into two categories:


#### **2.7 Fluid collections**

Persistent ascites is uncommon in children and is usually caused by past surgery or congenital lymphatic system problems. To minimize abdominal distension, diaphragm raising, and respiratory difficulty, refractory ascites may necessitate surgical interventions. Fluid accumulation in other organ systems (chest, heart, liver, etc.) can lead to organ dysfunction, failure, and, in the worst-case scenario, multi-organ failure.

When medical treatments (bed rest, diet changes, drugs, and fluid restriction) fail, surgical options include fluid drainage or shunting (paracentesis, pleurocentesis, cardiocentesis, chest drains, perito-venous shunt, transjugular intrahepatic portosystemic shunt—TIPS), and even organ transplantation [63]. Every procedure must be

incorporated in a wider vision of palliative care, balancing between the best therapy and the quality of life of the kid.

While ultrasound-guided paracentesis is normally reserved for patients who are toward the end of their lives [64], cuffed tunneled peritoneal catheters can be used for long-term external drainage in patients who have a longer life expectancy. A peritoneal catheter joined to a subcutaneous port or completely implanted peritoneovenous (PVS) shunting (such as the Denver shunt) may be used as an alternate instrument for intermittent aspiration in rare cases [65].

Malignant pleural effusion is also a major issue in cancer children's palliative care. The most common treatments for treating oncological children with life-threatening pleural effusions are repeated thoracentesis, pleurodesis, or insertion of pleural drainage [66, 67].

### **2.8 Intracranial hypertension**

Solid organ tumors account for around 30% of all malignancies in children, with brain tumors being the most frequent. Intracranial hypertension is the most aggressive indicator of central nervous system (CNS) neoplasms, and it can produce neurological symptoms such as seizures, worsening levels of awareness, and debilitation [68]. Shunting (ventriculo-peritoneal or ventriculo-atrial shunting) to reduce intracranial pressure can improve the quality of life, and drainage to reduce pressure (EVD-external ventricular drain) can be performed if shunting is contraindicated. These surgical operations must be proposed with caution, taking into account all parties involved in the child's palliative care plan. Each surgical intervention in a successful palliative care plan should strike a balance between proper pain and symptom control and avoiding unnecessary extension of suffering [69].

#### **2.9 Respiratory complications**

Almost 11% of advanced tumors in children cause upper respiratory tract compression [70]; in these circumstances, a tracheostomy should be performed to alleviate child discomfort, allow more effective airway suctioning and simpler movement, and simplify the capacity to speak and feed orally. Caregivers and patients should always be included in the surgical planning process to ensure the best stoma management and an acceptable quality of life, free of prejudice, and prejudice [71, 72].

#### **2.10 Infections**

Infections should be managed using the same principles as palliative care for children with cancer. Infections must be treated aggressively in order to eliminate the cause of infection (e.g. debridement, abscess drainage, and wound care). Blood cultures are required if central line-associated bloodstream infections (CLABSI) are suspected, and if confirmed, a decision on whether to remove, replace, or leave the line in place should be made [73].

#### **2.11 Selective intra-tumoral/intra-lesional therapies**

The surgical team in the palliative care program for children with cancer should not overlook this issue. The intra-arteriolar chemo-infusion by super-selective catheterization of the involved area in retinoblastoma is a well-known example [74]; transcatheter selective arterial chemoembolization (TACE) as adjuvant preoperative treatment for unresectable or chemoresistant hepatoblastoma is another one [75].
