Clinical Challenges in Emergency General Surgery: Cancer Emergencies

Behind The Knife: The Surgery Podcast

Join Drs. Ashlie Nadler, Jordan Nantais and Graham Skelhorne-Gross as they tackle Cancer Emergencies.
Case 1 - Learning Points:

1. These are complex patients and multidisciplinary care should be provided with input from oncology.
2. A step-up approach should be used, starting with medical management prior to considering surgery in appropriate patients.
3. Highly selected patients may benefit from surgery, namely those with a high performance status, a prognosis of months if the bowel obstruction was resolved, minimal carcinomatosis, and a single transition point. Diversion, bypass, or resection are all options, but a patient’s capacity to heal related to recent systemic therapy needs to be taken into account.
4. Consent for surgery should focus on goals of care, quality of life, and achievable outcomes, and highlight the inherent risk in patients with advanced disease and a limited lifespan.

Case 2 - Learning Points:

1. Colorectal malignancy is an exceedingly common cause of general surgical emergency and requires a thoughtful, systematic approach
2. The role of stenting as a bridge to surgery in obstructing distal colon malignancy is somewhat controversial but can help to avoid permanent stomas; however there is some potential risk of perforation and possibly disease recurrence
3. Treatment decisions should take place in the context of an informed discussion with the patient and consideration of both quantity and quality of life whenever possible
4. Consistent involvement of a multidisciplinary team, including radiology, enterostomal therapy, and surgical oncology can be extremely useful in guiding complex decisions

References:

1. Shariff F, Bogach J, Guidolin K, Nadler A. Malignant Bowel Obstruction Management Over Time: Are We Doing Anything New? A Current Narrative Review. Ann Surg Oncol. 2021 Oct 18. doi: 10.1245/s10434-021-10922-1. Epub ahead of print.
2. Ripamonti C, Gerdes H and Easson A. Management of malignant bowel obstruction. Eur J Cancer 2008 May;44(8):1105-15
3. Chen, T, Huang, Y. & Wang, G. Outcome of colon cancer initially presenting as colon perforation and obstruction. World J Surg Onc 15, 164 (2017).
4. Olmsted C, Johnson A, Kaboli P, et al. Use of palliative care and hospice among surgical and medical specialties in the Veterans Health Administration. JAMA Surg. 2014;149(11):1169–75.
5. Dunn GP, Martensen R, Weissman D. Surgical palliative care: a resident’s guide. Essex: American College of Surgeons; 2009.
6. Biondo S, Martí-Ragué J, Kreisler E, et al. A prospective study of outcomes of emergency and elective surgeries for complicated colonic cancer. Am J Surg. 2005;189:377–83.
7. National Comprehensive Cancer Network. https://www.nccn.org/. Accessed October 15, 2021.
8. Shariat-Madar B, Jayakrishnan TT, Gamblin TC, Turaga KK. Surgical management of bowel obstruction in patients with peritoneal carcinomatosis. J Surg Oncol. 2014 Nov;110(6):666-9. doi: 10.1002/jso.23707.

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