Current management of surgical oncologic emergencies

Gastroduodenal Perforation in Cancer Patients: Association with Chemotherapy and Prognosis

Background: Gastroduodenal perforation stands out as one of the complications in cancer patients. Despite its high mortality, its characteristics are still poorly described. This study aimed to evaluate the characteristics and outcomes of cancer patients who had gastroduodenal perforation, and the influence of chemotherapy (CMT) in these cases. Method: A retrospective analysis of patients who underwent emergency surgery with an intraoperative finding of gastroduodenal perforation. Patients who performed CMT within 60 days before perforation were considered as the CMT group. Results: Among 45 patients included, 16 (35.5%) were classified as the CMT group and the remaining 29 (64.5%) patients as the non-CMT group. There was no difference between the groups regarding sex, age, BMI, comorbidity, and laboratory exams. ECOG 2-3 was significantly more frequent in the CMT group (68.8% vs. 34.5% p = 0.027). Major postoperative complications were similar between both groups (75% vs. 58.6%, p = 0.272). The sepsis of abdominal focus was the main postoperative complication. The 30-day mortality was 55.6%, with no difference between non-CMT and CMT groups (62.5% vs. 51.7%, respectively; p = 0.486). A multivariate analysis of risk factors showed that only an age of ≥65 years was related to 30-day mortality. Conclusions: Patients with gastroduodenal perforation and oncologic treatment present high mortality, regardless of receiving recent CMT.

Factors influencing the delivery of cancer pathways: a summary of the literature

PURPOSE

The study aims to summarise the literature on cancer care pathways at the diagnostic and treatment phases. The objectives are to find factors influencing the delivery of cancer care pathways; to highlight any interrelating factors; to find gaps in the literature concerning areas of research; to summarise the strategies and recommendations implemented in the studies.

DESIGN/METHODOLOGY/APPROACH

The study used a qualitative approach and developed a causal loop diagram to summarise the current literature on cancer care pathways, from screening and diagnosis to treatment. A total of 46 papers was finally included in the analysis, which highlights the recurring themes in the literature.

FINDINGS

The study highlights the myriad areas of research applied to cancer care pathways. Factors influencing the delivery of cancer care pathways were classified into different albeit interrelated themes. These include access barriers to care, hospital emergency admissions, fast track diagnostics, delay in diagnosis, waiting time to treatment and strategies to increase system efficiency.

ORIGINALITY/VALUE

As far as the authors know, this is the first study to present a visual representation of the complex relationship between factors influencing the delivery of cancer care pathways.

Causes of death after emergency general surgical admission: population cohort study of mortality

Background

A substantial number of patients treated in emergency general surgery (EGS) services die within a year of discharge. The aim of this study was to analyse causes of death and their relationship to discharge diagnoses, in patients who died within 1 year of discharge from an EGS service in Scotland.

Methods

This was a population cohort study of all patients with an EGS admission in Scotland, UK, in the year before death. Patients admitted to EGS services between January 2008 and December 2017 were included. Data regarding patient admissions were obtained from the Information Services Division in Scotland, and cross-referenced to death certificate data, obtained from the National Records of Scotland.

Results

Of 507 308 patients admitted to EGS services, 7917 died while in hospital, and 52 094 within 1 year of discharge. For the latter, the median survival time was 67 (i.q.r. 21–168) days after EGS discharge. Malignancy accounted for 48 per cent of deaths and was the predominant cause of death in patients aged over 35 years. The cause of death was directly related to the discharge diagnosis in 56.5 per cent of patients. Symptom-based discharge diagnoses were often associated with a malignancy not diagnosed on admission.

Conclusion

When analysed by subsequent cause of death, EGS is a cancer-based specialty. Adequate follow-up and close links with oncology and palliative care services merit development.

The impact of urgent neurosurgery on the survival of cancer patients

Background:

Patients with cancer are subject to all neurosurgical procedures of the general population, even if they are not directly caused by the tumor or its metastases. We sought to evaluate the impact of urgent neurosurgery on the survival of patients with cancer.

Methods:

We included patients submitted to neurosurgeries not directly related to their tumors in a cancer center from 2009 to 2018. Primary endpoints were mortality in index hospitalization and overall survival.

Results:

We included 410 patients, 144 went through elective procedures, functional (26.4%) and debridement (73.6%) and 276 urgent neurosurgeries were performed: one hundred and sixty-three ventricular shunts (59%), and 113 intracranial hemorrhages (41%). Median age was 56 (IQR = 24), 142 (51.4%) of patients were metastatic, with 101 (36.6%) having brain metastasis. In 82 (33.7%) of the urgent surgeries, the patient died in the same admission. Urgent surgeries were associated with mortality in index hospitalization (OR 3.45, 95% CI 1.93–6.15), as well as non-primary brain tumors (OR 3.13, 95% CI 1.48–6.61). Median survival after urgent surgeries was 102 days, compared to 245 days in the control group (Log rank, P < 0.01). Lower survival probability was associated with metastasis (HR 1.75, 95%CI 1.15–2.66) and urgent surgeries (HR 1.49, 95% CI 1.18–1.89). Within the urgent surgeries alone, metastasis predicted lower survival probability (HR 1.75, 95% CI 1.15–2.67).

Conclusion:

Conditions that require urgent neurosurgery in patients with cancer have a very poor prognosis. We present concrete data on the magnitude of several factors that need to be taken into account when deciding whether or not to recommend surgery.

Comparison of colonic stents, stomas and resection for obstructive left colon cancer: a meta-analysis

BACKGROUND

Emergency surgery (ES) is the standard-of-care for left-sided obstructing colon cancer, with self-expanding metallic stents (SEMSs) and diverting colostomies (DCs) being alternative approaches. The aim of this study was to review the short- and long-term outcomes of SEMS versus ES or DC.

METHODS

Embase and Medline were searched for articles comparing SEMS versus ES or DC. Primary outcomes were survival and recurrence rates. Secondary outcomes were peri- and postoperative outcomes. SEMS-specific outcomes include success and complication rates. Pooled odds ratio and 95% confidence interval were estimated with DerSimonian and Laird random effects used to account for heterogeneity.

RESULTS

Thirty-three studies were included, involving 15,224 patients in 8 randomized controlled trials and 25 observational studies. There were high technical and clinical success rates for SEMS, with low rates of complications. Our meta-analysis revealed increased odds of laparoscopic surgery and anastomosis, and decreased stoma creation with SEMS compared to ES. SEMS led to fewer complications, including anastomotic leak, wound infection, ileus, myocardial infarction, and improved 90-day in-hospital mortality. There were no significant differences in 3- and 5-year overall, cancer-specific and disease-free survival. SEMS, compared to DC, led to decreased rates of stoma creation, higher rates of ileus and reoperation, and led to longer hospital stay.

CONCLUSIONS

SEMS leads to better short-term outcomes but confers no survival advantage over ES. It is unclear whether SEMS has better short-term outcomes compared to DC. There is a lack of randomized trials with long-term outcomes for SEMS versus DC, hence results should be interpreted with caution.

Outcomes following small bowel obstruction due to malignancy in the national audit of small bowel obstruction

INTRODUCTION

Patients with cancer who develop small bowel obstruction are at high risk of malnutrition and morbidity following compromise of gastrointestinal tract continuity. This study aimed to characterise current management and outcomes following malignant small bowel obstruction.

METHODS

A prospective, multicentre cohort study of patients with small bowel obstruction who presented to UK hospitals between 16th January and 13th March 2017. Patients who presented with small bowel obstruction due to primary tumours of the intestine (excluding left-sided colonic tumours) or disseminated intra-abdominal malignancy were included. Outcomes included 30-day mortality and in-hospital complications. Cox-proportional hazards models were used to generate adjusted effects estimates, which are presented as hazard ratios (HR) alongside the corresponding 95% confidence interval (95% CI). The threshold for statistical significance was set at the level of P ≤ 0.05 a-priori.

RESULTS

205 patients with malignant small bowel obstruction presented to emergency surgery services during the study period. Of these patients, 50 had obstruction due to right sided colon cancer, 143 due to disseminated intraabdominal malignancy, 10 had primary tumours of the small bowel and 2 patients had gastrointestinal stromal tumours. In total 100 out of 205 patients underwent a surgical intervention for obstruction. 30-day in-hospital mortality rate was 11.3% for those with primary tumours and 19.6% for those with disseminated malignancy. Severe risk of malnutrition was an independent predictor for poor mortality in this cohort (adjusted HR 16.18, 95% CI 1.86 to 140.84, p = 0.012). Patients with right-sided colon cancer had high rates of morbidity.

CONCLUSIONS

Mortality rates were high in patients with disseminated malignancy and in those with right sided colon cancer. Further research should identify optimal management strategy to reduce morbidity for these patient groups.

Efficacy of loop colostomy construction for acute left-sided colonic obstructions: a cohort analysis

PURPOSE

Acute primary resection as treatment for left-sided colonic obstruction (LSCO) is notorious for its high morbidity and mortality rates. Both stenting and loop colostomy construction can serve as a bridge to surgery, hereby avoiding the high morbidity and mortality rates associated with emergency resections. This study aims to investigate the safety of a loop colostomy in patients presenting with acute LSCO.

METHODS

Retrospective analysis of all patients that received a loop colostomy for LSCO between 2003 and 2015 was performed. Primary outcomes were mortality, major morbidity (Clavien-Dindo grades III-IV) and minor morbidity (Clavien-Dindo grades I-II).

RESULTS

One hundred forty-six patients presenting with acute LSCO received a diverting colostomy. After colostomy construction, mortality occurred in four patients (2.7%) and major complications were reported in 20 patients (13.7%). In 61 patients, the diverting colostomy served as a palliative measure, because of metastatic disease or unfitness for major surgery. The remaining 85 patients all underwent delayed resection, resulting in an overall mortality, major morbidity and minor morbidity of 6.9% (n = 6), 14.0% (n = 12) and 26.7% (n = 23), respectively.

CONCLUSIONS

Diverting colostomy construction is a minimally invasive and safe treatment option for LSCO. It can serve as a definite palliative measure, as well as a bridge to elective surgery. A diverting colostomy as a bridge to surgery might even be a valid alternative for emergency resections, since mortality and morbidity rates following colostomy construction and delayed resection appear lower than reported outcomes following primary resection.

Deviating colostomy construction versus stent placement as bridge to surgery for malignant left-sided colonic obstruction

BACKGROUND

Acute colonic decompression using a deviating colostomy (DC) or a self-expandable metal stent (SEMS) has been shown to lead to fewer complications and permanent stomas compared to acute resection in elderly patients with malignant left-sided colonic obstruction (LSCO). However, no consensus exists on which decompression method is superior, especially in patients treated with curative intend. This retrospective study therefore aimed to compare both decompression methods in potentially curable LSCO patients.

METHODS

All LSCO patients treated with curative intent between 2004 and 2013 in two teaching hospitals were retrospectively identified. In one institution, a DC was the standard of care, whereas in the other all patients were treated with SEMS.

RESULTS

In total, 88 eligible LSCO patients with limited disease and curative treatment options were included; 51 patients had a SEMS placed and 37 patients a DC constructed. All patients eventually underwent a subsequent elective resection. In sum, 235 patients were excluded due to benign or inoperable disease. No significant differences were found for hospital stay, morbidity, disease-free and overall survival and mortality. Major complications were seen in 13/51 (25.5 %) patients in the SEMS group and were mostly due to stent dysfunction (n = 7). Also, one stent-related perforation occurred. Major complications occurred in 4/37 (10.8 %) patients in the DC group, including abdominal sepsis (n = 3) and wound dehiscence (n = 1). Long-term complication rate was significantly higher in the DC group (29.7 vs. 9.8 %, p = 0.01), mainly due to a high incisional hernia rate. Fewer patients had a temporary colostomy following elective resection after SEMS placement (62.2 vs. 17.6 %, p < 0.01). Permanent colostomy rate was not significantly different.

CONCLUSION

SEMS and DC are both effective decompression methods for curable LSCO patients with comparable short- and long-term oncological outcomes; however, more surgical procedures are performed after DC due to an increased number of temporary colostomies and incisional hernia repairs.