Background
Oncologic surgical emergency may be defined as an acute, potentially life-threatening condition arising from cancer pathology, e.g., obstruction of hollow viscera, bleeding from the tumor, or its treatment such as cecal perforation in a neutropenic patient. Understanding the pathophysiology and prognosis of the surgical condition the patient presents with is therefore very important for appropriate management and improving outcomes. Broadly, cancer patients present with three main emergencies: obstruction, infection, and bleeding. The common emergency oncosurgeries are listed in Table 33.1 .
| Airway Emergencies |
| Airway obstruction and stridor from upper aerodigestive tract cancers |
| Tracheobronchial tree obstruction |
| Hemorrhage from upper aerodigestive tract cancers |
| Abdominal Problems |
| Acute intestinal/gastric outlet obstruction |
| Biliary tract obstruction |
| Hematemesis from upper GI malignancies |
| Perforations (GI and hematolymphoid tumors) |
| Choriocarcinoma leading to hemorrhage |
| Intraabdominal/intrathoracic leaks/hemorrhage |
| CNS Problems |
| Raised intracranial pressure (due to intracranial tumors, intracranial bleed with hematolymphoid malignancies) |
| Malignant spinal cord compression |
| Others |
| Malignant pathologic fractures |
Triage
Depending on the anatomic site of the problems and the resultant severity of their symptoms, the urgency of the situation can be decided. The World Society of Emergency Surgery study group initiative on Timing of Acute Care Surgery (TACS) classification described the nature of emergency surgeries and the ideal time for surgery. Prioritizing care of patients in need of surgical interventions is based on the color-coding system ( Table 33.2 ), which is used for injured patients requiring surgery in trauma centers. Similarly, the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) also classified the timing of intervention for emergency surgeries ( Table 33.3 ). Though these classifications and timelines are not meant for emergency oncosurgeries, they can be easily adopted for this purpose. In an excellent review, Eschamann and colleagues note the advantages of TACS classification. It allows continuous feedback via a regularly updated surgical plan, monitoring of the classifying urgency according to patients’ clinical condition, and ensures that the patient status is communicated, with the proviso of being time-dependent, i.e., urgent, immediate, etc., in an emergency. The World Society of Emergency Surgery study group notes some limitations of the NCEPOD classification system. The surgery and main symptoms outlined in NCEPOD may not always match the clinical situations. Factors other than pathophysiology processes, such as psychologic factors and quality of life issues, should influence the urgency of the surgery. For example, a body image issue may be the main issue for a young woman scheduled for breast reconstructive surgery for a malignant lesion. The TACS also has the following important advantages: adoption and consistent adherence to the triage system for oncosurgical emergencies will ensure that time to surgery (TTS) can be made into a quality improvement tool. Thus the actual timing to surgery (aTTS) can be checked against the ideal time to surgery (iTTS). This ratio, if lower than 1, indicates that the surgery occurred within the “ideal time.” A ratio higher than 1 indicates delayed surgery; the Acute Care Surgery team and management can then take measures to improve compliance and engage in a quality improvement cycle.
| Timing—iTTS From Diagnosis | Possible Clinical Scenarios (TACS) | Color Code | Note |
Immediate surgery | Bleeding emergencies | Immediate life-saving surgical intervention, resuscitative laparotomy. | |
| Within 1 h | Incarcerated hernia, perforated viscus, diffuse peritonitis, soft tissue infection accompanied with sepsis | Surgical intervention as soon as possible, but only after resuscitation (within 1–2 h). Administration of antibiotics upon diagnosis: no delay. | |
| Within 6 h | Soft tissue infection (abscess) not accompanied with sepsis | Administration of antibiotics upon diagnosis: no delay. | |
| Within 12 h | Appendicitis (local peritonitis), cholecystitis (optional) | Administration of antibiotics upon diagnosis: no delay. | |
Within 24 or 48 h | Second-look laparotomy | Schedule in advance. Intervention should occur during day time. |
| Immediate | Immediate life (1A), limb or organ-saving intervention (1B)—resuscitation simultaneous with intervention. Normally within minutes of decision to operate. Life-saving, other, e.g., limb or organ saving. |
| Urgent | Intervention for acute onset or clinical deterioration of potentially life-threatening conditions, for those conditions that may threaten the survival of limb or organ, for fixation of many fractures and for relief of pain or other distressing symptoms. Normally within hours of decision to operate. |
| Expedited | Patient requiring early treatment where the condition is not an immediate threat to life, limb, or organ survival. Normally within days of decision to operate. |
| Elective | Intervention planned or booked in advance of routine admission to hospital. Timing to suit patient, hospital, and staff. |
While it is recognized that additional categories or subcategories could be defined, it is important that the classification system remains as simple as possible to use.
Risk Stratification
In emergency surgeries the time available to evaluate the patient preoperatively and optimizing for surgery is limited. The key challenge is achieving meaningful improvement in the patient’s condition without causing delay in performing time-sensitive surgery. Prompt decision-making by senior caregivers is required to minimize delays. The time taken to correct any physiologic abnormalities needs to be balanced against the urgency for the surgery to be undertaken.
Cancer patients are sometimes cachectic. Cancer cachexia is a syndrome presenting as a significant loss of body weight due to muscle wasting (also called sarcopenia) and fat loss. The other signs are loss of appetite, anemia, and asthenia. Cachexia cannot be treated with conventional nutritional therapy.
There may be additional comorbidities associated with the particular cancer or related to the treatment (e.g., adriamycin-induced cardiomyopathy, reduced diffusing capacity for carbon monoxide (DLCO) following bleomycin, etc.). Occasionally, emergency surgical procedures may be necessary as a temporary remedy. Various audits have shown that the clinical outcomes of patients with surgical oncologic emergencies are often poor and the surgery is associated with higher short-term mortality (9.8%–13%) compared with elective surgeries. Risk factors for poor outcome after emergency oncosurgery are shown in Table 33.4 . All these factors have been shown to correlate with higher 30-day postoperative mortality. These predictors can be used for patient counseling and documentation for emergency oncosurgeries.
| Palliative intent of prior cancer treatment |
| Eastern Cooperative Oncology Group Performance Score (ECOG-PS) |
| Raised lactate dehydrogenase |
| Low handgrip strength |
| Low albumin (<28 g/L) |
| ASA physical status >3 |
Care Processes to Improve Patient Outcomes
The 4th National Emergency Laparotomy Audit (NELA) in the UK made the following recommendations for this purpose. It must be kept in mind that the NELA report is meant for all patients undergoing emergency laparotomies and may be useful in improving patient care and outcomes, but may not apply to oncosurgical emergencies. ,
- 1.
Improving outcomes and reducing complications: intrahospital variation can be reduced through standardization of processes and modification of systems.
- 2.
Ensuring all patients receive an assessment of their risk of death: preoperative assessment and documentation of risk has been encouraged, initially using the P-POSSUM model and more recently, the NELA risk prediction model.
- 3.
Delivering care within agreed time frames for all patients.
- 4.
Enabling consultant input in the perioperative period for all high-risk patients: consultant-led care—the right intervention, at the right time, and at right place with the right facilities available.
- 5.
Effective multidisciplinary working. This involves inputs and timely services from three departments/teams, i.e., Radiology, Critical Care, and the Elderly Care group (if required). The radiology services provide timely reports on computed tomography (CT) scans to prevent delays in emergency surgery without discrepancy in the reports. Critical care ensures adequate bed availability such that premature discharges are prevented. When required the Elderly Care group also provides input.
- 6.
Supporting quality improvement. Quality improvement is defined as a formal and systematic approach to analyzing the practice and improving performance to deliver timely, safe, efficient, effective, patient-centered equitable health care. , Health care managers can support this by adopting one of the quality improvement models such as the Model for Improvement (Plan-Do-Study-Act [PDSA] cycle) described by the Institute for Healthcare Improvement or the Six Sigma model (Define-Measure-Analyze-Improve-Control [DMAIC]) described by the American Society for Quality. ,
Optimizing Patient Condition
Poulton and Murray described the following strategies for improving the patient outcomes in patients undergoing emergency laparotomies. It must be kept in kind that these strategies may not be entirely applicable to emergency oncosurgical patients.
These strategies can be grouped into two categories:
1. Timely Antibiotics: The recommendation for elective surgery is that antibiotic for surgical prophylaxis be administered 60 min before surgical incision. However, patients presenting for emergency surgeries may have signs suggestive of sepsis at the time of admission. In these cases, intravenous antibiotics should be administered as soon as possible. The Surviving Sepsis Guidelines suggest administration of broad-spectrum antibiotics intravenously within 1 h of admission to the intensive care unit (ICU). This recommendation is based on a landmark retrospective study over a 6-year period in ICUs in the United States and Canada. The survival of patients with sepsis improved (79%) when antibiotics were administered before the development of shock. With every 1-h delay in administration of antibiotics after the hypotension set in, there was a decrease in survival by 7.6%.
2. Management of Hypovolemia and Correction of Electrolyte Disturbances: Cancer patients presenting for emergency surgery may have hypovolemia due to either presence of sepsis or hemorrhage due to previous surgery for cancer or from the untreated tumor itself. A patient presenting with abdominal emergency may have vasoplegia due to severe inflammatory response caused by sepsis, lost fluids due to nausea, vomiting or diarrhea, fluid sequestration within the bowel lumen, or intraabdominal hemorrhage. These patients may need administration of high-volume fluid resuscitation in the first 24–72 h of the perioperative period. The cancer patient may therefore present with mixed etiology of hypervolemia. A rapid correction of hypovolemia with appropriate intravenous fluids and/or blood and blood products (if the patient is coagulopathic) is essential. Perioperative blood transfusion has been shown to increase cancer recurrence rates and reduced disease-free survival in patients undergoing surgeries for various solid tumors. It is not possible to use the usual measures to reduce transfusion requirements such as autologous blood donation, preoperative erythropoietin therapy, or isovolemic hemodilution in an emergency. A lower transfusion trigger, i.e., 8 g/dL should be aimed at, unless the patient is in shock and needs an increased oxygen-carrying capacity. The transfusion of fresh frozen plasma (FFP) has also been shown to negatively impact patient outcomes. , Though the transfusion thresholds for blood and blood products in cancer patients remain unknown, in patients with massive blood loss, the only option is to replace the lost volume with blood and aim to correct coagulopathy, guided by viscoelastic hemostatic assays such as TEG or RoTEM.
Target Blood Pressure in Patients Undergoing Emergency Surgery
In a retrospective study of over 33,000 patients undergoing noncardiac surgery, Walsh and colleagues found that mean arterial pressure (MAP) <55 mmHg for increasing durations of time ranging from 5 min to >20 min led to a graded risk of increase in acute kidney injury (AKI) and acute myocardial injury (AMI), both diagnosed by raised biomarkers. Futier et al. (IMPRESS study) compared two strategies in 298 high-risk (of AKI) adults. The first strategy aimed to maintain systolic blood pressure (SBP) within 10% of the patient’s resting SBP using noradrenaline infusion. The second was the standard management strategy of treating SBP ≤80 mmHg or lower than 40% of the patient’s resting SBP intraoperatively and up to 4 h after the surgery using ephedrine boluses. The primary outcome, i.e., systemic inflammatory response syndrome (SIRS) and at least one organ dysfunction, occurred more commonly in the control group (52% vs. 38%; relative risk [RR], 0.73; 95% confidence interval [CI], 0.56–0.94; P = 0.02; AR difference, −14%; 95% CI, −25% to −2%), but there was no difference in mortality. Currently, there is no universally accepted definition of intraoperative hypotension, and in any case a single threshold will not fit all patients. An extensive literature review concluded that blood pressure targets should be decided by the following considerations: the surgery to be performed, the patient’s preoperative blood pressure (provided it is not too low or too high), and risk of hypotension-related organ dysfunction and bleeding due to hypertension. In patients with low blood pressure preoperatively, they suggest maintaining MAP between 60 and 65 mmHg unless bleeding is present. Perioperative goal-directed therapy was found to improve outcomes in acutely ill patients, septic or trauma patients, or those undergoing high-risk surgeries (baseline mortality expected to be >20%) when hemodynamic optimization to supranormal values (cardiac index [CI]) >4.5 L/m/m 2 , pulmonary artery occlusion pressure <18 mmHg, oxygen delivery of >600 mL/min/m 2 , and oxygen consumption of >170 mL/min/m 2 ) was performed before the development of organ failure. However, more recent trials have shown no benefit of goal-directed fluid therapy either in critically ill or major surgery patients.
1. Omitting/Optimizing Medication: Cancer patients may have several comorbidities and may be taking multiple medications. Considering the likelihood of perioperative hypotension and possible presence of AKI, medications such as ACE inhibitors or angiotensin receptor blockers should be avoided and may be changed to some other class of antihypertensive drug class if required. Beta blocker administration should be individualized but none should be added in the immediate preoperative period. The POISE trial evaluated the efficacy of extended release metoprolol, 100 mg administered 2–4 h preoperatively and within 6 h postoperatively, then 200 mg daily for the next 30 days in over 8000 high-risk patients undergoing noncardiac surgery. There was a reduction in cardiovascular deaths, myocardial infarction (MI), or cardiac arrest (5.8% vs. 6.9%, hazard ratio [HR], 0.84; 95% CI, 0.70–0.99, P = 0.04) in patients given metoprolol. However, there was an increased incidence of stroke (1.0% vs. 0.5%; HR, 2.17; P = 0.0053) and death (3.1% vs. 2.3%; HR, 1.33; P = 0.032) as compared with the placebo group. To obtain benefit from beta blocker therapy, it cannot be started in the immediate preoperative period, rather at least 30 days prior to surgery. This is not possible when the patients present for emergency oncosurgery, and therefore unless the patient is already taking beta blockers, they should not be started afresh. , If the patient is already taking statins, they should be continued. The decision regarding continuing or discontinuing antiplatelet agents and anticoagulants needs to be individualized. In patients with recently inserted drug eluting stents or mechanical valves, bridging therapy with intravenous unfractionated heparin may be required. If it is deemed essential, the effects of newer oral anticoagulants (NOACs) may be reversed using 4-factor prothrombin complex concentrate that contains coagulation factors II, VII, IX, and X, and also protein C and S or appropriate reversal agents such as idarucizumab or andexanet alfa, depending on the urgency of surgery. Idarucizumab is a humanized monoclonal antibody fragment (Fab). It binds to free and thrombin-bound dabigatran, nullifying its effect. Andexanet alfa acts as a decoy receptor for all FXa inhibitors (apixaban, edoxaban, and rivaroxaban) and by binding to them reverses their effect.
2. Nutrition: When emergency surgery is required, it is challenging to make a decision regarding initiating nutrition postoperatively. However, the patient’s nutritional status should be assessed preoperatively time permitting, and a postoperative nutritional strategy should be planned. The route of nutrition will depend on the nature of surgery and clinical status of the patient in the immediate postoperative period. For example, if the patient undergoes excision of a necrotizing fasciitis-affected area on the periphery or torso, an enteral feeding route may be possible, but not for someone undergoing resection of the colon and anastomosis. If the patient is still in shock postoperatively and needs vasopressor therapy, enteral nutrition should still be tried, at least in the form of trophic feeds for the multiple benefits described recently. Further increases in the amount of feeds to be given will depend on the clinical improvement in the patient condition, improvement in indices of tissue perfusion, and signs of feed intolerance, if any. If enteral feeding does not seem possible, parenteral nutrition may be considered within a week following surgery. In some patients when adequate nutrition cannot be achieved enterally, partial parenteral nutrition supplementation may be started to meet the goals.
3. Perioperative Glycemic Control: Patients with preexisting diabetes mellitus and patients who need emergency surgery will often have hyperglycemia. A study from the Leuven University almost two decades ago in 1548 patients (of which a large proportion were perioperative patients) showed that strict glycemic control (4.44–6.11 mmol/L) improved ICU survival. However, a subsequent study suggested a high incidence of hypoglycemia and no survival benefit of strict glycemic control in medical ICU patients. A large multicenter study from Australia and Canada showed that a blood glucose target of 9.99 mmol/L resulted in lower mortality than intensive sugar control. The current recommendation is to maintain blood glucose level in the preoperative or anesthetized patient at 9.99 mmol/L.
4. Preoperative Chest Physiotherapy: A recent multicenter study in more than 400 patients undergoing elective abdominal surgery found that 30 min of preoperative physiotherapy session resulted in a 15% absolute risk reduction in the postoperative pulmonary complications (PPCs). This may not be possible in emergency situations; however, early institution of physiotherapy in the postoperative period with early mobilization should go a long way toward reducing PPCs. The second part of optimization includes minimizing delays in surgery by optimizing the care pathway, which was discussed earlier.
Another study recommended the following strategies for improving outcomes in patients undergoing emergency general surgery: early recognition and resuscitation, early intervention if serum lactate >2 mmol/L, early identification and treatment of sepsis as per surviving sepsis guidelines (as one in five patients requiring emergency laparotomy fulfills sepsis criteria), prioritization to early surgical intervention, use of protocolized fluid management, and using a noninvasive cardiac output monitoring device to measure dynamic fluid response. In addition, postoperative admission of selected patients to ICU or HDU and continued care by the anesthesiologist and surgeon were also recommended.
Preoperative Airway Assessment
The ability to predict a difficult airway is critically important in emergency situations in situ to help identify the optimal approach to airway management. This is particularly important when confronted with a patient with cancer. The airway in a cancer patient may be difficult to secure if the patient is suffering from head and neck cancer or has previously undergone surgery for head and neck cancer, laryngeal tumors, and so on etc. The patient may be at high risk for regurgitation and aspiration of gastric content if a gastric outlet obstruction is present. In hypoxic, hemodynamically unstable, septic patients, the airway becomes physiologically challenging as the cardiopulmonary reserve of the patient reduces. Quick tests, such as the MACOCHA score ( Table 33.5 ), or the HEAVEN criteria ( Table 33.6 ), in addition to the existing difficult airway predicting tools like LEMON (Look externally, Evaluate 3-3-2 rule, Mallampati score, Obstruction, Neck mobility), can be useful for assessing the risk of difficult airway and preparation for management. ,
| Factors | Points |
| Factors Related to Patient | |
| Mallampati score III or IV | 5 |
| Obstructive sleep apnea syndrome | 2 |
| Reduced mobility of cervical spine | 1 |
| Limited mouth opening <3 cm | 1 |
| Factors Related to Pathology | |
| Coma | 1 |
| Severe hypoxemia (<80%) | 1 |
| Factors Related to Operator | |
| Nonanesthesiologist | 1 |
| Total | 12 |
| Hypoxemia | Oxygen saturation value ≤93% at the time of initial laryngoscopy |
| Extremes of size | Pediatric patient ≤8 years of age or clinical obesity |
| Anatomic challenge | Includes trauma, mass, swelling, foreign body, or other structural abnormality limiting laryngoscopic view |
| Vomit/blood/fluid | Clinically significant fluid present in the pharynx/hypopharynx at the time of laryngoscopy |
| Exsanguination | Suspected anemia that could potentially accelerate desaturation during rapid sequence intubation (RSI)-associated apnea |
| Neck | Limited cervical range-of-motion due to immobilization or arthritis |
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Frailty in the Perioperative Setting for Cancer Patients
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