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SURGICAL EMERGENCIES IN CANCER MANAGEMENT

SURGICAL EMERGENCIES IN CANCER MANAGEMENT. PROFESSOR V.K. GOLAKAI BSc, MD, ChM, FWACS, FICS, DSc(Med) PRINCESS MARINA HOSPITAL. OBJECTIVES OF PRESENTATION. Overview of tumour emergencies Common cancer emergencies Summary of approach to care Outline basic clinical protocols

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SURGICAL EMERGENCIES IN CANCER MANAGEMENT

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  1. SURGICAL EMERGENCIES IN CANCER MANAGEMENT PROFESSOR V.K. GOLAKAI BSc, MD, ChM, FWACS, FICS, DSc(Med) PRINCESS MARINA HOSPITAL

  2. OBJECTIVES OF PRESENTATION • Overview of tumour emergencies • Common cancer emergencies • Summary of approach to care • Outline basic clinical protocols • Set simple protocols for care • Empower management planning • Establish SOP’s for management

  3. DEFINITION A surgical cancer emergency: • Onset is acute or progressive; • Chief complaint is grave in nature; • Manifestation is cancer-related, • May need urgent surgical care.

  4. FEATURES OF CANCER EMERGENCIES • Aetiology is cancer-related • Condition is a complication of cancer • Hx + PE usually suggest primary cause • Diagnostic delays worsen outcome • Diagnostic tests merely confirmatory • Surgery should not be delayed • A surgical cancer emergency is not a diagnosis, but a disorder with features implicating malignant disease. • Symptom complex or syndrome suggestive and/ applicable to many conditions

  5. DECISION-MAKING IN CANCER EMERGENCIES • Is special admission warranted? • Early vs. delayed intervention • Focused vs. general investigations • ABC’s / Resus before intervention • Consider observation – how long? • Palliative vs. definitive intervention • Resources and methods for management • Prognostication (outcome, counselling)

  6. PILLARS OF DIAGNOSIS • Presenting complaints(1o / 2o) • Signs & symptoms (local, systemic) • Relevant history • Local findings • Systemic status • Fitness for surgical intervention • Timing of intervention • Type and extent of surgical intervention

  7. EPIDEMIOLOGY • Prevalence in elderly > young • More in > 40 (80%), less in < 20 (<5%) • Presentation progressive < acute • Patient in often in distress / toxic • Patient usually very ill / life-threatening • C/S/S confined to cavities (>90%) • Prognosis poor (survival days - < 6/12)

  8. PRESENTING COMPLAINTS/SIGNS 2. Secondary findings / complaints • Pain (gradual onset) – 80% • Confined to abdomen (60%) • Secondary lesions (HIV-A, KS, mets) • Progressive weight loss / cachexia • Anaemia (95% microcytic / hypochromic) • Dysphagia/Dyspnoea/Dysphonia/Distension • Haemoptosis / bloody pleural effusion • Advanced malnutrition (PEM)

  9. PRESENTING COMPLAINTS/SIGNS (2) 1. Recent abdominal distension • Fluid collections (ascites, effusion, blood) • Mass (palpable+/-, mobile, fixed) • Gaseous distension(peristalsis +/-, pain +/-) • Haemoperitoneum (bloody, tinged) • Obstruction vs ileus  Perforation • Vomiting (blood, food, bile, faeces) • Recent change in excretory function (BM, urinary incontinence / obstruction)

  10. PRESENTING COMPLAINTS/SIGNS (3) • Haemorrhage (Recent, Overt, Occult) • Upper (Haematemesis, haemoptosis) • Lower (Melena, Haematochezia) • Massive (Burgundy red, clots) • Combined (Mixed colour, liquid/clots) • Haematuria (Initial, mid-stream, terminal) • Haematocolpus • Disseminated intravasc. coagulopathy

  11. PRESENTING COMPLAINTS/SIGNS (4) 4 Miscellaneous signs/symptoms • Met. disorder (80% Acidosis, 20%Alkalosis) • Single / Multi-organ failure Renal 60%, Pulm 20%, CHF 10%, Liver 5%, Pancreas 3%, Skin 2%, CNS 1%) • Malignant lymphoedema Primary – breast, Pemhhigus Secondary – KS, mets • Personality changes (distress, stress anxiety, fear, facies, morbus extremis)

  12. MANAGEMENT APPROACH • High index suspicion (Age, Gender, Hx) • Judicious interpretation of findings • Expeditious diagnosis / management • Basic diagnostics (CXR, AXR, SXR, USG, CT-scan, ECG, Haematology, Biochemistry, Function tests, BGA’s) • Prompt resuscitation (ABC’s, Vasc. access, IVF, Transfusion., Correction of BE/BD) • Maintenance of optimal functional vital signs • Assuring fitness for intervention

  13. MANAGEMENT APPROACH (2) • Management co-existent disease (HTN, DM, CHF, Pulm. / Renal failure, S/MOFs) • Prompt / expeditious timely intervention • Temporary relief symptoms / distress Preparatory for definitive intervention Damage control – “salvage procedure” Diagnostics intervention Comfort • Emergency definitive surgery • Planned delayed definitive surgery

  14. MANAGEMENT APPROACH (3) • Post-operative care/management • Planned re-intervention (2nd look) • Counselling (pre, post, perspective) • Prognosis (< 15% 5YR SR) • Adjuvant care (CT, RT, Combined) • Final rites (dying patient, relatives) • Post mortem and Certificatyion

  15. COMMON DIFFERENTIAL DIAGNOSIS • CA OESOPHAGUS • Laryngeal CA • Lung CA • Gastric CA • Pancreas • Liver / Gallbladder / CBD

  16. COMMON DIFFERENTIAL DIAGNOSIS (2) • CA colon (Lt, Rt, Tr, closed loop) • CA rectum / anus • Musculo-skeletal (SA, Melanoma, KS) • Central Nervous system / Spinal cord • Mets (ascites, haemorrhage, effusion)

  17. COMMON COMPLICATIONS • Haemorrhage (CA, UC, Diverti. dis.) • Peroration (TB, colitis, obstruction) • Intestinal obstruction (ileus, mech.) • Jaundice (stones, inflam. Medical) • Gynae. (ovarian, uterus, cervix) • Fluid collections (ascites, effusions)

  18. COMMON COMPLICATIONS (2) • Lymphoedema (DVT, abscess) • Malnutrition / Cachexia • Pulm. (pneumonia, oedema) • HIVA conditions (KS, TB, Mets) • Peritonitis (1st, 2nd, PID) • Periton. collectn (blood, ascites, pus)

  19. TYPES OF MALIGNANT SURGICAL EMERGENCIES • Acute GIT(>55% of cases) • Acute gynae. (20% of cases) • Acute GUT (10% of cases) • HIVA conditions (8% of cases) • Acute Lung / pulm. (3% of cases) • CNS /spine (2% cases) • Skin / Musculo-skeletal (2% cases) • Mixed / combined (2% cases)

  20. Management outcome • Outcome depends on cancer type • Duration of symptoms and signs • Condition at presentation • Pre-existing / co-morbidities • Age and general physical status • Success of swift management • Type of intervention or none at all • Skill and experience of care-giver

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