Clinical Challenges in Emergency General Surgery: Cancer Emergencies
Behind The Knife: The Surgery Podcast
Behind The Knife: The Surgery Podcast
4.8 • 1.4K Ratings
🗓️ 15 November 2021
⏱️ 34 minutes
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Summary
Case 1 - Learning Points:
- These are complex patients and multidisciplinary care should be provided with input from oncology.
- A step-up approach should be used, starting with medical management prior to considering surgery in appropriate patients.
- 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.
- 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:
- Colorectal malignancy is an exceedingly common cause of general surgical emergency and requires a thoughtful, systematic approach
- 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
- 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
- Consistent involvement of a multidisciplinary team, including radiology, enterostomal therapy, and surgical oncology can be extremely useful in guiding complex decisions
References:
- 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.
- Ripamonti C, Gerdes H and Easson A. Management of malignant bowel obstruction. Eur J Cancer 2008 May;44(8):1105-15
- Chen, T, Huang, Y. & Wang, G. Outcome of colon cancer initially presenting as colon perforation and obstruction. World J Surg Onc 15, 164 (2017).
- 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.
- Dunn GP, Martensen R, Weissman D. Surgical palliative care: a resident’s guide. Essex: American College of Surgeons; 2009.
- 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.
- National Comprehensive Cancer Network. https://www.nccn.org/. Accessed October 15, 2021.
- 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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Transcript
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| 0:00.0 | behind the knife the surgery podcast where we take a behind the scenes intimate look at surgery |
| 0:06.0 | from leaders in the field. |
| 0:21.1 | Hi everyone, welcome back for episode two of our emergency general surgery series. |
| 0:26.3 | This one is called cancer emergencies. I'm really excited. This is a huge passion of mine |
| 0:31.3 | and we have two great cases. I'm joined by Jordan and Graham. Hi Ashley and hi Graham. This is a |
| 0:36.8 | great topic and I think a very important area to focus on. General surgical cancer emergencies |
| 0:42.0 | present in many flavors often as an initial presentation of cancer of the GI tract, |
| 0:46.5 | biliary system, potentially even the lymphatic system. These emergencies are typically due to |
| 0:51.8 | bleeding, obstruction or perforation. And of course we also see typical general surgery presentations |
| 0:57.6 | in patients who have cancers which may be complicated by the existence of those cancer |
| 1:01.6 | diagnoses. So an in-depth understanding of cancer therapies and prognosis is critical for the |
| 1:06.8 | oncology general surgeon. Hi everyone, I'm looking forward to this session and so lucky to work |
| 1:12.0 | with you both Dr. Nadler and Dr. Nadler. Of course Dr. Nadler is actually in addition to |
| 1:16.7 | being an acute care surgeon as a fellowship trained surgical oncologist. We pick this session |
| 1:22.4 | because these presentations can be really tough. There's so many different types of cancers that |
| 1:26.0 | were responsible for. We need to know how to initially work these patients up. We need to know |
| 1:31.0 | who needs an intervention now, who can wait, but maybe needs one on this admission, who should go |
| 1:35.5 | to a chemo or get radiation first, who needs to be presented at multidisciplinary rounds. And |
| 1:40.8 | you know I think for all the residents out there, we really want to know who needs an urgent |
| 1:44.6 | intervention. Who are we calling the staff in the middle of the night about? And then of course |
| 1:48.8 | if you do call your staff, they're going to ask you what do you want to do. So if you're going |
| 1:52.1 | to intervene, are you going to resect? If so, are you going to divert? Do you want to ask |
... |
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