Join Drs. Ashlie Nadler, Jordan Nantais and Graham Skelhorne-Gross as they tackle Cancer Emergencies.
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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