Perioperative Care of the Surgical Patient: Surgical Emergencies in Cancer

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 .

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.

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.

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.