Surgical Emergencies in the Cancer Patient

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Illig Ch. Kang, Ellie Maghami, Thomas J. Gernon Ch. Jackson, Henri R. Ford, Eugene S. Kim Ch. Blair Ch. Krouse, Brian Badgwell. Du kanske gillar. Lifespan David Sinclair Inbunden. Inbunden Engelska, Spara som favorit. Skickas inom vardagar. Skickas inom vardagar specialorder. This text provides a comprehensive textbook summarizing the presentation, workup, and surgical solutions for common emergencies in the cancer patient. The use of medications antibiotics, hormones, and biologic therapies and interventional radiologic procedures as adjuncts or as replacements for the surgical solutions are discussed.

Table of contents

The text covers emergencies that result as adverse effects for the systemic and local treatments for cancer, emergencies that result from mechanical issues with the cancer and those that result from surviving major extirpative surgery. Diagnosis and treatment of patients' immune-compromised or thrombocytopenic status from chemotherapy is discussed, as is surgical treatment in patients with prior complex surgical therapy or radiation treatment. Finally, the text covers alternatives to surgery, including new interventional radiologic and endoscopic procedures.

Surgical Emergencies in the Cancer Patient will be of great value to healthcare professionals at all levels who are involved in the treatment of emergencies in the cancer patient.

Surgical Emergencies In The Cancer Patient

When performing the propensity score matching procedure, 42 patients with elective operation and one patient with urgent operation had to be excluded because their characteristics could not be matched with patients from the other group. Hence, the propensity score-matched analysis was based on patients. After the matching procedure, the propensity score was virtually the same in the two patient groups 0. Distribution of propensity scores before and after propensity score analysis.

The left upper and lower panels show the distribution of the propensity scores for patients with urgent and elective operation before the matching procedure. The right upper and lower panels demonstrate the distribution of the propensity scores after bipartite propensity score matching. Kaplan—Meier curve for overall and disease-free survival in propensity score adjusted analysis. The present study is the first study using both Cox regression analyses as well as propensity scoring methods to assess the impact of urgent versus elective operation on overall and disease-free survival in patients undergoing resection for colorectal cancer.

This study provides evidence that patient characteristics are strongly biased regarding urgent operation. Optimal adjustment for this bias demonstrates no significant differences in overall and disease-free survival neither after multivariable Cox regression nor after propensity score-adjusted analyses. However, these studies did not clearly state whether patients were operated within hours or have been operated days after hospital admission. One of the strengths of our study is the clear definition of urgent surgery.

Surgical emergencies in oncology.

This may account for the rather low percentage of patients in this group. Urgent operation was not associated with poor survival in our study. Although unadjusted risk analysis did show reduced survival following urgent operation, this difference was no longer of statistical relevance after risk-adjustment. The increased risk observed in unadjusted analysis is clearly due to differences in baseline characteristics and not due to the urgent operation itself. Our results are supported by findings from recent studies which showed no statistical differences in long term survival [ 5 , 7 , 9 , 10 ].

These reports differ from some larger studies that reported poorer survival for colorectal cancer patients presenting as an emergency [ 1 — 3 , 6 ]. But it is not clear from these studies to what extent adjuvant therapy was administered and if so, differences were observed between the investigated groups. Furthermore the information if patients with neoadjuvant therapy were included in the respective studies is not provided. In our study, all patients receiving neoadjuvant treatment were excluded and administration of adjuvant chemotherapy was not different between the two groups.

Adjuvant chemotherapy was confirmed as an independent favorable prognostic factor for overall survival as well as the number of harvested lymph nodes. This is explained by the fact that peritonitis on the basis of perforated colorectal cancer is a common cause of emergency department presentation [ 24 ]. However, tumor perforation failed to be a prognostic factor for survival in our analysis. This is most likely based on the fact that not only free intraperitoneal rupture of the tumor was included in this group but also tumors showing localized perforation or those with penetration of the serosal surface in histological analysis.

Unfortunately, most of the published studies do not state the amount of resected lymph nodes [ 1 , 2 , 4 , 8 — 12 ]. This is somewhat surprising, giving the fact that the number of harvested lymph nodes is crucial for staging of colorectal cancer patients because lymph node involvement represents the strongest prognostic factor and serves as the most important selection criterion for adjuvant chemotherapy [ 25 ].

Additionally, the number of surgically removed and pathologically assessed lymph nodes influences the staging accuracy and impacts overall survival [ 26 , 27 ]. As a consensus standard, a minimum of 12 examined lymph nodes per patient is therefore recommended for accurate staging.

In the present investigation This demonstrates that proper oncologic resection is achievable in urgent operations. Furthermore, the comparable quality of oncologic resection in both groups may be an explanation for the unobserved differences in overall and disease-free survival. It is well known from the literature that both, surgeon as well as hospital specific specialisation and caseload are important predictors for outcome after colorectal cancer resection what seems to apply also for these results [ 28 , 29 ].

Our study has several limitations. First, this is a retrospective cohort study and not a randomized controlled trial. However, it is not possible to perform a randomized trial for this research question. A cohort study adopting Cox regression analyses as well as propensity-scoring methods probably represents the most appropriate and highest-evidence level study design.

Second, while we did comprehensive risk-adjustment for observed confounders, potential bias due to unknown or unobserved confounders, such as American Society of Anaesthesiologist ASA grade, comorbidities and adherence to cancer related follow-up care, cannot be completely excluded. And last, all operations in this study were performed or supervised by experienced surgeons of a tertiary care center, what may also have influenced survival rates.

In summary, urgent colorectal cancer resection does not influence overall and disease-free survival after risk-adjusting in multivariable Cox proportional as well as propensity score analyses. The observed association between urgent operation and oncologic outcome is caused by differences in patient and tumor characteristics.

Urgent operation itself is not a risk factor and colorectal cancer resection should therefore not be postponed for oncologic outcome reasons. Emergency presentation of colorectal cancer is associated with poor 5-year survival. Br J Surg. Emergency first presentation of colorectal cancer predicts significantly poorer outcomes: a review of consecutive Irish patients.

Surgical emergencies in oncology

Dis Colon Rectum. Emergency presentation of node-negative colorectal cancer treated with curative surgery is associated with poorer short and longer-term survival. Int J Colorectal Dis.

Oncologic colon cancer resection in emergency: are we doing enough? Surg Oncol. A prospective study of outcomes of emergency and elective surgeries for complicated colonic cancer. Am J Surg. Elective versus emergency surgery for patients with colorectal cancer. Emergency surgery for colon carcinoma. Colorectal cancer presenting as surgical emergencies. Impact of emergency surgery in the outcome of rectal and left colon carcinoma. World J Surg. An evolutionary role of the ED: outcomes of patients with colorectal cancers presenting to the ED were not compromised.

Am J Emerg Med. Emergency surgery for obstructing colorectal cancers: a comparison between right-sided and left-sided lesions.

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J Am Coll Surg. Nesbakken a. Short term outcome after emergency and elective surgery for colon cancer. Colorectal Dis. Short- and long-term outcomes after laparoscopic versus open emergency resection for colon cancer: an observational propensity score-matched study. Random survival forests. Ann App Statist.

Invited commentary: propensity scores. Am J Epidemiol. Rosenbaum PR. Model-based direct adjustment. J Am Stat Assoc. Optimal matching for observational studies.

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  • Bibliographic Information.
  • Surgical Emergencies in the Cancer Patient | JAMA Surgery | JAMA Network.
  • Rubin D. Estimating causal effects from large data sets using propensity scores.