Transcript 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
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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
DEFINITION
A surgical cancer emergency:
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Onset is acute or progressive;
Chief complaint is grave in nature;
Manifestation is cancer-related,
May need urgent surgical care.
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
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DECISION-MAKING IN
CANCER EMERGENCIES
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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)
PILLARS OF DIAGNOSIS
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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
EPIDEMIOLOGY
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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)
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)
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)
PRESENTING
COMPLAINTS/SIGNS (3)
3.
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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
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)
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
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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
MANAGEMENT
APPROACH (3)
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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
COMMON DIFFERENTIAL
DIAGNOSIS
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CA OESOPHAGUS
Laryngeal CA
Lung CA
Gastric CA
Pancreas
Liver / Gallbladder / CBD
COMMON DIFFERENTIAL
DIAGNOSIS (2)
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CA colon (Lt, Rt, Tr, closed loop)
CA rectum / anus
Musculo-skeletal (SA, Melanoma, KS)
Central Nervous system / Spinal cord
Mets (ascites, haemorrhage, effusion)
COMMON
COMPLICATIONS
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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)
COMMON
COMPLICATIONS (2)
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Lymphoedema (DVT, abscess)
Malnutrition / Cachexia
Pulm. (pneumonia, oedema)
HIVA conditions (KS, TB, Mets)
Peritonitis (1st, 2nd, PID)
Periton. collectn (blood, ascites, pus)
TYPES OF MALIGNANT
SURGICAL EMERGENCIES
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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)
Management outcome
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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