SURGICAL EMERGENCIES IN CANCER MANAGEMENT
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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
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:
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
DECISION-MAKING IN
CANCER EMERGENCIES
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
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
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.
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
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)
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
CA OESOPHAGUS
Laryngeal CA
Lung CA
Gastric CA
Pancreas
Liver / Gallbladder / CBD
COMMON DIFFERENTIAL
DIAGNOSIS (2)
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
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)
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
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
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