Surgical Emergengies In Oncology



There are a large number of emergencies seen in the practice of surgical oncology, and up to ten percent of patients with cancer may develop or present with surgical emergencies. Many of these patients need urgent intervention and good nursing care

Gastrointestinal emergencies
There a large number of gastrointestinal emergencies seen in oncological practice
Most of these are due to obstruction in the passage of intestines, due to recurrent or metastatic disease, lymph node or as a part of complication of surgeries or radiotherapy    Patients may primarily present too, with intestinal obstruction or jaundice

Intestinal obstruction
Investigation     Routine haemogram, s electrolytes, blood sugar, LFT, urea and creatinine, radiographs of chest and abdomen and ECG
A CECT scan can be done if facilities are available

Conservative management
Nil orally, I V Fluids, Ryles tube aspiration, monitoring of vitals, urinary output and abdominal girth
Many of these patients will be in a poor nutritional status and may need TPN
The same to continue for sub acute obstruction ,but surgical intervention may be needed for  acute obstruction, specially if patient has some life expectancy, These patients should be taken up for emergency surgery

Gastric outlet obstruction        gastrojejunostomy or feeding jejunostomy

Small bowel obstruction          resection and anastamosis of small gut

Right Large gut obstruction     ileocolic anastamosis, right hemicolectomy if possible  
Or Ileostomy

Left Large gut obstruction        Transverse colostomy, left hemicolectomy or             
Caecostomy

Rectal obstruction                     sigmoid colostomy or Hartman’s procedure

Dysphagia

Dysphagia may be due to growth larynx, hypopharynx or carcinoma esophagus and proximal stomach
These patients are managed with endoscopic placement of Ryles tube, or with gastrostomy or feeding jejunostomy
Surgical obstructive jaundice

This may be due to carcinoma gall bladder, cholangiocarcinoma, carcinoma stomach, and carcinoma head of pancrease, hepato cellular carcinoma or due to metastatic lymph nodes in the porta hepatis
These patients are in a critical state and need active care
Besides the routine workup these patients should undergo a coagulation profile, and preferably a MRCP and ERCP (endoscopic retrograde cholangio pancreaticogram)
They should be given injection Vit K and 10%glocuse
These patients should be monitored very carefully for urinary output, specially in post operative period and may need Inj Lasix or Mannitol

These patients can be offered definitive surgery, palliative surgery or non-operative palliation

Definitive surgery

Patients with periampulary ca,ca head of pancrease and lower cholangiocarcinoma can be offered Whipples procedure which entails pancreaticoduedenectomy with choledochojejunostomy,gastrojejunostomy and pancreaticojejunostomy

Patients with cholangiocarcinoma are offered resection and those with early ca gall bladder are managed with radical cholecystectomy

Palliative surgery

If the above cases are not amenable to definitive surgery, due to extensive disease or moribund state, they are offered palliative surgery
The palliative procedures can be, cholecystostomy. Cholecystojejunostomy, choledochojejunostomy, hepaticojejunostomy or segment three bypass
If these patients have gastric outlet obstruction along with obstructive jaundice then a double or triple bypass should be done, which includes any of the above procedure with gastro jejunostomy

Non operative palliation

Patients who are in a very moribund state should be offered non-surgical means to relieve obstructive jaundice
This can be done by a endoscopic placement of nasogastric tube or a biliary stent

Ascitis

Ascitis may be seen in ovarian malignancies, haematological malignancies or G I malignancies
They are managed with salt restriction, and use of lasix and aldectone and repeated peritoneal tapping .
Massive ascitis may need permanent internal shunts

Respiratory system

Airway obstruction  
May be due to growth larynx, or hypo pharynx, and need emergency tracheostomy

Pleural effusion
The    may be seen in pulmonary metastasis, carcinoma lung, or mesotheliomas
Managed with pleural tapping, inercostal drainage, placement of pigtail catheter and in cases of recurrent massive pleural effusion, internal shunts may be used
Malignant pleural effusion may be hemorrhagic too

Urinary system

Lower urinary tract obstruction may be seen in Ca prostate, Ca neck of bladder and in few cases of ca penis
These patients need suprapubic cystostomy

Obstruction of the ureteric orifices may occur due to ca urinary bladder or locally advanced malignancies of the pelvic organs. these cases or cases with uretiric obstruction may develop hydro ureteronephrosis
These patients need nephrostomy

Head and neck

Besides pain, dysphagia, difuculty in talking or airway obstruction, patients of the head and neck malignancy may develop severe bleeding due to erosion of major vessels, like lingual artery in ca tongue or a carotid blowout in massive malignant cervical lymphadenitis
These patients may need emergency ligation of the internal carotid artery

Limbs

Large fungating masses over the limb in soft tissue or bone tumors or skin malignancies may need urgent intervention due to  pain, bleeding and infection
These patients or those with non-viable limbs due to involvement of neurovascular bundle may need emergency operation

Paraplegia

Compression of the cord may be seen in involvement of the vertebra due to bony mestasis, commonly in ca prostate, thyroid or breast
Emergency laminectomy or decompression is needed in these patients

 
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