Surgical emergencies in advanced cancer patients: How to navigate a perilous time

In 2020, an estimated 1.8 million new cancer cases were diagnosed. Patients with advanced cancers may be at increased risk of surgical emergencies because of local tumor invasion, immunosuppression, radiation therapy, chemotherapy, and frequent endoscopic and percutaneous procedures. Surgeons often are confronted with the complex management of these patients after hours and do not always have access to input from the patient’s primary oncologist. Furthermore, when confronting a surgical oncology emergency, surgeons often are meeting the patient for the first time and lack the benefit of having an established relationship with the patient.

These factors can make the management of surgical emergencies in cancer patients quite challenging. However, this scenario also can be viewed as a unique opportunity to salvage a difficult situation in a patient’s cancer journey, alleviate patient suffering, or support patients and their families as they prepare for the death of their loved one.

CRP resource for surgeons

Fortunately, increasing evidence is available to help guide surgeons as they navigate these clinically, and often emotionally, difficult situations. A review of the challenges, data, and treatment algorithms for surgical emergencies in advanced cancer patients was reviewed as part of the 2021 American College of Surgeons (ACS) Cancer Research Program (CRP) Educational Series, January 28, 2021, and is now available online.

In discussions among the five-member panel, a common theme emerged: optimal management must be individualized to the patient. It is critical that surgeons take into consideration a patient’s age, nutritional and functional status, as well as cancer stage and future treatment options. In addition, the patient’s goals and desires must be taken into account. Within this framework, the panel discussed the three most common types of surgical emergencies affecting patients with advanced malignancies.

Managing common clinical scenarios

One of the most common clinical scenarios affecting patients with advanced cancer is obstruction, which can be of the biliary tree, gastric outlet, small bowel, colon, or rectum. Obstructions can be the direct result of a primary or metastatic tumor or may be secondary to interventions such as radiation or a prior surgical anastomosis. Some obstructions can be managed endoscopically with stents, whereas others may require an operative bypass or diverting stoma.

In determining which modality is optimal for each patient, it is helpful to understand the individual patient’s life expectancy. Percutaneous or endoscopic interventions may allow for an easier recovery at the expense of durability compared with operative procedures.¹ Given the increased use of minimally invasive surgery and the improvements in stent material, design, and endoscopic skill, this gap is slowly closing, and more recent studies suggest little difference in measured outcomes, such as total hospital stay (including readmissions), morbidity, or mortality.² The only consistently demonstrated difference is an increased need for repeat intervention over time with an endoscopic approach.

Similarly, in patients with a malignant gastric outlet obstruction, the decision to perform a surgical gastrojejunostomy bypass versus either endoscopic stenting or endoscopic bypass should depend on overall life expectancy.³ In patients with a life expectancy of more than six months, a durable surgical bypass may be more beneficial, whereas in patients with more advanced disease, endoscopic intervention is more appropriate. Endoscopic stents also can be used as a bridge to definitive surgical resection, for example in the setting of a resectable malignant gastric outlet obstruction.

Endoscopic stenting and enteral nutrition also may permit neoadjuvant therapy prior to definitive resection. Obstructing left-sided colon cancers may be successfully treated with expandable metallic stents as a bridge to neoadjuvant therapy. There are conflicting studies regarding whether preoperative stenting (biliary, gastric, or colonic) before oncologic surgery has an impact on long-term survival or recurrence; however, there clearly is a decrease in perioperative morbidity and mortality, as this procedure allows for preoperative optimization of nutritional, functional, and electrolyte/liver abnormalities.⁴

Bleeding can occur from either a primary or metastatic tumor or as a result of diagnostic or therapeutic interventions, such as a diagnostic biopsy procedure. Resuscitation and stabilization should be carried out in alignment with trauma resuscitation protocols, with a thorough evaluation for the site and source of bleeding. Often endoscopy, computed tomography arteriography, or angiograms can be helpful in identifying the source.

In the acute phase, hemostasis is the primary concern, and cancer treatment is secondary. Transcatheter arterial embolization can effectively induce hemostasis for hepatic bleeding secondary to malignancy, with hemostatic success ranging from 53 to 100 percent.⁵ Patients with acute hemorrhage resulting from rupture of advanced hepatocellular carcinoma and poor underlying liver function have a very high risk of death, regardless of intervention. Once stabilized, definitive cancer treatment, such as ablation, chemoembolization, or hepatic resection/transplantation can be considered.⁵

In contrast, most brisk gastrointestinal bleeds can only be temporized endoscopically and may require either interventional embolization or, rarely, surgical resection. Slower gastrointestinal bleeding often can be successfully palliated with a short course of radiation. With the increasing use of neoadjuvant therapy, it is important to discuss the likelihood of completing neoadjuvant therapy versus upfront surgical resection with the treating oncologist. For metastatic tumors, operative intervention is typically reserved for persistent bleeding despite embolization and radiation and in select patients with a good performance status, high likelihood of response to therapy, multiple therapy options, or indolent biology.

While undergoing cancer treatment, a patient’s immune system may become compromised, predisposing him or her to infections. In addition to common infections, such as cholecystitis or appendicitis, patients with cancer can develop unique infections, such as neutropenic enterocolitis or bowel perforation. The abdominal exam can be misleading in the severely immune-compromised patient, and repeated imaging may be required in addition to serial exams in this setting. After initial resuscitation, empiric antimicrobial coverage should be broadened in the setting of severe neutropenia.

Ideally, surgical intervention should be delayed until resolution of neutropenia, if possible, as the outcomes are greatly improved.⁶ Again, the paradigm of maximal supportive care, as well as discussion with the oncology team regarding a patient’s individual prognosis and treatment options, is critical. Spontaneous bowel perforation in the setting of treatment with bevacizumab in a newly diagnosed young breast cancer patient is very different from an elderly patient with bowel perforation because of peritoneal carcinomatosis progressing on third-line systemic therapy.

Increasingly, cancer patients are being treated with immunotherapy, such as check-point inhibitors, oncolytic viruses, and vaccines. Although these therapies generally are well tolerated, they can result in an acute immune response to the body’s own tissue (immune-related adverse events [irAEs]). Most of these irAEs are mild to moderate in severity; however, serious and occasionally life-threatening irAEs are reported in the literature, and treatment-related deaths occur in up to 2 percent of patients. Immunotherapy-related irAEs typically have a delayed onset and prolonged duration compared with chemotherapy-related adverse events.⁷ Once identified, they often are treated with immune suppression. Gastrointestinal irAEs typically present with diarrhea, but there are case reports of acute bowel perforation requiring surgical resection.⁸ The grossly affected bowel is resected, and a primary anastomosis can be safely performed unless significant preoperative steroid treatment has been implemented.

Conclusion

Despite ongoing advances in cancer treatment and improvements in outcomes, surgeons will continue to be involved in the complex management of surgical emergencies in this unique patient population. Hence, it is important for the evaluating surgeon to seek input from a patient’s oncologist in order to assess overall prognosis, carefully consider the range of treatment options, and individualize treatment for each patient and situation.

References

1. Smith AC, Dowsett JF, Russell RC, et al. Randomised trial of endoscopic stenting versus surgical bypass in malignant low bileduct obstruction. Lancet. 1994;344(8938):1655-1660.
2. Bliss LA, Eskander MF, Kent TS, et al. Early surgical bypass versus endoscopic stent placement in pancreatic cancer. HPB (Oxford) 2016;18(8):671-677.
3. Jeurnink SM, Steyerberg EW, van Hooft JE, et al. Surgical gastrojejunostomy or endoscopic stent placement for the palliation of malignant gastric outlet obstruction (SUSTENT study): A multicenter randomized trial. Gastrointest Endosc. 2010;71(3):490-499.
4. Lavanchy JL, Vaisnora L, Haltmeier T et al. Oncologic long-term outcomes of emergency versus elective resection for colorectal cancer. Int J Colorectal Dis. 2019;34(12):2091-2099.
5. Yoshida H, Mamada Y, Taniai N, Uchida E. Spontaneous ruptured hepatocellular carcinoma. Hepatol Res. 2016;46(1):13-21.
6. Badgwell BD, Cormier JN, Wray CJ et al. Challenges in surgical management of abdominal pain in the neutropenic cancer patient. Ann Surg. 2008;248(1):104-109.
7. Puzanov I, Diab A, Abdallah K, et al. Managing toxicities associated with immune checkpoint inhibitors: Consensus recommendations from the Society for Immunotherapy of Cancer (SITC) Toxicity Management Working Group. J Immunother Cancer. 2017;5(1):95.
8. Beck TN, Kudinov AE, Dulaimi E, Boumber Y. Case report: Reinitiating pembrolizumab treatment after small bowel perforation. BMC Cancer. 2019;19(1):379.