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7/29/2019 1 What to Do in the Urgent and Emergent Settings Daniel I. Chu MD FACS FASCRS Division of Gastrointestinal Surgery Department of Surgery 2019 AL/MS ACS Chapter Annual Meeting| July 26 th 2019 Metastatic Colorectal Cancer @DChu80 [email protected] The Overview | Who are We Talking About? Stage Distribution (%) 5-Year Survival (%)

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Page 1: d Z K À À ] Á n t Z } t d o l ] v P } µ M€¦ · d Z K À À ] Á n t Z } t d o l ] v P } µ M ^ P ] ] µ ] } v ~ 9 ñ rz ^ µ À ] À o ~ 9 ó l î õ l î ì í õ î d Z K

7/29/2019

1

What to Do in the Urgent and Emergent Settings

Daniel I. Chu MD FACS FASCRSDivision of Gastrointestinal SurgeryDepartment of Surgery

2019 AL/MS ACS Chapter Annual Meeting| July 26th 2019

Metastatic Colorectal Cancer

@DChu80 [email protected]

The Overview | Who are We Talking About?Stage Distribution (%) 5-Year Survival (%)

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The Overview | Who are We Talking About?

20% of CRC presents w/ metastasis

Stage Distribution (%) 5-Year Survival (%)

Overall 5-year survival: 10-15%

The Overview | Who are We Talking About?

Metastatic CRC Emergency Surgery+

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Elective

Urgent/Emergent

nfectionemorrhagebstructionerforation

The Overview | What Settings Are We Dealing With?

IHOP

Other operations in setting of metastasis

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Elective

Urgent/Emergent

nfectionemorrhagebstructionerforation

The Overview | What Settings Are We Dealing With?

IHOP

Other operations in setting of metastasis

Elective

Urgent/Emergent

nfectionemorrhagebstructionerforation

IHOP

The Overview | What Settings Are We Dealing With?

Other operations in setting of metastasis

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Elective

Urgent/Emergent

nfectionemorrhagebstructionerforation

IHOP

The Overview | What Settings Are We Dealing With?

Other operations in setting of metastasis

Key principles to remember in setting of metastasis

1. Determine resectability (R0?) [principle of oncology]

If resectable, consider primary operation or bridge operationIf non-resectable, consider palliative operation(s)

2. Keep it safe, simple and sweet [principle of acute care surgery]

3. Increased risks associated with metastatic disease (i.e. chemo).

Trust nothing, expect sabotage (a.k.a. post-op complications)Set realistic expectations for patients and families

Target the immediate problemDeal with reconstructions later – ostomies are okay

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Elective

Urgent/Emergent

nfectionemorrhagebstructionerforation

Other operations under chemotherapy

IHOP

The Setting | Obstruction

The Setting | Obstruction

Colo

n Ca

ncer

Rect

al C

ance

r

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The Setting | ObstructionCo

lon

Canc

erRe

ctal

Can

cer

The Strategies

1. Resection2. Diversion3. Bypass4. Stenting

The Setting | Obstruction

https://wjes.biomedcentral.com/articles/10.1186/s13017-018-0192-3

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The Setting | Obstruction

https://wjes.biomedcentral.com/articles/10.1186/s13017-018-0192-3

The Setting | Obstruction

https://wjes.biomedcentral.com/articles/10.1186/s13017-018-0192-3

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The Setting | Obstruction

https://wjes.biomedcentral.com/articles/10.1186/s13017-018-0192-3

The Setting | Obstruction

https://wjes.biomedcentral.com/articles/10.1186/s13017-018-0192-3

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The Setting | Obstruction | What About Stents?

Overall Survival

https://www.thieme-connect.com/products/ejournals/html/10.1055/s-2002-34271https://www.ncbi.nlm.nih.gov/pubmed/25120255 (Ann Surg Onc Feb 2015)* https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3051134/ (World J Gastro Feb 2011)* https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4069290/ (World J of Gastro June 2014)

The Setting | Obstruction | What About Stents?

https://www.thieme-connect.com/products/ejournals/html/10.1055/s-2002-34271https://www.ncbi.nlm.nih.gov/pubmed/25120255 (Ann Surg Onc Feb 2015)* https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3051134/ (World J Gastro Feb 2011)* https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4069290/ (World J of Gastro June 2014)

This meta-analysis of 1,136 pts (11 studies):

1. Overall survival (OS) similar2. Disease-free survival (DFS) similar3. Recurrence similar

Conclusion: Bridge-to-surgery (BTS) is acceptable strategy

Other studies*: High technical success ratesShorter LOS (9.5-10d vs. 15-18.8d)Less morbidity and mortality (0-4.2% vs. 5-10.5%)Lower stoma formation rate (12.7 vs. 54%)More defined role in palliative situations

Caveats: Risk of perforation (<5%)Early complications: Migration, pain, expansion (<20%)Late complications: Migration and occlusion (<15%)Cost-effectiveness is not established

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The Setting | Obstruction

https://wjes.biomedcentral.com/articles/10.1186/s13017-018-0192-3

Elective

Urgent/Emergent

nfectionemorrhagebstructionerforation

Other operations under chemotherapy

IHOP

The Setting | Perforation

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The Setting | Perforation

https://wjes.biomedcentral.com/articles/10.1186/s13017-018-0192-3

1. Target the perforation (resect)2. Decision then focuses on reconstruction3. If any doubt, proximal diversion or end diversion

Elective

Urgent/Emergent

nfectionemorrhagebstructionerforation

Other operations under chemotherapy

IHOP

The Setting | Infection

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Wound Care

Nutrition

The Setting | Infection

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4416749/pdf/pone.0124641.pdf

Antibiotics• IR (Drains)• Endo (Drains)• Surgery

Source Control

207 pts with surgical oncologic emergencies.2013-2014 @ Groningen, Netherlands.

Elective

Urgent/Emergent

nfectionemorrhagebstructionerforation

Other operations under chemotherapy

IHOP

The Setting | Hemorrhage

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The Setting | Hemorrhage

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4069290/ (World J of Gastro June 2014)https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3051134/https://www.ncbi.nlm.nih.gov/pubmed/15747077/ (DCR 2005 Courtney ED, et al.)https://www.ncbi.nlm.nih.gov/pubmed/15019921/ (J GI Surg Mar 2004 Kimmey MB et al.)

Elective

Urgent/Emergent

nfectionemorrhagebstructionerforation

IHOP

The Overview | What Settings Are We Dealing With?

Other operations in setting of metastasis

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Elective

Urgent/Emergent

nfectionemorrhagebstructionerforation

IHOP

The Overview | What Settings Are We Dealing With?

Other operations in setting of metastasis

The Setting | Other Operations

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4552078/ (J Trauma Acute Care Surg May 2015 Cooper Z, et al.) https://wjes.biomedcentral.com/track/pdf/10.1186/s13017-018-0192-3

2005-2012 ACS-NSQIP data875 patients with disseminated cancer

Indication for surgery: Perforation (n=499) or Obstruction (n=376)

Within 30-days:

1 out of 3 pts w/ perforation die.1 out of 6 pts w/ obstruction die.

These pts are high-risk.

Perforation Obstruction

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The Setting | Other Operations | Bevacizumab

https://jamanetwork.com/journals/jama/fullarticle/645368 (JAMA Feb 2011)

The Setting | Other Operations | Bevacizumab

https://jamanetwork.com/journals/jama/fullarticle/645368 (JAMA Feb 2011)

Bevacizumab associated w/ ↑ txt-related mortality.

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The Setting | Other Operations | Bevacizumab

https://www.ncbi.nlm.nih.gov/pubmed/18095268 (J Surg Oncology Feb 2008)https://www.ncbi.nlm.nih.gov/pubmed/25799132 (Can J Surg Jun 2015)

Case series of delayed anastomotic leaks (2+ yrs out)

Bevacizumab associated w/ increased risk of colonic

perforation in setting of stent

• Individualize to the patient and setting(s)

• Use best principles of oncology and acute care surgery

• Understand the high-risk profiles of this situation

Summary of What To Do in Urgent/Emergent Setting

Emergent

Elective

Metastatic CRC

1. Primary Resection +/- Diversion

Goal is an R0 resection

2. Bridge-to-Surgery (Diversion, Bypass or Stent)

3. Palliation (Diversion, Bypass or Stent)

+/- (neo)adjuvant therapies

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[email protected]@DChu80

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1. Compared to elective surgery, emergency surgery for colorectal cancer is associated with:

A. Shorter length-of-stay

B. Adverse outcomes including increased risk of mortality and decreased disease-free/overall survival.

C. Cost-savings

D. Reduced risk for an ostomy

Answer: B.

2. A 48-year old man presents to the emergency room with abdominal pain, distention, nausea and vomiting. An abdominal X-ray shows distended large bowel. His vitals are stable and he has no peritoneal signs. What is the next best diagnostic test?

A. Carcinoembryonic antigen (CEA) level

B. Computed tomography (CT) scan of abdomen and pelvis

C. Magnetic resonance imaging (MRI) of abdomen and pelvis

D. Left lower quadrant abdominal ultrasound

Answer: B.

3. A 46-year old woman is admitted to the hospital with a large bowel obstruction. CT scan of the chest, abdomen and pelvis demonstrates a near-obstructing rectal mass in addition to five lesions in the liver and two in the left lung. CEA level is 21 ng/mL. What is the next immediate best step in management?

A. Observation

B. Chemotherapy

C. Stent

D. Proximal diversion with an ostomy

Answer: D.

4. A 52-year old man with no significant past medical history presents with several days of worsening abdominal pain to the emergency room. Upright chest X-ray demonstrates free air. He is tachycardic and his abdominal exam is concerning for peritonitis. He is being resuscitated with intravenous fluids. What is the next best step in management?


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