Surgical emergencies in cancer patients can include obstruction of structures like the GI tract, bleeding, perforation, and infection. Obstruction of the GI tract is the most common emergency and can be caused by the tumor itself or cancer treatments. Management depends on the specific emergency and may involve medications, endoscopy, drainage procedures, or surgery. Infection is also a frequent complication due to cancer treatments weakening the immune system.

1. SURGICAL EMERGENCIES
PREPARED BY
MS THEERTHA P KRISHNA
IIND YEAR MSC NURSING
MIMS CON

2. INTRODUCTION
• An oncologic emergency is defined as an acute, potentially life threatening condition in a cancer patient that has developed as a result
of the malignant disease or its treatment.
• Many oncologic emergencies are signs of advanced, end-stage malignant disease. Oncologic emergencies can be divided into medical
or surgical.
• These oncologic emergencies are mostly categorized as metabolic, hematologic, cardiovascular, infectious, and structural

3. ETIOLOGY OF SURGICAL EMERGENCIES
• Causes of surgical emergencies may be related to multiple factors.
• These may be related to tumors and cancer treatments, or unrelated to cancer at all.

4. GENERAL SURGICAL EMERGENCIES
OBSTRUCTION
PERFORATION
BLEEDING
INFECTION
PATHOLOGICAL FRACTURE
MALIGNANT ASCITES
WOUND PROBLEMS

5. OBSTRUCTION
• Cancer patients can experience symptoms of obstruction of different structures and various causes.
• Obstruction is not always purely mechanical: in fact, extramural involvement is the pre-eminent etiology, and dysmotility
disorders due to mesenterial infiltration, bowel muscle or the celiac and enteric plexus might be classified as “functional
obstruction”, and might benefit most from medical therapy

6. CLASSIFICATION
OBSTRUCTION
GI TRACT
BILIARY TRACT
URINARY TRACT
AIRWAY
MALIGNANT SPINAL CORD
COMPRESSION

7. OBSTRUCTION OF GI TRACT
• Obstruction of the gastrointestinal tract is the most frequent emergency seen in surgical practice and is characterized
by clinical intolerance to oral intake resulting in nausea, vomiting, (abdominal) pain, and absence of stool passage.

8. CAUSES
Esophageal or gastric cancer
Intraluminal tumor presence
Intraluminal invasion
Extrinsic compression by tumor mass
Treatment-related edema
Worsening of obstructive symptoms due to chemo- or radiation therapy

9. CAUSES
Anastomotic strictures after surgery
Postoperative adhesions, intestinal strangulation or hernia, and structures following radiation
therapy.
Ogilvie’s syndrome
Volvulus, diverticulitis, intussusception, and anastomotic strictures

10. CLINICAL FEATURES
• Proximal obstructions cause more severe nausea and vomiting, early pain and anorexia, whereas more distal localizations
cause abdominal distension, late pain and impaired stool passage, with an increased risk of ischemic complications or
perforation.
• MBOs are progressive and incomplete, with worsening nausea, vomiting, pain and obstipation

11. DIAGNOSIS
Plain radiography
Contrast radiographs
Computed tomography
Magnetic resonance imaging (MRI)

12. MANAGEMENT
Role of medication
Role of endoscopy
Role of surgery

13. Role of medication
• Colicky and continuous pain can benefit use of opioids: morphine, hydromorphone and fentanyl.
• Non-opioid drugs: ketorolac; to prevent segmental contractions caused by opioid-related stimulation.
Reduction of nausea and vomiting: phenotiazines, haloperidol, anticholinergics, octreotide, metoclopramide and olanzapine.
• Corticosteroids: resolution of obstruction

14. Role of Endoscopy
• Placement of a percutaneous endoscopic gastrostomy (PEG), to serve as a venting device.
• “Endoscopic long-tube decompression” which comprises the passage of a proximal obstruction with an
endoscopically .
• Colonic stenting in cases of colonic obstruction. The procedure involves the insertion of a self-expanding metallic
stent via endoscopy.

15. Role of Surgery
• Gastric Outlet Obstruction: venting gastrostomy tube placement, endoscopic stent placement, and open or laparoscopic
gastro-jejunostomy.
• Small Bowel Obstruction: bowel resection, intestinal bypass, feeding tube placement , and a few unfortunate cases that require
ostomies.
• Large Bowel Obstruction : Endoscopic self expandable metallic stents .

16. OBSTRUCTION OF BILIARY TRACT
• ETIOLOGY
– Intraluminal tumor presence or invasion
– extrinsic compression by tumor mass
– post-radiation strictures
 – Anastomotic strictures after surgical resection
-Adenocarcinoma of the pancreatic head
- Periampullary neoplasms
 -Intra- or extrahepatic cholangiocarcinoma
- Metastatic lymphadenopathy in the hepatoduodenal ligament
Biliary obstruction can result in secondary cholangitis

17. CLINICAL FEATURES
Jaundice
Pruritus
Fever
 Abdominal pain
It can cause fibrosis, cirrhosis, and ultimately liver failure

18. MANAGEMENT
Percutaneous transhepatic or endoscopic (external or internal) draina ge biliary system
Balloon dilatation
 Stent placement
Endoscopic sphincterotomy
Surgical biliary-enteric bypass
Percutaneous transhepatic internal–external drainage catheter.
Galbladder outlet obstruction can be treated by cholecystectomy or percutaneous cholecystostomy

19. URINARY TRACT OBSTRUCTION
• ETIOLOGY
Extrinsic compression by retroperitoneal or pelvic mass
Intraluminal tumour presence or invasion
Postsurgical fibrosis, strictures pelvic inflammatory disease
Catheter induced edema
Post radiation strictures

20. SPECIFIC ETIOLOGY
• Retroperitoneal or pelvic malignant lesions can develop urinary tract obstruction .
• Pelvic cancers such as prostate carcinoma, cervical cancer, and bladder carcinoma can cause bladder outlet obstruction.
• Retroperitoneal malignancies, such as lymphoma, sarcoma, and metastatic lymphadenopathy from pelvic cancers, can cause ureteric
obstruction.
• Large pelvic masses, such as ovarian carcinoma and pelvic sarcoma can result in bilateral ureteric obstruction

21. CLINICAL FEATURES
Flank pain
 sudden anuria
Sometimes alternating polyuria
Progressive rise in serum creatinine
Hydronephrosis
Subsequent infection and/or renal failure

22. MANAGEMENT
• Percutaneous nephrostomy catheters or an ureteric stent for obstructions of the upper urinary tract, and a
suprapubic or transurethral bladder catheter in case of lower urinary tract obstruction.
• Endoscopic ureteric stent placement – Suprapubic or transurethral bladder catheter

23. AIRWAY OBSTRUCTION
• ETIOLOGY:
Foreign body aspiration
Airway edema
Hemorrhage
Angioedema or infection
Tracheal stenosis
Intraluminal tumor presence or invasion
Extrinsic compression by tumor of head, neck, and lung

24. CLINICAL FEATURES
• Dyspnea
• Cough
• Wheezing
• Dyspnea occurs in rest, usually accompanied by stridor and/or retraction
• Use of accessory muscles

25. MANAGEMENT
Tracheotomy/-stomy, intubation
Bronchoscopy with tumor debulking
Ablation, or stent placement
 Steroids
Chemotherapy or external beam radiation therapy

26. MALIGNANT SPINAL CORD COMPRESSION
• Malignant spinal cord compression (MSCC) is defined as compression, displacement, or encasement of the dural
sac by spinal epidural metastases or locally advanced cancer.
• Metastases from breast, renal, prostate and lung cancer are most common causes.

27. CLINICAL FEATURES
• Local or radicular pain, worsening when lying down or during percussion of the vertebral bodies.
• Symptoms can be accompanied with neurological signs such as incontinence and loss of sensory function.

28. MANAGEMENT
Glucocorticoids
External beam radiation therapy
 Hormonal therapy, chemotherapy
 Surgical decompression by laminectomy

29. BLEEDING
• Hemorrhagic events in cancer patients may be caused by malignant disease or medical treatment.
• Patients with visible bleeding can present with hematemesis, hemoptysis, hematochezia, melena, hematuria, vaginal
bleeding, echymoses, petechiae, epistaxis, or ulcerated skin lesions.
• Occult bleeding, i.e. intraperitoneal or retroperitoneal hemorrhage, can also develop

30. ETIOLOGY
• Tumor invasion
• Local vessel damage
• Treatment response of tumor
• Radiation injury
• Coagulopathies or abnormalities in platelet function number
• Solid tumors such as hepatocellular carcinoma, renal carcinoma, and melanoma
• Solid malignancies of the gastrointestinal tract and other hollow organs such as the bladder
• Chemotherapeutic agents and anti-angiogenic targeted therapies,

31. MECHANISM
• Direct vascular invasion, increased intratumoral pressure, increased venous pressure or portal hypertension, and
decreased autoregulatory mechanisms within the tumor vessels, can cause spontaneous bleeding

32. MANAGEMENT
Hemodynamic monitoring
Establishment of intravenous access
 Fluid resuscitation or even transfusion of blood products
Agents that advance bleeding or inhibit coagulation should be eliminated
Administration of clotting factor, vitamin K, vasopressin, somatostatin analogs, antifibrinolytic agents or blood products.
Hemostasis using injection of sclerosing agents, heater probe, electro- or photocoagulation.
Angiography and interventional radiologic embolization of blood vessels is minimal invasive

33. INFECTION
• Patients with cancer frequently suffer from malnutrition and immune deficiency secondary to the disease or its treatment.
• These factors can result in an increase in frequency, severity, and duration of infections, and also the development of
infections caused by non-common pathogens.
• Alterations in B-lymphocyte function are seen in multiple myeloma, chronic lymphocytic leukemia, and secondary to
chemotherapy.

34. INFECTION
• Immune deficient patients can develop infections of the gastrointestinal tract, such as perianal or perirectal abscesses,
severe mucositis, candidiasis, neutropenic enterocolitis and other intraabdominal infections.
• Neutropenic enterocolitis is a transmural inflammatory condition of the right colon and particularly the cecum, in
the setting of myelosuppression and profound neutropenia.

35. CLINICAL FEATURES
• Abdominal distention
• Diarrhea
• Fever and right lower quadrant tenderness and it may mimic acute appendicitis.
• Neutropenic enterocolitis can lead to bowel necrosis with perforation and sepsis

36. MANAGEMENT
Broad spectrum antimicrobial therapy
For neutropenic enterocolitis, initial therapy should be conservative with bowel rest, nasogastric suction, broad spectrum antibiotics,
administration of fluid and electrolytes, and total parenteral nutrition.
Indications for surgical drainage of perianal infections in patients with neutropenia is usually based on the white blood cell count and
the development of an abscess, since this is dependent on the presence of leukocytes.

37. PERFORATION
Perforation of primary tumor in the gastrointestinal tract is associated with a high risk
on spread of tumor cells into the peritoneal cavity.
Perforation of the intestine can occur in cancer patients after prolonged obstruction.
Colorectal carcinoma and gastrointestinal lymphoma are malignancies that are
associated with spontaneous perforation.

38. PERFORATION
Esophageal and gastric perforation can occur due to perforation of primary tumor.
Gallbladder perforation can be a complication of cholecystitis due to cholelithiasis, prolonged obstruction of the cystic duct, after biliary stent-
placement, or locoregional ablation of hepatic cancer.
Anti-angiogenesic drugs such as bevacizumab for colorectal cancer, or sunitinib and imatinib for gastrointestinal stromal tumors (gist), have been
associated with intestinal perforation

39. MANAGEMENT
Antimicrobial control is essential and broad spectrum antibiotics should be administered.
Urgent laparotomy
Image-guided percutaneous drainage
Percutaneous drainage by cholecystostomy catheter or by directly draining the fluid collection as bridge to
cholecystectomy

40. PATHOLOGICAL FRACTURE
Bone injury can result from primary bone tumors or metastases from lung, prostate, breast, kidney, thyroid cancer and all kinds of other
malignancies.
Bone injury in cancer patients becomes emergent in case of pathological fractures, spinal cord compression, hypercalciemia, bone marrow infiltration
and severe bone pain.
After radiation therapy, bone tissue can become hypovascular, hypocellular and hypoxic, and the bone has a decreased ability to replace the normal
collagen and cellular losses.

41. MANAGEMENT
Use of bisphosphonates
Acute cancer related fractures are an indication for surgery and are treated with internal fixation or joint
prostheses

42. MALIGNANT ASCITES
Ascites can be due to many causes, but the most frequent indication for consults for surgical oncologists is ascites
due to carcinomatosis .
Large-volume ascites can lead to abdominal pain and discomfort from distention, as well as shortness of breath due
to difficulty with inspiration.

43. MANAGEMENT
Systemic therapy can help control malignant ascites.
Ultrasound-guided aspiration
Peritoneovenous shunts

44. WOUND PROBLEMS
• Primary, recurrent, or metastatic tumors can lead to skin ulceration with bleeding, infection, drainage, and odor.
• Resection of lesions with thin overlying skin or bulky adenopathy can prevent subsequent major resection with
reconstruction.

45. CONCLUSION
There are various surgical emergencies that can occur in cancer patients and these can have either benign or malignant
origin.
The most frequent surgical emergency experienced by cancer patients is obstruction of the gastrointestinal tract. Obstruction
can also develop in other structures, such as the urinary tract, airway, or spinal cord.
Other surgical emergencies include perforation bleeding infections , and pathological fractures.