Surgical interventions in patients with hematologic malignancies

Abdominal emergency surgery in patients with hematological malignancies: a retrospective single-center analysis

BACKGROUND

Hematologic patients requiring abdominal emergency surgery are considered to be a high-risk population based on disease- and treatment-related immunosuppression. However, the optimal surgical therapy and perioperative management of patients with abdominal emergency surgery in patients with coexisting hematological malignancies remain unclear.

METHODS

We here report a single-center retrospective analysis aimed to investigate the impact of abdominal emergency surgery due to clinically suspected gastrointestinal perforation (group A), intestinal obstruction (group B), or acute cholecystitis (group C) on mortality and morbidity of patients with coexisting hematological malignancies. All patients included in this retrospective single-center study were identified by screening for the ICD 10 diagnostic codes for gastrointestinal perforation, intestinal obstruction, and ischemia and acute cholecystitis. In addition, a keyword search was performed in the database of all pathology reports in the given time frame.

RESULTS

A total of 56 patients were included in this study. Gastrointestinal perforation and intestinal obstruction occurred in 26 and 13 patients, respectively. Of those, 21 patients received a primary gastrointestinal anastomosis, and anastomotic leakage (AL) occurred in 33.3% and resulted in an AL-related 30-day mortality rate of 80%. The only factor associated with higher rates of AL was sepsis before surgery. In patients with suspected acute cholecystitis, postoperative bleeding events requiring abdominal packing occurred in three patients and lead to overall perioperative morbidity of 17.6% and surgery-related 30-day mortality of 5.9%.

CONCLUSION

In patients with known or suspected hematologic malignancies who require emergency abdominal surgery due to gastrointestinal perforation or intestinal obstruction, a temporary or permanent stoma might be preferred to a primary intestinal anastomosis.

Prognostic Impact of Neutropenia in Cancer Patients with Septic Shock: A 2009–2017 Nationwide Cohort Study

Simple Summary

The prognostic impact of neutropenia on mortality in cancer patients with septic shock remains controversial despite recent advances in cancer and sepsis management. This study aimed to determine whether neutropenia could be related to an increase in short-term and long-term mortality. This population-based, case–control study used data from the National Health Insurance Service of Korea. Adult cancer patients who presented to the emergency department with septic shock from 2009 to 2017 were analyzed. The 30-day and 1-year mortality rates were evaluated as short-term and long-term outcomes. After adjustment for confounders, neutropenia was independently associated with decreased 30-day and 1-year mortality rates. Neutropenia did not increase mortality in cancer patients with septic shock, suggesting that neutropenia may not be used as a single triage criterion for withholding intensive care in cancer patients presenting to the emergency department with septic shock.

Abstract

(1) Background: Neutropenia’s prognostic impact on mortality in cancer patients with septic shock remains controversial despite recent advances in cancer and sepsis management. This population-based, case–control study aimed to determine whether neutropenia could be related to an increase in short-term and long-term mortality. (2) Methods: This population-based, case–control study used data from the National Health Insurance Service of Korea. Adult cancer patients who presented to the emergency department with septic shock from 2009 to 2017 were included. The 30-day and 1-year mortality rates were evaluated as short-term and long-term outcomes. Cox proportional hazard regression was performed after adjusting for age, sex, Charlson comorbidity index, and neutropenia. (3) Results: In 43,466 adult cancer patients with septic shock, the 30-day and 1-year mortality rates were 52.1% and 81.3%, respectively. In total, 6391 patients had neutropenic septic shock, and the prevalent cancer type was lung cancer, followed by leukemia, non-Hodgkin’s lymphoma, stomach cancer, and colon cancer. Furthermore, 30-day and 1-year mortality was lower in patients with neutropenia than in those without neutropenia. After adjustment for confounders, neutropenia was independently associated with decreased 30-day and 1-year mortality rates. (4) Conclusions: In cancer patients presenting to the emergency department with septic shock, the presence of neutropenia did not increase mortality. This suggests that neutropenia may not be used as a single triage criterion for withholding intensive care in cancer patients presenting to the emergency department with septic shock.

Acute Abdominal Complications in Deeply Neutropenic Onco-Hematology Patients: A Retrospective Series of 105 Cases

BACKGROUND

Acute abdominal complications (AAC) in patients with deep neutropenia (DN) is challenging to manage because of the expected influence of AAC on oncological prognosis and higher surgical complication rate in a period of DN. In practice, these parameters are difficult to appreciate. This study reported our experience in managing these patients.

METHODS

All consecutive patients treated in our tertiary care cancer center between 2010 and 2020 who developed AAC in the context of a DN were retrospectively analyzed. AAC was defined as an infection (intra-abdominal, perineal, or cutaneous), bowel obstruction, or intra-abdominal hemorrhage.

FINDINGS

Among 105 patients, 18 (17%) required emergent surgery (group 1), 34 patients had a complication requiring surgical oversight (group 2), and 53 patients had a non-surgical etiology (group 3). Fifteen patients underwent surgery in the group 1, three in group 2, and one in group 3. Overall, 28 patients died during hospitalization. Mortality was statistically different between the groups (p = 0·01), with a higher rate in group 1 (n = 9/18, 50%) than in group 2 (n = 11/34, 32%) and group 3 (n = 8/53, 15%). All groups together had a median overall survival (OS) of 14 months and disease-free survival (DFS) of 10 months. OS was not comparable between the groups, and the median length of survival in group 1 was 6 months versus 8 months in group 2 and 23 months in group 3. In group 1, five patients (5/18, 28%) did not relapse at the end of the follow-up compared to 13 in group 2 (13/34, 38%) and 25 in group 3 (25/53, 47%). After discharge, OS and DFS were similar between the groups.

INTERPRETATION

The advent of an AAC necessitating surgery in the context of DN is a deadly event associated with a 50% mortality; nonetheless, in case of unpostponable emergencies, surgery can provide long-term survival in selected patients.

Acute abdomen in the immunocompromised patient: WSES, SIS-E, WSIS, AAST, and GAIS guidelines

Immunocompromised patients are a heterogeneous and diffuse category frequently presenting to the emergency department with acute surgical diseases. Diagnosis and treatment in immunocompromised patients are often complex and must be multidisciplinary. Misdiagnosis of an acute surgical disease may be followed by increased morbidity and mortality. Delayed diagnosis and treatment of surgical disease occur; these patients may seek medical assistance late because their symptoms are often ambiguous. Also, they develop unique surgical problems that do not affect the general population. Management of this population must be multidisciplinary.This paper presents the World Society of Emergency Surgery (WSES), Surgical Infection Society Europe (SIS-E), World Surgical Infection Society (WSIS), American Association for the Surgery of Trauma (AAST), and Global Alliance for Infection in Surgery (GAIS) joined guidelines about the management of acute abdomen in immunocompromised patients.

Mortality After General Surgery Among Hospitalized Patients With Hematologic Malignancy

BACKGROUND

Hospitalized patients with hematologic malignancies (HMs) may require abdominal operations for complications of malignancy, treatment sequelae, or unrelated abdominal pathology. We determined predictors of mortality after emergency general surgery for patients with HM using national-level data.

MATERIALS AND METHODS

We analyzed the 2010-2014 National Inpatient Sample for International Classification of Disease, Ninth Revision, Clinical Modification codes for HM and abdominal operations, comparing adult patient encounters with abdominal operations with HM to those without HM. Multivariate logistic regression was performed to identify predictors of mortality.

RESULTS

Of the 7.9 million adult inpatient encounters where abdominal surgery was performed, 82,187 (1%) had concomitant diagnoses of HM. Mortality among patient encounters with HM was significantly higher than without HM (9.0% versus 2.0%; P < 0.0001). Patient encounters with HM and surgery and a diagnosis of acute abdominal pain had mortality rates as high as 41%. The median standardized risk ratio for death after the top 25 general surgery procedures was 2.9 (interquartile range: 2.2-3.8) among patients with HM. In adjusted analyses, odds of mortality among patients with HM undergoing surgery were increased by concomitant acute abdominal pain diagnosis (odds ratio [OR] = 2.6; P < 0.0001), coagulopathy (OR = 2.0; P < 0.0001), aplastic anemia (OR = 1.7; P < 0.0001), peripheral vascular disease (OR = 1.4; P = 0.001), and weight loss (OR = 1.3; P < 0.0001).

CONCLUSIONS

Although uncommon, surgery on patients with HM is associated with mortality rates nearly five times higher than the general surgical population. Patients with HM requiring surgical intervention may be at particularly high odds of death and postoperative complications.

Factors associated with emergent colectomy in patients with neutropenic enterocolitis

PURPOSE

Neutropenic enterocolitis (NEC) is a severe complication of neutropenia. NEC is characterized by segmental ulceration, intramural inflammation, and necrosis. Factors present in patients who underwent colectomy have never been studied. The present study aimed to describe the clinical factors present in patients who underwent emergent colectomy for the treatment of neutropenic enterocolitis.

METHODS

Patients admitted with neutropenic enterocolitis from November 2009 to May 2018 were retrospectively analyzed. Logistic regression analysis was used to determine clinical factors associated with emergent colectomy.

RESULTS

Thirty-nine patients with NEC were identified. All patients had a hematological disorder. Medical treatment was the only management in 30 (76.9%) patients, and 9 (23.1%) patients underwent colectomy. No differences were found between the treatment groups regarding sex, age, or comorbidities. Patients were more likely to undergo colectomy if they developed abdominal distention (OR = 12, p = 0.027), hemodynamic failure (OR = 6, p = 0.042), respiratory failure (OR = 17.5, p = 0.002), multi-organic failure (OR = 9.6, p = 0.012), and if they required ICU admission (OR = 11.5, p = 0.007). Respiratory failure was the only independent risk factor for colectomy in multivariable analysis. In-hospital mortality for the medical and surgical treatment groups was 13.3% (n = 4) and 44.4% (n = 4), respectively (p = 0.043).

CONCLUSIONS

In our study, most NEC patients were treated conservatively. Patients were more likely to undergo colectomy if they developed organ failures or required ICU admission. Early surgical consultation is suggested in all patients with NEC.

Influence of neutropenia on mortality of critically ill cancer patients: results of a meta-analysis on individual data

Background

The study objective was to assess the influence of neutropenia on outcome of critically ill cancer patients by meta-analysis of individual data. Secondary objectives were to assess the influence of neutropenia on outcome of critically ill patients in prespecified subgroups (according to underlying tumor, period of admission, need for mechanical ventilation and use of granulocyte colony stimulating factor (G-CSF)).

Methods

Data sources were PubMed and the Cochrane database. Study selection included articles focusing on critically ill cancer patients published in English and studies in humans from May 2005 to May 2015. For study selection, the study eligibility was assessed by two investigators. Individual data from selected studies were obtained from corresponding authors.

Results

Overall, 114 studies were identified and authors of 30 studies (26.3% of selected studies) agreed to participate in this study. Of the 7515 included patients, three were excluded due to a missing major variable (neutropenia or mortality) leading to analysis of 7512 patients, including 1702 neutropenic patients (22.6%). After adjustment for confounders, and taking study effect into account, neutropenia was independently associated with mortality (OR 1.41; 95% CI 1.23–1.62; P = 0.03). When analyzed separately, neither admission period, underlying malignancy nor need for mechanical ventilation modified the prognostic influence of neutropenia on outcome. However, among patients for whom data on G-CSF administration were available (n = 1949; 25.9%), neutropenia was no longer associated with outcome in patients receiving G-CSF (OR 1.03; 95% CI 0.70–1.51; P = 0.90).

Conclusion

Among 7512 critically ill cancer patients included in this systematic review, neutropenia was independently associated with poor outcome despite a meaningful survival. Neutropenia was no longer significantly associated with outcome in patients treated by G-CSF, which may suggest a beneficial effect of G-CSF in neutropenic critically ill cancer patients.

Systematic review registration

PROSPERO CRD42015026347. Date of registration: Sept 18 2015

Electronic supplementary material

The online version of this article (10.1186/s13054-018-2076-z) contains supplementary material, which is available to authorized users.

The prognostic impact of abdominal surgery in cancer patients with neutropenic enterocolitis: a systematic review and meta-analysis, on behalf the Groupe de Recherche en Réanimation Respiratoire du patient d'Onco-Hématologie (GRRR-OH)

Neutropenic enterocolitis (NE) is a diagnostic and therapeutic challenge associated with high mortality rates, with controversial opinions on its optimal management. Physicians are usually reluctant to select surgery as the first-choice treatment, concerns being raised regarding the potential risks associated with abdominal surgery during neutropenia. Nevertheless, no published studies comforted this idea, literature is scarce and surgery has never been compared to medical treatment. This review and meta-analysis aimed to determine the prognostic impact of abdominal surgery on outcome of neutropenic cancer patients presenting with NE, versus medical conservative treatment. This meta-analysis included studies analyzing cancer patients presenting with NE, treated with surgical or medical treatment, searched by PubMed and Cochrane databases (1983–2016), according to PRISMA recommendations. The endpoint was hospital mortality. Fixed-effects models were used. The meta-analysis included 20 studies (385 patients). Overall estimated mortality was 42.2% (95% CI = 40.2–44.2). Abdominal surgery was associated with a favorable outcome with an OR of 0.41 (95% CI = 0.23–0.74; p = 0.003). Pre-defined subgroups analysis showed that neither period of admission, underlying malignancy nor neutropenia during the surgical procedure, influenced this result. Surgery was not associated with an excess risk of mortality compared to medical treatment. Defining the optimal indications of surgical treatment is needed.

Trial registration PROSPERO CRD42016048952

Outcomes in adult critically ill cancer patients with and without neutropenia: a systematic review and meta-analysis of the Groupe de Recherche en Réanimation Respiratoire du patient d'Onco-Hématologie (GRRR-OH)

PURPOSE

Whether neutropenia has an impact on the mortality of critically ill cancer patients remains controversial, yet it is widely used as an admission criterion and prognostic factor.

METHODS

Systematic review and meta-analysis. Studies on adult cancer patients and intensive care units were searched on PubMed and Cochrane databases (2005-2015). Summary estimates of mortality risk differences were calculated using the random-effects model.

RESULTS

Among the 1,528 citations identified, 38 studies reporting on 6,054 patients (2,097 neutropenic patients) were included. Median mortality across the studies was 54% [45–64], with unadjusted mortality in neutropenic and non-neutropenic critically ill patients of 60% [53–74] and 47% [41–68], respectively. Overall, neutropenia was associated with a 10% increased mortality risk (6%-14%; I² = 50%). The admission period was not associated with how neutropenia affected mortality. Mortality significantly dropped throughout the study decade [−11% (−13.5 to −8.4)]. This mortality drop was observed in non-neutropenic patients [−12.1% (−15.2 to −9.0)] but not in neutropenic patients [−3.8% (−8.1 to +5.6)].

Sensitivity analyses disclosed no differences in underlying malignancy, mechanical ventilation use, or Granulocyte-colony stimulating factor use. Seven studies allowed the adjustment of severity results (1,350 patients). Although pooled risk difference estimates were similar to non-adjusted results, there was no significant impact of neutropenia on mortality (risk difference of mortality, 9%; 95% CI, −15 to +33)

CONCLUSION

Although the unadjusted mortality of neutropenic patients was 11% higher, this effect disappeared when adjusted for severity. Therefore, when cancer patients become critically ill, neutropenia cannot be considered as a decision-making criterion.

Hematologic Malignancies Are Associated With Adverse Perioperative Outcomes After Total Hip Arthroplasty

BACKGROUND

Advancements in treating hematologic malignancies have improved survival, and these patients may be part of the growing population undergoing total hip arthroplasty (THA). Therefore, the purpose of this study was to evaluate the perioperative outcomes of THA in patients with hematologic malignancies.

METHODS

The Nationwide Inpatient Sample identified patients who underwent THA from 2000 to 2011 (n = 2,864,412). Patients diagnosed with any hematologic malignancy (n = 18,012) were further stratified into Hodgkin disease (n = 786), non-Hodgkin lymphoma (n = 5062), plasma cell dyscrasias (n = 2067), leukemia (n = 5644), myeloproliferative neoplasms (n = 3552), and myelodysplastic syndromes (n = 1082). Propensity matching for demographics, hospital characteristics, and comorbidities identified 17,810 patients with any hematologic malignancy and 17,888 controls; additional matching was performed to compare hematologic malignancy subtypes with controls. Multivariate regression was used to analyze surgical and medical complications, length of stay (LOS), and costs.

RESULTS

Compared to controls, hematologic malignancies increased the risk of any surgery-related complication (odds ratio [OR], 1.4; P < .0001) and any general medical complication (OR, 1.47; P < .0001). Additionally, hematologic malignancies were associated with an increase in LOS (0.16 days; P = .004) and increased costs ($1,101; P < .0001).

CONCLUSION

Patients with hematologic malignancies undergoing THA have an increased risk of perioperative complications, longer LOS, and higher costs. The risk quantification for adverse perioperative outcomes in association with increased cost may help to design different risk stratification and reimbursement methods in such populations.

Mortality in emergency surgical oncology

PURPOSE

Cancer patients can experience problems related to their disease or treatment. This study evaluated reasons for presentation at the emergency room (ER) and outcome of surgical oncology patients.

METHODS

A retrospective chart review for all surgical oncology patients who presented at the ER of the UMCG for surgical consultation between October 1, 2012, and March 31, 2013.

RESULTS

A total of 200 cancer patients visited the ER for surgical consultation: 53.5 % with complications of (previous) cancer treatment, 25.5 % with symptoms caused by malignant disease, and 21.0 % with symptoms not related to cancer or cancer treatment. The 30-day mortality rate for patients with progressive disease was 25.5 %, and overall mortality rate was 62.8 %. The most frequent reason for ER presentation was intestinal obstruction (26.5 %), of which 41.5 % was malignant. Most cancer patients (59.5 %) did not undergo surgery during follow-up. The 30-day mortality for these patients was 14.3 % and overall mortality was 37.8 %. Most patients who died within the first 30 days after ER presentation had not undergone any surgery after presentation (89.5 %).

CONCLUSIONS

There is great variation in mortality rates for cancer patients presenting at the ER for surgical consultation. The mortality in this study was greatest for patients with progressive disease (30-day mortality 25.5 % and overall mortality 62.8 %), and the majority of patients who died within 30 days (89.5 %) had not undergone surgery after ER presentation. Surgery should only be performed in the acute setting when essential and when the expected outcome is favorable for the patient.

Surgical emergencies in oncology

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. The literature was reviewed to construct a summary of potential surgical emergencies in oncology that any surgeon can be confronted with in daily practice, and to offer insight into the current approach for these wide ranged emergencies. Cancer patients can experience symptoms of obstruction of different structures and various causes. Obstruction of the gastrointestinal tract is the most frequent condition seen in surgical practice. Further surgical emergencies include infections due to immune deficiency, perforation of the gastrointestinal tract, bleeding events, and pathological fractures. For the institution of the appropriate treatment for any emergency, it is important to determine the underlying cause, since emergencies can be either benign or malignant of origin. Some emergencies are well managed with conservative or non-invasive treatment, whereas others require emergency surgery. The patient's performance status, cancer stage and prognosis, type and severity of the emergency, and the patient's wishes regarding invasiveness of treatment are essential during the decision making process for optimal management.