Skip to main content

Advertisement

SpringerLink
Log in

Does Chemotherapy Prior to Emergency Surgery Affect Patient Outcomes? Examination of 1912 Patients

  • Healthcare Policy and Outcomes
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Data regarding preoperative chemotherapy as a risk to surgical outcomes are limited. This study examines morbidity and mortality among patients necessitating emergent surgical procedures ≤30 days after chemotherapy.

Methods

We identified patients ≥18 years that received chemotherapy ≤30 days before emergency surgery (Chemo) in ACS NSQIP, 2005–2008. Subjects were compared with a control group who underwent similar emergent procedures (matched 1:1 on age and procedure/CPT code). Primary outcomes included 30-day postoperative morbidity and mortality. Log-transformed data, bivariate and multivariate linear and conditional logistic regression were used.

Results

A total of 1912 patients were identified (956/group). Patient demographics were similar. The Chemo group had lower BMI (26.3 vs 28.3, P < .001) and more frequent preoperative lab abnormalities. The number of days from admission to operation was greater in the chemo group (3.6 vs 2.6, P < .001). There was no difference in total operative time, days from operation to death, and total length of inpatient stay. Chemo patients were more likely to receive intraoperative transfusions (26.8 vs 18.7, P < .001; odds ratio [OR]: 1.59). Postoperatively, chemo patients had more major complications (44.0% vs 39.2%, P = .033; OR: 1.2), a greater risk of having ≥1 complication (45.0% vs 40.5%, P = .047; OR: 1.2), and higher mortality (22.4% vs 10.3%, P < .001; OR: 2.53). Multivariate analysis identified 3 variables predictive of mortality (chemotherapy, dyspnea, leukopenia), and 2 associated with a major complication (COPD, prolonged PTT).

Conclusions

Patients having emergent surgery after chemotherapy have more comorbidities and severe disease, which are associated with higher complication rates and mortality. Identifying modifiable parameters prior to surgery may improve postoperative outcomes.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Spira A, Ettinger DS. Multidisciplinary management of lung cancer. N Engl J Med. 2004;350:379–92.

    Article  PubMed  CAS  Google Scholar 

  2. Chang JH, Vines E, Bertsch H, Fraker DL, Czerniecki BJ, Rosato EF, et al. The impact of a multidisciplinary breast cancer center on recommendations for patient management: the University of Pennsylvania experience. Cancer. 2001;91:1231–7.

    Article  PubMed  CAS  Google Scholar 

  3. Fisher B, Bryant J, Wolmark N, Mamounas E, Brown A, Fisher ER, et al. Effect of preoperative chemotherapy on the outcome of women with operable breast cancer. J Clin Oncol. 1998;16:2672–85.

    PubMed  CAS  Google Scholar 

  4. Igaki H, Kato H, Ando N, Shinoda M, Shimizu H, Nakamura T, et al. A randomized trial of postoperative adjuvant chemotherapy with cisplatin and 5-fluorouracil versus neoadjuvant chemotherapy for clinical stage II/III squamous cell carcinoma of the thoracic esophagus (JCOG9907) (abstract). J Clin Oncol. 26(Suppl):4510.

  5. Gebski V, Burmeister B, Smithers BM, Foo K, Zalcberg J, Simes J. Survival benefits from neoadjuvant chemoradiotherapy or chemotherapy in oesophageal carcinoma: a meta-analysis. Lancet Oncol. 2007;8:226–34.

    Article  PubMed  CAS  Google Scholar 

  6. Sauer R, Becker H, Hohenberger W, Rödel C, Wittekind C, Fietkau R, et al. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med. 2004;351:1731–40.

    Article  PubMed  CAS  Google Scholar 

  7. Advanced Bladder Cancer Meta-analysis Collaboration. Neoadjuvant chemotherapy for invasive bladder cancer. Cochrane Database Syst Rev. 2004;(1):CD005246. doi:10.1002/14651858.CD005246.

  8. Daniel D, Crawford J. Myelotoxicity from chemotherapy. Semin Oncol. 2006;33:74–85.

    Article  PubMed  CAS  Google Scholar 

  9. Siegenthaler MP, Pisters KM, Merriman KW, Roth JA, Swisher SG, Walsh GL, et al. Preoperative chemotherapy for lung cancer does not increase surgical morbidity. Ann Thorac Surg. 2001;71:1105–11; discussion 1111–2.

    Article  PubMed  CAS  Google Scholar 

  10. Meric F, Milas M, Hunt KK, Hess KR, Pisters PW, Hildebrandt G, et al. Impact of neoadjuvant chemotherapy on postoperative morbidity in soft tissue sarcomas. J Clin Oncol. 2000;18:3378–83.

    PubMed  CAS  Google Scholar 

  11. Nordlinger B, Sorbye H, Glimelius B, Poston GJ, Schlag PM, Rougier P, et al. Perioperative chemotherapy with FOLFOX4 and surgery versus surgery alone for resectable liver metastases from colorectal cancer (EORTC Intergroup trial 40983): a randomised controlled trial. Lancet. 2008;371:1007–16.

    Article  PubMed  CAS  Google Scholar 

  12. Scoggins CR, Campbell ML, Landry CS, Slomiany BA, Woodall CE, McMasters KM, et al. Preoperative chemotherapy does not increase morbidity or mortality of hepatic resection for colorectal cancer metastases. Ann Surg Oncol. 2009;16:35–41.

    Article  PubMed  Google Scholar 

  13. Welsh FK, Tilney HS, Tekkis PP, John TG, Rees M. Safe liver resection following chemotherapy for colorectal metastases is a matter of timing. Br J Cancer. 2007;96:1037–42.

    Article  PubMed  CAS  Google Scholar 

  14. Brouquet A, Benoist S, Julie C, Penna C, Beauchet A, Rougier P, et al. Risk factors for chemotherapy-associated liver injuries: A multivariate analysis of a group of 146 patients with colorectal metastases. Surgery. 2009;145:362–71.

    Article  PubMed  Google Scholar 

  15. Fahy BN, Aloia TA, Jones SL, Bass BL, Fischer CP. Chemotherapy within 30 days prior to liver resection does not increase postoperative morbidity or mortality. HPB (Oxford). 2009;11:645–55.

    Article  Google Scholar 

  16. Habr-Gama A, Perez RO, Proscurshim I, Nunes Dos Santos RM, Kiss D, Gama-Rodrigues J, et al. Interval between surgery and neoadjuvant chemoradiation therapy for distal rectal cancer: does delayed surgery have an impact on outcome? Int J Radiat Oncol Biol Phys. 2008;71:1181–8.

    Article  PubMed  Google Scholar 

  17. Tulchinsky H, Shmueli E, Figer A, Klausner JM, Rabau M. An interval >7 weeks between neoadjuvant therapy and surgery improves pathologic complete response and disease-free survival in patients with locally advanced rectal cancer. Ann Surg Oncol. 2008;15:2661–7.

    Article  PubMed  Google Scholar 

  18. Lim SB, Choi HS, Jeong SY, Kim DY, Jung KH, Hong YS, et al. Optimal surgery time after preoperative chemoradiotherapy for locally advanced rectal cancers. Ann Surg. 2008;248:243–51.

    Article  PubMed  Google Scholar 

  19. Stein DE, Mahmoud NN, Anne PR, Rose DG, Isenberg GA, Goldstein SD, et al. Longer time interval between completion of neoadjuvant chemoradiation and surgical resection does not improve downstaging of rectal carcinoma. Dis Colon Rectum. 2003;46:448–53.

    Article  PubMed  Google Scholar 

  20. Ferrara JJ, Martin EW, Jr., Carey LC. Morbidity of emergency operations in patients with metastatic cancer receiving chemotherapy. Surgery. 1982;92:605–9.

    PubMed  CAS  Google Scholar 

  21. Hawkins JA, Mower WR, Nelson EW. Acute abdominal conditions in patients with leukemia. Am J Surg. 1985;150:739–42.

    Article  PubMed  CAS  Google Scholar 

  22. Koretz MJ, Neifeld JP. Emergency surgical treatment for patients with acute leukemia. Surg Gynecol Obstet. 1985;161:149–51.

    PubMed  CAS  Google Scholar 

  23. Khuri SF, Daley J, Henderson W, Barbour G, Lowry P, Irvin G, et al. The National Veterans Administration Surgical Risk Study: risk adjustment for the comparative assessment of the quality of surgical care. J Am Coll Surg. 1995;180:519–31.

    PubMed  CAS  Google Scholar 

  24. Khuri SF, Daley J, Henderson W, Hur K, Demakis J, Aust JB, et al. The Department of Veterans Affairs’ NSQIP: the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. National VA Surgical Quality Improvement Program. Ann Surg. 1998;228:491–507.

    Article  PubMed  CAS  Google Scholar 

  25. ACS-NSQIP participant use file user’s guide. http://acsnsqip.org/puf/docs/ACS_NSQIP_Participant_User_Data_File_User_Guide.pdf. Accessed 1 Oct 2010.

  26. ACS NSQIP program specifics: surgical case inclusion/exclusion overview. http://acsnsqip.org/main/program_case_inclusion_exclusion.asp. Accessed 1 Oct 2010.

  27. Kratz A, Ferraro M, Sluss PM, Lewandrowski KB. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Laboratory reference values. N Engl J Med. 2004;351:1548–63.

    Article  PubMed  CAS  Google Scholar 

  28. Borja-Cacho D, Parsons HM, Habermann EB, Rothenberger DA, Henderson WG, Al-Refaie WB. Assessment of ACS NSQIP’s predictive ability for adverse events after major cancer surgery. Ann Surg Oncol. 2010;17:2274–82.

    Article  PubMed  Google Scholar 

  29. Breslow N. Design and analysis of case-control studies. Annu Rev Public Health. 1982;3:29–54.

    Article  PubMed  CAS  Google Scholar 

  30. Nagelkerke NJ, Moses S, Plummer FA, Brunham RC, Fish D. Logistic regression in case-control studies: the effect of using independent as dependent variables. Stat Med. 1995;14:769–75.

    Article  PubMed  CAS  Google Scholar 

  31. Ingraham AM, Cohen ME, Bilimoria KY, Feinglass JM, Richards KE, Hall BL, et al. Comparison of hospital performance in nonemergency versus emergency colorectal operations at 142 hospitals. J Am Coll Surg. 2010;210:155–65.

    Article  PubMed  Google Scholar 

  32. Ingraham AM, Cohen ME, Bilimoria KY, Raval MV, Ko CY, Nathens AB, et al. Comparison of 30-day outcomes after emergency general surgery procedures: potential for targeted improvement. Surgery. 2010;148:217–38.

    Article  PubMed  Google Scholar 

  33. Dhungel B, Diggs BS, Hunter JG, Sheppard BC, Vetto JT, Dolan JP. Patient and peri-operative predictors of morbidity and mortality after esophagectomy: American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), 2005-2008. J Gastrointest Surg. 2010;14:1492–501.

    Article  PubMed  Google Scholar 

  34. Reim D, Huser N, Humberg D, Novotny A, Assfalg V, Matevossian E, et al. Preoperative clinically inapparent leucopenia in patients undergoing neoadjuvant chemotherapy for locally advanced gastric cancer is not a risk factor for surgical or general postoperative complications. J Surg Oncol. 2010;102:321–4.

    Article  PubMed  Google Scholar 

  35. Greenblatt DY, Kelly KJ, Rajamanickam V, Wan Y, Hanson T, Rettammel R, et al. Preoperative factors predict perioperative morbidity and mortality after pancreaticoduodenectomy. Ann Surg Oncol. 2011. Feb 20. [Epub ahead of print].

  36. Pereira ED, Fernandes AL, da Silva Ancao M, de Arauja Pereres C, Atallah AN, Faresin SM. Prospective assessment of the risk of postoperative pulmonary complications in patients submitted to upper abdominal surgery. Sao Paulo Med J. 1999;117:151–60.

    Article  PubMed  CAS  Google Scholar 

  37. Shiloach M, Frencher SK, Jr., Steeger JE, Rowell KS, Bartzokis K, Tomeh MG, et al. Toward robust information: data quality and inter-rater reliability in the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg. 2010;210:6–16.

    Article  PubMed  Google Scholar 

  38. Itani KM. Fifteen years of the National Surgical Quality Improvement Program in review. Am J Surg. 2009;198:S9–18.

    Article  PubMed  Google Scholar 

  39. Khuri SF, Henderson WG, Daley J, Jonasson O, Jones RS, Campbell DA Jr, et al. Successful implementation of the Department of Veterans Affairs’ National Surgical Quality Improvement Program in the private sector: the Patient Safety in Surgery study. Ann Surg. 2008;248:329–36.

    Article  PubMed  Google Scholar 

  40. Rowell KS, Turrentine FE, Hutter MM, Khuri SF, Henderson WG. Use of national surgical quality improvement program data as a catalyst for quality improvement. J Am Coll Surg. 2007;204:1293–300.

    Article  PubMed  Google Scholar 

  41. Birkmeyer JD, Shahian DM, Dimick JB, Finlayson SR, Flum DR, Ko CY, et al. Blueprint for a new American College of Surgeons: National Surgical Quality Improvement Program. J Am Coll Surg. 2008;207:777–82.

    Article  PubMed  Google Scholar 

Download references

Conflicts of interest

None.

Author information

Authors and Affiliations

  1. Department of Surgery, Yale University School of Medicine, New Haven, CT, USA

    Michael C. Sullivan MD, Sanziana A. Roman MD & Julie A. Sosa MD, MA

Authors
  1. Michael C. Sullivan MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sanziana A. Roman MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Julie A. Sosa MD, MA
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Sanziana A. Roman MD.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Sullivan, M.C., Roman, S.A. & Sosa, J.A. Does Chemotherapy Prior to Emergency Surgery Affect Patient Outcomes? Examination of 1912 Patients. Ann Surg Oncol 19, 11–18 (2012). https://doi.org/10.1245/s10434-011-1844-7

Download citation

  • Received:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1245/s10434-011-1844-7

Keywords

Search

Navigation