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

A total of 56 patients who underwent surgery for intestinal perforation, intestinal obstruction, and/or acute cholecystitis were identified and included in this analysis (Fig. 1). Patients’ demographics and characteristics are presented in Table 1 and Fig. 2.

Fig. 1figure 1

Flowchart of study design and population. Between January 2010 and May 2022, an estimated 5680 patients with hematological malignancies (including acute myeloid leukemia, myelodysplastic syndrome, multiple myeloma, acute lymphoblastic lymphoma, Hodgkin lymphoma, and non-Hodgkin lymphoma) were treated as inpatients at our department of hematology and oncology or department of stem cell transplantation. *Patients with chronic myeloid leukemia and myeloproliferative neoplasia were excluded

Table 1 Patients’ characteristicsFig. 2figure 2

Overview of the distribution of hematological malignancies for groups A–C. NHL: Non-Hodgkin lymphoma; myeloid neoplasia consisting of acute myeloid leukemia and myelodysplastic syndrome; aggressive NHL consisting of Burkitt lymphoma, diffuse large B cell lymphoma, mantel cell lymphoma, and anaplastic large cell lymphoma; indolent NHL consisting of follicular lymphoma and T cell large granular lymphocyte leukemia; and other consisting of hemophagocytic lymphohistiocytosis

Intestinal perforation (group A)Patients’ characteristics

A total of 26 patients underwent surgery for intestinal perforation. The median age was 62 years (IQR 35.3–71.5), and 23 patients were male (88.5%). The most common localization of gastrointestinal perforation was jejunum or ileum in 15 patients (57.7%), followed by colon or rectum in six patients (23.1%, Fig. 3). Gastric perforation occurred in four patients (15.4%). In addition, there was one duodenal perforation. The most frequent preexisting hematological malignancy was lymphoma (88.5%), mainly consisting of diffuse large B cell lymphoma and Burkitt lymphoma. Enteral or mesenteric involvement was known in 18 patients (69.2%). At the time of abdominal emergency surgery, eleven patients (42.3%) were recently treated with CD20-directed monoclonal antibodies and 12 with chemotherapy-based regimes (46.2%). One patient (3.8%) underwent autologous stem cell transplantation. Eight patients (30.7%) had perforations in the intestinal region affected by the underlying hematological malignancy during systemic treatment.

Fig. 3figure 3

Overview of the frequency of gastrointestinal perforations depending on localization (group A, n = 26)

In the majority of patients (18/26), gastrointestinal perforation occurred prior to treatment, during steroid pre-phase treatment, or during the first therapy cycle.

In group A, no patient had neutropenia > grade 2 before surgery, whereas thrombocytopenia > grade 2 occurred in three patients (11.5%). Surgical procedures for each group are presented in Table 2.

Table 2 Overview surgical event characteristics and surgical proceduresPerioperative morbidity and mortality analysis

Overall, surgery-related events occurred in eleven patients, which were predominantly AL (6/11). In all six patients, AL led to subsequent severe fecal peritonitis and septic shock requiring surgical revision with a lavage frequency of between 3 and 15 surgical interventions. AL with peritonitis and ongoing septic shock led to death in six patients. Other surgery-related events were intraabdominal abscess, impaired wound healing, necrotizing pancreatitis, bleeding, and entero-cutaneous fistula (refer to Table 3).

Table 3 Overview of perioperative morbidity

The overall 30-day mortality observed in group A was 19.2% (5/26) with an AL-related 30-day mortality of 80% (4/5). In group A, a total of 17 patients received a primary intestinal anastomosis. 30-day mortality was significantly higher in patients with AL compared to those without AL (p = 0.006). A stoma was primary created in eight patients (30.7%), of which only 1 patient (12.5%) died within 30 days due to pneumogenic septic shock. In general, none-AL-related causes of death were pneumogenic septic shock and cancer progression. Overall, 90-day mortality was 34.6% (9/26), with AL-related 90-day mortality of 55.6% (5/9).

Intestinal obstruction (group B)Patients’ characteristics

A total of 13 patients underwent surgery for intestinal obstruction. However, in five cases segmental intestinal ischemia was found intraoperatively instead of the suspected diagnosis of ileus. The median age was 64 years (IQR 46–70), and ten patients were male (76.9%). Small bowel obstruction occurred in nine patients (69.2%). The most frequent preexisting hematological malignancies were lymphatic malignancies (38.5%) including four patients with previously existing enteral or mesenterial involvement. The most common cause of intestinal obstruction was tumor obstruction in five patients, followed by adhesions in two patients. At the time of abdominal emergency surgery, five patients were treated with CD20-directed monoclonal antibodies (38.5%), eleven with chemotherapy-based regimes (84.6%), and three patients underwent allogeneic stem cell transplantation ≤ 100 days before surgery (23.1%).

Perioperative morbidity and mortality analysis

Overall, surgery-related events were observed in six patients (46.2%). Of those, AL was seen in one patient and impaired wound healing in another patient. Intestinal ischemia occurred in one patient. Bleeding complications were observed in three patients. Overall, 30-day mortality was 46.2% (6/13) only due to pneumogenic septic shock and cancer progression without any surgery-related deaths.

Perioperative morbidity of primary intestinal anastomosis and primary stoma creation

A total of 21 patients from groups A and B received a primary intestinal anastomosis. Overall, the AL rate was 33.3% (7/21). Six AL occurred after small bowel reconstruction and one after esophagojejunostomy. Five patients received a stapler anastomosis, whereas hand-sewn anastomosis was performed in 13 patients (unknown in the remaining three). The anastomotic technique had no significant influence on the occurrence of AL. Sepsis before surgery was associated with higher rates of AL (p = 0.02). Systemic treatment before surgery was not related to an increasing rate of AL (p = 0.35). Furthermore, lymphatic disease, perioperative neutropenia, and thrombocytopenia, CD20-directed treatment, chemotherapy, intensive chemotherapy with autologous or allogeneic stem cell transplantation, and systemic corticosteroids were not associated with higher rates of anastomotic leakages.

Primary stoma creation was performed in a total of 15 patients in group A and B. In these patients, no surgical complications were observed.

Acute cholecystitis (group C)Patients’ characteristics

A total of 17 patients underwent surgery for suspected acute cholecystitis. The median age was 58 years (IQR 36–71.5), and 13 patients were male (76.5%). Acalculous cholecystitis was observed in three patients (17.7%). At the time of abdominal emergency surgery, three patients (17.7%) were last treated with CD20-directed monoclonal antibodies and nine with chemotherapy-based regimes (52.9%). Four patients (23.5%) underwent allogeneic stem cell transplantation. Primary open cholecystectomy was performed in six patients (35.3%) and primary laparoscopic cholecystectomy in eleven patients (64.7%). The conversion was necessary for four of eleven patients leading to a conversion rate of 36.4%. Reasons for conversion were bleeding, advanced local peritonitis, gall bladder perforation, and septic shock (each in one patient).

Perioperative morbidity and mortality analysis

The overall 30-day mortality observed in group C was 47.1% (8/17), with a cholecystitis-related 30-day mortality of 5.9% (1/17). Other causes of death were acute liver failure in two patients due to lymphoma progression and pneumogenic septic shock in five patients including all patients with acalculous cholecystitis. Postoperative bleeding events requiring abdominal packing occurred in three patients and lead to overall perioperative morbidity of 17.6%.

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