Incidental peritoneal metastases in the setting of emergency surgery: Review of evidence and algorithm for oncologic decision-making

BACKGROUND: Incidental peritoneal surface metastases (PSM) identified during emergency surgery represent a challenging clinical scenario for surgeons. While peritoneal metastases are increasingly recognized as a regional disease amenable to cytoreductive surgery and intraperitoneal chemotherapy, guidelines for incidental findings in the emergency setting remain limited. METHODS: We performed a narrative, evidence-based review of PubMed, Scopus, and recent international consensus statements (2019-2025) addressing the management of PSM and their presentation in emergency surgical contexts. Relevant literature describing intraoperative strategies, diagnostic staging, and outcomes was synthesized. RESULTS: Approximately 15-30% of patients with PSM present in emergency settings. Key intraoperative principles include systematic peritoneal exploration, biopsy of representative implants, estimation of disease extent (Peritoneal Cancer Index, PCI), and avoidance of extensive resections or anastomoses that may preclude future cytoreductive procedures. When findings are unrelated to an oncologic diagnosis, treatment of the acute condition should proceed conservatively with adequate sampling. A proposed management algorithm emphasizes prioritizing stabilization, documentation, and referral to specialized PSM centers. CONCLUSIONS: The incidental detection of peritoneal metastases during emergency surgery should be approached as a potentially treatable oncologic finding rather than a terminal event. Adherence to an evidence-based surgical pathway ensures proper staging and facilitates timely multidisciplinary management that may improve long-term outcomes.