PIG Meeting: 4th March 2021

73yo male booked for lap chole due to recurrent choledocholithiasis

Background

• Choledocholithiasis – several admissions with sepsis requiring IV Abx and ERCPs
• Cardiac disease
  • Missed STEMI 2019 – DES to LAD, LCx occluded, not amenable to PCI
  • Polymorphic VT arrest 2019 2 days post ERCP, hypokalaemic.
  • 2nd polymorphic VT arrest 2/7 later (K+ normal)
  • AICD placed, nil shocks since.
  • Bisoprolol and amiodarone
• Paroxysmal AF – on dabigatran
• GORD
• Smoker
• Ex tolerance 5 METS as per DASI

Issues

• Cardiac status
  • TTE – EF 30-35%, stage I diastolic dysfx, mild MR, mild AR, e/o inferolateral RWMAs, biatrial moderate to severe enlargement.
  • Reviewed by cardiologist – Nil current e/o CCF, exercise tolerance only mildly limited

Discussion

• Should he have surgery?
  • SORT score 5.4% risk of death
  • Severe cholangitis in this man carries a high risk of morbidity and mortality, as does emergency surgery.
  • While his risk of death with elective surgery is not insignificant it is likely the lower risk option.

• Opportunities for optimisation?
  • Cardiologist r/v suggests HF reasonably controlled. Suggested ceasing Dabigatran 48h preop and switching to aspirin until resumption of anticoagulation.

• Postoperative care location
  • >5% risk of perioperative mortality widely considered to represent ‘high risk’ however limited ICU bed spaces necessitates thoughtful rationing of resources.
  • Extended recovery (i.e. 4hr stay) is a useful option – observe for dysrythymias, replenish electrolytes as needed, support normal physiology then, provided no issues arise, discharge to normal ward.