PIG Meeting: 1st April 2021
74yo male with a positive margin from a previous forehead SCC resection performed under LA. Consultation for suitability for general anaesthesia.
- Severe asthma secondary to ANCA-negative vasculitis(Chrurg Straus disease)
- FEV1 1.1L (38%), DLCO 53%
- Gardens, uses mobility scooter outside the home
- Maximal medical therapy trialled including monoclonal antibody tx. Now on mycophenylate and prednisone.
- OSA on CPAP – non-adherent at present due to forehead lesion interfering with mask
- Obesity with 30kg weight gain over 3yrs in setting of chronic steroids
- Are there non-surgical options for his SCC?
- Concern about asthma exacerbation due to pneumonitis risk with immune cancer therapy.
- Does not qualify for trials of novel agents due to lack of nodal or distant mets. Qualification on compassionate grounds thought ++ unlikely.
- Has already trialled radiation therapy – complicated by wound breakdown. Deemed not suitable for further radiotherapy.
- Is his SOB fully accounted for?
- TTE arranged due to orthopnoea but nil major abnormalities found
- Can he be optimised?
- Short course high dose steroids unhelpful due to known steroid insensitivity of his asthma.
- Resp physician feels no further optimisation possible.
- Should surgery proceed? What are the risks?
- Respiratory physician believes patient likely to live 2+ years with lung disease
- There is no documented lower limit of mechanical respiratory function at which general anaesthesia is contra-indicated.
- Wound breakdown felt to be biggest risk given immunosuppression and chronic steroid use for vasculitis
- NSQIP suggests 2.2% risk of death and 20% risk of morbidity for free flap surgery
- Low risk of post operative respiratory complications as per ARISCAT scoring but is the unique risk of severe, life threatening intraoperative bronchospasm accounted for in these scoring systems?
- Further discussion with surgeons about options for surgery – they report that there will need to be consultation with plastic surgery to minimize risk of wound breakdown. Will likely need 6 hour procedure.
- ICU level 2 booking if surgery does proceed
- Consideration of nasal CPAP
- Return to GP for assistance (e.g. dietician review) for weight loss preop