Completion gastrectomy and splenectomy in polymorbid patient

Gabrielle Morris

70yo male for completion gastrectomy for cancer, with curative intent

Background

  • Gastric cancer
  • Previous partial gastrectomy for ulcerative dx (+/- complications)
  • Hypertension
  • Ex-smoker since 6/12, now vaping, 70PYH. Spirometry normal.
  • IHD – CTCA showed 50% LAD stenosis, minor RCA dx. LBBB on ECG. 
  • TTE: EF lower limit of normal and stage I diastolic dysfunction.
  • Rheumatoid arthritis on monoclonal Ab therapy, nil known neck involvement.
  • Cerebellar dysfunction due to previous heavy ETOH and boxing
  • Peripheral neuropathy isolated to soles of feet. Concern that chemoRx may exacerbate this, leading to significant reduction in function
  • DASI METS 6.6

Issues

  • Expected difficult surgery – Major surgery and hostile abdomen
  • Perioperative risks
    • CPET showed peak VO2 23ml/kg/min, AT 12ml/kg/min but oscillatory breathing.
    • NSQIP – death 10%, complications 20%, increased care needs 20%
    • Patient v. motivated to improve fitness. Using a home exercise bike.
  • Nutrition
    • 12kg weight loss
    • Linked in with dietician
    • Fe and albumin reassuringly normal
    • Now on Sustagen

Discussion

  • What is oscillatory breathing?
    • Also known as periodic breathing.
    • Can be seen at rest or with exercise.
    • Multiple suggested mechanisms (incompletely understood): circulatory delay, reduced CO, increased chemosensitivity, pulmonary congestion etc.
    • Predictor of poor prognosis with HF and sudden death. 
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  • Any further investigations needed?
    • ? BNP indicated given the oscillatory breathing.
      • TTE and cardiologist review suggest nil CCF so seems unlikely
      • High risk already acknowledged, so BNP would not provide improved risk estimation
  • Appropriate to proceed with surgery?
    • High perioperative risks acknowledged but patient is well informed.
  • Analgesia?
    • Hostile abdomen may make rectus sheath catheters difficult for surgeons to insert.
    • More lateral TAP catheters under US guidance may be a better option
    • EDB possible however there were mixed opinions at the meeting. The MASTER trial showed no significant difference in adverse morbid outcomes in high-risk patients undergoing major abdominal surgery with and without epidural anaesthesia. There is evidence of substantial benefit for those at risk of postoperative pulmonary complications with improved intra- and postoperative analgesia and a reduction in respiratory complications.
  • Postop care location? Long, complicated surgery in a patient with known severe comorbidities.

Plan

  • Prehabilitation if surgery is delayed allowing for NACT.
  • Nil further investigations 
  • ICU 2
  • Analgesia plans for discussion with surgical team on the day