26yo, 197kg, female with grade 1 endometrial cancer for laparoscopic hysterectomy after failed treatment with Mirena for endometrial cancer.
- Endometrial cancer – being treated with mirena/curettes.
- Nulliparous woman, keen to have children, may do so via surrogate with egg donation.
- 2 x previous same procedure – one under GA igel 5, one under sedation with THRIVE. Both nil issues
- Overnight oximetry with ODI 48/hr and witnessed apnoeas.
- Did not attend for review by respiratory physician despite repeated attempts from team.
- HCO3 and PaCO2 normal on ABG, so no e/o obesity hypoventilation
- High BMI ++
- Unoptimised OSA
- Severe obesity, weight gain despite dietician review.
- Surgical options?
- Maximum allowable time frame before surgery to allow optimisation?
- Will laparoscopic be possible – open surgery can be more difficult in this setting.
- Surgeon has been learning a new per-vaginal laparoscopic technique but doesn’t feel comfortable enough to try it in such a challenging patient.
- Weight reduction surgery possible?
- Information for Sydney clinic previously provided to GP however with COVID issues and need for expedited surgery, seems unlikely this will procced before hysterectomy.
- Local options?
- Would weight loss allow her cancer to be downgraded or avoid the need for surgery due to reduced hyper-oestrogenic state? See attached summary article on obesity-related gynaecological cancers.
- OSA optimisation possible?
- Local guideline (currently under development) would suggest that without OHS pre-op optimisation of OSA is not needed, due to lack of evidence suggesting improved perioperative outcomes.
- Level of post-op care? If surgery able to proceed laparoscopically, ideal for patient, allowing normal ward care.
- Speak with gynae surgeon to determine maximal timeframe for optimisation
- 2 months
- Speak with local bariatric surgeon
- Yes, surgery possible locally in the public system. Gastric bypass for “severe reflux” or sleeve gastrectomy if patient gains support from local MP.
- Weight list ~12mths however this timeframe is used to develop rapport and engagement with the service’s dietician which is essential for postop success.
- Letter sent to GP with this info.
- Ensure patient referred to gynae-oncology dietician
- Ensure patient has appointment with resp team.
- Notification to procedural anesthetist once surgery date and allocations known.