Consult: 77-year-old man for consideration of laparoscopic partial gastrectomy

Background

• Recent hospital admission with Haemoglobin of 48, inpatient blood transfusion and iron infusion 
• Imaging revealed distal gastric tumour, no metastatic disease.
• Severe COPD
• AF – NOAC
• Asbestosis
• Peripheral Vascular Disease – previous bilateral LL stents
• CKD – Stage 1

Issues

• Spirometry in clinic and subsequent formal PFTs showed FEV₁ = 0.91 (39%), PEFR = 23%, FEF_25-75%=16% predicted.
• Recent Exacerbation COPD requiring steroid therapy
• Troponin rise to 50 during last admission, associated with anaemia
• Echocardiogram unremarkable
• DASI 3.9 MET’s
• CFS = 5. Scores greater than 3 indicate increasing risk of adverse perioperative outcomes. See Rockwood article on clinical frailty DOI:10.1503/cmaj.050051

Discussion

• Respiratory function very concerning, has stopped smoking and has regular reviews with respiratory physician. On optimal therapy.
• Increased risk of postoperative pulmonary complications:
  • GUPTA Postoperative respiratory failure risk =13% and postoperative pneumonia risk= 19%. 
  • ARISCAT score: 45 = High Risk of post-operative pulmonary complications.
• Aggressive pathology – opportunities for optimisation are time-limited
• Consensus that an open procedure would not be advisable in this patient. Surgical team in agreement with this assessment but should revisit this discussion preoperatively

Plan

• Further discussion with surgical team regarding meeting outcomes
• Proceed with laparoscopic gastrectomy
• ICU 2 postoperative bed