86-year-old man for consideration of laparoscopic right hemicolectomy
- Malignant Caecal Polyp = Not fully excised at colonoscopy
- No evidence of metastatic spread
- COPD – Last exacerbation 2018, required hospital admission
- Type II MI in context of LRTI
- AF – anticoagulated
- Moderate MR
- Mild OSA
- Exertional dyspnoea at clinic, spirometry showed severe obstruction with good bronchodilator response.
- Chest pain, new symptom. Occurring weekly. No cardiology follow-up since 2018
- Clinical Frailty scale 5
- Advanced age
- Perioperative risk assessment – NSQIP scoring above average for all variables including a 47% risk of functional decline and approx. 20 % risk of serious complications, discharge into care, and delirium. SORT score gives a 7% risk of death for an elective procedure
- Is there scope for repeat colonoscopy/further attempt at excision or a luminal-based procedure.
- Disease prognosis –uncertain regarding expected progression of cancer.
- If there is an increased likelihood of bowel obstruction, may expedite decision for surgery.
Increased Perioperative risk
- Risks discussed with patient and his son at the clinic. They both expressed that the perioperative risks were too great for them to proceed. Patient currently has a reasonable quality of life and would not be accepting of functional decline.
- Life expectancy calculated to be < 5 years. Discussion regarding online prediction tools for life expectancy and their use in complex perioperative decision-making.
- Prehabilitation and pulmonary rehab would be excellent opportunities to optimize respiratory function
- Non-invasive stress testing and an echocardiogram should be performed preoperatively.
- If attending prehab, we should initiate concurrent cardiac investigations.
- Formal PFT’s and respiratory review organized
- Discussion with surgical team – prognosis and surgical options
- Liaise with GP regarding prehabilitation via Kaden centre or pulmonary rehab
- Non-invasive cardiac stress testing and echocardiogram
- Re-review in clinic with results of above
UPDATE – surgical discussion. Histology revealed likelihood of very slow tumour progression. Surgeon in agreement with patient that no further management required at this stage. GP to organise prehab/pulmonary rehab and cardiac testing.