86-year-old man for consideration of laparoscopic right hemicolectomy

Background

• 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

Issues

• 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

Discussion

Surgical options

• 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.

Optimisation

• 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. 

Plan

• 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.