Hysterectomy, severe cardiomyopathy

Gabrielle Morris

69yo for hysterectomy. Open vs laparoscopic?

Background

  • Early endometrial cancer – hyperplasia. Nil local/distant metastases.
    • Initial hysteroscopy surgically challenging, difficult to obtain biopsy
    • Unable to access cervix, couldn’t insert Mirena.
  • Distance patient, Dubbo
  • Cognitive impairment, independent with ADLs. Attended with carer (niece). 
  • Challenging consult, limited history available
  • AF, apixaban.
  • BMI 45

Issues

  • Cardiomyopathy
    • Hysteroscopy done under (uneventful) spinal due to being ‘unfit for GA’. 
    • History unclear, letters from cardiologist suggest fast AF several years ago, presumed rate-related Cardiomyopathy.
    • EF was 25%, now improved to 60%
    • NYHA III dyspnoea. 
    • Cardiologist visits from Sydney and regularly reviews at indigenous clinic
  • Adrenal Mass
    • Incidental finding. Large 38x22x36mm on staging CT
    • Endocrinologists keen to Investigate as a possible functional mass. Pathology pending.
    • On ACE-I and Beta-blocker so aldosterone/renin test unable to be performed until these medicines are paused.
    • Potentially requires adrenalectomy
    • Functional mass may have caused tachycardia and subsequent cardiomyopathy

Discussion

Optimised from cardiac perspective?

  • Recent TTE reassuring
    • Remains dyspnoeic however BMI 45 and deconditioned are significant contributing factors

Endocrine Ix pre-operatively?

  • Prudent to proceed with gynaecological surgery without significant delay. 
  • Mirena could not be inserted to slow the cancer progression.
  • However a functional adrenal tumour will significantly alter management 
  • Urgent referral to endocrine completed after discussion with endocrine AT

Preoperative sleep studies?

  • STOPBANG 7 
  • ESS = 5
  • HCO3 = 29
  • Spo2 =96% RA
  • Some features to suggest possible Obesity hypoventilation Syndrome
  • No preoperative sleep studies indicated given ESS < 8, urgency of surgery, and further delay.

Distance patients in clinic 

  • Gynae-oncology distance patients are booked to have anaesthetic consult and surgical review on same day
  • Often travel long distances to the hospital and are seeing the anaesthetist first as the gynae clinics are in the afternoon
  • Not ideal as we might not know what operation is planned
  • Can liaise with the surgeon that afternoon
  • Helpful to send patient to gynae appointment with photocopy of anaesthetic chart and a mobile phone number so that the team can rapidly access the information they need and contact us to facilitate surgery.

Plan

  • Pathology including plasma metanephrines, 24-hour urinary catecholamines, TSH and Hb requested
  • Urgent endocrine review via telehealth organised