69yo for hysterectomy. Open vs laparoscopic?
- 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
- 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
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.
- Pathology including plasma metanephrines, 24-hour urinary catecholamines, TSH and Hb requested
- Urgent endocrine review via telehealth organised