Partial gastrectomy, severe resp dx

77-year-old man with gastric cancer. Previously discussed at PIG as a consult.

Background

  • COPD- severe obstructive disease. FEV1 – 0.95, FVC – 3.36
  • AF – DOAC

Issues

  • Presented with UGI bleed – Hb 48. No opportunity for NAC or optimisation
  • Referred to respiratory physician for investigation of lung masses. Thought to be non-cancerous.
  • Living at home with exertional dyspnoea
  • Patient and family keen to proceed with curative surgery

Post-operative progress

  • Admitted for procedure – lap assisted distal gastrectomy
  • ICU post-operative for 24 hours
  • Discharged to ward

72 hours post-op:

  • Acute dyspnoea, APO, and AKI. Readmitted to ICU
  • Treated for HAP; High-flow oxygen, fluid overloaded. 
  • Creatinine increasing, anuria, and delirium
  • CT showed no surgical complications, echo – nil significant
  • Difficult situation – no way forward. 
  • Evidence – When to start dialysis? Outcomes unchanged when started earlier vs later. Surgical patients do better but likely better baseline than medical patients.
  • MDT meeting – dialysis commenced over 5 days. Stabilised and went to ward. Declined again and now palliative.

Discussion:

  • Preoperatively predicted that this would be a likely outcome if had any postoperative complications involving major organs
  • Family well-informed preoperatively