62-year-old lady for Laparoscopic Hiatus hernia repair /Fundoplication

Background

• Epilepsy 
• Right hemicolectomy – Iatrogenic Perforation post colonoscopy 
• Significant mental health conditions – Bipolar affective disorder, PTSD, anxiety
• Chronic back pain, known to HIPs. Using cannabis oil, no opioids.
• Fe-deficiency anaemia

Issues

• Symptomatic Hiatus Hernia/GORD/Oesophageal dysmotility
  • Recurrent aspiration pneumonia 
  • 5-6 admissions in last 2 years
  • Sleeps on bed wedge
  • Eating clear soups and fasting from 5pm.
• Moderate COPD:
  • Formal PFTs: FEV = 1.34 (55%) DLCO = 42%
  • FEV1 in clinic significantly decreased from previous; 0.82 (39%)
  • Clinically not dyspnoeic 
  • DASI 3.9 METs. Independent with ADL’s
• Pulmonary nodules – non-malignant, thought to be inflammatory

Discussion

Perioperative Optimisation

• Recent spirometry indicates pulmonary function has deteriorated
  • sequelae of recurrent aspiration pneumonia?
  • Clinically no change
  • Clinic spirometry – often difficult to obtain good technique and therefore, accurate results
  • Formal PFT’s would be useful in this circumstance though unlikely to change management
• Regular review by respiratory physician:
  • Optimised, LABA and 2 inhaled steroids
  • Concerned regarding recurrent aspirations and feels surgery should proceed 

Risk of postoperative pulmonary complications (PPC)

• ARISCAT score = 13.3%, intermediate risk of in-hospital PPC
• GUPTA – 13.7% risk of post-op pneumonia

Disposition

• Open vs lap, unusual to have to convert to open procedure
• If open, would need rectus sheath catheters and possible ICU 2
• ICU 3 suitable for laparoscopic procedure planned

Plan

• Formal respiratory function tests and discussion with physician if any change
• ICU 3
• Discuss with procedural anaesthetist