Aspiration pneumonia, fundoplication

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