61-year-old man Oesophageal cancer for consideration of Oesophagectomy
- Morbid obesity – BMI 35
- Asthma – no admissions, daily salbutamol
- Distant ex-smoker
- NIDDM – single agent
- Hypertension and hypercholesterolaemia
- Main carer for wife (chronic back pain)
- Distal Oesophageal adenocarcinoma. T3N0
- Currently undergoing NAC with a view to trimodal therapy
- Multiple recent admissions – NG feeding, pancytopenia, and tachycardia
- Max test: HR =94% predicted RER=1.3 HRR = 7bpm
- peak vo2 = 9.8, AT = 5.1ml/kg/min, VE/VCO2 = 38
- High-risk category for major surgery – see departmental guideline below
- HR trajectory high, normal slope. Frequent finding in upper GI cancers
- Spirometry – mild obstructive defect
- Decreased fitness and deconditioning thought to be causative factors for poor CPET result
- VO2 and AT impacted by obesity as measured in ml/kg/min
- Perioperative clinic:
- wheelchair bound due to gout, normally walks with 4WW.
- 3.6 METs on DASI
- Normal Hb 125, Albumin 35, Troponin 4, HbA1c 5.4.
- Sinus tachycardia – 100bpm
- Extensive discussion with patient and wife regarding potential complications and high-risk nature of this surgery for him. Understands and is motivated to proceed, wants to continue to care for wife for as long as possible.
- Extremely high-risk surgical candidate, warrants further discussion after NAC and prehab
- Decompensating with NAC – unlikely that we will improve fitness during this period. Aim is to to maintain current level of fitness with light exercise. Attempt to improve fitness post-chemo and pre-surgery, usually with HITT-training.
- Young patient
- Sestamibi organised – DASI < 4 METs and multiple cardiac risk factors. Abnormal test may add to the discussion in future.
- Prehabilitation and physio during NAC
- Re-test CPET post-NAC
- Surgical review in interim