PIG Notes 25th May 2023

• Obesity and Reverse Total Shoulder Replacement
• Thoracotomy – patient declining op
• Caesarean section – JW
• Open AAA – Juxtarenal
• Complex lower limb vascular reconstructions
• Cholecystectomy – multimorbidity

70 y/o M with recurrent gallstone pancreatitis. Several other episodes this year, not requiring hospitalisation.

Background:

• OSA- occasional CPAP compliance
• NYHA- Class III for breathlessness. TTE – nil significant issues detected.
• BMI 40
• ESRF- haemodialysis 3 times a week 
  • 500ml fluid restriction (oliguric)
  • Secondary chronic anaemia, using an ESA + Fe
• R) nephrectomy 2022 – postoperative ICU admission for vasopressor support and hyperkalemia management
• 4WW, mobility scooter for longer distances. Reduced exercise tolerance since ICU admission.

Issues:

• Functional decline
• Multimorbidity

Discussion:

• Perioperative risks: NSQUIP: 6.4% serious, 0.8% risk of death, 26 % functional decline 
• Conservative management carries significant risks with recurrent episodes of gallstone pancreatitis
• Patient motivated for pre-habilitation 

Plan:

• Pre-habilitation 6 weeks
• Dietitian review ongoing (BMI ) through dialysis

56 y/o M  with critical left leg ischemia. Possible procedure would be a very long, very complex, multi-faceted reconstruction. Conservative management would eventually result in AKA which may be complicated by poor wound healing due to ongoing vascular compromise.

Background

• CLL- WCC 38
• Smoker – cigarettes currently 5/d (recently ceased marijuana)
• Exercise Tolerance- DASI 3.94 METs – Limited by acute limb pain 

Issues:

• Cardiovascular – Reduced exercise tolerance, ? prior non-transmural infarct in RCA territory on sestamibi (but nil reversible ischaemia). TTE pending.
• Ongoing smoking – multiple strategies discussed in clinic and NRT provided

Discussion:

• Optimisation opportunities preoperatively – smoking only
• Conservative management is a poor option 

Plan:

• Await TTE Report
• Smoking Cessation 
• Likely proceed to surgery given poor conservative mx option

77 y/o F with 5.5cm juxtarenal AAA- complex EVAR therefore preference for open procedure, and recent increase in size.

Patient’s sister died from AAA rupture leading to significant patient anxiety and exercise avoidance.

Background

• Dyslipidaemia
• Current Smoker- 75 year pack history. Reduced – currently 3/day. Normal spiro.
• CFS: 4

Issues

• Elevated risk CPET results – low AT (8.9ml/kg/min), acceptable peak VO2 (16.4). 

Discussion

• Absence of respiratory issues (beyond residual smoking) to deter from open procedure
• BP remained within target range for known AAA (<180 systolic) during CPET suggesting prehabilitative exercise will be feasible
• Patient engaged in planning prehabilitation. Previously active so understands the feel/goals of activity. 

Plan

• Pre-habilitation 4-6 weeks, no need to repeat CPET 

Proceed to open procedure

37 y/o F  for electives LSCS and tubal ligation

Background

• Previous LSCS with spinal 
• Current Pregnancy- gestational Hypertension (on Nifedipine) and elevated LFTS and proteinuria (concern for evolving HELP Syndrome) 

Issues

• Jehovah’s Witness
• Product discussion with patient and documented would accept: Cell salvage, FFP And cryoprecipitate

Discussion

• For re-discussion on day of procedure with patient (confidentially) 
• Patient wishes should be determined in absence of partner or church representative presence

Plan

• Planned procedure Wed 1/6 (Procedural anaesthetist at meeting and aware)

73y/o F for Left thoracotomy and biopsy for para-aortic left node (PET avid). Not EBUS amenable

Recent Admission with proximal myopathy (improved with steroids) and PET AVID lesion noted – ? paraneoplastic syndrome causing weakness.

Background

• ? Scleroderma/Dermatomyositis (Recent reviews by Rheumatology- still undergoing investigations)
• AF – apixaban
• HTN
• DASI METS < 4
• CFS 6
• COPD
  • FEV1 0.94 , FEV1 1.8, DLCO 39%
  • Exacerbation in Feb 23
  • 96% on RA, hyperinflation of chest on examination 

Issues

• Patient not keen for procedure due to concern about high risks
• NSQUIP – Risk of death >5%; 12% complications, Readmission 13%
• Severe COPD, likely not optimizable

Discussion

• ? natural history of disease once tissue diagnosis is obtained
• ? options for treatment of presumed cancer without tissue diagnosis
• ? risk of anaesthesia and procedure outweighs benefit
• Respecting patient autonomy 
• Options for less invasive surgery?

Plan

• To Discuss with Oncology team re ? option for empirical therapy due to the high risks, ? likely natural history without treatment
• Discuss with rheum/onc – ? myopathy due to dermatomyositis (not cancer), ? other non-cancerous diagnoses possible for the lymph node
• To discuss with surgical team – is a thoracotomy required for a tissue diagnosis or is there an alternative option

68 y/o F for Reverse total shoulder replacement

Background:

• BMI 60
• Diabetes :
  • HBAIC 7.8% (from 10.6)  -Improved control 
• CKD : eGFR 52
• HTN
• OSA- CPAP compliant
• Echo- moderate diastolic dysfunction
• Poor mobility – FASF, weekly physiotherapy and hydrotherapy
• DASI- Mets:3.63

Issues

• Exercise Tolerance reduced: SOB on arrival to clinic
• Poor diabetes control
• Opioid tolerant (30 BD oxycontin)
• High BMI

Discussion:

Proceed versus alternative therapy (Steroid injection/ Nerve blocks)

• Weight loss would assist pain and potentially avoid the need for surgery (note other shoulder becoming more problematic – ? due to FASF)
• Consideration of non-surgical management options for pain 
• Surgical team unaware of FASF use – ? will be able to use FASF after surgery, ? patient safe to mobilise without it

Plan

• Delay for 3 months
• Weight loss – Dietitian referral to free clinic 
• Contact GP re. iron replacement and GLP-1 antagonist (weight loss + DM optimisation)
• Exercise physiologist to optimise exercise tolerance and mobility – ? avoid need for FASF
• If surgery proceeds, would need ICU level 2 given risk of respiratory compromise with OSA and phrenic nerve block

PIG Notes 27th April 2023

• Congenital heart disease and endoscopy – update
• Recent ACS, Complex urologic issues
• POCD risk, cholecystectomy
• Value of OT versus risks
• Surgery after pericarditis

54yo lady, laparoscopic oopherectomy

Background

• Ovarian Cyst – on background of family history of ovarian cancer
• OSA – complaint with CPAP therapy
• PHTN – Stable, PASP = 50mmHG. Regular cardiology follow-up
• Pericardial Effusion, Restrictive Pericarditis, and Pleural Effusion – May 2022 requiring thoracoscopic drainage, pleurodesis, and pericardial biopsy. Aetiology unknown, no recurrence. On reducing dose prednisolone. NYHA 3 dyspnoea.
• NIDDM – HbA1c = 8.3%.
• COPD – mild, no admissions, Distant ex-smoker
• HTN and dyslipidaemia
• Schizophrenia, PTSD and depression – stable disease
• DASI METS 5.3

Issues

• Timing of surgery after pericarditis and pericardial/pleural effusions
• Opportunities for optimisation

Discussion

• Ideal timing from pericarditis – unknown
• ? Cardiopulmonary rehab – may be offered at Armidale
• Surgeon says no urgency for surgery given Ca125 stable however ? reliability of Ca125 given we don’t use it as a screening tool in general population. Must be guided by experience and expertise of the gynae oncology team.
• Indication for surgery – would likely meet the criteria for consideration of surgery even without her anxiety, given FHx
• ? discuss with rheumatologist or possibly at the PHTN MDT

Plan

• Discuss cardiopulmonary rehab with patient
• Discuss patient with rheumatologist
• Given stable, small pericardial effusion and no evidence of HD compromise, appropriate to proceed to surgery from HD-stability perspective.
• Unclear re timing of surgery at pericarditis – for further discussion with cardiologist.

80+ yo lady with fistula draining from hard palate to nasal cavity. Related to previous traumatic injury. Previously the cyst was not draining, causing recurrent infections. Now with fistula, patient experiences post nasal drip but no recurrent infections and nil other concerning fx. Option of surgical repair given to patient.

Background

• Metastatic SCC with axillary LN involvement (primary unknown). Recent radiotx to axilla.
• Bilateral massive PE Sep ’22 (presumably due to thrombophilia from SCC)

Issues

• ? appropriate to proceed with OT while SCC progression risk remains unclear. No oncologist review post radiotx. ? Plan.
• VTE mx and timing

Discussion

• Palate issue not affecting QoL. Surgeon agrees that surgery is not essential and certainly not time sensitive but patient keen to go ahead. Reasons unclear.
• Oncologist reviewed – review in 12/12. Nil concerns raised by them.
• Patient aware of VTE risks and other perioperative risks. 
•  >3/12 since PE therefore highest risk time has passed. Appropriate for temporary NOAC cessation.

Plan

• Discuss with patient and proceed if this remains their choice.