81yo male for revision of ileostomy for massive herniation of stoma

Background

• Previous ultra-low resection of rectal cancer in 2020 
• Bowel obstruction from parastomal hernia (2021) complicated by toxic megacolon (requiring multiple operative interventions) and T1RF requiring ICU admission
• Urothelial cancer: was awaiting open radical nephron-uretectomy → deemed inappropriate due to peak poor functional capacity with CPET: peakVO2 10.5mL/kg/min, AT 6.2mL/kg/min. Having palliative radiotherapy and expected survival >12months.
  • Has functionally improved since this period
• COPD. FEV1 1.39L
• HTN, hypercholesterolaemia
• IDDM
• CKD: eGFR ~40 (not expected to deteriorate with radiotherapy)
• Ex-smoker: 30PYH. 
• 4WW for longer distances; walking stick at home 
• Needs assistance around household

Issues

• Elevated perioperative risks
  • Frail (CFS 5)
  • Two previous episodes of postop T1RF
  • Very high risk prediction from CPET results, for any major surgery

• Lack of advanced care planning – patient + family member not engaged in discussion about ceilings of care
• Complex surgery due to hostile abdomen – Possibility of limited extra-peritoneal surgery however not guaranteed
• Quality of Life – currently reduced significantly by challenges and discomfort managing herniated stoma

Discussion

• Very high risk of perioperative morbidity and mortality – does the patient accept these risk in attempt to reduce discomfort/challenges from hernia?
• Would the patient engage in prehabilitation? 

Plan

• GP to provide ACD paperwork
• Prehabilitation arrangements
• MDT input regarding limitations of care and goals of care following prehabilitation
• Anaemia screen +/- iron 
• GP to encourage ACD discussions