PIG Notes June 29th 2023

• Stoma revision, high periop risks
• ? for open AAA
• Massive goitre, frail, comorbid
• TURBT, previous tetralogy of fallot
• Osteonecrosis of the jaw

82yo male for mandibular reconstruction

Background

• Parotid tumour with mandibular involvement → radiotherapy and subsequent trismus
• Previous AFOI for resection, but unsuccessful surgery
• Asbestosis with pleural plaques
• T2DM

Issues

• Osteonecrosis of mandible → seen by ENT outpatient clinic → nil acute intervention required
• Poor spirometry, but inadequate study due to being unable to fit mouth of spirometer mouth-piece. Reassuringly, able to ride bike 8-10km/d.

Discussion

• Reassuring functional capacity despite poor spirometry
• Has not been on any agents associated with osteonecrosis of jaw (denosumab)
• Reassuring the patient had successful AFOI in past. Previously good experience

Plan

• No acute changes or interventions required

66yo Cystoscopy + TURBT for bladder amyloidosis. Recent admission with haematuria and clot retention. 

Background

• Tetralogy of Fallot: full correction at 17yo. Tissue valve replacement (?which valve) in 2011
• AICD+PPM for CHB: 2 shocks (last in 2010). Paced 85% of time
• OSA – adherent to CPAP
• Amyloidosis – localized to bladder. No systemic manifestations

Issues

• PTSD from procedures as child – wanting to avoid procedures where possible
• Surgical options: ?flexible cystoscopy, but will require yearly TURBT
• Increased SOBOE: awaiting cardiology review and ECHO

Discussion

• Reasonable to await cardiology review
• Avoidance of procedure now (with conservative flexi cystoscopy) likely to lead to further hospital admissions with haematuria/retention and unlikely to avoid need for procedure
• Tetralogy of Fallot:
  • VSD with overriding aorta, RV outflow tract obstruction and RV hypertrophy
  • Presents in the neonatal period with murmur and/or cyanosis
  • In present times, patients usually undergo complete intracardiac repair during the neonatal or infant period
  • Common long term complications of repair include pulmonary regurgitation, RV failure, atrial arrhythmias, and ventricular arrhythmias. 

Plan

• Await cardiology review and TTE

89yo female total thyroidectomy for large goitre. Symptoms of SOB, dysphagia and orthopnoea.

Background

• HTN
• AF – no embolic events
• T2DM – HbA1c 7.8%. Occasional hypoglycaemia
• CFS – 5
• RA – no neck involvement
• CKD – eGFR 35
• Low ET: DASI 3.9METs
• Recent COVID infection in May

Issues

• ? Appropriateness for surgery

Discussion

• ? Requires further investigations for SOBOE – does the history fit with goitre as the cause of the symptoms
• High risk surgery, but patient is aware of risks and feels the symptoms from goitre are affecting her QoL
• Awaiting ACD planning

Plan

• Advanced care planning
• Consideration of TTE and further investigation for SOBOE to exclude causes separate to the goitre. 

60yo male. ? fitness for AAA repair for infrarenal AAA    

Background

• IHD – RCA disease: stented 2020. Subsequent dobutamine stress ECHO normal. Awaiting sestamibi.
• OSA – on CPAP
• Obesity – 114kg
• IDDM: HbA1c < 8.5%
• Rheuamtoid arthritis – hands and feet only
• DASI 5.5METs
• Respiratory:
  • PFTs: FEV1 2.52L, FEV1/FVC ratio 0.84. Minor restrictive pattern
  • Current smoker
  • OSA on CPAP

Issues

• Elevated perioperative risk
  • CPET:
    • Submaximal test. HR to 68% maximal (on beta-blocker). Limited by leg weakness
    • AT 4.78mL/kg/min, peakVO2 8.9mL/kg/min, V/VCO2 49.7 (all in high risk stratum)
    • No ischaemic ECG changes
    • Likely secondary to deconditioning and chronotropic limitation

Discussion

• Group understanding was that open procedure preferred in this setting due to patient age
• Chronologic age and physiologic age not equivalent
• May benefit from prehabilitation – SBP remained < 180mmHg during CPET which means exercise is possible (in context of AAA).
• Consideration for EVAR given high risk for open procedure

Plan

• Prehabilitation
• Smoking cessation
• Await results of sestamibi
• Discussion with surgeons regarding EVAR as option

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

PIG Notes June 22nd 2023

• Severe AS, timing of endoscopy
• Unexplained cardioresp symptoms, ? suitable for VATS
• Brittle asthma, dental extraction
• Non-epileptic seizures
• EVAR v. open AAA

60+ patient, infrarenal AAA

Background

• Asthma COPD
• Smoker
• HTN
• Inferior MI in 30s
• Exercise tolerance – DASI METS = 9, CPET/PFTs – DLCO near normal, FEV1 65% (reversible with bronchodilators), AT 13ml/kg/min, VO2peak 19ml/kg/min, VE/VCO2 36 (borderline elevated)
• Itinerant
• ETOH misuse/abuse

Issues

• Open vs endoluminal?
• Elevated fasting BGL – awaiting OGTT
• Bronchodilator responsiveness on PFTs – Symbicort commenced

Discussion

• Open procedure appropriate from risk perspective
• Without exacerbations of COPD, the addition of ICS to regular regime may increase M&M from pneumonia – suggest LABA/LAMA instead (see https://goldcopd.org/wp-content/uploads/2020/03/GOLD-2020-POCKET-GUIDE-ver1.0_FINAL-WMV.pdf)
• HbA1c is a reliable method of diagnose DM without the need for fasting or glucose tolerance testing

Plan

• Proceed
• ETOH reduction
• DM optimization preop if further testing reveals DM

50yo male for dental extraction

Background

• BMI 47
• OSA CPAP
• T2DM ozempic, HbA1C 8.7%, microvascular (peripheral neuropathy, nephropathy)
• “Seizure activity” 20 year hx, provoked by Valsalva maneouvre or irritant stimuli (e.g. BP cuff inflation, head in certain positions). EEGs show no epileptiform activity. Neurologists suggest it is not epilepsy.

Issues

• Magnesium sterate allergy (common incipient)
• Concerns around seizure activity and perioperative management

Discussion

• Excipient list in medications chosen by procedural anaesthetist will need to be checked
• Patient insistent that he wants a GA
• May have “seizure type” activity perioperatively. 

Plan

• Proceed to OT
• Manage any perioperative seizure-type activity as you usually would. Liaise with neurologist as needed.
• Check excipients in agents used.

26yo female, impacted wisdom teeth. Multiple reviews by consultant anaesthetists over 18 month period. Multiple delays secondary to undiagnosed/optimised OSA, asthma, then COVID.

Background

• Brittle asthma – ICU 2021
• OSA now on CPAP
• BMI 63
• Under public guardianship, ASD, appropriate during consultation

Issues

• Suitable to proceed to surgery?
• Level of postoperative care?

Discussion

• BMI unlikely to be optimisable in the short term
• Delays to surgery may lead to a need for emergency procedure due to periodontal infection
• Unlikely to be able to tolerate procedure under LA and may lead to challenge ++ to convert to GA mid-procedure
• Asthma now stable. Unlikely to suffer intraoperative asthma exacerbation
• ICU level 3 seems appropropriate given minor, short procedure with low likelihood of complications, despite poor baseline health

Plan

• Proceed to surgery
• ICU level 3
• GA