Category PIG Meeting Cases

CPET before oesophageal cancer

Gabrielle Morris

61-year-old man Oesophageal cancer for consideration of Oesophagectomy

Background:

  • 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)

Issues:

  • Distal Oesophageal adenocarcinoma. T3N0
  • Currently undergoing NAC with a view to trimodal therapy
  • Multiple recent admissions – NG feeding, pancytopenia, and tachycardia
  • CPET:
    • 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.

Discussion

  • 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.

Plan:

  • Sestamibi
  • Prehabilitation and physio during NAC
  • Re-test CPET post-NAC
  • Surgical review in interim

Perioperative anaemia

Gabrielle Morris

73-year-old man for Right laparoscopic adrenalectomy

Background:

  • Large adrenal adenoma – phaeochromocytoma excluded after extensive investigation
  • Cushing’s
  • Hypertension and high cholesterol
  • DASI 6.2 METs

Issues:

  • New ejection systolic murmur and RBBB noted in clinic
    • Echo – severe AS.
    • Exertional dyspnoea after 30 minutes of mowing. No angina
    • Surgery postponed for Cardiothoracic review
  • AVR with tissue valve 6 months ago, no anticoagulants
  • Recent admission:
    • HB 42 and melaena
    • FBC unremarkable otherwise.
    • Upper GI investigations normal.
    • Transfused to Hb 80. Currently stable.
    • Anaemia screen – negative
    • Colonoscopy – 2 years previously for positive family history. NAD. No repeated as inpatient.
  • Gastroenterology review – working diagnosis of angiodysplasia from AS. For review and possible pill cam as outpatient. Recommended to proceed with surgery if Hb remains stable.

Discussion

Plan:

  • Monitor Hb
  • No need for pill cam preoperatively if no ongoing losses
  • Postpone 6/52, surgical team in agreement

Declining cognition, ? nephrectomy

Gabrielle Morris

83yo male with a very large renal cancer for hand-assisted laparoscopic nephrectomy. Urologists had arranged a CPET to help the decision-making process.

Background:

  • HTN
  • Subcortical stroke 2017
  • RCC – large mass, visible externally and with a contralateral adrenal mass (likely metastasis).

Issues

  • CPET result
    • AT 8ml/kg/min and peak VO2 11ml/kg/min = elevated perioperative risk
    • Not always used in this context as with cancer requiring urgent surgical curative treatment it may not offer additional risk stratification. Minimal opportunity for cardiorespiratory optimisation.
  • Cognitive function
    • Surgeon noted that Patient coped well with wife present, but cognitive deficits were obvious when she was absent.
    • CPET MDT discussion prompted shared-decision making appointment at clinic
    • MMSE in clinic 12-13/30.

Discussion

  • Cognitive screening in clinic
    • Very concerning when a patient scores 12-13/30 on MMSE, but what about 19-20/30 (a common score). Trajectory of their cognitive decline is important, speak with GP and look for geriatrician reviews or other MMSE sources.
    • This patient’s MMSE was performed in front of his family which was useful in demonstrating to them clearly how frail he is.
    • Accelerating his cognitive decline postop was seen as the biggest risk for him with this surgery.
  • Goals of care/prognosis
    • What is the role of the contralateral met in his decision making?
    • Surgery thought to be at best curative, at worst palliative (bleeding and pain from renal capsular and peritoneal stretch (regardless of malignant v. benign status).
    • PET scans not always helpful in diagnosing malignant vs. benign renal lesions, due to physiologic uptake of FDG in the kidneys. Can be useful for diagnosing metastases.
    • Adrenal lesions, benign and malignant, also have variable PET avidity due to background high metabolic activity.

Plan

  • Family discussion ongoing but likely patient will decline surgery

Bilateral TKR?

Gabrielle Morris

67yo female booked for bilateral TKR but “not if BMI > 40”

Background:

  • Severe OA in knees and feet 
  • Mobilises with walking stick
  • HTN
  • CFS 5
  • BMI just under 40

Issues

  • Appropriate to do bilateral TKR
    • Patient wishes for bilateral procedure as she is the primary carer for her husband with melanoma and was distressed at prospect of delay to second TKR
    • Frail older patient, recovery is likely to be slow, and her ability to support her husband (especially if she has a complication) may be severely impacted.

Discussion:

  • Who is a good candidate for bilateral TKR?
    • ASA 1-2
    • Patients aged 50-60 or younger.

Plan:

  • Discuss concerns with surgeon. Likely unilateral TKR.

AVF, severe comorbidities

Gabrielle Morris

39yo male for formation L RCF next week

Background:

  • ESRD
    • Diabetic nephropathy exacerbated by an AKI
    • Currently dialysed through permacath. Some blockages (resolved) but nil infections.
    • Secondary anaemia – EPO, Hb 109
  • T1DM
  • Smoker 10/d and cannabis ++
  • Malnourished, dry weight 54kg

Issues

  • Difficult phone consultation
    • Patient extremely difficult to engage in conversation, became agitated with attempts to clarify information.
    • Unable to ascertain functional capacity
  • Poor diabetes control
    • Multiple admissions to ICU with DKA
    • Fasting sugars 10-15. HbA1c unknown
    • Ultra-long acting/mixed insulin at midday. How to manage this perioperatively?
    • Potential for optimisation?
  • Undifferentiated HFrEF
    • Sestamibi as part of transplant workup showed EF 30%, asymptomatic (as far as could be ascertained). New development.
    • Awaiting TTE (although pt unaware of this), no current booking, should we pursue this?

Discussion

  • HFrEF
    • In absence of F2F review, preop TTE may be helpful and is a necessary step for him, it is unlikely to change management.
    • Point-of-care TTEs from ICU unable to be located
    • Could this be uraemic cardiomyopathy?
      • Classically that would present as diastolic dysfunction with hypertrophy and fibrosis, although chronic severe hypertrophy may lead to cardiomyocyte death and systolic failure.
      • Fibrosis may lead to dysrhythmias and sudden cardiac death.
      • Thought due to pressure and volume overload (HTN and anaemia), fibroblastic growth factors, chronic inflammation, systemic oxidant stress, RAA activation, insulin resistance, abnormal mineral metabolism and endogenous cardiotonic steroids.
      • Response to traditional therapies is limited.
  • Endocrinologist says they have worked extremely hard to achieve the once daily ultra-long-acting insulin and no further optimisation possible.
  • Profoundly depressed or cognitively impaired?
    • Services available within renal or transplant spheres?

Plan

  • W/H ultralong acting insulin DOS and use insulin infusion while in hospital. Resume normal insulin with normal diet.
  • Attempt to obtain TTE but don’t delay surgery if not possible preop.
  • Line up a procedural anaesthetist who will confidently do the procedure under regional anaesthesia only.

Severe DCM, endovasular recanalisation

Gabrielle Morris

89yo lady for lower leg angiogram and popliteal recanalisation for non-healing ulcers.

Background:

  • IHD – recent NSTEMI, diagnosed after prompted to see GP by clinic doctor for SOB during phone consult. 3VD. For medical mx.
  • PVD – Ulcer now mostly healed while awaiting surgical mx.
  • CCF – recent admission with decompensation. TTE shows severe global dysfx due to DCM, EF 20-25%. Not thought solely due to IHD (but other contributors unknown)
  • CKD – eGFR 35 (likely over-estimation given her low weight)
  • Ex tolerance – vacuums, shops, 1 FOS ok

Discussion

  • Proceed with lower limb angiography/plasty?
    • Able to lie flat
    • Nothing beyond local anaesthetic needed
    • Risk of presenting for emergency procedure (e.g., partial lower limb amputations) if this low-physiologic stress, low risk procedure is avoided.
  • Optimisable?
    • For further discussions with cardiologist given severity of CCF and recent decompensation

Plan

  • Discuss with cardiologist as above
  • Proceed

Wegener’s granulomatosis, TEVAR

Gabrielle Morris

65yo male with a thoracic aortic 5.5cm descending aneurysm, endograft (fenestration for left subclavian) with rapid pacing.

Background:

  • IHD
  • HTN
  • Recent ex-smoker
  • OSA
  • CKD
  • Non-labelled thrombophilia (DVT/PE’s 70s) on Xarelto
  • DASI 5.1
  • Wegener’s recent diagnosis:
    • 3/12 history of increasing SOB (unable to complete 1 FOS) + palpitations
    • Cardiologist proceeded straight to angiogram due to high pre-test probability of obstructive CAD. Angiogram was ~ normal.
    • Respiratory review – diagnosed with Wegener’s granulomatosis
      • High dose prednisone improved his CXR changes/spirometry and an associated pancolitis.
      • Now on rituximab monthly

Issues

  • ? Fit for surgery
    • Immunologist says pt will never be cured from his vasculitis.
    • Aim is to wean off high dose prednisone
    • Surgeon is happy to wait
    • Graft may not be ideal with vasculitis.

Plan

  • Ongoing immunotherapy
  • Revisit in 3 months

Remote anaesthesia, poor exercise tolerance

Gabrielle Morris

45yo female for whole body MRI. Previously attempted with oral anxiolysis due to severe claustrophobia but patient became extremely distressed. Repeat attempt booked today under GA.

Background:

  • ? Myositis
    • Subjective muscle weakness since 18mths
    • CK 1500, weakly positive myositis antibodies
    • Rheumatologist advises only avenue for diagnosis is whole body MRI
    • Chest pains – CTPA negative, costochondritis, referred to cardiologist, CT heart (? CTCA) pending.
  • HTN
  • Asthma
  • BMI 55
  • Ex-tolerance 50m
  • PCOS (metformin)
  • Likely severe OSA (declined testing due to claustrophobia)

Discussion

  • Should procedure occur today?
    • Not reviewed in periop clinic as these bookings do not come through the surgical services pathway
    • Non-urgent procedure given lack of progression of symptoms over 18mth time frame.
    • Rheumatologist and patient both pushing for MRI today.
    • Remote location
  • What would we optimise if review had occurred?
    • OSA won’t affect this procedure (no incision, no opioids afterwards), patient declining testing and CPAP.
    • Significant preoperative weight loss unlikely
    • Ideal to know the outcome/concerns of the cardiologist involved, documentation missing.

Plan:

  • Attempt to contact cardiologist by phone. If they do not feel that severe IHD or other cardiac issue is likely, then should proceed with MRI under GA.

If cardiologist not able to be contacted and anaesthetist feels the low exercise tolerance and chest pain have a high pre-test probability for perioperative M&M, reasonable to postpone an elective procedure for periop review.

Severe lung dx, minor surgery

Gabrielle Morris

Male 77yo with a known bladder cancer for cystoscopy and diathermy.

Background:

  • HTN
  • COPD 48% FEV1
  • Smoker – 120PYH
  • Post-polio syndrome with chronic pain
  • Chronic lower back pain
  • Opioid tolerant ++ (160mg BD MS Contin, 10mg QID endone)

Issues:

  • Incidental finding of LUL lesion (SCC ON BX)
    • T3N0M0
    • May be a candidate for curative surgery

Discussion:

  • Should surgery proceed?
    • Similar level of morbidity to many of our urological patients
    • Minimally invasive procedure
    • Potential for significant morbidity prevention; diathermy of a small bladder cancer recurrence now will prevent large tumour (requiring larger procedure) or anaemia from bleeding at a later date
    • Low analgesia requirements so patient’s existing opioid tolerance not a huge concern
  • Opportunities for optimisation looking towards possible thoracic surgery
    • Smoking cessation
    • Opioid reduction

Plan:

  • Proceed with urology procedure
  • Contact GP/patient about optimisation opportunities