70s male, for neck dissection + tracheostomy. 

Background

• AF – rate controlled 
• High BMI 36 – undergoing intentional weight loss and physical activity regimen
• HTN 
• Ex smoker 
• T2DM 
• ?OSA – high STOPBANG score 

Issues

• Extensive surgery for a frail patient
• Patient understanding of treatment options and extent of surgery (unaware of tracheostomy component) – patient wanting to explore non-surgical options

Discussion

• Multiple comorbidities however patient self-motivated and already improving their fitness/health independently
• Extensive surgery but physiologically moderate stress due to peripheral nature
• OSA not needing optimization prior to this procedure. Nil other optimizable comorbidities identified.

Plan

• Referral to surgeons for further discussions with patient
• Suitable to proceed to surgery should that be the final plan
• Advanced care planning – booklet provided to patient

75 F for L3/4/5 laminectomy for canal stenosis – radiculopathy main symptom. Opioid naïve.

Background

• Severe COPD
  • LFTI q 2^nd yearly, requiring steroids and antibiotics
  • FEV1 0.58 (34%), FVC 1.29 (55%)
  • NYHA III-IV
  • Not on home O2. SpO2 93% RA in clinic, wheeze in chest.

• Severe reflux – previously aspiration during gastroscopy 

Issues

• High risk POPC
• ? alternatives to surgery
• Frailty – CFS 5-6

Discussion

• Reasonable to trial of conservative management with steroid injections 
• Patient accepts risk of death with surgery due to extremely poor QoL at present, if conservative management fails.
• Canal stenosis crosses a spectrum of severity, clinical implications and underlying pathology, meaning some may improve over time and be more amenable to non-surgical options. Others may not.
• Does not meet our criteria for urgent referral to respiratory physician due to likely non-optimisable disease (based on frequency of exacerbations).

Plan

• Trial of conservative management then likely surgical approach given patient accepting of risks. 
• ICU level 2, should surgery proceed
• Referral to HIPS for potential intervention
• Formal PFTs
• GP review of COPD given wheeze present in clinic.

79 M with recent TURBT demonstrating invasive bladder cancer.

Background

• Invasive bladder and prostate cancer (Gleeson 7)
• CABG – nil ongoing symptoms
• AF – apixaban
• Mild COPD and restrictive defect secondary to central obesity – NYHA III
• Stage 3 CKD 
• OSA – moderate/obstructive – not treated
• BMI 34, central 

Issues

• Perioperative risks
  • Risk assessment: NSQIP – 50% chance of serious complications, 6% risk of death, 60% risk of discharge to ‘other than home’, 12% delirium
  • ? patient’s ability to manage and cutaneous urinary stoma – currently needs assistance with shopping/cleaning
  • Patient values current independence

• ? Further Ix warranted for SOBOE
  • SOBOE – previously reviewed by Respiratory physician – likely deconditioned rather than a treatable cause 
  • TTE – nil significant findings (recent medical admission for urosepsis, long lie and myocardial injury – trop 200)

• Other non-surgical options?
  • Patient has yet to meet with surgical team to discuss diagnosis and treatment options

Discussion

• High risk procedure
• Surgical pathway seems likely to lead to loss of independence/function sooner than a non-surgical pathway
• Patient does not seem likely to engage meaningfully with prehab
• CPET unlikely to present any information not already known (high periop risk ++)

Plan

• Discussion with surgeons – alternative options (?RTx) due to periop risks
• No CPET 
• Refer to GP for assessment of early cognitive impairment 

46 yo M with a previous laparotomy and bowel resection for perforated diverticulitis (? IBD component). 

Background

• Myocarditis and associated cardiomyopathy -> normalised (?IBD secondary to mesalazine) 
• Family history of Huntington’s disease – indeterminant genetic testing, nil current symptoms
• BMI 32

Issues

• ? for prehabilitation
  • Not in peak fitness but “normal” exercise tolerance (DASI > 34, > 4 METS)
  • Surgeon keen for patient to undergo prehab
  • Challenges due to pain with hernia and stoma management

Discussion

• While DASI not indicative of high perioperative risk, patient likely to still benefit from improved fitness. 
• Surgery not planned until August therefore natural window of opportunity.

Plan

• Cardiac rehab may accept the patient for early supervised formal exercise
• Home, self guided exercise (with stationary bike?) afterwards
• Supervised sessions of HIIT through Team Care Arrangement immediately prior to surgery, to maximise benefit

PIG Notes July 20th 2023

• Nephrectomy, POCD and PPC risks
• Facial surgery, method of anaesthesia
• Severe COPD, colonoscopy
• Multimorbidity, colonoscopy
• CT colonography

CT colonography provides a computer-simulated endoluminal perspective of the air-filled distended colon. The technique uses conventional spiral or helical CT scan images acquired as an uninterrupted volume of data and employs sophisticated post-processing software to generate images that allow the operator to evaluate a cleansed colon in any chosen direction. 

CT colonography is an option for colorectal cancer (CRC) screening in asymptomatic average-risk individuals over the age of 50 years. Other indications for CT colonography include the evaluation of the proximal colon in patients with an obstructing CRC or evaluation of signs or symptoms of CRC in whom a colonoscopy cannot be performed due to intolerance, technical difficulty, or in whom a colonoscopy is contraindicated. (See ‘Indications’ above.)

Relative contraindications to CT colonography include the following:

•Active colonic inflammation (eg, acute diarrhea, active inflammatory bowel disease)

•Symptomatic colon-containing abdominal wall hernia

•Recent acute diverticulitis

•Recent colorectal surgery

•Recent deep endoscopic biopsy/polypectomy/mucosectomy

•Known or suspected colonic perforation

•Symptomatic or high-grade small bowel obstruction

Patient preparation consists of dietary restriction with a low-residue diet and clear liquids for 24 hours or more and bowel preparation with a laxative.

The available data suggest that CT colonography provides a similarly sensitive, less invasive alternative to colonoscopy in patients presenting with symptoms suggestive of CRC. CT colonography may be particularly valuable in patients with an obstructing CRC with the ability to tolerate a bowel preparation. In one study, performing a CT colonography led to a change in the surgical plan because of the presence of synchronous tumors in 1.4 percent of cases [59]. However, given that colonoscopy permits removal/biopsy of the lesion and any synchronous cancers or polyps that are seen during the same procedure, in our view, colonoscopy remains the gold standard for investigation of symptoms suggestive of CRC. CT colonography is preferred over barium enema where access to colonoscopy is limited.

(ref. UpToDate)

Background

• 79M for colonoscopy – previous positive FOBT, subsequent negative FOBT. Asymptomatic. Not anaemic.
• Acquired brain injury, limited understanding, difficult historian
• OSA
• Mod-severe COPD
• AF – on apixaban
• Heart failure (NYHA3) – recent admission for exacerbation requiring diuresis and fluid restriction
• Most recent echo – moderate diastolic dysfunction, moderate pulmonary hypertension
• Very limited exercise tolerance, limited due to SOB – difficult to quantify precisely due to quality of history.
• Lives alone but has carer 3 times weekly

Issues

• Appropriateness of proceeding: Similar to previous case, high risk/complex patient in terms of heart failure and cognitive limitations – should we proceed with colonoscopy?
  

Discussion

• What is the likelihood of intervention if cancer was found? More likely to be offered surgery than previous patient. And may prevent presentation with more advanced pathology down the track which would make intervention worthwhile. Discussion around life expectancy of patient and the fact that clinician prediction of life expectancy is very poor and limited models exist for prediction of life expectancy.
• What is the appropriateness of FOBT in this population? Pre test probability for this patient is low. 
• Discussion regarding low value healthcare involving low yield or futile therapies with minimal change to QOL in last years of life. 
  

Plan

• For CT colonography in the first instance.
• Would be reasonable to proceed with colonoscopy if indicated.
• Would likely need supervision for bowel prep given cognitive impairment and heart failure.

Background

• 81F for colonoscopy for altered bowel habit. Not anaemic.
• Severe COPD, stable hypothyroidism, breast ca,

Issues

• Appropriateness of proceeding:
  • Severe COPD, breathless with pursed lip breathing after walking along hallway to clinic room.
  • Known to Prof. Gibson, last correspondence suggests she is optimized.
  • Audible wheeze, sats 94% on RA.
  • Unable to shower self or make bed, DASI METS 3.97

Discussion

• Most patients can tolerate a colonoscopy
• If there was a complication (eg. aspiration) this would likely be terminal for this patient.
• Correspondence from the gastroenterologist suggested he thought it very unlikely he would find anything. If cancer was found, the patient is unlikely to be fit for surgery. 
• Discussion with gastroenterologist who agreed patient was extremely high risk and had been looking for consensus not to proceed. Mentioned that he had considered CT colonography as an alternative. This also requires prep but can be done without sedation and is much faster. Drawbacks are that it is diagnostic only, and may require subsequent colonoscopy.
• Discussion about limited anaesthetic time available for endoscopy, and increasingly more patients requiring anaesthetic support. Should we be more judicious in considering the use of this resource when CT colonography is a reasonable alternative in some?

Plan

• Patient referred back to gastroenterologist for a CT colonography.

Background

• Patient for biopsy of left lower eyelid, left canthus and nose, right cheek lesion
• Multiple cardiorespiratory comorbidities. Morbid obesity (BMI 59).
• Previous HARD card from 1991 noted with grade 3-4 view, however GA in 2019 with documented grade 2 view with bougie for intubation. 
• Significant anxiety – requesting sedation or GA. 

Issues

• Mode of anaesthesia: sedation or GA

Discussion

• Sedation problematic due to obesity and potential airway compromise with sedation. Compounded by issues with HFNP oxygen (or any supplemental oxygen) being applied given location of lesions, as well as limited access to airway if support is required. Additional problem with O2 and diathermy.

Plan

• General consensus for GA with ETT 

Background

• 80/M for right nephrectomy, incidental finding on USS for nocturia
• Severe COPD. Smoked since age 11, 100/day, quit 1 month ago.
• Spirometry in clinic: FEV1 36% pred, SpO2 96% on RA
• Staging CT showed bullous emphysema
• Functionally manages well, describes reasonable exercise tolerance, denies dyspnoea with daily activities. Walks around the block daily.
• Mini-cog 2/5

Issues

• Elevated perioperative risk:
  • Severe respiratory disease placing him at high risk for post-operative pulmonary complications
  • Risk for post-operative delirium/POCD
• Opportunity for optimisation?

Discussion

• CPET would be useful as an objective way of quantifying exercise tolerance over patient’s subjective report. This would aid quantification of perioperative risk. 
• Prehabilitation would also be useful and CPET would assist planning a program for this. 

Plan

• CPET testing followed by prehabilitation program