86-year-old man for consideration of laparoscopic right hemicolectomy
Malignant Caecal Polyp = Not fully excised at colonoscopy
No evidence of metastatic spread
COPD – Last exacerbation 2018, required hospital admission
Type II MI in context of LRTI
AF – anticoagulated
Exertional dyspnoea at clinic, spirometry showed severe obstruction with good bronchodilator response.
Chest pain, new symptom. Occurring weekly. No cardiology follow-up since 2018
Clinical Frailty scale 5
Perioperative risk assessment – NSQIP scoring above average for all variables including a 47% risk of functional decline and approx. 20 % risk of serious complications, discharge into care, and delirium. SORT score gives a 7% risk of death for an elective procedure
Is there scope for repeat colonoscopy/further attempt at excision or a luminal-based procedure.
Disease prognosis –uncertain regarding expected progression of cancer.
If there is an increased likelihood of bowel obstruction, may expedite decision for surgery.
Increased Perioperative risk
Risks discussed with patient and his son at the clinic. They both expressed that the perioperative risks were too great for them to proceed. Patient currently has a reasonable quality of life and would not be accepting of functional decline.
Life expectancy calculated to be < 5 years. Discussion regarding online prediction tools for life expectancy and their use in complex perioperative decision-making.
Prehabilitation and pulmonary rehab would be excellent opportunities to optimize respiratory function
Non-invasive stress testing and an echocardiogram should be performed preoperatively.
If attending prehab, we should initiate concurrent cardiac investigations.
Formal PFT’s and respiratory review organized
Discussion with surgical team – prognosis and surgical options
Liaise with GP regarding prehabilitation via Kaden centre or pulmonary rehab
Non-invasive cardiac stress testing and echocardiogram
Re-review in clinic with results of above
UPDATE – surgical discussion. Histology revealed likelihood of very slow tumour progression. Surgeon in agreement with patient that no further management required at this stage. GP to organise prehab/pulmonary rehab and cardiac testing.
Predictor of poor prognosis with HF and sudden death.
Any further investigations needed?
? BNP indicated given the oscillatory breathing.
TTE and cardiologist review suggest nil CCF so seems unlikely
High risk already acknowledged, so BNP would not provide improved risk estimation
Appropriate to proceed with surgery?
High perioperative risks acknowledged but patient is well informed.
Hostile abdomen may make rectus sheath catheters difficult for surgeons to insert.
More lateral TAP catheters under US guidance may be a better option
EDB possible however there were mixed opinions at the meeting. The MASTER trial showed no significant difference in adverse morbid outcomes in high-risk patients undergoing major abdominal surgery with and without epidural anaesthesia. There is evidence of substantial benefit for those at risk of postoperative pulmonary complications with improved intra- and postoperative analgesia and a reduction in respiratory complications.
Postop care location? Long, complicated surgery in a patient with known severe comorbidities.
Prehabilitation if surgery is delayed allowing for NACT.
Nil further investigations
Analgesia plans for discussion with surgical team on the day
82yo male for WLE of left and right ear lesions and right sided neck dissection.
NSTEMI Aug ’20 -> 2 x DES to LAD, 1 x DES to OM2, balloon angioplasty to OM1.
Angiogram for ongoing exertional angina June 2021 showed severe ostial LCx dx and PDA dx (70%)
Pt discussed at cardiology MDT, where possibility of CABG was raised.
Right facial SCC with metastasis to local nodes.
Difficulty communicating with the treating cardiologist
Cardiologist referred patient for recent angiogram, based on stable exertional angina
Cardiologist was happy for DAPT to cease for surgery but could not comment on whether further revascularization should occur before cancer surgery without reviewing the patient in person, which could not occur for several weeks.
Should revascularization be considered?
Exercise tolerance very reassuring – mows lawns, 7.3 METS on DASI.
Further revascularisation (PCI or CABG) would require DAPT for a period, delaying cancer surgery.
Revascularization may be indicated for symptom relief, unlikely in this patient to provide survival benefit or reduced perioperative risk, based on current evidence (ISCHAEMIA trial)
What to do about difficulties with communication with cardiologist?
Discussion at cardiology-anaesthetic weekly MDT – previous experience of canvassing opinions of additional cardiologist. If patient already known to one cardiologist, can create uncertainty with conflicting opinions.
Attempt to contact cardiologist and emphasise desire to avoid delays to cancer surgery to wait for delayed in-person review.
Update: Contacted cardiologist, who advised that surgery should proceed based on reassuring TTE showing normal LV systolic fx and patient’s very good exercise tolerance.