PIG Notes 17th June 2021

Cases

• Pyoderma gangrenosum and reversal ileostomy
• Thyroidectomy and chronic dyspnoea
• Colonoscopy after multiple cancellations
• TURP v. SPC for elderly polymorbid man
• Adrenalectomy for “non-active” adrenal mass

46-year-old man for Adrenalectomy.

Background

• Incidental finding of a non-active adrenal tumour in 2019 while being investigated for a testicular mass
• Normal urinary catecholamines at time of diagnosis
• Uncertainty as to cause of testicular mass
• Surgery being performed after a delay due to the coronavirus pandemic

Issues

Pathway to OT

• Distance patient. No fixed abode.
• Phone consult – reported some asthma and recreational cannabis use.
• DOS – presented with cough and sputum.
• Cancelled in anaesthetic bay, admitted to hospital under medical team and treated for LRTI/exacerbation of asthma
• Improved with treatment of infection and asthma therapy
• Decision made to rebook after one week. Surgeon unaware that patient listed

Intraoperative Events

• Profound hypertension and tachycardia after induction; SBP 250mmHg, HR 120bpm
• Resistant to propofol and increased depth of anaesthesia
• Entropy placed, values consistently below 10.
• Surgery not commenced
• Hypertension persisted despite GTN and phentolamine
• Given Hydralazine, labetalol, and morphine with some effect
• Surgery performed, no change in haemodynamic status with removal of adrenal mass

Postoperatively

• Ongoing hypertension, SBP 170-180mmHg. HR 80bpm
• Excessive pain despite 20mg morphine
• History revealed extensive cannabis use – 7g/week. Continued use throughout admission.
• Alcohol abuse – had been inpatient for a week and should be on AWS

Discussion

Differentials:

1. Phaeochromocytoma – undiagnosed at time of tumour discovery. No recent surgical or endocrine review. Literature states that during unplanned phaeochromocytoma surgery it is not uncommon to have catecholamine surges post tumour devascularisation due to lack of preoperative alpha and beta-blockade. (See attached BJA article)
2. Carcinoid syndrome – previous testicular mass of uncertain aetiology. May have Multiple Endocrine Neoplasia
3. Withdrawal from cannabis, alcohol, and possible other illicit drug use – hypertension and tachycardia are common in cannabis withdrawal, but this would be very unlikely given that patient was deeply anaesthetised

Patients presenting for surgery after a delay

• Common scenario that patient may see a surgeon and wait for a length of time before surgery. Magnified significantly by COVID.
• Should patients be reassessed by proceduralist before being booked?
• This is tricky, time-consuming and may cause more delays than benefits
• Possible that surgeons themselves may be keen to resolve, worth a discussion between specialties

87-year-old man. Consult for TURP.

Background:

• Bladder outlet obstruction
• ICU admission with urosepsis. IDC since discharge.
• TURP many years ago. Flexible cystoscopy showed regrowth of previous TUR tunnel.
• Patient and urology team keen for him to be catheter-free however patient very willing to have SPC.
•  

Issues:

• HFrEF 45%
• AF on DOAC. Previous DVT.
• Significant Rheumatoid Arthritis, on long-term steroid therapy
• Idiopathic Pulmonary Fibrosis
• Parkinson’s
• Cerebral Amyloid Angiopathy
• ECG in clinic showed bradycardia, P-waves present. Possible trifasicular block. Asymptomatic.

Discussion:

TURP Vs SPC

• General opinion that there are significant risks for perioperative cardiac and respiratory complications
• Advantages and disadvantages of both options weighed in detail
• It would be ideal for the patient to be catheter-free and a TURP could be done under a spinal
• However, TURP would require much longer period off-anticoagulation and risks of MACE unchanged by mode of anaesthesia

72-year-old man for colonoscopy via fast-track pathway following a positive FOB

Background:

• +ive FOB in community. No new bowel symptoms noted
• Initially planned for Cessnock hospital and was deemed unsuitable due to co-morbidities
• Presented to Belmont on day of procedure and was cancelled due to co-morbidities. Had already undergone bowel preparation.
• Notes form Belmont state “unsuitable for Belmont and possibly anywhere.’

Issues

• Significant chronic health conditions.
• Dementia. MMSE 4/15. Wife is man carer. Requires assistance with all ADLs
• OSA – requires CPAP but can’t tolerate
• IHD with 3 cardiac stents in situ
• Episodes of VT – 2 ablations in past
• Aortic regurgitation and mild pulmonary hypertension
• AF, anticoagulated with DOAC
• Significant orthopnoea, sleeps in chair
• NIDDM with excellent control. On SGLT2 only
• Noted to have raised CRP and ESR on perioperative bloods. WCC normal.

Discussion

FOB Pathway

• Excellent program for early detection of bowel cancer in patients
• Patients are fast-tracked to colonoscopy without seeing proceduralist in order to minimise delay
• May not have been beneficial in this Complex patient. Surgical/gastroenterologist review may have identified the patient complexities/uncertain suitability for colonoscopy
• Concerns expressed regarding cancellation on day of procedure after bowel prep. Not evident if plan in place to optimise/review patient prior to booking the colonoscopy at JHH

Should colonoscopy go ahead?

• Patient likely not suitable for surgical procedure if cancer discovered on colonoscopy
• May be able to have diagnostic or symptom-control procedure if required
• Consider CT Colonoscopy? may be difficult with orthopnoea

Raised ESR and CRP

• Not on any causative medications
• Unlikely to have a new diagnosis of inflammatory bowel disease at 72
• Consider discussion with gastroenterologist

Plan:

• Discuss with surgeon regarding suitability of procedure
• Gastroenterologist referral
• If colonoscopy proceeds, may require admission to hospital for bowel preparation.
• Pathway for referral of these complex patients between hospitals/perioperative clinics. Consider development of a referral pathway/guideline

67-year-old lady for left hemithyroidectomy

Background

• Moderate COPD. Can walk 100m on flat. Ceased smoking 10 years ago.
• OSA –Compliant with CPAP
• BMI 41
• Bipolar Affective Disorder – severe anxiety. Lives alone. Brother is enduring guardian
• Multinodular Goitre for many years. Euthyroid.

Issues

• Surgical letter states worsening dyspnoea. Uncertain if due to goitre.  Some tracheal deviation but no retrosternal extension
• Chronic dyspnoea. Documented over many years by respiratory physician
• Extensive investigations:  Spiro and DLCO around 50% of predicted

  Cardiac investigations including stress echo NAD

• Difficult to gain accurate history over phone. Patient not answering phone.
• Distance patient. No transport options
• Brother lives far away but calls her every night
• Discussed with brother – doesn’t feel she is any worse. SOB for many years
• Independent with ADLs. Shops and cooks for herself.
• GP declined to share medical information
• Referred back to respiratory physician; “better than she was 10 years ago.’ unsure why she needs a thyroidectomy.
• Discussion with surgeon who liaised with respiratory physician and GP. Decision to cancel as procedure not required.

Discussion

Phone consultation in Distance patients

• Clinical assessment can be very challenging in these circumstances.
• Surgeon seems to have had the same difficulties with telehealth
• How can we best assess distance patients? Face to face appointments would be the best way to assess but not always possible.
• Can we videocall vs ask GP for clinical assessment – again would require significant set-up
• Asking a local physician who knew the patient well turned out to be an ideal solution in this situation.

41-year-old man for reversal of ileostomy and repair of parastomal hernia

Background

• Pyoderma Gangrenosum affecting most of body
• Crohns disease – previous perforated ileum requiring emergency ileocolic resection
• Complex postoperative course with return to OT and long ICU stay. Total 6 months in hospital
• Non-ischaemic Cardiomyopathy, HFrEF 40%. Diagnosed during ICU stay ?Tachycardia induced due to sepsis ??steroid or infliximab-induced

Issues

• Significant deconditioning – chronic pain, parastomal hernia, osteoporosis
• Immunosuppressed on long-term steroids and infliximab therapy
• Infliximab management: should be ceased vs perform surgery mid- dosing cycle? Currently achieving reasonable disease control.

Discussion

Perioperative optimization

• Consider prehabilitation, some degree of deconditioning which may be reversible
• CPET  referral – ascertain baseline cardiorespiratory function and if further cardiac and respiratory investigations indicated
• Surgery may be more complex than usual – multiple previous laparotomies, should prepare for long and complex procedure

Immunosuppression

• Suggestion that ceasing the infliximab perioperatively may be more appropriate
• Need to liaise with dermatologist and gastroenterologist

Plan

• CPET and prehabilitation
• Discussion between treating teams regarding management of immunosuppression

PIG Notes June 10th 2021

Cases

• Complex airway and nasopharyngeal lymphoma recurrence
• Elderly patient with ? endometrial cancer, phone/distance patient complexities
• Unoptimised obesity, OSA and DM for gynae surgery

50 year old female for Laparoscopic salpingo-oopherectomy +/- laparotomy +/- mirena exchange. Multi-loculated ovarian mass on US.

Phone consultation.

Background

1. Morbid obesity – BMI 48
2. OSA – tested 6 years ago, not requiring CPAP, however now 25 kg heavier
3. Diabetes – poor control HbA1c 14%
4. Smoker – 20 per day.
5. Asthma – uses Ventolin once per month. No hospital admissions.

Issues

1. Diabetes optimization – was referred to rapid access
2. OSA – likely worse now. However limited time to optimize prior to surgery.
3. Smoking – advised to stop

Discussion

• How long to wait to optimize patient. This patient has many potentially modifiable preoperative risk factors. However following discussion with surgeons, they recommended a maximum delay of 1 month to optimize conditions, in order to avoid potential progression of disease.
• Attempt made to reduce smoking and optimize diabetes. Patient commenced on opti-insulin (old Lantus). Poorly compliant and limited interation with Rapid access diabetes service.
• ICU post operatively. Note previous OSA at lower weight not requiring CPAP. Uncertain invasiveness of procedure. At this stage listed as ICU3 – ie potential for ICU, however not requiring ICU bed prior to starting surgery. Note attached guide on management post operatively for those patients with known OSA. Ideal location post-operatively is with respiratory monitoring (RR and SaO2). ICU may be excess to needs, however is only option in current JHH set up.

89 year old female with PMB and bilateral pelvic masses.

Distant patient (Armidale), with proposed procedure – laparoscopy, BSO, D + C, cone biopsy or LLETZ +/- mirena insertion.

Background

1. AF on warfarin
2. CCF – managed medically, PRN frusemide. Low normal systolic function on most recent Echo.
3. CVA – 2012 with only remaining effect of impaired balance requiring walking stick.
4. HTN
5. Severe OSA – on CPAP with good compliance
6. Severe pulmonary hypertension on Echo cardiogram (2/21) Estimated PASP – 65mmHg.

Issues

• Phone consultation – patient requesting due to difficulty of transport and travel. Long conversation, including trends in weather and climate!
• Patient very involved in decision making around health care. At this stage uncertain about optimal management and location. Considering less invasive options at hospital in Armidale (i.e D and C/Mirena) vs travel to Newcastle for larger laparoscopy. Has even consulted her old GP for advice, who she felt had similar values to her own! All her local friends also have opinions to consider!
• Higher risk patient – NSQIP risk score – mortality 1.8%, serious morbidity 13%, discharge to location other than home 22%. Although DASI by phone was 4.6 METS.

Discussion

• Difficulty of phone consultation for ‘tricky’ patients. The triage criteria for phone vs face-to-face appointments was discussed. At this stage major surgery (LOS> 1day) was the baseline consideration for face to face. However the Preoperative clinic is taking feedback on other groups of patients who it is felt were better suited to face to face appointments. Note that there is currently Medicare funding for telehealth consultations until Dec 2021. Although it seems unlikely that a post-pandemic world will return to all face to face appointments!
• Invasive vs non-invasive treatment options for surgery. Patient was having ongoing consideration of treatment. At this stage she is planned for D and C on day of surgery in Newcastle.

61 year old male for EUA and nasopharyngeal biopsy – ? recurrence of nasopharyngeal B cell lymphoma.

Background

1. Nasopharyngeal B cell lymphoma 2020
2. Diagnosed in China in 2020 where patient was working
3. Treatment with chemotherapy (R-CHOP x 5)
4. Prolonged hospital admission and repatriation back to Australia
5. Complicated by recurrent aspiration pneumonia despite PEG tube, upper limb DVT requiring anticoagulation, MSSA bacteraemia due to CVC infection.
6. Severe depression post discharge – currently on Mirtazepine.
7. Ex-smoker (40 pack years)
8. SCC neck 3 years ago. Surgical resection of superficial SCC and lymph nodes.

Issues

• Phone consultation – however patient only able to answer yes/no to questions. Further information via D/C summary Concord hospital and niece.
• Limited airway assessment on phone!
• Aspiration risk. Ensure PEG feeds ceased at normal fasting times.

Discussion

• Difficulty of airway assessment for phone consultation was discussed. In particular the head and neck and ENT surgical patient population. Note that most ENT patients have FNE documented at their outpatient appointment on DMR. There is no photos, however detailed descriptions are made. Therefore do we need further airway assessment! The pros and cons of further assessment for airway planning was discussed. This patient had multiple featues of difficult airway and aspiration risk.
• Airway management for procedure. Pros and cons of ETT vs THRIVE were discussed. Note recurrent aspiration despite PEG. Question raised : does THRIVE increase aspiration risk? Limited evidence noted.
• Short notice patient seen 1 day prior to surgery. Phone call to treating anaesthetist to ‘pre-warn’ them of patient on list.