PIG Notes October 7th 2021

• Hysterectomy, severe cardiomyopathy
• AAA v. bowel cancer
• Perioperative Mx of Latent TB
• Ix of syncope prior to TKR
• Semi-urgent minor surgery, recent PCI

83yo male for cystoscopy and stent exchange due to chronic obstruction from uroepithelial carcinoma.

Background:

• Uroepithelial carcinoma
• PVD
• Impaired glucose tolerance
• AF. On apixaban.
• PPM for CHB (99% paced, underlying AF).
• HTN
• Dyslipidaemia

Issues:

• Recent PCI 
  • Type 2 MI Post-operatively after stent insertion
  • Ongoing intermittent chest pain last 6/12
  • PCI + rotablation for severe ostial RCA stenosis. 3/52 ago
  • For lifelong clopidogrel and apixaban.
  • Ureteric stent now 7/12 old, urologists keen ++ to replace

Discussion

Ideal timing of surgery?

• Discussed with treating cardiologist: happy to proceed 4-6 weeks post-PCI
• Requests to continue clopidogrel perioperatively. 
• Discussed with surgeon – happy with plan

Communication in the perioperative clinic

• Much time spent attempting to phone proceduralists and clinicians, they are often busy/scrubbed and then call back when we are with another patient 
• Email often a more effective tool – ability to CC all relevant clinicians and the HNELHD-JHHPeriopnurse@health.nsw.gov.au perioperative nurse address. 
• Provides a paper-trail of communication. Encourages multidisciplinary engagement. 
• Clinician email addresses usually available on their letterhead/website. 
• The urology registrars are setting up an email address to allow us to create a bank of patients for them to ask their consultants about on a regular basis. 

Cardiac Investigations in this patient post initial Type 2 MI

• Interestingly this patient had a sestamibi which showed ‘no major area of inducible ischaemia’ and that patient had no chest pain throughout the protocol. 
• Note that the stress ECG component of the test is difficult to interpret in the present of Ventricular-pacing. 
• See article on non-invasive cardiac stress testing (http://dx.doi.org/10.1136/heartjnl-2015-307764).)

80yo man for L TKR. 

Issues:

• Episode of LOC several years ago
• Isolated event. Nil seizure-like features.
• Witnessed by family members
• Extensive review by neurologist – EEG showed prominent epileptiform features in the temporal lobe which were reproducible on repeat testing. 
• EEG abnormalities resolved with commencement of Levetiracetam. 

• Bifascicular block on ECG, HR 59, no cardiologist review

Discussion

Should we be concerned about a cardiac cause for his LOC?

• Reassuring features:
  • One distant episode. 
  • Now treated for epilepsy. No further episodes.
  • EEG showed a gross abnormality and repeat EEG after treatment was normal.
• Concerning features:
  • Episode doesn’t really sound like a seizure. Sounds more cardiac in origin.
• Unlikely that a cardiologist be interested in one episode of LOC
• Holter = low risk study however likely wasted resource and burdensome to patient 

Plan:

• Proceed with surgery without further investigations.

60yo female, for hysteroscopy and D+C for abnormal uterine bleeding.

Background:

• Refugee from Democratic Republic of Congo
  • Arrived 2019.
  • 10yrs prior spent in refugee camp with 6 daughters. 
  • Difficult consultation. Patient requesting only her daughter act as interpreter. Language barrier difficult, particularly on phone

• Conversion disorder
  • Developed right sided full body pain, paraesthesia, and dysphagia (couldn’t swallow saliva) 2/7 after arrival in Australia.
  • Extensive medical review – nil organic cause found.
  • Management through HIPS.
  • Most symptoms now resolved.

• Latent TB diagnosed on screening. No treatment.
• Not COVID vaccinated, currently considering.

Discussion:

Implications of latent TB perioperatively?

• Lack of literature around latent TB
• ID advised:
  • Screen for symptoms – weight loss, night sweats, cough, haemoptysis
  • If nil symptoms present, no specific precautions needed.
• Should ensure gynae team know that patient has latent TB, as all organs can be affected, seeding can occur, and staff exposure from surgical sites.

Video-consulting in perioperative clinic 

• Facilitate improved communication in cases with communication barriers 
• May also assist with patients who require visual assessment; concerns about frailty/airway, or if F2F consultation impossible or better to avoid (e.g. moving between zones with different COVID regulations)
• Video is challenging to arrange for all patients as it impacts on efficiency and patient satisfaction as patients must “wait” in a virtual waiting room. 
• Audiovisual technology requirements – may be challenging for older patients but family and GP surgeries could help
• Video most beneficial as a targeted resource. May set up a specific clinic session for a group of patients to maximize clinic efficiency at other times.

53yo male for right hemicolectomy.

Background:

• Laparoscopic appendicectomy 12/12 ago, no issues.
• Mass found in Right Colon due appendicectomy
• ETOH binge drinker

Issues:

• 5cm AAA, asymptomatic
  • Incidental finding in workup for bowel cancer
  • Now 5.5cm, requires treatment

• HCV
  • Patient reported having HBV previously
  • On further investigation, diagnosed with HCV in 2015, with low titres. 
  • FibroScan – no cirrhosis. Planned for no active treatment but advised to await new treatments in the very near future. 
  • Lost to follow up after that.

Discussion:

EVAR v. Open repair AAA

• Concerns about longer recovery with open procedure, may delay cancer treatment
• Neurohumoral responses to major open abdominal surgery may accelerate cancer spread/progression
• On a population level, Uptodate suggests:
  • Randomized trials comparing open AAA repair with EVAR have found significantly improved 30-day M&M for EVAR but no significant differences in long-term outcomes up to 10 years.
  • A pooled analysis of these trials identified a 69% reduction in the risk for perioperative mortality for endovascular compared with open repair (odds ratio [OR] 0.33, 95% CI 0.17-0.64).
  • EVAR appears to be associated with the need for more secondary procedures and an ongoing future risk of aortic rupture. 

Surgical considerations

• If bowel surgery was more urgent (e.g. obstruction) would open or laparoscopic procedure be preferable with known large AAA? – unclear
• Abdominal CT often ordered by surgeons in suspected appendicitis in older age group, due to possibility of cancer

Role for HCV RNA PCR (BMJ best practice)

• Negative result confirms no current infection (whereas antibodies will always be +)
• Recommended 1^st line test if immunocompromised, as antibody testing may be negative due to failed/delayed seroconversion 
• Used to detect reinfection
• 15-45% of people will clear the virus spontaneously, so PCR tells you if they are viraemic.

Plan:

• Proceed with EVAR
• HCV PCR – no need for titres. If PCR + will need treatment for HCV.
• Proceed with bowel cancer surgery regardless of requirement for HCV Rx.
• Check alpha-fetoprotein level to screen for liver cancer

69yo for hysterectomy. Open vs laparoscopic?

Background

• Early endometrial cancer – hyperplasia. Nil local/distant metastases.
  • Initial hysteroscopy surgically challenging, difficult to obtain biopsy
  • Unable to access cervix, couldn’t insert Mirena.
• Distance patient, Dubbo
• Cognitive impairment, independent with ADLs. Attended with carer (niece). 
• Challenging consult, limited history available
• AF, apixaban.
• BMI 45

Issues

• Cardiomyopathy
  • Hysteroscopy done under (uneventful) spinal due to being ‘unfit for GA’. 
  • History unclear, letters from cardiologist suggest fast AF several years ago, presumed rate-related Cardiomyopathy.
  • EF was 25%, now improved to 60%
  • NYHA III dyspnoea. 
  • Cardiologist visits from Sydney and regularly reviews at indigenous clinic

• Adrenal Mass
  • Incidental finding. Large 38x22x36mm on staging CT
  • Endocrinologists keen to Investigate as a possible functional mass. Pathology pending.
  • On ACE-I and Beta-blocker so aldosterone/renin test unable to be performed until these medicines are paused.
  • Potentially requires adrenalectomy
  • Functional mass may have caused tachycardia and subsequent cardiomyopathy

Discussion

Optimised from cardiac perspective?

• Recent TTE reassuring
  • Remains dyspnoeic however BMI 45 and deconditioned are significant contributing factors

Endocrine Ix pre-operatively?

• Prudent to proceed with gynaecological surgery without significant delay. 
• Mirena could not be inserted to slow the cancer progression.
• However a functional adrenal tumour will significantly alter management 
• Urgent referral to endocrine completed after discussion with endocrine AT

Preoperative sleep studies?

• STOPBANG 7 
• ESS = 5
• HCO₃ = 29
• Spo2 =96% RA
• Some features to suggest possible Obesity hypoventilation Syndrome
• No preoperative sleep studies indicated given ESS < 8, urgency of surgery, and further delay.

Distance patients in clinic 

• Gynae-oncology distance patients are booked to have anaesthetic consult and surgical review on same day
• Often travel long distances to the hospital and are seeing the anaesthetist first as the gynae clinics are in the afternoon
• Not ideal as we might not know what operation is planned
• Can liaise with the surgeon that afternoon
• Helpful to send patient to gynae appointment with photocopy of anaesthetic chart and a mobile phone number so that the team can rapidly access the information they need and contact us to facilitate surgery.

Plan

• Pathology including plasma metanephrines, 24-hour urinary catecholamines, TSH and Hb requested
• Urgent endocrine review via telehealth organised

PIG Notes September 30th 2021

• TURBT v. parotidectomy
• von Willebrands Disease and Gynae Surgery
• Undiagnosed bleeding disorder, hysteroscopy
• Immunosuppressant, major arthroplasty
• PLIF, cirrhosis

51-year-old female for consideration of Posterior Lumbar Interbody Fusion for acute pain management

Background

• Osteomyelitis and Discitis – current inpatient for pain management
• Multiple vertebral crush fractures
• E-coli bacteraemia – resolving
• No nerve root impingement/neurological symptoms

Issues:

• COPD – current smoker. No formal spirometry
• Severe pulmonary hypertension and Tricuspid Regurgitation. Likely Cor-pulmonale
• Exercise tolerance – 50m on flat
• Recent ex IVDU with untreated Hepatitis C
• Childs-Pugh 3 Cirrhosis. Diagnosed following an upper GIH, gastroscopy showed varices.
• No regular gastroenterology follow-up or treatment

Discussion

Perioperative Optimisation

• Consensus that this is a high-risk patient and procedure.
• Undefined bleeding risk, need to assess preoperatively
• Gastroenterology advice should be sought preoperatively

Less invasive Surgical Options

• Main advantage to PLIF is analgesia, no neurological symptoms
• Neurosurgeon feels that vertebrae will self-fuse in coming weeks to months and results will be similar
• On discussion of co-morbidities surgical team have decided the procedure is currently too high risk for the indication

Plan:

• Delay currently
• Neurosurgical team to organise Gastro consult

64-year-old lady for left shoulder second stage revision/replacement     

Background

• Infected Left shoulder replacement – long hospital admission with multiple washouts/removal of hardware/insertion of spacer
• Colonised with pseudomonas

Issues

• Severe asthma – multiple admissions to ICU postoperatively with Type 1 Respiratory failure requiring NIV
• NYHA Class 3 dyspnoea. Daily Ventolin x3. Regular prednisolone requirement
• Recently commenced Mepolizumab immunotherapy with excellent response in symptoms and no steroid requirement
• Novel therapy, not frequently encountered perioperatively

Discussion

Management of Mepolizumab

• Ideal situation would be to continue given significant improvement in respiratory symptoms however uncertain effects on wound healing, infections rate with major joint surgery
• Absence of literature online
• Discussed with prescribing physician – Mepolizumab is a monoclonal antibody which targets human IL-5 with high affinity and specificity. IL-5 is the major cytokine responsible for the growth, differentiation, activation, and survival of eosinophils.
• Respiratory physician recommends continuation of therapy and has emphasized that there are no effects on neutrophils or other white cells

Plan

• Continue Mepolizumab as advised
• Discuss above with orthopaedic surgeons

43-year-old lady for Hysteroscopy/D&C

Background:

• Asthma and upper airway dysfunction – stable disease, well-controlled with inhaled therapies and regular respiratory review
• Cannabis smoker – daily

Issues

• Abnormal uterine bleeding – menorrhagia for 3/52 each month, using 6+ pads per day
• Bleeding significantly affecting QoL; unable to work, take children swimming.
• Fe-deficiency, no anaemia. 3 monthly iron infusions.
• Positive bleeding history – epistaxis x2 per week. Gum bleeding when brushes teeth.
• International Society of Thrombosis and Haemostasis (ISTH) Bleeding score = 4 

• Normal range is <4 in adult males, <6 in adult females and ❤ in children

Discussion

Preoperative interventions required?

• Discussed with haematology registrar, unusual pathology results; Factor VIII levels and antigens supra-normal indicating vWD unlikely
• Normal Full Blood Count, APTT slightly raised at 39
• Interestingly, lupus anticoagulant and fibrinogen were raised which would indicate a propensity for clotting rather than bleeding
• Urgent Haematology appointment organised – unlikely to occur preoperatively. Public outpatient system under pressure at present
• Consensus that it would be reasonable to proceed with above procedure

Surgical Options

• Discussed with Gynaecology Fellow, agreed it is important to address bleeding while awaiting further haematology review
• Options for Mirena will be presented to patient as a short-term management

Plan: 

• Proceed to surgery
• Haematology review pending