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).)

Ix of syncope prior to TKR

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.

Perioperative Mx of Latent TB

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.

AAA v bowel cancer

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 1st 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

Hysterectomy, severe cardiomyopathy

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

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

Immunosuppressant, major arthroplasty

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

Undiagnosed bleeding disorder, hysteroscopy

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 
Timeline

Description automatically generated
  • 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