Tag cholecystectomy

Laparoscopic cholecystectomy with severe COPD

garychleung

PIG Meeting: 18th February 2021

67 year old lady for elective laparoscopic Cholecystectomy

Background

  • Recent admission for obstructive cholangitis

Issues

  • Moderate-severe COPD.
  • Current smoker
  • Recent deterioration in exercise tolerate to 20-30m. NYHA class 3 dyspnoea.
  • Spirometry significantly deteriorated from previous. FEV1 = 0.63 (30% pred), FVC 0.94.
  • No active infection
  • On Clozapine under psychiatry care for schizophrenia

Discussion

  • Are there any alternatives to surgery? ERCP and sphincterotomy or stent?
  • Requires further discussion with surgical team, laparoscopic cholecystectomy is usual pathway for these patients 
  • Requires respiratory assessment and optimization. Potential benefits of perioperative steroid therapy
  • Cardiac assessment given on clozapine? Has echocardiogram booked to review any possible cardiac complication of clozapine therapy
  • Suggestion of potential benefits of preoperative hospital admission for respiratory optimization
  • Smoking cessation discussed

Plan

  • Defer for 4 weeks while awaiting respiratory review and echocardiogram
  • Further discussion with surgical team regarding respiratory co-morbidities and surgical options
  • Liaise with psychiatry team given current clozapine therapy

Elderly patient with severe heart disease for laparoscopic cholecystectomy

garychleung

PIG Meeting: 4th March 2021

73yo male booked for lap chole due to recurrent choledocholithiasis

Background

  • Choledocholithiasis – several admissions with sepsis requiring IV Abx and ERCPs
  • Cardiac disease
    • Missed STEMI 2019 – DES to LAD, LCx occluded, not amenable to PCI
    • Polymorphic VT arrest 2019 2 days post ERCP, hypokalaemic.
    • 2nd polymorphic VT arrest 2/7 later (K+ normal)
    • AICD placed, nil shocks since.
    • Bisoprolol and amiodarone
  • Paroxysmal AF – on dabigatran
  • GORD
  • Smoker
  • Ex tolerance 5 METS as per DASI

Issues

  • Cardiac status
    • TTE – EF 30-35%, stage I diastolic dysfx, mild MR, mild AR, e/o inferolateral RWMAs, biatrial moderate to severe enlargement.
    • Reviewed by cardiologist – Nil current e/o CCF, exercise tolerance only mildly limited

Discussion

  • Should he have surgery?
    • SORT score 5.4% risk of death
    • Severe cholangitis in this man carries a high risk of morbidity and mortality, as does emergency surgery.
    • While his risk of death with elective surgery is not insignificant it is likely the lower risk option.
  • Opportunities for optimisation?
    • Cardiologist r/v suggests HF reasonably controlled. Suggested ceasing Dabigatran 48h preop and switching to aspirin until resumption of anticoagulation.
  • Postoperative care location
    • >5% risk of perioperative mortality widely considered to represent ‘high risk’ however limited ICU bed spaces necessitates thoughtful rationing of resources.
    • Extended recovery (i.e. 4hr stay) is a useful option – observe for dysrythymias, replenish electrolytes as needed, support normal physiology then, provided no issues arise, discharge to normal ward.