November 16, 2006

Joint Medicine-Surgery

Conference

Learning Objectives

• Evaluation and management of the patient with a gallbladder mass

• Peri-operative management of the patient with a recent coronary stent

• Peri-operative management of the patient with a recent NSTEMI

Case

• The patient is a 51 year old Bangladeshi woman with a history of type 2 diabetes on oral agents and stable angina – April 8, 2006: presented to Bellevue with a NSTEMI,

peak troponin 0.45 mg/dl.• Cardiac cath revealed severe obstructions of the proximal

and mid LAD which were both successfully stented with drug- eluting sirolimus/Cypher stents

– April 25: Pt electively underwent a staged intervention of a severe RCA lesion with a Cypher stent

Case

• May 20: Pt presented with acute pancreatitis. – Amylase 1409, lipase 9896– AST 627, ALT 422, AlkP 166, Tbil 1.3, Dbil

0.8

• Imaging was perfomed

Gallbladder MassPresentation

• Often presents with typical biliary symptoms– Biliary colic– Acute cholecystitis– Obstructive jaundice

• Incidental finding on imaging– 1 cm is an often-used cutoff for intervention– Asymmetrical GB wall thickening

• Role of doppler imaging

Gallbladder MassDifferential Diagnosis

• Gallstones• Gallbladder polyp

– Mucosal lesion– Cholesterol “polyp”

• Adenomyomatosis• Adenocarcinoma• Metastatic cancer

– Melanoma most common

• Cholangiocarcinoma

Gallbladder MassRisk Factors for Cancer

• Gallstones – Present in 74-92% if patients with

cancer– Single large stone

• Porcelain gallbladder• Chronic cholecystitits

– Premalignant epithelial changes

• Biliary Salmonella typhi infection• Biliary adenomas• Choledochal cysts

http://www.uhrad.com/ctarc/ct186a2.jpg

Adenocarcinoma of Gallbladder

• Rapidly fatal disease • Resection only hope for cure

– Liver resection if T2-T4• 30-40% candidates for resection• 5 year survival:

– 5-10% overall– 38% if resected

• 85-100% for T1• 30-40% for T2 (80 to 90% with

radical resection in highly selected patients)

• T and N status predict survival• R0 resection predicts survival

Fong, et al. Annals of Surgery 232: 557 2000

Gallbladder MassManagement

• Imaging– Sonogram– CT scan

• Biopsy– Rarely indicated as it won’t change management– Perform if unresectable malignancy

• Cholecystectomy– Laparosopic

• If suspicion for malignancy is low• Must plan for potential liver bed resection• 10-15% port site recurrence

– Open• Indicated for malignancy to minimize abdominal wall

recurrence• Liver resection for T2-T4• T1 disease does not benefit from extended resection

Hepatobiliary Surgery and Antiplatelet Therapy

• Raw liver surface at risk for hemorrhage

• Hemostasis may be technically challenging– Argon laser coagulation– Thermal coagulation– Topical agents

• Patients with liver dysfunction due to cirrhosis or biliary obstruction may be coagulopathic

Medical Consult

• Surgery imposes multiple risks for perioperative cardiac complications:– Hypercoaguable state – Stress-induced ischemia

• This will compound the risk of being off antiplatelet therapy, particualrly clopidogrel, following drug-eluting stent (DES) implantation.

What is the optimal perioperative management following recent DES implantation and NSTEMI?

Endothelialization of DES following PCI

• Angioplasty and stenting neointimal hyperplasia secondary to smooth muscle infiltration and endothelial cell proliferation Restenosis.

• Elution of sirolimus or paclitaxel inhibits both smooth muscle and endothelial cell division.

• Decreased rate of re-endothelialization exposed struts of stent Thrombus formation.

Shuchman M.NEJM.2006.355.1949-52.

Recommended Courses of Antiplatelet Agents

• Antiplatelet agents should be continued until a stent is re-endothelialized.

• ACC/AHA recommended course of clopidogrel:– Bare metal: 6 weeks– Cyper/sirolimus: 3 months– Taxus/paclitaxel: 6 months

• Aspirin should be continued indefinitely.

Clinical Outcome of Patients Undergoing Non-Cardiac Surgery in the Two Months

Following Coronary Stenting • Methods: Retrospective review of 207 patients who

underwent non-cardiac surgery within 2 mos. following bare metal stent implanatation.

• Results: 8 patients (4%) had MI or in-stent thrombosis when <6 wks post-PCI. No events occurred at >7 wks post-PCI.

• Conclusions: When possible non-cardiac surgery should be delayed for at least 6 wks post-PCI.

Wilson SH, et al.JACC.2003;42:234-40.

Perioperaitve Risk after Recent PCI

• Kaluza GI, et al. JACC. 2000;35:1288-94.– 40 patients with PCI <6 wks before noncardiac

surgery,– 7 MI and 8 deaths. All deaths and MIs occurred when

surgery was <14d from stenting. 4 patients expired after undergoing surgery one day after stenting.

• Reddy PR; Vaitkus PT. Am J Cardiol 2005;95:755-7.– Retrospective analysis of 56 consecutive cases of

PCI followed by noncardiac surgery.– No patient developed a major cardiac event if surgery

occurred >42 days after stenting.

Bridging with Heparin

• Vicenzi MN,et al.Br J Anaesth.2006;96:686-93.– Prospective observational study of 103

patients with PCI (bare metal or DES) <1y prior to non-cardiac surgery. Perioperative heparin was administered to all patients.

• 4.9% overall mortality. 44.7% suffered perioperative complications. All but two adverse events were cardiac.

• Event rate 2 fold greater in patients with recent stents (<35d compared with >90d before surgery)..

Drug-Eluting Stents

• No specific data are avaliable on the perioperative management of patients with drug-eluting stents.

• Recommendations are based on expert opinion.

Perioperative Management of Drug-Eluting Stents

Following the surgical assessment of potential bleeding complications antiplatelet regimens may be based on cardiovascular risk:

• Lower-Risk Patients– Low dose Aspirin– Low dose clopridigrel

• Higher-Risk Patients: recent drug-eluting stent, history of in-stent thrombosis, unprotected left-main or bifurcation stenting– Glycoprotein IIB/IIIA inhibitor as “bridge therapy”

Auerbach A, Goldman L.Circulation.2006;113:1361-76.

Risk of Non-Cardiac Surgery in Patients with a Recent MI

• Acute MI (<7d) or Recent MI (>7d but <1mo.) with evidence of ischemic risk are major predictors of perioperative cardiovascular events.

• AHA/ACC guidelines recommend waiting 4-6 weeks before elective surgery in patients following MI without evidence of significant residual myocardium at risk.

• There are no specific trials in the literature addressing the optimal waiting period.

Eagle, KA,et al.JACC.2002;39:543-53.

Perioperative Risk Reduction For Cardiovascular Events in Patients with

Recent MI -Blockers• Statins• Usual cardiac care

– Initiation of antiplatelet agents as soon as bleeding risk is acceptably low

– Blood pressure control– Oxygen – Pain control

-Blockers

• Available evidence on outcomes is mixed:

– Less than 1100 patients have been randomized in clinical trials.

– The largest retrospective review to date suggested that patients with higher perioperative risk may benefit while those at low risk may be harmed.

Lindenauer NEJM 2005Retrospective study of a large, multicenter administrative database.

-Blockers• Patient Selection:

– Identify those at highest risk of perioperative cardiovascular complications.

– Caution with heart failure

• Agents and Administration:– Use -1 selective agents (metoprolol, atenolol)– Start up to 1 mo. before surgery if possible and continue through

the post-operative period– May use IV formulations perioperatively

• Target HR: – 60 BPM (blood pressure permitting)

Statins

• The literature regarding perioperative statin use is primarily from observational studies and 1 small randomized trial.

• The current avaliable evidence does not support starting statins in patients without a long-term indication.

Auerbach A, Goldman L. Circulation.2006;113(10):1361-76.

Case

• Plan was for three months (from April 25) of ASA and clopidogrel, 5 days off both meds, then surgery.

• July 5: Pt developed obstructive jaundice

• July 25: ERCP performed with sphincterotomy and sludge removal

Case

• August 3: Open cholecystectomy with wedge liver biopsy performed– Intraoperative biopsy did not reveal carcinoma– Final pathology c/w T2 gallbladder

adenocarcinoma

• August 31: Liver resection and lymph node dissection performed (0/7 LN+)

Case

• Ultimate diagnosis: stage IB gallbladder cancer T2 N0 M0

• Being evaluated for chemoradiation

Summary Learning Objectives:Gallbladder lesions

• Differential diagnosis:– Polyp, stone, adenomyomatosis,

adenocarcinoma

• Timing of surgery:– Suspicion of adenocarcinoma warrants early

intervention for chance of cure given aggressive disease biology

SummaryLearning Objectives:

Stents and non-cardiac surgery• Risk of in-stent thrombosis is high peri-

operatively if antiplatelet agents are removed prior to endothelialization of stents

• Consider nature of surgical procedure and risk of bleeding and challenges with hemostasis

• Recommended course of clopidogrel– Bare metal: 6 weeks– Cyper/sirolium: 3 months– Taxus/paclitaxel: 6 months

• Bridge with heparin or gp IIb/IIIa inhibitors

SummaryLearning Objectives:

Peri-operative management of recent MI

• Delay/cancel surgery if possible

• Aggressive beta-blockade

• Consider statins

• Usual cardiac care including oxygen, pain control, and initiation of antiplatelet agents as soon as bleeding risk is acceptably low

Thank you,

and stay tuned for the next

Joint

Medicine-Surgery

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