Surgical Oncology QA

Dan Newton MD General Surgery ResidentJeremy Turlington MD Cardiology Fellow

Background

Date: 2/2/15

Attending: Kaplan

Residents: Newton, Adams

Procedure: Proximal gastrectomy with esophagogastrostomy

Complication: Two acute MIs

Background

HPI: 70 year old man with epigastric pain EGD in September initially negative, repeat in

November showed 2.5cm ulcer in the cardia. Bx: adenocarcinoma

Background

PMH: HTN, hyperlipidemia CKD stage III (Cr 2.1, 1.6) GERD, gastric cancer Gout MI 6 years ago with no intervention

PSH: Bilat hip replacements 1998

Background

Family history: Brother with Hodgkin disease

Social history: 1/2 ppd smoker for many years, daily 1-2

drinks/day Unremarkable ROS

6

Background

Medications: Trazodone, Uloric, Percocet, Nexium,

Zofran, Combivent, TriCor, Celebrex, lisinopril, hydrochlorothiazide.▪ no beta blocker or statin

Allergies: NKDA

Preoperative principles

EGD Size, location (distance from GEJ), biopsy

8

Preoperative workup

Preoperative principles

CT abdomen/pelvis, usually CT chest Assess for regional and distant disease

Our patient LB: No nodal or distant disease seen

Preoperative controversies +/- PET CT +/- EUS, endoscopic resection +/- neoadjuvent chemotherapy for T2 or

higher disease

9

Preoperative workup

Muscularis propria

Serosa

Invasion of the serosa or beyond = T4

13

Procedure

Laparoscopic exploration recommended for T1b (muscularis mucosa) or greater disease to rule out unresectability

Adequate resection to achieve R0 resection (usually >4cm gross margin)

Goal of 15 or more LN (Dutch trial, Schwarz and Smith 2006)

Consider feeding J-tube

14

Procedure

Upper midline laparotomy Two small liver lesions biopsied-

benign No lesion palpable from outside the

stomach Gastrotomy created-- questionable

lesion high in the cardia on the lesser curve, confirmed by EGD.

15

Procedure

16

Procedure

17

Procedure

gastrotomy

stomach divided here

18

Procedure

Positive proximal margin on frozen section

resected further proximal margin negative for adenocarcinoma

19

D1 vs D2 nodal dissection

20

D1 vs D1 +D2 nodal dissection

Controversial addition of D2 higher operative morbidity

and mortality, but possibly lower recurrence and longer survival-- preferred in Asia

Dutch Gastric Cancer Group Trial supports D2

British Cooperative trial does not support D2

21

Reconstruction

22

Reconstruction

23

Postoperative Course

POD 0-1 required face tent oxygenation lasix for volume overload as seen on CXR

24

Postoperative Course

POD 1-2 Overnight worsened renal failure and

acute hypoxia requiring intubation EKG at 3am during decompensation,

troponin 1.7 returned at 6:30am and cardiology notified

Cardiology read of EKG was STE in lateral leads

25

Postoperative Course

Anticoagulation and PCI delayed by removal of epidural

BMS to proximal LAD

26

Postoperative Course

Extubated on POD3 / PPD2 failed swallow study initially but

improved Patient pulled NGT and anti-plt was held

for 2 days Diet advanced POD 9/ PPD7 recurrence of chest pain

BMS to OM2 Discharged POD 15

AKI improved, delirium improved

27

Cardiology: Preoperative risk stratification

Evaluate Risk

Step 1

Determine urgency of surgery EmergentGo to OR Urgent/ElectiveDetermine if pt has ACS

(Step 2)

Step 2

If pt has signs/symptoms of: ACS

▪ CP, SOB, DOE

Heart failure▪ SOB, PND, Orthopnea, LE edema, Elevated JVD, Rales

Arrhythmia▪ Palpitations, Dizziness, Pre-Syncope, Syncope

Valvular disorders▪ SOB, LE edema, Murmurs

Cardiology Consult

Low Risk Pathway

Step 3

Estimate peri-operative MACE Revised Goldman cardiac risk index

(RCRI)▪ Simpler, widely used, well validated

▪ High risk surgery (intraperitoneal, intrathoracic, vascular)

▪ Hx of ischemic heart disease▪ Hx of heart failure▪ Hx of cerebrovascular disease▪ Insulin dependent DM▪ Serum creatinine >2.0

Step 3

American College of Surgeons National Surgical Quality Improvement Program risk model calculator (ACS-NSQIP)▪ More complex, awaiting external validation

Step 4

Patient at low risk of MACE (<1%) Proceed with surgery

Elevated Risk Pathway

Step 5

Patient has elevated risk of MACE Determine functional capacity

▪ Duke Activity Status Index (DASI) Moderate or greater functional

capacity >10 METsProceed with surgery (Class

IIA) >/= 4-10 METsProceed with surgery

(Class IIB)

Step 6

Functional capacity is poor (<4 METs) or unknownteam discussion Yes pharmacologic stress test (vs

exercise stress test)▪ If test is abnormalcardiac

cath/revascularization▪ Proceed with surgery vs non-invasive treatment of

condition

▪ If test is normalproceed with surgery

Step 7

If testing is not going to change managementproceed with surgery or discuss non-invasive interventions

39

Assessment

Complication: Postoperative MI Increased length of stay Worsened performance status Discharge to SNF Slightly worsened renal failure

40

Assessment

Pre-op:- medication optimization- Patient disease- Preop testing

Post-op:-volume management- NGT security- Antiplatelet regimen

Intra-op:- volume management

Outcome: Postoperative

MI

41

Assessment

Prevention Assure careful history, obtain outside

records▪ Consider medicine or cardiology consult

Careful use of volume Strict antiplatelet regimen

Pathology

Primary Tumor (pT): PT1b: Tumor invades submucosa Regional Lymph Nodes (pN): PN0: No regional lymph node

metastasis Status of Regional Lymph Nodes: Number of Lymph Nodes Examined: 6 Number of Lymph Nodes Involved: 0 Distant Metastasis (pM): Not applicable ADDITIONAL NON-TUMOR: Additional Pathologic Findings: Intestinal metaplasia