Surgical Oncology QA Dan Newton MD General Surgery Resident Jeremy Turlington MD Cardiology Fellow

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Text of Surgical Oncology QA Dan Newton MD General Surgery Resident Jeremy Turlington MD Cardiology Fellow

  • Surgical Oncology QA Dan Newton MD General Surgery ResidentJeremy Turlington MD Cardiology Fellow

  • BackgroundDate:2/2/15Attending: KaplanResidents: Newton, Adams

    Procedure: Proximal gastrectomy with esophagogastrostomy

    Complication:Two acute MIs

  • BackgroundHPI: 70 year old man with epigastric painEGD in September initially negative, repeat in November showed 2.5cm ulcer in the cardia. Bx: adenocarcinoma

  • BackgroundPMH:HTN, hyperlipidemiaCKD stage III (Cr 2.1, 1.6)GERD, gastric cancerGoutMI 6 years ago with no interventionPSH:Bilat hip replacements 1998

  • BackgroundFamily history:Brother with Hodgkin diseaseSocial history:1/2 ppd smoker for many years, daily 1-2 drinks/dayUnremarkable ROS

  • 6BackgroundMedications:Trazodone, Uloric, Percocet, Nexium, Zofran, Combivent, TriCor, Celebrex, lisinopril, beta blocker or statinAllergies: NKDA

  • Preoperative principlesEGDSize, location (distance from GEJ), biopsy

  • 8Preoperative workup

  • Preoperative principlesCT abdomen/pelvis, usually CT chestAssess 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

  • 9Preoperative workupMuscularis propriaSerosaInvasion of the serosa or beyond = T4

  • 13ProcedureLaparoscopic exploration recommended for T1b (muscularis mucosa) or greater disease to rule out unresectabilityAdequate 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

  • 14ProcedureUpper midline laparotomyTwo small liver lesions biopsied- benignNo lesion palpable from outside the stomachGastrotomy created-- questionable lesion high in the cardia on the lesser curve, confirmed by EGD.

  • 15Procedure

  • 16Procedure

  • 17Proceduregastrotomystomach divided here

  • 18ProcedurePositive proximal margin on frozen sectionresected further proximal marginnegative for adenocarcinoma

  • 19D1 vs D2 nodal dissection

  • 20D1 vs D1 +D2 nodal dissectionControversialaddition of D2 higher operative morbidity and mortality, but possibly lower recurrence and longer survival-- preferred in AsiaDutch Gastric Cancer Group Trial supports D2

    British Cooperative trial does not support D2

  • 21Reconstruction

  • 22Reconstruction

  • 23Postoperative CoursePOD 0-1 required face tent oxygenationlasix for volume overload as seen on CXR

  • 24Postoperative CoursePOD 1-2Overnight worsened renal failure and acute hypoxia requiring intubationEKG at 3am during decompensation, troponin 1.7 returned at 6:30am and cardiology notifiedCardiology read of EKG was STE in lateral leads

  • 25Postoperative CourseAnticoagulation and PCI delayed by removal of epiduralBMS to proximal LAD

  • 26Postoperative CourseExtubated on POD3 / PPD2failed swallow study initially but improvedPatient pulled NGT and anti-plt was held for 2 daysDiet advancedPOD 9/ PPD7 recurrence of chest painBMS to OM2Discharged POD 15 AKI improved, delirium improved

  • 27Cardiology: Preoperative risk stratification

  • Evaluate Risk

  • Step 1Determine urgency of surgeryEmergentGo to ORUrgent/ElectiveDetermine if pt has ACS (Step 2)

  • Step 2If pt has signs/symptoms of:ACSCP, SOB, DOEHeart failureSOB, PND, Orthopnea, LE edema, Elevated JVD, RalesArrhythmiaPalpitations, Dizziness, Pre-Syncope, SyncopeValvular disordersSOB, LE edema, MurmursCardiology Consult

  • Low Risk Pathway

  • Step 3Estimate peri-operative MACERevised Goldman cardiac risk index (RCRI)Simpler, widely used, well validatedHigh risk surgery (intraperitoneal, intrathoracic, vascular)Hx of ischemic heart diseaseHx of heart failureHx of cerebrovascular diseaseInsulin dependent DMSerum creatinine >2.0

  • Step 3American College of Surgeons National Surgical Quality Improvement Program risk model calculator (ACS-NSQIP)More complex, awaiting external validation

  • Step 4Patient at low risk of MACE (
  • Elevated Risk Pathway

  • Step 5Patient has elevated risk of MACEDetermine functional capacityDuke Activity Status Index (DASI)Moderate or greater functional capacity>10 METsProceed with surgery (Class IIA)>/= 4-10 METsProceed with surgery (Class IIB)

  • Step 6Functional capacity is poor (
  • Step 7If testing is not going to change managementproceed with surgery or discuss non-invasive interventions

  • 39AssessmentComplication: Postoperative MIIncreased length of stayWorsened performance statusDischarge to SNFSlightly worsened renal failure

  • 40AssessmentPre-op: - medication optimization- Patient disease- Preop testingPost-op: -volume management- NGT security- Antiplatelet regimenIntra-op: - volume managementOutcome: Postoperative MI

  • 41AssessmentPreventionAssure careful history, obtain outside recordsConsider medicine or cardiology consultCareful use of volumeStrict 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