November 16, 2006

1
Joint Medicine-Surgery Conference

• November 16, 2006

2
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

3
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

4
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

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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

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Gallbladder MassDifferential Diagnosis

• Gallstones
• Gallbladder polyp
• Mucosal lesion
• Cholesterol polyp
• Adenomyomatosis
• Adenocarcinoma
• Metastatic cancer
• Melanoma most common
• Cholangiocarcinoma

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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

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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
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Gallbladder MassManagement

• Imaging
• Sonogram
• CT scan
• Biopsy
• Rarely indicated as it wont 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

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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

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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?

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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.

13
Shuchman M.NEJM.2006.355.1949-52.
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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.

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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 lt6 wks post-PCI. No events
  occurred at gt7 wks post-PCI.
• Conclusions When possible non-cardiac surgery
  should be delayed for at least 6 wks post-PCI.
• Wilson SH, et al.JACC.200342234-40.

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Perioperaitve Risk after Recent PCI

• Kaluza GI, et al. JACC. 2000351288-94.
• 40 patients with PCI lt6 wks before noncardiac
  surgery,
• 7 MI and 8 deaths. All deaths and MIs occurred
  when surgery was lt14d from stenting. 4 patients
  expired after undergoing surgery one day after
  stenting.
• Reddy PR Vaitkus PT. Am J Cardiol 200595755-7.
• Retrospective analysis of 56 consecutive cases of
  PCI followed by noncardiac surgery.
• No patient developed a major cardiac event if
  surgery occurred gt42 days after stenting.

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Bridging with Heparin

• Vicenzi MN,et al.Br J Anaesth.200696686-93.
• Prospective observational study of 103 patients
  with PCI (bare metal or DES) lt1y 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 (lt35d compared with gt90d before surgery)..

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Drug-Eluting Stents

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

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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.20061131361-76
  .

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

• Acute MI (lt7d) or Recent MI (gt7d but lt1mo.) 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.200239543-53.

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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

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?-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.

23
Lindenauer NEJM 2005 Retrospective study of a
large, multicenter administrative database.
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?-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)

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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.2006113(10)13
  61-76.

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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

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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)

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Case

• Ultimate diagnosis stage IB gallbladder cancer
  T2 N0 M0
• Being evaluated for chemoradiation

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Summary Learning ObjectivesGallbladder lesions

• Differential diagnosis
• Polyp, stone, adenomyomatosis, adenocarcinoma
• Timing of surgery
• Suspicion of adenocarcinoma warrants early
  intervention for chance of cure given aggressive
  disease biology

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SummaryLearning ObjectivesStents 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

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SummaryLearning ObjectivesPeri-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

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• Thank you,
• and stay tuned for the next
• Joint
• Medicine-Surgery
• Conference