PREPARATION FOR MAJOR OPERATION-CASE HISTORY

HISTORY

• James Brown, a 70-year-old retired farmer, with a proven carcinoma at the rectosigmoid junction admitted electively for an anterior resection of the rectum

Present complaint

• Seen urgently in outpatient clinic 3 weeks ago with a 5-week history of loose stools three to five times a day, without blood or mucus. GP reported three stool specimens were positive for occult blood. Lost about 4 kg in weight over the last 3 months, but has been trying to lose weight anyway.

Results of outpatient investigations • Flexible sigmoidoscopic examination-obvious fungating

tumour of upper rectum. Scope could not be passed beyond it. Biopsies confirmed adenocarcinoma

• Contrast enhanced CT scan of abdomen and pelvis-no other synchronous colonic cancers seen; liver free of metastases

• Chest X-ray-normal, no metastases • Transrectal ultrasound for local staging-no spread

outside the bowel wall • Blood tests: full blood count-haemoglobin 11.6 g/L,

otherwise normal. Urea and electrolytes, liver function tests-normal

Systems enquiry

• Generally well, but recent onset of shortness of breath after walking 200 metres on flat ground and occasional fast palpitations. No other cardiorespiratory symptoms. Poor stream on micturition. Nil else on systemic enquiry

Past medical history

• Appendicectomy aged 14; no anaesthetic complications. Serious farming injury to left elbow aged 20. Jaundiced during the Second World War in Asia, nil since. Hypertensive for 10 years and on drug treatment for 5 years. Diabetes discovered 3 years ago on routine urine testing, controlled by diet alone

Family history

• Mother was obese; died age 55 from complications of diabetes (gangrene). Older brother had major stroke at 64 but partially recovered. No family history of bowel cancer.

Social history

• Widowed for 2 years, wife died of breast cancer. Has one son and one daughter, both married with young children but living far away. Lives in own house with an upstairs lavatory, on a smallholding with a few stock animals. Lives independently, and uses car for shopping. Smoked 20 cigarettes a day since age 15; alcohol intake averages 4 units a day

Drug history

• Takes atenolol 50 mg (a beta-blocker) and bendroflumethiazide 2.5 mg (a diuretic) once a day in the morning for hypertension. Takes aspirin 75 mg daily 'for his heart'. Told in the past not to have penicillin, but cannot recall why; does not remember when he last had penicillin. Not allergic to iodine.

EXAMINATION

• General- Fit-looking man of 70, not obviously anxious. Tanned; not evidently anaemic; no cyanosis, jaundice, lymphadenopathy or clubbing; no thyroid enlargement. Fingers tobacco stained. Not febrile

Cardiovascular and respiratory system

• Pulse 68 beats per minute and regular. BP 150/110 mmHg. Soft systolic murmur at the left sternal edge. No ankle swelling and JVP not elevated. Extensive bilateral varicose veins. Chest examination unremarkable apart from a few crepitations which do not clear with coughing

Abdomen

• Moderately obese. Appendicectomy scar. Soft to palpation. No organomegaly. Possible mass in left iliac fossa-not indentable (i.e. not faeces). No groin hernias. External genitalia normal. Rectal examination-moderately enlarged smooth prostate and normal-coloured stool

Central nervous system and locomotor system

• Fixed flexion deformity of left elbow at 90°, otherwise normal

Problem Surgical significance Plan of action for each problem1. 'Mild' diabetes mellitus

No such thing as mild diabetes!Is it under good control?

All urine samples to be tested for glucoseFasting blood glucose estimation and HbA1cMay need sliding scale insulin perioperatively

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2. Obesity Multiple potential problems Early referral to anaesthetist

Lifting and handling on the ward and in the operating theatre

Is special bed or operating table required?Availability of hoist postoperatively

May make access difficult at operation Ensure adequate theatre time available plus at least two assistants

Predisposes to wound infection Consider delayed primary closure of wound if contaminated

Increased risk of deep vein thrombosis or pulmonary embolism

Prophylaxis, e.g. low dose heparin plus graduated compression stockings

3. Hypertension

How well is hypertension controlled on present medication?

Monitor blood pressure 4-hourly on admission and then decide about drug therapy

Is elevated BP on admission just due to anxiety?

Check pulse rate and BP at intervals over several hours

Are there other complications of hypertension such as ventricular hypertrophy or dilatation?

Perform (and check) ECG and chest X-ray. Echocardiography if indicated

4. Recent shortness of breath on exertion and palpitations

Are these merely symptoms of anxiety about the diagnosis or do they represent significant cardiac or respiratory disease?

Consult cardiologist re palpitationsECG and chest X-rayPossibly needs lung function tests

Recheck Hb-has anaemia worsened since outpatient visit?

5. Poor urinary stream and enlarged prostate

Possible carcinoma of prostate Transrectal ultrasound; biopsy if necessaryMeasure plasma PSA

Possible difficulty with catheterisation that will be required at operation

Anticipate-may need suprapubic catheterisation kit in theatre

Risk of postoperative urinary retention when catheter removed

Anticipate

6. Jaundice in the past

History suggestive of hepatitis Serological tests needed if hepatitis B or C is likely

7. Smoker Possible occult lung cancer Chest X-ray

Possible impaired lung function

Respiratory function tests

Increased risk of postoperative chest infections

Preoperative physiotherapy and breathing exercises

Increased risk of myocardial infarction

Postoperative oxygen therapy

8. Left elbow injury

May cause inconvenience during operation

Inform theatre staff about need for careful positioning on the operating table

9. Diuretic therapy Are electrolytes and renal function normal?

Plasma urea, electrolytes and creatinine estimations

10. Aspirin therapy Could gastric irritation partly account for the mild anaemia?

Use non gastric irritant analgesics

May cause excess bleeding at operation

Anticipate-stop 10-14 days before surgery if practicable

11. Possible penicillin allergy

A penicillin is often used for prophylaxis or treatment of postoperative infections

Record possible penicillin allergy; alternative drugs may have to be used

12. Cardiac murmur Is this clinically significant?Is cardiac antibiotic prophylaxis necessary?

Consult anaesthetist or cardiologist; consider echocardiogramConsult guidelines, e.g. BNF

13. Lives alone, looks after animals

Who will look after his animals while he is in hospital?

Discuss domestic arrangements and convalescence plans with medical social worker

Who will look after him when he returns home?

14. Low haemoglobin Not low enough to need preoperative transfusion but there is less reserve for the operation

Cross-match at least two units of blood to cover operation

Potentially extensive operation-may have large blood loss

Cross-match extra blood, i.e. at least 4 units in all

15. May need temporary or even permanent colostomy

What does he understand about stomas?Will he be able to cope?

Refer to stoma nurse for counselling and possible preoperative 'trial' of colostomy appliance (see Ch. 27)

16. Bowel will be opened during operation

Potential for faecal contamination of abdominal cavity and wound

Likely to need preoperative bowel preparation and will need perioperative prophylactic antibiotics

17. Lesion at pelvic brim Does it involve the ureter? Consider ultrasonography of kidneys to exclude hydronephrosis

18. Varicose veins Increases risk of DVT (already high because of major pelvic operation and age 70)

Give prophylaxis-low dose heparin, antiembolism stockingsEarly mobilisation