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Gallbladder Mass Management: Evaluation, Peri-operative Care, and Surgical Considerations

This joint medicine-surgery conference will focus on the evaluation and management of patients with gallbladder masses, including peri-operative care for patients with recent coronary stents or recent NSTEMI. Topics covered include differential diagnosis, risk factors for cancer, management options, and peri-operative risk assessment.

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Gallbladder Mass Management: Evaluation, Peri-operative Care, and Surgical Considerations

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  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

  5. 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

  6. Gallbladder MassDifferential Diagnosis • Gallstones • Gallbladder polyp • Mucosal lesion • Cholesterol “polyp” • Adenomyomatosis • Adenocarcinoma • Metastatic cancer • Melanoma most common • Cholangiocarcinoma

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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?

  12. 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.

  14. 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.

  15. 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.

  16. 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.

  17. 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)..

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

  19. 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.

  20. 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.

  21. 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

  22. -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.

  24. -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)

  25. 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.

  26. 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

  27. 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+)

  28. Case • Ultimate diagnosis: stage IB gallbladder cancer T2 N0 M0 • Being evaluated for chemoradiation

  29. 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

  30. 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

  31. 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

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

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