General Surgery

Case summary
An 89-year-old man presented with acute right-sided abdominal pain and shortness of breath. His medical history included a mechanical heart valve, coronary artery bypass graft, chronic obstructive pulmonary disease (COPD) and ischaemic cardiomyopathy. He was pacemaker dependent, and the COPD severely restricted his exercise capacity, limiting his walking ability to 50 metres. On arrival, he was in respiratory distress.

Clinical examination showed a distended abdomen with generalised tenderness and peritonism in the right lower quadrant. Blood tests showed mildly elevated inflammatory markers, high creatinine and an INR (international normalised ratio) of 2.7. Blood gases showed severe metabolic acidosis with high lactate. A non-contrast CT scan of the abdomen and pelvis showed ischaemia and pneumatosis extending from the caecum to the transverse colon. There was a calcified aneurysmal aorta and heavy calcification at the superior mesenteric artery ostium.

The surgical team was notified of the CT findings. These were confirmed by a second CT scan with intravenous contrast three hours later. The NELA score (National Emergency Laparotomy Audit) indicated 45 per cent risk of mortality. Both the surgical and anaesthetic teams sought advice from a senior colleague.

The notes document multiple surgical and anaesthetic discussions with the patient regarding surgery versus nonoperative management. Ultimately, the patient decided to proceed with surgery. The ICU team agreed to take the patient postoperatively with a ceiling of care in place. Before surgery, the patient was concerned he had no will in place to provide financial support to his current partner should he not survive. The patient obtained advice from a lawyer before his operation.

Four hours after being initially consulted, the consultant surgeon, assisted by the on-call Fellow, undertook a laparotomy, adhesiolysis and right hemicolectomy.

The patient slowly improved over the first few days, after which his progress plateaued. He remained ventilator dependent. On postoperative day 8, after a family meeting, a decision was made for one-way extubation. The patient passed away on postoperative day 11.

Discussion
This was a high-risk patient. The only alternative for this patient was not to offer surgery, which would have undoubtedly resulted in his death.

The on-call consultant surgeon was present and—given the difficult clinical situation—sought opinions from senior colleagues before proceeding. It is clear that the risk was discussed with the patient and the decision to operate well considered.

The decision to repeat the CT scan would have added to the surgical delay, as also the patient's insistence on completing a will and speaking with a lawyer. The operation was eventually performed five hours after the diagnosis was made via CT. It is doubtful these additional delays were significant.

Clinical lesson
ANZASM assessors frequently recommend that surgeons should not hesitate to seek support from colleagues when faced with difficult end of life decisions. As in this case, this advice is always likely to very helpful in clinical decision-making.

(Case selected by the ANZASM Committee for your information)