From the Guidelines
Cardiac risk assessment for patients undergoing laparoscopic colectomy should follow a stepwise approach, as outlined in the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery 1. This approach begins with a thorough preoperative evaluation, including determination of the urgency of surgery and assessment of clinical risk factors that may influence perioperative management.
- Patients with risk factors for or known coronary artery disease (CAD) should undergo clinical risk stratification using validated tools such as the Revised Cardiac Risk Index (RCRI) or the American College of Surgeons NSQIP risk calculator.
- High-risk patients, including those with known CAD, heart failure, significant arrhythmias, severe valvular disease, or multiple risk factors, should receive cardiology consultation.
- Preoperative testing may include electrocardiogram, echocardiogram, and stress testing for selected high-risk patients, though routine testing for all patients is not recommended.
- Beta-blockers should be continued perioperatively for patients already taking them, with metoprolol 25-100 mg twice daily being commonly used, as recommended by the 2014 ESC/ESA guidelines on non-cardiac surgery 1.
- Statins should be continued or initiated (atorvastatin 40 mg daily) for patients with atherosclerotic disease. During surgery, hemodynamic monitoring, maintaining normothermia, and careful fluid management are essential, as outlined in the ERAS Society recommendations for perioperative care in elective colonic surgery 1. The pneumoperitoneum created during laparoscopy can increase systemic vascular resistance and decrease cardiac output, requiring vigilant monitoring. Postoperatively, early mobilization, optimal pain control, and continued cardiac medication management are crucial to minimize cardiac complications during laparoscopic colectomy, which generally carries lower cardiac risk than open procedures due to reduced physiological stress and earlier recovery.
From the Research
Cardiac Risk Assessment for Laparoscopic Colectomy
- Cardiac risk assessment is crucial for patients undergoing laparoscopic colectomy, as the procedure can lead to significant hemodynamic changes 2.
- The use of non-invasive cardiac output monitoring, such as electrical cardiometry, can help detect cardio-hemodynamic changes that conventional monitors may miss 3.
- Patients with significant coexisting cardiopulmonary disease may experience alterations in cardiovascular performance during laparoscopic colectomy, including increases in systemic vascular resistance and decreases in cardiac index 2.
Management Strategies
- Preoperative stress testing and perioperative beta-blockers and statins may be considered as part of the management strategy, but the evidence base for these interventions is limited and guidelines should be based on credible randomised controlled trials 4.
- The use of perioperative beta-blockade has been shown to increase mortality in some studies, and its use should be carefully considered 4.
- A simple and safe technique for intracorporeal anastomosis, such as totally laparoscopic sigmoid colectomy, can be used to minimize the risks associated with laparoscopic colectomy 5.
Key Considerations
- Individual variation and extreme reactions among patients can occur during laparoscopic colectomy, and close monitoring of cardio-hemodynamic parameters is essential 3.
- The choice of approach, such as completely laparoscopic or hand-assisted, and the use of medial or lateral approach, should be based on the disease process, surgeon preference, and patient considerations 6.
- The goal of minimally invasive colectomy is to improve postoperative pain control, decrease length of hospital stay, decrease recovery time, decrease complications, and decrease the cost of colon resections 6.