Would you proceed with resection surgery for a patient with a history of Ischemic Heart Disease (IHD) with Coronary Artery Bypass Grafting (CABG), Diabetes Mellitus (DM), and End-Stage Renal Disease (ESRD) on peritoneal dialysis who has a cecal mass suspicious of malignancy, or deem them high risk?

From the Guidelines

I would proceed with resection surgery for this patient with cecal mass suspicious of malignancy, but with careful perioperative management due to their high-risk status. This patient has significant comorbidities including IHD with previous CABG, DM, and ESRD requiring peritoneal dialysis, which increases their surgical risk substantially. However, a cecal mass with malignancy potential generally warrants resection as the benefits of removing a potential cancer outweigh the risks of observation.

Preoperatively, the patient should undergo comprehensive cardiac evaluation including stress testing or coronary angiography to assess current cardiac function, as recommended by the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery 1. Nephrology consultation is essential to optimize dialysis scheduling—typically performing peritoneal dialysis the day before surgery and transitioning temporarily to hemodialysis postoperatively if needed. Glycemic control should be optimized with target blood glucose between 140-180 mg/dL.

Some key points to consider in the management of this patient include:

• The importance of careful perioperative management to minimize the risk of major adverse cardiac events (MACE) 1
• The need for comprehensive cardiac evaluation, including stress testing or coronary angiography, to assess current cardiac function 1
• The importance of optimizing dialysis scheduling and glycemic control to reduce the risk of perioperative complications 1
• The potential benefits of a minimally invasive surgical approach, if technically feasible, to reduce the risk of perioperative complications 1

Intraoperatively, invasive hemodynamic monitoring is recommended, and a minimally invasive surgical approach should be considered if technically feasible. Postoperatively, the patient will require ICU admission for close monitoring, careful fluid management, early resumption of dialysis, and aggressive pulmonary hygiene. While mortality risk is elevated (approximately 5-10% for major abdominal surgery in this population), untreated malignancy poses a greater long-term threat, making surgical intervention the preferred approach despite the high-risk profile.

From the Research

Patient Assessment

The patient in question has a history of Ischemic Heart Disease (IHD) with Coronary Artery Bypass Grafting (CABG), Diabetes Mellitus (DM), and End-Stage Renal Disease (ESRD) on peritoneal dialysis, and has been found to have a cecal mass suspicious of malignancy.

Surgical Risk Factors

• The patient's history of IHD with CABG indicates a high risk of cardiovascular complications during surgery 2.
• The presence of DM further increases the risk of cardiovascular disease and may affect wound healing and postoperative recovery 2, 3.
• ESRD on peritoneal dialysis is associated with an increased risk of cardiovascular mortality and morbidity, as well as other complications such as fluid overload and electrolyte imbalances 4, 5.
• The cecal mass suspicious of malignancy requires prompt attention, but the patient's underlying medical conditions must be carefully considered when evaluating the risks and benefits of surgery.

Perioperative Risks

• The study by 2 found a hospital mortality rate of 14.6% in patients with renal replacement therapy undergoing CABG, highlighting the high perioperative risk in this population.
• Another study by 6 reported a perioperative mortality rate of 5.7% in patients undergoing chronic dialysis and CABG, with a mean age of 62.5 years.
• The use of off-pump CABG (OPCAB) may be associated with lower morbidity and mortality rates in patients with ESRD, as reported by 6.

Management Considerations

• A thorough preoperative evaluation, including cardiac assessment and optimization of the patient's medical conditions, is essential to minimize the risks associated with surgery 3.
• The decision to proceed with resection surgery should be made on a case-by-case basis, taking into account the patient's overall health status, the severity of the cecal mass, and the potential benefits and risks of surgery.
• A multidisciplinary approach, involving surgeons, nephrologists, cardiologists, and other specialists, is crucial to ensure optimal management of the patient's complex medical conditions.