eP590 - Open Extended Right Colectomy with Primary Anastomosis Under Epidural Anesthesia

Purpose/Background: Surgical patients with COPD are at higher risk of postoperative complications including atelectasis, pneumonia, unplanned and prolonged intubation, and other postoperative pulmonary complications (2,3). The odds of these complications increase with more severe disease(3). Regional anesthesia can reduce the odds of these complications in patients with severe oxygen dependent COPD(1). The purpose of the case report is describing a case of right colon adenocarcinoma in a patient with oxygen dependent COPD with multiple prior abdominal surgeries who successfully underwent an open extended right hemicolectomy under epidural anesthesia and monitored anesthesia care (MAC) sedation.Methods/Interventions: This is a 65 year old female with a past medical history of oxygen dependent COPD, acute on chronic respiratory failure, and prior CVA who presented to our clinic in consultation for a newly diagnosed right colon cancer without metastasis found on recent colonoscopy. Her surgical history is significant for three exploratory laparotomies. Her extensive medical and surgery history deemed her an inappropriate candidate for both general endotracheal anesthesia as well as minimally invasive surgery, but she remained interested in resection.Results/Outcomes: A multidisciplinary discussion with the patient and the anesthesiology team was performed. The safest way to proceed would be under epidural anesthesia and MAC sedation. She was evaluated and extensively re-counseled of the risks of surgery by the perioperative medicine team. Her ACS NSQIP surgical risk was estimated at 15% of serious complications, and her ARISCAT score for postoperative pulmonary complications was calculated at 13.3%. She expressed understanding of the risks under good decision making capacity and consented for surgery under epidural anesthesia and MAC. In the operating room, the patient underwent epidural catheter placement followed by MAC sedation. A horizontal incision was made from the umbilicus extending laterally to open the abdomen. An Alexis wound retractor was placed and extensive lysis of adhesions was performed. The right colon was inspected and a mass was palpable at the hepatic flexure, necessitating an extended right colectomy. The right colon was mobilized in a medial to lateral fashion. The ileocolic and right branch of the middle colic arteries were divided at their base and resection was performed from the terminal Ileum to mid transverse colon. A primary side-to-side antiperistaltic anastomosis was performed between the terminal ileum and the transverse colon. The abdominal fascia was closed in two layers followed by closure of the skin. The patient was transferred to the PACU in stable condition on nasal cannula. There were no complications intraoperative or immediately post-operatively, and she progressed very well. She began ambulating on day 0 at baseline oxygen level. Pain was controlled with non-narcotic medications. She tolerated clear liquids well. She experienced return of bowel function on day three and was discharged home in stable condition.Conclusion/

Discussion: Severe COPD can have extensive limitations when it comes to surgical planning, often precluding the use of general anesthesia. Current data recommendations are to use regional and local anesthesia whenever possible for this patient population. We believe that this case demonstrates the safety and efficacy of using these regional anesthetic techniques for this population especially as it comes to resection of curable colorectal malignancies."Lateral Incision

A lateral incision was carried out due to the patients extensive history of abdominal laparotomies and abdominal scar tissue.
Specimen

Right colon with malignancy."