After many follow-up visits, it was found that the nodule gradually became larger and accompanied by consolidation, and the doctor strongly recommended that the patient be admitted to the hospital for surgical resection, because at this time, surgical resection can be performed by lung segmentectomy, which can not only achieve radical treatment but also preserve lung tissue to the greatest extent, which is indeed the best choice, which is what 65-year-old Mr. Liu is encountering.
Early surgical treatment is the only hope for a complete cure for lung cancer.
However, after the patient was admitted to the hospital, it was considered that the patient's physical condition was completely tolerant of surgery, but in the medical history questioning, the doctor found that the patient had undergone stent treatment for coronary heart disease 6 months ago, and used a more scientific and technological drug-coated stent, according to the anesthesia guidelines, this kind of stent treatment is not acceptable for elective surgery under general anesthesia within one year, how to deal with it next, on the one hand, it is considered that malignant lung tumor is --- fatal, and on the other hand, coronary heart disease - myocardial infarction recurrence, how to choose, To be, or not to be, that is the question 。 This is a real-life case that happened in a municipal tertiary hospital. As a result, the anesthesiology department and surgeons decided that there was a huge risk from both medical treatment and disputes, and the patient was transferred to a higher-level hospital for further treatment.
Medical care is a double-edged sword, and the fight against disease requires both doctors and patients to take responsibility together
Let's first analyze this matter from the perspective of the patient's interests:
1. If the patient can only wait for another 6 months before safe surgery according to the requirements of anesthesiology guidelines, then after 6 months, will the patient's lung mass enter the middle and advanced stages, and the five-year survival rate of the middle and advanced lung tumors is only about 25%, is the price of life as a bargaining chip?
Surgery for lung cancer is not an emergency surgery, but it should be done within a time limit
2. From the economic aspect, this operation is not a difficult and complicated operation, the result of the operation in this hospital and the superior hospital is the same, and the cost of treatment in this hospital is undoubtedly lower than that of the superior hospital, and the hidden cost of medical expenses may be higher than the medical cost itself, which may also be a problem for most people!
In China, there are many people who face poverty due to illness, and the state has actively introduced various policies to solve these problems
3. The biggest difference for this patient is that the anesthesia guidelines state that elective surgery under general anesthesia is not recommended for this patient within one year. This means that the risk of anesthesia is an obstacle to the operation, and further down to that the risk of myocardial infarction increases during anesthesia.
Cardiac stent implantation surgery has saved countless lives, but it has also brought many follow-up problems
The Expert Consensus on Anesthesia and Perioperative Management of Patients with Coronary Artery Disease for Non-Cardiac Surgery (2017) For patients who require non-cardiac surgery, clinicians need to jointly decide and weigh the relative risks of stopping or continuing antiplatelet therapy and surgery. A delay of 180 days may be considered for elective noncardiac surgery if the risk of surgical delay after drug-coated stent placement is greater than the risk of expected ischemia or stent thrombosis. Elective noncardiac surgery is not recommended for patients who need to discontinue dual antiplatelets during the perioperative period, within 30 days of bare metal stent implantation and within 12 months of drug-eluting stent implantation, and elective noncardiac surgery within 14 days of balloon dilation is not recommended for patients who need to discontinue aspirin during the perioperative period.
So why is it required in the anaesthesia guidelines?
Long-term oral anticoagulant drugs should be taken after stenting, and necessary bridging should be done before various medium and large surgeries
This is from the application of cardiac stents: there are two main drugs used in drug-coated stents, rapamycin and paclitaxel, most of the stents currently use rapamycin or derivatives of rapamycin, and a few use paclitaxel. After the stent is implanted in the body, the drug will be slowly released to inhibit the growth of scar tissue around the stent and keep the coronary arteries open, but the stent as a foreign body can stimulate some inflammation and immune response in the local tissue, which will stimulate local thrombosis until the inside of the stent is covered by vascular endothelial cells. Therefore, long-term oral anticoagulant drugs should be taken after stenting.
There are three things surgeons need to know: whether surgery is needed, what kind of surgery to do, and when to do it.
Therefore, for patients after cardiac stent implantation, unless it involves life-and-death emergency surgery, it is not recommended to undergo surgery at any time, but to follow the guidelines and recommendations to reasonably determine the timing of surgery and avoid the risk of surgery to the greatest extent.
So, how should we choose the most appropriate treatment for this patient?
As a surgeon, I personally believe that surgery is a double-edged sword, and you can't consider the benefits and losses unilaterally. The patient has been undergoing stenting for six months, and there are risks associated with thoracic nodule surgery, but if the surgery is postponed, the best time for lung tumor treatment will be missed, and the treatment effect will be greatly reduced. The risk of lung surgery in patients undergoing stent surgery is obvious. In the current medical technology situation, how to actively prevent foreseeable risks and do a good job in the treatment of risks should be actively considered, and the best solution should be selected with the active participation of patients and their families, after all, risks and opportunities are accompanied, and both doctors and patients are actively responsible, and risk sharing is the most positive treatment attitude. After all, this kind of situation is a spear and shield relationship everywhere, and there is no 100% insurance plan.
Medical care is a double-edged sword, life and death are a flick of the moment
Therefore, for this patient, my opinion is to recheck the patency of the coronary vessels with the patient's consent, if the vascular patency is good, the anticoagulant drugs can be suspended, the short-acting anticoagulant drugs can be used for bridging, the surgical treatment should be active, the anesthesia process should be closely monitored to ensure the coronary vascular perfusion, and the use of anticoagulant drugs should be resumed in time after surgery to ensure the safety of the perioperative period.
By the way, if the patient expects to have a high-risk surgery in the near future, should the heart stent be placed?
Myocardial infarction is a fatal thing, and life is greater than heaven.
Some patients need to undergo cardiogram examination before major surgery, if it is found that there is coronary stenosis, stent implantation surgery is required, how to consider this operation and major surgery? Bare metal stents can be placed before surgery, and dual antiplatelet drugs can be stopped 1~3 months after stent implantation, and antiplatelet therapy can be carried out after surgery. This will ensure the occurrence of myocardial infarction and the smooth implementation of major surgery.
This is Dr. Yu Futian to give you popular science education, if it is helpful to you, please give a thumbs up, and also invite you to actively promote medical science knowledge, and jointly contribute to public health, thank you for your support and trust, Dr. Yu will continue to explain common health knowledge to you in the simplest words, if you are interested, you can give attention.
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