Management of giant ovarian tumors in elderly adults: Preoperative evaluation using comprehensive geriatric assessment and estimation of physiologic ability and surgical stress and perioperative management effectiveness using Aron Alpha method and enhanced recovery after surgery

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Management of giant ovarian tumors in elderly adults: Preoperative evaluation using comprehensive geriatric assessment and estimation of physiologic ability and surgical stress and perioperative management effectiveness using Aron Alpha method and enhanced recovery after surgery

https://doi.org/10.21203/rs.3.rs-2430620/v1

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Purpose: We assessed the effectiveness of preoperative evaluation using comprehensive geriatric assessment (CGA) and estimation of physiologic ability and surgical stress (E-PASS), the Aron Alpha method, and perioperative management based on Enhanced Recovery After Surgery (ERAS) for giant ovarian tumors in elderly adults.

Methods: We focused on five giant ovarian tumor cases among elderly patients. Preoperative evaluation using the E-PASS scoring system and CGA was performed. Furthermore, the minimally invasive surgical method, the Aron Alpha method, was conducted, and we performed perioperative management using ERAS.

Results: The mean age was 75.8±8.8 years, and the comorbidities were hypertension in three cases, hyperlipidemia in two cases, angina pectoris in one case, cholecystitis in one case, and lower extremity varicose veins in one case. The mean tumor size was 21.0±5.4 cm. The examination using the E-PASS scoring system showed a preoperative risk score of 0.7±0.4, surgical stress score of 0, and comprehensive risk score of 0.3±0.3. In CGA, two cases had problems with instrumental activities of daily living and cognitive function. The mean duration of surgery was 89.0±16.6 minutes, and the mean blood loss was 56.0±65.4 mL. No surgery-associated complications were observed, and early postoperative ambulation, rehabilitation intervention, and postoperative analgesic management were conducted. No patients had prolonged hospitalization and activities of daily living decline.

Conclusion: We were able to confirm the usefulness and safety of the minimally invasive Aron Alpha method and ERAS-based perioperative management of giant ovarian tumors in elderly patients by performing a detailed preoperative evaluation using CGA and E-PASS.

Laparoscopy

ascites cytology

ovarian tumor

cystadenoma

cystic

postoperative cognitive dysfunction

The Aron Alpha method for giant ovarian tumors is minimally invasive and can be performed without leakage of ovarian tumor fluid into the peritoneal cavity. This procedure was considered to be useful for gigantic ovarian tumors in the elderly whose malignancy cannot be ruled out.

In recent years, there has been an increase in surgeries conducted in elderly patients due to the progression into an aging society. Elderly people have reduced organ reserve capacity, wound healing capacity, weakened immune system, and increased comorbidities; postoperative complications may significantly impact prognosis in critical cases [1, 2]. Therefore, it is important for perioperative management to strictly evaluate the patient’s ability to withstand the planned anesthesia and surgical invasion. The estimation of physiologic ability and surgical stress (E-PASS) scoring system is a preoperative evaluation system that predicts postoperative complications and in-hospital mortality, and evaluates surgical risks [3, 4]. It was proposed by Haga et al. in 1999 [4] and reported to be simple, reproducible, and useful because it can be calculated from general examination and surgical items [3–6].

Furthermore, the high risk of postoperative complications (including delirium) from surgical treatment in the elderly necessitates evaluating the underlying disease and the daily life activities from multiple perspectives using established evaluation techniques for physical, psychological, and social aspects; one such evaluation method is the comprehensive geriatric assessment (CGA) [7]. It has been reported that this evaluation can provide medical care and welfare services, reduce hospitalizations, shorten hospitalization length, and reduce the mortality rate [8, 9].

Additionally, preventing the postoperative decline in activities of daily living (ADL) and the onset of postoperative cognitive dysfunction (POCD) should be the target in older adults. The Enhanced Recovery After Surgery (ERAS) packages implement evidence-based perioperative management strategies aimed at reducing patient anxiety and pain before and after surgery, postoperative complications, length of hospital stay associated with early recovery of the patient, and medical expenses [10, 11]; adoption of this protocol has been reported to contribute to a reduction in postoperative complications, length of postoperative hospital stay and the economic burden on patients [12, 13].

However, in treating a giant ovarian mass, it may be difficult to diagnose as benign or malignant before surgery; several diagnoses are malignant in the final pathological diagnosis. In malignant ovarian tumors, there is a risk of the disease stage progression due to the intraoperative rupture of the tumor capsule [14] and the high risk of ovarian malignant tumors recurrence [15]; therefore, it is important to prevent tumor fluid leakage of large ovarian tumors into the peritoneal cavity. Furthermore, due to the potential risk, the conventional method involves an increased surgical wound size and invasiveness. Elderly patients, considered to have a higher risk of postoperative complications, length of hospital stay, and postoperative death than younger patients, need a minimally invasive procedure that less affects the decline in physical function associated with surgery. Therefore, we have conducted minimally invasive surgery using the Aron Alpha method for giant ovarian tumors.

This study focused on five cases of giant tumors (major diameter ≥ 15 cm) in elderly patients aged 65 years and older; preoperative evaluation was performed (using the E-PASS scoring system and CGA), the Aron Alpha method and perioperative management (using ERAS) were conducted.

Suspected cases of malignant tumor were excluded from the surgical procedure; however, cases with a possible borderline malignancy or where a malignant tumor could not be completely ruled out underwent the procedure when informed consent was obtained from the patients and their respective families. Among the 24 patients who underwent the Aron Alpha method for giant ovarian tumors (defined in this study as ovarian tumors ≥15 cm along the maximum diameter on preoperative MRI or pelvic X-ray CT) between January 2016 and September 2022 in our hospital, five patients aged 65 years or older were included. We performed preoperative evaluation using the E-PASS scoring system (Table 1) and comprehensive geriatric assessment (CGA).

Table 1 Estimation of physiologic ability and surgical stress (E-PASS) scoring system

1．PRS=-0.0686+0.00345X1 +0.323X2 +0.205X3 +0.153X4+ 0.148X5 +0.0666X6

X1, age; X2, presence (1) or absence (0) of severe heart disease; X3, presence (1) or absence (0) of severe pulmonary disease; X4, presence (1) or absence（0） of diabetes mellitus; X5, Performance status index (0-4); X6, American Society of Anesthesiologists physiological status classification (1-5)

Severe heart disease was defined as heart failure of New York Heart Association Class III or IV, or severe arrythmia requiring mechanical support. Severe pulmonary disease was defined as any condition with a %VC of less than 60 % and/or a FEV1.0% of less

than 50 %. Performance status index was based on the definition by Japanese Society for Cancer Therapy.

2．SSS =-0.342+0.0139X1+0.0392X2+0.352X3

X1, blood loss/body weight (g/kg); X2, operation time (h) ; X3, extent of skin incision（0 : minor incisions for laparoscopic or thoracoscopic surgery [including scope-assisted surgery]; 1 : laparotomy or thoracotomy alone ; 2: both laparotomy and thoracotomy)

3．CRS=-0.328+0.936 (PRS) +0.976 (SSS)

The E-PASS scoring system consists of a preoperative risk score (PRS) and surgical stress score (SSS), and a comprehensive risk score (CRS) is calculated from these values.

Surgical technique

Surgery was started under general anesthesia in the lithotripsy position. A 10-mm scope was inserted from the umbilical region using the open method. After observing the inside of the abdominal cavity (for adhesions and lesions), ascites was collected, and ascites cytology was conducted (Fig. 1a).

After observing the abdominal cavity, a small incision of about 3–6 cm was made in the midline of the lower abdomen, and a Gosset retractor (Natsume Seisakusho Co. Ltd., Tokyo) (Fig. 1b). To prevent the dripping of Aron Alpha (Aron Alpha A “Sankyo”® [Daiichi Sankyo Co., Ltd., Tokyo]) into the surrounding tissues in advance, we spread gauze around the tumor to prevent adhesion to other organs (Fig. 1c). Aron Alpha was applied to the tumor surface in a grid pattern and manually compressed from within a sterile plastic bag to adhere to the tumor (Fig. 1d). After confirming that Aron Alpha adhered to the tumor, a cross-shaped incision was made inside the plastic bag with a knife, the tumor and plastic bag were clamped with Kocher forceps, and the tumor fluid was aspirated from the plastic bag (Fig. 1e). This procedure prevented the leakage of tumor contents into the peritoneal cavity. After a certain volume of tumor fluid was aspirated, the ovarian tumor was guided out of the body, and the fluid was further aspirated. Thereafter, the tumor was lifted out of the body (Fig. 1f), and the running of the ureter was confirmed, the infundibulopelvic ligament was ligated and cut, and the affected appendage was removed.

In addition, the contralateral appendage was removed on the affected side by ligating and cutting the infundibulopelvic ligament. After removing the appendages on both sides, the intraperitoneal cavity was washed with physiological saline, and a pleated drain tube (MD-45408S, Akita Sumitomo Bake Co., Ltd., Akita) was placed in the Douglas cavity to complete the operation.

Regarding postoperative proceedings, our hospital adopted the ERAS protocol, perioperative management, and early rehabilitation intervention from the day after surgery. In addition, age, history of pregnancy and delivery, comorbidities, E-PASS scoring system, CGA, operation time, blood loss volume, postoperative complications, histopathological diagnosis, and length of hospital stay were retrospectively examined from the information in medical records. This study was approved by the International University of Health and Welfare Hospital Ethics Committee (approval number 22-B-32, date of approval: Nov 16, 2022). Furthermore, the opt-out procedure was disclosed on the International University of Health and Welfare Hospital website, and subjects were notified that they could consent to the research at any time.

Numerical data are shown as mean±standard deviation.

Table 2 shows the backgrounds of the five subjects. The mean age was 75.8 ± 8.8 years (65–87 years), all were multiparous, and the mean BMI was 24.2 ± 3.6 (21.1–30.2). Comorbidities included hypertension in three cases, hyperlipidemia in two cases, angina pectoris in one case, cholecystitis in one case, and lower extremity varicose veins in one case. The mean diameter of the tumor size was 21.0 ± 5.4 cm (16–28 cm), and the chief complaints were abdominal distension in four cases, with Case 4 being asymptomatic, which was indicated during the examination. In the examination with the E-PASS scoring system, the preoperative risk score (PRS) was 0.7 ± 0.4 (0.4–1.2), the surgical stress score (SSS) was 0, and the comprehensive risk score (CRS) was 0.3 ± 0.3 (0.4–0.8) (Table 3). In CGA, Instrumental Activities of Daily Living (IADL) and cognitive function problems were observed in Cases 1 and 4, and we performed evaluations of IADL and the Mini Mental State Examination (MMSE). Case 1 had an IADL of 7 and mild dementia; Case 4 had an IADL of 5 and mild dementia. Table 4 shows the surgical results. The mean operation time was 89.0 ± 16.6 minutes (65–108 minutes); additionally, Cases 3 and 5 underwent hysterectomy. The mean blood loss was 56.0 ± 65.4 mL (10–150 mL).

Table 2

Patient background
Case	Age (years)	BMI (kg/㎡)	Number of pregnancies (count)	Number of deliveries (count)	Comorbidities	Symptoms	Maximum tumor diameter (cm)
1	82	21.8	5	3	Lower extremity varicose veins	Abdominal distension	16
2	72	23.4	5	3	Hyperlipidemia, hypertension	Abdominal distension	25
3	72	21.1	5	2	Cholecystitis, hypertension	Abdominal distension	16
4	87	24.5	4	3	Angina pectoris, hypertension	Asymptomatic	20
5	65	30.2	2	2	Hyperlipidemia	Abdominal distension	28
BMI: body mass index

Table 3

Estimation of physiologic ability and surgical stress (E-PASS) scoring system for each case
Case	PRS	SSS	CRS
1	1.2	0	0.8
2	0.5	0	0.1
3	0.5	0	0.1
4	1	0	0.6
5	0.4	0	0.1
PRS: Preoperative risk score, SSS: surgical stress score, CRS: comprehensive risk score

Table 4

Surgical results
Case	Operation time (min)	Bleeding amount (mL)	Ascites cytology	Histopathological examination	Length of hospital stay (days)
1	99	10	class I	Mature cystic teratoma	7
2	80	10	class I	Mucinous cystadenoma	8
3	108	100	class I	Mucinous cystadenoma of borderline malignancy	7
4	65	10	class I	Mucinous cystadenoma	7
5	93	150	class I	Endometrioic cyst adenoma	8

Ascites cytology was negative in all cases, and histopathological examination results of the excised specimens showed mucinous cystadenoma in two cases, demonstrating mucinous cystadenoma of borderline malignancy, mature cystic teratoma, and endometriotic cystadenoma. Surgical complications were not observed. Furthermore, postoperative management, including early rehabilitation intervention, was conducted from the day after surgery based on the ERAS. The average length of hospital stay was 7.4 ± 0.5 days (7–8 days), with no cases of prolonged hospital stay. None of the patients exhibited a decline in ADL or cognitive impairment after hospital discharge.

Elderly people have reduced overall functions such as reduced organ reserve, wound healing ability, and immune function. In addition, comorbidities such as hypertension and diabetes and organ dysfunctions, including cardiopulmonary function, are commonly exhibited. Furthermore, postoperative dietary intake is slow in the elderly, and postoperative complications have been said to increase due to malnutrition and deterioration of functions such as swallowing; collectively, these factors increase hospital stay length and the risk of postoperative death [1, 2]. The general condition, organ functions, and the degree of complications vary in the elderly; the decision to conduct surgery should be based on general condition rather than age alone.

Preoperative evaluation methods (that predict postoperative complications associated with general conditions and surgery to ensure postoperative complications are prevented and surgery conducted more safely) in addition to the E-PASS scoring system [3] adopted in this study include the Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (POSSUM) published in England in 1991 [16], VA Score (announced in the United States in 1997) [17], and the Donati Model (announced in Italy in 2004) [18]. The E-PASS scoring system evaluates and calculates the age, the presence or absence of severe heart disease, severe lung disease, or diabetes, the performance status, and the American Society of Anesthesiologists (ASA) physical status. Furthermore, the surgical invasion score is calculated by evaluating the amount of blood loss per body weight (g/kg), operation time, and area of the surgical incision. Collectively, the scores are combined, and the total risk score is evaluated to calculate postoperative complications and in-hospital mortality. This simple system does not require special equipment and can be calculated from general examination and surgical items. Compared to other risk evaluation scores, this system is universally easier to implement, and its usefulness in predicting postoperative complications and in-hospital mortality has been reported [3–6]. Supposing the results of the comprehensive preoperative evaluation by the E-PASS scoring system indicate that the patient cannot withstand the anticipated standard anesthesia and surgical invasion, the next best measures need to be considered. In addition, it is thought that evaluating these factors will help in selecting surgical methods such as non-radical surgery, palliative surgery, and non-surgical treatments.

Furthermore, since the risk of postoperative complications, such as delirium, is high in the surgical treatment of the elderly, risk needs to be estimated from various perspectives before surgery, for which the comprehensive geriatric assessment can be performed [7]. CGA evaluates the disease and the physical functions (that are needed for anesthesia and surgery, cardiopulmonary function, ADL, exercise capacity, nutritional status, cognitive function, communication ability, sensory function, family environment, family support situation, and financial problems); these factors are combined to determine the possibility of surgery tolerance, surgical indications, surgical content, and surgical methods. Although the family environment and financial problems do not directly affect the indication for surgery, it is essential to consider postoperative care and lifestyle before surgery. It has been reported that the provision of medical and welfare services, according to this evaluation, helps reduce the number of hospitalizations, shorten the length of hospitalization, and lower the mortality rate [8, 9]. In this study, Cases 1 and 4 had problems with IADL and cognitive function; evaluations of IADL and MMSE were performed. Case 1 had an IADL of 7 and mild dementia, and Case 4 had an IADL of 5 and mild dementia.

In addition, postoperative functional recovery must be considered in the elderly. ERAS, reported by Fearon [10, 11], aims to reduce postoperative complications and promote functional recovery by packaging and implementing evidence-based perioperative management strategies to reduce metabolic stress and achieve optimal pain relief, early oral nutrition, and ambulation. Evaluation using ERAS established that minimally invasive surgery to minimize postoperative dysfunction and promote early ambulation contributes to shortening the postoperative hospital stay and reducing the economic burden on patients [12, 13].

Additionally, elderly patients may develop POCD. The primary risk factor for its onset is aging; the incidence of POCD one week after surgery was 30–50% and 10–15% three months after surgery, with the majority being elderly patients [19]. A detailed mechanism of POCD onset has not been elucidated; however, the involvement of neuroinflammation is suggested [20, 21]. Consequently, perioperative management that suppresses neuroinflammation efficiently is indicated in the prevention. Evidently, minimally invasive, shortened surgery time, active use of postoperative analgesics and anti-inflammatory drugs, and preoperative exercise and cognitive function training have been suggested to be effective in preventing POCD [20, 21].

In the cases examined in this study, we performed appropriate preoperative evaluation using the E-PASS scoring system and CGA, and perioperative management based on ERAS, such as early postoperative ambulation, rehabilitation intervention, and postoperative analgesic management. Results showed that all patients were discharged as planned without postoperative complications or decline in ADL, and no POCD occurred two months after surgery.

However, there were concerns with giant ovarian tumors in terms of identifying them as benign or malignant before surgery. Preoperative diagnosis involves referring to diagnostic imaging and tumor markers and, if necessary, conducting intraoperative cytology and rapid histopathological examination. There are several cases where the possibility of a borderline malignancy or a malignancy cannot be ruled out, and there are cases where the final pathological diagnosis is a malignant tumor. If the ovarian tumor is malignant, or if the tumor content leaks into the peritoneal cavity due to intraoperative capsule rupture, there will be an increased risk of progression of disease stage [14] or recurrence [15]; therefore, it is vital to remove the tumor without allowing tumor fluid leakage into the peritoneal cavity. As a result of this phenomenon, the conventional surgical method entails a larger surgical wound and greater surgical invasion. The surgery should be short and minimally invasive to reduce the risks associated with surgery for the elderly. For relatively large ovarian tumors, we adopted the Aron Alpha method, which involves the use of laparoscopy, Aron Alpha for medical use, and sterilized plastic bags to conduct a small laparotomy (incision of 3–6 cm) to remove the contents of the tumor without leaking it into the abdominal cavity. The relevance of this procedure is to ensure the adhesion of the tumor with the plastic bag. To achieve the desired adhesion, it was necessary to dry the moisture on the surface of the ovarian tumor with gauze and apply the Aron Alpha to the tumor surface at an appropriate amount in a grid pattern to increase the area exposed to air, speed up the polymerization and curing time, and increase the adhesion strength.

Furthermore, after the tumor and sterilized plastic bag were adhered, a cross-shaped incision was made on the tumor in the plastic bag with a knife, and the tumor wall and plastic bag were clamped with Kocher forceps at the four points of the incision. This ensured the adhesion of the plastic bag with the tumor, and by aspirating the contents of the tumor and discharging out of the body by shrinking the tumor, it was possible to remove the tumor without leaking tumor fluid into the abdominal cavity, thereby contributing to the reduction of surgical invasion and shortening of operation time. Additionally, the significance of using a laparoscope in the procedure is as follows: (i.) to check for adhesions between the abdominal wall and the tumor, (ii.) to help collect ascites without blood contamination, (iii.) to make observations all over the abdominal cavity (including the upper abdomen) and, (iv.) to help create the possibility of adding biopsy or partial excision for histopathological diagnosis; in cases where there is a peritoneal lesion, it allows for the thorough observation of peritoneal cavity including its upper portion.

Furthermore, since this surgical technique is easy and inexpensive, it helps resect relatively large ovarian tumors. In future, we plan to verify the efficacy and safety of this surgical procedure based on more elderly patient cases.

It is essential to use the E-PASS scoring system and CGA to evaluate the general condition, cognitive function, and risk of postoperative complications and examine the treatment policy and carry out perioperative management using ERAS when planning surgical treatment for the elderly. Furthermore, the Aron Alpha method for giant ovarian tumors is minimally invasive and can be implemented without leakage of the ovarian tumor fluid into the peritoneal cavity. Therefore, this procedure is useful for giant ovarian tumors in the elderly whose possibility of malignancy cannot be ruled out.

Acknowledgments

None.

Funding: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

Competing interests: The authors have no relevant financial or non-financial interests to disclose.

Author contributions: Kaoru Kakinuma and Toshiyuki Kakinuma developed and drafted the manuscript. All authors designed the data collection instruments, collected data, and carried out the initial analyses. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Availability of data and material: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Code availability: Not applicable.

Ethics approval: This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the International University of Health and Welfare Hospital Ethics Committee (approval number 22-B-32, date of approval: November 16, 2022).

Consent to participate: Verbal and written informed consent was obtained from all individual participants included in the study.

Consent to publish; The research participants provided verbal and written informed consent for publication of the images in all Figures.

Conflict of Interest Statement

The authors declare that they have no conflict of interest.

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Management of giant ovarian tumors in elderly adults: Preoperative evaluation using comprehensive geriatric assessment and estimation of physiologic ability and surgical stress and perioperative management effectiveness using Aron Alpha method and enhanced recovery after surgery

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