Outcomes of octogenarians and nonagenarians in elective major gynecologic surgery

doi:10.1016/j.ajog.2006.03.085

American Journal of Obstetrics and Gynecology

Volume 195, Issue 2, August 2006, Pages 547-552

https://doi.org/10.1016/j.ajog.2006.03.085 Get rights and content

Objective

The purpose of this study was to determine whether age is a risk factor for perioperative and postoperative complications.

Study design

This was a retrospective case-control study of 120 women over age 79 (group 1) compared with 1,497 younger patients 50-79 (group 2) undergoing major elective gynecologic surgery.

Results

Mean length of stay was 4.8 days for group 1, compared with 3.8 for group 2 (P = .018). Patients hospitalized longer than 1 week was higher (P < .01) among group 1. There were statistically significant increases in UTI, psychiatric events, pulmonary edema, respiratory failure, sepsis, and hypovolemic shock. No significant difference in mortality rate was noted (group 1: 0.83%, n = 1 vs group 2: 0.47%, n = 7).

Conclusion

Although length of stay for the elderly is slightly increased, mortality and complication rates are comparable to younger patients with few exceptions. We conclude that age need not be the sole determinant in the decision to undergo major elective gynecologic surgery.

Section snippets

Material and methods

This was a retrospective case control study of 120 patients over the age of 79 (group 1) who underwent major gynecologic procedures between January 1, 1995, and December 31, 2003 in a single tertiary care regional hospital. These patients are compared to a younger cohort (ages 50-79) of 1497 females undergoing similar procedures during the same time period (group 2). Approval for this study was obtained through the Medical Research Advisory Committee at Memorial Health University Medical

Results

One hundred twenty patients over the age of 79 (group 1) were compared to a younger cohort of 1,497 patients (group 2). The mean ages of the 2 groups were 83.34 (range 80-94) and 61.92 (range 50-79), respectively. There were 51 abdominal hysterectomies, 22 vulvar surgeries, 19 laparotomies, 14 vaginal hysterectomies, and 14 procedures for incontinence and pelvic floor prolapse in group 1 (Table I). Seven simple partial, 11 simple complete, 1 radical partial, and 3 radical complete vulvectomies

Comment

Our study is one of the larger case series of elderly patients undergoing major surgery, and is the first in the gynecologic literature to include a younger control group examining both benign and malignant cases to date. The size of retrospective case series published has ranged between 54 and 267 elderly women, none of which were compared to a younger cohort of patients.10, 11, 12, 13, 14, 15, 16, 17 Giannice et al compared 36 women undergoing surgery with pelvic lymphadenectomy to 72 women

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Cited by (26)

Complications of disease and therapy
2023, DiSaia and Creasman Clinical Gynecologic Oncology
Women with gynecologic cancers often experience complications associated with their primary disease process or from the cancer-directed treatment. In addition, many women have medical comorbidities, are obese, or are elderly, all of which may further complicate treatment decisions and therapy. Minimizing these problems requires the clinician to astutely evaluate the patient, be proactive in prevention strategies, and provide early intervention. Complications of disease are, in fact, commonly the primary presenting symptom (chief complaint) of a gynecologic cancer. Common symptoms of gynecologic cancers include vaginal bleeding (cervical and endometrial cancers), urinary tract obstruction or fistulae (cervical cancer), or intestinal obstruction or weight loss (ovarian cancer). Although some complications have been discussed previously in this text, it seems appropriate to devote a chapter exclusively to complications of disease and therapy. Not all possible complications can be covered, and readers are referred to texts that expand on them; however, the more common complications and their management are discussed.
Intra-, peri- and postoperative complications in pelvic organ prolapse surgery in geriatric women
2018, European Journal of Obstetrics and Gynecology and Reproductive Biology
Citation Excerpt :
The majority of non-severe complications were urinary tract infections. This corresponds to other studies in which urinary tract infections were observed in up to 15.8%–35.6% of gynecological surgeries [15,18]. There was one woman who suffered from prolonged pain after surgery.
Pelvic organ prolapse is a common problem among geriatric women. Advanced age is associated with a high prevalence of comorbidities that can lead to restrictive use of surgical treatment. With rising life expectancy it is predicted that surgical treatment in these women will be seen more frequently. Inconsistently there is a lack of clinical trials giving attention to elderly women suffering from pelvic organ prolapse. The aim of this study was to quantify the rate of complications in elderly women undergoing surgery for pelvic organ prolapse.
72 women aged ≥75 years who underwent surgical correction for pelvic organ prolapse were included in this study. Demographics, comorbidities, intra-, peri- and postoperative severe and non-severe complications were recorded. Additionally we compared the pre- and postoperative presence of symptoms linked to pelvic organ prolapse. Follow-up for the review of pelvic floor symptoms was six month.
The mean age was 81.4 years. Four (5.6%) of the patients had a severe intra-, peri- or postoperative complication (two bowel injuries, one bleeding requiring blood transfusion, one resuscitation). All women with severe complications showed no persistent problem at the time of discharge or during the follow-up period. There was a significant postoperative decrease in pelvic organ prolapse connected symptoms, such as stress urinary incontinence (p = .013), voiding dysfunction (p < .001), recurrent urinary tract infection (p = .001) and rectal outlet obstruction (p = .006).
Elderly women undergoing an operation for pelvic organ prolapse have a low risk of complication and benefit from surgery. Age alone should not be a contraindication to surgery.
Complications of disease and therapy
2018, Clinical Gynecologic Oncology
Hysterectomy for benign disease: Clinical practice guidelines from the French College of Obstetrics and Gynecology
2016, European Journal of Obstetrics and Gynecology and Reproductive Biology
Citation Excerpt :
Advanced age is not a risk factor for bowel problems after hysterectomy (LE4) [54]. The prevalence of gastrointestinal injury does not seem to correlate with surgical experience (LE3) [55,56]. The prevalence of postoperative reflex ileus is 0.1% to 1.2% in the case of hysterectomy for benign disease [38,57–59].
The objective of the study was to draw up French College of Obstetrics and Gynecology (CNGOF) clinical practice guidelines based on the best available evidence concerning hysterectomy for benign disease.
Each recommendation for practice was allocated a grade, which depends on the level of evidence (clinical practice guidelines).
Hysterectomy should be performed by a high-volume surgeon (>10 hysterectomy procedures per year) (grade C). Stimulant laxatives taken as a rectal enema are not recommended prior to hysterectomy (grade C). It is recommended to carry out vaginal disinfection using povidone-iodine solution prior to hysterectomy (grade B). Antibiotic prophylaxis is recommended during hysterectomy, regardless of the surgical approach (grade B). The vaginal or laparoscopic approach is recommended for hysterectomy for benign disease (grade B), even if the uterus is large and/or the patient is obese (grade C). The choice between these two surgical approaches depends on other parameters, such as the surgeon's experience, the mode of anesthesia, and organizational constraints (duration of surgery and medical economic factors). Vaginal hysterectomy is not contraindicated in nulliparous women (grade C) or in women with previous cesarean section (grade C). No specific hemostatic technique is recommended with a view to avoiding urinary tract injury (grade C). In the absence of ovarian disease and a personal or family history of breast/ovarian carcinoma, the ovaries should be preserved in pre-menopausal women (grade B). Subtotal hysterectomy is not recommended with a view to reducing the risk of peri- or postoperative complications (grade B).
The application of these recommendations should minimize risks associated with hysterectomy.
Urinary, infectious and digestive adverse events related to benign hysterectomy and the associated surgery on the Fallopian tube: Guidelines
2015, Journal de Gynecologie Obstetrique et Biologie de la Reproduction
Éditer des recommandations pour la pratique clinique concernant les complications urinaires, infectieuses, digestives des hystérectomies d’indication bénigne et de leurs gestes associés, par le Collège national des gynécologues et obstétriciens français (CNGOF).
Revue de la littérature en utilisant des mots-clés suivants : benign hysterectomy; urinary injury; bladder injury; ureteral injury; vesicovaginal fistula; infection; bowel injury; salpingectomy.
Il est recommandé de ne pas dépasser 24 h de sondage vésicale postopératoire (grade B). En cas de sondage peropératoire, il est possible d’enlever la sonde immédiatement après l’hystérectomie (grade C). Aucune technique d’hémostase ne peut être recommandée par rapport aux autres dans le seul but d’éviter des plaies urinaires (grade C). Il n’y a pas d’argument pour recommander la fenestration du ligament large, l’urétérolyse, la mise de sondes JJ ou l’utilisation d’un manipulateur utérin pour la prévention des plaies urétérales lors d’une hystérectomie d’indication bénigne. Une antibioprophylaxie par une céphalosporine est recommandée lors d’une hystérectomie quelle que soit la voie d’abord utilisée (grade B). Une préparation digestive mécanique n’est pas recommandée avant une hystérectomie d’indication bénigne (grade B). En l’absence de pathologie ovarienne et/ou d’antécédents personnels ou familiaux de cancer du sein/ovaire, il est recommandé de conserver les ovaires en pré-ménopause (grade B). En post-ménopause, le choix éclairé de la patiente et la voie d’abord doivent être prises en compte dans la décision d’annexectomie. Comme la protection conférée par l’association hystérectomie et salpingectomie dans la prévention du cancer de l’ovaire n’a pas été évaluée, une salpingectomie bilatérale systématique n’est donc pas recommandée (accord professionnel).
L’application de ces recommandations devrait limiter les risques de complications viscérales lors d’une hystérectomie d’indication bénigne.
To provide clinical practice guidelines from the French College of Obstetrics and Gynecology (CNGOF) based on the best evidence available, concerning the urinary, infectious and digestive adverse events related to benign hysterectomy and the associated surgery including opportunistic salpingectomy and adnexectomy.
Review of literature using following keywords: benign hysterectomy; urinary injury; bladder injury; ureteral injury; vesicovaginal fistula; infection; bowel injury; salpingectomy.
Urinary catheter should be removed before 24 h following uncomplicated hysterectomy (grade B). In case of urinary catheter during hysterectomy, immediate postoperative removal is possible (grade C). No hemostasis technics can be recommended to avoid urinary injury (grade C). There is not any evidence to recommend to perform a window in the broad ligament or an ureterolysis, to put ureteral stent or a uterine manipulator in order to avoid ureteral injury. An antibiotic prophylaxis by a cephalosporin is always recommended (grade B). Mechanical bowel preparation before hysterectomy is not recommended (grade B). If there is no ovarian cyst/disease and no familial or personnal history of ovarian/breast cancer, ovarian conservation is recommended in premenopausal women (grade B). In postmenaopausal women, informed consent and surgical approach should be taken in account to perform a salpingo-oophorectomy. Since the association salpingectomy and hysterectomy is not assessed in the prevention of ovarian cancer, systematic bilateral salpingectomy is not recommended (expert consensus).
Practical application of these guidelines should decrease the prevalence of visceral complications associated with benign hysterectomy.
Understanding and managing medication in elderly people
2013, Best Practice and Research: Clinical Obstetrics and Gynaecology
Citation Excerpt :
Seek haematology advice for people with impaired clotting, low platelet counts or who are unable to stop anti-platelet agents before surgery. Comorbidities, including diabetes mellitus, ischaemic heart disease, heart failure, hypertension and COPD are common in elderly people admitted for gynaecological procedures [89]. Patients included in the 2010 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) in the UK commonly had these comorbidities [90].
Ageing alters drug handling by the body (pharmacokinetics) and response to medications (pharmacodynamics). Multiple comorbidities increase the risk of adverse drug reactions and medication burden, with increased potential for drug interactions. Elderly people are seldom included in clinical trials, so underestimation of benefits and overestimation of risk may lead to under-treatment. Cognitive and functional changes associated with ageing may make it difficult for elderly people to adhere to treatment regimens. In this review, we consider these issues, with particular reference to drugs prescribed for gynaecology patients (the ‘gynaecology formulary’). It will focus on key areas of gynaecological practice, including prescribing anticholinergic drugs, hormone treatments and anticancer drugs, and perioperative issues relating to anaesthesia, analgesia and anticoagulation. Implications of common comorbidities, including osteoporosis, diabetes mellitus and cardiovascular disease, for prescribing in gynaecological patients will also be considered.

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William Hoskins, MD, is a Georgia Cancer Scholar and is supported in part by the Georgia Cancer Coalition

Presented at the Sixty-Eighth Annual Meeting of the South Atlantic Association of Obstetricians and Gynecologists, Orlando, FL, January 29-February 1, 2006.

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Transactions from the 68th Annual Meeting of the South Atlantic Association of Obstetricians and GynecologistOutcomes of octogenarians and nonagenarians in elective major gynecologic surgery

Objective

Study design

Results

Conclusion

Section snippets

Material and methods

Results

Comment

Clin Geriatric Med

Am J Obstet Gynecol

J Am Coll Surg

Am J Obstet Gynecol

Gynecol Oncol

Gynecol Oncol

Am J Surg

Biology of aging

Transactions from the 68th Annual Meeting of the South Atlantic Association of Obstetricians and Gynecologist
Outcomes of octogenarians and nonagenarians in elective major gynecologic surgery