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10.1245/ASO.2004.03.080
Annals of Surgical Oncology 11:219-225 (2004)
© 2004 Society of Surgical Oncology
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ORIGINAL ARTICLES

Perioperative Morbidity and Mortality in Elderly Gynecological Oncological Patients (>=70 Years) by the American Society of Anesthesiologists Physical Status Classes

Raffaella Giannice, MD, PhD, Elvira Foti, MD, PhD, Antonella Poerio, MD, Elisabetta Marana, MD, PhD, Salvatore Mancuso, MD, PhD and Giovanni Scambia, MD, PhD

From the Department of Obstetrics and Gynaecology (RG, EF, AP, SM, GS), Catholic University of Sacred Heart of Rome, Rome, Italy; Department of Obstetrics and Gynaecology (RG), Civil Hospital of Legnano, Milan, Italy; and Department of Anaesthesiology (EM), Catholic University of Sacred Heart of Rome, Rome, Italy.

Correspondence: Address correspondence and reprint requests to: Giovanni Scambia, MD, PhD, Department of Obstetrics and Gynaecology, Catholic University of Sacred Heart, Largo A. Gemelli 8, 00168, Rome, Italy; Fax: 39-06-355-08736; E-mail: giovanniscambia{at}libero.it


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Background: We evaluated the morbidity and mortality associated with American Society of Anesthesiologists (ASA) classes III and IV versus ASA classes I and II in elderly women (>=70 years) undergoing gynecological oncological surgery.

Methods: From 1986 to 2000, we retrospectively collected patients >=70 years of age undergoing oncological gynecological surgery. The study population consisted of 121 ASA class III and IV patients. The control group consisted of the same number of patients with ASA classes I and II, and these were matched to study patients (1:1) by clinical and surgical data. The morbidity and mortality of patients with ASA status III and IV were analyzed before and after 1992.

Results: In ASA class III and IV patients, compared with ASA class I and II, a higher rate of severe morbidity (P = .000) occurred, whereas the median postoperative stay was similar (8 days). No differences between patients with ASA class III and IV and ASA class I and II for median operative time, transfusion rate, or median blood loss were found. Mortality was 3% in ASA classes III and IV.

Conclusions: Our study suggests that surgery in elderly gynecological oncological patients aged >=70 years with ASA class III or IV results in an acceptable perioperative morbidity and mortality rate.

Key Words: Elderly patients • Morbidity • Mortality • Gynecological cancer • Oncological surgery • ASA classes


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
During the past 50 years, because of improvements in general health care and nutrition, a significant prolongation of the average human life span has been achieved in developed countries. In Europe, gynecological cancers occur in 58% of women after 65 years of age.1 A large increase in the population of elderly cancer patients, and, with aging, an increase in associated chronic medical illnesses, is forecast, so the problem of how to treat this group of patients will become more and more relevant.2–4

Currently, elderly cancer patients do not receive the same standard treatments as their younger counterparts. This is mainly due to age-related organ failure, which, with concomitant diseases, results in an increased risk of complications.5,6 In the past, surgery—particularly radical abdominal operations—has been considered with caution in this age group of patients because the great risk of complications may outweigh the uncertain therapeutic benefits.

However, surgery remains in many instances the best option for the treatment of solid malignancies at any age. In recent years, new developments in the fields of anesthesia and perioperative medical care and in surgical techniques have reduced the surgical exclusion criteria and increased the general safety and rate of operability in elderly patients.7–11 Therefore, it seems that elderly gynecological cancer patients can expect a 5-year survival rate comparable to that of their younger counterparts.10,12

Alternatives to surgery might be radiotherapy and chemotherapy, which are usually used as palliative or adjuvant treatments in younger patients. The complications related to these treatments increase with age because of organ failure and comorbid conditions.13–16 The expectations of the elderly patients concerning cancer therapy were analyzed in a study by Nordin et al.,17 in which >90% of the study population (189 elderly cancer patients) desired a radical therapy that could offer greater survival odds even at the cost of increased morbidity.

For all these reasons, surgical therapy assumes a relevant position in the treatment of elderly patients. Nevertheless, because poor physical status increases the surgical risk, an accurate preoperative selection of elderly patients on the basis of the functional status is advisable.18

Until now, no studies in gynecological surgery have analyzed the perioperative morbidity and mortality in relation to the physical status of elderly patients. The comorbidities and performance status are significant variables that affect the patient’s probability of recovering from surgery. The acceptable morbidity and mortality rate reported in the literature regarding gynecological cancer surgery of elderly women could be due to selection of patients with a good physical status and, therefore, a lower surgical risk.

The purpose of this study was to evaluate, among elderly women (aged >=70 years) who underwent gynecological oncological surgery, the morbidity and mortality in patients with a poor functional status (corresponding to American Society of Anesthesiologists [ASA] classes III and IV) versus patients with a good physical status (corresponding to ASA classes I and II).


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
In a retrospective study, we evaluated patients aged >=70 years who had undergone oncological gynecological surgery between January 1986 and December 2000 at the Department of Gynaecologic Oncology of the Catholic University of the Sacred Heart of Rome. The study population consisted of all patients placed in ASA classes III and IV. The control group consisted of the same number of patients placed in ASA classes I and II. Controls were matched to study cases as closely as possible with a 1:1 ratio by age, site and stage of tumor, body mass index, year, and type of surgery.

Clinical and surgical data were collected from patient charts. Early stages (I–II) and advanced stages (III–IV) of disease were considered according to the International Federation of Gynecology and Obstetrics. Before surgery, the patients’ physical status was evaluated by the standard physical status classification system of the ASA, summarized19 in Table 1, and complete clinical and instrumental staging was performed in all patients as appropriate for each tumor site and type of comorbidity. Patients were considered obese if the body mass index was >=30 kg/m2. We considered ischemic cardiopathy (treated angina pectoris class II or higher and previous myocardial infarction <6 months previously), a left ventricular ejection fraction <50% with echocardiographic evaluation, and chronic heart failure as severe cardiopathies.20 Pulmonary pathologies were considered severe if the preoperative arterial blood gas analysis PaO2 was <60 mm Hg, PCO2 was >45 mm Hg in free air, the maximum volume of ventilation (at preoperative respiratory function tests) at the pyrometer was <50%, the forced vital capacity was <30%, the forced expiratory volume in 1 second was <1 L, and the residual volume/total lung capacity was >50% of predicted.21


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  		TABLE 1. American Society of Anesthesiologists physical status classification19
 
Surgical procedures were performed by the same surgeons with the techniques previously reported.22–26 The surgical learning curve reached a plateau around 1992. From 1992, the layer-by-layer dissection of the anterior parametrium according to the technique proposed by Sakamoto was performed for cervical cancer, as described in detail elsewhere.22 The radical vulvectomy was performed by using the technique of separated vulvar and inguinal incisions.27 After 1992, an intraperitoneal or retroperitoneal drain was not placed in all patients undergoing radical surgery, and the pelvic and paracolic gutters of the peritoneum were left open to reduce the incidence of lymphocyst and febrile morbidity.28 The perioperative management after 1992 has been previously reported.7

We considered as major surgery the following procedures: systematic lymphadenectomy; radical hysterectomy by Piver class29 2 to 4, with or without systematic pelvic or aortic lymphadenectomy; hysterectomy or adnexectomy (with multiple biopsies, radical omentectomy, and appendectomy); hemicolectomy; and radical vulvectomy with groin dissection.27 Minor surgery included exploratory laparotomy, hysterectomy class 1,26 simple vulvectomy, second look, and simple adnexectomy.

Postoperative complications were graded according to the glossary of complications by Chassagne et al.30 Fever was considered in the case of two oral temperatures >38°C measured at least 4 hours apart, starting 24 hours after surgery. Pulmonary embolism was considered if documented by pulmonary scintigraphy or deep venous thrombosis only if diagnosed from Doppler ultrasound examination and sepsis in the case of positive blood culture. The patients were judged adequately treated if they were submitted to a standard surgical procedure for the stage and the type of tumor. We evaluated the results of surgery on the entire series. In addition, we analyzed surgical characteristics and postoperative parameters by dividing patients into two groups (from January 1986 to December 1991 and from January 1992 to December 2000), to evaluate possible differences due to the technical and medical modifications introduced in 1991. Finally, in all patients submitted to major surgical procedures, we analyzed intraoperative and postoperative morbidity and mortality in women with ASA class III or IV versus ASA class I or II.

Median values between the two groups were compared by using the Mann-Whitney U-test, and frequency data were compared by using Fisher’s exact test or the {chi}2 test, as appropriate. Statistical significance was defined as P < .05.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
A total of 323 patients aged >=70 years were submitted to surgery for gynecological malignancies (uterine, ovarian, cervical, and vulvar cancer) from January 1986 to December 2000: 136 women were assigned to ASA classes III and IV, whereas 187 women were assigned to ASA classes I and II. Among these, 121 patients were matched as a control group with the study population.

Clinical characteristics are listed in Table 2. As we expected, there was a significantly higher rate of patients with advanced age (>=80 years) and with comorbidities in the ASA III and IV group compared with the ASA I and II group.


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  		TABLE 2. Patient characteristics by ASA physical status
 
Analyzing the comorbidities by ASA class groups, cardiovascular diseases, severe pulmonary diseases, diabetes, and vascular diseases were significantly more frequent in ASA III and IV patients in comparison with ASA I and II patients. Mild cardiac diseases affected 33 (27%) ASA III and IV patients versus 12 (10%) ASA class I and II patients (P = .000). Severe cardiac diseases occurred in 42 (35%) ASA III and IV patients versus no ASA class I and II patients (P = .00). Severe pulmonary diseases affected 29 (24%) ASA III and IV patients, in comparison to no ASA class I and II patients (P = .00). Vascular diseases occurred in 26 (21%) ASA III and IV patients versus 9 (7%) ASA class I and II patients (P = .00). Finally, diabetes affected 34 (28%) ASA III and IV patients, in comparison to 20 (16%) ASA class I and II patients (P = .04).

Surgical procedures are listed in Table 3. There were no statistical differences between ASA III and IV and ASA class I and II patients concerning the major surgical procedure rate, median operative time, number of intraoperative transfusions, complication rate, median blood loss, or reoperations required. The median operative time was 120 minutes (range, 20–360 minutes) in ASA III and IV patients versus 110 minutes (range, 20–390 minutes) in ASA class I and II patients (P = not significant). The number of intraoperative transfusions was 3 (2%) in ASA III and IV patients versus 8 (7%) in ASA class I and II patients (P = not significant). The median blood loss was 300 mL (range, 50–2100 mL) in ASA III and IV patients versus 300 mL (range, 50–1500 mL) in ASA class I and II patients (P = not significant). One intestinal lesion, one bladder lesion, and one injury of the saphenous vein occurred during surgery in ASA III and IV patients (2%), whereas in ASA class I and II patients, four intestinal and three bladder lesions occurred (6%). All intraoperative injuries were promptly repaired without postoperative complications.


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  		TABLE 3. Surgical procedures by ASA physical status
 
Five (4%) ASA III and IV patients needed reoperation: two for deep wound dehiscence, one for a pelvic abscess and deep wound dehiscence, one for intestinal fistulas and deep wound dehiscence, and the last for retroperitoneal abscess and deep wound dehiscence. Three ASA class I and II patients (3%) underwent reoperation for deep wound dehiscence.

A significantly higher rate of postoperative morbidity occurred in ASA III and IV patients compared with ASA class I and II patients (48% vs. 28%, respectively; P = .000; Table 4). The incidence of severe postoperative complications was statistically significantly higher in ASA III and IV patients compared with ASA class I and II patients (17% vs. 5%; P = .000). Table 5 shows the distribution of the postoperative complications: the two groups did not differ with respect to infectious and surgical morbidity. Overall severe cardiovascular and pulmonary complications were significantly more frequent in ASA III and IV patients than in ASA I and II patients.


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  		TABLE 4. Postoperative complicationsa by ASA physical status
 

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  		TABLE 5. Postoperative complicationsa by ASA physical status
 
No patient died during the operation or in the following 24 hours. All cases of death in ASA classes III and IV occurred in patients with stage III or IV disease. The causes of death in the three patients were congestive cardiac failure not responsive to medical treatment (on the third postoperative day; n =1), myocardial infarction (on the eighth postoperative day; n =1), and pulmonary embolus (on the first postoperative day; n =1). The two patients who died as a result of cardiac complications had no previous cardiovascular diseases. The patient who died on the first postoperative day of a pulmonary embolus had a history of myocardial infarction.

Analyzing intraoperative and postoperative morbidity in patients submitted to major surgical procedures, we found no statistical differences between the 42 (35%) ASA III and IV patients and 47 (39%) ASA class I and II patients in median blood loss (450 vs. 600 mL), intraoperative complications (2% vs. 11%), further surgery required (2% in both groups), or transfusion rate (5% vs. 13%). In patients submitted to major surgical procedures, mild postoperative complications occurred in 16 (38%) ASA III and IV patients versus 15 (32%) ASA class I and II patients (P = not significant); severe postoperative complications occurred in 3 (7%) ASA III and IV women in comparison to 2 (4%) ASA class I and II women. No patient died during the operation or in the postoperative period.

The analysis of ASA III and IV patients by the period of surgery (1986–1991 vs. 1992–2000) is shown in Table 6. The distribution of clinical and surgical characteristics was similar in the two groups. In the second period of the study, more ASA III and IV patients were operated on compared with the first period of the study (98 vs. 23, respectively; P < .01). In the period 1992 to 2000, compared with 1986 to 1991, there was a statistically significantly lower postoperative complication rate (58% vs. 83%, respectively; P = .05) and a shorter median postoperative stay (8 vs. 13 days, respectively; P = .05). The mortality rate was similar in both periods (4% vs. 2%, respectively).


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  		TABLE 6. Clinical and surgical parameters in 121 high-risk patients (with ASA physical status III or IV) by period of surgery
 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
In this study, the postoperative morbidity and mortality rates, according to ASA physical status, were analyzed in elderly women aged >=70 years who underwent gynecological cancer surgery. Until now, no studies have reported the morbidity and mortality rate by ASA physical status (expression of the comorbidity grade) in elderly gynecological cancer patients.

Our data suggest that elderly patients with a poor physical status could receive surgical treatment with an acceptable postoperative morbidity and mortality rate. In fact, we found a severe morbidity rate of 17% in ASA class III and IV patients; this rate is similar to that reported in a large series of elderly patients undergoing surgery for gynecological malignancies, which ranged from 17% to 29%9–12; the difference was that the reported rates were performed on the entire elderly population, with or without comorbidities.

During the overall study period, we observed that the severe concomitant diseases (ASA III and IV patients) compared with the moderate concomitant diseases (ASA class I and II patients) were directly associated with an increase in the postoperative morbidity but not with the median hospital stay. Massad et al.,6 in their study of 155 patients undergoing gynecological oncological major surgery, came to the same conclusions. Dean et al.,31 in a retrospective analysis of 179 elderly patients submitted to oncological gynecological surgery, found that the number of comorbid medical conditions could predict the frequency of postoperative complications, but contrary to our results, they found a longer time of hospitalization, especially in patients with more than one comorbidity.

Regarding postoperative morbidity, however, the complications observed in patients with poor physical status were resolved without long-term consequences. In particular, the postoperative thromboembolic accident rate was not significantly increased in ASA III and IV patients, despite the significant incidence of advanced age and associated illnesses, particularly concomitant vascular diseases. The use of antithrombotic measures contributed to control this life-threatening complication.

In the ASA III and IV group, we found a mortality rate similar to that in the literature,9,32–34 as previously reported.7 However, there was no correlation between ASA class III and IV patients and mortality: the locally advanced stage of disease at surgery, which would be expected to adversely affect survival, was the only risk factor associated to the mortality.

When the two periods of surgery were analyzed, interesting data emerged: compared with those in the 1986 to 1991 period, ASA III and IV patients who underwent surgery from 1992 on had a markedly reduced complication rate. This result could be related to the introduction of new surgical techniques22–28 and to a semi-intensive and multidisciplinary management routine practiced in the second period of the study.

In particular, in our department (in addition to antithrombotic and antibiotic prophylaxis), elderly patients were submitted to routine serial monitoring of the blood pressure, cardiac frequency, liquid balance, oral temperature, blood parameters, respiratory gymnastics, early mobilization, and accurate pain relief. When necessary, an observational period in the intensive care unit for the first 24 hours after surgery was implemented.

From 1992 on in elderly patients in ASA classes I and II, we observed that the perioperative complication rate and the median postoperative stay (with a length similar to that reported for ASA III and IV patients in the same period) were comparable to those previously shown in our younger patient series and in the literature.22–26 Fuchtner et al.12 showed, in a series of 90 patients with a median age of 41 years who were submitted to gynecological oncological surgery, a 10% intraoperative complication rate, a 38% mild postoperative complication rate, and a 4% severe postoperative complication rate. Kirschner et al.32 reported a severe morbidity rate of 9% among 77 patients with a median age of 42 years undergoing surgery for gynecological cancer.

Finally, in the analysis of patients submitted to major surgical procedures, we found no statistically significant difference in terms of morbidity and mortality between ASA III and IV patients and ASA I and II patients.

In conclusion, poor physical status should not be a significant contraindication for the treatment of elderly patients with gynecological cancer, and the benefits of surgical treatment should not be denied these patients. These data encourage us to continue to study this population of elderly patients with gynecological malignancies at high surgical risk and with poor physical status, who, in this way, may gain the advantage of more appropriate surgical treatment in the future.


   FOOTNOTES
 
Surgery in elderly gynecological oncological patients aged >=70 years with American Society of Anesthesiologists classes III and IV resulted in an acceptable perioperative morbidity and mortality rate.

Received for publication March 24, 2003. Accepted for publication October 2, 2003.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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