Minimally invasive surgery in frail patients

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1 Minimally invasive surgery in frail patients Prof. Leon Snyman Gynaecological Oncology Unit Department Obstetrics & Gynaecology

2 Minimally invasive procedures Entering a body cavity with no or minimal tissue damage Gynaecology Laparoscopy Hysteroscopy Vaginal hysterectomy?

3 Ageing Associated with progressive loss of functional reserve in all organ systems Increased vulnerability to stressors

4 Frail patients Mostly elderly patients No uniformly accepted definition Decreased physiological reserve affecting multiple systems

5 For the purpose of this discussion Minimally invasive diagnostic and therapeutic procedures in elderly women who are frail

6 Silver tsunami United Kingdom 13% of women born in 1951 will be alive in % of girls born in 2013 will celebrate their 100 th birthday Same tendencies in other countries

7 Cancer and geriatrics 40% of all malignancies occur in patients older than 70 years Majority of patients undergoing surgery for solid tumours are elderly Roughly 40% of them are frail

8 What do the elderly want They want to be investigated They want to be treated

9 What do they get When diagnosed with cancer Less likely to be operated Less likely to receive radiotherapy or chemotherapy Poor palliation fear of addiction to opioids

10 The elderly In the literature if you are 65 years and a patient, you are regarded as an elderly patient Age is not an absolute contra-indication for surgical procedures Not all elderly women are frail

11 Manifestations of frailty Clinically Unintentional weight loss Exhaustion Weakness Relative immobility (slow walking speed) Decrease in physical activity

12 Frailty and surgery Frailty is generally accepted as a marker of increased risk, complications, and mortality in surgery

13 Frailty and surgery More complications Longer hospital stay Increased overall cost of care

14 Minimally invasive procedures Benefits Less pain Less morbidity Less blood loss Shorter hospital stay Quicker recovery

15 Data in elderly General surgery Cholecystectomy Appendectomy Colectomy Nephrectomy

16 Data in elderly Gynaecology Endometrial cancer Cervical cancer Sacrocolpopexy Adnexal pathology

17 Some studies Bogani et al 2014 Laparoscopic surgery with women >85 years with endometrial cancer Safe and effective option Less post-op complications compared to open surgery Better than abdominal or vaginal approach

18 Cervical cancer Park et al to 78 years old, n = 99 Laparoscopic radical hysterectomy better surgical outcomes

19 Minimally invasive procedures MIS not a risky procedure The benefits of MIS are applicable to elderly patients as well and they probably benefit more Age is not a contra-indication

20 Pre-operative risk factors Functional status Congestive heart failure Liu et al 2000 Leung et al 2001

21 Decision making The frail patient with a problem Needs diagnostic or therapeutic procedure The surgical and anaesthetic risk needs to be assessed Decision should then be made considering the above risk

22 How to assess risk Clinically Risk assessment tools

23 Pre-operative assessment Thorough history Clinical examination Multi-disciplinary approach Anaesthetic consultation Physician / cardiologist /Nephrologist / etc Physiotherapist

24 Surgical risk Mortality and morbidity depends on Presence and severity of coexisting disease Emergency surgery indication for surgery Invasiveness of the procedure

25 Surgical risk clinical Highest mortality Patients over age 80 (inpatient and outpatient procedures) A prior diagnosis of heart failure confers a particularly high risk for mortality, even after minor outpatient procedures

26 Some risk factors CVS Previous MI Heart failure Arrhythmias mortality risk Diabetes Obesity Infection

27 Risk assessment tools Comprehensive geriatric assessment (GCA) Time consuming Difficult to use in clinical practice

28 Risk assessment tools American Society of Anaesthesiology classification (ASA) Quantifies pre-op status and estimates anaesthetic risk ASA 1 to 5

29 Modified frailty index (MFI) History of Diabetes Functional status COPD or pneumonia Congestive heart failure MI Percutaneous coronary intervention, cardiac surgery or angina Treatment for hypertension Peripheral vascular disease or rest pain Impaired sensorium TIA or CVA CVA with neurological deficit Minimum score = 0 Maximum score = 11

30 Risk assessment tools Timed Up and Go (TUG) Quantify functional mobility to identify the frail Predicts risk of post-operative functional outcome, prolonged hospital stay and delirium Huisman et al 2014

31 TUG Measures the time in seconds a person needs to get up from a chair, walk 3 meters and return to the chair Mean of two efforts Normal : 20 seconds Huisman et al 2014

32 TUG Absolute risk of major complications oncogeriatric surgery Normal TUG 14.7% TUG 50% 3.4 times higher risk of developing major complications within 30 days Huisman et al 2014

33 Avoid complications Once risk has been assessed Steps to avoid complications

34 Intra-operative Meticulous attention to detail Careful positioning to avoid peripheral neurological damage

35 Intra-operative Anaesthetics Generally, older patients are more susceptible to the effects of all intravenous and volatile anaesthetic agents, and the duration of drug effect is often prolonged Strict and careful fluid therapy Adequate pain relief

36 Post-op complications Fluid therapy Inadequate pain relief is associated with increased incidence of delirium and other morbidity in older patients Early mobilisation and fall prevention VTE prophylaxis

37 Procedures Hysteroscopy Office hysteroscopy Assessment endocervical canal Endometrial assessment and biopsy Polypectomy Insertion LNG-IUS

38 Procedures Laparoscopy Seldom diagnostic only Assessment and removal adnexal pathology Oncological TLH TLRH Lymph nodes

39 The role of MIS in the frail Depends The condition to be diagnosed or treated QOL Oncology - treatment or palliation The condition of the frail patient The wishes of the patient

40 Decision making Assess the risk factors Identify the objective of the planned procedure Decide if the risk-benefit ratio is acceptable If the patient is able to make the decision, then the patient must make the decision

41 Finally MIS in itself low risk When indicated should be the preferred choice Elderly patients tolerate laparoscopic procedures well It is the patient s decision