Successful perioperative management for a giant ovarian tumor in older adults: A case report

Abstract

BACKGROUND

Accurate preoperative assessment of physical function is vital for determining surgical indications and selecting appropriate procedures in older adults. In potentially malignant cases of giant ovarian tumors, tumor capsule intraoperative rupture can cause upstaging and increase malignant ovarian tumor recurrence risk; thus, avoiding it is essential.

CASE SUMMARY

An 81-year-old woman with a giant ovarian tumor underwent preoperative evaluation using the estimation of physiologic ability and surgical stress (E-PASS) scoring system and the FRAIL scale. Laparoscopy-assisted surgery was performed using the Aron alpha method, and postoperative management followed the enhanced recovery after surgery (ERAS) protocol, resulting in successful perioperative management without complications. The patient exhibited a 30 cm cystic mass in the ovary identified on abdominal computed tomography. Preoperative assessment using E-PASS and FRAIL Scale yielded a preoperative risk score, surgical stress score, and comprehensive risk score of 0.49, 0.41, and 0.53, respectively, corresponding to a 4.2% in-hospital mortality rate. The FRAIL scale indicated a state of frailty. Following an anesthesiology consultation on the overall condition and surgical feasibility, the Aron alpha method was performed. Postoperatively, ERAS-based management was implemented, and the patient was discharged on postoperative day 5. Activities of daily living or cognitive function remained unchanged.

CONCLUSION

Detailed preoperative evaluation and the Aron alpha method could assist older women with giant ovarian tumors, with suspected malignancy.

Key Words: Giant ovarian tumor; Aron alpha method; Estimation of physiologic ability and surgical stress; Frailty; Clinical frailty scale; Enhanced recovery after surgery; Older patients; Laparoscopy; Case report

Core Tip: When planning surgical treatment for elderly patients, their overall health and postoperative risks must be appropriately assessed using the estimation of physiologic ability and surgical stress scoring system and the FRAIL scale. Accordingly, the treatment plan and perioperative management may be implemented using the enhanced recovery after surgery protocol. Furthermore, the Aron alpha method for giant ovarian tumors enables minimal invasive surgery without leaking the ovarian tumor contents into the abdominal cavity. This surgical technique helps elderly patients with giant ovarian tumors of uncertain malignancy.

INTRODUCTION

With the recent aging of the population, opportunities to perform surgery on older adults have been increasing. In general, older adults tend to have reduced physiologic reserve, impaired wound healing ability, weakened immune function, and comorbidities. As a result, postoperative complications are more likely to occur, and when severe, they can have a significant impact on prognosis[1-3]. Postoperative complications in older adults are directly associated with prolonged hospitalization, decreased quality of life, and increased economic burden. However, advances in perioperative care, surgical techniques, and anesthesia management in recent years have contributed to a decline in surgical mortality among older adults, and age alone is no longer considered a risk factor[4,5]. Moreover, because actual age and biological age do not necessarily coincide, the response to surgical stress and postoperative outcomes must be assessed individually for each case[6]. Therefore, prior to perioperative management, it is crucial to rigorously assess physiologic reserve and determine whether the patient can tolerate the planned anesthesia and surgical stress. Efforts to reduce perioperative risk should not focus solely on individual organ function but also include a comprehensive assessment of frailty, delirium, polypharmacy, and nutritional status. As part of preoperative evaluation, tools such as the estimation of physiologic ability and surgical stress (E-PASS) scoring system have been used to quantify patients’ physiological function and surgical stress, thereby predicting postoperative complications and in-hospital mortality to assess surgical risk (Table 1)[3,4]. Proposed by Haga et al[7] in 1999, the E-PASS system is based on commonly available laboratory and surgical parameters, offering a simple yet reliable method for risk assessment[7-10].

Table 1 Estimation of physiologic ability and surgical stress scoring system.

Calculation of preoperative risk, surgical stress, and comprehensive risk scores
Score formula
PRS: -0.0686 + 0.00345X1 + 0.323X2 + 0.205X3 + 0.153X4 + 0.148X5 + 0.0666X6
SSS: -0.342 + 0.0139Y1 + 0.0392Y2 + 0.352Y3
CRS: -0.328 + 0.936 (PRS) + 0.976 (SSS)
Age, serious heart disease, serious pulmonary disease, and diabetes mellitus are defined as present 1 or absent 0
PRS, X1 age, X2 serious heart disease, X3 serious pulmonary disease, X4 diabetes mellitus, X5 performance status (0-4), X6 ASA score (1-5), SSS, Y1 blood loss/body weight (g/kg), Y2 operating time (hour), Y3 skin incision length (0: Minor incision, 1: Laparotomy or thoracotomy only, 2: Laparotomy and thoracotomy) CRS

The estimation of physiologic ability and surgical stress scoring system consists of the preoperative risk score and the surgical stress score to calculate the comprehensive risk score. E-PASS: Estimation of physiologic ability and surgical stress; PRS: Preoperative risk score; SSS: Surgical stress score; CRS: Comprehensive risk score.

Frailty has been reported to heighten sensitivity to surgical and anesthetic stress, increase postoperative complications, and prolong hospitalization; thus, preoperative frailty assessment is important[11]. The FRAIL scale has been reported to be a simple and versatile tool for assessing frailty in older surgical patients[12].

For perioperative management, the enhanced recovery after surgery (ERAS) protocol encompasses evidence-based strategies to reduce patient anxiety and discomfort, minimize postoperative complications, shorten hospital stays through early recovery, and lower medical costs. Implementation of the ERAS protocol has been reported to reduce postoperative complications, shorten postoperative hospital stays, and decrease the financial burden on patients[13-16].

Furthermore, in cases of giant ovarian tumors, preoperative differentiation between benign and malignant lesions is often difficult, and some cases are ultimately diagnosed as malignant in the final pathological examination. When an ovarian tumor is malignant, intraoperative rupture of the tumor capsule poses a risk of disease upstaging[17] and increases the risk of ovarian cancer recurrence[18]; therefore, preventing leakage of the tumor’s contents into the abdominal cavity is crucial. Removing giant ovarian tumors by conventional methods requires a large incision, resulting in greater surgical invasiveness. Because older adults have higher risks of postoperative complications, prolonged hospitalization, and postoperative mortality compared with younger patients, less invasive surgical approaches are preferred. We have previously reported the use of a medical instant adhesive (“Aron alpha method”) in minimally invasive laparoscopy-assisted surgery for giant ovarian tumors[19].

In this report, we present a case of a giant ovarian tumor in an older adult who underwent preoperative evaluation using the E-PASS scoring system and the FRAIL scale, followed by laparoscopy-assisted surgery with the Aron alpha method, and perioperative management under the ERAS protocol, which collectively resulted in a favorable outcome. We obtained informed consent both verbally and in writing.

CASE PRESENTATION

Chief complaints

Age: 81 years. Abdominal distension.

History of present illness

The patient noticed abdominal distension for the previous 3 months and consulted a physician. An abdominal mass reaching the level of the umbilicus was detected, and she was referred to our hospital for further evaluation and treatment. She visited our outpatient clinic, walking with a cane, but was independent in activities of daily living (ADL).

History of past illness

Subarachnoid hemorrhage at age 34 (treated with clipping surgery). Comorbidities: Hypertension, hyperlipidemia.

Personal and family history

Two pregnancies, two children.

Physical examination

Height, 155.0 cm; weight, 60.0 kg [body mass index (BMI), 25.0 kg/m²]; body temperature, 36.4 °C; blood pressure, 154/72 mmHg; pulse, 52 bpm (regular); SpO₂, 98% (room air). Speculum examination: No abnormal findings in the cervix or vaginal wall. No abnormal bleeding or discharge. Bimanual examination: A soft, elastic pelvic mass palpable up to three fingerbreadths above the umbilicus, with no tenderness. Cervical cytology: Negative for intraepithelial lesion or malignancy. Endometrial cytology: Negative.

Laboratory examinations

White blood cell count, 6000/μL; red blood cell count, 3.71 × 10⁶/μL; hemoglobin, 12.8 g/dL; platelet count, 149 × 10³/μL; total protein, 7.0 g/dL; total bilirubin, 0.8 mg/dL; aspartate aminotransferase, 23 IU/L; alanine aminotransferase, 25 IU/L; alkaline phosphatase, 105 U/L; lactate dehydrogenase, 242 U/L; gamma-glutamyl transpeptidase, 12 IU/L; creatine phosphokinase, 116 IU/L; blood urea nitrogen, 24.8 mg/dL; serum creatinine, 0.94 mg/dL; sodium, 144 mEq/L; potassium, 3.9 mEq/L; blood sugar, 107 mg/dL; prothrombin time-international normalized ratio, 0.92; activated partial thromboplastin time, 27.6 seconds; and D-dimer, 0.9 μg/mL.

Tumor markers: Cancer antigen, 125 9.9 U/mL; carcinoembryonic antigen, 2.1 ng/mL; and carbohydrate antigen 19-9, 10.2 U/mL. Cardiopulmonary function assessment: Electrocardiogram demonstrated no ST-T abnormalities. Echocardiography revealed a left ventricular ejection fraction of 67.8% with good wall motion. Chest X-ray exhibited no abnormalities. Pulmonary function test results indicated a percent vital capacity of 135.8 and a forced expiratory volume in one second percent of 129.2, suggesting preserved respiratory function. E-PASS: The preoperative risk score (PRS), surgical stress score (SSS), and comprehensive risk score (CRS) were 0.49, 0.41, and 0.53, respectively, corresponding to an estimated in-hospital mortality rate of 4.2%. FRAIL scale: The patient exhibited three components (subjective fatigue, reduced daily activity, and reduced physical function) and was therefore classified as frail.

Imaging examinations

Ultrasonography findings: A large cystic mass occupying the entire abdominal cavity from the upper abdomen to the pelvis was observed. Pelvic computed tomography findings: A large cystic mass measuring approximately 30 cm occupied the abdominal and pelvic cavities. No apparent cystic clustering, solid components, or irregular septa were observed within the tumor (Figure 1).

Figure 1 Pelvic computed tomography image a giant cystic mass measuring 30 cm in its longest diameter and extending to the area above the umbilicus was observed. No clustered cystic formations, solid components, or irregular septa were detected within the tumor.

FINAL DIAGNOSIS

Based on these results, we discussed with the anesthesiologists the feasibility of laparoscopy-assisted adnexectomy under general anesthesia and determined that surgery could safely be performed. After providing a thorough explanation to the patient and her family, the following procedure was conducted.

TREATMENT

Under general anesthesia, the patient was placed in the lithotomy position, and the surgery was initiated. A 10-mm scope was inserted through the umbilicus to inspect the peritoneal cavity for adhesions or lesions. Ascitic fluid was collected for cytological examination (Figure 2A). The giant ovarian tumor originated from the left ovary. After intra-abdominal inspection, a transverse incision approximately 4 cm in length was made in the lower abdomen. To prevent spillage of Aron alpha (Aron alpha a “Sankyo”^®, Daiichi Sankyo Co., Tokyo) onto surrounding tissues and adhesion to other organs, gauze was placed around the tumor (Figure 2B). Aron alpha was applied in a grid pattern to the tumor surface, and a sterilized vinyl bag was pressed manually against the tumor to adhere it firmly (Figure 2C). Once adhesion of Aron alpha to the tumor was confirmed, the vinyl bag was cross-incised from the inside using a scalpel (Figure 2D), and both the tumor and the vinyl bag were clamped with Kocher forceps. The cystic contents were then aspirated from within the bag (Figure 2E), successfully preventing leakage of the tumor fluid into the abdominal cavity. After sufficient aspiration, the ovarian tumor was gently moved outside the body (Figure 2F). The ureteral course was identified, and the infundibulopelvic ligament was ligated and transected, allowing removal of the affected adnexa. The contralateral adnexa were treated in the same manner, with ligation and transection of the infundibulopelvic ligament followed by adnexal excision. After bilateral adnexectomy, the peritoneal cavity was irrigated with saline, and the surgery was completed.

Figure 2 Intraoperative findings. A: The peritoneal cavity was observed laparoscopically, and ascitic fluid was collected for cytological examination; B: After laparoscopic inspection, a midline lower abdominal incision of approximately 4 cm was made. To prevent the medical instant adhesive (Aron alpha) from dripping onto surrounding tissues, gauze was placed around the operative field, and Aron alpha was applied to the tumor surface in a grid pattern; C: A sterilized vinyl bag was tightly adhered to the ovarian tumor; D: After confirming that the Aron alpha had bonded firmly, the tumor was punctured through the vinyl using a scalpel; E: The cystic fluid inside the tumor was aspirated through the vinyl bag using a suction tube; F: After aspirating most of the cystic contents, the ovarian tumor was exteriorized, and additional fluid was aspirated. The tumor was then elevated outside the body, the course of the ureter was confirmed, and the infundibulopelvic ligament was ligated and transected, followed by removal of the adnexa.

The total operative time was 1 hour and 25 minutes, with minimal blood loss. The postoperative course was uneventful. Following the ERAS protocol, multidisciplinary postoperative management, including early rehabilitation intervention, nutritional and pain management, was provided in collaboration with physical therapists, occupational therapists, dietitians, and pharmacists to promote early mobilization.

OUTCOME AND FOLLOW-UP

The patient was discharged as scheduled on postoperative day 5. After discharge, there was no decline in ADL or cognitive function. Ascitic cytology was negative, and the pathological diagnosis was serous cystadenoma (Figures 3).

Figure 3 Resected specimen and histopathological findings. A: The inner surface of the cyst was smooth, with no evidence of solid proliferation; B and C: The cystic inner surface was lined by cuboidal epithelium without atypia, findings suggestive of cystadenoma. No features suspicious for malignancy were observed. Hematoxylin and eosin staining; B: × 20, C: × 400.

DISCUSSION

Older adults exhibit lower physiological function and physiologic reserve, and once complications occur, recovery tends to take longer[3]. In preoperative assessment, in addition to evaluating the disease for which surgical treatment is indicated, it is important to consider that older adults often have preexisting comorbidities. Compared with younger individuals, older adults have higher rates of diabetes, hypertension, chronic cardiac disease, chronic obstructive pulmonary disease, chronic kidney disease, and a history of cerebral infarction, and it is not uncommon for them to have multiple coexisting conditions[20]. Because general condition, organ function, and the severity of comorbidities vary widely among older adults, and given that actual and biological age do not necessarily coincide, decisions regarding surgery should be based on overall physical status rather than age alone.

To prevent postoperative complications and perform surgery as safely as possible, various preoperative evaluation methods have been developed to predict postoperative outcomes and overall operative risk. In addition to the E-PASS scoring system used in our case, other methods have been developed in the United States [American Society of Anesthesiologists (ASA) score and the Charlson comorbidity index] and the United Kingdom [physiological and operative severity score for the enUmeration of mortality and morbidity (POSSUM) score][21-23]. The ASA score evaluates smoking and drinking history, BMI, preexisting diseases, and cardiovascular or cerebrovascular events within the previous three months. The Charlson comorbidity index assigns scores based on the presence or absence of comorbidities, including cardiovascular and cerebrovascular disease, chronic lung disease, diabetes, and collagen disease. Nonetheless, neither of these two systems incorporates age as a factor. The POSSUM score calculates predicted complication and mortality rates based on a physiological score that includes age, preoperative laboratory data, and comorbidities, and an operative severity score that quantifies operative factors. Although age is included in this system, patients aged 71 years and older are grouped together; therefore, it does not distinguish between patients aged 71-80 and those aged 80 years or older. Conversely, the E-PASS used in the present case comprises three components: The PRS, which represents the patient’s physiological status; the SSS, which reflects the magnitude of the surgical procedure; and the CRS, which integrates both. The PRS includes age as a factor, making this method more age-sensitive compared with the systems mentioned above. Furthermore, E-PASS distinguishes between laparoscopic and open procedures, aligning it more closely with current surgical practices. It is a simple scoring system that does not require special equipment and can be calculated from routine preoperative tests and surgical data. Compared with other risk assessment tools, it is easy to implement universally, and several studies have demonstrated its use for predicting postoperative complications and in-hospital mortality[7-10]. If the comprehensive preoperative evaluation using the E-PASS scoring system suggests that the patient is unlikely to tolerate standard anesthesia or surgical stress, alternative strategies should be considered. Thus, such evaluations are valuable not only for estimating perioperative risk but also for guiding the selection of surgical procedures, including non-curative, palliative, or non-surgical options, according to the patient’s overall condition.

Recently, in surgery, the concept of frailty-a condition where vulnerability to health disturbances rises due to age-related functional decline and reduced physiologic reserve-has garnered increasing attention. Preoperative frailty has been shown to be strongly associated with adverse outcomes such as perioperative mortality and postoperative complications, as well as discharge to facilities other than home[23]. Therefore, including frailty assessment in the preoperative evaluation of older adults is essential. In this case, the patient was frail, presenting with three items on the FRAIL scale: Subjective fatigue, reduced daily activity, and decreased physical function. Accordingly, it was necessary to consider not only postoperative functional recovery but also the prevention of further frailty progression.

Originating in Northern Europe, the concept of ERAS has been proposed as a perioperative management approach to promote postoperative recovery and improve prognosis in surgical patients. Its effectiveness has been reported in cardiovascular and gastrointestinal surgery, and it is now being adopted for a wide range of surgical procedures. By implementing evidence-based perioperative management strategies in an integrated manner, ERAS aims to reduce metabolic stress, provide optimal pain relief, and promote early oral intake and mobilization. These measures help reduce postoperative complications and enhance functional recovery. Studies have shown that ERAS-based management, including minimally invasive surgery to minimize postoperative dysfunction and early mobilization, contributes to shorter postoperative hospital stays and reduced financial burden on patients[13-16].

In the present case, appropriate preoperative evaluation was performed using the E-PASS scoring system and the FRAIL scale. In addition, perioperative management based on ERAS principles, including early postoperative mobilization, timely rehabilitation interventions, and effective postoperative pain control, was implemented. Consequently, the patient was discharged as scheduled without any postoperative complications or decline in ADL.

In the management of giant ovarian tumors, preoperative diagnosis is based on imaging findings and tumor markers, and when necessary, intraoperative cytology or frozen section histopathological examinations are performed. Nonetheless, the possibility of borderline or malignant disease cannot be ruled out, and in many cases, the final pathological diagnosis reveals malignancy. When an ovarian tumor is malignant, intraoperative rupture of the tumor capsule and spillage of its contents into the peritoneal cavity carry the risk of disease upstaging[14] and increased recurrence risk[15]. Therefore, it is crucial to remove the tumor without allowing any leakage of the cystic contents into the abdominal cavity. However, conventional surgical methods often require a large incision, resulting in greater surgical invasiveness. To minimize the risks associated with surgery in older adults, operations should be as brief and minimally invasive as possible. In our previous cases of giant ovarian tumors, we employed the method combining laparoscopy and a technique using medical-grade Aron alpha adhesive and a sterilized vinyl bag, allowing tumor removal through laparoscopy-assisted surgery without intraperitoneal spillage of tumor contents[19]. This technique, referred to as the Aron alpha method, is based on securely adhering the tumor surface to the vinyl bag. To achieve this, moisture on the tumor surface is wiped off with gauze to dry off the tumor. Additionally, it is important to apply Aron alpha in a grid pattern to increase the surface area exposed to air, thereby accelerating polymerization and hardening and enhancing adhesion. After the tumor is bonded to the sterilized vinyl bag, a cruciform incision is made in the tumor from the inside of the bag using a scalpel. The incision edges are then clamped with Kocher forceps, grasping both the tumor wall and the vinyl bag to ensure a tight seal. The cystic contents are aspirated as the tumor is gradually reduced in size and extracted from the body, making it possible to remove the tumor without leakage of its contents into the peritoneal cavity. This technique reduces surgical invasiveness and shortens operation time without exacerbating the underlying condition. Furthermore, the use of laparoscopy in combination with this method offers several advantages: It allows confirmation of adhesions between the tumor and surrounding organs or tissues, collection of ascitic fluid without blood contamination, and comprehensive inspection of the abdominal cavity, including the upper abdomen. If intraperitoneal lesions are found, additional biopsy or tumor excision can be performed for histopathological diagnosis. Moreover, this surgical technique is simple to perform, and the required materials are inexpensive, making it a useful option for the removal of large ovarian tumors.

CONCLUSION

When planning surgical treatment for older adults, it is essential to appropriately evaluate systemic conditions and postoperative complication risk using tools such as the E-PASS scoring system and FRAIL scale, and to manage the perioperative period using the ERAS approach. The Aron alpha method enables minimally invasive removal of giant ovarian tumors without intraperitoneal spillage of cyst contents, and is considered a useful surgical option for older adults with giant ovarian tumors in which malignancy cannot be ruled out.