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9. Urinar

Tract Complications 8

13. Drake MJ, Noble JG. Ureteric trauma in

necolo

ic sur

. Int Urogynecol J.

;

108

–

14. McMaster-Fa

RA, Jones RA. Laparoscopic

sterectom

ureteric in

: a

omparison o

e initia

275 cases an

ast 1000 cases using stap

es. O

stet

neco

Surv. 200

6;6

1:443–444.

15. Ku JH, Kim ME, JeonYS, Lee NK, Par

YH. Minima

y invasive management o

reteral injuries recognised late after obstetric and gynecologic surgery. Injury Int

J Care Injured

2003;3

4:4

–4

83.

16. Meiro D, Moriel EZ, Zilberman M, Farkas A. Evaluation and treatment of iatro

enic

reteral in

uries durin

obstetric and

naecolo

ic operations for nonmali

nant

J Am Coll Sur

994;178:144–148

17. Chan JK, Morrow J, Manetta A. Prevention of ureteral in

uries in

necolo

sur

m J O

stet G

neco

2003

;

188

–

77.

18. Nez

. Operative G

neco

ogic Laparoscop

. Princip

es an

Tec

niques. New Yor

McGraw-Hi

Hea

Pro

essions Division

;

2000.

19. Aronson MP, Bose TM. Urinary tract injury in pe

vic surgery. C

in O

stet G

neco

2002;

45:4

–4

0. Smith RB, Ehrlich RM, Taneja SS.

omplications of Urologic Surgery: Prevention an

Management.

hiladel

hia: WB Saunders; 2001.

21. Goodno JA, Powers TW, Harris VD. Ureteral in

necolo

ic sur

: a ten

ear review in a communit

hospital.

m J Obstet G

necol. 1995;172:1817–1822

22. Liapis A, Ba

as P, Giannopou

ous V, Creatsas G. Uretera

uries

urin

naeco-

ica

sur

. Int Urog

neco

2001

391

–

3. Piscite

i JT, Sime

DL, A

ison WA. W

o s

ave intravenous pye

ograms

ore

ysterectomy

enign

isease?

stet G

neco

. 1987

9:541–545.

4. Kuno K, Menzin A, Kau

er HH, et a

. Prop

actic uretera

cat

eterization in

gynecologic surgery. Urology.

1998;

100

4–

1008

5. Bothwell WN, Bleicher RJ, Dent TL. Prophylactic ureteral catheterization in colon

. Dis Colon Rectum. 1994;37:330–334.

6. Low RK, Mor

an ME. Laparoscopic use of the ureteral illuminator. Urology.

1993;42:455–457.

27. Lin BL, Iwata Y. Modiﬁ

ed cystoscopy to evaluate unilateral traumatic injury of the

reter

urin

vic sur

m J O

stet G

neco

990;162:1343–1344.

https://t.me/med1917

0. The High-Risk G

necolog

Patient:

ssessment and Mana

emen

uy W. Glove

Paul G.W. Cramp

ern surgica

, anaest

etic, an

nursing care

as increase

e sa

ety o

yneco

ogica

surgery. C

inicians as we

as patients may consi

er it to

outine, wit

very

ow ris

. However,

or a sma

ort o

patients t

e p

ysi

ological insult of surgery exposes them to signiﬁ

cant risks of morbidity and

orta

ity; t

ese patients are usua

y e

y, o

ten wit

ignancy or car

monary comor

ities, an

aving major or emergency surgery. T

ing causes o

intensive treatment unit (ITU) a

mission in postoperative

yneco

ogy patients are

emorr

age, in

ection, an

car

iorespiratory

ure,

in t

ese patients t

e 6-mont

morta

ity is 26% [1]. For t

ose age

9 years

aving major open proce

ures, t

e 60-

ay morta

ity rate is up to 5% [2]. T

enge remains to accurate

y i

enti

y t

ose patients w

ave t

est

, to strati

y t

eir

eve

ris

, an

to mo

y management to ame

iorate

the hazards. Doing so facilitates the beneﬁ

ts of surgery for a group of patients

or w

om it may previous

ave

een

enie

. In any

care system wit

imite

resources, it is imperative t

at suc

resources are targete

appropri

y towar

ose wit

est ris

The Physiological Insul

ajor surgery represents a pro

oun

ysio

ogica

stress (Ta

e 10.1). T

atient’s response attempts to maintain p

ysio

ogica

omeostasis an

uce an interna

environment con

ucive to

ing an

recovery

e patient’s a

ity to mount an a

equate stress response an

to to

erate

e consequences o

at response is vita

to t

eir outcome. In particu

ar, t

bility to increase oxygen delivery (D

to supp

y t

e increase

meta

eman

s o

e tissues is critica

. Fai

ure to

o so

s to an accumu

ation o

oxygen

t, w

is mani

este

as myocar

isc

emia, organ

unction,

poor woun

ing, an

ections. S

oema

er et a

. [3]

emonstrate

oxygen debt after major surgery was signiﬁ

cantly greater in those who died or

major comp

ications compare

to survivors. Moreover, w

e oxygen

eve

ops even in t

ose wit

sta

emo

ynamic parameters, an increase

n D

ove norma

ues is associate

wit

improve

outcome [4].

https://t.me/med1917

10. The High-Risk G

necolog

Patient: Assessment and Management 85

e sp

anc

nic circu

ation is particu

y vu

nera

e to

ypoper

usion

uring t

e perioperative perio

ing to

acteria

trans

ocation, en

otox-

emia, and stimulation of the inﬂ

ammatory cytokine cascade. Low gastric

mucosa

pH [5] an

raise

eve

s o

inter

in-6 [6] are

associate

wit

poorer ou

come

An A

roach to the Assessment of R

he assessment of risk is important for counselin

the patient, directin

anesthetic and sur

ical technique, and

uidin

the level of postoperative care.

There should be a reasonable ex

ectation that the

reo

erative assessment will

le 1

Summar

of Ph

siological Stress b

Organ S

ste

Card

ovascular System

Sympat

rena

activation

Increase

oxygen consumption (V

)

Myocar

oxygen supp

eman

anc

Blood loss and

luid shi

ects o

anesthesia

Resp

ratory System

Respiratory depression

rom anesthesia/analgesi

Diaphragmatic dys

unctio

Impaire

cou

Ate

ect

sis

Ren

potension an

povo

emi

rotoxins

ectro

istur

ances

str

ntest

l Tr

Pre- and

osto

erative starvation

Splanchnic h

poperfusio

wel ile

pergl

cemia

tein c

abol

ther

Activation of s

stemic inflammator

and coagulation cascade

Impaired thermore

ulatio

Immunosuppression (general anesthesia, opiates, malignanc

, blood transfusion

)

https://t.me/med1917

6 G.W. Glover and P.G.W. Cram

ter mana

ement an

ere

improve outcome. T

e American Co

e o

/American Heart Association (ACC/AHA) su

ests t

at ris

ppreciate

in terms o

e impact o

owin

actors:

inica

mar

ers

. Leve

s o

unctiona

capacit

3. Surgery-speciﬁ

Clinic

l M

rker

asis o

assessment s

e t

istory an

examination, ai

e t

oug

interpretation o

simp

e tests. Comor

ities suc

yperten

sion, ischemic heart disease, vascular disease, atrial ﬁ

brillation, heart failure,

etes me

itus, smo

ing, c

ronic o

structive pu

monary

isease, or o

esit

icate t

at t

ere is un

ying p

ysio

ogica

impairment. Nutrition status is

mportant, as

y mass in

exes are associate

wit

ncrease in comp

ications. E

uci

ating t

e presence o

est pain,

yspnea,

pitations, syncope, ort

ostatic into

erance,

imite

exercise to

erance, an

inica

examination

or t

e presence o

inica

signs gives

urt

er in

ormation

out t

e state o

isease process. A

itiona

y, simp

e tests suc

as t

resting electrocardiogram (ECG) and biochemistry may detect or reﬁ

ne t

ssessment o

ying con

itions. To gui

e interpretation, t

ese

actors

have been incorporated into a variety of speciﬁ

c ris

-pre

iction mo

s. T

owing are some common

y use

examp

es.

The American Society of Anesthesiologists (ASA) classiﬁ

cation (Ta

0.2) is a su

jective assessment

ase

on c

inica

mar

ers. W

e t

e negative

positive pre

ictive va

ue o

e gra

ing is

ow, increasing score

oes

orre

ate wit

overa

outcome

Many of these tools are speciﬁ

cally aimed at the assessment of cardiac risk.

Most have identiﬁ

ed factors associated with adverse events in large observa-

iona

stu

ies an

use

is in

ormation to create a weig

scoring system.

Examples are the Goldman cardiac risk index [7], later modiﬁ

ed by Detsky [8]

Tabl

e 1

American Societ

Anesthesiologists (ASA) Classi

ication

rox

mat

SA Perio

erative

rade Patient Characteristics Mortalit

)

Hea

patient 0.0

Mild s

stemic disease that does not limit

unction 0.4

Severe systemic disease with

unctional limitation 4.5

Incapacitating s

stemic disease that is a constant threat to li

e 2

Mori

atient not ex

ecte

to survive

hou

rs wit

hou

rgery

ote: The suffix

is added to the ASA grade to indicate emergency surgery.

https://t.me/med1917

10. The High-Risk G

necolog

Patient: Assessment and Management 87

e Lee score [9]. More recent

y t

ese scoring systems

ave

een revise

and many of the factors have been incorporated into the comprehensive guide

ines

y t

e ACC/AHA (Ta

e 10.3), up

ate

in 2002 [10]

recent review [11] examined postoperative pulmonary morbidity and

found that the following clinical markers were predictive of respiratory failure

after noncardiac surgery: advanced age, ASA Grade

, functional depen-

dence, and a history of chronic obstructive pulmonary disease or congestive

heart failure, as well as high-risk procedures and serum albumin

0 g/L. The

relationship with smoking and obesity was inconclusive, and simple pulmo-

nary function tests were no better than clinical assessment.

e p

ysio

ogica

operative severity score

or t

e enumeration o

morbidity and mortality (POSSUM) score is used as an audit tool to provide

risk-adjusted operative mortality rates and to predict 30-day morbidity and

mortality. It uses 12 physiological variables (age, heart rate, blood pressure,

Glasgow Coma Score (GCS), presence of cardiac signs, ECG abnormalities, an

respiratory problems, and key blood results) and 6 operative factors (urgency,

malignancy, peritoneal soiling, blood loss, reoperation, and severity o

). While ori

inall

derived from a

eneral sur

ical population, POSSUM

has been validated in gynecological oncology patients to predict morbidit

rates, a

oug

it ten

to overrate morta

ity ris

s [12]

unct

onal Capac

ssessing functional capacity translates a positive history or test result into

an estimate of ph

siolo

ical reserve, which is important to operative outcome.

The inability to climb 2 ﬂ

ights of stairs has a positive predictive value of 90%

for postoperative cardiopulmonar

complications after hi

h-risk sur

[13].

siolo

ical reserve is conceptualized b

metabolic equivalent levels (METs).

One MET is an expression of the ox

en consumption of a restin

40-

ear-old

70 kg man (approximately 3.5 mL/kg/min). Everyday activities are expressed

le 1

0.3.

American College of Cardiolog

/American Heart Association Clinical Predictors

of Increased Perio

erative Cardiovascular Risk (MI, heart failure, death

)

Interme

te Clinic

or Clinical Predictors Predictors Minor Clinical Predictors

Unsta

e coronar

romes Mi

angina pectoris A

vance

Decom

ensated heart

ailure Previous MI Abnormal EC

Signi

icant arr

thmias Compensated or prior heart Rh

thm other than sinus

Severe valvular disease

ailure Low

unctional capacity

Diabetes mellitus (especially History o

insu

epen

ent) Uncontro

ypertension

Renal insu

iciency

CG, electrocardiogram; CVA, cerebrovascular accident

https://t.me/med1917

8 G.W. Glover and P.G.W. Cram

s mu

tip

es o

ase

ine, provi

e to t

e patient’s a

ncrease D

Ris

is increase

atients w

o cannot reac

4 METS [14]

ight of stairs, brisk walking on the ﬂ

at, playing a round of

olf ).

e static tests o

unction suc

as restin

ocar

rap

o not

ict a

verse outcome,

namic tests suc

as exercise ECG or

utamine

tress ec

ocar

rap

etter, an

e ACC/AHA

ines provi

reco

dat

the

use.

An accurate assessment of ph

siolo

ical reserve is obtained b

cardiopul-

onar

exercise (CPX) testin

—a noninvasive and easil

performed test that

orrelates well with postoperative outcome. The patient performs

raduated

xercise on a bic

cle er

ometer while O

consum

tion, CO

roduction, and

the ECG are monitored. When the metabolic demands exceed the capacit

aerobic metabolism, then anaerobic metabolism be

ins and C

roduction

exceeds

consum

tion—the anaerobic threshold (AT). The AT is well belo

the maximum aerobic capacit

and is independent of motivation, and thus the

test is well tolerated even in the elderl

. Older et al. [15] used CPX to tria

48 patients (a

ears or with cardiopulmonar

disease) havin

to 3 mana

ement strate

ies. Those patients with an AT

11 mL/k

/min

ose

avin

aortic or esop

sur

) (28%) were a

mitte

to t

TU preoperativel

for optimization with a pulmonar

arter

catheter (PAC)

nd then returned there postoperativel

. Those with an AT

1 mL/k

/min but

ith CPX-induced m

ocardial ischemia (21%) were mana

ed on the hi

ependenc

unit (HDU), and all others (51%) were mana

ed routinel

on the

ard. In-hospital cardiovascular mortalit

was 4.6% in the ITU

roup, 1.7%

n the HDU

roup, and 0% in the ward

roup, demonstratin

the ver

redictive value of CPX testin

in distin

uishin

those at risk from their lower-

isk counterparts. This method allows the tar

etin

of critical-care facilities to

those who will beneﬁ

t most and may result in cost savings by preventing

nnecessar

admissions.

urgery-Spec

c R

he de

ree of perioperative risk is closel

related to the ma

nitude of the

siolo

ical stress imposed b

the procedure. This relates to factors such as

uration of sur

, invasion of bod

cavities, bacterial contamination, thermal

stress, blood and ﬂ

uid loss, prolonged starvation, the interruption of normal

edications, and the de

ree of postoperative pain and immobilit

. The ACC

AHA stratiﬁ

cation for noncardiac surgical procedures can be modiﬁ

ﬁ

eld of gynecology (Table 10.4).

t can be seen that the hi

hest perioperative risk exists in patients with

evere and limiting comorbidities, patients with malignancy, and patients

avin

or sur

. The combination of poor cardiac function and ischemic

eart disease is particularl

worrisome. Chronolo

ical a

e per se should not

e used to discriminate among patients. By making a multifaceted assess

ent, one can stratify risk for the individual patient, and this risk must be

https://t.me/med1917

10. The High-Risk G

necolog

Patient: Assessment and Management 89

communicated to the patient in a wa

that allows meanin

ful interpretation.

All members of the multidisciplinar

team must consider the risk when plan

ning care, ensuring that the expected beneﬁ

ts justify potential risks. Below we

discuss some general principles of management with particular reference to

recent evidence on improving surgical outcomes.

anagement of the H

gh-R

sk Pat

reoperative Mana

emen

iscip

inary approac

e emp

oye

in t

e preparation o

patients, invo

ving t

e surgeon, anest

etist, primary care p

ysician, specia

ist

ysician, an

ers. Me

ica

management s

e optimize

to treat

intercurrent i

ness an

maximize p

ysio

ogica

reserve. As most nonsurgica

mor

ity is

ue to car

iovascu

isease, t

e strongest evi

ence re

ates to

optimizing t

e car

iovascu

ar system an

preventing myocar

isc

emia.

Here t

e car

ogist may p

ay an important ro

e. Muc

is wor

een

one in genera

surgica

vascu

ar patients

ut s

e equa

y app

ica

-ris

gyneco

ogica

surgery. T

e most compre

ensive gui

ines

ave

een pu

y t

e ACC/AHA [10]. In genera

, in

ications

or preoperative

treatment o

ypertension, va

eart

isease, arr

mias, an

con

tion a

norma

ities, an

or revascu

arization proce

ures

or isc

emic

eart

isease, are t

e same as in t

e nonoperative setting. Recent

owever, t

ere

has been interest in speciﬁ

c perioperative medical therapy to reduce rates of

car

iovascu

ar mor

ity

Myocard

al Ischem

n the perioperative period, m

ocardial ischemia or infarction is frequentl

related to an imbalance between m

ocardial ox

en suppl

and demand rather

than plaque rupture and coronar

thrombosis. Dru

s that modulate the s

pathoadrenal response reduce m

ocardial ox

en demand and ma

prevent

ischemic e

isodes. Initial trials o

blockers in hi

h-risk patients showed

promisin

results [16]; however, the

have been criticized for methodolo

ical

aws, and a recent metaanalysis [17] has concluded that the evidence is

le 1

Risk Stratification b

pe of Surger

Low Risk Intermediate Risk Hi

h Risk

Endoscopic procedures Moderate open Major g

ne-oncolog

Minor laparoscopic procedures abdominopelvic procedures, procedures (malignanc

case surger

e.g., total abdominal increases risk o

ITU

sterectom

/pro

apse repair a

mission

5 times)

https://t.me/med1917

0 G.W. Glover and P.G.W. Cram

insufﬁ

ciently robust to allow deﬁ

nite conclusions. An ongoing large, multi-

enter, ran

omize

contro

tria

(Peri-O

erative Isc

emia Eva

uation

iti

-a

onists (e.

., c

oni-

ine)

ave

een s

own to re

uce rates o

car

iac events in t

ose wit

coronar

arter

isease [18].

Optimizing Ox

gen Deliver

e o

servationa

wor

y B

oema

to t

ypot

esis t

ysio

ogica

manipu

ation aime

at ac

ieving “supranorma

” goa

s (car

iac

ex [CI]

.5 L m

;

600 mL m

; an

70 mL m

may improve outcome an

as coine

e term “goa

irecte

erapy” (GDT).

arge num

er o

tria

ave eva

uate

ypot

esis [19,20]. Most ear

stu

ies a

mitte

patients to t

e ITU preoperative

y an

use

a PAC to gui

e a

ministration o

crysta

s, pac

s, oxygen, an

inotropes or

ino

ators to ac

ieve

emo

ynamic goa

s in t

e protoco

groups—so-ca

preoptimization. Frequent

y t

ese goa

s cou

e ac

ieve

simp

y wit

administration of ﬂ

uid. Those studies targeting supranormal goals, especially

in t

est-ris

patients, s

owe

impressive re

uctions in

ospita

stay, mor

ity, an

morta

ity. One o

e main

imitations o

is approac

is t

at not a

ospita

ave t

aci

ities to a

mit patients to t

e ITU

preoperative

eyon

car

iovascu

ar ris

management, a recent review [21]

strategies to re

uce mor

ity in t

e o

ese woman requiring surgery. T

t t

e importance o

iscip

inary care, care

case se

ection, an

careful surgical planning to minimize the risks of hemorrhage, infection, and

thromboembolism

Intraoperat

ve Mana

ement

ubse

uent work has built on the

rinci

les of

reo

timization but uti

ized the intraoperative period to perform the hemod

namic optimization.

an et al. [22] randomized 100 patients havin

or sur

(33%

neco

logical procedures) to standard care with ﬂ

uid administration guided by pulse

ate, blood

ressure, urine out

ut, and central venous

ressure or to a

rotocol

aimed at optimizing stroke volume (and therefore CI) and aortic ﬂ

FTc; a variable that correlates well with left ventricular preload) as

uided b

n esopha

eal Doppler monitor. The esopha

eal Doppler monitor revealed

ubclinical h

povolemia, and thus the protocol

roup received more colloid

han the well-matched control group and had less nausea and vomiting, a

aster return of bowel function, and shorter len

th of hospital sta

A study in colorectal surgical patients optimized intraoperative ﬂ

the esophageal Doppler monitor and conﬁ

rmed shorter hospital stay, reduced

ntermediate and ma

or complications, and a faster return to diet in the pro

ocol

roup compared to standard mana

ement [23]. The authors noted a

https://t.me/med1917

10. The High-Risk G

necolog

Patient: Assessment and Management 91

reduced level of the inﬂ

ammatory cytokine interleukin-6, suggesting that

improvin

car

iac output an

ere

ore or

an per

usion ma

attenuate t

ammatory cascade.

er aspects o

anest

etic intraoperative care ma

e a

e to improve

outcome in the high-risk patient. A recent review highlighted the beneﬁ

epidural anesthesia and anal

esia, includin

improvements in the balance o

ocar

en supp

eman

to a 30% re

uction in car

iac

mor

; preservation o

monar

mec

anics, wit

40%

ewer pneumo-

nias; s

orter

uration o

eus

ess

oss;

ewer t

rom

oem

comp

ications;

etter preservation o

immunit

; an

an overa

uction in

ospita

sta

[24]. As

et no stu

as s

own an improvement in

morta

ity attri

uta

e to epi

ura

ana

gesia.

er as

ects o

care, suc

as maintenance o

normot

ermia an

measures

to minimize a

eneic

trans

usion (a

nown immunosuppressant), ma

mprove outcomes

n ma

or sur

ostoperat

ve Management

ll hi

h-risk patients havin

or sur

should be cared for postopera

tivel

in a critical-care environment. However, differences in the provision of

uch facilities make this infeasible and risks ur

ent cancer procedures bein

canceled. One solution has been the provision of an extended, overni

ht-sta

postanesthetic care unit with the facilities for HDU-level monitorin

and

nursin

. As discussed, CPX testin

provides a rational wa

of determinin

who will beneﬁ

t most from limited resources and reduces the overall use of

beds.

here such facilities exist, GDT has been extended into the

osto

erative

period. Pearse et al. [25] anal

zed 122 hi

h-risk patients admitted to the ITU

postoperativel

. After randomization, the

performed GDT for a duration o

8 hours,

uided b

lithium indicator dilution and pulse power anal

sis (LiDCO

plus) to measure cardiac output, aimin

for a D

600

mL mi

usin

uid and the inodilator dopexamine when required. They demonstrated a

reduction in complications (44% vs 68%—mainl

cardiovascular and infec

tions) and median duration of hospital sta

(11 da

s vs 14 da

s), althou

there was no signiﬁ

cant difference in mortality.

or sur

be associated with a prolon

ed period of starvation,

with potentiall

deleterious consequences. A stud

of 122 patients havin

necolo

ical oncolo

sur

compared earl

feedin

on da

1 to a conser-

vative regime of nasogastric decompression and feeding only after ﬁ

rst passage

of ﬂ

atus [26]. The protocol group had faster return to normal bowel function

and a shorter hospital sta

, with no increase in complications

Other aspects of the postoperative care are beneﬁ

cial, including epidural

anal

esia, lun

expansion techniques, earl

mobilization, and thromboem

bolic proph

laxis.

https://t.me/med1917

2 G.W. Glover and P.G.W. Cram

ncl

e most

neco

ica

sur

is per

orme

in a popu

ation at

ow ris

mor

or morta

, it is important to reco

nize t

or a minorit

, t

ncidence of serious complications is hi

h. Performed properl

and with the

recent

ines, appropriate assessment is capa

e o

enti

ese

-ris

patients. T

erea

ter, a tar

ete

, mu

iscip

inar

pproac

, wit

meticu

ous care

ore,

urin

, an

ter sur

, wi

provi

est

ossi

e outcome

or t

e in

ivi

atient an

maximize

imite

esources. Clinical

overnance mandates that our practice adhere to the

hest standards, is evidence based, and is sub

ect to re

ular audit.

erences

1. Heinonen S, T

rvainen E, Penttinen J, et al. Need for critical care in

naecolo

: a

opu

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ase

ana

sis.

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2. Unpu

ata, persona

communication.

3. S

oema

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PL, Kram HB. Ro

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oxygen

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4. B

RD, S

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. Haemo

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atterns in surviving an

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5. Bennett-Guerrero E. Automated detection of gastric luminal partial pressure of C

Anaesthesiology. 2000;92:38–45

6. Roumen RM, Hendriks T, van der Ven Jon

ekri

J, et al. C

tokine patterns after

or vascular sur

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wit

sequent ARDS an

MOF. Ann Sur

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7. Go

man L, Ca

era DL, Nuss

aum SR, et a

. Mu

actoria

ex o

car

iovascu

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patients. N Eng

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45–

8. Dets

y AS, A

rams HB, McLauc

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icting car

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9. Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation

of a simple index for prediction of cardiac risk of major non-cardiac surgery.

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https://t.me/med1917

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