Should a 70-year-old patient with well-controlled hypertension (HTN) and peritoneal carcinomatosis, currently having a groin abscess without fever, postpone debulking surgery and what is their preoperative risk stratification?

From the Guidelines

The 70-year-old patient with well-controlled hypertension and peritoneal carcinomatosis should postpone their debulking surgery until the groin abscess is treated, even without fever. The patient would be classified as intermediate to high risk for perioperative complications based on their age, hypertension, and malignancy. The abscess represents an active infection that should be addressed with incision and drainage followed by appropriate antibiotics (such as a combination of vancomycin 15-20 mg/kg IV every 12 hours plus either piperacillin-tazobactam 4.5g IV every 6 hours or meropenem 1g IV every 8 hours) for 5-7 days before proceeding with major surgery 1. Proceeding with debulking surgery in the presence of an untreated abscess significantly increases the risk of surgical site infection, sepsis, and poor wound healing. Additionally, the patient's peritoneal carcinomatosis already places them at higher risk for poor surgical outcomes and prolonged recovery. Once the infection is resolved, a comprehensive preoperative assessment including cardiac evaluation, pulmonary function testing, and nutritional status optimization should be completed before scheduling the debulking procedure, as preoperative optimization is crucial for major abdominal surgery and physiological preparation for surgery is important 1. The patient's well-controlled hypertension should also be optimized before surgery, as optimization of hypertension is important for reducing the risk of postoperative morbidity and mortality 1. The guidelines for perioperative care in elective rectal/pelvic surgery also recommend preoperative evaluation to identify medical conditions and risk factors for postoperative morbidity and mortality 1. In this case, the patient's groin abscess and peritoneal carcinomatosis are significant risk factors that need to be addressed before proceeding with debulking surgery. The diagnosis and management of complicated intra-abdominal infection in adults and children guidelines also recommend an appropriate source control procedure to drain infected foci, control ongoing peritoneal contamination by diversion or resection, and restore anatomic and physiological function to the extent feasible 1. Therefore, treating the groin abscess and optimizing the patient's condition before surgery is essential for reducing the risk of postoperative complications and improving outcomes.

From the Research

Preoperative Risk Stratification

• The patient's current condition includes well-controlled hypertension and peritoneal carcinomatosis, with a groin abscess but no fever, which are important factors to consider in preoperative risk stratification 2, 3.
• The presence of a groin abscess may increase the risk of surgical site infection (SSI), as seen in studies on groin wound infections after vascular exposure 3.
• However, the absence of fever suggests that the infection may be localized and not systemic, which could impact the decision to postpone surgery.

Postponing Surgery

• There is no clear evidence to suggest that debulking surgery should be postponed solely due to the presence of a groin abscess without fever 2, 4.
• In fact, studies on abscess management suggest that incision and drainage, as well as antibiotic treatment, can be effective in managing abscesses, including those in the groin area 2, 4.
• Additionally, a study on groin surgery and risk of recurrence in lymph node positive patients with vulvar squamous cell carcinoma found that debulking of clinically involved lymph nodes was related to a significant lower risk of complications compared to more radical surgery 5.

Risk Factors for Surgical Site Infection

• The patient's factors, such as age (70 years old) and comorbidities (well-controlled hypertension), should be considered when assessing the risk of SSI 3, 6.
• Other risk factors for SSI, such as female sex, body mass index ≥30 kg/m2, and increased operative time, should also be taken into account 3, 6.
• The use of preventative measures, such as prophylactic flaps, transverse incisions, and closed-incision negative pressure wound therapy, may help reduce the risk of SSI 6.