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Tabriz N, Uslar VN, Tabriz I, Weyhe D. Relationship between age and outcome in thyroid surgery: a prospective observational study. Innov Surg Sci 2017; 2:211-217. [PMID: 31579754 PMCID: PMC6754023 DOI: 10.1515/iss-2017-0023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 06/08/2017] [Indexed: 11/15/2022] Open
Abstract
Background: The occurrence of thyroid nodules and goiter increases with age. In general, surgery age is a predictor of perioperative morbidity. In thyroid surgery, there are different data on the role of age on morbidity. We investigated the influence of age on the outcome in thyroid surgery in a prospective single cohort study with a follow-up after 1 year. Methods: Total thyroidectomy or hemithyroidectomy was performed in euthyroid benign thyroid goiters (n=152). The primary endpoint was surgery duration. The secondary endpoints were weight of resected tissue, body mass index (BMI), amount and type of perioperative and long-term complications, and quality of life (QoL) preoperatively and 1 year postoperatively. Results: A significant three-way interactive relationship between age, surgery duration, and amount of resected tissue was found. An increase in any of these variables results in an increase in both other variables. The amount of perioperative complications was associated with resected tissue size. The QoL increases significantly after surgery by up to 10% and decreases significantly with age (mean QoL after surgery=84.9 of 100 for the youngest group and 75.7 of 100 for the oldest group). No long-term complications were recorded. Conclusion: The number of thyroid operations, especially of benign thyroid goiters, decreases annually in Germany. This can be explained by the fact that, on the one hand, the surgical indications are made more restrictive as conspicuous nodes are better clarified by improved technical aids. On the other hand, conservative measures (i.e. L-thyroxine and iodide administration) are used to achieve a size regimen of the goiter. Our results show that perioperative complications increase with patients’ age and surgery duration. However, the more restrictive surgical decision also entails the risk that patients will have to be operated at an older age and possibly with a bigger goiter, which is associated with higher operative morbidity. Therefore, in addition to the possibility of conservative therapy of the symptomatic goiter, the affected patients should also be thoroughly informed about the option to perform elective early thyroid surgery with regard to improved postoperative QoL and to keep the overall stress at a minimum for elderly patients.
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Affiliation(s)
- Navid Tabriz
- School of Medicine and Health Sciences, Medical Campus University of Oldenburg, University Hospital for Visceral Surgery, Pius-Hospital Oldenburg, Georgstr. 12, 26121 Oldenburg, Germany
| | - Verena Nicole Uslar
- School of Medicine and Health Sciences, Medical Campus University of Oldenburg, University Hospital for Visceral Surgery, Pius-Hospital Oldenburg, Oldenburg, Germany
| | - Inga Tabriz
- School of Medicine and Health Sciences, Medical Campus University of Oldenburg, University Hospital for Visceral Surgery, Pius-Hospital Oldenburg, Oldenburg, Germany
| | - Dirk Weyhe
- School of Medicine and Health Sciences, Medical Campus University of Oldenburg, University Hospital for Visceral Surgery, Pius-Hospital Oldenburg, Oldenburg, Germany
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Roque-Castellano C, Marchena-Gómez J, Fariña-Castro R, Acosta-Mérida MA, Armas-Ojeda MD, Sánchez-Guédez MI. Perioperative Blood Transfusion is Associated with an Increased Mortality in Older Surgical Patients. World J Surg 2016; 40:1795-801. [DOI: 10.1007/s00268-016-3521-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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3
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Tartaglia F, Russo G, Sgueglia M, Blasi S, Tortorelli G, Tromba L, Krizzuk D, Merola R. Total thyroidectomy in geriatric patients: a retrospective study. Int J Surg 2014; 12 Suppl 2:S33-S36. [PMID: 25167851 DOI: 10.1016/j.ijsu.2014.08.386] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 06/15/2014] [Indexed: 11/19/2022]
Abstract
In the English literature there is no single definition that identifies elderly patients. In our retrospective study, we divided total thyroidectomized patients operated on from 2000 to 2010 in the Department of Surgical Sciences of the "Sapienza" University of Rome, in two groups: group 1 consists of 448 patients over 65 years and group 2 consists of 1275 patients under 65 years. We compared both groups in terms of indications for surgery, histological diagnoses, postoperative complications (laryngeal nerv palsy, hypocalcemia, bleeding and seroma) and mortality. The results showed no statistically significant differences between the two groups with respect to the type of surgical indication, the type of comorbidities, the incidence of postoperative complications and perioperative mortality. The only data discordant with those in the international literature was the incidence of neoplastic disease that is found to be slightly greater in group 2. In conclusion, total thyroidectomy in patients over 65 years is a safe procedure and is not burdened with a higher percentage of postoperative complications, even if requires a careful preoperative assessment of risk factors related to comorbidity.
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Affiliation(s)
- F Tartaglia
- Department of Surgical Sciences - "Sapienza" University of Rome, Rome, Italy.
| | - G Russo
- Department of Surgical Sciences - "Sapienza" University of Rome, Rome, Italy.
| | - M Sgueglia
- Department of Surgical Sciences - "Sapienza" University of Rome, Rome, Italy.
| | - S Blasi
- Department of Surgical Sciences - "Sapienza" University of Rome, Rome, Italy.
| | - G Tortorelli
- Department of Surgical Sciences - "Sapienza" University of Rome, Rome, Italy.
| | - L Tromba
- Department of Surgical Sciences - "Sapienza" University of Rome, Rome, Italy.
| | - D Krizzuk
- Department of Surgical Sciences - "Sapienza" University of Rome, Rome, Italy.
| | - R Merola
- Department of Surgical Sciences - "Sapienza" University of Rome, Rome, Italy.
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Horwood J, Ratnam S, Maw A. Decisions to operate: the ASA grade 5 dilemma. Ann R Coll Surg Engl 2011; 93:365-9. [PMID: 21943459 PMCID: PMC3365453 DOI: 10.1308/003588411x581367] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2011] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Deciding to operate on high risk patients suffering catastrophic surgical emergencies can be problematic. Patients are frequently classed as American Society of Anesthesiologists (ASA) grade 5 and, as a result, aggressive but potentially lifesaving intervention is withheld. The aim of our study was to review the short-term outcomes in patients who were classed as ASA grade 5 but subsequently underwent surgery despite this and to compare the ASA scoring model to other predictors of surgical outcome. METHODS All patients undergoing emergency surgery with an ASA grade of 5 were identified. Patient demographics, indications for surgery, intraoperative findings and outcomes were recorded. In addition to the ASA scores, retrospective Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P POSSUM) and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were calculated and compared to the observed outcomes. RESULTS Nine patients (39%) survived to discharge. ASA grade was a poor predictor of outcome. P POSSUM and APACHE II scores correlated significantly with each other and with observed outcomes when predicting surgical mortality. The median stay for survivors in the intensive care unit was nine days. CONCLUSIONS In times of an ageing population, the number of patients suffering catastrophic surgical events will increase. Intervention, with little hope of a cure, a return to independent living or an acceptable quality of life, leads to unnecessary end-of-life suffering for patients and their relatives, and consumes sparse resources. The accuracy and reliability of ASA grade 5 as an outcome predictor has been questioned. P POSSUM and APACHE II scoring systems are significantly better predictors of outcome and should be used more frequently to aid surgical decision-making in high risk patients.
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Affiliation(s)
- J Horwood
- Department of General Surgery, Glan Clwyd Hospital, Rhyl, UK.
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5
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Nichols KG, Prytherch DR, Fancourt MF, Gilkison WTC, Kyle SM, Mosquera DA. RISK-ADJUSTED GENERAL SURGICAL AUDIT IN OCTOGENARIANS. ANZ J Surg 2008; 78:990-4. [DOI: 10.1111/j.1445-2197.2008.04718.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Arenal JJ, Teresa GD, Tinoco C, Toledano M, Said A. Abdominal Surgery in Nonagenarians: Short-Term Results. Surg Today 2007; 37:1064-7. [DOI: 10.1007/s00595-007-3537-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2007] [Accepted: 04/02/2007] [Indexed: 11/28/2022]
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Hotta T, Takifuji K, Yokoyama S, Matsuda K, Higashiguchi T, Tominaga T, Oku Y, Nasu T, Yamaue H. Rectal cancer surgery in the elderly: analysis of consecutive 158 patients with stage III rectal cancer. Langenbecks Arch Surg 2007; 392:549-58. [PMID: 17593386 DOI: 10.1007/s00423-007-0199-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2006] [Accepted: 05/04/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND It is difficult to establish a clear-cut indication for rectal surgery in elderly patients because of greater risk. We tried to clarify the factors associated with the short-term and long-term outcomes between elderly and younger patients. MATERIALS AND METHODS We clarified the potential predictors of the cancer-related and disease-free survivals after surgery, the factors associated with the elderly, preoperative comorbid conditions, and postoperative complications in 158 patients with stage III rectal cancer who underwent surgery, including 33 elderly patients (>or=75 years) and 125 younger patients (<75 years). RESULTS An old age and macroscopic types 3 and 4 were independent poor prognostic factors of cancer-related survival, whereas the disease-free survival of the younger patients was not longer than for the elderly patients. Interestingly, the survival rate in the elderly patients with recurrence was shorter than that in the younger patients. Histopathological type except well differentiated and without chemotherapy were significant tumor characteristics associated with the elderly patients. On preoperative comorbid conditions, elderly patients have more cardiovascular diseases than younger patients, whereas there were no significant differences in the postoperative complications. CONCLUSION Strength of the adjuvant and intensive therapies after recurrence may contribute to gain long-term survival in the elderly rectal cancer patients.
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Affiliation(s)
- Tsukasa Hotta
- Second Department of Surgery, Wakayama Medical University, School of Medicine, 811-1, Kimiidera, Wakayama, 641-8510, Japan
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Bufalari A, Giustozzi G, Burattini MF, Servili S, Bussotti C, Lucaroni E, Ricci E, Sciannameo F. Rectal cancer surgery in the elderly: a multivariate analysis of outcome risk factors. J Surg Oncol 2006; 93:173-80. [PMID: 16482596 DOI: 10.1002/jso.20300] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND AND OBJECTIVES Geriatric population life expectancy is rapidly increasing and the impact of major surgical procedures is not well defined. The purpose of this study was to compare short term surgical results assessing mortality and morbidity and long-term survival and disease-free interval in elective rectal surgery patients older than 65 years of age. The main independent risk factors of mortality, morbidity, and overall and disease-free survival were also identified. METHODS Out of 177 rectal cancer accepted consecutively from 1991 to 2002, we studied the main clinical and pathological parameters comparing patients older and younger than 65 years. Data have been collected in a database and variables considered were studied by univariate analysis; independent predictive factors of 30-day mortality and morbidity were identified by multiple logistic regression analysis. Overall, cancer specific and disease-free survival curves were obtained with the Kaplan-Meier method and results compared with the log-rank test. Independent risk factors of overall and disease-free survival have been identified by multivariate logistic regression analysis. RESULTS In patients younger and older than 65 years postoperative mortality (3.2% vs. 9.6%) and morbidity (30% vs. 29%) were not significantly different. Variables independently associated with 30-day mortality were the duration of surgical procedures and postoperative complications. The Kaplan-Meier survival curves showed a significantly worst overall survival (P = 0.003), cancer specific survival (P = 0.02), and disease-free survival (P = 0.03) in patients aged 65 years or more. Multivariate analysis showed that pT, grading, preoperative CEA level, gender, and site of the tumor along the rectum, the number of blood transfusion and the age group of more than 65 years are independent risk factors for both overall survival and disease-free interval. The presence of residual disease was an adjunctive factor of overall survival, whereas the Astler and Coller staging was a risk factor for the disease-free survival. CONCLUSION The short-term prognosis for elective rectal cancer procedure in patients over 65 years of age was comparable to that of younger patients, whereas long term cancer-related survival was statistically worst in older patients.
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Affiliation(s)
- Andrea Bufalari
- Department of Surgery, Division of Surgical Oncology, University of Perugia, Perugia, Italy.
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Tan KY, Chen CM, Ng C, Tan SM, Tay KH. Which Octogenarians Do Poorly After Major Open Abdominal Surgery in Our Asian Population? World J Surg 2006; 30:547-52. [PMID: 16568231 DOI: 10.1007/s00268-005-0224-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND As the elderly population grows and surgeons are faced with more octogenarians, there is a need to know how our Asian patients fair after major surgery. METHODS A retrospective review of 125 octogenarians who underwent major abdominal surgery between January 1997 and September 2003 was performed. Preoperative condition was assessed using a weighted index of comorbidity used in Charlson Comorbidity Index and classification of patients according to the American Society of Anaesthesiologists (ASA). Outcome was measured as to whether complications developed, 30-day mortality and whether there was return to premorbid function. RESULTS The patients had a mean age of 84.6 years (range: 80-106). Nearly half (48.8%, n = 61) the cases were emergency cases. The median index of comorbidity was 3, and 29.6% of patients were classified either ASA III or IV. The operations were mostly stomach, small bowel or large bowel resection. Multivariate analysis revealed that emergency operations were associated with significantly increased odds of morbidity. The overall 30-day mortality was 5.6%, being only 4.7% for elective cases, despite high morbidity rates. ASA classification, comorbidity index >5, development of acute coronary syndrome and anastomotic leakage were found on multivariate analysis to significantly increase the odds of mortality. For elective cases, 82.8% of patients were able to return to their premorbid functional status. Development of complications and comorbidity index >5 were found to predict failure of its occurrence. Low serum albumin and haemoglobin and renal impairment were also predictors of adverse outcome. CONCLUSIONS Efforts to improve outcome in geriatric surgery patients should emphasize a shift of attitude towards elective surgery rather than doing emergency operations when complications occur and also target the optimization of predictors of adverse outcome. Octogenarians should not be denied elective surgery.
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Affiliation(s)
- Kok-Yang Tan
- Department of General Surgery, Changi General Hospital, 2 Simei Street 3, 529889, Singapore.
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10
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Burns-Cox N, Campbell WB, van Nmmen BAJ, Vercaeren PMK, Lucarotti M. Surgical care and outcome for patients in their nineties. Br J Surg 2005. [DOI: 10.1046/j.1365-2168.1997.02621.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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11
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Ríos A, Rodríguez JM, Galindo PJ, Canteras M, Parrilla P. Surgical treatment for multinodular goitres in geriatric patients. Langenbecks Arch Surg 2005; 390:236-42. [PMID: 15654642 DOI: 10.1007/s00423-004-0521-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2004] [Accepted: 09/09/2004] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although age is not a contraindication for thyroid surgery, few elderly patients undergo surgery due to the greater risk of morbidity. The aims of this study are to determine in patients aged >65 years: (1) whether the indications for surgery on multinodular goitre (MG) differ with respect to younger patients; (2) the surgical results; and (3) whether the postsurgery morbidity and mortality rates are higher. PATIENTS AND METHOD Eighty-one patients aged over 65 years who were receiving surgery for MG were analysed; 40 49%) presented with associated co-morbidities. Sixty percent had thyroid symptoms, either compressive and/or toxic. All underwent programmed surgery following stabilisation and strict control of their co-morbidities. As a control group we used 510 MG patients receiving surgery and aged between 30 and 65 years. RESULTS Compared with the control group the geriatric patients had a longer time of goitre evolution (P=0.032), greater presence of symptoms (P=0.001) and a higher percentage of intrathoracic component (P=0.001). Compressive symptoms were the major indication for surgery (P=0.001). Postoperative complications occurred in 40% of the patients, a higher rate than in the control group (28%; P=0.011), although a large percentage of those complications were transitory. Definitive complications included two recurrent laryngeal nerve injuries (2.5%). The preoperative symptoms remitted in all the patients, and only three were associated with a thyroid carcinoma, one of which was anaplastic. CONCLUSIONS MG operated on in elderly patients has a longer evolution and an intrathoracic component, and surgery is indicated restrictively. With close monitoring of the co-morbidities and a programmed operation the results with regard to morbidity and mortality are similar to those obtained at younger ages.
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Affiliation(s)
- Antonio Ríos
- Department of General Surgery and Digestive Apparatus I, Virgen de la Arrixaca University Hospital, Murcia, Spain.
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Abstract
Oncology in elderly and frail patients is a subject of increasing importance due to demographic developments in our society. So far, patient age has been highly important for the indication of oncologic operations. This paradigm needs to be changed, since preoperative diagnostics, operative techniques, and postoperative intensive care have improved substantially over the past years. Reviewing the literature, we found that oncologic operations can be performed safely with the same morbidity, mortality, and length of hospital stay as with younger patients. Pre-existing comorbidities are the most important factor in elderly patients. Procedures must be safe and palliation needs to be effective more than curative procedures. To conclude: an surgery should always be considered in the therapeutic strategy for elderly and frail patients.
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Affiliation(s)
- N Senninger
- Klinik und Poliklinik für Allgemeine Chirurgie, Westfälische Wilhelms-Universität, Münster.
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13
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Ríos A, Manuel Rodríguez J, José Galindo P, Torregrosa NM, Canteras M, Parrilla P. Tratamiento quirúrgico del bocio multinodular en pacientes geriátricos. Cir Esp 2004. [DOI: 10.1016/s0009-739x(04)72283-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Falvo L, Catania A, Sorrenti S, D'Andrea V, Berni A, De Stefano M, De Antoni E. Prognostic significance of the age factor in the thyroid cancer: Statistical analysis. J Surg Oncol 2004; 88:217-22. [PMID: 15565630 DOI: 10.1002/jso.20140] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND OBJECTIVES To determine whether thyroid carcinoma in elderly patients presents any peculiar characteristics, whether the greater biological aggressiveness of the neoplasm modifies the surgical treatment selected, and whether age greater than 70 years represents an independent prognostic factor. METHODS Retrospective analysis of case histories from the Department of Surgery of "La Sapienza" University of Rome; 403 patients subjected to total thyroidectomy between 1993 and 1999, with a minimum follow-up period of 3 years subdivided into three groups: group I (patients aged between 20 and 50 years), group II (patients aged between 51 and 70 years) and group III (patients aged >70 years). The surgical and postoperative treatment is uniform in all study groups. RESULTS Age greater than 70 years entails a significant increase in mortality; the mortality rate in the three groups was found to be 3%, 9% and 54%, respectively. Prognosis is significantly worse in the elderly patients group (group III) than in group I (P < or = 0.001) and in group II (P < or = 0.001); group II mortality was significantly higher than that of group I (P = 0.005); in group III, the neoplasm displays features of greater biological aggressiveness (greater incidence of undifferentiated forms, presence of lymph nodes at diagnosis and vascular invasion, locally advanced forms, greater incidence of stage IV). CONCLUSIONS Statistical analysis shows that the greater biological aggressiveness of the neoplasm in elderly patients worsens the prognosis, although an age exceeding 70 years itself represents an unfavourable prognostic factor; total thyroidectomy does not present any counter-indications in elderly patients.
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Affiliation(s)
- Laura Falvo
- Division of General Surgery, Department of Surgical Sciences, University of Rome "La Sapienza", Rome, Italy.
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Passler C, Avanessian R, Kaczirek K, Prager G, Scheuba C, Schindl M, Niederle B. Schilddrusenchirurgie im Alter. Eur Surg 2001. [DOI: 10.1046/j.1563-2563.2001.01076.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Seshadri PA, Mamazza J, Schlachta CM, Cadeddu MO, Poulin EC. Laparoscopic colorectal resection in octogenarians. Surg Endosc 2001; 15:802-5. [PMID: 11443476 DOI: 10.1007/s00464-001-0017-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/1999] [Accepted: 07/25/2000] [Indexed: 10/26/2022]
Abstract
BACKGROUND The number and proportion of patients aged ?80 years are increasing. These patients often require surgical care and suffer subsequent high rates of morbidity and mortality. However, the surgical outcomes of laparoscopic colorectal resection in octogenarians are not well documented. METHODS Octogenarians were identified from a large prospective database comprising 507 consecutive laparoscopic colorectal resections performed between 1991 and 1999 in a university setting. Preoperative comorbidity and surgical outcomes were analyzed. RESULTS Sixty-two patients (30 men, 32 women) aged ?80 years were identified. Their mean age and weight were 85 years and 63 kg, respectively. Seven patients (11%) were converted to an open procedure. Four (6%) intraoperative complications occurred in four patients (one colon perforation, one small bowel perforation, one burned gallbladder serosa, and one missed lesion), necessitating two conversions. Twenty -four postoperative complications occurred in 19 patients (31%) (six ileus [10%], five wound infections [8%], five cardiac problems [8%], two urinary retentions [3%], two hemorrhages [3%], one abscess [2%], one pneumonia [2%], and two other [3%]). Intraoperative complications did not increase postoperative morbidity. Three patients (5%) died within 30 days of surgery. When the procedure was completed laparoscopically, the overall median postoperative hospital stay was 10.0 days; occurrence of a postoperative complication increased the median length of stay to 15.0 days. CONCLUSIONS These results are superior to published historical controls involving open colorectal resection in octogenarians. Overall mortality, lung, and urinary tract complications were decreased, and there were no reoperations for small bowel obstruction. Laparoscopic colorectal resection is technically feasible and can be done safely in elderly patients. Results require randomization against those for open surgery to elucida te the real advantages of this technique.
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Affiliation(s)
- P A Seshadri
- The University of Toronto Center for Minimally Invasive Surgery, St. Michael's Hospital, Wellesly Central Site, 160 Wellesley Street E, Jones Building #218, Toronto, Ontario, M4Y 1J3, Canada
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17
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Rigberg D, Cole M, Hiyama D, Mcfadden D. Surgery in the Nineties. Am Surg 2000. [DOI: 10.1177/000313480006600902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
The population of the United States is aging, and by 2020 it is estimated that 16 per cent of U.S. citizens will be over 65 years of age. Little has been published about the results of surgery in nonagenarians but mortality rates of 45 per cent are reported. Given recent improvements in perioperative care we reviewed the experience with major general surgical operative procedures in nonagenarians. We reviewed the charts of patients greater than or equal to 90 years of age who underwent general surgical procedures at UCLA Medical Center since 1986. No patients were excluded. Thirty-two patients were identified. Most (87.5%) patients had significant premorbid conditions. The most common diagnoses were cancer (12), incarcerated hernia (seven), trauma (three), colonic volvulus (two), and cholecystitis (two). Overall perioperative mortality was 9.4 per cent (3 of 32). Twenty-two surgeries (69%) were performed on an emergency basis, and all three deaths were in this group (13.6%). Overall morbidity rate was 57 per cent. Mean intensive care unit stay was 4.8 days. Most patients were discharged home. Our findings support the perioperative safety of elective general surgery in nonagenarians (0% mortality and 20% morbidity). We also found an acceptable risk (13.6% mortality and 68% morbidity) for emergency procedures despite significant comorbid conditions. Most of the patients had acceptable functional outcomes.
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Affiliation(s)
- David Rigberg
- Division of General Surgery, UCLA Medical Center, Los Angeles, California
| | - Michael Cole
- Division of General Surgery, UCLA Medical Center, Los Angeles, California
| | - Daryl Hiyama
- Division of General Surgery, UCLA Medical Center, Los Angeles, California
| | - David Mcfadden
- Division of General Surgery, UCLA Medical Center, Los Angeles, California
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Maxwell JG, Tyler BA, Rutledge R, Brinker CC, Maxwell BG, Covington DL. Cholecystectomy in patients aged 80 and older. Am J Surg 1998; 176:627-31. [PMID: 9926803 DOI: 10.1016/s0002-9610(98)00282-7] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND We assessed whether the increase in performance of laparoscopic cholecystectomy has affected patients aged 80 and older and if outcomes of a laparoscopic approach in this population would show improvement over those for open surgery. METHODS We analyzed an 11-state discharge database obtained from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project. Release 1 contains a 20% sample of United States hospitals for the period 1988 to 1992. Diagnosis-related group (DRG) codes 197 and 198 were searched, and demographics, type of surgery, and outcome measures were analyzed. RESULTS In 5 years, 350,451 patients underwent cholecystectomy with the DRG codes listed. Of those, 18,500 patients were aged 80 to 105. The total number of cholecystectomies increased each year. Performance of laparoscopic cholecystectomy rose rapidly and that of open cholecystectomy decreased. Overall mortality with laparoscopic cholecystectomy was 1.8%, was lower than that of open cholecystectomy, was lower in women, and decreased with time. CONCLUSIONS Patients aged 80 and older have participated in the increased performance of cholecystectomy and the switch to laparoscopic cholecystectomy. This has a low mortality, low length of stay, and higher proportion of patients being discharged to home compared with patients having open cholecystectomy.
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Affiliation(s)
- J G Maxwell
- Department of Surgery, University of North Carolina at Chapel Hill, USA
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Girvent M, Maestro S, Hernández R, Carajol I, Monné J, Sancho JJ, Gubern JM, Sitges-Serra A. Euthyroid sick syndrome, associated endocrine abnormalities, and outcome in elderly patients undergoing emergency operation. Surgery 1998; 123:560-7. [PMID: 9591009 DOI: 10.1067/msy.1998.87238] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Emergency operation in the elderly carries a high risk of death. We investigated the incidence of euthyroid sick syndrome (ESS) and associated nutritional and endocrine abnormalities and their relationship to postoperative outcome in this population. METHODS Sixty-six patients older than 70 years of age requiring emergency operations were assessed before any therapeutic intervention. Values for thyroid hormones, catecholamines, cortisol, interleukin-6, interleukin-1, C-reactive protein, and the Acute Physiology and Chronic Health Evaluation II score were determined. Nutritional assessment was carried out. Mortality rates and duration of hospital stay were related to ESS and albumin concentrations. RESULTS ESS was diagnosed in 34 patients (51.50%) and was associated with worse Acute Physiology and Chronic Health Evaluation II scores (10.9 vs 8.6; p = 0.004), hypoalbuminemia (34.7 vs 40.8 gm/L; p = 0.0001), lower triceps skinfold (11.8 vs 14.6 mm; p = 0.03), and higher cortisol and norepinephrine levels (937 vs 741 nmol/L [p = 0.04] and 358 vs 250 pg/ml [p = 0.02], respectively), interleukin-6 plasma concentrations (347 vs 113 pg/ml; p = 0.01), death rate (20% vs 0%; p = 0.02), and length of hospital stay (17.2 vs 11.8 days; p = 0.03). A serum albumin level less than 35 gm/L was virtually always associated with ESS. CONCLUSIONS ESS is highly prevalent in the elderly with acute surgical problems and is associated with poor nutrition, higher sympathetic response, and worse postoperative outcome. The serum albumin level at admission is a specific marker of ESS.
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Affiliation(s)
- M Girvent
- Department of Surgery, Hospital Universitari del Mar, Barcelona, Spain
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Burns-Cox N, Campbell WB, van Nmmen BAJ, Vercaeren PMK, Lucarotti M. Surgical care and outcome for patients in their nineties. Br J Surg 1997. [DOI: 10.1002/bjs.1800840417] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
The general surgical profile of octogenarians compared with that of younger patients, and risk factors predictive of operative mortality and morbidity, were determined retrospectively using a computer database for all patients admitted between 1989 and 1993. There were 934 admissions of octogenarians and surgery was performed in 447 cases (47.9 percent). The admission rate of patients over 80 years of age increased during the 5-year period from 4.6 to 9.0 per cent, and was significantly higher than that of geriatric patients aged 65-79 years (P < 0.01). Emergency admissions (63.6 percent) and operations (42.3 percent) were more frequent in patients aged over 80 years (P < 0.01); emergency operations increased during the 5 years from 38 to 59 percent. Altogether, 83 deaths and 171 complications were recorded. The mortality rate of octogenarians was greater than that of younger patients (P < 0.01). Postoperative mortality and morbidity rates were 10.1 and 32.2 percent respectively. After multiple logistic regression analysis with stepwise backward elimination, an American Society of Anesthesiologists score of II-V (P < 0.01), the presence of two associated diseases (P < 0.01) and laparotomy procedures (P < 0.03) appeared to be independent risk factors for postoperative mortality and morbidity.
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Affiliation(s)
- A Bufalari
- Department of Surgery and Surgical Emergencies, University of Perugia, Italy
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Bittner R, Butters M, Ulrich M, Uppenbrink S, Beger HG. Total gastrectomy. Updated operative mortality and long-term survival with particular reference to patients older than 70 years of age. Ann Surg 1996; 224:37-42. [PMID: 8678615 PMCID: PMC1235244 DOI: 10.1097/00000658-199607000-00006] [Citation(s) in RCA: 89] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE The authors conducted a study of patients who underwent total gastrectomy for gastric malignancy to elucidate contributing factors that lead to successful management of this disease in geriatric patients. SUMMARY BACKGROUND DATA The average mortality rate for patients undergoing stomach surgery due to carcinoma is 7.8% according to the literature overview, still relatively high. Even higher mortality rates are observed for geriatric patients after a total gastrectomy. Because of epidemiologic changes, a total gastrectomy is required with growing frequency in these high-risk patients. METHODS The study involved 380 patients with a gastric malignancy. Risks and benefits of a total gastrectomy with radical lymphadenectomy at an advanced age were analyzed retrospectively in 163 patients older than 70 years of age. The results achieved in these patients were compared with those observed in 217 younger patients. RESULTS The 30-day mortality and morbidity rates for the elderly patients were 3% and 33.7%, respectively; for the younger patients, they were 0.46% and 21.2%, respectively. A statistically significant correlation was found between the presence of risk factors, the occurrence of complications, and the mortality rate. No difference was seen between the two age groups when risk factors were absent. The 5-year survival rate was 30%, with no difference between young and elderly patients. CONCLUSIONS The data prove that a total gastrectomy with a radical lymphadenectomy can be carried out safely in older patients, with long-term results comparable to those achieved in younger patients.
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Affiliation(s)
- R Bittner
- Department of General Surgery, Marienhospital Stuttgart, Germany
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Marchionni N, Fumagalli S, Di Bari M, Boncinelli L, Ferrucci L, Tarantini F, Matteucci L, Masotti G. Immediate and long-term survival after intra-aortic balloon pumping: is advanced age an independent, unfavorable prognostic factor? J Am Geriatr Soc 1995; 43:389-94. [PMID: 7706629 DOI: 10.1111/j.1532-5415.1995.tb05813.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To determine whether advanced age is an independent prognostic factor that may increase the risk of complications and reduce the immediate and long-term survival after treatment with intra-aortic balloon pumping (IABP) for acute ischemic heart disease. DESIGN Retrospective analysis of a clinical series and long-term follow-up study. PATIENTS A total of 142 patients (age range 23-86 years) in whom IABP was indicated following a standardized protocol. MEASUREMENTS Univariate analysis of the association between age and anamnestic, clinical, and hemodynamic data significantly affecting prognosis; multivariate logistic regression analysis of variables showing significant associations. RESULTS IABP-related complications were independent of age. At univariate analysis, pre-existing, noncardiac, associated conditions (chronic renal failure, stroke, bronchopulmonary disease) (P < .001), an indication to IABP for hemodynamic complications of acute myocardial infarction rather than for medically refractory myocardial ischemia (P < .001), a lack in hemodynamic response to IABP (P < .002), a prolonged delay to IABP initiation (P < .003), and advanced age (P < .025) were all predictors of in-hospital mortality. However, older patients were also more frequently affected by chronic comorbid conditions and by acute left ventricular failure as an indication to IABP. When these variables were entered into logistic regression models, the association between age and mortality was no longer statistically significant. Similarly, advancing age was associated (P < .012) with an increased mortality rate during an average follow-up of 94 +/- 9 months, but, again, such a significant association disappeared when simultaneously adjusting for New York Heart Association functional class, which was the single most important predictor of long-term mortality. CONCLUSIONS Several anamnestic and clinical variables, rather than advanced age itself, are independent, prognostic factors negatively affecting the outcome of treatment with IABP. Technique-related complications are independent of age. Thus, old age should not be considered as a criterion to exclude any patient, a priori, from the potential benefits of this type of cardiocirculatory assistance.
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Affiliation(s)
- N Marchionni
- Department of Gerontology and Geriatric Medicine, University of Florence, Italy
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Cattorini P, Marchionni N. Clinical decision-making and the "treat or not to treat" dilemma in geriatrics: ethical implications. AGING (MILAN, ITALY) 1994; 6:391-8. [PMID: 7748912 DOI: 10.1007/bf03324270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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