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Daba AB, Beshah DT, Tekletsadik EA. Magnitude of in-hospital mortality and its associated factors among patients undergone laparotomy at tertiary public hospitals, West Oromia, Ethiopia, 2022. BMC Surg 2024; 24:193. [PMID: 38902650 PMCID: PMC11188532 DOI: 10.1186/s12893-024-02477-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 06/10/2024] [Indexed: 06/22/2024] Open
Abstract
INTRODUCTION Laparotomy surgery, which involves making an incision in the abdominal cavity to treat serious abdominal disease and save the patient's life, causes significant deaths in both developed and developing countries, including Ethiopia. The number studies examining in-hospital mortality rates among individuals that undergone laparotomy surgery and associated risk factors is limited. OBJECTIVE To assess the magnitude of in-hospital mortality and its associated factors among patients undergone laparotomy at tertiary hospitals, West Oromia, Ethiopia, 2022. METHODS An institutional based retrospective cross-sectional study was conducted from January 1, 2017, to December 31, 2021. Data were collected using systematic random sampling and based on structured and pretested abstraction sheets from 548 medical records and patient register log. Data were checked for completeness and consistency, coded, imported using Epi-data version 4.6, cleaned and analyzed using SPSS version 25 software. Variables with p < 0.2 in the Bi-variable logistic regression analysis were included in the multivariate logistic regression analysis. The fit of the model was checked by the Hosmer‒Lemeshow test. Using the odds ratio adjusted to 95% CI and a p value of 0.05, statistical significance was declared. RESULTS A total of 512 patient charts were reviewed, and the response rate was 93.43%. The overall magnitude of in-hospital mortality was 7.42% [95% CI: 5.4-9.8]. American society of Anesthesiology physiological status greater than III [AOR = 7.64 (95% CI: 3.12-18.66)], systolic blood pressure less than 90 mmHg [AOR = 6.11 (95% CI: 1.98-18.80)], preoperative sepsis [AOR = 3.54 (95% CI: 1.53-8.19)], ICU admission [AOR = 4.75 (95% CI: 1.50-14.96)], and total hospital stay greater than 14 days [(AOR = 6.76 (95% CI: 2.50-18.26)] were significantly associated with mortality after laparotomy surgery. CONCUSSION In this study, overall in- hospital mortality was high. Early identification patient's American Society of Anesthesiologists physiological status and provision of early appropriate intervention, and pays special attention to patients admitted with low systolic blood pressure, preoperative sepsis, intensive care unit admission and prolonged hospital stay to improve patient outcomes after laparotomy surgery.
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Affiliation(s)
- Aliyi Benti Daba
- Institute of health science, Wallaga University, Nekemte, Ethiopia.
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Capece SJ, Browning CJ, Barros de Sousa CA, Shaak K, Yoon JY, Sangster W. Hemorrhoidectomy: Does Age Make a Difference? Dis Colon Rectum 2024; 67:820-825. [PMID: 38408874 DOI: 10.1097/dcr.0000000000003085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
BACKGROUND Grade II and III hemorrhoids often require a multimodal approach that may ultimately culminate in surgical resection. Age and overall medical conditioning around the time of diagnosis can often impact the decision. OBJECTIVE The objective of this study was to evaluate patients with a diagnosis of symptomatic grade II or grade III hemorrhoids and determine progression to hemorrhoidectomy based on age and the time interval between diagnosis and surgical intervention. DESIGN A retrospective cohort study. SETTINGS Group practice at a single institution. PATIENTS Patients aged 18 to 75 years with grade II or grade III internal hemorrhoids between 2015 and 2020 were included. Patients with thrombosed hemorrhoids or surgical contraindications to hemorrhoidectomy were excluded. A total of 961 patients met inclusion criteria for grade II (n = 442) and III (n = 519) hemorrhoids. INTERVENTION Treatments included hemorrhoidectomy, in-office procedures, and/or medical management. MAIN OUTCOME MEASURES Baseline demographics, treatment choices, and time to hemorrhoidectomy (if applicable) were stratified and analyzed on the basis of hemorrhoid grade (grade II and III) and age groupings that were predetermined by the authors (18-30, 31-50, and 51-75 years). RESULTS Patients with grade III versus grade II hemorrhoids were more likely to choose hemorrhoidectomy as the initial treatment management (27.6% vs 4.1%). Patients in the age groups of 18 to 30 and 30 to 50 years were more likely to choose hemorrhoidectomy as the initial treatment management compared to those in the age group of 51 to 75 years (23.5% and 22% vs 12.8%). In patients who were initially treated with medical management or office-based procedures and then progressed to hemorrhoidectomy, no significant differences in the length of time to hemorrhoidectomy were noted on the basis of hemorrhoid grade or age. LIMITATIONS Data only looked at age groups and their treatment selection. Personal biases of surgeon and patient may alter results. CONCLUSIONS Our study shows that the younger population tends to seek hemorrhoidectomy first over the older population. See Video Abstract . HEMORROIDECTOMA LA EDAD MARCA LA DIFERENCIA ANTECEDENTES:Las hemorroides de grado II y III a menudo requieren un abordaje multimodal que en última instancia puede culminar en una resección quirúrgica. La edad y el estado médico general en el momento del diagnóstico a menudo pueden afectar la decisión.OBJETIVO:El objetivo de este estudio fue evaluar a pacientes con diagnóstico de hemorroides sintomáticas grado II o grado III y determinar la progresión a hemorroidectomía en función de la edad y el intervalo de tiempo entre el diagnóstico y la intervención quirúrgica.DISEÑO:Estudio de cohorte retrospectivo.ESCENARIO:Práctica grupal en una sola institución.PACIENTES:Se incluyó a pacientes de 18 a 75 años con hemorroides internas de grado II o III entre 2015 y 2020. Se excluyeron los pacientes con hemorroides trombosadas o contraindicaciones quirúrgicas para hemorroidectomía. Un total de 961 pacientes cumplieron los criterios de inclusión para hemorroides de Grado II (n=442) y III (n=519).INTERVENCIÓN:Los tratamientos incluyeron hemorroidectomía, procedimientos en el consultorio y/o manejo médico.PRINCIPALES MEDIDAS DE RESULTADO:Los datos demográficos iniciales, las opciones de tratamiento y el tiempo hasta la hemorroidectomía (si corresponde) se estratificaron y analizaron según el grado de hemorroides (grado II y III) y los grupos de edad predeterminados por los autores (18-30, 31-50). y 51-75).RESULTADOS:Los pacientes con hemorroides de Grado III versus Grado II tuvieron más probabilidades de elegir la hemorroidectomía como tratamiento inicial (27,6% versus 4,1%). Los pacientes de los grupos de edad de 18 a 30 y de 30 a 50 años tenían más probabilidades de elegir la hemorroidectomía como tratamiento inicial en comparación con los de 51 a 75 años (23,5% y 22% frente a 12,8%). En los pacientes que inicialmente fueron tratados con manejo médico o procedimientos en el consultorio y luego progresaron a hemorroidectomía, no se observaron diferencias significativas en el tiempo hasta la hemorroidectomía según el grado o la edad de las hemorroides.LIMITACIONES:Los datos solo analizan los grupos de edad y su selección de tratamiento. Los sesgos personales del cirujano y del paciente pueden alterar los resultados.CONCLUSIÓN:Nuestro estudio muestra que la población más joven tiende a buscar primero la hemorroidectomía que la población de mayor edad. (Traducción-Dr. Felipe Bellolio ).
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Affiliation(s)
- Steven J Capece
- Lehigh Valley Health Network, Department of Surgery and Colorectal Surgery, Allentown, Pennsylvania
| | - Charles J Browning
- Lehigh Valley Health Network, Department of Surgery and Colorectal Surgery, Allentown, Pennsylvania
| | - Cesar A Barros de Sousa
- Lehigh Valley Health Network, Department of Surgery and Colorectal Surgery, Allentown, Pennsylvania
| | - Kyle Shaak
- Lehigh Valley Health Network, Network Office of Research and Innovation, Allentown, Pennsylvania
| | - Justin Y Yoon
- Lehigh Valley Health Network, Department of Surgery and Colorectal Surgery, Allentown, Pennsylvania
| | - William Sangster
- Lehigh Valley Health Network, Department of Surgery and Colorectal Surgery, Allentown, Pennsylvania
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Cao C, Han Y, Hu H, He Y, Luo J. Non-linear relationship between pulse pressure and the risk of pre-diabetes: a secondary retrospective Chinese cohort study. BMJ Open 2024; 14:e080018. [PMID: 38521517 PMCID: PMC10961532 DOI: 10.1136/bmjopen-2023-080018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 03/01/2024] [Indexed: 03/25/2024] Open
Abstract
OBJECTIVE Previous research has shown that pulse pressure (PP) has a significant role in the start and development of type 2 diabetes mellitus. However, there is little proof that PP and pre-diabetes mellitus (Pre-DM) are related. Our study aimed to investigate the relationship between PP and incident pre-DM in a substantial cohort of Chinese participants. DESIGN The 'DATADRYAD' database (www.Datadryad.org) was used to retrieve the data for this secondary retrospective cohort analysis. PARTICIPANTS Data from 182 672 Chinese individuals who participated in the medical examination programme were recorded in this retrospective cohort study between 2010 and 2016 across 32 sites and 11 cities in China. SETTING PP assessed at baseline and incident pre-DM during follow-up were the target-independent and dependent variables. The association between PP and pre-DM was investigated using Cox proportional hazards regression. PRIMARY OUTCOME MEASURES The outcome was incident pre-DM. Impaired fasting glucose levels (fasting blood glucose between 5.6 and 6.9 mmol/L) were used to define pre-DM. RESULTS After controlling for confounding variables, PP was positively correlated with incident pre-DM among Chinese adults (HR 1.009, 95% CI 1.007 to 1.010). Additionally, at a PP inflection point of 29 mm Hg, a non-linear connection between the PP and incident pre-DM was discovered. Increased PP was an independent risk factor for developing pre-DM when PP was greater than 29 mm Hg. However, their association was not significant when PP was less than 29 mm Hg. According to subgroup analyses, females, never-smokers and non-obesity correlated more significantly with PP and pre-DM. CONCLUSION We discovered that higher PP independently correlated with pre-DM risk in this study of Chinese participants. The connection between PP and incident pre-DM was also non-linear. High PP levels were related to a higher risk of pre-DM when PP was above 29 mm Hg. ARTICLE FOCUS Our study investigated the relationship between PP and incident pre-DM in a secondary retrospective cohort of Chinese participants.
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Affiliation(s)
- Changchun Cao
- Department of Rehabilitation, Shenzhen Dapeng New District Nan'ao People's Hospital, Shenzhen, Guangdong, China
| | - Yong Han
- Department of Emergency, Shenzhen Second People's Hospital, Shenzhen, Guangdong Province, China
| | - Haofei Hu
- Department of Nephrology, Shenzhen University First Affiliated Hospital, Shenzhen, Guangdong, China
| | - Yongcheng He
- Department of Nephrology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan Province, China
- Department of Nephrology, Shenzhen Hengsheng Hospital, Shenzhen, Guangdong Province, China
| | - Jiao Luo
- Department of Rehabilitation, Shenzhen Dapeng New District Nan'ao People's Hospital, Dapeng New District, Guangdong Province, China
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Yamaguchi K, Abe T, Matsumoto S, Nakajima K, Shimizu M, Takeuchi I. Laparoscopy for emergency abdominal surgery is associated with reduced physical functional decline in older patients: a cohort study. BMC Geriatr 2024; 24:250. [PMID: 38475701 DOI: 10.1186/s12877-024-04872-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 03/04/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND An increasing number of older patients require emergency abdominal surgery for acute abdomen. They are susceptible to surgical stress and lose their independence in performing daily activities. Laparoscopic surgery is associated with faster recovery, less postoperative pain, and shorter hospital stay. However, few studies have examined the relationship between laparoscopic surgery and physical functional decline. Thus, we aimed to examine the relationship between changes in physical function and the surgical procedure. METHODS In this was a single-center, retrospective cohort study, we enrolled patients who were aged ≥ 65 years and underwent emergency abdominal surgery for acute abdomen between January 1, 2019, and December 31, 2021. We assessed their activities of daily living using the Barthel Index. Functional decline was defined as a decrease of ≥ 20 points in Barthel Index at 28 days postoperatively, compared with the preoperative value. We evaluated an association between functional decline and surgical procedures among older patients, using multiple logistic regression analysis. RESULTS During the study period, 852 patients underwent emergency abdominal surgery. Among these, 280 patients were eligible for the analysis. Among them, 94 underwent laparoscopic surgery, while 186 underwent open surgery. Patients who underwent laparoscopic surgery showed a less functional decline at 28 days postoperatively (6 vs. 49, p < 0.001). After adjustments for other covariates, laparoscopic surgery was an independent preventive factor for postoperative functional decline (OR, 0.22; 95% CI, 0.05-0.83; p < 0.05). CONCLUSIONS In emergency abdominal surgery, laparoscopic surgery reduces postoperative physical functional decline in older patients. Widespread use of laparoscopic surgery can potentially preserve patient quality of life and may be important for the better development of emergency abdominal surgery.
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Affiliation(s)
- Keishi Yamaguchi
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 4-57 Urafunecho, Minamiku, Yokohama, 232-0024, Japan.
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan.
| | - Takeru Abe
- Center for Integrated Science and Humanities, Fukushima Medical University, Fukushima, Japan
| | - Shokei Matsumoto
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Kento Nakajima
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 4-57 Urafunecho, Minamiku, Yokohama, 232-0024, Japan
| | - Masayuki Shimizu
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Ichiro Takeuchi
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 4-57 Urafunecho, Minamiku, Yokohama, 232-0024, Japan
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Zogg CK, Falvey JR, Kodadek LM, Staudenmayer KL, Davis KA. The interaction between geriatric and neighborhood vulnerability: Delineating prehospital risk among older adult emergency general surgery patients. J Trauma Acute Care Surg 2024; 96:400-408. [PMID: 37962136 PMCID: PMC10922165 DOI: 10.1097/ta.0000000000004191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
BACKGROUND When presenting for emergency general surgery (EGS) care, older adults frequently experience increased risk of adverse outcomes owing to factors related to age ("geriatric vulnerability") and the social determinants of health unique to the places in which they live ("neighborhood vulnerability"). Little is known about how such factors collectively influence adverse outcomes. We sought to explore how the interaction between geriatric and neighborhood vulnerability influences EGS outcomes among older adults. METHODS Older adults, 65 years or older, hospitalized with an AAST-defined EGS condition were identified in the 2016 to 2019, 2021 Florida State Inpatient Database. Latent variable models combined the influence of patient age, multimorbidity, and Hospital Frailty Risk Score into a single metric of "geriatric vulnerability." Variations in geriatric vulnerability were then compared across differences in "neighborhood vulnerability" as measured by variations in Area Deprivation Index, Social Vulnerability Index, and their corresponding subthemes (e.g., access to transportation). RESULTS A total of 448,968 older adults were included. For patients living in the least vulnerable neighborhoods, increasing geriatric vulnerability resulted in up to six times greater risk of death (30-day risk-adjusted hazards ratio [HR], 6.32; 95% confidence interval [CI], 4.49-8.89). The effect was more than doubled among patients living in the most vulnerable neighborhoods, where increasing geriatric vulnerability resulted in up to 15 times greater risk of death (30-day risk-adjusted HR, 15.12; 95% CI, 12.57-18.19). When restricted to racial/ethnic minority patients, the multiplicative effect was four-times as high, resulting in corresponding 30-day HRs for mortality of 11.53 (95% CI, 4.51-29.44) versus 40.67 (95% CI, 22.73-72.78). Similar patterns were seen for death within 365 days. CONCLUSION Both geriatric and neighborhood vulnerability have been shown to affect prehospital risk among older patients. The results of this study build on that work, presenting the first in-depth look at the powerful multiplicative interaction between these two factors. The results show that where a patient resides can fundamentally alter expected outcomes for EGS care such that otherwise less vulnerable patients become functionally equivalent to those who are, at baseline, more aged, more frail, and more sick. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Cheryl K. Zogg
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Jason R. Falvey
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, MD
- Department of Epidemiology & Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Lisa M. Kodadek
- Department of Surgery, Yale School of Medicine, New Haven, CT
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Yamaguchi K, Matsumoto S, Abe T, Nakajima K, Senoo S, Shimizu M, Takeuchi I. Predictive value of total psoas muscle index for postoperative physical functional decline in older patients undergoing emergency abdominal surgery. BMC Surg 2023; 23:171. [PMID: 37355574 DOI: 10.1186/s12893-023-02085-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 06/19/2023] [Indexed: 06/26/2023] Open
Abstract
BACKGROUND Older individuals increasingly require emergency abdominal surgeries. They are susceptible to surgical stress and loss of independence in performing daily activities. We hypothesized that the psoas muscle volume would be significantly associated with postoperative functional decline (FD) in older patients undergoing emergency abdominal surgery and aimed to evaluate the use of the psoas muscle volume on computed tomography (CT) scans. METHODS A retrospective, single-center study of patients aged ≥ 65 years who had undergone emergency abdominal surgery between January 2019 and June 2021 was performed. We assessed patients' activities of daily living using the Barthel Index. FD was defined as a ≥ 5-point decrease between preoperative and 28-day postoperative values. The psoas muscle volume was measured by CT, which was used for diagnosis, and normalized by height to calculate total psoas muscle index (TPI). We evaluated associations between FD and TPI using receiver operating characteristics (ROC) analysis and multiple logistic regression analysis. RESULTS Of 238 eligible patients, 71 (29.8%) had clinical postoperative FD. Compared to the non-FD group, the FD group was significantly older and had a higher proportion of females, higher Charlson Comorbidity Index, lower body mass index, higher American Society of Anesthesiology score, lower serum albumin level, and lower TPI. ROC analyses revealed that TPI had the highest area under the curve (0.802; 95% confidence interval [CI], 0.75-0.86). A multivariable logistic regression model revealed that low TPI was an independent predictor of postoperative FD (odds ratio, 0.14; 95% CI, 0.06-0.32). CONCLUSIONS TPI can predict postoperative FD due to emergency abdominal surgery. Identification of patients who are at high risk of FD before surgery may be useful for enhancing the regionalized system of care for emergency general surgery.
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Affiliation(s)
- Keishi Yamaguchi
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 4-57 Urafunecho, Minami-Ku, Yokohama-Shi, Kanagawa, 232-0024, Japan
| | - Shokei Matsumoto
- Department of Trauma and Emergency Surgery, Saiseikai Yokohama-Shi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi-Ku, Yokohama-Shi, Kanagawa, 230-0012, Japan.
| | - Takeru Abe
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 4-57 Urafunecho, Minami-Ku, Yokohama-Shi, Kanagawa, 232-0024, Japan
| | - Kento Nakajima
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 4-57 Urafunecho, Minami-Ku, Yokohama-Shi, Kanagawa, 232-0024, Japan
| | - Satomi Senoo
- Department of Trauma and Emergency Surgery, Saiseikai Yokohama-Shi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi-Ku, Yokohama-Shi, Kanagawa, 230-0012, Japan
| | - Masayuki Shimizu
- Department of Trauma and Emergency Surgery, Saiseikai Yokohama-Shi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi-Ku, Yokohama-Shi, Kanagawa, 230-0012, Japan
| | - Ichiro Takeuchi
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 4-57 Urafunecho, Minami-Ku, Yokohama-Shi, Kanagawa, 232-0024, Japan
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Santiago RACB, Ali A, Ibrahim B, Mandel M, Muhsen BA, Obrzut M, Ranjan S, Borghei-Razavi H, Adada B. Safety of craniotomy for brain tumor resection in octogenarians and older patients - a matched - cohort analysis. Int J Neurosci 2023:1-7. [PMID: 36724879 DOI: 10.1080/00207454.2023.2174866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 01/19/2023] [Accepted: 01/25/2023] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The incidence of brain tumors has increased in elderly population overtime. Their eligibility to a major surgery remains a questionable subject. This study evaluated prognostic factors and 30-days morbidity and mortality in octogenarian population who underwent craniotomy for resection of brain tumor. MATERIALS AND METHODS A total of 154 patients were divided into two different groups: patients above 80 years old and patients below 65 years old. In both groups, patients were stratified based on diagnosis with benign tumors [meningioma] and malignant tumors [high-grade gliomas and metastases]. Multivariable logistic regression model with backward elimination method was utilized to identify the independent risk factors for 30-days readmission and post-operative complications. RESULTS The analysis revealed no significant difference in 30-day readmission (p = 0.7329), 30-day mortality (0.6854) or in post-operative complication (p = 0.3291) between age ≥ 80 and age ≤ 65 groups. A longer length of stay (LOS) was observed in the older patients (p = 0.0479). There was a significant difference in the pre-post KPS between the two groups (p < 0.0001). ASA (p = 0.0315) and KPS (p = 0.071) were found as important prognostic factors associated with post-operative mortality in both groups. CONCLUSION Octogenarians can withstand craniotomy without any significant increase in 30-day readmission, 30-day mortality and post-operative complications as compared to patients younger than age 65. The ASA score (>3) and/or KPS (<70) were the most important prognostic factors for 30-days readmission and mortality.
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Affiliation(s)
| | - Assad Ali
- Department of Neurosurgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - Bilal Ibrahim
- Department of Neurosurgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - Mauricio Mandel
- Department of Neurosurgery, Cleveland Clinic Florida, Weston, Florida, USA
| | | | - Michal Obrzut
- Department of Neurosurgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - Surabhi Ranjan
- Department of Neurosurgery, Cleveland Clinic Florida, Weston, Florida, USA
| | | | - Badih Adada
- Department of Neurosurgery, Cleveland Clinic Florida, Weston, Florida, USA
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Vigneron E, Leclerc J, Chanty H, Germain A, Ayav A. Is pancreatic head surgery safe in the elderly? HPB (Oxford) 2023; 25:425-430. [PMID: 36740565 DOI: 10.1016/j.hpb.2022.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 11/30/2022] [Accepted: 12/31/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND During the last century, life expectancy has doubled. As a result, senior patients with cancer are more frequently referred for possible surgery. Pancreatic surgery is a complex surgery associated with significant postoperative morbidity. Surgical decision-making in the elderly population can be difficult because outcomes in the elderly are poorly defined. Our objective is to characterize differences in mortality and morbidity for pancreatic surgery in the elderly population. METHODS A retrospective review of all patients undergoing pancreatic head surgery in our tertiary referral center from 2015 to 2021 was conducted. Analysis was performed for the entire cohort, classifying patients into three age groups: <70 years, 70-79 years, and ≥80 years. Data from these three groups were compared, including comorbidity, oncologic outcomes and postoperative complications. RESULTS A total of 326 patients underwent pancreatic head resection. The 90-day mortality increased from 2.9% to 5.3% to 15.4% with increasing age (p = 0,015). There were no differences among the three groups in terms of postoperative morbidity. There was no difference in disease-free survival (DFS), but overall survival was better in patients under 70 years (p = 0,046). CONCLUSION Compared to younger patients, patients over 80 years old have a higher risk of mortality despite similar postoperative morbidity.
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Affiliation(s)
- Estelle Vigneron
- Department of Digestive Surgery, University Hospital of Nancy-Brabois, Vandoeuvre-les-Nancy, France.
| | - Julie Leclerc
- Department of Digestive Surgery, University Hospital of Nancy-Brabois, Vandoeuvre-les-Nancy, France
| | - Hervé Chanty
- Department of Digestive Surgery, University Hospital of Nancy-Brabois, Vandoeuvre-les-Nancy, France
| | - Adeline Germain
- Department of Digestive Surgery, University Hospital of Nancy-Brabois, Vandoeuvre-les-Nancy, France
| | - Ahmet Ayav
- Department of Digestive Surgery, University Hospital of Nancy-Brabois, Vandoeuvre-les-Nancy, France
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Sebekos K, Guiab K, Stamelos G, Evans T, Siddiqi M, Brigode W, Capron G, Kaminsky M, Bokhari F. Effect of Age Alone on Outcome of Acute Surgical Conditions Among Healthy Patients (Non-smokers, Non-obese, and No Comorbid Conditions). Am Surg 2022:31348221091966. [PMID: 35522891 DOI: 10.1177/00031348221091966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The impact of age alone in relation to postoperative outcomes needs to be further elucidated. This study investigated whether increasing age was associated with increased morbidity and mortality for patients with no comorbidities undergoing acute care surgery (ACS). METHODS The 2016-2018 National Surgical Quality Improvement Project database was used to identify adult patients who underwent ACS performed on an urgent/emergent basis. Patients overweight or with pre-existing medical comorbidities were excluded. Patients were divided into age groups in decades. The association between outcomes and the different age groups, other patient characteristics, and perioperative factors was examined by multivariate logistic regression. RESULTS 22,770 patients were identified, of which 73.5% were appendectomies, and 21.6% were open procedures. Increasing age correlated with higher unadjusted complication rates and mortality. Multivariate analyses revealed that compared to patients ≤ 30 years old, mortality was not different for patients 31-60 years old, but it was higher for the age groups > 61 years old. Patients aged 51-60 and from 71 and above were associated with higher risks of complications. Subset analysis on octogenarians revealed a 1.14-fold higher odds of mortality for every year of increasing age. Preoperative risk factors including open procedure, wound class, and American Society of Anesthesiology (ASA) class were also associated with greater risks of mortality in octogenarians. CONCLUSION Patients older than age 50 were at higher risk for postoperative complications, and mortality significantly increased for each decade past 60 years old in healthy individuals.
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Affiliation(s)
| | - Keren Guiab
- 25430John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - George Stamelos
- 25430John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - Teresa Evans
- 25430John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - Mahwash Siddiqi
- 25430John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - William Brigode
- 25430John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | | | - Matthew Kaminsky
- 25430John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - Faran Bokhari
- 25430John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
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Marano L, Carbone L, Poto GE, Gambelli M, Nguefack Noudem LL, Grassi G, Manasci F, Curreri G, Giuliani A, Piagnerelli R, Savelli V, Marrelli D, Roviello F, Boccardi V. Handgrip strength predicts length of hospital stay in an abdominal surgical setting: the role of frailty beyond age. Aging Clin Exp Res 2022. [PMID: 35389186 DOI: 10.1007/s40520-022-02121-z/figures/1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
BACKGROUND Chronological age per se cannot be considered a prognostic risk factor for outcomes after elective surgery, whereas frailty could be. A simple and easy-to-get marker for frailty, such as handgrip strength (HGS), may support the surgeon in decision for an adequate healthcare plan. AIMS The aims of this study were to: (1) determine the prevalence of frailty in an abdominal surgery setting independent of age; (2) evaluate the predictive validity of HGS for the length of hospital stay (LOS). METHODS This is a retrospective study conducted in subjects who underwent abdominal surgical procedures. Only subjects with complete cognitive, functional, nutritional assessments and available measurement of HGS at admission were included. A final cohort of 108 patients were enrolled in the study. RESULTS Subjects had a mean age of 67.8 ± 15.8 years (age range 19-93 years old) and were mostly men. According to Fried's criteria, 17 (15.7%, 4F/13 M) were fit, 58 (23.7%; 24F/34 M) were pre-frail and 33 (30.6%; 20F/13 M) were frail. As expected, HGS significantly differed between groups having frail lower values as compared with pre-frail and fit persons (fit: 32.99 ± 10.34 kg; pre-frail: 27.49 ± 10.35 kg; frail: 15.96 ± 9.52 kg, p < 0.0001). A final regression analysis showed that HGS was significantly and inversely associated with LOS (p = 0.020) independent of multiple covariates, including age. DISCUSSION Most of the population undergoing abdominal surgery is pre-frail or frail. The measurement of handgrip strength is simple and inexpensive, and provides prognostic information for surgical outcomes. Muscle strength, as measured by handgrip dynamometry, is a strong predictor of LOS in a surgical setting.
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Affiliation(s)
- Luigi Marano
- Unit of General Surgery and Surgical Oncology, Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Ludovico Carbone
- Unit of General Surgery and Surgical Oncology, Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Gianmario Edoardo Poto
- Unit of General Surgery and Surgical Oncology, Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Margherita Gambelli
- Unit of General Surgery and Surgical Oncology, Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Leonelle Lore Nguefack Noudem
- Unit of General Surgery and Surgical Oncology, Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Giulia Grassi
- Unit of General Surgery and Surgical Oncology, Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Fabiana Manasci
- Unit of General Surgery and Surgical Oncology, Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Giulia Curreri
- Unit of General Surgery and Surgical Oncology, Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Alessandra Giuliani
- Unit of General Surgery and Surgical Oncology, Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Riccardo Piagnerelli
- Unit of General Surgery and Surgical Oncology, Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Vinno Savelli
- Unit of General Surgery and Surgical Oncology, Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Daniele Marrelli
- Unit of General Surgery and Surgical Oncology, Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Franco Roviello
- Unit of General Surgery and Surgical Oncology, Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Virginia Boccardi
- Section of Gerontology and Geriatrics, Department of Medicine and Surgery, University of Perugia, Perugia, Italy.
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Marano L, Carbone L, Poto GE, Gambelli M, Nguefack Noudem LL, Grassi G, Manasci F, Curreri G, Giuliani A, Piagnerelli R, Savelli V, Marrelli D, Roviello F, Boccardi V. Handgrip strength predicts length of hospital stay in an abdominal surgical setting: the role of frailty beyond age. Aging Clin Exp Res 2022; 34:811-817. [PMID: 35389186 PMCID: PMC9076715 DOI: 10.1007/s40520-022-02121-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/17/2022] [Indexed: 01/12/2023]
Abstract
Background Chronological age per se cannot be considered a prognostic risk factor for outcomes after elective surgery, whereas frailty could be. A simple and easy-to-get marker for frailty, such as handgrip strength (HGS), may support the surgeon in decision for an adequate healthcare plan. Aims The aims of this study were to: (1) determine the prevalence of frailty in an abdominal surgery setting independent of age; (2) evaluate the predictive validity of HGS for the length of hospital stay (LOS). Methods This is a retrospective study conducted in subjects who underwent abdominal surgical procedures. Only subjects with complete cognitive, functional, nutritional assessments and available measurement of HGS at admission were included. A final cohort of 108 patients were enrolled in the study. Results Subjects had a mean age of 67.8 ± 15.8 years (age range 19–93 years old) and were mostly men. According to Fried’s criteria, 17 (15.7%, 4F/13 M) were fit, 58 (23.7%; 24F/34 M) were pre-frail and 33 (30.6%; 20F/13 M) were frail. As expected, HGS significantly differed between groups having frail lower values as compared with pre-frail and fit persons (fit: 32.99 ± 10.34 kg; pre-frail: 27.49 ± 10.35 kg; frail: 15.96 ± 9.52 kg, p < 0.0001). A final regression analysis showed that HGS was significantly and inversely associated with LOS (p = 0.020) independent of multiple covariates, including age. Discussion Most of the population undergoing abdominal surgery is pre-frail or frail. The measurement of handgrip strength is simple and inexpensive, and provides prognostic information for surgical outcomes. Muscle strength, as measured by handgrip dynamometry, is a strong predictor of LOS in a surgical setting.
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Affiliation(s)
- Luigi Marano
- Unit of General Surgery and Surgical Oncology, Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Ludovico Carbone
- Unit of General Surgery and Surgical Oncology, Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Gianmario Edoardo Poto
- Unit of General Surgery and Surgical Oncology, Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Margherita Gambelli
- Unit of General Surgery and Surgical Oncology, Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Leonelle Lore Nguefack Noudem
- Unit of General Surgery and Surgical Oncology, Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Giulia Grassi
- Unit of General Surgery and Surgical Oncology, Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Fabiana Manasci
- Unit of General Surgery and Surgical Oncology, Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Giulia Curreri
- Unit of General Surgery and Surgical Oncology, Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Alessandra Giuliani
- Unit of General Surgery and Surgical Oncology, Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Riccardo Piagnerelli
- Unit of General Surgery and Surgical Oncology, Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Vinno Savelli
- Unit of General Surgery and Surgical Oncology, Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Daniele Marrelli
- Unit of General Surgery and Surgical Oncology, Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Franco Roviello
- Unit of General Surgery and Surgical Oncology, Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Virginia Boccardi
- Section of Gerontology and Geriatrics, Department of Medicine and Surgery, University of Perugia, Perugia, Italy.
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Civan Kahve A, Kaya H, Daylan Hİ, Ozpinar O, Goka E. Evaluation of Psychiatric Consultations of Elderly Hospitalized Patients: What are the Psychological Complaints and Diagnoses? ADVANCES IN GERONTOLOGY 2022. [DOI: 10.1134/s2079057022010064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Hao S, Reis HL, Wercholuk AN, Snyder RA, Parikh AA. Prehabilitation for Older Adults Undergoing Liver Resection: Getting Patients and Surgeons Up to Speed. J Am Med Dir Assoc 2022; 23:547-554. [PMID: 35247359 DOI: 10.1016/j.jamda.2022.01.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 01/19/2022] [Accepted: 01/27/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Morbidity rates following liver resection are high, especially among older adult patients. This review aims to evaluate the evidence surrounding prehabilitation in older patients anticipating liver resection and to describe how prehabilitation may be implemented. DESIGN Problem-based narrative review with case-based discussion. SETTING AND PARTICIPANTS All older adults anticipating liver resection inclusive of benign and malignant etiologies in the United States. METHODS Literature search was performed using MeSH terms and keywords in MEDLINE via PubMed, followed by a manual second search for relevant references within selected articles. Articles were excluded if not available in the English language or did not include patients undergoing hepatectomy. RESULTS Prehabilitation includes a range of activities including exercise, nutrition/dietary changes, and psychosocial interventions that may occur from several weeks to days preceding a surgical operation. Older adult patients who participate in prehabilitation may experience improvement in preoperative candidacy as well as improved postoperative quality of life and faster return to baseline; however, evidence supporting a reduction in postoperative length of stay and perioperative morbidity and mortality is conflicting. A variety of modalities are available for prehabilitation but lack consensus and standardization. For a provider desiring to prescribe prehabilitation, multidisciplinary assessments including geriatric, cardiopulmonary, and future remnant liver function can help determine individual patient needs and select appropriate interventions. CONCLUSIONS AND IMPLICATIONS In the older adult patient undergoing liver resection, the current body of literature suggests promising benefits of prehabilitation programs inclusive of functional assessment as well as multimodal interventions. Additional research is needed to determine best practices.
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Affiliation(s)
- Scarlett Hao
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Heidi L Reis
- Health Sciences Library, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Ashley N Wercholuk
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Rebecca A Snyder
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC, USA; Department of Public Health, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Alexander A Parikh
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC, USA.
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Quinn S, Akram W, Hao S, Honaker MD. Emergency Surgery for Diverticulitis: Relationship of Outcomes to Patient Age and Surgical Procedure. J Am Med Dir Assoc 2022; 23:616-622.e1. [PMID: 35245484 DOI: 10.1016/j.jamda.2022.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 02/01/2022] [Accepted: 02/01/2022] [Indexed: 01/27/2023]
Abstract
OBJECTIVES To compare outcomes in emergent surgical treatment of acute diverticulitis in the older population. DESIGN Retrospective multi-institute database cohort analysis. SETTINGS AND PARTICIPANTS American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) and NSQIP Colectomy Targeted Database. METHODS The American College of Surgeons National Surgical Quality Improvement Project Colectomy Targeted Database was merged with the main participate use file to identify adult patients undergoing emergent Hartmann procedure or primary anastomosis with diverting loop ileostomy for acute diverticulitis. Patients were subdivided into age cohorts (<65 years, 65-79 years, ≥80 years) and primary postoperative outcomes including mortality, morbidity, and readmission were compared using multivariate regression. RESULTS A total of 6091 patients were identified. On multivariate analysis, 30-day mortality was higher in patients undergoing a Hartmann procedure aged 65-79 years [odds ratio (OR) 2.39, P < .001] and ≥80 years (OR 6.28, P < .001) compared to patients aged <65 years. In patients undergoing a primary anastomosis with diverting loop ileostomy, 30-day morbidity was lower only in the cohort aged ≥80 years (OR 2.63, P = .04). Readmission rates were similar across age groups within each procedure cohort. Comparing the 2 procedures, readmission rates in patients aged 65-79 years who underwent a Hartmann procedure were lower than those that underwent a primary anastomosis with diverting loop ileostomy (OR 2.43, P = .001). In patients aged ≥80 years, readmission rates were lower in patients who underwent a primary anastomosis with diverting loop ileostomy (OR 0.12, P = .04). Thirty-day mortality was also lower in patients aged ≥80 years if they underwent a primary anastomosis with diverting loop ileostomy (OR 0.15, P = .03) but similar for patients aged 65-79 years (OR 0.81, P = .70). CONCLUSION AND IMPLICATIONS In patients undergoing a Hartmann procedure emergently for diverticulitis, mortality is higher in older patients. Patients aged ≥ 80 years had increased mortality if they underwent a Hartmann procedure compared to a primary anastomosis with diverting ileostomy; however, readmission rates vary with procedure performed. Careful consideration of age should be taken into account when operating emergently for diverticulitis.
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Affiliation(s)
- Seth Quinn
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Warqaa Akram
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Scarlett Hao
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Michael D Honaker
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC, USA.
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Lester PE, Ripley D, Grandelli R, Drew LA, Keegan M, Islam S. Interdisciplinary Protocol for Surgery in Older Persons: Development and Implementation. J Am Med Dir Assoc 2022; 23:555-562. [PMID: 35227669 DOI: 10.1016/j.jamda.2022.01.070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 01/11/2022] [Accepted: 01/13/2022] [Indexed: 10/19/2022]
Abstract
As the population ages, more older adults will undergo surgical procedures, and common physiologic changes can raise the risk for surgical complications while increasing morbidity and mortality. In conjunction with the National Surgical Quality Improvement Program, we piloted a comprehensive and interdisciplinary assessment and intervention protocol for perioperative care for patients aged ≥75 years undergoing elective general, gynecology-oncologic, and orthopedic surgery. The intervention included screening tools for cognitive, functional, and nutritional deficits, a Geriatric Nurse Champion on each inpatient surgical unit, and an interdisciplinary Geriatric Surgery Quality Committee. Our intervention group was compared to surgical patients during the same time period 1 year prior to the intervention, and the groups were well matched in demographics and comorbidities. The intervention group had significantly higher rates of advance care plan documentation in analysis of all patients (P < .001) and in subgroup analysis of those 85 and older (P = .006). The preintervention group had less postoperative delirium compared to the postintervention group but it was not significant and there was no difference in length of stay between groups. Various explanations for the minimal impact of the protocol exist: small sample size, presence of other hospital initiatives to reduce pressure ulcer and delirium, and clinician's awareness of project planning that led to incorporating ideas prior to official implementation. Future research implementing this protocol in naïve and/or underperforming institutions may demonstrate a greater effect. Larger sample size as well as implementation in other surgical fields may reveal a significant impact. However, if additional study does not reveal a meaningful impact of a comprehensive geriatric assessment for surgical patients, then consideration must be made regarding unrecognized factors in surgical care for older adults or perhaps that factors cannot be mitigated in older adults because they are intrinsically a higher surgical risk.
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Wu C, Ma D, Chen Y. Association of Pulse Pressure Difference and Diabetes Mellitus in Chinese People: A Cohort Study. Int J Gen Med 2021; 14:6601-6608. [PMID: 34703280 PMCID: PMC8523515 DOI: 10.2147/ijgm.s327841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 09/17/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Here, we sought to determine the association between pulse pressure difference and the incidence of type 2 diabetes mellitus (T2DM) in Chinese people. Methods This study involved 211,814 participants among whom 4156 had been diagnosed with T2DM. The correlation between pulse pressure difference and T2DM incidence in Chinese people was determined by multivariate analysis. A smooth curve fitting diagram was then used to explore correlation between pulse pressure difference and T2DM incidence. Finally, the inflection point in the correlation between pulse pressure difference and the T2DM incidence was located by piecewise linear regression. Results To understand the relationship, adjustments were made for sex, age, total serum cholesterol (TC), fasting blood glucose (FPG), triglyceride (TG), alanine aminotransferase (ALT), family history of diabetes, body mass index (BMI), blood urea nitrogen (BUN), drinking status, and smoking status. Diabetes incidence increased by 0.3% [HR 1.003 (1.001, 1.005), p = <0.05] for every 1mmHg increase in pulse pressure difference. Smooth curve analysis showed that, when pulse pressure difference was ≤35mmHg, diabetes incidence negatively correlated to pulse pressure difference [HR 0.972 (0.953, 0.972) p = 0.053]. However, when pulse pressure difference was >35mmHg, diabetes incidence increased with increasing pulse pressure difference [HR 1.044 (1.042, 1.047) p = <0.001]. And between pulse pressure difference and fasting blood glucose in the final visit, the blood glucose level increased with the elevation of pulse pressure. Conclusion The risk of diabetes was lowest at about 35mmHg pulse pressure difference.
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Affiliation(s)
- Chunlei Wu
- Department of Cardiac Surgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, 317000, People's Republic of China
| | - Denhua Ma
- Department of Cardiac Surgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, 317000, People's Republic of China
| | - Yu Chen
- Department of Cardiac Surgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, 317000, People's Republic of China
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Jang WM, Lee J, Eun SJ, Yim J, Kim Y, Kwak MY. Travel time to emergency care not by geographic time, but by optimal time: A nationwide cross-sectional study for establishing optimal hospital access time to emergency medical care in South Korea. PLoS One 2021; 16:e0251116. [PMID: 33939767 PMCID: PMC8092794 DOI: 10.1371/journal.pone.0251116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/20/2021] [Indexed: 11/18/2022] Open
Abstract
Increase in travel time, beyond a critical point, to emergency care may lead to a residential disparity in the outcome of patients with acute conditions. However, few studies have evaluated the evidence of travel time benchmarks in view of the association between travel time and outcome. Thus, this study aimed to establish the optimal hospital access time (OHAT) for emergency care in South Korea. We used nationwide healthcare claims data collected by the National Health Insurance System database of South Korea. Claims data of 445,548 patients who had visited emergency centers between January 1, 2006 and December 31, 2014 were analyzed. Travel time, by vehicle from the residence of the patient, to the emergency center was calculated. Thirteen emergency care-sensitive conditions (ECSCs) were selected by a multidisciplinary expert panel. The 30-day mortality after discharge was set as the outcome measure of emergency care. A change-point analysis was performed to identify the threshold where the mortality of ECSCs changed significantly. The differences in risk-adjusted mortality between patients living outside of OHAT and those living inside OHAT were evaluated. Five ECSCs showed a significant threshold where the mortality changed according to their OHAT. These were intracranial injury, acute myocardial infarction, other acute ischemic heart disease, fracture of the femur, and sepsis. The calculated OHAT were 71-80 min, 31-40 min, 70-80 min, 41-50 min, and 61-70 min, respectively. Those who lived outside the OHAT had higher risks of death, even after adjustment (adjusted OR: 1.04-7.21; 95% CI: 1.03-26.34). In conclusion, the OHAT for emergency care with no significant increase in mortality is in the 31-80 min range. Optimal travel time to hospital should be established by optimal time for outcomes, and not by geographic time, to resolve the disparities in geographical accessibility to emergency care.
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Affiliation(s)
- Won Mo Jang
- Department of Public Health and Community Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Juyeon Lee
- Center for Public Health, National Medical Center, Seoul, South Korea
| | - Sang Jun Eun
- Department of Preventive Medicine, Chungnam National University College of Medicine, Daejeon, South Korea
| | - Jun Yim
- Center for Public Health, National Medical Center, Seoul, South Korea
- Department of Citizen Health, University of Seoul, Seoul, South Korea
| | - Yoon Kim
- Institute of Health Policy and Management, Medical Research Center, Seoul National University, Seoul, South Korea
- Department of Health Policy and Management, Seoul National University College of Medicine, Seoul, South Korea
| | - Mi Young Kwak
- Center for Public Health, National Medical Center, Seoul, South Korea
- * E-mail:
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Mueller JL, Molina G, Ferrone CR, Chang DC, Vagefi P, Tanabe KK, Clancy TE, Qadan M. Open hepatic resection in the elderly at two tertiary referral centers. Am J Surg 2021; 222:594-598. [PMID: 33518291 DOI: 10.1016/j.amjsurg.2021.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/20/2020] [Accepted: 01/16/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Surgeons are being increasingly called upon to operate on the very elderly. This study aimed to evaluate outcomes following hepatectomy in patients ≥80 years of age at two tertiary care centers. METHODS All adult patients who underwent liver resection from 2001 to 2017 were included. Primary outcome was 90-day postoperative mortality. Secondary outcomes included 30-day postoperative mortality and postoperative complications. RESULTS Between 2001 and 2017, 2397 patients underwent liver resection. On unadjusted analysis, patients ≥80 years of age had higher rates of 90-day mortality (13.3% vs. 3.6%, p < 0.001), 30-day mortality (5.6% vs. 1.8%, p = 0.01), MI (7.9% vs. 3.5%, p = 0.04), and UTI (10.0% vs. 4.5%, p = 0.02). On multivariable analysis, age ≥80 years was significantly associated with 90-day postoperative mortality (OR 4.51, 95%CI 2.11-9.67, p < 0.001). CONCLUSIONS Across these two major referral tertiary care centers, very elderly patients had higher rates of 90-day and 30-day postoperative mortality on both unadjusted and adjusted analyses.
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Affiliation(s)
- Jessica L Mueller
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - George Molina
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | | | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Parsia Vagefi
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Kenneth K Tanabe
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Thomas E Clancy
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.
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Shchatsko A, Purcell LN, Tignanelli CJ, Charles A. The Effect of Organ System Surgery on Intensive Care Unit Mortality in a Cohort of Critically Ill Surgical Patients. Am Surg 2020; 87:1230-1237. [PMID: 33342251 DOI: 10.1177/0003134820956353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The critical illness burden in the United States is growing with an aging population obtaining surgical intervention despite age-related comorbidities. The effect of organ system surgical intervention on intensive care units (ICUs) mortality is unknown. METHODS We performed an 8-year retrospective analysis of surgical ICU patients. Poisson regression analysis was performed assessing the relative risk of in-hospital mortality based on surgical intervention. RESULTS Of 468 000 ICU patients included, 97 968 (20.9%) were surgical admissions and 97 859 (99.9%) had complete outcomes data. Nonsurvivors were older (68.8 ± 15.4 vs. 62.7 ± 15.8 years, P < .001) with higher Acute Physiology, Age, Chronic Health Evaluation (APACHE) III Scores (81.4 ± 33.6 vs. 46.7 ± 20.1, P < .001. Patients with gastrointestinal (GI) (n = 1,558, 7.8%), musculoskeletal (n = 277, 5.5%), and neurological (n = 884, 4.6%) system operations had the highest mortality. Upon Poisson regression model, patients undergoing emergent operative interventions on the neurologic system (RR 1.86, 95% CI 1.67-2.07, P < .001) had increased relative risk of mortality when compared to emergent operative interventions on the cardiovascular system after controlling for pertinent covariates. Elective operative interventions on the respiratory (RR 2.39, 95% CI 2.03-2.80, P < .001), GI (RR 2.34, 95% CI 2.10-2.61, P < .001), and skin and soft tissue (RR 2.26, 95% CI 1.77-2.89, P < .001) systems had increased risk of mortality when compared to elective cardiovascular system surgery after controlling for pertinent covariates. CONCLUSION We found significant differences in the risk of mortality based on organ system of operative intervention. The prognostication of critically ill patients undergoing surgical intervention is currently not accounted for in prognostic scoring systems.
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Affiliation(s)
- Anastasiya Shchatsko
- Department of Surgery, Central Michigan University College of Medicine, Saginaw, USA
| | - Laura N Purcell
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
| | | | - Anthony Charles
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
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20
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Increased Morbidity and Mortality of Emergency Laparotomy in Elderly Patients. World J Surg 2020; 44:711-720. [PMID: 31646368 DOI: 10.1007/s00268-019-05240-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND There is an increasing incidence of elderly patients requiring emergency laparotomy. Our study compares the outcomes of elderly patients undergoing emergency laparotomy against the outcomes of non-elderly patients. METHODOLOGY Patients who underwent emergency laparotomy between 2015 and 2017 from the National University Hospital, Singapore, were included. Apart from demographic data, indication of surgery and surgical procedure performed were collected. Prospectively collected nutritional scores were evaluated. Outcome measures included duration of surgery, length of ICU and total hospital stay, post-operative complications, and mortality indices. We performed multivariate Cox regression analysis to determine the contribution of various risk factors towards overall survival following emergency laparotomy. RESULTS A total of 170 emergency laparotomies were performed. Compared to non-elderly patients, elderly patients had a significantly longer mean stay in hospital (31.5 vs. 18.6 days, p = 0.006) and mean stay in ICU (13.1 vs. 5.3 days, p = 0.003). More elderly patients suffered from post-laparotomy complications compared with non-elderly patients (65.8% vs. 37.4%, p < 0.001). 30-day mortality (31.5% vs. 8.8%, p = 0.019) and 1-year mortality (27.9% vs. 14.3%, p = 0.023) were higher in elderly patients compared with non-elderly patients. Interestingly, there was no statistically significant difference between elderly and non-elderly groups in both the global 3-MinNS as well as the global SGA nutritional scores. ASA status (HR 2.61, 95% CI 1.05-6.45, p = 0.038) was an independent risk factor for decreased survival following emergency laparotomy. Notably, while age ≥ 65 demonstrated a significant correlation with survival on univariate analysis (HR 1.03 (1.01-1.05), p = 0.003), this effect was lost following multivariate regression (HR 1.01 (0.453-2.23), p = 0.989). CONCLUSION Elderly patients suffer worse morbidity and mortality following emergency laparotomy. This is likely contributed by comorbidities resulting in higher ASA status.
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Meltzer RS, Kooby DA, Switchenko JM, Datta J, Carpizo DR, Maithel SK, Shah MM. Does Major Pancreatic Surgery Have Utility in Nonagenarians with Pancreas Cancer? Ann Surg Oncol 2020; 28:2265-2272. [PMID: 33141373 DOI: 10.1245/s10434-020-09279-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 10/04/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE This study aims to define the role of surgery and assess different therapies for nonagenarians with localized, nonmetastatic pancreatic adenocarcinoma (PDAC). METHODS The National Cancer Database (NCDB) was queried for patients ≥ 90 years of age with nonmetastatic, localized PDAC from 2004-2016. Postoperative mortality was assessed at 30 and 90 days in patients receiving pancreatoduodenectomy or total pancreatectomy. Overall survival (OS) was compared between three treatment groups: surgery alone, chemotherapy alone, and chemoradiation (chemoRT) alone. RESULTS Of 380,524 patients with PDAC, 98 patients ≥ 90 years of age underwent curative-intent resection; 55% were female and 75% had a Charlson-Deyo comorbidity score of 0. A total of 17% received postoperative chemotherapy, 51.1% had poorly differentiated tumors with a median tumor size of 3 cm, 55.1% had positive lymph nodes, and 19.4% had positive resection margins. Postoperative median length of stay was 11 days. Postoperative 30- and 90-day mortality was 10.0% and 18.9%, respectively. Median OS for the surgery alone group was 11.6 months compared with 20.4 months in those receiving adjuvant therapy (p = 0.01). Among nonoperative PDAC patients, median OS in patients receiving chemotherapy only (n = 207) was 7.2 months, while chemoRT only (n = 100) was similar to surgery only (11 versus 11.6 months, p = 0.97). CONCLUSIONS Even in well-selected nonagenarians, pancreatoduodenectomy or total pancreatectomy carries a high mortality rate. While adjuvant therapy after resection provides the best survival, it is seldom achieved, and chemoRT alone affords identical survival statistics as surgery alone. These data suggest it is reasonable to consider chemoRT as initial therapy, then reassess candidacy for resection if performance status allows.
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Affiliation(s)
| | - David A Kooby
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, Georgia
| | - Jeffrey M Switchenko
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Jashodeep Datta
- Division of Surgical Oncology, University of Miami Miller School of Medicine, Miami, USA
| | - Darren R Carpizo
- Division of Surgical Oncology, Wilmot Cancer Institute, University of Rochester, Rochester, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, Georgia
| | - Mihir M Shah
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, Georgia.
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Dworsky JQ, Shenoy R, Childers CP, Russell MM. Older veterans undergoing inpatient surgery: What is the compliance with best practice guidelines? Surgery 2020; 169:356-361. [PMID: 33077200 DOI: 10.1016/j.surg.2020.08.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 08/01/2020] [Accepted: 08/27/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND The United States population is aging, and the number of older adults requiring operative care is increasing at a rapid rate. In order to address this issue, the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society created best practice guidelines surrounding optimal perioperative care for the older adult surgical patient. This study aimed to determine the documented compliance with these guidelines at a single institution. METHODS A retrospective chart review was performed on 86 older adults undergoing elective, inpatient coronary artery bypass graft, prostatectomy, or colectomy over a 2-year period (1/2016-12/2017) at a single Veterans Affairs institution. The primary outcome was compliance with the 38 measures from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society Best Practice Guidelines. The secondary outcome was postoperative (including geriatric-specific) complications. RESULTS The mean reported compliance across all measures was 41% ± 4%. Of 38 analyzed measures, compliance for 10 measures was achieved for 0 patients, and only 1 patient for 7 measures. There was variance in compliance by phase of care (P < .05) with a high of 56% ± 8% (immediate preoperative phase of care) and a low of 35% ± 4% (intraoperative phase of care). CONCLUSION Overall reported compliance with the Best Practice Guidelines of the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society is low (41%) at this institution. This study identifies a need to improve the care provided to the vulnerable population of older adults undergoing an operation. Future work is needed to understand barriers for implementation and how compliance relates to outcomes.
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Affiliation(s)
- Jill Q Dworsky
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Rivfka Shenoy
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, CA; National Clinician Scholars Program, University of California, Los Angeles, CA
| | | | - Marcia M Russell
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, CA.
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Olufajo OA, Wilson A, Yehayes B, Zeineddin A, Cornwell EE, Williams M. Trends in the Surgical Management and Outcomes of Complicated Peptic Ulcer Disease. Am Surg 2020; 86:856-864. [PMID: 32916073 DOI: 10.1177/0003134820939929] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Older data indicate that less patients undergo surgery for complicated peptic ulcer disease (PUD). We evaluated contemporary trends in the surgical management and outcomes of patients with complicated PUD. METHODS The National Inpatient Sample (2005-2014) was queried for patients with complicated PUD (hemorrhage, perforation, or obstruction). Trend analyses were used to evaluate changes in management and outcomes. RESULTS There were 1 570 696 admissions for complicated PUD during the study period. Majority (87.0%) presented with hemorrhage, 10.6% presented with perforation, and 2.4% had an obstruction. The average age was 67 years. Overall, admissions with complicated PUD decreased from 180 054 in 2005 to 150 335 in 2014. The proportion of patients managed operatively decreased from 2.5% to 1.9% in the hemorrhage group, 75.0% to 67.4% in the perforation group, and 26.0% to 20.2% in the obstruction group (all P-trend < .05). Overall, among patients managed operatively, the use of acid-reducing procedures decreased from 25.9% to 13.9%, mortality decreased from 11.9% to 9.4% (both P-trend < .001), while complications remained stable (10.4% to 10.3%, P-trend = .830). CONCLUSIONS There are fewer admissions with complicated PUD and more patients are treated nonoperatively. Despite subtle improvements, significant proportions of patients still die from complicated PUD indicating the need for improved preoperative optimization and postoperative care among these patients.
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Affiliation(s)
- Olubode A Olufajo
- 8369 Department of Surgery, Clive O. Callender Howard-Harvard Health Sciences Outcomes Research Center, Howard University College of Medicine, Washington, DC, USA
| | - Amanda Wilson
- 8369 Department of Surgery, Clive O. Callender Howard-Harvard Health Sciences Outcomes Research Center, Howard University College of Medicine, Washington, DC, USA
| | - Bruke Yehayes
- 8369 Department of Surgery, Clive O. Callender Howard-Harvard Health Sciences Outcomes Research Center, Howard University College of Medicine, Washington, DC, USA
| | - Ahmad Zeineddin
- 8369 Department of Surgery, Clive O. Callender Howard-Harvard Health Sciences Outcomes Research Center, Howard University College of Medicine, Washington, DC, USA
| | - Edward E Cornwell
- 8369 Department of Surgery, Clive O. Callender Howard-Harvard Health Sciences Outcomes Research Center, Howard University College of Medicine, Washington, DC, USA
| | - Mallory Williams
- 8369 Department of Surgery, Clive O. Callender Howard-Harvard Health Sciences Outcomes Research Center, Howard University College of Medicine, Washington, DC, USA
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Increasing Frailty, Not Increasing Age, Results in Increased Length of Stay Following Vestibular Schwannoma Surgery. Otol Neurotol 2020; 41:e1243-e1249. [DOI: 10.1097/mao.0000000000002831] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Laparoscopic Repair of Perforated Peptic Ulcer in the Elderly: An Interim Analysis of the FRAILESEL Italian Multicenter Prospective Cohort Study. Surg Laparosc Endosc Percutan Tech 2020; 31:2-7. [PMID: 32675754 DOI: 10.1097/sle.0000000000000826] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 06/05/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The number of elderly patients requiring emergency surgical intervention has increased dramatically. Perforated peptic ulcer (PPU) complications, such as perforation, have remained relatively stable and associated morbidity remains between 10% and 20%. Advances in perioperative care have greatly improved the outcomes of laparoscopic emergency surgery, allowing increasing numbers of patients, even the elderly, to undergo safe repair. The aim of this study was to evaluate the feasibility, safety, and outcome of laparoscopic gastric repair in the elderly using the database of the FRAILESEL (Frailty and Emergency Surgery in the Elderly) study. MATERIALS AND METHODS This is a retrospective analysis carried out on data of the FRAILESEL study. Data on all the elderly patients who underwent emergency abdominal surgery for PPU from January 2017 to December 2017 at 36 Italian surgical departments were analyzed. Patients who underwent PPU repair were further divided into a laparoscopic gastroduodenal repair (LGR) cohort and an open gastroduodenal repair (OGR) cohort, and the clinicopathologic features of the patients in both the groups were compared. RESULTS Sixty-seven patients fulfilled the inclusion criteria. Thirty-three patients (47.8%) underwent LGR. The LGR patients had less blood loss and shorter postoperative stay, even if the difference was not statistically significant. The mean operative time was significantively higher in the OGR (OGR 96.5±27.7 vs. LGR 78.6±16.3 P=0.000). The rate of death after laparoscopic surgery was similar to the rate of the open surgery. Multivariate analysis indicated that only age (P=0.018), admission haemoblogbin (Hb) level (P=0.006), platelet count (P=0.16), lactate level (P=0.47), and Mannheim Peritonitis Index (P=0.18) were independent variables associated with the risk of overall mortality. CONCLUSIONS LGR is safe and feasible in elderly patients with PPU and it is associated with better perioperative outcomes. However, patient selection and preoperative frailty evaluation in the elderly population are the key to achieving better outcomes.
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Aitken RM, Partridge JSL, Oliver CM, Murray D, Hare S, Lockwood S, Beckley-Hoelscher N, Dhesi JK. Older patients undergoing emergency laparotomy: observations from the National Emergency Laparotomy Audit (NELA) years 1-4. Age Ageing 2020; 49:656-663. [PMID: 32484859 DOI: 10.1093/ageing/afaa075] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND older patients aged ≥65 years constitute the majority of the National Emergency Laparotomy Audit (NELA) population. To better understand this group and inform future service changes, this paper aims to describe patient characteristics, outcomes and process measures across age cohorts and temporally in the 4-year period (2014-2017) since NELA was established. METHODS patient-level data were populated from the NELA data set years 1-4 and linked with Office of National Statistics mortality data. Descriptive data were compared between groups delineated by age, NELA year and geriatrician review. Primary outcomes were 30- and 90-day mortality, length of stay (LOS) and discharge to care-home accommodation. RESULTS in total, 93,415 NELA patients were included in the analysis. The median age was 67 years. Patients aged ≥65 years had higher 30-day (15.3 versus 4.9%, P < 0.001) and 90-day mortality (20.4 versus 7.2%, P < 0.001) rates, longer LOS (median 15.2 versus 11.3 days, P < 0.001) and greater likelihood of discharge to care-home accommodation compared with younger patients (6.7 versus 1.9%, P < 0.001). Mortality rate reduction over time was greater in older compared with younger patients. The proportion of older NELA patients seen by a geriatrician post-operatively increased over years 1-4 (8.5 to 16.5%, P < 0.001). Post-operative geriatrician review was associated with reduced mortality (30-day odds ratio [OR] 0.38, confidence interval [CI] 0.35-0.42, P < 0.001; 90-day OR 0.6, CI 0.56-0.65, P < 0.001). CONCLUSIONS older NELA patients have poorer post-operative outcomes. The greatest reduction in mortality rates over time were observed in the oldest cohorts. This may be due to several interventions including increased perioperative geriatrician input.
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Affiliation(s)
- Rachel M Aitken
- Perioperative Care of Older People undergoing Surgery (POPS), Department of Ageing and Health, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- National Emergency Laparotomy Audit, Royal College of Anaesthetists, London, UK
| | - Judith S L Partridge
- Perioperative Care of Older People undergoing Surgery (POPS), Department of Ageing and Health, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Division of Primary Care and Public Health Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Charles Matthew Oliver
- National Emergency Laparotomy Audit, Royal College of Anaesthetists, London, UK
- Health Systems Research, UCL Division of Targeted Intervention, London, UK
| | - Dave Murray
- National Emergency Laparotomy Audit, Royal College of Anaesthetists, London, UK
- Department of Anaesthesia, James Cook University Hospital, Middlesbrough, UK
| | - Sarah Hare
- National Emergency Laparotomy Audit, Royal College of Anaesthetists, London, UK
- Department of Anaesthesia, Medway Maritime Hospital, Kent, UK
| | - Sonia Lockwood
- National Emergency Laparotomy Audit, Royal College of Anaesthetists, London, UK
- General Surgery Unit, Bradford Royal Infirmary, Bradford Teaching Hospitals, Bradford, UK
| | | | - Jugdeep K Dhesi
- Perioperative Care of Older People undergoing Surgery (POPS), Department of Ageing and Health, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Division of Primary Care and Public Health Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
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Ruiz de Gopegui Miguelena P, Martínez Lamazares MT, Miguelena Hycka J, Claraco Vega LM, Gurpegui Puente M. Influence of frailty in the outcome of surgical patients over 70 years old with admission criteria in ICU. Cir Esp 2020; 99:41-48. [PMID: 32507310 DOI: 10.1016/j.ciresp.2020.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/17/2020] [Accepted: 04/26/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Frailty degree can influence more than age or severity in the outcome of patients older than 70 years undergoing surgery of the digestive system that require immediate postoperative control in the ICU. METHODS A prospective and observational study of patients over 70 years of age who were admitted to the surgical ICU of a third level hospital immediately after an elective or emergent surgical intervention on the digestive system from June 1, 2018 until June 1, 2019. The variables age, frailty Clinical Frailty Scale (CFS), and modified Frailty Index (mFI), severity (APACHE II), type of surgery, surgical pathology were recorded upon admission. A bivariate analysis was performed to assess the influence of frailty and severity on hospital morbidity and mortality and baseline situation of the patient (in terms of dependence) at 6 months. RESULTS A total of 90 patients were recruited, 54.4% of whom were reoperated; 74.4% were initially discharged from the ICU, with 28.4% of readmission and directly associated to frailty (CFS and mFI: P<0.01). The overall mortality at 6 months was 44.5% being CFS (OR = 64.3; P<0.05, 95% CI: 12.3-333.9) and APACHE II (OR = 1.17; P<0.05; 95% CI: 1.04-1.32) the covariates that best related. CONCLUSIONS The estimation of frailty by CSF and mFI is directly associated to the surgical morbidity and readmission of elderly and severe patients admitted to the ICU. In addition, CFS and mFI has been efficient as a predictive of mortality at 6 months.
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Yamamoto M, Ikeda M, Matsumoto T, Takemoto M, Sumimoto R, Kobayashi T, Ohdan H. Hemorrhoidectomy for elderly patients aged 75 years or more, before and after studies. Ann Med Surg (Lond) 2020; 55:88-92. [PMID: 32477502 PMCID: PMC7251490 DOI: 10.1016/j.amsu.2020.04.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 04/29/2020] [Indexed: 02/07/2023] Open
Abstract
Background The incidence of hemorrhoids requiring hemorrhoidectomy among the elderly has been increasing. Old age is sometimes considered a contraindication for surgery. The relationship between age and complications of hemorrhoidectomy for elderly patients is not well established. This study aimed to compare the clinicopathological features and postoperative outcomes of hemorrhoidectomy in the elderly (≥75 years old) and non-elderly patients (<75 years old). Methods A total of 100 patients who underwent hemorrhoidectomy for hemorrhoids of Goligher classification grades 3 and 4 at our institution between 2014 and 2018 were enrolled. The clinical characteristics were compared between the elderly and non-elderly patients. Pain scores were measured at 6, 12, 24, and 48 h after surgery. The risk factors for postoperative complications were identified. Results A total of 34 patients were classified as elderly patients. In the elderly group, aspartate aminotransferase levels were higher while the albumin levels and cholinesterase levels were lower and the platelet counts were significantly lower. The blood urea nitrogen levels were higher and estimated glomerular filtration rates and hemoglobin levels were significantly lower in the elderly group. The pain scores significantly decreased at 48 h postoperatively compared to those recorded at 6 h postoperatively in both groups. Multivariate analysis identified Goligher classification grade 4 and high neutrophil to lymphocyte ratio at the indicators of complications. Conclusions Hemorrhoids due to impairment of liver function and kidney function were dominant in elderly patients. Aging itself was not a risk factor for postoperative complications. The feasibility of hemorrhoidectomy for the elderly is not remained clear. The incidence of postoperative complications was comparable regardless of age. The risk factor for complication was Goligher classification grade 4 and high NLR.
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Affiliation(s)
- Masateru Yamamoto
- Department of Surgery, National Hospital Organization Yanai Medical Center, Yamaguchi, Japan.,Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masanobu Ikeda
- Department of Surgery, National Hospital Organization Yanai Medical Center, Yamaguchi, Japan
| | - Tomio Matsumoto
- Department of Surgery, National Hospital Organization Yanai Medical Center, Yamaguchi, Japan
| | - Masahiko Takemoto
- Department of Surgery, National Hospital Organization Yanai Medical Center, Yamaguchi, Japan
| | - Ryo Sumimoto
- Department of Surgery, National Hospital Organization Yanai Medical Center, Yamaguchi, Japan
| | - Tsuyoshi Kobayashi
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Chernock B, Hwang F, Berlin A, Pentakota SR, Singh R, Singh R, Mosenthal AC. Emergency abdominal surgery in patients presenting from skilled nursing facilities: Opportunities for palliative care. Am J Surg 2020; 219:1076-1082. [DOI: 10.1016/j.amjsurg.2019.09.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 09/06/2019] [Accepted: 09/17/2019] [Indexed: 01/16/2023]
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Khan KA, Subramanian T, Richters M, Mubarik A, Saad Abdalla Al-Zawi A, Thorn CC, Chalstrey S, Gunasekera S. Working Collaboratively: Outcomes of Geriatrician Input in Older Patients Undergoing Emergency Laparotomy in a District General Hospital. Cureus 2020; 12:e7069. [PMID: 32104643 PMCID: PMC7039363 DOI: 10.7759/cureus.7069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
With the increasing median age of survival in the UK, there is an increased burden on the provision of medical and surgical care to the population. The 2010 National Confidential Enquiry into Patient Outcome and Death report, "An Age Old Problem," emphasizes the early involvement of surgical and geriatric consultant input to improve perioperative care in older patients. This study describes the development of a Geriatric Surgical Liaison Service aimed at providing consultant-led geriatrician support to improve the outcomes of older patients undergoing Emergency Laparotomy (EL). The primary outcome is the reduction in length of stay (LOS) compared to baseline data prior to geriatrician involvement. The service was designed to include one clinical session involving a consultant geriatrician and two and a half days with a junior doctor in a week. Data was collected prospectively from February 2018 till July 2018 for surgical patients aged ≥ 70 years, who underwent EL, had an inpatient stay of more than seven days, and who were diagnosed with delirium or incurred inpatient falls (intervention group). Baseline data, prior to geriatrician involvement, were collected retrospectively for EL patients aged ≥ 70 years from December 2015 until May 2016. Length of stay and 30-day mortality were also compared between the two cohorts undergoing EL. A total of 69 patients were included in the intervention group; 45 patients underwent EL and their mean LOS was 17.5 days, which was reduced from 22.5 days prior to geriatrician involvement (n=57). There was no difference in median length of stay and 30-day mortality between the retrospective baseline group and the intervention groups. In the intervention group, 8.5% of patients had a new medical diagnosis and 26.8% of patients were offered follow-ups. Although statistically not significant (p=0.40), a shorter stay in hospital by five days can potentially have a positive impact on patient outcomes by reducing psychosocial, cognitive, and functional deconditioning. This would also improve patient flow, release capacity, and waiting times and would be of benefit to the financially strained National Health Service (NHS). Overall, our study suggests that a collaborative, consultant-led geriatric service can improve the management of older surgical patients by potentially reducing length of stay, identifying high-risk patients, and facilitating early and appropriate specialty input alongside adequate and required outpatient follow-up.
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Affiliation(s)
- Kashuf A Khan
- General Surgery, Royal Shrewsbury and Telford National Health Service (NHS) Trust, Shrewsbury, GBR
| | - Thejasvi Subramanian
- General Surgery, Good Hope Hospital, University Hospitals Birmingham, Birmingham, GBR
| | - Megan Richters
- Internal Medicine, Great Western Hospital National Health Service (NHS) Foundation Trust, Swindon, GBR
| | - Ayesha Mubarik
- Family Medicine, Whiston Hospital, St Helens and Knowsley Teaching Hospitals National Health Service (NHS) Trust, Rochdale, GBR
| | | | - Christopher C Thorn
- General Surgery, Great Western Hospital National Health Service (NHS) Foundation Trust, Swindon, GBR
| | - Susan Chalstrey
- Otolaryngology, Great Western Hospital National Health Service (NHS) Foundation Trust, Swindon, GBR
| | - Savithri Gunasekera
- Geriatrics, Frimley Health National Health Service (NHS) Foundation Trust, Frimley, GBR
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The immense heterogeneity of frailty in neurosurgery: a systematic literature review. Neurosurg Rev 2020; 44:189-201. [PMID: 31953785 DOI: 10.1007/s10143-020-01241-2] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 01/07/2020] [Accepted: 01/08/2020] [Indexed: 12/21/2022]
Abstract
The aim of this study was to review and analyze the neurosurgery body of literature to document the current knowledge of frailty within neurosurgery, standardizing terminology and how frailty is defined, including the different levels of frailty, while determining what conclusions can be drawn about frailty's impact on neurosurgical outcomes. While multiple studies on frailty in neurosurgery exist, no literature reviews have been conducted. Therefore, we performed a literature review in order to organize, tabulate, and present findings from the data to broaden the understanding about what we know from frailty and neurosurgery. We performed a PubMed search to identify studies that evaluated frailty and neurosurgery. The terms "frail," "frailty," "neurosurgery," "spine surgery," "craniotomy," and "neurological surgery" were all used in the query. We then organized, analyzed, and summarized the comprehensive frailty and neurosurgical literature. The literature contained 25 published studies analyzing frailty in neurosurgery between December 2015 and December 2018. Five of these studies were cranial neurosurgical studies, the remaining studies focused on spinal neurosurgery. Over 100,000 surgical cases were analyzed among the 25 studies. Of these, 18 studies demonstrated that increasing frailty was associated with increased rate of complications, 10 studies showed that frailty was associated with higher mortality rates, 11 studies demonstrated an association between frailty and increased hospital length of stay, and 5 studies noted that higher frailty was associated with discharge to a higher level of care. The current body of literature repeatedly demonstrates that frailty is associated with worse outcomes across the neurosurgical subspecialties.
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Tan HL, Chia STX, Nadkarni NV, Ang SY, Seow DCC, Wong TH. Frailty and functional decline after emergency abdominal surgery in the elderly: a prospective cohort study. World J Emerg Surg 2019; 14:62. [PMID: 31892937 PMCID: PMC6937965 DOI: 10.1186/s13017-019-0280-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 11/25/2019] [Indexed: 11/10/2022] Open
Abstract
Background Frailty has been associated with an increased risk of adverse postoperative outcomes in elderly patients. We examined the impact of preoperative frailty on loss of functional independence following emergency abdominal surgery in the elderly. Methods This prospective cohort study was performed at a tertiary hospital, enrolling patients 65 years of age and above who underwent emergency abdominal surgery from June 2016 to February 2018. Premorbid variables, perioperative characteristics and outcomes were collected. Two frailty measures were compared in this study-the Modified Fried's Frailty Criteria (mFFC) and Modified Frailty Index-11 (mFI-11). Patients were followed-up for 1 year. Results A total of 109 patients were prospectively recruited. At baseline, 101 (92.7%) were functionally independent, of whom seven (6.9%) had loss of independence at 1 year; 28 (25.7%) and 81 (74.3%) patients were frail and non-frail (by mFFC) respectively. On univariate analysis, age, Charlson Comorbidity Index and frailty (mFFC) (univariate OR 13.00, 95% CI 2.21-76.63, p < 0.01) were significantly associated with loss of functional independence at 1 year. However, frailty, as assessed by mFI-11, showed a weaker correlation than mFFC (univariate OR 4.42, 95% CI 0.84-23.12, p = 0.06). On multivariable analysis, only premorbid frailty (by mFFC) remained statistically significant (OR 15.63, 95% CI 2.12-111.11, p < 0.01). Conclusions The mFFC is useful for frailty screening amongst elderly patients undergoing emergency abdominal surgery and is a predictor for loss of functional independence at 1 year. Including the risk of loss of functional independence in perioperative discussions with patients and caregivers is important for patient-centric emergency surgical care. Early recognition of this at-risk group could help with discharge planning and priority for post-discharge support should be considered.
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Affiliation(s)
- Hwee Leong Tan
- 1Department of General Surgery, Singapore General Hospital, 20 College Road, Academia Level 5, Singapore, 169856 Singapore
| | - Shermain Theng Xin Chia
- 2SingHealth Internal Medicine Residency, Singapore General Hospital, 20 College Road, Academia Level 3, Singapore, 169856 Singapore
| | - Nivedita Vikas Nadkarni
- 3Centre for Quantitative Medicine, Duke-NUS Graduate Medical School, 8 College Rd, Singapore, 169857 Singapore
| | - Shin Yuh Ang
- 4Nursing Division, Nursing Quality, Research & Transformation, Singapore General Hospital, Outram Road, Singapore, 169608 Singapore
| | - Dennis Chuen Chai Seow
- 5Department of Geriatric Medicine, Singapore General Hospital, 20 College Road, Academia Level 3, Singapore, 169856 Singapore
| | - Ting Hway Wong
- 1Department of General Surgery, Singapore General Hospital, 20 College Road, Academia Level 5, Singapore, 169856 Singapore.,6Duke-NUS Medical School, 8 College Rd, Singapore, 169857 Singapore
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Zeng J, Zheng G, Li Y, Yang Y. Preoperative Pulse Pressure and Adverse Postoperative Outcomes: A Meta-Analysis. J Cardiothorac Vasc Anesth 2019; 34:624-631. [PMID: 31986286 DOI: 10.1053/j.jvca.2019.09.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 08/29/2019] [Accepted: 09/25/2019] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To evaluate the association between preoperative pulse pressure (PP) and the incidences of renal, neurologic, cardiac, and mortality outcomes after surgery. DESIGN Systematic review and meta-analysis of cohort studies. SETTING Hospitals. PARTICIPANTS Patients who underwent cardiac or noncardiac surgeries. INTERVENTION The preoperative PP was measured. MEASUREMENT AND MAIN RESULTS Relevant cohort studies were obtained by systematic search of PubMed and Embase databases. A randomized effect model was used to pool the results. The multivariate adjusted risk ratio (RR) and its 95% confidence intervals (CI) were calculated to reflect the association between preoperative PP and adverse postoperative outcomes. Twelve cohort studies that included 40,143 patients who had undergone cardiac, vascular, or noncardiac surgery were included in the meta-analysis. The results showed that above a threshold of 40 mmHg, an increase in preoperative PP of 10 mmHg was independently associated with increased risk for renal events (adjusted RR: 1.13, 95% CI 1.08-1.19, p < 0.001; I2 = 0%), neurologic events (adjusted RR: 1.75, 95% CI 1.01-3.02, p = 0.04; I2 = 70%), cardiac events (adjusted RR: 1.19, 95% CI 1.03-1.37, p = 0.01; I2 = 0%), major cardiovascular adverse events (adjusted RR: 1.62, 95% CI 1.10-2.41, p = 0.02; I2 = 0%), and overall mortality (adjusted RR: 1.13, 95% CI 1.07-1.20, p < 0.001; I2 = 0%) after surgery. CONCLUSIONS Patients with higher-than-normal preoperative PP are at increased risk for adverse postoperative outcomes.
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Affiliation(s)
- Jin Zeng
- Department of Anesthesiology, The First Affiliated Hospital of Jinan University, Guangzhou, China; Department of Anesthesiology, Liuzhou People's Hospital, Liuzhou, China
| | - Guoquan Zheng
- Department of Anesthesiology, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Yalan Li
- Department of Anesthesiology, The First Affiliated Hospital of Jinan University, Guangzhou, China.
| | - Yuanyuan Yang
- Out-patient Department, Liuzhou People's Hospital, Liuzhou, China
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Sucher JF, Mangram AJ, Dzandu JK. Utilization of Geriatric Consultation and Team-Based Care. Clin Geriatr Med 2019; 35:27-33. [DOI: 10.1016/j.cger.2018.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Emergency surgery in older patients. Wideochir Inne Tech Maloinwazyjne 2018; 14:182-186. [PMID: 31118981 PMCID: PMC6528122 DOI: 10.5114/wiitm.2018.77628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 07/13/2018] [Indexed: 01/23/2023] Open
Abstract
Introduction At present, emergency guidelines do not differentiate between younger adults and older persons. The changing socioeconomic situation associated with the aging population will be challenging for the healthcare system and requires new medical guidelines to best accommodate it. Aim To analyze whether the age and comorbidities of a patient affect acute care surgical outcomes. Material and methods We performed a retrospective study of 161 patients who were admitted in emergency to the Department of General, Minimally Invasive and Elderly Surgery in Olsztyn between May and October 2017. Patients were divided into three age groups. Outcomes in patients older than 80 years were compared with corresponding statistical predictions of morbidity and mortality, as calculated using the Physiologic and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM). Results Patients in the 80+ age group had a higher mortality rate in comparison with those in the other age groups, and a higher number of comorbidities (p = 0.002 and p = 0.001, respectively). The POSSUM morbidity and mortality rates were significantly higher for the older patients who died than for the older patients who were discharged (p = 0.013 and p = 0.003, respectively). Conclusions Decisions about suitable therapy in the acute care setting should be made after consideration of the overall health of a patient. This study shows that age itself has a huge impact on postoperative results. The older the patient is, the higher the risk of perioperative death. We recommend patient evaluation using the POSSUM scale to better predict this risk.
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Vilches-Moraga A, Fox J, Paracha A, Gomez-Quintanilla A, Epstein J, Pearce L. Predicting in-hospital mortality in older general surgical patients. Ann R Coll Surg Engl 2018; 100:529-533. [PMID: 29909664 DOI: 10.1308/rcsann.2018.0086] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Introduction A significant number of emergency general surgical admissions occur in older patients. Clinical decision making in this group is challenging and current risk prediction tools extrapolate data from cohorts of younger patients. This is the first UK study to examine risk factors predicting in-hospital mortality in older acute surgical patients undergoing comprehensive geriatric assessment. Methods This was a prospective study of consecutive patients aged ≥75 years admitted non-electively to general surgery wards between September 2014 and February 2017 who were reviewed by an elderly medicine in-reach service. Results A total of 577 patients were included with a mean age of 82.9 years. There was a female predominance (56%). The majority were living at home alone or with carers (93%) and most were independent in basic activities of daily living (79%). Over two-thirds (69%) were mobile with no walking aids or use of a walking stick and overt here-quarters (79%) had no cognitive impairment. Seventy-seven per cent of patients were managed non-operatively. The in-hospital mortality rate was 6.9%. Female sex (p=0.031), dependence in activities of daily living (p<0.001), cognitive impairment (p<0.001) and incontinence (p<0.001) were predictors of in-hospital mortality. ASA (American Society of Anesthesiologists) grade ≥3 was also associated with increased in-hospital mortality (odds ratio: 5.3, 95% confidence interval: 2.6-10.7). Conclusions Older general surgical patients present a high level of complexity. This study highlights the predictive role of mobility, functional and cognitive impairment when assessing this population. Accurate risk stratification requires global assessment by teams experienced in care of the older patient rather than the traditional focus on co-morbidities.
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Affiliation(s)
| | - J Fox
- Salford Royal NHS Foundation Trust , UK
| | - A Paracha
- Salford Royal NHS Foundation Trust , UK
| | | | - J Epstein
- Salford Royal NHS Foundation Trust , UK
| | - L Pearce
- Salford Royal NHS Foundation Trust , UK
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Perioperative Outcome in Geriatric Patients. CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0267-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Ruscelli P, Popivanov G, Tabola R, Polistena A, Sanguinetti A, Avenia N, Renzi C, Cirocchi R, Ursi P, Fingerhut A. Modified Paul-Mikulicz jejunostomy in frail geriatric patients undergoing emergency small bowel resection. MINERVA CHIR 2018; 74:121-125. [PMID: 29795063 DOI: 10.23736/s0026-4733.18.07714-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Proximal or extended bowel resections are sometimes necessary during emergency surgery of the small bowel and call for creating a high small bowel stomy as a part of damage control surgery. Secondary restoration of intestinal continuity in the frail geriatric patient, further weakened by subsequent severe malabsorption may be prohibitive. METHODS Six patients underwent emergency small bowel resection for proximal jejunal disease (83.3% high-grade adhesive SBO and 16.7% jejunal diverticulitis complicated with perforation). With the intention to avoid end jejunostomy and the need for repeat laparotomy for bowel continuity restoration we modified the classic Paul-Mikulicz jejunostomy. RESULTS The postoperative course was uneventful in four patients whose general condition improved considerably. At six-month follow-up, neither patients required parenteral nutrition. CONCLUSIONS This modified stoma can have the advantage of allowing a partial passage of the enteric contents, reducing the degree of malabsorption, and rendering jejunostomy reversal easy to perform later.
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Affiliation(s)
- Paolo Ruscelli
- Unit of Emergency Surgery, Torrette Hospital, Faculty of Medicine and Surgery, Polytechnic University of Marche, Ancona, Italy
| | - Georgi Popivanov
- Military Medical Academy-Sofia, Clinic of Endoscopic, Endocrine Surgery and Coloproctology, Sofia, Bulgaria
| | - Renata Tabola
- Department and Clinic of Gastrointestinal and General Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Andrea Polistena
- Unit of General Surgery and Surgical Specialties, University of Perugia, Terni, Italy
| | | | - Nicola Avenia
- Unit of General Surgery and Surgical Specialties, University of Perugia, Terni, Italy
| | - Claudio Renzi
- Department of Surgery and Biochemical Sciences, University of Perugia, Terni, Italy
| | - Roberto Cirocchi
- Department of Surgery and Biochemical Sciences, University of Perugia, Terni, Italy -
| | - Pietro Ursi
- Department of General Surgery and Surgical Specialties, Sapienza University, Rome, Italy
| | - Abe Fingerhut
- Section for Surgical Research, Medical University of Graz, Graz, Austria
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Vilches-Moraga A, Fox J. Geriatricians and the older emergency general surgical patient: proactive assessment and patient centred interventions. Salford-POP-GS. Aging Clin Exp Res 2018; 30:277-282. [PMID: 29411329 PMCID: PMC5856886 DOI: 10.1007/s40520-017-0886-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 12/22/2017] [Indexed: 01/31/2023]
Abstract
Increasing numbers of older patients require Emergency admission under General Surgery (EGS). This is a group of heterogeneous and often complex individuals with varying degrees of multimorbidity, polypharmacy, functional, mobility and cognitive impairment. Our article describes the benefits of comprehensive assessment coupled with patient-centred multiprofessional interventions and timely discharge planning. We discuss diverse service models and describe our experience in the planning, development and consolidation of a perioperative service for older EGS patients.
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Affiliation(s)
- Arturo Vilches-Moraga
- Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK.
- Salford Royal NHS Foundation Trust, Salford, UK.
| | - Jenny Fox
- Salford Royal NHS Foundation Trust, Salford, UK
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Costa G, Massa G. Frailty and emergency surgery in the elderly: protocol of a prospective, multicenter study in Italy for evaluating perioperative outcome (The FRAILESEL Study). Updates Surg 2018; 70:97-104. [PMID: 29383680 DOI: 10.1007/s13304-018-0511-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 01/13/2018] [Indexed: 02/07/2023]
Abstract
Improvements in living conditions and progress in medical management have resulted in better quality of life and longer life expectancy. Therefore, the number of older people undergoing surgery is increasing. Frailty is often described as a syndrome in aged patients where there is augmented vulnerability due to progressive loss of functional reserves. Studies suggest that frailty predisposes elderly to worsening outcome after surgery. Since emergency surgery is associated with higher mortality rates, it is paramount to have an accurate stratification of surgical risk in such patients. The aim of our study is to characterize the clinicopathological findings, management, and short-term outcome of elderly patients undergoing emergency surgery. The secondary objectives are to evaluate the presence and influence of frailty and analyze the prognostic role of existing risk-scores. The final FRAILESEL protocol was approved by the Ethical Committee of "Sapienza" University of Rome, Italy. The FRAILESEL study is a nationwide, Italian, multicenter, observational study conducted through a resident-led model. Patients over 65 years of age who require emergency surgical procedures will be included in this study. The primary outcome measures are 30-day postoperative mortality and morbidity rates. The Clavien-Dindo classification system is used to categorize complications. The secondary outcome measures include length of hospital stay, length of stay in intensive care unit, and predictive value for morbidity and mortality of several frailty and surgical risk-scores. The results of the FRAILESEL study will be disseminated through national and international conference presentations and peer-reviewed journals. The study is also registered at ClinicalTrials.gov (ClinicalTrials.gov identifier: NCT02825082).
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Affiliation(s)
- Gianluca Costa
- Surgical and Medical Department of Translational Medicine, Sant'Andrea Teaching Hospital, "Sapienza" University, 00189, Rome, Italy
| | - Giulia Massa
- Surgical and Medical Department of Translational Medicine, Sant'Andrea Teaching Hospital, "Sapienza" University, 00189, Rome, Italy.
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Slot KM, Peters JVM, Vandertop WP, Verbaan D, Peerdeman SM. Meningioma surgery in younger and older adults: patient profile and surgical outcomes. Eur Geriatr Med 2017; 9:95-101. [PMID: 29430269 PMCID: PMC5797210 DOI: 10.1007/s41999-017-0015-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 12/02/2017] [Indexed: 12/22/2022]
Abstract
Background Due to increasing life expectancy, the number of older patients harboring a meningioma is expected to increase. We determined whether preoperative variables and postoperative clinical outcome differ between younger and older adults. Methods Medical records of meningioma patients were retrospectively analyzed. Preoperative variables were age, gender, neurological symptoms, Karnofsky Performance Status (KPS), American Society of Anesthesiologists Physical Status (ASA)-classification and tumor characteristics. Clinical outcome was assessed using complication rates, length of hospital stay and destination after discharge. After 6–12 and 12–18-month KPS, neurological symptoms and Glasgow Outcome Scale (GOS) scores were assessed for older (age ≥ 65 years) and younger adults (18–65 years) using Mann–Whitney U, T test, Pearson’s Chi square or Fisher’s exact. Results 89 patients were included (23 ≥ 65 years). Before surgery, older patients scored higher on ASA classification (p = 0.003) and lower on KPS (p = 0.017). There was no significant difference postoperatively in mortality, complications and duration of hospital stay. Less older patients were discharged directly to home compared to younger adults (52 vs 80%, respectively; p = 0.004). In surviving patients, less older subjects had a good recovery (GOS 4–5) at 6–12 months’ follow-up compared to younger subjects (64 vs 93%, respectively; p = 0.035). At 12–18 months, there was no significant difference in good recovery between both age groups (82 vs 92%). Conclusion In this cohort, outcome was worse for patients ≥ 65 years old in terms of discharge destination and good recovery at 6–12 months. At 12–18 months follow-up, older subjects performed not significantly different from younger ones. Careful patient selection seems essential to reach good results in meningioma surgery for patients ≥ 65 years old.
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Affiliation(s)
- K Mariam Slot
- Neurosurgical Center Amsterdam, VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands.
- Neurosurgical Center Amsterdam, Academic Medical Center, Amsterdam, The Netherlands.
| | - Jocelyne V M Peters
- Neurosurgical Center Amsterdam, VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - W Peter Vandertop
- Neurosurgical Center Amsterdam, VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
- Neurosurgical Center Amsterdam, Academic Medical Center, Amsterdam, The Netherlands
| | - Dagmar Verbaan
- Neurosurgical Center Amsterdam, Academic Medical Center, Amsterdam, The Netherlands
| | - Saskia M Peerdeman
- Neurosurgical Center Amsterdam, VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
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Vilches-Moraga A, Fox J, Paracha A, Gomez-Quintanilla A, Maevis T, Epstein J, Thomson A. Baseline characteristics and clinical outcomes of older patients admitted as an emergency to general surgical wards. Salford-POPS – GS. Eur Geriatr Med 2017. [DOI: 10.1016/j.eurger.2017.07.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Fariña-Castro R, Roque-Castellano C, Marchena-Gómez J, Rodríguez-Pérez A. Five-year survival after surgery in nonagenarian patients. Geriatr Gerontol Int 2017; 17:2389-2395. [PMID: 28675571 DOI: 10.1111/ggi.13081] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 02/14/2017] [Accepted: 03/28/2017] [Indexed: 11/26/2022]
Abstract
AIM In countries with longer life expectancies, the nonagenarian population is increasing. Therefore, there is greater demand for healthcare, including surgical procedures. The aim of the present study was to determine the outcomes of surgery carried out on nonagenarians in terms of long-term survival after the procedure. METHODS We carried out a cross-longitudinal study on a cohort of 159 nonagenarian patients, who underwent a non-cardiac, non-traumatic surgical procedure in our institution between January 1999 and December 2011. The following variables were recorded: sociodemographic characteristics, American Society of Anesthesiologists score, Charlson Comorbidity Index, surgical site, postoperative complications, operative mortality and long-term survival. The output variable was long-term survival. RESULTS Of the 159 patients,99 women (62%) and 60 men (38%), with a mean age of 91.8 years (SD ± 2.0 years), 44 cases were operations for malignant disorders (28%), 117 cases (74%) under emergency conditions and 42 cases (26%) were elective treatments. The operative mortality was 29%, 4.8% for elective surgery and 37.6% for emergency surgery (P < 0.001). The postoperative complication rate, including death, was 60%. The probability of survival at 1, 3, and 5 years was 59.6%, 35.8% and 24.1%, respectively. In multivariate analysis, American Society of Anesthesiologists score (HR 2.07, 95% CI 1.58-2.72), emergency surgery (HR 1.64, 95% CI 1.05-2.57) and postoperative medical complications (HR 2.58, 95% CI 1.73-3.85) were independently related to 5-year survival. CONCLUSIONS These findings support the perioperative safety of elective general surgery in nonagenarian patients. In selected nonagenarian patients with no cognitive impairment, surgery must not be denied. These data might be useful for surgical decision-making or informed consent for nonagerians. Geriatr Gerontol Int 2017; 17: 2389-2395.
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Affiliation(s)
- Roberto Fariña-Castro
- Department of Anesthesiology, University Hospital of Gran Canaria Dr. Negrín, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Cristina Roque-Castellano
- Department of General and Digestive Surgery, University Hospital of Gran Canaria Dr. Negrín, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Joaquín Marchena-Gómez
- Department of General and Digestive Surgery, University Hospital of Gran Canaria Dr. Negrín, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Aurelio Rodríguez-Pérez
- Department of Anesthesiology, University Hospital of Gran Canaria Dr. Negrín, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
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