Risk Factors for Mortality and Morbidity in Elderly Patients Presenting with Digestive Surgical Emergencies

Effect of emergency general surgery on postoperative performance status in patients aged over 90 years

Background

Functional deterioration following emergency general surgery (EGS) poses a significant challenge in super-elderly patients. However, limited research has focused on assessing the deterioration in postoperative performance status (PS). This study aimed to investigate the impact of EGS on PS deterioration in super-elderly patients, and the extent to which deteriorated PS is recovered.

Methods

This historical cohort study comprised 77 super-elderly patients who underwent EGS between July 2015 and December 2020. Functional deterioration was evaluated by comparing preoperative and postoperative Eastern Cooperative Oncology Group Performance Status (ECOG-PS). The Emergency Surgical Score (ESS) was used as a risk-adjustment tool. Questionnaires were mailed to the patients and their families to assess post-discharge PS and obtain their impressions of EGS.

Results

Postoperative PS deteriorated in 35/77 patients (45.5 %). Significant differences were observed between the groups in terms of sex, serum C-reactive protein (CRP) levels, ESS scores, preoperative ECOG-PS, duration of operation, and major complications. Multivariate analysis of preoperative factors showed that ESS ≥7 (OR: 3.7, 95 % CI: 1.0-13), preoperative ECOG-PS ≤2 (OR: 5.9, 95 % CI: 1.7-21), and female sex (OR: 5.8, 95 % CI: 1.6-21) were associated with postoperative ECOG-PS deterioration. According to the questionnaire results, PS recovery post-discharge was observed in 6/36 (17 %) patients, and 34/36 (94 %) patients and their families expressed positive impressions of EGS.

Conclusions

EGS in super-elderly patients highly caused a deterioration in their PS, particularly in patients with maintained preoperative PS. PS hardly recovered; however, most patients and their families had positive impressions of the EGS.

Key message

We assessed the pre- and postoperative performance status of super-elderly patients who underwent emergency general surgery. Surgery caused a marked deterioration in patients' functional performance, which seldom recovered postoperatively.

Outcomes of Laparoscopic Versus Open Surgery in Elderly Patients with Rectal Cancer

Background:

Laparoscopic colorectal resection has been gaining popularity over the past two decades-and the number of elderly patients with colorectal cancer treated with a surgical modality has gradually increased. However, studies about laparoscopic rectal surgery in elderly patients with long-term oncologic outcomes are limited. In this study, we evaluated the safety and effectiveness of laparoscopic resection in patients with rectal cancer aged ≥80 y.

Methods:

From 2007-2015, a total of 84 consecutive patients with rectal cancer from a single institution were included, 45 patients undergoing laparoscopic rectal resection were compared with 39 patients undergoing open rectal resection.

Results:

The two groups were well balanced in terms of age, gender, body mass index, American society of anesthesiologists scores, previous abdominal surgery, neoadjuvant therapy, tumor stage, distance of tumor from the anal verge, and comorbidities. One (2.2%) patient in the laparoscopic group required conversion to open surgery. Laparoscopic surgery was associated with significantly longer operating time (160.1±28.2 versus 148.2±41.3 min; P=0.031), less intraoperative blood loss (80.5±20.9 versus 160.3±42.4 mL; P=0.002), less need of blood transfusion (6.7% versus 20.5%; P=0.003), a shorter time to diet recovery (2.5±1.5 versus 4.9±1.1; P=0.015) and postoperative hospital stay (7.5±4.5 versus 10.8±4.2; P=0.035), lower overall postoperative complication rate (8.9% versus 20.5%; P=0.017), and wound-related complication rate (4.4% versus 10.2%; P=0.013) when compared with open surgery. Specimen length, no. of retrieced lymph nodes, positive distal and circumferential margin rate, mortality rate, and reoperation rate were not significantly different between two groups. The disease-free and overall 5-year survival rates were similar between two groups.

Conclusions:

Laparoscopic rectal surgery is safe and feasible in patients aged≥80 y and is associated with similar long-term oncologic outcomes when compared with open surgery.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

AIM

There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland.

METHODS

Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines.

RESULTS

All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

Continuous thoracic spinal anesthesia with local anesthetic plus midazolam and ketamine is superior to local anesthetic plus fentanyl in major abdominal surgery

BACKGROUND

Limited studies have applied thoracic continuous spinal anesthesia in abdominal surgery, relying exclusively on opioids. This retrospective study analyzes 2 different schemes of thoracic continuous spinal anesthesia and postoperative analgesia in elderly patients undergoing major abdominal surgery.

METHODS

A total of 98 patients aged ≥ 75 years were divided into 2 groups. The control group (60 patients) received bupivacaine plus fentanyl, whereas the study group (38 patients) received bupivacaine plus ketamine and midazolam. Both received analogous postoperative continuous intrathecal analgesia. Several perioperative variables were evaluated.

RESULTS

Spinal anesthesia was performed without complications in all patients. Doses of noradrenaline administered, incidence of respiratory depression, need for intraoperative sedation, and time to first flatus were significantly reduced in the bupivacaine plus ketamine and midazolam group.

CONCLUSION

In a population of frail, elderly patients, thoracic continuous spinal anesthesia with local anesthetic plus midazolam and ketamine was superior to local anesthetic plus fentanyl. In the group receiving local anesthetic plus midazolam and ketamine, the incidence of respiratory depression was reduced, and doses of norepinephrine and intraoperative sedating medications were lower. Intraoperative anesthesia and postoperative analgesia were similar in both groups.

Sarcopenia predicts 90-day mortality in elderly patients undergoing emergency abdominal surgery

PURPOSE

Image-based measurement of sarcopenia is an established predictor of a decreased outcome for a large variety of surgical procedures. Sarcopenia in elderly patients undergoing emergency abdominal surgery has not been well studied. This study aims to investigate the association between the total psoas area (TPA) and postoperative mortality after 90 days in a group of elderly emergency laparotomy patients.

METHODS

We retrospectively reviewed the emergency CT-scans of 150 elderly patients from a consecutive cohort undergoing emergency abdominal surgery at our surgical center. TPA was measured manually at the level of L3 and indexed to patient height. Sarcopenia was defined as having a TPA index below the first quartile for gender in the cohort. Other collected variables were age, vital status/date of death, ASA-score, surgical procedure, and WHO performance score.

RESULTS

Overall 90-day mortality was 42.7%. Sarcopenic patients had a higher 90-day mortality (60.5%) than non-sarcopenic patients (36.6%), corresponding to an odds ratio of 2.66 (95% confidence interval 1.2-5.7, p = 0.01). Sarcopenic patients had an increased mortality compared with non-sarcopenic patients (p = 0.0009, Log-rank test), with a clear separation of the two groups within 30 days postoperatively. In a multivariate logistic regression model, with age, ASA-score, and WHO performance score as covariates, sarcopenia was independently associated with 90-day mortality.

CONCLUSION

Manual measurement of TPA on an abdominal CT-scan is a relevant risk factor for postoperative mortality in elderly patients undergoing high-risk emergency abdominal surgery. Incorporation of sarcopenia in postoperative risk-prediction models in emergency abdominal surgery should be considered.