Long-term outcomes of major abdominal surgery and postoperative delirium after multimodal prehabilitation of older patients

EAES/SAGES evidence-based recommendations and expert consensus on optimization of perioperative care in older adults

BACKGROUND

As the population ages, more older adults are presenting for surgery. Age-related declines in physiological reserve and functional capacity can result in frailty and poor outcomes after surgery. Hence, optimizing perioperative care in older patients is imperative. Enhanced Recovery After Surgery (ERAS) pathways and Minimally Invasive Surgery (MIS) may influence surgical outcomes, but current use and impact on older adults patients is unknown. The aim of this study was to provide evidence-based recommendations on perioperative care of older adults undergoing major abdominal surgery.

METHODS

Expert consensus determined working definitions for key terms and metrics related to perioperative care. A systematic literature review and meta-analysis was performed using the PubMed, Embase, Cochrane Library, and Clinicaltrials.gov databases for 24 pre-defined key questions in the topic areas of prehabilitation, MIS, and ERAS in major abdominal surgery (colorectal, upper gastrointestinal (UGI), Hernia, and hepatopancreatic biliary (HPB)) to generate evidence-based recommendations following the GRADE methodology.

RESULT

Older adults were defined as 65 years and older. Over 20,000 articles were initially retrieved from search parameters. Evidence synthesis was performed across the three topic areas from 172 studies, with meta-analyses conducted for MIS and ERAS topics. The use of MIS and ERAS was recommended for older adult patients particularly when undergoing colorectal surgery. Expert opinion recommended prehabilitation, cessation of smoking and alcohol, and correction of anemia in all colorectal, UGI, Hernia, and HPB procedures in older adults. All recommendations were conditional, with low to very low certainty of evidence, with the exception of ERAS program in colorectal surgery.

CONCLUSIONS

MIS and ERAS are recommended in older adults undergoing major abdominal surgery, with evidence supporting use in colorectal surgery. Though expert opinion supported prehabilitation, there is insufficient evidence supporting use. This work has identified evidence gaps for further studies to optimize older adults undergoing major abdominal surgery.

Development of an individualized model for predicting postoperative delirium in elderly patients with hepatocellular carcinoma

Postoperative delirium (POD) is a common complication in older patients with hepatocellular carcinoma (HCC) that adversely impacts clinical outcomes. We aimed to evaluate the risk factors for POD and to construct a predictive nomogram. Data for a total of 1481 older patients (training set: n=1109; validation set: n=372) who received liver resection for HCC were retrospectively retrieved from two prospective databases. The receiver operating characteristic (ROC) curve, calibration plot, and decision curve analysis (DCA) were used to evaluate the performance. The rate of POD was 13.3% (148/1109) in the training set and 16.4% (61/372) in the validation set. Multivariate analysis of the training set revealed that factors including age, history of cerebrovascular disease, American Society of Anesthesiologists (ASA) classification, albumin level, and surgical approach had significant effects on POD. The area under the ROC curves (AUC) for the nomogram, incorporating the aforementioned predictors, was 0.798 (95% CI 0.752-0.843) and 0.808 (95% CI 0.754-0.861) for the training and validation sets, respectively. The calibration curves of both sets showed a degree of agreement between the nomogram and the actual probability. DCA demonstrated that the newly established nomogram was highly effective for clinical decision-making. We developed and validated a nomogram with high sensitivity to assist clinicians in estimating the individual risk of POD in older patients with HCC.

Intravenous infusion of dexmedetomidine during the surgery to prevent postoperative delirium and postoperative cognitive dysfunction undergoing non-cardiac surgery: a meta-analysis of randomized controlled trials

BACKGROUND

Dexmedetomidine plays a pivotal role in mitigating postoperative delirium and cognitive dysfunction while enhancing the overall quality of life among surgical patients. Nevertheless, the influence of dexmedetomidine on such complications in various anaesthesia techniques remains inadequately explored. As such, in the present study, a meta-analysis was conducted to comprehensively evaluate its effects on postoperative delirium and cognitive dysfunction.

METHODS

A number of databases were searched for randomised controlled trials comparing intravenous dexmedetomidine to other interventions in preventing postoperative delirium and cognitive dysfunction in non-cardiac and non-neurosurgical patients. These databases included PubMed, Embase, and Cochrane Library. Statistical analysis and graphing were performed using Review Manager, STATA, the second version of the Cochrane risk-of-bias tool for randomised controlled trials, and GRADE profiler.

MAIN RESULTS

This meta-analysis comprised a total of 24 randomised controlled trials, including 20 trials assessing postoperative delirium and 6 trials assessing postoperative cognitive dysfunction. Across these 24 studies, a statistically significant positive association was observed between intravenous administration of dexmedetomidine and a reduced incidence of postoperative delirium (RR: 0.55; 95% CI 0.47 to 0.64, p < 0.00001, I2 = 2%) and postoperative cognitive dysfunction (RR: 0.60; 95% CI 0.38 to 0.96, p = 0.03, I2 = 60%). Subgroup analysis did not reveal a significant difference in the incidence of postoperative delirium between the general anaesthesia and non-general anaesthesia groups, but a significant difference was observed in the incidence of postoperative cognitive dysfunction. Nonetheless, when the data were pooled, it was evident that the utilisation of dexmedetomidine was associated with an increased incidence of hypotension (RR: 1.42; 95% CI 1.08 to 1.86, p = 0.01, I2 = 0%) and bradycardia (RR: 1.66; 95% CI 1.23 to 2.26, p = 0.001, I2 = 0%) compared with other interventions. However, there was no significantly higher occurrence of hypertension in the DEX groups (RR = 1.35, 95% CI 0.81-2.24, p = 0.25, I2 = 0%).

CONCLUSION

Compared with other interventions, intravenous dexmedetomidine infusion during non-cardiac and non-neurosurgical procedures may significantly reduce the risk of postoperative delirium and cognitive dysfunction. The results of subgroup analysis reveal a consistent preventive effect on postoperative delirium in both general and non-general anaesthesia groups. Meanwhile, continuous infusion during general anaesthesia was more effective in reducing the risk of cognitive dysfunction. Despite such findings, hypotension and bradycardia were more frequent in patients who received dexmedetomidine during surgery.

Association between postoperative delirium and adverse outcomes in older surgical patients: A systematic review and meta-analysis

STUDY OBJECTIVE

To assess the incidence of postoperative delirium and its outcomes in older non-cardiac surgical patients.

DESIGN

A systematic review and meta-analysis with multiple databases searched from inception to February 22, 2022.

SETTING

Postoperative assessments.

PATIENTS

Non-cardiac and non-neurological surgical patients aged ≥60 years with and without postoperative delirium. Included studies must report ≥1 postoperative outcome. Studies with a small sample size (N < 100 subjects) were excluded.

MEASUREMENTS

Outcomes comprised the pooled incidence of postoperative delirium and its postoperative outcomes, including mortality, complications, unplanned intensive care unit admissions, length of stay, and non-home discharge. For dichotomous and continuous outcomes, OR and difference in means were computed, respectively, with a 95% CI.

MAIN RESULTS

Fifty-four studies (20,988 patients, 31 elective studies, 23 emergency studies) were included. The pooled incidence of postoperative delirium was 19% (95% CI: 16%, 23%) after elective surgery and 32% (95% CI: 25%, 39%) after emergency surgery. In elective surgery, postoperative delirium was associated with increased mortality at 1-month (OR: 6.60; 95% CI: 1.58, 27.66), 6-month (OR: 5.69; 95% CI: 2.33, 13.88), and 1-year (OR: 2.87; 95% CI: 1.63, 5.06). The odds of postoperative complications, unplanned intensive care unit admissions, prolonged length of hospital stay, and non-home discharge were also higher in delirium cases. In emergency surgery, patients with postoperative delirium had greater odds of mortality at 1-month (OR: 3.56; 95% CI: 1.77, 7.15), 6-month (OR: 2.60; 95% CI: 1.88, 3.61), and 1-year (OR: 2.30; 95% CI: 1.77, 3.00).

CONCLUSIONS

Postoperative delirium was associated with higher odds of mortality, postoperative complications, unplanned intensive care unit admissions, length of hospital stay, and non-home discharge. Prevention and perioperative management of delirium may optimize surgical outcomes.

Cost-effectiveness of prehabilitation prior to elective surgery: a systematic review of economic evaluations

BACKGROUND

Prehabilitation aims at enhancing patients' functional capacity and overall health status to enable them to withstand a forthcoming stressor like surgery. Our aim was to synthesise the evidence on the cost-effectiveness of prehabilitation for patients awaiting elective surgery compared with usual preoperative care.

METHODS

We searched PubMed, Embase, the CRD database, ClinicalTrials.gov, the WHO ICTRP and the dissertation databases OADT and DART. Studies comparing prehabilitation for patients with elective surgery to usual preoperative care were included if they reported cost outcomes. All types of economic evaluations (EEs) were included. The primary outcome of the review was cost-effectiveness based on cost-utility analyses (CUAs). The risk of bias of trial-based EEs was assessed with the Cochrane risk of bias 2 tool and the ROBINS-I tool and the credibility of model-based EEs with the ISPOR checklist. Methodological quality of full EEs was assessed using the CHEC checklist. The EEs' results were synthesised narratively using vote counting based on direction of effect.

RESULTS

We included 45 unique studies: 25 completed EEs and 20 ongoing studies. Of the completed EEs, 22 were trial-based and three model-based, corresponding to four CUAs, three cost-effectiveness analyses, two cost-benefit analyses, 12 cost-consequence analyses and four cost-minimization analyses. Three of the four trial-based CUAs (75%) found prehabilitation cost-effective, i.e. more effective and/or less costly than usual care. Overall, 16/25 (64.0%) EEs found prehabilitation cost-effective. When excluding studies of insufficient credibility/critical risk of bias, this number reduced to 14/23 (60.9%). In 8/25 (32.0%), cost-effectiveness was unclear, e.g. because prehabilitation was more effective and more costly, and in one EE prehabilitation was not cost-effective.

CONCLUSIONS

We found some evidence that prehabilitation for patients awaiting elective surgery is cost-effective compared to usual preoperative care. However, we suspect a relevant risk of publication bias, and most EEs were of high risk of bias and/or low methodological quality. Furthermore, there was relevant heterogeneity depending on the population, intervention and methods. Future EEs should be performed over a longer time horizon and apply a more comprehensive perspective.

TRIAL REGISTRATION

PROSPERO CRD42020182813.

Effect of Perioperative Dexmedetomidine Infusion on Postoperative Delirium in Elderly Patients Undergoing Oral and Maxillofacial Surgery: A Randomized Controlled Clinical Trial

Purpose

The aim of the study was to determine whether perioperative dexmedetomidine administration can improve postoperative delirium in elderly patients undergoing oral and maxillofacial surgery.

Patients and Methods

This was a prospective double-blind randomized controlled clinical trial conducted in Cangzhou Central Hospital from December 2021 to March 2022. Patients aged 65 and older underwent oral and maxillofacial surgery under general anesthesia. Eligible patients were randomly assigned to dexmedetomidine or control group. Dexmedetomidine was injected intravenously from 10 min before induction of anesthesia to 30 min before the end of surgery in dexmedetomidine group, while patients in the control group were given normal saline at the same rate during the same time period. The primary measurement indicators were the incidence and duration of delirium in the first five days after surgery. The secondary measurement indicators were Visual Analogue Score (VAS) for the first 24 hours following surgery, subjective sleep quality score within 24 hours postoperatively and intraoperative adverse reactions.

Results

One hundred and twenty patients were randomly assigned. Baseline characteristics were similar between two groups. The incidence and duration of postoperative delirium did not differ statistically between two groups (all P > 0.05). Compared with control group, VAS scores in dexmedetomidine group were significantly lower at 6, 12, and 24 hours after surgery (all P < 0.05); moreover, Richards-Campbell Sleep Questionnaire (RCSQ) results were significantly improved 1 day after surgery in dexmedetomidine group (P < 0.05). Dexmedetomidine-related adverse reactions were similar in both groups (P > 0.05).

Conclusion

Intravenous infusion of dexmedetomidine 10 min before induction of anesthesia to half an hour before the end of surgery did not improve postoperative delirium in elderly patients undergoing oral and maxillofacial surgery; however, dexmedetomidine may be associated with decreased postoperative pain and improved postoperative sleep quality.

The clinical impact of frailty on the postoperative outcomes of patients undergoing appendectomy: propensity score-matched analysis of 2011-2017 US hospitals

BACKGROUND

The presence of clinical frailty can pose an escalated risk toward surgical outcomes including in cases that involve minimally invasive procedures. Given this premise, we evaluate the effects of frailty on post-appendectomy outcomes using a national in-hospital registry.

METHODS

2011-2017 National Inpatient Sample was used to isolate inpatient appendectomy cases; the population as stratified using Johns Hopkins ACG clinical frailty, expressed as either binary or ternary (prefrailty, frailty, and without frailty) indicators. The controls were matched to frailty-present groups using propensity score matching and compared to various endpoints, including mortality, length of stay (LOS), hospitalization costs, and postoperative complications.

RESULTS

Post-match, there were 11,758 with and without frailty per binary; and 1236 frail, 10,522 pre-frail with respective equal number controls per ternary indicator. Using binary term, frail patients had higher mortality (4.22 vs 1.49% OR 2.92 95%CI 2.45-3.47), LOS (14.3 vs 5.35d p < 0.001), and costs ($160,700 vs $64,141 p < 0.001). In multivariate, frail patients had higher mortality (aOR 2.77 95%CI 2.32-3.31), as well as higher rates of postoperative complications. Using ternary term, frail patients had higher mortality (5.02 vs 2.27% OR 2.28 95%CI 1.45-3.59), LOS (18.9 vs 5.66 day p < 0.001) and costs ($200,517 vs $66,193 p < 0.001). In multivariate, frail patients had higher mortality (aOR 2.16 95%CI 1.35-3.43) and complications. Those with pre-frailty had higher mortality (4.12 vs 1.47% OR 2.88 95%CI 2.39-3.46), LOS (13.8 vs 5.34 day p < 0.001) and costs ($156,022 vs $63,772 p < 0.001). In multivariate, pre-frailty patients had higher mortality (aOR 2.79 95%CI 2.31-3.37) and complications.

CONCLUSIONS

Frailty and prefrailty (using the ternary indicator) are associated with increased postoperative mortality and complication in patients who undergo appendectomy; given this finding, it is imperative that these vulnerable patients are identified early in the preoperative phase and are provided risk-modifying measures to ameliorate risks and optimize outcomes.

Current Landscape of Nutrition Within Prehabilitation Oncology Research: A Scoping Review

Background: Prehabilitation aims to improve functional capacity prior to cancer treatment to achieve better psychosocial and clinical outcomes. Prehabilitation interventions vary considerably in design and delivery. In order to identify gaps in knowledge and facilitate the design of future studies, we undertook a scoping review of prehabilitation studies to map the range of work on prehabilitation being carried out in any cancer type and with a particular focus on diet or nutrition interventions. Objectives: Firstly, to describe the type of prehabilitation programs currently being conducted. Secondly, to describe the extent to which prehabilitation studies involved aspects of nutrition, including assessment, interventions, implementation, and outcomes. Eligibility Criteria: Any study of quantitative or qualitative design that employed a formal prehabilitation program before cancer treatment ("prehabilitation" listed in keywords, title, or abstract). Sources of Evidence: Search was conducted in July 2020 using MEDLINE, PubMed, EMBASE, EMCARE, CINAHL, and AMED. Charting Methods: Quantitative data were reported as frequencies. Qualitative nutrition data were charted using a framework analysis that reflects the Nutrition Care Process Model: assessment, intervention, and monitoring/evaluation of the nutrition intervention. Results: Five hundred fifty unique articles were identified: 110 studies met inclusion criteria of a formal prehabilitation study in oncology. prehabilitation studies were mostly cohort studies (41%) or randomized-controlled trials (38%) of multimodal (49%), or exercise-only (44%) interventions that were applied before surgery (94%). Nutrition assessment was inconsistently applied across these studies, and often conducted without validated tools (46%). Of the 110 studies, 37 (34%) included a nutrition treatment component. Half of these studies provided the goal for the nutrition component of their prehabilitation program; of these goals, less than half referenced accepted nutrition guidelines in surgery or oncology. Nutrition interventions largely consisted of counseling with dietary supplementation. The nutrition intervention was indiscernible in 24% of studies. Two-thirds of studies did not monitor the nutrition intervention nor evaluate nutrition outcomes. Conclusion: Prehabilitation literature lacks standardized and validated nutritional assessment, is frequently conducted without evidence-based nutrition interventions, and is typically implemented without monitoring the nutrition intervention or evaluating the intervention's contribution to outcomes. We suggest that the development of a core outcome set could improve the quality of the studies, enable pooling of evidence, and address some of the research gaps identified.

The Role of Behavioral Science in Personalized Multimodal Prehabilitation in Cancer

Multimodal prehabilitation is increasingly recognized as an important component of the pre-operative pathway in oncology. It aims to optimize physical and psychological health through delivery of a series of tailored interventions including exercise, nutrition, and psychological support. At the core of this prescription is a need for considerable health behavior change, to ensure that patients are engaged with and adhere to these interventions and experience the associated benefits. To date the prehabilitation literature has focused on testing the efficacy of devised exercise and nutritional interventions with a primary focus on physiological and mechanistic outcomes with little consideration for the role of behavioral science, supporting individual behavior change or optimizing patient engagement. Changing health behavior is complex and to maximize success, prehabilitation programs should draw on latest insights from the field of behavioral science. Behavioral science offers extensive knowledge on theories and models of health behavior change to further advance intervention effectiveness. Similarly, interventions developed with a person-centered approach, taking into consideration individual needs and preferences will increase engagement. In this article, we will provide an overview of the extent to which the existing prehabilitation literature incorporates behavioral science, as well as studies that have explored patient's attitudes toward prehabilitation. We will go on to describe and critique ongoing trials in a variety of contexts within oncology prehabilitation and discuss how current scientific knowledge may be enhanced from a behavioral science perspective. We will also consider the role of “surgery schools” and detail practical recommendations that can be embedded in existing or emerging clinical settings.

Image-Guided Proton Therapy for Elderly Patients with Hepatocellular Carcinoma: High Local Control and Quality of Life Preservation

This study retrospectively investigated the efficacy and safety of image-guided proton therapy (IGPT) for elderly (≥80 years old) hepatocellular carcinoma (HCC) patients. Proton therapy was performed using respiratory-gated and image-guided techniques. Seventy-one elderly HCC patients were treated using IGPT. The Child-Pugh score was A5 in 49 patients, A6 in 15, and B7-9 in 7. Forty-seven patients with a peripherally located tumor were administered 66 gray relative biological effectiveness (GyRBE) in 10 fractions, whereas 24 with a centrally located tumor received 72.6 GyRBE in 22 fractions. The median follow-up period of surviving patients was 33 months (range: 9-68). Two-year overall survival (OS) and local control (LC) rates estimated by the Kaplan-Meier method were 76% (95% confidence interval: 66-87%) and 88% (80-97%), respectively. According to the Common Terminology Criteria for Adverse Events version 4.0, no grade 2 or higher radiation-induced liver disease was observed, and only 1 patient developed grade 3 dermatitis. The quality of life score (European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 version 3.0, QLQ-HCC18, and SF-36) did not change after 1 year, except for the three-mental component summary (SF-36, improvement). IGPT is a safe and effective treatment for HCC in elderly patients.