Frailty Predicts Loss of Independence After Liver Surgery

Feeble, Fallen, and Forgetting: Association of Cognitive Impairment and Falls on Outcomes of Major Intraabdominal Surgeries in Older Adults

INTRODUCTION

Both cognitive impairment/dementia (CID) and falls occur more commonly in older adults compared to younger patients. This study aims to analyze the association of a history of CID or falls with the postoperative outcomes of older adults undergoing major intraabdominal surgeries on a national level.

METHODS

We retrospectively analyzed the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) 2022 Participant Use Data File. Our primary outcome was postoperative mortality. Statistical analysis was performed using Chi-square test, and multivariate regression analysis.

RESULTS

On multivariable regression analyses, both a history of CID (OR: 1.9; CI: 1.5-2.5; p <0.01) and a fall (OR: 1.8, CI: 1.4 -2.3; p <0.01) were independently associated with higher adjusted odds of mortality. History of CID or falls was also a predictor of overall complications, major complications, and discharge to a care facility.

CONCLUSION

A history of CID or falls in older adults prior to major intraabdominal surgeries is associated with a high risk of postoperative mortality and morbidity. Further studies are required to establish the causal relation of these factors and the steps to mitigate the risk of associated adverse outcomes.

The minimally invasive approach confers improved outcomes in frail cancer patients undergoing hepatectomy: an American College of Surgeons National Surgical Quality Improvement Program analysis

BACKGROUND

Morbidity for liver resection has decreased, and frail patients are undergoing surgery. The effect of minimally invasive liver resection (MILR) is unknown. This study aimed to evaluate the effect of MILR on the outcomes in frail patients.

METHODS

Elective hepatectomies from the 2014-2020 American College of Surgeons National Surgical Quality Improvement Program hepatectomy-specific Participant User File were reviewed. The 5-factor modified frailty index (mFI-5) was used. It includes diabetes mellitus, hypertension, functional status, heart failure, and dyspnea. Patients were considered frail if their mFI-5 score was ≥2.

RESULTS

A total of 3116 patients were included: 2117 (67.9%) in the minor hepatectomy group and 999 (32%) in the major hepatectomy group. There were 2254 open cases and 862 MILRs. Postoperatively, patients in the minor hepatectomy group who underwent MILR had lower rates of prolonged length of stay (LOS), nonhome discharge, transfusion, major complications, and minor complications (P < .05). Postoperatively, patients in the major hepatectomy group who underwent MILR had lower rates of prolonged LOS and any complication (P < .05). In the minor hepatectomy group, MILR remained independently predictive of lower rates of prolonged LOS (odds ratio [OR], 0.34; 95% CI, 0.28-0.42), nonhome discharge (OR, 0.58; 95% CI, 0.41-0.84), transfusion (OR, 0.72; 95% CI, 0.54-0.96), major complication (OR, 0.78; 95% CI, 0.62-1.00), and any complication (OR, 0.73; 95% CI, 0.58-0.92). In the major hepatectomy group, MILR remained independently predictive of prolonged LOS (OR, 0.60; 95% CI, 0.40-0.89).

CONCLUSION

MILR resulted in lower rates of complications in the minor hepatectomy group and shorter LOS in the major hepatectomy group. The minimally invasive approach to hepatectomy may benefit frail patients with cancer.

Does the Surgical Approach Affect the Incidence of Post-Hepatectomy Liver Failure in Cirrhotic Patients? An Analysis of the NSQIP Database

Background: The association between surgical approach and post-hepatectomy liver failure (PHLF) in cirrhotic patients is poorly understood. We hypothesize that patients will have similar rates of liver failure regardless of whether they undergo minimally invasive liver resection (MILR) or open liver resection (OLR) in major liver resections. In contrast, there will be lower rates of PHLF in patients undergoing minor hepatectomy via the MILR approach.Methods: Propensity score matching was used to analyze regression by matching the MILR to the OLR cohort. Patient demographics from the American College of Surgeons National Surgical Quality Improvement Program, including race, age, gender, and ethnicity, were matched. Chronic obstructive pulmonary disease, congestive heart failure, smoking, hypertension, diabetes, renal failure, dyspnea, dialysis dependence, body mass index, and American Society of Anesthesiologists (ASA) classification (>ASA III) were among the preoperative patient characteristics subject to matching. PHLF (Grade A vs B. vs C) was our primary outcome measure.Results: A total of 2129 cirrhotic patients were included in the study. In the minor hepatectomy group, patients undergoing an OLR were more likely to get discharged to a facility (7.0% vs 4.4%; P = .03), had greater hospital length of stay (5 vs 3 days; P = .02), and had a greater need for invasive postoperative interventions (10.7% vs 4.6%; P < .01). They were also noted to have higher rates of organ space superficial surgical infections (SSIs) (7.3% vs 3.7%; P = .003), Clostridium difficile infection (.9% vs .1%; P = .05), renal insufficiency (2.1% vs .1%; P < .01), unplanned intubations (3.1% vs 1.4%; P = .03), and Grade C liver failure (2.3% vs .9%; P = .03).Conclusion: A higher incidence of PHLF grade C was found in patients undergoing OLR in the minor hepatectomy group. Therefore, in cirrhotic patients who can tolerate minimally invasive approaches, MILR should be offered to prevent postoperative complications as part of their optimization plan.

Effect of conditions being present at time of surgery (PATOS) on outcomes in liver surgery

INTRODUCTION

Information about condition(s) being present at time of surgery (PATOS) in the American College of Surgeons (ASC) National Surgical Quality Improvement Program (NSQIP) database can influence the postoperative complication rates after liver surgeries. Here, we compare the postoperative complication rates with and without taking condition(s) being PATOS into account.

METHODS

We retrospectively reviewed the ACS NSQIP Participant User Files (PUFs) from 2015 through 2019. We analyzed rates of eight different postoperative complications: superficial surgical site infection (SSI), deep SSI, organ space SSI, pneumonia, urinary tract infection, ventilator, sepsis, and septic shock. In addition, we calculated the percent change in event rates after taking into account whether a condition is PATOS.

RESULTS

Of the 22,463 patients in the ACS NSQIP PUFs for liver surgery, 334 (1.49%) had one or more conditions PATOS. The percentages of patients with PATOS events ranged from 2.03% for superficial SSI to 14.74% for sepsis. For all complications, event rates declined when taking condition(s) PATOS into account. From 2015 through 2019, the observed-to-expected ratios for most complications remained unchanged.

CONCLUSION

Whether a condition is PATOS is important in reporting postoperative complication rates for patients undergoing liver surgery. When taking whether a condition is PATOS into account, we demonstrated an overall decrease in event rates across all eight postoperative complications.

Outcomes in elderly patients undergoing hepatic resection compared to ablative therapy for hepatocellular carcinoma

BACKGROUND AND OBJECTIVES

Hepatic resection is an excellent option in the care of patients with hepatocellular carcinoma (HCC). Elderly patients often forego hepatic resection in favor of liver-directed ablative therapies due to the increased likelihood of adverse postoperative outcomes due to age. We sought to determine long-term outcomes in patients who underwent hepatic resection compared to liver-directed ablative therapy in this patient population.

METHODS

We queried the National Cancer Database for elderly patients (≥70 years) diagnosed with HCC between 2004 and 2018. The primary outcome was overall survival (OS) computed using the Kaplan-Meier method and Cox proportional hazard regression.

RESULTS

A total of 10 032 patients were included in this analysis. On unadjusted analysis (p < 0.001) as well as multivariable analysis (hazard ratio: 0.65, 95% confidence interval: 0.57-0.73), hepatic resection was associated with improved OS. The protective association between hepatic resection and OS persisted after 1:1 propensity score matching.

CONCLUSIONS

Hepatic resection is associated with improved survival for well-selected elderly patients with HCC. While age is often thought of as influencing the decision to offer surgery, our study, in combination with others, demonstrates that it should not. Instead, other objective indicators of performance and functional status may be considered.

Association between chronic steroids and outcomes in hepatobiliary and pancreatic surgery

BACKGROUND

Chronic steroid use has been associated with increased postoperative complication; however, the association between chronic steroids and hepatobiliary and pancreatic surgery through all aspects of disease etiologies and types of surgery performed remains an area of active research. Therefore, this study analyzed the association of chronic steroids use with outcomes after hepatobiliary and pancreatic surgery.

METHODS

The National Surgical Quality Improvement Program Participant Use Data Files for hepatobiliary and pancreatic surgeries performed between 2015 and 2019 were analyzed for chronic steroid use and postoperative adverse events.

RESULTS

A total of 54,382 patients underwent hepatobiliary or pancreatic surgery during the study period, of which 1672 (3.1%) were on chronic steroids. In patients undergoing pancreatic surgery, steroid use was associated with higher rates of pneumonia (odds ratio [OR] 1.3, 95% confidence interval [95% CI] 1.2-2.2), unplanned intubation (OR 1.2, 95% CI 1.1-2.3), readmission (OR 1.4, 95% CI 1.3-2.4), intraoperative or postoperative transfusions (OR 1.5, 95% CI 1.2-2.3), being more likely to remain on a ventilator for greater than 48 h (OR 1.4, 95% CI 1.2-1.9), and greater mortality (OR 1.2, 95% CI 1.1-3.1) when compared to those, not on chronic steroids. In patients undergoing hepatobiliary surgery, chronic steroid use was associated with higher rates of sepsis (OR 1.3, 95% CI 1.2-2.9), unplanned intubation (OR 1.4, 95% CI 1.2-2.7), intraoperative or postoperative transfusions (OR 1.5, 95% CI 1.3-2.3), and readmission (OR 1.2, 95% CI 1.0-1.9). There was no difference in pancreatic fistula rates or post-hepatectomy liver failure rates after pancreatic and hepatobiliary resections, respectively.

CONCLUSION

Chronic steroids use was associated with higher rates of poor outcomes both perioperatively and postoperatively in pancreatic and hepatobiliary surgery. These results will allow clinicians to be better equipped to counsel patients on surgery's increased risks and establish various perioperative protocols for chronic steroid users.