Loss of independence after emergency inguinal hernia repair in elderly patients: How aggressive should we be?

Outcomes of Emergency Groin Hernia Repair in the Elderly: A Systematic Review

Introduction: The number of surgeries for groin hernia (GH) among the elderly follows the increase in life expectancy of the population. The greater number and severity of comorbidities in this group increases the surgical risk, promoting discussion regarding the indication of elective surgery and the benefits of watchful waiting approach (WWA). The aim of the present study was to evaluate the outcomes of emergency hernia surgery among the elderly population. Materials and methods: A systematic review was performed in Pubmed and Scielo databases for the past early 10 years, until July 2022. The subject was groin hernia in the emergency setting focusing the elderly population. The PRISMA statement was followed and the classification of elderly was based on the World Health Organization's definition. Results: A total of 1,037 results were returned and we ended with nine original articles with emphasis in groin hernia in the emergency among the elderly population. In these subjects, the complications rate ranged between 21.2% and 28.9% and the mortality rate ranged between 1.2% and 6%. Cardiopulmonary disease, high ASA and Charlson's scales were associated with greater risk of complications and death. Conclusion: Emergency GH surgery in the elderly population carries an increased risk of complications and mortality. GH surgery is safe or, at least, less harmful when done electively. The risk and benefits of WWA and upfront surgery needs to be assessed and exposed to the patients. Our review sugest that elective surgery should be the option over WWA in this patient population.

Validation of the self-reported domains of the Edmonton Frail Scale in patients 65 years of age and older

INTRODUCTION

In the era of virtual care, self-reported tools are beneficial for preoperative assessments and facilitating postoperative planning. We have previously reported the use of the Edmonton Frailty Scale (EFS) as a valid preoperative assessment tool.

OBJECTIVE

We wished to validate the self-reported domains of the EFS (srEFS) by examining its association with loss of independence (LOI) and mortality.

METHODS

This is a post-hoc analysis of a single-institution observational study of patients 65 years of age or older undergoing multi-specialty surgical procedures and assessed with the EFS in the preoperative setting. Exploratory data analysis was used to determine the threshold for identifying frailty using the srEFS. Procedures were classified using the Operative Stress Score (OSS) scored 1 to 5 (lowest to highest). Hierarchical Condition Category (HCC) was utilized to risk-adjust. LOI was described as requiring more support at discharge and mortality was defined as death occurring up to 30 days following surgery. Receiver operating characteristic (ROC) curves were used to determine the ability of the srEFS to predict the outcomes of interest in relation to the EFS.

RESULTS

Five hundred thirty-five patients were included. Exploratory analysis confirmed best positive predictive value for srEFS was greater or equal to 5. Overall, 113 (21 percent) patients were considered high risk for frailty (HRF) and 179 (33 percent) patients had an OSS greater or equal to 5. LOI occurred in 7 percent (38 patients) and the mortality rate was 4 percent (21 patients). ROC analysis showed that the srEFS performed similar to the standard EFS with no difference in discriminatory thresholds for predicting LOI and mortality. Examination of the domains of the EFS not included in the srEFS demonstrated a lack of association between cognitive decline and the outcomes of interest. However, functional status assessed with either the Get up and Go (EFS only) or self-reported ADLs was independently associated with increased risk for LOI.

CONCLUSION

This study shows that self-reported EFS may be an optional preoperative tool that can be used in the virtual setting to identify patients at HRF. Early identification of patients at risk for LOI and mortality provides an opportunity to implement targeted strategies to improve patient care.