Enhancing the American College of Surgeons NSQIP Surgical Risk Calculator to Predict Geriatric Outcomes

Delirium risk profiles in a population-based study of United States older adults undergoing common noncardiac surgeries

BACKGROUND

Older adults often require surgical care and are at elevated risk of delirium. We explored delirium risk profiles across the population of U.S. older adults who underwent one of 10 common noncardiac surgeries.

METHODS

We analyzed Health and Retirement Study (HRS) participants linked with Medicare billing data who underwent the following 10 noncardiac surgeries from 2000 to 2018 at age 65 or more: total knee arthroplasty (TKA), total hip arthroplasty (THA), spine surgery, cholecystectomy, colorectal surgery, hernia repair (ventral, umbilical, or incisional), endarterectomy, prostatectomy, transurethral resection of the prostate (TURP), and hysterectomy. Demographic and health covariates were obtained from the HRS dataset. Latent cognitive ability was calculated from cognitive testing, proxy reports, and demographics at the preoperative HRS interview. We compared standardized differences for delirium risk factors across the 10 surgeries and qualitatively clustered them into phenotypical subgroups.

RESULTS

We analyzed 7424 older adults (mean age 76 ± 6 years, 45% male). Endarterectomy patients presented with the highest burden of nearly all health and cognitive factors, implying higher delirium risk (e.g., stroke, 22%; depressive symptoms, 30%; high school or less education, 73%; frailty, 42%; lowest latent cognitive ability). A second "general surgery" phenotype, including cholecystectomy, colorectal, and hernia surgery patients, experienced more frailty (29%-32%) and depressive symptoms (24%-26%), with moderate comorbidity burden. A third "pain" phenotype, which included TKA, THA, and spine surgery patients, commonly reported moderate or severe pain (47%-53%) and impairment in activities of daily living (ADL, 23%-30%), but fewer comorbid medical conditions. The remaining surgery types (hysterectomy, prostatectomy, TURP) were not phenotypically grouped and generally had lower risk features for delirium.

CONCLUSION

In an epidemiological cohort of US older adults, we identified clinically meaningful heterogeneity in delirium risk profiles across different surgical types, which may have implications for delirium risk stratification and delirium prevention or treatment.

A Novel Nomogram Developed Based on Preoperative Immune Inflammation-Related Indicators for the Prediction of Postoperative Delirium Risk in Elderly Hip Fracture Cases: A Single-Center Retrospective Cohort Study

Objective

Postoperative delirium (POD) commonly occurs in elderly individuals following hip fracture surgery, with unclear pathophysiological mechanism. Inflammation is a known factor affecting the onset of delirium. The current work aimed to examine the associations of preoperative immune inflammation-related indicators with POD occurrence in elderly cases following hip fracture surgery.

Methods

The current retrospective cohort study included 437 elderly cases administered hip fracture surgery from January 2018 to December 2023. The clinicodemographic data and laboratory findings of all cases were retrospectively analyzed. Immune inflammation-related indicators were assessed, eg, MLR, NLR and PLR, as well as SII and SIRI. The bootstrap method was employed to assign cases at 7:3 to the training (48 and 258 cases in the POD and no-POD groups, respectively) and internal validation (13 and 118 cases in the POD and no-POD groups, respectively) cohorts. Next, LASSO, univariable and multivariable logistic regression analyses were applied to determine risk factors in the training cohort, based on which a nomogram model was built. The obtained nomogram was examined for accuracy by calibration plot analysis. Finally, the nomogram's clinical value was assessed by decision curve analysis (DCA), followed by internal validation based on the training cohort.

Results

Of all 437 cases, 61 developed POD, indicating a POD incidence of 13.96%. LASSO regression and multivariable analyses revealed preoperative SIRI independently predicted POD in the training cohort. The developed nomogram had an area under the curve (AUC) of 0.991 (95% CI 0.983~0.998) in the training cohort versus 0.986 (95% CI 0.966~1.000) in the validation cohort. Calibration curve analysis revealed nomogram-predicted and actual probabilities were in line. DCA demonstrated the novel nomogram could confer net benefits for POD prediction in elderly cases administered hip fracture surgery.

Conclusion

The immune inflammation-related indicators SIRI could predict POD in elderly cases following hip fracture surgery.

Priority areas for outcomes improvement among older adults undergoing inpatient general surgery inclusive of geriatric-pertinent complications

BACKGROUND

Comprehensive studies on priority areas for improving geriatric surgery outcomes, inclusive of geriatric-pertinent data, are limited.

METHODS

The ACS NSQIP geriatric database (2014-2018) was used to abstract older adults (≥65 years) undergoing inpatient general surgery procedures. Thirty-day complication, functional decline, and mortality rates were analyzed, with a focus on two geriatric-pertinent complications: delirium and new/worsening pressure ulcers.

RESULTS

There were 9062 patients; 41.9% were ≥75 years. Mean age was 73.9 years. The majority of patients were female (54.0%), White (77.7%), and had independent functional status before surgery (94.0%). Overall 30-day complication, functional decline, and mortality rates were 33.6%, 34.5%, and 3.5%, respectively; failure to the rescue rate was 9.7%. Including geriatric-pertinent complications increased the overall complication rate by 20.4%. Delirium emerged as the leading complication (11.9%), followed by bleeding (11.1%), and wound-related complications (10.1%); these three accounted for 53.7% of complications. Delirium and pressure ulcers were associated with a >50% rate of postoperative functional decline (52.0% and 71.4%, respectively); pressure ulcers were also notable for a 25.5% failure to the rescue rate. Both were also among complications most likely to occur following the 3 most common procedures (colorectal surgery, pancreatic resections, and exploratory laparotomy), which overall accounted for approximately 79.6% of complications, 73.4% of patients experiencing functional decline, and 82.3% of mortality.

CONCLUSIONS

Delirium is the leading complication among older adults undergoing inpatient surgery. Overall, a small number of complications and procedure groups account for most surgical morbidity and mortality among older adults and thus constitute priority areas for outcomes improvement.

The impact of geriatric-specific variables on long-term outcomes in patients with hepatopancreatobiliary and colorectal cancer selected for resection

BACKGROUND

Preoperative geriatric-specific variables (GSV) influence short-term morbidity in surgical patients, but their impact on long-term survival in elderly patients with cancer remains undefined.

STUDY DESIGN

This observational cohort study included patients ≥65 years who underwent hepatopancreatobiliary or colorectal operations for malignancy between 2014 and 2020. Individual patient data included merged ACS NSQIP data, Procedure Targeted, and Geriatric Surgery Research variables. Patients were stratified by age: 65-74, 75-84, and ≥85 and presence of these GSVs: mobility aid, preoperative falls, surrogate signed consent, and living alone. Bivariable and multivariable analyses were used to evaluate 1-year mortality and postoperative discharge to facility.

RESULTS

577 patients were included: 62.6 % were 65-74 years old, 31.7 % 75-84, and 5.7 % ≥ 85. 96 patients were discharged to a facility with frequency increasing with age group (11.4 % vs 22.4 % vs 42.4 %, respectively, p < 0.001). 73 patients (12.7 %) died during 1-year follow-up, 32.9 % from cancer recurrence. One-year mortality was associated with undergoing hepatopancreatobiliary operations (p = 0.017), discharge to a facility (p = 0.047), and a surrogate signing consent (p = 0.035). Increasing age (p < 0.001), hepatopancreatobiliary resection (p = 0.002), living home alone (p < 0.001), and mobility aid use (p < 0.001) were associated with discharge to a facility.

CONCLUSION

Geriatric-specific variables, living alone and use of a mobility aid, were associated with discharge to a facility. A surrogate signing consent and discharge to a facility were associated with 1-year mortality. These findings underscore the importance of preoperative patient selection and optimization, efficacious discharge planning, and informed decision-making in the care of elderly cancer patients.

Mortality burden from variation in provision of surgical care in emergency general surgery: a cohort study using the National Inpatient Sample

Background

The decision to undertake a surgical intervention for an emergency general surgery (EGS) condition (appendicitis, diverticulitis, cholecystitis, hernia, peptic ulcer, bowel obstruction, ischemic bowel) involves a complex consideration of factors, particularly in older adults. We hypothesized that identifying variability in the application of operative management could highlight a potential pathway to improve patient survival and outcomes.

Methods

We included adults aged 65+ years with an EGS condition from the 2016-2017 National Inpatient Sample. Operative management was determined from procedure codes. Each patient was assigned a propensity score (PS) for the likelihood of undergoing an operation, modeled from patient and hospital factors: EGS diagnosis, age, gender, race, presence of shock, comorbidities, and hospital EGS volumes. Low and high probability for surgery was defined using a PS cut-off of 0.5. We identified two model-concordant groups (no surgery-low probability, surgery-high probability) and two model-discordant groups (no surgery-high probability, surgery-low probability). Logistic regression estimated the adjusted OR (AOR) of in-hospital mortality for each group.

Results

Of 375 546 admissions, 21.2% underwent surgery. Model-discordant care occurred in 14.6%; 5.9% had no surgery despite a high PS and 8.7% received surgery with low PS. In the adjusted regression, model-discordant care was associated with significantly increased mortality: no surgery-high probability AOR 2.06 (1.86 to 2.27), surgery-low probability AOR 1.57 (1.49 to 1.65). Model-concordant care showed a protective effect against mortality (AOR 0.83, 0.74 to 0.92).

Conclusions

Nearly one in seven EGS patients received model-discordant care, which was associated with higher mortality. Our study suggests that streamlined treatment protocols can be applied in EGS patients as a means to save lives.

Level of evidence

III.

Strengthening the use of artificial intelligence within healthcare delivery organizations: balancing regulatory compliance and patient safety

OBJECTIVES

Surface the urgent dilemma that healthcare delivery organizations (HDOs) face navigating the US Food and Drug Administration (FDA) final guidance on the use of clinical decision support (CDS) software.

MATERIALS AND METHODS

We use sepsis as a case study to highlight the patient safety and regulatory compliance tradeoffs that 6129 hospitals in the United States must navigate.

RESULTS

Sepsis CDS remains in broad, routine use. There is no commercially available sepsis CDS system that is FDA cleared as a medical device. There is no public disclosure of an HDO turning off sepsis CDS due to regulatory compliance concerns. And there is no public disclosure of FDA enforcement action against an HDO for using sepsis CDS that is not cleared as a medical device.

DISCUSSION AND CONCLUSION

We present multiple policy interventions that would relieve the current tension to enable HDOs to utilize artificial intelligence to improve patient care while also addressing FDA concerns about product safety, efficacy, and equity.

Association between increased systemic immune-inflammation index and postoperative delirium in older intertrochanteric fracture patients

BACKGROUND AND PURPOSE

The systemic immune-inflammation index (SII), a novel inflammation index derived from the counts of circulating platelets, neutrophils and lymphocytes, has been studied in the treatment of acute cancer and ischemic stroke (AIS). However, the clinical value of the SII in postoperative delirium patients has not been further investigated. The purpose of our research was to study the incidence and preoperative risk factors for postoperative delirium (POD) and verify whether the SII could serve as a potential marker for POD in older intertrochanteric fracture patients. Finally, we created a novel nomogram for predicting POD in older patients with intertrochanteric fractures.

METHODS

We enrolled elderly patients with intertrochanteric fractures who underwent proximal femoral nail antirotation (PFNA) between February 2021 and April 2023. Univariate and multivariate logistic analyses were subsequently performed to confirm the risk factors and construct a nomogram model.Calibration curve and clinical decision curve analysis (DCA) were used to assess the model's fitting performance. The performance of the nomogram was evaluated for discrimination, calibration, and clinical utility.

RESULTS

A total of 293 patients were eligible for inclusion in the study, 25.6% (75/293) of whom had POD. The POD patients had higher SII values than the non-POD patients. The SII was strongly correlated with POD in older intertrochanteric fracture patients, and the optimal cutoff value was 752.6 × 109. Multivariate analysis revealed that age, diabetes, total albumin, SII > 752.6 × 109 and a CRP > 20.25 mg/L were independent risk factors for POD patients. By incorporating these 5 factors, the model achieved a concordance index of 0.745 (95% CI, 0.683-0.808) and had a well-fitted calibration curve and good clinical application value.

CONCLUSION

The SII is a simple and valuable biomarker for POD, and the new nomogram model can be used to accurately predict the occurrence of POD. They can be utilized in clinical practice to identify those at high risk of POD in older intertrochanteric fracture patients.

Predictive value of the G8 screening tool for postoperative complications in older adults undergoing cancer surgery: A systematic review and meta-analysis

INTRODUCTION

Older adults with cancer who are being considered for cancer surgery are heterogenous, with variation in their physical, mental, and social baselines and risk of postoperative complications. Due in part to the complex nature of this population, the optimal preoperative evaluation method is not clearly defined. In this study we investigated whether geriatric-8 (G8), a screening tool for older patients with cancer that determines the need for a full geriatric assessment, is suitable for assessing the risk of postoperative complications in this population being considered for surgery.

MATERIALS AND METHODS

Studies that enrolled older patients undergoing cancer surgery and compared prevalence of postoperative complications in G8 "high" (≥15) patients and G8 "low" (<15) patients were identified using PubMed and EMBASE. A meta-analysis was conducted to calculate the risk ratio of postoperative complication rate. Postoperative mortality was systematically reviewed.

RESULTS

Eleven studies published between 2017 and 2022 were included in our analysis with a total of 2,691 older patients who underwent various types of cancer surgery and were characterized by their G8 scores: 1,255 G8 high (≥15) patients and 1,436 G8 low (<15) patients. G8 low patients had a significantly higher prevalence of postoperative complications than G8 high patients (risk ratio [95% confidence interval]: 1.56 [1.18-2.07], p = 0.002, I2 = 79%).

DISCUSSION

G8 can be an effective and efficient preoperative tool to assess risk of postoperative complications in older adults undergoing cancer surgery and identify potential need for further evaluation of an individual's risk with a comprehensive geriatric assessment.

Role of pre-operative counseling with NSQIP surgical risk calculator in the surgical patients

Introduction

Patient satisfaction is important tool to monitor health care performance and quality of health plans, emphasizing effective counseling and consent processes. The objective of the study is to assess patient satisfaction and anxiety with the use of NSQIP surgical risk calculator in comparison to standardized questionnaires.

Methodology

This is an interventional prospective randomized study. Difference in patient satisfaction is assessed by a 7-point Likert scale and anxiety assessment by 5-point Likert scale of Amsterdam Preoperative Anxiety and Information Scale (APAIS) questionnaire written in Nepalese. Satisfaction scores were compared using analysis of variance (ANOVA), or the Kruskal-Wallis test. P- value <0.05 was considered statistically significant.

Results

Satisfaction score regarding comfort during counseling and consent process was similar with and without use of NSQIP surgical risk calculator (83.3 % and 76.9 %, respectively). Satisfaction score regarding plan of anesthesia was 63.33 % with the use of NSQIP and 53.8 % without NSQIP tool. 30.76 % of patients with high school education developed negative feelings following counseling when NSQIP tool was not used (p value 0.002). NSQIP usage increased anxiety about anesthesia and surgery and led to higher continual thinking about the procedure.Duration of counseling was 12 min with NSQIP tool use in comparison to 9.67 min following conventional counseling (p value 0.047).

Conclusion

NSQIP surgical risk calculator is a reliable tool that can be used alongside conventional methods during preoperative period for decision-making and counseling with similar satisfaction scores but a higher incidence of anxiety and continual thinking about procedures.

Circulating metabolic markers after surgery identify patients at risk for severe postoperative complications: a prospective cohort study in colorectal cancer

BACKGROUND

Early detection of postoperative complications after colorectal cancer (CRC) surgery is associated with improved outcomes. The aim was to investigate early metabolomics signatures capable to detect patients at risk for severe postoperative complications after CRC surgery.

MATERIALS AND METHODS

Prospective cohort study of patients undergoing CRC surgery from 2015 to 2018. Plasma samples were collected before and after surgery, and analyzed by mass spectrometry obtaining 188 metabolites and 21 ratios. Postoperative complications were registered with Clavien-Dindo Classification and Comprehensive Complication Index.

RESULTS

One hundred forty-six patients were included. Surgery substantially modified metabolome and metabolic changes after surgery were quantitatively associated with the severity of postoperative complications. The strongest positive relationship with both Clavien-Dindo and Comprehensive Complication Index (β=4.09 and 63.05, P <0.001) corresponded to kynurenine/tryptophan, against an inverse relationship with lysophosphatidylcholines (LPCs) and phosphatidylcholines (PCs). Patients with LPC18:2/PCa36:2 below the cut-off 0.084 µM/µM resulted in a sevenfold higher risk of major complications (OR=7.38, 95% CI: 2.82-21.25, P <0.001), while kynurenine/tryptophan above 0.067 µM/µM a ninefold (OR=9.35, 95% CI: 3.03-32.66, P <0.001). Hexadecanoylcarnitine below 0.093 µM displayed a 12-fold higher risk of anastomotic leakage-related complications (OR=11.99, 95% CI: 2.62-80.79, P =0.004).

CONCLUSION

Surgery-induced phospholipids and amino acid dysregulation is associated with the severity of postoperative complications after CRC surgery, including anastomotic leakage-related outcomes. The authors provide quantitative insight on metabolic markers, measuring vulnerability to postoperative morbidity that might help guide early decision-making and improve surgical outcomes.

Assessing the mFI-5 frailty score and functional status in geriatric patients undergoing inguinal hernia repairs

PURPOSE

The modified 5-factor frailty index (mFI-5) is a prognostic tool based on five comorbidities from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database-hypertension, congestive heart failure, chronic obstructive pulmonary disease (COPD), diabetes, and non-independent functional status. Our study investigates the mFI-5 index's ability to predict morbidity, length of stay (LOS), and discharge destination in geriatric patients undergoing inguinal hernia repairs, as well as assesses the interplay of baseline functional status.

METHODS

Patients aged ≥ 65 years who underwent inguinal or femoral hernia repairs from the 2018-2020 NSQIP database were studied. Separate analyses were performed for emergent and elective cohorts. Stratification was performed according to the sum of mFI-5 variables: mFI = 0, mFI = 1, mFI ≥ 2.

RESULTS

A total of 41,897 consisted of 92.9% elective and 7.1% emergent cases. The sample was 37.8% mFI = 0, 47.2% mFI = 1, and 15.0% mFI ≥ 2. Median age was 73 (IQR 68-78). Of emergent mFI ≥ 2 cases, 24.2% had non-independent functional status, versus only 4.8% in elective cases. Area under the curve was calculated for emergent and elective groups, including mortality (0.86, 0.80), pneumonia (0.82, 0.77), discharge destination not home (0.78, 0.73), prolonged LOS (0.69, 0.66), and infection (0.71, 0.62). Of index variables, dependent functional status was correlated with increased complications in elective and emergent cohorts, while COPD was significant in elective cases (OR > 2.0, p < 0.05).

CONCLUSION

The mFI-5 is predictive of complications in geriatric inguinal hernia repairs, especially in emergent cases. Frail patients with non-independent functional status are most at risk and, thus require proactive and watchful perioperative care.

Prediction models for postoperative delirium in elderly patients with machine-learning algorithms and SHapley Additive exPlanations

Postoperative delirium (POD) is a common and severe complication in elderly patients with hip fractures. Identifying high-risk patients with POD can help improve the outcome of patients with hip fractures. We conducted a retrospective study on elderly patients (≥65 years of age) who underwent orthopedic surgery with hip fracture between January 2014 and August 2019. Conventional logistic regression and five machine-learning algorithms were used to construct prediction models of POD. A nomogram for POD prediction was built with the logistic regression method. The area under the receiver operating characteristic curve (AUC-ROC), accuracy, sensitivity, and precision were calculated to evaluate different models. Feature importance of individuals was interpreted using Shapley Additive Explanations (SHAP). About 797 patients were enrolled in the study, with the incidence of POD at 9.28% (74/797). The age, renal insufficiency, chronic obstructive pulmonary disease (COPD), use of antipsychotics, lactate dehydrogenase (LDH), and C-reactive protein are used to build a nomogram for POD with an AUC of 0.71. The AUCs of five machine-learning models are 0.81 (Random Forest), 0.80 (GBM), 0.68 (AdaBoost), 0.77 (XGBoost), and 0.70 (SVM). The sensitivities of the six models range from 68.8% (logistic regression and SVM) to 91.9% (Random Forest). The precisions of the six machine-learning models range from 18.3% (logistic regression) to 67.8% (SVM). Six prediction models of POD in patients with hip fractures were constructed using logistic regression and five machine-learning algorithms. The application of machine-learning algorithms could provide convenient POD risk stratification to benefit elderly hip fracture patients.

Strategies for Perioperative Optimization in Upper Extremity Fracture Care

Perioperative optimization in upper extremity fracture care must balance the need for timely treatment with the benefits of medical optimization. Care pathways directed at optimizing glycemic control, chronic anticoagulation, smoking history, nutrition, and frailty can reduce surgical risk in upper extremity fracture care. The development of multidisciplinary approaches that tie risk modification with risk stratification is needed.

Frailty and Preoperative Palliative Care in Surgical Oncology

In this paper, we discuss surgical palliative care for patients with cancer through the lens of frailty and the preoperative context. Historically, palliative care principles such as complex symptom management, high-risk decision-making and communication have played an important role in preoperative discussions of oncologic surgery for both palliative and curative intent. There is increasing motivation among surgeons to integrate palliative care into the perioperative period in order to more effectively and comprehensively address potential adverse functional and quality of life outcomes. We discuss how the concept of frailty, and various instruments to measure frailty, have impacted perioperative decision-making, review the roots of surgical risk stratification and counseling on acceptable perioperative risk, and explore the preoperative setting as a possible avenue by which primary and specialty palliative care integration may have beneficial impact for patients considering oncologic resections.

Evaluation of the ACS-NSQIP Surgical Risk Calculator in Patients with Hepatic Metastases from Colorectal Cancer Undergoing Liver Resection

BACKGROUND

The American College of Surgeons National Surgical Quality Improvement Program surgical risk calculator (ACS-NSQIP SRC) has been designed to predict morbidity and mortality and help stratify surgical patients. This study evaluates the performance of the SRC for patients undergoing surgery for colorectal liver metastases (CRLM).

METHODS

SRC was retrospectively computed for patients undergoing liver or simultaneous colon and liver surgery for colorectal cancer (CRC) in two high tertiary referral centres from 2011 to 2020. C-statistics and Brier score were calculated as a mean of discrimination and calibration respectively, for both group and for every level of surgeon adjustment score (SAS) for liver resections in case of simultaneous liver-colon surgery. An AUC ≥ 0.7 shows acceptable discrimination; a Brier score next to 0 means the prediction tool has good calibration.

RESULTS

Four hundred ten patients were included, 153 underwent simultaneous resection, and 257 underwent liver-only resections. For simultaneous surgery, the ACS-NSQIP SRC showed good calibration and discrimination only for cardiac complication (AUC = 0.720, 0.740, and 0.702 for liver resection unadjusted, SAS-2, and SAS-3 respectively; 0.714 for colon resection; and Brier score = 0.04 in every case). For liver-only surgery, it only showed good calibration for cardiac complications (Brier score = 0.03). The SRC underestimated the incidence of overall complications, pneumonia, cardiac complications, and the length of hospital stay.

CONCLUSIONS

ACS-NSQIP SRC showed good predicting capabilities only for 1 out of 5 evaluated outcomes; therefore, it is not a reliable tool for patients undergoing liver surgery for CRLM, both in the simultaneous and staged resections.

Impact of Prehabilitation on Postoperative Mortality and the Need for Non-Home Discharge in High-Risk Surgical Patients

BACKGROUND

The preoperative period is an important target for interventions (eg Surgical Prehabilitation and Readiness [SPAR]) that can improve postoperative outcomes for older patients with comorbidities.

STUDY DESIGN

To determine whether a preoperative multidisciplinary prehabilitation program (SPAR) reduces postoperative 30-day mortality and the need for non-home discharge in high-risk surgical patients, surgical patients enrolled in a prehabilitation program targeting physical activity, pulmonary function, nutrition, and mindfulness were compared with historical control patients from 1 institution's American College of Surgeons (ACS) NSQIP database. SPAR patients were propensity score-matched 1:3 to pre-SPAR NSQIP patients, and their outcomes were compared. The ACS NSQIP Surgical Risk Calculator was used to compare observed-to-expected ratios for postoperative outcomes.

RESULTS

A total of 246 patients were enrolled in SPAR. A 6-month compliance audit revealed that overall patient adherence to the SPAR program was 89%. At the time of analysis, 118 SPAR patients underwent surgery with 30 days of follow-up. Compared with pre-SPAR NSQIP patients (n = 4,028), SPAR patients were significantly older with worse functional status and more comorbidities. Compared with propensity score-matched pre-SPAR NSQIP patients, SPAR patients had significantly decreased 30-day mortality (0% vs 4.1%, p = 0.036) and decreased need for discharge to postacute care facilities (6.5% vs 15.9%, p = 0.014). Similarly, SPAR patients exhibited decreased observed 30-day mortality (observed-to-expected ratio 0.41) and need for discharge to a facility (observed-to-expected ratio 0.56) compared with their expected outcomes using the ACS NSQIP Surgical Risk Calculator.

CONCLUSIONS

The SPAR program is safe and feasible and may reduce postoperative mortality and the need for discharge to postacute care facilities in high-risk surgical patients.

What If We Do Not Operate? Outcomes of Nonoperatively Managed Emergency General Surgery Patients

INTRODUCTION

Although two-thirds of patients with emergency general surgery (EGS) conditions are managed nonoperatively, their long-term outcomes are not well described. We describe outcomes of nonoperative management in a cohort of older EGS patients and estimate the projected risk of operative management using the NSQIP Surgical Risk Calculator (SRC).

MATERIALS AND METHODS

We studied single-center inpatients aged 65 y and more with an EGS consult who did not undergo an operation (January 2019-December 2020). For each patient, we recorded the surgeon's recommendation as either an operation was "Not Needed" (medical management preferred) or "Not Recommended" (risk outweighed benefits). Our main outcome of interest was mortality at 30 d and 1 y. Our secondary outcome of interest was SRC-projected 30-day postoperative mortality risk (median % [interquartile range]), calculated using hypothetical low-risk and high-risk operations.

RESULTS

We included 204 patients (60% female, median age 75 y), for whom an operation was "Not Needed" in 81% and "Not Recommended" in 19%. In this cohort, 11% died at 30 d and 23% died at 1 y. Mortality was higher for the "Not Recommended" cohort (37% versus 5% at 30 d and 53% versus 16% at 1 y, P < 0.05). The SRC-projected 30-day postoperative mortality risk was 3.7% (1.3-8.7) for low-risk and 5.8% (2-11.8) for high-risk operations.

CONCLUSIONS

Nonoperative management in older EGS patients is associated with very high risk of short-term and long-term mortality, particularly if a surgeon advised that risks of surgery outweighed benefits. The SRC may underestimate risk in the highest-risk patients.

Interpretation and Use of Applied/Operational Machine Learning and Artificial Intelligence in Surgery

Applications for artificial intelligence (AI) and machine learning in surgery include image interpretation, data summarization, automated narrative construction, trajectory and risk prediction, and operative navigation and robotics. The pace of development has been exponential, and some AI applications are working well. However, demonstrations of clinical utility, validity, and equity have lagged algorithm development and limited widespread adoption of AI into clinical practice. Outdated computing infrastructure and regulatory challenges which promote data silos are key barriers. Multidisciplinary teams will be needed to address these challenges and to build AI systems that are relevant, equitable, and dynamic.

Intraoperative allogeneic transfusion is associated with postoperative delirium in older patients after total knee and hip arthroplasty

Objective

To determine whether intraoperative transfusion of allogeneic or autologous blood is associated with an increased incidence of postoperative delirium (POD) after total knee arthroplasty (TKA) and total hip arthroplasty (THA).

Methods

The medical records of 1,143 older (≥65 years old) patients who received an intraoperative blood transfusion while undergoing total knee or hip arthroplasty at the First Medical Center of Chinese PLA General Hospital from 2014 to 2019 were reviewed; of these patients, 742 (64.92%) received allogeneic blood, while 401 (35.08%) received autologous blood. Patients who received autologous transfusion were paired with those received allogeneic transfusion using 1:1 propensity score matching method. The primary outcome was POD. The secondary outcomes were postoperative complications, including heart failure, deep vein thrombosis, myocardial infarction, stroke, and lung infection. Multivariable nominal logistic regression was used to identify any independent associations between intraoperative blood transfusions and POD, and secondary postoperative complications, respectively.

Results

Postoperative delirium occurred in 6.6% (49/742) of patients who had received an allogeneic blood transfusion and in 2.0% (8/401) of patients who had received an autologous blood transfusion. It is noteworthy that the multivariable logistic regression demonstrated a significant association between intraoperative allogeneic blood transfusion and POD (odds ratio [OR]: 4.11; 95% confidence interval [CI]: 1.95-9.77; p < 0.001). After PSM, Allogeneic transfusion was also the strongest predictor for POD (OR: 4.43; 95% CI: 2.09-10.58; p < 0.001).

Conclusions

In the patients who had received THA or TKA, intraoperative allogeneic blood transfusions were associated with an increased risk of POD.

Frailty Predicts Loss of Independence After Liver Surgery

BACKGROUND

Loss of independence (LOI) is a significant concern in patients undergoing liver surgery. Although the risks of morbidity and mortality have been well studied, there is a dearth of data regarding the risk of LOI. Therefore, this study aimed to assess predictors of LOI after liver surgery.

METHODS

This study utilized the National Surgical Quality Improvement Program (NSQIP) data from 2015 to 2018 from a retrospective cohort study of patients undergoing liver resections. LOI was defined as the change from preoperative functional independence to the postoperative discharge requirement in a post-care facility. Frailty was defined using the modified frailty index-5 (mFI-5).

RESULTS

A total of 22,463 patients underwent hepatectomy via the NSQIP during the study period. In total, 22,067 participants were included in the analysis. A total of 4.7% of patients had LOI after surgery and were discharged to a rehabilitation center or nursing facility. mFI-1 was an independent predictor of LOI (OR:2.2 [1.9-4.3]). However, the odds for LOI were higher (OR:5.1[2.5-8.2]) in patients with mFI ≥ 2.

CONCLUSION

LOI is an important outcome of liver surgery. Frailty is a predictor of LOI and should be used as a guide to inform patients about the potential outcomes.

External Validation of the American College of Surgeons Surgical Risk Calculator in Elderly Patients Undergoing General Surgery Operations

Preoperative risk stratification in the elderly surgical patient is an essential part of contemporary perioperative care and can be done with the use of the American College of Surgeons Surgical Risk Calculator (ACS-SRC). However, data on the generalizability of the ACS-SRC in the elderly is scarce. In this study, we report an external validation of the ACS-RC in a geriatric cohort. A retrospective analysis of a prospectively maintained database was performed including patients aged > 65 who underwent general surgery procedures during 2012−2017 in a Greek academic centre. The predictive ability of the ACS-SRC for post-operative outcomes was tested with the use of Brier scores, discrimination, and calibration metrics. 471 patients were included in the analysis. 30-day postoperative mortality was 3.2%. Overall, Brier scores were lower than cut-off values for almost all outcomes. Discrimination was good for serious complications (c-statistic: 0.816; 95% CI: 0.762−0.869) and death (c-statistic: 0.824; 95% CI: 0.719−0.929). The Hosmer-Lemeshow test showed good calibration for all outcomes examined. Predicted and observed length of stay (LOS) presented significant differences for emergency and for elective cases. The ACS-SRC demonstrated good predictive performance in our sample and can aid preoperative estimation of multiple outcomes except for the prediction of post-operative LOS.

Association Between Frailty and Time Alive and At Home After Cancer Surgery Among Older Adults: A Population-Based Analysis

BACKGROUND

Although frailty is known to impact short-term postoperative outcomes, its long-term impact is unknown. This study examined the association between frailty and remaining alive and at home after cancer surgery among older adults.

METHODS

Adults aged ≥70 years undergoing cancer resection were included in this population-based retrospective cohort study using linked administrative datasets in Ontario, Canada. The probability of remaining alive and at home in the 5 years after cancer resection was evaluated using Kaplan-Meier methods. Extended Cox regression with time-varying effects examined the association between frailty and remaining alive and at home.

RESULTS

Of 82,037 patients, 6,443 (7.9%) had preoperative frailty. With median follow-up of 47 months (interquartile range, 23-81 months), patients with frailty had a significantly lower probability of remaining alive and at home 5 years after cancer surgery compared with those without frailty (39.1% [95% CI, 37.8%-40.4%] vs 62.5% [95% CI, 62.1%-63.9%]). After adjusting for age, sex, rural living, material deprivation, immigration status, cancer type, surgical procedure intensity, year of surgery, and receipt of perioperative therapy, frailty remained associated with increased hazards of not remaining alive and at home. This increase was highest 31 to 90 days after surgery (hazard ratio [HR], 2.00 [95% CI, 1.78-2.24]) and remained significantly elevated beyond 1 year after surgery (HR, 1.56 [95% CI, 1.48-1.64]). This pattern was observed across cancer sites, including those requiring low-intensity surgery (breast and melanoma).

CONCLUSIONS

Preoperative frailty was independently associated with a decreased probability of remaining alive and at home after cancer surgery among older adults. This relationship persisted over time for all cancer types beyond short-term mortality and the initial postoperative period. Frailty assessment may be useful for all candidates for cancer surgery, and these data can be used when counseling, selecting, and preparing patients for surgery.

Comparison of logistic regression and machine learning methods for predicting postoperative delirium in elderly patients: A retrospective study

AIMS

To compare the performance of logistic regression and machine learning methods in predicting postoperative delirium (POD) in elderly patients.

METHOD

This was a retrospective study of perioperative medical data from patients undergoing non-cardiac and non-neurology surgery over 65 years old from January 2014 to August 2019. Forty-six perioperative variables were used to predict POD. A traditional logistic regression and five machine learning models (Random Forest, GBM, AdaBoost, XGBoost, and a stacking ensemble model) were compared by the area under the receiver operating characteristic curve (AUC-ROC), sensitivity, specificity, and precision.

RESULTS

In total, 29,756 patients were enrolled, and the incidence of POD was 3.22% after variable screening. AUCs were 0.783 (0.765-0.8) for the logistic regression method, 0.78 for random forest, 0.76 for GBM, 0.74 for AdaBoost, 0.73 for XGBoost, and 0.77 for the stacking ensemble model. The respective sensitivities for the 6 aforementioned models were 74.2%, 72.2%, 76.8%, 63.6%, 71.6%, and 67.4%. The respective specificities for the 6 aforementioned models were 70.7%, 99.8%, 96.5%, 98.8%, 96.5%, and 96.1%. The respective precision values for the 6 aforementioned models were 7.8%, 52.3%, 55.6%, 57%, 54.5%, and 56.4%.

CONCLUSIONS

The optimal application of the logistic regression model could provide quick and convenient POD risk identification to help improve the perioperative management of surgical patients because of its better sensitivity, fewer variables, and easier interpretability than the machine learning model.

Evaluating the Impact of Preoperative Geriatric-Specific Variables and Modified Frailty Index on Postoperative Outcomes After Elective Pancreatic Surgery

BACKGROUND

Pursuing pancreatic resection in elderly patients is often complex and limited by concern for functional status and postoperative risk. This study examines the associations between two different preoperative functional status metrics with postoperative outcomes in the geriatric population.

METHODS

Patients who participated in the ACS NSQIP Geriatric Surgery Research File pilot program (2014-2018) undergoing elective pancreatic operations were included. Two clinically meaningful functional status scores were calculated: the presence of one or more geriatric-specific variable (GSV) and a 5-factor modified frailty index (mFI-5). Multivariable logistic regression adjusting for ACS NSQIP-estimated risk was performed to evaluate associations between preoperative GSV, mFI-5 and 30-day outcome measures.

RESULTS

A total of 1266 patients were included: 808 (64%) age 65-74, 302 (24%) age 75-80, and 156 (12%) age ≥ 81; 843 (67%) patients underwent pancreatoduodenectomy. Operations were performed for pancreatic adenocarcinoma in 712 (56%) patients. Older patients had greater likelihood of postoperative morbidity (35% vs 31% vs 47%, by age group, p = 0.004) and discharge to a facility (12% vs 23% vs 48%, by age group, p < 0.001). Adjusting for ACS NSQIP predicted risk, patients with a preoperative GSV were more likely to require reoperation and discharge to a facility (OR 1.81 [95% CI 1.03-3.16] and 3.95 [95% CI 2.91-5.38], respectively). The mFI-5 was not associated with postoperative outcomes (all p ≥ 0.18).

CONCLUSION

The presence of a preoperative GSV is associated with reoperation and discharge to a skilled facility following elective pancreatic resection. Geriatric-specific variables should be considered in joint preoperative decision making to optimize care.

Systemic immune-inflammation index predicts postoperative delirium in elderly patients after surgery: a retrospective cohort study

Background

Postoperative delirium (POD) is a common complication among elderly patients after surgery. It is unclear whether the systemic immune-inflammation index (SII) can be a predictor of POD. We explored the prognostic value of the SII in predicting POD in elderly patients undergoing non-neurosurgery and non-cardiac surgery in a large retrospective cohort.

Methods

We enrolled elderly patients undergoing non-neurosurgery and non-cardiac surgery between January 2014 and August 2019. Univariate and multivariate logistic regression analyses were performed to explore the correlation between POD and the SII value as both a continuous and categorical variable. Then, propensity score matching (PSM) analysis was applied to eliminate the confounding effect of covariates and prove our results. Subgroup analyses were then performed to discover the association between the SII and POD in different subgroups.

Results

A total of 29,608 patients with a median age of 70 years (IQR: 67–74) were enrolled in the retrospective cohort. The cut-off value of the SII was 650, which was determined by the receiver operating characteristic (ROC) curve. The ORs of an SII value > 650 was 2.709 (95% CI:2.373–3.092, P < 0.001), 1.615 (95% CI:1.384–1.882, P < 0.001), 1.855 (95% CI:1.602–2.146, P < 0.001), and 1.302 (95% CI:1.106–1.531, P = 0.001) for prediction of POD in univariate model and three multivariate regression models. After PSM, the OR of an SII value > 650 was 1.301 (95% CI: 1.062–1.598, P = 0.011). The subgroup analysis indicated that the SII indicates a significantly increased risk of POD in patients with Hb < 130 g/L, 4*10⁹/L < WBC ≤ 10*10⁹/L, albumin < 39 g/L, or duration of MAP < 60 mmHg ≥ 5 min. The SII was found to be a useful prognostic predictor of POD for patients of different ages, sexes, and ASA classifications.

Conclusions

The SII had a predictive value for POD in patients undergoing non-neurosurgery and non-cardiac surgery. As an index generated from routine blood tests, the SII has advantages regarding cost and time. After further validation, the SII may provide a new option for POD prediction.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03418-4.

Evaluation of the American College of Surgeons National Surgical Quality Improvement Program Risk Calculator to predict outcomes after hysterectomies

OBJECTIVE

To evaluate the American College of Surgeons (ACS) surgical risk calculator's reliability in predicting outcomes in hysterectomies.

METHODS

This is a prospective cohort study at a large community-based hospital. Twenty-one preoperative and postoperative criteria were abstracted from the electronic medical record and entered into the online ACS calculator to determine a risk score. Logistical regression was used to determine the association between risk score and actual outcome. The prediction capability was analyzed with c-statistic, Hosmer-Lemeshow, and Brier score.

RESULTS

A total of 634 hysterectomies were performed during the study period from January to April 2019. Patients were predominantly 55 years old, white (53%) and overweight (body mass index 30). Predicted perioperative adverse events were significantly higher than actual adverse events across all domains. In all, 54/634 (8.5%) patients experienced postoperative urinary tract infection. C-statistics for return to operating room, renal failure, and readmission were 0.607 (95% C Statistic index [CI] 0.370-0.845), 0.882 (95% CI 0.802-0.962), 0.637 (95% CI 0.524-0.750), respectively. Brier scores approached one in all categorical domains.

CONCLUSION

The ACS surgical risk calculator holds the promise of predicting postoperative complications or length of stay for patients undergoing hysterectomy. Further adjustment to this tool is required before it can be advocated for use in the clinical setting.

Applying Evidence-based Principles to Guide Emergency Surgery in Older Adults

Although outcomes for older adults undergoing elective surgery are generally comparable to younger patients, outcomes associated with emergency surgery are poor. These adverse outcomes are in part because of the physiologic changes associated with aging, increased odds of comorbidities in older adults, and a lower probability of presenting with classic "red flag" physical examination findings. Existing evidence-based perioperative best practice guidelines perform better for elective compared with emergency surgery; so, decision making for older adults undergoing emergency surgery can be challenging for surgeons and other clinicians and may rely on subjective experience. To aid surgical decision making, clinicians should assess premorbid functional status, evaluate for the presence of geriatric syndromes, and consider social determinants of health. Documentation of care preferences and a surrogate decision maker are critical. In discussing the risks and benefits of surgery, patient-centered narrative formats with inclusion of geriatric-specific outcomes are important. Use of risk calculators can be meaningful, although limitations exist. After surgery, daily evaluation for common postoperative complications should be considered, as well as early discharge planning and palliative care consultation, if appropriate. The role of the geriatrician in emergency surgery for older adults may vary based on the acuity of patient presentation, but perioperative consultation and comanagement are strongly recommended to optimize care delivery and patient outcomes.

Postoperative delirium in older patients with cancer: the role of psychological distress and social support

PURPOSE OF REVIEW

Delirium is a common and important adverse event in the perioperative period. Older people with cancer are at significant risk, and outcomes are poor. There is increasing awareness of the effect of psychological distress and social support on pathogenesis and outcomes of delirium in this setting. This review aimed to describe recent research in this evolving area.

RECENT FINDINGS

Across six recent studies of postoperative delirium in older people with cancer, delirium incidence ranged from 8 to 19.8%. Poor social support and high levels of distress are implicated in the development of postoperative delirium. Distress can be related to negative emotional reaction to diagnosis, preconception of cancer diagnosis and interactions with the healthcare system. Prevention of delirium is key, and multicomponent interventions show evidence of effectiveness. 'Emotional distress' has been included in a new core outcome set for studies of interventions to prevent and/or treat delirium.

SUMMARY

Postoperative delirium in older adults with cancer is common and is associated with increased morbidity and mortality. Psychological distress and social support play an important role, but there are many unmet research needs in this area.

Understanding the role of informal caregivers in postoperative care transitions for older patients

BACKGROUND

Older adults may have new care needs and functional limitations after surgery. Many rely on informal caregivers (unpaid family or friends) after discharge but the extent of informal support is unknown. We sought to examine the role of informal postoperative caregiving on transitions of care for older adults undergoing routine surgical procedures.

MATERIALS AND METHODS

We performed a retrospective cohort study using ACS NSQIP Geriatric Pilot Project data, 2014-2018. Patients were ≥65 years and underwent an inpatient surgical procedure. Patients who lived at home alone were compared with those who lived with support from informal caregivers (family and/or friends). Primary outcomes were discharge destination (home vs. post-acute care) and readmission within 30 days. Multivariable logistic regression was used to determine the association between support at home, discharge destination, and readmission.

RESULTS

Of 18,494 patients, 25% lived alone before surgery. There was no difference in loss of independence (decline in functional status or new use of mobility aid) after surgery between patients who lived alone or with others (18.7% vs. 19.5%, p = 0.24). Nevertheless, twice as many patients who lived alone were discharged to a non-home location (10.2% vs. 5.1%; OR: 2.24, CI: 1.93-2.56). Patients who lived alone and were discharged home with new informal caregivers had increased odds of readmission (OR: 1.43, CI: 1.09-1.86).

CONCLUSION

Living alone independently predicts discharge to post-acute care, and patients who received new informal caregiver support at home have higher odds of readmission. These findings highlight opportunities to improve discharge planning and care.

Inadequate prediction of postoperative complications in breast cancer surgery: An evaluation of the ACS Surgical Risk Calculator

BACKGROUND

The American College of Surgeon (ACS) Surgical Risk Calculator is an online tool that helps surgeons estimate the risk of postoperative complications for numerous surgical procedures across several surgical specialties.

METHODS

We evaluated the predictive performance of the calculator in 385 cancer patients undergoing breast surgery. Calculator-predicted complication rates were compared with observed complication rates; calculator performance was evaluated using calibration and discrimination analyses.

RESULTS

The mean calculator-predicted rates for any complication (4.1%) and serious complication (3.2%) were significantly lower than the observed rates (11.2% and 5.2%, respectively). The area under the curve was 0.617 for any complication and 0.682 for serious complications. p Values for the Hosmer-Lemeshow test were significant (<.05) for both outcomes. Brier scores were 0.102 for any complication and 0.048 for serious complication.

CONCLUSIONS

The ACS risk calculator is not an ideal tool for predicting individual risk of complications following breast surgery in a Mexican cohort. The most valuable use of the calculator may reside in its role as an aid for patient-led surgery planning. The possibility of introducing breast surgery-specific data could improve the performance of the calculator. Furthermore, a disease-specific calculator could provide more accurate predictions and include complications more frequently found in breast cancer surgery.

A Fall Within 3 Months Before Total Joint Arthroplasty is Associated With Adverse Outcomes in Elderly Patients

BACKGROUND

Falls are associated with morbidity and death in the elderly. The consequences of falls after total joint arthroplasty (TJA) are known, but the consequences of preoperative falls are unclear. We assessed associations between preoperative fall history and hospital readmission rates and discharge disposition after primary TJA.

METHODS

We queried the National Surgical Quality Improvement Program Geriatric Pilot Project for cases of primary total hip arthroplasty (THA) (n = 3671) and total knee arthroplasty (TKA) (n = 6194) performed between 2014 and 2018 for patients aged ≥65 years. Patient characteristics, comorbidities, functional status indicators, and 30-day outcomes were compared among patients with falls occurring within 3 months, from >3 to 6 months, and from >6 to 12 months before surgery, and patients with no falls in the year before surgery. The timing of falls was assessed for independent associations with hospital readmission and discharge to a skilled care facility (SCF). Alpha = 0.05.

RESULTS

Patients who fell within 3 months before surgery had greater odds of SCF discharge (for THA, odds ratio [OR] 2.5, 95% confidence interval [CI] 1.8-3.4; for TKA, OR 1.8, 95% CI 1.4-2.3) and hospital readmission (for THA, OR 1.8, 95% CI 1.1-3.0; for TKA, OR 2.4, 95% CI 1.6-3.5) compared with the no-fall cohort. No such associations were observed for the other two fall cohorts.

CONCLUSION

Falls within 3 months before primary TJA are associated with SCF discharge and readmission for patients aged ≥65 years. Fall history screening should be included in preoperative evaluation.

LEVEL OF EVIDENCE

III.

Preoperative Cognitive Impairment as a Perioperative Risk Factor in Patients Undergoing Total Knee Arthroplasty

Background:

The study assessed whether pre-existing cognitive impairment (CI) prior to elective total knee arthroplasty (TKA) is associated with worse postoperative outcomes such as delirium, in-hospital medical complications, 30-day mortality, hospital length of stay and non-home discharge.

Methods:

A retrospective database analysis from the NSQIP Geriatric Surgery Pilot Project was used. There was an initial cohort of 6350 patients undergoing elective TKA, 104 patients with CI were propensity score matched to 104 patients without CI.

Results:

Analysis demonstrated a significantly increased incidence of post-operative delirium (POD) in the cohort with pre-op CI (p = < .001), a worsened functional status (p = < .001) and increased nonhome discharge postoperatively compared to the group without CI (p = 0.029). Other post-operative outcomes included 30-day mortality of 0% in both groups, and low rate of complications such as infection (2.88% vs 0.96%), pneumonia (1.92% vs 0%), failure to wean (0.96% vs 0%), and reintubation (0.96% vs 0%). Some other differences between the CI group and non-CI group, although not statistically significant, included increased rate of transfusion (10.58% vs 6.73%), and sepsis (1.92% vs 0%). The length of stay was increased in the non-CI group (4.28% vs 2.32%, p = 0.122).

Conclusion:

CI in patients undergoing TKA is associated with an increased risk of POD, worsened postoperative functional status, and discharge to non-home facility.

Prehabilitative exercise hastens recovery from isoflurane in diabetic and non-diabetic rats

Diabetes has been demonstrated to be one of the strongest predictors of risk for postoperative delirium and functional decline in older patients undergoing surgery. Exercise is often prescribed as a treatment for diabetic patients and regular physical activity is hypothesized to decrease the risk of postoperative cognitive impairments. Prior studies suggest that anesthetic emergence trajectories and recovery are predictive of risk for later postoperative cognitive impairments. Therapeutic strategies aimed at improving emergence and recovery from anesthesia may therefore be beneficial for diabetic patients. Wistar (n = 32) and Goto-Kakizaki (GK) type 2 diabetic (n = 32) rats between 3-4 months old underwent treadmill exercise for 30 min/day for ten days or remained inactive. Pre-anesthesia spontaneous alternation behavior was recorded with a Y-maze. Rats then received a 2-h exposure to 1.5-2 % isoflurane or oxygen only. The time to reach anesthetic emergence and post-anesthesia recovery behaviors was recorded for each rat. Postsynaptic density protein-95 (PSD-95), an important scaffolding protein required for synaptic plasticity, protein levels were quantified from hippocampus using western blot. Spontaneous alternation behavior (p = 0.044) and arm entries (p < 0.001) were decreased in GK rats. There was no difference between groups in emergence times from isoflurane, but exercise hastened the recovery time (p = 0.008) for both Wistar and GK rats. Following 10 days of exercise, both Wistar and GK rats show increased levels of PSD-95 in the hippocampus. Prehabilitation with moderate intensity exercise, even on a short timescale, is beneficial for recovery from isoflurane in rats, regardless of metabolic disease status.

Incorporating Outcomes that Matter to Older Adults into Surgical Research

This editorial comments on the article by Thillainadesan et al. in this issue.

Geriatric Risk Prediction Models for Major Gastroenterological Surgery using the National Clinical Database in Japan: A Multicenter Prospective Cohort Study

OBJECTIVES

To investigate the effect of geriatric variables on five newly added outcomes and create risk models for predicting these outcomes.

SUMMARY BACKGROUND DATA

Because there is a current lack of geriatric research focusing on geriatric outcomes using a national surgical database in Japan, there is a need to investigate outcomes associated with major gastroenterological surgery using these data.

METHODS

This multicenter prospective cohort study was conducted at 26 surgery departments across 21 institutions in Japan using the National Clinical Database (NCD) surgical registry. In total, 22 new geriatric variables were imported from the ACS NSQIP geriatric pilot study. The following five geriatric outcomes were defined: 1) postoperative delirium, 2) physical function on postoperative day 30, 3) fall risk on discharge, 4) discharge other than home with social service, and 5) functional decline on discharge, and geriatric risk prediction models for major gastroenterological surgery were created.

RESULTS

Between January 2018 and December 2018, data on 3,981 procedures from seven major gastroenterological surgeries were collected and analyzed. Older age and preoperative geriatric variables (Origin status from home, History of dementia, Use of mobility aid, Fall history, and Not competent on admission) were strongly associated with postoperative outcomes. Geriatric risk prediction models for these outcomes were created, with C-statistic values ranging from 0.74 to 0.90, demonstrating model validity and sufficiency of fit.

CONCLUSIONS

The risk models for the newly defined five geriatric outcomes that we created can be used in the decision-making process or provision of care in geriatric patients.

The American College of Surgeons Geriatric Surgery Verification Program and the Practicing Colorectal Surgeon

The population is aging and older adults are increasingly undergoing surgery. Colorectal surgeons need to understand the risks inherent in the care of older adults and identify concrete ways to improve the quality of care for this vulnerable population. Goals for the practicing colorectal surgeon include: 1) introduce the American College of Surgeons’ (ACS) Geriatric Surgery Verification (GSV) Program and understand the intersection with colorectal surgery, 2) examine the 30 evidence-based GSV standards and how they can achieve better outcomes after colorectal surgery, and 3) outline the value and benefits for colorectal surgeons of implementing such a program.

Evidence-Based Management of Calculous Biliary Disease for the Acute Care Surgeon

Background: Gallstones and cholecystitis are common clinical problems. There is a wide spectrum of disease severity, from rare symptoms of biliary colic to severe cholecystitis with marked gallbladder infection and inflammation that can cause life-threatening sepsis. The care of such patients is similarly varied and multi-disciplinary. Despite the prevalence of cholecystitis, there remain questions about how to manage patients appropriately. Methods: A multi-disciplinary team created institutional cholecystitis guidelines, and supporting evidence was compiled for review. Results: Even in "routine" cholecystitis, patient triage and work-up can be variable, resulting in unnecessary tests and delay to cholecystectomy. Beyond this, there are new treatment options available that may serve special populations particularly well, although the appropriate pattern of emerging endoscopic and percutaneous treatment modalities is not well defined. Conclusions: This review outlines evidence-based management of cholecystitis from diagnosis to treatment with a focused discussion of special populations and emerging therapies.

Loss of Independence in Older Patients after Operation for Colorectal Cancer

BACKGROUND

Disease-free survival is the cornerstone for colorectal cancer outcomes. Maintenance of independence may represent the preferred cancer outcome in older patients. Frailty and cognitive impairment are associated with adverse clinical outcomes after operation in patients ≥65 years. The aim of this study was to determine the impact of frailty and cognitive impairment on loss of independence (LOI) among colorectal cancer patients.

STUDY DESIGN

From 2016 to 2018, patients undergoing operation for colorectal cancer and having geriatric-specific American College of Surgeons NSQIP variables recorded were included. Frailty was assessed using the modified frailty index. Loss of independence was defined by the need for assistance with activities of daily living. Complications were assessed using the Clavien-Dindo (CD) scoring system. Multivariable analyses examining LOI, length of stay (LOS), and 30-day postoperative complication and readmission were performed.

RESULTS

There were 1,676 patients included. Preoperatively, 118 (7%) patients reported cognitive impairment, 388 (23%) patients used a mobility aid, and 82 (5%) patients were partially or totally dependent. Loss of independence upon discharge was seen in 344 (20.5%) patients and was independently associated with an increase in LOS (incidence rate ratio [IRR] 1.44, 95% CI 1.30 to 1.59) and major complication (odds ratio [OR] 1.86, 95% CI 1.36 to 2.53). Risk factors predictive of LOI upon discharge were increasing age, cognitive impairment, use of mobility aid, and postoperative delirium. In patients ≥80 years old, 93 (18%) had LOI at 30 days. Risk factors predictive of LOI at 30 days included a preoperative mobility aid, postoperative delirium, and the need for a new mobility aid.

CONCLUSIONS

One of 5 older patients undergoing operation for colorectal cancer experience LOI, and risk factors include a decline in cognition and mobility. Future studies should evaluate risks for long-term LOI and explore interventions to optimize this patient population.