Increased psychiatric morbidity after abdominal aortic surgery: risk factors for stress-related disorders

Multimodal Prehabilitation for Patients Undergoing Endovascular Aortic Aneurysm Repair Surgery: A Feasibility Study

BACKGROUND

Elective treatment options for aortic abdominal aneurysms include open repair or the less-invasive endovascular aortic aneurysm repair (EVAR). Recovery from EVAR is generally considered easier and faster than open repair. Despite this, EVAR remains a major procedure, and average return to preoperative quality of life is at least 3 months. The purpose of this study is to determine the safety and feasibility of multimodal prehabilitation, a multidisciplinary preoperative optimization intervention, in patients undergoing EVAR and its impact on perioperative functional capacity and quality of life.

METHODS

Candidates for EVAR with an infra-renal abdominal aortic aneurysm <7.5cm were invited to participate in a 6-week multimodal prehabilitation program that included (1) supervised and home-based exercise, (2) nutritional support, (3) psychosocial support, and (4) smoking cessation. Functional capacity and quality of life were assessed at baseline, before surgery and 6 weeks postoperatively. Recruitment rate, safety, and compliance were also assessed.

RESULTS

A total of 24 patients were included, 17 males (70%) and 7 females (30%). No adverse events occurred during the program. Compliance to each component of the program (median [Q1-Q3]) was 66% [67] for supervised training, 100% [67] for home-based training, and 100% [100] for nutrition. The multimodal prehabilitation program elicited a significant increase in functional capacity and quality of life preoperatively.

CONCLUSION

Multimodal prehabilitation for patients awaiting EVAR is feasible and safe. Multimodal prehabilitation improves both functional capacity and quality of life preoperatively. Further research is needed to assess the impact of multimodal prehabilitation on postoperative quality of life and functional capacity.

CLINICAL IMPACT

Multimodal prehabilitation is safe and feasible in patients awaiting endovascular aneurysm repair. The importance of this finding is that multimodal prehabilitation can be safely delivered preoperatively in patients awaiting EVAR. Although further research is needed, multimodal prehabilitation seems to improve preoperative functional capacity and quality of life. This could have an impact for the future implementation of prehabilitation interventions in order to increase functional reserve and quality of life preoperatively so that this high-risk population can cope better with the surgical stress and return to their normal life faster postoperatively.

Patients' health and quality of life after complex endovascular aortic repair: A prospective cohort study

RATIONALE

Complex endovascular aortic repair often involves multiple major procedures over time with a high risk of complications and little time for recovery. This exposes patients to great stress, both physically and mentally, with potentially long-lasting effects. There is limited knowledge about these effects and who is most at risk - information on this could help vascular nurses and other healthcare professionals anticipate and meet care needs.

AIM

To investigate the health and quality of life effects of complex endovascular aortic repair, in relation to patients' demographic and health characteristics.

DESIGN

A prospective cohort study.

METHODS

Patients undergoing elective complex endovascular aortic repair were consecutively recruited from one university hospital during one year (n=25). Self-report questionnaires on health disability (WHODAS 2.0), quality of life (WHOQoL-BREF) and symptoms of anxiety and depression (HADS) were filled out preoperatively and repeated one and six months postoperatively. Prospective changes in health and quality of life, and associations with patient demographics and preoperative health characteristics, were assessed. Ethical approval was obtained prior to study performance.

RESULTS

Overall, patients had significantly greater health disability at one month (WHODAS 2.0 score median 31.5, range 1.1-63.0) than preoperatively (median 13.6, range 0.0-41.3) (n=22, p=.017); the majority had recovered at six months (median 11.4, range 3.3-58.7) (n=18, p=.042). No significant effects were seen in quality of life and symptoms of anxiety and depression (p>.05). However, the participants showed heterogeneity, with certain individuals not recovered at six months (n=8). Factors associated with worse six-month outcomes were being female, age < 70 years, postoperative complications, and history of anxiety or depression.

CONCLUSIONS

Complex endovascular aortic repair have limited long-term negative effects on patients' health and quality of life. However, some patients are not recovered at six months postoperatively, which could be explained by individual characteristics. To improve recovery outcomes, vascular nurses and other health care professionals should be aware of the possible recovery trajectories and factors associated with impaired recovery, and use them to anticipate and meet the patients' individual care needs.

Quantifying the burden of survivorship associated with infrarenal abdominal aortic aneurysms

OBJECTIVES

Survivorship encompasses the physical, psychological, social, functional, and economic experience of a living with a chronic condition for both the patient and their caregiver. It is made up of nine distinct domains and remains understudied in nononcological pathologies, including infrarenal abdominal aortic aneurysmal disease (AAA). This review aims to quantify the extent to which existing AAA literature addresses the burden of survivorship.

METHODS

The MEDLINE, EMBASE, and PsychINFO databases were searched from 1989 through September 2022. Randomized controlled trials, observational studies, and case series were included. Eligible studies had to detail outcomes related to survivorship in patients with AAA. Owing to the heterogeneity between studies and outcomes, no meta-analysis was conducted. Study quality was assessed with specific risk of bias tools.

RESULTS

A total of 158 studies were included. Of these, only five (treatment complications, physical functioning, comorbidities, caregivers, and mental health) of the nine domains of survivorship have been studied previously. The available evidence is of variable quality; most studies display a moderate to high risk of bias, are of an observational study design, are based within a limited number of countries, and consist of an insufficient follow-up period. The most frequent complication after EVAR was endoleak. EVAR is associated with poorer long-term outcomes compared with open surgical repair in most studies retrieved. EVAR showed better outcomes in regard to physical functioning in the short term, but this advantage was lost in the long term. The most common comorbidity studied was obesity. No significant differences were found between open surgical repair and EVAR in terms of impact on caregivers. Depression is associated with various comorbidities and increased the risk of a nonhospital discharge.

CONCLUSIONS

This review highlights the absence of robust evidence regarding survivorship in AAA. As a result, contemporary treatment guidelines rely on historic quality-of-life data that are narrow in scope and nonrepresentative of contemporary clinical practice. As such, there is an urgent need to reevaluate the aims and methodology associated with traditional quality-of-life research moving forward.

Benefits of Prehabilitation before Complex Aortic Surgery

The purpose of this narrative review was to detail and discuss the underlying principles and benefits of preoperative interventions addressing risk factors for perioperative adverse events in open aortic surgery (OAS). The term "complex aortic disease" encompasses juxta/pararenal aortic and thoraco-abdominal aneurysms, chronic aortic dissection and occlusive aorto-iliac pathology. Although endovascular surgery has been increasingly favored, OAS remains a durable option, but by necessity involves extensive surgical approaches and aortic cross-clamping and requires a trained multidisciplinary team. The physiological stress of OAS in a fragile and comorbid patient group mandates thoughtful preoperative risk assessment and the implementation of measures dedicated to improving outcomes. Cardiac and pulmonary complications are one of the most frequent adverse events following major OAS and their incidences are correlated to the patient's functional status and previous comorbidities. Prehabilitation should be considered in patients with risk factors for pulmonary complications including advanced age, previous chronic obstructive pulmonary disease, and congestive heart failure with the aid of pulmonary function tests. It should also be combined with other measures to improve postoperative course and be included in the more general concept of enhanced recovery after surgery (ERAS). Although the current level of evidence regarding the effectiveness of ERAS in the setting of OAS remains low, an increasing body of literature has promoted its implementation in other specialties. Consequently, vascular teams should commit to improving the current evidence through studies to make ERAS the standard of care for OAS.

Post-traumatic stress following total hysterectomy for benign disease: an observational prospective study

PURPOSE

Over the last decade, there has been growing interest in the psychophysical integrity of surgical patients in the context of healthcare events. In the present study, we aimed to evaluate the incidence rate of postoperative distress symptoms, namely post-traumatic stress disorder (PTSD), following total hysterectomy for benign disease. We also investigated possible associations between sociodemographic characteristics, clinical outcomes, anxiety, depression, and PTSD.

METHODS

We prospectively enrolled 100 consecutive patients who underwent total hysterectomy for benign disease between 01/01/2019 and 15/04/2019. Demographic and surgical-related characteristics have been registered. The Hospital Anxiety and Depression Scale (HADS) questionnaire was administered preoperatively (Time1), postoperatively (Time2), and at follow-up clinical evaluation, between two and three months after surgery (Time3). PTSD was defined based on the results of the Post-traumatic Stress Disorder Checklist for DSM-5 (PCL-5) at Time3.

RESULTS

At Time3, the median PCL-5 score was 12,8 (0-70), and 16.4% of patients had PTSD symptoms (PCL-5 > 33). No correlation between sociodemographic or gynecologic characteristics and PTSD was detected. A significant association between depression (HADS > 8) at Time2 (p = 0.002) and Time3 (p < 0.001) and PTSD symptoms was shown.

CONCLUSION

Hysterectomy for benign disease is associated with a non-negligible risk of PTDS; the use of the HADS questionnaires might be useful to select patients who might benefit from dedicated psychological support.

Trajectory of Recovery in PROMIS Global Physical Health After Surgical Fracture Fixation

INTRODUCTION

Patient-reported outcomes (PROs) provide data on the effect of conditions and treatments on patients' lives without third party interpretation. Mounting evidence suggests that PROs may be useful in elective procedure decision making, but its utility in trauma remains unclear. Longitudinally collected PROs may prove effective in identifying patients recovering below the norm. We sought to document recovery trajectory in patients with and without complication and to evaluate the sources of variability in functional recovery after injury.

METHODS

This retrospective study included 831 patients with trauma, identified via Current Procedural Terminology (CPT) codes for surgical extremity and/or pelvic/acetabular fracture management between 2014 and 2018. Global Physical Health (GPH) scores collected via the PROMIS Global Health in a 14-month window after injury were analyzed using mixed-effects modeling.

RESULTS

A curvilinear GPH recovery trajectory was observed where patients demonstrated an initial positive recovery trajectory (B = 1.28, P < 0.001) gradually decelerating over time (B = -0.07, P < 0.001). Patients who experienced complications requiring revision surgery demonstrated markedly lower GPH scores. Several notable predictors of postoperative physical health recovery were identified, including both between-person (B = 0.52, 95% CI, 0.48 to 0.56) and within-person (B = 0.41, 95% CI, 0.36 to 0.46) Global Mental Health (GMH) score, Body Mass Index (BMI) (B = -0.07, 95% CI, -0.12 to -0.02), two or more psychiatric diagnoses (B = -0.97, 95% CI, -1.84 to 0.09), Injury Severity Score 10 to 15 and 16+ (B = -2.62, 95% CI, -4.81 to 0.42 and B = -2.17, 95% CI, -3.60 to 0.74, respectively), readmission for complication (B = -2.64, 95% CI, -3.60 to 1.68), and lower extremity or multiextremity fracture (relative to upper extremity) (B = -3.61, 95% CI, 4.45 to 2.78, B = -4.11, 95% CI, -5.77 to 2.44, respectively). Additional analysis suggests that GMH scores are related to the presence of psychiatric diagnoses.

DISCUSSION

This study establishes a normal course of recovery as reflected by PROMIS GPH score to serve as an index for monitoring individual postoperative course. Patients who experienced a complication demonstrated markedly lower GPH across all time points, potentially allowing earlier identification of at-risk patients. Furthermore, GMH may represent a modifiable risk factor that could profoundly affect physical recovery.

LEVEL OF EVIDENCE

Level III (Prognostic Study = Retrospective Cohort).

Increased depression risk in patients with abdominal aortic aneurysm: a nationwide cohort study

Purpose

Abdominal aortic aneurysm (AAA) is a critical disease. Most studies of AAA consider reoperation rate, complications, or mortality, but do not consider a patient's mental state. However, there is a possibility of interaction between AAA and depression in disease development and prognosis. We investigated the incidence and risk ratio of depression in patients with AAA using nationwide data.

Methods

We selected subjects from National Health Insurance System database who were diagnosed with AAA between 2009 and 2015 and survived at least 1 year after diagnosis or AAA surgery (n = 10,373). We determined the control group using propensity score matching by age and sex. The control group had about 3 times the number of subjects as the AAA cohort (n = 31,119).

Results

The incidence of depression was 1.4 times higher in the AAA group than the control group. We further analyzed the incidence of depression in the AAA group according to treatment modalities (nonsurgical vs. surgical or nonsurgical vs. open surgical aneurysm repair vs. endovascular aneurysm repair) but found no significant difference among them. The incidence of depression was significantly higher in patients aged <65 years than in patients aged ≥65 years (hazard ratio, 1.539 vs. 1.270; P < 0.001).

Conclusion

The incidence of depression was higher in the AAA group, with an especially high risk for depression in patients aged <65 years. The psychiatric status of patients with AAA should be carefully monitored for clinicians to intervene when appropriate.

Anxiety and depression scores in patients subjected to aortic and iliac aneurysm repair procedures

OBJECTIVE

This study examines the changes in anxiety and depression scores of 84 patients subjected to aortic or iliac aneurysm correction with no previous psychiatric history.

METHODS

Patients were referred to the evaluation using the Beck Anxiety and Depression Inventories no more than 3 days before surgery (i.e., preoperative [Pre-Op]), 30 days after revascularization (i.e., Early postoperative [PO]), and at least 6 months after revascularization (i.e., Late PO).

RESULTS

Mean anxiety scores declined from baseline at both the Early (mean difference: 2.75, p<0.001) and Late PO (mean difference: 2.74, p=0.001). The depression levels showed no significant variation in either evaluation (Early PO; mean difference: -0.84, p>0.05, Late PO: 0.87, p=0.05). A more severe degree of anxiety at baseline was related to better anxiety results both in the Early PO (p=0.041) and Late PO (p=0.008). An endovascular technique was related to the improvement in depression symptoms in the Early PO (p=0.01) but the worsening of the symptoms in the Late PO (p=0.033).

CONCLUSIONS

Patients subjected to aortoiliac aneurysm corrections have a higher incidence of anxiety and depressive symptoms. Anxiety symptoms, but not the depressive ones, improved considerably following the successful treatment. The formal psychiatric evaluation may be beneficial for patients with less improvement in the symptom.

Infection and Mechanical Complications Are Risk Factors for New Diagnosis of a Mental Health Disorder After Total Joint Arthroplasty

Background

Prior studies have demonstrated that depression is an independent risk factor for developing a prosthetic joint infection (PJI) after total joint arthroplasty (TJA). To our knowledge, there is no literature examining whether PJI or aseptic failure increases the risk of developing a new mental health diagnosis.

Methods

PearlDiver Patient Database (Colorado Springs, CO) was used to identify 80,826 patients who underwent TJA without a pre-existing diagnosis of depression, anxiety, a stress and/or adjustment disorder, and/or current use of a selective serotonin reuptake inhibitor within the year prior to surgery. The odds of developing a new mental health issue or being prescribed a selective serotonin reuptake inhibitor within 1 year of an uncomplicated TJA was compared to those who developed PJI or mechanical failure within 90 days after TJA as well as to those who subsequently underwent revision surgery within 30 days of either complication using Fisher’s exact test and Baptista-Pike.

Results

A total of 6474 (8%) patients were diagnosed with a new mental health issue after TJA. PJI or mechanical failure led to significantly higher odds of new diagnoses with an odds ratio of 1.67 (95% confidence interval = 1.26, 2.22) and 1.57 (1.24, 2.00), respectively. Undergoing revision surgery for PJI or mechanical failure increased the odds of developing a new mental health diagnosis to 2.10 (1.29, 3.42) and 2.24 (1.36, 3.72), respectively. There was no significant difference comparing those who developed PJI vs those who sustained mechanical complications.

Conclusion

Patients who sustain complications after TJA are at increased odds of receiving a new mental health diagnosis, an effect further amplified if revision surgery is required.

Psychological sequelae of colonic resections

AIM

The prevalence of anxiety, depression and post-traumatic stress disorder (PTSD) in the general population has been estimated to be 5.9%, 3.3% and 4.4% respectively. The aim of this study was to determine whether psychological problems are more prevalent following colorectal surgery.

METHOD

Patients who had undergone colorectal resection in a 2-year period across four centres were asked to complete validated screening questionnaires for anxiety, depression and PTSD (GAD-7, PHQ-9, PCL-5) 12-48 months after surgery. Risk factors were identified using multiple linear regression analysis.

RESULTS

After excluding those who had died or received palliative diagnoses, questionnaires were sent to 1150 patients. 371 responded (32.3% response rate); median age 67 (20-99) years; 51% were men. 58% of patients underwent surgery for cancer; 23% had emergency surgery. 28% of patients screened positive for at least one psychological condition, with 20% screening positive for anxiety, 22% for depression and 14% for PTSD. Patients who were younger, women, had surgery as an emergency, for benign conditions, had stomas and had critical care stay were more likely to have poorer psychological outcomes. Multiple linear regression found that only younger age (P = 0.000) and female gender (P = 0.048) were significant risk factors.

CONCLUSION

The prevalence of anxiety, depression and PTSD appears to be high in patients who have undergone colorectal surgery. Younger patients and women are particularly at risk. Further work is needed to determine how best to prevent, detect and treat people with adverse psychological outcomes following colorectal surgery.

Risk of Suicide and Self-harm Is Increased After Bariatric Surgery-a Systematic Review and Meta-analysis

BACKGROUND

Bariatric surgery is endorsed by multiple societies as the most effective treatment for obesity. Psychosocial functioning has also been noted to improve for most patients after bariatric surgery. However, some studies have shown an increase in post-operative suicide risk. The aim of this study was to review the published literature and evaluate the association of bariatric surgery with suicide events and suicide/self-harm attempts in patients who have undergone weight loss surgery.

METHODS

MEDLINE and Embase were searched from inception through January 2018 for retrospective or prospective studies reporting mortality outcomes and self-harm or suicide rates after bariatric procedures. The primary outcome was the pooled event rate with 95% confidence interval (95% CI) for suicide. Secondary outcomes were suicide/self-harm attempts after bariatric surgery compared to same population prior to surgery and to matched control subjects, with the respective calculated odds ratios (OR) and 95% CI.

RESULTS

From 227 citations, 32 studies with 148,643 subjects were eligible for inclusion. The patients were predominantly females (76.9%). Roux-en-Y gastric bypass (RYGB) was the most commonly performed procedure (58.9%). The post-bariatric suicide event rate was 2.7/1000 patients (95% CI 0.0019-0.0038), while the suicide/self-harm attempt event rate was 17/1000 patients (95% CI 0.01-0.03). The self-harm/suicide attempt risk was higher after bariatric surgery within the same population with OR of 1.9 (95% CI 1.23-2.95), and compared to matched control subjects, OR 3.8 (95% CI, 2.19-6.59).

CONCLUSIONS

Post-bariatric surgery patients had higher self-harm/suicide attempt risk compared to age-, sex-, and BMI-matched controls. Various pre- and post-surgical psychosocial, pharmacokinetic, physiologic, and medical factors may be involved.

Symptoms of Depression and Risk of Abdominal Aortic Aneurysm: A HUNT Study

Background

Depression is associated with cardiovascular diseases, but the evidence is scarce regarding depression and risk of abdominal aortic aneurysms (AAA). The aim was to determine whether individuals with depressive symptoms have increased risk of AAA.

Methods and Results

This population‐based prospective study included 59 136 participants (52.4% women) aged 50 to 106 years from the HUNT (Norwegian Nord‐Trøndelag Health Study). Symptoms of depression were assessed using the depression subscale of the Hospital Anxiety and Depression Scale (HADS). During a median follow‐up of 13 years, there were 742 incident cases of AAA (201 women). A total of 6401 individuals (12.3%) reported depressive symptoms (defined as HADS depression scale [HADS‐D]) ≥8) (52.5% women). The annual incidence rate of AAA was 1.0 per 1000 individuals. At all ages, the estimated proportion of individuals diagnosed with AAA was higher among those with depressive symptoms (log‐rank test, P<0.001). People with HADS‐D ≥8 were older than those with HADS‐D<8 (median 57.8 versus 52.3 years, P<0.001) and a statistically significantly higher proportion of them (P<0.001) were smokers, overweight or obese, and reported a history of coronary heart disease, diabetes mellitus, and hypertension. In a Cox proportional hazard regression model adjusted for these factors, individuals with depressive symptoms had a ≈30% higher risk of AAA than those without (hazard ratio, 1.32, 95% CI 1.08–1.61, P=0.007).

Conclusions

This study shows that individuals with depressive symptoms have significantly higher risk of incident AAA, after adjustments for established risk factors.

Psychiatric Illness Is Common in Elderly Fracture Patients

OBJECTIVES

To (1) describe the prevalence of psychiatric illness in fracture patients ≥70 years of age and (2) investigate the association between psychiatric illness and complications requiring unplanned readmission in elderly patients.

DESIGN

Retrospective cohort study.

PATIENTS/PARTICIPANTS

One thousand one hundred eighty-six patients ≥70 years of age with surgically treated fractures and ≥1-month follow-up treated from 2012 to 2017.

INTERVENTION

None.

MAIN OUTCOME MEASURE

Complication requiring unplanned readmission.

RESULTS

Forty-four percent of patients ≥70 years of age have psychiatric comorbidities, and of those, 34% had >1 diagnosis. There was a higher rate of readmission among patients with psychiatric diagnosis compared with those without psychiatric diagnosis (35% vs. 21%, P < 0.001). There was a higher prevalence of psychiatric illness among patients 70 years of age or older compared with patients less than 70 years of age (44% vs. 39%, P = 0.007). Multivariate regression analysis controlling for age, sex, Charlson Comorbidity Index, dementia, delirium during admission, tobacco use, substance abuse, Injury Severity Score, fracture location, number of procedures, and number of fractures demonstrated an independent association between psychiatric illness and unplanned readmission (adjusted OR 1.54, 95% confidence interval, 1.15-2.07, P = 0.003).

CONCLUSIONS

Almost half of the elderly patients in the present cohort have psychiatric comorbidities. Furthermore, psychiatric illness is an independent predictor of unplanned readmission, which may have substantial consequences for recovery and cost of care. This emphasizes the need for more attention to these issues in geriatric patient populations and the need to identify means to influence the downstream consequences of these comorbidities.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk Factors for Preoperative Anxiety and Depression in Patients Scheduled for Abdominal Aortic Aneurysm Repair

Background

Perioperative emotional disorders of patients underwent abdominal aortic aneurysm (AAA) repair is an emerging area of study, and preoperative mental distress of those patients remains poorly understood. The aim of this study was to investigate the prevalence and identify the risk factors of preoperative anxiety and depression in patients scheduled for AAA repair.

Methods

A total of 189 patients who underwent elective AAA repair between 2015 and 2016 were included in this study. These patients were preoperatively evaluated by Hospital Anxiety and Depression Scale (HADS). Demographics and anxiety and depression scores of the patients were documented. Logistic regression was used to identify the independent risk factors of preoperative anxiety and depression.

Results

A total of 150 AAA patients were included in final analysis. Of these 150 patients, 44 patients (29.3%) had borderline anxiety or clinical anxiety, and 42 patients (28.0%) were found to have borderline or clinical depression. Female (odds ratio [OR]: 2.81, 95% confidence interval [CI]: 1.08-7.26), the American Society of Anesthesiologists (ASA) Grade 3/4 (OR: 4.34, 95% CI: 1.13-16.68), higher education (OR: 1.44, 95% CI: 1.02-2.04), and abdominal or back pain (OR: 3.08, 95% CI: 1.20-7.87) were identified as significant independent risk factors of abnormal HADS-anxiety in overall patients; and higher level of education (OR: 1.87, 95% CI: 1.16-3.01) was predictive of anxiety in patients planned for endovascular aortic repair. Besides, higher body mass index (BMI) (OR: 1.18, 95% CI: 1.04-1.33) and abdominal or back pain (OR: 3.93, 95% CI: 1.70-9.11) were predictive of abnormal preoperative HADS-depression in overall patients.

Conclusion

As for patients scheduled for AAA repair, female, higher ASA, higher level of education, and symptom may be independent risk factors for preoperative anxiety, and symptom and higher BMI may predict preoperative depression.

Linked Hospital and Primary Care Database Analysis of the Incidence and Impact of Psychiatric Morbidity Following Gastrointestinal Cancer Surgery in England

OBJECTIVE

To evaluate risk of psychiatric morbidity and its impact on survival in gastrointestinal surgery.

BACKGROUND

Psychiatric morbidity related to surgery is poorly understood, and may be evaluated using linked hospital and primary care data.

METHODS

Patients undergoing gastrointestinal surgery from 2000 to 2011 with linkage of Clinical Practice Research Datalink (CPRD), Hospital Episodes Statistics (HES), Office of National Statistics (ONS), and National Cancer Intelligence Network (NCIN) databases were studied. Psychiatric morbidity was defined as a diagnosis code in CPRD or HES, or a prescription code for psychiatric medication in the 36 months before (preoperative) or 12 months after (postoperative) surgery. Newly diagnosed psychiatric morbidity was measured in patients without preoperative psychiatric morbidity.

RESULTS

In our study, 14,797 (23.8%) and 47,279 (76.2%) patients had surgery for cancer and benign disease, respectively. Postoperative psychiatric morbidity was observed in 10.1% (1500/14797) of patients undergoing cancer surgery. Logistic regression revealed that when adjusted for other factors, cancer diagnosis [odds ratio (OR) = 1.19] independently predicted postoperative psychiatric morbidity (P < 0.05). Hepatopancreaticobiliary resection (OR = 2.40) and esophagogastrectomy (OR = 2.55) carried the highest risks of postoperative psychiatric morbidity (P < 0.05). Preoperative psychiatric morbidity (OR = 1.16) and newly diagnosed psychiatric morbidity (OR = 1.87) were associated with increased 1-year mortality in cancer patients only (P < 0.05).

CONCLUSIONS

Postoperative psychiatric morbidity affected a tenth of patients who underwent gastrointestinal cancer surgery and was associated with increased mortality. Strategies to identify patients at risk preoperatively and to reduce the observed adverse impact of postoperative psychiatric morbidity should be part of perioperative care in complex cancer patients.

Prevalence and Determinants of Depression and Anxiety Symptoms in Surgical Patients

OBJECTIVES

Mood disorders are prevalent in hospitalized patients. However, risk factors for early diagnosis have not been studied exclusively in surgical patients. Our study aimed to investigate the prevalence and determinants of depression and anxiety symptoms in surgical patients.

METHODS

We included 392 surgical patients in this prospective cross-sectional study, which took place between June 2011 and June 2012. The Hospital Anxiety and Depression Scale (HADS) was used to screen for symptoms of depression and anxiety at weekly interviews. Regression analysis was performed to identify risk factors for early (the day after admission) and late (one week or more) in-hospital psychiatry symptoms.

RESULTS

Depression and anxiety symptoms increased from the time of admission toward longer hospital stay. Scores obtained in the second and third weeks of admission were associated with the need for surgery while HADS in the third week was associated with lack of familial support and being under the poverty line (p < 0.050). Regression model analysis showed that early depression was associated with female gender, and early anxiety was inversely affected by female gender and protected by higher education level. A history of mood disorder was a risk factor. Later anxiety was also associated with longer hospital stay.

CONCLUSIONS

Depression and anxiety symptoms are a major concern in surgical patients especially in females and those with a history of mood disorders or lower educational level. Patients with a longer hospital stay, in particular, those with underlying diseases, postoperative complications, lack of familial support, and the need for reoperation were also at increased risk.

Psychiatric Illness Is Common Among Patients with Orthopaedic Polytrauma and Is Linked with Poor Outcomes

BACKGROUND

Psychiatric disorders are common, and their functional consequences may be underappreciated by non-mental health-care providers. There exist limited data regarding the frequency of psychiatric illness in patients who sustain orthopaedic polytrauma. The purpose of this study was to describe the prevalence of psychiatric illness in patients with orthopaedic polytrauma, to determine whether psychiatric illnesses were identified and were accommodated by trauma providers, and, finally, to investigate any associations between postoperative complications and psychiatric illness.

METHODS

Three hundred and thirty-two skeletally mature patients with surgically treated axial and/or femoral fractures and injuries to other body systems (Injury Severity Score of ≥ 16 points) were identified from a database at a Level-I trauma center. These included 238 men and ninety-four women with a mean value (and standard deviation) of 39 ± 16 years for age and 27 ± 12 points for the Injury Severity Score. Records were reviewed for preexisting diagnoses of psychiatric disorders. The inpatient courses and discharge recommendations regarding treatment of psychiatric illness were analyzed. Complications in the six-month postoperative period were determined by an independent committee.

RESULTS

Preexisting psychiatric disorders were identified in 130 patients (39.2%), including depression in seventy-four patients (22.3%) and substance abuse in fifty-six patients (16.9%). Patients managed by an orthopaedic surgery service were less likely to receive their home psychiatric medications while hospitalized (p = 0.001) and were less likely to receive instructions for psychiatric follow-up at discharge (p = 0.087). Postoperative complications occurred in sixty-six patients (19.9%) overall; depression was an independent predictor of increased complications, with an odds ratio of 2.956 (95% confidence interval, 1.502 to 5.816).

CONCLUSIONS

Psychiatric illness was common among individuals who sustained orthopaedic polytrauma, and patients with depression had more complications. This study highlights the need for greater attention to mental health disorders in this population.

Depression and postoperative complications: an overview

BACKGROUND

The interaction of depression and anesthesia and surgery may result in significant increases in morbidity and mortality of patients. Major depressive disorder is a frequent complication of surgery, which may lead to further morbidity and mortality.

LITERATURE SEARCH

Several electronic data bases, including PubMed, were searched pairing "depression" with surgery, postoperative complications, postoperative cognitive impairment, cognition disorder, intensive care unit, mild cognitive impairment and Alzheimer's disease.

REVIEW OF THE LITERATURE

The suppression of the immune system in depressive disorders may expose the patients to increased rates of postoperative infections and increased mortality from cancer. Depression is commonly associated with cognitive impairment, which may be exacerbated postoperatively. There is evidence that acute postoperative pain causes depression and depression lowers the threshold for pain. Depression is also a strong predictor and correlate of chronic post-surgical pain. Many studies have identified depression as an independent risk factor for development of postoperative delirium, which may be a cause for a long and incomplete recovery after surgery. Depression is also frequent in intensive care unit patients and is associated with a lower health-related quality of life and increased mortality. Depression and anxiety have been widely reported soon after coronary artery bypass surgery and remain evident one year after surgery. They may increase the likelihood for new coronary artery events, further hospitalizations and increased mortality. Morbidly obese patients who undergo bariatric surgery have an increased risk of depression. Postoperative depression may also be associated with less weight loss at one year and longer. The extent of preoperative depression in patients scheduled for lumbar discectomy is a predictor of functional outcome and patient's dissatisfaction, especially after revision surgery. General postoperative mortality is increased.

CONCLUSIONS

Depression is a frequent cause of morbidity in surgery patients suffering from a wide range of conditions. Depression may be identified through the use of Patient Health Questionnaire-9 or similar instruments. Counseling interventions may be useful in ameliorating depression, but should be subject to clinical trials.

Presurgical Psychological and Neuroendocrine Predictors of Psychiatric Morbidity After Major Vascular Surgery: A Prospective Longitudinal Study

OBJECTIVES

Major life stressors, including major surgeries, are often followed by psychiatric symptoms and disorders. Prior retrospective work found abdominal aortic aneurysm (AAA) repair is followed by increased psychiatric morbidity, which may adversely influence physical and functional recovery. Identifying risk factors before surgery, such as dysregulation in stress response systems, might be useful in improving preventative intervention.

METHODS

Two hundred sixteen patients receiving open AAA or aortofemoral bypass surgeries, endovascular AAA repair, or nonsurgical AAA treatment were recruited from two vascular surgery services. Psychiatric symptoms and salivary cortisol measures (waking, 4 PM, and 11 PM, before and after low-dose dexamethasone) were obtained at intake and 3- and 9-month follow-ups.

RESULTS

After open surgeries, 18% of patients had new psychiatric disorders, compared with 4% of patients receiving endovascular AAA repair or nonsurgical treatment (odds ratio = 6.0, 95% confidence interval = 1.6-22.1, p = .007). Having a history of major depression predicted the onset of new disorders in surgical patients. Presurgical cortisol levels were associated with both baseline (r = 0.23, p < .05) and 9-month (r = 0.32, p < .01) psychiatric symptoms (cortisol B = 1.0, standard error = 0.48, p < .05, in repeated-measures mixed model).

CONCLUSIONS

Open AAA repair surgery is prospectively linked to the development of psychiatric morbidity, and history of depression elevates risk. Cortisol measures before surgery are associated with current and future psychological functioning, suggesting potential neurobiological mechanisms that may contribute to vulnerability. These results can help identify surgical patients at risk and point to potential targets for risk reduction interventions.

Postoperative pain and subsequent PTSD-related symptoms in patients undergoing lung resection for suspected cancer

BACKGROUND

Because lung cancer resection is at the crossroad between cancer and high-risk surgery, we hypothesized that the patients undergoing lung resection for cancer are exposed to develop a post-traumatic stress disorder (PTSD) syndrome-related symptoms.

METHODS

Forty-seven adult patients were included in the study. Patients were eligible for inclusion if they underwent lung resection for suspected cancer, if they were able to speak and read French, and if they agreed to be reached for a telephone interview. We assessed before, immediately after, and 3 months after surgery the presence of symptoms of anxiety and depression (Hospital Anxiety and Depression Scale) and PTSD-related symptoms (impact of events scale revised [IES-R]). At the 3-month assessment, an IES-R score > 22 was used as criteria for predicting the patients at risk of PTSD-related symptoms.

RESULTS

We identified an IES-R score higher than 22 in 24 participants (51%). Patients with a preoperatory Hospital Anxiety and Depression Scale(anxiety) score more than 7 (T0) and a maximal visual analogic scale score more than 40 during the first 24 hours after surgery were more likely to develop PTSD-related symptoms at 3-months with odd ratios at 4.61 [1.20-17.73] (p = 0.03) and 1.34 [1.05-1.75] (p = 0.02).

CONCLUSION

The prevalence of PTSD-related symptoms after lung cancer resection is high, showing that lung cancer patients undergoing surgical resection are at high risk of postprocedure burden. The presence of preoperative symptoms of anxiety and acute procedural pain during the early postoperative period are strong predictors for developing PTSD-related symptoms after lung cancer surgery.

Patients' experience of open repair of abdominal aortic aneurysm--preoperative information, hospital care and recovery

AIMS AND OBJECTIVES

The aim was to elucidate patients' lived experience of the care pathway of going through open surgery for abdominal aortic aneurysm.

BACKGROUND

Open surgical treatment has a great impact on patients' health-related quality of life both before and after treatment. The transition from being independent and asymptomatic to dependent on nursing care can be difficult. To facilitate this process and provide high-quality care, patients' needs must be better understood.

DESIGN

An exploratory descriptive design was chosen to describe and understand patients' lived experience.

METHOD

Audio-taped interviews were performed three months postoperatively, covering the care pathway before and after surgery. Interviews were analysed with qualitative content analysis.

RESULTS

The informants made a transition from becoming aware of the deadly risk associated with abdominal aortic aneurysm to gradually understanding the physical and emotional impact of the surgical procedure during the recovery process. The experience of not understanding fully the risks of undergoing surgery or its consequences on daily life made the informants unprepared for complications and limitations during the recovery period. Many concerns emerged, with a need for more dialogue and opportunities to understand their own care than those provided by the health care staff.

CONCLUSIONS

To facilitate the transition process, health care staff should consider patients' unpreparedness for the physical and emotional impact that can follow diagnosis and treatment for abdominal aortic aneurysm and recognise the need for dialogue to enhance participation during recovery.

RELEVANCE TO CLINICAL PRACTICE

Throughout the care pathway, patients' need for information and for opportunities to reflect on bodily and emotional reactions to the diagnosis and treatment of abdominal aortic aneurysm should be recognised by nurses and physicians to support patients getting realistic expectations of the consequences of treatment and facilitate participation in decisions concerning care and medical treatment.

Pain in the aftermath of trauma is a risk factor for post-traumatic stress disorder

BACKGROUND

Identifying risk factors for the development of post-traumatic stress disorder (PTSD) is important for understanding and ultimately preventing the disorder. This study assessed pain shortly after traumatic injury (i.e. peritraumatic pain) as a risk factor for PTSD.

METHOD

Participants (n=115) were patients admitted to a Level 1 Surgical Trauma Center. Admission to this service reflected a severe physical injury requiring specialized, emergent trauma care. Participants completed a pain questionnaire within 48 h of traumatic injury and a PTSD diagnostic module 4 and 8 months later.

RESULTS

Peritraumatic pain was associated with an increased risk of PTSD, even after controlling for a number of other significant risk factors other than acute stress disorder symptoms. An increase of 0.5 s.d. from the mean in a 0-10 pain rating scale 24-48 h after injury was associated with an increased odds of PTSD at 4 months by more than fivefold, and at 8 months by almost sevenfold. A single item regarding amount of pain at the time of hospital admission correctly classified 65% of participants.

CONCLUSIONS

If these findings are replicated in other samples, high levels of peritraumatic pain could be used to identify individuals at elevated risk for PTSD following traumatic injury.

The prevalence of post traumatic stress disorder in survivors of ICU treatment: a systematic review

OBJECTIVE

To determine the prevalence of post traumatic stress disorder in survivors of intensive care treatment.

DESIGN

Systematic literature review including Medline, Embase, CINAHL, PsycINFO and references from identified papers.

STUDY SELECTION

Studies determining the prevalence of PTSD in adult patients who had at least 24[Symbol: see text]h treatment on an intensive care unit. Independent duplicate data extraction. Study quality was evaluated in terms of study design and method and timing of PTSD assessment. DATA SYNTHESIS AND RESULTS: Of the 1472 citations identified, 30 studies meeting the selection criteria were reviewed. PTSD was diagnosed by standardised clinical interview alone in 2 studies. A self-report measure alone was used in 19 studies to measure PTSD symptomatology. The remaining 9 studies applied both standardised clinical interview and a self-report measure. The reported prevalence of PTSD was 0-64% when diagnosed by standardised clinical interview and 5-64% by self-report measure. PTSD assessments occurred 7 days to 8 years after intensive care discharge.

CONCLUSION

The true prevalence of PTSD and the optimum timing and method of PTSD assessment have not yet been determined in intensive care unit survivors. Deficiencies in design, methodology and reporting make interpretation and comparison of quoted prevalence rates difficult, and rigorous longitudinal studies are needed.

Final 12-year follow-up of Surgery versus Surveillance in the UK Small Aneurysm Trial

Background

The aim was to determine whether early open surgical repair would benefit patients with small abdominal aortic aneurysm compared with surveillance on long-term follow-up.

Methods

The 1090 patients who were enrolled into the UK Small Aneurysm Trial between 1991 and 1995 were followed up for aneurysm repair and mortality until November 2005.

Results

By November 2005, 714 patients (65·5 per cent) had died, 929 (85·2 per cent) had undergone aneurysm repair, 150 (13·8 per cent) had died without aneurysm repair and 11 (1·0 per cent) remained alive without aneurysm repair. After 12 years, mortality in the surgery and surveillance groups was 63·9 and 67·3 per cent respectively, unadjusted hazard ratio 0·90 (P = 0·139). Three-quarters of the surveillance group eventually had aneurysm repair, with a 30-day elective mortality of 6·3 per cent (versus 5·0 per cent in the early surgery group, P = 0·366). Estimates suggested that the cost of treatment was 17 per cent higher in the early surgery group, with a mean difference of £1326. The death rate in these patients was about twice that in the population matched for age and sex.

Conclusion

There was no long-term survival benefit of early elective open repair of small abdominal aortic aneurysms. Even after successful aneurysm repair, the mortality among these patients was higher than in the general population.

Long-term prevalence of post-traumatic stress disorder symptoms in patients after secondary peritonitis

Introduction

The aim of this study was to determine the long-term prevalence of post-traumatic stress disorder (PTSD) symptomology in patients following secondary peritonitis and to determine whether the prevalence of PTSD-related symptoms differed between patients admitted to the intensive care unit (ICU) and patients admitted only to the surgical ward.

Method

A retrospective cohort of consecutive patients treated for secondary peritonitis was sent a postal survey containing a self-report questionnaire, namely the Post-traumatic Stress Syndrome 10-question inventory (PTSS-10). From a database of 278 patients undergoing surgery for secondary peritonitis between 1994 and 2000, 131 patients were long-term survivors (follow-up period at least four years) and were eligible for inclusion in our study, conducted at a tertiary referral hospital in Amsterdam, The Netherlands.

Results

The response rate was 86%, yielding a cohort of 100 patients; 61% of these patients had been admitted to the ICU. PTSD-related symptoms were found in 24% (95% confidence interval 17% to 33%) of patients when a PTSS-10 score of 35 was chosen as the cutoff, whereas the prevalence of PTSD symptomology when borderline patients scoring 27 points or more were included was 38% (95% confidence interval 29% to 48%). In a multivariate analyses controlling for age, sex, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, number of relaparotomies and length of hospital stay, the likelihood of ICU-admitted patients having PTSD symptomology was 4.3 times higher (95% confidence interval 1.11 to 16.5) than patients not admitted to the ICU, using a PTSS-10 score cutoff of 35 or greater. Older patients and males were less likely to report PTSD symptoms.

Conclusion

Nearly a quarter of patients receiving surgical treatment for secondary peritonitis developed PTSD symptoms. Patients admitted to the ICU were at significantly greater risk for having PTSD symptoms after adjusting for baseline differences, in particular age.

Delirium, cognitive dysfunction and posttraumatic stress disorder

PURPOSE OF REVIEW

In the critically ill patient, disease and the therapies we use impact on brain function. Simple tools are now available to recognise such problems. This review highlights neuropsychiatric and cognitive observations that have direct relevance to patient care and outcome.

RECENT FINDINGS

Delirium is a common event, especially the hypoactive forms in the elderly. The recognition of significant cognitive dysfunction is worrying since it has profound implications for how we treat and manage patients within intensive care and beyond. The most important message is that the 'awake' intensive care unit patient is not necessarily free of significant brain dysfunction. There is also the added complication of psychological disturbances related to real or imagined delusional experiences underlying the importance of memory and recall. Longer-term implications, particularly debilitating conditions such as posttraumatic stress disorder, mean that there is a need for improved post-intensive care unit rehabilitation care.

SUMMARY

Health professionals working with the critically ill must routinely include the assessment of brain cognitive function. While some of the consequences may be unavoidable, we need to reassess our sedation and care practices to ensure we are not confounding the problem. Practical options to improve outcome are being developed and emphasise that the recovery from critical illness is psychological as well as physical.