New developments in geriatric surgery

Surgical need among the ageing population of Uganda

BACKGROUND

Uganda's ageing population (age 50 years and older) will nearly double from 2015 to 2050. HIV/AIDS, diabetes, stroke among other disease processes have been studied in the elderly population. However, the burden of disease from surgically-treatable conditions is unknown.

OBJECTIVES

To determine the proportion of adults above 50 years with unmet surgical need and deaths attributable to probable surgically-treatable conditions.

METHODS

A cluster randomized sample representing the national population of Uganda was enumerated. The previously validated Surgeons Overseas assessment of surgical need instrument, a head-to-toe verbal interview, was used to determine any surgically-treatable conditions in two randomly-selected living household members. Deaths were detailed by heads of households. Weighted metrics are calculated taking sampling design into consideration and Taylor series linearization was used for sampling error estimation.

RESULTS

The study enumerated 425 individuals above age 50 years. The prevalence proportion of unmet surgical need was 27.8% (95%CI, 22.1-34.3). This extrapolates to 694,722 (95%CI, 552,279-857,157) individuals living with one or more surgically treatable conditions. The North sub-region was observed to have the highest prevalence proportion. Nearly two out of five household deaths (37.9%) were attributed to probable surgically treatable causes.

CONCLUSION

There is disproportionately high need for surgical care among the ageing population of Uganda with approximately 700,000 consultations needed.

Aortic aneurysm trials in octogenarians: Are we really measuring the outcomes that matter?

Purpose

This study is a systematic review to determine the types of outcomes reported in abdominal aortic aneurysm (AAA) studies of patients aged 80 and over. Specifically, it determines the types of patient-centered outcomes reported.

Method

MEDLINE and EMBASE were searched from 2000 to 2014 for studies on AAA surgery with outcome data on patients aged 80 and over. Outcomes were categorized according to Donabedian’s framework for health quality indicators, with further classification as procedural, complication, resource or patient-centered outcome indicators.

Findings

Forty studies were reviewed. Patient-centered outcomes were infrequently reported (13%, n=5), with limited outcomes specifically relevant to older patients. No studies reported physical function, activities of daily living or cognition using validated assessment methods. Short-term mortality (95%, n=38) and complications (85%, n=34) were reported most frequently.

Conclusion

Reporting of aortic surgery outcomes in patients aged 80 and over requires a focus upon outcomes of primary importance to people of this age.

Changing Epidemiology of Intestinal Obstruction in Ghana: Signs of Increasing Surgical Capacity and an Aging Population

INTRODUCTION

This study aimed to describe the epidemiology and outcomes of intestinal obstruction at a tertiary hospital in Ghana over time.

METHODS

Records of all patients admitted to a tertiary hospital from 2007 to 2011 with intestinal obstruction were identified using ICD-9 codes. Sociodemographic and clinical data were compared to a previously published series of intestinal obstructions from 1998 to 2003. Factors contributing to longer than expected hospital stays and death were further examined.

RESULTS

Of the 230 records reviewed, 108 patients (47%) had obstructions due to adhesions, 50 (21%) had volvulus, 22 (7%) had an ileus from perforation and 14 (6%) had intussusception. Hernia fell from the 1st to the 8th most common cause of obstruction. Patients with intestinal obstruction were older in 2007-2011 compared to those presenting between 1998 and 2003 (p < 0.001); conditions associated with older age (e.g., volvulus and neoplasia) were more frequently encountered (p < 0.001). Age over 50 years was strong factor of in-hospital death (adjusted OR 14.2, 95% CI 1.41-142.95).

CONCLUSION

Efforts to reduce hernia backlog and expand the surgical workforce may have had an effect on intestinal obstruction epidemiology in Ghana. Increasing aging-related pathology and a higher risk of death in elderly patients suggest that improvement in geriatric surgical care is urgently needed.

Prevalence of surgical conditions in individuals aged more than 50 years: a cluster-based household survey in Sierra Leone

BACKGROUND

With the demographic transition disproportionately affecting developing nations, the healthcare burden associated with the elderly is likely to be compounded by poor baseline surgical capacity in these settings. We sought to assess the prevalence of surgical disease and disability in the elderly population of Sierra Leone to guide future development strategies.

METHODS

A cluster randomized, cross-sectional household survey was carried out countrywide in Sierra Leone from January 9th to February 3rd 2012. Using a standardized questionnaire, household member demographics, deaths occurring during the previous 12 months, and presence of any current surgical condition were elucidated. A retrospective analysis of individuals aged 50 and over was performed.

RESULTS

The survey included 1,843 households with a total of 3,645 respondents. Of these, 13.6 % (496/3,645) were aged over 50 years. Of the elderly individuals in our sample, 301 (60.7 %) reported a current surgical condition. Of current surgical disease identified among elderly individuals (n = 530), 349 (65.8 %) described it as disabling, and 223 (42.1 %) sought help from traditional medicine practitioners. Women (odds ratio [OR] 0.60; 95 % confidence interval [CI] 0.40-0.90) and individuals living in urban settings (OR 0.44, 95 % CI 0.26-0.75) were less likely to report a current surgical problem. Of the 230 elderly deaths in the previous year, 83 (36.1 %) reported a surgical condition in the week prior.

CONCLUSIONS

The unmet burden of surgical disease is prevalent in the elderly in low-resource settings. This patient population is expected to grow significantly in the coming years, and more resources should be allocated to address their surgical needs.

Surgical need in an aging population: A cluster-based household survey in Nepal

BACKGROUND

With an aging global population comes an obligate and substantial burden of noncommunicable disease, especially in low- and middle-income countries. An unknown proportion of this burden is treatable with surgical expertise. For health system planning, this study aimed to estimate the operative needs of individuals older than 50 of age years in Nepal.

METHODS

A 2-stage, cluster randomized, community-based survey was performed in Nepal using the validated Surgeons OverSeas Surgical Assessment Survey (SOSAS). SOSAS collects household demographics and selects household members randomly for verbal, head-to-toe examinations for surgical conditions; moreover, SOSAS also completes a verbal autopsy for deaths in the preceding year. Only respondents older than 50 years were included in the analysis.

RESULTS

The survey sampled 1,350 households, totaling 2,695 individuals (97% response rate). Of these, 273 surgical conditions were reported by 507 persons ages ≥ 50 years. Extrapolating, there are potentially 2.1 million people older than 50 years of age with surgically treatable conditions who need care in Nepal (95% confidence interval 1.8-2.4 million; 46,000-62,600 per 100,000 persons). One in 5 deaths was potentially treatable or palliated by surgical care. Although growths or masses (including hernias and goiters) were the surgical condition reported most commonly (25%), injuries and fractures also were common and associated with the greatest disability. Literacy and distance to secondary and tertiary health facilities were associated with lack of care for operative conditions (P < .05).

CONCLUSION

There is a large, unmet surgical need among the elderly in Nepal. Low literacy and distance from a capable health facility are the greatest barriers to care. As the global population ages, there is an increasing need to improve surgical services and strengthen health systems to care for this group.

Outcome of pancreaticoduodenectomy in octogenarians: Single institution's experience and review of the literature

INTRODUCTION

Pancreatic and perampullary neoplasms in patients aged 80 or older trouble the surgeons because of the risk of surgical treatment. We have reviewed our experience and literature's reports of pancreaticoduodenectomy in octogenarians, evaluating early results and long-term survival in pancreatic cancer group.

METHODS

Three hundred eighty-five patients who underwent pancreaticoduodenectomy for neoplasms from 1998 to 2011 were included in the study, and were divided in two groups: group 1, patients younger than 80 years of age, and group 2, patients 80 years of age and older. Operative morbidity, mortality, disease-free and long-term survival were analysed. English literature was systematically searched for pancreatic resection's outcome in octogenarians.

RESULTS

There were 385 pancreaticoduodenectomies: 362 patients were in group 1 and 23 patients in group 2. There was no significant difference regarding gender, and pathologic findings between the two groups. Complications' rate (40 vs. 43%), mortality rate (4% vs. 0%), and overall median survival for pancreatic cancer patients were not statistically different in the two groups (median 21 vs. 19 months). Literature's review showed 14 reports of pancreatic resection in octogenarians. Most of the studies (particularly in centres with high-volume pancreatic surgery) showed that outcome after pancreatectomy was not different in octogenarians or in younger patients.

CONCLUSION

Pancreaticoduodenectomy is an acceptable option for elderly patients. Age alone should not be considered a contraindication to major pancreatic resection, but a careful preoperative evaluation and an accurate postoperative management are mandatory.

The redefinition of aging in American surgery

CONTEXT

Adults aged sixty-five and over account for a large fraction of all surgeries performed in the United States each year. While historical growth in rates of surgery in this population is commonly attributed to financial incentives and technological innovations, the shifts in thought that underpinned the spread of surgery among the U.S. elderly remain largely unexplored. We examined changing perspectives on aging over time in American surgery through two case studies: the expansion of general surgical procedures among older U.S. adults between 1945 and 1965, and the spread of coronary artery bypass grafting (CABG) among the U.S. elderly between 1975 and 1995.

METHODS

For this article, we used close readings of historical journal articles, textbook excerpts, survey reports, and government documents related to surgery and aging.

FINDINGS

Similar perspectives on aging informed the spread of both general surgical procedures among older adults after World War II and CABG in the elderly from the mid-1970s onward. In each case, surgeons argued against earlier views that surgery was contraindicated in old age using rhetoric that negated the relevance of age to medical decisions. Furthermore, surgeons elevated other types of information-such as the presence or absence of chronic diseases-to supplant age as an explanation for the high operative mortality rates seen among older patients. By stressing the modifiability of operative risk in the elderly, surgeons' arguments positioned old age itself as a new surgical "frontier."

CONCLUSIONS

Surgeons' arguments for the expansion of surgery among the U.S. elderly over time worked to negate the relevance of age to medical decisions and to portray the wider use of surgery in the elderly as uniformly beneficial. While potentially promoting broader access to surgical care, such perspectives may also have contributed to ongoing health policy challenges by normalizing surgery at any stage in the life-course, with implications for current patterns of surgical utilization and medical spending.