Perioperative care of geriatric patients

Efficacy and Safety of Surgical Resection in Elderly Patients with Hepatocellular Carcinoma: A Systematic Review and Meta-Analysis

Background/Aims

: With increased life expectancy, the management of elderly hepatocellular carcinoma (HCC) patients became a crucial issue, yet it is still challenging due to comorbidities and high surgical risks. While surgical resection is considered as primary treatment for eligible HCC patients, systematic evidence on its outcomes in elderly patients remains scarce. In this review, we aimed to analyze the efficacy and safety outcomes of surgical resection in elderly HCC patients.

Methods

: The studies included in this meta-analysis were selected from Ovid-MEDLINE, Ovid-Embase, CENTRAL, KoreaMed, KMbase, and KISS databases following a predefined protocol. Efficacy outcomes included overall survival and disease-free survival, while the safety outcomes included postoperative mortality and complications.

Results

: Patients in the elderly group (≥65 years) who underwent surgery exhibited non-inferior overall survival (hazard ratio [HR], 1.26; 95% confidence interval [CI], 0.92 to 1.74) and disease-free survival (HR, 1.03; 95% CI, 0.99 to 1.08) compared to the non-elderly group. Overall postoperative mortality exhibited no statistical difference (odds ratio [OR], 1.07; 95% CI, 0.87 to 1.31), but 30-day, 90-day, and in-hospital mortality were higher in the elderly group. The incidence of overall complications was higher in the elderly group (OR, 1.44; 95% CI, 1.22 to 1.69). Sensitivity analysis for the super elderly group (≥80 years) showed significantly higher in-hospital mortality compared to the non-super elderly group (OR, 2.51; 95% CI, 1.16 to 5.45).

Conclusions

: The efficacy outcome of surgical resection in the elderly HCC patients was not worse than that in the non-elderly HCC patients, while in-hospital mortality and complications rates were higher. Therefore, surgical resection should be purposefully considered in the elderly population, with careful candidate selection.

Socioeconomic Factors Associated With Thymoma Survival in the United States

INTRODUCTION

The effects of socioeconomic factors on patients diagnosed with thymomas have not been previously studied. We propose these factors have an important association with survival. Thymoma is the most common tumor of the anterior mediastinum. Compared to other neoplasms which can integrate different therapeutic approaches for treatment, the most effective therapy for local and locally advanced thymoma is complete surgical resection. This study aimed to elaborate on socioeconomic variables and their potential effects on the survival outcomes in patients diagnosed with thymoma.

METHODS

Clinical data from the Surveillance, Epidemiology, and End Results 22 registry from 1975-2019 was used to define overall and cancer-specific survival of thymoma. The unadjusted analysis was followed by fitting a Cox proportional hazards model that included all variables assessed with Kaplan-Meier curves. An unadjusted Kaplan-Meier analysis was performed first comparing time to death by decade, age, race, ethnicity, sex, income, and region separately. The primary outcome was survival measured in months.

RESULTS

We identified 1821 patients aged 18 y or over from the Surveillance, Epidemiology, and End Results database with a thymoma diagnosis between the years 1975 and 2019. The demographic variables considered were age, race, ethnicity (Hispanic/non-Hispanic), sex (male/female), inflation-adjusted income in 2019 dollars, and community size. We observed a decrease in mortality from thymic neoplasm across the decades. For each subsequent year, mortality risk decreased by 3.5% (P <0.001). The mortality risk of older patients was significantly higher. Compared to the youngest group, the mortality risk was 52.8% higher in the 50-year-old to 65-year-old category (P = 0.021). The mortality risk was 339% times higher in the 65 + age group (P <0.001). Income may be associated with risk reduction. Patients making greater than $75,000 had a 40.1% lower mortality risk than those making less than $50,000 (P = 0.029). The survival rate categorized by race was similar between Blacks and Whites but tended to be higher for the Asian and Pacific Islander groups without reaching statistical significance (P = 0.12).

CONCLUSIONS

Medical advancements have improved the overall thymoma survival in the past four decades. Yet, demographic, and socioeconomic factors such as age, income, and race may also play a role.

Association of Established Primary Care Use With Postoperative Mortality Following Emergency General Surgery Procedures

Importance

Sixty-five million individuals in the US live in primary care shortage areas with nearly one-third of Medicare patients in need of a primary care health care professional. Periodic health examinations and preventive care visits have demonstrated a benefit for surgical patients; however, the impact of primary care health care professional shortages on adverse outcomes from surgery is largely unknown.

Objective

To determine if preoperative primary care utilization is associated with postoperative mortality following an emergency general surgery (EGS) operation among Black and White older adults.

Design, Setting, and Participants

This was a retrospective cohort study that took place at US hospitals with an emergency department. Participants were Medicare patients aged 66 years or older who were admitted from the emergency department for an EGS condition between July 1, 2015, and June 30, 2018, and underwent an operation on hospital day 0, 1, or 2. The analysis was performed during December 2022. Patients were classified into 1 of 5 EGS condition categories based on principal diagnosis codes; colorectal, general abdominal, hepatopancreatobiliary, intestinal obstruction, or upper gastrointestinal. Mixed-effects multivariable logistic regression was used in the risk-adjusted models. An interaction term model was used to measure effect modification by race.

Exposure

Primary care utilization in the year prior to presentation for an EGS operation.

Main Outcome and Measures

In-hospital, 30-day, 60-day, 90-day, and 180-day mortality.

Results

A total of 102 384 patients (mean age, 73.8 [SD, 11.5] years) were included in the study. Of those, 8559 were Black (8.4%) and 93 825 were White (91.6%). A total of 88 340 patients (86.3%) had seen a primary care physician in the year prior to their index hospitalization. After risk adjustment, patients with primary care exposure had 19% lower odds of in-hospital mortality than patients without primary care exposure (odds ratio [OR], 0.81; 95% CI, 0.72-0.92). At 30 days patients with primary care exposure had 27% lower odds of mortality (OR, 0.73; 95% CI, 0.67-0.80). This remained relatively stable at 60 days (OR, 0.75; 95% CI, 0.69-0.81), 90 days (OR, 0.74; 95% CI, 0.69-0.81), and 180 days (OR, 0.75; 95% CI, 0.70-0.81). None of the interactions between race and primary care physician exposure for mortality at any time interval were significantly different.

Conclusions and Relevance

In this observational study of Black and White Medicare patients, primary care utilization had no impact on in-hospital mortality for Black patients, but was associated with decreased mortality for White patients. Primary care utilization was associated with decreased mortality for both Black and White patients at 30, 60, 90 and 180 days.

Integrated postoperative care model for older colorectal surgery patients improves outcomes and reduces healthcare costs

BACKGROUND

Older surgical patients have an increased risk for postoperative complications, driving up healthcare costs. We determined if postoperative co-management of older surgery patients is associated with postoperative outcomes and hospital costs.

METHODS

Retrospective data were collected for patients ≥70 years old undergoing colorectal surgery at a community teaching hospital. Patient outcomes were compared between those receiving postoperative surgery co-management care through the Optimization of Senior Care and Recovery (OSCAR) program and controls who received standard of care. Main outcome measures were postoperative complications and hospital charges, 30-day readmission rate, length of stay (LOS), and transfer to intensive care during hospitalization. Multivariable linear regression was used to model total charge and multivariable logistic regression to model complications, adjusted for multiple variables (e.g., age, sex, race, body mass index, Charlson Comorbidity Index [CCI], American Society of Anesthesiologists score, surgery duration).

RESULTS

All 187 patients in the OSCAR and control groups had a similar mean CCI score of 2.7 (p = 0.95). Compared to the control group, OSCAR recipients experienced less postoperative delirium (17% vs. 8%; p = 0.05), cardiac arrhythmia (12% vs. 3%; p = 0.03), and clinical worsening requiring transfer to intensive care (20% vs. 6%; p < 0.005). OSCAR group patients had a shorter mean LOS among high-risk patients (CCI ≥3) (-1.8 days; p = 0.09) and those ≥80 years old (-2.3 days; p = 0.07) compared to the control group. Mean total hospital charge was $10,297 less per patient in the OSCAR group (p = 0.01), with $17,832 less per patient with CCI ≥3 (p = 0.01), than the control group.

CONCLUSIONS

A co-management care approach after colorectal surgery in older patients improves outcomes and decreases costs, with the most benefit going to the oldest patients and those with higher comorbidity scores.

Application of Care Bundles in Postanesthesia Recovery for Elderly Patients with Colorectal Cancer

Objective

Based on the postanesthesia recovery procedure for elderly patients with colorectal cancer, a care bundle program was conducted to validate its effectiveness.

Method

According to the characteristics of elderly patients with colorectal cancer, five measures including respiratory management, circulatory stability, pain assessment, body temperature monitoring, and internal environment stability were integrated into one bundle. Postanesthesia care unit (PACU) care bundle program for elderly patients was developed and used to improve recovery care. The monitoring data of the pre-PACB group given care bundles were collected and compared with the data of the post-PACB group who were given conventional recovery care.

Result

222 patients in post-PACB group had shorter intubation time than 291 patients in pre-PACB group (37.7 ± 24.4 min vs. 42.1 ± 23.3 min, P < 0.05). The length of stay in PACU was longer in pre-PACB group (89.9 ± 33.5 min vs. 81.6 ± 31.1 min, P < 0.05). More adverse events were found in the post-PACB group than in the pre-PACB group (72.1% vs. 34.0%).

Conclusion

After general anesthesia of patients with colorectal cancer, the application of the care bundles can improve the quality of recovery, shorten the intubation time and the length of stay in PACU, and reduce the complications caused by anesthesia.

Interdisciplinary Protocol for Surgery in Older Persons: Development and Implementation

As the population ages, more older adults will undergo surgical procedures, and common physiologic changes can raise the risk for surgical complications while increasing morbidity and mortality. In conjunction with the National Surgical Quality Improvement Program, we piloted a comprehensive and interdisciplinary assessment and intervention protocol for perioperative care for patients aged ≥75 years undergoing elective general, gynecology-oncologic, and orthopedic surgery. The intervention included screening tools for cognitive, functional, and nutritional deficits, a Geriatric Nurse Champion on each inpatient surgical unit, and an interdisciplinary Geriatric Surgery Quality Committee. Our intervention group was compared to surgical patients during the same time period 1 year prior to the intervention, and the groups were well matched in demographics and comorbidities. The intervention group had significantly higher rates of advance care plan documentation in analysis of all patients (P < .001) and in subgroup analysis of those 85 and older (P = .006). The preintervention group had less postoperative delirium compared to the postintervention group but it was not significant and there was no difference in length of stay between groups. Various explanations for the minimal impact of the protocol exist: small sample size, presence of other hospital initiatives to reduce pressure ulcer and delirium, and clinician's awareness of project planning that led to incorporating ideas prior to official implementation. Future research implementing this protocol in naïve and/or underperforming institutions may demonstrate a greater effect. Larger sample size as well as implementation in other surgical fields may reveal a significant impact. However, if additional study does not reveal a meaningful impact of a comprehensive geriatric assessment for surgical patients, then consideration must be made regarding unrecognized factors in surgical care for older adults or perhaps that factors cannot be mitigated in older adults because they are intrinsically a higher surgical risk.

Spontaneous extracapsular parathyroid adenoma hemorrhage: when surgery is required?

PURPOSE

Spontaneous bleeding is a rare but serious complication of parathyroid adenomas and few cases were reported in the literature. Clinical manifestations and treatment may vary but sometimes an immediate surgery is required. In other cases a conservative approach can be preferred based on clinical stability and patients' conditions. The purpose of this work is to describe our case and to carry out a review of the current literature on this topic.

METHODS

We reported a case of a parathyroid adenoma hemorrhage in an elderly patient describing its management. Moreover, a literature review of 57 cases was carried out, with the aim of collecting data about the most involved parathyroid gland and identifying the most correct management based on clinical manifestations and chosen treatments.

RESULTS

The patients had an age between 29 and 81 years (mean 56.9 ± 16.4 years). Forty-four patients were females (77.2%), whereas 12 were males (21.8%). Based on clinical severity, age, comorbidities and calcemic status, three possible scenarios were identified, each with a recommended management.

CONCLUSIONS

In parathyroid adenoma hemorrhages a careful clinical assessment is crucial to identify emergency conditions requiring immediate intubation, tracheostomy or neck exploration. Elderlies and comorbid patients have a higher risk of perioperative complications and indication for surgery should be evaluated case by case: whenever feasible, a conservative approach should be preferred in these subjects, especially in those with a stable course and without hypercalcemia-related symptoms.