1
|
Cohen JT, Beard RE, Cioffi WG, Miner TJ. Was It Worth It? Critical Evaluation of a Novel Outcomes Measure in Oncologic Palliative Surgery. J Am Coll Surg 2023; 236:1156-1162. [PMID: 36786475 DOI: 10.1097/xcs.0000000000000649] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
BACKGROUND Patient selection for palliative surgery is complex, and appropriate outcomes measures are incompletely defined. We explored the usefulness of a specific outcomes measure "was it worth it" in patients after palliative-intent operations for advanced malignancy. STUDY DESIGN A retrospective review of a comprehensive longitudinal palliative surgery database was performed at an academic tertiary care center. All patients who underwent palliative-intent operation for advanced cancer from 2003 to 2022 were included. Patient satisfaction ("was it worth it") was reported within 30 days of operation after palliative-intent surgery. RESULTS A total of 180 patients were identified, and 81.7% self-reported that their palliative surgery was "worth it." Patients who reported that their surgery was "not worth it" were significantly older and were more likely to have recurrent symptoms and to need reoperation. There was no significant difference in overall, recurrence-free, and reoperation-free survival for patients when comparing "worth it" with "not worth it." Initial symptom improvement was not significantly different between groups. Age older than 65 years (hazard ratio 0.25, 95% CI 0.07 to 0.80, p = 0.03), family engagement (hazard ratio 6.71, 95% CI 1.49 to 31.8, p = 0.01), and need for reoperation (hazard ratio 0.042, 95% CI 0.01 to 0.16, p < 0.0001) were all independently associated with patients reporting that their operation was "worth it." CONCLUSIONS Here we demonstrate that simply asking a patient "was it worth it" after a palliative-intent operation identifies a distinct cohort of patients that traditional outcomes measures fail to distinguish. Family engagement and durability of an intervention are critical factors in determining patient satisfaction after palliative intervention. These data highlight the need for highly individualized care with special attention paid to patients self-reporting that their operation was "not worth it."
Collapse
Affiliation(s)
- Joshua T Cohen
- From the Department of Surgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI
| | | | | | | |
Collapse
|
2
|
Abstract
Surgical palliation in oncology can be defined as "procedures employed with non-curative intent with the primary goal of improving symptoms caused by an advanced malignancy," and is an important aspect of the end-of-life care of patients with incurable malignancies. Palliative interventions may provide great benefit, but they also carry high risk for morbidity and mortality, which may be minimized with careful patient selection. This can be done by consideration of the patient and his or her indication for the given intervention via open communication, as well as prediction of benefits and risks to define the therapeutic index of the operation or procedure.
Collapse
Affiliation(s)
- Cassandra S Parker
- Department of Surgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, 593 Eddy Street, APC 443, Providence, RI 02903, USA
| | - Thomas J Miner
- Department of Surgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, 593 Eddy Street, APC 443, Providence, RI 02903, USA.
| |
Collapse
|
3
|
Laitamäki M, Alamylläri I, Kalliomäki M, Laukkarinen J, Ukkonen M, Junttila E. Scoring Systems May be Effective in Predicting Mortality Associated with Palliative Emergency Gastrointestinal Surgery: A Retrospective Observational Study. World J Surg 2021; 45:2694-2702. [PMID: 34059930 PMCID: PMC8322013 DOI: 10.1007/s00268-021-06170-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2021] [Indexed: 11/30/2022]
Abstract
Background Palliative emergency gastrointestinal surgery is associated with significant morbidity and mortality and weighing up the benefits and harms during the decision-making may be challenging. There are very few studies on surgery in palliative patient population. The aim of this retrospective study was to evaluate morbidity and mortality after palliative emergency gastrointestinal surgery and the usability of scoring systems in predicting the outcome. Methods Consecutive adult patients undergoing palliative emergency surgery at a tertiary hospital during the period 2015 to 2016 were included. Pre- and post-operative functional status, morbidity and mortality of patients were assessed. The predictive value of the American Society of Anesthesiologists (ASA) classification, the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator (ACS NSQIP SRC) and Palliative index (PI) in estimating morbidity and mortality were determined. Results A total of 93 patients (age 69 [28–92] years, 51% female) were included. Typical indications for surgery were bowel obstruction (52%) and securing food intake (30%). Pre-operatively two patients (2.2%) were totally dependent in daily activities, while post-operatively the respective share was 34% at discharge from hospital. The incidence of post-operative complications was 37% and 14% died during the hospital stay. One-, three-month and one-year mortality rates were 41%, 63% and 87%, respectively. While ASA score, PI score and ACS NSQIP did not predict post-operative morbidity, both ASA score and ACS NSQIP SRC predicted post-operative mortality. Conclusions Palliative emergency laparotomy is associated with significant post-operative mortality and morbidity. Scorings, such as ASA score and ACS NSQIP SRC predict mortality in this patient population.
Collapse
Affiliation(s)
- M Laitamäki
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - I Alamylläri
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - M Kalliomäki
- Department of Anaesthesiology and Intensive Care Medicine, Tampere University Hospital, Tampere, Finland
| | - J Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - M Ukkonen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland. .,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.
| | - E Junttila
- Department of Anaesthesiology and Intensive Care Medicine, Tampere University Hospital, Tampere, Finland
| |
Collapse
|
4
|
Cohen JT, Fallon EA, Charpentier KP, Cioffi WG, Miner TJ. Improving the value of palliative surgery by optimizing patient selection: The role of long-term survival on high impact palliative intent operations. Am J Surg 2020; 221:1018-1023. [PMID: 32980077 DOI: 10.1016/j.amjsurg.2020.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/24/2020] [Accepted: 08/25/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND In order to better characterize outcomes of palliative surgery (PS), we evaluated patients that experienced top quartile survival to elucidate predictors of high impact PS. METHODS All PS performed on advanced cancer patients from 2003 to 2017 were identified from a PS database. RESULTS 167 patients were identified. Multivariate analysis demonstrated the ability to rise from a chair was independently associated with top quartile survival (HR 7.61, 95% CI 2.12-48.82, p=0.008) as was the need for re-operation (HR 2.81, 95% CI 1.26-6.30, p=0.0012). Patients who were able to rise from a chair had significantly prolonged overall survival (320 vs 87 days, p < 0.001). CONCLUSIONS Although not the primary goal, long-term survival can be achieved following PS and is associated with re-operation and the ability to rise from a chair. These patients experience the benefits of PS for a longer period of time, which in turn maximizes value and positive impact. SUMMARY Long-term survival and symptom control can be achieved in highly selected advanced cancer patients following palliative surgery. The ability of the patient to independently rise from a chair and the provider to offer a re-operation when indicated are associated with long-term survival following a palliative operation.
Collapse
Affiliation(s)
- Joshua T Cohen
- Department of Surgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Eleanor A Fallon
- Department of Surgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Kevin P Charpentier
- Department of Surgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - William G Cioffi
- Department of Surgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Thomas J Miner
- Department of Surgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA.
| |
Collapse
|
5
|
Maeda Y, Shinohara T, Minagawa N, Kobayashi T, Koyama R, Shimada S, Tsunetoshi Y, Murayama K, Hasegawa H. A retrospective analysis of emergency surgery for cases of acute abdomen during cancer chemotherapy. Case series. Ann Med Surg (Lond) 2020; 57:143-147. [PMID: 32760583 PMCID: PMC7393459 DOI: 10.1016/j.amsu.2020.07.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 07/09/2020] [Indexed: 01/02/2023] Open
Abstract
Background Treatment for acute abdomen during chemotherapy is frequently difficult because of the complicated status of the patients, and there have been only a few case series summarizing the outcomes of emergent surgery during chemotherapy. The aim of this study was to clarify the clinical outcomes of emergency surgery for acute abdomen during chemotherapy and identify predictive factors associated with mortality. Methods We retrospectively analyzed the records of patients who underwent emergency surgery for acute abdomen within 30-days after anti-cancer drugs administration between 2009 and 2020. Results Thirty patients were identified. The primary malignancies were hematological (n = 7), colorectal (n = 4), lung (n = 4), stomach (n = 2), breast (n = 2), prostate (n = 2) and others (n = 5). Fifteen patients were treated with the regimen, including molecular-targeted anti-cancer drugs (Bevacizumab: 8 cases, Rituximab: 4, Ramucirumab: 2, and Gefitinib: 1). Indications for emergency surgery were perforation of the gastrointestinal tract (n = 24), appendicitis (n = 3), bowel obstruction (n = 2), and gallbladder perforation (n = 1). Severe morbidity (Clavien-Dindo IIIa or more) occurred in 8 cases (27%), and there were 6 in-hospital deaths (20%). Significant factors related to in-hospital death were age >70 years old (P = 0.029), poor performance status (ECOG score 1 or 2) (P = 0.0088), and serum albumin level <2.6 g/dl (P = 0.026). The incidence of acute abdomen (odds ratio 5.31, P = 0.00017) was significantly higher in the patients receiving anti-VEGF drugs than in those without anti-VEGF drugs. Conclusion This study identified three predictive factors associated with in-hospital death after emergency surgery during chemotherapy: an older age, poor performance status, and low serum albumin level.
Collapse
Affiliation(s)
- Yoshiaki Maeda
- Department of Gastrointestinal Surgery, Hokkaido Cancer Center, Japan
| | - Toshiki Shinohara
- Department of Gastrointestinal Surgery, Hokkaido Cancer Center, Japan
| | - Nozomi Minagawa
- Department of Gastrointestinal Surgery, Hokkaido Cancer Center, Japan
| | | | - Ryota Koyama
- Department of Gastrointestinal Surgery, Hokkaido Cancer Center, Japan
| | - Shingo Shimada
- Department of Gastrointestinal Surgery, Hokkaido Cancer Center, Japan
| | - Yusuke Tsunetoshi
- Department of Gastrointestinal Surgery, Hokkaido Cancer Center, Japan
| | - Keisuke Murayama
- Department of Gastrointestinal Surgery, Hokkaido Cancer Center, Japan
| | - Haruka Hasegawa
- Department of Gastrointestinal Surgery, Hokkaido Cancer Center, Japan
| |
Collapse
|
6
|
Cohen JT, Miner TJ. Patient selection in palliative surgery: Defining value. J Surg Oncol 2019; 120:35-44. [DOI: 10.1002/jso.25512] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 03/25/2019] [Accepted: 04/22/2019] [Indexed: 12/27/2022]
Affiliation(s)
- Joshua T. Cohen
- Department of Surgery, Rhode Island HospitalWarren Alpert Medical School of Brown UniversityProvidence Rhode Island
| | - Thomas J. Miner
- Department of Surgery, Rhode Island HospitalWarren Alpert Medical School of Brown UniversityProvidence Rhode Island
| |
Collapse
|
7
|
Roses RE, Folkert IW, Krouse RS. Malignant Bowel Obstruction: Reappraising the Value of Surgery. Surg Oncol Clin N Am 2018; 27:705-715. [PMID: 30213414 DOI: 10.1016/j.soc.2018.05.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Urgent palliative surgery in the setting of advanced malignancy is associated with significant morbidity, mortality, and cost. Malignant bowel obstruction is the most frequent indication for such intervention. Traditional surgical dogma is often invoked to justify associated risks and cost, but little evidence exists to support surgical over nonsurgical approaches. Evolving evidence may provide more meaningful guidance for treatment selection.
Collapse
Affiliation(s)
- Robert E Roses
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Silverstein Pavilion, Philadelphia, PA 19104, USA.
| | - Ian W Folkert
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Maloney Building, Philadelphia, PA 19104, USA
| | - Robert S Krouse
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA 19104, USA
| |
Collapse
|
8
|
Rodriguez RA, Fahy BN, McClain M, Morris KT. Estimation of Risk in Cancer Patients Undergoing Palliative Procedures by the American College of Surgeons Risk Calculator. J Palliat Med 2016; 19:1039-1042. [DOI: 10.1089/jpm.2015.0482] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Bridget N. Fahy
- Department of Surgery, University of New Mexico, Albuquerque, New Mexico
| | - Molly McClain
- Family and Community Medicine, University of New Mexico, Albuquerque, New Mexico
| | | |
Collapse
|
9
|
Folkert IW, Roses RE. Value in palliative cancer surgery: A critical assessment. J Surg Oncol 2016; 114:311-5. [PMID: 27393738 DOI: 10.1002/jso.24303] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 04/22/2016] [Indexed: 12/11/2022]
Abstract
Emergency operations are associated with increased morbidity, mortality, and cost compared to elective operations. Palliative and emergent surgery for patients with advanced malignancies is associated with additional risk and remains controversial. Emergent or palliative interventions can be broadly categorized according to indication. Tumor related complications (bleeding, obstruction, or perforation) merit specific consideration, as do specific presentations such as pneumoperitoneum, pneumatosis intestinalis, or peritonitis from other causes that may arise during active therapy for malignancies. Although nonoperative, endoscopic, and interventional treatment modalities are frequently available, surgery remains the only effective therapy in selected situations such as small intestinal obstruction and tumor perforation. Selection of patients for surgery requires consideration of factors including overall prognosis, performance status, and patients' priorities. Selection and risk assessment tools underscore the limited capacity of patients' with higher risk features for durable recovery but do not supplant nuanced clinical judgment. J. Surg. Oncol. 2016;114:311-315. © 2016 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Ian W Folkert
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert E Roses
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
10
|
Barber EL, Rutstein S, Miller WC, Gehrig PA. A preoperative personalized risk assessment calculator for elderly ovarian cancer patients undergoing primary cytoreductive surgery. Gynecol Oncol 2015; 139:401-6. [PMID: 26432038 PMCID: PMC4679512 DOI: 10.1016/j.ygyno.2015.09.080] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 09/19/2015] [Accepted: 09/27/2015] [Indexed: 01/16/2023]
Abstract
OBJECTIVE Cytoreductive surgery for ovarian cancer has higher rates of postoperative complication than neoadjuvant chemotherapy followed by surgery. If patients at high risk of postoperative complication were identified preoperatively, primary therapy could be tailored. Our objective was to develop a predictive model to estimate the risk of major postoperative complication after primary cytoreductive surgery among elderly ovarian cancer patients. METHODS Patients who underwent primary surgery for ovarian cancer between 2005 and 2013 were identified from the National Surgical Quality Improvement Project. Patients were selected using primary procedure CPT codes. Major complications were defined as grade 3 or higher complications on the validated Claviden-Dindo scale. Using logistic regression, we identified demographic and clinical characteristics predictive of postoperative complication. RESULTS We identified 2101 ovarian cancer patients of whom 35.9% were older than 65. Among women older than 65, the rate of major postoperative complication was 16.4%. Complications were directly associated with preoperative laboratory values (serum creatinine, platelets, white blood cell count, hematocrit), ascites, white race, and smoking status, and indirectly associated with albumin. Our predictive model had an area under receiver operating characteristic curve of 0.725. In order to not deny patients necessary surgery, we chose a 50% population rate of postoperative complication which produced model sensitivity of 9.8% and specificity of 98%. DISCUSSION Our predictive model uses easily and routinely obtained objective preoperative factors to estimate the risk of postoperative complication among elderly ovarian cancer patients. This information can be used to assess risk, manage postoperative expectations, and make decisions regarding initial treatment.
Collapse
Affiliation(s)
- Emma L Barber
- University of North Carolina, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Chapel Hill, NC, United States.
| | - Sarah Rutstein
- University of North Carolina, Department of Health Policy and Management, Gillings School of Public Health, Chapel Hill, NC, United States; University of North Carolina, Division of Infectious Diseases, Department of Internal Medicine, Chapel Hill, NC, United States
| | - William C Miller
- University of North Carolina, Division of Infectious Diseases, Department of Internal Medicine, Chapel Hill, NC, United States; University of North Carolina, Department of Epidemiology, Gillings School of Public Health, Chapel Hill, NC, United States
| | - Paola A Gehrig
- University of North Carolina, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Chapel Hill, NC, United States; Lineberger Clinical Cancer Center, University of North Carolina, Chapel Hill, NC, United States
| |
Collapse
|
11
|
Bosscher MRF, Bastiaannet E, van Leeuwen BL, Hoekstra HJ. Factors Associated with Short-Term Mortality After Surgical Oncologic Emergencies. Ann Surg Oncol 2015; 23:1803-14. [PMID: 26553441 PMCID: PMC4858551 DOI: 10.1245/s10434-015-4939-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Indexed: 01/29/2023]
Abstract
BACKGROUND The clinical outcome of patients with oncologic emergencies is often poor and mortality is high. It is important to determine which patients may benefit from invasive treatment, and for whom conservative treatment and/or palliative care would be appropriate. In this study, prognostic factors for clinical outcome are identified in order to facilitate the decision-making process for patients with surgical oncologic emergencies. METHODS This was a prospective registration study for patients over 18 years of age, who were consulted for surgical oncologic emergencies between November 2013 and April 2014. Multiple variables were registered upon emergency consultation, and the follow-up period was 90 days. Multivariate logistic regression analysis was performed to identify factors associated with 30- and 90-day mortality. RESULTS During the study period, 207 patients experienced surgical oncologic emergencies-101 (48.8 %) men and 106 (51.2 %) women, with a median age of 64 years (range 19-92). The 30-day mortality was 12.6 % and 90-day mortality was 21.7 %. Factors significantly associated with 30-day mortality were palliative intent of cancer treatment prior to emergency consultation (p = 0.006), Eastern Cooperative Oncology Group performance score (ECOG-PS) >0 (p for trend: p = 0.03), and raised lactate dehydrogenase (LDH) (p < 0.001). Additional factors associated with 90-day mortality were low handgrip strength (HGS) (p = 0.01) and low albumin (p = 0.002). CONCLUSIONS Defining the intent of prior cancer treatment and the ECOG-PS are of prognostic value when deciding on treatment for patients with surgical oncologic emergencies. Additional measurements of HGS, LDH, and albumin levels can serve as objective parameters to support the clinical assessment of individual prognosis.
Collapse
Affiliation(s)
- Marianne R F Bosscher
- Department of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Esther Bastiaannet
- Department of Surgery, Leiden University Medical Center, Leiden University, Leiden, The Netherlands.,Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden University, Leiden, The Netherlands
| | - Barbara L van Leeuwen
- Department of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Harald J Hoekstra
- Department of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| |
Collapse
|
12
|
Bosscher MRF, van Leeuwen BL, Hoekstra HJ. Current management of surgical oncologic emergencies. PLoS One 2015; 10:e0124641. [PMID: 25933135 PMCID: PMC4416749 DOI: 10.1371/journal.pone.0124641] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 03/16/2015] [Indexed: 11/19/2022] Open
Abstract
Objectives For some oncologic emergencies, surgical interventions are necessary for dissolution or temporary relieve. In the absence of guidelines, the most optimal method for decision making would be in a multidisciplinary cancer conference (MCC). In an acute setting, the opportunity for multidisciplinary discussion is often not available. In this study, the management and short term outcome of patients after surgical oncologic emergency consultation was analyzed. Method A prospective registration and follow up of adult patients with surgical oncologic emergencies between 01-11-2013 and 30-04-2014. The follow up period was 30 days. Results In total, 207 patients with surgical oncologic emergencies were included. Postoperative wound infections, malignant obstruction, and clinical deterioration due to progressive disease were the most frequent conditions for surgical oncologic emergency consultation. During the follow up period, 40% of patients underwent surgery. The median number of involved medical specialties was two. Only 30% of all patients were discussed in a MCC within 30 days after emergency consultation, and only 41% of the patients who underwent surgery were discussed in a MCC. For 79% of these patients, the surgical procedure was performed before the MCC. Mortality within 30 days was 13%. Conclusion In most cases, surgery occurred without discussing the patient in a MCC, regardless of the fact that multiple medical specialties were involved in the treatment process. There is a need for prognostic aids and acute oncology pathways with structural multidisciplinary management. These will provide in faster institution of the most appropriate personalized cancer care, and prevent unnecessary investigations or invasive therapy.
Collapse
Affiliation(s)
- Marianne R. F. Bosscher
- Department of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Barbara L. van Leeuwen
- Department of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Harald J. Hoekstra
- Department of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- * E-mail:
| |
Collapse
|
13
|
Søreide K, Desserud KF. Emergency surgery in the elderly: the balance between function, frailty, fatality and futility. Scand J Trauma Resusc Emerg Med 2015; 23:10. [PMID: 25645443 PMCID: PMC4320594 DOI: 10.1186/s13049-015-0099-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 01/21/2015] [Indexed: 12/15/2022] Open
Abstract
Becoming old is considered a privilege and results from the socioeconomic progress and improvements in health care systems worldwide. However, morbidity and mortality increases with age, and even more so in acute onset disease. With the current prospects of longevity, a considerable number of elderly patients will continue to live with good function and excellent quality of life after emergency surgical care. However, mortality in emergency surgery may be reported at 15-30%, doubled if associated with complications, and notably higher in patients over 75 years. A number of risks associated with death are reported, and a number of scores proposed for prediction of risk. Frailty, a decline in the physiological reserves that may make the person vulnerable to even the most minor of stressful event, appears to be a valid indicator and predictor of risk and poor outcome, but how to best address and measure frailty in the emergency setting is not clear. Futility may sometimes be clearly defined, but most often becomes a borderline decision between ethics, clinical predictions and patient communication for which no solid evidence currently exists. The number and severity of other underlying condition(s), as well as the treatment alternatives and their consequences, is a complex picture to interpret. Add in the onset of the acute surgical disease as a further potential detrimental factor on function and quality of life – and you have a perfect storm to handle. In this brief review, some of the challenging aspects related to emergency surgery in the elderly will be discussed. More research, including registries and trials, are needed for improved knowledge to a growing health care challenge.
Collapse
Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway. .,Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Kari F Desserud
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway.
| |
Collapse
|