Determinants of outcome in critically ill octogenarians after surgery: an observational study

Analysis of prognostic factors for postoperative complications and mortality in elderly patients undergoing emergency surgery for intestinal perforation or irreversible intestinal ischemia

Purpose

Because the global geriatric population continues to increase, the assessment of emergency surgical outcomes in elderly patients with acute peritonitis will become more important.

Methods

A retrospective review was conducted on the data of 174 elderly patients who underwent emergency surgery for intestinal perforation or intestinal infarction between June 2010 and November 2022. We conducted an analysis of the risk factors associated with postoperative complications and mortality by evaluating the characteristics of patients and their surgical outcomes.

Results

In our study, most patients (94.3%) had preexisting comorbidities, and many patients (84.5%) required transfer to the intensive care unit following emergency surgery. Postoperative complications were observed in 84 individuals (48.3%), with postoperative mortality occurring in 29 (16.7%). Multivariate analysis revealed preoperative acute renal injury, hypoalbuminemia, and postoperative ventilator support as significant predictors of postoperative mortality.

Conclusion

When elderly patients undergo emergency surgery for intestinal perforation or infarction, it is important to recognize that those with preoperative acute renal injury, hypoalbuminemia, and a need for postoperative ventilator support have a poor prognosis. Therefore, these patients require intensive care from the early stages of treatment.

The Hellenic Emergency Laparotomy Study (HELAS): A Prospective Multicentre Study on the Outcomes of Emergency Laparotomy in Greece

BACKGROUND

Emergency laparotomy (EL) is accompanied by high post-operative morbidity and mortality which varies significantly between countries and populations. The aim of this study is to report outcomes of emergency laparotomy in Greece and to compare them with the results of the National Emergency Laparotomy Audit (NELA).

METHODS

This is a multicentre prospective cohort study undertaken between 01.2019 and 05.2020 including consecutive patients subjected to EL in 11 Greek hospitals. EL was defined according to NELA criteria. Demographics, clinical variables, and post-operative outcomes were prospectively registered in an online database. Multivariable logistic regression analysis was used to identify independent predictors of post-operative mortality.

RESULTS

There were 633 patients, 53.9% males, ASA class III/IV 43.6%, older than 65 years 58.6%. The most common operations were small bowel resection (20.5%), peptic ulcer repair (12.0%), adhesiolysis (11.8%) and Hartmann's procedure (11.5%). 30-day post-operative mortality reached 16.3% and serious complications occurred in 10.9%. Factors associated with post-operative mortality were increasing age and ASA class, dependent functional status, ascites, severe sepsis, septic shock, and diabetes. HELAS cohort showed similarities with NELA patients in terms of demographics and preoperative risk. Post-operative utilisation of ICU was significantly lower in the Greek cohort (25.8% vs 56.8%) whereas 30-day post-operative mortality was significantly higher (16.3% vs 8.7%).

CONCLUSION

In this study, Greek patients experienced markedly worse mortality after emergency laparotomy compared with their British counterparts. This can be at least partly explained by underutilisation of critical care by surgical patients who are at high risk for death.

Perioperative fluid administration and complications in emergency gastrointestinal surgery-an observational study

BACKGROUND

The fluid balance associated with a better outcome following emergency surgery is unknown. The aim of this study was to explore the association of the perioperative fluid balance and postoperative complications during emergency gastrointestinal surgery.

METHODS

We retrospectively included patients undergoing emergency surgery for gastrointestinal obstruction or perforation. A perioperative fluid balance of 2.5 L divided the cohort in a conservative and liberal group. Outcome was Clavien-Dindo graded complications registered 90 days postoperatively. We used logistic regression adjusted for age, sex, American Society of Anesthesiologists' classification, use of epidural analgesia, use of vasopressor, type of surgery, intraabdominal pathology, and hospital. Predicted risk of complications was demonstrated on a continuous scale of the fluid balance.

RESULTS

We included 342 patients operated between July 2014 and July 2015 from three centers. The perioperative fluid balance was 1.6 L IQR [1.0 to 2.0] in the conservative vs. 3.6 L IQR [3.0 to 5.3] in the liberal group. Odds ratio of overall 2.6 (95% CI 1.5 to 4.4), p < 0.001, and cardiopulmonary complications 3.2 (95% CI 1.9 to 5.7), p < 0.001, were increased in the liberal group. A perioperative fluid balance of 0-2 L was associated with minimal risk of cardiopulmonary complications compared to 1.5-3.5 L for renal complications.

CONCLUSION

We found a perioperative fluid balance above 2.5 L to be associated with an increased risk of overall and cardiopulmonary complications following emergency surgery for gastrointestinal obstruction or perforation. A perioperative fluid balance of 0-2 L was associated with the lowest risk of cardiopulmonary complications and 1.5-3.5 L for renal complications.

Assessing differences in surgical outcomes following emergency abdominal exploration for complications of elective surgery and high-risk primary emergencies

Irrespective of its etiology, emergency surgical abdominal exploration (EAE) is considered a high-risk procedure with mortality rates exceeding 20%. The aim of this study was to evaluate differences in outcomes in patients who required EAE due to complications of complex elective abdominal procedures and those who required EAE due to high-risk primary abdominal emergencies. Patients undergoing EAE for acute surgical complications of complex abdominal elective surgical procedures (N = 293; Elective group) and patients undergoing EAE for high-risk primary abdominal emergencies (N = 776; Emergency group) from 2012 to 2019 at our institution were retrospectively assessed for morbidity and mortality. Postoperative complications occurred in 196 patients (66.94%) in the elective group and 585 patients (75.4%) in the emergency group. The relatively low complication burden in the elective group was also evidenced by a significantly lower comprehensive complication index score (54.00 ± 37.36 vs. 59.25 ± 37.08, p = 0.040). The in-hospital mortality rates were 31% (91 of 293) and 38% (295 of 776) in the elective and emergency groups, respectively. This difference between the two groups was statistically significant (p = 0.035). In multivariate analysis, age, peripheral artery disease, pneumonia, thromboembolic events, ICU stay, ventilator dependence, acute kidney failure and liver failure were independent predictors of mortality. Our data show that patients undergoing EAE due to acute complications of major elective surgery tolerate the procedure relatively well compared with patients undergoing EAE due to primary high-risk abdominal emergencies.

Development and Validation of a Risk Score to Predict the First Hip Fracture in the Oldest Old: A Retrospective Cohort Study

BACKGROUND

To evaluate whether the common risk factors and risk scores (FRAX, QFracture, and Garvan) can predict hip fracture in the oldest old (defined as people aged 80 and older) and to develop an oldest-old-specific 10-year hip fracture prediction risk algorithm.

METHODS

Subjects aged 80 years and older without history of hip fracture were studied. For the derivation cohort (N = 251, mean age = 83), participants were enrolled with a median follow-up time of 8.9 years. For the validation cohort (N = 599, mean age = 85), outpatients were enrolled with a median follow-up of 2.6 years. A five-factor risk score (the Hong Kong Osteoporosis Study [HKOS] score) for incident hip fracture was derived and validated, and its predictive accuracy was evaluated and compared with other risk scores.

RESULTS

In the derivation cohort, the C-statistics were .65, .61, .65, .76, and .78 for FRAX with bone mineral density (BMD), FRAX without BMD, QFracture, Garvan, and the HKOS score, respectively. The category-less net reclassification index and integrated discrimination improvement of the HKOS score showed a better reclassification of hip fracture than FRAX and QFracture (all p < .001) but not Garvan, while Garvan, but not HKOS score, showed a significant over-estimation in fracture risk (Hosmer-Lemeshow test p < .001). In the validation cohort, the HKOS score had a C-statistic of .81 and a considerable agreement between expected and observed fracture risk in calibration.

CONCLUSION

The HKOS score can predict 10-year incident hip fracture among the oldest old in Hong Kong. The score may be useful in identifying the oldest old patients at risk of hip fracture in both community-dwelling and hospital settings.

Outcomes of emergency abdominal surgery in octogenarians: A single-center analysis

BACKGROUND

The aim of this study was to assess outcomes of octogenarians undergoing emergency abdominal surgery (EAS).

METHODS

Octogenarians undergoing EAS 12/2011-12/2016 were retrospectively analysed. The outcomes were assessed by univariable and multivariable regression analysis.

RESULTS

One-hundred-forty patients with a median age of 83.9 years were included. EAS was performed for cholecystitis (27.1%), ileus (22.1%), hollow viscus perforation (16.4%), diverticulitis (12.9%), mesenteric ischemia (10.0%), incarcerated hernia (9.3%), and appendicitis (2.1%). The overall and early (within 7 days from surgery) mortality rate was 16.4% and 10.0%, respectively. Multivariable analysis revealed age (OR 1.24,CI95% 1.04-1.47,p = 0.015), ASA scores≥4 (OR 11.15,CI95% 2.39-52.02,p = 0.002), mesenteric ischemia (OR 52.60,CI95% 8.93-309.94,p < 0.001) and ICU admission (OR 9.23,CI95% 1.74-49.04,p = 0.009) as independent predictors for mortality. Postoperative withdrawal of care accounted for 36% of early mortalities.

CONCLUSIONS

One third of early mortality in octogenarians was due to postoperative withdrawal of care. An interdisciplinary decision-making including patients' and relatives' wishes may avoid ethically questionable interventions in octogenarians.

Establishing a proactive geriatrician led comprehensive geriatric assessment in older emergency surgery patients: Outcomes of a pilot study

INTRODUCTION

Increasing numbers of older adults are presenting with acute surgical disease to the unselected general surgical take. General surgeons have little training to manage these patients. We developed a pilot service of proactive geriatrician input into older emergency general surgical patients in a single institution. We wanted to demonstrate if geriatricians improve the management of these patients.

METHODS

Patients aged 70 years or older admitted acutely under the general surgeons were assessed proactively by a geriatrician using comprehensive geriatric assessment (CGA). Data were collected prospectively using a data collection form of any new issues detected and interventions made by the geriatricians in addition to the surgical plan. This information was entered into an excel database and analysed.

RESULTS

We obtained data for 447 patients between November 2016 and July 2017. CGA led to additional diagnoses or interventions in 83% of patients. The most common problems identified included a new medical diagnosis (35.2%), polypharmacy (30%), recent falls (19.7%), weight loss (17.2%) and uncontrolled pain (16.7%). Abbreviated mental tests were performed in 87.5% patients, with 22% being detected with cognitive impairment. Frailty screening was performed in 97% of patients resulting in 38% being identified as frail. New interventions included stopping medications (40%), starting medications (28%) and referral to multidisciplinary teams (70.1%). Length of stay was reduced by 0.55 days.

CONCLUSION

Proactive geriatrician input identifies medical diagnoses and geriatric syndromes missed by the surgical teams. Managing these issues has contributed to a reduced length of stay in these patients.

Robot-assisted surgery in elderly and very elderly population: our experience in oncologic and general surgery with literature review

BACKGROUND

Although there is no agreement on a definition of elderly, commonly an age cutoff of ≥65 or 75 years is used. Nowadays most of malignancies requiring surgical treatment are diagnosed in old population. Comorbidities and frailty represent well-known problems during and after surgery in elderly patients. Minimally invasive surgery offers earlier postoperative mobilization, less blood loss, lower morbidity as well as reduction in hospital stay and as such represents an interesting and validated option for elderly population. Robot-assisted surgery is a recent improvement of conventional minimally invasive surgery.

AIMS

We provided a complete review of old and very old patients undergoing robot-assisted surgery for oncologic and general surgery interventions.

PATIENTS AND METHODS

A retrospective review of all patients undergoing robot-assisted surgery in our General Surgery Unit from September 2012 to June 2016 was conducted. Analysis was performed for the entire cohort and in particular for three of the most performed surgeries (gastric resections, right colectomy, and liver resections) classifying patients into three age groups: ≤64, 65-79, and ≥80. Data from these three different age groups were compared and examined in respect of different outcomes: ASA score, comorbidities, oncologic outcomes, conversion rate, estimated blood loss, hospital stay, geriatric events, mortality, etc.

RESULTS

Using our in-patient robotic surgery database, we retrospectively examined 363 patients, who underwent robot-assisted surgery for different diseases (402 different robotic procedures): colorectal surgery, upper GI, HPB, etc.; the oncologic procedures were 81%. Male were 56%. The mean age was 65.63 years (18-89). Patients aged ≥65 years represented 61% and ≥80 years 13%. Overall conversion rate was of 6%, most in the group 65-79 years (59% of all conversions). The more frequent diseases treated were colorectal surgery 43%, followed by hepatobilopancreatic surgery 23.4%, upper gastro-intestinal 23.2%, and others 10.4%.

DISCUSSION

Robot-assisted surgery is a safe and effective technique in aging patient population too. There was no increased risk of death or morbidity compared to younger patients in the three groups examined. A higher conversion rate was observed in our experience for patients aged 65-79. Prolonged operative time and in any cases steep positions (Trendelenburg) have not represented a problem for the majority of patients.

CONCLUSIONS

In any case, considering the high direct costs, minimally invasive robot-assisted surgery should be performed on a case-by-case basis, tailored to each patient with their specific histories and comorbidities.

Surgery in the older person: Training needs for the provision of multidisciplinary care

Introduction Many older surgical patients are exposed to high risks of morbidity and mortality when undergoing both elective and emergency surgery. Methods We provide an overview of perioperative care teams and the educational opportunities available to surgeons who undertake surgery in the older person. Findings The number of older people undergoing surgery is increasing at a rate faster than the proportion of older people in the overall population. Management of the older surgical patient throughout the surgical pathway forms part of the Specialty Training Curriculum for Geriatric Medicine. While 'surgery in childhood' continues to form part of the general surgical higher training syllabus, surgery in the later years of life does not. There are limited postgraduate courses and training opportunities currently available to surgeons in this field. There is clear societal need to address perioperative care for older surgical patients, which has proved successful in some centers. Moreover, surgical trainees support the inclusion of geriatric medicine issues into their training. Conclusions The ageing population requires a multidisciplinary perioperative approach, with dedicated and appropriately trained clinicians and allied health care professionals to improve outcomes.

Emergency laparotomy in octogenarians: A 5-year study of morbidity and mortality

AIM: To determine the morbidity and mortality associated with emergency laparotomy for a clinically acute abdomen in patients aged ≥ 80 years.

METHODS: In this retrospective audit, octogenarians undergoing emergency laparotomy between 1st January 2005 and 1^st January 2010 were identified using the Galaxy Theatre System. Patients undergoing abdominal surgery through groin crease incisions or Lanz or Gridiron incisions were excluded. Also simple appendectomies were excluded. All patients were aged 80 years or more at the time of their surgery. Data were obtained using casenote review with a standardised proforma to determine patient age, American Society of Anesthesiologists (ASA) grade, indications for surgery, early (within 30 d) and late (after 30 d) complications, mortality and length of stay. Data were inserted into a Microsoft Excel spreadsheet and analysed.

RESULTS: One hundred patients were identified from the database (Galaxy) as having undergone emergency laparotomy. Of those, 55 underwent the procedure for intestinal procedures and 37 for secondary peritonitis. There was a 2:1 female predominance; average age 85 and ASA grade 3. Bowel resection was required in 51 out of the 100 patients and 22 (43%) died. Other procedures included appendicectomy, adhesiolysis, repair of AAA graft leak and colostomies for the pathological process resulting in an acute abdomen. Twelve of 100 patients (12%) suffered intra-operative complications, including splenic and bowel-serosal tears. Seventy patients (70%) had postoperative complications including myocardial infarction, wound infection, haematoma and sepsis. Overall mortality was 45/100 patients (45%). The major causes of death were sepsis (19/45 patients, 42%), underlying cancer (13/45 patients, 29%); with others including bowel obstruction (2/45 patients, 4%), myocardial and intestinal ischaemia and dementia.

CONCLUSION: Emergency laparotomy in octogenarians carries a significant morbidity and mortality. In particular, surgery requiring bowel resection has higher mortality than without resection.

Risk factors for postoperative mortality and morbidities in emergency surgeries

BACKGROUND

Emergency surgery itself induces high risk for postoperative mortality and morbidities; however, it remains unknown which concomitant pathological conditions of emergency surgeries are causative factors of deteriorating outcomes. This study examined the causal factors of postoperative mortality and morbidity in cases of emergency surgery.

METHODS

Patients undergoing emergency surgery from January to December 2007 were enrolled in this retrospective cohort study. Causal relationships were analyzed by stepwise multivariate logistic regression analysis between possible independent factors (sex, age, kind of surgical department, timing of surgery, duration of surgery, blood transfusion, deteriorated consciousness level, shock state, abnormal coagulate state, and history of hypertension, diabetes, ischemic heart disease, chronic obstructive pulmonary disease, renal failure, and anemia) and postoperative mortality or morbidities (failure of removal of tracheal tube after operation, tracheotomy, cerebral infarction, massive hemorrhage, severe hypotension, severe hypoxemia, and severe arrhythmia during or after surgery).

RESULTS

Shock, deteriorated consciousness level, chronic obstructive lung disease, and ischemic heart disease were significant risk factors for mortality (OR 14.2, 7.9, 6.4, and 3.8, respectively), and deteriorated consciousness level, blood transfusion, shock, chronic obstructive lung disease, diabetes, cardiovascular surgery, and operation longer than 2 h were significant risk factors for morbidity (OR 19.1, 3.3, 3.0, 2.5, 2.4, 2.4, and 1.8, respectively).

CONCLUSION

State of shock, deteriorated consciousness level, chronic obstructive lung disease, ischemic heart disease, hemorrhage requiring blood transfusion, age over 80 years, cardiovascular surgery, surgeries at night, and surgeries of duration more than 2 h cause patients to be strongly susceptible to postoperative mortality or morbidity in emergency surgeries.

The impact of age on outcome after major surgical procedures

PURPOSE

The aim of this study was to investigate the effects of age on outcome in a large cohort of surgical intensive care unit (ICU) patients.

METHODS

In this retrospective analysis of prospectively collected data, all 11537 adult patients admitted directly from the operating room to our 50-bed surgical ICU between January 1, 2004, and January 31, 2009, were included. Patients were classified into 5 subgroups according to age (18-50 [reference category], 51-65, 66-75, 76-85, >85 years).

RESULTS

Severity scores and the incidence of comorbid conditions on ICU admission increased steadily with age. Intensive care unit and hospital mortality rates were 4.4% and 8.7%, respectively, and increased with age to reach 12.4% and 28.2%, respectively, in patients older than 85 years. In multivariate logistic regression analysis, age was an independent risk factor for in-hospital death (odds ratio, 1.04; 95% confidence interval, 1.03-1.04, per year; P < .001). Gastrointestinal surgery was independently associated with a higher risk of in-hospital mortality in patients older than 50 years, whereas neurosurgery was associated with a higher risk of in-hospital death only in patients older than 65 years.

CONCLUSIONS

Mortality rates increase with age, with an exponential increase in patients older than 65 years. Age is an independent risk factor for in-hospital death, irrespective of the type of surgical intervention.

Mortality and postoperative care after emergency laparotomy

BACKGROUND AND OBJECTIVE

Emergency laparotomy is a common high-risk surgical procedure, but with few outcome data and few data on postoperative care. We aimed to observe mortality within a mixed general surgical population and to explore the potential impact of postoperative care on mortality.

METHOD

A prospective observational study of 124 patients undergoing emergency laparotomy. For all patients, overall mortality and 30-day survival were observed; the predicted death rate (PDR) using the P-POSSUM (Portsmouth predictor - Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity) score and the standardised mortality ratio (SMR) were calculated.

RESULTS

Twenty-four patients died (19.4%); 21 in the first 30 days (16.9%). Twenty-six patients were over 80 years; 10 died (38%). PDR for all patients was 27.4%. The overall SMR was 0.71. Eighty-seven patients (70.2%) followed a postanaesthesia care unit (PACU)-ward pathway (observed mortality 13.6%; mean PDR 15.4%; SMR 0.82). Thirty (24.2%) patients followed an ICU-high dependency unit (HDU)-ward pathway (observed mortality 40.0%; mean PDR 57.2%; SMR 0.69). Six patients (4.8%) followed a PACU-HDU-ward pathway (observed mortality 0%, mean PDR 41.8%, SMR 0.0).

CONCLUSION

Mortality after emergency laparotomy was high and very high in patients more than 80 years of age. The SMR was higher in the PACU-ward pathway compared to the ICU-HDU-ward pathway, suggesting room for improvement in the postoperative period.

Postoperative complications in elderly patients and their significance for long-term prognosis

PURPOSE OF REVIEW

To outline perioperative risk factors for postoperative mortality in older patients, the relationship of these factors with long-term mortality, and to examine possible strategies to reduce mortality.

RECENT FINDINGS

For patients aged 70 years and over 30-day mortality is about 6%, whereas 20% are likely to have at least one complication during their hospital stay. The mortality risk increases by 10% for every year after age 70. Mortality is also strongly associated with preoperative status and postoperative complications, particularly systemic inflammation and renal impairment. Unplanned postoperative intensive care unit admission is an important predictor for mortality. Requirement for postoperative vasopressors or inotropes is associated with 50% mortality in patients aged 80 years or more. Early postoperative complications are likely to be associated with an increased long-term (a year or more later) mortality. Strategies such as critical care outreach may decrease both 30-day and long-term mortality.

SUMMARY

Strategies are needed to prevent, or at least adequately manage, complications in elderly patients. Agreed international definitions for risks and complications can help in assessing risks and benefits.

What limits for acute care in the elderly?

PURPOSE OF REVIEW

This review aims to address the important question of the increasing life expectancy and the aging population in the healthcare system today. We try to give some elements that will help the reflection about the ethical stakes balancing the necessity of care in the increasing number of elderly patients and the limited resources available, in the special context of acute care.

RECENT FINDINGS

There is growing evidence that the chronological age itself is not a reliable marker of bad prognosis or of mortality. The new concept of frailty may better correlate with the aging process of the elderly. The frailty index is an integrative approach considering the multiple factors impacting on the aging individual. Applied in the practical arena, it might become a useful tool for clinicians.

SUMMARY

Aging implies many biological modifications at molecular, cellular, organic levels as well as of the behavior. Some aspects of these processes and their consequences on health are described. The frailty concept is detailed, and its potential interest explained. We conclude that the measurement of aging phenomenon, including the frailty index, may help us to better assess the true health and the required therapeutics of elderly patients.