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Harada K, Yamanaka K, Kurimoto M, Aoki H, Shinkura A, Hanabata Y, Kayano M, Tashima M, Tamura J. Effect of emergency general surgery on postoperative performance status in patients aged over 90 years. Surg Open Sci 2024; 17:1-5. [PMID: 38187005 PMCID: PMC10770739 DOI: 10.1016/j.sopen.2023.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/17/2023] [Accepted: 09/17/2023] [Indexed: 01/09/2024] Open
Abstract
Background Functional deterioration following emergency general surgery (EGS) poses a significant challenge in super-elderly patients. However, limited research has focused on assessing the deterioration in postoperative performance status (PS). This study aimed to investigate the impact of EGS on PS deterioration in super-elderly patients, and the extent to which deteriorated PS is recovered. Methods This historical cohort study comprised 77 super-elderly patients who underwent EGS between July 2015 and December 2020. Functional deterioration was evaluated by comparing preoperative and postoperative Eastern Cooperative Oncology Group Performance Status (ECOG-PS). The Emergency Surgical Score (ESS) was used as a risk-adjustment tool. Questionnaires were mailed to the patients and their families to assess post-discharge PS and obtain their impressions of EGS. Results Postoperative PS deteriorated in 35/77 patients (45.5 %). Significant differences were observed between the groups in terms of sex, serum C-reactive protein (CRP) levels, ESS scores, preoperative ECOG-PS, duration of operation, and major complications. Multivariate analysis of preoperative factors showed that ESS ≥7 (OR: 3.7, 95 % CI: 1.0-13), preoperative ECOG-PS ≤2 (OR: 5.9, 95 % CI: 1.7-21), and female sex (OR: 5.8, 95 % CI: 1.6-21) were associated with postoperative ECOG-PS deterioration. According to the questionnaire results, PS recovery post-discharge was observed in 6/36 (17 %) patients, and 34/36 (94 %) patients and their families expressed positive impressions of EGS. Conclusions EGS in super-elderly patients highly caused a deterioration in their PS, particularly in patients with maintained preoperative PS. PS hardly recovered; however, most patients and their families had positive impressions of the EGS. Key message We assessed the pre- and postoperative performance status of super-elderly patients who underwent emergency general surgery. Surgery caused a marked deterioration in patients' functional performance, which seldom recovered postoperatively.
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Affiliation(s)
- Kaichiro Harada
- Department of Surgery, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77, Higashinaniwa, Amagasaki, Hyogo, Japan
| | - Kenya Yamanaka
- Department of Surgery, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77, Higashinaniwa, Amagasaki, Hyogo, Japan
| | - Makoto Kurimoto
- Department of Surgery, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77, Higashinaniwa, Amagasaki, Hyogo, Japan
| | - Hikaru Aoki
- Department of Surgery, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77, Higashinaniwa, Amagasaki, Hyogo, Japan
| | - Akina Shinkura
- Department of Surgery, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77, Higashinaniwa, Amagasaki, Hyogo, Japan
| | - Yusuke Hanabata
- Department of Surgery, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77, Higashinaniwa, Amagasaki, Hyogo, Japan
| | - Masashi Kayano
- Department of Surgery, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77, Higashinaniwa, Amagasaki, Hyogo, Japan
| | - Misaki Tashima
- Department of Surgery, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77, Higashinaniwa, Amagasaki, Hyogo, Japan
| | - Jun Tamura
- Department of Surgery, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77, Higashinaniwa, Amagasaki, Hyogo, Japan
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Chua KSG, Kwan HX, Teo WS, Cao RX, Heng CP, Ratha Krishnan R. Changing Epidemiology and Functional Outcomes of Inpatient Rehabilitation in Asian Traumatic Brain Injury Cases before and during the COVID-19 Pandemic: A Retrospective Cohort Study. Life (Basel) 2023; 13:1475. [PMID: 37511850 PMCID: PMC10381117 DOI: 10.3390/life13071475] [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: 05/29/2023] [Revised: 06/27/2023] [Accepted: 06/28/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND This study aimed to compare acute injury and rehabilitation characteristics for traumatic brain injury (TBI) inpatients during the pre and post COVID-19 pandemic periods. METHODS A retrospective study of TBI inpatients between 1 April 2018 and 31 December 2019 (pre COVID-19 period), and 1 July 2020 and 31 March 2022 (post COVID-19 period) was performed to compare demographics, premorbid comorbidity, TBI characteristics, rehabilitation complications, admission and discharge functional independence measure (FIM®), length of stay and discharge status. RESULTS A total of 187 data sets were analyzed (82 pre COVID-19 and 105 post COVID-19). Post COVID-19 TBI inpatients were older by 11 years (pre COVID-19 mean 55 years vs. post COVID-19 mean 66 years, and p < 0.001), with 23% higher female inpatients (pre COVID-19 13.4% vs. post COVID-19 36.2%, and p < 0.001) and 25% higher presence of comorbidities (pre COVID-19 52.4% vs. post COVID-19 77.1%, and p < 0.001). In the post COVID-19 group, total discharge FIM (Td-FIM) was significantly lower by ~12 points (pre COVID-19 94.5 vs. post COVID-19 82, and p = 0.011), Td-FIM ≥ 91 was lower by ~18% (pre COVID-19 53.7% vs. post COVID-19 36.2%, and p = 0.017), and the need for caregivers increased by ~17% (pre COVID-19 68% vs. post COVID-19 85.4%, and p = 0.006) Conclusions: Our findings signal a demographic shift towards older, frailer TBI with lower functional independence levels post COVID-19.
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Affiliation(s)
- Karen Sui Geok Chua
- Institute of Rehabilitation Excellence (IREx), Tan Tock Seng Hospital Rehabilitation Centre, Singapore 569766, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 636921, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Hui Xuan Kwan
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 636921, Singapore
| | - Wee Shen Teo
- Institute of Rehabilitation Excellence (IREx), Tan Tock Seng Hospital Rehabilitation Centre, Singapore 569766, Singapore
| | - Ruo Xi Cao
- Institute of Rehabilitation Excellence (IREx), Tan Tock Seng Hospital Rehabilitation Centre, Singapore 569766, Singapore
| | - Choon Pooh Heng
- Clinical Research and Innovation Office, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Rathi Ratha Krishnan
- Institute of Rehabilitation Excellence (IREx), Tan Tock Seng Hospital Rehabilitation Centre, Singapore 569766, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 636921, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
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Deverakonda DL, Kishawi SK, Lapinski MF, Adomshick VJ, Siff JE, Brown LR, Ho VP. What If We Do Not Operate? Outcomes of Nonoperatively Managed Emergency General Surgery Patients. J Surg Res 2023; 284:29-36. [PMID: 36529078 PMCID: PMC9911375 DOI: 10.1016/j.jss.2022.11.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 11/18/2022] [Accepted: 11/20/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Although two-thirds of patients with emergency general surgery (EGS) conditions are managed nonoperatively, their long-term outcomes are not well described. We describe outcomes of nonoperative management in a cohort of older EGS patients and estimate the projected risk of operative management using the NSQIP Surgical Risk Calculator (SRC). MATERIALS AND METHODS We studied single-center inpatients aged 65 y and more with an EGS consult who did not undergo an operation (January 2019-December 2020). For each patient, we recorded the surgeon's recommendation as either an operation was "Not Needed" (medical management preferred) or "Not Recommended" (risk outweighed benefits). Our main outcome of interest was mortality at 30 d and 1 y. Our secondary outcome of interest was SRC-projected 30-day postoperative mortality risk (median % [interquartile range]), calculated using hypothetical low-risk and high-risk operations. RESULTS We included 204 patients (60% female, median age 75 y), for whom an operation was "Not Needed" in 81% and "Not Recommended" in 19%. In this cohort, 11% died at 30 d and 23% died at 1 y. Mortality was higher for the "Not Recommended" cohort (37% versus 5% at 30 d and 53% versus 16% at 1 y, P < 0.05). The SRC-projected 30-day postoperative mortality risk was 3.7% (1.3-8.7) for low-risk and 5.8% (2-11.8) for high-risk operations. CONCLUSIONS Nonoperative management in older EGS patients is associated with very high risk of short-term and long-term mortality, particularly if a surgeon advised that risks of surgery outweighed benefits. The SRC may underestimate risk in the highest-risk patients.
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Affiliation(s)
| | - Sami K Kishawi
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio; Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | | | | | - Jonathan E Siff
- Department of Emergency Medicine and the Center for Clinical Informatics Research and Education, MetroHealth Medical Center, Cleveland, Ohio
| | - Laura R Brown
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Vanessa P Ho
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio; Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio.
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4
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Ho VP, Bensken WP, Flippin JA, Santry HP, Claridge JA, Towe CW, Koroukian SM. Functional Status is Key to Long-term Survival in Emergency General Surgery Conditions. J Surg Res 2023; 283:224-232. [PMID: 36423470 PMCID: PMC9923717 DOI: 10.1016/j.jss.2022.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 06/29/2022] [Accepted: 10/17/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Emergency General Surgery (EGS) conditions in older patients constitutes a substantial public health burden due to high morbidity and mortality. We sought to utilize a supervised machine learning method to determine combinations of factors with the greatest influence on long-term survival in older EGS patients. METHODS We identified community dwelling participants admitted for EGS conditions from the Medicare Current Beneficiary Survey linked with claims (1992-2013). We categorized three binary domains of multimorbidity: chronic conditions, functional limitations, and geriatric syndromes (such as vision or hearing impairment, falls, incontinence). We also collected EGS disease type, age, and sex. We created a classification and regression tree (CART) model to identify groups of variables associated with our outcome of interest, three-year survival. We then performed Cox proportional hazards analysis to determine hazard ratios for each group with the lowest risk group as reference. RESULTS We identified 1960 patients (median age 79 [interquartile range [IQR]: 73, 85], 59.5% female). The CART model identified the presence of functional limitations as the primary splitting variable. The lowest risk group were patient aged ≤81 y with biliopancreatic disease and without functional limitations. The highest risk group was men aged ≥75 y with functional limitations (hazard ratio [HR] 11.09 (95% confidence interval [CI] 5.91-20.83)). Notably absent from the CART model were chronic conditions and geriatric syndromes. CONCLUSIONS More than the presence of chronic conditions or geriatric syndromes, functional limitations are an important predictor of long-term survival and must be included in presurgical assessment.
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Affiliation(s)
- Vanessa P Ho
- Department of Surgery, MetroHealth Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio; Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio.
| | - Wyatt P Bensken
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
| | - J Alford Flippin
- Department of Surgery, MetroHealth Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Heena P Santry
- Department of Surgery, Kettering Hospital, Columbus, Ohio
| | - Jeffrey A Claridge
- Department of Surgery, MetroHealth Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Christopher W Towe
- Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Siran M Koroukian
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
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Psoas attenuation and cross-sectional area improve performance of traditional sarcopenia measurements in predicting one-year mortality among elderly patients undergoing emergency abdominal surgery: a pilot study of five computed tomography techniques. Abdom Radiol (NY) 2023; 48:796-805. [PMID: 36383241 DOI: 10.1007/s00261-022-03652-9] [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: 05/31/2022] [Revised: 08/06/2022] [Accepted: 08/09/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Risk stratification is challenging in the growing population of geriatric patients requiring emergency surgery. Sarcopenia, which assesses muscle bulk, is a surrogate for frailty and predicts 1-year mortality, but does not incorporate potentially valuable additional information about muscle quality. OBJECTIVE To describe five different CT methods of measuring sarcopenia and muscle quality and to determine which method has the greatest sensitivity for predicting 1-year mortality following emergency abdominal surgery in elderly patients. METHODS This retrospective study includes 297 patients 70 years and older who underwent "urgent" or "emergent" laparotomy or laparoscopy for acute abdominal disease between 2006 and 2011 at a single quaternary academic medical center. All patients received a CT abdomen and pelvis with intravenous contrast within 1 month of surgery. Five different methods were applied to the psoas muscles on CT: method 1 (total psoas index TPI, which is total psoas area TPA normalized by height), method 2 ("pseudoarea" = anterior-posterior × transverse dimensions), method 3 (average HU), method 4 (TPA × HU), and method 5 ("pseudoarea" × HU). RESULTS For all five CT measures, mortality was greatest for the lowest quartile by univariate and adjusted Cox proportional hazard analyses at all time points up to 1-year. The C-statistic was highest for Method 4, using a composite index of TPA and Hounsfield Units, indicating the greatest predictive ability to estimate mortality at all time points. CONCLUSION Muscle quality and muscle size can be used in tandem to refine risk assessment of older patients undergoing emergency abdominal surgery. Routine calculation of the composite score of psoas cross-sectional area and HU in the emergency room setting may provide surgeons and patients valuable insight on the risk of 1-year mortality to guide preoperative decision-making and counseling. CLINICAL IMPACT Muscle quality and size, both strong independent predictors of surgical outcomes in older patients undergoing emergency abdominal surgery, may be used in tandem to refine risk assessment. A composite score of psoas muscle cross-sectional area and Hounsfield units on CT may provide insight on 1-year mortality in this patient population.
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Samper AFG, Herrera-Almario GE, Tulloch D, Blanco D, Cardoso LL, Rocha REN, Rajan R, Gracias V, Hanna JS. A granular analysis of service delivery for surgical system strengthening: Application of the Lancet indicators for policy development in Colombia. LANCET REGIONAL HEALTH. AMERICAS 2022; 10:100217. [PMID: 36777688 PMCID: PMC9904114 DOI: 10.1016/j.lana.2022.100217] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
BACKGROUND The Lancet Commission on Global Surgery (LCoGS) surgical indicators have given the surgical community metrics for objectively characterizing the disparity in access to surgical healthcare. However, aggregate national statistics lack sufficient specificity to inform strengthening plans at the community level. We performed a second-stage analysis of Colombian surgical system service delivery to inform the development of resource- and context-sensitive interventions to inform a revision of the Decennial Public Health Plan for access inequity resolution. METHODS Data from the year 2016 to inform total operative volume (TOV) and 30-day non-risk adjusted peri-operative mortality (POMR) were collected from the Colombian national health information system. TOV and POMR were sub-characterized by demographics, urgency, service line, disease pathology and facility location. FINDINGS In 2016, aggregate national mortality was 0·87%, while mortality attributable to elective and emergency surgery was 0·73% and 1·30%, respectively. The elderly experienced a 5·6-fold higher mortality, with 4·2% undergoing an operation within 30 days of dying. Individuals undergoing hepatobiliary, thoracic, cardiac, and neurosurgical operations experienced the highest mortality rates while obstetrics, general surgery, orthopaedics, and urology performed the largest procedure volume. Finally, analysis of operation and service line specific POMR reveals opportunities for improvement. INTERPRETATION This granular second-stage analysis provides actionable data which is fundamental to the development of resource and context-sensitive interventions to address gaps and inequities in surgical system service delivery. Furthermore, this analysis validates the modeling underlying development of the LCoGS indicators. These data will inform the assessment of implementation priorities and revision of the Colombian Decennial Public Health Plan. FUNDING None.
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Affiliation(s)
| | - Gabriel E. Herrera-Almario
- School of Medicine, Universidad de Los Andes, Bogotá, Colombia
- Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - David Tulloch
- Center for Remote Sensing and Spatial Analysis, Rutgers School of Environmental and Biological Sciences, New Brunswick, NJ, USA
| | - Daniela Blanco
- School of Medicine, Universidad de Los Andes, Bogotá, Colombia
| | | | | | - Roshni Rajan
- Rutgers Robert Wood Johnson Medical School, 125 Paterson St., Suite 6300, New Brunswick, NJ 08903, USA
| | - Vicente Gracias
- Rutgers Robert Wood Johnson Medical School, 125 Paterson St., Suite 6300, New Brunswick, NJ 08903, USA
- Rutgers Global Health Institute, New Brunswick, NJ, USA
| | - Joseph S. Hanna
- Rutgers Robert Wood Johnson Medical School, 125 Paterson St., Suite 6300, New Brunswick, NJ 08903, USA
- Rutgers Global Health Institute, New Brunswick, NJ, USA
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Suwanabol PA, Li Y, Abrahamse P, De Roo AC, Vu JV, Silveira MJ, Mody L, Dimick JB. Functional and Cognitive Decline Among Older Adults After High-risk Surgery. Ann Surg 2022; 275:e132-e139. [PMID: 32404660 PMCID: PMC8060894 DOI: 10.1097/sla.0000000000003950] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE The aim of this study was to determine whether older adults are at higher risk of lasting functional and cognitive decline after surgery, and the impact of decline on survival and healthcare use. SUMMARY BACKGROUND DATA Patient-centered outcomes after surgery are poorly characterized. METHODS Using data from the Health and Retirement Study linked with Medicare, we matched older adults (≥65 years) who underwent one of 163 high-risk elective operations (ie, inpatient mortality of ≥1%) with nonsurgical controls between 1992 and 2012. Functional decline was defined as an increase in the number of activities of daily living (ADLs) and/or instrumental activities of daily living (IADLs) requiring assistance from baseline. Cognitive decline was defined by worse response to a test of memory and mental processing from baseline. Using logistic regression, we examined whether surgery was associated with functional and cognitive decline, and whether declines were associated with poorer survival and increased healthcare use. RESULTS The matched cohort of patients who did not undergo surgery consisted of 3591 (75%) participants compared to 1197 (25%) who underwent surgery. Patients who underwent surgery were at higher risk of functional and cognitive declines [adjusted odds ratio (aOR) 1.52, 95% confidence interval (CI): 1.23-1.87 and aOR 1.32, 95% CI: 1.03-1.71]. Declines were associated with poorer long-term survival [hazard ratio (HR) 1.67, 95% CI: 1.43-1.94 and HR 1.35, 95% CI: 1.15-1.58], and were significantly associated with nearly all measures of increased healthcare utilization (P < 0.001). CONCLUSION Older adults undergoing high-risk surgery are at increased risk of developing lasting functional and cognitive declines.
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Affiliation(s)
| | - Yun Li
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine
| | - Paul Abrahamse
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine
| | | | | | - Maria J. Silveira
- Division of Geriatric and Palliative Medicine, Department of Medicine, University of Michigan
- Geriatrics Research Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System
| | - Lona Mody
- Division of Geriatric and Palliative Medicine, Department of Medicine, University of Michigan
- Geriatrics Research Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System
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FRAILTY INDEX AND INFLAMMATORY MARKERS IN ELDERLY PATIENTS WITH ACUTE SURGICAL ABDOMINAL PATHOLOGIES. WORLD OF MEDICINE AND BIOLOGY 2022. [DOI: 10.26724/2079-8334-2022-4-82-16-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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9
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Kennedy CA, Shipway D, Barry K. Frailty and emergency abdominal surgery: A systematic review and meta-analysis. Surgeon 2021; 20:e307-e314. [PMID: 34980559 DOI: 10.1016/j.surge.2021.11.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 02/09/2021] [Accepted: 11/29/2021] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Patients aged ≥65 years currently account for approximately 55% of all emergent operations. However, these patients account for 75% of post-operative mortality. Older age has long been associated with adverse outcomes from emergency surgery. However, old age is a heterogenous state. Recent studies have indicated that frailty may more accurately reflect true biological age and perioperative risk than chronological age alone in patients undergoing elective surgery. Few studies have evaluated the impact of frailty on post-operative outcomes in this setting. METHODS A systematic, electronic search for relevant publications was performed in November 2019 using Pubmed and Embase from 2009 to 2019. The latest search for articles was performed on February 16th, 2020. Articles were excluded if frailty was not measured using a frailty tool, or if patients did not undergo emergency general surgery (EGS). RESULTS The prevalence of frailty amongst patients undergoing emergency abdominal surgery was 30.8%. The all-cause mortality rate was 15.68%. The mortality rate amongst the frail undergoing EGS was 24.7%. Frailty was associated with an increased mortality rate compared with the non-frail (odds ratio (OR) 4.3, 95% CI 2.25-8.19%, p < 0.05, I2 = 80%). CONCLUSIONS There is strong evidence to suggest that frailty in the older population predicts post-operative mortality, complications, prolonged length of stay and the loss of independence. Collaborative working with medicine for the elderly physicians to target modifiable aspects of the frailty syndrome in the perioperative pathway may improve outcomes. Frailty scoring should be integrated into acute surgical assessment practice to aid decision-making and development of novel postoperative strategies.
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Affiliation(s)
| | - David Shipway
- Department of Medicine for Older People, North Bristol NHS Trust, UK; University of Bristol, UK
| | - Kevin Barry
- Discipline of Surgery, National University of Ireland, Galway, Ireland; Department of Surgical Affairs, Royal College of Surgeons, 121-122 St Stephen's Green, Dublin 2, Ireland
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10
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The role of serum lactate levels in predicting abdominal surgery in geriatric patients who had computed tomography. MARMARA MEDICAL JOURNAL 2021. [DOI: 10.5472/marumj.957405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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11
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Montroni I, Saur NM, Shahrokni A, Suwanabol PA, Chesney TR. Surgical Considerations for Older Adults With Cancer: A Multidimensional, Multiphase Pathway to Improve Care. J Clin Oncol 2021; 39:2090-2101. [PMID: 34043436 PMCID: PMC10476754 DOI: 10.1200/jco.21.00143] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 03/20/2021] [Accepted: 04/07/2021] [Indexed: 01/19/2023] Open
Affiliation(s)
- Isacco Montroni
- Colon and Rectal Surgery, Ospedale “per gli Infermi”, AUSL Romagna, Faenza, Italy
| | - Nicole M. Saur
- Division of Colon and Rectal Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Armin Shahrokni
- Geriatrics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Pasithorn A. Suwanabol
- Department of Surgery, Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Tyler R. Chesney
- Department of Surgery, St Michael's Hospital, Toronto, Ontario, Canada
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
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Lee KC, Sturgeon D, Lipsitz S, Weissman JS, Mitchell S, Cooper Z. Mortality and Health Care Utilization Among Medicare Patients Undergoing Emergency General Surgery vs Those With Acute Medical Conditions. JAMA Surg 2020; 155:216-223. [PMID: 31877209 DOI: 10.1001/jamasurg.2019.5087] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance Emergency general surgery (EGS) represents 11% of hospitalizations, and almost half of these hospitalized patients are older adults. Older adults have high rates of mortality and readmissions after EGS, yet little is known as to how these outcomes compare with acute medical conditions that have been targets for quality improvement. Objective To examine whether Medicare beneficiaries who undergo EGS experience similar 1-year outcomes compared with patients admitted with acute medical conditions. Design, Setting, and Participants This population-based, retrospective cohort study using Medicare claims data from January 1, 2008, to December 31, 2014, included adults 65 years or older with at least 1 year of Medicare claims who had urgent or emergency admissions for 1 of the 5 highest-burden EGS procedures (partial colectomy, small-bowel resection, peptic ulcer disease surgery, lysis of adhesions, or laparotomy) or a primary diagnosis of an acute medical condition (pneumonia, heart failure, or acute myocardial infarction). Patients undergoing EGS and those with acute medical conditions were matched 1:1 in a 2-step algorithm: (1) exact match by hospital or (2) propensity score match with age, sex, race/ethnicity, Charlson Comorbidity Index, individual comorbid conditions, claims-based frailty index, year of admission, and any intensive care unit stay. Data analysis was performed from July 16, 2018, to November 13, 2019. Exposures Partial colectomy, small-bowel resection, peptic ulcer disease surgery, lysis of adhesions, or laparotomy or a primary diagnosis pneumonia, heart failure, or acute myocardial infarction. Main Outcomes and Measures One-year mortality, postdischarge health care utilization (emergency department visit, additional hospitalization, intensive care unit stay, or total hospital encounters), and days at home during 1 year. Results A total of 481 417 matched pairs (mean [SD] age, 78.9 [7.8] years; 272 482 [56.6%] female) with adequate covariate balance were included in the study. Patients undergoing EGS experienced higher 30-day mortality (60 683 [12.6%] vs 56 713 [11.8%], P < .001) yet lower 1-year mortality (142 846 [29.7%] vs 158 385 [32.9%], P < .001) compared with medical patients. Among 409 363 pairs who survived discharge, medical patients experienced higher rates of total hospital encounters in the year after discharge (4 vs 3 per person-year; incidence rate ratio, 1.31; 95% CI, 1.30-1.32) but had similar mean days at home compared with patients undergoing EGS (293 vs 309 days; incident rate ratio, 1.004; 95% CI, 1.004-1.004). Conclusions and Relevance In this study, older patients undergoing EGS had similarly high 1-year rates of mortality, hospital use, and days away from home as acutely ill medical patients. These findings suggest that EGS should also be targeted for national quality improvement programs.
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Affiliation(s)
- Katherine C Lee
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Surgery, University of California at San Diego, La Jolla
| | - Daniel Sturgeon
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Stuart Lipsitz
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Joel S Weissman
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Susan Mitchell
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Zara Cooper
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.,Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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NeMoyer RE, Hanna JS, To J, LaFonte M, Butts CA. Cecal Volvulus Within a Left Inguinal Hernia : An Uncommon Problem Resulting in a Closed Loop Obstruction and Loss of Domain. Am Surg 2020; 86:1577-1579. [PMID: 32735450 DOI: 10.1177/0003134820940243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Rachel E NeMoyer
- Division of Acute Care Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Joseph S Hanna
- Division of Acute Care Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Jennifer To
- Division of Acute Care Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Marc LaFonte
- Division of Acute Care Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Christopher A Butts
- Division of Acute Care Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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14
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Seicean A, Seicean S, Neuhauser D, Fyda J, Mehta A, Weil RJ. Outcomes after neurosurgical operations in American Society of Anesthesiologists physical status (ASA) class 5 patients. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2020.100692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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15
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Lee KC, Walling AM, Senglaub SS, Kelley AS, Cooper Z. Defining Serious Illness Among Adult Surgical Patients. J Pain Symptom Manage 2019; 58:844-850.e2. [PMID: 31404642 PMCID: PMC7155422 DOI: 10.1016/j.jpainsymman.2019.08.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 08/01/2019] [Accepted: 08/02/2019] [Indexed: 12/21/2022]
Abstract
CONTEXT Palliative care (PC) for seriously ill surgical patients, including aligning treatments with patients' goals and managing symptoms, is associated with improved patient-oriented outcomes and decreased health care utilization. However, efforts to integrate PC alongside restorative surgical care are limited by the lack of a consensus definition for serious illness in the perioperative context. OBJECTIVES The objectives of this study were to develop a serious illness definition for surgical patients and identify a denominator for quality measurement efforts. METHODS We developed a preliminary definition including a set of criteria for 11 conditions and health states. Using the RAND-UCLA Appropriateness Method, a 12-member expert advisory panel rated the criteria for each condition and health state twice, once after an in-person moderated discussion, for validity (primary outcome) and feasibility of measurement. RESULTS All panelists completed both rounds of rating. All 11 conditions and health states defining serious illness for surgical patients were rated as valid. During the in-person discussion, panelists refined and narrowed criteria for two conditions (vulnerable elder, heart failure). The final definition included the following 11 conditions and health states: vulnerable elder, heart failure, advanced cancer, oxygen-dependent pulmonary disease, cirrhosis, end-stage renal disease, dementia, critical trauma, frailty, nursing home residency, and American Society of Anesthesiology Risk Score IV-V. CONCLUSION We identified a consensus definition for serious illness in surgery. Opportunities remain in measuring the prevalence, identifying health trajectories, and developing screening criteria to integrate PC with restorative surgical care.
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Affiliation(s)
- Katherine C Lee
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Surgery, University of California, San Diego, La Jolla, California, USA.
| | - Anne M Walling
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA; Greater Los Angeles Veterans Affairs Healthcare System, David Geffen School of Medicine at University of California, Los Angeles, California, USA; Affiliated Adjunct Staff, RAND Health, Los Angeles, California, USA
| | - Steven S Senglaub
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Amy S Kelley
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Zara Cooper
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA; Hebrew SeniorLife Marcus Institute for Aging Research, Boston, Massachusetts, USA; Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
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16
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Mortality after abdominal emergency surgery in nonagenarians. Eur J Trauma Emerg Surg 2019; 47:485-492. [PMID: 31664466 DOI: 10.1007/s00068-019-01247-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 10/11/2019] [Indexed: 12/21/2022]
Abstract
PURPOSE To search the pattern of diagnoses in nonagenarians undergoing emergency abdominal surgery between January 2009 and December 2013 in two hospitals. To test the hypothesis that pre-hospital functional status is an effective criterion for predicting postoperative mortality in nonagenarians after emergency abdominal surgery. METHODS The study is an observational study on 157 patients. Patients were identified from the operation database and perioperative data were extracted as prospectively information supplied by retrospective data from patient electronic files. The primary endpoints were short, middle and long-term mortality and the secondary endpoint was to identify preoperative factors associated with postoperative mortality. RESULTS The most frequent reason for operation was intestinal obstruction. Overall mortality in the cohort was 34% (n = 54) after 30 days and 54% (n = 84) after 1 year. Amongst patients developing a serious complication (classified as Clavien Dindo class III or greater) after surgery (n = 45) the mortality was 80% (n = 36) after 30 days and 89% (n = 40) after 1 year. In multivariate analysis, a high American Association of Anesthesiologists class (ASA) and a high Performance Status (PS) class (low performance) were significant predictors of post-operative mortality. CONCLUSION Our data support pre-admission functional status for predicting postoperative mortality after emergency abdominal surgery in nonagenarians.
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17
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Racial/Ethnic Disparities in Longer-term Outcomes Among Emergency General Surgery Patients: The Unique Experience of Universally Insured Older Adults. Ann Surg 2019; 268:968-979. [PMID: 28742704 DOI: 10.1097/sla.0000000000002449] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To determine whether racial/ethnic disparities in 30/90/180-day mortality, major morbidity, and unplanned readmissions exist among universally insured older adult (≥65 years) emergency general surgery patients; vary by diagnostic category; and can be explained by variations in geography, teaching status, age-cohort, and a hospital's percentage of minority patients. SUMMARY OF BACKGROUND DATA As the US population ages and discussions surrounding the optimal method of insurance provision increasingly enter into national debate, longer-term outcomes are of paramount concern. It remains unclear the extent to which insurance changes disparities throughout patients' postacute recovery period among older adults. METHODS Survival analysis of 2008 to 2014 Medicare data using risk-adjusted Cox proportional-hazards models. RESULTS A total of 6,779,649 older adults were included, of whom 82.8% identified as non-Hispanic white (NHW), 9.2% non-Hispanic black (NHB), 5.6% Hispanic, and 1.5% non-Hispanic Asian (NHA). Relative to NHW patients, each group of minority patients was significantly less likely to die [30-day NHB vs NHW hazard ratio (95% confidence interval): 0.88 (0.86-0.89)]. Differences became less apparent as outcomes approached 180 days [180-day NHB vs NHW: 1.00 (0.98-1.02)]. For major morbidity and unplanned readmission, differences among NHW, Hispanic, and NHA patients were comparable. NHB patients did consistently worse. Efforts to explain the occurrence found similar trends across diagnostic categories, but significant differences in disparities attributable to geography and the other included factors that combined accounted for up to 50% of readmission differences between racial/ethnic groups. CONCLUSION The study found an inversion of racial/ethnic mortality differences and mitigation of non-NHB morbidity/readmission differences among universally insured older adults that decreased with time. Persistent disparities among nonagenarian patients and hospitals managing a regionally large share of minority patients warrant particular concern.
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18
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Smith JW, Knight Davis J, Quatman-Yates CC, Waterman BL, Strassels SA, Wong JD, Heh VK, Baselice HE, Brock GN, Clark BC, Bridges JFP, Santry HP. Loss of Community-Dwelling Status Among Survivors of High-Acuity Emergency General Surgery Disease. J Am Geriatr Soc 2019; 67:2289-2297. [PMID: 31301180 DOI: 10.1111/jgs.16046] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 05/29/2019] [Accepted: 05/30/2019] [Indexed: 01/23/2023]
Abstract
OBJECTIVES To examine loss of community-dwelling status 9 months after hospitalization for high-acuity emergency general surgery (HA-EGS) disease among older Americans. DESIGN Retrospective analysis of claims data. SETTING US communities with Medicare beneficiaries. PARTICIPANTS Medicare beneficiaries age 65 years or older hospitalized urgently/emergently between January 1, 2015, and March 31, 2015, with a principal diagnosis representing potential life or organ threat (necrotizing soft tissue infections, hernias with gangrene, ischemic enteritis, perforated viscus, toxic colitis or gastroenteritis, peritonitis, intra-abdominal hemorrhage) and an operation of interest on hospital days 1 or 2 (N = 3319). MEASUREMENTS Demographic characteristics (age, race, and sex), comorbidities, principal diagnosis, complications, and index hospitalization disposition (died; discharged to skilled nursing facility [SNF], long-term acute care [LTAC], rehabilitation, hospice, home (with or without services), or acute care hospital; other) were measured. Survivors of index hospitalization were followed until December 31, 2015, on mortality and community-dwelling status (SNF/LTAC vs not). Descriptive statistics, Kaplan-Meier plots, and χ2 tests were used to describe and compare the cohort based on disposition. A multivariable logistic regression model, adjusted for age, sex, comorbidities, complications, and discharge disposition, determined independent predictors of loss of community-dwelling status at 9 months. RESULTS A total of 2922 (88%) survived index hospitalization. Likelihood of discharge to home decreased with increasing age, baseline comorbidities, and in-hospital complications. Overall, 418 (14.3%) HA-EGS survivors died during the follow-up period. Among those alive at 9 months, 10.3% were no longer community dwelling. Initial discharge disposition to any location other than home and three or more surgical complications during index hospitalization were independent predictors of residing in a SNF/LTAC 9 months after surviving HA-EGS. CONCLUSION Older Americans, known to prioritize living in the community, will experience substantial loss of independence due to HA-EGS. Long-term expectations after surviving HA-EGS must be framed from the perspective of the outcomes that older patients value the most. Further research is needed to examine the quality-of-life burden of EGS survivorship prospectively. J Am Geriatr Soc 67:2289-2297, 2019.
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Affiliation(s)
- Jason W Smith
- Department of Surgery, University of Louisville, Louisville, Kentucky
| | | | | | - Brittany L Waterman
- Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Scott A Strassels
- Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio.,Center for Surgical Health Assessment, Research, & Policy, Ohio State University, Columbus, Ohio
| | - Jen D Wong
- Department of Human Sciences, Ohio State University, Columbus, Ohio.,Office of Geriatrics and Inter-professional Aging Studies, Ohio State University, Columbus, Ohio
| | - Victor K Heh
- Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio.,Center for Surgical Health Assessment, Research, & Policy, Ohio State University, Columbus, Ohio
| | - Holly E Baselice
- Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio.,Center for Surgical Health Assessment, Research, & Policy, Ohio State University, Columbus, Ohio
| | - Guy N Brock
- Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio.,Center for Surgical Health Assessment, Research, & Policy, Ohio State University, Columbus, Ohio.,Department of Biomedical Informatics, Ohio State University, Columbus, Ohio
| | - Brian C Clark
- Ohio Musculoskeletal and Neurological Institute, Ohio University, Athens, Ohio.,Department of Biomedical Sciences, Ohio University, Athens, Ohio.,Division of Geriatric Medicine, Ohio University, Athens, Ohio
| | - John F P Bridges
- Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio.,Center for Surgical Health Assessment, Research, & Policy, Ohio State University, Columbus, Ohio.,Department of Biomedical Informatics, Ohio State University, Columbus, Ohio
| | - Heena P Santry
- Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio.,Center for Surgical Health Assessment, Research, & Policy, Ohio State University, Columbus, Ohio
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19
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DeWane MP, Sukumar N, Stolar MJ, Gill TM, Maung AA, Schuster KM, Davis KA, Becher RD. High-performance acute care hospitals: Excelling across multiple emergency general surgery operations in the geriatric patient. J Trauma Acute Care Surg 2019; 87:140-146. [PMID: 31259872 PMCID: PMC7656193 DOI: 10.1097/ta.0000000000002273] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND As the geriatric population grows, the need for hospitals performing high quality emergency general surgery (EGS) on older patients will increase. Identifying clusters of high-performing geriatric emergency general surgery hospitals would substantiate the need for in-depth analyses of hospital-specific structures and practices that benefit older EGS patients. The objectives of this study were therefore to identify clusters of hospitals based on mortality performance for geriatric patients undergoing common EGS operations and to determine if hospital performance was similar for all operation types. METHODS Hospitals in the California State Inpatient Database were included if they performed a range of eight common EGS operations in patients 65 years or older, with a minimum requirement of three of each operation performed over 2 years. Multivariable beta regression models were created to define hospital-level risk-adjusted mortality. Centroid cluster analysis was used to identify groups of hospitals based on mortality and to determine if mortality-performance differed by operation. RESULTS One hundred seven hospitals were included, performing a total of 24,279 operations in older patients. Hospitals separated into three distinct clusters: high, average, and low performers. The high-performing hospitals had survival rates 1 to 2 standard deviations better than the low-performers (p < 0.001). For each cluster, high performance in any one EGS operation consistently translated into high performance across all EGS operations. CONCLUSION Hospitals conducting EGS operations in the geriatric patient population cluster into three distinct groups based on their survival performance. High-performing hospitals significantly outperform the average and low performers across every operation. The high-performers achieve reliable, high-quality results regardless of operation type. Further qualitative research is needed to investigate the perioperative drivers of hospital performance in the geriatric EGS population. LEVEL OF EVIDENCE Study Type Prognostic, level III.
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Affiliation(s)
- Michael P DeWane
- From the Section of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery (M.P.D., A.A.M., K.M.S., K.A.D., R.D.B.), Yale School of Medicine; Yale Center for Analytical Sciences (N.S., M.J.S.), Yale School of Public Health; and Section of Geriatrics, Department of Internal Medicine (T.M.G.), Yale School of Medicine, New Haven, Connecticut
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20
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Engin A, Engin AB, Kurukahvecioglu O, Sepici-Dincel A. Perioperative Mortality Prediction Using Possum in Patients with Gastrointestinal Tumors: Do Immunological Variables Affect Individual Predictive Mortality Risk? Pteridines 2018. [DOI: 10.1515/pteridines-2018-0012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
The aim of this study was to evaluate whether the addition of immunological variables to the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) scoring system improves the predictability of postoperative mortality. One hundred and thirty-two consecutive patients who underwent moderate, major or major-plus elective surgical interventions for gastrointestinal tumors were scored using the POSSUM mortality risk analysis. Patients were placed in one of the two groups based on their POSSUM mortality rates which were either lower or higher than 5%. An additional 26 pre-operative and post-operative metabolic and immunological variables were measured and mortality-dependent variables were selected. Regression analysis with backward elimination of twelve pre-operative and post-operative variables correlating with POSSUM score revealed that post-operative neopterin, IL-6 and albumin were significantly dependent on the predicted mortality rates. According to these selected variables, the number of patients with a POSSUM predicted mortality rate higher than 5% increased from 64 to 88, but the percentage of the mean mortality decreased. Statistical differences between the original POSSUM and modified scoring system was highly significant (p<0.0001). The sensitivity and specificity of the modified scoring system was calculated to be 52.9% and 87.5%, respectively.
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Affiliation(s)
- Atilla Engin
- Gazi University, Faculty of Medicine, Department of General Surgery, TR 06500 Besevler, Ankara , Turkey
| | - Ayse Basak Engin
- Gazi University, Faculty of Pharmacy Department of Toxicology, TR 06330 Hipodrom, Ankara , Turkey
| | - Osman Kurukahvecioglu
- Gazi University, Faculty of Medicine, Department of General Surgery, TR 06500 Besevler, Ankara , Turkey
| | - Aylin Sepici-Dincel
- Gazi University, Faculty of Medicine, Department of Biochemistry, TR 06500 Besevler, Ankara , Turkey
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21
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Suwanabol PA, Reichstein AC, Suzer-Gurtekin ZT, Forman J, Silveira MJ, Mody L, Morris AM. Surgeons' Perceived Barriers to Palliative and End-of-Life Care: A Mixed Methods Study of a Surgical Society. J Palliat Med 2018; 21:780-788. [PMID: 29649396 DOI: 10.1089/jpm.2017.0470] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Nearly 20% of colorectal cancer (CRC) patients present with potentially incurable (Stage IV) disease, yet their physicians do not integrate cancer treatment with palliative care. Compared with patients treated by primary providers, surgical patients with terminal diseases are significantly less likely to receive palliative or end-of-life care. OBJECTIVE To describe surgeon perspectives on palliative and end-of-life care for patients with Stage IV CRCs. DESIGN This is a convergent mixed methods study using a validated survey instrument from the Critical Care Peer Workgroup of the Robert Wood Johnson Foundation's Promoting Excellence in End-of-Life Care Project with additional qualitative questions. SETTINGS Participants were all current, nonretired members of the American Society of Colon and Rectal Surgeons. MAIN OUTCOME MEASURES Surgeon-perceived barriers to palliative and end-of-life care for patients with Stage IV CRCs were identified. RESULTS Among 131 Internet survey respondents (response rate 16.5%), 76.1% reported no formal education in palliative care, and specifically noted inadequate training in techniques to forgo life-sustaining measures (37.9%) and communication (42.7%). Over half (61.8%) of surgeons cited unrealistic expectations among patients and families as a barrier to care, which also limited discussion of palliation. At the system level, absence of documentation, appropriate processes, and culture hindered the initiation of palliative care. Thematic analysis of open-ended questions confirmed and extended these findings through the following major barriers to palliative and end-of-life care: (1) surgeon knowledge and training; (2) communication challenges; (3) difficulty with prognostication; (4) patient and family factors encompassing unrealistic expectations and discordant preferences; and (5) systemic issues including culture and lack of documentation and appropriate resources. LIMITATIONS Generalizability is limited by the small sample size inherent to Internet surveys, which may contribute to selection bias. CONCLUSIONS Surgeons valued palliative and end-of-life care but reported multilevel barriers to its provision. These data will inform strategies to reduce these perceived barriers.
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Affiliation(s)
- Pasithorn A Suwanabol
- 1 Division of Colorectal Surgery, Department of Surgery, University of Michigan , Ann Arbor, Michigan
| | - Ari C Reichstein
- 2 Division of Colorectal Surgery, Department of Surgery, Allegheny Health Network , Pittsburgh, Pennsylvania
| | | | - Jane Forman
- 4 Center for Clinical Management Research , Veterans Affairs Health Services Research & Development, VA Ann Arbor Health Care System, Ann Arbor, Michigan
| | - Maria J Silveira
- 5 Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan , Ann Arbor, Michigan.,6 Geriatric Research, Education and Clinical Center (GRECC) , Veterans Affairs Health Affairs, VA Ann Arbor Health Care System, Ann Arbor, Michigan
| | - Lona Mody
- 5 Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan , Ann Arbor, Michigan.,6 Geriatric Research, Education and Clinical Center (GRECC) , Veterans Affairs Health Affairs, VA Ann Arbor Health Care System, Ann Arbor, Michigan
| | - Arden M Morris
- 7 Department of Surgery, S-SPIRE Center, Stanford University , Stanford, California
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22
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Sarcopenia increases risk of long-term mortality in elderly patients undergoing emergency abdominal surgery. J Trauma Acute Care Surg 2017; 83:1179-1186. [PMID: 28777289 DOI: 10.1097/ta.0000000000001657] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Frailty is associated with poor surgical outcomes in elderly patients but is difficult to measure in the emergency setting. Sarcopenia, or the loss of lean muscle mass, is a surrogate for frailty and can be measured using cross-sectional imaging. We sought to determine the impact of sarcopenia on 1-year mortality after emergency abdominal surgery in elderly patients. METHODS Sarcopenia was assessed in patients 70 years or older who underwent emergency abdominal surgery at a single hospital from 2006 to 2011. Average bilateral psoas muscle cross-sectional area at L3, normalized for height (Total Psoas Index [TPI]), was calculated using computed tomography. Sarcopenia was defined as TPI in the lowest sex-specific quartile. Primary outcome was mortality at 1 year. Secondary outcomes were in-hospital mortality and mortality at 30, 90, and 180 days. The association of sarcopenia with mortality was assessed using Cox proportional hazards regression and model performance judged using Harrell's C-statistic. RESULTS Two hundred ninety-seven of 390 emergency abdominal surgery patients had preoperative imaging and height. The median age was 79 years, and 1-year mortality was 32%. Sarcopenic and nonsarcopenic patients were comparable in age, sex, race, comorbidities, American Society of Anesthesiologists classification, procedure urgency and type, operative severity, and need for discharge to a nursing facility. Sarcopenic patients had lower body mass index, greater need for intensive care, and longer hospital length of stay (p < 0.05). Sarcopenia was independently associated with increased in-hospital mortality (risk ratio, 2.6; 95% confidence interval [CI], 1.6-3.7) and mortality at 30 days (hazard ratio [HR], 3.7; 95% CI, 1.9-7.4), 90 days (HR, 3.3; 95% CI, 1.8-6.0), 180 days (HR, 2.5; 95% CI, 1.4-4.4), and 1 year (HR, 2.4; 95% CI, 1.4-3.9). CONCLUSION Sarcopenia is associated with increased risk of mortality over 1 year in elderly patients undergoing emergency abdominal surgery. Sarcopenia defined by TPI is a simple and objective measure of frailty that identifies vulnerable patients for improved preoperative counseling, setting realistic goals of care, and consideration of less invasive approaches. LEVEL OF EVIDENCE Prognostic study, level III.
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23
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Thorsen K, Søreide JA, Søreide K. Long-Term Mortality in Patients Operated for Perforated Peptic Ulcer: Factors Limiting Longevity are Dominated by Older Age, Comorbidity Burden and Severe Postoperative Complications. World J Surg 2017; 41:410-418. [PMID: 27734076 DOI: 10.1007/s00268-016-3747-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Perforated peptic ulcer (PPU) is a surgical emergency associated with high short-term mortality. However, studies on long-term outcomes are scarce. Our aim was to investigate long-term survival after surgery for PPU. MATERIALS AND METHODS A population-based, consecutive cohort of patients who underwent surgery for PPU between 2001 and 2014 was reviewed, and the long-term mortality was assessed. Survival was investigated by univariate analysis (log-rank test) and displayed using Kaplan-Meier survival curves. Multivariable analysis of risk factors for long-term mortality was assessed by Cox proportional hazards regression and reported as hazard ratio (HR) with 95 % confidence intervals (CI). RESULTS A total of 234 patients were available for the calculation of ninety-day, one-year and two-year mortality, and the results showed rates of 19.2 % (45/234), 22.6 % (53/234) and 24.8 % (58/234), respectively. At the end of follow-up, a total of 109 of the 234 patients (46.6 %) had died. Excluding 37 (15.2 %) patients who died within 30 days of surgery, 197 patients had long-term follow-up (median 57 months, range 1-168) of which 36 % (71/197) died during the follow-up period. In multivariable analyses, age >60 years (HR 3.95, 95 % CI 1.81-8.65), active cancer (HR 3.49, 95 % CI 1.73-7.04), hypoalbuminemia (HR 1.65, 95 % CI 0.99-2.73), pulmonary disease (HR 2.06, 95 % CI 1.14-3.71), cardiovascular disease (HR 1.67, 95 % CI 1.01-2.79) and severe postoperative complications (HR 1.76, 95 % CI 1.07-2.89) during the initial stay for PPU were all independently associated with an increased risk of long-term mortality. Cause of long-term mortality was most frequently (18 of 71; 25 %) attributed to new onset sepsis and/or multiorgan failure. CONCLUSION The long-term mortality after surgery for PPU is high. One in every three patients died during follow-up. Older age, comorbidity and severe postoperative complications were risk factors for long-term mortality.
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Affiliation(s)
- K Thorsen
- Department of Gastrointestinal Surgery, Stavanger University Hospital, PO Box 8100, 4068, Stavanger, Norway.
| | - J A Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, PO Box 8100, 4068, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - K Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, PO Box 8100, 4068, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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24
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The Need to Consider Longer-term Outcomes of Care: Racial/Ethnic Disparities Among Adult and Older Adult Emergency General Surgery Patients at 30, 90, and 180 Days. Ann Surg 2017; 266:66-75. [PMID: 28140382 DOI: 10.1097/sla.0000000000001932] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Following calls from the National Institutes of Health and American College of Surgeons for "urgently needed" research, the objectives of the present study were to (1) ascertain whether differences in 30/90/180-day mortality, major morbidity, and unplanned readmissions exist among adult (18-64 yr) and older adult (≥65 yr) emergency general surgery (EGS) patients; (2) vary by diagnostic category; and (3) are explained by variations in insurance, income, teaching status, hospital EGS volume, and a hospital's proportion of minority patients. BACKGROUND Racial/ethnic disparities have been described in in-hospital and 30-day settings. How longer-term outcomes compare-a critical consideration for the lived experience of patients-has, however, only been limitedly considered. METHODS Survival analysis of 2007 to 2011 California State Inpatient Database using Cox proportional hazards models. RESULTS A total of 737,092 adults and 552,845 older adults were included. In both cohorts, significant differences in 30/90/180-day mortality, major morbidity, and unplanned readmissions were found, pointing to persistently worse outcomes between non-Hispanic Black and White patients [180-d readmission hazard ratio (95% confidence interval):1.04 (1.03-1.06)] and paradoxically better outcomes among Hispanic adults [0.85 (0.84-0.86)] that were not encountered among Hispanic older adults [1.06 (1.04-1.07)]. Stratified results demonstrated robust morbidity and readmission trends between non-Hispanic Black and White patients for the majority of diagnostic categories, whereas variations in insurance/income/teaching status/EGS volume/proportion of minority patients all significantly altered the effect-combined accounting for up to 80% of risk-adjusted differences between racial/ethnic groups. CONCLUSIONS Racial/ethnic disparities exist in longer-term outcomes of EGS patients and are, in part, determined by differences in factors associated with emergency care. Efforts such as these are needed to understand the interplay of influences-both in-hospital and during the equally critical, postacute phase-that underlie disparities' occurrence among surgical patients.
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Olufajo OA, Reznor G, Lipsitz SR, Cooper ZR, Haider AH, Salim A, Rangel EL. Preoperative assessment of surgical risk: creation of a scoring tool to estimate 1-year mortality after emergency abdominal surgery in the elderly patient. Am J Surg 2016; 213:771-777.e1. [PMID: 27743591 DOI: 10.1016/j.amjsurg.2016.08.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 08/07/2016] [Accepted: 08/07/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND The risk of mortality after emergency general surgery (EGS) in elderly patients is prolonged beyond initial hospitalization. Our objective was to develop a preoperative scoring tool to quantify risk of 1-year mortality. METHODS Three hundred ninety EGS patients aged 70 years or more were analyzed. Risk factors for 1-year mortality were identified using stepwise-forward logistic multivariate regression and weights assigned using natural logarithm of odds ratios. A geriatric emergency surgery mortality (GEM) score was derived from the aggregate of weighted scores. Leave-one-out cross-validation was performed. RESULTS One-year mortality was 32%. Risk factors and their weights were: acute kidney injury (2), American Society of Anesthesiology class greater than or equal to 4 (2), Charlson Comorbidity Index greater than or equal to 4 (1), albumin less than 3.5 mg/dL (1), and body mass index (less than 18.5 kg/m2 [1]; 18.5 to 29.9 kg/m2 [0]; ≥30 kg/m2 [-1]). One-year mortality was: GEM 0 to 1 (0% to 7%); GEM 2 to 5 (32% to 68%); GEM 6 to 8 (94% to 100%). C-statistics were .82 and .75 in training and validation data sets, respectively. CONCLUSIONS A simple score using 5 clinical variables predicts 1-year mortality after EGS with reasonable accuracy and assists in preoperative counseling.
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Affiliation(s)
- Olubode A Olufajo
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery Brigham and Women's Hospital, Boston, MA, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Gally Reznor
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Stuart R Lipsitz
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Zara R Cooper
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery Brigham and Women's Hospital, Boston, MA, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Adil H Haider
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery Brigham and Women's Hospital, Boston, MA, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ali Salim
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery Brigham and Women's Hospital, Boston, MA, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Erika L Rangel
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery Brigham and Women's Hospital, Boston, MA, USA.
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Zimmerman AM, Marwaha J, Nunez H, Harrington D, Heffernan D, Monaghan S, Adams C, Stephen A. Preoperative Myocardial Injury as a Predictor of Mortality in Emergency General Surgery: An Analysis Using the American College of Surgeons NSQIP Database. J Am Coll Surg 2016; 223:381-6. [PMID: 27163647 DOI: 10.1016/j.jamcollsurg.2016.04.043] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 04/19/2016] [Accepted: 04/19/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Recent studies have linked postoperative serum troponin elevation to mortality in a range of different clinical scenarios. To date, there has been no investigation into the significance of preoperative troponin elevation in emergency general surgery (EGS) patients. We define this as preoperative myocardial injury (PMI). We hypothesize that PMI seen in EGS patients may predict postoperative morbidity and mortality. STUDY DESIGN Using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database, we performed a retrospective review of all EGS cases between 2008 and 2014. Patients with preoperative troponin I drawn were compared. RESULTS There were 464 EGS patients who had troponin I measurements preoperatively. Eighty-two (18%) had preoperative troponin elevations. Patients with PMI were more likely to have the following preoperative physiologic derangements: acute renal failure (18% vs 4%; p = 0.002) and septic shock (40% vs 13%; p < 0.001). Patient comorbidities associated with PMI included congestive heart failure (13% vs 3%; p = 0.007), dialysis dependence (16% vs 3%; p = 0.002), and American Society of Anesthesiologists (ASA) class ≥ 4 (52% vs 29%; p < 0.001). Compared with controls, patients with PMI had higher rates of postoperative events (77% vs 52%; p < 0.001) and mortality (34% vs 13%; p = 0.009). Univariate analysis showed that patients with PMI had an increased risk of postoperative events (odds ratio [OR] 3.02; 95% CI 1.74 to 5.25) and mortality (OR 3.53; 95% CI 1.66 to 7.47). Multivariate analysis revealed preoperative troponin I elevation was an independent predictor of mortality (OR 3.03; 95% CI 1.19 to 7.72, p = 0.020). CONCLUSIONS Emergency general surgery patients with PMI are at increased risk for postoperative events and death. Preoperative myocardial injury is an independent predictor of mortality and has prognostic utility that can prepare surgical teams for adverse events so that they can be recognized, evaluated, and treated earlier.
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Affiliation(s)
- Asha M Zimmerman
- Department of Surgery, Alpert Medical School of Brown University, Providence, RI
| | - Jayson Marwaha
- Department of Surgery, Alpert Medical School of Brown University, Providence, RI
| | - Hector Nunez
- Department of Surgery, Alpert Medical School of Brown University, Providence, RI
| | - David Harrington
- Department of Surgery, Alpert Medical School of Brown University, Providence, RI
| | - Daithi Heffernan
- Department of Surgery, Alpert Medical School of Brown University, Providence, RI
| | - Sean Monaghan
- Department of Surgery, Alpert Medical School of Brown University, Providence, RI
| | - Charles Adams
- Department of Surgery, Alpert Medical School of Brown University, Providence, RI
| | - Andrew Stephen
- Department of Surgery, Alpert Medical School of Brown University, Providence, RI.
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Olufajo OA, Tulebaev S, Javedan H, Gates J, Wang J, Duarte M, Kelly E, Lilley E, Salim A, Cooper Z. Integrating Geriatric Consults into Routine Care of Older Trauma Patients: One-Year Experience of a Level I Trauma Center. J Am Coll Surg 2016; 222:1029-35. [PMID: 26968324 DOI: 10.1016/j.jamcollsurg.2015.12.058] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 12/02/2015] [Accepted: 12/28/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although involvement of geriatricians in the care of older trauma patients is associated with changes in processes of care and improved outcomes, few geriatrician consultations were ordered on our service. STUDY DESIGN Mandatory geriatric consults were initiated in September 2013 for all trauma patients 70 years and older admitted to our hospital. We prospectively collected data on patients admitted from October 2013 through September 2014 (postintervention) and compared their data with those of patients admitted from June 2011 through June 2012 (preintervention). We collected data on processes of care (DNR and do not intubate status, delirium, and referral for cognitive evaluation) and patient outcomes (mortality, readmission, and length of stay). Descriptive statistics and post-hoc power analyses were performed. RESULTS There were 215 and 191 patients included in the preintervention and postintervention cohorts, respectively. After the intervention, geriatric consults increased from 3.26% to 100%. Patients with DNR and do not intubate status increased from 10.23% to 38.22% (p < 0.01). Referral for formal cognitive evaluation increased from 2.33% to 14.21% (p < 0.01) and delirium documentation increased from 31.16% to 38.22% (p = 0.14). In-hospital mortality and 30-day mortality in the pre- and postintervention periods were 9.30% vs 5.24% (p = 0.12) and 11.63% vs 6.81% (p = 0.10), respectively. Intensive care unit readmission rate was 8.26% preintervention and 1.96% postintervention (p = 0.06). There were no changes in 30-day hospital readmission and length of stay. Power analyses showed more patients were needed to show statistically significant outcomes. CONCLUSIONS The initiation of mandatory geriatric consults on our trauma service was associated with improved advance care planning and increased multidisciplinary care. Ensuring involvement of geriatricians can aid in reducing adverse outcomes among geriatric trauma patients.
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Affiliation(s)
- Olubode A Olufajo
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, MA; Center for Surgery and Public Health, Harvard Medical School and Harvard T. H. Chan School of Public Health, Brigham and Women's Hospital, Boston, MA.
| | - Samir Tulebaev
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Houman Javedan
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Jonathan Gates
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Justin Wang
- Surgical ICU Translational Research Center, Brigham and Women's Hospital, Boston, MA
| | - Maria Duarte
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Edward Kelly
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Elizabeth Lilley
- Center for Surgery and Public Health, Harvard Medical School and Harvard T. H. Chan School of Public Health, Brigham and Women's Hospital, Boston, MA
| | - Ali Salim
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, MA; Center for Surgery and Public Health, Harvard Medical School and Harvard T. H. Chan School of Public Health, Brigham and Women's Hospital, Boston, MA
| | - Zara Cooper
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, MA; Center for Surgery and Public Health, Harvard Medical School and Harvard T. H. Chan School of Public Health, Brigham and Women's Hospital, Boston, MA
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Ethics and the Emergency Care of the Seriously Ill and Injured Elderly Patient. CURRENT GERIATRICS REPORTS 2016. [DOI: 10.1007/s13670-016-0156-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Desserud KF, Veen T, Søreide K. Emergency general surgery in the geriatric patient. Br J Surg 2015; 103:e52-61. [PMID: 26620724 DOI: 10.1002/bjs.10044] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 10/06/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Emergency general surgery in the elderly is a particular challenge to the surgeon in charge of their care. The aim was to review contemporary aspects of managing elderly patients needing emergency general surgery and possible alterations to their pathways of care. METHODS This was a narrative review based on a PubMed/MEDLINE literature search up until 15 September 2015 for publications relevant to emergency general surgery in the geriatric patient. RESULTS The number of patients presenting as an emergency with a general surgical condition increases with age. Up to one-quarter of all emergency admissions to hospital may be for general surgical conditions. Elderly patients are a particular challenge owing to added co-morbidity, use of drugs and risk of poor outcome. Frailty is an important potential risk factor, but difficult to monitor or manage in the emergency setting. Risk scores are not available universally. Outcomes are usually severalfold worse than after elective surgery, in terms of both higher morbidity and increased mortality. A care bundle including early diagnosis, resuscitation and organ system monitoring may benefit the elderly in particular. Communication with the patient and relatives throughout the care pathway is essential, as indications for surgery, level of care and likely outcomes may evolve. Ethical issues should also be addressed at every step on the pathway of care. CONCLUSION Emergency general surgery in the geriatric patient needs a tailored approach to improve outcomes and avoid futile care. Although some high-quality studies exist in related fields, the overall evidence base informing perioperative acute care for the elderly remains limited.
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Affiliation(s)
- K F Desserud
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - T Veen
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - K Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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