Peri-operative optimisation of elderly and frail patients: a narrative review

Impact of peri-operative frailty and operative stress on post-discharge mortality, readmission and days at home in Medicare beneficiaries

BACKGROUND

Understanding how patients' frailty and the physiological stress of surgical procedures affect postoperative outcomes may inform risk stratification of older patients undergoing surgery. The objective of the study was to examine the association of peri-operative frailty with mortality, 30-day readmission and days at home after non-cardiac surgical procedures of different physiological stress.

METHODS

This retrospective study used Medicare claims data from a 7.125% random sample of Medicare fee-for-service beneficiaries from 2015 to 2019 who were aged ≥ 65 years and underwent non-cardiac surgical procedure listed in the Operative Stress Score categories. The exposure of the study was claims-based frailty index (robust, < 0.15; pre-frail, 0.15 to < 0.25; mildly frail, 0.25 to < 0.35; and moderate-to-severely frail, ≥ 0.35) with Operative Stress Score categories being 1, very low stress to 5, very high stress. The primary outcome was all-cause mortality at 30 days and 365 days after the surgical procedure.

RESULTS

In total, 1,019,938 patients (mean (SD) age of 76.1 (7.3) years; 52.3% female; 16.8% frail) were included. The cumulative incidence of mortality generally increased with Operative Stress Score category, ranging from 5.0% (Operative Stress Score 2) to 24.9% (Operative Stress Score 4) at 365 days. Within each category, increasing frailty was associated with mortality at 30 days (hazard ratio comparing moderate-to-severe frailty vs. robust ranged from 1.59-3.91) and at 365 days (hazard ratio 1.30-4.04). The variation in postoperative outcomes by patients' frailty level was much greater than the variation by the operative stress category.

CONCLUSIONS

These results emphasise routine frailty screening before major and minor non-cardiac procedures and the need for greater clinician awareness of postoperative outcomes beyond 30 days in shared decision-making with older adults with frailty.

Impact of frailty on outcomes after cardiac surgery

OBJECTIVE

The study objective was to evaluate whether increasing frailty, as measured by the Clinical Frailty Scale, was associated with an increased risk of hospital mortality for patients undergoing cardiac surgery.

METHODS

A retrospective binational cohort study of 46,928 patients who underwent cardiac surgery in Australia and New Zealand was conducted. The primary exposure, frailty, was measured using the Clinical Frailty Scale. Associations between frailty and the primary outcome, hospital mortality, were evaluated using multivariable, mixed effects logistic regression models. Secondary outcomes including hospital and intensive care unit length of stay, invasive ventilation hours, need for renal replacement therapy and tracheostomy, and nonhome discharge were also evaluated.

RESULTS

A total of 3122 of 46,928 patients (6.7%) were classified as frail (Clinical Frailty Scale 5-8), and 93.3% (43,806/46,928) were nonfrail (Clinical Frailty Scale 1-4). Raw mortality was 4.2% (132/3122) in the frail group and 1.05% (461/43,806) in the nonfrail group. After multivariable adjustment for illness severity, age, elective status, type of surgery, hospital type, and country, frailty was significantly associated with increased hospital mortality (odds ratio, 2.879, 95% CI, 2.284-3.629, P < .001). Increasing Clinical Frailty Scale was also significantly associated with a higher risk of secondary outcomes, including length of stay in the hospital and intensive care unit, receipt of renal replacement therapy and tracheostomy, and increased duration of mechanical ventilation.

CONCLUSIONS

This study demonstrated that increasing Clinical Frailty Scale was strongly associated with increased hospital mortality, hospital and intensive care unit length of stay, invasive ventilation hours, renal replacement therapy, and tracheostomy insertion among patients undergoing cardiac surgery in Australia and New Zealand.

Comparison of three frailty scales for prediction of prolonged postoperative ileus following major abdominal surgery in elderly patients: a prospective cohort study

BACKGROUND

To determine whether frailty can predict prolonged postoperative ileus (PPOI) in older abdominal surgical patients; and to compare predictive ability of the FRAIL scale, the five-point modified frailty index (mFI-5) and Groningen Frailty Indicator (GFI) for PPOI.

METHODS

Patients (aged ≥ 65 years) undergoing major abdominal surgery at our institution between April 2022 to January 2023 were prospectively enrolled. Frailty was evaluated with FRAIL, mFI-5 and GFI before operation. Data on demographics, comorbidities, perioperative management, postoperative recovery of bowel function and PPOI occurrence were collected.

RESULTS

The incidence of frailty assessed with FRAIL, mFI-5 and GFI was 18.2%, 38.4% and 32.5% in a total of 203 patients, respectively. Ninety-five (46.8%) patients experienced PPOI. Time to first soft diet intake was longer in patients with frailty assessed by the three scales than that in patients without frailty. Frailty diagnosed by mFI-5 [Odds ratio (OR) 3.230, 95% confidence interval (CI) 1.572-6.638, P = 0.001] or GFI (OR 2.627, 95% CI 1.307-5.281, P = 0.007) was related to a higher risk of PPOI. Both mFI-5 [Area under curve (AUC) 0.653, 95% CI 0.577-0.730] and GFI (OR 2.627, 95% CI 1.307-5.281, P = 0.007) had insufficient accuracy for the prediction of PPOI in patients undergoing major abdominal surgery.

CONCLUSIONS

Elderly patients diagnosed as frail on the mFI-5 or GFI are at an increased risk of PPOI after major abdominal surgery. However, neither mFI-5 nor GFI can accurately identify individuals who will develop PPOI.

TRIAL REGISTRATION

This study was registered in Chinese Clinical Trial Registry (No. ChiCTR2200058178). The date of first registration, 31/03/2022, https://www.chictr.org.cn/ .

Robotic-assisted surgery in high-risk surgical patients with endometrial cancer

Many patients diagnosed with an endometrial cancer are at high-risk for surgery due to factors such as advanced age, raised body mass index or frailty. Minimally-invasive surgery, in particular robotic-assisted, is increasingly used in the surgical management of endometrial cancer however, there are a lack of clinical trials investigating outcomes in high-risk patient populations. This article will review the current evidence and identify areas of uncertainty where future research is needed.

Correlation of ultrasound measurement of limb muscle thickness and echo intensity with frailty assessment in elderly patients undergoing malignancies surgery

Introduction

It remains controversial which frailty score correlates with adverse outcomes. Instead of these subjective and time consuming scores, we studied whether ultrasound guided lower extremity thickness measurements more closely are associated with adverse outcomes.

Method

Patients undergoing gastrointestinal malignancy surgery were included as study subjects. Frailty was identified using the FRAIL scale assessment. Ultrasound measured the muscle thickness and echo intensity of the patient's upper and lower limbs. ANOVA was used to analyze the relationship between muscle data and frailty assessment. Significant indicators from the one-way analysis were included in the multivariate logistic regression equation.

Results

A total of 160 study subjects were included, 52 in the normal group, 78 in the prefrailty group, and 30 in the frailty group. The ANOVA showed that there were significant differences in age, hemoglobin, albumin, history of hypertension, history of coronary artery disease, the history of cerebrovascular disease, rate of postoperative complications, rate of transferring to intensive care unit, time out of bed, length of hospitalization, thickness and echo intensity of quadriceps femoris the vastus lateralis and the tibialis anterior, echo intensity of the medial gastrocnemius among the three groups (P < 0.05). Pearson's correlation analysis showed FRAIL score was correlated with muscle thickness and echo intensity of the lower limbs. Multifactor logistic regression analysis showed that the prefrailty group was positively correlated with age（β = 0.146, P = 0.004）, echo intensity of the medial gastrocnemius (β = 0.055, P = 0.031), and rate of postoperative complications（β = 1.439, P = 0.021）, also negatively correlated with muscle thickness of the tibialis anterior（β = -2.124, P = 0.007）. The frailty group was positively correlated with age（β = 0.22, P = 0.005）, tibialis anterior echo intensity (β = 0.082, P = 0.015), medial gastrocnemius echo intensity (β = 0.089, P = 0.026), cerebrovascular disease history (β = 2.311, P = 0.04), and postoperative complication rate (β = 2.684, P = 0.003). It was negatively correlated with albumin (β = -0.26, P = 0.017), quadriceps muscle thickness (β = -2.257, P = 0.017), and tibialis anterior muscle thickness (β = -5.408, P = 0.001).

Conclusion

Ultrasound measurement of lower (not upper) extremity muscle thickness and echo intensity was significantly associated with discriminating severity of frailty and postoperative outcomes than frailty scores in elderly patients.

Does preoperative multidisciplinary team assessment of high-risk patients improve the safety and outcomes of patients undergoing surgery?

BACKGROUND

International guidelines recommend preoperative multidisciplinary team (MDT) assessment for high-risk surgical patients. Preoperative MDT meetings can help to improve surgical care, but there is little evidence on whether they improve patient outcomes.

METHODS

This paper aims to share our experience of MDT meetings for high-risk surgical patients to underline their added value to the current standard of care. An observational study of a retrospective cohort of preoperative high-risk MDT meetings of a tertiary referral hospital between January 2015 and December 2020. For 249 patients the outcomes preoperative data, MDT decisions, and patient outcomes were collected from electronic health records.

MAIN RESULTS

A total of 249 patients were discussed at high-risk MDT meetings. Most of the patients (97%) were assessed as having an American Society of Anesthesiology score ≥ 3, and 219 (88%) had a European Society of Cardiology and European Society of Anaesthesiology risk score of intermediate or high. After MDT assessment, 154 (62%) were directly approved for surgery, and 39 (16%) were considered ineligible for surgery. The remaining 56 (23%) patients underwent additional assessments before reconsideration at a high-risk MDT meeting. The main reason for patients being discussed at the high-risk MDT meeting was to assess the risk-benefit ratio of surgery. Ultimately, 184 (74%) patients underwent surgery. Of the operated patients, 122 (66%) did not have a major complication in the postoperative period, and 149 patients (81%) were alive after one year.

CONCLUSIONS

This cohort study shows the vulnerability and complexity of high-risk patients but also shows that the use of an MDT assessment contributes too improved peri- and postoperative treatment strategies in high-risk patients. Most patients underwent surgery after careful risk assessment and, if deemed necessary, preoperative and perioperative treatment optimization to reduce their risk.

Acute Perioperative Pain Management of the Orthopaedic Patient: Guidance for Operationalizing Evidence Into Practice

Orthopaedic surgery often results in pain, with less than half of patients reporting adequate relief. Unrelieved acute pain occurring after surgery increases the risk of negative sequelae, including delayed healing, increased morbidity, pulmonary complications, limited rehabilitation participation, anxiety, depression, increased length of stay, prolonged duration of opioid use, and the development of chronic pain. Interventions that are individualized, evidence-informed, and applied within an ethical framework improve healthcare delivery for patients, clinicians, and healthcare organizations. Recommendations for using the principles of effective pain management from preoperative assessment through discharge are detailed, including recommendations for addressing barriers and challenges in applying these principles into clinical practice.

Anesthesia and perioperative pain relief in the frail elderly patient

Demand for anesthesia and analgesia for the frail elderly is continuously increasing as the likelihood of encountering very elderly, very vulnerable, and very compromised patients has, ever so subtly, increased over the last three decades. The anesthesiologist has, increasingly, been obliged to offer professional services to frail patients. Fortunately, there has been a dramatic improvement in medications, methods of drug delivery, critical monitoring, and anesthesia techniques. Specific methodologies peculiar to the frail are now taught and practiced across all anesthesia subspecialties. However, administering anesthesia for the frail elderly is vastly different to giving an anesthetic to the older patient. Frail patients are increasingly cared for in specialized units-geriatric intensive therapy units, post-acute care services, palliative, hospices, and supportive care and aged care facilities. Several medications (e.g., morphine-sparing analgesics) more suited to the frail have become universally available in most centers worldwide so that best-practice, evidence-based anesthesia combinations of drugs and techniques are now increasingly employed. Every anesthetic and pain management techniques in the frail elderly patient are going to be discussed in this review.

Enhanced Recovery After Surgery (ERAS) Program for Anterior Cervical Discectomy and Fusion (ACDF) in Patients Over 60 Years Old

Background

Enhanced recovery after surgery (ERAS) is currently widely used in many surgical specialties, but there is still a lack of concern about the cervical ERAS program for old patients (>60 years old). We aimed to determine whether our ERAS program significantly improved satisfaction and outcomes in old patients (>60 years old) with anterior cervical discectomy and fusion (ACDF).

Methods

This is a retrospective cohort study. The study enrolled patients if they were over the age of 60 years old underwent ACDF from July 2019 and June 2021 (ERAS group) and from January 2018 and June 2019 (non-ERAS group). Data including demographic, comorbidity, and surgical information were collected. We also evaluated ERAS process compliance, primary outcome, surgical complication, and length of stay (LOS).

Results

There were 135 patients in the ERAS group, and 122 patients in the non-ERAS group were included. A comparison of the demographic data revealed that there were no statistically significant intergroup differences observed between the group. Overall, ERAS pathway compliance was 91.9%. There were no significant differences in the fusion levels, operative time, intraoperative blood loss, postoperative VAS score, and complications between the ERAS and non-ERAS groups. In addition, there was no significant difference in readmission and mortality at 30-day follow-up between the two groups. However, we observed a statistically significant decrease in the LOS in the ERAS group (8.68±2.34 of ERAS group versus 10.43±4.05 in non-ERAS group, p=0.013).

Conclusion

This report describes the first ERAS protocol used in old patients with ACDF. Our ERAS program is safe and associated with incremental benefits with respect to LOS in old patients with ACDF.

Surgical outcome improvement by shared decision-making: value of a preoperative multidisciplinary target clinic for the elderly in colorectal surgery

PURPOSE

Frailty and comorbidities increase the risk of postoperative complications and raise treatment costs. Perioperative optimisation is shown to improve surgical outcomes for the elderly. The aim of this study was to assess the impact of introducing a multidisciplinary preoperative clinic for older patients (Colchester Older Persons' Evaluation for Surgery (COPES) clinic) undergoing major colorectal surgery.

METHODS

This 5-year single centre study included patients >65 years with ≥3 comorbidities undergoing major colorectal surgery. From October 2018, patients with these characteristics were evaluated and optimised in the COPES clinic by a geriatrician and an anaesthetist. Outcomes were compared to high-risk patients operated on prior to COPES (pre-COPES group). The primary outcomes were postoperative morbidity at discharge and 6 months measured by the Comprehensive Complication Index. Patients were matched on age and number of comorbidities.

RESULTS

A total of 54 patients were enrolled in the pre-COPES and 18 in the COPES group. After matching, the results were comparable for both groups. The length of stay was shorter in the COPES group and the recurrence rate was higher; however, it did not reach statistical significance in both findings.

CONCLUSION

This clinic intends to improve treatment quality, placing emphasis on shared decision-making. More focus should be put on patient-reported outcomes and experiences. Especially for elderly patients, quality of life and maintaining independence are often their priority. To determine the true value of a preoperative multidisciplinary clinic targeting elderly comorbid patients, a prospective study with larger cohort is needed, focusing not only on objective outcomes but also on patient-reported outcomes.

Frailty: the perioperative and anesthesia challenges of an emerging pandemic

Frailty is a complex and multisystem biological process characterized by reductions in physiological reserve. It is an increasingly common phenomena in the surgical population, and significantly impacts postoperative recovery. In this review, we will discuss the pathophysiology of frailty, as well as preoperative, intraoperative, and postoperative considerations for frailty care. We will also discuss the different models of postoperative care, including enhanced recovery pathways, as well as elective critical care admission. With discoveries of new effective interventions, and advances in healthcare information technology, optimized pathways could be developed to provide the best care possible that meets the challenges of perioperative frailty.

An ensemble machine learning approach to predict postoperative mortality in older patients undergoing emergency surgery

BACKGROUND

Prediction of preoperative frailty risk in the emergency setting is a challenging issue because preoperative evaluation cannot be done sufficiently. In a previous study, the preoperative frailty risk prediction model used only diagnostic and operation codes for emergency surgery and found poor predictive performance. This study developed a preoperative frailty prediction model using machine learning techniques that can be used in various clinical settings with improved predictive performance.

METHODS

This is a national cohort study including 22,448 patients who were older than 75 years and visited the hospital for emergency surgery from the cohort of older patients among the retrieved sample from the Korean National Health Insurance Service. The diagnostic and operation codes were one-hot encoded and entered into the predictive model using the extreme gradient boosting (XGBoost) as a machine learning technique. The predictive performance of the model for postoperative 90-day mortality was compared with those of previous frailty evaluation tools such as Operation Frailty Risk Score (OFRS) and Hospital Frailty Risk Score (HFRS) using the receiver operating characteristic curve analysis.

RESULTS

The predictive performance of the XGBoost, OFRS, and HFRS for postoperative 90-day mortality was 0.840, 0.607, and 0.588 on a c-statistics basis, respectively.

CONCLUSIONS

Using machine learning techniques, XGBoost to predict postoperative 90-day mortality, using diagnostic and operation codes, the prediction performance was improved significantly over the previous risk assessment models such as OFRS and HFRS.

Association between periodontitis and disc structural failure in older adults with lumbar degenerative disorders: A prospective cohort study

BACKGROUND

Bacterial microbiome as a putative trigger of inflammation might indicate the cascade of mouth-gut-disc axis for causing intervertebral disc (IVD) structural failures (such as IVD degeneration and endplate change) processed. However, direct evidence for the mouth-gut-disc axis still unclear. Therefore, it is interesting to explore periodontal inflammation related to IVD structural failures and clinical outcomes.

METHODS

This prospective cohort study enrolled older adults (aged ≥ 75 years) who scheduled to undergo elective open lumbar spine surgery. Demographic, radiological, clinical, and periodontal parameters were recorded. Independent samples t-test and Pearson's correlation analysis were calculated.

RESULTS

A total of 141 patients with lumbar degenerative disorders (56 males and 85 females; age 79.73 ± 3.34 years) were divided into edentulous group (19 patients), No/Mild group (84 patients), and Moderate/Severe group (38 patients). The incidence rates of IVD degeneration in each lumbar segmental level based on Pfirrmann grade and endplate change in the fourth and fifth lumbar vertebrae, and Visual Analogue Scale (VAS) low back pain (LBP) and leg pain of patients at preoperative in dentate group was significantly higher compared with edentulous group, especially the comparisons between Moderate/Severe and edentulous groups. There were no significant differences in the range of motion, lumbar lordosis, pelvic incidence, pelvic tilt, sacral slope, and disc height between dentate and edentulous groups. There was a positive association between plaque index (PLI) and pain scores (VAS LBP: r = 0.215, P = 0.030 and VAS leg pain: r = 0.309, P = 0.005), but no significant difference in Oswestry disability index (ODI) score.

CONCLUSION

Results show that the severity of periodontitis is associated with higher incidence rates of IVD degeneration and endplate change and clinical outcomes in older adults with lumbar degenerative disorders. Furthermore, the discovery of these relationships unveils a novel mechanism through which the alterations in oral microbiome composition potentially promote IVD degeneration and pain.

Risk Stratification of Elderly Patients Undergoing Spinal Surgery Using the Modified Frailty Index

STUDY DESIGN

Retrospective cohort.

OBJECTIVES

To validate the 11-item modified Frailty Index (mFI) as a perioperative risk stratification tool in elderly patients undergoing spine surgery.

METHODS

All consecutive cases of spine surgery in patients aged 65 years or older between July 2016 and June 2018 at a state-wide trauma center were retrospectively reviewed. The primary outcome was post-operative major complication rate (Clavien-Dindo Classification ≥ III). Secondary outcome measures included the rate of all complications, 6-month mortality and surgical site infection.

RESULTS

A total of 348 cases were identified. The major complication rate was significantly lower in patients with an mFI of 0 compared to ≥ 0.45 (18.3% versus 42.5%, P = .049). As the mFI increased from 0 to ≥ 0.45 there was a stepwise increase in risk of major complications (P < .001). Additionally, 6-month mortality rate was considerably lower when the mFI was 0 rather than ≥ 0.27 (4.2% versus 20.4%, P = .007). Multivariate analysis demonstrated an mFI ≥ 0.27 was significantly associated with an increased incidence of major complication (OR 2.80, 95% CI 1.46-5.35, P = .002), all complication (OR 2.93, 95% CI 1.70-15.11, P < .001), 6-month mortality (OR 7.39, 95% CI 2.55-21.43, P < .001) and surgical site infection (OR 4.43, 95% CI 1.71-11.51, P = .002). The American Society of Anesthesiologists' (ASA) index did not share a stepwise relationship with any outcome.

CONCLUSION

The mFI is significantly associated in a gradated fashion with increased morbidity and mortality. Patients with an mFI ≥ 0.27 are at greater risk of major complications, all-complications, 6-monthy mortality, and surgical site infection.

The enhanced recovery after surgery (ERAS) protocol in elderly patients with acute cholecystitis: A retrospective study

Enhanced recovery after surgery (ERAS) protocol is a perioperative management theory aimed at reducing the injury of surgical patients and accelerating postoperative recovery. It has been widely recognized and applied in elective surgery. This study aimed to evaluate the clinical value of the ERAS protocol during the perioperative period of laparoscopic cholecystectomy in elderly patients with acute cholecystitis. This study aimed to evaluate the clinical value of the ERAS protocol during the perioperative period of laparoscopic cholecystectomy in elderly patients with acute cholecystitis. We collected medical data from 126 elderly patients with acute cholecystitis from October 2018 to August 2021. Among the 126 patients, 70 were included in the ERAS group and 56 in the traditional group. We analyzed the clinical data and postoperative indicators of the 2 groups. No significant differences were observed regarding the general characteristics of the 2 groups (P > .05). The ERAS group had significantly earlier time to first flatus, time to first ambulation, and time to solid intake, compared with the traditional group (P < .001); additionally, the ERAS group had significantly shorter stay and gentler feeling of postoperative pain (P < .001). Furthermore, the ERAS group had significant incidences of lower postoperative lung (P = .029) and abdominal cavity infection (P = .025) compared to the traditional group. No significant difference was observed regarding the incidences of other postoperative complications between the 2 groups (P > .05). The ERAS protocol helps reduce elderly patients' stress reactions and accelerate postoperative recovery. Thus, it is effective and beneficial to implement the ERAS protocol during the perioperative period of elderly patients with acute cholecystitis.

Frailty assessment has come to stay: Retrospective analysis pilot study of two frailty scales in oncological older patients undergoing colorectal surgery

INTRODUCTION

Colorectal cancer is a disease of the elderly and its main treatment is surgery. Frailty, a clinical syndrome of decreased reserve, increases with age and has been recognized as a predictive factor for postoperative mortality. Our primary objective was to assess the association between two frailty scores and mortality within the first year after surgery, by retrospectively linking frailty scores to mortality data and comparing the strength of their association with mortality to that of the ASA Classification. The frailty scales used were: the Modified Frailty Index (MFI) and, the Risk Analysis Index-A (RAI-A) and the G8 screening test (G8). As secondary objectives, we assessed the relationship of the frailty scales with morbidity and compared all the scales with the ASA.

MATERIAL AND METHODS

We retrospectively studied 172 patients aged 65 years and older who underwent laparoscopic colorectal surgery for cancer between January 2017 and June 2018, following them up for 1year after surgery.

RESULTS

Both morbidity and mortality were significantly associated with all frailty scale scores (p<.001). The more frailty, the greater probability of prolonged hospital stay, complications, readmissions and emergency department visits. Using each scale, patients were categorized into two groups (frail and non-frail patients). The C-indexes for 1-year mortality with the RAI-A and, MFI and G8 were 0.89 and, 0.86 and 0.86 respectively. On the other hand, ASA status is not strongly associated with mortality, with a C-index of .63.

DISCUSSION

Frailty scores should begin to influence medical and surgical strategies and further research is needed to develop guidelines for interventions in geriatric patients.

Development and validation of a patient-specific model to predict postoperative SIRS in older patients: A two-center study

Introduction

Postoperative systemic inflammatory response syndrome (SIRS) is common in surgical patients especially in older patients, and the geriatric population with SIRS is more susceptible to sepsis, MODS, and even death. We aimed to develop and validate a model for predicting postoperative SIRS in older patients.

Methods

Patients aged ≥65 years who underwent general anesthesia in two centers of Third Affiliated Hospital of Sun Yat-sen University from January 2015 to September 2020 were included. The cohort was divided into training and validation cohorts. A simple nomogram was developed to predict the postoperative SIRS in the training cohort using two logistic regression models and the brute force algorithm. The discriminative performance of this model was determined by area under the receiver operating characteristics curve (AUC). The external validity of the nomogram was assessed in the validation cohort.

Results

A total of 5,904 patients spanning from January 2015 to December 2019 were enrolled in the training cohort and 1,105 patients from January 2020 to September 2020 comprised the temporal validation cohort, in which incidence rates of postoperative SIRS were 24.6 and 20.2%, respectively. Six feature variables were identified as valuable predictors to construct the nomogram, with high AUCs (0.800 [0.787, 0.813] and 0.822 [0.790, 0.854]) and relatively balanced sensitivity (0.718 and 0.739) as well as specificity (0.718 and 0.729) in both training and validation cohorts. An online risk calculator was established for clinical application.

Conclusion

We developed a patient-specific model that may assist in predicting postoperative SIRS among the aged patients.

Are Octogenarians at Higher Risk of Complications After Elective Lumbar Spinal Fusion Surgery? Analysis of a Cohort of 7880 Patients From the Kaiser Permanente Spine Registry

STUDY DESIGN

A retrospective cohort study with chart review.

OBJECTIVE

To determine if there is a difference in risk of adverse outcomes following elective posterior instrumented lumbar spinal fusions for patients aged 80 years and above compared with patients aged 50 to 79 years.

SUMMARY OF BACKGROUND DATA

Patients aged 80 years and above are undergoing elective lumbar spinal fusion surgery in increasing numbers. There are conflicting data on the risks of intraoperative and postoperative complications in these patients.

MATERIALS AND METHODS

Patients aged 80 years and above were compared with 50 to 79 years (reference group) using time-dependent multivariable Cox proportional hazards regression with a competing risk of death for longitudinal outcomes and multivariable logistic regression for binary outcomes. Outcome measures used were: (1) intraoperative complications (durotomy), (2) postoperative complications: 30-day outcomes (pneumonia); 90-day outcomes (deep vein thrombosis, pulmonary embolism, emergency room visits, readmission, reoperations, and mortality); and two-year outcomes (reoperations and mortality).

RESULTS

The cohort consisted of 7880 patients who underwent primary elective posterior instrumented lumbar spinal fusion (L1-S1) for degenerative disk disease or spondylolisthesis. This was subdivided into 596 patients were aged 80 years and above and 7284 patients aged 50 to 79. After adjustment, patients aged 80 years and above had a higher likelihood of durotomy [odds ratio (OR)=1.43, 95% confidence interval (CI)=1.02-2.02] and 30-day pneumonia (OR=1.81, 95% CI=1.01-3.23). However, there was a lower risk of reoperation within two years of the index procedure (hazard ratio=0.69, 95% CI=0.48-0.99). No differences were observed for mortality, readmissions, emergency room visits, pulmonary embolism, or deep vein thrombosis.

CONCLUSIONS

In a cohort of 7880 elective posterior instrumented lumbar fusion patients for degenerative disk disease or spondylolisthesis, we did not observe any significant risks of adverse events between patients aged 80 years and above and those aged 50 to 79 except for higher durotomies and 30-day pneumonia in the former. We believe octogenarians can safely undergo lumbar fusions, but proper preoperative screening is necessary to reduce the risks of 30-day pneumonia.

A Description of Interventions Prompted by Preoperative Comprehensive Geriatric Assessment and Optimization in Older Elective Noncardiac Surgical Patients

OBJECTIVES

Comprehensive Geriatric Assessment (CGA), a multicomponent, complex intervention, can be used to improve perioperative outcomes. This study aimed to describe the actions and interventions prompted by preoperative CGA and optimization in elective noncardiac, older, surgical patients.

DESIGN

Retrospective observational study.

SETTING AND PARTICIPANTS

Five hundred consecutive patients aged over 65 years attending a preoperative CGA and optimization clinic in a single academic center.

METHODS

A retrospective review of electronic clinical records was undertaken. CGA prompted actions and interventions were categorized a priori and examined according to the perioperative pathway and frailty status.

RESULTS

Patients received a median of nine interventions (IQR 6‒12, range 0‒28). Long-term condition medication changes were made in 375 (75.0%) patients, lifestyle advice provided in 269 (53.8%), therapy interventions delivered in 117 (23.4%), shared decision making documented in 495 (99.0%) with individualized admission plans documented in 410/426 (96.2%). Following CGA, 74/500 (14.8%) patients did not undergo surgery and were more likely to have benign pathology (69% vs 53%, P = .01), higher frailty scores (Edmonton Frail Scale 8 (IQR 5‒10) vs 4 (IQR 2-6), P < .001), lower functional status (Nottingham Extended Activities of Daily Living 33 (IQR 16‒47) vs 57 (IQR 45‒64), P < .001) or cognitive scores (Montreal Cognitive Assessment 19 (IQR 14‒24) vs 24 (IQR 20‒26), P < .001).

CONCLUSIONS AND IMPLICATIONS

This study provides a description of actions and interventions prompted by preoperative CGA at one center. Such a detailed exploration of the CGA process and the clinical skills necessary to deliver it, should be used to inform future multicenter studies and the development and implementation of perioperative services for older patients.

Before-and-After Study of the First Four Years of the Enhanced Recovery after Surgery (ERAS®) Programme in Older Adults Undergoing Elective Colorectal Cancer Surgery

BACKGROUND

The aim of this study was to determine whether the inclusion of older patients undergoing elective colorectal cancer resection in the Enhanced Recovery After Surgery (ERAS^®) programme could improve clinical outcomes during hospital admission.

METHODS

A before-and-after study in ≥70-year-old patients electively admitted for colorectal cancer resection was designed. In total, 213 patients were included in the ERAS^® group, and 158 were included in the control group.

RESULTS

The average age was 77.9 years old (SD 5.31) and 57.14% of them were men, with a Charlson Index score of 3.42 (SD 3.32). The ERAS^® group presented a lower transfusion rate of 42 (19.7%), compared to 75 (47.5%) in the control group (p < 0.001). The crude odds ratio (OR) for transfusion was 0.27 (95% CI 0.17-0.43; p < 0.001), and the adjusted odds ratio was 0.26 (95% CI 0.14-0.48; p < 0.001). The ERAS^® group had a lower percentage of patients with moderate-severe malnutrition on admission, at 23.4% (37 patients) against 36.2% in the control group (42 patients) (p = 0.023), with an OR of 0.47 (95% CI 0.29-0.75; p < 0.002) and an adjusted OR of 0.48 (95% CI 0.29-0.78; p = 0.003). The number of patients who required admission to the intensive care unit (ICU) was also markedly lower: 54 from the ERAS^® group (25.4%) versus 71 from the control group (44.9%) (p < 0.001).

CONCLUSIONS

The inclusion of ≥70-year-old adults in the ERAS^® programme resulted in a decrease in transfusions, number of erythrocyte concentrates transfused, and number of ICU admissions, along with improved nutritional status.

Anaesthetic Approach to Enhanced Recovery after Surgery for Kidney Transplantation: A Narrative Review

Enhanced recovery after surgery (ERAS) protocols are designed to reduce medical complications, the length of hospital stays (LoS), and healthcare costs. ERAS is considered safe and effective for kidney transplant (KTx) surgery. KTx recipients are often frail with multiple comorbidities. As these patients follow an extensive diagnostic pathway preoperatively, the ERAS protocol can ideally be implemented at this stage. Small singular changes in a long perioperative pathway can result in significant positive outcomes. We have investigated the current evidence for an ERAS pathway related to anaesthetic considerations in renal transplant surgery for adult recipients.

Addressing comorbidities in the perioperative setting and optimizing perioperative medicine education

PURPOSE OF REVIEW

Preoperative clinics and patient optimization are examples of collaborative, multidisciplinary care pathways that create value. This article reviews current literature to demonstrate the importance of preoperative enhancement of patients' cognitive and functional status. This article underscores the importance of formal training in multidisciplinary topics, such as frailty, brain health, and shared decision-making for anesthesiology house staff.

RECENT FINDINGS

Preoperative cognitive screening of older patients is a valuable metric for risk stratification and detection of patients at risk of postoperative delirium. Frailty is another syndrome that can be identified and optimized preoperatively. Sarcopenia has been shown to correlate with frailty; this shows promise as a method to detect frailty preoperatively.

SUMMARY

Anesthesiologists as perioperative physicians are in a unique position to lead and coordinate interdisciplinary conversations that incorporate patient goal concordant care and realistic assessment of perioperative complications. Formal house staff training in early recognition and management of patients at risk of adverse outcomes in the short and long term postoperatively improves patient outcomes and decreases healthcare spending.

Application of the New Preoperative Frailty Risk Score in Elderly Patients Undergoing Emergency Surgery

BACKGROUND

Predicting preoperative frailty risk in emergency surgery is difficult with limited information because preoperative evaluation is not commonly performed properly. A recent study attempted to predict preoperative frailty risk using only diagnostic and surgical codes that can be extracted from the electronic medical records system.

OBJECTIVE

This study aimed to validate whether the prediction model of preoperative frailty risk presented in the previous study is well applied to other medical hospitals' data.

METHODS

This is a retrospective cohort study including 1,557 patients (≥75 years old) who were admitted to a single institution for emergency operations between January 1, 2010, and December 31, 2019, for study analysis. The Charlson comorbidity index, Hospital Frailty Risk Score, and the recently developed Operation Frailty Risk Score (OFRS) were calculated using the patient's diagnostic and operation codes. The predictive performances of these calculated risk scores and the American Society of Anesthesiologists-Physical Status classification for postoperative 90-day mortality were compared by using the receiver operating characteristic curve analysis.

FINDINGS

The predictive performance of the OFRS, Charlson comorbidity index, American Society of Anesthesiologists-Physical Status, and Hospital Frailty Risk Score for postoperative 90-day mortality was 0.81, 0.630, 0.699, and 0.549 on a c-statistics basis, respectively.

CONCLUSIONS

The OFRS using diagnostic and operation codes may show the best predictive performance for 90-day mortality compared to other risk scores, and it can be the clinically applicable model to evaluate the preoperative frailty risk in elderly patients undergoing emergency surgery.

The Association of Frailty With Outcomes for Older Adults Undergoing Appendectomy

BACKGROUND

Frailty is a potential modifiable predictor of surgical outcomes in older adults. The impact of frailty following appendectomy, a common urgent operation, is unknown for older adults. The study aim was to assess if frailty is associated with worse perioperative outcomes after appendectomy in older adults.

METHODS

We used the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2016 to 2018 and identified patients 65 and older who underwent appendectomy for acute appendicitis. We identified frailty as a Modified Frailty Index (MFI) score ≥2. Multivariate logistic regression was used to assess the association of frailty with 30-day mortality, serious complications, readmission, and discharge to facility.

RESULTS

Five thousand seven hundred twenty-eight older adults underwent appendectomy, of which 29.1% were 75 or older, 53.3% female, 74.9% non-Hispanic White, and 17.1% frail. Frail patients experienced worse outcomes: mortality (frail: 1.0% vs non-frail: .3%, P = .001), serious complications (14.2% vs 8.0%, P = <.0001), and discharge to facility (9.3% vs 2.3%, P < .0001). On multivariate logistic regression, frailty was associated with increased mortality (odds ratio [OR] 3.34; 95% confidence interval [CI] 1.28-8.66), serious complications (OR 1.51; 95% CI: 1.17-1.93), and discharge to facility (OR 2.80; 95% CI: 2.00-3.93). Frailty was not significantly associated with readmission (P = .180).

CONCLUSIONS

Frailty is associated with worse postoperative outcomes following appendectomy in older adults. As frailty is potentially modifiable, it should be routinely assessed and utilized in perioperative optimization and counseling, especially with respect to patient-centered outcomes.

Complications and Mortality after Surgeries in Patients with Prior Stroke Who Received General and Neuraxial Anesthesia: A Propensity-Score Matched Study

Patients who previously suffered a stroke have increased risks of mortality and complications after surgeries, but the optimal anesthesia method is not fully understood. We aimed to compare the outcomes after surgeries for stroke patients who received general anesthesia (GA) and neuraxial anesthesia (NA). Using health insurance research data, we identified 36,149 stroke patients who underwent surgeries from 1 January 2008 to 31 December 2013. For balancing baseline covariates, the propensity-score-matching procedure was used to select adequate surgical patients who received GA and NA at a case–control ratio of 1:1. Multiple logistic regressions were applied to calculate adjusted odds ratios (ORs) with 95% confidence intervals (CIs) for postoperative mortality and complications between surgical patients with prior stroke who received GA and NA. Among the 4903 matched pairs with prior stroke, patients with GA had higher risks of pneumonia (OR 2.00, 95% CI 1.62–2.46), pulmonary embolism (OR 3.30, 95% CI 1.07–10.2), acute renal failure (OR 3.51, 95% CI 1.13–2.10), intensive care unit stay (OR 3.74, 95% CI 3.17–4.41), and in-hospital mortality (OR 2.02, 95% CI 1.16–3.51) than those who received NA. Postoperative adverse events were associated with GA in patients aged more than 60 years and those who received digestive surgery (OR 3.11, 95% CI 2.08–4.66). We found that stroke patients undergoing GA had increased postoperative complications and mortality after surgery compared with those who received NA. However, these findings need more validation and evaluation by clinical trials.

Validity and reliability of the Thai version of the simple frailty questionnaire (T-FRAIL) with modifications to improve its diagnostic properties in the preoperative setting

Background

Several methods are available for identifying frailty, but limited tools have been validated in Thai context. Our objective was to evaluate the validity and reliability of the Thai version of the Simple Frailty Questionnaire (T- FRAIL) compared to the Thai Frailty Index (TFI) and to explore modifications to improve its diagnostic properties.

Methods

The T-FRAIL was translated with permission using a standardized protocol, that included forward and back-translation. Content validity analysis was performed using input from 5 geriatricians. Test-retest reliability, concurrent validity, diagnostic properties, and options to increase the sensitivity of the questionnaire were explored. A cross-sectional study for evaluation validity and reliability was carried out among 3 hundred patients aged 60 or more undergoing elective surgery at a university hospital.

Results

The item content validity index (I-CVI) showed 1.0 for each questionnaire item. Test-retest reliability within a 7-day interval was done in 30 patients with a good intraclass correlation coefficient of 0.880. Compared with the TFI, the T-FRAIL yielded an excellent accuracy (area under the curve = 0.882). The identification of frailty using a score of 2 points or more provided the best Youden’s index at 63.1 with a sensitivity of 77.5% (95% CI 69.0–84.6) and a specificity of 85.6% (95% CI 79.6–90.3). A cutoff point of 1 out of 5 items for original T-FRAIL provided a sensitivity of 93.3% and a specificity of 61.1%. The modified T-FRAIL (T-FRAIL_M1), by reducing the “illnesses” criterion to 4 or more diseases, at a cutoff point at 1 had a sensitivity of 94.2% and a specificity of 57.8%. Another modified T-FRAIL (T-FRAIL_M2), by combining three components, at a cutoff point at 1 yielded a sensitivity of 85.8% and a specificity of 80.6%.

Conclusion

The T-FRAIL and its modification demonstrated satisfactory validity and reliability to identify frailty in elderly patients. The cutoff score of 1 point from 5 items from the original version of T-FRAIL and T-FRAIL_M1 provides a highly sensitive screening tool. T-FRAIL_M1 with a cutoff point of 2 and T-FRAIL_M2 yields reasonable sensitivity and specificity for practical use.

Frailty in Very Elderly Patients is Not Associated with Adverse Surgical or Oncological Outcomes in Extremity Surgery for Soft Tissue Sarcoma

Background

While surgery remains the mainstay of treatment for limb sarcoma, extreme old age is a relative contraindication to oncological surgery.

Methods

Patients >80 years referred with primary extremity soft-tissue sarcoma (ESTS) between 2007 and 2016 were retrospectively reviewed. Prognostic variables, including ASA status and Clinical Frailty Scores, were collected. Endpoints were perioperative morbidity, locoregional (LRR) and distant recurrence (DR), disease-specific survival (DSS) adjusted using competing risk modelling, and overall survival (OS).

Results

A total of 141 primary tumours were identified, with 116 undergoing resections. Main motives for nonoperative management were severe frailty or significant comorbidity (56.0%). The operative group had a median age of 84 (range 80-96) years and median follow-up of 16 months (range 0-95). 45.7% of patients received radiotherapy. Median hospital stay was 7 (range 0-40) days, with frailty (p = 0.25) and ASA (p = 0.28) not associated with prolonged admission. 12.9% developed significant complications, with one perioperative mortality.

24.1% had LRR, occurring at a median of 14.5 months. All patients with reported DR (28.4%), except one, died of their disease. Frailty did not confer a significant difference in adjusted LRFS (p = 0.95) and DMFS (p = 0.84). One- and 5-year adjusted DSS and OS was 87.0% versus 74.9% and 62.3% versus 27.4%, respectively. Frailty (CFS ≥4) was associated with worse OS (hazard ratio [HR] 2.49; 95% confidence interval [CI] 1.51-4.12; p < 0.001), however not with adjusted DSS (p = 0.16). Nonoperative management conferred a 1- and 5-year adjusted DSS was 58.3% and 44.4%, respectively.

Conclusions

Extremity surgery for sarcoma is well tolerated in the frail very elderly population with low morbidity and comparable oncological outcomes.

Utility and reliability of the Clinical Frailty Scale in patients scheduled for major vascular surgery: a prospective, observational, multicentre observer-blinded study

Background

Frailty is a distinctive health state associated with a loss of physiological reserve that results in higher rates of perioperative complications and impaired return to pre-morbid functional status. It is prevalent in the vascular population; however routine assessment is not common despite national guidance to the contrary. We aimed to evaluate the reliability of the Clinical Frailty Scale in assessing frailty in the surgical vascular population.

Methods

In this prospective, observational, observer-blinded study, we compared assessment of frailty in patients scheduled for major vascular surgery attending the pre-operative assessment clinic using the Clinical Frailty Scale against the Edmonton Frailty Scale.

The study investigator completed the Edmonton Frailty Scale assessment; this was compared to the Clinical Frailty Scale assessments performed by the pre-assessment consultant and pre-assessment nurse, who were blinded to the Edmonton Frailty Scale score. The inter-rater reliability of the Clinical Frailty Scale between the pre-assessment consultant and pre-assessment nurse was determined by comparing their frailty scores for each patient.

Results

Ninety-seven patients were included in the analysis (median age 72 years, 84% male and 16% female). There was a moderate level of agreement between the Edmonton and Clinical Frailty Scale score for both consultants (87.6% agreement) and pre-assessment nurses (87.6% agreement). There was a substantial level of agreement between consultants and pre-assessment nurses for the Clinical Frailty Scale (89.7% agreement)

Conclusions

The Clinical Frailty Scale is a useful tool to assess frailty in the vascular surgical population. It is more practical than the Edmonton Frailty Scale: quick to complete, requires minimal training and can be used when physical disability is present.

Trial registration

The study was approved by the Wales Health and Care Research Ethics Service (REC reference 17/WA/0160, IRAS 201173). Trial registration: NCT03403673. Registered 19 January 2018, https://clinicaltrials.gov/ct2/show/NCT03403673

Global research trends in perioperative care for the elderly: a bibliometric and visualized study

PURPOSE

Aged surgical patients are at a relatively higher risk of morbidity and mortality than younger surgical patients. The present study aimed to investigate the trends and research status of perioperative care for the elderly in the anesthesiology field.

METHODS

We screened manuscripts published between May 31, 1991, and May 31, 2020, from the Web of Science Core Collection (WoSCC). A clustered network was derived from all references cited in all of the included manuscripts. The top authors, journals, institutions, countries, keywords, co-cited articles, and trends were identified through bibliometric analysis and visualization using CiteSpace 5.8.R3 and VOSviewer 1.6.15.

RESULTS

We included a total of 1860 manuscripts published between 1991 and 2020. The number of publications on perioperative care for the elderly sharply increased from 2014 onwards. The United States of America and the University of California, San Francisco were the leading publication country (24.8%, 461/1860) and institution (2.6%, 48/1860), respectively. High-frequency keywords in cluster analysis included the type of anesthesia, postoperative pain management, postoperative cognitive dysfunction, and postoperative delirium, indicating postoperative cognitive dysfunction and postoperative delirium remain the focus areas for research in perioperative care for the elderly. Organ function protection was the new research focus according to the burst detection analysis of top keywords.

CONCLUSIONS

The number of studies on perioperative care for the elderly has increased apparently worldwide. Postoperative cognitive dysfunction and postoperative delirium remain primary research focus areas. Organ function protection appears to be the second most highly researched topic in the perioperative care for the elderly.

Open tibia/fibula in the elderly: A retrospective cohort study

The incidence of open tibia/fibula fractures in the elderly is increasing, but current national guidelines focus on the aggressive treatment of high-energy injuries in younger patients. There is conflicting evidence regarding whether older age affects treatment provision and outcomes in open fractures. The aim of this study was to determine if elderly patients are sustaining a different injury to younger patients and how their treatment and outcomes differ. This may have implications for future guidelines and verify their application in the elderly. In this retrospective single centre cohort study (December 2015-July 2018), we compared the injury characteristics, operative management and outcomes of elderly (≥65 years) and younger (18-65 years) patients with open tibia/fibula fractures. An extended cohort examined free flap reconstruction. In total, 157 patients were included. High-energy injuries were commoner in younger patients (88% vs 37%; p<0.001). Most were Gustilo-Anderson IIIb in both age groups. Elderly patients waited longer until debridement (21:19 vs 19:00 h) and had longer inpatient stays (23 vs 15 days). There was no difference in time to antibiotics, operative approach or post-operative complications. Despite the low-energy nature of elderly patients' injuries, the severity of soft tissue insult was equivalent to younger patients with high-energy injuries. Our data suggest that age and co-morbidities should not prohibit lower limb reconstruction. The current application of generic guidelines appears suitable in the elderly, particularly in the acute management. We suggest current management pathways and targets be reviewed to reflect the greater need for peri-operative optimisation and rehabilitation in elderly patients.

Risk assessment and risk stratification for perioperative complications and mitigation: Where should the focus be? How are we doing?

Various risk stratification tools are used to predict patients' risk of adverse outcomes. Most of these tools are based on type of surgery and patient comorbidities. Accuracy of risk prediction is improved when additional factors such as functional capacity are included. However, these tools are limited because data are obtained from specific patient populations, are simplified to aid ease of use, and do not account for improved treatment modalities that occur over time. Risk estimation allows for shared decision-making among the perioperative care team and the patient, for perioperative planning, and for opportunity for risk mitigation. Technological advancement in data collection will likely improve existing risk assessment and allow development of new options. Future research should focus on establishing and standardizing perioperative outcomes that include meaningful patient-centric considerations such as quality of life. We review available stratification tools and important risk assessment biomarkers that address the most common causes of adverse outcomes.

Predictive Model for the Assessment of Preoperative Frailty Risk in the Elderly

Adequate preoperative evaluation of frailty can greatly assist in the efficient allocation of hospital resources and planning treatments. However, most of the previous frailty evaluation methods, which are complicated, time-consuming, and can have inter-evaluator error, are difficult to apply in urgent situations. Thus, the authors aimed to develop and validate a predictive model for pre-operative frailty risk of elderly patients by using diagnostic and operation codes, which can be obtained easily and quickly from electronic records. We extracted the development cohort of 1762 people who were hospitalized for emergency operations at a single institution between 1 January 2012 and 31 December 2016. The temporal validation cohort from 1 January 2017 to 31 December 2018 in the same center was set. External validation was conducted on 6432 patients aged 75 years or older from 2012 to 2015 who had emergency surgery in the Korean national health insurance database. We developed the Operation Frailty Risk Score (OFRS) by assessing the association of Operation Group and Hospital Frailty Risk Score with the 90-day mortality through logistic regression analysis. We validated the OFRS in both the temporal validation cohort and two external validation cohorts. In the temporal validation cohort and the external validation cohort I and II, the c-statistics for OFRS to predict 90-day mortality were 0.728, 0.626, and 0.619, respectively. OFRS from these diagnostic codes and operation codes may help evaluate the peri-operative frailty risk before emergency surgery for elderly patients where history-taking and pre-operative testing cannot be performed.

The role of frailty in geriatric cranial neurosurgery for primary central nervous system neoplasms

OBJECTIVE

Frailty is a clinical state of increased vulnerability due to age-associated decline and has been well established as a perioperative risk factor. Geriatric patients have a higher risk of frailty, higher incidence of brain cancer, and increased postoperative complication rates compared to nongeriatric patients. Yet, literature describing the effects of frailty on short- and long-term complications in geriatric patients is limited. In this study, the authors evaluate the effects of frailty in geriatric patients receiving cranial neurosurgery for a primary CNS neoplasm.

METHODS

The authors conducted a retrospective cohort study of geriatric patients receiving cranial neurosurgery for a primary CNS neoplasm between 2010 and 2017 by using the Nationwide Readmission Database. Demographics and frailty were queried at primary admission, and readmissions were analyzed at 30-, 90-, and 180-day intervals. Complications of interest included infection, anemia, infarction, kidney injury, CSF leak, urinary tract infection, and mortality. Nearest-neighbor propensity score matching for demographics was implemented to identify nonfrail control patients with similar diagnoses and procedures. The analysis used Welch two-sample t-tests for continuous variables and chi-square test with odds ratios.

RESULTS

A total of 6713 frail patients and 6629 nonfrail patients were identified at primary admission. At primary admission, frail geriatric patients undergoing cranial neurosurgery had increased odds of developing acute posthemorrhagic anemia (OR 1.56, 95% CI 1.23-1.98; p = 0.00020); acute infection (OR 3.16, 95% CI 1.70-6.36; p = 0.00022); acute kidney injury (OR 1.32, 95% CI 1.07-1.62; p = 0.0088); urinary tract infection prior to discharge (OR 1.97, 95% CI 1.71-2.29; p < 0.0001); acute postoperative cerebral infarction (OR 1.57, 95% CI 1.17-2.11; p = 0.0026); and mortality (OR 1.64, 95% CI 1.22-2.24; p = 0.0012) compared to nonfrail geriatric patients receiving the same procedure. In addition, frail patients had a significantly increased inpatient length of stay (p < 0.0001) and all-payer hospital cost (p < 0.0001) compared to nonfrail patients at the time of primary admission. However, no significant difference was found between frail and nonfrail patients with regard to rates of infection, thromboembolism, CSF leak, dural tear, cerebral infarction, acute kidney injury, and mortality at all readmission time points.

CONCLUSIONS

Frailty may significantly increase the risks of short-term acute complications in geriatric patients receiving cranial neurosurgery for a primary CNS neoplasm. Long-term analysis revealed no significant difference in complications between frail and nonfrail patients. Further research is warranted to understand the effects and timeline of frailty in geriatric patients.

Healthcare professional preferences in the health and fitness assessment and optimization of older patients facing colorectal cancer surgery

AIM

There are few age- and fitness-specific, evidence-based guidelines for colorectal cancer surgery. The uptake of different assessment and optimization strategies is variable. The aim of this study was to explore healthcare professional opinion about these issues using a mixed methods design.

METHODS

Semi-structured qualitative interviews were undertaken with healthcare professionals from a single UK region involved in the treatment, assessment and optimization of colorectal surgery patients. Interviews were analysed using the framework approach. An online questionnaire survey was subsequently designed and disseminated to UK surgeons to quantitatively assess the importance of interview themes. Descriptive statistics were used to analyse questionnaire data.

RESULTS

Thirty-seven healthcare professionals out of 42 approached (response rate 88%) were interviewed across five hospitals in the south Yorkshire region. Three broad themes were developed: attitudes towards treatment of the older patient, methods of assessment of suitability and optimization strategies. The questionnaire was completed by 103 out of an estimated 256 surgeons (estimated response rate 40.2%). There was a difference in opinion regarding the role of major surgery in older patients, particularly when there is coexisting dementia. Assessment was not standardized. Access to optimization strategies was limited, particularly in the emergency setting.

CONCLUSION

There is wide variation in the process of assessment and provision of optimization strategies in UK practice. Lack of evidence-based guidelines, cost and time constraints restrict the development of services and pathways. Differences in opinion between surgeons towards patients with frailty or dementia may account for some of the variation in colorectal cancer outcomes.

The Relevance and Added Value of Geriatric Medicine (GM): Introducing GM to Non-Geriatricians

Geriatric Medicine (GM) holds a crucial role in promoting health and managing the complex medical, cognitive, social, and psychological issues of older people. However, basic principles of GM, essential for optimizing the care of older people, are commonly unknown or undermined, especially in countries where GM is still under development. This narrative review aims at providing insights into the role of GM to non-geriatrician readers and summarizing the main aspects of the added value of a geriatric approach across the spectrum of healthcare. Health practitioners of all specialties are frequently encountered with clinical conditions, common in older patients (such as cancer, hypertension, delirium, major neurocognitive and mental health disorders, malnutrition, and peri-operative complications), which could be more appropriately managed under the light of the approach of GM. The role of allied health professionals with specialized knowledge and skills in dealing with older people's issues is essential, and a multidisciplinary team is required for the delivery of optimal care in response to the needs and aspirations of older people. Thus, countries should assure the educational background of all health care providers and the specialized health and social care services required to meet the demands of a rapidly aging society.

Major Trauma in Elderly Patients: Worse Mortality and Outcomes in an Italian Trauma Center

Introduction:

Major trauma is the leading cause of mortality in the world in patients younger than 40 years. However, the proportion of elderly people who suffer trauma has increased significantly. The purpose of this study is to assess the correlation of old age with mortality and other unfavorable outcomes.

Methods:

We assessed on one hand, anatomical criteria such as ISS values and the number of body regions affected, on the other hand, hemodynamic instability criteria, various shock indices, and Glasgow Coma Scale. Finally, we also evaluated biochemical parameters, such as lactate, BE, and pH values. We conducted a prospective and monocentric observational study of all the patients referred to the Emergency Department of the IRCCS Fondazione Policlinico S. Matteo in Pavia for major trauma in 13 consecutive months: January 1, 2018–January 30, 2019. We compared the elderly population (>75 years) and the younger population (≤75).

Results:

We included 501 patients, among which 10% were over the age of 75 years. The mortality rate was higher among the older patients than among the younger (4% vs. 1.33%; P = 0.050). Hemodynamic instability was more common in the older patients than in the younger (26% vs. 9%; P < 0.001). More older patients (44%) had an ISS >16, in comparison with 32% of younger patients (P = 0.01).

Conclusions:

The elderly showed worse outcomes in terms of mortality, hospitalization rate, hemodynamic instability criteria, and anatomical and biochemical parameters.

Digital Support to Multimodal Community-Based Prehabilitation: Looking for Optimization of Health Value Generation

Prehabilitation has shown its potential for most intra-cavity surgery patients on enhancing preoperative functional capacity and postoperative outcomes. However, its large-scale implementation is limited by several constrictions, such as: i) unsolved practicalities of the service workflow, ii) challenges associated to change management in collaborative care; iii) insufficient access to prehabilitation; iv) relevant percentage of program drop-outs; v) need for program personalization; and, vi) economical sustainability. Transferability of prehabilitation programs from the hospital setting to the community would potentially provide a new scenario with greater accessibility, as well as offer an opportunity to effectively address the aforementioned issues and, thus, optimize healthcare value generation. A core aspect to take into account for an optimal management of prehabilitation programs is to use proper technological tools enabling: i) customizable and interoperable integrated care pathways facilitating personalization of the service and effective engagement among stakeholders; ii) remote monitoring (i.e. physical activity, physiological signs and patient-reported outcomes and experience measures) to support patient adherence to the program and empowerment for self-management; and, iii) use of health risk assessment supporting decision making for personalized service selection. The current manuscript details a proposal to bring digital innovation to community-based prehabilitation programs. Moreover, this approach has the potential to be adopted by programs supporting long-term management of cancer patients, chronic patients and prevention of multimorbidity in subjects at risk.

A clinical and biological review of keratoacanthoma

Keratoacanthoma (KA) is a common skin tumour that remains controversial regarding classification, epidemiology, diagnosis, prognosis and management. Classically, a KA manifests as a rapidly growing, well-differentiated, squamoid lesion with a predilection for sun-exposed sites in elderly people and a tendency to spontaneously regress. Historically, KAs have been considered a variant of cutaneous squamous cell carcinoma (cSCC) and are often reported as KA-type cSCC. However, the penchant for regression has led many to categorize KAs as biologically benign tumours with distinct pathophysiological mechanisms from malignant cSCC. The clinical and histopathological similarities between KA and cSCC, particularly the well-differentiated variant of cSCC, have made definitive differentiation difficult or impossible in many cases. The ambiguity between entities has led to the general recommendation for surgical excision of KAs to ensure a potentially malignant cSCC is not left untreated. This current standard creates unnecessary surgical morbidity and financial strain for patients, especially the at-risk elderly population. There have been no reports of death from a definitive KA to date, while cSCC has an approximate mortality rate of 1·5%. Reliably distinguishing cSCC from KA would shift management strategies for KAs towards less-invasive treatment modalities, prevent unnecessary surgical morbidity, and likely reduce associated healthcare costs. Herein, we review the pathophysiology and clinical characteristics of KA, and conclude on the balance of current evidence that KA is a benign lesion and distinct from cSCC.

Perioperative frailty: lessons learned and future directions

PURPOSE OF REVIEW

As the surgical population ages, preoperative diagnosis and optimization of frailty becomes increasingly important. Various concepts are used to define frailty, and several tools have been validated for use in the perioperative period. This article reviews current conceptual frameworks of frailty, references current literature and provides a practical approach to the preoperative frailty assessment with a focus on potential interventions.

RECENT FINDINGS

A multipronged approach toward preoperative optimization should be used in patients with frailty syndrome. Oral protein supplementation and immunonutrition therapy can reduce complications in patients with malnutrition. Initiating a preoperative physical exercise regimen may mitigate frailty. Nonpharmacologic interventions to reduce preoperative anxiety and improve mood are effective, low-cost adjuncts associated with improvement in postoperative outcomes. Engaging in shared decision making is a critical component of the preoperative evaluation of frail patients.

SUMMARY

Emerging evidence suggests that frailty may be mitigated with patient-specific, multidimensional preoperative interventions, thus potentially improving postoperative outcomes in this vulnerable patient population.

Preoperative Medical Referral Prior to Hepatopancreatic Surgery-Is It Worth it?

INTRODUCTION

Many patients who present for complex surgery have underlying medical comorbidities. While surgeons often refer these patients to medical appointments for preoperative "optimization" or "clearance," the actual impact of these visits remains poorly examined. The objective of the current study was to define the potential benefit of preoperative medical appointments on outcomes and costs associated with hepatopancreatic (HP) surgery.

METHODS

Patients with modifiable comorbidities undergoing HP surgery were identified in the Medicare claims data. The association of preoperative non-surgical visit and postoperative outcomes and expenditures was assessed using inverse propensity treatment weighting analysis and multivariable logistic regression.

RESULTS

Among the 5574 Medicare beneficiaries who underwent a hepatopancreatic surgery, one in seven patients (n = 830, 14.9%) was "optimized" preoperatively. On multivariable logistic regression analysis, age (OR 1.02; 95% CI 1.01-1.03; p = 0.006) and higher comorbidity burden (OR 1.03; 95% CI 1.01-1.05; p = 0.007) were associated with modest increased odds of being referred in the preoperative period for a non-surgical evaluation; the factor most associated with preoperative non-surgical visit was male patient sex (OR 1.33; 95% CI 1.14-1.56; p < 0.001). After adjustment for competing risk factors and random site effect, patients with an "optimization" visit had 28% lower odds (OR 0.72; 95% CI 0.59-0.86; p < 0.001) of experiencing an operative complication. Additionally, patients who had a non-surgical visit had 13% higher median total expenditures compared with individuals who did not undergo an "optimization" visit (p < 0.05).

CONCLUSION

In conclusion, roughly one in seven Medicare beneficiaries who underwent HP surgery may have been risk stratified by a non-surgical provider prior to surgery. Preoperative evaluation was associated with modestly lower odds of complications following HP surgery and higher Medicare expenditures. Further research is needed to determine its routine utility as a means to decrease the morbidity surrounding HP surgery.

Pathway for enhanced recovery after spinal surgery-a systematic review of evidence for use of individual components

Background

Enhanced recovery in spinal surgery (ERSS) has shown promising improvements in clinical and economical outcomes. We have proposed an ERSS pathway based on available evidence. We aimed to delineate the clinical efficacy of individual pathway components in ERSS through a systematic narrative review.

Methods

We included systematic reviews and meta-analysis, randomized controlled trials, non-randomized controlled studies, and observational studies in adults and pediatric patients evaluating any one of the 22 pre-defined components. Our primary outcomes included all-cause mortality, morbidity outcomes (e.g., pulmonary, cardiac, renal, surgical complications), patient-reported outcomes and experiences (e.g., pain, quality of care experience), and health services outcomes (e.g., length of stay and costs). Following databases (1990 onwards) were searched: MEDLINE, EMBASE, and Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). Two authors screened the citations, full-text articles, and extracted data. A narrative synthesis was provided. We constructed Evidence Profile (EP) tables for each component of the pathway, where appropriate information was available. Due to clinical and methodological heterogeneity, we did not conduct a meta-analyses. GRADE system was used to classify confidence in cumulative evidence for each component of the pathway.

Results

We identified 5423 relevant studies excluding duplicates as relating to the 22 pre-defined components of enhanced recovery in spinal surgery. We included 664 studies in the systematic review. We identified specific evidence within the context of spinal surgery for 14/22 proposed components. Evidence was summarized in EP tables where suitable. We performed thematic synthesis without EP for 6/22 elements. We identified appropriate societal guidelines for the remainder of the components.

Conclusions

We identified the following components with high quality of evidence as per GRADE system: pre-emptive analgesia, peri-operative blood conservation (antifibrinolytic use), surgical site preparation and antibiotic prophylaxis. There was moderate level of evidence for implementation of prehabilitation, minimally invasive surgery, multimodal perioperative analgesia, intravenous lignocaine and ketamine use as well as early mobilization. This review allows for the first formalized evidence-based unified protocol in the field of ERSS.

Further studies validating the multimodal ERSS framework are essential to guide the future evolution of care in patients undergoing spinal surgery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01281-1.

The effects of a preoperative multidisciplinary conference on outcomes for high-risk patients with challenging surgical treatment options: a retrospective study

BACKGROUND

Surgical options for patients vary with age and comorbidities, advances in medical technology and patients' wishes. This complexity can make it difficult for surgeons to determine appropriate treatment plans independently. At our institution, final decisions regarding treatment for patients are made at multidisciplinary meetings, termed High-Risk Conferences, led by the Patient Safety Committee.

METHODS

In this retrospective study, we assessed the reasons for convening High-Risk Conferences, the final decisions made and treatment outcomes using conference records and patient medical records for conferences conducted at our institution from April 2010 to March 2018.

RESULTS

A total of 410 High-Risk Conferences were conducted for 406 patients during the study period. The department with the most conferences was cardiovascular surgery (24%), and the reasons for convening conferences included the presence of severe comorbidities (51%), highly difficult surgeries (41%) and nonmedical/personal issues (8%). Treatment changes were made for 49 patients (12%), including surgical modifications for 20 patients and surgery cancellation for 29. The most common surgical modification was procedure reduction (16 patients); 4 deaths were reported. Follow-up was available for 21 patients for whom surgery was cancelled, with 11 deaths reported.

CONCLUSIONS

Given that some change to the treatment plan was made for 12% of the patients discussed at the High-Risk Conferences, we conclude that participants of these conferences did not always agree with the original surgical plan and that the multidisciplinary decision-making process of the conferences served to allow for modifications. Many of the modifications involved reductions in procedures to reflect a more conservative approach, which might have decreased perioperative mortality and the incidence of complications as well as unnecessary surgeries. High-risk patients have complex issues, and it is difficult to verify statistically whether outcomes are associated with changes in course of treatment. Nevertheless, these conferences might be useful from a patient safety perspective and minimize the potential for legal disputes.

Assessment of predictive validity and feasibility of Edmonton Frail Scale in identifying postoperative complications among elderly patients: a prospective observational study

Frailty is defined as diminished physiological reserve predisposing one to adverse outcomes when exposed to stressors. Currently, there is no standardized Frail assessment tool used perioperatively. Edmonton Frail Scale (EFS), which is validated for use by non-geriatricians and in selected surgical populations, is a candidate for this role. However, little evaluation of its use has been carried out in the Asian populations so far. This is a prospective observational study done among patients aged 70 years and above attended Preoperative Assessment Clinic (PAC) in Singapore General Hospital prior to major abdominal surgery from December 2017 to September 2018. The Comprehensive Complication Index (CCI) and Postoperative Morbidity Survey (POMS) were used to assess their postoperative morbidity respectively. Patient’s acceptability of EFS was measured using the QQ-10 questionnaire and the inter-rater reliability of EFS was assessed by Kappa statistics and Bland Altman plot. The primary aim of this study is to assess if frailty measured by EFS is predictive of postoperative complications in elderly patients undergoing elective major abdominal surgery. We also aim to assess the feasibility of implementing EFS as a standard tool in the outpatient preoperative assessment clinic setting. EFS score was found to be a significant predictor of postoperative morbidity. (OR 1.35, p < 0.001) Each point increase in EFS score was associated with a 3 point increase in CCI score. (Coefficient b 2.944, p < 0.001) EFS score more than 4 has a fair predictability of both early and 30-day postoperative complications. Feasibility study demonstrated an overall acceptance of the EFS among our patients with good inter-rater agreement.

Perioperative Management of Elderly patients (PriME): recommendations from an Italian intersociety consensus

BACKGROUND

Surgical outcomes in geriatric patients may be complicated by factors such as multiple comorbidities, low functional performance, frailty, reduced homeostatic capacity, and cognitive impairment. An integrated multidisciplinary approach to management is, therefore, essential in this population, but at present, the use of such an approach is uncommon. The Perioperative Management of Elderly patients (PriME) project has been established to address this issue.

AIMS

To develop evidence-based recommendations for the integrated care of geriatric surgical patients.

METHODS

A 14-member Expert Task Force of surgeons, anesthetists, and geriatricians was established to develop evidence-based recommendations for the pre-, intra-, and postoperative care of hospitalized older patients (≥ 65 years) undergoing elective surgery. A modified Delphi approach was used to achieve consensus, and the strength of recommendations and quality of evidence was rated using the U.S. Preventative Services Task Force criteria.

RESULTS

A total of 81 recommendations were proposed, covering preoperative evaluation and care (30 items), intraoperative management (19 items), and postoperative care and discharge (32 items).

CONCLUSIONS

These recommendations should facilitate the multidisciplinary management of older surgical patients, integrating the expertise of the surgeon, the anesthetist, the geriatrician, and other specialists and health care professionals (where available) as needed. These roles may vary according to the phase and setting of care and the patient's conditions.

Peri-operative management of frailty in the orthopedic patient

The purpose of this investigation was to summarize current research on diagnosis, outcomes, and management of frail patients undergoing orthopedic surgery. Because frail patients are at increased risk of negative post-operative outcomes including increased 30-day mortality and post-operative complications including infections and delirium, such a review is timely. Strategies including supervised exercise training programs before surgery, early identification of frailty, prophylactic antibiotics, regular drug chart review, regular monitoring of electrolytes, and other strategies to prevent post-operative delirium are helpful in the management of frail orthopedic patients. It is important for surgeons and anesthesiologists to take action in attempt to alleviate adverse post-operative outcomes in frail patients. Ultimately, more research is needed to identify new strategies and to evaluate whether pre-operative optimization can effectively mitigate post-operative outcomes in large-scale randomized controlled trials.

Preoperative frailty assessment combined with prehabilitation and nutrition strategies: Emerging concepts and clinical outcomes

Important elements of the preoperative assessment that should be addressed for the older adult population include frailty, comorbidities, nutritional status, cognition, and medications. Frailty has emerged as a plausible predictor of adverse outcomes after surgery. It is present in older patients and is characterized by multisystem physiologic decline, increased vulnerability to stressors, and adverse clinical outcomes. Preoperative preparation may include a prehabilitation program, which aims to address nutritional insufficiencies, modify chronic polypharmacy, and enhance physical and respiratory conditions prior to hospital admission. Special considerations are taken for particularly high-risk patients, where the approach to prehabilitation can address specific, individual risk factors. Identifying patients who are nutritionally deficient allows practitioners to intervene preoperatively to optimize their nutritional status, and different strategies are available, such as immunonutrition. Previous studies have shown an association between increased frailty and the risk of postoperative complications, morbidity, hospital length of stay, and 30-day and long-term mortality following general surgical procedures. Evidence from numerous studies suggests a potential benefit of including a standard assessment of frailty as part of the preoperative workup of older adult patients. Studies addressing validated frailty assessments and the quantification of their predictive capabilities in various surgeries are warranted.