Emergency Major Abdominal Surgical Procedures in Older Adults: A Systematic Review of Mortality and Functional Outcomes

Impact of malnutrition on the clinical evolution in a cohort of older patients undergoing emergency surgery for abdominal pathology

PURPOSE

Analyse the influence of the nutritional status of older patients undergoing emergency abdominal surgery on postoperative complications, mortality and mean length of hospital stay.

METHODS

We performed a longitudinal observational study including patients older than 80 years who underwent emergency surgery by the general surgery service for abdominal pathology, who were followed by the geriatrics service between September 2018 and May 2021. Malnutrition was diagnosed using Global Leadership Initiative on Malnutrition (GLIM) criteria, classifying patients as malnourished and normonourished. A comprehensive geriatric assessment was performed on patients, and postoperative complications, mean length of hospital stay and mortality in-hospital were recorded.

RESULTS

131 patients were included, 84 of them were malnourished and 47 normonourished. Mean age was 86±4.7 years. Malnourished patients had higher incidence of new-onset atrial fibrillation (odds ratio [OR]: 6.1, 95% confidence interval [CI]: 1.33-27.6, p<0.05), urinary tract infection (OR 4.72, 95% CI: 1.02-21.95, p<0.05) and bacteraemia (OR 3.51, 95% CI: 1.14-11.1, p<0.05), compared with normonourished patients. Surgical complications were more frequent in malnourished patients (OR 3.34, 95% CI: 1.5-7.44, p<0.05). Mean length of hospital stay in malnourished patients was longer (22.6 (±14.1)) compared with normonourished patients (15.3 (±11.9)) (p<0.005).

CONCLUSION

Malnutrition in older patients (mean age 86 years old) undergoing emergency abdominal surgery is associated with a poorer clinical course; thus, it must be considered in the evaluation and follow-up of these patients.

A Step Beyond Mortality: Identifying Factors of Prolonged Hospital Stay for Emergency General Surgery Conditions in a Low- and Middle-Income Country

INTRODUCTION

While various factors leading to prolonged length of stay (LOS) have been identified for emergency general surgery (EGS), there is limited literature on specific factors for individual emergent specialties. This study aimed to identify patient factors and in-hospital complications associated with prolonged LOS for gastrointestinal (GI) and non-GI-related EGS presentations in a low-resource setting.

METHODS

Data from 2010 to 2019 were retrieved from one of the largest tertiary care centers in Pakistan. We included adult patients (≥18 y) with index admissions for primary EGS conditions mapped to surgical areas defined by the American Association for Surgery of Trauma. Multivariable linear regression models were created to ascertain factors associated with prolonged LOS for 11 American Association for Surgery of Trauma -defined surgical areas.

RESULTS

The mean age of 31,499 patients was 48.87 ± 16.82 y, where 23,198 (73.65%) patients underwent surgery. Undergoing emergency surgery was independently associated with increased LOS for all surgical areas (all P values < 0.05), except for hepatic-pancreatic-biliary. Sepsis and septic shock were the most common complications for both operated and nonoperated patients and were significantly associated with increased LOS for most of the surgical areas. For non-GI-related surgical areas, uninsured patients had significantly greater LOS for soft tissue conditions only (β: 0.85; 95% CI: 0.49, 1.21).

CONCLUSIONS

Different specialties have different drivers for prolonged hospital stay in EGS. This underscores the need to identify and address patient factors and in-hospital complications early on, according to individual specialties. Specific strategies catered to these factors will optimize preoperative care and reduce complications, ultimately decreasing patients' stay after an EGS presentation.

Development and Validation of Futility of Resuscitation Measure in Older Adult Trauma Patients

INTRODUCTION

This study aimed to develop and validate Futility of Resuscitation Measure (FoRM) for predicting the futility of resuscitation among older adult trauma patients.

METHODS

This is a retrospective analysis of the American College of Surgeons-Trauma Quality Improvement Program database (2017-2018) (derivation cohort) and American College of Surgeons level I trauma center database (2017-2022) (validation cohort). We included all severely injured (injury severity score >15) older adult (aged ≥60 y) trauma patients. Patients were stratified into decades of age. Injury characteristics (severe traumatic brain injury [Glasgow Coma Scale ≤ 8], traumatic brain injury midline shift), physiologic parameters (lowest in-hospital systolic blood pressure [≤1 h], prehospital cardiac arrest), and interventions employed (4-h packed red blood cell transfusions, emergency department resuscitative thoracotomy, resuscitative endovascular balloon occlusion of the aorta, emergency laparotomy [≤2 h], early vasopressor requirement [≤6 h], and craniectomy) were identified. Regression coefficient-based weighted scoring system was developed using the Schneeweiss method and subsequently validated using institutional database.

RESULTS

A total of 5562 patients in derivation cohort and 873 in validation cohort were identified. Mortality was 31% in the derivation cohort and FoRM had excellent discriminative power to predict mortality (area under the receiver operator characteristic = 0.860; 95% confidence interval [0.847-0.872], P < 0.001). Patients with a FoRM score of >16 had a less than 10% chance of survival, while those with a FoRM score of >20 had a less than 5% chance of survival. In validation cohort, mortality rate was 17% and FoRM had good discriminative power (area under the receiver operator characteristic = 0.76; 95% confidence interval [0.71-0.80], P < 0.001).

CONCLUSIONS

FoRM can reliably identify the risk of futile resuscitation among older adult patients admitted to our level I trauma center.

Should We Operate Nonagenarians with Symptomatic Giant Paraesophageal Hernias?

Introduction: Hiatal hernia (HH) is a common disorder of the upper gastrointestinal (UGI) tract that general surgeons encounter. Giant paraesophageal is a subtype of HH in which more than 30% of the stomach is located in the chest. It can cause symptoms such as dysphagia, UGI bleeding, gastroesophageal reflux disease, and vomiting. As the life expectancy of the general population increases, the incidence of giant HH increases and can cause morbidity, including recurrent admissions and prolonged length of hospitalization. In this article, we describe a cohort of nonagenarian patients with HH who were admitted to our institution and were treated either surgically or medically. Methods: We retrospectively reviewed our prospectively maintained database of all nonagenarians who were admitted to our center between 2018 and 2022 with the diagnosis of HH. We compared the demographic data, clinical data, and outcomes between patients undergoing operative and nonoperative management. Results: Twenty patients of age over 90 years were hospitalized with HH-related symptoms. Six underwent surgery, whereas 14 received medical management. Surgical patients had fewer overall hospitalization days, shorter length of stay, and less blood product requirements. Notably two cases of in-hospital mortality occurred in the nonoperative group, whereas none occurred in the operative group. All surgical procedures were performed laparoscopically, with two minor perioperative complications. Conclusion: In selected nonagenarian patients, laparoscopic HH repair is safe and should be considered favorably. It can reduce hospitalization time and can mitigate morbidity.

Investigating the link between frailty and outcomes in geriatric patients with isolated rib fractures

Background

Studies have shown an increased risk of morbidity in elderly patients suffering rib fractures from blunt trauma. The association between frailty and rib fractures on adverse outcomes is still ill-defined. In the current investigation, we sought to delineate the association between frailty, measured using the Orthopedic Frailty Score (OFS), and outcomes in geriatric patients with isolated rib fractures.

Methods

All geriatric (aged 65 years or older) patients registered in the 2013-2019 Trauma Quality Improvement database with a conservatively managed isolated rib fracture were considered for inclusion. An isolated rib fracture was defined as the presence of ≥1 rib fracture, a thorax Abbreviated Injury Scale (AIS) between 1 and 5, an AIS ≤1 in all other regions, as well as the absence of pneumothorax, hemothorax, or pulmonary contusion. Based on patients' OFS, patients were classified as non-frail (OFS 0), pre-frail (OFS 1), or frail (OFS ≥2). The prevalence ratio (PR) of composite complications, in-hospital mortality, failure-to-rescue (FTR), and intensive care unit (ICU) admission between the OFS groups was determined using Poisson regression models to adjust for potential confounding.

Results

A total of 65 375 patients met the study's inclusion criteria of whom 60% were non-frail, 29% were pre-frail, and 11% were frail. There was a stepwise increased risk of complications, in-hospital mortality, and FTR from non-frail to pre-frail and frail. Compared with non-frail patients, frail patients exhibited a 87% increased risk of in-hospital mortality [adjusted PR (95% CI): 1.87 (1.52-2.31), p<0.001], a 44% increased risk of complications [adjusted PR (95% CI): 1.44 (1.23-1.67), p<0.001], a doubling in the risk of FTR [adjusted PR (95% CI): 2.08 (1.45-2.98), p<0.001], and a 17% increased risk of ICU admission [adjusted PR (95% CI): 1.17 (1.11-1.23), p<0.001].

Conclusion

There is a strong association between frailty, measured using the OFS, and adverse outcomes in geriatric patients managed conservatively for rib fractures.

Risk factors for in-hospital mortality after emergency colorectal surgery in octogenarians: results of a cohort study from a referral center

PURPOSE

The objective of this study was to investigate predictive factors of mortality in emergency colorectal surgery in octogenarian patients.

METHODS

It is a retrospective cohort study conducted at a single-institution tertiary referral center. Consecutive patients who underwent emergency colorectal surgery between January 2015 and January 2020 were identified. The primary endpoint was 30-day mortality. Univariate and multivariate analyses were performed using a logistic regression model.

RESULTS

A total of 111 patients were identified (43 men, 68 women). Mean age was 85.7 ± 3.7 years (80-96). Main diagnoses included complicated sigmoiditis in 38 patients (34.3%), cancer in 35 patients (31.5%), and ischemic colitis in 31 patients (27.9%). An ASA score of 3 or higher was observed in 88.3% of patients. The mean Charlson score was 5.9. The Possum score was 35.9% for mortality and 79.3% for morbidity. The 30-day mortality rate was 25.2%. Univariate analysis of preoperative risk factors for mortality shows that the history of valvular heart disease (p = 0.008), intensive care unit provenance (p = 0.003), preoperative sepsis (p < 0.001), diagnosis of ischemic colitis (p = 0.012), creatinine (p = 0.006) and lactate levels (p = 0.01) were significantly associated with 30-day mortality, and patients coming from home had a lower 30-day mortality rate (p = 0.018). Intraoperative variables associated with 30-day mortality included ileostomy creation (p = 0.022) and temporary laparostomy (p = 0.004). At multivariate analysis, only lactate (p = 0.032) and creatinine levels (p = 0.027) were found to be independent predictors of 30-day mortality, home provenance was an independent protective factor (p = 0.004). Mean follow-up was 3.4 years. Survival at 1 and 3 years was 57.6 and 47.7%.

CONCLUSION

Emergency colorectal surgery is challenging. However, age should not be a contraindication. The 30-day mortality rate (25.2%) is one of the lowest in the literature. Hyperlactatemia (> 2mmol/L) and creatinine levels appear to be independent predictors of mortality.

Trends and outcomes of emergency general surgery in elderly and highly elderly population in a single regional emergency center

Purpose

The number of elderly patients, especially aged ≥80 years, undergoing emergency surgery is gradually increasing. The aim of this study was to find out the trends and results of emergency general surgery for elderly patients over 9 years in an emergency medical center in South Korea, where the population is aging most rapidly.

Methods

The clinical characteristics, outcomes, and medical expenses of emergency general surgery for the elderly (aged 65-79 years) and highly elderly (aged ≥80 years) patients who visited to a regional emergency medical center from 2012 to 2020 were analyzed.

Results

The number of highly elderly patients increased with each 3-year interval, whereas the proportion of patients aged 19-79 years was similar, and that of pediatric patients was decreasing. The higher the age group, the higher the mortality (young adult vs. elderly vs. highly elderly: odds ratio [OR], 1 vs. 3.689 vs. 11.293; P < 0.001) and complication rates (OR, 1 vs. 2.840 vs. 4.633; P < 0.001), and longer length of hospital stay (β = 0.949, P = 0.001) even after adjusting for the type of surgery and the American Society of Anesthesiologists physical status classification. Non-covered medical expenses were significantly related to the age groups (β = 151,608.802, P < 0.001).

Conclusion

The higher age group was associated with increased number of unfavorable outcomes after emergency general surgery, along with increased medical cost. Efforts to prevent emergency surgery for elderly patients and a specialized treatment system are needed.

Functional Status is Key to Long-term Survival in Emergency General Surgery Conditions

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.

Prospective validation and application of the Trauma-Specific Frailty Index: Results of an American Association for the Surgery of Trauma multi-institutional observational trial

BACKGROUND

The frailty index is a known predictor of adverse outcomes in geriatric patients. Trauma-Specific Frailty Index (TSFI) was created and validated at a single center to accurately identify frailty and reliably predict worse outcomes among geriatric trauma patients. This study aims to prospectively validate the TSFI in a multi-institutional cohort of geriatric trauma patients.

METHODS

This is a prospective, observational, multi-institutional trial across 17 American College of Surgeons Levels I, II, and III trauma centers. All geriatric trauma patients (65 years and older) presenting during a 3-year period were included. Frailty status was measured within 24 hours of admission using the TSFI (15 variables), and patients were stratified into nonfrail (TSFI, ≤0.12), prefrail (TSFI, 0.13-0.25), and frail (TSFI, >0.25) groups. Outcome measures included index admission mortality, discharge to rehabilitation centers or skilled nursing facilities (rehab/SNFs), and 3-month postdischarge readmissions, fall recurrences, complications, and mortality among survivors of index admission.

RESULTS

A total of 1,321 geriatric trauma patients were identified and enrolled for validation of TSFI (nonfrail, 435 [33%]; prefrail, 392 [30%]; frail, 494 [37%]). The mean ± SD age was 77 ± 8 years; the median (interquartile range) Injury Severity Score was 9 (5-13). Overall, 179 patients (14%) had a major complication, 554 (42%) were discharged to rehab/SNFs, and 63 (5%) died during the index admission. Compared with nonfrail patients, frail patients had significantly higher odds of mortality (adjusted odds ratio [aOR], 1.93; p = 0.018), major complications (aOR, 3.55; p < 0.001), and discharge to rehab/SNFs (aOR, 1.98; p < 0.001). In addition, frailty was significantly associated with higher adjusted odds of mortality, major complications, readmissions, and fall recurrence at 3 months postdischarge ( p < 0.05).

CONCLUSION

External applicability of the TSFI (15 variables) was evident at a multicenter cohort of 17 American College of Surgeons trauma centers in geriatric trauma patients. The TSFI emerged as an independent predictor of worse outcomes, both in the short-term and 3-month postdischarge.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Low skeletal muscle mass predicts poor prognosis of elderly patients after emergency laparotomy: A single Asian institution experience

INTRODUCTION

Sarcopenia, defined as low skeletal muscle mass and poor muscle function, has been associated with worse postoperative recovery. This study aims to evaluate the significance of low muscle mass in the elderly who require emergency surgeries and the postoperative outcomes.

METHOD

Data from the emergency laparotomy database were retrieved from Khoo Teck Puat Hospital, Singapore, between 2016 and 2019. A retrospective analysis was performed on patients aged 65 years and above. Data collected included skeletal muscle index (SMI) on computed tomography scan, length of stay, complications and mortality. Low muscle mass was determined based on 25th percentile values and correlation with previous population studies.

RESULTS

A total of 289 patients were included for analysis. Low muscle mass was defined as L3 SMI of <22.09cm2/m2 for females and <33.4cm2/m2 for males, respectively. Seventeen percent of our patients were considered to have significantly low muscle mass. In this group, the length of stay (20.8 versus 16.2 P=0.041), rate of Clavien-Dindo IV complications (18.4% vs 7.5% P=0.035) and 1-year mortality (28.6% vs 14.6%, P=0.03) were higher. Further multivariate analysis showed that patients with low muscle mass had increased mortality within a year (odds ratio 2.16, 95% confidence interval 1.02-4.55, P=0.04). Kaplan-Meier analysis also shows that the 1-year overall survival was significantly lower in patients with low muscle mass.

CONCLUSION

Patients with low muscle mass have significantly higher post-surgical complication rates and increased mortality.

Derivation and external validation of a 30-day mortality risk prediction model for older patients having emergency general surgery

BACKGROUND

Older people (≥65 yr) are at increased risk of morbidity and mortality after emergency general surgery. Risk prediction models are needed to guide decision making in this high-risk population. Existing models have substantial limitations and lack external validation, potentially limiting their applicability in clinical use. We aimed to derive and validate, both internally and externally, a multivariable model to predict 30-day mortality risk in older patients undergoing emergency general surgery.

METHODS

After protocol publication, we used the National Surgical Quality Improvement Program (NSQIP) database (2012-6; estimated to contain 90% data from the USA and 10% from Canada) to derive and internally validate a model to predict 30-day mortality for older people having emergency general surgery using logistic regression with elastic net regularisation. Internal validation was done with 10-fold cross-validation. External validation was done using a temporally separate health administrative database exclusively from Ontario, Canada.

RESULTS

Overall, 6012 (12.0%) of the 50 221 patients died within 30 days. The model demonstrated strong discrimination (area under the curve [AUC]=0.871) and calibration across the spectrum of observed and predicted risks. Ten-fold internal cross-validation demonstrated minimal optimism (AUC=0.851, optimism 0.019 [standard deviation=0.06]) with excellent calibration. External validation demonstrated lower discrimination (AUC=0.700) and degraded calibration.

CONCLUSION

A multivariable mortality risk prediction model was strongly discriminative and well calibrated internally. However, poor external validation suggests the model may not be generalisable to non-NSQIP data and hospitals. The findings highlight the importance of external validation before clinical application of risk models.

Applying Evidence-based Principles to Guide Emergency Surgery in Older Adults

Although outcomes for older adults undergoing elective surgery are generally comparable to younger patients, outcomes associated with emergency surgery are poor. These adverse outcomes are in part because of the physiologic changes associated with aging, increased odds of comorbidities in older adults, and a lower probability of presenting with classic "red flag" physical examination findings. Existing evidence-based perioperative best practice guidelines perform better for elective compared with emergency surgery; so, decision making for older adults undergoing emergency surgery can be challenging for surgeons and other clinicians and may rely on subjective experience. To aid surgical decision making, clinicians should assess premorbid functional status, evaluate for the presence of geriatric syndromes, and consider social determinants of health. Documentation of care preferences and a surrogate decision maker are critical. In discussing the risks and benefits of surgery, patient-centered narrative formats with inclusion of geriatric-specific outcomes are important. Use of risk calculators can be meaningful, although limitations exist. After surgery, daily evaluation for common postoperative complications should be considered, as well as early discharge planning and palliative care consultation, if appropriate. The role of the geriatrician in emergency surgery for older adults may vary based on the acuity of patient presentation, but perioperative consultation and comanagement are strongly recommended to optimize care delivery and patient outcomes.

What Should We Recommend for Colorectal Cancer Screening in Adults Aged 75 and Older?

The current recommendation to stop colorectal cancer screening for older adults is based on a lack of evidence due to systematic exclusion of this population from trials. Older adults are a heterogenous population with many available strategies for patient-centered assessment and decision-making. Evolutions in management strategies for colorectal cancer have made safe and effective options available to older adults, and the rationale to screen for treatable disease more reasonably, especially given the aging Canadian population. In this commentary, we review the current screening guidelines and the evidence upon which they were built, the unique considerations for screening older adults, new treatment options, the risks and benefits of increased screening and potential considerations for the new guidelines.

Adhesive small bowel obstruction in elderly patients: a single-center analysis of treatment strategies and clinical outcomes

INTRODUCTION

The incidence of adhesive bowel obstruction (ASBO) progressively increases with age. Strong evidences on the influencing role of age on ASBO clinical course and management are still lacking. Aim of this study is to retrospectively analyze the clinical outcomes of patients older than 65 years of age admitted to a tertiary referral Emergency Department with a diagnosis of ASBO.

MATERIALS AND METHODS

We reviewed the clinical records of patients admitted for ASBO in the period 2014-2019. Patients were divided in elderly (≥65 years) and non-elderly (<65 years). Primary endpoint was to compare the all-cause in-hospital mortality and the occurrence of major complications in the two groups. Secondary endpoint was a comparison of clinical presentation, clinical course and management.

RESULTS

We enrolled 285 elderly and 492 non-elderly patients. Vomit was more frequent in the elderly (51.9% vs 34.6%; p < .001), while no difference was evidenced for the remaining symptoms of ASBO presentation. A higher rate of non-operative management (NOM) (26.3% vs 16.5%; p = .010), ICU admission (16% vs 0.6%; p < .001), mortality (2.1% vs 0.2%; p = .007) and cumulative major complications (8.8% vs 3.3%; p = .001), as well as a prolonged hospitalization (8.2 vs 5.4 days; p < .001) was evidenced in the ≥65 years group. Multivariate analysis identified increasing age (OR:2.8; 95%CI:1.09-7.2; p = .040) and Charlson comorbidity index ≥ 2 (OR:2.5; 95% CI:1.2-6.4; p = .050) as the only independent predictors of cumulative major complications.

CONCLUSIONS

Despite the similarity in terms of clinical presentation, elderly patient present higher mortality rate and occurrence of major complications. A comprehensive geriatric assessment is recommended to optimize the diagnostic and clinical strategies in case of ASBO.

Activities of daily living associated with postoperative intensive care unit survival in elderly patients following elective major abdominal surgery: An observational cohort study

Elderly patients who undergo major abdominal surgery are being in increasing numbers. Intensive care unit (ICU) survival is critical for surgical decision-making process. Activities of daily living (ADL) are associated with clinical outcomes in the elderly. We aimed to investigate the relationship between ADL and postoperative ICU survival in elderly patients following elective major abdominal surgery.We conducted a retrospective cohort study involving patients aged ≥65 years admitted to the surgical intensive care unit (SICU) following elective major abdominal surgery. Data from all patients were extracted from the electronic medical records. The Barthel Index (BI) was used to assess the level of dependency in ADL at the time of hospital admission.ICU survivors group had higher Barthel Index (BI) scores than non-survivors group (P < .001). With the increase of BI score, postoperative ICU survival rate gradually increased. The ICU survivals in patients with BI 0-20, BI 21-40, BI 41-60, BI 61-80 and BI 81-100 were 55.7%, 67.6%, 72.4%, 83.3% and 84.2%, respectively. In logistic regression, The Barthel Index (BI) was significantly correlated with the postoperative ICU survival in elderly patients following elective major abdominal surgery (OR = 1.33, 95% CI: 1.20-1.47, P = .02). The area under the receiver operating characteristic (ROC) curve of Barthel Index in predicting postoperative ICU survival was 0.704 (95% CI, 0.638-0.771). Kaplan-Meier survival curve in BI≥30 patients and BI < 30 patients showed significantly different.Activity of daily living upon admission was associated with postoperative intensive care unit survival in elderly patients following elective major abdominal surgery. The Barthel Index(BI) ≥30 was associated with increased postoperative ICU survival. For the elderly with better functional status, they could be given more surgery opportunities. For those elderly patients BI < 30, these results provide useful information for clinicians, patients and their families to make palliative care decisions.

Elderly Patients Benefit From Enhanced Recovery Protocols After Colorectal Surgery

BACKGROUND

Enhanced recovery protocols (ERAS) aim to decrease physiological stress response to surgery and maintain postoperative physiological function. Proponents of ERAS state these protocols decrease lengths of stay (LOS) and complication rates. Our aim was to assess whether elderly patients receive the same benefit as younger patients using ERAS protocols.

METHODS

We queried patients from 2015 to 2017 at our institution with Enhanced Recovery in Surgery (ERIN) variables from the targeted colectomy NSQIP database. The patients were divided into sextiles and analyzed for readmission, LOS, return of bowel function, tolerating diet, mobilization, and multimodal pain management comparing the youngest sextile to the oldest sextile.

RESULTS

Two hundred sixty-two patients (73% colectomies) were enrolled in ERAS. When compared with the youngest sextile (age 19-43.8), the oldest sextile (age 71.4-92.5) had similar readmission rates at 9.8% versus 9.5% (P-value = 0.87), quicker return of bowel function, average 1.9 d versus 3.7 d (P-value < 0.01), and tolerated diet quicker, average POD 2.4 d versus 5.1 d (P-value < 0.01). There was a slight decrease in the use of multimodal pain management 88% versus 100% (P-value = 0.07), but mobilization on POD1 was slightly better in the elderly at 80% versus 78% (P-value = 0.76). Elderly patients enrolled in ERAS had an average LOS of 4.9 days versus 7.8 in the younger patients (P-value = 0.08). Among elderly non-ERAS patients average LOS was 14.6 days.

CONCLUSION

Overall, elderly patients fared better or the same on the ERIN variables analyzed than the younger cohort. ERAS protocols are beneficial and applicable to elderly patients undergoing colorectal surgery.

Sarcopenia estimation using psoas major enhances P-POSSUM mortality prediction in older patients undergoing emergency laparotomy: cross-sectional study

INTRODUCTION

Emergency laparotomy is a considerable component of a colorectal surgeon's workload and conveys substantial morbidity and mortality, particularly in older patients. Frailty is associated with poorer surgical outcomes. Frailty and sarcopenia assessment using Computed Tomography (CT) calculation of psoas major area predicts outcomes in elective and emergency surgery. Current risk predictors do not incorporate frailty metrics. We investigated whether sarcopenia measurement enhanced mortality prediction in over-65 s who underwent emergency laparotomy and emergency colorectal resection.

METHODS

An analysis of data collected prospectively during the National Emergency Laparotomy Audit (NELA) was conducted. Psoas major (PM) cross-sectional area was measured at the L3 level and a ratio of PM to L3 vertebral body area (PML3) was calculated. Outcome measures included inpatient, 30-day and 90-day mortality. Statistical analysis was conducted using Mann-Whitney, Chi-squared and receiver operating characteristics (ROC). Logistic regression was conducted using P-POSSUM variables with and without the addition of PML3.

RESULTS

Nine-hundred and forty-four over-65 s underwent emergency laparotomy from three United Kingdom hospitals were included. Median age was 76 years (IQR 70-82 years). Inpatient mortality was 21.9%, 30-day mortality was 16.3% and 90-day mortality was 20.7%. PML3 less than 0.39 for males and 0.31 for females indicated significantly worse outcomes (inpatient mortality 68% vs 5.6%, 30-day mortality 50.6% vs 4.0%,90-day mortality 64% vs 5.2%, p < 0.0001). PML3 was independently associated with mortality in multivariate analysis (p < 0.0001). Addition of PML3 to P-POSSUM variables improved area under the curve (AUC) on ROC analysis for inpatient mortality (P-POSSUM:0.78 vs P-POSSUM + PML3:0.917), 30-day mortality(P-POSSUM:0.802 vs P-POSSUM + PML3: 0.91) and 90-day mortality (P-POSSUM:0.79 vs P-POSSUM + PML3: 0.91).

CONCLUSION

PML3 is an accurate predictor of mortality in over-65 s undergoing emergency laparotomy. Addition of PML3 to POSSUM appears to improve mortality risk prediction.

Incorporating Outcomes that Matter to Older Adults into Surgical Research

This editorial comments on the article by Thillainadesan et al. in this issue.

The effect of comorbidity on mortality in elderly patients undergoing emergency abdominal surgery: a systematic review and metaanalysis

Background/aim

With the increase in the elderly population, the elderly proportion needing emergency surgery is also increasing. Despite medical advances in surgery and anesthesia, negative postoperative outcomes and high mortality rates are still present in elderly patients undergoing emergency surgery. Comorbidities are described as the main determining factors in poor outcomes. In this metaanalysis, it was aimed to investigate the effect of comorbidity on mortality in elderly patients undergoing emergency abdominal surgery.

Materials and methods

The studies published between 2010-2019 were scanned from databases of Google Scholar, Cinahl, Pub Med, Medline and Web of Science. Quality criteria proposed by Polit and Beck were used in the evaluation of the included studies. Interrater agreement was calculated by using the Kappa statistic, effect size by using the odds ratio, and heterogeneity among studies by using the Cochran’s Q statistics. Kendall’s Tau-b coefficient and funnel plot were used to determine publication bias.

Results

A total of 9 studies were included in the research. There was a total of 1330 cases in the studies. The total mortality rate was 21% (n = 279), the total rate of having a comorbid factor was 83.6% (n = 1112), and the rate of having a comorbid factor in mortality was 89.2% (n = 249). According to the fixed effects model, the total effect size of comorbid factors on causing mortality was not statistically significant with a value of 1.296 (C.I; 0.84-1.97; P > 0.05).

Conclusion

Our study revealed that comorbidity had no significant effect on causing mortality in geriatric patients undergoing emergency abdominal surgery. There are controversial results in the literature, and in order to reach more precise results, studies involving wider groups of patients and further studies examining the specific effect of certain comorbid conditions are needed.

Association of Frailty With Morbidity and Mortality in Emergency General Surgery by Procedural Risk Level

Importance

In this aging society, older patients are more commonly undergoing emergency general surgery (EGS). Although frailty has been associated with worse outcomes in this population, EGS encompasses a heterogeneous mix of procedures.

Objective

To determine if the association of frailty with morbidity and mortality in EGS patients varies based on the level of procedural risk.

Design, Setting, and Participants

This cross-sectional study analyzed Medicare inpatient claims file (January 2007-December 2015) and included all inpatients who underwent 1 of 7 previously described EGS procedures shown to represent 80% of EGS volume, complications, and mortality nationally. Analysis took place from September 2019 to January 2020.

Exposures

The primary exposure of interest was risk procedural level. EGS procedures were stratified as high risk (excision of small intestine, excision of large intestine, peptic ulcer repair, lysis of peritoneal adhesions, and laparotomy) and low risk (appendectomy and cholecystectomy).

Main Outcomes and Measures

The primary outcome was overall 30-day mortality after discharge. Frailty was assessed using a claims-based frailty index. Multivariate logistic regression analysis was used and was stratified by risk level.

Results

A total of 882 929 EGS patients were included in this study (mean [SD] age, 77.9 [7.5] years; 483 637 [54%] were female). Overall mortality was 4.5% (n = 40 304). The frailty index classified 12.6% (n = 111 513) of patients as frail, and mortality within this group was 9.9% (n = 11 307). High-risk procedures represented 53% (n = 468 098) of the caseload, and mortality was 6.8% (n = 31 979). For low-risk procedures, mortality was 2% (n = 8325). Frailty was significantly associated with mortality (odds ratio, 1.64; 95% CI, 1.60-1.68). After stratified analysis, this association remained significant for high-risk (odds ratio, 1.53; 95% CI, 1.49-1.58) and low-risk (odds ratio, 2.05; 95% CI, 1.94-2.17) procedures.

Conclusions and Relevance

Frailty was significantly associated with mortality in patients undergoing EGS, with an even greater association in low-risk procedures. Preoperative frailty assessment is imperative even in low-risk procedures.

Mortality and Health Care Utilization Among Medicare Patients Undergoing Emergency General Surgery vs Those With Acute Medical Conditions

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.

Psoas Attenuation and Mortality of Elderly Patients Undergoing Nontraumatic Emergency Laparotomy

BACKGROUND

Emergency laparotomy (EL) is an increasingly common procedure in the elderly. Factors associated with mortality in the subpopulation of frail patients have not been thoroughly investigated. Sarcopenia has been investigated as a surrogate for frailty and poor prognosis. Our primary aim was to evaluate the association between easily measured sarcopenia parameters and 30-day postoperative mortality in elderly patients undergoing EL. Length of stay (LOS) and admission to an intensive care unit were secondary end points.

METHODS

We conducted a retrospective cohort study, over a 5-year period, of patients aged 65 y and older who underwent EL at a tertiary university hospital. Sarcopenia was evaluated on admission computed tomography scan by two methods, first by psoas muscle attenuation and second by the product of perpendicular cross-sectional diameters (PCSDs). The lowest quartile of PCSDs and attenuation were defined as sarcopenic and compared with the rest of the cohort. Attenuation was stratified for the use of contrast enhancement. Multivariant logistic regression was performed to determine independent risk factors.

RESULTS

During the study period, 403 patients, older than 65 y, underwent EL. Of these, 283 fit the inclusion criteria and 65 (23%) patients died within 30 d of surgery. On bivariate analysis, psoas muscle attenuation, but not PCSDs, was found to be associated with 30-day mortality (OR = 2.43, 95% CI = 1.34-4.38, P = 0.003) and longer LOS (35.7 d versus 22.2 d, Δd 13.5, 95% CI = 6.4-20.7, P < 0.001). In a multivariate analysis, psoas muscle attenuation, but not PCSDs, was an independent risk factor for 30-day postoperative mortality (OR = 2.35, 95% CI = 1.16-4.76, P = 0.017) and longer LOS (Δd = 14.4, 95% CI = 7.7-21.0, P < 0.001). Neither of the sarcopenia parameters was associated with increased admission to an intensive care unit.

DISCUSSION

Psoas muscle attenuation is an independent risk factor for 30-day postoperative mortality and LOS after EL in the elderly population. This measurement can inform clinicians about the operative risk and hospital resource utilization.

Measuring sarcopenia on pre-operative CT in older adults undergoing emergency laparotomy: a comparison of three different calculations

INTRODUCTION

Sarcopenia is associated with outcomes in older-adults undergoing emergency surgery. Psoas major measurement is a surrogate marker of sarcopenia with multiple calculations existing normalising to body size and no consensus as to which is optimal. We compared three different psoas-major calculations to predict outcomes in older adults undergoing emergency laparotomy.

METHODS

Consecutive over 65s were identified from the National Emergency Laparotomy Audit(NELA) database at a single centre between 2014 and 2018. Psoas major was measured at the L3 level and normalised to height (psoas muscle index, PMI), L3 vertebral body (psoas muscle:L3 ratio, PML3) or body surface area (psoas:body surface area, PBSA) and each correlated to outcomes. Outcome measures included inpatient, 30-day and 90-day mortality. A comparison of the three calculations was performed using the Mann-Whitney U, chi-squared, receiver operating characteristic curves (ROC) and binary logistic regression.

RESULTS

Two hundred and sixty-four older adults underwent emergency laparotomy (median age, 75 years ((IQR, 70-81 years), 50% female)). Inpatient mortality was 19.6%, 30-day mortality was 15.1% and 90-day mortality was 18.5%. A total of 31.1% of males and 30% of females were sarcopenic (30.6% overall). A multivariate analysis confirmed each method of psoas major calculation (p < 0.0001) to be associated with mortality, as was ASA-grade (p < 0.0001). Area under the curve (AUC) was greatest for PML3 in predicting mortality (inpatient: PML3, 0.76; PMI, 0.71; PBSA, 0.70; 30-day: PML3, 0.74; PMI, 0.68; PBSA, 0.68; and 90-day: PML3, 0.78; PMI, 0.71; PBSA, 0.70). ASA-grade, P-POSSUM and PML3 were independently associated with mortality on multivariate analysis. ROC analysis of predictions from logistic regression models demonstrated PML3 to be more closely aligned to mortality than ASA or P-POSSUM (inpatient: AUC:PML3, 0.807; ASA, 0.783; P-POSSUM, 0.762; 30-day:AUC: PML3, 0.799; ASA, 0.784; P-POSSUM, 0.787; and 90-day: AUC:PML3, 0.805; ASA, 0.781; P-POSSUM, 0.756).

CONCLUSIONS

Sarcopenia was present in 30.6% of older adults undergoing emergency surgery and is associated with a significantly increased mortality. PML3 is superior to PMI or PBSA and should be considered the method of calculation of choice. Additionally, PML3 compares favourably to ASA and P-POSSUM.

Early Postoperative Death in Patients Undergoing Emergency High-Risk Surgery: Towards a Better Understanding of Patients for Whom Surgery May Not Be Beneficial

The timing, causes, and quality of care for patients who die after emergency laparotomy have not been extensively reported. A large database of 13,953 patients undergoing emergency laparotomy, between July 2014 and March 2017, from 28 hospitals in England was studied. Anonymized data was extracted on day of death, patient demographics, operative details, compliance with standards of care, and 30-day and in-patient mortality. Thirty-day mortality was 8.9%, and overall inpatient mortality was 9.8%. Almost 40% of postoperative deaths occurred within three days of surgery, and 70% of these early deaths occurred on the day of surgery or the first postoperative day. Such early deaths could be considered nonbeneficial surgery. Patients who died within three days of surgery had a significantly higher preoperative lactate, American Society of Anesthesiologists Physical Status (ASA-PS) grade, and Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (P-POSSUM). Compliance with perioperative standards of care based on the Emergency Laparotomy Collaborative care bundle was high overall and better for those patients who died within three days of surgery. Multidisciplinary team involvement from intensive care, care of the elderly physicians, and palliative care may help both the communication and the burden of responsibility in deciding on the risk–benefit of operative versus nonoperative approaches to care.

How best to palliate and treat emergency conditions in geriatric patients with colorectal cancer

Almost one third of colorectal cancer (CRC) cases are diagnosed in an emergency setting, mostly among geriatric patients. Clinical scenarios are often complex and decision making delicate. Besides the obvious need to consider the patient's and/or family and care givers' desires, the surgeon should be able to make the best educated guess on future outcomes in three areas: oncological prognosis, morbidity and mortality risk, and long-term functional loss. Using simple and brief tools for frailty screening reasonable treatment goals with curative or palliative intent can be planned. The most frequent clinical scenarios of CRC in emergency are bowel obstruction and perforation. We propose treatment algorithms based on assessment of the patient's overall reserve and discuss the indications, techniques and impact of a stoma in the geriatric patient. Bridge to surgery strategies may be best adapted to help the frail geriatric patient overcome the acute disease and maybe return to previous state of function. Post-operative morbidity and mortality rates are high in emergency surgery for CRC, but if the geriatric patient survives the post-operative period, oncological prognosis seems to be similar to younger patients. Because the occurrence of complications is the strongest predictor of functional decline and death, post-operative care plays a major role to optimize outcomes. Future studies should further investigate emergency surgery of CRC in the older adults focusing in particular on functional outcomes in order to help physicians counsel patients and families for a tailored treatment.

Defining Serious Illness Among Adult Surgical Patients

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.

Mortality after abdominal emergency surgery in nonagenarians

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.

Advantages and Challenges of an Interdisciplinary Palliative Care Team Approach to Surgical Care

Palliative care is an interdisciplinary field that focuses on optimizing quality of life for patients with serious, life-limiting illnesses and includes aggressive management of pain and symptoms; psychological, social, and spiritual support; and discussions of advance care planning, including treatment decision making and complex care coordination. Early palliative care is associated with increased quality of life, decreased symptom burden, decreased health care expenditures, and improved caregiver outcomes. This article discusses integrating interdisciplinary palliative care into surgical practice, and some current models of using and expanding palliative care skill sets in surgery, including training initiatives for both physicians and nurses.

Loss of Community-Dwelling Status Among Survivors of High-Acuity Emergency General Surgery Disease

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.

Emergency General Surgery in Older Adults: A Review

Older people are the fastest growing segment of the population and over-represented among people requiring emergency general surgery. Independent of comorbid and procedural factors, perioperative risk increases with increasing age. This effect is amplified with frailty or sarcopenia. Multidisciplinary perioperative care aligned with goals of care is most likely to achieve optimal patient and health system outcomes; however, substantial knowledge gaps exist in emergency general surgery for older people. Anesthesiologists are uniquely positioned to address these knowledge gaps, including optimizing goal-directed intraoperative care, appropriate provision of acute postoperative monitoring, and integration of principles of geriatric medicine in perioperative care.

Small bowel obstruction in the elderly: a plea for comprehensive acute geriatric care

Small bowel obstruction is one of the most frequent emergencies in general surgery, commonly affecting elderly patients. Morbidity and mortality from small bowel obstruction in elderly is high. Significant progress has been made in the diagnosis and management of bowel obstruction in recent years. But little is known whether this progress has benefitted outcomes in elderly patients, particularly those who are frail or have a malignancy as cause of the obstruction, and when considering quality of life and functioning as outcomes. In this review, we discuss the specific challenges and needs of elderly in diagnosis and treatment of small bowel obstruction. We address quality of life aspects and explore how the concept of geriatric assessment can be utilized to improve decision-making and outcomes for elderly patients with a small bowel obstruction.

Pre-operative psoas major measurement compared to P-POSSUM as a prognostic indicator in over-80s undergoing emergency laparotomy

INTRODUCTION

Emergency laparotomy in patients over the age of 80 is associated with high morbidity and mortality. Accurate risk prediction in this patient population is desirable. Sarcopenia has been shown to be associated with outcome in multiple clinical settings and the psoas major muscle as measured on computed tomography (CT) imaging has been demonstrated as a marker of sarcopenia. We aim to assess the use of psoas major measurement on pre-operative CT as a prognostic indicator in over-80s undergoing emergency laparotomy and compare this measurement to P-POSSUM.

METHODS

A retrospective interrogation of the prospectively collected National Emergency Laparotomy Database including all over-80s undergoing emergency laparotomy between January 2014 and September 2016 was conducted. Demographic, operative data and P-POSSUM data were collected and analysed. Computed tomography (CT) images were accessed and analysed, and cross-sectional areas of psoas major and the corresponding lumbar vertebral body at the level of the L3 inferior end plate were calculated. The ratio of psoas major-to-L3 cross-sectional area (PM:L3) was calculated for each patient. Mann-Whitney U test and receiver-operating characteristics (ROC) curves were used for statistical analysis.

RESULTS

One hundred and three over-80s underwent emergency laparotomy. Male:female ratio was 60:43. Median age was 84 years (range 80-98 years). 30-day mortality was 19.4%.90-day mortality was 25.2%. Median PM:L3 ratio in patients who died as an inpatient was 0.3 and PM:L3 ratio in patients who survived to discharge was 0.52 (p < 0.0001). Median PM:L3 ratio in patient who died within 30 days post-op was 0.28 and 0.48 in those patients who survived to 30 days (p < 0.0001). Median PM:L3 ratio in patient who died within 90 days post-op was 0.28 and 0.51 in those patients who survived to 90 days (p < 0.0001). ROC analysis gave an area under the curve (AUC) of 0.85 for in-patient mortality, 0.86 for 30-day mortality, and 0.88 for 90-day mortality. ROC analysis for P-POSSUM in this data set demonstrated an AUC of 0.51 for in-patient mortality and 0.75 for 30- and 90-day mortality.

CONCLUSION

CT imaging of the abdomen and pelvis is routinely used in over-80s prior to emergency laparotomy making PM:L3 calculation feasible for the majority of patients in this group. PM:L3 ratio is a useful prognostic indicator for prediction of mortality in patients over the age of 80. PM:L3 is superior to the P-POSSUM score in this series.

The role of the neutrophil:lymphocyte ratio (NLR) and the CRP:albumin ratio (CAR) in predicting mortality following emergency laparotomy in the over 80 age group

INTRODUCTION

Emergency laparotomy in the elderly is an increasingly common procedure which carries high morbidity and mortality. Risk prediction tools, although imperfect, can help guide management decisions. Novel markers of surgical outcomes may contribute to these scoring systems. The neutrophil:lymphocyte ratio (NLR) and CRP:albumin ratio (CAR) have been associated with outcomes in malignancy and sepsis. We assessed the use of ratio NLR and CAR as prognostic indicators in patients over the age of 80 undergoing emergency laparotomy.

METHODS

A retrospective analysis of all patients over the age of 80 who underwent emergency laparotomy during a 3 year period was conducted. Pre and post-operative NLR and CAR were assessed in relation to outcome measures including inpatient, 30-day and 90-day mortality. Statistical analysis was conducted with Mann-Whitney U, receiver operating characteristics, Spearmans rank correlation coefficient and chi-squared tests.

RESULTS

One hundred and thirty-six patients over the age of 80 underwent emergency laparotomy. Median age was 84 years (range 80-96 years). Overall inpatient mortality was 19.2%. Pre-operative and post-operative NLR and CAR were significantly raised in patients with sepsis v no sepsis (p < 0.05). Pre-operative NLR was significantly associated with inpatient (p = 0.046), 30-day (p = 0.02) and 90-day mortality (p = 0.01) in patients with visceral perforation. A pre-operative NLR value of greater than 8 was associated with significantly increased mortality (p = 0.016, AUC:0.78). CAR was not associated with mortality.

CONCLUSION

Pre-operative NLR is associated with mortality in patients with visceral perforation undergoing emergency laparotomy. NLR > 8 is associated with a poorer outcome in this group of patients. CAR was not associated with mortality in over-80s undergoing emergency laparotomy.

Utility of the "Surprise" Question in Predicting Survival among Older Patients with Acute Surgical Conditions

BACKGROUND

The surprise question is a validated tool for identifying patients with increased risk of death within one year who could, therefore, benefit from palliative care. However, its utility in surgery is unknown.

OBJECTIVE

We sought to determine whether the surprise question predicted 12-month mortality in older emergency general surgery patients.

DESIGN

This was a prospective cohort study.

SETTING/SUBJECTS

Emergency general surgery attendings and surgical residents in or beyond their third year of training at a single tertiary care academic hospital from January to July 2014.

MEASUREMENTS

Surgeons responded to the surprise question within 72 hours of evaluating patients, ≥65 years, hospitalized with an acute surgical condition. Patient data, including demographic and clinical characteristics, were extracted from the medical record. Mortality within 12 months of initial evaluation was determined by using Social Security death data.

RESULTS

Ten attending surgeons and 18 surgical residents provided 163 responses to the surprise question for 119 patients: 60% of responses were "No, I would not be surprised" and 40% were "Yes, I would be surprised." A "No" response was associated with increased odds of death within 12 months in binary logistic regression (OR 4.8 [95% CI 2.1-11.1]).

CONCLUSIONS

The surprise question is a valuable tool for identifying older patients with higher risk of death, and it may be a useful screening criterion for older emergency general surgery patients who would benefit from palliative care evaluation.

Predictors of emergency ventral hernia repair: Targets to improve patient access and guide patient selection for elective repair

BACKGROUND

Emergency operations are associated with worse outcomes than elective operations. If not repaired electively, ventral hernias are at risk of strangulating and requiring emergency repair. We sought to identify patient- and hospital-level factors associated with emergency ventral hernia repair in a nationally representative, United States sample.

METHODS

We abstracted data from the 2003-2011 Nationwide Inpatient Sample for adults (≥18 years) who underwent inpatient ventral hernia repair. Our primary outcome was emergency repair. We assessed differences in patient- and hospital-level factors as possible predictors of emergency repair using multivariable logistic regression. We examined secondary outcomes (mortality, total hospital cost, duration of stay) using multivariable logistic and generalized linear (family gamma; link log) regression.

RESULTS

After weighting to the United States population, we included 453,161 adults (39.5% emergency). Independent predictors of emergency repair included payer status (uninsured: odds ratio 3.50, [3.10, 3.96]; Medicaid: 1.29 [1.20, 1.39] compared with private insurance), race/ethnicity (black: 1.77 [1.64, 1.92]; Hispanic: 1.44 [1.28, 1.61] compared with white), age (≥85 years: 2.23 [2.00, 2.47] compared with <45 years), and comorbidities (Charlson Comorbidity Index ≥3: 1.68 [1.56, 1.80] compared with 0). After risk-adjustment, emergency repair was associated with greater odds of in-hospital death, greater costs, and longer hospital stay.

CONCLUSION

Inpatient ventral hernia repairs are frequently performed emergently, with worse outcomes in this group. Independent predictors of emergency repair include factors that may limit access to and/or selection for an elective operation. These predictors provide targets for interventions to improve access to elective care and inform patient selection with the goal of improving patient outcomes.

Postoperative Functional Outcomes in Older Adults

As the world's aging population grows, the surgical population is increasingly made up of older adults. Due to changes in physiologic function and increasing comorbidity burden, older adults are at increased risk of morbidity, mortality, and functional decline after surgery. In addition, decision to undergo surgery for the older adult may be based on the postoperative functional outcome rather than survival. Although few studies have evaluated an older adult's function as a postoperative outcome, surgeons are becoming increasingly aware of the importance of maintaining or regaining function in an older patient. Interventions to improve postoperative functional outcomes are being developed and show promising results. This review discusses existing literature on postoperative functional outcomes in older adults and recently developed interventions.