The ethics of surgery in the elderly demented patient with bowel obstruction

Comparative analysis of short-term outcomes after semielective and elective surgery for sigmoid volvulus

BACKGROUND

Data to guide surgical timing after colonic decompression for sigmoid volvulus are limited. Thus, we compared the postoperative outcomes of patients with sigmoid volvulus who underwent semielective (during index hospitalization after decompression) and elective surgery (subsequent elective hospitalization).

METHODS

We performed a retrospective review of 100% Medicare Provider Analysis and Review Files from 2016 to 2019, including Medicare beneficiaries aged ≥65 years who were urgently/emergently admitted for their index episode of volvulus and underwent colonic decompression followed by surgery.

RESULTS

The mean age of 2,053 patients was 78 (standard deviation 8 years); 7% had elective surgery and 93% had semielective surgery (including 12.5% on the same day as decompression). In a bivariate analysis, elective surgery was associated with greater rates of minimally invasive surgery (32.8% vs 12.6%, P < .001), lower rates of ostomy formation (2.9% vs 36.0%, P < .001), and greater rates of discharge home (89.8% vs 47.4%, P < .001) with similar cumulative length of stay (8 vs 9 days, not significant) compared with semielective surgery. In a multivariable logistic regression, elective surgery was associated with reduced odds of morbidity (odds ratio, 0.60; 95% confidence interval, 0.49-0.74) and similar odds of mortality (odds ratio, 0.79; 95% confidence interval, 0.50-1.25) compared with semielective surgery, which remained consistent after excluding patients with surgery on the same day as decompression.

CONCLUSIONS

After colonic decompression for sigmoid volvulus, elective surgery appears safe and is associated with favorable outcomes compared with semielective surgery. With the potential severe consequences of volvulus recurrence, these findings underscore the need for algorithms to predict recurrence risk to help guide careful patient selection for elective surgery.

Development and validation of multivariable predictive models for recurrence and mortality following nonoperative management of sigmoid volvulus

AIM

Sigmoid volvulus is a challenging condition, and deciding between elective surgery or expectant management can be complex. The aim of this study was to develop a tool for predicting the risk of recurrent sigmoid volvulus and all-cause mortality within 1 year following initial nonoperative management.

METHOD

This is a retrospective cohort study using Medicare claims data from 2016 to 2018 of beneficiaries admitted urgently/emergently for volvulus, undergoing colonic decompression and discharged alive without surgery (excluding those discharged to hospice). The primary outcomes were recurrent sigmoid volvulus and all-cause mortality within 1 year. Proportional hazards models and logistic regression were employed to identify risk factors and develop prediction equations, which were subsequently validated.

RESULTS

Among the 2078 patients managed nonoperatively, 36.1% experienced recurrent sigmoid volvulus and 28.6% died within 1 year. The prediction model for recurrence integrated age, sex, race, palliative care consultations and four comorbidities, achieving area under the curve values of 0.63 in both the training and testing samples. The model for mortality incorporated age, palliative care consultations and nine comorbidities, with area under the curve values of 0.76 in the training and 0.70 in the testing sample.

CONCLUSION

This study provides a straightforward predictive tool that utilizes easily accessible data to estimate individualized risks of recurrent sigmoid volvulus and all-cause mortality for older adults initially managed nonoperatively. The tool can assist clinicians and patients in making informed decisions about such risks. While the accuracy of the calculator was validated, further confirmation through external validation and prospective studies would enhance its clinical utility.

Sigmoid volvulus: Evaluating identification strategies and contemporary multicenter outcomes

BACKGROUND

There is limited epidemiologic data on sigmoid volvulus (SV) from non-endemic regions. Therefore, we performed a multicenter study to report contemporary outcomes and appraise literature-based methods that pair diagnostic and procedural codes to identify SV.

METHOD

Using an automated search for patients with 'volvulus' in our system from 2011 to 2021, we reviewed electronic charts to clarify the diagnosis, automatically replicate three strategies to identify SV, and retrieved 6-month outcomes.

RESULTS

Of 895 patients, 109 had SV. Literature-based strategies poorly identified SV. At the index admission, patients underwent endoscopic reduction alone (33%), emergent (16.5%), semi-elective (34%), or elective (16.5%) surgery. Endoscopic reduction alone had high recurrence rates and delayed surgery was associated with worse outcomes.

CONCLUSION

Literature-based strategies to identify SV suffer from misclassification bias which affects patient counseling. In this large series, one-third of patients do not undergo during their index admission despite improved outcomes with earlier surgery.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

AIM

There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland.

METHODS

Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines.

RESULTS

All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

Sigmoid volvulus after CABG surgery

We report a case of a geriatric patient who underwent CABG and developed sigmoid volvulus (SV) with recurrence. SV is a rarely reported complication of CABG. Timely diagnosis, management, and follow-up are strictly advised, particularly in geriatric patients. Immediate surgical measures are required to prevent volvulus-associated ischemia.

Sigmoid volvulus in young patients: Ą new twist on an old diagnosis

According to the literature, sigmoid volvulus typically develops in patients of an older age with co-morbidities such as a psychiatric illness or a bed-bound chronic illness. Recent reports suggest that it should also be considered in young individuals without any preceding medical history. Abdominal roentgenography is a cheap and effective diagnostic modality that can avoid a delay in diagnosis. The treatment of colonic volvulus remains controversial and relies upon the procedure selected and the most appropriate therapeutic approach in terms of the clinical status of the patient, the location of the problem, the suspected existence or identification of peritonitis, bowel viability, and the expertise of the surgical team. Presented here are four cases of young male patients with sigmoid volvulus. All of the patients were diagnosed radiologically prior to surgical intervention. Two of the patients initially underwent an endoscopic procedure that succeeded in one and that failed in the other. Three of the patients underwent a laparotomy.

Sigmoid volvulus

In sigmoid volvulus (SV), the sigmoid colon wraps around itself and its mesentery. SV accounts for 2% to 50% of all colonic obstructions and has an interesting geographic dispersion. SV generally affects adults, and it is more common in males. The etiology of SV is multifactorial and controversial; the main symptoms are abdominal pain, distention, and constipation, while the main signs are abdominal distention and tenderness. Routine laboratory findings are not pathognomonic: Plain abdominal X-ray radiographs show a dilated sigmoid colon and multiple small or large intestinal air-fluid levels, and abdominal CT and MRI demonstrate a whirled sigmoid mesentery. Flexible endoscopy shows a spiral sphincter-like twist of the mucosa. The diagnosis of SV is established by clinical, radiological, endoscopic, and sometimes operative findings. Although flexible endoscopic detorsion is advocated as the primary treatment choice, emergency surgery is required for patients who present with peritonitis, bowel gangrene, or perforation or for patients whose non-operative treatment is unsuccessful. Although emergency surgery includes various non-definitive or definitive procedures, resection with primary anastomosis is the most commonly recommended procedure. After a successful non-operative detorsion, elective sigmoid resection and anastomosis is recommended. The overall mortality is 10% to 50%, while the overall morbidity is 6% to 24%.

Short-term outcomes in older intensive care unit patients with dementia*

OBJECTIVE

To determine the impact of dementia on the outcomes of intensive care unit (ICU) care and use of ICU interventions among older patients.

DESIGN

Prospective observational cohort study.

SETTING

Urban university teaching hospital.

PATIENTS

Patients were 395 patients age >/=65 consecutively admitted to a medical ICU.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Dementia was determined by a previously validated proxy measure, the Modified Blessed Dementia Rating Scale. We chose cut points to focus on patients with moderate-severe dementia at baseline. Our primary outcomes included length of mechanical ventilation and ICU and hospital length of stay. Secondary outcomes included ICU readmission, changes in code status, discharge location, mortality, and use of ICU interventions. Medical record abstraction was performed to determine the rates of ICU outcomes, use of ICU interventions, and potential confounders. Our study documented a prevalence of moderate-severe dementia of 17% in patients age >/=65 admitted to the ICU. Patients with dementia were significantly older (80 vs. 76), more likely to be female (65% vs. 52%), and more likely to be admitted from a nursing home (46% vs. 11%). Patients with dementia had significantly higher Acute Physiology and Chronic Health Evaluation II scores on admission to the ICU (25 vs. 23). Patients with dementia were more likely to have their code status changed to less aggressive in the ICU (24% vs. 14%). There was no significant difference in readmission to the ICU, discharge location, ICU or hospital mortality rate, or use of ICU interventions between patients with and without dementia.

CONCLUSIONS

Our study documents no difference in outcomes from ICU care in older patients with and without dementia. There was no increased short-term mortality rate in older patients with dementia compared with those without dementia after admission to the ICU. Presumptions that outcomes from critical care are less favorable in patients with dementia should not drive treatment decisions in the ICU.

Consent and confusion--who decides?

Current trends in the NHS promote patient rights including the right to accept or refuse surgery. Valid consent when the patient appears to have fluctuating competence can place theatre nurses in a difficult position. This article explores the legal framework in which the Department of Health consent forms work and looks at the NMC's Code of Professional Conduct for standards of practice.

Abdominal surgical emergencies in the elderly

The evaluation of abdominal pain can be considerably more challenging in elderly patients. A higher likelihood of life-threatening pathology combined with a myriad of diagnostic pitfalls in this population mandate a more cautious approach with greater use of diagnostic resources and specialist consultation.