Elective Surgery Trends and Outcomes of Nonagenarians and Centenarians in Otolaryngology-Head and Neck Surgery: A NSQIP Study

OBJECTIVE

To describe types and outcomes of elective otolaryngological surgeries undergone by patients ≥90 years of age and to assess whether very old age is an independent risk factor for postsurgical complications and death.

METHODS

The National Surgical Quality Improvement Program, a validated national prospective surgical outcomes database, was used to identify all patients aged 65 years and older who underwent elective otolaryngological procedures from 2011 to 2020. Study outcomes included minor complications, major life-threatening complications, and 30-day mortality. Predictors of outcomes, including frailty, were identified using univariable analyses and age was added into the final logistic regression models with stepwise selection.

RESULTS

A total of 40,723 patients met inclusion criteria; 629 (1.5%) patients were ≥90 years of age. Of the 63,389 procedures, head and neck (67.6%) and facial plastics and reconstructive (15.0%) procedures were most common. The overall incidence of major life-threatening complications, minor complications, and death was 2.0%, 3.5%, and 0.4%, respectively. Age ≥90 was significantly associated with an increased risk for 30-day mortality, but not with major or minor postoperative complications. A high modified frailty index was significantly associated with an increased risk for major postoperative complications and death amongst patients ≥90 years.

CONCLUSIONS

Elective otolaryngological surgery can be safe in relatively healthy nonagenarians and centenarians, though there is a small increased risk of 30-day mortality. Although older age can predispose patients to other comorbidities, age alone should not deter surgeons and patients from considering elective otolaryngological procedures. Frailty may be a better predictor for surgical outcomes.

LEVEL OF EVIDENCE

Level IV Laryngoscope, 2024.

Predictive value of the G8 screening tool for postoperative complications in older adults undergoing cancer surgery: A systematic review and meta-analysis

INTRODUCTION

Older adults with cancer who are being considered for cancer surgery are heterogenous, with variation in their physical, mental, and social baselines and risk of postoperative complications. Due in part to the complex nature of this population, the optimal preoperative evaluation method is not clearly defined. In this study we investigated whether geriatric-8 (G8), a screening tool for older patients with cancer that determines the need for a full geriatric assessment, is suitable for assessing the risk of postoperative complications in this population being considered for surgery.

MATERIALS AND METHODS

Studies that enrolled older patients undergoing cancer surgery and compared prevalence of postoperative complications in G8 "high" (≥15) patients and G8 "low" (<15) patients were identified using PubMed and EMBASE. A meta-analysis was conducted to calculate the risk ratio of postoperative complication rate. Postoperative mortality was systematically reviewed.

RESULTS

Eleven studies published between 2017 and 2022 were included in our analysis with a total of 2,691 older patients who underwent various types of cancer surgery and were characterized by their G8 scores: 1,255 G8 high (≥15) patients and 1,436 G8 low (<15) patients. G8 low patients had a significantly higher prevalence of postoperative complications than G8 high patients (risk ratio [95% confidence interval]: 1.56 [1.18-2.07], p = 0.002, I2 = 79%).

DISCUSSION

G8 can be an effective and efficient preoperative tool to assess risk of postoperative complications in older adults undergoing cancer surgery and identify potential need for further evaluation of an individual's risk with a comprehensive geriatric assessment.

Surgical management of spinal pathologies in the octogenarian: a narrative review

Optimal management paradigms of spinal pathologies in the octogenarian population are controversial given the higher incidence of comorbidities with concern for poor prognosis and fear of increased complications associated with surgical management. In this narrative review, we aim to detail the complex clinical considerations when approaching odontoid screw fixation/instrumented fusion, spinal decompression, and spinal fusion in the octogenarian. Literature review was conducted via Google Scholar and PubMed databases, with literature selected based on statistical power and clinical relevance to the following pathologies/surgical techniques: odontoid fracture, surgical decompression, and surgical fusion in the octogenarian. The aforementioned pathologies were selected based on prevalence in the advanced-age population in which surgical screening techniques and management remain nonuniform. Preoperative evaluation of the octogenarian patient increasingly includes frailty, sarcopenia, and osteopenia/osteoporosis assessments. In cases of odontoid fracture, conservative management appears to provide beneficial clinical outcomes with lower rates of complication compared to surgery; however, rates of radiographic odontoid fusion are far lower in conservatively managed patients. Regarding surgical decompression and fusion, the presence of comorbidities may be more predictive of outcome rather than age status, with the advent of minimally invasive techniques providing safety and efficacy in the surgical management of this age cohort. Age status may be less pertinent than previously thought in the decision to pursue spinal surgery for odontoid fracture, spinal decompression, or spinal fusion; however, each of these procedures has respective risks and benefits that must be considered within the context of each patient's comorbidity profile.

Frailty is Not Associated with Worse Outcomes following Lower Extremity Angiograms for Limb Ischemia in Nonagenarians

BACKGROUND

Endovascular interventions are performed routinely with minimal risk in younger populations. The safety and efficacy of endovascular interventions in nonagenarians is under examined. We sought to examine the following (1) mortality and limb salvage rates in the nonagenarian population and (2) whether frailty was associated with outcomes following lower extremity (LE) interventions for both acute limb ischemia (ALI) and chronic limb threatening ischemia (CLTI).

METHODS

A retrospective review of patients ≥90 years who underwent a LE angiogram for ALI or CLTI over a 12-year period at a single institution was performed. Primary outcomes were 30-day and 12-month limb salvage and mortality rates. Patient demographics, 30-day complications, and 12-month target vessel reintervention (TVR) were reviewed. Frailty scores were calculated using the 11-factor modified frailty index (MFI-11).

RESULTS

From 2009 to 2021, 76 patients (36% male) with a mean age of 93 (range: 90-102) underwent endovascular procedures for ALI (n = 13) and CLTI (n = 63). 30-day amputation and mortality rates were 6% and 8%, respectively. Patient demographics, preoperative functional status, and TVR rates were not different between patients who had early amputation (≤30 days) and those who achieved limb salvage. Seventy-two patients (94%) had follow-up data at 30 days. There was an 8% mortality rate at 30 days. Of those alive at 30 days, 94% of patients had successful limb salvage. Fifty-eight patients had complete follow-up data at 12 months. Of the patients alive at 12-month follow-up (75%), the limb salvage rate was 98%. Patients with amputation at 30 days had a significantly higher mortality rate at 12 months compared to those who did not (83% vs. 19%; P < 0.01). Based on MFI-11 scoring, 35% of the population was considered frail (≥0.27). Frail patients did not have significantly different 30-day outcomes (limb salvage: 94% vs. 88%; mortality 8% vs. 9%, P = 0.41 and 0.94, respectively) or 12-month outcomes (limb salvage: 82% vs. 94%; mortality: 32% vs. 22%, P = 0.28 and 0.39, respectively).

CONCLUSIONS

Endovascular procedures can be done safely in nonagenarians with low mortality and amputation rates. Patients with early amputation are at significantly higher risk of death at 12 months. Frailty, as measured by a validated index, was not associated with early or late outcomes. When compared to immediate amputation, nonagenarian patients and their families should be counseled as to the benefit from a minimally invasive endovascular procedure.

Colonoscopy in the nonagenarian population

BACKGROUND

With increasing life expectancy, there is an increasing proportion of nonagenarians undergoing both elective and emergency surgical procedures. The decision as to whom will benefit from surgical procedures is however difficult to ascertain and still remains a challenge to clinicians. This study is aimed to evaluate the clinical outcomes of colonoscopy in the nonagenarian population, and to determine if the outcomes are acceptable for us to continue to offer such interventions.

METHODS

Retrospective study of patients of Dr. G.R (Gastroenterologist) and Dr. W.B (Colorectal Surgeon) between 1 January 2018 and 31 November 2022. All patients who were ≥90 years old and had a colonoscopy was included in the study. Exclusion criteria were patients who were less than 90 years old, had a flexible sigmoidoscopy or colonoscopy as part of their surgical procedure.

PRIMARY OUTCOME MEASURES

post-colonoscopy complications and length of stay.

SECONDARY OUTCOME MEASURES

reasons for colonoscopy, significant colonoscopy findings, 30-day morbidity and mortality.

RESULTS

Sixty patients were included in the study. Median age was 91 (90-100) years old. 33.3% of the patients were males. Seventy percent of the patients were ASA 3. Median length of hospital stay was 1 day. 11.7% of patients were found to have colorectal malignancy. There were no complications after the colonoscopy. There were no 30-day re-admission, morbidity or mortality.

CONCLUSION

Colonoscopy can be performed safely in carefully selected nonagenarian patients with acceptable low complication rates.

Outcomes of surgery in patients 90 years of age and older: A retrospective cohort study

BACKGROUND

Important trade-offs of risks versus benefits of surgery need to be discussed with older adults, in particular nonagenarians who are candidates for surgery. Data that examine specific outcomes of surgical interventions in this age group are sparse. We aimed to evaluate the clinical presentation and postoperative outcomes of nonagenarians undergoing surgery.

METHODS

A retrospective cohort study of consecutive patients 90 years of age and older who underwent surgery between 2014 and 2018 in general surgical ward of a large-volume academic center. Subgroups were designed according to type of surgery (elective versus emergency surgery) and diagnosis (oncology versus non-oncology). Preoperative assessments included Malnutrition Universal Screening Tool, Norton Scale, Morse Scale, Katz, and Lawton-Brody indices.

RESULTS

A total of 198 nonagenarians underwent surgery, of which 38% were elective and 62% were emergency surgery. Median follow-up was 26 months. More patients in the elective group compared with the emergency group had oncology diagnoses (42.1% and 14.7%, respectively, P < .001), resided preoperatively at home (93.4% and 77.9%, respectively, P = .003), and were functionally independent (71.1% and 41.8%, respectively, P = .0005). Postoperative 30-day mortality frequency was 6.6% in the elective group and 39.3% in the emergency group (P < .001). Two-year survival frequency of non-oncology group was 72.7% in elective surgeries and 40.6% in emergency surgeries (P < .001). Two-year survival frequency of oncology group was 37% in elective surgeries and 27.8% in emergency surgeries (P = .12).

CONCLUSION

Elective surgery in adults aged 90 and above can be safely performed with acceptable 2-year outcomes. Emergency surgery for oncology diagnoses carries dismal outcomes, so palliative approaches should be considered.

Factors affecting short-term survival in patients older than 85 treated with resection for stage II and III colon cancer

BACKGROUND

Patients ≥85 years of age have high rates of colon cancer but disproportionately poor outcomes. Factors affecting short-term (90-day) survival in patients ≥85 undergoing surgery for stage II and III colon cancer were examined to identify potentially modifiable factors to improve outcomes.

METHODS

The New York State Cancer Registry and Statewide Planning Research and Cooperative System were queried for patients ≥85 years who underwent colectomy for stage II and III colon cancer between 2004 and 2012. Regression analyses were performed for factors associated with 90-day mortality and stratified by elective and nonelective surgery.

RESULTS

In total, 3,779 patients ≥85 years of age underwent colectomy between 2004 and 2012 for stage II or III colon cancer. Of these, 48.4% underwent nonelective colectomy, 79.9% had an open operation, and 90-day survival was 83.2%. Worse survival was associated with nonelective surgery (odds ratio = 3.81, 95% confidence interval = 3.03-4.89). Improved survival in the nonelective and overall groups was associated with a minimally invasive operation (nonelective group: odds ratio = 0.35, 95% confidence interval = 0.21-0.58; overall group: odds ratio = 0.50, 95% confidence interval = 0.36-0.73) and discharged to another health care facility (nonelective group: odds ratio = 0.30, 95% confidence interval = 0.22-0.39; overall group: odds ratio = 0.42, 95% confidence interval = 0.33-0.53). High surgeon annual operating volume was associated with improved survival in the elective and nonelective groups (P < .001).

CONCLUSION

Factors associated with greater odds of 90-day mortality in this population include nonelective surgery, preoperative weight loss, and multiple comorbidities, whereas a minimally invasive approach was associated with lower mortality. Potential areas to improve outcomes in this population include using a multidisciplinary team approach, addressing frailty preoperatively when possible, and potentially reconsidering screening guidelines for colorectal cancer to reduce rates of emergency operations.

The future of urology: nonagenarians admitted to a urological ward

PURPOSE

To analyze the outcome of nonagenarians with urological conditions. As demographic changes will lead to a substantial rise of geriatric patients in need of health care services and as little is known on the outcome of these patients, we retrospectively analyzed a consecutive series of nonagenarians admitted to our urological ward.

MATERIALS AND METHODS

In a retrospective study we analyzed all nonagenarians admitted to our urological ward between 2014 and 2018. Patients were followed for 12 months and predictors for mortality were calculated.

RESULTS

A total of 152 patients with a mean age of 92 years entered this study. The most frequent indications for admission were macrohematuria, bladder dysfunction, urinary tract infection, hydronephrosis and urinary retention. A history of bladder cancer was present in 18% and of renal cell cancer in 5% of patients. Prostate cancer was present in 21%. The most frequent invasive interventions were the insertion of an irrigation catheter, cystoscopy, bladder tumor resection and insertion of a DJ-catheter. The mean length of hospitalization was 6.5 days. In-house mortality was 9% and the 12 months mortality rate 45%. The strongest predictor for a 12 months mortality was the CSHA-Frailty Scale.

CONCLUSION

Urogerontology is one of the biggest challenges in our field. The cohort of nonagenarians studied herein demonstrates a high rate of invasive interventions, an acceptable length of hospitalization and an in-house mortality in the range of 9%. The 12 months mortality rate is almost 50% and predictors thereof, as elaborated, might aid in the disease management of this ever-increasing cohort.

Comprehensive geriatric assessment: Influence on clinical results after colorectal surgery in advanced age patients

INTRODUCTION

The objective of this work was to analyse the postoperative clinical results of patients surgically treated for colorectal cancer in relation to the results of the preoperative comprehensive geriatric evaluation.

METHODS

Observational study in which postoperative morbidity and mortality at 30 and 90 days were analysed in a cohort of patients surgically treated for colorectal cancer according to age groups: group 1) between 75 and 79 years old; group 2) between 80 and 84 years old, and group 3) ≥85 years old. In addition to the anaesthetic risk assessment, patients were assessed with the Karnofsky, Barthel and Pfeiffer indexes. Mortality at 30 and 90 days after surgery was analysed in relation to the results of the comprehensive evaluation.

RESULTS

A total of 227 patients with colorectal cancer were included in the study period: 91 in group 1, 89 in group 2 and 47 in group 3. There were statistically significant differences in mortality at 30 days (p=0,029) but not at 90 days after surgery, according to age groups. Mortality at 90 days was significantly higher in patients with worse scores on the Karnofsky and Barthel scales.

CONCLUSIONS

Comprehensive geriatric assessment using different scales is a good tool to assess postoperative mortality in the mid-term postoperative period.