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Karabulut A, Umman V, Oral G, Erginoz E, Carkman MS. Assessing the effectiveness of ACS surgical risk calculator versus P-POSSUM in predicting mortality and morbidity for major hepatobiliary surgery: An observational study. Medicine (Baltimore) 2024; 103:e38973. [PMID: 38996128 PMCID: PMC11245204 DOI: 10.1097/md.0000000000038973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/14/2024] Open
Abstract
Risk assessment is difficult yet would provide valuable data for both the surgeons and the patients in major hepatobiliary surgeries. An ideal risk calculator should improve workflow through efficient, timely, and accurate risk stratification. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator (SRC) and Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (P-POSSUM) are surgical risk stratification tools used to assess postoperative morbidity. In this study, preoperative data from 300 patients undergoing major hepatobiliary surgeries performed at a single tertiary university hospital were retrospectively collected from electronic patient records and entered into the ACS-SRC and P-POSSUM systems, and the resulting risk scores were calculated and recorded accordingly. The ACS-NSQIP-M1 (C-statistics = 0.725) and M2 (C-statistics = 0.791) models showed better morbidity discrimination ability than P-POSSUM-M1 (C-statistics = 0.672) model. The P-POSSUM-M2 (C-statistics = 0.806) model showed better differentiation success in morbidity than other models. The ACS-NSQIP-M1 (C-statistics = 0.888) and M2 (C-statistics = 0.956) models showed better mortality discrimination than P-POSSUM-M1 (C-statistics = 0.776) model. The P-POSSUM-M2 (C-statistics = 0.948) model showed better mortality differentiation success than the ACS-NSQIP-M1 and P-POSSUM-M1 models. The use of ACS-SRC and P-POSSUM calculators for major hepatobiliary surgeries offers quantitative data to assess risks for both the surgeon and the patient. Integrating these calculators into preoperative evaluation practices can enhance decision-making processes for patients. The results of the statistical analyses indicated that the P-POSSUM-M2 model for morbidity and the ACS-NSQIP-M2 model for mortality exhibited superior overall performance.
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Affiliation(s)
- Ali Karabulut
- Department of General Surgery, Istanbul University Cerrahpasa - Cerrahpasa School of Medicine, Istanbul, Turkey
| | - Veysel Umman
- Department of General Surgery, Izmir University of Economics, School of Medicine, Izmir, Turkey
| | - Gunes Oral
- Department of General Surgery, Istanbul University Cerrahpasa - Cerrahpasa School of Medicine, Istanbul, Turkey
| | - Ergin Erginoz
- Department of General Surgery, Istanbul University Cerrahpasa - Cerrahpasa School of Medicine, Istanbul, Turkey
| | - Mehmet Sinan Carkman
- Department of General Surgery, Istanbul University Cerrahpasa - Cerrahpasa School of Medicine, Istanbul, Turkey
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Ogbuanya AUO, Eni UE, Umezurike DA, Obasi AA, Ikpeze S. Associated Factors of Leaked Repair Following Omentopexy for Perforated Peptic Ulcer Disease; a Cross-sectional Study. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2023; 12:e18. [PMID: 38371449 PMCID: PMC10871054 DOI: 10.22037/aaem.v12i1.2169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
Introduction Previous studies have reported numerous clinico-pathologic risk factors associated with increased risk of leaked repair following omental patch for perforated peptic ulcer disease (PPUD). This study aimed to analyze the risk factors associated with leaked repair of omental patch and document the management and outcome of established cases of leaked repair in a resource-poor setting. Methods This is a multicenter cross-sectional study of leaked repair after omental patch of PPUD between January 2016 to December 2022. Following primary repair of PPUD with omental pedicle reinforcement, associated factors of leaked repair were evaluated using univariate and multivariate analyses. Results Overall, 360 cases were evaluated (62.8% male). Leaked repair rate was 11.7% (42 cases). Those without immunosuppression were 3 times less likely to have leaked repair (aOR= 0.34; 95% CI: 0.16 - 0.72; p = 0.003) while those with sepsis were 4 times more likely to have leaked repair (aOR=4.16; 95% CI: 1.06 - 12.36; p = 0.018). Patients with delayed presentation (>48 hours) were 2.5 times more likely to have leaked repair than those who presented in 0 - 24 hours (aOR=2.51; 95% CI: 3.62 - 10.57; p = 0.044). Those with Perforation diameter 2.1-3.0 cm were 8 times (aOR=7.98; 95% CI: 2.63-24.21; p<0.0001), and those with perforation diameter > 3.0cm were 33 times (aOR=33.04; 95% CI: 10.98-100.25; p<0.0001) more likely to have leaked repair than those with perforation diameter of 0-1.0 cm. Similarly, in those with no perioperative shock, leaked repair was 4 times less likely to develop than those with perioperative shock (aOR= 0.42; 95% CI: 0.41-0.92; p = 0.041). There was significant statistical difference in morbidity (p = 0.003) and mortality (p < 0.0001) rates for cases of leaked repairs and successful repairs. Conclusion Leaked repair following omentopexy for peptic ulcer perforation was significantly associated with large perforation diameter, delayed presentation, sepsis, immunosuppressive therapy, and perioperative shock.
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Affiliation(s)
- Aloysius Ugwu-Olisa Ogbuanya
- Department of surgery, Alex Ekwueme Federal University Teaching Hospital, Abakaliki (AEFUTHA), Ebonyi State, Southeast Nigeria
- Department of Surgery, Ebonyi State University, Abakaliki (EBSU), Ebonyi State, Southeast Nigeria
- Department of surgery, Bishop Shanahan Specialist Hospital, Nsukka, Enugu state, Southeast Nigeria
- Department of Surgery, Mater Misericordie Hospital, Afikpo, Ebonyi State, Southeast Nigeria
- Department of Surgery, District Hospital, Nsukka, Enugu State, Southeast Nigeria
- Department of surgery, Alex Ekwueme Federal University, Ndufu-Alike, Ikwo (AEFUNAI), Ebonyi State, Southeast Nigeria
| | - Uche Emmanuel Eni
- Department of surgery, Alex Ekwueme Federal University Teaching Hospital, Abakaliki (AEFUTHA), Ebonyi State, Southeast Nigeria
- Department of Surgery, Ebonyi State University, Abakaliki (EBSU), Ebonyi State, Southeast Nigeria
- Department of surgery, Alex Ekwueme Federal University, Ndufu-Alike, Ikwo (AEFUNAI), Ebonyi State, Southeast Nigeria
| | - Daniel A Umezurike
- Department of surgery, Alex Ekwueme Federal University Teaching Hospital, Abakaliki (AEFUTHA), Ebonyi State, Southeast Nigeria
- Department of Surgery, Ebonyi State University, Abakaliki (EBSU), Ebonyi State, Southeast Nigeria
| | - Akputa A Obasi
- Department of surgery, Alex Ekwueme Federal University Teaching Hospital, Abakaliki (AEFUTHA), Ebonyi State, Southeast Nigeria
- Department of Surgery, Ebonyi State University, Abakaliki (EBSU), Ebonyi State, Southeast Nigeria
| | - Somadina Ikpeze
- Department of surgery, Alex Ekwueme Federal University Teaching Hospital, Abakaliki (AEFUTHA), Ebonyi State, Southeast Nigeria
- Department of Anatomy, Alex Ekwueme Federal University, Ndufu-Alike, Ikwo (AEFUNAI), Ebonyi State, Southeast Nigeria
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Ogbuanya AUO, Ugwu NB, Enemuo VC, Nnadozie UU, Eni UE, Ewah RL, Ajuluchuku UE, Umezurike DA, Onah LN. Emergency laparotomy for peritonitis in the elderly: A Multicentre observational study of outcomes in Sub-Saharan Africa. Afr J Emerg Med 2023; 13:265-273. [PMID: 37790994 PMCID: PMC10542594 DOI: 10.1016/j.afjem.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 08/24/2023] [Accepted: 08/29/2023] [Indexed: 10/05/2023] Open
Abstract
Background Globally, interest in surgical diseases in the elderly was rekindled recently mainly due to a surge in the aging population and their increased susceptibility to infections. In sub-Saharan Africa, infective diseases are major causes of high morbidity and mortality especially in elderly cohorts, hence this study was set to evaluate current status of this scourge in the elderly in our environment. Aim To document the aetiologic factors and analyze the impact of selected clinical and perioperative indices on mortality and morbidity rates of peritonitis in the elderly. Methods This was a multicenter prospective study involving elderly patients aged 65years and above managed between October 2015 and September 2021 in Southeast Nigeria. Results Of the 236 elderly patients examined, approximately two-third (150, 63.6%) were aged 65-74years. The rest were aged ≥ 75years. There were 142(60.2%) males and 94(39.8%) females. Perforated peptic ulcer (89,37.7%) was the most common cause of peritonitis followed by ruptured appendix (59, 25.0%), then typhoid perforation (44,18.6%). However, typhoid perforation was the deadliest with a crude mortality rate of 40.9%. Overall, morbidity and mortality rates were 33.8% and 28.5% respectively. The main independent predictors of mortality were peritonitis arising from typhoid perforation (p = 0.036), late presentation (p = 0.004), district location of hospital (p = 0.011) and intestinal resection (p = 0.003). Conclusion Generalized peritonitis is a cause of significant morbidity and mortality in the elderly patients in our environment. Perforated peptic ulcer was the most common cause, but typhoid perforation remains the deadliest. Late presentation, district hospital setting and bowel resection were associated with elevated mortality.
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Affiliation(s)
- Aloysius Ugwu-Olisa Ogbuanya
- Department of surgery, Alex Ekwueme Federal University Teaching Hospital, Abakaliki (AEFUTHA), Ebonyi State, Nigeria
- Department of Surgery, Ebonyi State University, Abakaliki (EBSU), Ebonyi State, Nigeria
- Department of surgery, Bishop Shanahan Specialist Hospital, Nsukka, Enugu state, Nigeria
- Department of Surgery, Mater Misericordie Hospital, Afikpo, Ebonyi State, Nigeria
- Department of Surgery, District Hospital, Nsukka, Enugu State, Nigeria
| | - Nonyelum Benedett Ugwu
- Department of surgery, Bishop Shanahan Specialist Hospital, Nsukka, Enugu state, Nigeria
- Department of Anaesthesia, Ebonyi State University, Abakaliki, Ebonyi State, Nigeria
| | - Vincent C Enemuo
- Department of surgery, Alex Ekwueme Federal University Teaching Hospital, Abakaliki (AEFUTHA), Ebonyi State, Nigeria
- Department of surgery, University of Nigeria, Nsukka, Enugu State, Nigeria
- Department of surgery, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu State, Nigeria
| | - Ugochukwu U Nnadozie
- Department of surgery, Alex Ekwueme Federal University Teaching Hospital, Abakaliki (AEFUTHA), Ebonyi State, Nigeria
- Department of Surgery, Ebonyi State University, Abakaliki (EBSU), Ebonyi State, Nigeria
| | - Uche Emmanuel Eni
- Department of surgery, Alex Ekwueme Federal University Teaching Hospital, Abakaliki (AEFUTHA), Ebonyi State, Nigeria
- Department of Surgery, Ebonyi State University, Abakaliki (EBSU), Ebonyi State, Nigeria
| | - Richard L Ewah
- Department of Surgery, Ebonyi State University, Abakaliki (EBSU), Ebonyi State, Nigeria
- Department of Surgery, Mater Misericordie Hospital, Afikpo, Ebonyi State, Nigeria
- Department of Anaesthesia, Alex Ekwueme Federal University Teaching Hospital, Abakaliki (AEFUTHA), Ebonyi State, Nigeria
| | - Uzoamaka E Ajuluchuku
- Department of surgery, Alex Ekwueme Federal University Teaching Hospital, Abakaliki (AEFUTHA), Ebonyi State, Nigeria
- Department of Surgery, Ebonyi State University, Abakaliki (EBSU), Ebonyi State, Nigeria
| | - Daniel A Umezurike
- Department of surgery, Alex Ekwueme Federal University Teaching Hospital, Abakaliki (AEFUTHA), Ebonyi State, Nigeria
- Department of Surgery, Ebonyi State University, Abakaliki (EBSU), Ebonyi State, Nigeria
| | - Livinus N Onah
- Department of Obstetric and Gynaecology, Enugu State University Teaching Hospital Enugu, Nigeria
- Department of Obstetric and Gynaecology, Enugu State University of Science and Technology, Enugu, Nigeria
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Kim HS, Kim HI, Yoon YJ, Yeom JH, Kim MG. Analysis of prognostic factors for postoperative complications and mortality in elderly patients undergoing emergency surgery for intestinal perforation or irreversible intestinal ischemia. Ann Surg Treat Res 2023; 105:198-206. [PMID: 37908381 PMCID: PMC10613825 DOI: 10.4174/astr.2023.105.4.198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/17/2023] [Accepted: 08/23/2023] [Indexed: 11/02/2023] Open
Abstract
Purpose Because the global geriatric population continues to increase, the assessment of emergency surgical outcomes in elderly patients with acute peritonitis will become more important. Methods A retrospective review was conducted on the data of 174 elderly patients who underwent emergency surgery for intestinal perforation or intestinal infarction between June 2010 and November 2022. We conducted an analysis of the risk factors associated with postoperative complications and mortality by evaluating the characteristics of patients and their surgical outcomes. Results In our study, most patients (94.3%) had preexisting comorbidities, and many patients (84.5%) required transfer to the intensive care unit following emergency surgery. Postoperative complications were observed in 84 individuals (48.3%), with postoperative mortality occurring in 29 (16.7%). Multivariate analysis revealed preoperative acute renal injury, hypoalbuminemia, and postoperative ventilator support as significant predictors of postoperative mortality. Conclusion When elderly patients undergo emergency surgery for intestinal perforation or infarction, it is important to recognize that those with preoperative acute renal injury, hypoalbuminemia, and a need for postoperative ventilator support have a poor prognosis. Therefore, these patients require intensive care from the early stages of treatment.
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Affiliation(s)
- Hyung Suk Kim
- Department of Surgery, Hanyang University Guri Hospital, Hanyang University School of Medicine, Seoul, Korea
| | - Hyun Il Kim
- Department of Surgery, Hanyang University Guri Hospital, Hanyang University School of Medicine, Seoul, Korea
| | - Young Joon Yoon
- Department of Anesthesiology, Hanyang University Guri Hospital, Hanyang University School of Medicine, Seoul, Korea
| | - Jong Hoon Yeom
- Department of Anesthesiology, Hanyang University Guri Hospital, Hanyang University School of Medicine, Seoul, Korea
| | - Min Gyu Kim
- Department of Surgery, Hanyang University Guri Hospital, Hanyang University School of Medicine, Seoul, Korea
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Vahapoğlu A, Çavuş Z, Korkan F, Özakin O, Türkmen ÜA. Is a guideline required to predict the intensive care unit need of patients over 65 years of age during the pre-operative period? A comparison of the American Society of Anesthesiologists, lung ultrasound score, Charlson age-added comorbidity index, surgi. ULUS TRAVMA ACIL CER 2023; 29:1004-1012. [PMID: 37681718 PMCID: PMC10560819 DOI: 10.14744/tjtes.2023.43082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 06/14/2023] [Accepted: 06/20/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND All pre-operative, intra-operative, and post-operative variables of the patients at 65 years of age who had a surgi-cal procedure determine the necessity of post-operative intensive care unit (ICU) monitoring. The indication for post-operative ICU is detected through ideal scoring systems related to the surgery and anesthesia that will be performed easily and fast would prevent the development of morbidity and mortality in high-risk patients. In the present study, we compared the efficacy of the American Society of Anesthesiologists (ASA) score, lung ultrasound score (LUSS), Charlson age-added comorbidity index (CACI), and surgical outcome risk tool (SORT) score of the indication for ICU. The hypothesis of our study is to show that real visual LUSS is superior to the screening test SORT, CACI, and the other score, ASA, for ICU indication determination. METHODS The study enrolled 101 patients over 65 years of age who will have surgical procedures under elective conditions. De-mographic features, clinical parameters, ICU indications, ASA, LUSS, CACI, and SORTs of the patients were calculated prospectively and recorded. The effects of patients' ASA, LUSS, CACI, and SORT on determining the need for postoperative ICU admission were examined. RESULTS The age of patients who needed post-operative ICU admission was significantly higher than those who did not need post-operative ICU admission (P<0.001). The groups did not show differences in terms of gender, body mass index, smoking, and type of anesthesia (P>0.05). ASA, LUSS, CACI, and SORT were significantly higher for patients who needed post-operative ICU admission (P<0.001). The proportion of patients who needed post-operative ICU admission was higher for patients with post-operative ICU indication (P<0.001). The number of consultations was significantly higher for patients who needed post-operative ICU admission (P<0.001). SORT was found to be the highest accuracy for predicting the need for post-operative ICU admission. CONCLUSION It was detected that ASA, LUSS, CACI, and SORT are effective for the determination of the ICU indication in the pre-operative evaluation process of patients over the age of 65 who had elective surgery. However, the efficiency of SORT was found to be superior to the others.
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Affiliation(s)
- Ayşe Vahapoğlu
- Department of Anesthesiology and Reanimation Clinic, Health Sciences University Gaziosmanpaşa Training and Research Hospital, İstanbul-Türkiye
| | - Zuhal Çavuş
- Department of Anesthesiology and Reanimation Clinic, Health Sciences University Gaziosmanpaşa Training and Research Hospital, İstanbul-Türkiye
| | - Fatma Korkan
- Department of Anesthesiology and Reanimation Clinic, Health Sciences University Gaziosmanpaşa Training and Research Hospital, İstanbul-Türkiye
| | - Oğuz Özakin
- Department of Anesthesiology and Reanimation Clinic, Health Sciences University Gaziosmanpaşa Training and Research Hospital, İstanbul-Türkiye
| | - Ülkü Aygen Türkmen
- Department of Anesthesiology and Reanimation Clinic, Health Sciences University Gaziosmanpaşa Training and Research Hospital, İstanbul-Türkiye
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Kent I, Ghuman A, Sadran L, Rov A, Lifschitz G, Rudnicki Y, White I, Goldberg N, Avital S. Emergency Colectomies in the Elderly Population—Perioperative Mortality Risk-Factors and Long-Term Outcomes. J Clin Med 2023; 12:jcm12072465. [PMID: 37048549 PMCID: PMC10095288 DOI: 10.3390/jcm12072465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/05/2023] [Accepted: 03/13/2023] [Indexed: 03/28/2023] Open
Abstract
Background: As the population ages emergency surgeries among the elderly population, including colonic resections, is also increasing. Data regarding the short- and long-term outcomes in this population is scarce. Methods: A retrospective study was performed to investigate mortality and mortality risk factors associated with emergent colectomies in older compared to younger patients in a single university affiliated tertiary hospital. Patients with metastatic disease, colectomy due to trauma or index colectomy within 30 days prior to emergent surgery were excluded. Results: Operative outcomes compared among age groups, included 30-day mortality, mortality risk-factors and long-term survival. 613 eligible patients were included in the cohort. Mean age was 69.4 years, 45.1% were female. Patients were divided into four age groups: 18–59, 60–69, 70–79 and ≥80-years. Thirty-day mortality rates were 3.2%, 11%, 29.3% and 37.8%, respectively and 22% for the entire cohort. Risk-factors for perioperative death in the younger group were related to severity of ASA score and WBC count. In groups 60–69, 70–79, main risk-factors were ADL dependency and ASA score. In the ≥80 group, risk-factors affecting perioperative mortality, included ASA score, pre-operative albumin, creatinine, WBC levels, cancer etiology, ADL dependency, and dementia. Long-term survival differed significantly between age groups. Conclusion: Perioperative mortality with emergency colectomy increases with patients’ age. Patients older than eighty-years undergoing urgent colectomies have extremely high mortality rates, leading to a huge burden on medical services. Evaluating risk-factors for mortality and pre-operative discussion with patients and families is important. Screening the elderly population for colonic pathologies can result in early diagnosis potentially leading to elective surgeries with decreased mortality.
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Kumar A, Puri G, Rathore YS, Chumber S, Trikha A, Ranjan P, Kataria K, Bhattacharjee HK. Illness wellness scale: novel grading system for performance status of patients under surgical care. ANZ J Surg 2022; 93:1190-1196. [PMID: 36259225 DOI: 10.1111/ans.18112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 10/02/2022] [Accepted: 10/03/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Grading the illness using clinical parameters is essential for the daily progress of inpatients. Existing systems do not incorporate these parameters holistically. The study was designed to internally validate the illness wellness scale, based upon clinical assessment of the patients requiring surgical care, for their risk stratification and uniformity of communication between health care providers. METHODS Prospective observational study conducted at a tertiary care hospital. An expert panel devised the scale, and it was modified after feedback from 100 health care providers. A total of 210 patients (150 for internal validation and 60 for inter-observer variability) who required care under the department of surgical disciplines were enrolled. This included patients presenting to surgery OPD, admitted to COVID/non-COVID surgical wards and ICUs, aged ≥16 years. RESULTS The response rate of the final illness wellness scale was 95% with 86% positive feedback and a mean of 1.7 on the Likert scale for ease of use (one being very easy and five being difficult). It showed excellent consistency and minimal inter-observer variability with the intra-class correlation coefficient (ICC) above 0.9. In the internal validation cohort (n = 150), univariate and multivariable analysis of factors affecting mortality revealed that categorical risk stratification, age ≥ 60 years, presence or absence of co-morbidities especially hypertension and chronic kidney disease significantly affect mortality. CONCLUSIONS The Illness wellness scale is an effective tool for uniformly communicating between health care professionals and is also a strong predictor of risk stratification and mortality in patients requiring surgical care.
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Affiliation(s)
- Arun Kumar
- Department of Surgical Disciplines, AIIMS, New Delhi, India
| | - Gopal Puri
- Department of Surgical Disciplines, AIIMS, New Delhi, India
| | | | - Sunil Chumber
- Department of Surgical Disciplines, AIIMS, New Delhi, India
| | - Anjan Trikha
- Department of Anaesthesiology and Critical Care, AIIMS, New Delhi, India
| | - Piyush Ranjan
- Department of Surgical Disciplines, AIIMS, New Delhi, India
| | - Kamal Kataria
- Department of Surgical Disciplines, AIIMS, New Delhi, India
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Zhang XM, Wu XJ, Cao J, Guo N, Bo HX, Ma YF, Jiao J, Zhu C. Effect of the Age-Adjusted Charlson Comorbidity Index on All-Cause Mortality and Readmission in Older Surgical Patients: A National Multicenter, Prospective Cohort Study. Front Med (Lausanne) 2022; 9:896451. [PMID: 35836941 PMCID: PMC9274287 DOI: 10.3389/fmed.2022.896451] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 05/31/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundIdentifying a high-risk group of older people before surgical procedures is very important. The study aimed to explore the association between the age-adjusted Charlson comorbidity index (ACCI) and all-cause mortality and readmission among older Chinese surgical patients (age ≥65 years).MethodsA large-scale cohort study was performed in 25 general public hospitals from six different geographic regions of China. Trained registered nurses gathered data on clinical and sociodemographic characteristics. All-cause mortality was recorded when patients died during hospitalization or during the 90-day follow-up period. Readmission was also tracked from hospital discharge to the 90-day follow-up. The ACCI, in assessing comorbidities, was categorized into two groups (≥5 vs. <5). A multiple regression model was used to examine the association between the ACCI and all-cause mortality and readmission.ResultsThere were 3,911 older surgical patients (mean = 72.46, SD = 6.22) in our study, with 1,934 (49.45%) males. The average ACCI score was 4.77 (SD = 1.99), and all-cause mortality was 2.51% (high ACCI = 5.06% vs. low ACCI = 0.66%, P < 0.001). After controlling for all potential confounders, the ACCI score was an independent risk factor for 90-day hospital readmission (OR = 1.18, 95% CI: 1.14, 1.23) and 90-day all-cause mortality (OR = 1.26, 95% CI: 1.16–1.36). Furthermore, older surgical patients with a high ACCI (≥5) had an increased risk of all-cause mortality (OR = 6.13, 95% CI: 3.17, 11.85) and readmission (OR = 2.13, 95% CI: 1.78, 2.56) compared to those with a low ACCI (<5). The discrimination performance of the ACCI was moderate for mortality (AUC:0.758, 95% CI: 0.715–0.80; specificity = 0.591, sensitivity = 0.846) but poor for readmission (AUC: 0.627, 95% CI: 0.605–0.648; specificity = 0.620; sensitivity = 0.590).ConclusionsThe ACCI is an independent risk factor for all-cause mortality and hospital readmission among older Chinese surgical patients and could be a potential risk assessment tool to stratify high-risk older patients for surgical procedures.
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Macmillan P, Frye J, Bunnalai T, Kaups K. Crisis Standards of Care Guidelines for the COVID-19 Pandemic: Fresno Resource Allocation Guide (FRAG). Cureus 2021; 13:e19662. [PMID: 34976456 PMCID: PMC8680015 DOI: 10.7759/cureus.19662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2021] [Indexed: 11/06/2022] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has forced healthcare providers and policymakers to look candidly at the possibility that critical care resources, such as ventilators, medical staff, extracorporeal membrane oxygenation (ECMO), bilevel positive airway pressure (BiPAP) machines, and high-flow oxygen, may become scarce or depleted if the virus continues to move throughout the United States unabated. With hospitalizations and ICU occupancy rates rapidly increasing all over the US, we must face the uncomfortable truth that a triage system, much like on the battlefields of war, will need to be implemented. Ethical concerns abound, but the process for addressing limited resources must continue to be explored. Multiple frameworks have previously been developed to address the use of limited medical resources during catastrophic public health emergencies. Many crisis care guidelines and protocols address the maximizing of surge capabilities and allocation of resource use (specifically, ventilators). While overwhelming scenarios unfolded in Europe and then on the East Coast of the United States in March of 2020, our hospital system in central California was obligated to consider previously unimaginable scenarios. In an effort to pro-actively address these, an expert group, consisting of intensivists (adult and pediatric), trauma surgery, palliative care, and ethicists was organized to develop guidelines for resource allocation to be utilized for our medical system in the event of a public health emergency. As part of this process, existing guidelines and consensus documents were reviewed. A novel system for ventilator allocation was developed, termed the Fresno Resource Allocation Guide (FRAG). As the pandemic continued to surge into 2021, we began to look at other resources, such as oxygen delivery systems other than ventilators, as well as healthcare team members. This resource allocation guide takes into account a depletion in critical care supplies for adults and children. It employs ethical principles and evidence-based tools for critical care.
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Slama EM, Hosseini M, Staszak RM, Setya VR. Open Cholecystostomy Under Local Anesthesia for Acute Cholecystitis in the Elderly and High-Risk Surgical Patients. Am Surg 2021; 88:434-438. [PMID: 34734555 DOI: 10.1177/00031348211050593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The morbidity and mortality rates associated with cholecystectomy for acute cholecystitis are higher in the critically ill elderly population. As an alternative to cholecystectomy, we report the results of treatment of acute cholecystitis in the elderly after open cholecystolithotomy with cholecystostomy tube placement under local anesthesia. METHODS A case series was performed on 5 patients from August 2007 to April 2010 who presented with acute cholecystitis and underwent an open cholecystolithotomy and tube placement. Thirty-day mortality, intra- and immediate-postoperative complications, clinical improvement after drainage, additional biliary procedures needed, and outcome after cholecystostomy tube removal were recorded. RESULTS Open cholecystolithotomy and tube placement were performed successfully in all patients and permitted resolution of the acute attack in all after a mean period of 3.75 days. Thirty-day mortality was 0%. Patients did not experience any intraoperative complications. We observed 100% rate of successful short-term outcomes in our patients including resolution pain, and objectively, normalization of leukocytosis, and defervescence. None of the patients required emergency cholecystectomy. All patients had their cholecystostomy tubes removed at a mean postoperative day 27. There were no cases of biliary leakage or tube dislodgement. There were no recurrences of acute cholecystitis within the mean follow-up of 20.75 months. DISCUSSION Emergency open cholecystolithotomy and cholecystostomy tube placement represent an effective, safe, and definitive alternative treatment strategy for acute gallstone cholecystitis in selected elderly patients with a mortality rate of 0% in the authors' experience.
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Affiliation(s)
- Eliza M Slama
- Department of Surgery, 21963Ascension Saint Agnes Hospital, Baltimore, MD, USA
| | - Motahar Hosseini
- Department of Cardiothoracic Surgery, 4352Mayo Clinic, Rochester, MN, USA
| | - Ryan M Staszak
- Department of Trauma, Acute Care, and Critical Care Surgery, 328945Pennsylvania State University Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Viney R Setya
- Department of Surgery, 21963Ascension Saint Agnes Hospital, Baltimore, MD, USA
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11
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Yu H, Gild P, Pompe RS, Vetterlein MW, Ludwig TA, Soave A, Kölker M, Maurer V, Marks P, Becker A, Punke MA, Fisch M, Rink M, Dahlem R, Meyer CP. Anesthetic Technique (Spinal vs. General Anesthesia) in Holmium Laser Enucleation of the Prostate: Retrospective Analysis of Procedural and Functional Outcomes among 1,159 Patients. Urol Int 2021; 107:336-343. [PMID: 34404060 DOI: 10.1159/000517542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 03/29/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of the study was to compare procedural efficacy, early and late functional outcomes in holmium laser enucleation of the prostate (HoLEP) under spinal anesthesia (SA) versus general anesthesia (GA). METHODS We retrospectively reviewed patients undergoing HoLEP at our institution between 2012 and 2017. Standard pre-, peri-, and postoperative characteristics were compared according to anesthetic technique. Multivariable logistic regression analyses (MVAs) were employed to study the impact of SA on procedural efficacy and postoperative complications. RESULTS Our study cohort consisted of 1,159 patients, of whom 374 (32%) underwent HoLEP under SA. While a medical history of any anticoagulation/antiplatelet therapy except low-dose acetylsalicylic acid was significantly more common among patients undergoing GA (16% vs. 10%, p = 0.001), no other significant differences in preoperative characteristics were noted including age, body mass index, American Society of Anesthesiologists Classification (ASA), prostate size, or International Prostate Symptom Score (IPSS), and quality of life scores. Patients under SA exhibited shorter times of enucleation 42 min (interquartile range [IQR]:27-59 vs. 45 min [IQR: 31-68], p = 0.002), and combined time of enucleation/morcellation/coagulation (57 min [IQR: 38-85] vs. 64 min [IQR: 43-93], p = 0.002), as well as fewer complications (Clavien-Dindo ≥3) (12 [3.2%] vs. 55 [7%], p = 0.013). These associations were confirmed in MVA. Patients did not differ significantly with regard to early micturition including post-void residual volume and maximum flow-rate improvement. At a median follow-up of 33 months (IQR: 32-44), patients with SA had a lower IPSS score (median 3 [IQR: 1-6] vs. 4 [IQR: 2-7], p = 0.039). However, no significant differences were observed with respect to any urinary incontinence, urge symptoms, and postoperative pain. CONCLUSION In this large retrospective series, HoLEP under SA was a safe and efficacious procedure with comparable early and long-term functional outcomes.
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Affiliation(s)
- Hang Yu
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Philipp Gild
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Raisa S Pompe
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Malte W Vetterlein
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tim A Ludwig
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Armin Soave
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mara Kölker
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Valentin Maurer
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Phillip Marks
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Becker
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Urology, University Medical Center Frankfurt, Frankfurt, Germany
| | - Mark-Andree Punke
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Margit Fisch
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Rink
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Roland Dahlem
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian P Meyer
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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12
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External Prospective Validation of the Modified CriSTAL Score for 30- and 90-day Mortality in Geriatric Urgent Surgical Patients. J Gastrointest Surg 2021; 25:2083-2090. [PMID: 33111261 DOI: 10.1007/s11605-020-04822-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 10/01/2020] [Indexed: 01/31/2023]
Abstract
OBJECTIVE This study aimed to determine the predictive accuracy of the modified clinical prognostic tool Criteria for Screening and Triaging to Appropriate aLternative care (CriSTAL) to predict 30-day and 90-day mortality in older patients undergoing urgent abdominal surgery. BACKGROUND Anticipating the mid-term mortality of older patients undergoing urgent surgery is complex and flawed with uncertainty. METHODS A prospective study of consecutive ≥ 65 years old presenting at the emergency department who subsequently underwent urgent abdominal surgery. The modified CriSTAL score was calculated in the sample using the FRAIL scale instead of the Clinical Frailty Scale. Discrimination (area under the receiver-operating characteristic (AUROC)) and model calibration were used to test the predictive accuracy of the modified CriSTAL score for death within 30-day mortality as the primary outcome. RESULTS A total of 500 patients (median age 78 years) were enrolled. The observed 30-day and 90-day mortality rate were 11.6% and 13.6%. The modified CriSTAL tool AUROC curve to predict 30-day and 90-day mortality was 0.78 and 0.77. The model was well calibrated according to the Hosmer-Lemeshow test (p: 0.302) and the calibration plots to predict 30-day and 90-day mortality. CONCLUSIONS The modified CriSTAL tool (with FRAIL scale as frailty instrument) had good discriminant power and was well calibrated to predict 30-day and 90-day mortality in elderly patients undergoing urgent abdominal surgery. The modified CriSTAL tool is an easy preoperative tool that could assist in the prognosis of postoperative outcomes and decision-making discussions with patients before for urgent abdominal surgery.
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13
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Dobaria V, Hadaya J, Sanaiha Y, Aguayo E, Sareh S, Benharash P. The Pragmatic Impact of Frailty on Outcomes of Coronary Artery Bypass Grafting. Ann Thorac Surg 2021; 112:108-115. [DOI: 10.1016/j.athoracsur.2020.08.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 07/12/2020] [Accepted: 08/18/2021] [Indexed: 12/14/2022]
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14
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Kao AM, Maloney SR, Prasad T, Reinke CE, May AK, Heniford BT, Ross SW. The CELIOtomy Risk Score: An effort to minimize futile surgery with analysis of early postoperative mortality after emergency laparotomy. Surgery 2020; 168:676-683. [DOI: 10.1016/j.surg.2020.05.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 05/26/2020] [Accepted: 05/27/2020] [Indexed: 10/23/2022]
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15
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Usefulness of pre- and intraoperative risk scores in nonagenarian surgical patients. J Anesth 2020; 34:650-657. [PMID: 32448952 DOI: 10.1007/s00540-020-02799-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 05/16/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE Preoperative assessment at extreme ages would identify patients at a high risk of developing postoperative complications. The objective of this study was to compare the usefulness of different risk scales in a series of nonagenarian surgical patients. METHODS A total of 244 surgical nonagenarians, 148 women (60.7%), median age 91 years (IQR: 90-93), were analysed. The following scales were evaluated: preoperative status (ASA-PS, Charlson Comorbidity Index, Lee Index, Reiss Index, and surgical mortality probability model-S-MPM); intraoperative status (Surgical Apgar Score and SASA score), and, as output variables, surgical outcomes (morbidity measured by the Comprehensive Complication Index-CCI, and death). Univariate analysis and receiver operating characteristic curves (ROC) were performed. Area under ROC curves (AUROC) were evaluated to define the best predictors of poor outcomes. RESULTS Operative mortality was 27.0%, and 73.4% presented some type of postoperative complication. Operative mortality was associated with the ASA-PS score (p < 0.001), Reiss Index (p < 0.001), Lee Index (p = 0.010), S-MPM (p < 0.001), Surgical Apgar Score (p < 0.001), SASA score (p < 0.001), and emergency surgery (p < 0.001). Postoperative complications were related to the ASA-PS score (p = 0.001), Reiss Index (p < 0.001), Lee Index (p < 0.001), S-MPM (p < 0.001), Surgical Apgar Score (p < 0.001) and SASA score (p < 0.001). The best predictors of operative mortality and complications were the SASA and Surgical Apgar Score (AUROCs > 0.88). CONCLUSION As in the general population, the Surgical Apgar Score and SASA score are the best predictors of operative mortality and morbidity in nonagenarian patients. These risk scales should be considered in the perioperative management of these patients.
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16
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Sahara K, Paredes AZ, Merath K, Tsilimigras DI, Bagante F, Ratti F, Marques HP, Soubrane O, Beal EW, Lam V, Poultsides GA, Popescu I, Alexandrescu S, Martel G, Aklile W, Guglielmi A, Hugh T, Aldrighetti L, Endo I, Pawlik TM. Evaluation of the ACS NSQIP Surgical Risk Calculator in Elderly Patients Undergoing Hepatectomy for Hepatocellular Carcinoma. J Gastrointest Surg 2020; 24:551-559. [PMID: 30937717 DOI: 10.1007/s11605-019-04174-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 02/20/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) surgical risk calculator (SRC) aims to help predict patient-specific risk for morbidity and mortality. The performance of the SRC among an elderly population undergoing curative-intent hepatectomy for hepatocellular carcinoma (HCC) remains unknown. METHODS Patients > 70 years of age who underwent hepatectomy for HCC between 1998 and 2017 were identified using a multi-institutional international database. To estimate the performance of SRC, 12 observed postoperative outcomes were compared with median SRC-predicted risk, and C-statistics and Brier scores were calculated. RESULTS Among 500 patients, median age was 75 years (IQR 72-78). Most patients (n = 324, 64.8%) underwent a minor hepatectomy, while 35.2% underwent a major hepatectomy. The observed incidence of venous thromboembolism (VTE) (3.2%) and renal failure (RF) (4.4%) exceeded the median predicted risk (VTE, 1.8%; IQR 1.5-3.1 and RF, 1.0%; IQR 0.5-2.0). In contrast, the observed incidence of 30-day readmission (7.0%) and non-home discharge (2.5%) was lower than median-predicted risk (30-day readmission, 9.4%; IQR 7.4-12.8 and non-home discharge, 5.7%; IQR 3.3-11.7). Only 57.8% and 71.2% of patients who experienced readmission (C-statistic, 0.578; 95%CI 0.468-0.688) or mortality (C-statistic, 0.712; 95%CI 0.508-0.917) were correctly identified by the model. CONCLUSION Among elderly patients undergoing hepatectomy for HCC, the SRC underestimated the risk of complications such as VTE and RF, while being no better than chance in estimating the risk of readmission. The ACS SRC has limited clinical applicability in estimating perioperative risk among elderly patients being considered for hepatic resection of HCC.
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Affiliation(s)
- Kota Sahara
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.,Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Anghela Z Paredes
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Katiuscha Merath
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Fabio Bagante
- Department of Surgery, University of Verona, Verona, Italy
| | | | - Hugo P Marques
- Department of Surgery, Curry Cabral Hospital, Lisbon, Portugal
| | - Olivier Soubrane
- Department of Hepatobiliopancreatic Surgery, APHP, Beaujon Hospital, Clichy, France
| | - Eliza W Beal
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Vincent Lam
- Department of Surgery, Westmead Hospital, Sydney, Australia
| | | | - Irinel Popescu
- Department of Surgery, Fundeni Clinical Institute, Bucharest, Romania
| | | | | | - Workneh Aklile
- Department of Surgery, University of Ottawa, Ottawa, Canada
| | | | - Tom Hugh
- Department of Surgery, The University of Sydney, School of Medicine, Sydney, Australia
| | | | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Timothy M Pawlik
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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Ceresoli GL, Rossi A. Approved and emerging treatments of malignant pleural mesothelioma in elderly patients. Expert Rev Respir Med 2019; 13:1179-1188. [PMID: 31596154 DOI: 10.1080/17476348.2019.1678386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Introduction: Malignant pleural mesothelioma (MPM) is a rare neoplasm with asbestos exposure as the dominant etiologic agent. Owing to the long latent period following exposure, MPM is often diagnosed late in life. Despite this, elderly patients are under-represented in clinical trials. To date, data regarding the tolerability and efficacy of anticancer treatments for elderly patients affected by MPM are still lacking.Areas covered: The current state-of-the-art of approved treatments employed in the treatment of MPM elderly patients is reviewed and discussed, with a look to emerging therapies. A structured search of bibliographic databases for peer-reviewed research literature and of main meeting abstracts using a focused review question was undertaken.Expert opinion: Even though the median age of MPM patients enrolled in the most recent experimental trials is increasing, no specific analysis has been reported so far in the elderly. Moreover, no data are available for the 'oldest of the elderly' (>75 years). Treatment of elderly patients with MPM is one of the major challenges to the clinician. There is a clear need of large, well-conducted retrospective studies and above all of prospective investigations in this patient population, both in the first-and in the second-line setting.
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Affiliation(s)
- Giovanni Luca Ceresoli
- Division of Medical Oncology, Thoracic and Urologic Oncology Unit, Cliniche Humanitas Gavazzeni, Bergamo, Italy
| | - Antonio Rossi
- Division of Medical Oncology, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo (FG), Italy
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Nag DS, Dembla A, Mahanty PR, Kant S, Chatterjee A, Samaddar DP, Chugh P. Comparative analysis of APACHE-II and P-POSSUM scoring systems in predicting postoperative mortality in patients undergoing emergency laparotomy. World J Clin Cases 2019; 7:2227-2237. [PMID: 31531317 PMCID: PMC6718800 DOI: 10.12998/wjcc.v7.i16.2227] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 06/28/2019] [Accepted: 07/20/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Laparotomy remains one of the commonest emergency surgical procedures. Early prognostic evaluation would aid in selecting the high-risk patients for an aggressive treatment. Awareness about risks could potentially contribute to the quality of perioperative care and optimum utilization of resources. Portsmouth modification of Physiological and operative severity for the enumeration of mortality and morbidity (P-POSSUM) and the acute physiology and chronic health evaluation II (APACHE-II) have been the most widely used scoring systems for emergency laparotomies. It is always better to have a single scoring system to predict outcomes and audit healthcare organizations.
AIM To compare the ability of APACHE-II and P-POSSUM to predict postoperative morbidity and mortality in patients undergoing emergency laparotomy.
METHODS All patients undergoing emergency laparotomy at the Tata Main Hospital, Jamshedpur between December 2013 and November 2014 were included in the study. In this observational study, P-POSSUM and APACHE-II scoring were done, and the outcome analysis evaluated with mortality being the primary outcome.
RESULTS For P-POSSUM, at a cut off value of 63 to predict mortality using receiver operating characteristics curve analysis, the area under the curve was 0.989; and for APACHE-II, at the cut off value of 24, the area under the curve was 0.965.
CONCLUSION Because the ability of APACHE-II to predict mortality was similar to P-POSSUM and APACHE-II does not need scoring for intra-operative findings and histopathology reports, APACHE-II can be used pre-operatively to assess the risk in patients undergoing emergency laparotomy. However, for audit purposes, either of the two scoring systems can be used.
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Affiliation(s)
- Deb Sanjay Nag
- Department of Anaesthesiology and Critical Care, Tata Main Hospital, Jamshedpur 831001, India
| | - Ankur Dembla
- Department of Anaesthesiology and Critical Care, Darya Ram Hospital, Sonipat 131001, India
| | - Pratap Rudra Mahanty
- Department of Anaesthesiology and Critical Care, Tata Main Hospital, Jamshedpur 831001, India
| | - Shashi Kant
- Department of Anaesthesiology and Critical Care, Tata Main Hospital, Jamshedpur 831001, India
| | - Abhishek Chatterjee
- Department of Anaesthesiology and Critical Care, Tata Main Hospital, Jamshedpur 831001, India
| | - Devi Prasad Samaddar
- Department of Anaesthesiology and Critical Care, Tata Main Hospital, Jamshedpur 831001, India
| | - Parul Chugh
- Department of Biomedical Statistics, Sir Ganga Ram Hospital, New Delhi 110060, India
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Lima MJM, Cristelo DFM, Mourão JB. Physiological and operative severity score for the enumeration of mortality and morbidity, frailty, and perioperative quality of life in the elderly. Saudi J Anaesth 2019; 13:3-8. [PMID: 30692881 PMCID: PMC6329238 DOI: 10.4103/sja.sja_275_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background: Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) is a validated instrument used to predict morbidity. The aim of our study was to evaluate the performance of the POSSUM score system on predicting perioperative frailty and quality of life (QOL) in elderly surgical patients. Patients and Methods: An observational prospective study was conducted during 3 months. POSSUM was used to determine operative morbidity risk. Patients with a POSSUM score ≥26 were considered as having a high POSSUM (PHP). WHODAS 2.0, EuroQOL-5 dimensions (EQ-5D), Charlson score, and the Clinical Frailty Scale were used to assess the QOL and frailty. Chi-square, Fisher's exact, or Mann–Whitney tests were used for comparisons. Results: Two hundred and thirty-five patients were included. Median age was 69 years; 58% were ASA I/II and 42% ASA III/IV. Frailty was present in 53 patients (23%). Median POSSUM score was 26. Patients PHP were older (median age 71 vs. 68, P = 0.008), more frequently ASA III/IV (P = 0.001), had higher median Charlson scores (7 vs. 5, P = 0.006) and were more frail (49% vs. 26%, P < 0.001). PHP presented more problems in EQ-5D dimensions preoperatively (mobility: 59% vs 41%, P = 0.008; care: 41% vs. 25%, P = 0.013; activity: 52% vs. 32%, P = 0.002; pain: 59% vs. 45%, P = 0.041) but not anxiety (P = 0.137). Three months after surgery, PHP patients presented more problems in mobility: 63% vs. 38%, P < 0.001; care: 48% vs. 31%, P = 0.009; activity: 58% vs. 44%, P = 0.036; pain 59% vs. 37%, P = 0.001 and anxiety: 54% vs. 50%, P = 0.025. Conclusions: Patients PHP were frailer and had worse perioperative QOL.
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Affiliation(s)
| | | | - Joana B Mourão
- Faculty of Medicine, Porto University, Porto, Portugal.,Department of Anaesthesiology, Centro Hospitalar São João, Porto, Portugal
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Soluble Urokinase Plasminogen Activator Receptor (suPAR) as an Added Predictor to Existing Preoperative Risk Assessments. World J Surg 2018; 43:780-790. [PMID: 30390135 DOI: 10.1007/s00268-018-4841-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Risk assessment strategies, such as using the American Society of Anesthesiologists (ASA) physical status classification, attempt to identify surgical high-risk patients. Soluble urokinase plasminogen activator receptor (suPAR) is a biomarker reflecting overall systemic inflammation and immune activation, and it could potentially improve the identification of high-risk surgical patients. METHODS We included patients acutely admitted to the emergency department who subsequently underwent surgery within 90 days of admission. Patients were stratified into low-risk or high-risk groups, according to ASA classification (ASAlow: ASA I-II; ASAhigh: ASA III-VI) and suPAR level, measured at admission (suPARhigh above and suPARlow below 5.5 ng/ml), respectively. Pre-specified complications were identified in national registries and electronic medical records. The association between ASA classification, suPAR level, CRP and the rate of postoperative complications was analyzed with logistic regression and Cox regression analyses, estimating odds ratios and hazard ratios (HRs). RESULTS During 90-day follow-up from surgery, 31 (7.0%) patients died and 158 (35.6%) patients had postoperative complications. After adjusting for age, sex, and ASA classification, the HR for 90-day postoperative mortality was 2.5 (95% CI 1.6-4.0) for every doubling of suPAR level. suPAR was significantly better than CRP at predicting mortality and all complications (P = 0.0036 and P = 0.0041, respectively). Combining ASA classification and suPAR level significantly improved prediction of mortality and the occurrence of a postoperative complication within 90 days after surgery (P < 0.0001). CONCLUSION Measuring suPAR levels in acutely admitted patients may aid in identifying high-risk patients and improve prediction of postoperative complications.
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Preoperative Predictors of Mortality in Short-Term Continuous-Flow Ventricular Assist Devices. ASAIO J 2018; 65:769-774. [PMID: 30325847 DOI: 10.1097/mat.0000000000000902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Short-term continuous-flow ventricular assist devices (STCF-VADs) are increasingly being utilized to support critically ill patients, despite limited information regarding overall outcomes. All adult patients supported with an STCF-VAD between June 2009 and December 2015 were included in this retrospective single-center study. Associations between preoperative characteristics and unsuccessful bridge (death on device or within 30 days postdecannulation) were assessed using logistic regression. A total of 61 patients (77% male) were identified with a median age at implant of 54.6 years. Left VADs were implanted in 51%, right VADs in 21%, and both VADs in 28%, and patients were supported for a median of 11 days. Overall, 23% were weaned to recovery, 13% underwent heart transplantation, 16% converted to long-term VADs, and 48% had an unsuccessful bridge. In multivariable analysis, only renal insufficiency or dialysis (odds ratio = 7.53; p = 0.002) remained a significant independent predictor of an unsuccessful bridge. Short-term continuous-flow VADs can successfully bridge adult patients with mortality around 50%. Preimplant renal insufficiency or dialysis is correlated with an unsuccessful bridge in our patient population, likely reflecting the severity of illness preimplant. Further studies are required to determine whether this factor remains significant in a larger patient population.
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Lee DW, Baik J, Yun G, Jeon S, Kim HJ, Kim ES, Lee HJ, Kwon JY. A prospective pilotstudy comparing the anesthetic effects of an alpha-2 agonist during holmium laser resection of the prostate and transurethral resection for prostate surgery for benign prostatic hyperplasia patients using selective alpha-1 blockers. BMC Anesthesiol 2018; 18:136. [PMID: 30261833 PMCID: PMC6161351 DOI: 10.1186/s12871-018-0598-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 09/19/2018] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND To examine the response to an α2receptor agonist used as a sedative for patients using long-term selective α1 blockers. METHODS Sixty-nine consecutive patients undergoing transurethral prostate resection or holmium laser resection of the prostateunder spinal anesthesia were divided into two groups; group N (n = 37), which did not receive α1 blockers, and group T (n = 32), which was administered tamsulosin for at least 1 month before the study. Bispectral index scores, Modified Observer's Assessment of Alertness/Sedation scale scores, heart rate, and mean blood pressure were obtained under sedation using dexmedetomidine for 30 min during surgery. RESULTS The only significant difference found between the groups were mean bloodpressure 15 min after the first loading dose injection of dexmedetomidine. Differencesbetween both groupswere noted at 15 min(group T: 100.2 ± 12.9 mmHg; group N: 90.0 ± 17.5 mmHg; P = 0.08), 20 min (group T: 99.8 ± 12.3 mmHg; group N: 87.4 ± 15.0 mmHg; P < 0.00), 25 min (group T: 99.3 ± 13.4 mmHg; group N: 85.4 ± 13.8 mmHg; P < 0.00), and 30 min (group T: 98.8 ± 13.1 mmHg; group N: 84.5 ± 13.5 mmHg; P < 0.00). CONCLUSIONS The use of α2 agonists is appropriate during surgery for benign prostatic hyperplasia patients using tamsulosin, and there is no need to alter the dose. Alertness with anesthesia involving α2 agents was maintained for patients using long-term tamsulosin and patients who did not use tamsulosin. TRIAL REGISTRATION The study was retrospectively registered with the Clinical Research Informational Service ( KCT0002967 , July 2, 2018).
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Affiliation(s)
- Do-Won Lee
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Biomedical Research Institute, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan-si, 49241, South Korea
| | - Jiseok Baik
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Biomedical Research Institute, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan-si, 49241, South Korea.
| | - Giyoung Yun
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Biomedical Research Institute, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan-si, 49241, South Korea
| | - Soeun Jeon
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Biomedical Research Institute, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan-si, 49241, South Korea
| | - Hyae-Jin Kim
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Biomedical Research Institute, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan-si, 49241, South Korea
| | - Eun-Soo Kim
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Biomedical Research Institute, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan-si, 49241, South Korea
| | - Hyeon Jeong Lee
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Biomedical Research Institute, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan-si, 49241, South Korea
| | - Jae-Young Kwon
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Biomedical Research Institute, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan-si, 49241, South Korea
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Eamer G, Al-Amoodi MJH, Holroyd-Leduc J, Rolfson DB, Warkentin LM, Khadaroo RG. Review of risk assessment tools to predict morbidity and mortality in elderly surgical patients. Am J Surg 2018; 216:585-594. [PMID: 29776643 DOI: 10.1016/j.amjsurg.2018.04.006] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 03/23/2018] [Accepted: 04/11/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Informed surgical consent requires accurate estimation of risks and benefits. Multiple risk assessment tools are available; however, most are not widely used or are specific to certain interventions. Assessing surgical risk is especially challenging in elderly patients because of their range of comorbidities, level of frailty, or severity of illness and a number of available surgical interventions. DATA SOURCES We searched MEDLINE from January 2014 to July 2017 for studies that used risk assessment tools in studies on elderly surgical patients. We then sought the original articles describing each assessment tool and subsequent validation studies. CONCLUSIONS We identified risk assessment tools that can improve surgical risk assessment in elderly surgical patients. The majority of the identified tools are not commonly used for pre-operative risk assessment. NSQIP-PMP, mFI and SURPAS are promising tools. Age is commonly used to predict risk, but frailty may be a more appropriate measure.
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Affiliation(s)
- Gilgamesh Eamer
- Department of Surgery, University of Alberta, Edmonton, Canada
| | | | - Jayna Holroyd-Leduc
- Department of Community Health Sciences, University of Calgary, Calgary, Canada; Department of Medicine, University of Calgary, Calgary, Canada
| | | | | | - Rachel G Khadaroo
- Department of Surgery, University of Alberta, Edmonton, Canada; Department of Critical Care Medicine, University of Alberta, Edmonton, Canada.
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24
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Risk Factors for Mortality and Morbidity in Elderly Patients Presenting with Digestive Surgical Emergencies. World J Surg 2017; 42:1988-1996. [DOI: 10.1007/s00268-017-4419-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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25
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Sartelli M, Catena F, Abu-Zidan FM, Ansaloni L, Biffl WL, Boermeester MA, Ceresoli M, Chiara O, Coccolini F, De Waele JJ, Di Saverio S, Eckmann C, Fraga GP, Giannella M, Girardis M, Griffiths EA, Kashuk J, Kirkpatrick AW, Khokha V, Kluger Y, Labricciosa FM, Leppaniemi A, Maier RV, May AK, Malangoni M, Martin-Loeches I, Mazuski J, Montravers P, Peitzman A, Pereira BM, Reis T, Sakakushev B, Sganga G, Soreide K, Sugrue M, Ulrych J, Vincent JL, Viale P, Moore EE. Management of intra-abdominal infections: recommendations by the WSES 2016 consensus conference. World J Emerg Surg 2017; 12:22. [PMID: 28484510 PMCID: PMC5418731 DOI: 10.1186/s13017-017-0132-7] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 04/25/2017] [Indexed: 12/18/2022] Open
Abstract
This paper reports on the consensus conference on the management of intra-abdominal infections (IAIs) which was held on July 23, 2016, in Dublin, Ireland, as a part of the annual World Society of Emergency Surgery (WSES) meeting. This document covers all aspects of the management of IAIs. The Grading of Recommendations Assessment, Development and Evaluation recommendation is used, and this document represents the executive summary of the consensus conference findings.
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Affiliation(s)
| | - Fausto Catena
- Department of Emergency Surgery, Maggiore Hospital, Parma, Italy
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Luca Ansaloni
- General Surgery Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Walter L Biffl
- Acute Care Surgery, The Queen's Medical Center, Honolulu, HI USA
| | | | - Marco Ceresoli
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Osvaldo Chiara
- Emergency Department, Trauma Center, Niguarda Hospital, Milan, Italy
| | - Federico Coccolini
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Jan J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | | | - Christian Eckmann
- Department of General, Visceral, and Thoracic Surgery, Klinikum Peine, Academic Hospital of Medical University Hannover, Hannover, Germany
| | - Gustavo P Fraga
- Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Maddalena Giannella
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | | | - Ewen A Griffiths
- General and Upper GI Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - Jeffry Kashuk
- Department of Surgery, Assia Medical Group, Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel
| | - Andrew W Kirkpatrick
- Departments of Surgery, Critical Care Medicine, and the Regional Trauma Service, Foothills Medical Centre, Calgary, AB Canada
| | - Vladimir Khokha
- Department of Emergency Surgery, Mozyr City Hospital, Mozyr, Belarus
| | - Yoram Kluger
- Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Francesco M Labricciosa
- Department of Biomedical Sciences and Public Health, Unit of Hygiene, Preventive Medicine and Public Health, UNIVPM, Ancona, Italy
| | - Ari Leppaniemi
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - Ronald V Maier
- Department of Surgery, University of Washington, Seattle, WA USA
| | - Addison K May
- Departments of Surgery and Anesthesiology, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN USA
| | | | - Ignacio Martin-Loeches
- Multidisciplinary Intensive Care Research Organization (MICRO), Wellcome Trust-HRB Clinical Research, Department of Clinical Medicine, Trinity Centre for Health Sciences, St James's University Hospital, Dublin, Ireland
| | - John Mazuski
- Department of Surgery, School of Medicine, Washington University in Saint Louis, St. Louis, MO USA
| | - Philippe Montravers
- Département d'Anesthésie-Réanimation, CHU Bichat Claude-Bernard-HUPNVS, Assistance Publique-Hôpitaux de Paris, University Denis Diderot, Paris, France
| | - Andrew Peitzman
- Department of Surgery, UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA USA
| | - Bruno M Pereira
- Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Tarcisio Reis
- Emergency post-operative Department, Otavio De Freitas Hospital and Osvaldo Cruz Hospital Recife, Recife, Brazil
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Gabriele Sganga
- Department of Surgery, Catholic University of Sacred Heart, Rome, Italy
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Michael Sugrue
- Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, Ireland
| | - Jan Ulrych
- 1st Department of Surgery, Department of Abdominal, Thoracic Surgery and Traumatology, General University Hospital, Praha, Czech Republic
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - Pierluigi Viale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Ernest E Moore
- Department of Surgery, University of Colorado, Denver, CO USA
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Bailey JG, Davis PJB, Levy AR, Molinari M, Johnson PM. The impact of adverse events on health care costs for older adults undergoing nonelective abdominal surgery. Can J Surg 2017; 59:172-9. [PMID: 26999476 DOI: 10.1503/cjs.013915] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Postoperative complications have been identified as an important and potentially preventable cause of increased hospital costs. While older adults are at increased risk of experiencing complications and other adverse events, very little research has specifically examined how these events impact inpatient costs. We sought to examine the association between postoperative complications, hospital mortality and loss of independence and direct inpatient health care costs in patients 70 years or older who underwent nonelective abdominal surgery. METHODS We prospectively enrolled consecutive patients 70 years or older who underwent nonelective abdominal surgery between July 1, 2011, and Sept. 30, 2012. Detailed patient-level data were collected regarding demographics, diagnosis, treatment and outcomes. Patient-level resource tracking was used to calculate direct hospital costs (2012 $CDN). We examined the association between complications, hospital mortality and loss of independence cost using multiple linear regression. RESULTS During the study period 212 patients underwent surgery. Overall, 51.9% of patients experienced a nonfatal complication (32.5% minor and 19.4% major), 6.6% died in hospital and 22.6% experienced a loss of independence. On multivariate analysis nonfatal complications (p < 0.001), hospital mortality (p = 0.021) and loss of independence at discharge (p < 0.001) were independently associated with health care costs. These adverse events respectively accounted for 30%, 4% and 10% of the total costs of hospital care. CONCLUSION Adverse events were common after abdominal surgery in older adults and accounted for 44% of overall costs. This represents a substantial opportunity for better patient outcomes and cost savings with quality improvement strategies tailored to the needs of this high-risk surgical population.
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Affiliation(s)
- Jonathan G Bailey
- From the Division of General Surgery, Dalhousie University, Halifax, NS (Bailey, Davis, Molinari, Johnson); and the Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS (Levy, Molinari, Johnson)
| | - Philip J B Davis
- From the Division of General Surgery, Dalhousie University, Halifax, NS (Bailey, Davis, Molinari, Johnson); and the Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS (Levy, Molinari, Johnson)
| | - Adrian R Levy
- From the Division of General Surgery, Dalhousie University, Halifax, NS (Bailey, Davis, Molinari, Johnson); and the Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS (Levy, Molinari, Johnson)
| | - Michele Molinari
- From the Division of General Surgery, Dalhousie University, Halifax, NS (Bailey, Davis, Molinari, Johnson); and the Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS (Levy, Molinari, Johnson)
| | - Paul M Johnson
- From the Division of General Surgery, Dalhousie University, Halifax, NS (Bailey, Davis, Molinari, Johnson); and the Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS (Levy, Molinari, Johnson)
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Sharrock AE, McLachlan J, Chambers R, Bailey IS, Kirkby-Bott J. Emergency Abdominal Surgery in the Elderly: Can We Predict Mortality? World J Surg 2017; 41:402-409. [PMID: 27783141 PMCID: PMC5258798 DOI: 10.1007/s00268-016-3751-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND The United Kingdom population is ageing. Half of patients requiring an emergency laparotomy are aged over 70, 20 % die within 30 days, and less than half receive good care. Frailty and delay in management are associated with poor surgical outcomes. P-POSSUM risk scoring is widely accepted, but its validity in patients aged over 70 undergoing emergency laparotomy is unclear. AIMS To assess if P-POSSUM risk stratification reliably predicts inpatient mortality in this group and establish whether those who died within 30 days received delayed care. METHODS Observational study of consecutive patients aged 70 and over fulfilling the National Emergency Laparotomy Audit criteria from a tertiary hospital. The predictive value of pre-operative P-POSSUM, ASA, lactate and other routine variables was assessed. Surgical review, decision to operate, consultant surgical review, antibiotic prescription, laparotomy and discharge or death time points were assessed by 30-day survival. RESULTS One hundred and ninety-three patients were included. This represented 46.28 % of those undergoing an emergency laparotomy in our centre. Pre-operative P-POSSUM scoring, ASA grade and lactate were moderate predictors of mortality (AUC 0.784 and 0.771, respectively, lactate AUC 0.705, all p ≤ 0.001). No correlation existed between pre-operative P-POSSUM and days to death (p = 0.209), nor were there delays in key management timings in those who died in 30 days. CONCLUSIONS P-POSSUM scoring may predict inpatient mortality with moderate discrimination. Addition of frailty scoring in this high-risk group might better identify those with a high risk of mortality after emergency laparotomy and would be a fertile area for further research.
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Affiliation(s)
- Anna E Sharrock
- Emergency General Surgery Department, Southampton General Hospital, Southampton, UK.
- Inflammation, Repair and Development Section, National Heart and Lung Institute, Imperial College, London, UK.
| | - Jenny McLachlan
- Anaesthetics Department, Southampton General Hospital, Southampton, UK
| | - Robert Chambers
- Anaesthetics Department, Southampton General Hospital, Southampton, UK
- General Intensive Care Department, Southampton General Hospital, Southampton, UK
| | - Ian S Bailey
- Emergency General Surgery Department, Southampton General Hospital, Southampton, UK
| | - James Kirkby-Bott
- Emergency General Surgery Department, Southampton General Hospital, Southampton, UK
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Åkerberg D, Björnsson B, Ansari D. Factors influencing receipt of adjuvant chemotherapy after surgery for pancreatic cancer: a two-center retrospective cohort study. Scand J Gastroenterol 2017; 52:56-60. [PMID: 27598522 DOI: 10.1080/00365521.2016.1228118] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The addition of adjuvant chemotherapy after surgical resection has improved survival rates for patients with pancreatic ductal adenocarcinoma (PDAC). However, outside clinical trials, many operated patients still do not receive adjuvant chemotherapy due to clinical and tumor-related factors. The aim of this study was to investigate factors that may influence the receipt of adjuvant chemotherapy and the effect on long-term survival. MATERIALS AND METHODS Patients undergoing macroscopically curative resection for PDAC at the University Hospitals in Lund and Linköping, Sweden, between 1 January 2007 and 31 December 2015, were retrospectively reviewed. Clinical and pathological data were compared between adjuvant and non-adjuvant chemotherapy groups and factors affecting chemotherapy receipt were analyzed by multiple logistic regression. Multivariable Cox regression analysis was performed to select predictive variables for survival. RESULTS A total of 233 patients were analyzed. Adjuvant chemotherapy was administered to 167 patients (71.7%). The likelihood of receiving adjuvant chemotherapy decreased with age, OR 0.91, 95% CI 0.86-0.95, p < .001. Moreover, patients with severe postoperative complications (Clavien-Dindo grade ≥ III) were less likely to receive adjuvant chemotherapy, OR 0.31, 95% CI 0.14-0.71, p = .005. The presence of lymph node metastases on histopathological reporting was associated with increased likelihood of initiating adjuvant chemotherapy, OR 2.19, 95% CI 1.09-4.40, p = .028. Adjuvant chemotherapy was an independent factor for prolonged survival on multivariable Cox regression analysis, HR 0.45 (95% CI 0.31-0.65), p < .001. CONCLUSIONS Age, postoperative complications and the presence of lymph node metastases affect the likelihood of receiving adjuvant chemotherapy after PDAC surgery.
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Affiliation(s)
- Daniel Åkerberg
- a Department of Surgery, Clinical Sciences Lund , Lund University and Skåne University Hospital , Lund , Sweden
| | - Bergthor Björnsson
- b Department of Surgery and Department of Clinical and Experimental Medicine , Linköping University , Linköping , Sweden
| | - Daniel Ansari
- a Department of Surgery, Clinical Sciences Lund , Lund University and Skåne University Hospital , Lund , Sweden
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Tyagi A, Nagpal N, Sidhu DS, Singh A, Tyagi A. Portsmouth physiological and operative severity score for the Enumeration of Mortality and morbidity scoring system in general surgical practice and identifying risk factors for poor outcome. J Nat Sci Biol Med 2017; 8:22-25. [PMID: 28250670 PMCID: PMC5320818 DOI: 10.4103/0976-9668.198342] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background: Estimation of the outcome is paramount in disease stratification and subsequent management in severely ill surgical patients. Risk scoring helps us quantify the prospects of adverse outcome in a patient. Portsmouth-Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (P-POSSUM) the world over has proved itself as a worthy scoring system and the present study was done to evaluate the feasibility of P-POSSUM as a risk scoring system as a tool in efficacious prediction of mortality and morbidity in our demographic profile. Materials and Methods: Validity of P-POSSUM was assessed prospectively in fifty major general surgeries performed at our hospital from May 2011 to October 2012. Data were collected to obtain P-POSSUM score, and statistical analysis was performed. Results: Majority (72%) of patients was male and mean age was 40.24 ± 18.6 years. Seventy-eight percentage procedures were emergency laparotomies commonly performed for perforation peritonitis. Mean physiological score was 17.56 ± 7.6, and operative score was 17.76 ± 4.5 (total score = 35.3 ± 10.4). The ratio of observed to expected mortality rate was 0.86 and morbidity rate was 0.78. Discussion: P-POSSUM accurately predicted both mortality and morbidity in patients who underwent major surgical procedures in our setup. Thus, it helped us in identifying patients who required preferential attention and aggressive management. Widespread application of this tool can result in better distribution of care among high-risk surgical patients.
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Affiliation(s)
- Ashish Tyagi
- Department of Surgery, Saraswathi Institute of Medical Sciences, Hapur, Uttar Pradesh, India
| | - Nitin Nagpal
- Department of Surgery, GGS Medical College, Faridkot, Punjab, India
| | - D S Sidhu
- Department of Surgery, GGS Medical College, Faridkot, Punjab, India
| | - Amandeep Singh
- Department of Surgery, GGS Medical College, Faridkot, Punjab, India
| | - Anjali Tyagi
- Department of ENT, Saraswathi Institute of Medical Sciences, Hapur, Uttar Pradesh, India
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EUS to the Rescue: Endoscopic Ultrasound-Guided Transgastric Cholecystostomy in Acute Cholecystitis. Dig Dis Sci 2016; 61:3436-3439. [PMID: 26611858 DOI: 10.1007/s10620-015-3974-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 11/11/2015] [Indexed: 12/09/2022]
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Kilci O, Un C, Sacan O, Gamli M, Baskan S, Baydar M, Ozkurt B. Postoperative Mortality after Hip Fracture Surgery: A 3 Years Follow Up. PLoS One 2016; 11:e0162097. [PMID: 27788137 PMCID: PMC5082940 DOI: 10.1371/journal.pone.0162097] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 08/17/2016] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND AND AIMS To determine mortality rates and predisposing factors in patients operated for a hip fracture in a 3-year follow-up period. METHODS The study included patients who underwent primary surgery for a hip fracture.The inclusion criteria were traumatic, non-traumatic, osteoporotic and pathological hip fractures requiring surgery in all age groups and both genders. Patients with periprosthetic fractures or previous contralateral hip fracture surgery and patients who could not be contacted by telephone were excluded. At 36 months after surgery, evaluation was made using a structured telephone interview and a detailed examination of the hospital medical records, especially the documents written during anesthesia by the anesthesiologists and the documents written at the time of follow-up visits by the orthopaedic surgeons. A total of 124 cases were analyzed and 4 patients were excluded due to exclusion criteria. The collected data included demographics, type of fracture, co-morbidities, American Society of Anesthesiologists (ASA) scores, anesthesia techniques, operation type (intramedullary nailing or arthroplasty; cemented-noncemented), peroperative complications, refracture during the follow-up period, survival period and mortality causes. RESULTS The total 120 patients evaluated comprised 74 females(61.7%) and 46 males(38.3%) with a mean age of 76.9±12.8 years (range 23-95 years). The ASA scores were ASA I (0.8%), ASA II (21.7%), ASA III (53.3%) and ASA IV (24.2%). Mortality was seen in 44 patients (36.7%) and 76 patients (63.3%) survived during the 36-month follow-up period. Of the surviving patients, 59.1% were female and 40.9% were male.The survival period ranged between 1-1190 days. The cumulative mortality rate in the first, second and third years were 29.17%, 33.33% and 36.67% respectively. The factors associated with mortality were determined as increasing age, high ASA score, coronary artery disease, congestive heart failure, Alzheimer's disease, Parkinson's disease, malignancycementation and peroperative complications such as hypotension (p<0.05). Mortality was highest in the first month after fracture. CONCLUSION The results of this study showed higher mortality rates in patients with high ASA scores due to associated co-morbidities such as congestive heart failure, malignancy and Alzheimer's disease or Parkinson's disease. The use of cemented prosthesis was also seen to significantly increase mortality whereas no effect was seen from the anesthesia technique used. Treatment of these patients with a multidiciplinary approach in an orthogeriatric ward is essential. There is a need for further studies concerning cemented vs. uncemented implant use and identification of the best anesthesia technique to decrease mortality rates in these patients.
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Affiliation(s)
- Oya Kilci
- Department of Anesthesiology and Reanimation, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Canan Un
- Department of Anesthesiology and Reanimation, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Ozlem Sacan
- Department of Anesthesiology and Reanimation, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Mehmet Gamli
- Department of Anesthesiology and Reanimation, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Semih Baskan
- Department of Anesthesiology and Reanimation, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Mustafa Baydar
- Department of Anesthesiology and Reanimation, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Bulent Ozkurt
- Department of Orthopedics and Traumatology, Ankara Numune Training and Research Hospital, Ankara, Turkey
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Orkaby AR, Forman DE. Assessing Risks and Benefits of Invasive Cardiac Procedures in Patients with Advanced Multimorbidity. Clin Geriatr Med 2016; 32:359-71. [PMID: 27113152 DOI: 10.1016/j.cger.2016.01.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Age-related cardiovascular disease in older adults is more likely to occur in combination with other age-related diseases, with mounting interactive complexity as multiple morbidities accumulate. Although invasive cardiac procedures are frequently recommended for cardiovascular disease, their value is less certain in the context of age-related intricacies of care. Tools for risk assessment before invasive procedures are insensitive to risks corresponding to the unique challenges of older adults. Recognizing multimorbidity and other age-related risks provides opportunities to intervene and moderate dangers. By refocusing risk assessment in terms of patient-centered goals, the fundamental utility of invasive cardiac procedures may be reconsidered and alternative therapies prioritized.
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Affiliation(s)
- Ariela R Orkaby
- Division of Cardiology, VA Boston Healthcare System, 400 Veterans of Foreign Wars Pkwy, West Roxbury, MA 02132, USA; Division of Aging, Brigham & Women's Hospital, 1620 Tremont Street, Boston, MA 02120, USA
| | - Daniel E Forman
- Section of Geriatric Cardiology, University of Pittsburgh Medical Center, 3471 Fifth Avenue, Suite 500, Pittsburgh, PA 15213, USA; Geriatric Research, Education, and Clinical Center, VA Pittsburgh Healthcare System, University Dr C, Pittsburgh, PA 15240, USA.
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Lees MC, Merani S, Tauh K, Khadaroo RG. Perioperative factors predicting poor outcome in elderly patients following emergency general surgery: a multivariate regression analysis. Can J Surg 2015. [PMID: 26204143 DOI: 10.1503/cjs.011614] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Older adults (≥ 65 yr) are the fastest growing population and are presenting in increasing numbers for acute surgical care. Emergency surgery is frequently life threatening for older patients. Our objective was to identify predictors of mortality and poor outcome among elderly patients undergoing emergency general surgery. METHODS We conducted a retrospective cohort study of patients aged 65-80 years undergoing emergency general surgery between 2009 and 2010 at a tertiary care centre. Demographics, comorbidities, in-hospital complications, mortality and disposition characteristics of patients were collected. Logistic regression analysis was used to identify covariate-adjusted predictors of in-hospital mortality and discharge of patients home. RESULTS Our analysis included 257 patients with a mean age of 72 years; 52% were men. In-hospital mortality was 12%. Mortality was associated with patients who had higher American Society of Anesthesiologists (ASA) class (odds ratio [OR] 3.85, 95% confidence interval [CI] 1.43-10.33, p = 0.008) and in-hospital complications (OR 1.93, 95% CI 1.32-2.83, p = 0.001). Nearly two-thirds of patients discharged home were younger (OR 0.92, 95% CI 0.85-0.99, p = 0.036), had lower ASA class (OR 0.45, 95% CI 0.27-0.74, p = 0.002) and fewer in-hospital complications (OR 0.69, 95% CI 0.53-0.90, p = 0.007). CONCLUSION American Society of Anesthesiologists class and in-hospital complications are perioperative predictors of mortality and disposition in the older surgical population. Understanding the predictors of poor outcome and the importance of preventing in-hospital complications in older patients will have important clinical utility in terms of preoperative counselling, improving health care and discharging patients home.
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Affiliation(s)
- Mackenzie C Lees
- From the Division of General Surgery, Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta. (Lees, Merani, Khadaroo); and the Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta (Khadaroo), Edmonton, Alta
| | - Shaheed Merani
- From the Division of General Surgery, Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta. (Lees, Merani, Khadaroo); and the Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta (Khadaroo), Edmonton, Alta
| | - Keerit Tauh
- From the Division of General Surgery, Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta. (Lees, Merani, Khadaroo); and the Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta (Khadaroo), Edmonton, Alta
| | - Rachel G Khadaroo
- From the Division of General Surgery, Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta. (Lees, Merani, Khadaroo); and the Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta (Khadaroo), Edmonton, Alta
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Nag DS. Assessing the risk: Scoring systems for outcome prediction in emergency laparotomies. Biomedicine (Taipei) 2015; 5:20. [PMID: 26615537 PMCID: PMC4662940 DOI: 10.7603/s40681-015-0020-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 05/29/2015] [Indexed: 02/05/2023] Open
Abstract
Emergency laparotomy is the commonest emergency surgical procedure in most hospitals and includes over 400 diverse surgical procedures. Despite the evolution of medicine and surgical practices, the mortality in patients needing emergency laparotomy remains abnormally high. Although surgical risk assessment first started with the ASA Physical Status score in 1941, efforts to find an ideal scoring system that accurately estimates the risk of mortality, continues till today. While many scoring systems have been developed, no single scoring system has been validated across multiple centers and geographical locations. While some scoring systems can predict the risk merely based upon preoperative findings and parameters, some rely on intra-operative assessment and histopathology reports to accurately stratify the risk of mortality. Although most scoring systems can potentially be used to compare risk-adjusted mortality across hospitals and amongst surgeons, only those which are based on preoperative findings can be used for risk prognostication and identify high-risk patients before surgery for an aggressive treatment. The recognition of the fact, that in the absence of outcome data in these patients, it would be impossible to evaluate the impact of quality improvement initiatives on risk-adjusted mortality, hospital groups and surgical societies have got together and started to pool data and analyze it. Appropriate scoring systems for emergency laparotomies would help in risk prognostication, risk-adjusted audit and assess the impact of quality improvement initiative in patient care across hospitals. Large multi-centric studies across varied geographic locations and surgical practices need to assess and validate the ideal and most apt scoring system for emergency laparotomies. While APACHE-II and P-POSSUM continue to be the most commonly used scoring system in emergency laparotomies,studies need to compare them in their ability to predict mortality and explore if either has a higher sensitivity and specificity than the other.
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Affiliation(s)
- Deb Sanjay Nag
- Department of Anaesthesiology & Critical Care, Tata Main Hospital, 831001, Jamshedpur, India.
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Sharma R, Ranjan V, Jain S, Joshi T, Tyagi A, Chaphekar R. A prospective study evaluating utility of Mannheim peritonitis index in predicting prognosis of perforation peritonitis. J Nat Sci Biol Med 2015; 6:S49-52. [PMID: 26604619 PMCID: PMC4630763 DOI: 10.4103/0976-9668.166076] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aims: We aimed to validate Mannheim peritonitis index (MPI) for prediction of outcome in patients with perforation peritonitis. Materials and Methods: A prospective study involving 100 subjects operated for perforation peritonitis over the period of 2 years was designed. Postevaluation of predesigned performa, MPI score was calculated and analyzed for each patient with death being the main outcome measure. The MPI scores were divided into three categories; scores <15 (category 1), 16-25 (category 2), and >25 (category 3). Results: Our study consisted of 82 males and 18 females (male:female ratio 4.56:1), with the mean patients age of 37.96 ± 17.49 years. 47, 26, and 27 cases belonged to MPI score categories 1, 2, and 3, respectively. The most common origin of sepsis was ileal with small intestine dominating the source of perforation. When the individual parameters of MPI score were assessed against the mortality only, age >50 years (P = 0.015), organ failure (P = 0.0001), noncolonic origin of sepsis (P = 0.002), and generalized peritonitis (P = 0.0001) significantly associated with mortality. The sensitivity of MPI was 92% with a specificity of 78% in receiver operating characteristic curves. Conclusion: MPI is an effective tool for prediction of mortality in cases of perforation peritonitis.
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Affiliation(s)
- Rajesh Sharma
- Department of General Surgery, Sri Aurobindo Medical College and PostGraduate Institute, Indore, Madhya Pradesh, India
| | - Vikrant Ranjan
- Department of General Surgery, Sri Aurobindo Medical College and PostGraduate Institute, Indore, Madhya Pradesh, India
| | - Suraj Jain
- Department of General Surgery, Sri Aurobindo Medical College and PostGraduate Institute, Indore, Madhya Pradesh, India
| | - Tulika Joshi
- Department of Obstetrics and Gynecology, Index Medical College Hospital and Research Institute, Indore, Madhya Pradesh, India
| | - Anurag Tyagi
- Department of General Surgery, Sri Aurobindo Medical College and PostGraduate Institute, Indore, Madhya Pradesh, India
| | - Rohan Chaphekar
- Department of General Surgery, Sri Aurobindo Medical College and PostGraduate Institute, Indore, Madhya Pradesh, India
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Oliver CM, Walker E, Giannaris S, Grocott MPW, Moonesinghe SR. Risk assessment tools validated for patients undergoing emergency laparotomy: a systematic review. Br J Anaesth 2015; 115:849-60. [PMID: 26537629 DOI: 10.1093/bja/aev350] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Emergency laparotomies are performed commonly throughout the world, but one in six patients die within a month of surgery. Current international initiatives to reduce the considerable associated morbidity and mortality are founded upon delivering individualised perioperative care. However, while the identification of high-risk patients requires the routine assessment of individual risk, no method of doing so has been demonstrated to be practical and reliable across the commonly encountered spectrum of presentations, co-morbidities and operative procedures. A systematic review of Embase and Medline identified 20 validation studies assessing 25 risk assessment tools in patients undergoing emergency laparotomy. The most frequently studied general tools were APACHE II, ASA-PS and P-POSSUM. Comparative, quantitative analysis of tool performance was not feasible due to the heterogeneity of study design, poor reporting and infrequent within-study statistical comparison of tool performance. Reporting of calibration was notably absent in many prognostic tool validation studies. APACHE II demonstrated the most consistent discrimination of individual outcome across a variety of patient groups undergoing emergency laparotomy when used either preoperatively or postoperatively (area under the curve 0.76-0.98). While APACHE systems were designed for use in critical care, the ability of APACHE II to generate individual risk estimates from objective, exclusively preoperative data items may lead to better-informed shared decisions, triage and perioperative management of patients undergoing emergency laparotomy. Future endeavours should include the recalibration of APACHE II and P-POSSUM in contemporary cohorts, modifications to enable prediction of morbidity and assessment of the impact of adoption of these tools on clinical practice and patient outcomes.
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Affiliation(s)
- C M Oliver
- UCL/UCLH Surgical Outcome Research Centre (SOuRCe), 3rd Floor, Maples Link Corridor, University College Hospital, 235 Euston Road, London NW1 2BU, UK National Institute of Academic Anaesthesia Health Services Research Centre, Royal College of Anaesthetists, London, UK Centre for Anaesthesia, University College London, London, UK
| | - E Walker
- UCL/UCLH Surgical Outcome Research Centre (SOuRCe), 3rd Floor, Maples Link Corridor, University College Hospital, 235 Euston Road, London NW1 2BU, UK National Institute of Academic Anaesthesia Health Services Research Centre, Royal College of Anaesthetists, London, UK Centre for Anaesthesia, University College London, London, UK
| | - S Giannaris
- Centre for Anaesthesia, University College London, London, UK
| | - M P W Grocott
- National Institute of Academic Anaesthesia Health Services Research Centre, Royal College of Anaesthetists, London, UK University Hospital Southampton NHS Foundation Trust, Southampton, UK Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences Faculty of Medicine, University of Southampton, Southampton, UK University Hospital Southampton NHS Foundation Trust/University of Southampton, NIHR Respiratory Biomedical Research Unit, Southampton, UK
| | - S R Moonesinghe
- UCL/UCLH Surgical Outcome Research Centre (SOuRCe), 3rd Floor, Maples Link Corridor, University College Hospital, 235 Euston Road, London NW1 2BU, UK National Institute of Academic Anaesthesia Health Services Research Centre, Royal College of Anaesthetists, London, UK Centre for Anaesthesia, University College London, London, UK
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Stonelake S, Thomson P, Suggett N. Identification of the high risk emergency surgical patient: Which risk prediction model should be used? Ann Med Surg (Lond) 2015; 4:240-7. [PMID: 26468369 PMCID: PMC4543083 DOI: 10.1016/j.amsu.2015.07.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 07/20/2015] [Accepted: 07/20/2015] [Indexed: 11/28/2022] Open
Abstract
Introduction National guidance states that all patients having emergency surgery should have a mortality risk assessment calculated on admission so that the ‘high risk’ patient can receive the appropriate seniority and level of care. We aimed to assess if peri-operative risk scoring tools could accurately calculate mortality and morbidity risk. Methods Mortality risk scores for 86 consecutive emergency laparotomies, were calculated using pre-operative (ASA, Lee index) and post-operative (POSSUM, P-POSSUM and CR-POSSUM) risk calculation tools. Morbidity risk scores were calculated using the POSSUM predicted morbidity and compared against actual morbidity according to the Clavien–Dindo classification. Results The actual mortality was 10.5%. The average predicted risk scores for all laparotomies were: ASA 26.5%, Lee Index 2.5%, POSSUM 29.5%, P-POSSUM 18.5%, CR-POSSUM 10.5%. Complications occurred following 67 laparotomies (78%). The majority (51%) of complications were classified as Clavien–Dindo grade 2–3 (non-life-threatening). Patients having a POSSUM morbidity risk of greater than 50% developed significantly more life-threatening complications (CD 4–5) compared with those who predicted less than or equal to 50% morbidity risk (P = 0.01). Discussion Pre-operative risk stratification remains a challenge because the Lee Index under-predicts and ASA over-predicts mortality risk. Post-operative risk scoring using the CR-POSSUM is more accurate and we suggest can be used to identify patients who require intensive care post-operatively. Conclusions In the absence of accurate risk scoring tools that can be used on admission to hospital it is not possible to reliably audit the achievement of national standards of care for the ‘high-risk’ patient. Emergency surgical patients require a mortality risk assessment upon admission. There is wide variability of risk prediction in the available risk scoring methods. Pre-operative risk scores do not reliably identify the high risk surgical patient. The CR-POSSUM score predicts mortality risk accurately in emergency laparotomy. The CR-POSSUM may be a useful tool in guiding the level of post-operative care.
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Affiliation(s)
- Stephen Stonelake
- Sandwell General Hospital, Lyndon, West Bromwich, West Midlands, B71 4HJ, UK
| | - Peter Thomson
- Whipps Cross Hospital, Whipps Cross Road, London, E11 1NR, UK
| | - Nigel Suggett
- Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK
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Using the age-adjusted Charlson comorbidity index to predict outcomes in emergency general surgery. J Trauma Acute Care Surg 2015; 78:318-23. [PMID: 25757117 DOI: 10.1097/ta.0000000000000457] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND We evaluated the role of the Charlson age-comorbidity index (CACI), a weighted comorbidity index that reflects cumulative increased likelihood of 1-year mortality, in predicting perioperative outcomes in an emergency general surgery population at a large Canadian teaching hospital. METHODS A retrospective chart review of emergency general surgery admissions in 2010 was conducted. Patients who had surgery were identified. Mode of surgery and CACI were recorded, as well as measures of outcome, including 30-day mortality and intensive care unit (ICU) admission. A multivariate stepwise logistic regression model was created to assess the effect of age-adjusted Charlson comorbidity index on postoperative outcomes while controlling for the effect of possible confounders. The prediction ability of CACI for mortality was assessed using receiver operating characteristic analyses considering the area under the curve and its 95% confidence intervals (CIs). RESULTS Of the 529 admissions to general surgery from the emergency department, 257 patients underwent a surgical intervention. The CACI scores ranged from 0 to 16. We described a total of 11 deaths (4.3%) and 30 ICU admissions (11.7%). CACI was associated with an increased risk of 30-day mortality (adjusted odds ratio,1.39; 95% CI, 1.11-1.73; p = 0.0034). Receiver operating characteristic analysis was consistent with high accuracy of CACI for mortality prediction alone, resulting in area under the curve or c statistic of 0.90 (95% CI, 0.84-0.95). CACI was similar in predicting mortality to a multivariate model. CACI was also found to be associated with ICU admission (adjusted odds ratio, 1.17; 95% CI, 1.01-1.37; p < 0.0382). CACI is not as good a predictor for ICU admission when compared with the multivariate model. CONCLUSION We have shown that the CACI is a valid tool for 30-day mortality prediction in the context of emergency general surgery. LEVEL OF EVIDENCE Prognostic study, level III.
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Acute cholecystitis: WSES position statement. World J Emerg Surg 2014; 9:58. [PMID: 25422672 PMCID: PMC4242474 DOI: 10.1186/1749-7922-9-58] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 09/29/2014] [Indexed: 12/16/2022] Open
Abstract
Background The management of acute calculous cholecystitis still offers room for debate in terms of diagnosis, severity scores, treatment options and timing for surgery. Material and methods A systematic review about the treatment of acute cholecystitis has been completed. The recommendations of recent guidelines have also been examined taking into account the results of the review. Results The evidence available in the literature supports the recommendation about laparoscopic cholecystectomy as treatment of choice for acute cholecystitis. Surgery should be performed as soon as possible after the diagnosis because early treatment reduces total hospital stay and does not increase complication or conversion rates. The antibiotics can play different roles and attention should be posed to the risk of emerging resistance. A surgical or percutaneous drainage of the gallbladder is advocated by some authors in the advanced forms of inflammation or patients with severe co-morbidities; however, the available evidence does not support it, and further studies are necessary to clarify its role.
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Surgical risk model for acute diffuse peritonitis based on a Japanese nationwide database: an initial report on the surgical and 30-day mortality. Surg Today 2014; 45:1233-43. [PMID: 25228380 DOI: 10.1007/s00595-014-1026-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 08/12/2014] [Indexed: 01/10/2023]
Abstract
PURPOSE Acute diffuse peritonitis (ADP) is an important surgical complication associated with high morbidity and mortality; however, the risk factors associated with a poor outcome have remained controversial. This study aimed in collecting integrated data using a web-based national database system to build a risk model for mortality after surgery for ADP. METHODS We included cases registered in the National Clinical Database in Japan. After data cleanup, 8,482 surgical cases of ADP from 1,285 hospitals treated between January 1 and December 31, 2011 were analyzed. RESULTS The raw 30-day and surgical mortality rates were 9.0 and 14.1 %, respectively. The odds ratios (>2.0) for 30-day mortality were as follows: American Society of Anesthesiologists (ASA) class 3, 2.69; ASA class 4, 4.28; ASA class 5, 8.65; previous percutaneous coronary intervention (PCI), 2.05; previous surgery for peripheral vascular disease (PVD), 2.45 and disseminated cancer, 2.16. The odds ratios (>2.0) for surgical mortality were as follows: ASA class 3, 2.27; ASA class 4, 4.67; ASA class 5, 6.54, and disseminated cancer, 2.09. The C-indices of 30-day and surgical mortality were 0.851 and 0.852, respectively. CONCLUSION This is the first report of risk stratification after surgery for ADP using a nationwide surgical database. This system could be useful to predict the outcome of surgery for ADP and for evaluations and benchmark performance studies.
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Ozen A, Unal EU, Kubat E, Turkcan BS, Caliskan A, Aytekin B, Aksoyek A, Birincioglu CL, Pac M. Glasgow aneurysm scores in patients undergoing open surgical procedure for aortic aneurysm. Vascular 2014; 23:277-80. [PMID: 25183698 DOI: 10.1177/1708538114548263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND To assess the applicability of the Glasgow aneurysm score (GAS) in patients with aortic aneurysm undergoing an elective open surgical procedure in our hospital. MATERIALS AND METHODS A total of 105 patients undergoing elective open surgical procedure between January 2006 and June 2012 were evaluated retrospectively. Glasgow aneurysm score (GAS) was calculated as age+7 points for myocardial disease, +10 points for cerebrovascular disease, and +14 points for renal disease. The best cut-off value for GAS was determined using the ROC curve analysis. RESULTS The hospital mortality rate was 3.8% (4 patients). GAS was significantly lower in patients who survived the operation (76.05 ± 14.71 vs. 92.0 ± 10.8 respectively, p = 0.031). The ICU stay was also significantly lower in patients who survived the operation (2.37 ± 5.23) compared to the nonsurvivors (25.67 ± 13.80, p = 0.001). No significant difference was observed regarding age, duration of hospital stay, and aortic diameter. The area under the ROC curve was 0.818 and for a 100% sensitivity rate, the cut-off value for GAS was 77.5 with a 58.4% specificity rate (p = 0.031). All patients with a GAS < 77.5 were alive after surgery. CONCLUSION The GAS appears to be a reliable clinical predictor for in hospital mortality following elective repair of abdominal aortic aneurysm following open surgical procedure.
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Affiliation(s)
- Anil Ozen
- Department of Cardiovascular Surgery, Turkey Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Ertekin Utku Unal
- Department of Cardiovascular Surgery, Turkey Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Emre Kubat
- Department of Cardiovascular Surgery, Turkey Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Basak Soran Turkcan
- Department of Cardiovascular Surgery, Turkey Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Aytac Caliskan
- Department of Cardiovascular Surgery, Turkey Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Bahadir Aytekin
- Department of Cardiovascular Surgery, Turkey Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Aysen Aksoyek
- Department of Cardiovascular Surgery, Turkey Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Cemal Levent Birincioglu
- Department of Cardiovascular Surgery, Turkey Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Mustafa Pac
- Department of Cardiovascular Surgery, Turkey Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
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Davis P, Hayden J, Springer J, Bailey J, Molinari M, Johnson P. Prognostic factors for morbidity and mortality in elderly patients undergoing acute gastrointestinal surgery: a systematic review. Can J Surg 2014. [PMID: 24666459 DOI: 10.1503/cjs.006413] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Elderly patients undergoing acute gastrointestinal (GI) surgery experience increased morbidity and mortality compared with younger and elective patients. Prognostic factors can be used to counsel patients of these risks and, if modifiable, to minimize them. We reviewed the literature on prognostic factors for adverse outcomes in elderly patients undergoing acute GI surgery. METHODS We searched PubMed and Embase using a strategy developed in collaboration with an expert librarian. Studies examining independent associations between prognostic factors and morbidity or mortality in patients aged 65 and older undergoing acute GI surgery were selected. We extracted data using a standardized form and assessed study quality using the QUIPS tool. RESULTS Nine cohort studies representing 2958 patients satisfied our selection criteria. All studies focused on postoperative mortality. Thirty-four prognostic factors were examined, with significant variability across studies. There was limited or conflicting evidence for most prognostic factors. Meta-analysis was only possible for the American Society of Anesthesiologists (ASA) score, which was found to be associated with mortality in 4 studies (pooled odds ratio 2.77, 95% confidence interval 0.92-8.41). CONCLUSION While acute GI surgery in elderly patients is becoming increasingly common, the literature on prognostic factors for morbidity and mortality in this patient population lags behind. Further research is needed to help guide patient care and potentially improve outcomes.
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Affiliation(s)
- Philip Davis
- The Faculty of Medicine, Departments of Emergency Medicine Dalhousie University, Halifax, NS
| | - Jill Hayden
- Community Health and Epidemiology and Dalhousie University, Halifax, NS
| | - Jeremy Springer
- The Division of General Surgery, Dalhousie University, Halifax, NS
| | - Jonathon Bailey
- The Division of General Surgery, Dalhousie University, Halifax, NS
| | - Michele Molinari
- The Division of General Surgery, Dalhousie University, Halifax, NS
| | - Paul Johnson
- The Division of General Surgery, Dalhousie University, Halifax, NS
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Özen A, Unal EU, Mola S, Erkengel I, Kiris E, Aksöyek A, Saritas A, Birincioğlu CL. Glasgow aneurysm score in predicting outcome after ruptured abdominal aortic aneurysm. Vascular 2014; 23:120-3. [PMID: 24841850 DOI: 10.1177/1708538114533539] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To assess the ability of Glasgow Aneurysm Score in predicting postoperative mortality for ruptured aortic aneurysm which may assist in decision making regarding the open surgical repair of an individual patient. METHODS A total of 121 patients diagnosed of ruptured abdominal aortic aneurysm who underwent open surgery in our hospital between 1999 and 2013 were included. The Glasgow Aneurysm Score for each patient was graded according to the Glasgow Aneurysm Score (Glasgow Aneurysm Score = age in years + 17 for shock + 7 for myocardial disease + 10 for cerebrovascular disease + 14 for renal disease). The groups were divided as Group 1 (containing the patients who died) and Group 2 (the patients who were discharged). The Glasgow Aneurysm Scores amongst the groups were compared. RESULTS Out of 121 patients, 108 (89.3%) were males and 13 (10.7%) were females. The in-hospital mortality was 48 patients (39.7%). The Glasgow Aneurysm Score was 84.15 ± 15.94 in Group 1 and 75.14 ± 14.67 in Group 2 which revealed significance (p = 0.002). The most appropriate cut-off value for Glasgow Aneurysm Score was determined as 78.5 (AUC = 0.669, p = 0.002, sensitivity: 64.6%, specificity: 60.3%). Glasgow Aneurysm Score value above 78.5 is associated with almost threefold increase in mortality (p = 0.007, OR:2.76, 95% CI 1.30-5.89). In further logistic regression models, Glasgow Aneurysm Score value and preoperative hematocrit values were found to be independent predictors for mortality (p = 0.023 and p = 0.007, respectively). CONCLUSION Glasgow Aneurysm Score may have a predictive value for outcome of patients with ruptured abdominal aortic aneurysm undergoing open surgical procedure and it appears to be a useful tool in clinical decision-making of an individual patient when integrated with clinical experience.
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Affiliation(s)
- Anıl Özen
- Türkiye Yüksek İhtisas Hospital, Cardiovascular Surgery Clinic, Ankara, Turkey
| | - Ertekin Utku Unal
- Türkiye Yüksek İhtisas Hospital, Cardiovascular Surgery Clinic, Ankara, Turkey
| | - Serkan Mola
- Türkiye Yüksek İhtisas Hospital, Cardiovascular Surgery Clinic, Ankara, Turkey
| | - Ibrahim Erkengel
- Türkiye Yüksek İhtisas Hospital, Cardiovascular Surgery Clinic, Ankara, Turkey
| | - Erman Kiris
- Türkiye Yüksek İhtisas Hospital, Cardiovascular Surgery Clinic, Ankara, Turkey
| | - Aysen Aksöyek
- Türkiye Yüksek İhtisas Hospital, Cardiovascular Surgery Clinic, Ankara, Turkey
| | - Ahmet Saritas
- Türkiye Yüksek İhtisas Hospital, Cardiovascular Surgery Clinic, Ankara, Turkey
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Green G, Shaikh I, Fernandes R, Wegstapel H. Emergency laparotomy in octogenarians: A 5-year study of morbidity and mortality. World J Gastrointest Surg 2013; 5:216-221. [PMID: 23894689 PMCID: PMC3715657 DOI: 10.4240/wjgs.v5.i7.216] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Revised: 04/22/2013] [Accepted: 07/01/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the morbidity and mortality associated with emergency laparotomy for a clinically acute abdomen in patients aged ≥ 80 years.
METHODS: In this retrospective audit, octogenarians undergoing emergency laparotomy between 1st January 2005 and 1st January 2010 were identified using the Galaxy Theatre System. Patients undergoing abdominal surgery through groin crease incisions or Lanz or Gridiron incisions were excluded. Also simple appendectomies were excluded. All patients were aged 80 years or more at the time of their surgery. Data were obtained using casenote review with a standardised proforma to determine patient age, American Society of Anesthesiologists (ASA) grade, indications for surgery, early (within 30 d) and late (after 30 d) complications, mortality and length of stay. Data were inserted into a Microsoft Excel spreadsheet and analysed.
RESULTS: One hundred patients were identified from the database (Galaxy) as having undergone emergency laparotomy. Of those, 55 underwent the procedure for intestinal procedures and 37 for secondary peritonitis. There was a 2:1 female predominance; average age 85 and ASA grade 3. Bowel resection was required in 51 out of the 100 patients and 22 (43%) died. Other procedures included appendicectomy, adhesiolysis, repair of AAA graft leak and colostomies for the pathological process resulting in an acute abdomen. Twelve of 100 patients (12%) suffered intra-operative complications, including splenic and bowel-serosal tears. Seventy patients (70%) had postoperative complications including myocardial infarction, wound infection, haematoma and sepsis. Overall mortality was 45/100 patients (45%). The major causes of death were sepsis (19/45 patients, 42%), underlying cancer (13/45 patients, 29%); with others including bowel obstruction (2/45 patients, 4%), myocardial and intestinal ischaemia and dementia.
CONCLUSION: Emergency laparotomy in octogenarians carries a significant morbidity and mortality. In particular, surgery requiring bowel resection has higher mortality than without resection.
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APACHE II and Mannheim Peritonitis Index (MPI) fail to predict lethality in septic peritonitis in immunosuppressed solid organ transplant recipients. Eur Surg 2013. [DOI: 10.1007/s10353-013-0218-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Shah N, Hamilton M. Clinical review: Can we predict which patients are at risk of complications following surgery? Crit Care 2013; 17:226. [PMID: 23672931 PMCID: PMC3672530 DOI: 10.1186/cc11904] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
There are a vast number of operations carried out every year, with a small proportion of patients being at highest risk of mortality and morbidity. There has been considerable work to try and identify these high-risk patients. In this paper, we look in detail at the commonly used perioperative risk prediction models. Finally, we will be looking at the evolution and evidence for functional assessment and the National Surgical Quality Improvement Program (in the USA), both topical and exciting areas of perioperative prediction.
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Affiliation(s)
- Nirav Shah
- General Intensive Care Unit, St George's Hospital, Blackshaw Road, Tooting, London, SW17 0QT, UK
| | - Mark Hamilton
- General Intensive Care Unit, St George's Hospital, Blackshaw Road, Tooting, London, SW17 0QT, UK
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Patel S, Lutz JM, Panchagnula U, Bansal S. Anesthesia and perioperative management of colorectal surgical patients - specific issues (part 2). J Anaesthesiol Clin Pharmacol 2012; 28:304-13. [PMID: 22869934 PMCID: PMC3409937 DOI: 10.4103/0970-9185.98321] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Colorectal surgery carries significant morbidity and mortality, which is associated with an enormous use of healthcare resources. Patients with pre-existing morbidities, and those undergoing emergency colorectal surgery due to complications such as perforation, obstruction, or ischemia / infarction are at an increased risk for adverse outcomes. Fluid therapy in emergency colorectal surgical patients can be challenging as hypovolemic and septic shock may coexist. Abdominal sepsis is a serious complication and may be diagnosed during pre-, intra-, or postoperative periods. Early suspicion and recognition of medical and / or surgical complications are essential. The critical care management of complicated colorectal surgical patients require collaborative and multidisciplinary efforts.
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Affiliation(s)
- Santosh Patel
- Department of Anesthesia, The Pennine Acute NHS Trust, Rochdale and Honorary Lecturer, School of Biomedicine, University of Manchester, United Kingdom
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Al-Temimi MH, Griffee M, Enniss TM, Preston R, Vargo D, Overton S, Kimball E, Barton R, Nirula R. When is death inevitable after emergency laparotomy? Analysis of the American College of Surgeons National Surgical Quality Improvement Program database. J Am Coll Surg 2012; 215:503-11. [PMID: 22789546 DOI: 10.1016/j.jamcollsurg.2012.06.004] [Citation(s) in RCA: 155] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Revised: 05/11/2012] [Accepted: 06/08/2012] [Indexed: 11/24/2022]
Abstract
BACKGROUND In an era of increasing demands to provide high-quality health care, surgeons need an accurate preoperative risk assessment tool to facilitate informed decision-making for themselves and their patients. Emergency laparotomy procedures have a high risk profile, but the currently available risk-assessment models for emergency laparotomy are either unreliable (eg, small sample size or single center study), difficult to calculate preoperatively, or are specific to the geriatric population. STUDY DESIGN The American College of Surgeons National Surgical Quality Improvement Program database (2005 to 2009) was used to develop logistic regression models for 30-day mortality after emergency laparotomy. Two models were created, one with the knowledge of the postoperative diagnosis and one without. Models' calibration and discrimination were judged using the receiver operating characteristics curves and the Hosmer-Lemeshow test. RESULTS There were 37,553 patients who had undergone emergency laparotomy, with a 14% mortality rate. The American Society of Anesthesiologists classification system, functional status, sepsis, and age were the variables most significantly associated with mortality. Patients older than 90 years of age, with an American Society of Anesthesiologists class V, septic shock, dependent functional status, and abnormal white blood cell count have a <10% probability of survival. CONCLUSIONS The models developed in this study have a high discriminative ability to stratify the operative risk in a broad range of acute abdominal emergencies. These data will assist surgeons, patients, and their families in making end-of-life decisions in the face of medical futility with greater certainty when emergency surgery is being contemplated.
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Affiliation(s)
- Mohammed H Al-Temimi
- Division of Public Health, Department of Family and Preventive Medicine, University of Utah, Salt Lake City, UT 84132, USA
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Damhuis RAM, Wijnhoven BPL, Plaisier PW, Kirkels WJ, Kranse R, van Lanschot JJ. Comparison of 30-day, 90-day and in-hospital postoperative mortality for eight different cancer types. Br J Surg 2012; 99:1149-54. [PMID: 22718521 DOI: 10.1002/bjs.8813] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2012] [Indexed: 01/29/2023]
Abstract
BACKGROUND Various definitions are used to calculate postoperative mortality. As variation hampers comparability between reports, a study was performed to evaluate the impact of using different definitions for several types of cancer surgery. METHODS Population-based data for the period 1997-2008 were retrieved from the Rotterdam Cancer Registry for resectional surgery of oesophageal, gastric, colonic, rectal, breast, lung, renal and bladder cancer. Postoperative deaths were tabulated as 30-day, in-hospital or 90-day mortality. Postdischarge deaths were defined as those occurring after discharge from hospital but within 30 days. RESULTS This study included 40,474 patients. Thirty-day mortality rates were highest after gastric (8·8 per cent) and colonic (6·0 per cent) surgery, and lowest after breast (0·2 per cent) and renal (2·0 per cent) procedures. For most tumour types, the difference between 30-day and in-hospital rates was less than 1 per cent. For bladder and oesophageal cancer, however, the in-hospital mortality rate was considerably higher at 5·1 per cent (+1·3 per cent) and 7·3 per cent (+2·8 per cent) respectively. For gastric, colonic and lung cancer, 1·0 per cent of patients died after discharge. For gastric, lung and bladder cancer, more than 3 per cent of patients died between discharge and 90 days. CONCLUSION The 30-day definition is recommended as an international standard because it includes the great majority of surgery-related deaths and is not subject to discharge procedures. The 90-day definition, however, captures mortality from multiple causes; although this may be of less interest to surgeons, the data may be valuable when providing information to patients before surgery.
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Affiliation(s)
- R A M Damhuis
- Comprehensive Cancer Centre the Netherlands, Utrecht, The Netherlands.
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Modini C, Romagnoli F, De Milito R, Romeo V, Petroni R, La Torre F, Catani M. Octogenarians: an increasing challenge for acute care and colorectal surgeons. An outcomes analysis of emergency colorectal surgery in the elderly. Colorectal Dis 2012; 14:e312-8. [PMID: 22230094 DOI: 10.1111/j.1463-1318.2012.02934.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
AIM Emergency surgery is associated with higher mortality rates, especially in elderly patients presenting with emergent colorectal disease. The aim of this study was to determine the outcomes in elderly patients following emergency colorectal resection, with particular focus on octogenarians who presented a sixfold higher mortality rate with respect to other patients. METHOD This study examined 355 patients who underwent surgery at an Emergency Department for complications of colorectal disease between January 2007 and December 2009. Morbidity and mortality were analyzed on the basis of patients' characteristics and presentation. Univariate and logistic regression analyses were performed on morbidity and mortality risk factors. RESULTS Two-hundred and fifteen patients of > 65 years of age were included, 93 of whom were ≥ 80 years of age. The global mortality rate was 16%. In patients ≥ 80 years of age the mortality rate was 30%. The difference in mortality rate between patients < 80 years of age vs patients ≥ 80 years of age was 24%. In resected patients ≥ 80 years of age, American Society of Anesthesiology grade, colonic ischaemia, neurological comorbidity and anastomotic dehiscence were identified as independent risk factors in both univariate and logistic regression analyses. The morbidity rate was approximately 17%, and no significant difference in morbidity was found between the two groups. CONCLUSION The results of this study show that fitness status and micro vascular impairment impact significantly on mortality in the elderly, particularly in octogenarians. Although the outcomes observed were compatible with the literature, the six fold higher mortality rate observed in the most elderly patients identifies a group for which death prevention is best achieved with aggressive resuscitation and intensive postoperative care, rather than timing of surgery.
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Affiliation(s)
- C Modini
- DEAII-Emergency Department, Sapienza Università di Roma, Umberto I Policlinico di Roma, Rome, Italy
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