Activities of daily living and quality of life of elderly patients after elective surgery for gastric and colorectal cancers

Preoperative geriatric assessment and follow-up of patients older than 75 years undergoing elective surgery for suspected colorectal cancer

OBJECTIVES

We investigated the predictive value of specific tools used in a Comprehensive Geriatric Assessment (CGA) with regard to postoperative outcome in patients 75 years and older undergoing elective colorectal cancer (CRC) surgery. Furthermore, recovery was followed over the first postoperative year using the same assessment tools.

MATERIAL AND METHODS

Baseline clinical and CGA variables including functional and nutritional status, pressure sore risk, fall risk, cognition, depression, polypharmacy, comorbidity, and health-related quality-of-life (HRQoL) were prospectively recorded. Outcome variables were postoperative complications and length of stay (LOS). Patients were likewise followed up at one, three and twelve months postoperatively.

RESULTS

Forty-nine patients underwent surgery (median age 81 years). Forty-three per cent had ASA (American Society of Anesthesiologists) class 2 47% had ASA class 3. Postoperative complications occurred in 32.7%. Median LOS was eight days. In univariate analyses, none of the parameters tested predicted postoperative complication or LOS. During follow-up, all patients recovered to baseline values apart from HRQoL which was still reduced at three and twelve months (p = .017). Nutritional status had improved twelve months after surgery (p = .011).

CONCLUSIONS

No association could be found in this study between the results of a comprehensive geriatric assessment and prolonged length of stay or postoperative complication rate after elective surgery for colorectal cancer. Patients recovered well during the first year after surgery. Quality of life, however, was still lower than prior to surgery.

Postoperative Recovery in Frail, Pre-frail, and Non-frail Elderly Patients Following Abdominal Surgery

BACKGROUND

The objective of this study is to explore the association between frailty and surgical recovery over a 6-month period, in elderly patients undergoing elective abdominal surgery.

METHODS

A total of 144 patients were categorized as frail, pre-frail, and non-frail based on five criteria: weight loss, exhaustion, weakness, slowness, and low activity. Recovery to preoperative functional status (activities of daily living (ADL) and instrumental activities of daily living (IADL)), cognition, quality of life, and mental health was assessed at 1, 3, and 6 months postoperatively. A repeated measure logistic regression was used to analyze the effect of frailty on recovery over time. The effect of frailty on hospitalization outcomes was also evaluated.

RESULTS

Mean age was 78 ± 5 years with 17.4% of patients categorized as frail, 60.4% pre-frail, and 22.2% non-frail. At 6 months, the percent of patients who had recovered to preoperative values were: ADL 90%; IADL 76%; cognition 75.5%; mental health 66%; and quality of life 70%. While more frail patients experienced adverse hospitalization outcomes and fewer had recovered to preoperative functional status, these differences were not found to be statistically significant. Overall, frailty status was not significantly associated with the trajectory of recovery or hospitalization outcomes.

CONCLUSION

Strong, institutional commitment to quality surgical care, as well as appropriate strategies for older patients, may have mitigated the impact of frailty on recovery. Further research is needed to examine the role of frailty in the surgical recovery process.

Physiological and operative severity score for the enumeration of mortality and morbidity, frailty, and perioperative quality of life in the elderly

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.

The Preoperative Geriatric Nutritional Risk Index Predicts Postoperative Complications in Elderly Patients with Gastric Cancer Undergoing Gastrectomy

BACKGROUND/AIM

The relationship between the preoperative Geriatric Nutritional Risk Index (GNRI) and morbidity of patients with gastric cancer (GC) undergoing gastrectomy has not yet been reported. Our study aimed to investigate whether preoperative GNRI is associated with short-term outcomes in elderly patients with GC.

PATIENTS AND METHODS

This study enrolled 348 elderly patients with GC who were more than 75 years old and underwent curative gastrectomy for GC at our Institution between January 2006 and December 2015. GNRI was invoked to stratify patients as high (GNRI≥92; n=190) or low (GNRI<92; n=158) GNRI nutritional status. The clinicopathologic features and short-term outcomes were compared.

RESULTS

In multivariate analysis, low GNRI emerged as an independent predictor of postoperative complications (Clavien Dindo classification grade II≤). Low GNRI demonstrated significantly more frequent extra-surgical complications than high GNRI. Significantly more patients with low GNRI suffered from postoperative pneumoniae than patients with high GNRI (p=0.013). On the other hand, the incidence of surgical field complications such as leakage, pancreatic fistula and intraabdominal abscess did not differ significantly between the groups.

CONCLUSION

GNRI is useful in predicting postoperative complications of elderly patients with GC undergoing gastrectomy. Preoperative GNRI has merit as a gauge of postoperative complications in the extra-surgical field, especially pneumonia. There was no relationship between preoperative GNRI and surgical field complications in this setting.

Should Surgical Treatment Be Provided to Patients with Colorectal Cancer Who Are Aged 90 Years or Older?

PURPOSE

The number of patients aged ≥ 90 years is increasing worldwide; however, the treatment guidelines for colorectal cancer in elderly patients remain unclear. This study aimed to investigate the clinical outcomes of patients with primary colorectal cancer aged ≥ 90 years.

METHODS

We retrospectively reviewed the medical records of 100 patients (aged ≥ 90 years) with primary colorectal adenocarcinoma. Their demographic and clinical characteristics and surgical outcomes were assessed.

RESULTS

The patients who underwent tumor resections (n = 71) showed longer overall and cancer-specific survival than those who underwent non-operative treatments (n = 29) (median overall survival time: 23.92 months vs. 2.99 months, P < 0.0001). Age, body mass index, performance status, advanced cancer stage (stages 3 and 4), and treatment strategy were identified as risk factors, prognostic factors, and predictors of overall survival. No significant differences in the postoperative morbidity rate, in-hospital mortality rate, and survival time were found between the elective laparoscopic (n = 27) and elective open (n = 37) surgery subgroups. However, the in-hospital mortality rate was 6.25% (4/64) in the patients who underwent elective open surgeries and 42.9% (3/7) in those who underwent emergent open surgeries (p = 0.0179).

CONCLUSIONS

In clinical practice, surgical treatment should not be denied to patients with primary colorectal cancer aged ≥ 90 years. However, the high complication and mortality rates for emergency surgeries act as a deterrent. Further studies to eliminate the bias between operative and non-operative groups may be needed to validate our results.

Clinical outcomes after varicose vein procedures in octogenarians within the Vascular Quality Initiative Varicose Vein Registry

BACKGROUND

Whereas chronic venous insufficiency and varicose veins (VVs) are a universally recognized problem, they are frequently underappreciated as major contributors to long-term morbidity in the elderly despite the increasing prevalence with age. Previous studies have demonstrated that chronic venous insufficiency and VV treatments in patients ≥65 years old yield an overall benefit; however, there have been few data as to whether octogenarians are undergoing these procedures and with what success. As such, our objectives were to investigate the procedures selected, to examine clinical outcomes after VV procedures in elderly patients ≥80 years old, and to explore complication rates (both systemic and leg specific) after VV procedures in patients ≥80 years old.

METHODS

We performed a retrospective review using the Vascular Quality Initiative Varicose Vein Registry of all VV procedures performed for ≥C2 disease from January 2015 to February 2017. We divided all procedures into three age groups: patients <65 years, patients ≥65 to 79 years, and patients ≥80 years. Statistical testing included χ² test for categorical variables and Student t-test for continuous variables. Two comparisons were performed: first, comparing patients <65 years old with patients ≥65 to 79 years old; and second, comparing patients ≥65 to 79 years old with patients ≥80 years old.

RESULTS

There were a total of 12,262 procedures performed, with 8608 procedures in the patients <65 years, 3226 in patients 65 to 79 years, and 428 procedures in patients ≥80 years. A total of 22,050 veins were treated during the 12,262 procedures. Almost half of procedures (46.51%; n = 5703) had only one vein treated during a single procedure. Between age groups, the percentage of one vein treated increased as the patient's age increased, ranging from 45.39% (n = 3875) for patients <65 years to 48.55% (n = 1555) for patients between 65 and 79 years and 64.08% (n = 273) for patients ≥80 years. Patients in the group ≥80 years had an overall lower average body mass index and were more likely to be receiving anticoagulation and to undergo truncal procedures alone compared with the other groups. The group ≥80 years had a significant improvement in both Venous Clinical Severity Score (4.37 ± 4.16; P < .001) and patient-reported outcomes (8.79 ± 7.27; P < .001) from before to after the procedure. Overall complications were low in all age groups. The octogenarians had no higher risk of systemic complications.

CONCLUSIONS

Vascular specialists are performing VV procedures in octogenarians and are more likely to perform truncal only therapy. In addition, octogenarians have statistically significant improvement of Venous Clinical Severity Score and patient-reported outcomes with a low risk of complications despite more advanced venous disease at presentation.

Measurement of patient reported disability using WHODAS 2.0 before and after surgical intervention in Madagascar

BACKGROUND

Patient reported outcomes (PRO) measure the quality of care from the patient's perspective. PROs are an important measure of surgical outcome and can be used to calculate health gains after surgical treatment. The World Health Organisation Disability Assessment Schedule (WHODAS) 2.0 is a PRO used to evaluate pre and post-operative disability across a range of surgical specialities. In this study, Mercy Ships, a non-governmental organisation (NGO), used WHODAS 2.0 to evaluate patient reported disability in 401 consecutive patients in Madagascar. We hypothesised that surgical interventions would decrease pre-operative patient reported disability across a range of specialties (maxillofacial, plastic, orthopaedic, general and obstetric fistula surgery).

METHOD

WHODAS 2.0 was administered preoperatively by face-to-face interview, and at 3 months post-operatively by telephone. Demographic data, American Society of Anesthesiologists (ASA) physical classification score, duration of surgery, length of hospital stay, and in-hospital post-operative complications were collected from a separately maintained patient database. The primary outcome measure was difference in pre- and post-operative WHODAS 2.0 scores.

RESULTS

No differences were seen between the two groups in preoperative disability (p = 0.25), ASA score (p = 0.46), or duration of surgery (p = 0.85). At 3 months 44% (176/401) of patients were available for telephone for postoperative evaluation. All had a significant reduction in their disability score from 8.4% to 1.0% (p < 0.001), 17 experienced a post-operative complication, but none had residual disability and there were no deaths. The group lost to follow-up were more likely to be female (65% versus 50%, p < 0.05), were younger (mean age 31 versus 35, p < 0.05), had longer hospital stays (10 versus 4 days, p < 0.001), and were more likely to have experienced post-operative complications (p < 0.05).

CONCLUSION

This study demonstrates that surgical intervention in a LMIC decreases patient reported disability as measured by WHODAS 2.0.

Functional recovery and patient-reported outcomes after surgery

This manuscript centers on what surgeons, patients, and hospital administrations want and need to know about the crucial role of functional recovery and patients' reported outcome measure, above all in the elderly population. From all angles, it is clear that elderly patients are unique and their cancer care should be individualized and approached in a multidisciplinary fashion. Evaluation of patient fitness to undergo surgery should be undertaken in the elective and emergent settings. If patients are deemed fit for treatment, they should be offered the appropriate treatment, regardless of their age. This includes proceeding with surgery and/or chemotherapy and utilizing minimally invasive techniques, when appropriate. In addition, quality of life should be a priority in the care of elderly patients and patient-reported outcomes should be assessed and reported.

Identifying older adults at risk of harm following elective surgery: a systematic review and meta-analysis

BACKGROUND

Elective surgeries can be associated with significant harm to older adults. The present study aimed to identify the prognostic factors associated with the development of postoperative complications among older adults undergoing elective surgery.

METHODS

Medline, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and AgeLine were searched for articles published between inception and April 21, 2016. Prospective studies reporting prognostic factors associated with postoperative complications (composite outcome of medical and surgical complications), functional decline, mortality, post-hospitalization discharge destination, and prolonged hospitalization among older adults undergoing elective surgery were included. Study characteristics and prognostic factors associated with the outcomes of interest were extracted independently by two reviewers. Random effects meta-analysis models were used to derive pooled effect estimates for prognostic factors and incidences of adverse outcomes.

RESULTS

Of the 5692 titles and abstracts that were screened for inclusion, 44 studies (12,281 patients) reported on the following adverse postoperative outcomes: postoperative complications (n =28), postoperative mortality (n = 11), length of hospitalization (n = 21), functional decline (n = 6), and destination at discharge from hospital (n = 13). The pooled incidence of postoperative complications was 25.17% (95% confidence interval (CI) 18.03-33.98%, number needed to follow = 4). The geriatric syndromes of frailty (odds ratio (OR) 2.16, 95% CI 1.29-3.62) and cognitive impairment (OR 2.01, 95% CI 1.44-2.81) were associated with developing postoperative complications; however, there was no association with traditionally assessed prognostic factors such as age (OR 1.07, 95% CI 1.00-1.14) or American Society of Anesthesiologists status (OR 2.62, 95% CI 0.78-8.79). Besides frailty, other potentially modifiable prognostic factors, including depressive symptoms (OR 1.77, 95% CI 1.22-2.56) and smoking (OR 2.43, 95% CI 1.32-4.46), were also associated with developing postoperative complications.

CONCLUSION

Geriatric syndromes are important prognostic factors for postoperative complications. We identified potentially modifiable prognostic factors (e.g., frailty, depressive symptoms, and smoking) associated with developing postoperative complications that can be targeted preoperatively to optimize care.

Predicting activities of daily living for cancer patients using an ontology-guided machine learning methodology

Background

Bio-ontologies are becoming increasingly important in knowledge representation and in the machine learning (ML) fields. This paper presents a ML approach that incorporates bio-ontologies and its application to the SEER-MHOS dataset to discover patterns of patient characteristics that impact the ability to perform activities of daily living (ADLs). Bio-ontologies are used to provide computable knowledge for ML methods to “understand” biomedical data.

Results

This retrospective study included 723 cancer patients from the SEER-MHOS dataset. Two ML methods were applied to create predictive models for ADL disabilities for the first year after a patient’s cancer diagnosis. The first method is a standard rule learning algorithm; the second is that same algorithm additionally equipped with methods for reasoning with ontologies. The models showed that a patient’s race, ethnicity, smoking preference, treatment plan and tumor characteristics including histology, staging, cancer site, and morphology were predictors for ADL performance levels one year after cancer diagnosis. The ontology-guided ML method was more accurate at predicting ADL performance levels (P < 0.1) than methods without ontologies.

Conclusions

This study demonstrated that bio-ontologies can be harnessed to provide medical knowledge for ML algorithms. The presented method demonstrates that encoding specific types of hierarchical relationships to guide rule learning is possible, and can be extended to other types of semantic relationships present in biomedical ontologies. The ontology-guided ML method achieved better performance than the method without ontologies. The presented method can also be used to promote the effectiveness and efficiency of ML in healthcare, in which use of background knowledge and consistency with existing clinical expertise is critical.

Colorectal cancer surgery in the very elderly patient: a systematic review of laparoscopic versus open colorectal resection

INTRODUCTION

Colorectal cancer is the second most common cause of death from neoplastic disease in men and third in women of all ages. Globally, life expectancy is increasing, and consequently, an increasing number of operations are being performed on more elderly patients with the trend set to continue. Elderly patients are more likely to have cardiovascular and pulmonary comorbidities that are associated with increased peri-operative risk. They further tend to present with more locally advanced disease, more likely to obstruct or have disseminated disease. The aim of this review was to investigate the feasibility of laparoscopic colorectal resection in very elderly patients, and whether there are benefits over open surgery for colorectal cancer.

METHODS

A systematic literature search was performed on Medline, Pubmed, Embase and Google Scholar. All comparative studies evaluating patients undergoing laparoscopic versus open surgery for colorectal cancer in the patients population over 85 were included. The primary outcomes were 30-day mortality and 30-day overall morbidity. Secondary outcomes were operating time, time to oral diet, number of retrieved lymph nodes, blood loss and 5-year survival.

RESULTS

The search provided 1507 citations. Sixty-nine articles were retrieved for full text analysis, and only six retrospective studies met the inclusion criteria. Overall mortality for elective laparoscopic resection was 2.92% and morbidity 23%. No single study showed a significant difference between laparoscopic and open surgery for morbidity or mortality, but pooled data analysis demonstrated reduced morbidity in the laparoscopic group (p = 0.032). Patients undergoing laparoscopic surgery are more likely to have a shorter hospital stay and a shorter time to oral diet.

CONCLUSION

Elective laparoscopic resection for colorectal cancer in the over 85 age group is feasible and safe and offers similar advantages over open surgery to those demonstrated in patients of younger ages.

Estimation of V-POSSUM and E-PASS Scores in Prediction of Acute Kidney Injury in Patients after Elective Open Abdominal Aortic Aneurysm Surgery

BACKGROUND

V-POSSUM and E-PASS scoring systems are usually used to predict morbidity and early mortality in surgical patients. We conducted this study to assess the validity of the V-POSSUM and E-PASS scores in predicting risk of acute kidney injury (AKI) development in patients undergoing elective open abdominal aortic aneurysm (AAA) repair.

METHODS

We studied a consecutive series of 171 patients with AAA, qualified for elective open infrarenal repair. Patients underwent a thorough examination, and the physiological and surgical stress components of the V-POSSUM and E-PASS scores were calculated. The classification of patients in terms of postoperative AKI was performed in accordance with KDIGO criteria.

RESULTS

AKI was recognized in 62 patients. In these patients, we found significantly higher physiological and surgical stress components of V-POSSUM and E-PASS scores in relation to patients without AKI. ROC analysis showed that the E-PASS score with a cutoff point ≥0.796 and the V-POSSUM score (morbidity) with a cutoff point ≥77.2% with sensitivity of 75.8% and 74.2%, respectively, and with specificity of 83.5% for both, identified patients with postoperative AKI.

CONCLUSIONS

V-POSSUM and E-PASS scores have similar good properties in predicting postoperative AKI in patients undergoing elective open AAA repair.

The short-term impact of colorectal cancer treatment on physical activity, functional status and quality of life: a systematic review

BACKGROUND

Physical activity, functional status and quality of life (QoL) are important determinants of the quality of life (QoL) after colorectal cancer (CRC) treatment; however, little is known on how the treatment impacts these outcomes. Having this understanding could help clinicians develop and implement strategies that would enhance or maintain the QoL of CRC patients.

OBJECTIVES

To identify the impact of curative CRC treatment (surgery with or without radiotherapy and/or chemotherapy) on physical activity, functional status and QoL within one year of treatment or diagnosis.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

Colorectal cancer survivors aged 18 years and over.

TYPES OF INTERVENTIONS

Curative CRC treatment, which was surgery with or without radiotherapy and/or chemotherapy.

TYPES OF STUDIES

Pre- and post-observational and experimental studies.

OUTCOMES

Physical activity, ability to perform activities of daily living (functional status) and QoL.

SEARCH STRATEGY

CINAHL, Embase, MEDLINE, OpenGrey and ProQuest Dissertations and Theses were used to obtain published and unpublished studies in English. The date range was the start of indexing to February 2015.

METHODOLOGICAL QUALITY

All studies were assessed independently by two reviewers for relevance, eligibility and methodological quality.

DATA EXTRACTION

Data from included papers were extracted using a modified data extraction tool. Data that were presented graphically were extracted using online software.

DATA SYNTHESIS

The differences between postoperative and baseline values were calculated using the Review Manager 5.3.5 (Copenhagen: The Nordic Cochrane Centre, Cochrane) calculator and expressed as mean difference and their corresponding 95% confidence interval. Where possible, study results were pooled in statistical meta-analysis. The physical activity, functional status and some QoL results are presented in a narrative and table form.

RESULTS

A total of 23 studies were included in this review: two studies (N = 2019 patients) evaluated physical activity, two studies (N = 6908 patients) assessed functional status and 22 studies (N = 2890 patients) measured QoL. Physical activity was observed to decrease at six months after treatment. The functional status of CRC patients decreased, particularly in the elderly (Summary of findings 1 and 2). As for QoL, only the physical and functional aspects were seen to decline up to six months, but scores almost returned to baseline levels at one year after treatment. The QoL studies that used the European Organization for Research and Treatment of Cancer QLQ-C30 tool were pooled in statistical meta-analysis and summarized in Summary of findings 2. The results must be interpreted carefully due to the heterogeneity of studies and scarcity of recent studies.

CONCLUSION

In spite of the limitations, it is likely that the physical and functional capacity of CRC survivors deteriorates after treatment.

IMPLICATIONS FOR PRACTICE

The period between diagnosis and treatment provides an opportunity for clinicians to implement interventions (e.g. exercise interventions) that could enhance or restore the physical and functional capacity of CRC survivors.

IMPLICATIONS FOR RESEARCH

The paucity of studies and heterogeneity need to be addressed. The outcomes for colon and rectal cancer survivors, ostomates and non-ostomates must be analyzed separately.

Delivering tailored surgery to older cancer patients: Preoperative geriatric assessment domains and screening tools - A systematic review of systematic reviews

The onco-geriatric population is increasing and thus more and more elderly will require surgery; an important treatment modality for many cancer types. This population's heterogeneity demands preoperative risk stratification, which has led to the introduction of Geriatric Assessment (GA) and associated screening tools in surgical oncology. Many reviews have investigated the use of GA in onco-geriatric patients. Discrepancies in outcomes between studies currently hamper the implementation of a preoperative GA in clinical practice. A systematic review of systematic reviews was performed in order to investigate assessment tools of the most commonly included GA domains and their predictive ability regarding the adverse postoperative outcomes. All domains - except polypharmacy - were, to a varying degree, associated with different adverse postoperative outcomes. Functional status, comorbidity and frailty were assessed most frequently and were most often significant. The association between domain impairments and adverse postoperative outcomes appeared to be greatly influenced by the study population characteristics and selection bias, as well as the type of assessment tool used due to possible ceiling effects and its sensitivity to detect domain impairments. Frailty seems to be the most important predictor, which underpins the importance of an integrated approach. As it is unlikely that one universal GA will fit all, feasibility, based on the time, expertise, and resources available in daily clinical practice as well as the patient population to hand, should be taken into consideration, when tailoring the 'optimal GA'.

Postoperative Functional Outcomes in Older Adults

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

E-PASS score as a useful predictor of postoperative complications and mortality after colorectal surgery in elderly patients

PURPOSE

The aim of this study was to clarify whether a surgical-specific risk scoring system estimating the physiologic ability and surgical stress (E-PASS) score was useful for prediction of postoperative morbidity and mortality.

METHODS

The E-PASS score consists of the preoperative risk score (PRS), surgical stress score (SSS), and the comprehensive risk score (CRS). Conventional scoring systems [colorectal physiologic and operative severity score for the enumeration of mortality (CR-POSSUM) and the prognostic nutritional index (PNI)] were also examined. We retrospectively compared these scores in patients with or without postoperative complications. We assessed the relationship between these scores, clinicopathological features and postoperative mortality.

RESULTS

Postoperative complications developed in 78 patients (33%). American Society of Anesthesiologists score, performance status, PNI score, PRS, SSS, and CRS were significantly higher in patients with postoperative complications than in those without postoperative complications (p < 0.05). The area under the receiver operating characteristic curve (AUC) was highest for E-PASS [E-PASS (PRS, 0.74; SSS, 0.62; CRS, 0.78), PNI (0.62), CR-POSSUM (PS, 0.57; OSS, 0.52)]. Multivariate logistic analysis identified CRS ≥ 0.2 as a significant determinant of postoperative complications (p < 0.01; hazard ratio, 4.84). Overall survival was significantly better in the CRS < 0.2 group than in the CRS > 0.2 group (p < 0.01).

CONCLUSIONS

The E-PASS score system was a useful predictor of postoperative complications and mortality, especially in patients with advanced age.

A systematic review of instruments for measuring outcomes in economic evaluation within aged care

BACKGROUND

This paper describes the methods and results of a systematic review to identify instruments used to measure quality of life outcomes in older people. The primary focus of the review was to identify instruments suitable for application with older people within economic evaluations conducted in the aged care sector.

METHODS

Online databases searched were PubMed, Medline, Scopus, and Web of Science, PsycInfo, CINAHL, Embase and Informit. Studies that met the following criteria were included: 1) study population exclusively above 65 years of age 2) measured health status, health related quality of life or quality of life outcomes more broadly through use of an instrument developed for this purpose, 3) used a generic preference based instrument or an older person specific preference based or non-preference based instrument or both, and 4) published in journals in the English language after 2000.

RESULTS

The most commonly applied generic preference based instrument in both the community and residential aged care context was the EuroQol - 5 Dimensions (EQ-5D), followed by the Adult Social Care Outcomes Toolkit (ASCOT) and the Health Utilities Index (HUI2/3). The most widely applied older person specific instrument was the ICEpop CAPability measure for Older people (ICECAP-O) in both community and residential aged care.

CONCLUSION

In the absence of an ideal instrument for incorporating into economic evaluations in the aged care sector, this review recommends the use of a generic preference based measure of health related quality of life such as the EQ-5D to obtain quality adjusted life years, in combination with an instrument that has a broader quality of life focus like the ASCOT, which was designed specifically for evaluating interventions in social care or the ICECAP-O, a capability measure for older people.

Relationship between physical activity and function in elderly patients discharged after surgical treatment for gastrointestinal cancer

[Purpose] The purpose of the present study was to observe changes in physical activity (PA) from before surgery to after discharge among elderly patients with gastrointestinal cancer and to examine the relationships between PA, function, and physique after discharge in these patients. [Subjects and Methods] The study participants were 18 elderly patients who underwent surgical treatment for gastrointestinal cancer [10 males and 8 females, aged 71.4 ± 4.2 years (mean ± SD)]. We evaluated patients' PA, function, and physique before surgery and after discharge. Calorie consumption as calculated using the International Physical Activity Questionnaire (IPAQ) short version was measured for PA. Isometric knee extension force (IKEF), the timed up and go test (TUGT), and the 6-minute walk distance (6MWD) were measured for function. The body mass index (BMI) was calculated for physique. [Results] Significant declines in PA and BMI were observed after discharge among the study participants. In addition, a significant correlation between PA and IKEF was observed in the discharge phase. [Conclusion] These results suggest that PA after discharge is significantly less than that before surgery and related to the functioning of the lower extremities in the same period in elderly patients who undergo surgical treatment for gastrointestinal cancer.

Optimal Preoperative Evaluation and Perioperative Care of the Geriatric Patient: A Surgeon's Perspective

The elderly preoperative patient benefits from an assessment that includes more than a routine physical examination and electrocardiogram. Such an assessment includes domains likely to affect the elderly: cognition, functionality, frailty, polypharmacy, nutrition, and social support. This fosters decisions based on functional age rather than chronologic age and on each patient as an individual. One such assessment is that promulgated by the American College of Surgeons National Surgery Quality Improvement Program/American Geriatrics Society Best Practice Guidelines. We should not miss any opportunity to improve results in this growing population of surgical patients.

Assessment of patient-reported outcome measures in the surgical treatment of patients with gastric cancer

Background

Gastric cancer is responsible for 10 % of all cancer-related deaths worldwide. With improved operative techniques and neo-adjuvant therapy, survival rates are increasing. Outcomes of interest are shifting to quality of life (QOL), with many different tools available. The aim of this study was to assess which patient-reported outcome measures (PROMs) are used to measure QOL after a gastrectomy for cancer.

Methods

A comprehensive search was conducted for original articles investigating QOL after gastrectomy. Two authors independently selected relevant articles, conducted clinical appraisal and extracted data (P.J. and J.S.).

Results

Out of 3414 articles, 26 studies were included, including a total of 4690 patients. These studies included ten different PROMs, which could be divided into generic, symptom-specific and disease-specific questionnaires. The EORTC and the FACT questionnaires use an oncological overall QOL module and an organ-specific module. Only one validation study regarding the use of the EORTC after surgery for gastric cancer was available, demonstrating good psychometric properties and clinical validity.

Conclusions

A great variety of PROMs are being used in the measurement of QOL after surgery for gastric cancer. A questionnaire with a general module along with a disease-specific module for the assessment of QOL seems most desirable, such as the EORTC and the FACT with their specific modules. Both are developed in different treatment modalities, such as in surgical patients. EORTC is the most widely used questionnaire and therefore allows for comparison of new studies to existing data. Future studies are needed to assess content validity in surgical gastric cancer patients.

Short-term postoperative functional outcomes in older women undergoing prolapse surgery

OBJECTIVE

To evaluate whether preoperative markers of functional status predict postoperative functional outcomes in older women undergoing surgery for pelvic organ prolapse (POP).

METHODS

Prospective cohort study of women aged 60 years or older who underwent surgery for prolapse. Preoperative functional status was measured using number of functional limitations (such as difficulty walking or climbing), American Society of Anesthesiologists class, anemia, and history of recent weight loss. Our primary outcome was the number of postoperative functional limitations and secondary outcomes were failure to return to baseline functional status and length of stay after surgery. We determined the association of preoperative functional status markers with postoperative outcomes using univariable and multivariable regression.

RESULTS

In 127 women, presence of a preoperative functional limitation was a significant predictor of a 0.55 (95% confidence interval [CI] 0.36-0.74) increase in the number of postoperative functional limitations after controlling for age, number of preoperative functional limitations, comorbidities, depression, surgeon, type of procedure, and complications (P<.001). History of recent weight loss and anemia increased risk for failure to return to baseline functional status after controlling for surgeon, type of surgery, and complications (relative risk 2.44, 95% CI 1.26-4.71 and relative risk 2.72, 95% CI 1.29-5.75), respectively). Preoperative markers associated with longer length of stay after surgery were American Society of Anesthesiologists class III (0.83 days, 95% CI 0.20-1.46) and history of weight loss (0.84 days, 95% CI 0.13-1.54).

CONCLUSION

Preoperative markers of functional status are useful in predicting short-term postoperative functional outcomes in older women undergoing surgery for POP.

LEVEL OF EVIDENCE

: II.

Changes in gastrointestinal cancer resection rates

Background

Many developments in medicine are likely to have influenced the treatment of gastrointestinal cancer, including rates of resection. This study sought to investigate changes in surgical resection rates over time among patients with gastrointestinal cancer.

Methods

Patients diagnosed between 1995 and 2012 in the Eindhoven Cancer Registry area were included. Multivariable logistic regression analysis was used to determine the independent influence of interval of diagnosis on the likelihood of having a resection.

Results

Among 43 370 patients, crude resection rates decreased between 1995 and 2012 for gastric, colonic and rectal cancer, most notably for patients aged at least 85 years with gastric cancer (from 37·3 to 13·3 per cent), and patients aged 75–84 years and 85 years or more with rectal cancer (from 80·5 to 64·4 per cent, and from 58·9 to 36·0 per cent respectively). After adjustment for patient and tumour characteristics, patients diagnosed between 2008 and 2012 with gastric (odds ratio (OR) 0·71, 95 per cent c.i. 0·55 to 0·92), colonic (OR 0·52, 0·44 to 0·62), rectal (OR 0·39, 0·33 to 0·48) and periampullary (OR 0·42, 0·27 to 0·66) cancers were less likely to undergo resection than those diagnosed between 1995 and 1998. Patients diagnosed with pancreatic cancer were more likely to undergo resection in recent periods (OR 4·13, 2·57 to 6·64).

Conclusion

Resection rates have fallen over time for several gastrointestinal cancers. This might reflect increased availability of other treatments, better selection of patients as a result of improved diagnostic accuracy, risk-avoiding behaviour and transparency related to surgical outcomes at hospital and surgeon level.

Age-Related Morbidity and Mortality with Cytoreductive Surgery

INTRODUCTION

Cytoreduction and intraperitoneal chemotherapy (IPC) are increasingly considered in older patients. We sought to better characterize the influence of age on 30-day outcomes following this procedure.

METHODS

The ACS NSQIP database was queried for patients who underwent IPC and a concurrent intra-abdominal operation (2005-2012). Thirty-day death and serious morbidity (DSM) was the primary outcome. Trends in DSM by age were defined using Joinpoint regression. Univariate and multivariate logistic regression identified factors associated with DSM.

RESULTS

In 1085 patients, DSM increased at a significant rate after age 50 (0.6 %/year, p = 0.001). Patients ≥60 (n = 376) represented 35 % of the study population. Age ≥60 years was independently associated with DSM (odds ratio [OR] 1.6, p = 0.001). The older patient population (≥60 years) experienced 44 % morbidity and 3.2 % mortality. In these patients, preoperative weight loss, low preoperative albumin, splenectomy, intraoperative transfusion, contaminated or dirty wound classification, and prolonged operative time were all independently significantly associated with increased DSM. In the absence of these factors (n = 45), the DSM rate was 11 %. Rates of DSM increased to 33, 63, and 100 % in patients with 1 factor, 2-3 factors, and 4 or more factors (n = 14; p < 0.001), respectively. Venous thromboembolism, sepsis, postoperative bleeding, and respiratory complications were significantly more common among those aged 60 years and older (p < 0.05 each).

CONCLUSIONS

The risk of DSM increases with age in patients undergoing cytoreduction and IPC. Risk can be stratified using a limited number of patient and operative characteristics.

Screening for predictors of adverse outcome in onco-geriatric surgical patients: A multicenter prospective cohort study

AIMS

The aim of this study was to investigate the predictive ability of screening tools regarding the occurrence of major postoperative complications in onco-geriatric surgical patients and to propose a scoring system.

METHODS

328 patients ≥ 70 years undergoing surgery for solid tumors were prospectively recruited. Preoperatively, twelve screening tools were administered. Primary endpoint was the incidence of major complications within 30 days. Odds ratios (OR) and 95% confidence intervals (95% CI) were estimated using logistic regression. A scoring system was derived from multivariate logistic regression analysis. The area under the receiver operating characteristic curve (AUC) was applied to evaluate model performance.

RESULTS

At a median age of 76 years, 61 patients (18.6%) experienced major complications. In multivariate analysis, Timed Up and Go (TUG), ASA-classification and Nutritional Risk Screening (NRS) were predictors of major complications (TUG>20 OR 3.1, 95% CI 1.1-8.6; ASA ≥ 3 OR 2.8, 95% CI 1.2-6.3; NRS impaired OR 3.3, 95% CI 1.6-6.8). The scoring system, including TUG, ASA, NRS, gender and type of surgery, showed good accuracy (AUC: 0.81, 95% CI 0.75-0.86). The negative predictive value with a cut-off point >8 was 93.8% and the positive predictive value was 40.3%.

CONCLUSIONS

A substantial number of patients experience major postoperative complications. TUG, ASA and NRS are screening tools predictive of the occurrence of major postoperative complications and, together with gender and type of surgery, compose a good scoring system.

Measurement of Disability-free Survival after Surgery

Background:

Survival and freedom from disability are arguably the most important patient-centered outcomes after surgery, but it is unclear how postoperative disability should be measured. The authors thus evaluated the World Health Organization Disability Assessment Schedule 2.0 in a surgical population.

Methods:

The authors examined the psychometric properties of World Health Organization Disability Assessment Schedule 2.0 in a diverse cohort of 510 surgical patients. The authors assessed clinical acceptability, validity, reliability, and responsiveness up to 12 months after surgery.

Results:

Criterion and convergent validity of World Health Organization Disability Assessment Schedule 2.0 were supported by good correlation with the 40-item quality of recovery scale at 30 days after surgery (r = −0.70) and at 3, 6, and 12 months after surgery with physical functioning (The Katz index of independence in Activities of Daily Living; r = −0.70, r = −0.60, and rho = −0.47); quality of life (EQ-5D; r = −0.57, −0.60, and −0.52); and pain interference scores (modified Brief Pain Inventory Short Form; r = 0.72, 0.74, and 0.81) (all P &lt; 0.0005). Construct validity was supported by increased hospital stay (6.9 vs. 5.3 days, P = 0.008) and increased day 30 complications (20% vs. 11%, P = 0.042) in patients with new disability. There was excellent internal consistency with Cronbach’s α and split-half coefficients greater than 0.90 at all time points (all P &lt; 0.0005). Responsiveness was excellent with effect sizes of 3.4, 3.0, and 1.0 at 3, 6, and 12 months after surgery, respectively.

Conclusions:

World Health Organization Disability Assessment Schedule 2.0 is a clinically acceptable, valid, reliable, and responsive instrument for measuring postoperative disability in a diverse surgical population. Its use as an endpoint in future perioperative studies can provide outcome data that are meaningful to clinicians and patients alike.

Short-term outcomes of laparoscopic surgery for colorectal cancer in oldest-old patients

BACKGROUND/AIMS

Oldest-old patients generally have several comorbidities, and laparoscopic-assisted colectomy (LAC) has not been performed on these patients. However, the surgical technique of LAC has improved, and its indications have been extended. The aim of this study was to evaluate the safety and effectiveness of LAC for patients over 85 years old.

METHODS

Fifty-eight patients over 85 years old who underwent colectomy were retrospectively analyzed. The patients were divided into two groups (LAC group n = 15; open surgery group (Open group) n = 43), and clinicopathological features, surgical characteristics, and outcomes were compared.

RESULTS

There were no significant differences in clinical background characteristics between the groups. The LAC group had longer operation time and greater lymph node dissection (both p < 0.01). Postoperatively, the use of analgesics (p = 0.01) was less and the start of oral liquid intake (p = 0.03) was faster in the LAC group. Postoperative complications occurred in 3 patients (20%) in the LAC group and 13 patients (30%) in the Open group (p = 0.66); delirium (n = 6) and sub-ileus (n = 4) developed only in the Open group.

CONCLUSION

After LAC, elderly patients tended to have less postoperative pain and started oral liquid intake earlier. LAC can be safe and effective, preventing postoperative complications that occur specifically in oldest-old patients.

Preoperative and early postoperative quality of life after major surgery - a prospective observational study

BACKGROUND

Changes in health-related quality of life (HRQoL) several days after surgery have rarely been investigated. We aimed to estimate the perioperative change of HRQoL, to identify patients with clinically relevant decrease in postoperative HRQoL and to establish factors associated with this decrease in HRQoL at day 30 after major surgery.

METHODS

Patients scheduled for major surgery at a university hospital were enrolled. Based on the HRQoL SF-12 questionnaire, the preoperative physical component summary (PCS) score, preoperative mental component summary (MCS) score, and postoperative PCS and MCS scores at day 30 were recorded. Minimal clinically important difference (MCID) was defined as those with a decrease of at least one half of the standard deviation (SD) of preoperative PCS or MCS scores. Differences between the groups with or without decreased HRQoL were investigated using univariate comparisons. A multiple logistic regression model was performed to evaluate the predictive value of potential perioperative variables.

RESULTS

The mean ± SD preoperative PCS score was 38.5 ± 10.6, postoperative score was 35.1 ± 7.8 (p = .004) in 85 patients. Thirty-five patients (41.2%) had a clinically relevant decrease of the postoperative PCS score. A normal to high preoperative exercise metabolic capacity measured with metabolic equivalent of task (MET) (p = .01) was a predictor of the decrease in postoperative PCS. The mean preoperative MCS scores (p = .395) were 42.2 (SD 12.8) preoperative, and 43.45 (SD 12.4) postoperative, respectively.

CONCLUSIONS

Major surgery decreases postoperative PCS scores of HRQoL at 30 days. A normal to high exercise capacity was a predictor of a clinically relevant decrease of postoperative PCS scores.

TRIAL REGISTRATION

07-107 (Ethical Committee NAC of Geneva University Hospitals).

A Review and Meta-analysis of Colorectal Cancer Utilities

OBJECTIVE

To perform a systematic review of utility weights for colorectal cancer (CRC) health states reported in the scientific literature and to determine the effects of disease factors, patient characteristics, and utility methods on utility values.

METHODS

We identified 26 articles written in English and published from January 1980 to January 2013, providing 351 unique utilities for CRC health states elicited from 6546 unique respondents. The CRC utility data were analyzed using linear mixed-effects models with CRC type, stage, time to or from initial care, utility measurement instrument, and administration method as independent variables.

RESULTS

In the base case model, the estimated utility for a patient with stage I to III CRC more than 1 year after surgery, rated using a self-administered time tradeoff instrument, was 0.90. Stage, time to or from initial care, and utility measurement instrument were associated with statistically significant utility differences ranging from -0.19 to 0.02. Utilities for patients with stage IV cancer were 0.19 lower (P < 0.001) than for those with stage I to III cancer. Utilities elicited at more than 1 year after surgery were 0.05 higher than those elicited at 3 months after surgery (P = 0.008). Estimates of differences between utility measurement instruments were sensitive to how repeated scores in the same patient group were treated, and other findings were sensitive to how the disease stage was modeled and method of administration.

CONCLUSIONS

Variations in reported utilities are associated with factors such as cancer stage, time to or from initial care, and utility measurement instrument. More research is needed to study why apparently similar patients report different quality of life.

Personalized surgical management of colorectal cancer in elderly population

Colorectal cancer (CRC) in the elderly is extremely common but only a few clinicians are familiar with the complexity of issues which present in the geriatric population. In this phase of the life cycle, treatment is frequently suboptimal. Despite the fact that, nowadays, older people tend to be healthier than in previous generations, surgical undertreatment is frequently encountered. On the other hand, surgical overtreatment in the vulnerable or frail patient can lead to unacceptable postoperative outcomes with high mortality or persistent disability. Unfortunately, due to the geriatric patient being traditionally excluded from randomized controlled trials for a variety of factors (heterogeneity, frailty, etc.), there is a dearth of evidence-based clinical guidelines for the management of these patients. The objective of this review was to summarize the most relevant clinical studies available in order to assist clinicians in the management of CRC in the elderly. More than in any other patient group, both surgical and non-surgical management strategies should be carefully individualized in the elderly population affected by CRC. Although cure and sphincter preservation are the primary goals, many other variables need to be taken into account, such as maintenance of cognitive status, independence, life expectancy and quality of life.

Meaningful outcome measures in cardiac surgery

The most common cardiac surgical procedures are coronary artery bypass graft surgery and aortic or mitral valve repair or replacement. Underlying conditions include coronary artery disease and heart failure, manifesting as exertional angina, dyspnea, and poor exercise tolerance. The major goals of surgery are to alleviate symptoms and improve patient survival. These, therefore, should inform the choice of primary outcome measures in clinical studies enrolling patients undergoing cardiac surgery. Studies focusing on surrogate outcome measures are relied on all too often. Many are of questionable significance and often have no convincing relationship with patient outcome. Traditional "hard endpoint" outcome measures include serious complications and death with the former including myocardial infarction (MI) and stroke. Such serious adverse outcomes are commonly collected in registries, but because they occur infrequently, they need to be large to reliably detect true associations and treatment effects. For this reason, some investigators combine several outcomes into a single composite endpoint. Cardiovascular trials commonly use major adverse cardiac events (MACEs) as a composite primary endpoint. However, there is no standard definition for MACE. Most include MI, stroke, and death; others include rehospitalization for heart failure, revascularization, cardiac arrest, or bleeding complications. An influential trial in noncardiac surgery found that perioperative beta-blockers reduced the risk of MI but increased the risk of stroke and death. Such conflicting findings challenge the veracity of such composite endpoints and raise a far more important question: which of these endpoints, or even others that were unmeasured, are most important to a patient recovering from surgery? Given the primary aims of cardiac surgery are to relieve symptoms and improve good quality survival, it is disability-free survival that is the ultimate outcome measure. The question then becomes: what is disability and how should it be quantified after cardiac surgery?

Haloperidol prophylaxis does not prevent postoperative delirium in elderly patients: a randomized, open-label prospective trial

PURPOSE

Postoperative delirium is the most common postoperative complication in the elderly. The purpose of this study was to evaluate the safety and effectiveness of the preventive administration of low-dose haloperidol on the development of postoperative delirium after abdominal or orthopedic surgery in elderly patients.

SUBJECTS

A total of 119 patients aged 75 years or older who underwent elective surgery for digestive or orthopedic disease were included in this study.

METHODS

Patients were divided into those who did (intervention group, n = 59) and did not (control group, n = 60) receive 2.5 mg of haloperidol at 18:00 daily for 3 days after surgery; a randomized, open-label prospective study was performed on these groups. The primary endpoint was the incidence of postoperative delirium during the first 7 days after the operation.

RESULTS

The incidence of postoperative delirium in all patients was 37.8%. No side effects involving haloperidol were noted; however, the incidences of postoperative delirium were 42.4 and 33.3% in the intervention and control groups, respectively, which were not significantly different (p = 0.309). No significant effect of the treatment was observed on the severity or persistence of postoperative delirium.

CONCLUSIONS

The preventive administration of low-dose haloperidol did not induce any adverse events, but also did not significantly decrease the incidence or severity of postoperative delirium or shorten its persistence.

Prediction of long-term mortality by preoperative health-related quality-of-life in elderly onco-surgical patients

Objective

Aim of this study was to evaluate the association between preoperative health-related quality of life (HRQoL) and mortality in a cohort of elderly patients (>65 years) with gastrointestinal, gynecological and genitourinary carcinomas.

Design

Prospective cohort pilot study.

Setting

Tertiary university hospital in Germany.

Patients

Between June 2008 and July 2010 and after ethical committee approval and written informed consent, 126 patients scheduled for onco-surgery were included. Prior to surgery as well as 3 and 12 months postoperatively all participants completed the EORTC-QLQ-C30 questionnaire (measuring self-reported health-related quality of life). Additionally, demographic and clinical data including the Mini Mental State Examination (MMSE) were collected. Surgery and anesthesia were conducted according to the standard operating procedures. Primary endpoint was the cumulative mortality rate over 12 months after one year. Changes in Quality of life were considered as secondary outcome.

Results

Mortality after one year was 28%. In univariable and multivariable logistic regression analysis baseline HRQoL self-reported cognitive function (OR per point: 0.98; CI 95% 0.96–0.99; p = 0.024) and higher symptom burden for appetite loss (per point: OR 1.02; CI 95% 1.00–1.03; p = 0.014) were predictive for long-term mortality. Additionally the MMSE as an objective measure of cognitive impairment (per point: OR 0.69; CI 95% 0.51–0.96; p = 0.026) as well as severity of surgery (OR 0.31; CI 95% 0.11–0.93; p = 0.036) were predictive for long-term mortality. Global health status 12 months after surgery was comparable to the baseline levels in survivors despite moderate impairments in other domains.

Conclusion

This study showed that objective and self-reported cognitive functioning together with appetite loss were prognostic for mortality in elderly cancer patients. In addition, impaired cognitive dysfunction and severity of surgery were predictive for one-year mortality whereas in this selected population scheduled for surgery age, gender, cancer site and metastases were not.

Frailty indicators and functional status in older patients after colorectal cancer surgery

OBJECTIVES

The number of older survivors from colorectal cancer is increasing, but little is known regarding long-term consequences of cancer treatment in this patient group. Physical function is an important outcome for older patients, affecting both autonomy and quality of life. We aimed to investigate physical function in older patients with colorectal cancer before and after surgery, and to examine the role of individual frailty indicators as predictors of functional decline.

MATERIAL AND METHODS

We present 16-28 months follow-up data of older patients after elective surgery for colorectal cancer. During a home-visit, physical function was evaluated by activities of daily living (ADL), instrumental activities of daily living (IADL), the timed up-and-go (TUG) test, and grip strength. Measurements were compared with those obtained preoperatively using the Wilcoxon signed rank test. Frailty indicators were dichotomized and implemented in logistic regression models to explore their associations to a decline in the physical function scores.

RESULTS

Eighty-four patients were included and the median age was 82 years. There was a significant decrease in ADL (p = 0.04) and IADL scores (p ≤ 0.001) at follow-up. We found no associations between frailty indicators and the risk of decline in physical functioning.

CONCLUSION

In our population of older patients with surgically treated colorectal cancer, there was a significant decline in ADL- and IADL-scores at follow-up. No change was found in TUG or grip strength, and frailty indicators did not predict decline in physical function.

The Surgical Recovery Score correlates with the development of complications following elective colectomy

BACKGROUND

The Surgical Recovery Score (SRS) is a validated, comprehensive recovery assessment tool used to measure functional recovery after major surgery. To further evaluate its clinical applicability, this study investigated whether the SRS correlates with clinical outcomes and the occurrence of complications after elective colectomy.

MATERIALS AND METHODS

We conducted a retrospective review of prospectively collected data for consecutive patients undergoing elective colonic resection within an enhanced recovery program at our institution from September 2008 to September 2011. We administered the 31-item SRS questionnaire preoperatively (baseline) and on postoperative days 1, 3, 7, 14, and 30. We scored individual questionnaires as a percentage of the maximum possible score, with a higher SRS indicating improved functional recovery (range, 17-100). We prospectively recorded clinical outcomes and graded 30-d complications as per the Clavien-Dindo classification. We conducted univariate and logistic regression analysis to determine the correlation of the SRS to the development of complications.

RESULTS

We evaluated 134 patients, 62 of whom developed minor complications (grades 1-2) (46%) and 21 of whom developed major complications (grades 3-5) (16%). The SRS was similar at baseline in the complicated and uncomplicated groups but significantly lower on postoperative days 3, 7, 14, and 30 in patients who developed major complications, and on days 7 and 14 in patients who developed minor complications. In a logistic regression analysis, the SRS on postoperative day 3 was independently associated with the development of any complication, as well as major complications specifically.

CONCLUSIONS

In addition to measuring functional recovery, the SRS closely correlates with the development of complications after elective colectomy and offers a reliable outcome measure to assess overall postoperative recovery.

Postoperative function following radical surgery in gastric and colorectal cancer patients over 80 years of age--an objection to "ageism"

PURPOSE

With rapid growth in the elderly population, the number of elderly cancer patients who should be offered life-prolonging radical surgery has been increasing. The aim of this report is to demonstrate the outcome of elective radical surgery for gastric or colorectal cancer patients 80 years of age or older, including the natural course of recovery of functional independence, in order to avoid the negative attitude held toward surgery that is due only to patients' high chronological age.

METHODS

Physical condition, ADL, and QOL of 108 patients 80 years of age or older with gastric or colorectal cancer were evaluated preoperatively and at the 1st, 3rd, and 6th postoperative months.

RESULTS

There were no operative deaths, and the morbidity rate was 27.9%. Only 6% of the patients showed a decrease in ADL at the 6th postoperative month. This decrease typically occurred following discharge from the hospital. Patient QOL showed recovery to an extent equal to or better than average preoperative scores.

CONCLUSIONS

Of the patients who underwent elective surgery for gastric or colorectal cancer, only a few showed a protracted decline in ADL, and most exhibited better QOL after surgery. Surgical treatment should therefore be considered, whenever needed, for elderly patients 80 years of age or older with gastric or colorectal cancer.

Functional status after colon cancer surgery in elderly nursing home residents

OBJECTIVES

To determine functional status and mortality rates after colon cancer surgery in older nursing home residents.

DESIGN

Retrospective cohort study.

SETTING

Nursing homes in the United States.

PARTICIPANTS

Six thousand eight hundred twenty-two nursing home residents aged 65 and older who underwent surgery for colon cancer in the United States between 1999 and 2005.

MEASUREMENTS

Changes in functional status were assessed before and after surgery using the Minimum Data Set Activity of Daily Living (MDS-ADL) summary scale, a 28-point scale in which score increases as functional dependence increases. Regression techniques were used to identify patient characteristics associated with mortality and functional decline 1 year after surgery.

RESULTS

On average, residents who underwent colectomy had a 3.9-point worsening in MDS-ADL score at 1 year. One year after surgery, rates of mortality and sustained functional decline were 53% and 24%, respectively. In multivariate analysis, older age (≥ 80 vs 65-69, adjusted relative risk (ARR) = 1.53, 95% confidence interval (CI) = 1.15-2.04, P < .001), readmission after surgical hospitalization (ARR = 1.15, 95% CI = 1.03-1.29, P = .02), surgical complications (ARR = 1.11, 95% CI = 1.02-1.21, P = .01), and functional decline before surgery (ARR = 1.21, 95% CI = 1.11-1.32, P < .001) were associated with functional decline at 1 year.

CONCLUSION

Mortality and sustained functional decline are common after colon cancer surgery in nursing home residents. Initiatives aimed at improving surgical outcomes are needed in this vulnerable population.

Fall risk in adult inpatients with leukemia undergoing induction chemotherapy

Falls are a major concern for patients with acute myeloid leukemia who are admitted to the hospital for induction chemotherapy. Patients with cancer are at risk for rapidly changing health status and, therefore, need a different kind of fall surveillance than those in other inpatient units. Fall risk most likely will change throughout an inpatient's stay. Oncology nurses can start addressing this issue by reviewing the documented data of falls in this patient population.

Robotic-Assisted Parathyroidectomy

Objective. Targeted parathyroidectomy is the gold standard for localized parathyroid disease. A robotic-assisted approach has not been investigated. The aim was to assess the feasibility of a robotic technique that avoids a neck scar.

Study Design. Feasibility study.

Setting. Tertiary referral center.

Subjects and Methods. Eleven patients with primary hyperparathyroidism were prospectively evaluated. Triple modality concordant localization was a prerequisite. All patients underwent robotic-assisted parathyroidectomy (RAP). Outcome variables assessed were operative time, voice change, biochemical cure, and histopathological confirmation. Patient-reported outcome measures (PROMs) included subjective assessment of pain and scar cosmesis, Voice Handicap Index 2, and EQ-5D quality-of-life assessment. Mean follow-up was 6 months (range, 3-12 months).

Results. The parathyroid adenoma was successfully excised in all cases with negligible blood loss (<5 mL). There was 1 conversion. There was no voice change in any case. Robot docking time plateaued to 10 minutes after 8 cases. Mean exposure and console times (31 and 51 minutes, respectively) were affected by body habitus. The mean visual analog scale for scar cosmesis was 75% on the first postoperative day, improving to 92% at 6 months and 95% at 1 year. Pain scores decreased to 8% at 2 weeks. All 5 EQ-5D quality-of-life parameters significantly improved following surgery.

Conclusion. The robotic approach is feasible for performing targeted parathyroidectomy that avoids a neck scar. The clinical efficacy and cost-effectiveness of the robotic approach compared with conventional targeted parathyroidectomy warrant further evaluation to establish if this represents a viable alternative to the existing targeted techniques.

Ear-worn body sensor network device: an objective tool for functional postoperative home recovery monitoring

Patients' functional recovery at home following surgery may be evaluated by monitoring their activities of daily living. Existing tools for assessing these activities are labor-intensive to administer and rely heavily on recall. This study describes the use of a wireless ear-worn activity recognition sensor to monitor postoperative activity levels continuously using a Bayesian activity classification framework. The device was used to monitor the postoperative recovery of five patients following abdominal surgery. Activity was classified into four groups ranging from very low (level 0) to high (level 3). Overall, patients were found to be undertaking a higher proportion of level 0 activities on postoperative day 1 which was gradually replaced by higher-level activities over the next 3 days. This study demonstrates how a pervasive healthcare technology can objectively monitor functional recovery in the unsupervised home setting. This may be a useful adjunct to existing postoperative monitoring systems.