Operative and prognostic parameters associated with elective versus emergency surgery in a retrospective cohort of elderly patients

One-Year Survival and Postoperative Complications in Older Patients with Intertrochanteric Fractures: Association with Polypharmacy-A Multicenter Retrospective Cohort Study

INTRODUCTION

Polypharmacy is common in older patients and associated with adverse outcomes. However, the association with outcomes in patients with intertrochanteric fractures remains unclear. This study aimed to investigate associations between polypharmacy and 1-year survival (primary outcome) and postoperative complications (secondary outcome), in older patients undergoing surgical treatment for intertrochanteric fractures.

PATIENTS AND METHODS

This multicenter retrospective study initially identified 1864 patients who underwent surgical treatment for intertrochanteric fractures between 2016 and 2020. We excluded those aged < 65 years, with polytrauma, or with Charlson Comorbidity Index (CCI) > 3 or insufficient data. Patients were classified into polypharmacy (≥ 5 medications) and non-polypharmacy (< 5 medications) groups. We performed two analyses: (1) complete case analysis using 1:1 propensity score matching (498 pairs) with variables including age, sex, body mass index (BMI), CCI, residence before admission, fracture type, American Society of Anesthesiologists (ASA) physical status (PS), and Parker Mobility Score, followed by Kaplan-Meier survival analysis with log-rank test and chi-squared test for complications and (2) multivariate Cox regression analysis using multiple imputation (CART method, five imputed datasets) of the eligible cohort (N = 1608), adjusting for the same variables.

RESULTS

In the matched cohort, the 1-year survival rate was significantly lower in the polypharmacy group (91.3%; 95% CI 87.7-93.8) compared with the non-polypharmacy group (94.0%; 95% CI 90.9-96.1; P = 0.027). Postoperative complications showed no significant differences between groups. Cox regression analysis revealed that advanced age, male sex, ASA-PS, and polypharmacy were associated with decreased survival, while higher Parker Mobility Score and normal and higher BMI showed improved survival.

CONCLUSIONS

Polypharmacy was associated with lower postoperative survival in older patients with intertrochanteric fractures and few comorbidities. As a potentially modifiable factor, medication review through multidisciplinary collaboration might contribute to improved outcomes.

Related variations: A novel approach for detecting patterns of regional variations in healthcare utilisation rates

Regional variations in healthcare utilisation rates are ubiquitous and persistent. In settings where an aggregate national health service budget is allocated primarily on a per capita basis, little regional variation in total healthcare utilisation rates will be observed. However, for specific treatments, large variations in utilisation rates are observed, iymplying a substitution effect at some point in service delivery. The current paper investigates the extent to which this substitution effect occurs within or between specialties, particularly distinguishing between emergency versus elective care. We used data from Statistics Norway and the Norwegian Patient Registry on eight somatic surgeries for all patients treated from 2010 to 2015. We calculated Diagnosis-Related Group (DRG) -weight per capita in 19 hospital regions. We applied principal component analysis (PCA) to demonstrate patterns in DRG-weight, annual relative changes in DRG-weight, and DRG-weight production for elective care. We show that treatments with similar characteristics cluster within regions. Treatment frequency explains 29% of the total variation in treatment rates. In a dynamic model, treatments with a high degree of emergency care are negatively correlated with treatments with a high degree of elective care. Furthermore, when considering only elective care treatments, the substitution effect occurs between specialties and explains 49% of the variation. When designing policies aimed at reducing regional variations in healthcare utilisation, a distinction between elective and emergency care as well as substitution effects need to be considered.

Octogenarian patients with colon cancer - postoperative morbidity and mortality are the major challenges

Background

Few studies have addressed colon cancer surgery outcomes in an unselected cohort of octogenarian patients. The present study aimed to evaluate the relative survival of octogenarian patients after a major resection of colon cancer with a curative intent.

Methods

All patients diagnosed with colon cancer at Levanger Hospital between 1980 and 2016 were included. We performed logistic regression to test for associations between 90-day mortality and explanatory variables. We performed a relative survival analysis to identify factors associated with short- and long-term survival.

Results

Among 237 octogenarian patients treated with major resections with curative intent, the 90-day mortality was 9.3%. Among 215 patients that survived the first 90 days, the 5 year relative survival rate was 98.7%. The 90-day mortality of octogenarian patients was significantly higher than that of younger patients, but the long-term survival converged with that of younger patients. Among octogenarian patients, the incidence of colon cancer more than doubled during our 37-year observation period. The relative increase in patients undergoing surgery exceeded the increase in incidence; hence, more patients were selected for surgery over time. A high 90-day mortality was associated with older age, a high American Society of Anaesthesiologists (ASA) score, and emergency surgery. Moreover, worse long-term survival was associated with a high Charlson Comorbidity Index, a high ASA score, a worse TNM stage, emergency surgery and residual tumours. Both the 90-day and long-term survival rates improved over time.

Conclusion

Among octogenarian patients with colon cancer that underwent major resections with curative intent, the 90-day mortality was high, but after surviving 90 days, the relative long-term survival rate was comparable to that of younger patients. Further improvements in survival will primarily require measures to reduce the 90-day mortality risk.

Intracranial Meningioma in Elderly Patients. Retrospective Multicentric Risk and Surgical Factors Study of Morbidity and Mortality

With the increasing life expectancy, a large number of intracranial meningiomas (IM) have been identified in elderly patients. There is no general consensus regarding the management for IMs nor studies regarding the outcome of older patients undergoing meningioma surgery. We aimed to determine whether preoperative variables and postoperative clinical outcomes differ between age groups after meningioma surgery. We analyzed data from all patients who had undergone IM surgery from our departments. The final cohort consisted of 340 patients affected by IM with ASA class I-II: 188 in the young group (<65) and 152 in the elderly. The two subgroups did not present significant differences concerning biological characteristics of tumor, localization, diameters, lesion and edema volumes and surgical radicality. Despite these comparable data, elderly presented with a significantly lower Karnofsky Performance status value on admission and remained consistently lower during the follow-up. We establish instead that there is no intrinsic correlation to the presence of IM and no significant increased risk of complications or recurrence in elderly patients, but rather only an increased risk of reduced performance status with mortality related to the comorbidity of the patient, primarily cardiovascular disease, and an intrinsic frailty of the aged population.

Indications for Emergency Abdominal Surgeries in Older Patients: 7-Year Experience of a Single Centre

The majority of patients undergoing emergency laparotomy are older adults that carry the highest mortality. More research into the development of targeted interventions is required. Therefore, the aim of the study was to analyse the indications for emergency abdominal surgery in patients aged ≥ 65 admitted to the Department of General Surgery. The study included consecutive patients aged ≥ 65 who underwent emergency abdominal surgery within 48 h after admission at one institution. In 2010–2017, 986 patients were enrolled in the study (female 57%, male 43%). Patients were divided into three age groups, 65–70, 71–84 and ≥ 85, with 255 patients (25.9%), 562 patients (57.0%) and 169 patients (17.1%) in each group, respectively. In the first and second age groups, the most common indications for surgery were acute cholecystitis, non-malignant ileus, colorectal cancer complications and acute appendicitis. In the oldest patients, the most common indications were complications of colorectal cancer, acute cholecystitis, non-malignant ileus and complications of diverticulosis. In the women, the biggest differences in indications between age groups were colorectal cancer (p = 0.025) and peptic ulcer disease complications (p = 0.005); in the men, the biggest difference was seen for complicated diverticulitis (p = 0.001). The most frequent comorbidities were heart diseases (81.0%), followed by endocrine (33.6%) and vascular diseases (22.7%). The three most common indications for emergency surgery in older patients at our institution were acute cholecystitis, colorectal cancer complications and non-malignant bowel obstruction, affecting 59.5% of this group of patients. Elective surgery and endoscopic screening have the potential to prevent major part of these acute diseases. However, further prospective research is necessary on this field, particularly among frail, older patients.

Association of County-Level Social Vulnerability with Elective Versus Non-elective Colorectal Surgery

INTRODUCTION

A person's community, or lived environment, may play an important role in achieving optimal health outcomes. The objective of the current study was to assess the association of county-level vulnerability with the probability of having a non-elective colon resection. We hypothesized that individuals from areas with a high social vulnerability would be at greater risk of non-elective colon resection compared with patients from low social vulnerability areas.

METHODS

Patients aged 65-99 who underwent a colon resection for a primary diagnosis of either diverticulitis (n = 11,812) or colon cancer (n = 33,312) were identified in Medicare Part A and Part B for years 2016-2017. Logistic regression analysis was used to evaluate differences in probability of undergoing an elective versus non-elective operation from counties relative to county-level social vulnerability index (SVI). Secondary outcomes included postoperative complications, mortality, readmission, and index hospitalization expenditure.

RESULTS

Among 45,124 patients, 11,812 (26.2%) underwent a colon resection for diverticulitis, while 33,312 (73.8%) had a resection for colon cancer; 31,012 (68.7%) patients had an elective procedure (diverticulitis n = 7291 (61.7%) vs. cancer n = 23,721 (71.2%)), while 14,112 (31.3%) had an emergent operation (diverticulitis n = 4521 (38.3%) vs. cancer n = 9591 (28.8%)). Patients with a high SVI were more likely to undergo an emergent colon operation compared with low SVI patients (43.7% vs. 40.4%) (p < 0.001). The association of high SVI with increased risk of an emergent colon operation was similar among patients with diverticulitis (emergent: low SVI 37.2% vs. high SVI 40.4%) or colon cancer (emergent: low SVI 26.0% vs. high SVI 29.9%) (both p < 0.05). On multivariable analyses, risk-adjusted probability of undergoing an urgent/emergent operation remained associated with SVI (p < 0.05).

CONCLUSION

Patients residing in vulnerable communities characterized by a high SVI were more likely to undergo a non-elective colon resection for either diverticulitis or colon cancer. Patients from high SVI areas had a higher risk of postoperative complications, as well as index hospitalization expenditures; however, there were no differences in mortality or readmission rates.

Effect of Lung Recruitment Maneuvers on Reduction of Atelectasis Determined by Lung Ultrasound in Patients More Than 60 Years Old Undergoing Laparoscopic Surgery for Colorectal Carcinoma: A Prospective Study at a Single Center

Background

Atelectasis occurs in patients of all ages during various surgeries. Previous studies have mainly focused on perioperative atelectasis in infants. However, research on the incidence of atelectasis among elderly patients, particularly those undergoing laparoscopic surgeries, is limited. Therefore, this prospective study aimed to investigate the effect of lung recruitment maneuvers (LRMs) on the reduction of atelectasis determined by lung ultrasound in patients more than 60 years old undergoing laparoscopic surgery for colorectal carcinoma.

Material/Methods

In this evaluator-blinded clinical study, 42 patients more than 60 years old diagnosed with colorectal carcinoma were randomly grouped either into a lung recruitment maneuver (RM) group or control (C) group. All patients were scheduled for laparoscopic surgery under general anesthesia using the lung-protective ventilation strategy. Lung ultrasonography was carried out at 3 predetermined time intervals. Patients in the RM group received ultrasound-guided recruitment maneuvers once atelectasis was discovered by lung ultrasound. Scores of lung ultrasound were used for assessing the severity of lung atelectasis.

Results

At the end of the operation, the occurrence of atelectasis was 100% in the RM group and 95% in the C group. After RMs, the frequency of atelectasis in the RM group and C group was 50% and 95%, respectively (P<0.01). Postoperative pulmonary complications were not different between the 2 groups.

Conclusions

At a single center, patients more than 60 years old undergoing laparoscopic surgery for colorectal carcinoma had a prevalence of lung atelectasis of 100% and although LRMs significantly reduced the incidence of pulmonary atelectasis, they did not improve postoperative pulmonary complications.

Mortality and Outcome in Elderly Patients Undergoing Emergent or Elective Cranial Surgery

OBJECTIVE

Due to the aging population, the number of elderly patients in need of cranial surgery for various neurosurgical pathologies is growing. We sought to compare mortality and outcome of elderly patients undergoing cranial surgery with a younger population.

METHODS

This was a retrospective analysis of adult patients undergoing craniotomy or craniectomy for various indications. Patients were allocated to 4 age groups (<65 years, 65-74 years, 75-84 years, ≥85 years; groups 1-4, respectively). Primary outcome was 30-day mortality rate, whereas secondary outcome measurements were clinical outcome measured by the modified Rankin Scale score, morbidity (bleeding, infection, and thromboembolic complications), length of stay (LOS), and discharge location.

RESULTS

We included 838 consecutive patients. Overall, 30-day mortality was 5.0% (n = 42), showing significant difference between the groups (2.8%, 7.3%, 7.5%, and 22.7% groups 1-4, respectively; P < 0.001). Mortality remained statistically significantly different between the groups also after stratification for elective or emergent surgery. Cumulative 30-day mortality-free rate was significantly different between the groups as well (log rank test χ² = 24.58, P < 0.001). Elderly patients showed significantly greater rates of bleeding (P = 0.003), longer LOS (P < 0.001), more discharges to rehabilitation facilities (P = 0.008), and a trend toward worst modified Rankin Scale score at follow-up (P = 0.08). After multivariate regression analysis, age (≥75 years) and lower preoperative Glasgow Coma Scale score (<14) were significantly associated with greater mortality rates, whereas postoperative thrombosis prophylaxis was a protective factor for mortality.

CONCLUSIONS

In patients undergoing craniotomy or craniectomy, advanced age seems to be associated with greater mortality and bleeding rates, longer LOS, and more discharge to rehabilitation facilities.

Improvement in pre-operative risk assessment in adults undergoing noncardiac surgery by a process-oriented score: A prospective single-centre study

BACKGROUND

Pre-operative risk assessment is important to quantify the patient's risks of morbidity and mortality, but its quality differs. We created a process-oriented score (PRO-score) for risk evaluation of adults as a three-stage warning score checklist with concrete guidance. It contains the contents of current guidelines and the assessment of vital signs.

OBJECTIVES

We investigated whether the PRO-score is suitable to detect 'red flag' warning signs not only in American Society of Anesthesiologists (ASA) physical status (PS) 3 or 4 patients but also in ASA-PS 1 or 2 patients. Resulting medical, therapeutic or structural consequences were recorded.

DESIGN

Prospective single-centre study.

SETTING

The study was performed in a German university hospital between November 2015 and December 2018.

PATIENTS

We included 54 455 adult patients undergoing a pre-operative risk assessment for general or regional anaesthesia and elective noncardiac surgery.

RESULTS

In all, 388 patients presented 'red flag' warning signs in the PRO-score during risk assessment; 85 (21.9%) were labelled ASA-PS 1 or 2, 244 (62.9%) ASA-PS 3 and 59 (15.2%) ASA-PS 4. Additional examinations were performed in 179 patients and technical tests in 175 patients (ASA-PS 1 or 2: 53 and 63 patients, respectively). After re-evaluation of the peri-operative risk in an interdisciplinary conference, surgery was cancelled in 44 patients (ASA-PS 1 and 2, 17 patients) or performed under local anaesthesia in 15 patients (ASA-PS 1 and 2, 2 patients). A downgrading to PRO-score 2 was reached in 168 patients after therapeutic interventions (ASA-PS 1 and 2, 54 patients). Undergoing surgery despite 'red flag' events resulted in major complications in 34 patients, and 16 patients died (ASA-PS 1 or 2: 7 and 3 patients, respectively).

CONCLUSION

The PRO-score detected warning signs in 'healthy' ASA-PS 1 or 2 and in ASA-PS 3 or 4 patients. Furthermore, it influenced the management of these patients, and thus improved the process quality of risk assessment. The physical examination should include the assessment of vital signs.

The Effect of Increased Neutrophil Lymphocyte Ratio on Mortality in Patients Operated on Due to Hip Fracture

Introduction

In this study, we aimed to examine the effect of neutrophil-lymphocyte ratio (NLR) on mortality and morbidity in elderly patients over the age of 65 who presented to our clinic and were operated on due to hip fracture.

Methods

The study included patients over the age of 65 who were operated on in our hospital between January 2014 and December 2018 due to hip fracture. Those with multiple fractures and those who were operated on due to cancer-related fracture were excluded. Patients' age, gender, American Society of Anesthesiologists (ASA) score, preoperative waiting time, type of anesthesia, operation duration, amount of erythrocyte suspension used, and duration of intensive care unit (ICU) stay were recorded. The effect of increased preoperative and postoperative 5th day neutrophil-lymphocyte ratios (NLR 1 and NLR 5, respectively) on mortality and morbidity was investigated.

Results

We examined 132 patients operated on due to hip fracture. NLR 5 was higher among patients who were admitted to the ICU (p = 0.007) and among those who died (p = 0.007). Additionally, the rate of increase of NLR 5 was higher among patients who were admitted to the ICU (p = 0.044) and among those died (p = 0.009).

Conclusion

The rate of increase of NLR in the postoperative period can be used as a criterion for predicting mortality in patients who are operated on due to hip fracture.