The Emergency Surgery Frailty Index (EmSFI): development and internal validation of a novel simple bedside risk score for elderly patients undergoing emergency surgery

The investigation of effect on foot plantar massage on functional recovery in older adults with general surgery, randomized clinical trial

OBJECTIVE

Foot massage is known to be effective on the emotional state (anxiety, depression, etc.) in the postoperative period. However, studies on its effect on functional level are insufficient.

AIM

The study aimed to investigate the impact of foot plantar massage on functional recovery in older adults undergoing general surgery, employing a randomized clinical trial design.

METHODS

A total of 70 older adults aged 65 years and above who underwent abdominal surgery were included. Various assessments were conducted, including pain levels (Visual Analogue Scale), fear of mobility (Tampa Scale for Kinesiophobia), functional independence (Functional Independence Measure), balance (Berg Balance Scale), basic mobility (Rivermead Mobility Index), mental function status (Standardized Mini-Mental State Examination), and delirium (Nu-DESC).

RESULTS

Statistically significant differences were observed in some assessment parameters within the groups during the 2nd and 3rd measurement times, with the intervention group demonstrating significant mean differences.

DISCUSSIONS

The literature underscores the increase in kinesiophobia scores post-general/abdominal surgery in older adults, emphasizing the importance of evaluating functional level and kinesiophobia to expedite discharge processes and potentially plan early post-discharge rehabilitation to mitigate readmissions for functional reasons.

CONCLUSIONS

Ultimately, foot massage was found to be effective in reducing kinesiophobia, improving balance, mobility, daily living skills, and mental status in older adults post-abdominal surgery, thereby advocating for the facilitation of post-discharge rehabilitation programs or the reduction of readmission rates.

THE CLINICAL TRIALS NUMBER

NCT05534490.

Indocyanine green fluorescence angiography could reduce the risk of anastomotic leakage in rectal cancer surgery: a systematic review and meta-analysis of randomized controlled trials

AIM

Several papers have shown that use of indocyanine green (ICG) decreases incidence of anastomotic leakage (AL) during colonic surgery, but no clear evidence has been found for rectal cancer surgery. Therefore, with this systematic review and meta-analysis of randomized controlled trials (RCTs) we aimed to assess if ICG could also reduce risk of AL in rectal cancer surgery.

METHOD

PubMed, Scopus, CINAHL and Cochrane databases were searched for RCTs assessing the effect of intraoperative ICG on the incidence of AL of the colorectal anastomosis. Pooled relative risk (RR) and pooled risk difference (RD) were obtained using models with random effects. Risk of bias was evaluated with the Rob2 tool and the quality of evidence was assessed using the GRADE Pro tool.

RESULTS

Four RCTs were included for analysis, with a total of 1510 patients (743 controls and 767 ICG patients). The rate of AL was 9% in the ICG group (69/767) and 13.9% (103/743) in the control group (p = 0.003, RR -0.5, 95% CI -0.827 to -0.172, heterogeneity test 0%, p = 0.460). The RD in terms of incidence of AL was significantly decreased by 4.51% (p = 0.031, 95% CI -0.086 to -0.004, heterogeneity test 28%, p = 0.182) when using ICG.

CONCLUSION

Our meta-analysis suggested that use of ICG during rectal cancer surgery could reduce the rate of AL.

Efficacy of blood parameters as indicators of the need for overdue urgent cholecystectomy in elderly patients with acute cholecystitis

BACKGROUND

Although early cholecystectomy is recommended for patients with acute cholecystitis, conservative treatment followed by delayed cholecystectomy (DC) is a highly preferred modality, especially in older adult patients. However, some severe cases require overdue urgent cholecystectomy (OC). This study aimed to evaluate the ability of laboratory findings and Tokyo severity classification (TokyoSC) to differentiate those with the need for OC among elderly patients.

METHODS

Laboratory/radiological/clinical findings of geriatric patients with acute cholecystitis on admission and TokyoSC were retrospectively analyzed. The DC and OC groups were compared.

RESULTS

The mean age of the 164 patients was 72.3±6.4 years. White blood cell, neutrophil (NEU), immature granulocyte (IG), C-reactive protein, neutrophil-to-lymphocyte ratio (NLR), and TokyoSC parameters were all significant at P<0.001 in differentiation. NLR had a specificity of 98%, and TokyoSC had a sensitivity of 98%.

CONCLUSION

NLR, NEU, IG, and TokyoSC were effective in differentiating patients who needed OC while planning conservative treatment + DC for older adult patients who were followed up due to acute cholecystitis. If the NLR is >9.9 and TokyoSC is moderate/high, early cholecystectomy should be preferred instead of conservative treatment + DC in aged patients.

A systematic review of predictive accuracy via c-statistic of preoperative frailty tests for extended length of stay, post-operative complications, and mortality

Frailty, as an age-related syndrome of reduced physiological reserve, contributes significantly to post-operative outcomes. With the aging population, frailty poses a significant threat to patients and health systems. Since 2012, preoperative frailty assessment has been recommended, yet its implementation has been inhibited by the vast number of frailty tests and lack of consensus. Since the anesthesiologist is the best placed for perioperative care, an anesthesia-tailored preoperative frailty test must be simple, quick, universally applicable to all surgeries, accurate, and ideally available in an app or online form. This systematic review attempted to rank frailty tests by predictive accuracy using the c-statistic in the outcomes of extended length of stay, 3-month post-operative complications, and 3-month mortality, as well as feasibility outcomes including time to completion, equipment and training requirements, cost, and database compatibility. Presenting findings of all frailty tests as a future reference for anesthesiologists, Clinical Frailty Scale was found to have the best combination of accuracy and feasibility for mortality with speed of completion and phone app availability; Edmonton Frailty Scale had the best accuracy for post-operative complications with opportunity for self-reporting. Finally, extended length of stay had too little data for recommendation of a frailty test. This review also demonstrated the need for changing research emphasis from odds ratios to metrics that measure the accuracy of a test itself, such as the c-statistic.

The Emergency Surgery Frailty Index (EmSFI) in Elderly Patients with Acute Appendicitis: An External Validation of Prognostic Score

BACKGROUND

Identification of reliable risk-stratification tools is critical for surgical decision making, particularly in frail and elderly. The aim of the study is to validate the Emergency Surgery Frailty Index (EmSFI), in over 65 years old patients operated on for acute appendicitis.

METHODS

An observational study was conducted enrolling elderly patients with diagnosis of acute appendicitis who underwent emergency appendicectomy or right colectomy, between 2016 and 2021. All patients were treated according to the last SIFIPAC/WSES/SICG/SIMEU guidelines.

RESULTS

Overall, 61 patients were analyzed. Complication rate was higher for patients in the second EmSFI risk Class. Moreover, ROC analyses identified 3 as the best cutoff value in predicting risk of adverse postoperative events. Complication rate was higher in oldest elderly patients-over 80 years-(42.9 vs 22.5%; p 0.05) and was mainly related to medical complications (42.9 vs 12.5%, p 0.007). However, intestinal obstruction, peri-appendicular abscess on preoperative CT, peritonitis and a longer duration of surgery are related with increased risk of complications in the group of patients under 80 years.

CONCLUSION

The EmSFI score results a valid prognostic marker for frailty status, and it may support the surgeon in emergency setting for acute appendicitis. Patients aged 80 years or older have a higher risk of complications, independent from those factors which relate to increased morbidity in younger elderly patients. Age alone is not a reliable indicator of the real surgical risk, but it must encourage the adoption of multidisciplinary collaborative models of care for this group of patients.

An ensemble machine learning approach to predict postoperative mortality in older patients undergoing emergency surgery

BACKGROUND

Prediction of preoperative frailty risk in the emergency setting is a challenging issue because preoperative evaluation cannot be done sufficiently. In a previous study, the preoperative frailty risk prediction model used only diagnostic and operation codes for emergency surgery and found poor predictive performance. This study developed a preoperative frailty prediction model using machine learning techniques that can be used in various clinical settings with improved predictive performance.

METHODS

This is a national cohort study including 22,448 patients who were older than 75 years and visited the hospital for emergency surgery from the cohort of older patients among the retrieved sample from the Korean National Health Insurance Service. The diagnostic and operation codes were one-hot encoded and entered into the predictive model using the extreme gradient boosting (XGBoost) as a machine learning technique. The predictive performance of the model for postoperative 90-day mortality was compared with those of previous frailty evaluation tools such as Operation Frailty Risk Score (OFRS) and Hospital Frailty Risk Score (HFRS) using the receiver operating characteristic curve analysis.

RESULTS

The predictive performance of the XGBoost, OFRS, and HFRS for postoperative 90-day mortality was 0.840, 0.607, and 0.588 on a c-statistics basis, respectively.

CONCLUSIONS

Using machine learning techniques, XGBoost to predict postoperative 90-day mortality, using diagnostic and operation codes, the prediction performance was improved significantly over the previous risk assessment models such as OFRS and HFRS.

Gastro-intestinal emergency surgery: Evaluation of morbidity and mortality. Protocol of a prospective, multicenter study in Italy for evaluating the burden of abdominal emergency surgery in different age groups. (The GESEMM study)

Gastrointestinal emergencies (GE) are frequently encountered in emergency department (ED), and patients can present with wide-ranging symptoms. more than 3 million patients admitted to US hospitals each year for EGS diagnoses, more than the sum of all new cancer diagnoses. In addition to the complexity of the urgent surgical patient (often suffering from multiple co-morbidities), there is the unpredictability and the severity of the event. In the light of this, these patients need a rapid decision-making process that allows a correct diagnosis and an adequate and timely treatment. The primary endpoint of this Italian nationwide study is to analyze the clinicopathological findings, management strategies and short-term outcomes of gastrointestinal emergency procedures performed in patients over 18. Secondary endpoints will be to evaluate to analyze the prognostic role of existing risk-scores to define the most suitable scoring system for gastro-intestinal surgical emergency. The primary outcomes are 30-day overall postoperative morbidity and mortality rates. Secondary outcomes are 30-day postoperative morbidity and mortality rates, stratified for each procedure or cause of intervention, length of hospital stay, admission and length of stay in ICU, and place of discharge (home or rehabilitation or care facility). In conclusion, to improve the level of care that should be reserved for these patients, we aim to analyze the clinicopathological findings, management strategies and short-term outcomes of gastrointestinal emergency procedures performed in patients over 18, to analyze the prognostic role of existing risk-scores and to define new tools suitable for EGS. This process could ameliorate outcomes and avoid futile treatments. These results may potentially influence the survival of many high-risk EGS procedure.

Metabolic Syndrome (MetS), Systemic Inflammatory Response Syndrome (SIRS), and Frailty: Is There any Room for Good Outcome in the Elderly Undergoing Emergency Surgery?

Background

Patients with MetS or SIRS experience higher rates of mortality and morbidity, across both cardiac and noncardiac surgery. Frailty assessment has acquired increasing importance in recent years as it predisposes elderly patients to a worse outcome. The aim of our study was to investigate the influence of MetS, SIRS, and with or without frailty on elderly patients undergoing emergency surgical procedures.

Methods

We analyzed data of all patients with nonmalignant diseases requiring an emergency surgical procedure from January 2017 to December 2020. The occurrence of MetS was identified using modified definition criteria used by the NCEP-ATP III Expert Panel: obesity, hypertension, diabetes, or if medication for high triglycerides or for low HDL cholesterol was taken. Systemic inflammatory response syndrome (SIRS) was evaluated according to the original consensus study (Sepsis-1). The frailty profile was investigated by the 5-modified Frailty Index (5-mFI) and the Emergency Surgery Frailty Index (EmSFI). Postoperative complications have been reported and categorized according to the Clavien-Dindo (C-D) classification system. Morbidity and mortality have been mainly considered as the 30-day standard period definition.

Results

Of the 2,318 patients included in this study, 1,010 (43.6%) fulfilled the criteria for MetS (MetsG group). Both 5-Items score and EmsFI showed greater fragility in patients with MetS. All patients with MetS showed more frequently a CACI index greater than 6. The occurrence of SIRS was higher in MetSG. LOS was longer in patients with MetS (MetSG 11.4 ± 12 days vs. n-MetSG 10.5 ± 10.2 days, p = 0.046). MetSG has a significantly higher rate of morbidity (353 (35.%) vs. 385 (29.4%), p = 0.005). The mortality rate in patients with MetS (98/1010, 10%) was similar to that in patients without it (129/1308, 10%). Considering patients with MetS who developed SIRS and those who had frailty or both, the occurrence of these conditions was associated with a higher rate of morbidity and mortality.

Conclusion

Impact of MetS and SIRS on elderly surgical patient outcomes has yet to be fully elucidated. The present study showed a 43.6% incidence of MetS in the elderly population. In conclusion, age per se should be not considered anymore as the main variable to estimate patient outcomes, while MetS and Frailty should have always a pivotal role.

Outcomes of emergency laparoscopy in the elderly

INTRODUCTION

This paper assessed the association between operative approach and postoperative in-hospital mortality in elderly patients undergoing emergency abdominal surgery. Patients undergoing emergency laparotomy have high morbidity and mortality rates. One-third of patients requiring emergency surgery are over 75 years old, and their in-hospital mortality rate exceeds 17%. Fewer than 20% of emergency abdominal operations in the UK are attempted laparoscopically, and only 10% are completed laparoscopically. Little is known about how laparoscopic emergency surgery in the elderly might affect outcomes.

METHODS

An observational UK study was performed using the prospectively maintained National Emergency Laparotomy Audit (NELA) database. Operative approach, NELA risk-prediction score and in-hospital mortality were recorded. The effect of operative approach on in-hospital mortality was analysed, both on a national basis and in a high-volume laparoscopic centre.

RESULTS

A total of 47,667 patients were included in the study, of whom 15,068 were over 75 years of age. Nationally, surgery was completed by the laparoscopic approach in 7.8% of patients aged over 75; both crude mortality (9.2%) and risk-adjusted mortality (7.1%) were significantly reduced (p<0.0001). In our unit, surgery was completed laparoscopically in 48.4% of patients aged over 75; both crude mortality (6.6%) and risk-adjusted mortality (3.3%) were significantly reduced (p<0.0001).

CONCLUSION

Laparoscopy in emergency surgery has been shown in this study to significantly reduce in-hospital mortality in elderly patients and should be embraced in every centre dealing with emergency abdominal surgery.

Identifying relationships between kinesiophobia, functional level, mobility, and pain in older adults after surgery

BACKGROUND

Further data on the causes of functional independence or disability after surgery are needed to explain the clinical decision-making process for older patients, their families, and policy-makers. There are a limited number of studies showing the relationship between kinesiophobia, functional status, pain and mobility in older adults after surgery.

AIMS

The study aims to investigate relationships among kinesiophobia, pain, mobility, and functional status in older adults after surgery.

METHODS

A comparative-descriptive and cross-sectional study. The research was conducted with 99 older adults in the general surgery clinic after surgery. A Visual Analogue Scale was used to evaluate pain levels, the Standardized Mini-Mental State Examination to evaluate mental function status, the Functional Independence Measure to assess functional independence in daily activities, the Rivermead Mobility Index to evaluate basic mobility in daily life, and the Tampa Scale for Kinesiophobia to assess fear of mobility.

RESULTS

Regression analysis revealed a significant negative correlation between social security and kinesiophobia, and also between functional level and type of anesthesia and mental status in older women (R² = - 0.185, p = 0.005; R² = - 0.167, p = 0.011 and p = 0.005, respectively).

DISCUSSION

In the literature, there are no standardized procedures during the evaluation and rehabilitation of older adults after abdominal or thoracic surgery, etc. operations. This study will contribute to the current literature by attracting interest in this field and increasing the evaluations performed.

CONCLUSIONS

The study findings emphasize the importance of evaluating the functional, mobility, mental and kinesiophobic status of older adults after surgery in clinics, rehabilitation centers, or research.

Clinical-pathological features and treatment of acute appendicitis in the very elderly: an interim analysis of the FRAILESEL Italian multicentre prospective study

BACKGROUND

Emergency abdominal surgery in the elderly represents a global issue. Diagnosis of AA in old patients is often more difficult. Appendectomy remains the gold standard of treatment and, even though it is performed almost exclusively with a minimally invasive technique, it can still represent a great risk for the elderly patient, especially above 80 years of age. A careful selection of elderly patients to be directed to surgery is, therefore, fundamental. The primary aim was to critically appraise and compare the clinical-pathological characteristics and the outcomes between oldest old (≥ 80 years) and elderly (65-79 years) patients with Acute Appendicitis (AA).

METHODS

The FRAILESEL is a large, nationwide, multicentre, prospective study investigating the perioperative outcomes of patients aged ≥ 65 years who underwent emergency abdominal surgery. Particular focus has been directed to the clinical and biochemical presentation as well as to the need for operative procedures, type of surgical approach, morbidity and mortality, and in-hospital length of stay. Two multivariate logistic regression analyses were performed to assess perioperative risk factors for morbidity and mortality.

RESULTS

182 patients fulfilled the inclusion criteria. Mean age, ileocecal resection, OAD and ASA score ≥ 3 were related with both overall and major complication. The multivariate analysis showed that MPI and complicated appendicitis were independent factors associated with overall complications. OAD and ASA scores ≥ 3 were independent factors for both overall and major complications.

CONCLUSIONS

Age ≥ 80 years is not an independent risk factor for morbidities. POCUS is safe and effective for the diagnosis; however, a CECT is often needed. Having the oldest old a smaller functional organ reserve, an earlier intervention should be considered especially because they often show a delay in presentation and frequently exhibit a complicated appendicitis.