No news is good news? Three-year postdischarge mortality of octogenarian and nonagenarian patients following emergency general surgery

Influence of elevated liver enzyme level on 30-day mortality rates in patients undergoing nonemergency orthopedic surgery

BACKGROUND

The effect of elevated preoperative liver enzyme levels on postoperative outcomes is a topic of concern to clinicians. This study explored the association between elevated preoperative liver enzyme levels and surgical outcomes in patients undergoing orthopedic surgery.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program database, we obtained data on adult patients who received nonemergency orthopedic surgery under general anesthesia between 2011 and 2021.

RESULTS

We evaluated the data of 477,524 patients, of whom 6.1% (24 197 patients) had elevated preoperative serum glutamic oxaloacetic transaminase (SGOT) levels. An elevated SGOT level was significantly associated with 30-day postoperative mortality (adjusted hazard ratio, 1.62; 95% confidence interval, 1.39 to 1.90). We determined that the mortality rate rose with SGOT levels. The results remained unchanged after propensity score matching.

CONCLUSION

Elevated preoperative SGOT levels constitute an independent risk factor for 30-day postoperative mortality and are proportionately associated with the risk of 30-day postoperative mortality.

The interaction between geriatric and neighborhood vulnerability: Delineating prehospital risk among older adult emergency general surgery patients

BACKGROUND

When presenting for emergency general surgery (EGS) care, older adults frequently experience increased risk of adverse outcomes owing to factors related to age ("geriatric vulnerability") and the social determinants of health unique to the places in which they live ("neighborhood vulnerability"). Little is known about how such factors collectively influence adverse outcomes. We sought to explore how the interaction between geriatric and neighborhood vulnerability influences EGS outcomes among older adults.

METHODS

Older adults, 65 years or older, hospitalized with an AAST-defined EGS condition were identified in the 2016 to 2019, 2021 Florida State Inpatient Database. Latent variable models combined the influence of patient age, multimorbidity, and Hospital Frailty Risk Score into a single metric of "geriatric vulnerability." Variations in geriatric vulnerability were then compared across differences in "neighborhood vulnerability" as measured by variations in Area Deprivation Index, Social Vulnerability Index, and their corresponding subthemes (e.g., access to transportation).

RESULTS

A total of 448,968 older adults were included. For patients living in the least vulnerable neighborhoods, increasing geriatric vulnerability resulted in up to six times greater risk of death (30-day risk-adjusted hazards ratio [HR], 6.32; 95% confidence interval [CI], 4.49-8.89). The effect was more than doubled among patients living in the most vulnerable neighborhoods, where increasing geriatric vulnerability resulted in up to 15 times greater risk of death (30-day risk-adjusted HR, 15.12; 95% CI, 12.57-18.19). When restricted to racial/ethnic minority patients, the multiplicative effect was four-times as high, resulting in corresponding 30-day HRs for mortality of 11.53 (95% CI, 4.51-29.44) versus 40.67 (95% CI, 22.73-72.78). Similar patterns were seen for death within 365 days.

CONCLUSION

Both geriatric and neighborhood vulnerability have been shown to affect prehospital risk among older patients. The results of this study build on that work, presenting the first in-depth look at the powerful multiplicative interaction between these two factors. The results show that where a patient resides can fundamentally alter expected outcomes for EGS care such that otherwise less vulnerable patients become functionally equivalent to those who are, at baseline, more aged, more frail, and more sick.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Effect of emergency general surgery on postoperative performance status in patients aged over 90 years

Background

Functional deterioration following emergency general surgery (EGS) poses a significant challenge in super-elderly patients. However, limited research has focused on assessing the deterioration in postoperative performance status (PS). This study aimed to investigate the impact of EGS on PS deterioration in super-elderly patients, and the extent to which deteriorated PS is recovered.

Methods

This historical cohort study comprised 77 super-elderly patients who underwent EGS between July 2015 and December 2020. Functional deterioration was evaluated by comparing preoperative and postoperative Eastern Cooperative Oncology Group Performance Status (ECOG-PS). The Emergency Surgical Score (ESS) was used as a risk-adjustment tool. Questionnaires were mailed to the patients and their families to assess post-discharge PS and obtain their impressions of EGS.

Results

Postoperative PS deteriorated in 35/77 patients (45.5 %). Significant differences were observed between the groups in terms of sex, serum C-reactive protein (CRP) levels, ESS scores, preoperative ECOG-PS, duration of operation, and major complications. Multivariate analysis of preoperative factors showed that ESS ≥7 (OR: 3.7, 95 % CI: 1.0-13), preoperative ECOG-PS ≤2 (OR: 5.9, 95 % CI: 1.7-21), and female sex (OR: 5.8, 95 % CI: 1.6-21) were associated with postoperative ECOG-PS deterioration. According to the questionnaire results, PS recovery post-discharge was observed in 6/36 (17 %) patients, and 34/36 (94 %) patients and their families expressed positive impressions of EGS.

Conclusions

EGS in super-elderly patients highly caused a deterioration in their PS, particularly in patients with maintained preoperative PS. PS hardly recovered; however, most patients and their families had positive impressions of the EGS.

Key message

We assessed the pre- and postoperative performance status of super-elderly patients who underwent emergency general surgery. Surgery caused a marked deterioration in patients' functional performance, which seldom recovered postoperatively.

Applying Evidence-based Principles to Guide Emergency Surgery in Older Adults

Although outcomes for older adults undergoing elective surgery are generally comparable to younger patients, outcomes associated with emergency surgery are poor. These adverse outcomes are in part because of the physiologic changes associated with aging, increased odds of comorbidities in older adults, and a lower probability of presenting with classic "red flag" physical examination findings. Existing evidence-based perioperative best practice guidelines perform better for elective compared with emergency surgery; so, decision making for older adults undergoing emergency surgery can be challenging for surgeons and other clinicians and may rely on subjective experience. To aid surgical decision making, clinicians should assess premorbid functional status, evaluate for the presence of geriatric syndromes, and consider social determinants of health. Documentation of care preferences and a surrogate decision maker are critical. In discussing the risks and benefits of surgery, patient-centered narrative formats with inclusion of geriatric-specific outcomes are important. Use of risk calculators can be meaningful, although limitations exist. After surgery, daily evaluation for common postoperative complications should be considered, as well as early discharge planning and palliative care consultation, if appropriate. The role of the geriatrician in emergency surgery for older adults may vary based on the acuity of patient presentation, but perioperative consultation and comanagement are strongly recommended to optimize care delivery and patient outcomes.

Long-term Outcomes After Emergency Laparotomy: a Retrospective Study

BACKGROUND

Emergency laparotomy (EL) is a common surgical operation with poor outcomes. Patients undergoing EL are often frail and have chronic comorbidities, but studies focused on the long-term outcomes after EL are lacking. The aim of the present study was to examine the long-term mortality after EL.

METHODS

We conducted a retrospective single-center cohort study of 674 adults undergoing midline EL between May 2015 and December 2017. The follow-up lasted until September 2020. The primary outcome was 2-year mortality after surgery. The secondary outcome was factors associated with mortality during follow-up.

RESULTS

A total of 554 (82%) patients survived > 90 days after EL and were included in the analysis. Of these patients, 120 (18%) died during the follow-up. The survivors were younger than the non-survivors (median [IQR] 64 [49-74] vs. 71 [63-80] years, p < 0.001). In a Cox regression model, death during follow-up was associated with longer duration of operation (OR 2.21 [95% CI 1.27-3.83]), higher ASA classification (OR 2.37 [1.15-4.88]), higher CCI score (OR 4.74 [3.15-7.14]), and postoperative medical complications (OR 1.61 [1.05-2.47]).

CONCLUSIONS

Patient-related factors, such as higher ASA classification and CCI score, were the most remarkable factors associated with poor long-term outcome and mortality after EL.

Factors affecting 30-day postoperative complications after emergency surgery during the COVID-19 outbreak: A multicentre cohort study

Introduction

Coronavirus disease 2019 (COVID-19) has influenced (surgical) care worldwide. Measures were taken to prioritize surgical care in order to maintain capacity for COVID-19 healthcare. However, the influence of these measures on emergency surgery is limited. Therefore, the aim of this study is to describe the trends in emergency surgery and determine the factors influencing the risk of postoperative complications during the first wave of the COVID-19 pandemic.

Methods

This multicentre retrospective cohort study investigated all emergency patients operated on from March 9th to June 30th, 2020. The primary endpoint was identifying the number of emergency surgical procedures performed. Secondary endpoints were determining the number of postoperative complications and factors determining the risk of postoperative complications, which were calculated by multivariate analysis with odds ratio (OR) and 95% confidence (CI) intervals.

Results

In total, 1399 patients who underwent an emergency surgical procedure were included. An increase in the number of emergency vascular and trauma surgical procedures occurred during the study period. In contrast, the number of emergency general and oncological surgical procedures performed remained stable. An increased age (OR 1.01, 95% CI 1.00–1.02; p = 0.024), American Society of Anaesthesiologists (ASA) (OR 1.34, 95% CI 1.09–1.64; p = 0.005), and surgical discipline were independent predictors for an increased risk of postoperative complications.

Conclusion

The performance of emergency vascular and trauma surgical procedures increased. The performance of emergency general and oncological surgical procedures remained stable. In addition, increased age, ASA, and surgical discipline were independent predictors for an increased risk of postoperative complications.

The risk and predictors of mortality in octogenarians undergoing emergency laparotomy: a multicentre retrospective cohort study

OBJECTIVES

This study aims to evaluate the risk of postoperative mortality in octogenarians undergoing emergency laparotomy.

METHODS

In compliance with STROCSS guideline for observational studies, we conducted a multicentre retrospective cohort study. All consecutive patients aged over 80 with acute abdominal pathology requiring emergency laparotomy between April 2014 and August 2019 were considered eligible for inclusion. The primary outcome measure was 30-day postoperative mortality, and the secondary outcome measures were in-hospital mortality and 1-year mortality. Statistical analyses included simple descriptive statistics, binary logistic regression analyses, and Kaplan-Meier survival statistics.

RESULTS

A total of 523 octogenarians were eligible for inclusion. Emergency laparotomy in octogenarians was associated with 21.8% (95% CI 18.3-25.6%) 30-day postoperative mortality, 22.6% (95% CI 19.0-26.4%) in-hospital mortality, and 40.2% (95% CI 35.9-44.5%) 1-year mortality. Binary logistic regression analysis identified ASA status (OR, 2.49; 95% CI 1.82-3.38, P < 0.0001) and peritoneal contamination (OR, 2.00; 95% CI 1.30-3.08, P = 0.002) as predictors of 30-day postoperative mortality. The ASA status (OR, 1.92; 95% CI 1.50-2.46, P < 0.0001), peritoneal contamination (OR, 1.57; 95% CI 1.07-2.48, P = 0.020), and presence of malignancy (OR, 2.06; 95% CI 1.36-3.10, P = 0.001) were predictors of 1-year mortality. Log-rank test showed significant difference in postoperative survival rates among patients with different ASA status (P < 0.0001) and between patients with and without peritoneal contamination (P = 0.0011).

CONCLUSIONS

Emergency laparotomies in patients older than 80 years with ASA status more than 3 in the presence of peritoneal contamination carry a high risk of immediate postoperative and 1-year mortality. This should be taken into account in communications with patients and their relatives, consent process, and multidisciplinary decision-making process for operative or non-operative management of such patients.

Meta-analysis of mortality risk in octogenarians undergoing emergency general surgery operations

BACKGROUND

This study aimed to quantify the risk of perioperative mortality in octogenarians undergoing emergency general surgical operations and to compare such risk between octogenarians and nonoctogenarians.

METHODS

A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards to identify studies reporting the mortality risk in patients aged over 80 years undergoing emergency general surgery operations. The primary outcome measure was 30-day mortality, which was stratified based on American Society of Anesthesiologists (ASA) status and procedure type. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation system. Random-effects models were applied to calculate pooled outcome data.

RESULTS

Analysis of 66,701 octogenarians from 22 studies showed that the risk of 30-day mortality was 26% (95% confidence interval 18%-34%) for all operations: 29% (95% confidence interval 25%-33%) for emergency laparotomy; 9% (95% confidence interval 1%-23%) for nonlaparotomy emergency operations; 21% (95% confidence interval 13%-30%) for colon resection; 17% (95% confidence interval 11%-25%) for small bowel resection; 9% (95% confidence interval 7%-11%) for adhesiolysis; 6% (95% confidence interval 5.9%-6.8%) for perforated ulcer repair; 3% (95% confidence interval 2.6%-4%) for appendicectomy; 3% (95% confidence interval 2.8%-3.3%) for cholecystectomy; and 5% (95% confidence interval 0.2%-14%) for hernia repair. When stratified based on the patient's ASA status, the risk was 11% (95% confidence interval 4%-20%) for ASA 2 status, 22% (95% confidence interval 10%-36%) for ASA 3 status, 39% (95% confidence interval 29%-48%) for ASA 4 status, and 94% (95% confidence interval 77%-100%) for ASA 5 status. The risk was higher in octogenarians compared with nonoctogenarians (odds ratio: 4.07, 95% confidence interval 2.40-6.89), patients aged 70 to 79 (odds ratio: 1.21, 95% confidence interval 1.13-1.31), and patients aged 50 to 79 (odds ratio: 2.03, 95% confidence interval 1.68-2.45).

CONCLUSION

The risk of perioperative mortality in octogenarians undergoing emergency general surgical operations is high. The risk of perioperative death in this group is higher than in younger patients. Laparotomy, bowel resection, and ASA status above 3 carry the highest risk.