Impact of the lung allocation score on survival beyond 1 year

Implementation of the lung allocation score (LAS) in 2005 led to transplantation of older and sicker patients without altering 1-year survival. However, long-term survival has not been assessed and emphasizing the 1-year survival metric may actually sustain 1-year survival while not reflecting worsening longer-term survival. Therefore, we assessed overall and conditional 1-year survival; and the effect of crossing the 1-year threshold on hazard of death in three temporal cohorts: historical (1995-2000), pre-LAS (2001-2005) and post-LAS (2005-2010). One-year survival post-LAS remained similar to pre-LAS (83.1% vs. 82.1%) and better than historical controls (75%). Overall survival in the pre- and post-LAS cohorts was also similar. However, long-term survival among patients surviving beyond 1 year was worse than pre-LAS and similar to historical controls. Also, the hazard of death increased significantly in months 13 (1.44, 95% CI 1.10-1.87) and 14 (1.43, 95% CI 1.09-1.87) post-LAS but not in the other cohorts. While implementation of the LAS has not reduced overall survival, decreased survival among patients surviving beyond 1 year in the post-LAS cohort and the increased mortality occurring immediately after 1 year suggest a potential negative long-term effect of the LAS and an unintended consequence of increased emphasis on the 1-year survival metric.

Deriving the indications for laparoscopic appendectomy from a comparison of the outcomes of laparoscopic and open appendectomy

BACKGROUND

Indications for laparoscopic appendectomy (LA) remain controversial and poorly defined. We sought to identify indications for LA through a comparison of LA and open appendectomies (OA).

METHODS

We reviewed demographics, coexisting medical conditions, radiology and pathology data, hospital course, and complications from charts on all LA patients and a comparison group of OA done from 1991 to 1998.

RESULTS

The following were significantly associated with LA: female sex, higher mean body mass index (BMI), coexisting medical problems, private insurance, and daytime surgery. The OA group was significantly more likely to have: a radiology report suggesting the diagnosis of acute appendicitis, perforation of the appendix, intensive care unit admission, and complications in their hospital course. Forty-one percent of the LA patients did not have appendicitis, compared with 20% of the OA patients.

CONCLUSIONS

Daytime surgery, women, private insurance, coexisting medical problems, prior abdominal surgery, higher BMI, and less severe disease appear to be used by surgeons as indicators for LA. The threshold for surgical exploration appears to be lower for LA.

Carotid endarterectomy reoperations in a regional medical center

Large, randomized prospective clinical trials have not addressed the safety of reoperation for recurrent carotid disease. Our purpose was to determine whether outcomes for carotid endarterectomy for recurrent disease were different from those for primary or contralateral carotid endarterectomy. We reviewed all carotid endarterectomies done in our regional medical center hospital from 1979 through 1997. We analyzed 1656 primary procedures, 377 contralateral carotid procedures, and 63 reoperations. Operation for recurrent disease was done in 3 per cent of those having primary operations. Patients in the three groups did not differ significantly with regard to age, race, or sex. Seventy per cent of patients were symptomatic with transient ischemic attacks, amaurosis, and reversible ischemic neurological deficit being most prominent. There were no deaths and three strokes in the reoperation group for a combined stroke and death rate of 4.8 per cent. This was not significantly different from that of 3.2 per cent for the stroke and death rate for the primary group and 3.5 per cent for the contralateral group. Carotid endarterectomy is a safe treatment for recurrent carotid artery disease.

Left-side preference in carotid endarterectomies

Although the incidence of carotid atheromatous disease is presumably equal between the right and left carotid arteries, right and left carotid endarterectomies (CEs) may not be performed with equal frequency on the two sides. This study sought to examine whether right and left CEs are performed with equal frequency and whether there are any differences in outcome between these groups. Detailed chart review was performed on all CEs performed from 1979 through 1998 at our institution, and those lacking side data were excluded. Data were collected on the side of the procedure, demographics, comorbid conditions, details of the procedure, hospital stay, and major complications. The surgeons performing CE were surveyed about their practice of considering side factors. CE was performed on the left in 1190 (52%) of 2305 procedures; 1115 (48%) of the procedures were right CEs. This difference is statistically significant (P = 0.014). No significant differences in demographics, comorbidity, presence of symptoms before surgery, length of stay, or postoperative morbidity or mortality between the left and right groups were found. A majority of the surgeons surveyed indicated they do consider the relationship of side of the carotid disease to the patient's dominant side. The significant difference in the performance of left CE more often than right has not been previously reported. This may reflect willingness by surgeons to intervene more frequently in carotid disease on the side supplying the dominant hemisphere. A prospective CE outcome study that identifies the side of CE and the patient's dominant side is needed for further exploration of this issue.

Carotid endarterectomy in the community hospital in patients age 80 and older

OBJECTIVE

To determine whether the rates of death and complications of carotid endarterectomy (CE) were different in the octogenarian population than in patients younger than age 80.

SUMMARY BACKGROUND DATA

The utility of CE depends on the ability of the surgeon and hospital to attain low rates of death and complications, including all subgroups of the patient population. In the past 30 years, the number of people age 85 and older has increased 274%.

METHODS

Detailed chart review was carried out on all CE procedures done from 1979 through 1998. Descriptive demographic data, risk factors, surgical details, length of stay, deaths, and complications were recorded.

RESULTS

A total of 2,398 CEs were performed in 1,970 patients; 2,180 procedures were performed in 1,783 patients younger than 80, and 218 CEs were performed in 187 patients age 80 and older. Sixty-five percent of the octogenarians and 67% of patients younger than age 80 had neurologic symptoms. Among asymptomatic patients, 89% had stenosis of 75% or more. There were 62 strokes in the 2,180 procedures in the younger group, for a stroke rate of 2.8%, and 7 strokes in the 218 procedures in the older group, for a stroke rate of 3.2%. The death rates were 0.9% for the octogenarians and 1.4% for the younger group.

CONCLUSIONS

Carotid endarterectomy can be safely performed in a community hospital in patients age 80 and older. Outcomes in octogenarians were not significantly different than those of younger patients and were within the range required for CE to be considered beneficial in the prevention of stroke.

Cholecystectomy in patients aged 80 and older

BACKGROUND

We assessed whether the increase in performance of laparoscopic cholecystectomy has affected patients aged 80 and older and if outcomes of a laparoscopic approach in this population would show improvement over those for open surgery.

METHODS

We analyzed an 11-state discharge database obtained from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project. Release 1 contains a 20% sample of United States hospitals for the period 1988 to 1992. Diagnosis-related group (DRG) codes 197 and 198 were searched, and demographics, type of surgery, and outcome measures were analyzed.

RESULTS

In 5 years, 350,451 patients underwent cholecystectomy with the DRG codes listed. Of those, 18,500 patients were aged 80 to 105. The total number of cholecystectomies increased each year. Performance of laparoscopic cholecystectomy rose rapidly and that of open cholecystectomy decreased. Overall mortality with laparoscopic cholecystectomy was 1.8%, was lower than that of open cholecystectomy, was lower in women, and decreased with time.

CONCLUSIONS

Patients aged 80 and older have participated in the increased performance of cholecystectomy and the switch to laparoscopic cholecystectomy. This has a low mortality, low length of stay, and higher proportion of patients being discharged to home compared with patients having open cholecystectomy.

Laparoscopic cholecystectomy in octogenarians

Performance of laparoscopic cholecystectomy (LC) is increasing, and patients age 80 and over comprise an increasingly larger proportion of the LC population. This study documents that the increase is accompanied by safe outcome in this patient population. However, the evidence also suggests that cholelithiasis appears to have been a neglected condition in this age group. The prevalence of nonelective procedures, the conversion rate to an open operation, more intraoperative complications, and the percentage having evidence of common bile duct stone passage all support this assertion. With the technology of LC, we are now appropriately addressing the problem with a treatment that allows less surgical trauma to the patient and shorter recovery time. Same-day LC surgery for the octogenarian appears to be very safe and would justify a decision to perform earlier LC in these patients. Surgery done before the appearance of comorbid conditions that increase the surgical and anesthetic risks may result in improved outcomes for the elderly at lower cost. Even when necessary in the already hospitalized patient, LC can be accomplished with morbidity and mortality comparable to those of elective abdominal procedures in younger populations.