Frailty and Emergency Surgery: Results of a Systematic Review and Meta-Analysis

Background

Frailty, a "syndrome of loss of reserves," is a decade old concept. Initially it was used mainly in geriatrics but lately its use has been extended into other specialties including surgery. Our main objective was to examine the association between frailty and mortality, between frailty and length of hospital stay (LOS) and frailty and readmission within 30 days in the emergency surgical population.

Methods

Studies reporting on frailty in the emergency surgical population were eligible. MEDLINE (via PubMed), EMBASE, Scopus, CENTRAL, and Web of Science were searched with terms related to acute surgery and frail*. We searched for eligible articles without any restrictions on the 2nd of November 2020. Odds ratios (OR) and weighted mean differences (WMD) were calculated with 95% confidence intervals (CI), using a random effect model. Risk of bias assessment was performed according to the recommendations of the Cochrane Collaboration. As the finally selected studies were either prospective or retrospective cohorts, the "Quality In Prognosis Studies" (QUIPS) tool was used.

Results

At the end of the selection process 21 eligible studies with total 562.070 participants from 8 countries were included in the qualitative and the quantitative synthesis. Patients living with frailty have higher chance of dying within 30 days after an emergency surgical admission (OR: 1.99; CI: 1.76-2.21; p < 0.001). We found a tendency of increased LOS with frailty in acute surgical patients (WMD: 4.75 days; CI: 1.79-7.71; p = 0.002). Patients living with frailty have increased chance of 30-day readmission after discharge (OR: 1.36; CI: 1.06-1.75; p = 0.015).

Conclusions

Although there is good evidence that living with frailty increases the chance of unfavorable outcomes, further research needs to be done to assess the benefits and costs of frailty screening for emergency surgical patients.

Systematic Review Registration

The review protocol was registered on the PROSPERO International Prospective Register of Systematic Reviews (CRD42021224689).

HPV prevalence and p16INKa overexpression in non-smoking non-drinking oral cavity cancer patients

OBJECTIVE

Our aim was to compare HPV and p16INK4a (p16) expression and their influence on survival and prognosis in oral cavity squamous cell cancer (OCSCC), between non-smokers and non-drinkers (NSND) and smokers and drinkers (SD).

SUBJECTS AND METHODS

Patients with OCSCC treated with surgery from 2000 to 2010 were included in the study. Patients who did not smoke at all or smoked less than 10 pack per years and did not drink alcohol on a daily basis were considered the NSND group. An equal number of SD were the control group. HPV presence was determined from paraffin-embedded blocks investigated by PCR analysis. p16 expression was evaluated with immunohistochemistry.

RESULTS

The NSND group were mostly younger or older female patients with tongue or gingival cancers. p16 expression was significantly more frequent in NSND patients (27% vs 10%). Patients with stronger p16 expression had significantly worse survival, especially for tongue cancers (P = 0.026). In Cox multivariate analysis, both HPV and p16 expression carried a negative prognosis for NSND patients (P = 0.0351 and P = 0.0260).

CONCLUSIONS

NSND are a specific population of OCSCC patients. In contrast to oropharyngeal cancer, HPV and p16 expression in OCSCC are negative predictive factors, especially in NSND patients.

Salivary and serum interleukin 6 and basic fibroblast growth factor levels in patients with oral squamous cell carcinoma

AIM

A role of various cytokines has been implicated in the pathogenesis of many carcinomas, and albeit the role of interleukin 6 (IL-6) and basic fibroblast growth factor (bFGF) in sera has been studied in patients with oral carcinomas, data upon salivary IL-6 and bFGF are lacking. The aim of this study was to evaluate levels of IL-6 and bFGF in the saliva and serum of patients with oral squamous cell carcinoma.

METHODS

Salivary and serum IL-6 and bFGF were evaluated in a group of 33 patients (28 men, 5 women) with oral squamous cell carcinoma (OSCC), age range 40-73 years , mean 54.05 years. Control group consisted of 23 healhy participants, mean age 25 years.

RESULTS

Serum IL-6 and bFGF levels were not significantly different between patients with OSCC and healthy controls. Elevated levels of salivary IL-6 and bFGF in patients with OSCC when compared to the healthy controls were found (p<0.001).

CONCLUSIONS

The conclusion is drawn that higher levels of salivary IL-6 and bFGF in patients with OSCC might originate from the local production, probably from carcinoma cells.

Emphysematous gastritis -- case report and review of the literature

Emphysematous gastritis is a rare form of phlegmonous gastritis caused by invasion of the stomach wall by gas-forming bacteria. This clinical entity was first described by Fraenkel in 1889. The authors report the case of a 58-year-old patient with end-stage renal failure under treatment with hemodialysis for the past year. He was admitted on account of pain in the lower abdomen. During the diagnostic procedure, emphysematous gastritis and acute cholecystitis were confirmed. An acute abdomen developed and an emergency laparotomy was performed. During the procedure, the necrotic gallbladder was removed. The patient died on the following day due to multiorgan failure and septic shock. According to the literature, emphysematous gastritis is generally a fatal disease. Air in the wall of the stomach is a rare finding with a broad differential diagnosis.

Reconstruction following radical maxillectomy with flaps supplied by the subscapular artery

The authors present their experience of 27 cases with repairs of defects following radical maxillectomies with free flaps. A total of 28 flaps were used (five latissimus dorsi, six scapula, 16 combination flaps of scapula and latissimus dorsi and one combination of scapula, latissimus dorsi and serratus anterior flap). Only one scapula flap was completely lost and in three cases where a combination of scapula and latissimus dorsi flap was used, partial necrosis of one component occurred. The authors first choice for reconstruction is a scapula bone flap raised on the angular artery combined with the latissimus dorsi flap. The combination of flaps with a long pedicle and of the bony and muscular components provides the surgeon with the option of customizing the flap to meet individual patient needs. For intraoral closure the authors prefer the latissimus dorsi muscle which rarely requires secondary procedures for prosthesis placement following epithelialization and atrophy. The main disadvantage of the flap is the difficulty of two teams working simultaneously, thus increasing the average operating time. All postoperative corrections and prosthetic rehabilitation should be postponed for at least 2 months following surgery because of postoperative swelling.

Microvascular free flap reconstructive options in patients with partial and total maxillectomy defects

OBJECTIVE

To evaluate and discuss the free flap reconstructive options for patients with partial and total maxillectomy defects.

DESIGN

Retrospective review of cases.

SETTING

Two tertiary referral centers.

PATIENTS

Fifty-one patients had partial or total maxillectomy defects resulting from oncologic surgical resection, and 7 had partial maxillectomy defects resulting from trauma. Inferior or partial maxillectomy defects included 10 anterior arch and hemipalate defects and 12 subtotal or total palate defects. Total maxillectomy defects with and without orbital exenteration included 36 maxilla defects with hemipalate and malar eminence.

INTERVENTION

There were 11 fibula, 14 rectus abdominis, 9 scapular, 10 radial forearm, 5 latissimus dorsi, and 13 combination latissimus dorsi and scapular flaps.

MAIN OUTCOME MEASURES

Separation of the oral cavity from the sinonasal cavities, diet, type of dental restoration, type of orbital restoration, speech intelligibility, and complications.

RESULTS

Only 1 flap failure was reported. There was loss of bone in 2 flaps and loss of the skin paddle in 1 flap. All palatal defects were sealed by the separation of the oral and sinonasal cavities. Thirty-eight patients were able to eat a regular diet while the remaining patients maintained a soft diet. All patients conversed on the telephone without difficulty in intelligibility. Eight patients had an implant-borne dental prosthetic, and 30 patients had a conventional partial prosthetic. Orbit restoration was achieved in 2 patients with an implant-borne prosthetic, and 6 patients retained a standard orbit prosthetic.

CONCLUSIONS

Free flap reconstruction of the maxilla creates reproducible permanent separation of the oral and sinonasal cavities in a single-stage procedure. In addition, there exists the potential for dental rehabilitation with restoration of masticatory and phonatory function. Free flap reconstruction also provides a good cosmetic result, which improves patients' outlook and contributes to their overall well-being. Reconstructive flaps are designed to fit specific maxillary defects and patient needs to provide optimally functional and cosmetic results.

Are the new staging rules better for T4 oral cancer?

BACKGROUND

In order to find whether the changes in primary tumor definition influence the distribution of T (tumor extent) stages and prognoses, a retrospective study was undertaken.

PATIENTS AND METHODS

There were 1,040 patients with adequate data for staging and 868 of those patients underwent surgical treatment. Among the surgically treated patients, 187 fulfilled the new (American Joint Committee on Cancer [AJCC]/International Union Against Cancer 1988) and 77 fulfilled the old (AJCC 1977) criteria for T4 tumors. The distribution of all patients, rate of patients initially treated with surgery, incidence of metastases, and survival were analyzed.

RESULTS

The neck was clinically positive (N+) in 50% of T4 patients staged according to the new rules and 69% of patients staged according to the old rules. The 5-year overall survival rate for T4-staged patients irrespective of therapy was 29% using the new rules and 13% using the old rules. The 5-year disease-free survival rate for T4-operated patients was 60% using the new rules and 45% using the old rules.

CONCLUSIONS

The previous AJCC rules for the T4 tumors were a better indicator of poor prognosis.

Extended anterior subcranial approach for skull base tumors: long-term results

The extended anterior subcranial approach differs significantly from more traditional surgical approaches to the skull base in that it allows a broad inferior access to the anterior skull base planes with tumor exposure from below rather than via the transfrontal route. The authors initially used the subcranial approach in 1978 for the treatment of high-velocity skull base trauma and certain craniofacial anomalies. In 1980 they expanded the indications to include the combined neurosurgical-otolaryngological resection of various skull base tumors. Osteotomy of the frontonasoorbital external skeletal frame provides optimum anterior access to the orbital and sphenoethmoidal planes as well as to the nasal and paranasal cavities while avoiding frontal lobe retraction and the external facial incisions characteristic of transcranial and transfacial approaches. The improved visualization of the anterior skull base and clival-sphenoidal region facilitates en bloc tumor removal, optic nerve decompression, exposure of the medial aspect of the cavernous sinus, and watertight realignment of the anterior cranial base dura. In this report the authors present their experience over the past 13 years with 104 patients who underwent operation via the extended subcranial approach. Because extensive frontal lobe manipulation and external facial incisions are avoided with this approach, intensive care unit and overall hospital stay are reduced, related complications are minimized, and postoperative cosmetic appearance is enhanced. The extended anterior subcranial method is therefore an excellent alternative to traditional transfacial-transcranial skull base approaches for the removal of selected skull base tumors.

Maxillofacial war injuries in civilians and servicemen during the aggression against Croatia

Although civilian populations have been heavily involved in most of the recent wars and conflicts throughout the world, most reports analyzed casualty data of military personnel, often leaving civilian casualties excluded or underestimated. A comparison of epidemiologic and medical data for maxillofacial injuries between civilians and servicemen (policemen, soldiers, and United Nations Protection Forces) during the aggression against Croatia is attempted. Of the 220 casualties admitted to the Department of Maxillofacial Surgery in Zagreb between August 1991 and December 1992, almost one-fourth were civilians. A significant difference between civilians and servicemen was noted in age and sex distribution. The incidence and severity of maxillofacial and associated injuries is almost equal, and the pattern of injuries is of the same type for civilian and military personnel.

Musculomucosal nasolabial island flaps for floor of mouth reconstruction

A modification of the musculomucosal nasolabial island flap based on the facial artery for reconstruction of anterior floor of mouth defects is presented. Surgical technique and advantages in comparison to conventional nasolabial flaps are described. A series of 14 flaps in 8 patients is presented.

A method of zygomatic arch stabilization

A new method for zygomatic arch stabilization with a silicone tube placed under the zygomatic arch is described. The method is safe, easy to perform and, in our experience, without complications.

Evaluation of mandibular fracture treatment

A total of 124 patients treated for mandibular fractures were analyzed. Patients were divided into three groups according to treatment: intermaxillary fixation, wire fixation and mini-plate fixation. For each method, the success of treatment was evaluated with respect to surgical approach, fracture site and injury to treatment interval. Five basic parameters were used for evaluation of the outcome: occlusion, appearance, mastication, duration of IMF and complications. The treatment was surveyed based on both the surgeon's and patient's-evaluation. All parameters were scored and average values for every parameter calculated. The most successful treatment was achieved with mini-plate fixation in symphyseal and angle fractures. Intermaxillary fixation is indicated for mandibular body fractures with or without minimal displacement and a sufficient number of teeth. However, mini-plate fixation should be used for fractures with displacement. Wire fixation has been shown to be the poorest choice for all sites. Results showed that the intraoral approach has advantages over the extraoral one. The optimal time for treatment of mandibular fractures is within 72 h from time of injury. Even in fractures older than 7 days we recommended mini-plate fixation.

[Preoperative irradiation of larynx and hypopharynx carcinoma]

30 patients with carcinoma of the larynx or hypopharynx were irradiated preoperatively with a dosis of 1,500 to 4,500 rads. The results are compared with those of an identical group of patients who were only operated. The operation was mostly partial (20 cases). In laryngeal cancer the cure rate after two years was 69% and 47%, in hypopharyngeal cancer 43% and 28% respectively.