Preoperative functional status is associated with discharge to nonhome in geriatric individuals

INTRODUCTION

Discharging older individuals to rehabilitation facilities is associated with adverse outcomes, including readmission or increased mortality rate. As preoperative functional status is an important factor impacting patient outcome, we hypothesized that this would be associated with patient disposition to nonhome locations.

MATERIALS AND METHODS

A retrospective analysis was performed using data from the 2013-2018 American College of Surgeons National Surgical Quality Improvement Program, including targeted variables from the Geriatric Pilot Project. Patients aged 65 and older in 33 institutions across the nation were included (n = 44,219). Preoperative functional status was categorized as independent, partially dependent, and dependent. The primary outcome was home versus nonhome disposition. Nonhome was defined as rehabilitation facility and nursing home. Descriptive analyses were performed. Variables associated with postoperative discharge to nonhome were identified using logistic regression.

RESULTS

The largest percentage of operations was orthopedics (40.8%), followed by general surgery (29.2%) and vascular operations (10.0%). The majority of the patients were independent before operations (93.1% independent, 6% partially dependent, and 0.9% totally dependent). In regression analyses, patients who were partially dependent preoperatively had five times higher odds of discharging to nonhome, compared to patients who were independent (odds ratio [OR] 5.04, p < 0.01). Similarly, patients who were totally dependent had 3.2 higher odds of discharging to nonhome than patients who were independent (OR 3.22, p < 0.01).

CONCLUSION

Better preoperative functional status is associated with patient discharge to home in older adults. Preoperative interventions aimed at improving functional status, such as prehabilitation, may be beneficial in improving patient outcomes.

Application of the RAND-UCLA Appropriateness Methodology to a Large Multidisciplinary Stakeholder Group Evaluating the Validity and Feasibility of Patient-Centered Standards in Geriatric Surgery

OBJECTIVES

To explore (1) differences in validity and feasibility ratings for geriatric surgical standards across a diverse stakeholder group (surgeons vs. nonsurgeons, health care providers vs. nonproviders, including patient-family, advocacy, and regulatory agencies); (2) whether three multidisciplinary discussion subgroups would reach similar conclusions.

DATA SOURCE/STUDY SETTING

Primary data (ratings) were reported from 58 stakeholder organizations.

STUDY DESIGN

An adaptation of the RAND-UCLA Appropriateness Methodology (RAM) process was conducted in May 2016.

DATA COLLECTION/EXTRACTION METHODS

Stakeholders self-administered ratings on paper, returned via mail (Round 1) and in-person (Round 2).

PRINCIPAL FINDINGS

In Round 1, surgeons rated standards more critically (91.2 percent valid; 64.9 percent feasible) than nonsurgeons (100 percent valid; 87.0 percent feasible) but increased ratings in Round 2 (98.7 percent valid; 90.6 percent feasible), aligning with nonsurgeons (99.7 percent valid; 96.1 percent feasible). Three parallel subgroups rated validity at 96.8 percent (group 1), 100 percent (group 2), and 97.4 percent (group 3). Feasibility ratings were 76.9 percent (group 1), 96.1 percent (group 2), and 92.2 percent (group 3).

CONCLUSIONS

There are differences in validity and feasibility ratings by health professions, with surgeons rating standards more critically than nonsurgeons. However, three separate discussion subgroups rated a high proportion (96-100 percent) of standards as valid, indicating the RAM can be successfully applied to a large stakeholder group.

Optimal Preoperative Evaluation and Perioperative Care of the Geriatric Patient: A Surgeon's Perspective

The elderly preoperative patient benefits from an assessment that includes more than a routine physical examination and electrocardiogram. Such an assessment includes domains likely to affect the elderly: cognition, functionality, frailty, polypharmacy, nutrition, and social support. This fosters decisions based on functional age rather than chronologic age and on each patient as an individual. One such assessment is that promulgated by the American College of Surgeons National Surgery Quality Improvement Program/American Geriatrics Society Best Practice Guidelines. We should not miss any opportunity to improve results in this growing population of surgical patients.

Non-intubated video-assisted thoracic surgery as the modality of choice for treatment of recurrent pleural effusions

This review will establish that the best mode of treatment for recurrent pleural effusions is non-intubated video-assisted thoracic surgery (VATS) with chemical talc pleurodesis. The nature of recurrent pleural effusions mandates that any definitive and effective treatment of this condition should ideally provide direct visualization of the effusion, complete initial drainage, a low risk outpatient procedure, a high patient satisfaction rate, a high rate of pleurodesis and a high diagnostic yield for tissue diagnosis. There are various methods available for treatment of this condition including thoracostomy tube placement with bedside chemical pleurodesis, thoracentesis, placement of an indwelling pleural catheter, pleurectomy and VATS drainage with talc pleurodesis. Of these treatment options VATS drainage with the use of local anesthetic and intravenous sedation is the method that offers most of the desired outcomes, thus making it the best treatment modality.

Non-intubated video-assisted thoracic surgery in patients aged 80 years and older

BACKGROUND

Video-assisted thoracic surgery (VATS) is routinely performed with general anesthesia and double-lumen endotracheal intubation, but this technique may stress an elderly patient's functional reserve. We chose to study the safety and efficacy of non-intubated VATS, utilizing local anesthesia, sedation, and spontaneous ventilation in the elderly.

METHODS

The medical records of all patients aged 80 years and older who underwent VATS under local anesthesia and sedation during the time period 6/1/2002 to 6/1/2010 at Geisinger Health System (Pennsylvania, USA) and 10/1/2011 to 12/31/2014 at Sinai Hospital (Maryland, USA) were retrospectively reviewed. Unsuccessful attempts at this technique were eligible for inclusion but there were none. No patient was excluded based on comorbidity.

RESULTS

A total of 96 patients ranging in age from 80 to 104 years underwent 102 non-intubated VATS procedures: pleural biopsy/effusion drainage with or without talc 73, drainage of empyema 17, evacuate hemothorax 4, pericardial window 3, lung biopsy 2, treat chylothorax 2, treat pneumothorax 1. No patient required intubation or conversion to thoracotomy. No patient required a subsequent procedure or biopsy. Complications occurred in three patients (3.1% morbidity): cerebrovascular accident, pulmonary embolism, prolonged air leak. One 94-year-old patient died from overanticoagulation and two 84-year-old patients died of their advanced lung cancers (3.1% morbidity).

CONCLUSIONS

Non-intubated VATS utilizing local anesthesia and sedation in the elderly is well tolerated and safe for a number of indications.

Summary of the panel session at the 38th Annual Surgical Symposium of the Association of VA Surgeons: what is the big deal about frailty?

Owing to the phenomenon known as "global graying," elderly-specific conditions, including frailty, will become more prominent among patients undergoing surgery. The concept of frailty, its effect on surgical outcomes, and its assessment and management were discussed during the 38th Annual Surgical Symposium of the Association of VA Surgeons panel session entitled "What's the Big Deal about Frailty?" and held in New Haven, Connecticut, on April 7, 2014. The expert panel discussed the following questions and topics: (1) Why is frailty so important? (2) How do we identify the frail patient prior to the operating room? (3) The current state of the art: preoperative frail evaluation. (4) Preoperative interventions for frailty prior to operation: do they work? (5) Intraoperative management of the frail patient: does anesthesia play a role? (6) Postoperative care of the frail patient: is rescue the issue? This special communication summarizes the panel session topics and provides highlights of the expert panel's discussions and relevant key points regarding care for the geriatric frail surgical patient.

ProvenCare lung cancer: a multi-institutional improvement collaborative

Geisinger's ProvenCare™ Program (for elective coronary artery bypass surgery, total hip replacement, and others) has shown that the principles of reliability science, facilitated by a robust electronic health record and institutional commitment, allow the re-engineering of complicated clinical processes. This eliminates unwarranted variation and promotes the completion of evidence-based elements of care. It has not been established that ProvenCare can be generalized to other institutions. Now, under the auspices of the American College of Surgeons Commission on Cancer, ProvenCare has been adapted to a multi-institutional collaborative for the care of the patient with resectable lung cancer.

Epiphrenic esophageal diverticula: spectrum of symptoms and consequences

Patients with esophageal diverticula may present with a variety of symptoms. Many of these symptoms mimic less serious disease, making diagnosis of esophageal diverticulum difficult for many primary care physicians. Delayed or missed diagnosis of this disorder may lead to more serious problems including gastrointestinal bleeding, aspiration pneumonia, and cancer. Our case series illustrates a variety of symptoms observed among three patients who were diagnosed and surgically treated for esophageal diverticulum. Appropriate diagnosis and management of esophageal diverticulum results in resolution of symptoms and decreased risk of morbidity.

Video-assisted thoracic surgery utilizing local anesthesia and sedation

OBJECTIVE

Video-assisted thoracic surgery (VATS) is usually performed with general anesthesia and double-lumen endotracheal intubation, but minor procedures have been carried out with patients spontaneously breathing and with epidural or regional analgesia. We have broadened our indications for VATS utilizing purely local anesthesia and sedation.

METHODS

The medical records of all patients undergoing VATS under local anesthesia and sedation at Geisinger Wyoming Valley Medical Center between 7/1/02 and 6/1/06 were reviewed. All procedures were performed in the operating room with patients in full lateral position; no patient had endotracheal intubation or epidural or nerve block analgesia.

RESULTS

One hundred and fifteen patients, ranging in age from 21 to 88 years and in size from 40 to 172 kg, underwent 126 video-assisted thoracic operations: pleural biopsy/effusion drainage with or without talc 81, drainage of empyema 21, lung biopsy 18, evacuate hemothorax 3, pericardial window 2, biopsy chest wall mass 1. No patient required intubation or conversion to thoracotomy. Three patients who underwent lung biopsy died of their underlying disease (cytomegalovirus and pneumocystis, primary amyloidosis, metastatic cancer to contra-lateral lung) on postoperative days 18, 14, and 4, respectively. One patient developed transient renal insufficiency attributed to ketorolac.

CONCLUSION

VATS utilizing local anesthesia and sedation is well tolerated, safe, and valuable for an increasing number of indications.

Abdominal Compartment Syndrome After Late Repair of Bochdalek Hernia

Abdominal compartment syndrome is a potential complication of laparotomy, but it is rarely anticipated by thoracic surgeons. We present the case of a 16-year-old girl who manifested this syndrome after emergency repair of a Bochdalek congenital diaphragmatic hernia. Techniques for recognition, measurement, treatment, and prevention are discussed.

Cervical rib variant: report of a case

It is taught that, when a cervical rib is present, the subclavian vessels and brachial plexus always arch over it. The present case reemphasizes that the brachial plexus may be split by the cervical rib.

Annular pancreas and intermittent duodenal obstruction in an alcoholic adult

Annular pancreas is a congenital anomaly which, though present at birth, may cause few symptoms until adulthood. A case of annular pancreas with intermittent duodenal obstruction is described in a 49-year-old alcoholic man. Few other entities cause such obstruction. In similar cases, clinical suspicion of annular pancreas may lead to prompt diagnosis and treatment.

Experiences with laser bronchoscopy

Laser bronchoscopy was performed 87 times in 58 patients over a three-year period at Wilkes-Barre General Hospital. Fifty-six patients (97 percent) had malignant disease, including bronchogenic carcinoma (46), metastatic neoplasm to bronchus or lung (eight), or direct extension of esophageal carcinoma (two); benign pathology included tracheal papillomatosis (one) and granulation tissue (one). Eighty-six percent of tumors were proximally located (trachea, carina, mainstem bronchi). A standardized procedure utilizing both rigid and flexible bronchoscopy and the Nd:YAG laser was employed, with two deaths (2.3 percent) and eight complications (9.2 percent). Results were good or excellent in all five patients treated for bleeding and in 68 of 82 patients (83 percent) treated for obstruction. The patient with an obstructing or bleeding endobronchial lesion can achieve palliation through Nd:YAG laser bronchoscopic resection.

Three decades of treatment of esophageal squamous carcinoma at the Massachusetts General Hospital

Seven hundred one patients with squamous cell carcinoma of the esophagus who were treated between 1950 and 1979 were retrospectively studied. The percentage of male patients decreased over the three decades (80% to 69%); the proportion of cigarette and alcohol abusers doubled. The esophageal carcinoma was located as follows: upper third, 24.7%; middle third, 52.8%, and lower third, 22.5%. There was disparity in clinical, surgical, and pathologic staging. More than two thirds of the patients thought to have stage II lesions preoperatively proved to have stage III lesions on pathologic examination; nearly one half of patients thought to have stage II disease intraoperatively were found to have pathologic stage III lesions. This "upgrading" of stage was chiefly a result of histologic recognition of nodal metastasis or extension of carcinoma into surrounding tissues. Operation was performed in 411 cases (58.6%) and resection was performed in 261 (37.2% overall). The postoperative death rate after resection fell from 30.5% in the 1950s to 10.4% in the 1970s, with respiratory complications the predominant cause of death. Analyses were based on treatment directed at the carcinoma itself: radiotherapy, 340 cases (48.5%); resection, 176 cases (25.1%); resection plus radiotherapy, 85 cases (12.1%); no definitive treatment, 100 cases (14.3%). Overall survival for the 701 patients was 13% at 2 years and 6% at 5 years (mean survival, 16.4 months); this did not differ by decade. Survival clearly differed by treatment (p = 0.001); resection plus radiotherapy provided the best survival (35% at 2 years; 20% at 5 years; mean of 32.5 months) followed by resection (18% at 2 years; 7% at 5 years; mean of 17.5 months), radiotherapy (9% at 2 years; 3% at 5 years; mean of 12.7 months), and no treatment (0% at 2 years; 0% at 5 years; mean of 2.5 months). Survival in patients who did not have resection did not differ by decade but survival in patients with resections improved in the last two decades. Patients with pathologic stage II lesions had greatly improved survival (54% at 2 years; 25% at 5 years; mean of 42.7 months) compared with patients with stage III disease (12% at 2 years; 6% at 5 years; (mean of 15.1 months) (p = 0.001).

Lung cancer with skin metastasis

Cutaneous metastasis from lung cancer is rare, but physicians should understand its significance. We treated eight such patients during a 30-month period at Wilkes-Barre (Pa) General Hospital. The seven men and one woman ranged in age from 46 to 72 years (mean, 59 years). In three, the skin lesion was the first manifestation of the underlying cancer and in another three, it was found coincident with the lung mass. Pathologic findings included small-cell undifferentiated carcinoma in four patients, squamous cell carcinoma in three patients, and large-cell undifferentiated carcinoma in one patient. Seven of the eight primary lung lesions were in the upper lobes. Six patients had clinically occult visceral metastases at the time of skin biopsy. Only one patient survived more than six months following skin metastasis. Biopsy specimens must be taken from all new skin lesions, particularly in patients who smoke or who already have a history of lung cancer.

Surgery in centenarians

Surgical problems do not end on a person's centennial, and as our overall population ages, physicians will see increasing numbers of these most senior citizens requiring surgery. Accordingly, the records of all century-old patients who have undergone surgery at the Massachusetts General Hospital in the years 1979 to 1983 were reviewed. Three men and three women ranged in age from 100 to 104 years at the time of surgery. One patient experienced complications, but all survived their operation and lived one to two years afterward. The centenarian has already been tested by life and found exceptionally fit. Selectivity and meticulous attention to detail remain paramount in treating these patients, but elective surgery should not be deferred, nor emergency surgery denied the centenarian on the basis of chronologic age.

Substernal goiter

The literature on substernal goiter from the seventeenth century to the present is reviewed. Substernal goiter may be defined as any thyroid enlargement that has its greater mass inferior to the thoracic inlet. Truly ectopic mediastinal goiters are rare, and most substernal goiters arise from and maintain some attachment to the cervical thyroid gland. Patients are generally in the fifth decade of life, and women predominate. Most patients experience dyspnea, stridor, or dysphagia, but 15 to 50% are asymptomatic; symptoms are often positional, and acute stridor may occur. Ten to twenty percent have no cervical mass or tracheal deviation on examination, and virtually all patients are euthyroid. Standard chest roentgenograms are often diagnostic, but computed tomographic or radioactive iodine scans may be helpful. The presence of a substernal goiter in all but the highest-risk patients is an indication for resection, usually through a cervical collar incision; an occasional patient will require sternotomy or thoracotomy. Death or major complications should be rare postoperatively. Substernal goiters are adenomatous and benign, but carcinoma occurs in 2 to 3% and may be occult. Patients should be followed closely, as these goiters may recur.

Substernal goiter. Analysis of 80 patients from Massachusetts General Hospital

Eighty patients at the Massachusetts General Hospital underwent resection of substernal goiter in the years 1976 to 1982. Mean age of the 50 women and 30 men was 56 years, and 10 (19 percent) had undergone prior thyroid surgery. The most common symptoms were cervical mass (69 percent), dysphagia (33 percent), and dyspnea (28 percent); 13 percent were asymptomatic. On examination, cervical mass was present in most (90 percent) but not all patients, 51 percent were obese, and more than one third had tracheal deviation. Fifty-one of 52 patients tested were euthyroid and one was mildly hypothyroid. Chest radiographs showed tracheal deviation in 79 percent and soft tissue mass in 56 percent. Seventy-eight patients underwent resection through a cervical collar incision only; one had cervical incision plus upper partial sternotomy; and one required cervical incision plus full median sternotomy. Pathologic examination revealed multinodular goiter in 41 (51 percent), follicular adenoma in 35 (44 percent), and Hashimoto's thyroiditis in 4 (5 percent). Mean goiter weight was 104 g, and the mean greatest dimension was 9 cm. Occult papillary carcinoma was found in two patients. There were no deaths or major complications. Analysis of our data indicate the following: (1) Substernal goiter may exist in the absence of symptoms or signs. (2) Extensive radiologic evaluation and thyroid function testing are rarely required. (3) With rare exceptions, substernal goiter represents an extension of a cervical growth through the thoracic inlet and can be approached through a cervical collar incision. (4) Histologically, these are multinodular goiters or follicular adenomas, although Hashimoto's thyroiditis may occur. (5) Given the small but present risks of acute stridor or occult malignancy and the negligible surgical risk, operation should be recommended. (6) Patients should be followed since, with or without levothyroxine, goiters may recur.

Clostridium septicum infection and malignancy

Evidence mounts favoring the relationship, albeit unexplained, between Clostridium septicum infection and malignancy, particularly hematologic or intestinal malignancy. Seven patients with C. septicum gangrene or sepsis have been treated at the Massachusetts General Hospital in the years 1977-79. All of these patients have had associated malignant disease: four patients had colon adenocarcinomas, two patients had acute myeloblastic leukemias, and one patient had breast carcinoma. In six of the seven patients, the malignancy was in an advanced state; the breast carcinoma showed no evidence of recurrence after mastectomy, 17 years earlier. A bowel portal of entry is postulated in five patients. Despite prompt use of appropriate antibiotics, the only survivors were two of the four patients who underwent early extensive debridement. These results suggest that, in the patient with C. septicum infection, malignancy should be sought; that, in the septic patient with known malignancy, C. septicum should be considered; and that, in the absence of external source in the patient with clostridial myonecrosis or sepsis, the cecum or distal ileum should be considered a likely site of infection. Increased awareness of this association between C. septicum and malignancy, and aggressive surgical treatment, may result in improvement in the present 50-70% mortality rate.

Severe low-pressure cuff tracheal injury in burn patients

Two cases are presented of severe tracheal damage secondary to low-pressure high-volume endotracheal tube cuffs monitored carefully against over-inflation. Our patients' findings suggest that in the presence of tracheal inhalation injury or severe tracheal infection strict monitoring of pressures, though essential, does not preclude tracheal trauma from a low-pressure cuff, trauma to a degree generally ascribed only to high-pressure "stiff" cuffs. There is probably no arbitrarily safe level of cuff pressure in these patients; any amount of pressure is likely to further harm the tracheal wall and must be weighed into the risk-benefit equation for prolonged intubation.