Highlights • Six frailty screening tests in elderly patients undergoing emergency surgery. • The VES-13: the best screening instrument; highest sensitivity and negative predictive value. • Allows for ...tailored treatment of high-risk group of elderly patients.
•The SAS predictor of postoperative mortality and morbidity in the older patients.•The G8 and the SAS allow postoperative department allocation in the older patients.•The combination of the G8 and ...the SAS may improve the outcomes of older patients.
The Surgical Apgar Score (SAS) is a simple and rapid scoring system predicting postoperative mortality and morbidity. However, it remains unknown whether it might be useful in fit and frail older patients undergoing abdominal emergency surgery.
Consecutive patients ≥65 years, needing emergency abdominal surgery were enrolled in this prospective study. Additionally to the SAS, the G8 screening score was used to determine the frailty status. The logistic regression analysis was conducted investigating the association between the scores and 30-day postoperative outcomes.
The study sample comprised 315 older patients (165 female, 150 male) with a median age of 77 (range 65–100) years old. The prevalence of frailty was 60.3%. The most frequent surgical indications were acute cholecystitis, followed by ileus, complicated diverticulitis, ulcer perforation, complication of gastric cancer and other causes. The decreasing SAS was significantly associated with the increasing likelihood of both 30-day postoperative major complications (p < 0.01) and death (p < 0.01) both in fit and frail older patients. Multivariate analyses have identified the G8, frailty screening test, and the SAS score as independent factors that predict postoperative adverse events. The model combining both scores increased the discriminatory ability for 30-day postoperative major morbidity and mortality.
The SAS confirmed to be a simple and powerful predictor of 30-day postoperative morbidity and mortality both in fit and frail older patients undergoing emergency abdominal surgery. The department allocation algorithm based of the combination of the G8 and the SAS may be considered as an option to improve the outcomes of older patients undergoing abdominal emergency surgery.
The elderly constitute the group of patients who most often undergo elective urological procedures, and they are at the highest risk of poor surgical outcomes because of comorbidity and frailty. The ...current model of qualification for surgery is often subjective and based on tools which do not address the characteristics of the elderly. The Comprehensive Geriatric Assessment (CGA) and screening tools can help in the evaluation of older, particularly frail patients. The aim of the study was to review the literature on the usefulness of preoperative geriatric evaluation in patients undergoing urological treatment. The review was based on MEDLINE/PubMed, Embase and Cochrane Library bibliographic databases from 2000-2017 for full-text, English-language publications meeting pre-defined criteria. Six prospective and 3 retrospective studies were selected for further analysis. The patient populations, methods of geriatric assessment, interventions, and outcome measures varied between the studies. None of the studies were randomized controlled trials. In 2 studies, the CGA was used; in other studies, rather basic screening tests were used. In only 2 studies, an intervention was performed after the CGA. In general, the variables of the CGA were both prospectively and retrospectively significant predictors of complications of urological surgery. Although the use of CGA is not a standard practice in everyday urological clinical practice, components of the CGA appear to be predictive of postoperative complications. Therefore, inclusion of geriatric assessment as part of routine preoperative care in geriatric urology patients should be considered. Because of the lack of randomized controlled trials on preoperative CGAs in urology patients, further studies are needed.
The majority of patients undergoing emergency laparotomy are older adults that carry the highest mortality. More research into the development of targeted interventions is required. Therefore, the ...aim of the study was to analyse the indications for emergency abdominal surgery in patients aged ≥ 65 admitted to the Department of General Surgery. The study included consecutive patients aged ≥ 65 who underwent emergency abdominal surgery within 48 h after admission at one institution. In 2010–2017, 986 patients were enrolled in the study (female 57%, male 43%). Patients were divided into three age groups, 65–70, 71–84 and ≥ 85, with 255 patients (25.9%), 562 patients (57.0%) and 169 patients (17.1%) in each group, respectively. In the first and second age groups, the most common indications for surgery were acute cholecystitis, non-malignant ileus, colorectal cancer complications and acute appendicitis. In the oldest patients, the most common indications were complications of colorectal cancer, acute cholecystitis, non-malignant ileus and complications of diverticulosis. In the women, the biggest differences in indications between age groups were colorectal cancer (
p
= 0.025) and peptic ulcer disease complications (
p
= 0.005); in the men, the biggest difference was seen for complicated diverticulitis (
p
= 0.001). The most frequent comorbidities were heart diseases (81.0%), followed by endocrine (33.6%) and vascular diseases (22.7%). The three most common indications for emergency surgery in older patients at our institution were acute cholecystitis, colorectal cancer complications and non-malignant bowel obstruction, affecting 59.5% of this group of patients. Elective surgery and endoscopic screening have the potential to prevent major part of these acute diseases. However, further prospective research is necessary on this field, particularly among frail, older patients.
The main aim was to review the results of studies investigating individual domains of geriatric assessment (GA), and GA as a whole, among older patients undergoing laparoscopic surgery. A systematic ...literature search was performed for papers published between 2009 and 2020. Ten studies were evaluated, including 1940 patients. The ADL or the I-ADL, was used in 90% of studies, followed by the GDS (80%), the MMSE (70%), polypharmacy (70%), the MNA(60%), the CCI (50%), the CIRS (20%), the BOMC score (10%) and the Clock Drawing Test (10%). Only dependency in the functional domain could be recognized as a reliable risk factor for postoperative complications in the majority of the studies. All authors have confirmed the effectiveness of a cumulative GA (OR 3.1-6.0). Cumulative GA is recommended to predict the morbidity of the older patient after laparoscopic surgery. For the individual domains (apart from physical function) the results are too inconsistent to reach any clinical conclusion.
Laparoscopic appendectomy (LA) for treatment of acute appendicitis has gained acceptance with its considerable benefits over open appendectomy. LA, however, can involve some adverse outcomes: ...morbidity, prolonged length of hospital stay (LOS) and hospital readmission. Identification of predictive factors may help to identify and tailor treatment for patients with higher risk of these adverse events. Our aim was to identify risk factors for serious morbidity, prolonged LOS and hospital readmission after LA. A database compiled information of patients admitted for acute appendicitis from eighteen Polish and German surgical centers. It included factors related to the patient characteristics, peri- and postoperative period. Univariate and multivariate logistic regression models were used to identify risk factors for serious perioperative complications, prolonged LOS, and hospital readmissions in acute appendicitis cases. 4618 laparoscopic appendectomy patients were included. First, although several risk factors for serious perioperative complications (C-D III-V) were found in the univariate analysis, in the multivariate model only the presence of intraoperative adverse events (OR 4.09, 95% CI 1.32-12.65, p = 0.014) and complicated appendicitis (OR 3.63, 95% CI 1.74-7.61, p = 0.001) was statistically significant. Second, prolonged LOS was associated with the presence of complicated appendicitis (OR 2.8, 95% CI: 1.53-5.12, p = 0.001), postoperative morbidity (OR 5.01, 95% CI: 2.33-10.75, p < 0.001), conversions (OR 6.48, 95% CI: 3.48-12.08, p < 0.001) and reinterventions after primary procedure (OR 8.79, 95% CI: 3.2-24.14, p < 0.001) in the multivariate model. Third, although several risk factors for hospital readmissions were found in univariate analysis, in the multivariate model only the presence of postoperative complications (OR 10.33, 95% CI: 4.27-25.00), reintervention after primary procedure (OR 5.62, 95% CI: 2.17-14.54), and LA performed by resident (OR 1.96, 95% CI: 1.03-3.70) remained significant. Laparoscopic appendectomy is a safe procedure associated with low rates of complications, prolonged LOS, and readmissions. Risk factors for these adverse events include complicated appendicitis, postoperative morbidity, conversion, and re-intervention after the primary procedure. Any occurrence of these factors during treatment should alert the healthcare team to identify the patients that require more customized treatment to minimize the risk for adverse outcomes.
Frailty increases the risk of poor surgical outcomes in the older population. Some intraoperative factors may also influence the final result and can be evaluated. The Surgical Apgar Score (SAS) is a ...simple system predicting postoperative mortality and morbidity. However, the utility of the SAS remains unknown in fit and frail older patients undergoing elective laparoscopic cholecystectomy due to benign gallbladder diseases.
To evaluate the usefulness of the SAS in predicting 30-day morbidity and 1-year mortality in older fit and frail patients undergoing elective laparoscopic cholecystectomy.
Consecutive patients (≥ 70 years) were enrolled in the prospective study. The Comprehensive Geriatric Assessment (CGA) was used to diagnose frailty. Logistic regression was conducted to investigate the association between the scores and the outcomes.
The study included 144 consecutive older patients with a median age of 76 (range: 70-91) years. The prevalence of frailty was 44.4%. The 30-day mortality and morbidity were 0% and 11.8%, respectively. The 1-year mortality was 6.3% and 7 out of 9 occurred in the frail group. SAS < 7 points was identified as an independent predictor of 30-day postoperative morbidity (OR = 5.1; 95% CI: 1.5-18.1). Age > 85 years (OR = 1.9; 95% CI: 1.2-16.4) and frailty (OR = 3.4; 95% CI: 1.1-19.3) were predictors of 1-year mortality.
Laparoscopic cholecystectomy can be safely performed in older fit and frail patients. The SAS, not age, turned out to be the most important predictor of 30-day morbidity. Frailty and age > 85 years were predictors of 1-year mortality. Older patients with SAS < 7 points should be followed meticulously in order to diagnose and treat potential complications early on.
Several postoperative outcome scoring systems have been developed and validated, combining both pre- and intraoperative factors. Among others are The Portsmouth Physiological and Operative Severity ...Score for the enUmeration of Mortality and Morbidity (P-POSSUM), the Estimation of Physiologic Ability and Surgical Stress (E-PASS), and the Surgical Apgar Score combined with the American Society of Anesthesiologists (SASA) physical status classification. The aim of this study is to compare the above scoring systems in the prediction of 30-day postoperative mortality and major morbidity in older patients undergoing emergency abdominal surgery. Patients ≥ 65 years were enrolled into the study. Pre- and intraoperative variables were used to calculate the scores and the ROC curve; logistic regression analysis was performed. The study sample comprised 427 older patients with a median age of 77 (range 65–100) years. The most frequent surgical indications were cholecystitis, followed by ileus, complication of colorectal cancer, complicated diverticulitis, and appendicitis. Decreasing SASA and increasing E-PASS and POSSUM/P-POSSUM scores were significantly associated with both 30-day postoperative major complications and death. Multivariate analyses identified all the scores as independent variables to predict postoperative outcomes. The areas under the ROC curve were 0.66–0.81 for predicting mortality and 0.67–0.79 for predicting morbidity (
p
< 0.01). All the scores were confirmed to be predictive of 30-day postoperative morbidity and mortality. The SASA and the E-PASS scores demonstrated the highest discriminatory ability. However, SASA was found to combine effectiveness and simplicity. Based on this study, we therefore recommend SASA for postoperative risk evaluation in older patients undergoing emergency abdominal surgery.
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