IMPORTANCE Surgery in older patients often poses risks of death, complications, and functional decline. Prior to surgery, evaluations of health-related priorities, realistic assessments of surgical ...risks, and individualized optimization strategies are essential. OBJECTIVE To review surgical decision making for older adult patients by 2 measures: defining treatment goals for elderly patients and reviewing the evidence relating risk factors to adverse outcomes. Assessment and optimization strategies for older surgical patients are proposed. EVIDENCE ACQUISITION A review of studies relating geriatric conditions such as functional and cognitive impairment, malnutrition, facility residence, and frailty to postoperative mortality and complications (including delirium, discharge to an institution, and functional decline). Medline, EMBASE, and Web of Science databases were searched for articles published between January 1, 2000, and December 31, 2013, that included patients older than 60 years. RESULTS This review identified 54 studies of older patients; 28 that examined preoperative clinical features associated with mortality (n = 1 422 433 patients) and 26 that examined factors associated with surgical complications (n = 136 083 patients). There was substantial heterogeneity in study methods, measures, and outcomes. The absolute risk and risk ratios relating preoperative clinical conditions to mortality varied widely: 10% to 40% for cognitive impairment (adjusted hazard ratio HR, 1.26 95% CI, 1.06-1.49 to 5.77 95% CI, 1.55-21.55), 10% to 17% for malnutrition (adjusted odds ratio OR, 0.88 95% CI, 0.78-1.01 to 59.2 95% CI, 3.6-982.9), and 11% to 41% for institutionalization (adjusted OR, 1.5 95% CI, 1.02-2.21 to 3.27 95% CI, 2.81-3.81).) Risk ratios for functional dependence relating to mortality ranged from an adjusted HR of 1.02 (95% CI, 0.99-1.04) to an adjusted OR of 18.7 (95% CI, 1.6-215.3) and for frailty relating to mortality, ranged from an adjusted HR of 1.10 (95% CI, 1.04-1.16) to an adjusted OR of 11.7 (95% CI not reported) (P < .001). Preoperative cognitive impairment (adjusted OR, 2.2; 95% CI, 1.4-2.7) was associated with postoperative delirium (adjusted OR, 17.0; 95% CI, 1.2-239.8; P < .05). Frailty was associated with a 3- to 13-fold increased risk of discharge to a facility (adjusted OR, 3.16 95% CI, 1.0-9.99 to 13.02 95% CI, 5.14-32.98). CONCLUSIONS AND RELEVANCE Geriatric conditions may be associated with adverse surgical outcomes. A comprehensive evaluation of treatment goals and communication of realistic risk estimates are essential to guide individualized decision making.
Background
Little is known about the breadth and quality of nonobstetric surgical care delivered by nonphysician clinicians (NPCs) in low-resource settings. We aimed to document the scope of NPC ...surgical practice and characterize outcomes after major surgery performed by nonphysicians in Tanzania.
Methods
A retrospective records review of major surgical procedures (MSPs) performed in 2012 was conducted at seven hospitals in Pwani Region, Tanzania. Patient and procedure characteristics and level of surgical care provider were documented for each procedure. Rates of postoperative morbidity and mortality after nonobstetric MSPs performed by NPCs and physicians were compared using multivariate logistic regression.
Results
There were 6.5 surgical care providers per 100,000 population performing a mean rate of 461 procedures per 100,000 population during the study period. Of these cases, 1,698 (34.7 %) were nonobstetric MSPs. NPCs performed 55.8 % of nonobstetric MSPs followed by surgical specialists (28.7 %) and medical officers (15.5 %). The most common nonobstetric MSPs performed by NPCs were elective groin hernia repair, prostatectomy, exploratory laparotomy, and hydrocelectomy. Postoperative mortality was 1.7 % and 1.5 % in cases done by NPCs and physicians respectively. There was no significant difference in outcomes after procedures performed by NPCs compared with physicians.
Conclusions
Surgical output is low and the workforce is limited in Tanzania. NPCs performed the majority of major surgical procedures during the study period. Outcomes after nonobstetric major surgical procedures done by NPCs and physicians were similar. Task-shifting of surgical care to nonphysicians may be a safe and sustainable way to address the global surgical workforce crisis.
Routine preoperative laboratory testing is not recommended for American Society of Anesthesiologists classification 1 or 2 patients before low-risk ambulatory surgery.
The 2017 National Surgical ...Quality Improvement Program data set was retrospectively queried for American Society of Anesthesiologists class 1 and 2 patients who underwent low-risk, elective outpatient anorectal, breast, endocrine, gynecologic, hernia, otolaryngology, oral-maxillofacial, orthopedic, plastic/reconstructive, urologic, and vascular operations. Preoperative laboratory testing was defined as any chemistry, hematology, coagulation, or liver function studies obtained ≤30 days preoperatively. Demographics, comorbidities, and outcomes were compared between those with and without testing. The numbers needed to test to prevent serious morbidity or any complication were calculated. Laboratory testing costs were estimated using Centers for Medicare and Medicaid Services data.
Of 111,589 patients studied, 57,590 (51.6%) received preoperative laboratory testing; 26,709 (46.4%) had at least 1 abnormal result. Factors associated with receiving preoperative laboratory testing included increasing age, female sex, non-White race/ethnicity, American Society of Anesthesiologists class 2, diabetes, dyspnea, hypertension, obesity, and steroid use. Mortality did not differ between patients with and without testing. The complication rate was 2.5% among tested patients and 1.7% among patients without tests (P < .01). The numbers needed to test was 599 for serious morbidity and 133 for any complication. An estimated $373 million annually is spent on preoperative laboratory testing in this population.
Despite American Society of Anesthesiologists guidelines, a majority of American Society of Anesthesiologists class 1 and 2 patients undergo preoperative laboratory testing before elective low-risk outpatient surgery. The differences in the rates of complications between patients with and without testing is low. Preoperative testing should be used more judiciously in this population, which may lead to cost savings.
Background
Surgical conditions represent an immense yet underrecognized source of disease burden globally. Characterizing the burden of surgical disease has been defined as a priority research agenda ...in global surgery. Little is known about the epidemiology of inguinal hernia, a common easily treatable surgical condition, in resource-poor settings.
Methods
Using data from the National Health and Nutrition Examination Survey prospective cohort study of inguinal hernia, we created a method to estimate hernia epidemiology in Ghana. We calculated inguinal hernia incidence and prevalence using Ghanaian demographic data and projected hernia prevalence under three surgical rate and hernia incidence scenarios. Disability adjusted life-years (DALYs) associated with inguinal hernia along with costs for surgical repair were estimated.
Results
According to this approach, the prevalence of inguinal hernia in the Ghanaian general population is 3.15 % (range 2.79–3.50 %). Symptomatic hernias number 530,082 (range 469,501–588,980). The annual incidence of symptomatic hernias is 210 (range 186–233) per 100,000 population. At the estimated Ghanaian hernia repair rate of 30 per 100,000, a backlog of 1 million hernias in need of repair develop over 10 years. The cost of repairing all symptomatic hernias in Ghana is estimated at US$53 million, and US$106 million would be required to eliminate hernias over a 10-year period. Nearly 5 million DALYs would be averted with the repair of prevalent cases of symptomatic hernia in Ghana.
Conclusions
Data generated by our method indicate the extent to which Ghana lacks the surgical capacity to address its significant inguinal hernia disease burden. This approach provides a simple framework for calculating inguinal hernia epidemiology in resource-poor settings that may be used for advocacy and program planning in multiple country contexts.
Colorectal surgery is a core component of general surgery. The volume of colorectal surgery performed by general surgery residents throughout training has not been studied. This study aims to analyze ...trends observed in colorectal-specific case numbers logged by general surgery residents over 16 years.
Case number data for general surgery residents was extracted from the publicly available, annually published Accreditation Council for Graduate Medical Education (ACGME) database from 2003 to 2019. Cases were categorized as open or laparoscopic colectomy/proctectomy, colectomy with ileoanal pull-thru, abdomino-perineal resection (APR), transanal rectal tumor excision (TRE), anorectal procedure, colonoscopy, and total colorectal cases. The average case numbers per category was calculated for each year. Linear regression analyzed trends in case categories for all residents and those logged as surgeon chief and junior residents.
ACGME accredited general surgery residency programs.
Not applicable.
General surgery residents reported increased numbers of all, chief, and junior resident colorectal cases over the study period (124.5-173.7 cases/yr; 38.4-53.0 cases/yr; 86.4-120.6 cases/yr, all p = 0.00). Average cases for all, chief, and junior residents have increased for laparoscopic colectomy/proctectomy (4.6-26.4 cases/year; 2.7-12.9 cases/year; 2.0-13.5 cases/year, all p = 0.00), anorectal surgeries (26.7-37.7 cases/year; 5.4-9.9 cases/year; 21.3-27.8 cases/year, all p = 0.00), and colonoscopies (35.9-70.6 cases/year, p = 0.00; 6.6-14.1 cases/year, p = 0.01; 29.4-56.5 cases/year, p = 0.00). Average cases for all, chief, and junior residents have decreased for open colectomy/proctectomy (52.0-34.9 cases/year; 21.2-14.3 cases/year; 30.9-20.6 cases/year, all p = 0.00), APR (3.3-2.7 cases/year, p = 0.00; 1.8-1.3 cases/year, p = 0.00; 1.5-1.4 cases/year, p = 0.02), TRE (1.9-1.1 cases/year; 0.7-0.4 cases/year; 1.2-0.6 cases/year, all p = 0.00). Ileoanal pull-thru did not demonstrate a linear trend.
The increase in exposure to colectomies/proctectomies, anorectal procedures and colonoscopies is encouraging, as these common colorectal operations will be encountered in general surgery practice. The observed low case numbers for TRE, APR, and ileoanal pull-thru suggest a need for specialized training.
Objective Even in the setting of duplex ultrasound (DUS) surveillance, a significant number of lower extremity vein bypass grafts (LEVBGs) become occluded as a first event. We sought to identify ...factors that may contribute to these primary occlusions. Methods This was a retrospective analysis of the Project of Ex Vivo Graft Engineering via Transfection III (PREVENT III) multicenter randomized clinical trial, in which 1404 patients with critical limb ischemia (CLI) underwent LEVBG with 1-year follow-up. Subjects were to undergo DUS at regular intervals (1, 3, 6, and 12 months), with reintervention based on prespecified DUS criteria. Patients who had nontechnical graft occlusion as the initial graft-related event were identified, and multivariate analysis was used to determine factors associated with primary graft occlusion. Results Primary vein graft occlusion occurred in 200 subjects and accounted for 36% of all primary patency events and 64% of all graft occlusions in the trial. Primary occlusion events were evenly distributed throughout the first postoperative year. Rates of recurrent CLI, loss of secondary patency, and major amputation in those with primary occlusion were 55%, 79%, and 22% respectively as compared to 18%, 10%, and 10% for subjects without primary occlusion ( P < .001). On multivariate analysis, African-American race (subdistribution hazard ratio SHR, 1.50; 95% confidence interval CI, 1.06-2.12), a graft diameter <3 mm (SHR, 2.31; 95% CI, 1.33-4.01), and nonadherence with ultrasound surveillance (SHR, 1.58; 95% CI, 1.10-2.27) were independently associated with primary graft occlusion. Of the 123 subjects who received their last scheduled surveillance DUS prior to a primary occlusion event, 39 had a critical ultrasound abnormality identified but failed to undergo graft revision, while 84 had no critical ultrasound abnormality identified. Among these 84 subjects, female gender (SHR, 1.65; 95% CI, 1.07-2.54), and graft diameter <3 mm (SHR, 2.12; 95% CI, 1.03-4.37) were independent factors associated with unheralded graft occlusion. Conclusions Among patients undergoing LEVBG for CLI, almost half of primary patency events are occlusions even in the setting of a DUS surveillance protocol. African Americans, patients with smaller-diameter grafts, and those who are nonadherent with surveillance ultrasound are at increased risk. Failure to intervene on critical findings, and lack of sensitivity of DUS threshold criteria to predict thrombosis, are also important contributors. These findings suggest that prevention of vein graft thrombosis requires further improvements in risk stratification, surveillance, and the timing of reinterventions.
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