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Emergency Abdominal Operations in the Elderly: A Multivariate Regression Analysis of 430 Consecutive Patients with Acute Abdomen
Abstract
This study is intended to ascertain if outcome of acute abdominal surgery among elderly patients with acute abdominal pain have improved.
Altogether 456 patients aged >65 years underwent emergency abdominal surgery between the years 2007 and 2009 in our hospital. After excluding emergency reoperations of elective surgery, a total of 430 consecutive patients were included in this retrospective audit. The key factors under analysis in this study were the occurrence of major complications and death from any cause within 30 days after the operation. In addition, we compared our results to our previously published data some 20 years ago.
The most common diagnoses were cholecystitis (n = 139, 32.3 %, incidence of 125 per 100,000 elderly persons), incarcerated hernia (n = 60, 13.9 %, 54/100,000), malignancy related (n = 50, 11.6 %, 45/100,000), or acute appendicitis (n = 46, 10.7 %, 41/100,000). The majority of operations (80.7 %) were performed using open technique. Of all 112 laparoscopic procedures, 25.9 % were converted to open surgery. Reoperations were rare and postoperative surgical complications were not associated with statistically significant increase in mortality, even if reoperation was needed. The 30-day mortality and morbidity rates were 14.2 and 31.9 %, respectively. Logistic regression analysis showed that patient's age (p = 0.014), atrial fibrillation (p = 0.017), low body mass index (p = 0.001), open surgery (p = 0.029), ASA grade III or more (p < 0.001), and previous history of malignancies (p = 0.010) were likely to increase mortality.
Despite modern diagnostics and improved surgical techniques, the results of emergency abdominal surgery still have relatively high morbidity and mortality as reported in earlier studies.
... El anciano se caracteriza por la presencia de grandes síndromes de etiología multifactorial y presentación atípica, de ahí la importancia de hacer una buena valoración para poder establecer un diagnóstico y un tratamiento oportunos. (6) La enfermedad que más frecuentemente se operó de urgencia en el presente estudio fueron las hernias complicadas de la pared abdominal; estos resultados son similares a los de Morera y colaboradores (7) y Alonso (13) y difieren de los de Ukkonen y colaboradores (14) en una serie de 456 pacientes mayores de 65 años intervenidos de urgencia, en la que un 32,3% de la población fue intervenida de colecistolitiasis, que fue la intervención más frecuente. ...
... La mayoría de los pacientes no presentaron complicaciones postoperatoria, lo que también se ha notificado recientemente en estudios multivariados de intervenciones de urgencia. (14) Diversos autores han demostrado los éxitos de la cirugía geriátrica debido a una mejor preparación preoperatoria de los enfermos, a los avances en Anestesia y Reanimación, a una mayor experiencia en las diversas opciones y técnicas quirúrgicas y al mayor control de las complicaciones postoperatorias. (4,5,6,7) Consecuentemente, para el manejo de cualquier enfermedad quirúrgica en el adulto mayor, se deben tener en cuenta consideraciones especiales. ...
... (4,5,6,7) Consecuentemente, para el manejo de cualquier enfermedad quirúrgica en el adulto mayor, se deben tener en cuenta consideraciones especiales. (13,14,15) Estos resultados responden a la estrategia de diagnóstico que se implementa en el Servicio de Cirugía General y que se basa en detectar qué pacientes precisarán especial atención, evaluando no solo la edad sino también la denominada reserva fisiológica o el estado funcional que, junto al tratamiento multidisciplinario, han contribuido a disminuir la morbilidad y la mortalidad en ancianos con abdomen agudo quirúrgico. Otro argumento potencial radica en la vasta experiencia de los Especialistas en Cirugía del centro estudiado. ...
Introducción:
con el envejecimiento de la población un número cada vez mayor de pacientes asisten a consulta por síntomas abdominales agudos que requieren una atención oportuna e integral.
Objetivo:
describir las causas y la evolución del abdomen agudo quirúrgico en el adulto mayor.
Métodos:
se realizó un estudio observacional descriptivo en el Hospital “Arnaldo Milián Castro” de la Provincia de Villa Clara de enero de 2017 a diciembre de 2018. La población estuvo constituida por 780 pacientes que ingresaron a los Servicios de Cirugía por abdomen agudo. Constituyeron variables de estudio el sexo, la edad, la causa de abdomen agudo quirúrgico y las complicaciones postquirúrgicas. Se emplearon métodos de la estadística descriptiva. La información fue extraída de las historias clínicas.
Resultados:
el 54,2% fueron hombres y se observó predominio del grupo de edad comprendido entre 60 y 70 años. Las hernias de la pared abdominal complicadas fueron la enfermedad de mayor incidencia (34,7%), el 81,4% de los adultos mayores intervenidos no presentaron complicaciones postquirúrgicas y la mortalidad fue de 1,4%.
Conclusiones:
las principales causas de abdomen agudo quirúrgico en el paciente adulto mayor en esta serie fueron la hernia de la pared abdominal complicada, la apendicitis aguda, la oclusión intestinal y la colecistitis aguda. Se presentaron bajas tasa de complicaciones y mortalidad. El control del abdomen agudo quirúrgico depende de la evaluación cuidadosa del cuadro agudo y de la corrección electiva de las enfermedades abdominales conocidas.
... To determine the prognostic role of comorbidities in patients admitted to the emergency department and underwent abdominal surgery. Four of the studies [2,4,18,19] we included in our study examined the effect of the type of surgery on mortality. The statistical analysis of these studies examined the effect of commonly used types of surgery on mortality. ...
... Four of the studies [2,3,4,8] evaluated within the scope of the metaanalysis reported findings that some specific diseases (such as heart and kidney failure, chronic obstructive pulmonary disease) increased mortality, whereas five studies [18][19][20][21][22] reported that comorbid factors had no effect on mortality in elderly patients undergoing emergency abdominal surgery. In our study, the overall effect score was P > 0.05, and it was confirmed that comorbid factor had no effect on mortality in elderly patients undergoing emergency abdominal surgery. ...
... Some authors report that certain types of surgery are risk factors for mortality in old individuals [18]. Several studies are available in the literature, reporting that surgery for mesenteric ischemia, peptic ulcer perforation [2,6,19], and intestinal obstruction [4,6] are associated with high mortality. Of the studies we included in our study, four of them [2,4,18,19] examined the effect of the type of surgery on mortality. ...
Background/aim:
With the increase in the elderly population, the elderly proportion needing emergency surgery is also increasing. Despite medical advances in surgery and anesthesia, negative postoperative outcomes and high mortality rates are still present in elderly patients undergoing emergency surgery. Comorbidities are described as the main determining factors in poor outcomes. In this metaanalysis, it was aimed to investigate the effect of comorbidity on mortality in elderly patients undergoing emergency abdominal surgery.
Materials and methods:
The studies published between 2010-2019 were scanned from databases of Google Scholar, Cinahl, Pub Med, Medline and Web of Science. Quality criteria proposed by Polit and Beck were used in the evaluation of the included studies. Interrater agreement was calculated by using the Kappa statistic, effect size by using the odds ratio, and heterogeneity among studies by using the Cochran’s Q statistics. Kendall’s Tau-b coefficient and funnel plot were used to determine publication bias.
Results:
A total of 9 studies were included in the research. There was a total of 1330 cases in the studies. The total mortality rate was 21% (n = 279), the total rate of having a comorbid factor was 83.6% (n = 1112), and the rate of having a comorbid factor in mortality was 89.2% (n = 249). According to the fixed effects model, the total effect size of comorbid factors on causing mortality was not statistically significant with a value of 1.296 (C.I; 0.84-1.97; P > 0.05).
Conclusion:
Our study revealed that comorbidity had no significant effect on causing mortality in geriatric patients undergoing emergency abdominal surgery. There are controversial results in the literature, and in order to reach more precise results, studies involving wider groups of patients and further studies examining the specific effect of certain comorbid conditions are needed.
... The mean age of the cohort was 76.16 ± 7.42 years old. Male patients had a lower body mass index (BMI) than female patients (23.34 ± 3.71 vs. 24.09 ± 4.14 kg/m 2 , p=0.001). ...
... The number of geriatric surgeries is increasing worldwide (23). Despite the fact that surgical outcomes have improved with the advancement of perioperative care, abdominal emergencies in elderly patients remain challenging for surgeons, and the mortality rate can exceed 20% (8,24). As the existing preoperative risk assessment tools such as the ASA classi cation system, CCI, and ACS NSQIP re ect underlying comorbidities, the functional and physiological status of the patients is often overlooked. ...
... Our overall complication (11.6%) and mortality (8.5%) rates were slightly lower than those reported in the literature (8,24,46). This could be attributed to the pooling of diseases with low morbidity and mortality rates, such as appendicitis and cholecystitis, which accounted for more than 30% of the cohort. ...
Background: Frailty has been shown to be an independent negative predictor of surgical outcomes in geriatric patients. Traditional measurements of frailty are impractical in emergency settings, and computed tomography (CT)-measured skeletal muscle mass has been proposed as an alternative. However, the cutoff values of these CT metrics for frailty are still unknown, and their impact on abdominal emergencies in the elderly population is unclear.
Study Design: A total of 462 young trauma patients aged 18-40 years were analyzed to establish sex-specific reference cutoff values for the CT-measured muscle index (MI) and muscle gauge (MG) values. The impacts of low MI and MG values were investigated in 1192 elderly patients (aged ≥ 65 years) undergoing abdominal surgery.
Results: The sex-specific cutoff values for MI and MG were determined by adopting European Working Group on Sarcopenia in Older People (EWGSOP) guidelines. The correlation between MG and ageing was significantly stronger than that between MI and ageing. With regard to the MG, the L4 psoas muscle gauge (L4 PMG) was further investigated in an elderly cohort owing to its high predictive value and ease of use in the clinical setting. A low L4 PMG value was an independent risk factor for overall complications and mortality in elderly patients with abdominal emergencies.
Conclusion: The current study was the largest study investigating the correlations between MG values and ageing in the Asian population. Frailty, as indicated by a low L4 PMG value, may help surgeons during preoperative decision making regarding geriatric patients with abdominal emergencies.
... The number of geriatric surgeries is increasing worldwide [25]. Despite the fact that surgical outcomes have improved with the advancement of perioperative care, abdominal emergencies in elderly patients remain challenging for surgeons, and the mortality rate can exceed 20% [8,26]. As the existing preoperative risk assessment tools such as the ASA classification system, CCI, and ACS NSQIP reflect underlying comorbidities, the functional and physiological status of the patients is often overlooked. ...
... Our overall complication (11.6%) and mortality (8.5%) rates were slightly lower than those reported in the literature [8,26,44]. This could be attributed to the pooling of diseases with low morbidity and mortality rates, such as appendicitis and cholecystitis, which accounted for more than 30% of the cohort. ...
Background
Frailty has been shown to be an independent negative predictor of surgical outcomes in geriatric patients. Traditional measurements of muscle strength and mass are impractical in emergency settings, and computed tomography (CT)-measured skeletal muscle mass has been proposed as an alternative. However, the cutoff values for low muscle mass are still unknown, and their impact on abdominal emergencies in the elderly population is unclear.MethodsA total of 462 young trauma patients aged 18–40 years were analyzed to establish sex-specific reference cutoff values for the CT-measured muscle index (MI) and muscle gauge (MG) values. The impacts of low MI and MG values were investigated in 1192 elderly patients (aged ≥ 65 years) undergoing abdominal surgery.ResultsThe sex-specific cutoff values for MI and MG were determined by adopting European Working Group on Sarcopenia in Older People 2 guidelines. The correlation between MG and aging was significantly stronger than that between MI and ageing. With regard to the MG, the L4 psoas muscle gauge (L4 PMG) was further investigated in an elderly cohort owing to its high predictive value and ease of use in the clinical setting. A low L4 PMG value was an independent risk factor for overall complications and mortality in elderly patients with abdominal emergencies.Conclusion
The current study was the largest study investigating the correlations between MG values and aging in the Asian population. A low L4 PMG value may help surgeons during preoperative decision making regarding geriatric patients with abdominal emergencies.
... In Italy, according to the Italian National Institute for Statistics (Istituto Nazionale di Statistica, ISTAT), there were approximately 13.5 million people aged 65 and older in 2016, representing 22.3% of inhabitants [3,4], and this value will continue to grow in the following years. Recovery, particularly for surgical emergencies, is considered complicated in the elderly [5][6][7], who tend to have longer hospital stays [7][8][9] (this is related to comorbidities, an elevated number of drugs taken, and reduced physical and mental reserves) [3,5,8,9]. Not all patients of the same age have the same risks or frailty issues (in Surgeries 2021, 2 120 multiple physiological systems, this is defined as age-related cumulative decline, and is considered a better predictor of mortality and morbidity than chronological age in the elderly). ...
... Not all patients of the same age have the same risks or frailty issues (in Surgeries 2021, 2 120 multiple physiological systems, this is defined as age-related cumulative decline, and is considered a better predictor of mortality and morbidity than chronological age in the elderly). In the surgical field, the most frequent emergency diagnoses in the elderly are acute incarcerated hernia, cholecystitis, bowel obstruction and/or infarction, colic obstruction, and acute appendicitis [6]. Frailty assessment could facilitate identification of vulnerable surgical patients and, consequently, identify the appropriate surgical and anesthetic management [2]. ...
Background: the general population is aging across the world. Therefore, even surgical interventions in the elderly—in particular those involving emergency surgical admissions—are becoming more frequent. The elderly population is often frail (in multiple physiological systems, this is often defined as age-related cumulative decline). This study involved a 2-year follow-up evaluation of frail elderly patients treated with urgent surgical intervention at Santa Maria Regina della Misericordia Hospital, General Surgery Department, in Adria (Italy). Method: a prospective, single-center, 2-year follow-up study of 120 patients >65 years old, treated at our department for surgical abdominal emergencies. We considered co-morbidities (ASA—American Society of Anesthesiologists Physical Status Classification System—score), type of surgery (laparoscopy, laparotomy or converted), frailty score, mortality, and complications at 30 days and at 2 years. Conclusions: 70 (58.4%) patients had laparoscopy, 49 (40.8) had laparotomy, and in 1 (0.8%) case, surgery was converted from laparoscopy to laparotomy. Mortality strictly depends on the type of surgery (laparotomy vs. laparoscopy), complications during recovery, and a lower Fried frailty criteria score, on average. The long-term follow-up can be a useful tool to highlight a safer surgical approach, such as laparoscopy, in frail elderly patients. We consider the laparoscopic approach feasible in emergency situations, with similar or better outcomes than laparotomy, especially in frail elderly patients.
... Firstly, categories of operations are broad (comprising simple and large procedures) and, therefore, the conclusions arising from the current analysis are only general. It should be mentioned, however, that in other, more detailed studies examining particular diseases or procedures, the studied populations were significantly smaller (up to thousands of participants) [22,23] than the population examined in our study (millions). Secondly, age is not a single mortality predictor [23,24], and other factors such as American Society of Anesthesiologists class, frailty index, sarcopenia, co-morbidities (like cancer), low grade inflammation and various in-hospital complications also affect post-operative mortality rate in the elderly [7][8][9][24][25][26][27][28]. ...
... It should be mentioned, however, that in other, more detailed studies examining particular diseases or procedures, the studied populations were significantly smaller (up to thousands of participants) [22,23] than the population examined in our study (millions). Secondly, age is not a single mortality predictor [23,24], and other factors such as American Society of Anesthesiologists class, frailty index, sarcopenia, co-morbidities (like cancer), low grade inflammation and various in-hospital complications also affect post-operative mortality rate in the elderly [7][8][9][24][25][26][27][28]. However, majority of such data were not disposed in the NHF database. ...
Background:
Surgery-related mortality depends on a number of factors including the type of surgical procedure, quality of healthcare, co-morbidities, and age of patient. The objective of the study was to assess the in-hospital mortality in the elderly undergoing surgical treatment.
Methods:
This was a national data-based retrospective cohort study. Data were extracted from the National Health Fund, a public organization financing medical procedures in Poland. Adult citizens who underwent 9,344,384 surgical interventions (including 3,093,254 cases in seniors who were above 65 years old) between 2009 and 2012 were included in this study. Overall, surgery type-dependent, age-stratified in-hospital mortality related to surgery was assessed.
Results:
Overall in-hospital surgery-related mortality rate in seniors was stable (approximately 2 % annually, P for trend = 0.104). It doubled with each successive decade of life (1.2, 2.3, 5.6, and 13 % in 65-74, 75-84, 85-94 and ≥95 years old groups, respectively, in 2012). In ≥75-year-old mortality exceeded 10 % only after neurological surgeries, in ≥85-year-old after neurological, vascular, gastrointestinal, and endocrinological surgeries, and in ≥95-year-old also after heart and circulation, bones and muscles, liver, pancreas, and spleen operations. However, even in the oldest individuals it was low after genitourinary, female genital tract, head and neck, and eye surgeries.
Conclusions:
The overall rate of in-hospital mortality after surgery, although increasing with age, is rather low up to the ninth decade of life. Whereas some surgeries pose a significant risk, others may be relatively safe even in the oldest subjects.
... Gallbladder illness is one of the most prevalent reasons for adult hospitalization for acute abdomen and the most common reason for abdominal surgery in the elderly [15,16] . ...
Background: In the mid-1980s, laparoscopic cholecystectomy [LC] was introduced to Europe as a replacement option to open cholecystectomy [OC], a surgery that had been used for almost a century. This technique has quickly achieved general acceptance as the treatment of choice for symptomatic cholelithiasis patients.Objective: To review the experience and understanding with LC in patients with benign gallbladder diseases and to compare the results as per different adult age groups [18-30 years, 31– 45 years and 46-60 years]. Patients and Methods: The research was a retrospective review of 150 patients with elective LC for benign gallbladder disease. According to their ages, the patients were split into three groups: Group A [18-30 years, n = 34], Group B [31–45 years, n = 76], and Group C [46-60 years, n = 40]. A four-port approach was employed to conduct LC.Results: A total of 150 patients were involved in our study, with Group A [18-30 years, n = 34], Group B [31–45 years, n = 76], and Group C [46-60 years, n = 40] being the three age groups. Males numbered 90, while females numbered 60. In Groups A, B, and C, the mean ages were 24.60±3.14, 38.99±8.06, and 51.32±5.06, respectively. All three groups had statistically significant co-incidental biliary diseases [p=0.03914]. The majority of individuals with acute cholecystitis can have a laparoscopic cholecystectomy. However, compared to normal cholecystectomy, the complication incidence appears to be modest in laparoscopic cholecystectomy.Conclusion: LC is an effective and safe treatment for individuals with benign gallbladder illnesses, especially those who are elderly. However, surgeons should be aware of these disorders and use caution in these instances both before and after surgery.
... These patients are at high risk of procedural adverse events and tend to have septic complications with multiple organ dysfunction that inevitably lead to death [28,29]. If we consider our entire primary emergency cohort including those patients with minor emergencies, the overall mortality rate is less than 15%, which is within the range of mortality rates reported in the literature [30][31][32]. ...
Background
Obesity has been shown to increase the rates of morbidity and occasionally mortality in patients undergoing nonbariatric elective surgery. However, little is known about the impact of obesity on outcomes after surgery for high-risk abdominal emergencies.
Methods
A single-center retrospective evaluation of outcomes in high-risk abdominal emergency patients categorized by body mass index (BMI) was conducted. Patient demographics, comorbidities, and operative details were analyzed. Patients with normal weight (BMI 18.5–24.9) served as comparators. Multivariable linear and logistic regression analyses were performed to assess the impact of obesity on surgical outcomes.
Results
In total, 886 patients with BMI < 18.5 (underweight; n = 50), 18.5–24.9 (normal weight; n = 306), 25–29.9 (overweight; n = 336) and ≥ 30 (obese; n = 194) based on the World Health Organization (WHO) weight classification criteria met the inclusion criteria. Compared to normal-weight patients, patients with overweight and obesity were older and more likely to be male. The rates of comorbidity (100% vs 91.2%, p = < 0.0001), morbidity (77.8% vs 65.6%, p = 0.003), and in-hospital mortality (44.8% vs 30.4%, p = 0.001) were all higher in patients with obesity than in normal-weight patients. Patients with obesity had an increased intensive care unit length of stay (ICU LOS) (13 days vs 9 days, p = 0.019) and hospital LOS (21.4 days vs 18.1 days, p = 0.081) and prolonged ventilation (39.1% vs 19.6%, p = 0.003). As BMI deviated from the normal range, the morbidity and mortality rates increased incrementally, with the highest morbidity (87.9%) and mortality (54.5%) rates observed in morbidly obese patients (BMI ≥ 40).
Conclusions
Patients with obesity were the most likely to have coexisting conditions, experience postoperative complications, and die during the first admission following EL for high-risk abdominal emergencies.
... gency laparotomy. [8][9][10] Several perioperative risk scoring systems have been developed to assess the outcomes in surgical patients in elective or emergent situations. 5) These systems of identifying high-risk patients and providing them with the appropriate level of care include the American Society of Anesthesiology (ASA) grades, Portsmouth Physiological and Operative Severity Score (P-POSSUM) for the enumeration of mortality and morbidity, American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator, and National Emergency Laparotomy Audit (NELA) risk prediction calculator. ...
Background:
Older patients undergoing emergency laparotomy have high morbidity and mortality rates. Preoperative risk assessment with good predictors is an appropriate measure in this population. Frailty status is significantly associated with postoperative outcomes in older adults. This study aimed to investigate the effect of preoperative risk factors and frailty on short-term outcomes following emergency surgery for acute abdomen in older patients.
Methods:
This study included older patients (≥65 years of age) who underwent emergency abdominal surgery. We retrospectively analyzed their demographic and clinical variables and used the modified Frailty Index-11 to evaluate their frailty status. The primary outcome was the 30-day mortality rate. We also analyzed risk factors of mortality in these patients.
Results:
The study included 150 patients with a median age of 74 years. The mortality rate was 17.3% (n = 26). We observed significantly higher mortality rates in patients who were obese and who had higher American Society of Anesthesiology (ASA grades) (p < 0.05). The mortality rate was significantly higher in pre-frail and frail patients (p < 0.001). Septic shock was associated with the development of mortality (p < 0.001). Multivariate regression analysis revealed that ASA grade was the only independent risk factor for mortality (odds ratio [OR] = 19.642, 95% confidence interval [CI]: 3.886-99.274, p < 0.001).
Conclusion:
Older patients with obesity and frailty presenting with higher ASA grades and septic shock had the worst survival following emergency abdominal surgery. The ASA grade was an independent risk factor for mortality.
... Major emergency abdominal surgery (MEAS) is associated with a high incidence of complications (1) and increased mortality in general and in the elderly population in particular, where complication rates exceed 30% and one-year mortality rates reach 25% (2)(3)(4). Elderly people, defined as people at 65 years or older (5), frequently experience severe complications or high mortality due to age, co-morbidity, polypharmacy and pathological response to surgery (3,6,7). Their physical functional level deteriorates during hospitalisation, increasing the risk of postsurgery dependency on homecare service and family (8,9). ...
Rationale
Knowledge of how elderly patients undergoing major emergency abdominal surgery and their close family members experience the course of illness is limited. Little is known about how such surgery and hospitalisation affect elderly patients' daily life after discharge. It is well known that such patients have an increased risk of mortality and that their physical functional level often decreases during hospitalisation, which can make them dependent on family or homecare services. Critical illness and caregiving for a close relative can be a stressful experience for families, which are at risk of developing stress‐related symptoms.
Aim
To explore how elderly patients and their families experience the course of illness during hospitalisation and the first month at home after discharge.
Method
A phenomenological study was conducted to gain in‐depth descriptions through 15 family interviews with 15 patients who had undergone major emergency abdominal surgery and 20 of their close adult family members. Data were analysed using a phenomenological approach inspired by Giorgi.
Findings
The essence of the phenomenon is captured in three themes: (1) Being emotionally overwhelmed, (2) Wanting to be cared for and (3) Finding a way back to life.
Conclusion
Patients and their close family members experienced the course of illness as a challenging journey where they longed for life to become as it was before illness. They experienced illness as a sudden life‐threatening incidence. In this situation, it was crucial to be met with empathy from healthcare professionals. The patients’ experience of fatigue and powerlessness remained intense one month after discharge and affected their and their close family members’ lives.
... About 35-41% patients with abdominal pain are admitted while a quarter of the patients are discharged [3]. Even with modern diagnostic tools and improved surgical skills older age and comorbid conditions pose a relatively higher morbidity and mortality [6]. Increased risk is found in populations with diabetes and those who are immunocompromised, children and the elderly; there is six to eight-fold increase in the mortality in the elderly compared to younger patients [7]. ...
Background:
Abdominal pain in adults represents a wide range of illnesses, often warranting immediate intervention. This study is to fill the gap in the knowledge about incidence, presentation, causes and mortality from abdominal pain in an established emergency department of a tertiary hospital in Tanzania.
Methods:
This was a prospective cohort study of adult (age ≥ 18 years) patients presenting to the Emergency Medicine Department of Muhimbili National Hospital (EMD-MNH) in Dar Es Salaam, Tanzania with non-traumatic abdominal pain from September 2017 to October 2017. A case report form was used to record data on demographics, clinical presentation, management, diagnosis, outcomes and patient follow-up. The primary outcome of mortality was summarized using descriptive statistics; secondary outcome was, risks for mortality.
Results:
Among 3381 adult patients present during the study period, 288 (8.5%) presented with abdominal pain, and of these 199 (69%) patients were enrolled in our study. Median age was 47 years (IQR 35-60 years), 126 (63%) were female, and 118 (59%) were referred from another hospital. Most common final diagnoses were malignancies 71 (36%), intestinal obstruction 11 (6%) and peptic ulcer disease 9 (5%). Most common EMD interventions given were intravenous fluids 57 (21%), analgesia 49 (25%) and antibiotics 40 (20%). 160 (80%) were admitted of which 15 (8%) underwent surgery directly from EMD. 24-h and 7-day mortality were 4 (2%) and 7 (4%) respectively, while overall in hospital-mortality was 16 (8%). Among the risk factors for mortality were male sex Relative Risk (RR) 2.88 (p = 0.03), hypoglycemia (RR) 5.7 (p = 0.004), ICU admission (RR) 14 (p < 0.0001), receipt of IV fluids (RR) 3.2 (p = 0.0151) and need for surgery (RR) 6.6 (p = 0.0001).
Conclusion:
Abdominal pain was associated with significant morbidity and mortality as evidenced by a very high admission rate, need for surgical intervention and a high in-hospital mortality rate. Future studies and quality improvement efforts should focus on identifying why such differences exist and how to reduce the mortality.
... The reported mortality rates for patients submitted to any type of surgical intervention were 8.8%, with a lower rate for the laparoscopic procedures (2.2%) compared to open (11.2%). Similar studies reported higher mortality rates approaching 15%, with comparable overall morbidity rates [49]. It is important to highlight that 84.2% of our cohort had an ASA score ≤ 3. Therefore, our population lower morbidity may also be related to a lower baseline prevalence of comorbidity than prior studies which enrolled overall sicker patients. ...
As the world population is aging rapidly, emergency abdominal surgery for acute abdomen in the elderly represents a global issue, both in developed and developing countries. Data regarding all the elderly patients who underwent emergency abdominal surgery from January 2017 to December 2017 at 36 Italian surgical departments were analyzed with the aim to appraise the contemporary reality regarding the use of emergency laparoscopy for acute abdomen in the elderly. 1993 patients were enrolled. 1369 (68.7%) patients were operated with an open technique; whereas, 624 (31.3%) underwent a laparoscopic operation. The postoperative morbidity rate was 32.6%, with a statically significant difference between the open and the laparoscopic groups (36.2% versus 22.1%, p < 0.001). The reported mortality rate was 8.8%, with a statistically significant difference between the open and the laparoscopic groups (11.2% versus 2.2%, p < 0.001). Our results demonstrated that patients in the ASA II (58.1%), ASA III (68.7%) and ASA IV (88.5%) groups were operated with the traditional open technique in most of the cases. Only a small percentage of patients underwent laparoscopy for perforated gastro-duodenal ulcer repair (18.9%), adhesiolyses with/without small bowel resection (12.2%), and large bowel resection (10.7%). Conversion to open technique was associated with a higher mortality rate (11.1% versus 2.2%, p < 0.001) and overall morbidity (38.9% versus 22.1%, p = 0.001) compared with patients who did not undergo conversion. High creatinine (p < 0.001) and glycaemia (p = 0.006) levels, low hemoglobin levels (p < 0.001), oral anticoagulation therapy (p = 0.001), acute respiratory failure (p < 0.001), presence of malignancy (p = 0.001), SIRS (p < 0.001) and open surgical approach (p < 0.001) were associated with an increased risk of postoperative morbidity. Regardless of technical progress, elderly patients undergoing emergency surgery are at very high risk for in-hospital complications. A detailed analysis of complications and mortality in the present study showed that almost 9% of elderly patients died after surgery for acute abdomen, and over 32% developed complications.
... Following acute abdominal surgery, patients have been found to have limited physical performance in the first post-operative week, with low 24-hour physical activity levels, and subsequently higher risk for pulmonary complications. The main factors preventing independent mobilization within the first week appear to be physical fatigue and abdominal pain [2]. A Finnish study carried out on elderly patients undergoing acute abdominal surgeries found higher age, atrial fibrillation, low body mass index, open surgery, ASA grade 3 or more, and previous history of malignancies to be the factors likely to increase mortality [4]. ...
... Given their increased rates of comorbidities and decreased physiologic reserve, the care of older patients suffering from high-acuity, time-dependent EGS conditions can be challenging, resulting in suboptimal outcomes. 20,21 This study's result-that a large, highperforming cluster of hospitals consistently outperforms other lesser clusters-suggests that even with this challenging patient-population, certain institutions are highly reliable. One potential conclusion is that these hospitals have systems of care in place that explain their superior results and their ability to protect patients despite unexpected events. ...
Background:
As the geriatric population grows, the need for hospitals performing high quality emergency general surgery (EGS) on older patients will increase. Identifying clusters of high-performing geriatric emergency general surgery hospitals would substantiate the need for in-depth analyses of hospital-specific structures and practices that benefit older EGS patients. The objectives of this study were therefore to identify clusters of hospitals based on mortality performance for geriatric patients undergoing common EGS operations and to determine if hospital performance was similar for all operation types.
Methods:
Hospitals in the California State Inpatient Database were included if they performed a range of eight common EGS operations in patients 65 years or older, with a minimum requirement of three of each operation performed over 2 years. Multivariable beta regression models were created to define hospital-level risk-adjusted mortality. Centroid cluster analysis was used to identify groups of hospitals based on mortality and to determine if mortality-performance differed by operation.
Results:
One hundred seven hospitals were included, performing a total of 24,279 operations in older patients. Hospitals separated into three distinct clusters: high, average, and low performers. The high-performing hospitals had survival rates 1 to 2 standard deviations better than the low-performers (p < 0.001). For each cluster, high performance in any one EGS operation consistently translated into high performance across all EGS operations.
Conclusion:
Hospitals conducting EGS operations in the geriatric patient population cluster into three distinct groups based on their survival performance. High-performing hospitals significantly outperform the average and low performers across every operation. The high-performers achieve reliable, high-quality results regardless of operation type. Further qualitative research is needed to investigate the perioperative drivers of hospital performance in the geriatric EGS population.
Level of evidence:
Study Type Prognostic, level III.
... La colecistectomía es la cirugía más frecuente realizada en adultos mayores 12 . En 2015, Ukkonen 13 , publicó una serie de 456 pacientes > 65 años intervenidos de urgencia, en la cual un 32,3% de la población fue intervenida de colecistolitiasis, siendo la intervención más frecuente. Esta información se contrapone con el estudio nacional de Altamirano 10 , quien estudió una población de 205 enfermos mayores de 65 años intervenidos de urgencia, siendo un 25% de estos octogenarios, este estudio identificó una menor tasa de intervenciones biliares con un 25,9%. ...
Introducción:
Existe una tendencia global al envejecimiento y con ello un aumento de patologías asociadas. En Chile la prevalencia de la colelitiasis o colecistolitiasis aumenta con la edad, siendo la cole-cistectomía una de las cirugías más frecuentes. Existen escasos estudios latinoamericanos referentes a la realidad de la población octogenaria expuesta a este problema.
Objetivo:
Estudiar la morbimortalidad posoperatoria en pacientes octogenarios operados de colecistectomía. Definir la precisión de distintas herramientas diagnósticas preoperatorias, estudiar variables operatorias y precisar costos hospitalarios.
Materiales y Método:
Estudio observacional retrospectivo de la ficha clínica electrónica del Hospital Clínico de la Universidad de Chile, entre enero de 2012 y mayo de 2017. Se incluyeron pacientes con edad igual o mayor a 80 años, en quienes se realizó una colecistectomía electiva o de urgencia por patología benigna.
Resultados:
Se incluyeron 145 pacientes, 51,7% fueron mujeres, el promedio de edad fue de 84,1 años y un 74,5% presentaba comorbilidades. El 62,1% de los casos ingresó por urgencia. 26,2% de toda la muestra presentó coledocolitiasis. La colecistectomía fue laparoscópica en 73,8% de la muestra global, la tasa de conversión fue de 14,5% en población de urgencia y 1,8% en población electiva (p = 0,009). La población operada totalmente por vía laparoscópica con coledocolitiasis fue resuelta en un 95,2% a través de Rendez-vous, con una tasa de éxito del 100%. La tasa de complicaciones fue de 17,9% siendo en su mayoría médicas, la mortalidad quirúrgica fue de 2,1%, siendo todos casos de urgencia. El costo promedio de atención en salud hospitalaria fue de $5.888.104 pesos chilenos (U$9.000).
Conclusión:
El paciente octogenario con colecistolitiasis representa un desafío quirúrgico, dado un mayor número de comorbilidades, un cuadro clínico más agresivo y una elevada tasa de coledocolitiasis. Es aconsejable valorar el abordaje mínimamente invasivo y realizar una colangiografía intraoperatoria de rutina.
... Gallbladder disease is among the leading causes for hospital admission for acute abdomen among adults and the most common indication for abdominal surgery in the elderly [7,8]. In situations when LC is unsafe the surgeon might have to convert to an open procedure. ...
Background
The purpose of the study was to identify risk factors for conversion of laparoscopic cholecystectomy and risk factors for postoperative complications in acute calculous cholecystitis. The most common complications arising from cholecystectomy were also to be identified. MethodsA total of 499 consecutive patients, who had undergone emergent cholecystectomy with diagnosis of cholecystitis in Meilahti Hospital in 2013–2014, were identified from the hospital database. Of the identified patients, 400 had acute calculous cholecystitis of which 27 patients with surgery initiated as open cholecystectomy were excluded, resulting in 373 patients for the final analysis. The Clavien-Dindo classification of surgical complications was used. ResultsLaparoscopic cholecystectomy was initiated in 373 patients of which 84 (22.5%) were converted to open surgery. Multivariate logistic regression identified C-reactive protein (CRP) over 150 mg/l, age over 65 years, diabetes, gangrene of the gallbladder and an abscess as risk factors for conversion. Complications were experienced by 67 (18.0%) patients. Multivariate logistic regression identified age over 65 years, male gender, impaired renal function and conversion as risk factors for complications. Conclusions
Advanced cholecystitis with high CRP, gangrene or an abscess increase the risk of conversion. The risk of postoperative complications is higher after conversion. Early identification and treatment of acute calculous cholecystitis might reduce the number of patients with advanced cholecystitis and thus improve outcomes.
... Laparoscopy (lap) has gained an important role in many surgical specialties since the last decade, becoming the gold standard in the treatment of some surgical problems (1)(2)(3)(4). ...
AIM: To evaluate the role of laparoscopy in the treatment of surgical emergency in old population.
PATIENTS AND METHODS: Over-70 years-old patients submitted to emergency abdominal surgery from January 2013 to December 2014 were collected and grouped according to admission diagnoses. These accounted small bowel obstruction, colonic acute disease, appendicitis, ventral hernia, gastro-duodenal perforation, biliary disease. In each group it was analyzed the operation time (OT), the morbidity rate and the mortality rate comparing open and laparoscopic management using T-test and Chi-square test.
RESULTS: 159 over 70-years-old patients underwent emergency surgery in the General and Emergency surgery Operative Unit (O.U.) of the Policlinic of Palermo. 75 patients were managed by a laparoscopic approach and 84 underwent traditional open emergency surgery. T-Test for OT and Chi-square test for morbidity rate and mortality rate showed no differences in small bowel emergencies (p=0,4; 0,25<p<0,9; 0,25<p<0,9), in colonic acute diseases (p=0,35; 0,25<p<0,9; 0,25<p<0,9), in appendicitis (p=0,22; 0,05<p<0,1; 0,25<p<0,9), in complicated ventral hernia (p=0,12; p>0,9; p>0,95) and in gastro-duodenal perforation (p=0,9; p>0.9; p>0.95). In cholecystitis, laparoscopy group showed lower OT (T-Test: p= 0,0002) while Chi-square test for morbidity rate (0,1<p<0,25) and mortality rate (0,25<p<0,9) showed no differences.
CONCLUSIONS: The collected data showed the feasibility of laparoscopic management as an alternative to open surgery in surgical emergencies in elderly population.
Introduction
Patients aged ≥65 years currently account for approximately 55% of all emergent operations. However, these patients account for 75% of post-operative mortality. Older age has long been associated with adverse outcomes from emergency surgery. However, old age is a heterogenous state. Recent studies have indicated that frailty may more accurately reflect true biological age and perioperative risk than chronological age alone in patients undergoing elective surgery. Few studies have evaluated the impact of frailty on post-operative outcomes in this setting.
Methods
A systematic, electronic search for relevant publications was performed in November 2019 using Pubmed and Embase from 2009 to 2019. The latest search for articles was performed on February 16th, 2020. Articles were excluded if frailty was not measured using a frailty tool, or if patients did not undergo emergency general surgery (EGS).
Results
The prevalence of frailty amongst patients undergoing emergency abdominal surgery was 30.8%. The all-cause mortality rate was 15.68%. The mortality rate amongst the frail undergoing EGS was 24.7%. Frailty was associated with an increased mortality rate compared with the non-frail (odds ratio (OR) 4.3, 95% CI 2.25–8.19%, p < 0.05, I² = 80%).
Conclusions
There is strong evidence to suggest that frailty in the older population predicts post-operative mortality, complications, prolonged length of stay and the loss of independence. Collaborative working with medicine for the elderly physicians to target modifiable aspects of the frailty syndrome in the perioperative pathway may improve outcomes. Frailty scoring should be integrated into acute surgical assessment practice to aid decision-making and development of novel postoperative strategies.
Nowadays, procedures in older adults with complicated surgical pathologies have increased due to technological advances and the general aging of the population. We present a case report of a 67-year-old female with an acute abdomen who was diagnosed in a preoperative tomographic study and during surgery with a complicated Meckel diverticulum. After, with histopathological result, the diagnosis of a gastrointestinal stromal tumor (GIST) that was attached to the omphalomesenteric duct was done. Both Meckel’s diverticulum and GIST are pathologies that generally represent incidental findings. Thus, the particularities of this case are shaped by the clinical presentation in an elderly patient with atypical acute abdominal pain, the low index of suspicion of both pathologies exposed and the particular location of the GIST found.
The elderly might differ from the general population when facing surgery, due to their lack of reserve, comorbidities, and other frailty conditions. This is also related to the emergency abdominal surgery. Considering that almost half of all emergency surgical procedures are performed in the elderly and given the increasing aging population, an analysis of the implications of the economic burden of emergency abdominal surgery in the elderly needs to be undertaken. To this regard, both direct and indirect costs that may emerge when the focus is on this specific group of patients are considered. Through a narrative literature review, this chapter aims at identifying the economic consequences of emergency abdominal surgery in the elderly given the conventional procedures and the laparoscopy. The finding will shade lights on the role of the laparoscopy procedure and will contribute to raise the awareness about the need to undertake dedicated actions from the health professionals’ perspective as well as from the hospital managers’ one.
Objective: To find the outcomes of laparoscopic cholecystectomy in gall bladders with all grades peri-operative inflammation.
Study Design: Prospective observational study.
Place and Duration of Study: Combined Military Hospital, Rawalpindi, from Nov 2018 to Aug 2019.
Methodology: All patients with symptomatic gall bladder disease who underwent laparoscopic cholecystectomy (emergency/elective procedure) and American Anesthesiology Society (ASA) Score 1 or 2 were included in the study.
Results: A total of 330 patients with a mean ± SD age of 48.01 ± 14.13 years underwent laparoscopic cholecystectomy. Out of 330 patients, 129 (39.1%) had acute inflammation of gall bladder while 201 (69.9%) cases were operated electively. The rate of conversion and complications were somehow lesser in both categories as the overall conversion rate was 15 (4.5%).
Conclusion: Laparoscopic cholecystectomy is the gold standard treatment for symptomatic gall stones. Moreover, it is safe option in acute and chronic inflammation of Gall bladder if performed by a experienced laparoscopic surgeon.
Emergency general surgery (EGS) in the elderly is common and includes any unplanned surgical procedure performed in the abdomen. This may include, but is not limited to, laparotomy, colectomy, small bowel resection, cholecystectomy, operative management of peptic ulcer disease, lysis of peritoneal adhesions, and appendectomy and other procedures. Surgical decision-making in the elderly has been a topic of recent research and will continue to evolve. In this introductory chapter, we will review the current state of research in EGS in the elderly, although the optimal definition of what constitutes as elderly is not entirely clear. The main question that needs to be answered is: among elderly EGS patient samples, what factors predict adverse outcomes such as mortality, morbidity, and readmission rate? This question is not easily answered from the current evidence base, but answers likely depend on comorbidities, surgical decision-making, and many other factors. Moreover, the majority of studies reported today are retrospective, and thus there is an acute need for prospective studies in EGS in the elderly.
Background
In chronic anticoagulant users undergoing surgery, bleeding and thromboembolism are common and serious complications. Many studies on mainly elective or minor emergency surgical procedures with low associated risks have focused on these outcomes. In comparison, patients undergoing high-risk emergency abdominal surgical procedures have not received sufficient attention. This study aimed to compare outcomes between oral anticoagulant users and nonusers who required emergency laparotomy for high-risk abdominal emergencies.
Methods
Patients who underwent surgery for abdominal emergencies at our institution between January 2012 and July 2019 were retrospectively reviewed.
Results
There were 875 patients, including 370 anticoagulant users and 505 nonusers. Of the 370 anticoagulant users, 189 (51.3), 77 (20.8%), 45 (12.2%), and 59 (15.9%) were prescribed antiplatelets, a vitamin k antagonist, a direct oral anticoagulant, and a combination drug regimen, respectively. The most common high-risk emergencies requiring surgery in both groups were perforated viscus (25.7% vs 40.9%), mesenteric ischemia with enteric necrosis (27% vs 12.8%), and bowel obstruction (17.6% vs 28.1%). The overall bleeding rate was higher (29.2% vs 22%, p = 0.015) in anticoagulant users than in nonusers, but the major bleeding rate was similar (17.8% vs 14.1%, p = 0.129) between the two groups. The rates of thromboembolic events and mortality were significantly higher in anticoagulant users than in nonusers (25.7% vs 9.7%, p < 0.0001 and 39.7% vs 31.1%, p = 0.01, respectively). Liver cirrhosis, peripheral arterial diseases, reoperation, and blood product transfusion were independent predictors of the overall risk of bleeding or TEEs, according to the multivariate analysis. In this model, liver cirrhosis had the largest overall effect on mortality, followed by pneumonia, thromboembolism, peripheral arterial disease, blood product transfusion, and atrial fibrillation. The use of oral anticoagulants was not an independent predictor of either bleeding or in-hospital mortality. The use of oral anticoagulants was associated with a decreased risk of all-cause in-hospital mortality.
Conclusion
Based on our results, the continued use of oral anticoagulants is more protective than harmful considering the overall outcomes in this subset of patients.
Laparoscopic cholecystectomy is the “gold standard” in the treatment of symptomatic gallbladder’s lithiasis. Difficult gallbladder (DGB) means a procedure with an increased surgical risk and high conversion rate compared to standard cholecystectomy. Acute cholecystitis is the most frequent clinical condition and also scleroatrophic cholecystitis and cholecystectomy in cirrhosis represent a difficult gallbladder pattern. The conversion rate increases depending on the degree of gallbladder inflammation, patient comorbidities, and the skills of surgeon.
Background Gallbladder is an ovate shaped organ lying beneath the liver. Stones can form in the gallbladder and that pathology is known as cholelithiasis. Cholelithiasis is one of the commonest conditions encountered by surgeons all over the world. Laparoscopic Cholecystectomy is a technique in which gallbladder is removed laparoscopically.
Background: Analyzing the data of the International Register of Open Abdomen (IROA), the feasibility of open abdomen treatment has been demonstrated at every age. This new analysis on the IROA database investigates the risk factors for mortality in elderly patients treated with open abdomen for intra-abdominal infection.
Methods: Data were derived from the IROA, a prospective observational international cohort study that enrolled patients treated with open abdomen worldwide. AAn univariate analysis of potential risk factors was performed. Inclusion criteria were patients older than 65 years and treated with open abdomen for intra-abdominal infection. End point was overall mortality, calculated within 30 days after open abdomen management, after 1-month and 1-year follow-up.
Results: A total of 116 patients was analyzed with mean age of 76 ± 7 years. Definitive closure was achieved in 93 patients (93/116, 80.2%) for a mean open abdomen duration of 5.0 ± 5.0 days. Complicated patients were 101 (101/116, 87.1%) for a total of 201 complications. Overall, 62 out of 116 patients (53.4%) died: 23 patients (23/62, 37.1%) during open abdomen management, 29 patients (46.8%) within 30 days after abdominal closure, 9 patients (14.5%) after 1-month follow-up, and 1 patient (1.6%) after 1-year follow-up. Age did not affect mortality (75 ± 6 years in alive patients versus 77 ± 7 years in dead patients, p = 0.773). Definitive abdominal closure was the most important factor to prevent mortality.
Conclusions: This study confirmed that age alone cannot be considered a determinant for death, even in elderly patients managed with open abdomen for severe intra-abdominal infection.
Introduction:
Abdominal pain (AP) is one of the most frequent clinical condition observed in elderly patients. The differential diagnosis is wide and definitive diagnosis is often difficult due to delayed symptoms, altered laboratory parameters, pre-existing medical disorders, abuse of drugs and in absence of an accurate medical history.
Evidence acquisition:
A systematic literature review was carried out through PubMed database for studies published in the last ten years. The following search string was used: {("geriatric"[Title] OR "older"[Title] OR "aged"[Title] OR "elderly"[Title]) AND ((("abdomen"[Title] AND "acute"[Title]) OR "acute abdomen"[Title] OR ("acute"[Title] AND "abdomen"[Title])) OR ("abdominal"[Title] AND "pain"[title]) OR "abdominal pain"[Title])}. Full articles and abstracts were included. Case reports, commentaries, editorials and letters were excluded from the analysis.
Evidence synthesis:
As the age of people presenting AP advances, both rates of surgical procedures and mortality rate increase.
Conclusions:
A systematic approach based on the organization of differential diagnoses into categories, may provide a helpful framework by the combined use of history-taking, physical examination, and results of diagnostic studies. In elderly patients admitted to the emergency department, a crucial role is played by a prompt use of radiological investigations in order to discriminate between older subjects admitted to the emergency department with abdominal pain and pathological cases requiring immediate surgical treatment.
Introduction: There is a global tendency to aging and associated pathologies. In Chile, the prevalence of cholecystolithiasis increases with age, cholecystectomy is one of the most frequent surgeries in the contry. There are few latinamerican studies regarding the reality of the elderly exposed to this problem. Objective: Study postoperative morbimortality in octogenarian patients undergoing cholecystectomy. Define the accuracy of different preoperative diagnostic tools, study operative variables and specify hospital costs. Materials and Method: Retrospective observational study of the Clinical Hospital of the University of Chile, between January 2012 and May 2017. Patients with age equal to or greater than 80 years were included, in whom an elective or emergency cholecystectomy was performed for benign pathology. Results: A total of 145 patients were included, 51.7% were women, the average age was 84.1 years, and 74.5% had comorbidities. The admission was throw the emergency department in 62.1% of the cases. Choledocholithiasis was diagnosed in 26.2% of the entire sample. Cholecystectomy was fully laparoscopic in 73.8% of the overall sample, the conversion rate was 14.5% in the emergency population and 1.8% in the elective population (p = 0.009). The population operated fully laparoscopically, that had choledocholithiasis, was resolved in 95.2% through Rendezvous technique, with a 100% clearance rate of common bile duct. The complication rate was 17.9%, most being medical. The surgical mortality was 2.1%, all cases operated from emergency. The average cost of hospital health care was $5,888,104.3 Chilean pesos (U$9.000). Conclusion: The octogenarian patient with cholecystolithiasis represents a surgical challenge, given a greater number of comorbidities, a more aggressive clinical setting and a high rate of choledocolithiasis. It is advisable to assess the minimally invasive approach and perform routine intraoperative cholangiography. In the postoperative period, the cardiopulmonary status and the infectious complications of the surgical site should be monitored closely.
Background:
The aim of this study was to assess outcomes of octogenarians undergoing emergency abdominal surgery (EAS).
Methods:
Octogenarians undergoing EAS 12/2011-12/2016 were retrospectively analysed. The outcomes were assessed by univariable and multivariable regression analysis.
Results:
One-hundred-forty patients with a median age of 83.9 years were included. EAS was performed for cholecystitis (27.1%), ileus (22.1%), hollow viscus perforation (16.4%), diverticulitis (12.9%), mesenteric ischemia (10.0%), incarcerated hernia (9.3%), and appendicitis (2.1%). The overall and early (within 7 days from surgery) mortality rate was 16.4% and 10.0%, respectively. Multivariable analysis revealed age (OR 1.24,CI95% 1.04-1.47,p = 0.015), ASA scores≥4 (OR 11.15,CI95% 2.39-52.02,p = 0.002), mesenteric ischemia (OR 52.60,CI95% 8.93-309.94,p < 0.001) and ICU admission (OR 9.23,CI95% 1.74-49.04,p = 0.009) as independent predictors for mortality. Postoperative withdrawal of care accounted for 36% of early mortalities.
Conclusions:
One third of early mortality in octogenarians was due to postoperative withdrawal of care. An interdisciplinary decision-making including patients' and relatives' wishes may avoid ethically questionable interventions in octogenarians.
Background
This study investigated age‐related differences in surgically treated patients with gastric cancer, and aimed to identify factors associated with outcome.
Methods
Data from the Dutch Upper Gastrointestinal Cancer Audit were used. All patients with non‐cardia gastric cancer registered between 2011 and 2015 who underwent surgery were selected. Patients were analysed by age group (less than 70 years versus 70 years or more). Multivariable logistic regression was used to assess the influence of clinicopathological factors on morbidity and mortality.
Results
A total of 1109 patients younger than 70 years and 1206 aged 70 years or more were included. Patients aged at least 70 years had more perioperative or postoperative complications (41·2 versus 32·5 per cent; P < 0·001) and a higher 30‐day mortality rate (7·9 versus 3·2 per cent; P < 0·001) than those younger than 70 years. In multivariable analysis, age 70 years or more was associated with a higher risk of complications (odds ratio 1·29, 95 per cent c.i. 1·05 to 1·59). Postoperative mortality was not significantly associated with age. In the entire cohort, morbidity and mortality were influenced most by ASA grade, neoadjuvant chemotherapy and type of resection.
Conclusion
ASA grade, neoadjuvant chemotherapy and type of resection are independent predictors of morbidity and death in patients with gastric cancer, irrespective of age.
Der Begriff „akutes Abdomen“ bezeichnet einen schwerwiegenden Bauchbefund, charakterisiert durch plötzlichen Beginn, Schmerz, Abwehrspannung und muskuläre Rigidität, der gewöhnlich eine notfallmäßige Operation erfordert, was im angelsächsischen Sprachraum zu dem Terminus „chirurgisches Abdomen“ geführt hat. „Akutes Abdomen“ beschreibt ein klinisches Bild, keine Diagnose. Davon zu unterscheiden sind Patienten mit akutem Bauchschmerz. Dieser stellt ein sehr häufiges Krankheitsbild dar, ca. 10 % aller Aufnahmen in einer Notfallambulanz sind hierauf zurückzuführen, und erfordert in maximal 20 % der Fälle eine chirurgische Intervention – altersabhängig. Dementsprechend unterschiedlich ist die Prognose beider Krankheitsbilder.
AMI is an uncommon but serious disease often associated with a bad prognosis, associated with occlusion of Superior Mesenteric Artery (SMA) for embolism or thrombosis (67.2 %), mesenteric venous thrombosis (15.7 %), and non-occlusive mesenteric ischemia (15.4 %). Clinical markers are often aspecific and symptoms low suggestive. The gold standard for the diagnosis is multidetector CT Angiography (CTA) with sensibility of 93.3 % and specificity of 95.9 %. Abdominal exploration could be useful to confirm cases of AMI without signs of SMA occlusion at CTA. Few reports have been found on the diagnostic role of Exploratory Laparoscopy. To increase the sensibility of laparoscopy in the diagnosis of AMI in the last ten years, some studies had shown the possibility of using fluorescein to underline the bowel areas of interest by ischemia. The best of laparoscopy in AMI diagnosis remains the second look and bedside use (directly in ICU when possible) overall in patients with Aortic dissection type B (preferable chronic type). In a limited number of cases, it is possible to evaluate bowel perfusion laparoscopically and at the same time perform a laparoscopical bowel resection of residual ischemic segments. However, laparoscopic primary access overall in AoD is an important tool for leading therapeutic decision and timing. Finally, laparoscopy may be a feasible alternative to CTA in patients with kidney failure that contraindicates injection of iodate CT contrast medium.
Due to the steady increase in the elderly population, the issue of frail patients with acute abdomen management is ever more actual. Many questions remain unsolved, concerning both the indication to surgery and the type of surgical approach, open or laparoscopic. This chapter describes the specific problems of the elderly patient, providing to the emergency surgeon, who has to take a quick and often lonely therapeutic choice, a survey of the literature upon which to base a rational approach to treating frail patients with acute abdomen. Some diseases, such as cholecystitis, appendicitis, and complicated Hinchey stage 3 diverticulitis, can be treated with laparoscopic approach, if the answer to a series of 11 questions is always “yes.”
Intraabdominal infections represent a diagnostic and therapeutic challenge in the elderly population. Atypical presentations, diagnostic delays, additional comorbidities, and decreased physiologic reserve contribute to high morbidity and mortality, particularly among frail patients undergoing emergency abdominal surgery. While many infections are the result of age-related inflammatory, mechanical, or obstructive processes, infectious complications of feeding tubes are also common. The pillars of treatment are source control of the infection and judicious use of antibiotics. A patient-centered approach considering the invasiveness, risk, and efficacy of a procedure for achieving the desired outcomes is recommended. Structured communication and time-limited trials help ensure goal-concordant treatment.
Background:
Emergency general surgery in the elderly is a particular challenge to the surgeon in charge of their care. The aim was to review contemporary aspects of managing elderly patients needing emergency general surgery and possible alterations to their pathways of care.
Methods:
This was a narrative review based on a PubMed/MEDLINE literature search up until 15 September 2015 for publications relevant to emergency general surgery in the geriatric patient.
Results:
The number of patients presenting as an emergency with a general surgical condition increases with age. Up to one-quarter of all emergency admissions to hospital may be for general surgical conditions. Elderly patients are a particular challenge owing to added co-morbidity, use of drugs and risk of poor outcome. Frailty is an important potential risk factor, but difficult to monitor or manage in the emergency setting. Risk scores are not available universally. Outcomes are usually severalfold worse than after elective surgery, in terms of both higher morbidity and increased mortality. A care bundle including early diagnosis, resuscitation and organ system monitoring may benefit the elderly in particular. Communication with the patient and relatives throughout the care pathway is essential, as indications for surgery, level of care and likely outcomes may evolve. Ethical issues should also be addressed at every step on the pathway of care.
Conclusion:
Emergency general surgery in the geriatric patient needs a tailored approach to improve outcomes and avoid futile care. Although some high-quality studies exist in related fields, the overall evidence base informing perioperative acute care for the elderly remains limited.
To assess the frequency of warfarin use, the achieved international normalised ratio (INR) balance among warfarin users and the primary healthcare outpatient costs of patients with atrial fibrillation (AF).
Retrospective, non-interventional registry study.
Primary healthcare.
All patients with AF (n=2746) treated in one Finnish health centre between October 2010 and March 2012.
Data on healthcare resource use, warfarin use, individually defined target INR range and INR test results were collected from the primary healthcare database for patients with AF diagnosis. The analysed dataset consisted of a 1-year follow-up. Warfarin treatment balance was estimated with the proportion of time spent in the therapeutic INR range (TTR). The cost of used healthcare resources was valued separately with national and service provider unit costs to estimate the total outpatient treatment costs. The factors potentially impacting the treatment costs were assessed with a generalised linear regression model.
Approximately 50% of the patients with AF with CHADS-VASc ≥1 used warfarin. The average TTR was 65.2% but increased to 74.5% among patients using warfarin continuously (ie, without gaps exceeding 56 days between successive INR tests) during follow-up. One-third of the patients had a TTR of below 60%. The average outpatient costs in the patient cohort were €314.44 with the national unit costs and €560.26 with the service provider unit costs. The costs among warfarin users were, on average, €524.11 or €939.54 higher compared with the costs among non-users, depending on the used unit costs. A higher TTR was associated with lower outpatient costs.
The patients in the study centre using warfarin were, on average, well controlled on warfarin, yet one-third of patients had a TTR of below 60%.
Nonagenarian population is growing, and so is the number of them needing emergency surgery. Yet, their treatment is often based on the outcomes of younger patients: although old age is known to be a risk factor for surgery, its level is not clear. This is a prospective, observational study to describe the population. It is aimed at providing quantified scientific evidence of the current procedures and their outcomes.
All non-traumatic nonagenarians who underwent surgery between July 2006 and September 2010 in our University Hospital were recruited and followed up over a month after discharge. A descriptive statistical analysis was performed.
Of the approximately 12 660 surgical emergencies, 102 were nonagenarians: 69.6% were women, who mostly had an ASA score III (62.7%). Perioperative morbidity and mortality rates of 61.6% [95% confidence interval (CI): 52.33-71.19%] and 35.3% (95% CI: 26.01-44.57%), respectively, were found statistically associated with preoperative neoplasms. The most frequent causes of surgery were acute limb arterial thrombosis (20), incarcerated hernia (17), and bowel occlusion (14). Confusion, renal failure, and abdominal problems accounted for the most frequent causes of morbidity. Among them, abdominal complications, cardiogenic pulmonary oedema, aspiration, stroke, and renal failure were associated with mortality.
The study gave scientific support and actual figures to many intuitive beliefs: morbidity and mortality are high and are associated with many preoperative comorbidities. All this, combined with an already reduced life expectancy, and a presumably low physiological reserve makes these patients particularly vulnerable to emergency surgery.
Elderly patients still have the highest postoperative mortality and morbidity rate in the adult surgical population. Preoperative
clinical assessment to detect patients at high risk of postoperative events, and specific intraoperative and postoperative
anaesthesia management are important to minimize postoperative adverse events in the elderly.
Br J Anaesth 2001; 87: 608–24
Objective:
Although quality assessment is gaining increasing attention, there is still no consensus on how to define and grade postoperative complications. This shortcoming hampers comparison of outcome data among different centers and therapies and over time.
Patients and methods:
A classification of complications published by one of the authors in 1992 was critically re-evaluated and modified to increase its accuracy and its acceptability in the surgical community. Modifications mainly focused on the manner of reporting life-threatening and permanently disabling complications. The new grading system still mostly relies on the therapy used to treat the complication. The classification was tested in a cohort of 6336 patients who underwent elective general surgery at our institution. The reproducibility and personal judgment of the classification were evaluated through an international survey with 2 questionnaires sent to 10 surgical centers worldwide.
Results:
The new ranking system significantly correlated with complexity of surgery (P < 0.0001) as well as with the length of the hospital stay (P < 0.0001). A total of 144 surgeons from 10 different centers around the world and at different levels of training returned the survey. Ninety percent of the case presentations were correctly graded. The classification was considered to be simple (92% of the respondents), reproducible (91%), logical (92%), useful (90%), and comprehensive (89%). The answers of both questionnaires were not dependent on the origin of the reply and the level of training of the surgeons.
Conclusions:
The new complication classification appears reliable and may represent a compelling tool for quality assessment in surgery in all parts of the world.
Perforated peptic ulcer (PPU) is a common surgical emergency that carries high mortality and morbidity rates. Globally, one-quarter of a million people die from peptic ulcer disease each year. Strategies to improve outcomes are needed.
PubMed was searched for evidence related to the surgical treatment of patients with PPU. The clinical registries of trials were examined for other available or ongoing studies. Randomized clinical trials (RCTs), systematic reviews and meta-analyses were preferred.
Deaths from peptic ulcer disease eclipse those of several other common emergencies. The reported incidence of PPU is 3·8-14 per 100 000 and the mortality rate is 10-25 per cent. The possibility of non-operative management has been assessed in one small RCT of 83 patients, with success in 29 (73 per cent) of 40, and only in patients aged less than 70 years. Adherence to a perioperative sepsis protocol decreased mortality in a cohort study, with a relative risk (RR) reduction of 0·63 (95 per cent confidence interval (c.i.) 0·41 to 0·97). Based on meta-analysis of three RCTs (315 patients), laparoscopic and open surgery for PPU are equivalent, but patient selection remains a challenge. Eradication of Helicobacter pylori after surgical repair of PPI reduces both the short-term (RR 2·97, 95 per cent c.i. 1·06 to 8·29) and 1-year (RR 1·49, 1·10 to 2·03) risk of ulcer recurrence.
Mortality and morbidity from PPU can be reduced by adherence to perioperative strategies.
The objectives of our study were to determine the association between age and postoperative outcomes after emergency surgery for diverticulitis and to identify risk factors for postoperative mortality among elderly patients.
All patients from the American College of Surgeons National Surgical Quality Improvement Program 2005-2009 Participant User Files undergoing emergent surgery for diverticulitis were included. Multivariate logistic regression was used to determine the association between age and postoperative morbidity and mortality after adjustment for perioperative variables. A separate regression model was used to determine risk factors for postoperative mortality among elderly patients, with specific postoperative complications being included as potential predictors.
We included 2,264 patients for analysis, of whom 1,267 (56%) were <65 years old (nonelderly), 648 (28.6%) were 65-79 years old (elderly), and 349 (15.4%) were ≥80 years old (super-elderly). Advanced age was a significant predictor of 30-day postoperative mortality, and to a lesser extent postoperative morbidity. Among those patients ≥65 years old, super-elderly age classification remained a significant predictor of mortality after adjustment for the presence or absence of postoperative complications. Mortality among elderly and super-elderly patients was greatest in the setting of specific complications, such as septic shock, prolonged postoperative mechanical ventilation, and acute renal failure.
Advanced age is an independent risk factor for death after emergency surgery for diverticulitis, with mortality being greatest among elderly patients who experience certain postoperative complications. Prevention of these complications should form the cornerstone of initiatives designed to lower the mortality associated with emergency surgery in elderly patients.
Gallstone disease increases with age. The aims of this study were to measure short-term outcomes from cholecystectomy in hospitalized elderly patients, assess the effect of age, and identify predictors of outcomes.
This was a cross-sectional analysis, using the Health Care Utilization Project Nationwide Inpatient Sample (1999-2006), of elderly patients (aged 65-79 and ≥80 years) and a comparison group (aged 50-64 years) hospitalized for cholecystectomy. Linear and logistic regression models were used to evaluate age and outcome relationships. Main outcomes were in-hospital mortality, complications, discharge disposition, mean length of stay, and cost.
A total of 149,855 patients aged 65 to 79 years, 62,561 patients aged ≥ 80 years, and 145,675 subjects aged 50 to 64 years were included. Elderly patients had multiple biliary diagnoses and longer times to surgery from admission and underwent more open procedures. Patients aged 65 to 79 years and those aged ≥80 years had higher adjusted odds of mortality (odds ratios [ORs], 2.36 and 5.91, respectively), complications (ORs, 1.57 and 2.39), nonroutine discharge (ORs, 3.02 and 10.76), longer length of stay (ORs, 1.11 and 1.31), and higher cost (ORs, 1.09 and 1.22) than younger patients.
Elderly patients undergoing inpatient cholecystectomy have complex disease, with worse outcomes. Longer time from admission to surgery predicts poor outcome.
The incidence of acute appendicitis has declined in many countries. The aim of this study was to determine the trends in incidence of acute appendicitis (AA), appendectomies for AA, and nonspecific abdominal pain (NSAP) in Finland between 1987 and 2007.
We carried out a national register study. Demographic features were investigated. Diagnoses and procedures were classified according to the World Health Organization International Classification of Diseases. Data were analyzed for each of all five University Hospital districts (UHD) of Finland.
During the observation period of 21 years, 186,558 appendectomies were performed in Finland, of which 137,528 (74%) cases were reported as AA. The incidence of acute appendicitis declined 32%. The diagnostic accuracy improved from 73 to 82% and was higher in men. The accuracy rate among the male patients was stable throughout the two decades; among the female patients it rose from 63 to 75%. The incidence of appendicitis was highest in patients aged 15-24 years. The average incidence of NSAP was 34/10,000/year, and it was higher in older age groups. There was a large geographical disparity in the incidence of NSAP.
The incidence of acute appendicitis as well as the incidence of appendectomies is declining in Finland. The incidence of the NSAP has also been declining but we did not find any correlations between the incidences of the acute appendicitis and NSAP. There were clear geographical differences in the incidence of NSAP but not in the incidence of AA.
Gallstones remain a common clinical problem requiring skilled operative and nonoperative management. The aim of the present population-based study was to investigate causes of gallstone-related mortality in Scotland.
Surgical deaths were peer reviewed between 1997 and 2006 through the Scottish Audit of Surgical Mortality (SASM); data were analyzed for patients in whom the principal diagnosis on admission was gallstone disease.
Gallstone disease was responsible for 790/43,271 (1.83%) of the surgical deaths recorded, with an overall mortality for cholecystectomy of 0.307% (176/57,352), endoscopic retrograde cholangiopancreatography (ERCP) of 0.313% (117/37,345), and cholecystostomy of 2.1% (12/578) across the decade. However, the majority of patients who died were elderly (47.6% ≥ 80 years or older) and were managed conservatively. Deaths following cholecystectomy usually followed emergency admission (76%) and were more likely to have been associated with postoperative medical complications (n = 189) than surgical complications (n = 36).
Although cholecystectomy is a relatively safe procedure, patients who die as a result of gallstone disease tend to be elderly, to have been admitted as emergency cases, and to have had co-morbidities. Future combined medical and surgical perioperative management may reduce the mortality rate associated with gallstones.
To identify rapidly modifiable risk factors that would improve surgical outcomes in elderly patients undergoing emergent colorectal procedures who are at high risk for morbidity and mortality.
Retrospective review. Patients were identified on the basis of Current Procedural Terminology codes and admission through the emergency department. Medical records were reviewed and data were abstracted for comorbidities, procedural details, and in-hospital morbidity and mortality.
University tertiary referral center.
Two hundred ninety-two patients 65 years or older undergoing emergency colorectal procedures from January 1, 2000, through December 31, 2006.
Postoperative morbidity (intensive care unit days, ventilator days, pneumonia, deep venous thrombosis, pulmonary embolus, myocardial infarction, and cerebrovascular accident) and mortality.
The most frequent presenting diagnoses were obstructing or perforated colorectal carcinoma (30%) and perforated diverticulitis (25%). Average age at presentation was 78.1 years, and in-hospital mortality was 15%. One hundred one patients (35%) experienced a total of 195 complications. Pneumonia (25%), persistent or recurrent respiratory failure (15%), and myocardial infarction (12%) were the most frequent complications. Operative time, shock, renal insufficiency, and significant intra-abdominal contamination or frank peritonitis were associated with morbidity. Age, septic shock at presentation, large estimated intraoperative blood loss, delay to operation, and development of a complication were associated with in-hospital mortality.
Emergent colorectal procedures in the elderly are associated with significant morbidity and mortality. Minimizing the delay to definitive operative care may improve outcomes. These procedures frequently involve locally advanced colorectal cancer, emphasizing the need for improved colorectal cancer screening.
If the pace of increase in life expectancy in developed countries over the past two centuries continues through the 21st century, most babies born since 2000 in France, Germany, Italy, the UK, the USA, Canada, Japan, and other countries with long life expectancies will celebrate their 100th birthdays. Although trends differ between countries, populations of nearly all such countries are ageing as a result of low fertility, low immigration, and long lives. A key question is: are increases in life expectancy accompanied by a concurrent postponement of functional limitations and disability? The answer is still open, but research suggests that ageing processes are modifiable and that people are living longer without severe disability. This finding, together with technological and medical development and redistribution of work, will be important for our chances to meet the challenges of ageing populations.
Comparison of primary anastomosis (PA) and Hartmann's procedure (HP) in perforated diverticulitis is biased as the patient groups are different in age, comorbidity and severity of disease. Still, PA has been advocated as the procedure of choice. The aim of this study was to compare the two surgical procedures after eliminating this selection bias using a propensity score model.
Sixty-five HP and 46 PA patients who underwent emergency laparotomy for perforated diverticulitis were analysed. Multivariate logistic regression using the Mannheim peritonitis index, Colorectal Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity, Charlson comorbidity index and Hinchey score was performed to determine the propensity score.
Patients with HP had significantly higher scores, median age and were more often on immunosuppressive medication. Unadjusted logistic regression for outcome showed a significant risk of HP vs PA for nonsurgical morbidity (odds ratio 3.25, 95% CI: 1.26-8.43; P = 0.015), but not for mortality and surgical morbidity. After adjusting for the propensity score, outcome was not significantly different. Patients with PA had a clinical leak rate of 28% and none of the patients with leakage had a protective ileostomy. Patients with PA and leak had higher Charlson scores whereas all other scores were similar to nonleak patients.
The theory that PA is generally superior to HP cannot be supported. HP remains a safe technique for emergency colectomy in perforated diverticulitis, especially in elderly patients with multiple comorbidities. If PA is performed, a protective ileostomy must be considered.
We reviewed 201 consecutive patients aged over 65 years who were operated on for acute abdomen during the period 1986-89. Emergency procedures were most commonly performed on the biliary tract (24%), the appendix (20%), bowel (15%) and abdominal wall (12%). The postoperative morbidity was 26%, and the mortality rate of 22% was related most commonly to mesenterial thrombosis and intestinal obstruction. In fatal cases, 44% of the patients were over 80 years old and 64% were placed into the ASA classes IV-V. Eighty-four patients (42%) underwent postoperative intensive care, and 22 re-operations (9.0%) were performed. The mean hospital stay was 12 days and 70% of patients returned home after surgery. In conclusion, the outcome of emergency abdominal surgery in patients under 80 years of age and with no serious co-existing diseases has improved. Very old patients in ASA classes 4-5 still have a poor outcome.
A retrospective analysis of 224 patients was carried out to evaluate the outcome of elderly patients after operation for acute abdominal pain. The mean (+/- SD) age of the patients was 74.6 (+/- 6.4) years (range 65-96) and the male/female ratio was 104/120. The most common causes for an emergency operation were acute biliary disease (26%), acute appendicitis (18%), gastrointestinal cancer (11%) and incarcerated hernia (10%). Twenty-nine patients (13%) died during the one-month postoperative period. The most common causes of death were gastrointestinal cancer (24%), ischaemic heart disease (14%) and complicated peptic ulcer disease (14%). Ninety-two (41%) patients had non-lethal postoperative complications, the commonest of which were wound infection or dehiscence (28%), urinary tract infection (17%), and paralytic ileus (8%). Ten patients were reoperated on for postoperative complications. The mean hospitalization time was 12.5 days (range 1-99). The results in the analysis of the long-term outcome (mean follow-up time 21 months) revealed that 17% of the primarily survived patients had died. Living patients were satisfied with the treatment and only a few patients were institutionalised after surgery. We conclude that both the short-term and long-term outcome of elderly patients after an emergency abdominal operation is good in benign diseases, and active surgery is justified.
The population of the United States is aging, and by 2020 it is estimated that 16 per cent of U.S. citizens will be over 65 years of age. Little has been published about the results of surgery in nonagenarians but mortality rates of 45 per cent are reported. Given recent improvements in perioperative care we reviewed the experience with major general surgical operative procedures in nonagenarians. We reviewed the charts of patients greater than or equal to 90 years of age who underwent general surgical procedures at UCLA Medical Center since 1986. No patients were excluded. Thirty-two patients were identified. Most (87.5%) patients had significant premorbid conditions. The most common diagnoses were cancer (12), incarcerated hernia (seven), trauma (three), colonic volvulus (two), and cholecystitis (two). Overall perioperative mortality was 9.4 per cent (3 of 32). Twenty-two surgeries (69%) were performed on an emergency basis, and all three deaths were in this group (13.6%). Overall morbidity rate was 57 per cent. Mean intensive care unit stay was 4.8 days. Most patients were discharged home. Our findings support the perioperative safety of elective general surgery in nonagenarians (0% mortality and 20% morbidity). We also found an acceptable risk (13.6% mortality and 68% morbidity) for emergency procedures despite significant comorbid conditions. Most of the patients had acceptable functional outcomes.
The prevalence of cholesterol gallstones is increased in obese persons. The risk is especially high in those with the highest body mass index (relative risk 5-6). Weight loss further increases the risk of gallstones: the prevalence of new gallstones reaches 10-12% after 8-16 weeks of low-calorie diet and more than 30% within 12-18 months after gastric by-pass surgery. About one-third of the stones are symptomatic. The increased prevalence of stones is mostly due to supersaturation of bile with cholesterol, because of an increased synthesis by the liver and secretion into bile. Saturation is further increased during weight loss. It returns toward normal after weight stabilization at a lower level, allowing spontaneous stone dissolution in some cases. Identified risk factors for gallstones during weight loss are a relative loss of weight greater than 24% of initial body weight, a rate of weight loss greater than 1.5 kg per week, a very low calorie diet with no fat, a long overnight fast period and a high serum triglyceride level. Ursodeoxycholic acid decreases cholesterol saturation of bile and gallstone incidence during weight loss. Other preventive measures include a control of weight loss rate, a reduction of the length of overnight fast, and maintenance of a small amount of fat in the diet.
Elderly patients who have appendicitis have a greater morbidity and mortality rate when compared with younger patients. We hypothesized that recent changes in the diagnosis and management of appendicitis in elderly patients might affect the outcome.
Retrospective review.
Large metropolitan teaching hospital.
All patients aged 70 years and older who underwent appendectomy for appendicitis between January 1, 1991, and December 31, 2000, were divided into groups 1 (those treated from January 1, 1991, through December 31, 1995) and 2 (those treated from January 1, 1996, through December 31, 2000).
Age, sex, preoperative evaluation, operative duration and findings, postoperative course, duration of hospital stay, and mortality rate. Continuous and categorical variables were analyzed using t and chi(2) tests, respectively.
Ninety-five patients met inclusionary criteria. The mean age (78 years), sex, preoperative suggestion of appendicitis (group 1, 39 [83%] of 47 patients; group 2, 45 [94%] of 48 patients), and duration of the preoperative hospitalization over 24 hours (group 1, 11 patients [23%]; group 2, 9 patients [19%]) were similar in both groups. There was an increasing use of diagnostic computed tomography (group 1, 13 patients [28%]; group 2, 32 patients [67%]; P<.001) and laparoscopy (group 1, 14 patients [30%]; group 2, 23 patients [48%]; P =.02) between the 2 study periods associated with no significant difference in the duration of hospitalization, frequency of appendiceal perforation or abscess, occurrence of complications, or mortality. The length of operating time increased in the second period (ie, January 1, 1996, through December 31, 2000).
Appendicitis in elderly patients continues to be a challenging surgical problem. While computed tomography may represent a useful diagnostic tool and laparoscopic appendectomy may be appropriate therapy for selected patients, neither has affected outcome when measured for morbidity and mortality rates. Overall results might improve with earlier consideration of the diagnosis in elderly patients with abdominal pain, followed by prompt surgical consultation and operation.
To predict the impact of the aging population on the demand for surgical procedures.
The population is expanding and aging. According to the US Census Bureau, the domestic population will increase 7.9% by 2010, and 17.0% by 2020. The fastest growing segment of this population consists of individuals over the age of 65; their numbers are expected to increase 13.3% by 2010 and 53.2% by 2020.
Data on the age-specific rates of surgical procedures were obtained from the 1996 National Hospital Discharge Survey and the National Survey of Ambulatory Surgery. These procedure rates were combined with corresponding relative value units from the Centers for Medicare and Medicaid Services. The result quantifies the amount of surgical work used by an average individual within specific age groups (<15 years old, 15-44 years old, 45-64 years old, 65+ years old). This estimate of work per capita was combined with population forecasts to predict future use of surgical services.
Based on the assumption that age-specific per capita use of surgical services will remain constant, we predict significant increases (14-47%) in the amount of work in all surgical fields. These increases vary widely by specialty.
The aging of the US population will result in significant growth in the demand for surgical services. Surgeons need to develop strategies to manage an increased workload without sacrificing quality of care.
Although quality assessment is gaining increasing attention, there is still no consensus on how to define and grade postoperative complications. This shortcoming hampers comparison of outcome data among different centers and therapies and over time.
A classification of complications published by one of the authors in 1992 was critically re-evaluated and modified to increase its accuracy and its acceptability in the surgical community. Modifications mainly focused on the manner of reporting life-threatening and permanently disabling complications. The new grading system still mostly relies on the therapy used to treat the complication. The classification was tested in a cohort of 6336 patients who underwent elective general surgery at our institution. The reproducibility and personal judgment of the classification were evaluated through an international survey with 2 questionnaires sent to 10 surgical centers worldwide.
The new ranking system significantly correlated with complexity of surgery (P < 0.0001) as well as with the length of the hospital stay (P < 0.0001). A total of 144 surgeons from 10 different centers around the world and at different levels of training returned the survey. Ninety percent of the case presentations were correctly graded. The classification was considered to be simple (92% of the respondents), reproducible (91%), logical (92%), useful (90%), and comprehensive (89%). The answers of both questionnaires were not dependent on the origin of the reply and the level of training of the surgeons.
The new complication classification appears reliable and may represent a compelling tool for quality assessment in surgery in all parts of the world.
Only a few small studies have evaluated risk factors related to early death following emergency surgery for colonic cancer. The aim of this study was to identify risk factors for death within 30 days after such surgery.
Some 2157 patients who underwent emergency treatment for colonic cancer from May 2001 to December 2005 were identified from the national colorectal cancer registry. Thirty-day mortality rates were calculated and risk factors for early death were identified using logistic regression analysis.
The overall 30-day mortality rate was 22.1 per cent. The strongest risk factor for early death was postoperative medical complications (cardiopulmonary, renal, thromboembolic and infectious), with an odds ratio of 11.7 (95 per cent confidence interval 8.8 to 15.5). Such complications occurred in 24.4 per cent of patients, of whom 57.8 per cent died. Other independent risk factors were age at least 71 years, male sex, American Society of Anesthesiologists grade III or more, palliative outcome, tumour perforation, splenectomy and adverse intraoperative surgical events. Postoperative surgical complications were noted in 20.4 per cent of the patients but had no statistically significant influence on mortality.
Emergency surgery for colonic cancer is still associated with an increased risk of death. There is a need for a system providing increased safety in the perioperative period.
Health behaviour and health among Finnish Elderly
- E Laitelainen
- S Helakorpi
- A Nissinen
- A Uutela
The World Health Organization (2011) Global health and aging Available from http
- Dc Oct
Postoperative medical complications are the main cause of early death after emergency surgery for colonic cancer
- LH Iversen