Elective and emergency abdominal surgery in patients 90 years of age or older

Abstract

Elective and emergency abdominal surgery in patients 90 years of age or olderBackground: Few studies have examined perioperative outcomes in nonagenarians undergoing abdominal surgery, and fewer have reported on 1-year mortality. Our objectives were to determine the outcomes of abdominal surgery in nonagenarians and to assess the performance of Physiologic and Operative Severity Score for enUmeration of Mortality and morbidity (POSSUM) and Portsmouth-POSSUM (p-POSSUM) as predictors of mortality. Methods:We conducted a retrospective chart review of all patients 90 years and older who underwent abdominal surgery between 2000 and 2007 at a tertiary care hospital. Results:We included 145 patients (median age 91, range 90-101 yr). The most common diagnoses were colorectal cancer (19.3%) and hernias (19.3%), and the most common procedures were bowel resection with anastomosis (25.5%) and hernia repair (18.6%). Overall in-hospital mortality was 15.2% (20.8% in the emergent group and 9.6% in the elective group; p = 0.06). The 1-year mortality (49.1% v. 27.8%; p = 0.016), complication (81.9% v. 61.6%; p = 0.007) and intensive care unit admission rates (44.4% v. 11.0%; p < 0.001) were significantly higher among emergent than elective surgical patients. The operative indications and procedures associated with the highest in-hospital mortality were large bowel obstruction (42.3%) and bowel resection with anastomosis (27.0%). Both the POSSUM and p-POSSUM scoring systems significantly overpredicted mortality, particularly in higher risk groups. Conclusion:Nonagenarians undergoing abdominal surgery have substantial operative morbidity and mortality, particularly in emergent surgical cases. Nearly 50% of patients who undergo emergency procedures die within 1 year after surgery. The POSSUM and p-POSSUM scoring systems were not reliable predictors of in-hospital mortality.Contexte : Peu d'études se sont penchées sur les résultats périopératoires de la chirurgie abdominale chez les nonagénaires, et moins encore ont mesuré leur mortalité à 1 an. Nous avions pour objectifs de déterminer l'issue de la chirurgie abdominale chez les nonagénaires et de mesurer les indices POSSUM (Physiologic and Operative Severity Score for enUmeration of Mortality and morbidity) et p-POSSUM (Portsmouth-POSSUM) en tant que prédicteurs de la mortalité. Résultats : Nous avons inclus 145 patients (âge médian 91 ans, éventail de 90 à 101 ans). Les diagnostics les plus fréquents étaient le cancer colorectal (19,3 %) et les hernies (19,3 %), tandis que les interventions les plus courantes ont été la résection intestinale avec anastomose (25,5 %) et la réparation de hernie (18,6 %). La mortalité perhospitalière globale a été de 15,2 % (20,8 % dans le groupe ayant subi une intervention d'urgence et de 9,6 % dans le groupe ayant subi une intervention élective; p = 0,06). Les taux à 1 an pour ce qui est de la mortalité (49,1 % c. 27,8 %; p = 0,016), des complications (81,9 % c. 61,6 %; p = 0,007) et des admissions aux unités de soins intensifs (44,4 % c. 11,0 %; ...

A composite index for predicting readmission following emergency general surgery

“…2,8,18 Similar to Primatesta and Goldacre, 15 we also observed a high correlation between 30-day readmissions and postoperative complications in emergency surgery patients. It is not surprising that patients who were readmitted with poor health often had at least one complication postoperatively.…”

“…8,15–17 What distinguishes our study is the observation of easy-to-measure risk factors for 30-day readmissions, including the SAS. Reynolds et al 5 did look at the extension of the SAS as a mortality predictor across more surgical specialties, including emergency surgery.…”

Perioperative factors predicting poor outcome in elderly patients following emergency general surgery: a multivariate regression analysis

“…Three of the more common scoring systems to predict outcome are the Reported Edmonton Frail Scale (REFS), the Acute Physiology and Chronic Health Evaluation II (APACHE II) and the Physiologic and Operative Severity Score for the enUmeration of Morbidity and mortality (POSSUM). There are several reasons these are often not used in the acute surgical setting; the APACHE II score requires an extensive workup often not conducive to acute surgical situations, 18 the POSSUM scoring system may overestimate mortality in low-risk patients while underestimating the risk in elderly patients or those undergoing emergency surgery, [19][20][21] and the REFS scale uses more comprehensive subjective geriatric measures (v. physiologic), 22 which are not always possible to obtain quickly preoperatively. By contrast, ASA class can be quickly determined on admission.…”

Six screening instruments for frailty in older patients qualified for emergency abdominal surgery

“…It is also possible that a 30-day follow-up may be not long enough to observe the true number of deaths calculated based on the screening tests. Racz, Dubois, Katchky, and Wall (2012) observed a 20.8% in-hospital mortality and a 49.1% 1-year mortality in case of older patients qualified for abdominal emergency surgery. Moreover, most of the primary validating studies have been population-based and have been carried out with long observation periods.…”