The use of emergency laparoscopy for acute abdomen in the elderly: the FRAILESEL Italian Multicenter Prospective Cohort Study

Abstract

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.

The Emergency Surgery Frailty Index (EmSFI): development and internal validation of a novel simple bedside risk score for elderly patients undergoing emergency surgery

“…The organ or body-district affected by surgical pathologies requiring emergency procedure is listed in Table 1. On the basis of our previous studies [12,13] and according to literature evidences, a preliminary univariate analysis was performed assessing the relationship between several items and the risk of developing postoperative complications. Any variable with p value ≤ 0.20 at univariate analysis was entered into a multivariate model to assess the weight of the variables consistently associated with the outcome.…”

“…Furthermore, different diseases in the same organ as well as the same procedure with different surgical approach are burdened by different morbidity and mortality rates [12].…”

Clinical-pathological features and treatment of acute appendicitis in the very elderly: an interim analysis of the FRAILESEL Italian multicentre prospective study

“…This report originates from the FRAILESEL (Frailty and Emergency Surgery in the Elderly) study (ClinicalTrials.gov identi er: NCT02825082) (8,23,24). The FRAILESEL is a large, nationwide, multicenter, prospective study that investigated the perioperative outcomes of patients aged ≥ 65 years who underwent emergency abdominal surgery over a period of consecutive 18 months (January 2017 and June 2018).…”

“…(20) Appendectomy remains the gold standard of treatment and, even though it is now performed almost exclusively with a minimally invasive technique, it can still represent a great risk for the elderly patient, especially above 80 years of age and in the event of multiple comorbidities. (14,21,22,23) A careful selection of elderly patients to be directed to surgery versus those who can bene t only from antibiotic therapy is therefore fundamental, since if a "white" appendectomy rate is acceptable in young people, especially in women, this cannot be reproduced in the elderly because they have not the same ability to tolerate the stress induced by the surgical procedure. (1,24) In this study, we focus our attention on the subgroup over 80 years old compared to the subgroup of elderly patient between 65-79 years old.…”

Multidisciplinary management of elderly patients with rectal cancer: recommendations from the SICG (Italian Society of Geriatric Surgery), SIFIPAC (Italian Society of Surgical Pathophysiology), SICE (Italian Society of Endoscopic Surgery and new technologies), and the WSES (World Society of Emergency Surgery) International Consensus Project

“…There is a paucity of clinical trial evidence explicitly addressing the risks and benefits of all aspects of rectal cancer in the elderly, which is mainly attributable to the fact that older adults comprise a heterogenous population covering a spectrum from very frail to fit patients. Moreover, although surgeons are usually accustomed to operating on elderly patients, both in emergency and elective settings [ 4 ], recent data indicate that older adults affected by rectal cancer are more likely to be offered a suboptimal range of care for their disease.…”