Approach In Elderly Patients Research Articles

Evaluation of factors predicting loss of benefit provided by laparoscopic distal pancreatectomy compared to open approach.

Several studies showed safety and feasibility of laparoscopic distal pancreatectomy (LDP) as compared to open distal pancreatectomy (ODP). Patients who underwent LDP or ODP (2015-2019) were included. A 1:1 propensity score matching (PSM) was used to reduce the effect of treatment selection bias. Aim of this study was to identify those factors influencing the loss of benefit (defined as a significantly better outcome compared to ODP) after LDP. Overall, 387 patients underwent DP (n = 250 LDP, n = 137 ODP). After PSM, 274 patients (n = 137 LDP, n = 137 ODP) were selected. LDP was associated with reduced intraoperative blood loss (median: 200mL vs. 250mL, p < 0.001), decreased wound infection rate (1% vs. 9%, p = 0.044) and shorter time to functional recovery (TFR) (median: 4days vs. 5days, p = 0.002). Consequently, TFR > 5days and blood loss > 250mL were defined as loss of benefit after LDP. In the LDP group, age > 70years [Odds Ratio (OR) 2.744, p = 0.022] and duration of surgery > 208min (OR 2.957, p = 0.019) were predictors of TFR > 5days and intraoperative blood loss > 250mL, respectively. No differences in terms of TFR were found between ODP and LDP groups in patients > 70years (p = 0.102). Intraoperative blood loss was significantly higher in the ODP group, also when the analysis was limited to surgical procedures with operative time > 208min (p = 0.003). In conclusion, LDP seems comparable to ODP in terms of TFR in patients aged > 70years. This finding could be helpful in the choice of the best surgical approach in elderly patients undergoing potentially challenging DPs.

The effectiveness and safety of neurosurgical treatment via retrosigmoid approach in elderly patients with trigeminal neuralgia

ObjectiveThe purpose of this study was to evaluate the effectiveness and safety of retrosigmoid approach in treating older patients with trigeminal neuralgia (TN). MethodsIn this retrospective study, 49patients (65 and over, elderly group) and 85 patients (under 65, young group) underwent MVD, MVD + PSR or PSR for idiopathic TN from July 2009 to December 2018. The two groups were compared for immediate, long-term pain outcome and postoperative complications. All perioperative data were collected from medical records and telephone interviews. The pain outcomes were assessed with the Barrow Neurological Institute (BNI) pain score. ResultsThe length of follow-up was 13.2 to 124.8 months. 91.8% of the elderly patients and 89.4% of the young patients achieve “Good” immediate pain outcome (BNI I-II), the proportion were 73.5% and 60.0%, respectively, in long-term pain outcome. No statistically significant differences existed in the immediate and long-term pain outcome between the elderly and young patients (P = 0.768 and P = 0.116, respectively). In the grouping analysis, whether in the pure MVD group or the PSR-related group, the immediate and long-term pain outcomes of elderly patients were not significantly different from those of younger patients. Meanwhile, there was no significant difference in the incidence of neurological and non-neurological complications between two groups. ConclusionsCompared with young patients, the treatment for TN in elderly patients via retrosigmoid approach has the same favorable pain outcome. The safety of this procedure for elderly TN patients is similar to that in young patients.

Management of femoral neck fractures with the ALMIS approach in elderly patients: Outcomes compared to posterior approach

IntroductionOver the last 2 decades, several minimally invasive surgical techniques and approaches have been introduced for hip arthroplasty, including anterolateral minimally invasive surgery (ALMIS) introduced by Röttinger in 2004. As described, this muscle sparing approach promises faster recovery and lower dislocation rates. Although there has been a peaked recent interest in minimally invasive surgery (MIS) hip arthroplasty, few studies support the superiority of ALMIS compared to the more traditional posterior approach. The present study examines the safety and early complications of elderly patients undergoing ALMIS compared to a posterior approach for hemiarthroplasty of displaced femoral neck fractures. MethodsIn a retrograde level III case-control study, 100 consecutive elderly patients with primary hip arthroplasty were divided into two groups. The first group consisted of 50 consecutive cases operated with the ALMIS approach and the second group of 50 consecutive cases operated through a posterior approach. Operative time, postoperative complication rates, length of hospitalization, blood loss, and leg-length discrepancy, were reviewed retrospectively. ResultsNo differences were observed in post-operative complications. Overall, the operative time was significantly greater in the ALMIS group compared to the posterior approach group (75 ± 12 vs 67.5 ± 16 min, respectively; p ≤ 0.01). However, the operating time of the second half of the ALMIS cohort (N = 25), did not differ from the posterior approach group (72.7 ± 10.5 vs 67.5 ± 16, respectively; p = 0.19). Leg length discrepancy was significantly less in the ALMIS group compared to the posterior exposure group (1.5 ± 3.2 vs 3.2 ± 3.3, respectively; P≤0.1). ConclusionsThe results of the retrograde analysis, although limited in sample size, shows no major differences in ALMIS compared to a more traditional posterior approach in terms of immediate post-operative complications. Although the overall operating time was longer in the patients treated with ALMIS, the second cohort of patients treated with this method had an operating time that was similar to that observed with posterior approach. Leg-length discrepancies were significantly less in patients treated with ALMIS.

Response-Adapted Sequential Treatment with Azacitidine and Intensive Chemotherapy in Patients > 60 Years Old with Newly Diagnosed AML: Results of the RAS-Azic Trial of the East German Study Group (OSHO)

▪Age >60 years (y) is independently associated with poorer outcomes in AML. An increasing incidence of s-AML and t-AML as well as age-related genetic abnormalities increase the likelihood of resistance to treatment. After intensive chemotherapy (IC), complete remission (CR/CRi) rates of 48-51% and a day (d) 90 mortality of 19-27% are reported (Niederwieser et al, ASH 2016). In pts >65y, azacitidine (AZA), a hypomethylating agenet, yields CR/CRi rates of 27.8% and a one-year survival (OS) of 46.5% (Dombret et al, Blood 2015). In the RAS-AZIC (DRKS00004519) study, a multicenter, investigator-initiated, combined phase I/II trial, AZA was integrated with IC in an individualized response-based approach in pts >60y with newly diagnosed AML. The rationale was a treatment sequence with a low probability of toxicity and a high probability of efficacy. Outcomes are presented. Patients and methods: In the phase I part, upfront AZA (75 mg/m2/day s.c) for 7 d followed by IC (Mitoxantrone 10 mg/m2/day d 1-3 and cytarabine 1g/m2/BID d1,3,5,7) on d17 was declared admissible through a 3+3 design (n=9). Between June, 2014 and May, 2016, 103 pts received priming with AZA followed by IC or AZA in phase II (Fig. 1) based on bone marrow (BM) blasts d15 (<45 vs >45%) and CR/CRi d56, previousely identified as predictors for long-term response to AZA in AML (Al-Ali et al, Leuk Lymph 2012). AZA maintenance was offered to pts in remission until relapse or allogeneic HCT. Primary objective was d90 response (OR) [CR/CRi/PR] in the 109 pts who received the maximal tolerated priming dose of AZA. Safety, d90 mortality, OS, EFS; RFS were further end points. Protocol treatment was considered non-inferior to standard IC if, on an intention-to-treat basis, an OR >61% was reached. Adverse events (AEs) were reported according to the NCI CTCAE 4.03. All pts gave written informed consent. Results: Median age was 70 (61-85) y. A median of 6 comorbidities/patient were reported [hypertension, n=55 (50%); cardiac disorders, n=47 (43%); diabetes mellitus, n=26 (24%); history of non-myeloid neoplasia, n=22 (20%)]. Median baseline BM blasts and WBC were 50% and 4.3 (range 0.4-153)x109/L respectively. Type of AML was de novo AML (63.3%), s-AML (23.9%), and t-AML (12.8%). Genetic risk according to the 2010 ELN stratification was high in 28%, int-I and II each in 23.4%, favorable in 14%; and not evaluable in 11.2%. All pts received first-line AZA, 90% and 78% of pts received protocol assigned treatment based on d15 BM blasts and d56 response respectively [AZA1+AZA2, n=24 (22%); AZA1+AZA2+IC1, n=30 (27.5); AZA1+ IC1, n=35 (32.2%); AZA1+ IC1+IC2, n=9 (8.3%)]. Hematologic and non-hematologic AEs lead to a postponement of response-adapted IC1 in 5.4% and 8% of pts respectively. Overall, infections were the most frequent non-hematologic AE [> grade 2 in 26.5%, 21%, and 53.5% of pts under AZA1, AZA2, and IC respectively]. Day 90 OR and mortality were 63.3% [CR/CRi 56.9%; PR 6.4%] and 10% respectively. OR was 73%, 80%, 52%, and 50% in favorable, int-I, int-II, and high-risk genetics respectively (p=0.07). One-year OS, EFS, and RFS were 63.8% (95% CI, 55% to 73%), 46% (95% CI, 36% to 55%), and 50% (95% CI, 38% to 62%) respectively. Age, baseline BM blasts, WBC, type of AML, FLT3/NPM1 mutational status,and d15 blasts <45%/>45% had no impact on OR and OS. In pts >75y, OS was 69% compared to 59.3% in pts < 64y (p=0.4). OS and EFS were associated with d90 OR. After a median follow-up of 19.7 months (m), median survival and EFS times for responders were 23.2 and 15.8 vs. 6.7 and 4.7m for non-responders respectively (p<000). High risk genetics were associated with a poorer OS [median survival times were not reached for favorable and int-I; 15.3 and 11.4m in int-II and high risk respectively] (p=0.002). Similar associations were found for EFS (p=0.002) and RFS (p=0.005) (Fig. 2). Conclusion: With a response-adapted approach in elderly patients with AML, favorable outcomes with low toxicity are possible even in patients >70 years. The well-known negative impact of pretreatment variables such as increasing age or type of AML on outcome could, at least partly, be ameliorated with treatment. The results of this trial emphasize that age alone should not be the determinant of treatment decisions. [Display omitted] DisclosuresJaekel:Celgene: Other: Travel support. Maschmeyer:Boehringer-Ingelheim: Honoraria; AstraZeneca: Honoraria; Astellas: Honoraria; Janssen-Cilag: Honoraria; Basilea: Honoraria; Bristol-Meyers Squibb: Honoraria; Celgene: Honoraria; Merck-Serono: Honoraria; Pfizer: Honoraria, Travel support; Gilead: Honoraria; Amgen: Honoraria; Bristol-Meyers Squibb: Other: Travel support. Al-Ali:Gilead: Consultancy, Honoraria; Alexion: Honoraria; Celgene: Consultancy, Honoraria, Research Funding; Novartis: Consultancy, Honoraria, Research Funding.

Hypomethylating Agents Versus Intensive Chemotherapy in Elderly Patients (Age ≥ 70) with Acute Myeloid Leukemia with High White Blood Cell Count

▪BackgroundAcute myeloid leukemia (AML) is primarily a disease of older adults, with 40-50% of patients ≥ 70 years old at diagnosis. Optimal frontline therapy for elderly AML patients remains controversial. Intensive chemotherapy (IC) is often favored in those AML patients who present with leukocytosis (P-AML), yet the evidence to support this practice as opposed to lower intensity therapy is scarce. We aimed to investigate the outcomes of older patients with P-AML based on treatment choice of intensive chemotherapy (IC) vs hypomethylating agents (HMA).MethodsWe retrospectively analyzed 983 elderly AML patients (age ≥ 70 years) treated at Moffitt Cancer Center between 1995 and 2016. Patients with prior exposure to HMA for non-AML diagnoses were excluded. We focused on P-AML patients, defined as baseline WBC ≥ 10x109/L, who received initial therapy with either: intensive chemotherapy (IC) (defined as daunorubicin/cytarabine or equivalent) or hypomethylating agents (HMA) (azacitidine (AZA) or decitabine (DEC)). Age, type of AML, history of antecedent hematologic disease, cytogenetics (per European LeukemiaNet (ELN) criteria), Eastern Cooperative Oncology Group (ECOG) performance status, Charlson comorbidity Index (CCI), complete blood counts and myeloblast percentage at time of diagnosis were obtained for each patient. Kaplan-Meier analysis was performed to calculate overall survival (OS) and the log-rank test was used to determine significance where a p-value of 0.05 was defined as significant. Fisher's exact t-test, hazard ratios (HR) and confidence interval (CI) were calculated using GraphPad Prism v7.03. Univariate and multivariate analysis for the baseline characteristics and type of therapy were performed using SPSS v24.0 to determine prognostic impact.ResultsWithin the entire cohort of older AML patients, we identified 156 who were treated with either HMA (n=41) or IC (n=115). Baseline characteristics of these patients are described in Figure 1A. Significant baseline differences in age, hemoglobin, WBC, ELN cytogenetic category, marrow blast %, and CCI score were observed between the HMA and IC groups. Most notably, the HMA group were older (median age 77 yrs vs 74 yrs, p=0.0037), had a higher incidence of poor-risk cytogenetics (36.6% vs 7%), and were more likely to have CCI score ≥ 3 (29.3% vs 8.7%).Median time of initial treatment was 4.3 months (range: 0.10-70.0 months) in the HMA group compared to 0.5 months (range: 0.33-1.90months) in the IC group. Median OS of the entire group was 7.85 mo. Median OS in the HMA-treated patients was superior to IC treated patients (13.7 mo vs. 5.1 mo, HR 0.63, 95% CI 0.443 - 0.886, p=0.0082) (Figure 1B). The 12 month survival rate was 55.0% in the HMA group and 31.0% in the IC group (p=0.0082). Fifty-two (33%) patients achieved CR/CRi. There was no difference in CR/CRi rates between HMA or IC treated cohorts (30.0% vs. 34.8%, p=0.6983). Rate of relapse upon achievement of CR/CRi was not statistically significant between HMA and IC cohort (41.7% vs. 62.5%, p=0.3181). The 30-day mortality rate was lower in the HMA group compared to the IC group (7.3% vs 24.4%, p=0.0217).Univariate analysis identified treatment type (p<0.0001), cytogenetic risk category (p <0.0001), and ECOG performance status (p<0.0001) as significant prognostic factors for OS. Multivariate analysis identified IC treatment (HR 2.01, 95% CI 1.24-3.26, p=0.005) and poor ECOG performance status (HR 4.30, 95% CI 1.182-15.659, p=0.027) as independent negative predictors of OS.ConclusionsElderly patients (age ≥ 70) with proliferative AML appear to achieve a survival advantage with HMA-based frontline therapy compared to IC, despite a disproportionately higher incidence of traditionally adverse prognostic features (poor-risk cytogenetics, high CCI score) in the HMA group. The reasons for this observation are unclear, but could relate to a higher early death rate with IC or biologic/molecular features that induce greater sensitivity to HMAs, which should be studied in future analyses. Although this study was limited by small size and retrospective nature, our findings cast doubt on the notion that intensive therapy should be the standard frontline approach in elderly patients proliferative/high WBC AML. [Display omitted] DisclosuresSallman:Celgene: Research Funding. Padron:Incyte: Honoraria, Research Funding. Komrokji:Novartis: Honoraria, Speakers Bureau; Celgene: Honoraria. Lancet:Biopath, Biosight, Boehringer Ingelheim, Celator/Jazz, Celgene, Janssen, Karyopharm Therapeutics, and Novartis: Consultancy; Pfizer: Other: Institutional research funding.

Oncologic and survival outcomes in elderly patients with locally advanced rectal cancer receiving neoadjuvant chemoradiotherapy and total mesorectal excision.

The efficacy of the addition of neoadjuvant chemotherapy to neoadjuvant chemoradiotherapy and total mesorectal excision for locally advanced rectal cancer in elderly patients has not been established. A total of 3096 locally advanced rectal cancer patients who received neoadjuvant chemotherapy, along with neoadjuvant chemoradiotherapy and total mesorectal excision, with or without adjuvant chemotherapy, between January 2010 and December 2018, were studied retrospectively. Patients were divided into elderly (>75years) and younger (≤75years) groups, and propensity score matching was used to balance a potentially confounding clinical bias. Overall survival, cancer-specific survival, disease-free survival, distant metastasis-free survival and local recurrence-free survival rates for the two groups were compared. Hazard ratios (HR) with 95% confidence intervals (CI) for different clinicopathological variables were calculated to determine predictors of 3-year overall survival. Mean follow-up was 39.0 (range, 5-140) months. The overall 3-year overall survival, cancer-specific survival, disease-free survival, distant metastasis-free survival and locoregional relapse-free survival rates were 86.1, 87.6, 80.0, 82.4 and 95.4%, respectively. Only 3-year overall survival rates differed significantly between the elderly (77.2%) and younger (88.9%) groups (P=0.01). Cancer-specific survival, disease-free survival, distant metastasis-free survival and locoregional relapse-free survival rates did not differ significantly between the two groups. Significant negative independent prognostic factors for 3-year overall survival were age>75years (HR=2.016, 95% CI 1.157-23.511, P=0.01) and high pathologic TNM stage (yp stage III, P<0.001). For elderly locally advanced rectal cancer patients who have good health and performance status, the addition of neoadjuvant chemotherapy to neoadjuvant chemoradiotherapy and total mesorectal excision can result in disease-related survival rates and oncological outcomes similar to those experienced by younger patients. The decision to use this treatment approach in elderly patients should not be based solely on chronological age.

Improved Balance and Gait Ability and Basic Activities of Daily Living after Comprehensive Geriatric Care in Frail Older Patients with Fractures.

(1) Purpose: Comprehensive geriatric care (CGC) is a multidisciplinary treatment approach for elderly patients. We aimed to investigate outcomes in fracture patients who had been treated using this approach in a large geriatric unit. (2) Methods: This observational cohort study assessed the gait function (using the Tinetti Balance and Gait Test (TBGT)) and basic activities of daily living (ADL) (using the Barthel index (BI)) before and after CGC and compared the results. Baseline data, walking ability assessments (Timed Up and Go, TUG), and cognitive status (mini mental status examination, MMSE) were also analyzed in the subgroup of patients with versus without fractures. (3) Results: Out of 1263 hospitalized patients, 1099 received CGC (median age: 83.1 years (IQR: 79.0–87.8 years); 64.1% were female). TBGT improvement was observed in 90.7% and BI increased in 82.7% of fracture patients. A TBGT improvement of >5 was noted in 47.3% and was associated with female sex, a lower BI at admission (median: 40 versus 45; p = 0.010), and poorer mobility on admission (TUG: median 5 versus 4; p = 0.001). An improvement in BI of ≥15 was observed in 63.0% of the cases, and was associated with a better cognitive status (MMSE: median 25 versus 18; p = 0.001) and inversely associated with diabetes mellitus and a previous stroke. (4) Conclusion: CGC in specialized geriatric units improves the balance and gait and the basic ADL in geriatric patients. After fracture, female patients are more likely to experience improvements in gait and balance, while patients with better cognitive condition are more likely to experience improvements in ADL.

Minimally Invasive Short-Segment Anteroposterior Surgery for Thoracolumbar Osteoporotic Fractures with Canal Compromise: A Prospective Study with a Minimum 2-Year Follow-up

Study DesignA prospective study with a minimum follow-up of 24 months.PurposeThis study aimed to evaluate the results of minimally invasive anteroposterior surgery for osteoporotic vertebral fractures (OVFs) associated with bony spinal canal compromise in elderly patients.Overview of LiteratureThere is a recent increase in the incidence of osteoporosis with OVFs, causing an increasing burden on medical systems.MethodsThe study included 47 patients, of whom 45 completed a minimum of 24-month follow-up. The inclusion criteria were OVF types 3 and 4 according to the osteoporotic fracture classification in patients aged ≥65 years with bony stenosis. The surgical management consisted of anterior corpectomy and decompression using a thoracoscopic or mini-laparotomy approach, together with posterior percutaneous cement-augmented short-segment fixation. Self-reported outcome measures included Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) in the preoperative phase and regular follow-up at a minimum of 24 months. Radiological measures included segmental lordosis, dual-energy X-ray absorptiometry for osteoporosis assessment, and radiological fracture healing.ResultsThere were 33 patients with lumbar fracture and 12 patients with thoracic fracture. Thirteen patients had preoperative neurological deficits. The mean age was 77.4±8.3 years. The mean preoperative VAS score was 8.12±1.5, and the mean ODI score was 24.4±8.2. The mean preoperative sagittal Cobb angle was 6.3°±4.2° kyphosis. The mean operative time was 220.3±55.5 minutes, with a mean blood loss of 360.75±200.6 mL. After a mean follow-up of 32.6±6.4 months, the mean VAS significantly improved to 2.3, and the ODI to 12. Only three patients still had a partial neurological deficit. The mean final sagittal Cobb angle was significantly better, with 12.5°±4.3° of lordosis.ConclusionsShort-segment percutaneous fixation with cement augmentation combined with minimally invasive anterior decompression and corpectomy is a less invasive and safe approach in elderly patients with OVF and canal compromise.

Therapeutic effects of full endoscopic spine surgery via transforaminal approach in elderly patients with lumbar spinal stenosis: A retrospective clinical study.

This study aimed to investigate the therapeutic effects of full endoscopic spine surgery on clinical and radiological outcomes in elderly patients over 70 years with lumbar spinal stenosis, without any obvious segmental instability. A total of 47 patients (27 males, 20 females; the mean age=74.23±5.16) above 70 years who underwent a transforaminal percutaneous endoscopic decompression with the diagnosis of lumbar spinal stenosis, were included in this retrospective study. The mean follow-up was 26±2.97 months. The clinical efficacy of the surgical procedure was assessed by the Oswestry disability index (ODI) and the visual analog scale (VAS) of the leg and lower back at 1 week, 3 months, and 1 year postoperatively, and at the final follow-up examination. Modified MacNab criteria was also performed to assess the clinical efficiency of surgery at the final follow-up. An excellent outcome as per modified MacNab criteria was obtained in 9 patients (19.1%), a good outcome in 33 patients (70.2%), a fair outcome in 3 patients (6.4%), and poor results in 2 patients (4.3%). The mean ODI score significantly improved from 71.29±5.69 preoperatively to 32.05±10.71 at postoperative 1 week, 30.27±9.89 at 3 months, 27.23±8.47 at 1 year, and 23.11±9.97 at the final follow-up (p<0.05 for each evaluation point). The mean VAS score of the leg and lower back significantly decreased from 6.10±0.96 and 5.71±1.13 preoperatively to 1.69±0.96, 2.24±1.01 at postoperative 1 week, 1.69±0.84, 2.45±0.87 at 3 months, 1.71±0.81, 2.38±0.79 at 1 year, and 1.71±0.92, 2.48±0.67 at the final follow-up, respectively (p<0.05 for each evaluation term). Postoperative computed tomography or magnetic resonance imaging showed adequate decompression of the central or lateral recess and removal of combined herniated discs. The results of our preliminary study have demonstrated that full endoscopic spine surgery is a safe and efficient technique for the therapy of neurogenic claudication and radiculopathy in elderly patients with lumbar spinal stenosis. Level IV, Therapeutic Study.

The impact of surgical approach on short- and long-term outcomes after rectal cancer resection in elderly patients: a national cancer database propensity score matched comparison of robotic, laparoscopic, and open approaches.

Elderly patients are underrepresented in studies demonstrating the advantages of laparoscopy for the management of colorectal diseases. Moreover, few studies have examined the robotic approach in this population. In this retrospective analysis, we compare outcomes for open, laparoscopic, and robotic approaches in elderly patients with nonmetastatic rectal cancer. The U.S. National Cancer Database was queried for patients aged ≥ 65 with nonmetastatic adenocarcinoma of the rectum who underwent surgical resection from 2010 to 2016. Groups were separated based on approach (open, laparoscopic, robotic). One-to-one nearest neighbor propensity score matching (PSM) ± 1% caliper was performed across surgical approach cohorts to balance potential confounding covariates. Kaplan-Meier estimation and Cox-proportional hazards regression were used to analyze the primary outcome of survival. Secondary outcomes were analyzed by way of logistic regression. Inclusion criteria and PSM identified 1891 patients per approach (n = 5673). PSM provided adequate discrimination between cohorts (0.6 < AUC < 0.8), and potential confounding covariates did not significantly differ (respective P > 0.05). After PSM, robotic and laparoscopic approaches were associated with decreased odds of 90day mortality compared to the open approach (P < 0.05). Compared to laparoscopy, a robotic approach was associated with increased odds of ≥ 12 regional lymph nodes examined and negative circumferential resection margin (P < 0.05). No differences were seen in 30day or 90day mortality between robotic and laparoscopic approaches. Cox proportional hazards regression showed that both robotic and laparoscopic approaches were significantly associated with decreased mortality hazards relative to open. Our study demonstrates that in elderly patients, minimally invasive surgery for rectal adenocarcinoma was associated with equivalent or improved short- and long-term mortality over open surgery. Compared to laparoscopy, the robotic approach showed no survival disadvantage and greater odds of an appropriate oncological resection. Our study adds evidence to the conclusion that robotic rectal surgery can be safely performed in patients regardless of age.

Time efficiency of direct anterior hip arthroplasty compared to postero-lateral approach in elderly patients.

IntroductionPrimary arthroplasty of the hip joint is currently one of the most commonly performed procedures in orthopedics. In Poland we are observing significant changes in the age structure. With the prolonged life more and more elderly patients require musculoskeletal surgery to maintain comfortable and painless mobility. Reducing the duration of the procedure reduces the costs of anesthesiology, surgical and instrument teams, as well as the operating room technical team. The aim of the study was to compare the time required to perform hip joint arthroplasty by the direct anterior approach (DAA) with the postero-lateral approach (PLA) in our hospital.Material and methodsA retrospective analysis of 559 total and bipolar cemented and cementless hip replacement procedures based on two operative approaches – the minimally invasive DAA over the course of 2 years, and the standard PLA over the course of 3 years – was performed.ResultsStatistically significant differences were observed between the approaches used for cementless total arthroplasty with regard to the mean treatment times: 51.9 min for the 272 DAA cases, and 78.3 min for the 190 PLA cases (p < 0.0001). For the cementless hemi-arthroplasty procedure, the mean treatment times were 46.9 min in 36 patients for DAA, and 48.2 min for 61 patients for PLA (p = 0.57).ConclusionsMinimally invasive DAA significantly shortens the time of the procedure in elderly patients compared to PLA. Further study is needed to analyze other aspects of those two approaches.

Comparison of total hip arthroplasty with minimally invasive SuperPath approach vs. conventional posterolateral approach in elderly patients: A one-year follow-up randomized controlled research

ObjectiveTo compare difference between SuperPath approach and conventional posterolateral approach in total hip arthroplasty (THA) in elderly patients. MethodsThe present prospective randomized controlled single blinded study enrolled a total of 96 elderly patients who received THA in our hospital during April 2015 to December 2018. All patients were randomly divided into the SuperPath group and the conventional group. General demographic characteristics and intraoperative data, as well as hospitalization time were recorded. Harris scores were used for measurement of hip function and visual analogue scale (VAS) was used for pain measurement. Serum levels of C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) and creatine phosphokinase (CK) were measured before and 24 h after surgery. Gait analysis was conducted by the method of footprints. ResultsThe mean surgical time was remarkably longer, the mean blood loss and incision length were significantly lower and the hospitalization time was also shorter in the SuperPath group compared with the conventional group. Both levels of CRP and CK were remarkably lower in the SuperPath group. At time points of 7 d and 1 mon after surgery, the VAS scores were significantly lower, and at 7 d, 1 mon and 3 mon the Harris scores were markedly higher in the SuperPath group compared with the conventional group. The step length and stride speed were significantly larger in the SuperPath group at 7 d and 1 mon after surgery than the conventional group. Joint dislocation was found in 2 cases of patients in the conventional group and no dislocation case was found in the SuperPath group. The angles of anteversion showed no significant difference, while the angles of abduction were significantly lower in the SuperPath group. ConclusionPatients with SuperPath approach had lower levels of CRP, ESR and CK, better hip function and less pain, as well as better gait condition than patients with conventional posterolateral approach in elderly patients.

Evaluation Of The Median And Paramedian Approach In Spinal Anesthesia In Elderly Patients

Objective: Spinal anesthesia is frequently used in many surgical procedures. Although both median and paramedian approaches are used in spinal anesthesia, the conventional median approach is preferred. Reportedly, degenerative changes in elderly patients are less affected by the paramedian approach during spinal anesthesia. In this study, we aim to determine which of the two methods is superior in elderly patients. Method: This study, patients were treated with the median approach or paramedian approach during spinal anesthesia after appropriate procedural preparation. Results: Overall, 103 patients were included in the study. The success rate was 90.5% in the paramedian approach and 79.1% in the median approach. The duration of the procedure was shorter in the paramedian approach than in the median approach (14.4 ± 8.2 versus 28.4 ± 24.9, p = 0.004). During the procedure, the repetition from another interval was more in the median approach than in the statistically insignificant level due to the contact with the spinal bones and failure. The average age of the patients with the procedure duration was <30 s was higher than those with procedure duration ≥30 s. Conclusions: In elderly patients, the success rate of the paramedian approach in the first attempt and repeated trials increased, the procedure time was shortened, and the surgery could be performed more comfortably without touching the spinal bones independent of the flexion position. Therefore, we believe that the paramedian approach is a faster, safer, and more successful method compared with the median approach in elderly patients.

Conservative treatment versus invasive approach in elderly patients with myocardial infarction without ST-segment elevation

Conservative treatment versus invasive approach in elderly patients with myocardial infarction without ST-segment elevation

Laparoscopic versus Open Colectomy for Elderly Patients with Colon Cancer: A Propensity Score Analysis with the Controlling Nutritional Status (CONUT) Score

The feasibility of laparoscopic surgery for elderly patients remains unclear, as these patients usually present with comorbidities. Recently, the controlling nutritional status (CONUT) score has drawn attention as an evaluation score of patients’ general status as well as a predictor of survival. We retrospectively analyzed overall survival in 424 patients aged ≥75 years with colon cancer, who underwent curative surgery (laparoscopic (n = 167) or open surgery (n = 257)) between January 2004 and December 2013. To adjust for heterogeneity in both groups, a propensity score-matched analysis was performed, with the CONUT score as a confounding covariate. 5-year overall survival rates of patients with normal (0–1), mildly abnormal (2–4), or abnormal (≥5) CONUT score were 88.6%, 79.4%, and 41.4%, respectively (p < 0.001). T3 or less, N negative, late period (2009–2013), and normal CONUT score were associated with the tendency to undergo laparoscopic surgery (p < 0.001). The analysis of the propensity score-matched cohort (124 pairs) revealed that patients in the laparoscopic surgery group had a similar prognosis to those in the open surgery group, with a 5-year overall survival of 91.9% vs. 82.0%, respectively (p = 0.102). Laparoscopic surgery for colon cancer is an acceptable surgical approach in elderly patients.

Is Laparoscopic Gastrectomy More Advantageous for Elderly Patients Than for Young Patients with Resectable Advanced Gastric Cancer?

Laparoscopic gastrectomy (LG) is now practiced widely, but it is unclear whether LG is the appropriate approach for elderly patients with resectable advanced gastric cancer. The aim of this study was to examine whether LG is more or less advantageous for elderly patients than for young patients. We collected data on 571 consecutive patients who underwent gastrectomy for pT2-4 gastric cancer between January 2001 and December 2015. After adjustment with one-to-one propensity score matching, short-term and long-term outcomes were compared between the LG and open gastrectomy (OG) groups among young (age < 70years) and elderly (age ≥ 70years) patients. The LG group had a significantly longer operative time (P < 0.001) and less blood loss (P < 0.001) than the OG group among young and elderly patients. There were no significant differences regarding complications. Although disease-specific survival was similar between the LG and OG groups among young and elderly patients, LG was associated with more favorable overall survival than OG only among elderly patients (hazard ratio 0.67; 95% confidence interval 0.35-1.26). Death from respiratory diseases occurred more frequently in the OG group (10.9%) than in the LG group (0%) for elderly patients (P = 0.012). LG for resectable advanced gastric cancer was not inferior to OG in terms of both short-term and long-term outcomes regardless of patient age. In elderly patients, LG may improve overall survival by reducing mortality from respiratory diseases.

Factors Affecting Hospital Stay in Patients Aged &gt;65 Years who Underwent Urological Intervention

Purpose: The geriatric patient population is predominant in urologic surgeries. The perioperative period of geriatric patients is affected by several factors. This study aimed to investigate the factors affecting morbidity and hospital stay in patients aged &gt;65 years, who underwent urological intervention. Materials and Methods: The data of patients aged &gt;65 years, who underwent urological surgery, were retrospectively evaluated. Age; sex; the American Society of Anesthesiologists (ASA) physical status; type and method of surgical intervention; duration of surgery; anesthesia method; concomitant diseases; preoperative values of blood serum albumin, potassium, creatinine, and hemoglobin (Hb); presence of infection; admission to the intensive care unit; and duration of hospital stay were recorded. The effects of the data obtained on hospital stay were evaluated.P&lt; 0.05 was considered statistically significant. Results: Surgical method, duration of surgery, anesthesia method, presence of a comorbid disease, ASA physical status, preoperative values of blood serum albumin and Hb, presence of infection, and intensive care hospitalization had a significant effect on hospital stay, and particularly, long duration of surgery, ASA physical status, and low serum albumin levels were found to be the most effective factors to prolong hospital stay. Conclusion: In older patients who undergo a urological intervention, advanced age is not the only risk factor. The length of hospital stay is affected by a number of interrelated factors. A detailed preoperative evaluation and preparation with a multidisciplinary approach in elderly patients may prevent additional problems that may occur, ensuring the determination of the most appropriate surgical and anesthetic method.

Peripheral neuropathy in elderly patients

Background: Among others, a peripheral polyneuropathy lead to an increased risk for fall in elderly frail patients. Aims: Therefore, we aimed to investigate the frequency of a polyneuropathy in elderly patients treated in a specialized geriatric unit with a selected neurological expertise. Methods: Patients hospitalized for comprehensive geriatric care in our geriatric unit were selected for the analysis. For proving the presence of a polyneuropathy, we performed extended electrophysiological examinations in patients with a current fall event or at risk for falling. Results: We included in the final analysis 378 patients (median age was 82.1 years (IQR: 77.2 - 87.6 years, 64.6%were female). The diagnosis of polyneuropathy was identified in 340 patients (89.9%); in patients with a current fall event (n=173) a polyneuropathy was identified in 154 subjects (89%); in 31.5% of the cases the polyneuropathy was caused by diabetes mellitus, in 47.6% no etiology could be identified. In patients with polyneuropathy higher rates of individuals aged &ge;80 years (67.1% versus 50%; p=0.038), with heart insufficiency (26.5% versus 7.9%; p=0.038) and renal insufficiency (45.6% versus 18.4%; p=0.001) were detected. The diagnosis of a polyneuropathy was associated with the factor renal insufficiency (OR: 2.680; CI: 1.100 - 6.529; p=0.03). Conclusion: Applying specific electrophysiological examinations in the particular setting of a specialized geriatric unit, we detected in a high proportion of patients a polyneuropathy (90%). Our results underline the benefit considering this approach in elderly patients at risk for fall hospitalized for comprehensive geriatric care.

Locally Advanced Rectal Cancer: Treatment Approach in Elderly Patients.

Independently of age, evidence-based guidelines recommend a multidisciplinary treatment approach in patients with locally advanced rectal cancer (LARC). But actually, elderly patients are grossly underrepresented in clinical trials, accounting < 10% of enrolled cases. Therefore, LARC management in elderly patients remains a crucial issue in daily practice, especially due to their frailty. Multiple clinical factors, including general health status, cognitive status, co-morbidity, disability, and life expectancy should be considered to understand the complexities of geriatric assessment and then define therapy. We use a patient-centered approach in order to tailor the optimal treatment strategy. We treat fit elderly patients as younger patients, including neoadjuvant chemoradiotherapy (CRT), surgery, and adjuvant chemotherapy. Whereas, in vulnerable and frail patients, we propose standard CRT (vulnerable patients) or radiotherapy alone (frail patients).

Lower eyelid ectropion as a sequela of different underlying diseases in maxillo-facial surgery: Diagnostics and treatment approaches

PurposeThis study investigated the outcome of lower eyelid ectropion (LEE) treatment in patients with another primary periorbital or mid-facial pathology. Materials and methodsThis 18-year monocentric retrospective cohort study included patients admitted for various leading mid-facial pathologies and presenting with a LEE. The primary diagnosis, surgical pretreatment, ectropion type, ectropion severity score (ESS), and surgical techniques were recorded. The primary endpoint was the postoperative ESS score. ResultsOverall, 40 patients (female n = 16, male n = 24, average age 70.8 years), primarily with periorbital skin cancer (n = 21, 52.5%), facial palsy (n = 7, 17%), trauma (n = 6, 15%), or other pathologies (n = 6, 15%), were included. Surgical procedures mostly addressed a correction of anterior and posterior lamellae (n = 22, 55%), with isolated anterior lamellae in only a few cases (n = 10, 25%). The ESS score significantly decreased from 4.8 ± 1.8 to 1.3 ± 1.3 (paired t-test, p < 0.001) after a mean follow-up of 23.8 months. ConclusionLEE constitutes a relevant problem. Due to preexisting canthal ligament laxity in patients undergoing oncologic or traumatic midface surgery, the risk of ectropion has so far been underestimated. Bilamellar approaches in elderly patients are likely to be obligatory in any case.