Geriatric Surgery Research Articles

A nationwide web-based survey of oncologic surgeons to clarify the current status of preoperative assessment for elderly cancer surgery patients in Japan

Elderly cancer patients requiring surgical treatment are increasing, and the deterioration of quality of life and shortening of healthy life expectancy due to postoperative complications represent major problems. This study investigated the current status of medical treatment, including perioperative evaluations, for elderly cancer patients requiring surgical treatment at cancer treatment facilities nationwide. A total of 436 cancer care facilities around Japan were invited to participate in this web-based survey regarding management of cancer patients ≥ 65 years old who had undergone surgical treatment in 2018. A total of 919 department heads from 245 facilities agreed to participate. Although most respondents answered that performance status, preoperative examinations, and comorbidities were important when deciding on a treatment plan, age, Geriatric Assessment (GA), and guidelines were "not important" for > 10% of all respondents. GA was familiar to 195 department heads (21%), and awareness of GA was significantly lower among respondents from medical education institutions than the other types of hospitals (18.5% vs 26.3%; P = 0.006). This large survey revealed that the use of GA is not widespread, and its awareness in medical education institutions remains low. We believe that accumulating evidence of geriatric oncology surgery is an urgent issue in Japan.

Enhanced Recovery after Surgery Protocols in Geriatric Surgery: Are They Effective in Our Older Patients Too?

Enhanced Recovery after Surgery Protocols in Geriatric Surgery: Are They Effective in Our Older Patients Too?

Do Our Geriatric Surgery Patients Utilizing ERAS Protocols Have Increased Risk for Developing Acute Kidney Injury?

Demshar, Timothy DO; Horattas, Mark C. MD, FACS; Horattas, Ileana MD; Bahr, Kelly RN Author Information

Factors Associated with Malnutrition and Its Impact on Postoperative Outcomes in Older Patients

Malnutrition is associated with dismal treatment outcomes in older patients but its impact in geriatric surgery has not been studied extensively. Herein, we report the prevalence of malnutrition risk, its risk factors and its association with postoperative outcomes in older patients undergoing operations of general surgery. This is a retrospective analysis of a prospectively maintained database including patients older than 65 years who were to undergo general surgery operations between 2012 and 2017. The Malnutrition Universal Screening Tool (MUST) was used for nutritional risk. Demographics, socioeconomic data, site and magnitude of the operation, various measures of comorbidity and functional dependence as well as postoperative complications based on Clavien–Dindo classification and length of stay were recorded. There were 501 patients. A total of 28.6% of them were at intermediate malnutrition risk (MUST = 1) and 14.6% were at high malnutrition risk (MUST ≥ 2). Variables independently associated with malnutrition risk (MUST ≥ 1) were smoking (Odds Ratio, OR:1.6, p = 0.041), upper gastrointestinal (GI) tract surgery (OR:20.4, p < 0.001), hepatobiliary-pancreatic surgery (OR:3.7, p = 0.001), lower GI surgery (OR:5.2, p < 0.001) and American Society of Anesthesiologists (ASA) class III/IV (OR:2.8, p = 0.001). In the multiple regression analysis adjusted for several confounding variables, the MUST score was significantly associated with postoperative death (OR:9.1, p = 0.047 for MUST = 1 and OR:11.9, p = 0.035 for MUST score ≥ 2) and postoperative hospital stay (adjusted incidence rate ratio, 1.3, p = 0.041 for MUST = 1 and 1.7, p < 0.001 for MUST ≥ 2). Malnutrition risk was highly prevalent in this sample, particularly in patients with operations of the gastrointestinal tract, in patients with poor physical status and it was associated with postoperative mortality and length of stay.

Preliminary data demonstrate the Geriatric Surgery Verification program reduces postoperative length of stay.

The Geriatric Surgery Verification (GSV) Program promotes clinical standards aimed to optimize the quality of surgical care delivered to older adults. The purpose of this study was to determine if preliminary implementation of the GSV Program standards improves surgical outcomes. Prospective study with cohort matching. Data from a single institution compared with a national data set cohort. All patients aged ≥75 years undergoing inpatient operations between January 2018 and December 2019 were included. Cohort matching by age and procedure code was performed using a national data set. Baseline pre- and intraoperative characteristics prospectively recorded using Veterans Affairs Surgical Quality Improvement Program (VASQIP) variable definitions. Postoperative outcomes were recorded including complications as defined by VASQIP, 30-day mortality, and length of stay. A total of 162 patients participated in the GSV program, and 308 patients comprised the matched comparison group. There was no difference in postoperative occurrence of one or more complications (p= 0.81) or 30-day mortality (p= 0.61). Patients cared for by the GSV Program had a reduced postoperative length of stay (median 4 days [range 1,31] vs. 5 days [range 1,86]; p< 0.01; and mean 5.4± 4.8 vs. 8.8± 11.8 days; p< 0.01) compared with the matched cohort. In a multivariable regression model, the GSV Program's reduced length of stay was independent of other associated covariates including age, operative time, and comorbidities (p< 0.01). Preliminary implementation of the GSV Program standards reduces length of stay in older adults undergoing inpatient operations. This finding demonstrates both the clinical and financial value of the GSV Program.

Socially conscious surgical care must prioritize older adults

TopicA commentary on social justice issues in geriatric surgery Future directionsRecognizing social determinants of health and racism as a contributing mechanism for inequities in the care of older adult surgical patients Knowledge gapsIdentifying the role of the surgeon in achieving health equity for older adults PurposeIncrease recognition of opportunities for antiracist care in everyday surgical practice, including shared decision-making and palliative care State of the artPatient treatment goals documented in their own words. Social needs screening in older adult surgical patients Technology gapsPlatform for clear documentation of surgical treatments offered and patient treatment goals, social determinants of health and social risk factors, and collaborative treatment and discharge plans discussed across multidisciplinary, elder-friendly teams

Comparison of mortality rate between patient with or without dementia following geriatric hip fracture surgery

Comparison of mortality rate between patient with or without dementia following geriatric hip fracture surgery

Preoperative Cognitive Impairment as a Perioperative Risk Factor in Patients Undergoing Total Knee Arthroplasty.

Background:The study assessed whether pre-existing cognitive impairment (CI) prior to elective total knee arthroplasty (TKA) is associated with worse postoperative outcomes such as delirium, in-hospital medical complications, 30-day mortality, hospital length of stay and non-home discharge.Methods:A retrospective database analysis from the NSQIP Geriatric Surgery Pilot Project was used. There was an initial cohort of 6350 patients undergoing elective TKA, 104 patients with CI were propensity score matched to 104 patients without CI.Results:Analysis demonstrated a significantly increased incidence of post-operative delirium (POD) in the cohort with pre-op CI (p = < .001), a worsened functional status (p = < .001) and increased nonhome discharge postoperatively compared to the group without CI (p = 0.029). Other post-operative outcomes included 30-day mortality of 0% in both groups, and low rate of complications such as infection (2.88% vs 0.96%), pneumonia (1.92% vs 0%), failure to wean (0.96% vs 0%), and reintubation (0.96% vs 0%). Some other differences between the CI group and non-CI group, although not statistically significant, included increased rate of transfusion (10.58% vs 6.73%), and sepsis (1.92% vs 0%). The length of stay was increased in the non-CI group (4.28% vs 2.32%, p = 0.122).Conclusion:CI in patients undergoing TKA is associated with an increased risk of POD, worsened postoperative functional status, and discharge to non-home facility.

Recent Approaches in Geriatric Surgery

Fizyolojik yaşlanmanın biyolojik kayıplar ve atipik hastalık süreçleri adına yarattığı kimi riskler mevcuttur. Bu risklerin yönetilebilmesi adına cerrahi müdahaleler gerekebilmektedir. Geriatrik cerrahide hedefler kişinin sağlıklı ömür uzunluğunu, hayatta kalma süresini ve yaşam kalitesini olabildiğince uzatmaktır. Geriatrik cerrahi öncesinde, sırasında ve sonrasında diğer yaş gruplarında alınan önlemlere ek olarak planlanması gereken tedbirler ve düzenlemelerin güncel yaklaşımlar ve bilimsel kılavuzlar ışığında incelenmesi gerekmektedir.

Building a Framework for Care of Older Patients in an Academic Setting: High Risk Geriatrics Ambulatory Care Program

BACKGROUND: Traditional models of geriatric medicine and health system reimbursement structure often force ambulatory care teams to function as high-volume delivery programs, thereby dis-servicing our most vulnerable and frail older patients. This “high cost and high needs” labeled demographic requires uniquely adapted plans from medical and social work providers. METHODS: To better examine opportunities for improved framework for geriatric ambulatory care, the Acute Life Interventions, Goals & Needs (ALIGN) Program has launched several inter-professional pilot programs, each with intention to explore components of health care service to older patients, and feasibility of implementation in other health care systems. Three current models include the ALIGN Program itself, a telemedicine community paramedicine program, and a geriatric surgery co-management program. RESULTS: Preliminary results are forthcoming, with initial promising findings. For the first 126 patients enrolled, mean emergency room (ED) visits 6 months prior to ALIGN enrollment were 1.7 visits per person, reduced to 0.7 ED visits/person 6 months post-graduation from the program, and 126 fewer ED visits. Mean hospitalization 6 months prior to enrollment was 0.32 per person, whereas 6 months post-graduation was 0.2 hospitalizations/person, totaling 40.32 hospitalizations saved. Mean length of stay in the hospital 6 months prior to ALIGN enrollment for the 22 patients admitted was 7.7 days, reduced to 7.3 days post-graduation, and 32 fewer hospital days in the small subset of patients requiring hospitalization despite program interventions. CONCLUSION: The ALIGN Program’s multi-professional and flexible modularity highlights promising innovative frameworks for ambulatory geriatrics care, warranting further exploration and collaboration.

The American College of Surgeons Geriatric Surgery Verification Program and the Practicing Colorectal Surgeon

The population is aging and older adults are increasingly undergoing surgery. Colorectal surgeons need to understand the risks inherent in the care of older adults and identify concrete ways to improve the quality of care for this vulnerable population. Goals for the practicing colorectal surgeon include: 1) introduce the American College of Surgeons’ (ACS) Geriatric Surgery Verification (GSV) Program and understand the intersection with colorectal surgery, 2) examine the 30 evidence-based GSV standards and how they can achieve better outcomes after colorectal surgery, and 3) outline the value and benefits for colorectal surgeons of implementing such a program.

Prioritizing Quality Improvement in Geriatric Surgery in 7 Veterans Administration Hospitals: Current Levels of Implementation of Standards Defined by the American College of Surgeons: Geriatric Surgery Verification Program through Structured Processes

Shu'aib Kazaure, Hadiza MD; Lagoo-Deenadayalan, Sandhya A. MBBS FACS; Ahuja, Vanita MD; Dacey Seib, Carolyn MD, FACS; Balentine, Courtney MD; Christopher Iannuzzi, James MD; Nichols Robinson, Thomas MD, FACS; Russell, Marcia MD Author Information

Improving Surgical Outcomes Prior to Incision: Superior Outcomes in the Geriatric Surgery Population after Prehabilitation

Improving Surgical Outcomes Prior to Incision: Superior Outcomes in the Geriatric Surgery Population after Prehabilitation

Evaluation of Postoperative Functional Health Status Decline Among Older Adults

Functional outcomes have value for older adults who undergo surgical procedures. Preventing postoperative functional decline in this patient population necessitates the identification of the factors associated with this outcome and minimizing their implications. To assess the prevalence of functional decline 30 days after a surgical procedure among older adults 80 years or older, examine the risk factors of this decline, and identify ways to minimize this decline by addressing its mutable factors. This retrospective cohort study used patient data from the Geriatric Surgery Pilot Project, a multi-institutional data registry of the American College of Surgeons National Surgical Quality Improvement Program. Inclusion criteria were patients 80 years or older who underwent a surgical procedure that required an inpatient stay at 1 of 23 hospitals enrolled in the Geriatric Surgery Pilot Project from January 1, 2015, to December 31, 2018, and had preoperative and postoperative functional health status data. Data analysis was performed from January 7, 2019, to December 2, 2019. Adults 80 years or older who underwent an inpatient surgical procedure. The primary outcome was 30-day postoperative functional decline defined by a change in functional health status from admission or before the surgical procedure (ie, from independent to partially or totally dependent, or from partially dependent to totally dependent). Functional health status was measured by a patient's ability to perform activities of daily living. Secondary outcomes were hospital readmission and 30-day postoperative living location. Of the 2013 patients analyzed in this study, 1128 were women (56.0%) and the mean (SD) age was 84.9 (3.9) years. Functional decline at 30 days after the surgical procedure was present in 406 patients (20.2%). Prevalence of this outcome increased with age, with 337 of 1751 patients aged 80 to 89 years (19.2%) experiencing decline compared with 69 of 262 patients 90 years or older (26.3%). In a risk-adjusted model, the geriatric-specific risk factors statistically significantly associated with this outcome included preoperative mobility aid use (odds ratio [OR] 1.76; 95% CI, 1.39-2.22; P < .001) and malnutrition (OR, 1.88; 95% CI, 1.04-3.43; P = .04) as well as postoperative delirium (OR, 2.20; 95% CI, 1.60-3.02; P < .001), pressure ulcer (OR, 1.83; 95% CI, 1.02-3.30; P = .04), and mobility aid at discharge (OR, 2.49; 95% CI, 1.72-3.59; P < .001). Among patients with a 30-day functional decline, 106 (26.1%) required hospital readmission and only 219 (53.9%) were living at home compared with 388 patients (95.6%) living at home before the procedure. In this study, 1 in 5 older adults experienced a functional decline that persisted 30 days after a surgical procedure, an outcome that appeared to be associated with several geriatric-specific risk factors. Future trials are needed to evaluate whether the prevention or mitigation of these factors can decrease the rates of postoperative functional decline in this patient population.

Relationship Between Newly Established Perioperative DNR Status and Perioperative Outcomes in the Elderly Population: A NSQIP Database Analysis.

Background: Health care practitioners have developed complex algorithms to numerically calculate surgical risk. We examined the association between the initiation of a new do-not-resuscitate (DNR) status during hospitalization and postoperative outcomes, including mortality. We hypothesized that new DNR status would be associated with similar complication rates, even though mortality rates may be higher. Methods: A retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Geriatric Surgery Research File. Two cohorts were defined by the presence of a new DNR status during the hospitalization that was not present on hospital admission. Multivariable logistic regression was used to control for differences between the DNR and non-DNR cohorts. The primary outcome was 30-day mortality. Secondary outcomes included rates of postoperative complications, including returning to the operating room, reintubation, failure to wean from ventilation, surgical site infections, dehiscence, pneumonia, acute kidney injury, renal failure, stroke, cardiac arrest, acute myocardial infarction, transfusion requirements, sepsis, urinary tract infections, venous thromboembolisms, total number of complications for each patient, and hospital length of stay. Results: In our geriatric population with a newly established DNR status, the mortality rate was 39.29%, significantly greater than the non-DNR population after multivariable regression. Secondary outcomes also occurred at an increased rate in the DNR cohort including surgical site infections (8.29% vs 4.04%), pneumonia (18% vs 2.26%), renal insufficiency (2.43% vs 0.35%), acute renal failure (5% vs 0.19%), stroke (3% vs 0.36%), acute myocardial infarction (6.29% vs 0.95%), and cardiac arrest (5.86% vs 0.51%). Conclusions: The initiation of a new DNR status during hospitalization is associated with a significantly higher burden of both morbidity and mortality. This contrasts with prior studies that did not show an increased rate of adverse outcomes and suggests that a new DNR status in postoperative patients may reflect a consequence of adverse postoperative events. The informed consent process in older patients at risk for adverse outcomes after surgery should include discussions regarding goals of care and acceptable risk.

Launching a Geriatric Surgery Center: Recommendations from the Society for Perioperative Assessment and Quality Improvement.

To prepare for the increasing numbers of older adults undergoing surgery, the American College of Surgeons (ACS) has recently launched the Geriatric Surgery Verification Program with the goal of encouraging the creation of centers of geriatric surgery. Meanwhile, the Society for Perioperative Assessment and Quality Improvement (SPAQI) has published recommendations for the preoperative management of frailty, which state that teams should actively screen for frailty before surgery and that pathways, including geriatric comanagement, shared decision-making, and multimodal prehabilitation, should be embedded in routine care to help improve patient outcomes. Both SPAQI and the ACS advocate for a multidisciplinary approach to improve the value of care for older adults undergoing surgery. However, the best way to implement geriatric services in the surgical setting is yet to be determined. In this statement, we will describe the SPAQI recommendations for launching a geriatric surgery center and the process by which its value should be assessed over time.

The impact of frailty on the economic evaluation of geriatric surgery: hospital costs and opportunity costs based on meta-analysis

Objectives: We used a systematic review and meta-analysis to analyze the difference in costs between surgery for frail and non-frail elderly patients. The opportunity cost of frailty in geriatric surgery is estimated using the results.Methodology: Two literature reviews were carried out between 2000 and 2019: (1) studies comparing total hospital costs of frail and non-frail surgical patients; (2) studies evaluating the length of hospital stay and cost for surgical geriatric patients. We performed a meta-analysis of the items selected in the first review. We subsequently calculated the opportunity cost of frail patients, based on the design of a cost/time variable.Results: Twelve articles in the first review were selected (272,717 non-frail and 16,461 frail). Fourteen articles were selected from the second review. Frail patients had higher hospital costs than non-frail patients (22,282.541 € and 16,388.844, p < .001) and a longer hospital stay (10.16 days and 8.4 (p < .001)). The estimated opportunity cost in frail patients is 1,019.56 € (cost/time unit factor of 579.30 €/day).Conclusions: Frail surgical geriatric patients generate a higher total hospital cost, and an opportunity cost arising from not operating in the best possible state of health. Preoperatively treating the frailty of elderly patients will improve the use of health resources

COVID-19 and Long-term Planning for Procedure-based Specialties During Extended Mitigation and Suppression Strategies

COVID-19 and Long-term Planning for Procedure-based Specialties During Extended Mitigation and Suppression Strategies

Safety of Major Abdominal Operations in the Elderly: A Study of Geriatric-Specific Determinants of Health.

BackgroundPreoperative assessment of geriatric-specific determinants of health may enhance perioperative risk stratification among elderly patients. This study examines effects of geriatric-specific variables on postoperative outcomes in patients undergoing elective major abdominal operations.MethodsPatients included in the ACS NSQIP pilot Geriatric Surgery Research File program who underwent elective pancreatic, liver, and colorectal operations between 2014 and 2016 were examined. Multivariable analyses were performed to evaluate associations between patient-specific geriatric variables and risk of death, morbidity, readmission, and discharge destination.ResultsA total of 4165 patients were included. Patients ≥85 years were more likely to die, experience postoperative morbidity, and be discharged to a facility (all p ≤ 0.039) than younger patients. Preoperatively, patients ≥85 years were more likely to use a mobility aid, have a prior fall, have consent signed by a surrogate, and to live alone at home prior to operation (all p < 0.001). After adjustment for ACS NSQIP-estimated probabilities of morbidity or mortality, no geriatric-specific preoperative risk factors were significantly associated with increased risk of death or complications in any age group (all p > 0.055). Patients 75–84 and ≥85 years were more likely to be discharged to facility (OR 2.33 and 4.75, respectively, both p < 0.001) compared to patients 65–74 years. All geriatric-specific variables: use of mobility aid, living alone, consent signed by a surrogate, and fall history, were significantly associated with discharge to a facility (all p ≤ 0.001).ConclusionsAfter adjusting for comorbid conditions, geriatric-specific variables are not associated with postoperative mortality and morbidity among elderly patients; however, geriatric-specific variables are significantly associated with discharge to a facility.

Association of Geriatric-Specific Variables with 30-Day Hospital Readmission Risk of Elderly Surgical Patients: A NSQIP Analysis

Elderly patients (65 years of age and older) undergo an increasing number of operations performed annually in the US and they present with unique healthcare needs. Preventing postoperative readmission remains an important challenge to improving surgical care. This study examined whether geriatric-specific variables were independently associated with postoperative readmissions of elderly patients. The American College of Surgeons (ACS) Geriatric Surgery Research File (GSRF) was joined with the ACS NSQIP Participant Use Data Files for 2014 to 2016. This data set included 13 GSRF variables and 26 ACS NSQIP variables. Associations between clinically relevant variables and readmission were tested with multivariable logistic regression. The data represented 6,039 general surgery patients age 65 years and older. Fifty-eight percent of patients had colorectal operations, 19% pancreatic or hepatobiliary, 15% hernia, 4% thyroid or esophageal, and 3% had appendix operations. Twenty-four percent of patients experienced an NSQIP-defined 30-day postoperative complication and 3% died within 30 days after operation. Eleven percent of patients had unplanned 30-day readmission. Standard NSQIP variables, including 30-day composite morbidity (odds ratio [OR] 5.11; 95% CI, 4.24 to 6.16; p < 0.001), reoperation (OR 2.8; 95% CI, 2.07 to 3.79; p < 0.001), and steroid use (1.42; 95% CI, 1.03 to 1.96; p= 0.03) were associated with readmission. In addition, GSRF variables, including incompetent on admission (OR 1.63; 95% CI, 1.11 to 2.38; p= 0.01), fall risk at discharge (OR 1.42; 95% CI, 1.11 to 1.82; p= 0.005), use of mobility aid (OR 1.26; 95% CI, 1.02 to 1.56; p= 0.03), and discharged home with skilled care (OR, 1.22; 95% CI, 1.0 to 1.49; p= 0.04) were associated with readmission. Four GSRF and 3 current standard ACS NSQIP variables were important in the evaluation of postoperative readmission of elderly patients. Geriatric-specific variables contributed to the explanation of the relationship between clinical variables and readmissions in elderly surgical patients.