Procedures In Older Patients Research Articles

Surgical Outcomes in Octogenarians with Heart Failure and Reduced Ejection Fraction following Isolated Coronary Artery Bypass Grafting-A Propensity Score Matched Analysis.

Background/Objectives: The demographic shift towards an aging population necessitates a reevaluation of surgical interventions like coronary artery bypass grafting (CABG) in octogenarians. This study aims to elucidate the outcomes of CABG in octogenarians with heart failure and reduced ejection fraction (HFrEF), a group traditionally considered at high risk for such procedures. Methods: Conducted across four academic hospitals in Germany from 2017 to 2023, this retrospective multicenter study assessed 100 patients (50 octogenarians ≥80 years and 50 non-octogenarians <80 years) with HFrEF undergoing isolated CABG. Through propensity score matching, the study aimed to compare the incidence of major adverse cardiac and cerebrovascular events (MACCEs), as well as other clinical endpoints, between the two groups. Statistical analyses included chi-square, ANOVA, Mann-Whitney U test, Cox regression, and logistic regression, aiming to identify significant differences in outcomes. Results: The study revealed no significant difference in the combined incidence of MACCEs between octogenarians and non-octogenarians (OR: 0.790, 95% CI: 0.174-3.576, p = 0.759). Mortality rates were similar across groups (7% each, p = 1.000), as were occurrences of postoperative myocardial infarction (2% each, p = 1.000) and stroke (3% total). Secondary outcomes like delirium (17% total, no significant age group difference, p = 0.755), acute kidney injury (18% total, p = 0.664), and the need for dialysis (14% total, p = 1.000) also showed no differences between age groups. Interestingly, non-octogenarians required more packed red blood cells during their stay (p = 0.008), while other postoperative care metrics, such as hospital and ICU length of stay and ventilation hours, were comparable across groups. Conclusion: This multicenter study highlights that CABG is a viable and safe surgical option for octogenarians with HFrEF, challenging prior assumptions about the elevated risks associated with performing this procedure in older patients. The absence of significant differences in the incidence of MACCEs and other postoperative complications across age groups emphasizes the importance of careful patient selection and perioperative management. These findings advocate for a more inclusive approach to surgical treatment for octogenarians with HFrEF, suggesting that age alone should not be a determinant for CABG eligibility. This study contributes critical insights into optimizing care for a high-risk demographic, indicating a need for tailored guidelines that accommodate the aging population with complex cardiac conditions.

A feasibility study of urinary catheter removal protocol following transurethral prostatectomy procedure in older patients

AbstractWe hypothesized that older patients who underwent a urinary catheter removal protocol would not have an increased risk of postoperative complications. We further hypothesized that the revised protocol would be more suitable for clinical application. This study aimed to develop a urinary catheter removal protocol after Transurethral Resection of the Prostate and to assess the feasibility of the protocol to support catheter removal and promote recovery of self‐voiding function. Delayed catheter removal after Transurethral Resection of the Prostate was associated with urinary tract infection and longer hospital stays. However, no strategy has been described to promote recovery of self‐voiding function after catheter removal after Transurethral Resection of the Prostate. The urinary catheter removal protocol was developed through expert consensus, including strategies for caring for urinary catheters, assessment of urinary catheter removal, and strategies after urinary catheter removal. Moreover, a quasi‐experimental design was adopted in the urology ward of a tertiary care medical centre in southern Taiwan. Patients aged ≥65 years who underwent Transurethral Resection of the Prostate were included. A total of 13 patients (intervention = 5; control = 8) were included in the feasibility evaluation. A urinary catheter removal protocol after Transurethral Resection of the Prostate was developed and the consensus among experts on the urinary catheter removal protocol was 99%. There were no significant differences in terms of bleeding, urine retention, urinary tract infection, or re‐catheterization between the two groups. However, in the intervention group, the pain score decreased significantly on the second day after Transurethral Resection of the Prostate. This revised urinary catheter removal protocol after Transurethral Resection of the Prostate may be suitable for clinical applications. However, small size reduces the statistical power of the findings and further studies are needed to examine the current protocol does not have an increased risk of postoperative complications.

Cognitive function in older patients and their stress challenge using different anesthesia regimes: a single center observational study

BackgroundWith increasing age older patients are at higher risk for cognitive decline after surgery. Even tailored anesthesia procedures in older patients remain a high risk for postoperative cognitive disorder. Additional stress derived from anxiety and anesthesia itself can negatively impact postoperative cognitive outcomes. The objective of this study was to evaluate the impact of general versus regional anesthesia on postoperative cognitive disorder and indicators of perioperative stress in elderly undergoing surgery.MethodsIn this single center prospective study between December 2014 and November 2015, 46 patients aged 50 to 85 years undergoing dermatology surgery were enrolled. Patients were stratified by receiving general versus regional nerve anesthesia. On three consecutive days, saliva cortisol levels were analyzed three times per day. Cognitive function was assessed on the day before and the day after surgery using comprehensive neuropsychological testing of multiple cognitive functions including memory, executive function, attention and processing speed.ResultsComparing the regional anesthesia group (RAG, n = 28) with the general anesthesia group (GAG, n = 18) no significant difference in the postoperative cognitive function was observed. However, patients in the GAG had significantly higher postoperative cortisol levels when compared to patients in the RAG. In both groups, a peak of cortisol value was detected on the day of surgery, which was higher in the GAG in comparison to the RAG.ConclusionsWe did not observe a difference in postoperative cognitive function between patients undergoing regional or general anesthesia for dermatology surgery. However, we found lower cortisol level in the RAG. Based on these findings, future studies should investigate alternatives to reduce stress in a general anesthesia setting.Trial registrationClinicalTrials.gov ID: NCT02505815.

Coronary procedures via distal transradial access in older as compared with non-older patients: Insights from the DISTRACTION registry.

Older patients are at a higher risk of access site complications and bleeding. Systematic reviews and meta-analysis have highlighted the benefits of distal over proximal transradial access (mainly, lower rates of radial artery occlusion and faster hemostasis). We aimed to evaluate the feasibility and safety of distal transradial access (dTRA) for routine coronary procedures in older patients compared with non-older patients. Retrospective analysis of a large and real-world sample of 5524 consecutive all-comers patients who underwent coronary procedures via dTRA were included in the DISTRACTION registry. In the older patients (greater than or equal to 65 years) group (n = 2594, 47%), there were higher rates of hypertension (83% vs 71.1%; P less than .0001), diabetes (45.1% vs 34.7%; P less than .0001), previous stroke (2.9% vs 2%; P=.0425), chronic heart failure (9.2% vs 7.1%; P=.0040), severe aortic valvar disease (4.2% vs 2.9%; P=.0070), chronic kidney disease stages 3 and 4 (8.1% vs 3.1%; P less than .0001), previous percutaneous coronary intervention (27.2% vs 24.5%; P=.0253), previous coronary artery bypass grafting (5.1% vs 2.2%; P less than .0001), cardiogenic shock at presentation (1.3% vs 0.4%; P=.0003), rotational atherectomy (0.7% vs 0.2%; P=.0050), and left main percutaneous coronary intervention (2.7% vs 1.5%; P=.0033). No significant differences were observed in the rates of access site crossovers. No major adverse cerebrovascular and cardiac events directly related to dTRA, no hand/thumb dysfunction or ischemia after any procedure, and no access site-related hematomas (early discharge after transradial stenting of coronary arteries greater than or equal to 2) were recorded. Despite more comorbidities, more complex coronary disease, and more challenging presentation, the adoption of dTRA as the default approach for routine coronary procedures in older patients, by proficient operators, appears to be safe and feasible.

Role of new drug therapies and innovative procedures in older patients with heart failure: from trials to clinical practice.

During earliest years, new drug-therapies and novel interventional therapies have been tested to modify the detrimental effect of secondary valve diseases, adverse ventricular remodelling and persistent fluid overload in HF patients. However, the increased prevalence of older or very old patients with HF has made their widespread implementation more problematic due to complex comorbidity, frailty, or overt disability. This growing older population, often excluded by randomized trials, but with elevated risk of hospitalization, required a different clinical and management approach that allows clinicians to take full advantage in reducing mortality and morbidity from these new pharmacological and instrumental therapies. In this perspective, the role of multidisciplinary Heart Team is mandatory for better define a correct decision-making process and tailoring the best pharmacological therapy in each patient and to program a continuum care in a post-acute phase of treatment. In addition, the possibility to plan multicentre registries of several complex cases evaluated by Heart Team could become a very important source of real world data to further refine indications and contraindications of different highly technological therapeutic approach, today based often on randomized clinical trials that do not represent faithfully the current clinical practice population.

Swiss National Registry on Catheter Ablation Procedures: Changing Trends over the Last 20 Years.

The Swiss Ablation Registry provides a national database for electrophysiologic studies and catheter ablations. We analyzed the database to provide an in-depth look at changing trends over the last 20 years. During the study period a total of 78622 catheter ablations (age 61.0 ± 1.2 years; 63.7% male) were performed in 29 centers. The number of ablations increased by approximately ten-fold in 20 years. Ablation for atrial fibrillation (AF) was the main driver behind this increase, with more than hundred-fold (39.7% of all ablations in 2019). Atrioventricular-nodal-reentrant-tachycardia (AVNRT) and accessory pathways, being the main indications for ablation in 2000 (44.1%/25.1%, respectively), made up of only a small proportion (15.2%/3.5%,) respectively in 2019. Fluoroscopy, ablation, and procedure durations were reduced for all ablations over time. The highest repeat ablations were performed for ventricular tachycardia and AF (24.4%/24.3%). The majority of ablations (63.0%) are currently performed in private hospitals and non-university public hospitals whereas university hospitals had dominated (82.4%) at the turn of the century. A pronounced increase in the number of catheter ablations in Switzerland was accompanied by a marked decrease in fluoroscopy, ablation, and procedure durations. We observed a shift toward more complex procedures in older patients with comorbidities.

Definition and assessment of frailty in older patients: the surgical, anaesthesiological and oncological perspective.

The number of oncology, surgery and anaesthesia procedures in older patients has greatly increased in recent years due to ageing populations. Older patients are typically characterised by physical changes such as comorbidities, decline in physiological activities and cognitive impairment. All these factors, together with polypharmacological therapies, may substantially impact perioperative outcome, quality of recovery and, more in general, quality of life. A comprehensive multidisciplinary approach to perioperative care is thus needed. The assessment of frailty has a central role in the pre-operative evaluation of older patients and, with a multidisciplinary approach. The best surgical procedures and oncologic therapies can be accurately discussed in the pre- and post-operative periods. All clinicians involved in this scenario should be proactive in multidisciplinary care to achieve better outcomes.

Bacterial Flora of the Nose and Paranasal Sinuses Among Patients Over 65 Years Old with Chronic Rhinosinusitis Who Underwent Endoscopic Sinus Surgery.

PurposeChronic rhinosinusitis (CRS) is one of the most common chronic diseases in the geriatric population. However, CRS inflammatory mechanisms in older people have not been thoroughly investigated. Our work aimed to analyze the bacterial flora of the nose and paranasal sinuses in patients with CRS over 65 years of age, including comorbidities, previously performed endoscopic sinus surgery (ESS), presence or absence of polyps and the extent of the inflammatory process.Patients and MethodsThe study involved 529 patients between 18 and 84 years of age with chronic rhinosinusitis who underwent endoscopic sinus surgery. There were 101 patients separated over 65 years of age (M = 52, K = 49, mean age 69 ± 0.7 years). The control group consisted of 168 patients aged 18–40 years with CRS. The bacterial culture of material collected from the patients during ESS was analyzed.ResultsIn the group of patients over 65 years of age, more frequent occurrence of Proteus spp. and Pseudomonas aeruginosa was found in comparison to younger patients. In older patients with bronchial asthma, the occurrence of S. aureus, Escherichia coli, and Citrobacter spp. was more frequent than in control group. Multiple sinus surgical procedures in older patients were associated with the dominance of Staphylococcus aureus and Escherichia coli, which was not demonstrated in the control group. There were no statistically significant differences between the occurrence of bacterial strain and the presence of polyps, both in the group of patients over 65 years of age as well as in the control group.ConclusionThe bacterial flora of patients with CRS is different in older and younger patients. A different therapeutic approach should be considered in older patients with CRS, but this problem requires further studies.

Can Sural Fasciocutaneous Flaps Be Effective in Patients Older Than 65?

Many studies have evaluated the reverse sural fasciocutaneous flap for coverage of wounds on the distal lower extremity, and many of these have focused on younger, healthy patients. However, to our knowledge, there has been no dedicated study focusing on older patients. We believe there is a generalized concern about performing these procedures in older patients because of microvascular changes associated with aging. (1) What is the likelihood of flap survival in a small series of patients older than 64 years who underwent reverse sural artery fasciocutaneous flap for coverage of lower extremity wounds? (2) What additional procedures did patients undergo after treatment with this flap? From 2009 to 2018, we identified 16 patients, 64 years or older, who underwent a retrograde sural fasciocutaneous flap. Patients were a mean (range) age of 71.5 years (64 to 87). The average size of the flaps was 30 cm (range 12 to 64 cm). The reverse sural artery flap was indicated when the skin could not be closed primarily and there was not a suitable vascularized bed of tissue for a split-thickness skin graft. All patients underwent a wide-based pedicle (3 cm to 4 cm), reverse sural artery fasciocutaneous flap with all but one completed in a "flap delay" manner, between 2 to 7 days, and without the use of microsurgery or doppler. Thirteen flaps were done to cover wounds that occurred over fractures while three were performed to cover chronic wounds. We performed a retrospective review of the electronic health record to ascertain patient comorbidities, age, timing of coverage, and size of the wound. In all, 94% of flaps (15 of 16) survived with 100% viability. One flap had 30% skin necrosis at the distal tip. The flap ultimately healed with in-office wound care, and epithelization occurred over the intact fascia. A total of five additional procedures were performed in five patients. Although the flap ultimately healed, an 87-year-old patient with partial flap necrosis ultimately elected for below-knee amputation for a persistent tibial infected nonunion. Another patient, despite a healed flap, eventually underwent a below-knee amputation 3 years later for a chronic osteomyelitis present before undergoing the reverse sural flap. One patient developed a pseudomonal infection of their Gustillo-Anderson IIIB open tibia fracture, resulting in a surgical procedure for débridement, after which the flap healed. Two patients underwent underlying hardware removal to relieve wound tension and allow for complete flap healing. No patients underwent further coverage procedures. In this small series, we found fewer complications than have been observed in prior studies, despite our series consisting solely of higher-risk, older patients. We believe this may have been attributable to the period of delay before placing the flap, which has been previously associated with higher flap survival and which allows for an extra recipient-site débridement. We believe this procedure can be performed by appropriately trained orthopaedic surgeons because it does not need microsurgery. Level IV, therapeutic study.

Repeated Cerebrospinal Fluid Removal Procedure in Older Patients With Idiopathic Normal Pressure Hydrocephalus Ineligible for Surgical Treatment

ObjectivesTo evaluate the effects of repeated cerebrospinal fluid (CSF) tap procedures in idiopathic normal pressure hydrocephalus (iNPH) patients ineligible for surgical treatment. DesignProspective, monocentric, pilot study. SettingUniversity hospital. ParticipantsThirty-nine patients aged 75 years and older, ineligible for shunting surgical intervention. InterventionRepeated CSF taps. MeasurementsAll patients underwent a comprehensive geriatric assessment before and after each CSF tap. Adverse events were recorded. ResultsNo major side effect was reported. Eleven patients showed no response to the first CSF tap test and were excluded. In the remaining 28 patients, all physical and cognitive functions improved after the drainage procedures, except for continence (which seemed poorly influenced). According to clinical judgment, the mean time frame of benefit between CSF taps was 7 months. Patients withdrawing from the protocol during the clinical follow-up showed a worsening of functional and cognitive performances after the interruption. Conclusions/ImplicationsPeriodic CSF therapeutic taps are safe, allow a better control of iNPH symptoms, and prevent functional decline in geriatric patients.

Glycogenic acanthosis on mouth clinically present as white plaque

ABSTRACT Glycogenic acanthosis is a benign condition, commonly observed during endoscopic procedures in older patients, which present as slightly elevated whitish plaques often on the lower third of the oesophagus. Microscopically, glycogenic acanthosis is composed of hyperplastic squamous epithelium with intracytoplasmic glycogen deposits. The extraoesophageal glycogenic acanthosis is extremely rare, with only three case reports in the English-language literature. We report a white lesion showing glycogenic acanthosis-like features located on the left posterolateral border of the tongue, affecting a 56-year-old male patient. The medical history was non-contributory and the patient did not show any lesions during endoscopic examination of the oesophagus, stomach, and upper duodenum. Glycogenic acanthosis is a benign condition, which should be included in the differential diagnosis when assessing oral white lesions. It is important also to recognize this benign condition early and rule out the possibility of other more severe diseases, but further studies were necessary for better define their potential for persistence or recurrence, as observed in the current case.

Patients' preferences and existential perspective: what to consider and how should patient's expectations be guided?

With an ageing population, surgical procedures in older patients are becoming increasingly more common. This can pose clinical and ethical dilemmas, during which clinicians need to make complex decisions. In this paper we discuss the importance of assessing mental capacity to assess if the older patient can make his or her own decisions relating to surgery. We also discuss the importance of understanding ethical principles, in order that clinicians can better guide patient's decision-making. In addition, we look at ageism, frailty, and co-morbidities, and their influence on clinician's decisions regarding surgery in older patients. Further to this, we look at the influence of evidence-based medicine on treatment options, and the under representation of older people in clinical trials and the importance of this. Finally, we consider the importance of considered decisions regarding resuscitation, when considering surgical intervention in older patients. We conclude that patient-centred individualised care, considering patients expectations, wishes, and priorities is vital, whilst aiming to improve or maintain quality of life, and minimise risks when able.

Fusión de la primera articulación metatarsofalángica en el tratamiento del hallux valgus en pacientes geriátricos

Historically first metatarsophalangeal joint fusion has been used to treat patients with joint arthritis or as a salvage procedure for iatrogenic deformities. For the past 20 years the author has used this procedure in older patients with hallux valgus deformity, and it has proven to be a safe and reliable technique. The paper describes the rationale for use of joint fusion as a primary option for hallux valgus repair in this patient population as opposed to other procedures. The surgical technique, fixation, and aftercare are also described.

Use of 1st metatarsophalangeal joint fusion for repair of geriatric hallux valgus deformity

Historically first metatarsophlangeal joint fusion has been used to treat patients with joint arthritis or as a salvage procedure for iatrogenic deformities. For the past 20 years the author has used this procedure in older patients with hallux valgus deformity, and it has proven to be a safe and reliable technique. The paper describes the rationale for use of joint fusion as a primary option for hallux valgus repair in this patient population as opposed to other procedures. The surgical technique, fixation, and aftercare are also described.

Laparoscopic posterior mesh rectopexy for rectal prolapse is a safe procedure in older patients: A prospective follow-up study

The aim of this study is to examine the clinical and functional outcome of laparoscopic posterior rectopexy in a consecutive series of adult patients with full-thickness rectal prolapse. Preoperative data on demography, life-style practices, medication, comorbidity, and previous surgery for rectal prolapse were ascertained from patient charts. Information on operative procedure, and pre- and postoperative complications were recorded. Short- and long-term follow-up were done after a median of 60 days and 2 years after surgery. Between 1 February 2009 to 1 June 2012, 81 laparoscopic posterior rectopexies were done. Male-to-female ratio was 4:77, median age 73 [57-80.5] years and median ASA Grade 2. Conversion to open surgery was done in 6.2%, the median operating time was 82 min [66 - 102] and median length of hospital stay was 2 days [2-5.7]. Minor and major complications were seen in 5.3% and 14.8%, respectively. The 30-day mortality rate was 1.2%. Constipation or incontinence improved or disappeared in 65.2% and 74.4%, respectively. The cumulated recurrence rate was 11.1% after a median observation time of 2 years. Laparoscopic posterior rectopexy is a safe and well-tolerated procedure in older patients and can be done with acceptable complications and recurrence rates and short hospital stays. Laparoscopic posterior rectopexy seems to improve bowel function in many patients.

Risk Factors for Short-term Adverse Events and Readmission After Arthroscopic Meniscectomy

Background: Recent studies have questioned the efficacy of meniscectomy in older patients with and without evidence of osteoarthritis; however, it continues to be frequently performed. There is limited information about age and other risk factors for adverse events and readmission after the procedure. This knowledge is vital to understand the true risk profile of this common surgery. Purpose: To investigate if age and medical comorbidities were risk factors for postoperative adverse events and readmission after meniscectomy. Study Design: Case-control study; Level of evidence, 3. Methods: Patients who underwent arthroscopic meniscectomy between 2005 and 2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Age ≥65 years and medical comorbidities were evaluated as risk factors for any adverse event (AAE), severe adverse events (SAEs), and readmission after meniscectomy using univariate and multivariate analyses. Results: A total of 17,774 patients who underwent meniscectomy were identified. The mean age was 53.0 ± 13.6 years. A total of 3420 patients (19.2%) were ≥65 years. Overall, 208 patients (1.17%) had AAE, 203 patients (1.14%) had an SAE, and 102 patients were readmitted (0.97%). Multivariate logistic regression analyses demonstrated no significant differences between age groups for the occurrence of AAE, SAEs, and readmission. Patients with American Society of Anesthesiologists classification ≥3 had increased odds of AAE (odds ratio [OR], 1.58), SAEs (OR, 1.59), and readmission (OR, 1.99). Patients with diabetes had increased odds of AAE (OR, 1.57) and SAEs (OR, 1.51). Smokers had increased odds of readmission (OR, 1.67). Patients with pulmonary disease had increased odds of AAE (OR, 1.76) and SAEs (OR, 1.70). Conclusion: Meniscectomy is a safe procedure in older patients, as age over 65 years did not increase the odds of any of the adverse events studied. However, regardless of age, patients with an increased comorbidity burden and those with a history of smoking are at increased risk of adverse events and/or readmission after the procedure. Clinical Relevance: Knowledge of these risk factors for adverse events and readmission provides essential information for patient selection and preoperative counseling.

The future of fast-track surgery

Since its introduction in the 1990s, the concept of multimodal perioperative care (fast-track surgery, enhanced recovery programmes) has gained widespread acceptance and is now considered as a standard of care. Most studies that support this approach relate to colorectal surgery, but similar data have been published across surgical specialties with major economic benefits1–4. The implementation process has been described in detail and is essentially based on the simple question: ‘Why is the postoperative patient in hospital today?’1,5. The relevant question may therefore be asked – what next? Postoperative length of stay is often seen as the key outcome for fast-track surgery and, although this may not always be appropriate, whatever is used as a primary outcome measure must be justified adequately. It should also be emphasized that significant progress in fast-track care demands inclusion and implementation of all of its basic components. Many studies have not implemented the most important aspects of the care programmes that were originally described, including patient information, effective thoracic epidural analgesia with sufficient local anaesthetic that facilitates early mobilization, reduced ileus and rapid reintroduction of oral feeding, or the use of non-opioid analgesia, where appropriate, in open or minimally invasive surgery. An important issue that needs to be addressed in future is detailed analysis of ‘medical’ versus ‘surgical’ morbidity6. To improve further our understanding of perioperative risk, future studies must analyse how one specific complication might lead to another: for instance, whether a pneumonia or myocardial infarction led to an anastomotic dehiscence; or a wound dehiscence with reoperation led to a subsequent pneumonia, myocardial infarction or thromboembolic complication6. Initial ‘medical’ morbidity may depend on perioperative care principles and pre-existing comorbidity, in contrast to an initial ‘surgical’ complication, which may depend on surgical technique, and therefore require a different approach from fast-track methodology. How might the fast-track approach evolve further, as surgeons perform an ever-increasing number of major procedures in older patients with comorbidities, with greater risks of postoperative complications, prolonged hospital stay and death6? Preoperative evaluation of operative risk may not be helpful unless evidence-based perioperative interventions are available and instituted. Thus, the specific role of preoperative morbidity, such as smoking, diabetes and cardiopulmonary disease, in determining the risk of postoperative morbidity needs to be reassessed in studies with a fully implemented fast-track procedure-specific programme6. We also need to have a second look at the relative roles of the different components of the fast-track programme (for example type of analgesia and fluid management1,5) and analyse where progress can be made in order to reduce perioperative risk and morbidity, instead of focusing on length of stay as the primary outcome. The surgical stress response is proportional to the degree of insult and the main factor that contributes to postoperative organ dysfunction1,2. Every effort should therefore be made to reduce those responses that are undesirable. Regional anaesthetic techniques have a powerful effect on the catabolic response, reducing cardiac demands, pain, pulmonary dysfunction and ileus. Regional anaesthesia should be used whenever possible on a procedure-specific basis7. Inflammatory responses contribute to pain, fatigue and organ dysfunction. They can be modified pharmacologically by preoperative glucocorticoids8. Significant reductions in pain, nausea and vomiting, and early fatigue have been demonstrated, facilitating early recovery, so far without demonstrable side-effects. More procedure-specific and dosefinding studies are required. A single preoperative glucocorticoid dose in a larger amount than used for conventional nausea and vomiting prophylaxis might, for instance, be an important contributory factor to improving fast-track programmes in high-risk patients. Minimally invasive surgery also reduces the inflammatory response, although the contribution that this plays in the context of fast-track programmes in colonic surgery is difficult to interpret, as the care programmes used in the ‘open’ groups have often not been fully implemented6,9,10. Therefore, future efforts to assess early postoperative outcome effects of minimally invasive surgery should include randomized studies with fully implemented fasttrack programmes11. Newer developments in minimally invasive surgery

Older patients suffer from adverse histopathological features after radical cystectomy

Radical cystectomy (RC) remains a complex procedure in older patients. Perioperative morbidity can be significant and it can represent a limitation for its indication in this population. The aim of the present study was to evaluate the outcomes of RC in elderly patients from a large single-center cohort. A total of 447 patients who underwent RC between 1996 and 2009 at our institution were considered. Patients were stratified by age (≤70 vs >70 years). Logistic regression analyses were carried out comparing both groups regarding clinical, perioperative and histopathological findings, as well as complications according to the modified Clavien system and survival. Data of 390 patients were available for the analysis. Of these, 265 (67.9%) versus 125 (32.1%) patients were <70 versus ≥70 years-of-age. The median age was 61 and 75 years, respectively. In the elderly, ASA score (P < 0.001), delay between transurethral resection of the bladder (TURBT) and RC (P = 0.004), and number of perioperative blood transfusions (P = 0.002) were significantly higher. Additionally, a clear trend towards higher stages (pT3-4) was observed (P = 0.04). However, complications, and overall and cancer-specific mortality were not increased in older patients. Finally, age was identified as a significant risk factor for upstaging (P = 0.04). Upstaging between TURBT and final histopathology in patients <70 versus ≥70 years occurred in 45% versus 58%, respectively (P = 0.03). RC is equally feasible in older patients without increasing morbidity or mortality. On the contrary, older patients have a higher risk of significant upstaging and advanced stages at final histopathology. These findings suggest that RC should neither be delayed in nor withheld from elderly patients.

National Utilization and Outcome of Carotid Artery Revascularization in Octogenarians

The benefits of carotid endarterectomy (CEA) and carotid artery angioplasty and stenting (CAS) in octogenarians remain unclear. Octogenarians were excluded from seminal CEA trials. CAS may have increased complications in this patient cohort. The objective of this study was to examine the national utilization and outcome of CEA and CAS in octogenarians. The Nationwide Inpatient Sample (2004-2005) was utilized. ICD-9 codes were used to identify CEA and CAS cases. Outcomes included in-hospital stroke and death. Comparisons were performed between older and younger patients. Analysis was performed among octogenarians to identify whether improved outcomes were noted with either procedure. A total of 54,658 cases were analyzed; 10,826 were in octogenarians (19.8%). Octogenarians who underwent carotid procedures were more likely to be female (45.6% vs 41.5%, P < .001) and to die in the hospital (1.0% vs 0.6%, P < .001) than younger patients who underwent carotid procedures. There were no overall differences in the prevalence of preoperative symptoms (5.4% vs 5.3%), the use of CAS as opposed to CEA (6.0% vs 5.8%), or the overall rate of periprocedural stroke (1.1% vs 1.1%) between octogenarians and younger patients. However, asymptomatic octogenarians were more likely to undergo CAS (as opposed to CEA) than asymptomatic younger patients (10.1% vs 5.7%, P < .001). In separate analysis of octogenarians alone, it was noted that they had a significantly higher rate of periprocedural stroke with CAS than with CEA (2.2% vs 1.1%, P < .01). The increased rate of stroke with CAS as opposed to CEA was noted in both asymptomatic (1.9% vs 0.9%, P = .04) and symptomatic (5.2% vs 2.3%, P = .18) octogenarians. Nationally, octogenarians comprise nearly 20% of patients undergoing carotid revascularization procedures, despite concern regarding the benefits of these procedures in older patients, particularly when asymptomatic. In spite of additional specific concerns regarding the complication rate of CAS in patients older than 80 years of age, asymptomatic octogenarians underwent CAS as opposed to CEA significantly more frequently than younger patients. However, their periprocedural stroke rate overall was equally low when compared to younger patients. Furthermore, among octogenarians, the rate of periprocedural stroke was significantly higher with CAS than with CEA, and this remained a significant finding when asymptomatic cases were separately examined. CEA may be the treatment of choice for properly selected octogenarians, unless compelling reasons exist to perform CAS.

The Power and Peril of Administrative Databases

Archives of Internal Medicine Implantable Cardiac Device Procedures in Older Patients: Use and In-Hospital Outcomes Jason P. Swindle, MPH; Michael W. Rich, MD; Patrick McCann, MD; Thomas E. Burroughs, PhD; Paul J. Hauptman, MD Background: Although the effectiveness of implantable cardioverter defibrillators (ICDs) and cardiac resynchronization therapy (CRT) alone or in combination is well established, limited data are available on device use and short-term outcomes in older patients. We sought to characterize age-specific practices and outcomes among patients with heart failure undergoing device implantation using a large nationally representative administrative database. Methods: The cohort comprised patients older than 18 years with a diagnosis of heart failure who underwent implantation of an ICD or CRT between January 1, 2004, and December 31, 2005. Data included patient demographics, comorbidities, type of device, procedural complications, length of stay, total cost of hospitalization, and hospital characteristics. Multivariate stepwise logistic regression analysis was used to identify risk factors for in-hospital mortality. Results: We identified 26 887 patients who received an implantable device. The median age was 70.0 years (17.5% were ≥80 years), 72.6% were male, and 31.3% were of nonwhite race/ethnicity. Compared with younger patients, those 80 years or older were more likely to receive CRT alone. In-hospital mortality increased from 0.7% among patients younger than 80 years to 2.2% among those aged 80 to 85 years and 2.2% among those older than 85 years ( P Conclusions: Despite the fact that most device trials have excluded patients 80 years or older, more than one-fifth of ICD and CRT devices are implanted in this age group. Advanced age is an independent predictor of in-hospital mortality following device implantation, suggesting that additional study is needed to define criteria for appropriate device use in older patients.