Surgery In Older Patients Research Articles

Breast cancer surgery in older women: outcomes of the Bridging Age Gap in Breast Cancer study.

Breast cancer surgery in older women is variable and sometimes non-standard owing to concerns about morbidity. Bridging the Age Gap in Breast Cancer is a prospective multicentre cohort study aiming to determine factors influencing treatment selection and outcomes from surgery for older patients with breast cancer. Women aged at least 70 years with operable breast cancer were recruited from 57 UK breast units between 2013 and 2018. Associations between patient and tumour characteristics and type of surgery in the breast and axilla were evaluated using univariable and multivariable analyses. Oncological outcomes, adverse events and quality-of-life (QoL) outcomes were monitored for 2 years. Among 3375 women recruited, surgery was performed in 2816 patients, of whom 24 with inadequate data were excluded. Sixty-two women had bilateral tumours, giving a total of 2854 surgical events. Median age was 76 (range 70-95) years. Breast surgery comprised mastectomy in 1138 and breast-conserving surgery in 1716 procedures. Axillary surgery comprised axillary lymph node dissection in 575 and sentinel node biopsy in 2203; 76 had no axillary surgery. Age, frailty, dementia and co-morbidities were predictors of mastectomy (multivariable odds ratio (OR) for age 1·06, 95 per cent c.i. 1·05 to 1·08). Age, frailty and co-morbidity were significant predictors of no axillary surgery (OR for age 0·91, 0·87 to 0·96). The rate of adverse events was moderate (551 of 2854, 19·3 per cent), with no 30-day mortality. Long-term QoL and functional independence were adversely affected by surgery. Breast cancer surgery is safe in women aged 70 years or more, with serious adverse events being rare and no mortality. Age, ill health and frailty all influence surgical decision-making. Surgery has a negative impact on QoL and independence, which must be considered when counselling patients about choices.

A retrospective observational study of enhanced recovery after surgery in older patients undergoing elective colorectal surgery.

Enhanced recovery programs (ERPs) in colorectal surgery have demonstrated beneficial effects on postoperative complications, return of bowel function, length of stay, and costs, without increasing readmissions or mortality. However, ERPs were not specifically designed for older patients and feasibility in older patients has been questioned. The aim of this study was to assess ERP adherence and outcomes in older patients and to identify risk factors for postoperative complications and prolonged length of stay. Retrospective analysis of consecutive patients (≥70 years) undergoing elective colorectal resection in a tertiary referral hospital in 2017. Ninety-six patients were included. Adherence rates were above 80% in 18 of 21 ERP interventions considered. The lowest adherence rates were noted for preoperative carbohydrate loading and cessation of intravenous fluids. Postoperative complications (Clavien-Dindo ≥2) and prolonged postoperative length of stay (>75th percentile) were observed in 39.6% and 26.3%, respectively. Median length of stay was 7 days. The 30-day mortality, readmission and reoperation rates were 2.1%, 12.6% and 8.3%, respectively. Multivariable analysis indicated that polypharmacy and site of surgery were independent risk factors for postoperative complications, while higher age, American Society of Anesthesiologists class and preoperative radiotherapy were independent risk factors for prolonged postoperative length of stay. ERP adherence in older patients undergoing colorectal resection is high and ERP is therefore considered feasible. Postoperative complications and prolonged postoperative length of stay are common, so at risk patients should be targeted with tailored geriatric interventions.

Indications for Emergency Abdominal Surgeries in Older Patients: 7-Year Experience of a Single Centre

The majority of patients undergoing emergency laparotomy are older adults that carry the highest mortality. More research into the development of targeted interventions is required. Therefore, the aim of the study was to analyse the indications for emergency abdominal surgery in patients aged ≥ 65 admitted to the Department of General Surgery. The study included consecutive patients aged ≥ 65 who underwent emergency abdominal surgery within 48 h after admission at one institution. In 2010–2017, 986 patients were enrolled in the study (female 57%, male 43%). Patients were divided into three age groups, 65–70, 71–84 and ≥ 85, with 255 patients (25.9%), 562 patients (57.0%) and 169 patients (17.1%) in each group, respectively. In the first and second age groups, the most common indications for surgery were acute cholecystitis, non-malignant ileus, colorectal cancer complications and acute appendicitis. In the oldest patients, the most common indications were complications of colorectal cancer, acute cholecystitis, non-malignant ileus and complications of diverticulosis. In the women, the biggest differences in indications between age groups were colorectal cancer (p = 0.025) and peptic ulcer disease complications (p = 0.005); in the men, the biggest difference was seen for complicated diverticulitis (p = 0.001). The most frequent comorbidities were heart diseases (81.0%), followed by endocrine (33.6%) and vascular diseases (22.7%). The three most common indications for emergency surgery in older patients at our institution were acute cholecystitis, colorectal cancer complications and non-malignant bowel obstruction, affecting 59.5% of this group of patients. Elective surgery and endoscopic screening have the potential to prevent major part of these acute diseases. However, further prospective research is necessary on this field, particularly among frail, older patients.

Can a Simple Geriatric Assessment Predict the Outcome of TURP?

Purpose: To determine the impact of a simple preoperative geriatric assessment on the outcome in older patients with recurrent urinary retention who underwent desobstructive surgery. Patients and Methods: Patients aged 75 years or older with recurrent urinary retention referred for TURP entered this prospective, multicentre study. Several demographic, intra- and postoperative parameters were assessed. Preoperative geriatric assessment was performed by the 7-item Canadian Study of Health and Ageing (CSHA) frailty scale (1: very fit, 7: severely frail; completion takes less than a minute). The main outcome parameters were successful voiding rates at discharge and 3 months postoperatively. Results: A total of 54 patients were recruited; 42 (77.8%) patients had a CSHA index of 1–3 and were considered as “fit”, the remaining 12 (22.2%) formed the “frail” group (CSHA index 4–7). Age was identical in both cohorts (79.5 ± 3.7 vs. 79.7 ± 3.3 years); differences were demonstrable for the American Society of Anesthesiologists (ASA) score (p = 0.001), the number of daily medications (>4: 32 vs. 75%, p = 0.02), falls within the past 6 months (12 vs. 33%), and the necessity of home/nursing care (5 vs. 42%, p = 0.004). Intra- and perioperative complications, duration of postoperative catheterization, and length of hospitalization were identical in both cohorts. The success rate at discharge was 80.6% in fit and 75.0% in frail patients; the respective values at 3 months were 95.2 and 83.3%. Conclusions: A simple 1-min geriatric assessment tool can predict – to a certain extent – the outcome of desobstructive surgery in older patients with recurrent urinary retention. Fit patients achieve an excellent outcome while frail patients might benefit from a more in-depth urodynamic/geriatric evaluation.

Impact of frailty and mild cognitive impairment on delirium after cardiac surgery in older patients

BackgroundFrailty and cognitive impairment are well-known risk factors of delirium after cardiac surgery. Frailty is closely associated with cognitive impairment. This study aimed to examine how frailty and cognitive impairment affect the incidence of delirium after cardiac surgery in older patients. MethodsIn total, 89 patients (aged ≥65 years) who underwent cardiac surgery between April 2016 and December 2017 were included (74.9 ± 5.5 years, male 64.1%). They were divided according to the combination of frailty and mild cognitive impairment (MCI): Group 1, non-frailty and non-MCI; Group 2, non-frailty and MCI; Group 3, frailty and non-MCI; and Group 4, frailty and MCI. Frailty was defined as a score of at least 3 points according to the Japanese version of the Cardiovascular Health Study criteria, and MCI was defined as a Montreal Cognitive Assessment score less than 26. Delirium was evaluated using the Intensive Care Delirium Screening Checklist, and a score of 4 or higher indicated delirium. Multivariate logistic regression analysis was performed to examine the influence of the combination of frailty and MCI on delirium after cardiac surgery. ResultsIn total, 31 patients (34.8%) showed postoperative delirium. Multivariate analysis-adjusted baseline characteristics (reference, Group 1) showed that only Group 4 had a risk of delirium after cardiac surgery (odds ratio, 7.494; 95% confidence interval 1.539–36.494). ConclusionPreoperative coexistence of frailty and MCI poses the greatest risk of delirium after cardiac surgery. Therefore, attention should be paid to both physical and cognitive function prior to surgery. Further studies are warranted to investigate the optimal intervention for high-risk patients.

Long-Term Weight Loss, Metabolic Outcomes, and Quality of Life at 10Years After Roux-en-Y Gastric Bypass Are Independent of Patients' Age at Baseline.

Conflicting data have been published for bariatric surgery in older patients, with no long-term large-scale studies available. Our aim was to provide long-term (> 10years) results on weight loss, metabolic outcomes, and quality of life in a large homogenous series of Roux-en-Y gastric bypass (RYGB) patients, according to age at baseline. All consecutive patients who underwent primary RYGB between 1999 and 2007, and therefore eligible for 10-year follow-up, were retrospectively analyzed. According to their age at baseline, they were divided into three groups: A (< 40years), B (40-54years), and C (≥ 55years). Categorical variables were compared with the χ2 test and continuous variables with ANOVA. Our series consisted of 820 patients, with a 10-year follow-up of 80.6%. Although group C (11% of all patients) had significantly more comorbidities at baseline, there was no difference in postoperative morbidity and mortality between groups. Weight loss was significantly less for group C patients up to the 7th postoperative year, but no difference remained thereafter. 10-year %total weight loss was 32.2, 32.9, and 32.3 respectively in groups A, B, and C. After 10years, glycemic control and lipid profile improved similarly, rates of partial or complete remission of diabetes and hypertension were identical, and quality of life presented a significant improvement for all patients with no inter-group difference. Our results suggest similar short- and long-term outcomes after RYGB for patients ≥ 55years compared to younger ones; the relative benefit might even be higher for older patients, given their increased comorbidity at baseline.

Inverse Association of Age with Risk of Lymph Node Metastasis in Superficial Colorectal Cancer: A Large Population-Based Study.

Superficial colorectal cancer (SCRC) is defined as colorectal cancer (CRC) confined to the mucosa or submucosa. Endoscopic resection (ER) is widely used to resect differentiated SCRC from patients without lymph node metastasis (LNM). However, it is unclear whether ER is suitable for use with patients with differentiated early-onset SCRC because early-onset CRC is more aggressive. Therefore, we aimed to investigate the association between age of CRC onset and LNM. We retrieved data for patients with surgically resected differentiated-type SCRCs from the Surveillance, Epidemiology, and End Results (SEER) database. Rate of LNM was compared among patients aged 18-39, 40-49, 50-59, 60-69, and ≥70 years. The association between age and LNM was further examined using multivariate logistic regression. We retrieved 34,506 records of differentiated SCRCs from the SEER database, including 667 patients aged 18-39 years, 2,385 aged 40-49, 8,075 aged 50-59 years, 9,577 aged 60-69 years, and 13,802 aged ≥70 years. Rates of LNM were 15.74%, 14.13%, 10.67%, 8.07%, and 6.76% for patients aged 18-39, 40-49, 50-59, 60-69, and ≥70 years, respectively. We found an inverse correlation between age at diagnosis and risk of LNM from the univariate analysis (p < .001). Compared with patients aged 18-39, the odds ratios with 95% confidence interval (CI) for patients aged 40-49, 50-59, 60-69, and ≥70 years were 0.90 (0.71-1.15, p = .376), 0.69 (0.56-0.87, p = .001), 0.54 (0.43-0.68, p < .001), and 0.47 (0.38-0.60, p < .001), respectively. In differentiated SCRCs, younger age at diagnosis was associated with higher risk of LNM. Endoscopic resection (ER) is widely used to resect differentiated superficial colorectal cancer (SCRC) without lymph node metastasis (LNM). However, no study has ever investigated risk of LNM of early-onset SCRC compared with average onset SCRC to explore whether ER is suitable for early-onset SCRC. To the authors' knowledge, this population-based study is the first study to find inverse correlation between age at diagnosis and risk of LNM in differentiated SCRCs. This finding indicates that ER may not be suitable for young patients with differentiated SCRC. Because the 30-day operative mortality after surgery is higher but the risk of LNM is lower in older patients compared with younger patients, ER for differentiated SCRCs may be advantageous over surgery for older patients.

Potential Opioid-Related Adverse Drug Events Are Associated With Decreased Revenue in Hip Replacement Surgery in the Older Population.

Introduction:Opioid-related adverse drug events (ORADEs) are an increasingly recognized complication associated with the common prescription of opioids after orthopedic surgery. In this study, we attempted to understand how potential ORADEs following hip replacement surgery in older patients affected hospital length of stay, hospital revenue, and their association with specific risk factors and clinically relevant diseases occurring during hospitalization.Methods:We conducted a retrospective study using the Centers for Medicare and Medicaid Services Administrative Database to analyze Medicare discharges after hip replacement surgery to identify potential ORADEs. The impact of potential ORADEs on mean hospital length of stay (LOS) and hospital revenue was analyzed.Results:The potential ORADE rate in patients who underwent hip replacement surgery was 8.6%. The mean LOS for discharges with a potential ORADE was 1.41 days longer than that for discharges without an ORADE. The mean hospital revenue per day with a potential ORADE was US$1708 less than without an ORADE. Potential ORADEs were also found to be strongly associated with poor patient outcomes such as pneumonia, septicemia, and shock.Discussion:Potential ORADEs in hip replacement surgery in older patients are associated with longer hospitalizations, decreased hospital revenue per day, certain patient risk factors, and clinically relevant diseases occurring during hospitalizations. Our finding of an association between potential ORADEs and decreased hospital revenue per day may be attributed to the management of these adverse events, as a patient may need to undergo additional testing, may need additional treatment regimens, and may need a higher level of care.Conclusion:By reducing the use of opioids and employing a multimodal analgesic approach, we may improve patient care, decrease hospital lengths of stay, and increase hospital revenue

The effect of age on survival after endoscopic resection versus surgery for T1a esophageal cancer

BackgroundEndoscopic resection has emerged as a treatment option for T1a esophageal cancer, but the impact of age on patient selection for surgery versus endoscopic resection has not been well studied. We hypothesized that endoscopic resection would be associated with improved survival compared with surgery in older patients with early esophageal cancer and worse survival in younger patients. MethodsThe National Cancer Database was used to identify patients with cT1aN0M0 esophageal cancer (2010-2015) treated with endoscopic resection or esophagectomy. The relationship between age and treatment effect on survival was modeled with an interaction term in a Cox proportional hazards regression. The primary outcome was overall survival. ResultsA total of 831 patients met study criteria: A total of 448 patients (54%) underwent endoscopic resection, and 383 patients (46%) underwent esophagectomy. In a multivariable Cox model, the interaction term between patient age and type of treatment was nonsignificant (P = .11), suggesting that age did not influence the effect of endoscopic resection compared with surgery on survival. In 285 propensity score–matched patients receiving endoscopic resection or surgery, surgery was associated with similar survival compared with endoscopic resection (hazard ratio, 1.40; 95% confidence interval, 0.97-2.03). ConclusionsEndoscopic resection was associated with similar survival compared with surgery in patients with cT1a esophageal cancer regardless of age. Endoscopic resection can be considered for patients at low risk of nodal involvement across all age groups as an alternative to surgery for T1a esophageal cancer.

Physical performance has a strong association with poor surgical outcome in older patients with colorectal cancer

BackgroundLow lumbar skeletal muscle mass and density have been associated with adverse outcomes in different populations with colorectal cancer (CRC). We aimed to determine whether skeletal muscle mass, density, and physical performance are associated with postoperative complications and overall survival (OS) in older CRC patients. MethodsWe analysed consecutive patients (≥70 years) undergoing elective surgery for non-metastatic CRC (stage I-III). Lumbar skeletal muscle mass and muscle density were measured using abdominal CT-images obtained prior to surgery. Low skeletal muscle mass and low muscle density were defined using commonly used thresholds and by gender-specific quartiles (Q). The preoperative use of a mobility aid served as a marker for physical performance. Cox regression proportional hazard models were used to investigate the association between the independent variables and OS. Results174 Patients were included (mean age 78.0), with median follow-up 2.6 years. 36 Patients (21%) used a mobility aid preoperatively. Low muscle density (Q1 vs Q4) and not muscle mass was associated with worse postoperative outcomes, including severe complications (p < 0.05). Use of a mobility aid was associated with more complications, including severe complications (39% vs 17%, p = 0.004) and OS (HR 2.65, CI 1.29–5.44, p = 0.01). However, patients with mobility aid use and low skeletal muscle mass had worse OS (HR 5.68, p = 0.003). ConclusionLow skeletal muscle density and not muscle mass was associated with more complications after colorectal surgery in older patients. Physical performance has the strongest association for poor surgical outcomes and should be investigated when measuring skeletal muscle mass and density.

Emergency General Surgery in Older Patients: Where Are We Now?

The purpose of this chapter is to provide a review of the literature around emergency general surgery in older patients. Emergency general surgery has a high mortality rate and with the population ageing at an unprecedented rate, older patients have an increased mortality risk due to their age alone. Complications are higher and older patients are more likely not to be discharged home following surgery. However, accurately predicting risk of surgery in elderly patients is very difficult. Simple measures such as concurrent comprehensive geriatric assessment with surgical assessment may help care for the older surgical patient more holistically and offer improved outcomes. With the increasing ageing population and life expectancy, there needs to be a more focus on developing comprehensive programmes for older patients undergoing emergency surgery, to ensure they do not develop complications and to reduce mortality rates.

To resect or not to resect? Risks and benefits of surgery in older patients with glioblastoma

IntroductionGlioblastoma multiforme (GBM) has a peak incidence in patients older than 65 years. The aim of the present study is to evaluate the impact of surgical strategy on short- and long-term outcomes of older GBM patients. MethodsA total of 273 older patients (65–84 years) from 2006 to 2014 were operated in our neurosurgical center. The study endpoints were postoperative change of the Karnofsky performance status scale (KPS) and overall survival (OS). The extent of resection (EOR) was categorized into gross total resection (GTR, >95% by volume), subtotal resection (STR, ≤95%) and stereotactic biopsy (SB). The subgroup analyses were performed in two age groups dichotomized at 75 years. ResultsEOR was associated with the risk of postoperative decline of KPS only in patients aged ≥75 years (p = 0.0002/p = 0.0014 for SB vs. GTR and STR respectively), but not in the age group 65–74 years (p = 0.1511/p = 0.2701). The mean OS in the whole cohort was 8.4 months (±9.6). GTR was superior to SB with regards to OS (p < 0.0001/p = 0.0017). STR revealed a more favorable OS than SB only in patients aged 65–74 years (p = 0.0077). Multivariate analysis confirmed that only GTR was independently associated with OS (p < 0.0001/p = 0.013). ConclusionsGTR may provide a better OS even in GBM patients with advanced age. STR still shows a benefit over SB for OS in older patients <75 years. For older individuals, SB presents a safer option with regards to the risk of postoperative morbidity and should be favored in cases, when the surgical alternative is limited to STR.

Retrospective analysis of the 13-year trend in acute and elective surgery for patients aged 60 years and over at Auckland City Hospital, New Zealand

BackgroundAs the worldwide population has aged, the number of surgical procedures performed on older patients has increased. It is not known whether this increase has been proportional to growth in...

Effectiveness of radiotherapy after breast-conserving surgery in older patients with T1-2N0 breast cancer

PurposeIn the Netherlands, radiotherapy after breast-conserving surgery (BCS) is omitted in up to 30% of patients aged ≥ 75 years. Although omission of radiotherapy is considered an option for older women treated with endocrine treatment, the majority of these patients do not receive systemic treatment following Dutch treatment guidelines. Therefore, the aim of this study was to evaluate the effect of omission of radiotherapy on locoregional recurrence risk in this patient population.MethodsPatients aged ≥ 75 years undergone BCS for T1-2N0 breast cancer diagnosed between 2003 and 2009 were selected from the Netherlands Cancer Registry. To minimize confounding by indication, hospital variation was used to assess the impact of radiotherapy-use on locoregional recurrence risk using cox proportional hazards regression. Hazards ratios with 95% confidence interval (CI) were estimated.ResultsOverall, 2390 patients were included. Of the patients with hormone receptor-positive breast cancer, 39.3% received endocrine treatment. Five-year incidences of locoregional recurrence were 1.9%, 2.8%, and 3.0% in patients treated at hospitals with higher (average radiotherapy-use 96.0%), moderate (88.0%), and lower radiotherapy-use (72.2%) respectively, and nine-year incidences were 2.2%, 3.1%, and 3.2% respectively. Adjusted hazard ratios were 1.46 (95% CI 0.77–2.78) and 1.50 (95% CI 0.79–2.85) for patients treated at hospitals with moderate and lower radiotherapy-use, compared to patient treated at hospitals with higher radiotherapy-use.ConclusionsDespite endocrine treatment in only 39.3%, locoregional recurrence risk was low, even in patients treated at hospitals with lower radiotherapy-use. This provides reasonable grounds to consider omission of radiotherapy in patients aged ≥ 75 years with T1-2N0 breast cancer.

2019 Canadian Surgery Forum Abstracts.

# 01. The future of general surgery training: a Canadian resident nationwide Delphi consensus statement {#article-title-2} Various pedagogical models have been introduced in an attempt to improve and restructure surgical training, but significant obstacles remain. Before implementing national

Bariatric surgery is safe and effective in Medicare patients regardless of age: an analysis of primary gastric bypass and sleeve gastrectomy outcomes

BackgroundNumerous studies have shown that bariatric surgery in older patients is safe and effective. However, both the Agency for Healthcare Research and Quality (AHRQ) and a Medicare Evidence Advisory Committee (MEDCAC) have cited gaps in the evidence for outcomes in Medicare patients undergoing bariatric surgery. These gaps are predominantly in the safety and outcomes evidence in Medicare patients younger than 65 years old (Centers for Medicare and Medicaid Services [CMS] < 65). ObjectivesThe aim of our study was to review both the safety and efficacy of gastric bypass (RYGB) and sleeve gastrectomy (SG) in Medicare patients compared with other payers. SettingA single academic medical center. MethodsA prospectively maintained database of 3300 patients who underwent bariatric surgery between January 2007 and December 2017 was utilized. The outcomes of Medicare patients undergoing RYGB and SG were analyzed and compared to those of similar patients covered by Medicaid or Commercial insurers. ResultsThere were too few patients with commercial insurance older than 65 to compare to those with Medicare (CMS ≥ 65). Mortality at 90 days for CMS ≥ 65 was 1.3% and the overall complication rate was 20.1% (minor 15.6%; major 7.1%). Total weight loss (TWL) at 6 months and 1, 2, and 3 years was 25.3%, 30.0%, 29.9%, and 29.4% respectively. For any time after surgery, 23% of CMS ≥ 65 had complete remission of diabetes and 45% had partial remission.Demographic analysis of CMS < 65 found Medicare patients were significantly older with more diabetes, hypertension and hyperlipidemia than those with commercial payers. Mortality at 90 days for CMS < 65 was 0.6% and the overall complication rate was 18.3% (minor 14.3%; major 4.7%). Mortality was not significantly different between payers. After adjustment for baseline differences and comparing to the Medicare group, the commercial group was less likely to have minor complications (P = .019), any complications (P = .007), and extended length of stay (P < .001). The TWL for the entire cohort age <65 at 6 months and 1, 2, and 3 years was 28.1%, 34.1%, 34.1%, and 31.8% respectively. After adjusting for differences, there was no significant difference in TWL between payers. For any time after surgery, complete remission of diabetes was 45% in CMS < 65 patients and partial remission was 59%. The comparison of remission between groups was then adjusted for DiaRem score and surgery type. CMS < 65 patients had significantly less partial remission of diabetes than commercial patients (P = .034) but no difference in complete remission. ConclusionsRYGB and SG are both safe and effective in Medicare patients of all ages. CMS ≥ 65 have acceptable mortality and complication rates with TWL and diabetes remission similar to younger patients. CMS < 65 patients are older than those with commercial insurance with more comorbid disease. While they have longer hospital stays after bariatric surgery, their weight loss and complete remission of diabetes are no different than patients with Medicaid or commercial insurance. This study helps fill an important evidence gap in bariatric surgical patients raised by both Agency for Healthcare Research and Quality, and a Medicare Evidence Advisory Committee.

Factors related to physical functioning decline after cardiac surgery in older patients: A multicenter retrospective study

BackgroundAs few studies have examined physical functioning changes after cardiac surgery, the factors related to the decline in physical functioning remain unclear. This study aimed to investigate the factors related to physical functioning decline after cardiac surgery in older patients. MethodsThe final study sample consisted of 523 older (≥65 years) patients (age 74.2±6.1 years, 66% male) who underwent cardiac surgery at 8 Japanese institutions. We excluded patients who were unable to walk independently or had a slow gait speed (<0.8m/s) before surgery, and those who were unable to regain independent walking after surgery. We divided the patients into two groups, a decline-in-gait-speed group and a non-decline-in-gait-speed group, according to whether their gait speed was less than 0.8m/s at discharge. We analyzed patients’ clinical characteristics to identify the factors that predicted the postoperative decline in gait speed. ResultsEighty-nine patients (17.0%) showed a postoperative decline in gait speed. Multivariate logistic regression analysis showed that the following factors predicted a postoperative decline in gait speed: age [odds ratio (OR) 1.06, 95% confidence interval (CI) 1.02–1.11]; estimated glomerular filtration rate (OR 0.98, CI 0.96–0.99); preoperative gait speed (OR 0.01, CI 0.00–0.08); and the postoperative day on which the patient could walk independently (OR 1.08, CI 1.02–1.14). ConclusionsPhysical functioning declined in 17% of patients after surgery. The decline could be predicted by several clinical factors, including some that are modifiable. These results suggest that further interventional research on rehabilitation before and after cardiac surgery for older patients might help overcome the decline in physical functioning.

Safety of Laparoscopic Oncologic Resection in Elderly Patients with Colorectal Cancer: A Multicenter Retrospective Study Based on Perioperative Short-Term Outcomes

Objectives: Over the last century, unthinkable goals have been achieved in health care and medical sciences, leading to longer life expectancy. Although cancer affects all ages, it disproportionately targets older individuals. Thus, surgical oncologists are confronted with increasing numbers of older patients presenting with multiple chronic conditions. We intended to investigate the safety of oncologic resection in older patients with colorectal cancer (CRC) based on perioperative outcomes. Materials and Methods: We retrospectively collected and analyzed data from older patients (>85 years) who underwent curative resection for stage II or III CRC between January 2007 and August 2017 at four hospitals (St. Vincent's Hospital, Incheon St. Mary's Hospital, Seoul St. Mary's Hospital, and Yeouido St. Mary's Hospital). Results: A total of 140 patients were enrolled in this study. The mean age was 87.1, the mean stay in the intensive care unit after surgery was 1.6 ± 3.8 days, and the mean postoperative hospital stay was 10.5 ± 3.8 days, D3 lymph node dissection was performed in 67.0% of patients, and D2 lymph node dissection was performed in 33.0%. Postoperative complications occurred in 38 patients (27.9%). In the univariate analysis, the risk factors for postoperative complications were the omission of mechanical bowel preparation (P = .039) and open surgery (P = .031). Conclusions: Oncologic resection in selected older patients with CRC might be a relatively safe treatment option. In particular, a laparoscopic approach might be a safer surgical method than open surgery in older patients with CRC.

In-hospital perforation risk in acute appendicitis: Age matters

BackgroundControversy exists regarding how quickly an adult with appendicitis requires surgery to prevent perforation, and recent literature on antibiotic use as definitive treatment has complicated this question further. Since perforation is associated with worse outcomes, particularly in the elderly, efforts to prevent this complication are warranted. We studied risk factors for in-hospital perforation in patients diagnosed by admission CT with non-perforated acute appendicitis. MethodsWe evaluated baseline demographics, symptom duration, and time from admission to antibiotics and surgery. Outcome measure was perforation diagnosed intra-operatively by attending surgeon. ResultsOf 700 patients, 84 (12%) sustained in-hospital perforation; time from admission to operation or antibiotics were not associated. Duration of symptoms >24 h (aOR = 2.23, 95% CI = 1.33–3.72, p < 0.001) increased perforation risk. Patient age over 46 years (aOR = 4.54, 95% CI = 2.04–10.06, p < 0.001) was also associated with higher risk that increased with increasing age. ConclusionTime to operation and antibiotic timing were not associated with in-hospital perforation in a general adult population. However, these findings suggest a possible benefit to expedient surgery in older patients.

Improving Care of Cleft-Related Velopharyngeal Incompetence on Humanitarian Missions Using a Multidisciplinary Team Approach.

Proper evaluation and analysis of speech surgery outcomes for cleft-related velopharyngeal incompetence in children and young adults performed on humanitarian missions is poorly characterized. The aim of this study is to examine the effect of using a multidisciplinary team on cleft-related humanitarian missions. The effect on patient selection, velopharyngeal mechanism imaging, and speech outcomes after surgery will be highlighted. A review of the Medical Readiness Training Exercise database for craniofacial missions to the Dominican Republic from 2009 to 2011 was performed. A speech pathologist and a craniofacial surgeon evaluated all patients with a diagnosis of cleft palate and speech abnormalities. Patients were screened using speech analysis and selective nasal endoscopy. Data collected included sex, age, diagnosis, speech scores, date, and type of surgical procedure-that is, pharyngeal flap (PF) versus sphincter pharyngoplasty (SP), morbidity, and mortality. One hundred twenty-six patients with cleft palate were screened during the study period by a craniofacial surgeon and secondarily by a speech pathologist. Twenty-eight patients were identified with nasal quality speech of whom 12 patients (12/126 = 9.5% of total surgical cases) underwent PF/SP surgery after previous primary repair of a cleft palate defect. The 16 remaining patients (16/28 = 57%) with nonsurgical speech abnormalities were determined that surgery was not going to be beneficial and they were spared unnecessary surgery after speech pathology evaluation and nasal endoscopy. Eight patients were female and 4 patients were male; average age was 13.3 years (range 4-27 years). Seven pharyngeal flaps (58%) and 5 (42%) sphincter pharyngoplasty procedures were performed. The average presurgical speech score was 11.4 (range 6-24). There was a significant decrease in postsurgical speech scores with the average postsurgical speech score of 5.2 (range 0-21, P value = 0.0028). Follow-up evaluation averaged 18 months (range 6-24). Average hospital stay was 2 days for PF/SP surgery. Two patients, both with developmental delay, retained speech scores greater than 6. There were no major complications or reoperations. Pharyngeal flap/sphincter pharyngoplasty surgery in young adults resulted in improved speech scores and comprehensibility after speech surgery on Medical Readiness Training Exercise military humanitarian missions. Speech surgery in older patients in relatively austere environments is safe and effective. After comprehensive multidisciplinary team evaluation, 43% of the patients who were screened to have velopharyngeal incompetence were identified as surgical candidates. Fifty-seven percent of patients evaluated by speech pathologist were recommend nonsurgical solution toward improving speech scores sparing them unnecessary surgery. The incorporation of a speech pathologist to the humanitarian mission resulted in identifying surgical candidates who would benefit the most from intervention and improved speech surgery outcomes.