Surgery In Geriatric Patients Research Articles

Thyroid surgery in geriatric patients: a literature review.

BackgroundThyroid disease is common in the elderly population. The incidence of hypothyroidism and multinodular goitre gradually increases with age. In view of a growth of aging population, we performed a literature review about the feasibility of thyroid surgery in the elderly.MethodsWe conducted a literature search in the PubMed database in September 2012 and all English-language publications on thyroidectomy in geriatric patients since 2002 were retrieved. The potential original articles mainly focusing on thyroidectomy in elderly patients were all identified and full texts were obtained and reviewed for further hand data retrieving.ResultsWe retrieved five papers based on different primary end-point. Four were retrospective non randomized studies and one was prospective non randomized study. At last 65, 70, 75 and 80 years were used as an age cut-off. All studies evaluate the indications of thyroidectomy in geriatric patients, postoperative morbility and mortality. Only one study specifically assesses the rate of the rehospitalization after thyroidectomy among the elderly.ConclusionsThyroid nodules are particularly important in elderly patients, as the incidence of malignancy increases and they are usually more aggressive tumors. An age of at least 70 years is an independent risk factor for complications after general surgery procedures. Thyroid surgery in patients aged 70 years or older is safe and the relatively high rate of thyroid carcinoma and toxic goiter may justify an aggressive approach. A programmed operation with a careful pre-operative evaluation and a risk stratification should make the surgical procedures less hazardous, specially in 80 years old patients with an high ASA score.

Regional Anesthesia as Compared with General Anesthesia for Surgery in Geriatric Patients with Hip Fracture: Does It Decrease Morbidity, Mortality, and Health Care Costs? Results of a Single-Centered Study

Hip fracture in geriatric patients has a substantial economic impact and represents a major cause of morbidity and mortality in this population. At our institution, a regional anesthesia program was instituted for patients undergoing surgery for hip fracture. This retrospective cohort review examines the effects of regional anesthesia (from mainly after July 2007) vs general anesthesia (mainly prior to July 2007) on morbidity, mortality and hospitalization costs. This retrospective cohort study involved data collection from electronic and paper charts of 308 patients who underwent surgery for hip fracture from September 2006 to December 2008. Data on postoperative morbidity, in-patient mortality, and cost of hospitalization (as estimated from data on hospital charges) were collected and analyzed. Seventy-three patients received regional anesthesia and 235 patients received general anesthesia. During July 2007, approximately halfway through the study period, a regional anesthesia and analgesia program was introduced. The average cost of hospitalization in patients who received surgery for hip fracture was no different between patients who receive regional or general anesthesia ($16,789 + 631 vs $16,815 + 643, respectively, P = 0.9557). Delay in surgery and intensive care unit (ICU) admission resulted in significantly higher hospitalization costs. Age, male gender, African American race and ICU admission were associated with increased in-hospital mortality. In-hospital mortality and rates of readmission are not statistically different between the two anesthesia groups. There is no difference in postoperative morbidity, rates of rehospitalization, in-patient mortality or hospitalization costs in geriatric patients undergoing regional or general anesthesia for repair of hip fracture. Delay in surgery beyond 3 days and ICU admission both increase cost of hospitalization.

Spinal anesthesia with low dose bupivacaine-fentanyl combination: a good alternative for day case TURP surgery in geriatric patients

Spinal anesthesia with low dose bupivacaine-fentanyl combination: a good alternative for day case TURP surgery in geriatric patients

Spine surgery in geriatric patients: Sometimes unnecessary, too much, or too little

Background:Although the frequency of spinal surgical procedures has been increasing, particularly in patients of age 65 and over (geriatric), multiple overlapping comorbidities increase their risk/complication rates. Nevertheless, sometimes these high-risk geriatric patients are considered for “unnecessary”, too much (instrumented fusions), or too little [minimally invasive surgery (MIS)] spine surgery.Methods:In a review of the literature and reanalysis of data from prior studies, attention was focused on the increasing number of operations offered to geriatric patients, their increased comorbidities, and the offers for “unnecessary” spine fusions, including both major open and MIS procedures.Results:In the literature, the frequency of spine operations, particularly instrumented fusions, has markedly increased in patients of age 65 and older. Specifically, in a 2010 report, a 28-fold increase in anterior discectomy and fusion was observed for geriatric patients. Geriatric patients with more comorbid factors, including diabetes, hypertension, coronary artery disease (prior procedures), depression, and obesity, experience higher postoperative complication rates and costs. Sometimes “unnecessary”, too much (instrumented fusions), and too little (MIS spine) surgeries were offered to geriatric patients, which increased the morbidity. One study observed a 10% complication rate for decompression alone (average age 76.4), a 40% complication rate for decompression/limited fusion (average age 70.4), and a 56% complication rate for full curve fusions (average age 62.5).Conclusions:Increasingly, spine operations in geriatric patients with multiple comorbidities are sometimes “unnecessary”, offer too much surgery (instrumentation), or too little surgery (MIS).

Perioperative oral nutritional supplements in normally or mildly undernourished geriatric patients submitted to surgery for hip fracture: A randomized clinical trial

Oral nutritional supplements have been recommended after orthopedic surgery in geriatric patients. This has been shown to be effective even in normally nourished or mildly undernourished geriatric patients. Whether perioperative administration of these products is also effective and suitable is not known. Randomized, controlled, open, paralleled two-arms clinical trial, comparing energy-protein supplements (40 g of protein and 400 kcal per day), with no intervention in normally nourished or mildly undernourished patients. Outcomes were serum proteins, body mass index, postoperative complications among others. 60 Elderly patients were included. Patients in the intervention group (n = 30) ingested 52.2 ± 12.1% of the prescribed supplements per day for 5.8 ± 1.8 days before surgery and until hospital discharge. There was a significant change in serum albumin at follow-up (F = 22.536, P < 0.001), and between the two groups (F = 5.763, P = 0.002), favouring the intervention. The same was observed for serum prealbumin (F = 6.654, P = 0.001 within subjects, F = 2.865, P = 0.045 for interaction). Logistic regression showed that only supplemented proteins per day (OR[95%CI] = 0.925[0.869-0.985]) were associated with less postoperative complications (R(2) = 0.323, χ(2) = 11.541, P = 0.003). Perioperative supplements in geriatric patients with hip fracture submitted to surgery showed better recovery of plasma proteins. Higher daily protein intakes were associated with less postoperative complications.

Clinical Comparison of 12 mg Ropivacaine and 8 mg Bupivacaine, Both with 20 µg Fentanyl, in Spinal Anaesthesia for Major Orthopaedic Surgery in Geriatric Patients

Objective: The aim of this study was to compare the haemodynamic and anaesthetic effects of 12 mg ropivacaine and 8 mg bupivacaine, both with 20 µg fentanyl, in spinal anaesthesia for major orthopaedic surgery in geriatric patients. Subjects and Methods: Sixty American Society of Anesthesiologists (ASA) II–III patients scheduled for hip arthroplasty were randomly assigned to receive an intrathecal injection of either 12 mg ropivacaine with 20 µg fentanyl (group R, aged 70 ± 7 years, range 67–89) or 8 mg hyperbaric bupivacaine with 20 µg fentanyl (group B, aged 69 ± 6 years, range 66–92). Motor and sensory block, haemodynamics and side effects were recorded. Results: Mean levels of sensory block were similar, but the onset time of sensory block in group B (2.52 ± 0.69 min) was shorter than that in group R (3.17–0.72 min); the difference was statistically significant (p < 0.01), and the number of patients who had motor Bromage scale 3 in group B (24) was greater than in group R (16). The difference was also statistically significant (p < 0.05). Systolic and diastolic arterial pressures (SAP, DAP) and heart rate (HR) decreased after the block in both groups. SAP (after the 60th and 120th min of block), DAP (all measurement times), and HR (after the 20th, 25th and 30th min of block) were lower in group B than in group R. Conclusions: The data showed that 12 mg of ropivacaine and 8 mg of bupivacaine with 20 µg fentanyl in spinal anaesthesia can provide sufficient motor and sensory block for major orthopaedic surgery in geriatric patients. However, ropivacaine caused less motor block and haemodynamic side effects than bupivacaine during the procedure.

Effects of Oral Nutritional Supplements in Normally Nourished or Mildly Undernourished Geriatric Patients After Surgery for Hip Fracture: A Randomized Clinical Trial

Oral nutritional supplements have been recommended after orthopedic surgery in geriatric patients to reduce postoperative complications. However, tolerability of supplements could be a limitation, and their universal use is not supported by the heterogeneity of previous studies, especially in patients without malnutrition. This study is a randomized, controlled, open, parallel, 3-arm clinical trial comparing supplementation with protein powder dissolved in liquids to aim at 36 g of protein per day, energy and protein supplements to aim at 37.6 g of protein and 500 kcal per day, or no intervention in normally nourished or mildly undernourished patients. Outcomes were serum albumin, prealbumin, retinol-binding globulin, and body mass index, among others. Postoperative complications were also recorded. Ninety patients aged 83.8 +/- 6.6 years were included. The mean ingested amount of supplements was 41.1% +/- 20.6% in the protein powder supplement group and 51.4% +/- 13.2% in the energy protein supplement group (t = 2.278, P = .027). Postoperative supplements had no effect on the nutrition status during in-hospital follow-up, as assessed by serum albumin (P = .251), prealbumin (P = .530), retinol-binding globulin (P = .552), or body mass index (P = .582). Multivariate analysis showed that length of hospital stay with an established complication until its resolution (beta = .230, P = .031), total hospital stay (beta = .450, P < .001), baseline body mass index (beta = .204, P = .045), and total daily ingested proteins per body weight (beta = .252, P = .018) were predictive variables on the change in serum albumin (R2 = 0.409, F = 11.246, P < .001). Oral nutritional supplements in normally nourished or only mildly undernourished geriatric patients with hip fracture submitted to surgery may be of interest for patients with postoperative complications and long hospital stays.

Cardiac Anesthesia and Surgery in Geriatric Patients

The average age of US population is steadily increasing, with more than 15 million people aged 80 and older. Coronary artery disease and degenerative cardiovascular diseases are particularly prevalent in this population. Consequently, an increasing number of elderly patients are referred for surgical intervention. Advanced age is associated with decreased physiologic reserve and significant comorbidity. Thorough preoperative assessment, identification of the risk factors for perioperative morbidity and mortality, and optimal preparation are critical in these patients. Age-related changes in comorbidities and altered pharmacokinetics and pharmacodynamics impacts anesthetic management, perioperative monitoring, postoperative care, and outcome. This article updates the age-related changes in organ subsystems relevant to cardiac anesthesia, perioperative issues, and intraoperative management. Early and late operative outcome in octogenarians undergoing cardiac surgery are reviewed. The data clearly indicate that no patient group is "too old" for cardiac surgery and that excellent outcomes can be achieved in selected group of elderly patients.

Which Octogenarians Do Poorly After Major Open Abdominal Surgery in Our Asian Population?

As the elderly population grows and surgeons are faced with more octogenarians, there is a need to know how our Asian patients fair after major surgery. A retrospective review of 125 octogenarians who underwent major abdominal surgery between January 1997 and September 2003 was performed. Preoperative condition was assessed using a weighted index of comorbidity used in Charlson Comorbidity Index and classification of patients according to the American Society of Anaesthesiologists (ASA). Outcome was measured as to whether complications developed, 30-day mortality and whether there was return to premorbid function. The patients had a mean age of 84.6 years (range: 80-106). Nearly half (48.8%, n = 61) the cases were emergency cases. The median index of comorbidity was 3, and 29.6% of patients were classified either ASA III or IV. The operations were mostly stomach, small bowel or large bowel resection. Multivariate analysis revealed that emergency operations were associated with significantly increased odds of morbidity. The overall 30-day mortality was 5.6%, being only 4.7% for elective cases, despite high morbidity rates. ASA classification, comorbidity index >5, development of acute coronary syndrome and anastomotic leakage were found on multivariate analysis to significantly increase the odds of mortality. For elective cases, 82.8% of patients were able to return to their premorbid functional status. Development of complications and comorbidity index >5 were found to predict failure of its occurrence. Low serum albumin and haemoglobin and renal impairment were also predictors of adverse outcome. Efforts to improve outcome in geriatric surgery patients should emphasize a shift of attitude towards elective surgery rather than doing emergency operations when complications occur and also target the optimization of predictors of adverse outcome. Octogenarians should not be denied elective surgery.

Comparison of Three Diffferent Modalities for Combined Spinal Epidural Anesthesia and Spinal Anesthesia in Geriatric Patients

Background: Combined spinal epidural anesthesia (CSE) combines the rapid onset and intensity of a subarachnoid blockade with the flexibility of an epidural catheter, thereby allowing the intraoperative extension of anesthesia and postoperative epidural analgesia. This study investigated the effects of hyperbaric bupivacaine during CSE for lower limb orthopedic surgery in geriatric patients. Methods: Group 1 received a subarachnoid injection of 8 mg of bupivacaine and an epidural catheter. Group 2 received a subarachnoid injection of 5 mg of bupivacaine and fentanyl, 10 and an epidural top-up with 3 ml saline. Group 3 received a subarachnoid injection of 5 mg of bupivacaine and fentanyl 10 with an epidural top-up of 6 ml saline. Group 4 received a subarachnoid injection of 6 mg of bupivacaine and an epidural top-up with 6 ml saline. The maximal level of the sensory blockade, the time of onset to the maximal sensory blockade, the two segment regression time, the time for sensory regression to the tenth thoracic dermatome (T10) and the motor recovery to modified Bromage Scale 0 were compared. After recording the baseline systolic blood pressure and heart rate, the systolic blood pressure and heart rate were recorded at 5 min intervals. Results: There were significant differences in the two-segment regression times, the times to motor recovery between the groups. However, the intraoperative blood pressure and heart rate were similar. Conclusions: In terms of the peri-operative side effects and recovery from the blocks, CSE was better for lower limb orthopedic surgery in geriatric patients than spinal anesthesia.

Perioperative Changes in Thromboelastogram in Elderly Patients Receiving Major Orthopedic Surgery

Background: There is a high incidence of thromboembolism after major orthopedic surgery. However, more perioperative thromboembolic complications are expected after orthopedic surgery in geriatric patients due to the more offensive therapeutic measures and the increasing number of such patients with multimorbidity. Therefore it is important to investigate the perioperative blood coagulation status in detail. Methods: Forty-five patients who were over 65 years old and scheduled for major orthopedic surgery were enrolled in this study. Patients with preoperative coagulation abnormalities, or receiving anticoagulants or antiplatelet medications were excluded. Preoperative thromboelastography (TEG), intraoperative TEG after blood loss equaling approximately 10% of the estimated blood volume, and postoperative TEG at the recovery room were measured and compared. Results: During the operation, the R time and coagulation time (r + k) showed significant decreases, whereas the alpha angle, maximum amplitude (MA) and TEG index increased significantly (P ＜ 0.05), indicating increased coagulability. The A60, CL30 and CL60 also increased, indicating decreased fibrinolysis (P ＜ 0.05). These hypercoagulable findings were relieved after surgery to levels similar to those observed preoperatively. Conclusions: The intraoperative coagulability increased compared with the preoperative and postoperative period according to the TEG. This means that the intraoperative period is the period of most susceptibility to thromboembolic complications.

Delayed respiratory depression after interscalene blockade for shoulder surgery in geriatric patients

Delayed respiratory depression after interscalene blockade for shoulder surgery in geriatric patients

Evolution During Half a Century of the Results of Digestive Surgery in Geriatric Patients. A Review of the Literature, Experience at C.H.U. Brugmann and the Medium Term Outlook

The undertaking of complex and major surgical procedures on frail elderly patients with multiple disorders has always been and still remains a controversial and enigmatic issue. At the same time, in an increasingly ageing society, the need for such procedures will extend and patients will expect a more favourable outcome. Surgery in old age will, therefore, pose an ongoing challenge. With better anaesthetic management, surgical techniques and comprehensive geriatric assessment, the overall results for all surgery have improved remarkably over the last few decades. Stringent pre-operative assessment and rigorous post-operative care have achieved a significant reduction in mortality and morbidity; surgery has become a lot safer.

Bariatric surgery in geriatric patients: Still controversial?

Bariatric surgery in geriatric patients: Still controversial?

Colorectal cancer in geriatric patients: Endoscopic diagnosis and surgical treatment

To investigate the prevalence of colorectal cancer in geriatric patients undergoing endoscopy and to analyze their outcome. All consecutive patients older than 80 years who underwent lower gastrointestinal endoscopy between January 1995 and December 2002 at our institution were included. Patients with endoscopic diagnosis of colorectal cancer were evaluated with respect to indication, localization and stage of cancer, therapeutic consequences, and survival. Colorectal cancer was diagnosed in 88 patients (6% of all endoscopies, 55 women and 33 men, mean age 85.2 years). Frequent indications were lower gastrointestinal bleeding (25%), anemia (24%) or sonographic suspicion of tumor (10%). Localization of cancer was predominantly the sigmoid colon (27%), the rectum (26%), and the ascending colon (20%). Stage Dukes A was rare (1%), but Dukes D was diagnosed in 22% of cases. Curative surgery was performed in 54 patients (61.4%), in the remaining 34 patients (38.6%) surgical treatment was not feasible due to malnutrition and asthenia or cardiopulmonary comorbidity (15 patients), distant metastases (11 patients) or refusal of operation (8 patients). Patients undergoing surgery had a very low in-hospital mortality rate (2%). Operated patients had a one-year and three-year survival rate of 88% and 49%, and the survival rates for non-operated patients amounted to 46% and 13% respectively. Nearly two-thirds of 88 geriatric patients with endoscopic diagnosis of colorectal cancer underwent successful surgery at a very low perioperative mortality rate, resulting in significantly higher survival rates. Hence, the clinical relevance of lower gastrointestinal endoscopy and oncologic surgery in geriatric patients is demonstrated.

Dermatologic surgery in geriatric patients: psychosocial considerations and perioperative decision-making.

Dermatologic surgery, both for cutaneous malignancies and for management of the visible signs of photodamage, is frequently performed on older persons. To review common psychologic and physiologic limitations among the elderly that may affect their ability to tolerate cutaneous surgery and to outline a stepwise approach for management of these conditions during the perioperative period. Literature review, MEDLINE (1966-2001) search, and personal experience. Communication with patients, their families, and their physicians, management of patients' underlying medical problems, and special sensitivity to patients' cognitive and physiologic limitations can minimize perioperative risk during cutaneous surgery in the elderly. Given appropriate physician management, elderly patients can usually safely undergo cutaneous surgery.

Dermatologic Surgery in Geriatric Patients

Dermatologic Surgery in Geriatric Patients

Normalization of hypertensive responses during ambulatory surgical stress by perioperative music.

The purpose of this study was to determine whether cognitive appraisals of stress level and hypertensive responses to ambulatory ophthalmic surgery can be ameliorated by patient-selected music. We studied 40 elderly individuals requiring ophthalmic surgery, 20 in an experimental group (mean age, 74 years) and 20 in a control group (mean age, 77 years). All patients had an established resting blood pressure <140/90 mm Hg. In the experimental group self-selected music was provided by headphones throughout the preoperative, surgical, and postoperative periods. In the control group patients had neither headphones nor music. All patients received similar (weight-determined) doses of alfentanil and midazolam during surgery. Heart rate, blood pressure, and patient-reported stress and coping levels were the dependent variables. In both groups, blood pressure values were normal (approximately 129/82 mm Hg) during screening examinations 1 week before surgery. On the day of surgery both groups displayed increased preoperative blood pressures (approximately 159/92 mm Hg) associated with increases in heart rate (by approximately 17 beats/min). Intraoperative blood pressures in the experimental group returned quickly to screening baseline values, whereas the control group experienced persistent elevations in intraoperative blood pressure similar to preoperative levels. Over the course of the surgical experience, patients with music reported significant reductions in perceived stress and increases in coping abilities (p < .001), whereas those without music did not. The perceived stress of ambulatory surgery in geriatric patients is associated with a clinical hypertensive response that is ameliorated by self-selected perioperative music, which also decreases perceived stress and increases patients' sense of personal control and well-being.

Brain tumor surgery in geriatric patients: a critical analysis in 44 patients over 80 years

BACKGROUND The decision of whether to operate on brain tumors in elderly patients has not been made easier despite diagnostic and therapeutic advances facilitating their diagnosis. Little is known about the outcome of brain tumor surgery in patients 80 years or older probably because the number of these patients, although increasing, is still small. METHODS The results of brain tumor surgery in 44 patients aged 80–86 years (mean age 83 years) were analyzed to determine which factors are relevant in the evaluation of the operative risk. The following parameters were analyzed with regard to the outcome: tumor volume, location, histopathology, preoperative condition, and concomitant diseases. RESULTS At discharge 19 patients (43%) had improved while 14 (32%) remained unchanged. Nevertheless, the overall results were unsatisfactory in 10 patients (23%), of whom 5 died in hospital. Tumor location, volume, and histopathology did not correlate with the outcome. The preoperative cerebrovascular condition and the existence of multiple concomitant diseases were clearly the determining factors for the outcome. CONCLUSIONS These results indicate that patients with life-threatening tumors or those causing persistent and intolerable brain dysfunction suffering from symptomatic cerebrovascular atherosclerosis as well as from multiple treatment requiring concomitant diseases did definitely not benefit from surgery.

Respiratory Depression After 5 [micro sign]g of Intrathecal Sufentanil

Respiratory Depression After 5 [micro sign]g of Intrathecal Sufentanil