RESUMEN
BACKGROUND: Frailty has been shown to be a good predictor of post-operative complications and death in patients undergoing gastrointestinal surgery. The aim of this study was to analyze the differences between frail and non-frail patients undergoing colorectal cancer surgery, as well as the impact of frailty on long-term survival in these patients. METHODS: A cohort of 149 patients aged 70 years and older who underwent elective surgery for colorectal cancer was followed-up for at least 5 years. The sample was divided into two groups: frail and non-frail patients. The Canadian Study of Health and Aging-Clinical Frailty Scale (CSHA-CFS) was used to detect frailty. The two groups were compared with regard to demographic data, comorbidities, functional and cognitive statuses, surgical risk, surgical variables, tumor extent, and post-operative outcomes, which were mortality at 30 days, 90 days, and 1 year after the procedure. Univariate and multivariate analyses were also performed to determine which of the predictive variables were related to 5-year survival. RESULTS: Out of the 149 patients, 96 (64.4%) were men and 53 (35.6%) were women, with a median age of 75 years (IQR 72-80). According to the CSHA-CFS scale, 59 (39.6%) patients were frail, and 90 (60.4%) patients were not frail. Frail patients were significantly older and had more impaired cognitive status, worse functional status, more comorbidities, more operative mortality, and more serious complications than non-frail patients. Comorbidities, as measured by the Charlson Comorbidity Index (p = 0.001); the Lawton-Brody Index (p = 0.011); failure to perform an anastomosis (p = 0.024); nodal involvement (p = 0.005); distant metastases (p < 0.001); high TNM stage (p = 0.004); and anastomosis dehiscence (p = 0.013) were significant univariate predictors of a poor prognosis on univariate analysis. Multivariate analysis of long-term survival, with adjustment for age, frailty, comorbidities and TNM stage, showed that comorbidities (p = 0.002; HR 1.30; 95% CI 1.10-1.54) and TNM stage (p = 0.014; HR 2.06; 95% CI 1.16-3.67) were the only independent risk factors for survival at 5 years. CONCLUSIONS: Frailty is associated with poor short-term post-operative outcomes, but it does not seem to affect long-term survival in older patients with colorectal cancer. Instead, comorbidities and tumor stage are good predictors of long-term survival.
Asunto(s)
Cirugía Colorrectal , Procedimientos Quirúrgicos del Sistema Digestivo , Fragilidad , Neoplasias , Anciano , Anciano de 80 o más Años , Canadá , Preescolar , Femenino , Fragilidad/epidemiología , Evaluación Geriátrica , Humanos , Masculino , Pronóstico , Factores de RiesgoRESUMEN
BACKGROUND: Advanced age is a risk factor for colorectal cancer, and very elderly patients often need to be surgically treated. This study aimed to analyze the outcomes of a cohort of nonagenarian patients operated on for colorectal cancer. METHODS: Observational study conducted on a cohort of 40 nonagenarian patients, who were treated surgically for colorectal cancer between 2000 and 2018 in our institution. Clinical data, ASA score, Charlson Comorbidity Index, Surgical Mortality Probability Model, tumor characteristics, and nature and technical features of the surgical procedure, were recorded. The Comprehensive Complication Index (CCI) and survival time after the procedure were recorded as outcome variables. Univariate and multivariate analyses were performed in order to define risk factors for postoperative complications and long-term survival. RESULTS: Out of the 40 patients, 13 (32.5%) were men, 27 (67.5%) women, and mean age 91.6 years (SD ± 1.5). In 24 patients (60%), surgery was elective, and in 16 patients (40%), surgery was emergent. Curative surgery with intestinal resection was performed in 34 patients (85%). In 22 patients (55%), intestinal continuity was restored by performing an anastomosis. The median CCI was 22.6 (IRQ 0.0-42.6). Operative mortality was 10% (4 patients). Cumulative survival at 1, 3, and 5 years was 70%, 47%, and 29%, respectively. In multivariate analysis, only the need for transfusion remained as an independent prognostic factor for complications (p = 0.021) and TNM tumor stage as a significant predictor of survival (HR 3.0, CI95% 1.3-7.2). CONCLUSIONS: Colorectal cancer surgery is relatively safe in selected nonagenarian patients and may achieve long-term survival.
Asunto(s)
Neoplasias Colorrectales/cirugía , Anciano de 80 o más Años , Neoplasias Colorrectales/mortalidad , Neoplasias Colorrectales/patología , Procedimientos Quirúrgicos del Sistema Digestivo/métodos , Procedimientos Quirúrgicos del Sistema Digestivo/estadística & datos numéricos , Femenino , Humanos , Masculino , Seguridad del Paciente , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Tasa de SupervivenciaRESUMEN
PURPOSE: Preoperative assessment at extreme ages would identify patients at a high risk of developing postoperative complications. The objective of this study was to compare the usefulness of different risk scales in a series of nonagenarian surgical patients. METHODS: A total of 244 surgical nonagenarians, 148 women (60.7%), median age 91 years (IQR: 90-93), were analysed. The following scales were evaluated: preoperative status (ASA-PS, Charlson Comorbidity Index, Lee Index, Reiss Index, and surgical mortality probability model-S-MPM); intraoperative status (Surgical Apgar Score and SASA score), and, as output variables, surgical outcomes (morbidity measured by the Comprehensive Complication Index-CCI, and death). Univariate analysis and receiver operating characteristic curves (ROC) were performed. Area under ROC curves (AUROC) were evaluated to define the best predictors of poor outcomes. RESULTS: Operative mortality was 27.0%, and 73.4% presented some type of postoperative complication. Operative mortality was associated with the ASA-PS score (p < 0.001), Reiss Index (p < 0.001), Lee Index (p = 0.010), S-MPM (p < 0.001), Surgical Apgar Score (p < 0.001), SASA score (p < 0.001), and emergency surgery (p < 0.001). Postoperative complications were related to the ASA-PS score (p = 0.001), Reiss Index (p < 0.001), Lee Index (p < 0.001), S-MPM (p < 0.001), Surgical Apgar Score (p < 0.001) and SASA score (p < 0.001). The best predictors of operative mortality and complications were the SASA and Surgical Apgar Score (AUROCs > 0.88). CONCLUSION: As in the general population, the Surgical Apgar Score and SASA score are the best predictors of operative mortality and morbidity in nonagenarian patients. These risk scales should be considered in the perioperative management of these patients.
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Complicaciones Posoperatorias , Anciano de 80 o más Años , Femenino , Humanos , Morbilidad , Complicaciones Posoperatorias/epidemiología , Curva ROC , Estudios Retrospectivos , Medición de Riesgo , Factores de RiesgoRESUMEN
AIM: The number of nonagenarians undergoing surgery has increased considerably in recent decades as a result of population aging. Greater knowledge of the most influential factors affecting perioperative morbidity and mortality would improve the quality of care and provision of health resources for these patients. The objective of the present study was to analyze the perioperative mortality, and its most determinant factors, among nonagenarian patients who underwent a surgical procedure in the Department of General and Digestive Surgery. METHODS: A retrospective descriptive study was carried out in a cohort of 159 consecutive non-selected surgical nonagenarian patients. Clinical data, type of operation, perioperative hemodynamic instability, the need for blood transfusion and medical/surgical complications were evaluated as predictor variables. The outcome variable was operative mortality. RESULTS: The mean age was 91.8 years (SD ± 2.0); there were 60 men (37.7%) and 99 (62.3%) women. Perioperative mortality was 28.93% (46 patients). The variables age (P = 0.025), American Society of Anesthesiologists physical status score (P < 0.001), neoplastic pathology (P = 0.025), intestinal surgery (P = 0.001), emergent surgery (P ≤ 0.001), perioperative blood transfusion (P = 0.003), postoperative medical complications (P < 0.001) and surgical complications (P = 0.022) showed a statistically significant correlation with mortality. American Society of Anesthesiologists physical status score (P = 0.007), emergent surgery (P < 0.032) and perioperative blood transfusion (P = 0.047) were identified as independent predictors of mortality. CONCLUSIONS: Surgery should not be denied to nonagenarian patients based only on their age. Emergency surgery and American Society of Anesthesiologists physical status classification are the most significant factors when deciding whether to intervene. Geriatr Gerontol Int 2019; 19: 293-298.
Asunto(s)
Tratamiento de Urgencia , Evaluación Geriátrica/métodos , Periodo Perioperatorio/mortalidad , Complicaciones Posoperatorias/epidemiología , Medición de Riesgo , Procedimientos Quirúrgicos Operativos , Anciano de 80 o más Años , Anestesiología/estadística & datos numéricos , Tratamiento de Urgencia/métodos , Tratamiento de Urgencia/mortalidad , Femenino , Disparidades en el Estado de Salud , Humanos , Masculino , Proyectos de Investigación , Estudios Retrospectivos , Medición de Riesgo/métodos , Medición de Riesgo/normas , Factores de Riesgo , España/epidemiología , Procedimientos Quirúrgicos Operativos/métodos , Procedimientos Quirúrgicos Operativos/mortalidadRESUMEN
AIM: In countries with longer life expectancies, the nonagenarian population is increasing. Therefore, there is greater demand for healthcare, including surgical procedures. The aim of the present study was to determine the outcomes of surgery carried out on nonagenarians in terms of long-term survival after the procedure. METHODS: We carried out a cross-longitudinal study on a cohort of 159 nonagenarian patients, who underwent a non-cardiac, non-traumatic surgical procedure in our institution between January 1999 and December 2011. The following variables were recorded: sociodemographic characteristics, American Society of Anesthesiologists score, Charlson Comorbidity Index, surgical site, postoperative complications, operative mortality and long-term survival. The output variable was long-term survival. RESULTS: Of the 159 patients,99 women (62%) and 60 men (38%), with a mean age of 91.8 years (SD ± 2.0 years), 44 cases were operations for malignant disorders (28%), 117 cases (74%) under emergency conditions and 42 cases (26%) were elective treatments. The operative mortality was 29%, 4.8% for elective surgery and 37.6% for emergency surgery (P < 0.001). The postoperative complication rate, including death, was 60%. The probability of survival at 1, 3, and 5 years was 59.6%, 35.8% and 24.1%, respectively. In multivariate analysis, American Society of Anesthesiologists score (HR 2.07, 95% CI 1.58-2.72), emergency surgery (HR 1.64, 95% CI 1.05-2.57) and postoperative medical complications (HR 2.58, 95% CI 1.73-3.85) were independently related to 5-year survival. CONCLUSIONS: These findings support the perioperative safety of elective general surgery in nonagenarian patients. In selected nonagenarian patients with no cognitive impairment, surgery must not be denied. These data might be useful for surgical decision-making or informed consent for nonagerians. Geriatr Gerontol Int 2017; 17: 2389-2395.
Asunto(s)
Anciano de 80 o más Años , Complicaciones Intraoperatorias/mortalidad , Complicaciones Posoperatorias/epidemiología , Procedimientos Quirúrgicos Operativos/efectos adversos , Procedimientos Quirúrgicos Operativos/mortalidad , Tasa de Supervivencia , Procedimientos Quirúrgicos Electivos , Tratamiento de Urgencia , Femenino , Humanos , Estudios Longitudinales , Masculino , Análisis Multivariante , Estudios Retrospectivos , Factores de RiesgoRESUMEN
BACKGROUND: More surgical interventions are being performed on octogenarian patients. The aim of this study was to identify factors associated with operative mortality and to determine if perioperative transfusions could affect mortality outcomes in a nonselected series of octogenarian patients undergoing surgery. METHODS: A descriptive cross-sectional study was performed on a population of 413 consecutive patients over 80 years old, treated surgically, and divided into two groups: transfused and nontransfused patients. The following variables were recorded: sociodemographic characteristics, main diagnoses, surgical procedure and its characteristics, ASA score, Charlson comorbidity index (CCI), National Nosocomial Infection Surveillance (NNIS) index, transfusion requirements, the Clavien-Dindo classification of surgical complications, and operative mortality. RESULTS: The mean age of the patients was 84.5 years (SD + 3.6). Transfused (25.2 %) and nontransfused patients had similar characteristics; except for neoplasia (P <0.001), NNIS (P = 0.008), operative mortality (P = 0.004), and complications according to Clavien-Dindo score (P <0.001). Operative mortality was 20.1 % (83 patients). The predictive variables associated with operative mortality were ASA score (P <0.001), emergency surgery (P <0.001), and blood transfusion (P = 0.004). After adjusting for the variables age, ASA class, NNIS, emergency surgery, and neoplasia, the multivariate analysis showed that the perioperative transfusion in octogenarian patients continued to be significantly associated with operative mortality (P = 0.019; OR 1.97, 95 % CI 1.12-3.47). CONCLUSION: Perioperative transfusion is an independent predictor of postoperative mortality in surgical octogenarian patients.
Asunto(s)
Procedimientos Quirúrgicos Operativos/mortalidad , Reacción a la Transfusión , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Transfusión Sanguínea/mortalidad , Infección Hospitalaria/mortalidad , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Atención Perioperativa/efectos adversos , Atención Perioperativa/métodos , Periodo Posoperatorio , Factores de Riesgo , España/epidemiología , Procedimientos Quirúrgicos Operativos/efectos adversosRESUMEN
BACKGROUND AND AIMS: Hartmann's operation is widely used for the surgical treatment of complicated left colonic disease. However, many patients never undergo reanastomosis. This study analyzes the factors related to the decision of restoring intestinal continuity. MATERIALS AND METHODS: Between 1997 and 2004, 162 patients underwent Hartmann's operation in our institution. Age, sex, anesthetic risk evaluation (ASA score), underlying disorder (neoplastic vs non-neoplastic), prevalence of colonic reconstruction, as well as postoperative length of hospital stay, perioperative mortality and complications due to the latter procedure were analyzed. Long-term survival was also recorded. RESULTS: Patients' mean age was 68.7 years (SD +/- 14.9); 104 were men (64.2%) and 58 were women (35.8%). Hartmann's operation mortality was 20.4%. Forty-two colonic continuity restorations were performed (25.9%). Mean time until reconstruction procedure was 13.3 months. There were no deaths (mortality 0%), but 23 cases suffered complications (54.8%). No suture dehiscence was observed. Estimated probability of being alive 1, 3, and 5 years after the initial operation was 64.1, 50.4, and 44.3%, respectively. Significant univariate predictors of reversal were male sex (p = 0.003), non-neoplastic disorder (p = 0.004), younger age (p = 0.001) and lower anesthetic risk (p = 0.009). In the multivariate analysis, independent predictive factors were age (OR: 0.94; 95% CI: 0.91-0.98), non-neoplastic disorder (OR: 0.16; 95% CI: 0.05-0.45), and lower anesthetic risk (OR: 0.22; 95% CI: 0.08-0.58). CONCLUSIONS: Hartmann's procedure implies a high mortality and a low percentage of restoration of intestinal continuity. In selected patients, closure of Hartmann's colostomy is a safe procedure, but has a significant morbidity.