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More octogenarians muscling through emergent surgeries




CHICAGO – An increasing number of octogenarians are undergoing emergent surgeries, but the mortality associated with these procedures has not changed significantly, a national ACS/NSQIP analysis found.

From 2005 to 2012, overall mortality among 5,016 octogenarians actually decreased slightly from 8.8% to 7.3%. This reduction was driven by declining death rates for appendectomy from 6.7% to 2.4%, ventral hernia repair from 11% to 4%, and cholecystectomy from 5% to 3%.

Only octogenarians undergoing a Hartmann’s procedure were more likely to die over the 7-year study period, increasing from 14.3% to 21.7%, Dr. Busayo Irojah, of Wellspan Health York (Pa.) Hospital, reported at the American College of Surgeons (ACS)/National Surgical Quality Improvement Program (NSQIP) National Conference.

In all, 1,440 patients, mean age 84 years, underwent appendectomy (35% open; 65% laparoscopic), 1,252 cholecystectomy (34% open; 66% laparoscopic), 1,197 ventral (umbilical/inguinal) hernia repair (96% open; 4% laparoscopic), and 1,127 Hartmann’s procedure.

Mortality was lower for laparoscopic than for open procedures; appendectomy (2.1% vs. 4.2%; P = .024), cholecystectomy (3.1% vs. 11.6%; P less than .0001), and hernia repair (1.9% vs. 5.8%; P = .22), Dr. Irojah reported.

In multivariate analysis that adjusted for 31 variables including patient characteristics, medical comorbidities, and hospital characteristics, significant predictors of mortality were: sepsis (Odds ratio, 2.5; P less than .01), DNR status (OR, 2.4; P less than .001), previous cardiac surgery (OR, 2.3; P = .003), postoperative renal failure (OR, 2.6; P = .03), poor functional health status (OR, 4.5; P less than .001), and disseminated cancer (OR 6.5; P = .01).

Super elders

Poor functional status was also a strong predictor of morbidity and mortality in the “super elderly” following cholecystectomy in a separate analysis, also led by Dr. Irojah.

The study involved 1,017 patients, aged 90 years and older, who underwent cholecystectomy from 2005 to 2012 in the ACS/NSQIP database. Of these cases, 78% were laparoscopic, 22% open, 80% emergent, and 20% elective.

Mortality was three times higher for an open than a laparoscopic procedure (12.2% vs. 3.8%; P less than .01) and twice as high for emergent than elective cases (10% vs. 4.5%; P less than .01).

In multivariate analysis that adjusted for 25 variables, significant independent predictors of mortality were: preoperative total dependence vs. functional independence (OR, 12.75), postoperative acute renal failure (OR 19.46), postoperative myocardial infarction (OR 71.16), and an open approach (OR, 5.44; all P values less than .00).

“Mortality following both elective and emergent cholecystectomy in patients ninety and over is higher than the general population; hence preoperative optimization is essential and nonoperative management might be reasonable in high-risk patients,” Dr. Irojah observed.

The odds of a complication were double for super elders undergoing open cholecystectomy (OR, 2.4; P less than .01) and at least four times higher for those with poor preoperative functional health status (OR, 4.2; P less than .01), undergoing emergency surgery (OR 4.3; P = .03), or who were Hispanic (OR 4.9; P less than .01), Dr. Irojah reported.

An outpatient procedure, however, was protective for morbidity (OR, 0.39: P = .03) in multivariate analysis adjusted for 13 variables.

“We are trying to educate primary care in our area on the need to avoid emergency operation and preemptively assess for elective operation. Secondarily, we are discussing palliative care with families of elderly higher-risk patients,” senior author and colleague Dr. Vanita Ahuja said in an interview.

The study authors reported having no disclosures.

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