Geriatric approach to the treatment of senile patients with colorectal cancer

Introduction. The lack of consensus guidelines for the treatment of colorectal cancer (CRC) in senile patients, the high incidence of early postoperative complications after radical surgery caused the search for the most optimal approach to the management of this category of patients.The aim is to introduce a geriatric approach to the treatment of colorectal cancer in senile patients, reduce the incidence of Clavien–Dindo grade 4 early postoperative complications.Materials and methods. 190 senile patients who underwent radical surgery with D3 lymphadenectomy with stage II and III colorectal cancer were enrolled in the study. They were divided into two groups: the control group included 100 patients who underwent standard treatment, the study group included 90 patients, to whom the geriatric approach with a comprehensive geriatric assessment (CGA) and subsequent pre-rehabilitation was applied. A comparative intergroup analysis was performed on the basis of obtained data.Results. The study group differed from the control group in higher polymorbidity and high operational and anesthetic risk (p <0.001). Implementation of geriatric pre-rehabilitation with due account for CGA results and correction of polymorbidity improved chances of providing surgical care using laparoscopic and robotic technologies. The frequency of intraoperative blood transfusion and prolonged mechanical ventilation in the study group was reduced (p <0.001 and p = 0.009, respectively). Predictors that increase the chances of developing acute postoperative myocardial infarction were identified. They included the patient’s male gender (p = 0.004), redo surgery after development of early postoperative complications (p = 0.043), prolonged mechanical ventilation (p = 0.052), increased length of stay in the intensive care unit (p = 0.011), and comorbidity (p = 0.022). The introduction of the geriatric approach made it possible to reduce the risk of postoperative myocardial infarction by 17.86 times (p = 0.007).Conclusion. The geriatric approach to the senile patients with colorectal cancer makes it possible to expand the indications for radical treatment in severe polymorbidity and senile asthenia, as well as to reduce the incidence of early postoperative complications.

N-Terminal Pro-B-Type Natriuretic Peptide as a Predictor of Adverse Outcomes After Off-Pump Coronary Artery Bypass Surgery: A Prospective Study

Background: The strength of association between preoperative natriuretic peptide levels and adverse outcomes after cardiac surgery recently has been studied in different research, but results still are diversely variable. Methods: Sixty-five consecutive patients undergoing elective off-pump coronary artery bypass grafting prospectively were recruited. Preoperative levels of NTproBNP were measured in venous blood samples collected before induction of anesthesia. Results: The average age was 57.62 ± 7.21. Of the patients, 86.15% were male. Euro-scoreII averaged 1.76 ± 0.34. The mean preoperative NTproBNP levels were 312.41 ± 329.93 pg/mL. Only two patients died (3%). Three patients required prolonged mechanical ventilation (4.6%). Four patients (6%) suffered from new onset postoperative AF. Five patients (7.6%) had low cardiac output, of which three needed IABP, and four patients (6%) had postoperative myocardial infarction. The mean ICU stay was 3.37 ± 0.84 days, and the mean hospital stay was 6.38 ± 1.3 days. There were no significant differences in preoperative NTproBNP levels in patients who had or didn’t have any of the postoperative complications or in-hospital mortality (P > .05). Conclusion: Our study showed no significant correlation between preoperative NTproBNP levels and postoperative low cardiac output, atrial fibrillation, postoperative myocardial infarction, length of ICU stay, prolonged mechanical ventilation, length of hospital stay as well as in-hospital mortality following elective off-pump CABG. Therefore, more prospective specific studies are needed to delineate the role of preoperative natriuretic peptides as significant predictors of poor outcomes after CABG surgery.

An International, Multicenter Retrospective Observational Study to Assess Technical Success and Clinical Outcomes of Patients Treated with an Endovascular Aneurysm Sealing Device for Type III Endoleak

Introduction: Type III endoleaks post-endovascular aortic aneurysm repair (EVAR) warrant treatment because they increase pressure within the aneurysm sac leading to increased rupture risk. The treatment may be difficult with regular endovascular devices. Endovascular aneurysm sealing (EVAS) might provide a treatment option for type III endoleaks, especially if located near the flow divider. This study aims to analyze clinical outcomes of EVAS for type III endoleaks after EVAR. Methods: This is an international, retrospective, observational cohort study including data from 8 European institutions. Results: A total of 20 patients were identified of which 80% had a type IIIb endoleak and the remainder (20%) a type IIIa endoleak. The median time between EVAR and EVAS was 49.5 months (28.5–89). Mean AAA diameter prior to EVAS revision was 76.6±19.9 mm. Technical success was achieved in 95%, 1 patient had technical failure due to a postoperative myocardial infarction resulting in death. Mean follow-up was 22.8±15.2 months. During follow-up 1 patient had a type Ia endoleak, and 1 patient had a new type IIIa endoleak at an untreated location. There were 5 patients with aneurysm growth. Five patients underwent AAA-related reinterventions indications being: growth with type II endoleak (n=3), type Ia endoleak (n=1), and iliac aneurysm (n=1). At 1-year follow-up, the freedom from clinical failure was 77.5%, freedom from all-cause mortality 94.7%, freedom from aneurysm-related mortality 95%, and freedom from aneurysm-related reinterventions 93.8%. Conclusion: The EVAS relining can be safely performed to treat type III endoleaks with an acceptable technical success rate, a low 30-day mortality rate and no secondary ruptures at short-term follow-up. The relatively low clinical success rates, related to reinterventions and AAA enlargement, highlight the need for prolonged follow-up.

Postoperative mortality in hip fracture patients stratified by the Revised Cardiac Risk Index: a Swedish nationwide retrospective cohort study

ObjectivesThe Revised Cardiac Risk Index (RCRI) is a tool that can be used to evaluate the 30-day risk of postoperative myocardial infarction, cardiac arrest and mortality. This study aims to confirm its association with postoperative mortality in patients who underwent hip fracture surgery.MethodsAll adults who underwent primary emergency hip fracture surgery in Sweden between January 1, 2008 and December 31, 2017 were included in this study. The database was retrieved by cross-referencing the Swedish National Quality Register for hip fractures with the Swedish National Board of Health and Welfare registers. The outcomes of interest were the association between the RCRI score and mortality at 30 days, 90 days and 1 year postoperatively.Results134 915 cases were included in the current study. There was a statistically significant linear trend in postoperative mortality with increasing RCRI scores at 30 days, 90 days and 1 year. An RCRI score ≥4 was associated with a 3.1 times greater risk of 30-day postoperative mortality (adjusted incidence rate ratio (IRR) 3.13, p<0.001), a 2.5 times greater risk of 90-day postoperative mortality (adjusted IRR 2.54, p<0.001) and a 2.8 times greater risk of 1-year postoperative mortality (adjusted HR 2.81, p<0.001) compared with that observed with an RCRI score of 0.ConclusionAn increasing RCRI score is strongly associated with an elevated risk 30-day, 90-day and 1-year postoperative mortality after primary hip fracture surgery. The objective and easily retrievable nature of the variables included in the RCRI calculation makes it an appealing choice for risk stratification in the clinical setting.Levels of evidenceLevel III.

Preoperative evaluation of the pacient with bronchopulmonary cancer

BACKGROUND.In the Republic of Moldova, we have reported 983 cases of bronchopulmonary cancer (BPC) annually, in 2019. This impressive number of patients requires a more efficient mobilization of the medical system to solve these cases. AIM. The high incidence of newly diagnosed cases of BPC in advanced stages implies a reserved attitude for the surgical treatment of these patients, as well as the presence of associated pathologies, compromise more the situations, and the possibility to provide effective solutions to solve these cases. The group of patients who have tertiary prevention as a measure of treatment becomes imposing. This order of ideas outlines the need for a different medical-surgical approach for this category of patients. METHODS AND RESULTS.For the assessment of functional criteria for operability for patients with BPC, especially in advanced lung cancer, using comorbidity scores (ASA, Charlson, Elixhauser) and the formation of indications for surgical treatment are significant, because surgery offers the greatest opportunity for healing. The team responsible for the preoperative assessment should include both a perioperative mortality risk assessment and a postoperative pulmonary function prediction to optimally advise patients on anticipated outcomes. Due to both advanced cancer on presentation and comorbid conditions, only one-third of patients are ultimately considered candidates for surgical resection. Despite modern surgical, anesthetic, and postoperative techniques, there is still a perioperative mortality rate of 1-5%. Postoperative myocardial infarction is an important source of morbidity and mortality for those undergoing extensive lung resections, especially trans-pericardial pneumonectomies. Until surgery is suggested, preoperative evaluation of the cardiovascular system should be required for the existence of active heart disease (unstable angina, recent myocardial infarction, decompensated heart failure, arrhythmias, or valve defects).In addition to identifying cardiac risk factors, a preoperative assessment is incomplete without quantifying a patient's functional capacity. This can be achieved by the results of a formal stress test, measured in units of metabolic equivalents of task (MET). Geriatric assessment (GA) is a method used to collect information about the physical condition of elderly patients, which may be useful in estimating life expectancy and predicting treatment toxicity. GA includes an assessment of functional status, fatigue, cognitive function, mental health, nutritional status, the individual's ability to complete instrumental activities of daily living, comorbidities, social support, and the presence of geriatric syndromes. CONCLUSIONS. A thorough analysis of the results of diagnostic tests, referring to the functional evaluation of patients with advanced BPC and/or comorbidities, would allow the extension of surgical indications to obtain new results and increase over time the survival and quality of life of these patients.

Surgical Outcomes of Distal Pancreatectomy in Elderly Patients

Background The extent to which age impacts surgical outcomes remains poorly characterized. This study aims to evaluate the impact of age on 30-day outcomes in patients after distal pancreatectomy. Methods Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2017), distal pancreatectomy patients were identified and age-stratified, groups A (≤75 years) and B (>75 years). Outcomes included 30-day mortality, morbidity, readmissions, operative time (min), and hospital length of stay (LOS, days). Results Of 3042 total patients identified, 1686 (55.4%) were women. A total of 2649 patients (87.1%) were in group A. Overall, both groups had similar baseline characteristics with the exception of the following: diabetes mellitus (24.8% vs. 30.0%, P = .03), smoking (19.3% vs. 4.8%, P < .001), congestive heart failure (.5% vs. 1.8%, P = .010), hypertension (HTN) (47.9% vs. 72.5%, P < .001), bleeding disorders (3.1% vs. 5.3%, P = .036), the American Society of Anesthesiologists (ASA) (III-V) scores (67.6% vs. 85.5%, P < .001), and body mass index (29.2 [±6.7] vs. 27.4 [±5.6], P = .001). Deep surgical site infection was higher in group A (12.1% vs. 6.6%, P = .001), while acute renal failure (ARF) and postoperative myocardial infarction (MI) were higher in group B. 30-day readmissions were higher in group A (17.4% vs. 12.2%, P = .011) despite no statistically significant difference in LOS (7.10 [±6.36] vs. 7.30 [±4.93] days, P = .553) or overall morbidity (29.4% vs. 28.8%, P = .859). Conclusion(s) Those undergoing distal pancreatectomy experienced similar overall morbidity and mortality outcomes regardless of age. However, those older than 75 years had more cardiovascular risk factors, which may have contributed to their higher rates of postoperative ARF and MI.

Postoperative myocardial infarction in lung cancer patients with: incidence rate, clinical features, prognostic factors

Aim. To study the incidence, clinical features and predictors of postoperative myocardial infarction (MI) after lung cancer surgery.Material and methods. The retrospective analysis included 2051 patients (1373 males and 678 females, mean age, 65,5 [62-69] years), who underwent thoracotomy for non-small cell lung cancer. At the first stage, the incidence rate of postoperative MI (%) was calculated with 95% confidential interval (CI) in relation to sex, age and extent of surgery. At the second stage, the case-control study was carried out in groups with MI revealed on the first stage (n=33) and without MI (n=130), formed by individual criteria-based matching. A comparative intergroup analysis was performed and prognostic value of 60 clinical perioperative indicators was assessed by odds ratio (OR). The features associated with MI in the univariateregression model were introduced into multivariate stepwise logistic regression. Independent MI predictors was revealed.Results. The postoperative IM incidence rate amounted to 1,61 [0,67-1,76]%. MI was more frequently diagnosed in men than women (0,29%), and after pneumonectomy (3,92%) compared with less operative extent (0,37%). MI was associated with comorbidities, smoking intensity, right pneumonectomy, preoperative increase in white blood cells, neutrophils and monocytes, blood loss volume, surgery duration, postoperative heart rate, preoperative decrease in serum total protein, postoperative haemoglobin, haematocrit, red blood cells decrease, and intraoperative blood pressure (BP). By means of multivariate logistic regression, the following factors with most accurate MI prediction were established: postoperative heart rate (OR, 4,06 [95% CI 1,58-10,43]), Sokolow-Lyon index (OR, 1,54 [95% CI 1,14-2,07]), ACS-NSQIP value for cardiac complications (OR, 3,86 [95% CI 1,36-10,92]), preoperative serum total protein (OR, 0,17 [95% CI 0,040,71]) and white blood cells (CR 1,54 [95% CI 1,03-2,31]), minimal intraoperative systolic BP (OR, 0,35 [95% CI 0,15-0,83]).Conclusion. Postoperative MI incidence in lung cancer patients accounts for 1,61%. Following independent predictors for postoperative MI were established: Sokolow-Lyon index, preoperative serum total protein and leukocytes levels, ACS-NSQIP value, minimal intraoperative systolic BP and postoperative heart rate.

Abstract 14288: Substantial Hospital-level Variation in Troponin Testing After Non-cardiac Surgery

Introduction: There is an increasing emphasis in detecting postoperative myocardial infarction (PMI) using routine troponin testing after non-cardiac surgery. However, clinical practice guidelines vary considerably in their recommendations. We conducted a population-based cohort study in Ontario, Canada to assess the degree of hospital-level variation associated with troponin testing after three commonly performed surgeries. Methods: We conducted a retrospective cohort study of adults (40-105 y) undergoing major orthopedic, colorectal, or vascular surgery in Ontario, Canada from January 1, 2010 to December 31, 2017. Hierarchical logistic regression modeling was used to model the association of patient, surgery, and hospital factors with postoperative troponin testing, while accounting for clustering at the hospital level. Results: We identified 176,454 eligible patients. Canadian Cardiovascular Society guidelines recommended troponin testing for 73.5%, 90.8% and 95.6% of orthopedic, colorectal, and vascular surgery patients respectively, but only 6.7%, 16.6%, and 50.2% were actually tested. Inter hospital variation in testing rates was considerable for the three surgeries (Figure; 0-33%, 0-38% and 18-84%). Even after risk-adjustment, the median odds ratio for testing across hospitals was still 1.74, 1.63, and 2.65 for orthopedic, colorectal, and vascular surgery, respectively. This corresponded to intraclass correlation coefficients of 9.3%, 7.4%, and 24.2% respectively. Conclusion: Despite strong recommendations by Canadian guidelines for troponin testing after non-cardiac surgery, testing rates were low overall and varied significantly across hospitals.

Postoperative Cardiogenic Shock

Postoperative cardiogenic shock describes the management of a postoperative coronary artery bypass graft patient who develops early postoperative shock; after a brief discussion of the different potential causes, the chapter focuses on postoperative myocardial infarction due to graft failure. It reviews the assessment and treatment of patients with postoperative myocardial ischemia causing shock; it then outlines the immediate steps to take for diagnosis and patient stabilization, before discussing the definitive management strategy. A stepwise discussion covering fluids and pharmacological and mechanical support is provided to help guide management decisions. The chapter then outlines revascularization as the optimal treatment and fundamental goal.