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Results of emergency colectomy in nonagenarians and octogenarians previously labeled as prohibitive surgical risk

Abstract

Purpose

There are no standardized criteria for what constitutes prohibitive risk for emergency abdominal surgery.

Methods

A retrospective review was performed comparing two groups of patients having emergent colectomy. One group had previously been labeled as being prohibitive surgical risk and the other was a contemporary, non-prohibitive risk group also requiring emergency colectomy. All operations were performed by a single surgeon.

Results

There were 27 prohibitive risk patients and 81 non-prohibitive risk (control group) patients. The average age of the prohibitive risk group was 85 years (range 78–99) compared to the control group mean age of 52 years (18–79, p < 0.00001). Prohibitive risk was due to extremes of age combined with congestive heart failure in 44%, followed by chronic obstructive pulmonary disease combined with heart failure in 19%. The groups were closely matched by the type of colectomy performed. The total complication rate was much higher in the prohibitive risk group compared to the non-prohibitive risk patients (81% versus 48%, p 0.005). But the 30-day mortality rate was similar between groups (7% versus 4%, p 0.6).

Conclusion

Patients who are labeled as prohibitive surgical risk may be inaccurately assessed in the majority of cases. Additional research will need to be performed to evaluate the presence of quantifiable high-risk physiological conditions, and not just comorbidities, that place a patient at high risk of death after abdominal surgery. Until then, elderly patients should not be denied colectomy based upon comorbidities alone.

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Abbreviations

CHF:

Congestive heart failure

COPD:

Chronic obstructive pulmonary disease

HFrEF:

Heart failure with reduced ejection fraction

ASA:

American Society of Anesthesiologists

MI:

Myocardial infarction

C. diff:

Clostridioides difficile

AC:

American College of Surgeons

References

  1. Raslau D, Bierle DM, Stephenson CR, Mikhail MA, Kebede EB, Mauck KF. Preoperative cardiac risk assessment. Mayo Clin Proc. 2020;95:1064–79.

    Article  Google Scholar 

  2. Bose S, Talmor D. Who is a high-risk surgical patient? Curr Opin Crit Care. 2018;24:547–53.

    Article  Google Scholar 

  3. Barbagallo M, Dominguez LJ, Cucinotta D. The place of frailty and vulnerability in the surgical risk assessment: should we move from complexity to simplicity? Aging Clin Exp Res. 2018;30:237–9.

    Article  Google Scholar 

  4. Shem Tov L, Matot I. Frailty and anesthesia. Curr Opin Anaesthesiol. 2017;30:409–17.

    Article  Google Scholar 

  5. Davenport DL, Bowe EA, Henderson WG, Khuri SF, Mentzer RM Jr. National surgical quality improvement program (NSQIP) risk factors can be used to validate American Society of Anesthesiologists physical status classification levels. Ann Surg. 2006;243:636–41.

    Article  Google Scholar 

  6. Matsuyama T, Iranami H, Fujii K, Inoue M, Nakagawa R, Kawashima K. Risk factors for postoperative mortality and morbidities in emergency surgeries. J Anesth. 2013;27:838–43.

    Article  Google Scholar 

  7. Turrentine FE, Wang H, Simpson VB, Jones RS. Surgical risk factors, morbidity, and mortality in elderly patients. J Am Coll Surg. 2006;203:865–7.

    Article  Google Scholar 

  8. Joseph B, Zangbar B, Pandit V, Fain M, Mohler MJ, Kulvatunyou N, et al. Emergency general surgery in the elderly: too old or too frail? J Am Coll Surg. 2016;222:805–13.

    Article  Google Scholar 

  9. D’Souza RS, Johnson RL, Bettini L, Schulte PJ, Burkle C. Room for improvement: a systematic review and meta-analysis on the informed consent process for emergency surgery. Mayo Clin Proc. 2019;94:1786–98.

    Article  Google Scholar 

  10. Santhirapala R, Partridge J, MacEwen CJ. The older surgical patient- to operate or not? A state of the art review. Anaesthesia. 2020;75(Suppl 1):e46-53.

    PubMed  Google Scholar 

  11. Tashiro T, Pislaru SV, Blustin JM, Nkomo VT, Abel MD, Scott CG, et al. Perioperative risk of major non-cardiac surgery in patients with severe aortic stenosis: a reappraisal in contemporary practice. Eur Heart J. 2014;35:2372–81.

    Article  Google Scholar 

  12. Seyfarth HJ, Gille J, Sablotzki A, Gerlach S, Malcharek M, Gosse A, et al. Perioperative management of patients with severe pulmonary hypertension in major orthopedic surgery: experience-based recommendations. GMS Interdiscip Plast Reconstr Surg DGPW. 2015. https://doi.org/10.3205/iprs000062.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Kaw R, Pasupuleti V, Deshpande A, Hamieh T, Walker E, Minai OA. Pulmonary hypertension: an important predictor of outcomes in patients undergoing non-cardiac surgery. Respir Med. 2011;105:619–24.

    Article  Google Scholar 

  14. Hanley C, Donahoe L, Slinger P. Fit for surgery? What’s new in preoperative assessment of the high-risk patient undergoing pulmonary resection. J Cardiothorac Vasc Anesth. 2020;S1053–0770(20):31204. https://doi.org/10.1053/j.jvca.2020.11.025.

    Article  Google Scholar 

  15. Thomas DR, Ritchie CS. Preoperative assessment of older adults. J Am Geriatr Soc. 1995;43:811–21.

    CAS  Article  Google Scholar 

  16. Fergus J, Nelson DW, Sung M, Lavotshkin LDS, Difronzo LA, O’Connor VV. Pancreatectomy in stage I pancreas cancer: national underutilization of surgery persists. HPB (Oxford). 2020;22:1703–10.

    Article  Google Scholar 

  17. R Core Team. R: a language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria, 2021. https://www.R-project.org/.

  18. von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370:1453–7.

    Article  Google Scholar 

  19. Guh AY, Mu Y, Winston LG, Johnston H, Olson D, Farley MM, et al. Trends in US burden of clostridioides difficile infection and outcomes. N Engl J Med. 2020;382:1320–30.

    CAS  Article  Google Scholar 

  20. Malhotra R, Bakken K, D’Elia E, Lewis GD. Cardiopulmonary exercise testing in heart failure. JACC Heart Fail. 2016;4:607–16.

    Article  Google Scholar 

  21. Older P, Smith R, Courtney P, Hone R. Preoperative evaluation of cardiac failure and ischemia in elderly patients by cardiopulmonary exercise testing. Chest. 1993;104:701–4.

    CAS  Article  Google Scholar 

  22. Older P, Hall A, Hader R. Cardiopulmonary exercise testing as a screening test for perioperative management of major surgery in the elderly. Chest. 1999;116:355–62.

    CAS  Article  Google Scholar 

  23. Brunelli A, Charloux A, Bolliger CT, Rocco G, Sculier JP, Varela G, et al. ERS/ESTS clinical guidelines on fitness for radical therapy in lung cancer patients (surgery and chemotherapy). Eur Respir J. 2009;34:17–41.

    CAS  Article  Google Scholar 

  24. Bapoje SR, Whitaker JF, Schulz T, Chu ES, Albert RK. Preoperative evaluation of the patient with pulmonary disease. Chest. 2007;132:1637–45.

    Article  Google Scholar 

  25. Armstrong P, Congleton J, Fountain SW, Jagoe T, McAuley DF, MacMahon J, et al. Guidelines on the selection of patients with lung cancer for surgery. Thorax. 2001;56:89–108.

    Article  Google Scholar 

  26. Bilimoria KY, Liu Y, Paruch JL, Zhou L, Kmiecik TE, Ko CY, et al. Development and evaluation of the universal ACS NSQIP surgical risk calculator: a decision aid and informed consent tool for patients and surgeons. J Am Coll Surg. 2013;217:833–42.

    Article  Google Scholar 

  27. Horvath B, Kloesel B, Todd MM, Cole DJ, Prielipp RC. The evolution, current value, and future of the American Society of Anesthesiologists physical status classification system. Anesthesiology. 2021;135:904–19.

    Article  Google Scholar 

  28. Khaneki S, Bronsert MR, Henderson WG, Yazdanfar M, Lambert-Kerzner A, Hammermeister KE, et al. Comparison of accuracy of prediction of postoperative mortality and morbidity between a new parsimonious risk calculator (SURPAS) and the ACS surgical risk calculator. Am J Surg. 2020;219:1065–72.

    Article  Google Scholar 

  29. Tocchi C, Dixon J, Naylor M, Sangchoon J, McCorkle R. Development of a frailty index measure for older adults: the frailty index for elders. J Nurs Meas. 2014;22:223–40.

    Article  Google Scholar 

  30. Subramaniam S, Aalberg JJ, Soriano RP, Divino CM. New 5-factor modified frailty index using American College of Surgeons NSQIP data. J Am Coll Surg. 2018;226:173–81.

    Article  Google Scholar 

  31. Kongkaewpaisan N, Lee JM, Eid AI, Kongwibulwut M, Kelsey H, King D, et al. Can the emergency surgery score be used as a triage tool predicting the postoperative need for an ICU admission? Am J Surg. 2019;217:24–8.

    Article  Google Scholar 

  32. Copeland GP. The POSSUM system of surgical audit. Arch Surg. 2002;137:15–9.

    Article  Google Scholar 

  33. Hizette P, Simoens C, Massaut J, Thill V, Smets D, da Costa PM. Septic shock in digestive surgery: a retrospective study of 89 patients. Hepatogastroenterology. 2009;56:1615–21.

    PubMed  Google Scholar 

  34. Sanaiha Y, Juo YY, Aguayo E, Seo YJ, Dobaria V, Ziaeian B, et al. Incidence and trends of cardiac complications in major abdominal surgery. Surgery. 2018;164:539–45.

    Article  Google Scholar 

  35. Wolsted H, Moller AM, Tolstrup MB, Vester-Andersen M. A description of deaths following emergency abdominal surgery. World J Surg. 2017;41:3105–10.

    Article  Google Scholar 

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Funding

No funding was received for conducting this study.

Author information

Authors and Affiliations

Authors

Contributions

Both authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by JAC and TN. The first draft of the manuscript was written by JAC and all authors commented on previous versions of the manuscript. Both authors read and approved the final manuscript.

Corresponding author

Correspondence to John Alfred Carr.

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Conflict of interests

Neither author has any conflicts of interest nor any financial disclosures to declare, except that the lead author is one of the section editors for the European Journal of Trauma and Emergency Surgery.

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Cite this article

Carr, J.A., NeCamp, T. Results of emergency colectomy in nonagenarians and octogenarians previously labeled as prohibitive surgical risk. Eur J Trauma Emerg Surg (2022). https://doi.org/10.1007/s00068-022-02030-w

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  • DOI: https://doi.org/10.1007/s00068-022-02030-w

Keywords

  • Emergency
  • Colectomy
  • Prohibitive risk
  • Nonagenarians
  • Risk assessment