Geriatric Dermatologic Surgery Part I: Frailty assessment and palliative treatments in the geriatric dermatology population.

Longer life expectancy and increasing keratinocyte carcinoma incidence contribute to an increase in geriatric patients presenting for dermatologic surgery. Unique considerations accompany geriatric patients including goals of care, physiologic changes in medication metabolism, cognitive decline, and frailty. Limited geriatric training in dermatology residency has created a knowledge gap and dermatologic surgeons should be familiar with challenges facing older patients to provide interventions more congruent with goals and avoid overtreatment. Frailty assessments including the Geriatric 8 and Karnofsky Performance Scale are efficient tools to identify patients who are at risk for poor outcomes and complications. When frail patients are identified, goals of care discussions can be aided using structured palliative care frameworks including the 4Ms, REMAP, and Serious Illness Conversation Guide. Most geriatric patients will tolerate standard of care treatments including invasive modalities like Mohs surgery and excision. However, for frail patients, non-standard treatments including topicals, energy-based devices, and intralesional chemotherapy may be appropriate options to limit patient morbidity while offering reasonable disease control.

Geriatric Dermatologic Surgery Part II: Peri and intraoperative considerations in the geriatric dermatologic surgery patient.

Geriatric patients compose a growing proportion of the dermatologic surgical population. Dermatologists and dermatologic surgeons should be cognizant of the unique physiologic considerations that accompany this group to deliver highly effective care. The purpose of this article is to discuss the unique preoperative, intraoperative, and postoperative considerations geriatric patients present with to provide goal-concordant care. Preoperative considerations include medication optimization and anxiolysis. Intraoperative considerations such as fall-risk assessment and prevention, sundowning, familial support, and pharmacologic interactions will be discussed. Lastly, effective methods for optimizing post-operative wound care, home care, and follow up are reviewed.

Safety and efficacy of robotic anti-reflux surgery in geriatric patients: a comparative analysis.

INTRODUCTION: As our population ages, older adults are being considered for anti-reflux surgery (ARS). Geriatric patients typically have heightened surgical risk, and literature has shown mixed results regarding postoperative outcomes. We sought to evaluate the safety and efficacy of robotic ARS in the geriatric population. METHODS: We conducted a single-institution review of ARS procedures performed between 2009 and 2023. Patients ≥ 65 were assigned to the geriatric cohort. We compared operative details, lengths of stay (LOS), readmissions, reoperations, and complications between the two cohorts. The gastroesophageal reflux disease health-related quality of life (GERD-HRQL) survey and review of clinic notes were used to evaluate ARS efficacy. RESULTS: 628 patients were included, with 190 in the geriatric cohort. This cohort had a higher frequency of diabetes (16.3% vs 5.9% p < 0.0001), hypertension (50.0% vs 21.5% p < 0.0001), and heart disease (17.9% vs 2.3% p < 0.0001). Geriatric patients were more likely to exhibit hiatal hernias on imaging (51.6% vs 34.2% p < 0.0001) and were more likely to have large hernias (30.0% vs 7.1% p < 0.0001). Older adults were more likely to undergo Toupet fundoplications (58.4% vs 41.3%, p < 0.0001), Collis gastroplasties (9.5% vs 2.7% p < 0.0001), and relaxing incisions (11.6% vs 1.4% p < 0.0001). Operative time was longer for geriatric patients (132.0 min vs 104.5 min p < 0.0001). There were no significant differences in LOS, readmissions, or reoperations between cohorts. Geriatric patients exhibited lower rates of complications (7.4% vs. 14.6%, p = 0.011), but similar complication grades. Both groups had significant reduction in symptom scores from preoperative values. There were no significant differences in the reported symptoms between cohorts at any follow-up timepoint. CONCLUSION: Geriatric robotic ARS patients tend to do as well as younger adults regarding postoperative and symptomatic outcomes, despite presenting with larger hiatal hernias and shorter esophagi. Clinicians should be aware of possible need for lengthening procedures or relaxing incisions in this population.

Laparoscopy for emergency abdominal surgery is associated with reduced physical functional decline in older patients: a cohort study.

BACKGROUND: An increasing number of older patients require emergency abdominal surgery for acute abdomen. They are susceptible to surgical stress and lose their independence in performing daily activities. Laparoscopic surgery is associated with faster recovery, less postoperative pain, and shorter hospital stay. However, few studies have examined the relationship between laparoscopic surgery and physical functional decline. Thus, we aimed to examine the relationship between changes in physical function and the surgical procedure. METHODS: In this was a single-center, retrospective cohort study, we enrolled patients who were aged ≥ 65 years and underwent emergency abdominal surgery for acute abdomen between January 1, 2019, and December 31, 2021. We assessed their activities of daily living using the Barthel Index. Functional decline was defined as a decrease of ≥ 20 points in Barthel Index at 28 days postoperatively, compared with the preoperative value. We evaluated an association between functional decline and surgical procedures among older patients, using multiple logistic regression analysis. RESULTS: During the study period, 852 patients underwent emergency abdominal surgery. Among these, 280 patients were eligible for the analysis. Among them, 94 underwent laparoscopic surgery, while 186 underwent open surgery. Patients who underwent laparoscopic surgery showed a less functional decline at 28 days postoperatively (6 vs. 49, p < 0.001). After adjustments for other covariates, laparoscopic surgery was an independent preventive factor for postoperative functional decline (OR, 0.22; 95% CI, 0.05-0.83; p < 0.05). CONCLUSIONS: In emergency abdominal surgery, laparoscopic surgery reduces postoperative physical functional decline in older patients. Widespread use of laparoscopic surgery can potentially preserve patient quality of life and may be important for the better development of emergency abdominal surgery.

Pancreaticoduodenectomy in patients < 75 years versus ≥ 75 years old: a comparative study.

OBJECTIVE: This study aimed to compare the postoperative outcomes of < 75-year-old patients and ≥ 75-year-old patients who underwent pancreaticoduodenectomy (PD) for pancreatic head and periampullary region tumors. METHODS: Patients who underwent PD in our hospital between February 2019 and December 2023 were evaluated. Demographics, Eastern Cooperative Oncology Group Performance Status (ECOG-PS) scores, American Society of Anesthesiologists (ASA) scores, comorbidities, hospital stays, complications, and clinicopathological features were analyzed. Patients were divided into < 75 years (Group A) and ≥ 75 years (Group B) groups and compared. RESULTS: The median age of the entire cohort (n = 155) was 66 years (IQR = 16). There was a significant difference between Group A (n = 128) and Group B (n = 27) regarding the ECOG-PS and ASA scores. There was no significant difference between the groups regarding postoperative complications. The 30-day mortality rate was greater in Group B (p = 0.017). Group B had a cumulative median survival of 10 months, whereas Group A had a median survival of 28 months, with a statistically significant difference (p < 0.001). When age groups were stratified according to ECOG-PS, for ECOG-PS 2-3 Group A, survival was 15 months; for ECOG-PS 2-3 Group B, survival was eight months, and the difference was not statistically significant (p = 0.628). CONCLUSIONS: With the increasing aging population, patient selection for PD should not be based solely on age. This study demonstrated that PD is safe for patients older than 75 years. In older patients, performance status and the optimization of comorbidities should be considered when deciding on a candidate's suitability for surgery.

Robot-assisted partial nephrectomy in patients aged 75 years or older - comparing the risk of complications with their younger counterparts.

BACKGROUND & AIM: More elderly patients are diagnosed with kidney tumors where partial nephrectomy is technically possible. We investigated whether patients ≥ 75 years old had an increased risk of complications following robot-assisted partial nephrectomy (RAPN) compared to younger patients. METHODS: Retrospective, consecutive study including patients who underwent RAPN between May 2016 - April 2023. Preoperative data, operative data and complications within 90 days were recorded by patient record review. Complications were classified according to Clavien-Dindo (CD). RESULTS: 451 patients underwent RAPN and a postoperative complication was recorded in 131 (29%) patients of which 28 (6%) were CD ≥ III. Any postoperative complication was recorded in 24/113 patients (21%) < 55 years, 40/127 patients (31%) 55-64 years, 45/151 patients (42%) 65-74 years, and 22/60 patients (37%) ≥ 75 years. Comparable numbers for a CD ≥ III postoperative complication were 2/113 (2%) < 55 years, 6/127 (7%) 55-64 years, 12/151 (8%) 65-74 years, and 5/60 (8%) ≥ 75 years. In multivariate logistic regression analysis, patients ≥ 75 years had a non-significant increased risk of complications when controlling for preoperative variables (OR 1.82 [95% CI 0.80-4.13]) or perioperative variables (OR 1.98 [95% CI 0.86-4.58]) compared to patients < 55 years. Two patients died postoperatively. Both were ≥ 75 years (2/60, 3%). DISCUSSION AND CONCLUSIONS: Selected patients ≥ 75 years can undergo RAPN without a significantly increased risk of postoperative complications. However, a mortality rate of 3% in this age group indicates that these patients are frail when postoperative complications occur.

Evaluation of perioperative pressure injury in adults 65 years and older: A prospective cohort study.

INTRODUCTION: Old age is an important risk factor for the formation of pressure injury (PI). The aim of this study was to investigate the incidence, risk factors, characteristics of PI and suitability of risk assessment tools for patients aged 65 years and older. METHOD: This prospective monocentric cohort study was conducted in Turkey between September 2022 and March 2023. Data were collected from a total of 240 surgical patients aged 65 years and older using a skin assessment form and the Braden and Munro scales for PI risk assessment. RESULTS: The patients had a mean age of 72.90 ± 5.53 years, 123 (51 %) were male, 203 (85 %) had chronic diseases, and the mean operative time was 194.83 ± 99.45 min. PI occurred in 45 patients (18.8 %). PIs were most commonly stage I and located in the coccyx region. Postoperative Munro score, postoperative Braden score, and operative time were significant in univariate analyses (p < 0.001). According to the multiple logistic regression model, a postoperative Munro score ≥26 and postoperative Braden score ≤20 were independent factors associated with increased risk of PI. CONCLUSION: Measures to prevent PI in surgical patients should begin in the preoperative period. Age alone may not be a risk factor in geriatric surgical patients. The Munro and Braden PI risk assessment scales can be used in geriatric surgical patients, but changes in cut-off score calculations may be required and additional age-related risk factors should be evaluated.

Laparoscopic Heller-Dor myotomy in elderly achalasia patients: a single center experience with PSM analysis.

INTRODUCTION: Achalasia is a rare esophageal motility disorder of unknown etiology. With the ageing of the general population, treatment in elderly patients has become increasingly common; however, the gold standard treatment in this population remains unclear. The aim of this study was to evaluate the outcomes of laparoscopic Heller-Dor myotomy (LHM) in geriatric patients. MATERIAL AND METHODS: In this study, consecutive achalasia patients undergoing LHM at the University Hospital 'Federico II' of Naples from November 2018 to November 2022 were prospectively enrolled. Patients were divided into two groups based on their age at intervention: elderly (≥70 years) and younger (<70 years). The two study groups were compared by minimizing the different distribution of covariates through a propensity score matching analysis (PSM). RESULTS: In both populations, there was a significant improvement in terms of manometric parameters and symptoms after surgery. After applying one-on-one PSM, we obtained a total population of 48 achalasia patients divided into two groups (24 patients each). No significant differences were found in terms of demographic characteristics as well as preoperative and intraoperative variables between two groups. At 12 months from surgery, integrated relaxation pressure (IRP) was significantly lower in patients ≥ 70 years (p = 0.032), while younger patients scored significantly less at the post-operative Eckardt score (p = 0.047). CONCLUSIONS: Laparoscopic Heller-Dor myotomy is a safe and effective treatment even in elderly patients with rapid post-operative recovery, improvement of symptoms and manometric parameters.

Open Abdomen in Elderly Patients With Surgical Sepsis: Predictors of Mortality.

INTRODUCTION: Elderly patients are frequently presenting with emergency surgical conditions. The open abdomen technique is widely used in abdominal emergencies needing rapid control of intrabdominal contamination. However, specific predictors of mortality identifying candidates for comfort care are understudied. METHODS: The 2013-2017 the American College of Surgeons-National Surgical Quality Improvement Program database was queried for emergent laparotomies performed in geriatric patients with sepsis or septic shock in whom fascial closure was delayed. Patients with acute mesenteric ischemia were excluded. The primary outcome was 30-d mortality. Univariable analysis, followed by multivariable logistic regression, was performed. Mortality was computed for combinations of the five predictors with the highest odds ratios (OR). RESULTS: A total of 1399 patients were identified. The median age was 73 (69-79) y, and 54.7% were female. 30-d mortality was 50.6%. In the multivariable analysis, the most important predictors were as follows: American Society of Anesthesiologists status 5 (OR = 4.80, 95% confidence interval [CI], 1.85-12.49 P = 0.002), dialysis dependence (OR = 2.65, 95% CI 1.54-4.57, P < 0.001), congestive hearth failure (OR = 2.53, 95% CI 1.52-4.21, P < 0.001), disseminated cancer (OR = 2.61, 95% CI 1.55-4.38, P < 0.001), and preoperative platelet count of <100,000 cells/µL (OR = 1.87, 95% CI 1.15-3.04, P = 0.011). The presence of two or more of these factors resulted in over 80% mortality. The absence of all these risk factors results in a survival rate of 62.1%. CONCLUSIONS: In elderly patients, surgical sepsis or septic shock requiring an open abdomen for surgical management is highly lethal. The presence of several combinations of preoperative comorbidities is associated with a poor prognosis and can identify patients who can benefit from timely initiation of palliative care.

What If We Do Not Operate? Outcomes of Nonoperatively Managed Emergency General Surgery Patients.

INTRODUCTION: Although two-thirds of patients with emergency general surgery (EGS) conditions are managed nonoperatively, their long-term outcomes are not well described. We describe outcomes of nonoperative management in a cohort of older EGS patients and estimate the projected risk of operative management using the NSQIP Surgical Risk Calculator (SRC). MATERIALS AND METHODS: We studied single-center inpatients aged 65 y and more with an EGS consult who did not undergo an operation (January 2019-December 2020). For each patient, we recorded the surgeon's recommendation as either an operation was "Not Needed" (medical management preferred) or "Not Recommended" (risk outweighed benefits). Our main outcome of interest was mortality at 30 d and 1 y. Our secondary outcome of interest was SRC-projected 30-day postoperative mortality risk (median % [interquartile range]), calculated using hypothetical low-risk and high-risk operations. RESULTS: We included 204 patients (60% female, median age 75 y), for whom an operation was "Not Needed" in 81% and "Not Recommended" in 19%. In this cohort, 11% died at 30 d and 23% died at 1 y. Mortality was higher for the "Not Recommended" cohort (37% versus 5% at 30 d and 53% versus 16% at 1 y, P < 0.05). The SRC-projected 30-day postoperative mortality risk was 3.7% (1.3-8.7) for low-risk and 5.8% (2-11.8) for high-risk operations. CONCLUSIONS: Nonoperative management in older EGS patients is associated with very high risk of short-term and long-term mortality, particularly if a surgeon advised that risks of surgery outweighed benefits. The SRC may underestimate risk in the highest-risk patients.

Functional Status is Key to Long-term Survival in Emergency General Surgery Conditions.

INTRODUCTION: Emergency General Surgery (EGS) conditions in older patients constitutes a substantial public health burden due to high morbidity and mortality. We sought to utilize a supervised machine learning method to determine combinations of factors with the greatest influence on long-term survival in older EGS patients. METHODS: We identified community dwelling participants admitted for EGS conditions from the Medicare Current Beneficiary Survey linked with claims (1992-2013). We categorized three binary domains of multimorbidity: chronic conditions, functional limitations, and geriatric syndromes (such as vision or hearing impairment, falls, incontinence). We also collected EGS disease type, age, and sex. We created a classification and regression tree (CART) model to identify groups of variables associated with our outcome of interest, three-year survival. We then performed Cox proportional hazards analysis to determine hazard ratios for each group with the lowest risk group as reference. RESULTS: We identified 1960 patients (median age 79 [interquartile range [IQR]: 73, 85], 59.5% female). The CART model identified the presence of functional limitations as the primary splitting variable. The lowest risk group were patient aged ≤81 y with biliopancreatic disease and without functional limitations. The highest risk group was men aged ≥75 y with functional limitations (hazard ratio [HR] 11.09 (95% confidence interval [CI] 5.91-20.83)). Notably absent from the CART model were chronic conditions and geriatric syndromes. CONCLUSIONS: More than the presence of chronic conditions or geriatric syndromes, functional limitations are an important predictor of long-term survival and must be included in presurgical assessment.

Complexity of Transferred Geriatric Adults Requiring Emergency General Surgery: A Rural Tertiary Center Experience.

INTRODUCTION: As the American population ages, the number of geriatric adults requiring emergency general surgery (EGS) care is increasing. EGS regionalization could significantly affect the pattern of care for rural older adults. The aim of this study was to determine the current pattern of care for geriatric EGS patients at our rural academic center, with a focus on transfer status. MATERIALS AND METHODS: We performed a retrospective chart review of patients aged ≥65 undergoing EGS procedures within 48 h of admission from 2014 to 2019 at our rural academic medical center. We collected demographic, admission, operative, and outcomes data. The primary outcomes of interest were mortality and nonhome discharge. Univariate and multivariate analyses were performed. RESULTS: Over the 5-y study period, 674 patients underwent EGS procedures, with 407 (60%) transferred to our facility. Transfer patients (TPs) had higher American Society of Anesthesiology (ASA) scores (P < 0.001), higher rates of open abdomen (13% versus 5.6%, P = 0.001), and multiple operations (24 versus 11%, P < 0.001) than direct admit patients. However, after adjustment there was no difference in mortality (OR 1.64; 95% CI, 0.82-3.38) or nonhome discharge (OR 1.49; 95% CI, 0.95-2.36). CONCLUSIONS: At our institution, the majority of rural geriatric EGS patients were transferred from another hospital for care. These patients had higher medical and operative complexity than patients presenting directly to our facility for care. After adjustment, transfer status was not independently associated with in-hospital mortality or nonhome discharge. These patients were appropriately transferred given their level of complexity.

An Evaluation of Sex-Based Differences in Surrogate Consent for Older Adults Undergoing Surgical Intervention.

INTRODUCTION: Differences between female and male patients have been identified in many facets of medicine. We sought to understand whether differences in frequency of surrogate consent for operation exist between older female and male patients. MATERIALS AND METHODS: A descriptive study was designed using data from the hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program. Patients age 65 y and older who underwent operation between 2014 and 2018 were included. RESULTS: Of 51,618 patients identified, 3405 (6.6%) had surrogate consent for surgery. Overall, 7.7% of females had surrogate consent compared to 5.3% of males (P < 0.001). Stratified analysis based on age categories showed no difference in surrogate consent between female and male patients aged 65-74 yy (2.3% versus 2.6%, P = 0.16), but higher rates of surrogate consent in females than males among patients aged 75-84 y old (7.3% versus 5.6%, P < 0.001) and age ≥85 y (29.7% versus 20.8%, P < 0.001). A similar relationship was seen between sex and preoperative cognitive status. There was no difference in preoperative cognitive impairment in female and male patients age 65-74 y (4.4% versus 4.6%, P = 0.58), but higher rates of preoperative cognitive impairment were seen in females than males for those age 75-84 (9.5% versus 7.4%, P < 0.001) and aged ≥85 y (29.4% versus 21.3%, P < 0.001). Matching for age and cognitive impairment, there was no significant difference between rate of surrogate consent in males and females. CONCLUSIONS: Female patients are more likely than males to undergo surgery with surrogate consent. This difference is not based on patient sex alone - females undergoing operation are older than their male counterparts and more likely to be cognitively impaired.

Wedge Resection Versus Segmentectomy for Older Patients With Stage IA Non-Small-Cell Lung Cancer.

INTRODUCTION: Anatomic lung resection remains the standard of care for early-stage non-small-cell lung cancer (NSCLC), but wedge resection may offer similar survival in older adult patients. The objective of this study was to evaluate the survival of patients aged 80 y and older undergoing wedge resection versus segmentectomy for stage IA NSCLC using a large clinical registry. METHODS: Patients aged 80 y and older in the National Cancer Database who underwent wedge resection or segmentectomy for cT1a-b N0 M0 NSCLC between 2004 and 2018 were identified for an analysis. Survival was assessed using multivariable Cox proportional hazards analysis, propensity-score matching, and inverse probability weighting. A subgroup analysis of patients who underwent lymph node evaluation with their wedge resection or segmentectomy was also performed. RESULTS: Of the 2690 patients identified, 2272 (84%) underwent wedge resection and 418 (16%) underwent segmentectomy. Wedge resection was associated with worse 5-year overall survival relative to segmentectomy in multivariable-adjusted (adjusted Hazard Ratio: 1.26, [1.06-1.51], P = 0.01) and propensity score-matched analysis (49% [95% confidence interval {CI}: 42%-55%] versus 59% [95% CI: 52%-65%], P = 0.02). Among a subgroup of 1221 wedge resection and 347 segmentectomy patients who also received intraoperative lymph node evaluation, however, there were no significant differences in 5-year survival in multivariable-adjusted (adjusted Hazard Ratio: 1.12, [0.90-1.39], P = 0.31) or propensity score-matched analysis (55% [95% CI: 48%-62%] versus 61% [95% CI: 54%-68%], P = 0.10). CONCLUSIONS: In this national analysis, there were no significant differences in survival between older adult patients with stage IA NSCLC who underwent wedge resection versus segmentectomy when a lymph node evaluation was performed.

Effects of anti-osteoporosis therapy on the risk of secondary fractures and surgical complications following surgical fixation of proximal humerus fracture in older people.

BACKGROUND: age-related fragility fractures cause significant burden of disease. Within an ageing society, fracture and complication prevention will be essential to balance health expenditure growth. OBJECTIVE: to assess the effect of anti-osteoporotic therapy on surgical complications and secondary fractures after treatment of fragility fractures. PATIENTS AND METHODS: retrospective health insurance data from January 2008 to December 2019 of patients ≥65 years with proximal humeral fracture (PHF) treated using locked plate fixation (LPF) or reverse total shoulder arthroplasty were analysed. Cumulative incidences were calculated by Aalen-Johansen estimates. The influence of osteoporosis and pharmaceutical therapy on secondary fractures and surgical complications were analysed using multivariable Fine and Gray Cox regression models. RESULTS: a total of 43,310 patients (median age 79 years, 84.4% female) with a median follow-up of 40.9 months were included. Five years after PHF, 33.4% of the patients were newly diagnosed with osteoporosis and only 19.8% received anti-osteoporotic therapy. A total of 20.6% (20.1-21.1%) of the patients had at least one secondary fracture with a significant reduction of secondary fracture risk by anti-osteoporotic therapy (P < 0.001). An increased risk for surgical complications (hazard ratio: 1.35, 95% confidence interval: 1.25-1.47, P < 0.001) after LPF could be reversed by anti-osteoporotic therapy. While anti-osteoporotic therapy was more often used in female patients (35.3 vs 19.1%), male patients showed significantly stronger effects reducing the secondary fracture and surgical complication risk. CONCLUSIONS: a significant number of secondary fractures and surgical complications could be prevented by consequent osteoporosis diagnosis and treatment particularly in male patients. Health-politics and legislation must enforce guideline-based anti-osteoporotic therapy to mitigate burden of disease.

Small bowel obstruction in older patients: challenges in surgical management.

BACKGROUND: Small bowel obstruction (SBO) is a common disease affecting all segments of the population, including the frail elderly. Recent retrospective data suggest that earlier operative intervention may decrease morbidity. However, management decisions are influenced by surgical outcomes. Our goal was to determine the current surgical management of SBO in older patients with particular attention to frailty and the timing of surgery. STUDY DESIGN: A retrospective review of patients over the age of 65 with a diagnosis of bowel obstruction (ICD-10 K56*) using the 2016 National Inpatient Sample (NIS). Demographics included age, race, insurance status, medical comorbidities, and median household income by zip code. Elixhauser comorbidities were used to derive a previously published frailty score using the NIS dataset. Outcomes included time to operation, mortality, discharge disposition, and hospital length of stay. Associations between demographics, frailty, timing of surgery, and outcomes were determined. RESULTS: 264,670 patients were included. Nine percent of the cohort was frail; overall mortality was 5.7%. Frail had 1.82 increased odds of mortality (95% CI 1.64-2.03). Hospital LOS was 1.6 times as long for frail patients; a quarter of the frail were discharged home. Frail patients waited longer for surgery (3.58 days vs 2.44 days; p < 0.001). Patients transferred from another facility had increased mortality (aOR 1.58; 95% CI 1.36-1.83). There was an increasing mortality associated with a delay in surgery. CONCLUSION: Patients with frailty and SBO have higher mortality, more frequent discharge to dependent living, longer hospital length of stay, and longer wait to operative intervention. Mortality is also associated with male gender, black race, transfer status from another facility, self-pay status, and low household income. Every day in delay in surgical intervention for those who underwent operations led to higher mortality. If meeting operative indications, older patients with bowel obstruction have a higher chance of survival if they undergo surgery earlier.

Increased complication rates of salvage reverse total shoulder arthroplasty (RTSA) after failed locked plate fixation compared with primary RTSA in the treatment of proximal humeral fractures in elderly patients.

HYPOTHESIS: Common surgical treatment options for proximal humeral fractures in elderly patients include locked plate fixation (LPF) and reverse total shoulder arthroplasty (RTSA). It was hypothesized that secondary RTSA after LPF would be associated with higher complication rates and costs compared with primary RTSA. METHODS: We analyzed the health insurance data of patients aged ≥65 years who received RTSA for the treatment of a proximal humeral fracture between January 2013 and September 2019 with a pre-study phase of 5 years. Multivariable Cox, logistic, and linear regression models were used to evaluate the association between treatment group and complications, hospital length of stay, charges, and mortality rate during a 34-month follow-up period. RESULTS: A total of 14,220 patients underwent primary RTSA and 1282 patients underwent secondary RTSA after prior surgery using LPF for the treatment of proximal humeral fractures. After adjustment for patient characteristics, more surgical complications were observed after secondary RTSA during index hospitalization (odds ratio, 4.62; 95% confidence interval [CI], 4.00-5.34; P < .001) and long-term follow-up (hazard ratio, 1.52; 95% CI, 1.27-1.81; P < .001). Moreover, secondary RTSA was associated with an increased cumulative total cost of €6638.1 (95% CI, €6229.9-€7046.5; P < .001). If conversion from LPF to secondary RTSA occurred during index hospitalization, more major adverse events, more thromboembolic events, and a higher mortality rate were found in the short and long term (all P < .05). CONCLUSION: Secondary RTSA is associated with higher total costs and more complications. Hence, if surgical treatment of a proximal humeral fracture in an elderly patient is needed, prognostic factors for LPF need to be evaluated carefully. If in doubt, the surgeon should opt to perform primary RTSA as patients will benefit in the long term.

Fenestrated endovascular abdominal aortic aneurysm repair in octogenarians is associated with higher mortality and an increased incidence of nonhome discharge.

OBJECTIVE: Fenestrated endovascular abdominal aortic aneurysm repair (FEVAR) has been increasingly becoming the endovascular treatment of choice for patients with juxtarenal abdominal aortic aneurysms with an infrarenal neck, not suitable for traditional endovascular abdominal aortic aneurysm repair. Older patients are at a high risk of developing complications after elective procedures. A review of the literature showed mixed results for FEVAR in the elderly patient population. In the present study, we investigated the occurrence of mortality (both short and long term), discharge destination, and other postoperative outcomes in the octogenarian population who had undergone FEVAR for the management of abdominal aortic aneurysms in a large, national surgical database. METHODS: A retrospective analysis of patients who had undergone FEVAR in the Society for Vascular Surgery Vascular Quality Initiative database was performed from July 2010 to June 2019. The study cohort excluded patients aged <18 years and concomitant procedures for snorkeling of visceral branches of the aorta. The final selected cohort was divided into two patient groups: group I, patients aged <80 years (nonoctogenarians); and group II, patients aged ≥80 years (octogenarians). The primary outcomes were mortality at 30 days (short term), 6 months, and 1 year (long term) and the discharge destination. The secondary outcomes included postoperative length of stay, intensive care unit stay, postoperative major cardiac events, and the need for intervention. Computation of models to measure the outcomes and identify the risk factors contributing to mortality at 30 days and discharge to a nonhome destination was performed using multiple logistic regression analyses. Cox proportional hazards regression analysis was performed to study the long-term mortality in the patient groups. RESULTS: A total of 5507 patients had undergone FEVAR in the 9-year period in the Society for Vascular Surgery Vascular Quality Initiative database (group I, nonoctogenarians, n = 4424 [80.3%]; group II, octogenarians, n = 1156 [19.7%]). Octogenarians were more likely to be women, white, Medicare insured, and hypertensive. This group also had lower rates of former or current smokers, a lower glomerular filtration rate, a lower incidence of late-stage chronic kidney disease, and an aneurysm diameter >5.5 cm. Greater estimated blood loss and longer procedures were also noted in the octogenarian group compared with the nonoctogenarian group. Multiple logistic regression analysis showed that octogenarians had had greater mortality at 30 days (7.3%; adjusted odds ratio [aOR], 1.21; 95% confidence interval [CI], 1.0-1.45; P = .044), 6 months (13.7%; aOR, 1.52; 95% CI, 1.24-1.81; P < .001), and 1 year (17.5%; aOR, 1.67; 95% CI, 1.34-2.07; P < .001). The present analysis to measure the discharge destination showed that octogenarians had a greater risk of discharge to nonhome destinations (26.7%; aOR, 1.50; 95% CI, 1.24-1.81; P < .001). Octogenarians had a lower risk of ≥2 days of an intensive care unit stay (aOR, 0.76; 95% CI, 0.67-0.91; P < .001) but a greater risk of experiencing dysrhythmia (10.1%; aOR, 1.32; 95% CI, 1.01-7.1; P = .036) following the procedure compared with the nonoctogenarians. CONCLUSIONS: In our retrospective analysis of a large, national surgical database, we found that of the patients undergoing FEVAR to manage juxtarenal abdominal aortic aneurysms, octogenarians had greater mortality and a greater risk of being discharged to nonhome locations compared with nonoctogenarians.

Comparing the predictive accuracy of frailty instruments applied to preoperative electronic health data for adults undergoing noncardiac surgery.

BACKGROUND: Preoperative frailty is associated with increased risk of postoperative mortality and complications. Routine preoperative frailty assessment is underperformed. Automation of preoperative frailty assessment using electronic health data could improve adherence to guideline-based care if an accurate instrument is identified. METHODS: We conducted a retrospective cohort study of adults >65 yr undergoing elective noncardiac surgery between 2012 and 2018. Four frailty instruments were compared: Frailty Index, Hospital Frailty Risk Score, Risk Analysis Index-Administrative, and Adjusted Clinical Groups frailty-defining diagnoses indicator. We compared the predictive performance of each instrument added to a baseline model (age, sex, ASA physical status, and procedural risk) using discrimination, calibration, explained variance, net reclassification, and Brier score (binary outcomes); and explained variance, root mean squared error, and mean absolute prediction error (continuous outcomes). Primary outcome was 30-day mortality. Secondary outcomes included 365-day mortality, length of stay, non-home discharge, days alive at home, and 365-day costs. RESULTS: For this study, 171 576 patients met the inclusion criteria; 1370 (0.8%) died within 30 days. Compared with the baseline model predicting 30-day mortality (area under the curve [AUC] 0.85; R2 0.08), the addition of Hospital Frailty Risk Score led to the greatest improvement in discrimination (AUC 0.87), explained variance (R2 0.09), and net reclassification (Net Reclassification Index 0.65). Brier and calibration scores were comparable. CONCLUSIONS: All four frailty instruments significantly improved discrimination and risk reclassification when added to typically assessed preoperative risk factors. Accurate identification of the presence or absence of preoperative frailty using electronic frailty instruments may improve perioperative risk stratification. Future research should evaluate the impact of automated frailty assessment in guiding surgical planning and patient-centred optimisation amongst older surgical patients.

Postoperative delirium prediction using machine learning models and preoperative electronic health record data.

BACKGROUND: Accurate, pragmatic risk stratification for postoperative delirium (POD) is necessary to target preventative resources toward high-risk patients. Machine learning (ML) offers a novel approach to leveraging electronic health record (EHR) data for POD prediction. We sought to develop and internally validate a ML-derived POD risk prediction model using preoperative risk features, and to compare its performance to models developed with traditional logistic regression. METHODS: This was a retrospective analysis of preoperative EHR data from 24,885 adults undergoing a procedure requiring anesthesia care, recovering in the main post-anesthesia care unit, and staying in the hospital at least overnight between December 2016 and December 2019 at either of two hospitals in a tertiary care health system. One hundred fifteen preoperative risk features including demographics, comorbidities, nursing assessments, surgery type, and other preoperative EHR data were used to predict postoperative delirium (POD), defined as any instance of Nursing Delirium Screening Scale ≥2 or positive Confusion Assessment Method for the Intensive Care Unit within the first 7 postoperative days. Two ML models (Neural Network and XGBoost), two traditional logistic regression models ("clinician-guided" and "ML hybrid"), and a previously described delirium risk stratification tool (AWOL-S) were evaluated using the area under the receiver operating characteristic curve (AUC-ROC), sensitivity, specificity, positive likelihood ratio, and positive predictive value. Model calibration was assessed with a calibration curve. Patients with no POD assessments charted or at least 20% of input variables missing were excluded. RESULTS: POD incidence was 5.3%. The AUC-ROC for Neural Net was 0.841 [95% CI 0. 816-0.863] and for XGBoost was 0.851 [95% CI 0.827-0.874], which was significantly better than the clinician-guided (AUC-ROC 0.763 [0.734-0.793], p < 0.001) and ML hybrid (AUC-ROC 0.824 [0.800-0.849], p < 0.001) regression models and AWOL-S (AUC-ROC 0.762 [95% CI 0.713-0.812], p < 0.001). Neural Net, XGBoost, and ML hybrid models demonstrated excellent calibration, while calibration of the clinician-guided and AWOL-S models was moderate; they tended to overestimate delirium risk in those already at highest risk. CONCLUSION: Using pragmatically collected EHR data, two ML models predicted POD in a broad perioperative population with high discrimination. Optimal application of the models would provide automated, real-time delirium risk stratification to improve perioperative management of surgical patients at risk for POD.