Comorbidity assessment methods and their significance in predicting the results of treatment of older patients undergoing elective abdominal surgeries for cancer - A scoping review.

INTRODUCTION: The scoping review was performed to identify methods of comorbidity assessment and to evaluate their significance in predicting the results of treatment of older patients undergoing elective abdominal surgeries for cancer. MATERIALS AND METHODS: Ovid MEDLINE, Embase, CENTRAL, Web of Science, ClinicalTrials.gov and European Trials Register were searched for eligible studies investigating the impact of comorbidity on various postoperative outcomes of patients aged ≥65. Findings were narratively reported. RESULTS: The review identified 40 studies with a total population of 59,612 patients, using eight different methods of comorbidity assessment. The most used was Charlson Comorbidity Index (60 % of studies) and presence of specific comorbid conditions (38 %). No study provided rationale for the choice of specific comorbidity measure. Most of the included studies reported short-term results (75 %), such as postoperative complications (43 %) and mortality (18 %) as main clinical endpoint. The results were inconsistent across the studies. DISCUSSION: There is still no consensus regarding the choice of comorbidity measures and their role in postoperative outcome prediction. Further efforts are needed to develop new, well-designed, more effective comorbidity assessments tools.

Short- and long-term predictive power of the preoperative Geriatric Assessment components in older cancer patients undergoing high-risk abdominal surgery.

INTRODUCTION: The pathological stage of the cancer and presence of postoperative complications are the most important predictors of survival in older oncologic patients. Therefore, determining biological age, and risks connected with it, should be the key factor in the preoperative assessment. It may be accomplished by using a Geriatric Assessment (GA). However, it is not established which components are most useful for predicting short- and long-term postoperative outcomes in cancer patients undergoing high-risk abdominal surgery. MATERIALS AND METHODS: A total of 334 consecutive cancer patients aged ≥70 years underwent elective abdominal surgery and were followed-up prospectively for 12 months. The preoperative GA consisted of eight domains: functional, physical activity, comorbidity, polypharmacotherapy, nutritional, cognition, mood, and social support. Logistic regression analyses were used to analyse the predictive ability. RESULTS: All components of GA were independent risk factors of 30-day major morbidity apart from ADL, BOMC, Polypharmacy (OR 0.6-1.3; p < 0.001). However, ADL, TUG, the polypharmacy and the MOS-SSS turned out to be significant predictors of 30-day mortality (OR 0.72-1.46; p < 0.001). In turn, only ADL, CDT and MOS-SSS were valid predictors of 12-months mortality (OR 0.46-0.85; p < 0.001). Frailty (surrogate of the biological age), not the chronological age, were also independent predictors of all outcomes (OR 4.71-8.56 p < 0.001). CONCLUSION: Not the chronological age but components of GA and frailty are significant predictors of both 30-day postoperative outcome and 12-months mortality in older cancer patients undergoing high-risk abdominal surgery.

Frailty, geriatric assessment and prehabilitation in elderly patients undergoing urological surgery - is there a need for change of the daily clinical practice? Synthesis of the available literature.

INTRODUCTION: The population of older people is heterogeneous and constantly growing. Over 50% of urological operations are performed in elderly patients. Some elderly patients present with frailty syndrome - a state of increased vulnerability to external stressors resulting in increased risk of hospitalizations, adverse treatment outcomes and death. Currently, there is no widely accepted system of qualification and preparation for surgical treatment developed specifically for elderly patients. MATERIAL AND METHODS: We searched Medline/Pubmed, Embase and Cochrane Libraries databases from 2000-2020 (week 5). The following medical subject headings (MeSH) terms were used to ensure the sensitivity of the searches: geriatric assessment, frailty, urology, and prehabilitation. Relevant articles were also identified through a manual search of the reference lists of potentially relevant articles. RESULTS: A total of 23 papers met the criteria and were included in the current study. Screening for frailty seems to be promising in predicting adverse outcomes, but frail patients should undergo detailed geriatric assessment (GA) which may indicate a need for preoperative intervention which can be unavailable during the hospitalization. The concept of prehabilitation is becoming increasingly discussed in thoracic and abdominal surgery, but only a few studies are available in the field of urology. CONCLUSIONS: Geriatric assessment seems to be a valuable tool for urologists in daily clinical practice. A proper form of prehabilitation may provide enhanced recovery after surgery.

Geriatric assessment among elderly patients undergoing urological surgery: A systematic literature review.

The elderly constitute the group of patients who most often undergo elective urological procedures, and they are at the highest risk of poor surgical outcomes because of comorbidity and frailty. The current model of qualification for surgery is often subjective and based on tools which do not address the characteristics of the elderly. The Comprehensive Geriatric Assessment (CGA) and screening tools can help in the evaluation of older, particularly frail patients. The aim of the study was to review the literature on the usefulness of preoperative geriatric evaluation in patients undergoing urological treatment. The review was based on MEDLINE/PubMed, Embase and Cochrane Library bibliographic databases from 2000-2017 for full-text, English-language publications meeting pre-defined criteria. Six prospective and 3 retrospective studies were selected for further analysis. The patient populations, methods of geriatric assessment, interventions, and outcome measures varied between the studies. None of the studies were randomized controlled trials. In 2 studies, the CGA was used; in other studies, rather basic screening tests were used. In only 2 studies, an intervention was performed after the CGA. In general, the variables of the CGA were both prospectively and retrospectively significant predictors of complications of urological surgery. Although the use of CGA is not a standard practice in everyday urological clinical practice, components of the CGA appear to be predictive of postoperative complications. Therefore, inclusion of geriatric assessment as part of routine preoperative care in geriatric urology patients should be considered. Because of the lack of randomized controlled trials on preoperative CGAs in urology patients, further studies are needed.

Usefulness of scoring systems in outcome prediction for older cancer patients undergoing abdominal surgery.

BACKGROUND: Several postoperative outcome scoring systems have been developed and validated, combining both pre- and intraoperative factors. Among others are the Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM), the Estimation of Physiologic Ability and Stress (E-PASS) and the Surgical Apgar Score combined with the American Society of Anesthesiologists physical status classification (SASA). The aim of this study was to compare the above scoring systems in the prediction of 30-day postoperative outcome in older patients with cancer undergoing abdominal surgery. METHODS: Consecutive patients ≥70 years were prospectively enrolled. Pre- and intraoperative variables were used to calculate the scores, the ROC and perform logistic regression analysis. RESULTS: The study sample comprised 201 patients with a median age of 77 (range 70-93) years. The most common surgical procedure was for colorectal (75%), followed by gastric (10.4%) pancreas (7.0%), gall bladder (3.5%), small bowel (2.5%), and other (1.5%) types of cancer. All scores were independent predictors of 30-day postoperative mortality. In case of 30-day morbidity only SASA turned to be significant. The ROC curves were highly valid and area under the curve showed fair to good discriminatory ability (0.60-0.77) for 30-day postoperative mortality and fair (AUC 0.6) in case of SASA for the 30-day postoperative. CONCLUSION: The SASA, E-PASS, and P-POSSUM were confirmed to be predictive of 30-day postoperative mortality in older patients undergoing abdominal elective cancer surgery. Only SASA demonstrated as independent factor predicting postoperative 30-day major morbidity.

The Surgical Apgar score combined with Comprehensive Geriatric Assessment improves short- but not long-term outcome prediction in older patients undergoing abdominal cancer surgery.

OBJECTIVES: Frailty increases the risk of poor surgical outcomes in the older population. Some measurable intraoperative factors may also influence the final outcome. The Surgical Apgar Score (SAS) is a simple system predicting postoperative mortality and morbidity. However, the usefulness of the SAS remains unknown in fit and frail older patients. We aimed to test this, as well as investigate whether SAS can increase the predictive value of frailty in this group of patients. MATERIALS AND METHODS: Consecutive patients ≥70 years of age, needing elective abdominal surgery for cancer were enrolled in a prospective study. Comprehensive Geriatric Assessment was used to determine frailty. Logistic regression was conducted investigating the association between the scores and 30-day postoperative outcomes and 1-year mortality. RESULTS: The study included 165 older patients with a median age of 77 (range 70-93) years. The prevalence of frailty was 38.2%. The most significant predictors of short-term morbidity and mortality were frailty [OR 6.2 (95%CI 2.9-13.4) and 14.9 (95%CI 5.9-38)] and the SAS [OR 12.5 (95%CI 2.8-45) and 29.5 (95%CI 6.3-125)]. At long-term follow-up frailty was the best predictor of mortality: OR 4.6 (95%CI 1.8-17.6). CONCLUSION: Frailty and the SAS, not age, were significant predictors of 30-day postoperative morbidity and mortality both in fit and frail older patients undergoing elective abdominal cancer surgery. At 1-yearfollow-up frailty, not the SAS, was an independent risk factor of mortality. The combination of frailty and the SAS increased predictive accuracy and may be a target of care.

Geriatric Assessment as a qualification element for elective and emergency cholecystectomy in older patients.

BACKGROUND: Older patients experience a higher incidence of postoperative complications after cholecystectomy compared with younger patients. However, most studies have not considered patient frailty, particularly regarding emergency cholecystectomy. The aim of this prospective study was to evaluate outcomes in frail older patients eligible for elective and emergency cholecystectomy. METHODS: Preoperative Geriatric Assessment (GA) was performed in consecutive patients aged 65+ years, operated for biliary disease. The GA evaluated the functional, cognitive, comorbidity, depressive, nutritional, and polypharmacy status and patients with two or more abnormal domains were considered frail. Outcomes of interest were 30-day postoperative mortality, morbidity, and length of hospital stay (LOS). RESULTS: A total of 126 patients (median age 74; range 65-93 years) were included. There was no difference between elective frail and non-frail patients regarding postoperative mortality (0 %) and morbidity (6 % vs. 5 %; p = 0.76). LOS was not significantly longer in the frail group (5.6 vs. 4 days; p = 0.22). In the emergency-admitted patients, almost all complications occurred in the frail population (mortality 5 % vs. 0 %; morbidity 36.7 % vs. 3.3 %, compared with non-frail patients, respectively; p < 0.01) and LOS was significantly longer (10.3 (frail) vs. 6 days (non-frail);p = 0.03). Frail status was a significant independent predictive factor for postoperative complications in the emergency population, only (odds ratio: 3.4 (1.2-9.7); p = 0.02). CONCLUSIONS: Elective laparoscopic cholecystectomy is a safe and effective surgical technique also for older frail patients. In emergency settings, frail patients have significantly more complications and a longer LOS. However, the role of severity of frailty and the most reliable GA tools require further study. TRIAL REGISTRATION: ISRCTN14976998 (retrospectively registered).

Cumulative deficit model of geriatric assessment to predict the postoperative outcomes of older patients with solid abdominal cancer.

OBJECTIVE: The geriatric assessment (GA) has proven to be of great value for clinicians treating older patients. However, a clear consensus on the optimal set of GA instruments is lacking, particularly for surgical patients. Therefore, the aim of this prospective study was to compare the prevalence of frailty, depending on the number of incorporated GA domains, and to evaluate its accuracy in predicting postoperative outcome. MATERIALS AND METHODS: Seventy-five patients aged 65 years and older, qualified for abdominal surgery due to solid cancer, were enrolled. The GA included a wide variety of validated tools that evaluate functional, mobility, nutritional, co-morbidity, polypharmacy, and psychosocial domains. RESULTS: Depending on the number of incorporated GA domains the frequency of frailty was 23-97%. The cumulative score rather than individual components of the GA, turned out to be an independent risk factor of 30-day postoperative morbidity. In predicting 30-day "any" and "major" morbidities, the area under the curve was 0.67-0.72 and 0.70-0.82 (model including the severity of the surgery) vs. 0.57-0.66 and 0.50-0.65 (model not including the severity of the surgery), respectively. CONCLUSION: The number of incorporated GA domains has a great influence on the prevalence of frailty and on adequate surgical risk assessment. The summary deficit score based on Pre-operative Assessment of Cancer in the Elderly (PACE) or the GA consisting of functional, mobility, cognitive, depression, nutritional, co-morbidity, polypharmacy, and social support assessment domains can predict 30-day postoperative morbidity. However, only models with addition of the severity of surgery show moderate to good predictive value.

Low-anterior-resection syndrome. How does neoadjuvant radiotherapy and low resection of the rectum influence the function of anal sphincters in patients with rectal cancer? Preliminary results of a functional assessment study.

UNLABELLED: The aim of the study was to assess the influence of neoadjuvant radiotherapy and resection of the rectum on the functional parameters of anal sphincters. MATERIAL AND METHODS: 20 patients with rectal cancer, qualified for low anterior rectal resection with neoadjuvant radiotherapy were enrolled in the study group. The study protocol included an anorectal manometry, electromyography and fecal incontinence questionnaire (FISI) before radiotherapy, after radiotherapy, and after the operation. RESULTS: Of the 20 patients 12 were included in the final analysis, because 8 patients were re-qualified to abdomino-perineal resection of the rectum after neoadjuvant treatment. There were no significant changes in anal pressures assessed 5 to 8 days after radiotherapy. In 3 cases (25%) pathological changes in RAIR reflex were found in the manometric examination. After low anterior resection mean basal anal pressures were significantly lower, whereas squeeze anal pressures did not change significantly. In 7 patients (58%) the RAIR reflex was pathological or even absent after low anterior resection. Changes in manometric parameters correlated with FISI incontinence assessment after the operation. In electromyographic examination action potentials of motoric units of the external anal sphincter were still present both after radiotherapy, and after operation. CONCLUSIONS: Fecal incontinence after low anterior resection of the rectum seems to be caused mostly by changes in autonomic functionality of anal sphincters and lack of compliance of the neorectum, since the influence of neoadjuvant radiotherapy and the operation itself on the somatic innervation of anal sphincters seems to be minimal.

Doppler-guided hemorrhoid artery ligation with Recto-Anal-Repair modification: functional evaluation and safety assessment of a new minimally invasive method of treatment of advanced hemorrhoidal disease.

PURPOSE: We present 12-month followup results of functional evaluation and safety assessment of a modification of hemorrhoidal artery ligation (DGHAL) called Recto-Anal-Repair (RAR) in treatment of advanced hemorrhoidal disease (HD). METHODS: Patients with grade III and IV HD underwent the RAR procedure (DGHAL combined with restoration of prolapsed hemorrhoids to their anatomical position with longitudinal sutures). Each patient had rectal examination, anorectal manometry, and QoL questionnaire performed before 3 months, and 12 months after RAR procedure. RESULTS: 20 patients completed 12-month followup. There were no major complications. 3 months after RAR, 5 cases of residual mucosal prolapse were detected (25%), while only 3 patients (15%) reported persistence of symptoms. 12 months after RAR, another 3 HD recurrences were detected, to a total of 8 patients (40%) with HD recurrence. Anal pressures after RAR were significantly lower than before (P < 0.05), and the effect was persistent 12 months after RAR. One patient (5%) reported occasional soiling 3 months after RAR. CONCLUSIONS: RAR seems to be a safe method of treatment of advanced HD with no major complications. The procedure has a significant influence on anal pressures, with no evidence of risk of fecal incontinence after the operation.