Association of Geriatric Comanagement and 90-Day Postoperative Mortality Among Patients Aged 75 Years and Older With Cancer.

Importance: Collaboration between geriatricians and surgeons in the perioperative treatment of older patients has been associated with improved outcomes in several nononcologic specialties. Similar associations may be possible among older patients with cancer. Objective: To investigate the associations of geriatric comanagement of care for older patients undergoing cancer-related surgical treatment with 90-day postoperative mortality, rate of adverse surgical events, and postoperative use of inpatient supportive care services. Design, Setting, and Participants: This retrospective cohort study assessed outcomes of patients who received geriatric comanaged care vs those who did not using multivariable logistic regression analysis, with 90-day mortality as the outcome and geriatric comanagement of care as the main variable, with adjustment for age, sex, American Society of Anesthesiology score, Memorial Sloan Kettering Frailty Index score, preoperative albumin level, operative time, and estimated blood loss. A similar model was used to assess the association of geriatric comanagement with adverse surgical events, defined as any major complication, readmission, or emergency department visit within 30 days. Patients aged 75 years and older who underwent an elective surgical procedure with a hospital stay of at least 1 day at a single tertiary-care cancer center between February 2015 and February 2018 were included. Data were analyzed from January to July 2019. Exposures: Postoperative care comanaged by the geriatrics service and surgical service (geriatric comanagement group) vs by the surgical service only (surgical service group). Main Outcomes and Measures: 90-day mortality, adverse surgical events, and use of supportive care services. Results: Of 1892 patients included, 1020 (53.9%) received geriatric comanagement of care; these patients, compared with those who received care managed by the surgery service only, were older (mean [SD] age, 81 [4] years vs 80 [4] years; P < .001), had longer operative time (mean [SD], 203 [146] minutes vs 138 [112] minutes; P < .001), and longer length of stay (median [interquartile range], 5 [3-8] days vs 4 [2-7] days; P < .001). There were no differences in the proportions of men (488 [47.8%] men vs 450 [51.6%] men; P = .11). Adverse surgical events were not significantly different between groups (odds ratio, 0.93 [95% CI, 0.73-1.18]; P = .54). However, the adjusted probability of death within 90 days after surgical treatment was 4.3% for the geriatric comanagement group vs 8.9% for the surgical service group (difference, 4.6% [95% CI, 2.3%-6.9%]; P < .001). Additionally, compared with patients who received postoperative care management from the surgery service only, a higher proportion of patients in the geriatric comanagement group received inpatient supportive care services, including physical therapy (555 patients [63.6%] vs 820 patients [80.4%]; P < .001), occupational therapy (220 patients [25.2%] vs 385 patients [37.7%]; P < .001), speech and swallow rehabilitation (42 patients [4.8%] vs 86 patients [8.4%]; P = .002), and nutrition services (637 patients [73.1%] vs 803 patients [78.7%]; P = .004). Conclusions and Relevance: This cohort study found that geriatric comanagement was associated with significantly lower 90-day postoperative mortality among older patients with cancer. These findings suggest that such patients may benefit from geriatric comanagement, which could improve their ability to survive adverse postoperative events.

Treating Anemia in the Preanesthesia Assessment Clinic: Results of a Retrospective Evaluation.

BACKGROUND: Perioperative anemia is challenging during hospital stay because anemia and red blood cell (RBC) transfusions are associated with an increased morbidity and mortality. With the implementation of patient blood management (PBM), a preanesthesia assessment clinic to screen and treat anemia before elective surgery was institutionalized at Muenster University Hospital, Germany. The main objective of this study was to evaluate the association between treating preoperative anemic patients with intravenous iron (IVI) and (primarily) presurgical hemoglobin levels and (secondarily) use of RBCs and mortality. METHODS: Between April 1, 2014, and July 4, 2016, patients scheduled for elective surgery with a risk for RBC transfusions >10% in 2013 were screened for preoperative anemia and, if indicated, treated with IVI. Patients' data, time span between visit in the anesthesia/PBM clinic and surgery, demographic data, type of surgery, the difference of hemoglobin levels between visit and surgery, RBC transfusion, infectious-related International Classification of Disease codes during hospital stay, and 1-year survival were determined retrospectively by screening electronic data files. In addition, patients were interviewed about adverse events, health-related events, and infections via telephone 30, 90, and 365 days after visiting the anesthesia/PBM clinic. RESULTS: A total of 1101 patients were seen in the anesthesia/PBM clinic between days -28 and -1 (median [Q1-Q3], -3 days [-1, -9 days]) before elective surgery. Approximately 29% of patients presented with anemia, 46.8% of these anemic patients were treated with ferric carboxymaltose (500-1000 mg).In the primary analysis, hemoglobin levels at median were associated with a reduction between the visit in the anesthesia/PBM clinic and the surgery in all nonanemic patients on beginning of medical treatment (nonanemic patients at median -2.8 g/dL [-4, -0.9 g/dL], while anemic patients without IVI presented with median differences of -0.8 g/dL [-2, 0 g/dL] and anemic patients with IVI of 0 g/dL [-1.0, 0.5 g/dL]). Hemoglobin levels raised best at substitution 22-28 days before surgery (0.95 g/dL [-0.35, 1.18 g/dL]). Due to the selection criteria, transfusion rates were high in the cohort. Overall, there was no association between IVI treatment and the use of RBC transfusions (odds ratio for use of RBCs in anemic patients, no IVI versus IVI: 1.14; 95% confidence interval, 0.72-1.82). Patients treated with or without IVI presented a comparable range of International Classification of Disease codes related to infections. Telephone interviews indicated similar adverse events, health-related events, and infections. Cox regression analysis showed an association between anemia and reduced survival, regardless of IVI. CONCLUSIONS: An anemia clinic within the preanesthesia assessment clinic is a feasible and effective approach to treat preoperative anemia. The IVI supplementation was safe but was associated with decreased RBC transfusions in gynecology/obstetric patients only. The conclusions from this retrospective analysis have to be tested in prospective, controlled trials.

Mortality after shoulder arthroplasty.

One year post-operative mortality among patients with primary elective total shoulder arthroplasty (ETSA) and traumatic shoulder arthroplasty (TSA) were compared to the general population of a large healthcare system. Standardized mortality ratios (SMRs) and 95% confidence intervals (CIs) were calculated. 614 ETSA patients, 1.0% one year mortality, and 168 TSA patients, 5.4% mortality rate, were evaluated. Patients with ETSA (SMR = 0.4, 95% CI 0.1-0.7) had lower odds of mortality than expected, while patients with TSA (SMR = 1.8, 95% CI 0.6-3.0) did not have higher than expected odds of mortality compared to the reference population. Understanding excess mortality following shoulder arthroplasty surgery allows providers to evaluate current practices and identify ways to optimize patients prior to surgery.

Short-term preoperative supplementation of an immunoenriched diet does not improve clinical outcome in well-nourished patients undergoing abdominal cancer surgery.

OBJECTIVE: A recent study suggested that the anti-inflammatory effect of immunonutrition starts after only two d. We therefore investigated the effect of an immunoenriched oral diet administered for three d preoperatively. METHODS: In this prospective, randomized, double-blind, placebo-controlled study, well-nourished patients (Nutrition Risk Screening 2002 <3) with gastrointestinal cancer who were scheduled for major elective abdominal cancer surgery were randomly assigned to either 750 mL of an immunoenriched formula (IEF group) or 750 mL of an isocaloric, isonitrogenous placebo diet (Con group) for 3 consecutive d preoperatively. RESULTS: A total of 108 patients (IEF group: n = 55; Con group: n = 53) were randomized. The two groups were comparable for all baseline and surgical characteristics. The overall mortality was 2.8% and not significantly different between the two groups (IEF group: 3.6% vs. Con group: 1.9%, P = 1.00). Intention-to-treat analysis showed no difference for the incidence of postoperative overall (IEF group: 29% vs. Con group: 30%; P = 1.00) and infectious (IEF group: 15% vs. Con group: 17%; P = 0.79) complications. Length of hospital stay was 12 ± 4.9 d in the IEF group and 11.6 ± 5.3 d in the Con group (P = 0.68). CONCLUSIONS: Preoperative oral supplementation with an immunoenriched diet for 3 d preoperatively did not improve postoperative outcome compared with the placebo in well-nourished patients with elective gastrointestinal cancer surgery.

Elective colonic surgery for cancer in the elderly: an investigation into postoperative mortality in English NHS hospitals between 1996 and 2007.

BACKGROUND: This study was primarily aimed to quantify perioperative mortality risk in elderly patients undergoing elective colonic resectional surgery. In addition, the safety of minimally invasive colonic surgery in this patient group was evaluated. METHODS: All patients aged > 75 undergoing elective colonic resection for colorectal malignancy between 1996 and 2007 in English NHS hospitals were included from the Hospital Episode Statistics (HES) dataset. RESULTS: Between the study dates, 28,746 patients > 75 years underwent elective colonic resection. The national annual number of colonic excisions carried out amongst elderly patients increased from 2188 patients in 1996/7 to 3240 patients in 2006/7. Following adjustment for gender, comorbidity and surgical approach, advancing age was an independent predictor for 30-day mortality (OR 2.47 for patients aged 85-89 vs 75-79, P < 0.001). Use of laparoscopy was a significant predictor of reduced perioperative mortality (OR 0.56, P = 0.003) once adjusted for advancing age, gender and comorbidity. Comparison of 30-day and 1-year postoperative mortality following elective colonic resection in patients aged 90 revealed a large excess of patients dying outside of the immediate perioperative period (10.1% and 26.2% for proximal cancers, respectively; 12.9% and 36.1% for distal colonic resections, respectively). CONCLUSIONS: Advancing age is an independent risk factor for postoperative death in elderly patients undergoing elective colonic resection for cancer. The risk of death in the elderly is extremely high and surgical decision-making should incorporate the mortality risk that occurs outside the immediate perioperative period. In this national series, patients selected for a laparoscopic procedure were at lower risk of perioperative death than those undergoing the conventional approach.

Immunonutrition in high-risk surgical patients: a systematic review and analysis of the literature.

BACKGROUND: Immunomodulating diets (IMDs) have been demonstrated to improve immune function and modulate inflammation. However, the clinical benefit of these diets in patients undergoing elective surgery is controversial. The goal of this meta-analysis was to determine the impact of IMDs on the clinical outcomes of high-risk patients undergoing elective surgery. METHODS: The review included prospective, controlled, clinical trials that compared the clinical outcome of elective surgical patients who were randomized to receive an IMD or a control enteral diet. Studies were stratified according to the type of IMD and the timing of the initiation of the IMD. Data were abstracted on study design, study size, patient population, and IMD used. The outcomes of interest were the acquisition of new infections, wound complications, length of hospital stay (LOS), and mortality. Meta-analytic techniques were used to analyze the data. RESULTS: Twenty-one relevant studies were identified, which included a total of 1918 patients. Immunonutrition significantly reduced the risk of acquired infections, wound complications, and LOS. The mortality rate was 1% in both groups. The treatment effect was similar regardless of the timing of the commencement of the IMD. The benefits of immunonutrition required both arginine and fish oil. CONCLUSIONS: An immunomodulating enteral diet containing increased amounts of both arginine and fish oil should be considered in all high-risk patients undergoing major surgery. Although the optimal timing cannot be determined from this study, it is suggested that immunonutrition be initiated preoperatively when feasible.

Changes in red blood cell transfusion practice during the past two decades: a retrospective analysis, with the Mayo database, of adult patients undergoing major spine surgery.

BACKGROUND: Others have reported significant changes in red blood cell (RBC) transfusion practice during the past two decades during knee, hip, prostate, and carotid surgery. Similar data for patients undergoing major spine surgery, however, are not available. STUDY DESIGN AND METHODS: After institutional review board approval, adult patients undergoing elective major spine surgery were stratified into one of two transfusion-related groups: 1) 1980 to 1985 (i.e., before human immunodeficiency virus screening, early practice group; n = 699) or 2) 1995 to 2000 (i.e., late practice group; n = 610). RESULTS: Patients in the late practice group were older, had greater numbers of preoperative coexisting diseases (e.g., hypertension, cardiac dysrhythmias, coronary artery disease, prior myocardial infarction, diabetes mellitus, renal disease, cerebrovascular disease, and asthma), and were exposed to longer operations (p < 0.01 for each variable). Over time, allogeneic RBC administration significantly decreased, whereas autologous and intraoperative autotransfusion significantly increased. Compared to the early practice group, all perioperative Hb concentrations were significantly lower than the late practice group, yet no significant difference in major morbidity or mortality was observed between groups. CONCLUSION: In this retrospective analysis, significantly lower acceptable perioperative Hb concentrations were observed in older patients having substantially worse baseline comorbidity and exposed to longer major spine operations, without significant change in the incidence of perioperative morbidity or mortality.

Transfusion thresholds in common elective surgical procedures in Finland.

BACKGROUND AND OBJECTIVES: Transfusion practices and thresholds in common elective surgical procedures were investigated in a nationwide multicenter survey in Finland. MATERIALS AND METHODS: The records of 764 total hip replacement (THR), 397 total knee replacement (TKR) and 343 transurethral resection of the prostate (TURP) patients were reviewed by four anesthesiologists. RESULTS: The allogeneic red cell (RBC) transfusion rates in THR, TKR and TURP operations were 92, 84 and 18%, respectively. In THR and TKR, 74% of patients who lost 20% or less of their blood volume during hospitalization were transfused with RBCs. Postoperatively, the median pretransfusion hemoglobin values were 9.6 g/dl in orthopedic operations and 10.7 g/dl in TURP. In some hospitals, the median transfusion threshold in TURP patients was as high as 11.2 g/dl. CONCLUSION: The transfusion thresholds in all operations were liberal compared to recent international recommendations. Inappropriate thresholds were reflected in the high transfusion rates. This study accentuates the need for continuous discussion and educational measures to find optimal indications for transfusion in surgery, and to rationalize the transfusion policy in Finland.