The Surgical Apgar Score and frailty as outcome predictors in short- and long-term evaluation of fit and frail older patients undergoing elective laparoscopic cholecystectomy - a prospective cohort study.

INTRODUCTION: Frailty increases the risk of poor surgical outcomes in the older population. Some intraoperative factors may also influence the final result and can be evaluated. The Surgical Apgar Score (SAS) is a simple system predicting postoperative mortality and morbidity. However, the utility of the SAS remains unknown in fit and frail older patients undergoing elective laparoscopic cholecystectomy due to benign gallbladder diseases. AIM: To evaluate the usefulness of the SAS in predicting 30-day morbidity and 1-year mortality in older fit and frail patients undergoing elective laparoscopic cholecystectomy. MATERIAL AND METHODS: Consecutive patients (≥ 70 years) were enrolled in the prospective study. The Comprehensive Geriatric Assessment (CGA) was used to diagnose frailty. Logistic regression was conducted to investigate the association between the scores and the outcomes. RESULTS: The study included 144 consecutive older patients with a median age of 76 (range: 70-91) years. The prevalence of frailty was 44.4%. The 30-day mortality and morbidity were 0% and 11.8%, respectively. The 1-year mortality was 6.3% and 7 out of 9 occurred in the frail group. SAS < 7 points was identified as an independent predictor of 30-day postoperative morbidity (OR = 5.1; 95% CI: 1.5-18.1). Age > 85 years (OR = 1.9; 95% CI: 1.2-16.4) and frailty (OR = 3.4; 95% CI: 1.1-19.3) were predictors of 1-year mortality. CONCLUSIONS: Laparoscopic cholecystectomy can be safely performed in older fit and frail patients. The SAS, not age, turned out to be the most important predictor of 30-day morbidity. Frailty and age > 85 years were predictors of 1-year mortality. Older patients with SAS < 7 points should be followed meticulously in order to diagnose and treat potential complications early on.

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).

Six screening instruments for frailty in older patients qualified for emergency abdominal surgery.

INTRODUCTION: The literature on geriatric assessment in emergency admitted patients is scarce, particularly there are no studies regarding the efficacy of frailty screening tests among patients qualified for emergency abdominal surgery. Therefore, the aim of this study was to compare the diagnostic accuracy of six screening instruments in this group of patients. MATERIAL AND METHODS: The diagnostic accuracy of the Vulnerable Elderly Survey (VES-13), Triage Risk Screening Tool (TRST), Geriatric-8 (G8), Groningen Frailty Index (GFI), Rockwood, Balducci score was evaluated in a prospective group of 184 consecutive patients ≥65 years of age. Outcome measure was sensitivity, specificity, positive and negative predictive values of these tests in prediciting 30-day postoperative outcome. RESULTS: Patients mean age was 76.9±5.8 (65-100) years. The prevalence of frailty, as diagnosed by screening methods, was: 50-79.9% (Balducci/Rockwood-G8). Multivariate analyses have identified all screening tests apart from Rockwood and TRST as independent factors that predict postoperative outcome. The sensitivity and negative predictive value in case of postoperative mortality were 60-91% (Rockwood-VES-13) and 30-93% (GFI-VES13). In case of postoperative morbidity they were 52-85% (Rockwood-VES-13 and G8) and 44-70% (Rockwood-VES-13), respectively. CONCLUSION: Considering these results, it is possible to perform safely and efficiently screening test for frailty in older patients qualified for emergency abdominal surgery. The VES-13 was the best screening instrument; it had the highest sensitivity and negative predictive value both for the postoperative mortality and morbidity. This instrument may offer physicians additional information that can be used in the postoperative optimisation of the treatment of these high-risk group of patients.

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.

The prognostic role of comorbidities in older patients qualified for emergency abdominal surgery.

UNLABELLED: Until now, the literature about the influence of specific comorbid conditions on outcome of emergency abdominal surgery in polish elderly patients is scars. The aim of the study was to determine the prognostic role of comorbidities in patients qualified for emergency abdominal surgery. MATERIAL AND METHODS: One hundred and eighty four consecutive patients(98 female and 86 male). 65 years of age were prospectively enrolled. The mean age was 76.9 ± 5.8 (range 65-100) years old. RESULTS: Only 16% of patients did not have any preoperative comorbidity. The 30-day mortality was 24.5% (45 patients). The 30-day morbidity was experienced by the 58.7% (108 patients), including 40 patients (21.7%) with minor complications and 68 patients (37%) with major complications, according to the Clavien-Dindo complications scale. The dysrhythmia (odds ratio 1.6, 95% CI 1.2-2.6, p=0.02), vascular disease (odds ratio 2.1, 95% CI 1.4- 3.1, p=0.02) and renal disease (odds ratio 1.4, 95% CI 1.2-2.8, p=0.01) were independent risk factors of 30-day morbidity. The vascular disease was also the independent risk factor of 30-day postoperative death in the multivariate regression analysis (odds ratio 1.9, 95% CI 1.3-2.8, p=0.001). CONCLUSIONS: Preoperative comorbidities are common among elderly patients qualified for emergency abdominal surgery. However, only some of them (the dysrhythmia, the vascular disease and the renal disease) are independent risk factors of postoperative adverse outcomes. Therefore, number of comorbidies alone should not be the reason for a limited treatment.

Screening for frailty among older patients with cancer that qualify for abdominal surgery.

OBJECTIVE: The Geriatric Assessment (GA) is an established method for evaluating and optimizing diagnostic and treatment plans. However, it requires experience and is time-consuming. Therefore, a variety of screening methods have been developed. The aim of this study was to compare their accuracy for predicting frailty among older patients with cancer qualified for abdominal surgery based on comparison to the GA. MATERIAL AND METHODS: One hundred and thirty five consecutive patients ≥65years of age were prospectively enrolled. The diagnostic performance of eight screening tests was evaluated: The Vulnerable Elderly Survey (VES-13), Triage Risk Screening Tool (TRST), Geriatric 8 (G8), Groningen Frailty Index (GFI), abbreviated Comprehensive Geriatric Assessment (aCGA), Rockwood, Balducci and Fried score. RESULTS: The prevalence of frailty as diagnosed by the GA was 73%. Screening methods identified frail patients in 40-75.5% of cases. The sensitivity and specificity of these tests in predicting frailty were 52%-97% (Fried score-G8) and 44-100% (G8-Rockwood score), respectively. The positive and negative predictive values were 82-100% (Balducci-Rockwood) and 43-84% (TRST-G8), respectively. Age significantly influenced the predictive value of the screening tests whereas gender and type of cancer did not. CONCLUSION: At present, there is no universal screening test that adequately identifies frailty in at risk older patients. The results of this study showed that the aCGA and G8 were the best screens for older patients with cancer that qualified for elective abdominal surgery; the G8 had the highest sensitivity and negative predictive value and the aCGA was a good overall assessment tool.

Vulnerable Elderly Survey 13 as a screening method for frailty in Polish elderly surgical patient--prospective study.

UNLABELLED: The Vulnerable Elders Survey (VES-13) is a simple function based frailty screening tool that can be also administered by the nonclinical personnel within 5 minutes and has been validated in the out- and in patient clinic and acute medical care settings. The aim of the study was to validate the accuracy of the VES-13 screening method for predicting the frailty syndrome based on a CGA in polish surgical patients. MATERIAL AND METHODS: We included prospectively 106 consecutive patients ≥65, that qualify for abdominal surgery (both due to oncological and benign reasons), at the tertiary referral hospital.We evaluated the diagnostic performance of VES-13 score comparing to the results from the CGA, accepted as the gold standard for identifying at risk frail elderly patients. RESULTS: The prevalence of frailty as diagnosed by CGA was 59.4%. There was significantly higher number of frail patients in the oncological group (78% vs. 31%; p<0.01). According to the frailty screening methods, the frailty prevalence was 45.3%. The VES-13 score had a 60% sensitivity and 78% specificity in detecting frailty syndrome. The positive and negative predictive value was 81% and 57%, respectively. The overall predictive capacity was intermediate (AUC=0.69) CONCLUSIONS: At present, the VES-13 screening tool for older patients cannot replace the comprehensive geriatric assessment; this is due to the insufficient discriminative power to select patients for further assessment. It might be helpful in a busy clinical practice and in facilities that do not have trained personal for geriatric assessment.