A retrospective study of colonoscopic surveillance in the elderly.

BACKGROUND: Aotearoa New Zealand (AoNZ) guidelines suggest surveillance colonoscopy should be carefully considered after age 75. The authors noted a cluster of patients presenting in their 8th and 9th decade of life with a new colorectal cancer (CRC) having previously been declined surveillance colonoscopy. METHODS: A 7-year retrospective analysis was performed of patients who underwent a colonoscopy aged between 71 and 75 years in the period between 2006 and 2012. Kaplan-Meier graphs were created with survival measured from the time of index colonoscopy. Log rank tests were used to determine any difference in survival distribution. Relative risk (RR) was calculated, and 95% confidence intervals (CI) reported. RESULTS: A total of 623 patients met inclusion criteria; 461 (74%) had no indication for surveillance colonoscopy and 162 (26%) had an indication. Of the 162 patients with an indication, 91 (56.2%) underwent surveillance colonoscopies after the age of 75. Twenty-three (3.7%) patients were diagnosed with a new CRC. Eighteen (78.2%) patients diagnosed with a new CRC underwent surgery. The median survival overall was 12.9 years (95% CI 12.2-13.5). This did not differ between patients with (13.1, 95% CI 12.1-14.1) or without (12.6, 95% CI 11.2-14.0) an indication for surveillance. CONCLUSION: This study found one quarter of patients who had a colonoscopy between the ages of 71-75 had an indication for surveillance colonoscopy. Most patients with a new CRC underwent surgery. This study suggests it may be appropriate to update the AoNZ guidelines and consider adopting a risk stratification tool to aid decision making.

Delayed ileostomy closure increases the odds of Clostridium difficile infection.

AIM: A diverting ileostomy is typically performed to divert intestinal contents in high-risk colorectal anastomoses. Ileostomy closure is associated with high rates of postoperative Clostridium difficile infection (CDI). Risk factors for the development of CDI are unclear; however, a correlation has been observed with delayed closure. This study aimed to assess the odds of developing CDI in patients who had a delay to reversal of ileostomy, compared to those who had no delay. METHODS: A retrospective cohort study was conducted of patients undergoing reversal of ileostomy between 2010 and 2019 at a single tertiary centre. A delay to reversal of ileostomy was defined if the procedure was performed at >365 days following the index procedure. CDI was defined as the presence of Clostridium difficile toxin associated with diarrhoea. Univariable logistic regression analysis was performed to estimate odds of CDI for each covariable, comparing patients who had a delay to reversal of ileostomy with those who did not. Multivariable logistic regression analysis was used to adjust for the potential confounding effects of covariables. RESULTS: Of 195 patients, 11 (5.6%), developed postoperative CDI. Multivariable analysis showed that delay to reversal of ileostomy was associated with a nearly 7-fold increase in odds of CDI (OR = 6.95, CI: 1.06-81.6; p-value = 0.03). CONCLUSION: A delay to reversal of ileostomy of >365 days was associated with a higher incidence of CDI postoperatively. Careful consideration should be given to the timing of reversal and appropriate preoperative counselling of patients.

Pre-operative frailty is predictive of adverse post-operative outcomes in colorectal cancer patients.

BACKGROUND: An increasing number of elderly patients are presenting for elective surgery. Pre-operative risk assessment in this population is inexact due to the complex interplay between age, comorbidity and functional status. Frailty assessment may provide a surrogate measure of a patient's physiological reserve and aid operative decision-making. The aim of this study is to determine the association between pre-operative frailty, as assessed using the Edmonton Frail Scale, and post-operative outcomes in elderly patients undergoing elective colorectal cancer surgery. METHODS: A prospective analysis of 86 patients over the age of 65 undergoing elective colorectal cancer surgery at a tertiary centre between October 2017 and October 2018 was performed. Frailty assessment was conducted pre-operatively using the Edmonton Frail Scale. Primary outcomes included length of stay and post-operative complication rates. Multivariable logistic regression analyses were used to determine the influence of frailty on post-operative outcomes including mortality, prolonged hospital admission, complication rates and quality of life. RESULTS: Of 86 patients, 12 (14.0%) were identified as frail. Frailty was associated with a significantly increased median length of stay (20 days versus 6 days, incidence rate ratio 2.83, P < 0.01) and a significantly increased risk of major post-operative complications (50.0% versus 6.7%, odds ratio 13.8, P < 0.01). Frailty was not associated with a significant reduction in quality of life scores at 30 and 90 days post-operatively. CONCLUSION: Frailty is associated with adverse post-operative outcomes in elderly patients undergoing elective colorectal cancer surgery. Frailty assessment is an important component of pre-operative risk assessment and may identify targets for pre-operative optimisation.

The association between low pre-operative step count and adverse post-operative outcomes in older patients undergoing colorectal cancer surgery.

BACKGROUND: Multiple tools exist estimating perioperative risk. With an ageing surgical demographic, frailty is becoming an increasingly important concept in perioperative medicine due to its association with adverse post-operative outcomes. Reduced physical activity is a hallmark of frailty, and we postulate that a low pre-operative step count may be an objective measure of frailty. This study aimed to determine the association between low pre-operative step count and post-operative outcomes in patients undergoing elective colorectal cancer surgery. METHODS: A prospective analysis of 85 older patients undergoing major elective colorectal surgery was performed at a tertiary centre between October 2017 and October 2018. Patients aged 65 years and over who met inclusion criteria were provided with an activity tracker to wear for 14 days prior to planned surgery. Their median daily step count was measured and a cut-off of < 2500 steps/day was used to define a reduced step count. Primary outcomes included length of stay and 30-day post-operative complication rate. Multivariable logistic regression analyses were used to analyze the influence of low pre-operative step count and other preoperative variables, on post-operative outcomes including mortality, prolonged hospital admission, and complication rates. RESULTS: Of 85 patients, 17 (20%) were identified as having a low pre-operative step count. A low pre-operative step count was associated with a significantly increased length of stay (14 vs. 6 days, IRR 2.09, 95% CI 1.55-2.83, p ≤ 0.01) and rate of major post-operative complications (29.4% vs. 8.8%, OR 3.34, 95% CI 1.03-14.3, p = 0.04). It was also associated with significantly increased rates of discharge to care facilities (p < 0.01) and requiring support on discharge (p = 0.03). CONCLUSION: Low pre-operative step count (< 2500 steps/day) is predictive of an increased risk of post-operative morbidity in patients undergoing elective colorectal surgery. Accurate preoperative identification may allow for treatment modification and tailored perioperative care. The possibility of using a wearable activity tracker as a simple but powerful pre-habilitation tool is raised as an important avenue for future study. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ACTRN12618000045213).

Sarcopenia, as Assessed by Psoas Cross-Sectional Area, Is Predictive of Adverse Postoperative Outcomes in Patients Undergoing Colorectal Cancer Surgery.

BACKGROUND: Frailty and sarcopenia are important concepts in surgical practice because of their association with adverse postoperative outcomes. Radiologically assessed psoas muscle mass has been proposed as a surrogate for sarcopenia and may be predictive of poor postoperative outcomes. OBJECTIVE: This study aimed to determine the association between sarcopenia, as assessed by psoas cross-sectional area, and postoperative outcomes in patients undergoing colorectal cancer surgery. DESIGN: This was a retrospective review of patient records from 2014 to 2016. SETTINGS: This study was conducted at a single tertiary center. PATIENTS: Patients undergoing elective resection of colorectal cancer were included. MAIN OUTCOME MEASURES: Sarcopenia was assessed using the total psoas index, calculated by measuring the cross-sectional area of the psoas muscle at the third lumbar vertebra and normalized for patient height. Preoperative and intraoperative variables, including the presence of preoperative sarcopenia, were evaluated as potential risk factors for adverse postoperative outcomes. RESULTS: Of 350 patients, 115 (32.9%) were identified as sarcopenic. Sarcopenia was associated with a significantly increased length of stay (13 days vs 7 days; OR, 1.31; 95% CI, 1.23-1.42; p < 0.01) and 1-year mortality (13.9% vs 0.9%; OR, 16.2; 95% CI, 4.34-83.4; p < 0.01). Sarcopenia was also associated with a significant increased risk of any complication (85.2% vs 34.5%; OR, 15.4; 95% CI, 8.39-29.7; p < 0.01) and of major complications (30.4% vs 8.9%; OR, 15.1; 95% CI, 7.16-33.2; p < 0.01). LIMITATIONS: This study was limited by its retrospective design and by being conducted in a single institution. Although reduced muscle mass is suggestive of sarcopenia, it does not assess a patient's physical function or other components of the frailty phenotype. CONCLUSION: Radiological sarcopenia is an important predictive risk factor for adverse postoperative outcomes in surgical patients. Computed tomography scans, which are routinely performed as part of staging, provide an opportunity to assess for sarcopenia preoperatively. See Video Abstract at http://links.lww.com/DCR/B201. LA SARCOPENIA, EVALUADA POR EL ÁREA TRANSVERSAL DE PSOAS, PREDICE RESULTADOS POSTOPERATORIOS ADVERSOS EN PACIENTES SOMETIDOS A CIRUGÍA DE CÁNCER COLORECTAL: La fragilidad y la sarcopenia son conceptos importantes en la práctica quirúrgica debido a su asociación con los resultados postoperatorios adversos. La masa muscular del psoas evaluada radiológicamente se ha propuesto como un sustituto de la sarcopenia y puede predecir resultados postoperatorios deficientes.Determinar la asociación entre la sarcopenia, según lo evaluado por el área transversal del psoas, y los resultados postoperatorios en pacientes sometidos a cirugía de cáncer colorrectal.Esta fue una revisión retrospectiva de los registros de pacientes de 2014 a 2016.Este estudio se llevo a cabo en un solo centro terciario.Se incluyeron pacientes sometidos a resección electiva de cáncer colorrectal.La sarcopenia se evaluó utilizando el índice de psoas total (TPI), calculado midiendo el área de la sección transversal del músculo psoas en la tercera vértebra lumbar y normalizado para la altura del paciente.Se evaluaron las variables preoperatorias e intraoperatorias, incluida la presencia de sarcopenia preoperatoria, como posibles factores de riesgo de resultados postoperatorios adversos.De 350 pacientes, 115 (32,9%) fueron identificados como sarcopénicos. La sarcopenia se asoció con un aumento significativo de la duración de la estancia (13 días frente a 7 días, OR 1.31, IC 95% 1.23-1.42, p < 0.01) y de la mortalidad al año (13.9% vs 0.9%, OR 16.2, IC 95% 4.34-83.4, p < 0.01). La sarcopenia también se asoció con un aumento significativo del riesgo de cualquier complicación (85.2% vs 34.5%, OR 15.4, IC 95% 8.39-29.7, p < 0.01) y de complicaciones mayores (30.4% vs 8.9%, OR 15.1 IC 95% 7.16-33,2, p < 0,01).Este estudio estuvo limitado por su diseño retrospectivo y por el hecho de que se realizó en una sola institución. Aunque la reducción de la masa muscular es un indicio de sarcopenia, no evalúa la función física del paciente ni otros componentes del fenotipo de fragilidad.La sarcopenia radiológica es un importante factor de riesgo predictivo para resultados postoperatorios adversos en pacientes quirúrgicos. Las tomografías computarizadas, que se realizan rutinariamente como parte de la estadificación, brindan la oportunidad de evaluar la sarcopenia antes de la operación. Consulte Video Resumen en http://links.lww.com/DCR/B201. (Traducción-Dr. Gonzalo Hagerman).

Prevalence of frailty in a tertiary hospital: A point prevalence observational study.

INTRODUCTION: Frailty is an important concept in modern healthcare due to its association with adverse outcomes. Its prevalence varies in the literature and there is a paucity of literature looking at the prevalence of frailty in an inpatient setting. Its significance lies on its impact on resource utilisation and costs. AIM: To determine the prevalence of frailty in the adult population in a tertiary New Zealand hospital. METHODS: Eligible patients aged 18 years and over were invited to participate, and frailty assessment was performed using the Reported Edmonton Frail Scale. A score of 8 or more was considered frail. Factors associated with frailty were assessed. RESULTS: Of 640 occupied inpatient beds, 420 patients were assessed. 220 patients were excluded, of which 89 were absent from their bed-space, 73 declined and 41 were critically unwell. The overall prevalence of frailty across assessed patients was 48.8%. The prevalence of frailty increased significantly with age; patients aged 85 and over were significantly more likely to be frail compared to those aged under 65 (OR 6.25, 95% CI 3.17-12.7). Maori patients were significantly more likely to be frail (OR 4.0, 95% CI 1.45-11.9). When compared to those patients admitted to a medical specialty, patients admitted to surgical specialty were less likely to be frail (OR 0.52 95% CI 0.31-0.86) and those admitted for rehabilitation were more likely to be frail (OR 1.86 95% CI 1.03-3.41). Frail patients were more likely to come from a rest home (OR 2.81, 95% CI 1.38-6.14) or hospital level care (OR 9.62, 95% CI 2.68-61.6). CONCLUSION: Frailty is highly prevalent in the hospital setting with 48.8% of all inpatients classified as frail. This high number of frail patients has significant resource implications and an increased understanding of the burden of frailty in this population may aid targeting of interventions towards this vulnerable population.

Frailty in surgical patients.

OBJECTIVE: To describe the current definitions, aetiology, assessment tools and clinical implications of frailty in modern surgical practice. BACKGROUND: Frailty is a critical issue in modern surgical practice due to its association with adverse health events and poor post-operative outcomes. The global population is rapidly ageing resulting in more older patients presenting for surgery. With this, the number of frail patients presenting for surgery is also increasing. Despite the identification of frailty as a significant predictor of poor health outcomes, there is currently no consensus on how to define, measure and diagnose this important syndrome. METHODS: Relevant references were identified through keyword searches of the Cochran, MEDLINE and EMbase databases. RESULTS: Despite the lack of a gold standard operational definition, frailty can be conceptualised as a state of increased vulnerability resulting from a decline in physiological reserve and function across multiple organ systems, such that the ability to withstand stressors is impaired. Multiple studies have shown a strong association between frailty and adverse peri-operative outcomes. Frailty may be assessed using multiple tools; however, the ideal tool for use in a clinical setting has yet to be identified. Despite the association between frailty and adverse outcomes, few interventions have been shown to improve outcomes in these patients. CONCLUSION: Frailty encompasses a group of individuals at high risk of adverse post-operative outcomes. Further work exploring ways to optimally assess and target interventions towards these patients should be the focus of ongoing research.