Predicting Functional Recovery and Quality of Life in Older Patients Undergoing Colorectal Cancer Surgery: Real-World Data From the International GOSAFE Study.

PURPOSE: The GOSAFE study evaluates risk factors for failing to achieve good quality of life (QoL) and functional recovery (FR) in older patients undergoing surgery for colon and rectal cancer. METHODS: Patients age 70 years and older undergoing major elective colorectal surgery were prospectively enrolled. Frailty assessment was performed and outcomes, including QoL (EQ-5D-3L) recorded (3/6 months postoperatively). Postoperative FR was defined as a combination of Activity of Daily Living ≥5 + Timed Up & Go test <20 seconds + MiniCog >2. RESULTS: Prospective complete data were available for 625/646 consecutive patients (96.9%; 435 colon and 190 rectal cancer), 52.6% men, and median age was 79.0 years (IQR, 74.6-82.9 years). Surgery was minimally invasive in 73% of patients (321/435 colon; 135/190 rectum). At 3-6 months, 68.9%-70.3% patients experienced equal/better QoL (72.8%-72.9% colon, 60.1%-63.9% rectal cancer). At logistic regression analysis, preoperative Flemish Triage Risk Screening Tool ≥2 (3-month odds ratio [OR], 1.68; 95% CI, 1.04 to 2.73; P = .034, 6-month OR, 1.71; 95% CI, 1.06 to 2.75; P = .027) and postoperative complications (3-month OR, 2.03; 95% CI, 1.20 to 3.42; P = .008, 6-month OR, 2.56; 95% CI, 1.15 to 5.68; P = .02) are associated with decreased QoL after colectomy. Eastern Collaborative Oncology Group performance status (ECOG PS) ≥2 is a strong predictor of postoperative QoL decline in the rectal cancer subgroup (OR, 3.81; 95% CI, 1.45 to 9.92; P = .006). FR was reported by 254/323 (78.6%) patients with colon and 94/133 (70.6%) with rectal cancer. Charlson Age Comorbidity Index ≥7 (OR, 2.59; 95% CI, 1.26 to 5.32; P = .009), ECOG ≥2 (OR, 3.12; 95% CI, 1.36 to 7.20; P = .007 colon; OR, 4.61; 95% CI, 1.45 to 14.63; P = .009 rectal surgery), severe complications (OR, 17.33; 95% CI, 7.30 to 40.8; P < .001), fTRST ≥2 (OR, 2.71; 95% CI, 1.40 to 5.25; P = .003), and palliative surgery (OR, 4.11; 95% CI, 1.29 to 13.07; P = .017) are risk factors for not achieving FR. CONCLUSION: The majority of older patients experience good QoL and stay independent after colorectal cancer surgery. Predictors for failing to achieve these essential outcomes are now defined to guide patients' and families' preoperative counseling.

Prevalence of frailty syndrome in urological patients undergoing major elective surgical procedure due to malignancy.

Introduction: The group of elderly urological patients is growing. A majority of urological operations is performed in this group. The current model of preoperative assessment is developed to be effective in younger groups of patients but not in the elderly. Frailty syndrome has been confirmed to be an effective risk stratification tool in many surgical settings. It can be diagnosed using a variety of screening tools, but the only objective tool is comprehensive geriatric assessment (CGA). However it is time consuming, difficult and to our best knowledge, has not been attempted in Polish urological patients. Material and methods: We assessed the prevalence of frailty in elderly urological patients undergoing surgery due to malignancy using CGA and screening tests. A total of 68 patients over 65 years of age qualified to elective major urological surgery underwent the preoperative assessment including use of traditional tools (medical history, physical examination, ASA score), CGA and frailty-screening tests. The 30-day postoperative complications rate using the Clavien-Dindo scale was also evaluated. Results: The mean age of patients was 71 years. The most common procedures were radical prostatectomy (47.1%), radical nephrectomy (36.6%) and radical cystectomy (11.8%). The prevalence of frailty was 39.7% using CGA and 4.4-10.3% using screening tests. The complication rate was significantly higher in frail individuals when using CGA. Conclusions: Frailty is common in urological elderly patients. The CGA is a time-consuming but reliable tool to diagnose frailty syndrome and predict complications. Screening tests can be useful for selecting patients who should undergo CGA but their predictive value is low.

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.

Diffusion-Weighted Magnetic Resonance Imaging of 103 Patients with Rectal Adenocarcinoma Identifies the Apparent Diffusion Coefficient as an Imaging Marker for Tumor Invasion and Regional Lymph Node Involvement.

BACKGROUND This retrospective study included 103 patients diagnosed with rectal adenocarcinoma at a single center in Poland who underwent preoperative diffusion-weighted magnetic resonance imaging (DWI) and aimed to determine whether the apparent diffusion coefficient (ADC) was an imaging marker for tumor invasion and regional lymph node involvement. MATERIAL AND METHODS We analyzed primary staging magnetic resonance examinations of the rectum of 103 consecutive patients with histologically proven non-mucinous adenocarcinoma who underwent surgical treatment. In 85 patients, surgery was preceded by long-course chemoradiotherapy (n=18) or short-course radiotherapy (n=67). The following DWI parameters were measured: ADC mean, minimum, maximum, and standard deviation in the region of interest (ADC SD-in-ROI). Values were compared between subgroups based on histological parameters from the report: tumor stage, lymph node stage, differentiation grade, the presence of extranodal tumor deposits, angioinvasion, and perineural invasion. Statistical analysis was performed using the Mann-Whitney U test and the unilateral t test. RESULTS ADC mean values were lower for cases in which postoperative histopathological examination lymph node invasion (P=0.04) and tumor deposits were found (P=0.04). Minimal ADC value was higher in cases in which tumor deposits were not found (P=0.009). ADC SD-in-ROI values were lower in cases in which lymph nodes invasion was confirmed (P=0.014). There were no statistically significant differences for other parameters. CONCLUSIONS The ADC values in pre-treatment DWI in patients with rectal adenocarcinoma were correlated with tumor invasion and regional lymph node metastases. Therefore, ADC values from the pre-treatment MRI may help plan adjuvant therapy in patients with rectal adenocarcinoma.

The significance of comorbidity burden among older patients undergoing abdominal emergency or elective surgery.

BACKGROUND: Comorbidities may cause complications in perioperative care and affect treatment outcomes of older patients. The study aim was to analyse comorbidity burdens with respect to their predictive power in outcome prediction in elderly qualified for abdominal elective or emergency surgery. METHODS: Consecutive patients undergoing major abdominal surgery between 2010 and 2017 at a secondary referral hospital were included in the retrospective study, for a total of 1586 patients. To explain the relationship between the comorbidity types and 30-day mortality and morbidity logistic regression analysis was performed. Morbidity was assessed using the Clavien-Dindo Score. Major complications were defined as a C-D score ≥ 3. We also presented the data concerning need for reoperation and ICU admission. RESULTS: 85.9% of patients had at least one comorbidity. In the group of emergency patients age and number of comorbidities were independent risk factors of 30-day mortality and major morbidity. In elective patients age, dementia (OR:3.52; 95%CI:1.35-9.20) and kidney disease (OR:1.64; 95%CI:1.04-2.57) were found to be independent risk factors of 30-day postoperative mortality. Age (1.04; 95%CI:1.00-1.08) and heart disease (OR:1.30, 95%CI:1.04-1.63) were found to be independent risk factors of 30-day major morbidity. CONCLUSIONS: In patients undergoing elective surgery 30-day mortality and morbidity was associated with age. 30-day mortality, but not morbidity was associated with kidney disease and dementia. 30-day morbidity, but not mortality, was associated with heart disease.

Congenital dysfibrinogenemia as a rare cause of recurrent gastrointestinal bleeding.

<b>Introduction: </b>Gastrointestinal bleeding is a common disease that surgeons encounter in everyday clinical practice. It is most often easy to diagnose and treat. However, rare causes of bleeding can lead to delayed diagnosis and ineffective treatment. Dysfibrinogenemia is a qualitative fibrinogen disorder in which functional fibrinogen level is reduced with normal antigenic level. <br><b> Case report:</b> Herein we present the case of a 59-year-old female with recurrent gastrointestinal bleeds, that turned out to be an unusual manifestation of congenital dysfibrinogenemia. Detailed imaging and endoscopic diagnostics revealed portal hypertension with a non-bleeding 1-cm gastrointestinal stromal tumor and multiple angiodysplastic lesions in close proximity.

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.

Usefulness of eight screening tools for predicting frailty and postoperative short- and long-term outcomes among older patients with cancer who qualify for abdominal surgery.

INTRODUCTION: The aim of this study was to compare the ability of eight frailty screening scores to predict short- (30-day major morbidity and mortality), long-term outcomes (12-month mortality) and to compare their accuracy for predicting frailty among older patients with cancer undergoing elective abdominal surgery with curative intent. MATERIALS AND METHODS: Consecutive patients aged ≥70 years were enrolled prospectively. The diagnostic performance of eight screening tests were 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. Frailty was defined based on the Geriatric Assessment (GA) with two (2ID) or three impaired domains (3ID). RESULTS: The study included 269 consecutive patients; median age 78 (range 70-94) years. The prevalence of frailty based on the reference GA was: 40.9% (2ID), 34.2% (3ID) and using screening tools 40-75.5%. The area under the curve (AUC) for predicting the postoperative outcome was: 0.58-0.75 (30-day morbidity), 0.54-0.71 (30-day mortality) and 0.59-0.74 (12-month mortality), respectively, being the highest for the G8. The AUC for the frailty screening tests was: 0.67-0.85 (at the 2ID) and 0.63-0.83 (at the 3ID), being the highest for the aCGA. CONCLUSION: The G8 was the best predictor of 30-day major morbidity, 30-day and 12-month mortality. It also had the highest sensitivity and negative predictive value in frailty screening, in case of both frailty definitions. In turn, the aCGA had the highest discriminatory ability in terms of frailty screening.

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.

Iatrogenic Common Iliac Vessel Injury During Routine Degenerative Lumbar Spine Surgery: Report of 2 Cases and Review of Literature.

BACKGROUND: Injury of the iliac vessels is a rare complication of lumbar spine surgery with potentially life-threatening consequences. We present 2 cases of iliac vessel injury that were treated with minimally invasive techniques. CASE DESCRIPTION: The first case was a laceration of the common iliac artery during a simple L4-L5 discectomy in which the injured artery was secured by stent implantation. The second case was an example of injury to the left iliac common vessel leading to acute lower limb ischemia and arteriovenous fistula formation after lumbar spinal canal stenosis surgery. The patient was treated in 2 steps. First, a temporary femorofemoral bypass was implanted to revascularize the right lower limb. The second step involved stent implantation in the right common iliac artery to close the arteriovenous fistula. Both patients were treated without extensive laparotomy and had good clinical outcomes. CONCLUSIONS: This case series emphasizes the benefit of quick minimally invasive vascular repair available in multidisciplinary centers.

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.

Comparison of stump closure techniques during laparoscopic appendectomies for complicated appendicitis - results from Pol-LA (Polish laparoscopic appendectomy) multicenter large cohort study.

Background: In general, the three main options for stump closure in laparoscopic appendectomy are clips, endoscopic staplers and endoloops. However, there is no gold standard, especially regarding complicated acute appendicitis which is generally associated with worse outcomes.Objectives: We aimed to assess the outcomes of different stump closure techniques during laparoscopic appendectomies for complicated appendicitisMethods: Our multicenter observational study of 18 surgical units assessed the outcomes of 1269 laparoscopic appendectomies for complicated appendicitis that used the three main stump closure techniques: clips, staplers and endoloops. Groups were compared in terms of peri- and postoperative outcomes.Results: Staplers were superior in terms of overall morbidity (9.79 vs. 3.29% vs. 7.41%, p = .017) and length of stay (4 vs. 3 vs. 4 days, p < .001) respectively for clips, staplers and endoloops. However, no differences in major complication rates, postoperative intraabdominal abscess formation, reintervention rates and readmission rates were found.Conclusion: Although our results show some clinical benefits of staplers for appendix stump closure, they are based on a non-randomized group of patients and are therefore prone to selection bias. Further well-designed trials taking into consideration not only the clinical benefits, but also, the economic aspects of the surgical treatment of complicated acute appendicitis are needed to confirm our results.

Author Correction: Risk factors for serious morbidity, prolonged length of stay and hospital readmission after laparoscopic appendectomy - results from Pol-LA (Polish Laparoscopic Appendectomy) multicenter large cohort study.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Risk factors for serious morbidity, prolonged length of stay and hospital readmission after laparoscopic appendectomy - results from Pol-LA (Polish Laparoscopic Appendectomy) multicenter large cohort study.

Laparoscopic appendectomy (LA) for treatment of acute appendicitis has gained acceptance with its considerable benefits over open appendectomy. LA, however, can involve some adverse outcomes: morbidity, prolonged length of hospital stay (LOS) and hospital readmission. Identification of predictive factors may help to identify and tailor treatment for patients with higher risk of these adverse events. Our aim was to identify risk factors for serious morbidity, prolonged LOS and hospital readmission after LA. A database compiled information of patients admitted for acute appendicitis from eighteen Polish and German surgical centers. It included factors related to the patient characteristics, peri- and postoperative period. Univariate and multivariate logistic regression models were used to identify risk factors for serious perioperative complications, prolonged LOS, and hospital readmissions in acute appendicitis cases. 4618 laparoscopic appendectomy patients were included. First, although several risk factors for serious perioperative complications (C-D III-V) were found in the univariate analysis, in the multivariate model only the presence of intraoperative adverse events (OR 4.09, 95% CI 1.32-12.65, p = 0.014) and complicated appendicitis (OR 3.63, 95% CI 1.74-7.61, p = 0.001) was statistically significant. Second, prolonged LOS was associated with the presence of complicated appendicitis (OR 2.8, 95% CI: 1.53-5.12, p = 0.001), postoperative morbidity (OR 5.01, 95% CI: 2.33-10.75, p < 0.001), conversions (OR 6.48, 95% CI: 3.48-12.08, p < 0.001) and reinterventions after primary procedure (OR 8.79, 95% CI: 3.2-24.14, p < 0.001) in the multivariate model. Third, although several risk factors for hospital readmissions were found in univariate analysis, in the multivariate model only the presence of postoperative complications (OR 10.33, 95% CI: 4.27-25.00), reintervention after primary procedure (OR 5.62, 95% CI: 2.17-14.54), and LA performed by resident (OR 1.96, 95% CI: 1.03-3.70) remained significant. Laparoscopic appendectomy is a safe procedure associated with low rates of complications, prolonged LOS, and readmissions. Risk factors for these adverse events include complicated appendicitis, postoperative morbidity, conversion, and re-intervention after the primary procedure. Any occurrence of these factors during treatment should alert the healthcare team to identify the patients that require more customized treatment to minimize the risk for adverse outcomes.

Complicated appendicitis: Risk factors and outcomes of laparoscopic appendectomy - Polish laparoscopic appendectomy results from a multicenter, large-cohort study.

BACKGROUND: Preoperative classification of complicated and uncomplicated appendicitis (AA) is challenging. However, the differences in surgical outcomes necessitate the establishment of risk factors in developing, complicated AA. This study was an analysis of the clinical outcomes of laparoscopic appendectomies (LA), as well as preoperative risk factors for the development of complicated AA. METHODS: The data of 618 patients who underwent LA in 18 surgical units across Poland and Germany were collected in an online web-based database created by the Polish Videosurgery Society. The surgical outcomes of patients with complicated and uncomplicated appendicitis were compared. Uni- and multivariate logistic regression models were used to establish risk factors for the development of complicated appendicitis. RESULTS: In all, 1269 (27.5%) patients underwent LA for complicated appendicitis (Group 1) and 3349 (72.5%) for uncomplicated appendicitis (Group 2). The conversion rate, number of intra-operative adverse events, re-intervention rate, postoperative complications, and readmission rate was greater in Group 1. The preoperative risk factors associated with complicated appendicitis were: female sex (Odds ratio [OR]: 1.58), obesity (OR: 1.51), age >50 years (OR: 1.51), symptoms >48 hours (OR: 2.18), high Alvarado score (OR: 1.29 with every point), and C-reactive protein level >100 mg/L (OR: 3.92). CONCLUSION: Several demographic and clinical risk factors for complicated AA were identified. LA for complicated appendicitis was associated with poorer outcomes.

Treatment outcomes of pancreatic cancer in the elderly - literature review.

BACKGROUND: The older population is very heterogeneous with regard to the co-morbidityand the physical reserve. This can result in unacceptably high postoperative complications rates. Therefore, the aim of the study was to review the literature regarding the outcomes of older patients treated for pancreatic cancer, including the usage of minimal invasive techniques. METHODOLOGY: A review of the literature was carried out including studies on pancreatic cancer in older patients published between 2011 and 2016. RESULTS: Seventeen retrospective studies were included. The total number of patients was 9981 with the age range of 65 years and more. Studies on surgical treatment alone (1.4%), neoadjuvant/adjuvant treatment with or without surgery (89.4%) and palliative therapy (9.2%) were assessed separately. Appropriate comparison was diffcult due to the retrospective character and heterogeneity of the study population. Mortality was low, yet there was a great difference in morbidity ranging from some percent to even 100% of the study population. Long-term results were poor. CONCLUSIONS: The functional status, not the chronological age alone, is the factor limiting therapeutic options in older patients with pancreatic cancer.

The significant impact of age on the clinical outcomes of laparoscopic appendectomy: Results from the Polish Laparoscopic Appendectomy multicenter large cohort study.

Acute appendicitis (AA) is the most common surgical emergency and can occur at any age. Nearly all of the studies comparing outcomes of appendectomy between younger and older patients set cut-off point at 65 years. In this multicenter observational study, we aimed to compare laparoscopic appendectomy for AA in various groups of patients with particular interest in the elderly and very elderly in comparison to younger adults.Our multicenter observational study of 18 surgical units assessed the outcomes of 4618 laparoscopic appendectomies for AA. Patients were divided in 4 groups according to their age: Group 1-<40 years old; Group 2-between 40 and 64 years old; Group 3-between 65 and 74 years old; and Group 4-75 years old or older. Groups were compared in terms of peri- and postoperative outcomes.The ratio of complicated appendicitis grew with age (20.97% vs 37.50% vs 43.97% vs 56.84%, P < .001). Similarly, elderly patients more frequently suffered from perioperative complications (5.06% vs 9.3% vs 10.88% vs 13.68%, P < .001) and had the longest median length of stay (3 [Interquartile Range (IQR) 2-4] vs 3 [IQR 3-5], vs 4 [IQR 3-5], vs 5 [IQR 3-6], P < .001) as well as the rate of patients with prolonged length of hospital stay (LOS) >8 days. Logistic regression models comparing perioperative results of each of the 3 oldest groups compared with the youngest one showed significant differences in odds ratios of symptoms lasting >48 hours, presence of complicated appendicitis, perioperative morbidity, conversion rate, prolonged LOS (>8 days).The findings of this study confirm that the outcomes of laparoscopic approach to AA in different age groups are not the same regarding outcomes and the clinical picture. Older patients are at high risk both in the preoperative, intraoperative, and postoperative period. The differences are visible already at the age of 40 years old. Since delayed diagnosis and postponed surgery result in the development of complicated appendicitis, more effort should be placed in improving treatment patterns for the elderly and their clinical outcome.

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.

IgG4-related disease manifesting as an isolated gastric lesion- a literature review.

INTRODUCTION: IgG4-related disease (IgG4-RD) is a newly recognised disorder of unknown etiology and pathogenesis, characterised by dense IgG4+ cells infiltration and fibrosis. IgG4-RD can affect various organs, but gastrointestinal tract involvement is rare. First case of isolated gastric IgG4-RD reported in polish population was diagnosed in our Clinic and became the reason for conducting a literature review. MATERIALS AND METHODS: A literature review was performed using PubMed database. Eight studies of isolated gastric IgG4-RD, published between 2011 and 2017, and a case diagnosed by the authors were included. RESULTS: Three out of nine analysed patients had gastrointestinal complaints. In other cases lesions were detected accidentally. The majority of them were submucosal tumors while only one was a gastric ulcer. The most commonly affected was the stomach body. In all cases malignancy had been suspected, and the lesions were surgically removed. Diagnosis was based on the histopathology image and immunohistochemical staining. Only one patient had elevated IgG4 serum level. No case of recurrence or other organ involvement was reported. CONCLUSION: IgG4-related disease may manifest as an isolated gastric lesion and should be taken in consideration in differential diagnosis. Making an ultimate diagnosis without histopathological specimen examination seems to be difficult and can lead to misdiagnosis followed by inappropriate treatment. IgG4-RD responds well to steroid therapy. However, on this matter further studies are needed.

Knowledge, awareness, and attitude towards infection prevention and management among surgeons: identifying the surgeon champion.

Despite evidence supporting the effectiveness of best practices of infection prevention and management, many surgeons worldwide fail to implement them. Evidence-based practices tend to be underused in routine practice. Surgeons with knowledge in surgical infections should provide feedback to prescribers and integrate best practices among surgeons and implement changes within their team. Identifying a local opinion leader to serve as a champion within the surgical department may be important. The "surgeon champion" can integrate best clinical practices of infection prevention and management, drive behavior change in their colleagues, and interact with both infection control teams in promoting antimicrobial stewardship.