Urgent abdominal aortic aneurysm repair in patients over the age 80

We present three patients with successful surgical repair of abdominal aortic aneurysms with signs of imminent rupture in octogenarians. The patients presented with evidence of severe left ventricular dysfunction and reduced compliance either before or during surgery. Extremely cautious delivery of fluids and of after-load reducing agents was employed under the guidance of measurements of cardiac output and filling pressures from a pulmonary arterial catheter inserted prior to surgery.     

Emergency and elective surgery in patients over age 70

Emergency surgery in 100 patients over age 70 was associated with a 31 per cent morbidity and a 20 per cent mortality, significantly greater than the 6.8 per cent morbidity and 1.9 per cent mortality following elective procedures in the same age group (P less than .0005). Sixteen per cent (100 of 613) of all geriatric patients were operated on under emergent conditions and the postoperative hospitalization was often significantly prolonged when compared with similar elective operations (P less than .05). Emergency surgery was most commonly performed on the large bowel (25%), abdominal wall (17%), stomach (17%), biliary tract (11%), and small bowel (10%). Inguinal herniorraphy was the most frequently performed elective procedure (33%), followed by colon resection (25%), and cholecystectomy (12%). Fifty-nine per cent (23 of 39) of complications associated with urgent operation and 39 per cent (16 of 41) following elective surgery involved the cardiorespiratory systems and were frequently related to underlying diseases. Of the 20 patients who died in the intensive care unit of multisystem failure, 16 had undergone emergency procedures. Elective surgery in the elderly may be performed safely; however, emergency surgery entails a high risk to the patient and a high cost in hospital resources.     

Cardiac operations in patients over 80 years of age

Twenty-five patients between 80 and 89 years of age underwent a variety of cardiac surgical procedures. Operative mortality was 4%. Perioperative complications were frequent and resulted in an increased hospital stay postoperatively (mean 19.5 days). At a mean follow-up of 29.1 months, 21 patients (84%) are alive, with improvement in functional class from 3.4 to 2.0 (p less than 0.005). Cardiac operations can be performed in patients over 80 years of age with low mortality and significant symptomatic benefit. A high incidence of complications necessitates careful monitoring but should not represent a contraindication to the surgical management of advanced heart disease in this group.     

80岁以上高龄患者行腹腔镜胆囊切除术的临床研究

目的:探讨为80岁以上高龄患者行腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)的安全性及手术时机.方法:回顾分析为63例80岁以上患者施行LC的临床资料.结果:本组63例,占全部LC的0.76%(63/8 270),患者平均83.7岁.其中26例急诊手术;2例(3.2%)中转开腹,7...     

Results of resection for bronchogenic carcinoma in patients over the age of 80.

Thirty three patients aged over 80 years underwent resection for bronchogenic carcinoma. The operations performed were: lobectomy (21), segmentectomy (4), wedge resection (2), pneumonectomy (3), carinal resection (1). In two patients no resection was feasible. Three patients died within two months of surgery. The cumulative five year survival rate was 55%, 79% for patients with stage I carcinoma and 31% for stage III. It is considered that resection has an acceptable outcome in patients over 80 years.     

The impact of healthcare rationing on elective and emergency hernia repair

Purpose

In 2011 the local clinical commissioning group introduced a policy restricting funding for elective hernia repairs. Anecdotally, it was felt that this resulted in an increased number of emergency hernia repairs in our trust. Our primary objective was to assess whether this was actually the case. Our secondary objective was to quantify the risks of non-elective hernia repair.

Methods

We performed a retrospective cohort study, analysing all hernia surgeries performed between 2010 and 2013. The data were obtained from the trust Patient Information System. A total of 2556 patients underwent repair of inguinal, umbilical, incisional, femoral or ventral hernias over this time.

Results

As the policy intended, the number of elective hernia repairs reduced from 857 over 12 months before the funding restrictions to 606 in the same period afterwards (p < 0.001). Over the same time period, however, a significant rise in total emergency hernia repairs was demonstrated, increasing from 98 to 150 (p < 0.001). 30-day readmission rates also increased from 5.1 % before the policy introduction to 8.5 % afterwards (p = 0.006). In our data, the rate of bowel resection rises from 0.97 to 12.9 % for emergency operation compared to elective hernia repair (p < 0.001), while the median length of stay rises from less than 24 h to 3 days.

Conclusions

Our data suggest that the funding restrictions introduced in 2011 were followed by a statistically significant and unintended increase in emergency hernia repairs in our trust, with associated increased risks to patient safety.

     

Valve replacement in patients over 80 years of age]

Between January 1983 and October 1990, 20 patients age 80 years or older (mean 82 +/- 1.5 year, range 80 to 87 years) underwent valvular surgery at Clinic for Cardiovascular Surgery Zurich. The indication for operation was aortic stenosis in 19 patients, and mitral insufficiency after previous mitral valve replacement with a bioprosthesis in one. There were 15 elective operations, 2 urgent, and 3 emergency operations. Four of these patients had aortic valve replacement plus coronary artery bypass grafting. The operative mortality rate was 15% (3 patients). All patients were preoperative in NYHA classes III and IV. All survivors remained in NYHA classes I or II. The survivors have been followed from 6 to 70 months (mean 20 +/- 8 months). The actuarial survival rate at 1 and 5 years was 78.5% and 67%, respectively. Valvular replacement can be performed with increased but acceptable mortality and morbidity. Long-term results are encouraging.     

Total knee arthroplasty in patients over 80 years of age

We conducted this study to review the clinical and radiographic outcomes of patients 80 years of age or older who underwent total knee arthroplasty (TKA). We identified clinical results in 60 patients (66 knees) who had a mean age of 84 years (range, 80 to 95 years) and who underwent TKA. These were compared with a non-age-matched group of 63 patients (66 knees) who had a mean age of 69 years (range, 60 to 79 years). Four patients were lost to follow-up. After a mean 43-month follow-up (range, 24 to 117 months), Knee Society pain and function scores for the study group improved from 53 points (range, 25 to 70 points) and 53 points (range, 40 to 70 points), respectively, to 94 points (range, 75 to 100 points) and 87 points (range, 45 to 100 points). There were no implant failures, 2 surgical complications, and 13 medical complications. In the matching group, there were four surgical complications (two required revision) and two medical complications. There were no radiographic failures or progressive radiolucencies. Although the incidence of medical complications in the perioperative period may be higher, TKA is a safe and effective treatment for refractory joint pain in patients over 80 years of age.     

Chronic subdural hematoma in patients over 80 years of age]

Eighty cases of chronic subdural haematomas (SDH) in elderly patients (over 80 year-old) are reported retrospectively. The estimated incidence of the disease is 17 cases per 10(5) per year. The main presenting symptoms were confusion and impaired mentation. Surgical treatment was performed in all patients. Biological disorders deserved particular attention in the elderly SDH population. Complications occurred in 10% of patients, and recurrence of SDH was noted in 5% of patients. After their hospital discharge, 85% of patients returned to their previous neurological status. In this study, the age of patients did not appear to be a poor prognostic factor.     

Primary total hip replacement in patients over 80 years of age

We have reviewed 107 patients of 80 years or over who underwent primary total hip replacement. They had many more complications than younger patients. Thus, acute dislocation occurred in 15%, and became chronic in 9%; there were femoral shaft fractures in 4.6% and these, with shaft perforation gave universally poor results. Nevertheless, 75% of patients had a satisfactory outcome, with worthwhile relief of pain. It would seem sensible to warn elderly patients and their relatives of the increased risks in this age group.     

80岁以上胰十二指肠切除术体会

目的探讨80岁以上高龄病人行胰十二指肠切除术的可行性。方法回顾性分析我院1999—2003年收治的7例80岁以上病人胰十二指肠切除术资料。结果7例高龄病人并发症发生3例（42．9％），其中胃潴留3例次（42．9％），肺部感染2例次（28．6％），胰瘘、消化道出血、ARDS、切口感染均1例次（14．3％）。结论高龄不是手术禁忌证．力Ⅱ强围手术期处理和胰腺专业组手术是手术安全性和规范性的保证；对高龄病人强调术前或术中病理诊断。     

Endovascular repair or surveillance of patients with small AAA.

OBJECTIVE: To compare the outcome of patients with small abdominal aortic aneurysms (AAA) treated in a prospective trial of endovascular aneurysm repair (EVAR) to patients randomized to the surveillance arm of the UK Small Aneurysm Trial. METHOD: All patients with small AAA (< or = 5.5 cm diameter) treated with a stent graft (EVARsmall) in the multicenter AneuRx clinical trial from 1997 to 1999 were reviewed with follow up through 2003. A subgroup of patients (EVARmatch) who met the age (60-76 years) and aneurysm size (4.0-5.5 cm diameter) inclusion criteria of the UK Small Aneurysm Trial were compared to the published results of the surveillance patient cohort (UKsurveil) of the UK Small Aneurysm Trial (NEJM 346:1445, 2002). Endpoints of comparison were aneurysm rupture, fatal aneurysm rupture, operative mortality, aneurysm related death and overall mortality. The total patient years of follow-up for EVAR patients was 1369 years and for UK patients was 3048 years. Statistical comparisons of EVARmatch and UKsurveil patients were made for rates per 100 patient years of follow up (/100 years) to adjust for differences in follow-up time. RESULTS: The EVARsmall group of 478 patients comprised 40% of the total number of patients treated during the course of the AneuRx clinical trial. The EVARmatch group of 312 patients excluded 151 patients for age < 60 or > 76 years and 15 patients for AAA diameter < 4 cm. With the exception of age, there were no significant differences between EVARsmall and EVARmatch in pre-operative factors or post-operative outcomes. In comparison to the UKsurveil group of 527 patients, the EVARmatch group was slightly older (70 +/- 4 vs. 69 +/- 4 years, p = 0.009), had larger aneurysms (5.0 +/- 0.3 vs. 4.6 +/- 0.4 cm, p < 0.001), fewer women (7 vs. 18%, p < 0.001), and had a higher prevalence of diabetes and hypertension and a lower prevalence of smoking at baseline. Ruptures occurred in 1.6% of EVARmatch patients and 5.1% of UKsurveil patients; this difference was not significant when adjusted for the difference in length of follow up. Fatal aneurysm rupture rate, adjusted for follow up time, was four times higher in UKsurveil (0.8/100 patient years) than in EVARmatch (0.2/100 patient years, p < 0.001); this difference remained significant when adjusted for difference in gender mix. Elective operative mortality rate was significantly lower in EVARmatch (1.9%) than in UKsurveil (5.9%, p < 0.01). Aneurysm-related death rate was two times higher in UKsurveil (1.6/100 patient years) than in EVARmatch (0.8/100 patient years, p = 0.03). All-cause mortality rate was significantly higher in UKsurveil (8.3/100 patient years) than in EVARmatch (6.4/100 patient years, p = 0.02). CONCLUSIONS: It appears that endovascular repair of small abdominal aortic aneurysms (4.0-5.5 cm) significantly reduces the risk of fatal aneurysm rupture and aneurysm-related death and improves overall patient survival compared to an ultrasound surveillance strategy with selective open surgical repair.     

Digestive surgery in patients over 80 years of age. Apropos of 690 operations]

Between January 1981 and December 1990, 690 patients over the age of 80 years underwent gastrointestinal surgery. These operations were performed for diseases of the biliary tract in 248 cases (28%), colon or rectum in 238 cases (27%), stomach or duodenum in 130 cases (15%), small bowel in 32 cases (1.6%), oesophagus in 16 cases (1.8%), and for peritoneal carcinologic dissemination in 26 cases (3%). Emergency operation was performed in 43% of patients. Surgery was considered to be curative in 61% of patients. Overall postoperative mortality was 23%. The six following factors were associated with increased mortality: age over 85 years, ASA categories 3, 4, 5; surgery for malignant disease, peritonitis, palliative surgery, emergency surgery.     

The relationship between volume and outcome following elective open repair of abdominal aortic aneurysms (AAA) in 131 German hospitals.

OBJECTIVES: Several studies indicate that high-volume hospitals have better results in open repair of unruptured abdominal aortic aneurysms (AAA). Up to now no studies had addressed this question in German hospitals. DESIGN: Post-hoc-analysis from a prospective physician-led registry. MATERIAL AND METHODS: Since 1999, the German Society for Vascular Surgery has conducted a prospective registry for open and endovascular repair of AAAs. This study includes 131 hospitals who conducted n=10163 elective open repairs for unruptured AAA between 1999 to 2004. All perioperative variables including annual volume as a continuous variable were analysed in a step-wise logistic regression model. In order to define a threshold annual volume an additional logistic regression analysis was performed by use of annual volume groups (0-9, 10-19, 20-29, 30-39, 40-49, 50 or more). The relationship between annual volume and further outcome parameters (length of procedure, blood transfusion, length of stay) were also analyzed. RESULTS: The overall mortality rate was 3.2%. The stepwise logistic regression model identified the following predictors of an increased perioperative mortality: age (OR 1.084, 95% CI 1.066-1.102), AAA diameter (OR 1.008, 95% CI 1.001-1.016), length of procedure (OR 1.008, 95% CI 1.006-1.009), ASA-Score (OR 2.636, 95% CI 2.129-3.264), suprarenal clamping (OR 1.447, 95% CI 1.008-2,078), blood transfusion (OR 1.786, 95% CI 1.268-2.514). Annual volume was moderately predictive (OR 1.003, 95% CI 1-1.006) but failed to reach statistical significance (p=0.07). The analysis of volume groups identified a significantly higher risk for hospitals with an annual volume of 1-9 AAA-repairs by comparison to hospitals with an annual volume of 50 or more AAA-repairs (OR 1.903, 95% CI 1.124-3.222). Operations at low volume hospitals were also longer (p<0.001), with an extended postoperative stay (p<0.001) and a higher transfusion rate (p<0.001). CONCLUSIONS: Patient's age, ASA classification, AAA diameter, length of procedure, suprarenal clamping and blood transfusion are predictive variables for an increased perioperative mortality in elective open AAA repair. Mortality is also increased by a low annual volume. Further studies are needed to examine whether these data are applicable to all German hospitals.     

Renin-aldosterone system and atrial natriuretic peptide during anesthesia in orthopedic patients over 80 years of age.

STUDY OBJECTIVES: To investigate the changes in plasma atrial natriuretic peptide, renin activity, and aldosterone during isoflurane anesthesia in patients over 80 years. DESIGN: Prospective, randomized, controlled study. SETTING: Operating rooms and postanesthesia recovery room of Hirosaki University Hospital and Hakodate Watanabe Hospital. PATIENTS: 36 patients undergoing reduction of femur neck fracture (18 patients ranging in age from 80 to 99 years and 18 patients ranging in age from 40 to 59 years as control). INTERVENTION: In all patients, anesthesia was induced with intravenous (i.v.) thiopental sodium 3 to 5 mg/kg succinylcholine 0.5 to 1.0 mg/kg for facilitating tracheal intubation and was maintained with 1.2% to 2.0% isoflurane in 50% oxygen. MEASUREMENTS AND MAIN RESULTS: Plasma atrial natriuretic peptide (ANP), plasma renin activity (PRA), and plasma aldosterone (PA) levels were assayed. Blood samples were obtained on the following occasions: before the induction of anesthesia, 15 minutes after skin incision, 90 minutes after anesthesia induction, and the 60 minutes after the end of surgery. Plasma renin activity and PA levels in patients from 40 to 59 years increased significantly 90 minutes after induction, whereas PRA and PA levels in patients over 80 years were unchanged. There were significant differences in PRA and PA levels between both groups at any time of measurements. Plasma ANP levels of patients over 80 years were significantly elevated at 90 minutes induction. Plasma ANP levels in patients over 80 years at 90 minutes after the induction and 60 minutes after the end of surgery were significantly higher than those of patients from 40 to 59 years. Plasma renin activity in hypertensive patients over 80 years at 90 minutes after the induction was significantly lower than that observed in normotensive patients. The renal loss of sodium was increased in the hypertensive patients. CONCLUSIONS: Orthopedic patients over 80 years of age have decreased PRA and PA, increased ANP, and renal loss of sodium as compared with patients 40 to 59 years, during isoflurane anesthesia. Plasma renin activity at 90 minutes after induction was decreased in hypertensive patients over 80 years, but PA and ANP were not affected by hypertension during anesthesia.