神经损伤标志物与老年患者心脏瓣膜置换术后谵妄的相关性

探讨血浆中神经损伤标志物与老年患者心脏瓣膜置换术后谵妄发生的相关性。方法 将2018年12月至2019年12月在西部战区总医院住院并择期行心脏瓣膜置换手术的老年患者共109例纳入本研究。术后在监护室采用重症监护意识紊乱评估法评估谵妄。对比手术前后患者血浆中神经损伤标志物神经元特异性烯醇酶(NSE)和S100β的表达变化。患者基线资料,采用单因素和多因素logistic回归分析,明确NSE和S100β与谵妄发生的关系及其他谵妄的危险因素。结果 老年患者心脏瓣膜置换术后谵妄发生率为30.3％(33/109)。术后血浆中NSE和S100β水平均较术前明显升高(均P＜0.01)。多因素logistic回归分析表明:糖尿病(OR=1.76,95%CI 1.02~2.61;P=0.04)、机械通气时间(OR=3.11,95%CI 1.29~7.52;P＜0.01)、NSE浓度(OR=5.94,95%CI 1.53~12.04;P＜0.01)及S100β浓度(OR=5.11,95%CI 1.38~10.14;P＜0.01)是谵妄发生的危险因素。结论 神经损伤标志物NSE和S100β浓度与老年患者心脏瓣膜置换术后谵妄密切相关,血浆NSE和S100β浓度的升高可能是谵妄发生的有效预测因子。     

低体质量指数与老年危重患者术后并发症风险的相关性分析

目的评估老年患者术前体质量指数(BMI)与术后并发症发生风险的关系。方法本研究为对前期多中心随机对照研究中安慰剂组患者资料的二次分析。共纳入350例非心脏手术后入重症监护室(ICU)的老年患者(≥65岁)。主要终点是术后并发症发生情况。采用logistic回归模型分析术前BMI分级与术后并发症风险的关系。结果 350例患者中有35.1%(123例)发生术后并发症。logistic多因素回归分析显示,与正常体质量(BMI 18.5~23.9 kg/m~2)患者相比,体质量过低(BMI18.5 kg/m2)伴随术后并发症风险增加(OR=2.210,95%CI 1.069~4.570,P=0.032);而超重和肥胖(BMI≥24.0 kg/m2)对术后并发症风险无明显影响(OR=0.820,95%CI 0.497~1.354,P=0.438)。结论对于在全身麻醉下非心脏手术后入ICU的老年患者,体质量过低伴随术后并发症风险增加。     

老年高血压患者非心脏手术围术期主要不良心血管事件发生风险列线图模型构建与验证

背景临床上老年高血压患者非心脏手术围术期发生主要不良心血管事件(MACE)的风险较高,通过构建个体化预测非心脏手术围术期发生MACE的列线图模型极其重要。目的构建老年高血压患者非心脏手术围术期MACE发生风险列线图模型,并评估其区分度和一致性。方法选取2017年3月至2021年1月扬州大学附属医院收治的择期进行非心脏手术的老年高血压患者244例为研究对象。根据患者非心脏手术围术期MACE发生情况,将其分为MACE组(58例)和非MACE组(186例)。收集患者临床资料,采用单因素分析及多因素Logistic回归分析探讨老年高血压患者非心脏手术围术期发生MACE的影响因素;将确定的影响因素引入R 3.6.3软件及rms程序包,构建预测老年高血压患者非心脏手术围术期MACE发生风险的列线图模型;绘制受试者工作特征(ROC)曲线以评估该列线图模型的区分度,采用校准曲线与Hosmer-Lemeshow拟合优度检验评估其一致性。结果多因素Logistic回归分析结果显示,高血压分级[OR=4.432,95%CI(1.661,11.827)]、ST段压低≥0.05 mV[OR=2.894,95%CI(1.366,6.131)]、术中输入浓缩红细胞量[OR=1.014,95%CI(1.010,1.019)]、冠心病[OR=2.444,95%CI(1.172,5.099)]是老年高血压患者非心脏手术围术期发生MACE的影响因素(P<0.05)。基于多因素Logistic回归分析结果,构建预测老年高血压患者非心脏手术围术期MACE发生风险的列线图模型,该列线图模型预测老年高血压患者非心脏手术围术期发生MACE的曲线下面积为0.825[95%CI(0.766,0.884)]。列线图模型预测老年高血压患者非心脏手术围术期MACE发生风险的校准曲线与实际曲线基本吻合,且Hosmer-Lemeshow拟合优度检验结果显示,χ2=8.958、P=0.346。结论高血压分级、ST段压低≥0.05 mV情况、术中输入浓缩红细胞量、冠心病是老年高血压患者非心脏手术围术期发生MACE的影响因素,本研究基于以上4项影响因素构建的老年高血压患者非心脏手术围术期MACE发生风险列线图模型的区分度和一致性均较好。     

老年腹部大手术患者术后肺部并发症及相关因素分析北大核心CSCD

目的分析老年腹部大手术患者术后肺部并发症发生情况及相关因素。方法回顾性分析北京医院实施老年大型腹部手术患者的临床资料,对患者术后肺部并发症发生率进行描述,采用Logistic回归分析术后肺部并发症发生的相关因素。结果最终纳入分析96例患者资料,老年腹部大手术术后肺部并发症发生率为53.1%(51/96);Logistic回归分析结果显示,腹腔镜手术(OR=0.293,95%CI:0.100~0.865,P=0.026)是肺部并发症发生的保护因素,而驱动压力>18 cmH2O(1 cmH2O=0.098 kPa)(OR=3.300,95%CI:1.148~9.434,P=0.027)和术中出血量>500 ml(OR=4.444,95%CI:1.091~18.180,P=0.037)是肺部并发症发生的危险因素。结论老年患者腹部大手术术后肺部并发症发生率值得关注,腹腔镜手术是术后肺部并发症发生的保护因素,而驱动压力>18 cmH2O和出血量>500 ml会增加肺部并发症发生的风险。     

老年胸部非心脏手术术后新出现快速房颤危险因素分析

目的探讨老年胸部非心脏手术术后新出现快速房颤的危险因素,为防治快速房颤提供依据。方法入选2007年6月~2014年6月在兰州军区兰州总医院胸外科接受非心脏手术治疗的60岁的老年患者1289例,其中男性685例,女性604例,年龄60~91(72.8±9.6)岁。术后新出现快速房颤为快速房颤组(102例),未出现为无快速房颤组(1187例)。收集患者的资料包括既往病史、用药情况等。随访术后1个月内心源性死亡(心源性猝死、急性心肌梗死、失代偿性心功能不全)发生情况。结果与无快速房颤组比较,快速房颤组年龄75岁、糖尿病病史、慢性心功能不全病史、中重度肺功能损害病史、术前低钾血症以及开胸手术比例增加,差异有统计学意义(P均0.05)。经多因素回归分析,年龄75岁(OR=7.661,95%CI:3.886~15.105)、糖尿病病史(OR=30.22,95%CI:4.328~277.5)、慢性心功能不全病史(OR=29.34,95%CI:8.149~105.6)、中重度肺功能损害病史(OR=8.04,95%CI:2.858~22.61)、术前低钾血症(OR=6.58,95%CI:4.340~12.00)、开胸手术方式(OR=2.31,95%CI:0.935~13.74)是术后新出现快速房颤的危险因素。快速房颤组患者术后1个月随访时间内无心源性死亡生存率明显低于无快速房颤组,差异有统计学意义(P=0.0117)。结论年龄75岁,糖尿病、慢性心功能不全、中重度肺功能损害病史以及术前低钾血症和开胸手术是老年胸部非心脏手术术后新出现快速房颤的危险因素,应针对这些危险因素进行预防,减少术后快速房颤的发生。     

术前超敏C反应蛋白和B型脑钠肽前体水平在老年冠心病患者围术期心脏事件中的预测价值

目的评价老年冠心病(CHD)患者非心脏手术术前血清超敏C反应蛋白(hs-CRP)和B型脑钠肽前体(NT-proBNP)水平在围术期心脏事件(PCE)中的联合预测价值。方法前瞻性队列研究,106例年龄≥60岁择期拟行非心脏手术的CHD患者,术前采集病史和危险因素,术前检测静脉血中hs-CRP和NT-proBNP,监测术后即刻及3 d的12导联心电图和cTnI水平,并随访住院期间并发症。结果 PCE的发生率为18%。hsCRP的受试者工作特征曲线(ROC)的曲线下面积(AUC)为0.75(95%CI 0.64~0.87;P0.05),临界值为6.85 mg/L;NT-proBNP的AUC为0.71(95%CI 0.58~0.85;P0.01),临界值为86.9 pg/ml。术前hs-CRP≥6.85 mg/L且NT-pro BNP≥86.9 pg/ml是PCE发生的独立危险因素(OR 6.29;95%CI 1.89~20.92;P0.01)。术前hs-CRP≥6.85 mg/L且NT-proBNP≥86.9 pg/ml的患者为的高危人群,其PCE发生率为42%。结论老年CHD患者非心脏手术,术前血清hs-CRP≥6.85 mg/L且NT-proBNP≥86.9 pg/ml是PCE发生的独立危险因素。二者联合能够将该人群进行危险分层,其预测价值优于传统临床方法。     

红细胞分布宽度与血运重建术后缺血性心力衰竭患者预后的关系-CRISIS临床研究

目的:探讨红细胞分布宽度-变异系数(RDW-CV)对血运重建术后,冠心病合并射血分数降低心力衰竭患者(HFrEF)预后的影响。方法:回顾性分析行血运重建且术前30d内左心室射血分数(LVEF)≤40%患者1 247例,根据术前RDW-CV水平分为两组,即RDW-CV12.6%为升高组,另一组为正常组,平均随访时间达41.8个月。并对比两组全因死亡及心血管死亡等终点事件。结果:通过Cox回归分析发现高水平的RDW-CV是患者全因死亡(OR=2.363,95%CI:1.443~3.871,P=0.001),心血管死亡(OR=2.334,95%CI:1.163~4.684,P=0.011),心脏性猝死(OR=4.734,95%CI:1.131~19.806,P=0.034)的预测因素。结论:RDW-CV是影响血运重建术后冠心病合并HFrEF预后的危险因素。高水平的RDW-CV可增加患者的全因死亡、心血管死亡和心脏性猝死风险。     

老年结直肠癌术后1月肠梗阻发生率及影响因素分析

目的调查老年结直肠癌术后1月肠梗阻发生率,探讨术后肠梗阻发生的影响因素。方法回顾性收集339例老年结直肠癌患者临床资料,所有患者均接受根治性切除手术并经术后病理证实,术后随访1月,收集术后肠梗阻发生情况以及可能的影响因素,采用卡方检验进行单因素筛选,将可能的影响因素纳入多因素非条件Logistic回归进行分析。结果 339例老年结直肠癌患者术后1月共26例发生肠梗阻,发生率为7.67%;有术前肠梗阻、有大肠肿瘤切除史、TNM分期越高老年结直肠癌患者术后1月肠梗阻发生率显著高于无术前肠梗阻、无大肠肿瘤切除史和TNM越低的患者;腹腔镜手术后1月肠梗阻发生率显著低于开腹手术和中转开腹患者,差异均有统计学意义(P0.05);多因素非条件Logistic回归分析显示,术前肠梗阻(OR=1.894,95%CI:1.019~2.664)、TNM分期(OR=5.542,95%CI:2.264~8.721)是老年结直肠癌患者术后1月肠梗阻的危险因素,而腹腔镜手术(OR=0.261,95%CI:0.013~0.563)则是其保护因素。结论老年结直肠癌术后1月肠梗阻发生率较高,对于高危人群要重点预防,并提高手术操作技术,选择合理手术入路。     

SPPB术前衰弱评估在预测老年消化道恶性肿瘤术后并发症发生中的作用

目的 应用SPPB量表评估术前衰弱,判断其对老年消化道恶性肿瘤患者术后并发症的预测作用。方法 选取包头市中心医院普外科收治的82例老年消化道恶性肿瘤患者为研究对象。根据简易体能状况量表（SPPB）分为衰弱患者和非衰弱患者。收集患者临床资料,术后使用外科并发症分级系统评估术后并发症。采用Spearman秩相关分析术前衰弱与术后并发症的相关性,采用logistic回归分析影响老年消化道恶性肿瘤患者术后并发症的危险因素,构建受试者工作特征（ROC）曲线评价术前衰弱对术后并发症的预测价值。结果 衰弱患者并发症发生率为77.1%,高于非衰弱患者的20.6%。Spearman秩相关分析结果显示,术前衰弱与术后并发症呈正相关（r=0.558,P<0.001）。logistic多因素回归分析显示,术前衰弱（OR=8.502,95%CI:2.202～32.820,P=0.002）是老年消化道恶性肿瘤患者术后并发症的危险因素。ROC曲线结果表明,术前衰弱预测老年消化道恶性肿瘤患者术后发生并发症的曲线下面积为0.774(95%CI:0.564～0.798)。结论 术前衰弱是老年消化道恶性肿瘤患者术后发...     

高血压患者非心脏手术围手术期发生心脏事件的危险因素分析

目的探讨高血压患者行非心脏手术围手术期发生心脏事件的独立危险因素。方法选取罗定市人民医院心内科于2012年1月~2016年12月收治的高血压患者245例,均择期行非心脏手术,男性123例,女性122例。依据围手术期是否发生心脏事件分为发生心脏事件组(n=55)和未发生心脏事件组(n=190)。收集入选患者的病历资料,包括手术资料、病史、心电图以及实验室检查结果等。围手术期心脏事件为结局事件,包括术中及术后(仅限住院期间)发生的不稳定型心绞痛、心源性死亡、急性心肌梗死、充血性心力衰竭、严重的心律失常、非致死性心跳骤停等。结果与未发生心脏事件组比较,发生心脏事件组冠心病病史、METs≤4、ST段压低≥0.05 m V的比例以及术中输浓缩红细胞均升高,差异有统计学意义(P均0.05)。多因素Logistic回归分析显示,冠心病病史(OR=4.672,95%CI:1.648~12.990),METs≤4(OR=2.727,95%CI:1.079~6.892),ST段压低≥0.05 m V(OR=4.642,95%CI:1.865~11.557),术中输浓缩红细胞(OR=7.102,95%CI:2.791~18.073)为高血压患者非心脏手术围手术期发生心脏事件的独立危险因素。上述危险因素预测围手术期心脏事件的受试者工作特征(ROC)曲线下面积分别为:0.757、0.693、0.656、0.672。结论高血压患者非心脏手术围手术期发生心脏事件的独立危险因素分别为冠心病病史、METs≤4、ST段压低≥0.05 m V、术中输浓缩红细胞,冠心病病史预测围手术期心脏事件发生的准确性更高。     

Preoperative electrocardiogram abnormalities do not predict postoperative cardiac complications in geriatric surgical patients

OBJECTIVES: Preoperative electrocardiograms (ECGs) are routinely performed on older patients before surgery. Whether patients with abnormalities on preoperative ECGs have an increased likelihood of developing postoperative cardiac complications is unknown. This study was designed to determine whether abnormalities on preoperative ECGs were predictive of postoperative cardiac complications. DESIGN: Prospective observational study. SETTING: One of the teaching hospitals of the University of California, San Francisco, Medical Center. PARTICIPANTS: Five hundred thirteen patients aged 70 and older undergoing noncardiac surgery. MEASUREMENTS: Preoperative ECGs were analyzed using the Minnesota Codes. Predefined preoperative risk factors and in-hospital postoperative cardiac complications were measured. The association between ECG abnormalities and postoperative cardiac complications was determined by multivariate logistic regression after controlling for clinical covariates. Odds ratios (ORs) and 95% confidence intervals (CIs) were reported. RESULTS: Three hundred eighty-six of 513 patients (75.2%) had at least one abnormality on their preoperative ECGs. On multivariate analysis, the predictors of postoperative cardiac complications included American Society of Anesthesiologists physical status classification of 3 or greater (OR = 2.5, 95%CI = 1.28-4.89, P = .007) and a history of congestive heart failure (OR = 2.1, 95% CI = 1.1-5.1, P = .034). The presence of abnormalities on preoperative ECGs was not associated with an increased risk of postoperative cardiac complications (OR = 0.63, 95% CI = 0.28-1.40, P = .26). CONCLUSION: Abnormalities on preoperative ECGs are common but are of limited value in predicting postoperative cardiac complications in older patients undergoing noncardiac surgery. These results suggest that obtaining preoperative ECGs based on an age cutoff alone may not be indicated, because ECG abnormalities in older people are prevalent but nonspecific and less useful than the presence and severity of comorbidities in predicting postoperative cardiac complications.     

Preoperative plasma N-terminal pro-brain natriuretic peptide concentration and perioperative cardiovascular risk in elderly patients.

BACKGROUND: The prediction of perioperative cardiovascular complications is important in the medical management of patients undergoing noncardiac surgery. Several indices have been developed, but a simpler, more practical and accurate method is needed. The purpose of this study was to determine whether the N-terminal pro-brain natriuretic peptide (NT-proBNP) concentration before operation can be used to predict perioperative cardiovascular complications in elderly patients undergoing noncardiac surgery. METHODS AND RESULTS: The study group comprised 279 patients older than 60 years who were scheduled for elective surgery. The plasma NT-proBNP concentration, clinical cardiac indices and left ventricular ejection fraction were measured prior to operation. The postoperative cardiac outcomes were followed and predictors for postoperative cardiac risk were identified. Cardiovascular complications occurred in 25 patients (9.0%). Age, the incidence of prior ischemic heart disease or congestive heart failure, and the plasma NT-proBNP concentration were significantly higher in patients with perioperative cardiovascular complications than in those without. Using receiver operating characteristic analysis to predict perioperative cardiovascular events, a cut-off value of 201 pg/ml was identified as the optimal predictor of perioperative complications, showing a sensitivity of 80.0% and specificity of 81.1%. Multivariate analysis revealed that NT-proBNP >201 pg/ml (odds ratio (OR) 7.6, 95% confidence interval (CI) 2.2-26.6, p=0.003) and revised cardiac index > or =2 (OR 6.3, 95% CI 1.7-23.8, p=0.007) were independent predictors for perioperative cardiovascular complications. CONCLUSIONS: Elevated NT-proBNP levels are independently associated with an increase in the risk of perioperative cardiovascular complications in elderly patients undergoing noncardiac and nonvascular operations.     

Predicting adverse postoperative outcomes in patients aged 80 years or older

OBJECTIVE: The identification of reversible factors that are associated with postoperative morbidity in geriatric surgical patients is critical to improving perioperative outcomes in such patients. Our study aimed to compare the relative importance of intraoperative versus preoperative factors in predicting adverse postoperative outcomes in geriatric patients. DESIGN: Retrospective cohort study of consecutive patients undergoing noncardiac surgery in 1995. SETTING: Two University of California, San Francisco, teaching hospitals--Moffitt/Long and Mount Zion medical centers. PARTICIPANTS: All men and women 80 years of age or older undergoing noncardiac surgery. MEASUREMENTS: Medical records of all patients were reviewed to measure predefined pre- and intraoperative risk factors and postoperative outcomes. Predictors of postoperative outcomes were identified by multivariate logistic regression analyses. RESULTS: Three hundred sixty-seven patients were studied. The most prevalent preoperative risk factors were a history of hypertension and coronary artery, pulmonary, and neurologic diseases. Postoperative in-hospital mortality rate was 4.6%, and 25% of patients developed adverse postoperative outcomes, of which neurological and cardiovascular complications were the leading causes of morbidity (15% and 12%, respectively). By multivariate logistic regression, a history of neurological disease (odds ratio [OR] 4.0, 95% confidence interval [CI] 2.3 - 6.9, P = .0001), congestive heart failure (OR 2.7, 95% CI 1.4 - 5.3, P = .004), and a history of arrhythmia (OR 2.3, 95% CI 1.2 - 4.3, P = .01) increased the odds of adverse postoperative events. The only intraoperative event shown to be predictive of postoperative complications was the use of vasoactive agents (OR 8.0, 95% CI 1.6 - 40.5, P = .009). CONCLUSIONS: In this group of geriatric surgical patients, the overall postoperative in-hospital mortality rate was 4.6%, and 25% of the patients developed adverse postoperative outcomes involving either the neurological, cardiovascular, or pulmonary systems. Intraoperative events appeared to be less important than preoperative comorbidities in predicting adverse postoperative outcomes.     

Relative importance of preoperative health status versus intraoperative factors in predicting postoperative adverse outcomes in geriatric surgical patients

OBJECTIVES: To determine the prevalence and predictors of adverse postoperative outcomes in older surgical patients undergoing noncardiac surgery. DESIGN: Prospective cohort study of consecutive patients undergoing noncardiac surgery in 1997. SETTING: A medical school-affiliated teaching community hospital. PARTICIPANTS: Patients age 70 and older undergoing noncardiac surgery. Patients presenting for surgery requiring only local anesthesia or monitored anesthesia care were excluded. MEASUREMENTS: Potential pre- and intra-operative risk factors were measured and evaluated for their association with the occurrence of predefined in-hospital postoperative adverse outcomes. Univariate predictors of postoperative outcomes were first measured using the chi-square or Fisher's exact tests followed by multivariate logistic regression. Odds ratios (OR) with 95% confidence interval (CI), and two-sided P-values were reported. RESULTS: Five hundred forty-four consecutive patients were studied. Overall, 21% of patients developed one or more postoperative adverse outcomes and 3.7% died during the in-hospital postoperative period. Of all the adverse outcomes, cardiovascular complications (10.3%) were the leading cause of morbidity, followed by neurological (7.7%) and pulmonary complications (5.5%). By multivariate logistic regression analysis, American Society of Anesthesiologists (ASA) classification (OR = 2.7, CI = 1.6-4.4), emergency surgery (OR = 2.0, CI = 1.1-3.4), and intraoperative tachycardia (OR = 3.8, CI = 1.9-7.6) were the most important predictors of postoperative adverse outcomes. Of all the preoperative physical symptoms and signs, decreased functional status (OR = 3.0, CI = 1.4-6.4) and clinical signs of congestive heart failure (OR = 2.1, CI = 1.1-5.1) were the two most important predictors of postoperative adverse neurological and cardiac outcomes, respectively. The median hospital stay was 4 days. The patients who developed postoperative adverse outcomes had significantly longer median hospital stays (9 days) than those without complications (3 days), (P < .0001). CONCLUSION: Our study demonstrates that the postoperative mortality rate in geriatric surgical patients undergoing noncardiac surgery is low. Despite the prevalence of preoperative chronic medical conditions, most patients do well postoperatively. The ASA classification (a reflection of the severity of preoperative comorbidities), emergency surgery, and intraoperative tachycardia increase the odds of developing any postoperative adverse events. Future studies aimed at modifying some of the potentially reversible risk factors, such as preoperative heart function and intraoperative heart rate are warranted.     

Impact of mechanical bowel preparation in elective colorectal surgery:A meta-analysis

AIM To analyse the effect of mechanical bowel preparation vs no mechanical bowel preparation on outcome in patients undergoing elective colorectal surgery.METHODS Meta-analysis of randomised controlled trials and observational studies comparing adult patients receiving mechanical bowel preparation with those receiving no mechanical bowel preparation, subdivided into those receiving a single rectal enema and those who received no preparation at all prior to elective colorectal surgery. RESULTS A total of 36 studies(23 randomised controlled trials and 13 observational studies) including 21568 patients undergoing elective colorectal surgery were included. When all studies were considered, mechanical bowel preparation was not associated with any significant difference in anastomotic leak rates(OR = 0.90, 95%CI: 0.74 to 1.10, P = 0.32), surgical site infection(OR = 0.99, 95%CI: 0.80 to 1.24, P = 0.96), intraabdominal collection(OR = 0.86, 95%CI: 0.63 to 1.17, P = 0.34), mortality(OR = 0.85, 95%CI: 0.57 to 1.27, P = 0.43), reoperation(OR = 0.91, 95%CI: 0.75 to 1.12, P = 0.38) or hospital length of stay(overall mean difference 0.11 d, 95%CI:-0.51 to 0.73, P = 0.72), when compared with no mechanical bowel preparation, nor when evidence from just randomized controlledtrials was analysed. A sub-analysis of mechanical bowel preparation vs absolutely no preparation or a single rectal enema similarly revealed no differences in clinical outcome measures. CONCLUSION In the most comprehensive meta-analysis of mechanical bowel preparation in elective colorectal surgery to date, this study has suggested that the use of mechanical bowel preparation does not affect the incidence of postoperative complications when compared with no preparation. Hence, mechanical bowel preparation should not be administered routinely prior to elective colorectal surgery.     

Frailty is associated with postoperative complications in older adults with medical problems

We sought to test whether frailty may be predictive of operative risk in older adults with medical problems. One hundred and twenty-five patients at least 70 years of age had a previously developed frailty screen, the Edmonton Frail Scale (EFS), administered at a pre-surgical clinic, prior to elective non-cardiac surgery. A blinded chart audit assessed for postoperative medical complications, length of stay and inability to be discharged home. The mean age of patients was 77 (range 70-92) and most (82%) underwent orthopedic procedures. Increasing frailty was associated with postoperative complications (p=0.02), increased length of hospitalization (p=0.004) and inability to be discharged home (p=0.01), independent of age. EFS scores of 3 or less were associated with a lower risk of having a complication (age-adjusted OR 0.27, 95% CI 0.09-0.80, likelihood ratio of 0.33) and a higher chance (80%) of being discharged home (p<0.02). EFS scores exceeding 7 were associated with increased complications (OR 5.02, 95% CI 1.55-16.25, likelihood ratio of 3.9) and a lower chance of being discharged home (40%, p<0.02). This study suggests that a frailty screen can refine risk estimates of postoperative complications in older adults undergoing elective non-cardiac surgery.     

经内镜鼻胆管引流术与经内镜胆道支架置入术在低位恶性梗阻性黄疸术前胆道引流效果比较的Meta分析

目的比较经内镜鼻胆管引流术(ENBD)和经内镜胆道支架置入术(EBS)在低位恶性梗阻性黄疸术前胆道引流中的有效性及安全性。方法在中英文数据库中检索从建库至2020年8月发表的有关ENBD与EBS在低位恶性梗阻性黄疸术前胆道引流疗效对照研究的所有中英文文献,对纳入的研究进行质量评价和数据提取后,采用RevMan 5.3软件进行Meta分析,比较ENBD与EBS术前胆管炎发生率、术前胰腺炎发生率、支架障碍率、术前术后总并发症发生率、术后胰漏率的差异。结果最终纳入6项研究,包括1182例患者。Meta分析结果显示,在术前胰腺炎发生率、支架障碍率、术前术后总并发症发生率方面,ENBD组与EBS组比较差异均无统计学意义(OR分别为0.66、1.14、0.69,95%CI分别为0.44~0.99、0.56~2.31、0.41~1.15,P值分别为0.05、0.72、0.15)。但是,ENBD组相较于EBS降低了术前胆管炎发生率和术后胰漏率,差异均有统计学意义(OR分别为0.34、0.53,95%CI分别为0.23~0.50、0.32~0.88,P值分别为<0.00001、0.01)。结论对于诊断明确的低位恶性胆道梗阻患者,术前胆道引流使用ENBD优于使用EBS。未来需要更多的多中心大样本随机对照试验来验证这一结论。     

Hepatocellular carcinoma in the elderly:Meta-analysis and systematic literature review

AIM: To conduct a meta-analysis to investigate theclinical outcomes of surgical resection and locoregional treatments for hepatocellular carcinoma(HCC) in elderly patients defined as aged 70 years or more. METHODS: Literature documenting a comparison of clinical outcomes for elderly and non elderly patients with hepatocellular carcinoma was identified by searching Pub Med, Ovid, Cochrane Library, and Web of Science databases, for those from inception to March 2015 with no limits. Dichotomous outcomes and standard meta-analysis techniques were used. Heterogeneity was tested by the Cochrane Q statistic. Pooled estimates were measured using the fixed or random effect model.RESULTS: Twenty three studies were included with a total of 12482 patients. Of these patients, 6341 were treated with surgical resection, 3138 were treated with radiofrequency ablation(RFA), and 3003 were treated with transarterial chemoembolization(TACE). Of the patients who underwent surgical resection, the elderly had significantly more respiratory co-morbidities than the younger group, with both groups having a similar proportion of cardiovascular co-morbidities and diabetes. After 1 year, the elderly group had significantly increased survival rates after surgical resection compared to the younger group(OR = 0.762, 95%CI: 0.583-0.994, P = 0.045). However, the 3-year and 5-year survival outcomes with surgical resection between the two groups were similar(OR = 0.947, 95%CI: 0.777-1.154, P = 0.67 for the third year; and OR = 1.131, 95%CI: 0.895-1.430, P = 0.304 for the fifth year). Postoperative treatment complications were similar between the elderly and younger group. The elderly group and younger group had similar survival outcomes for the first and third year after RFA(OR = 1.5, 95%CI: 0.788-2.885, P = 0.217 and OR = 1.352, 95%CI: 0.940-1.944, P = 0.104). For the fifth year, the elderly group had significantly worse survival rates compared to the younger group after RFA(OR = 1.379, 95%CI: 1.079-1.763, P = 0.01). For patients who underwent TACE, the elderly group had significantlyincreased survival compared to the younger group for the first and third year(OR = 0.664, 95%CI: 0.548-0.805, P = 0.00 and OR = 0.795, 95%CI: 0.663-0.953, P = 0.013). At the fifth year, there were no significant differences in overall survival between the elderly group and younger group(OR = 1.256, 95%CI: 0.806-1.957, P = 0.313). CONCLUSION: The optimal management strategy for elderly patients with HCC is dependent on patient and tumor characteristics. Compared to patients less than 70, elderly patients have similar three year survival after resection and ablation and an improved three year survival after TACE. At five years, elderly patients had a lower survival after ablation but similar survival with resection and TACE as compared to younger patients. Heterogeneity of patient populations and selection bias can explain some of these findings. Overall, elderly patients have similar success, if not better, with these treatments and should be considered for all treatments after assessment of their clinical status and cancer burden.     

改良外科Apgar评分对肝门部胆管癌术后并发症的预测价值

目的探讨改良外科Apgar评分(mSAS)对肝门部胆管癌术后并发症的预测能力。方法回顾性分析2013年4月-2019年9月于中国医科大学附属盛京医院因肝门部胆管癌手术的患者188例,分为有并发症组(n=125)和无并发症组(n=63)。比较两组患者的临床资料,包括性别、年龄、CEA、CA19-9、Bismuth-Corlett分型、术前黄疸及Alb水平、外科Apgar评分(SAS)、手术方式等。偏态分布的计量资料两组间比较采用非参数Mann-Whitney U检验。计数资料两组间比较采用χ2检验。多因素分析采用logistic回归模型,并绘制受试者工作特征曲线(ROC曲线)。ROC曲线下面积(AUC)的比较采用Z检验。结果188例患者中125例术后出现了并发症,发生率为66.5%。并发症组与无并发症组间mSAS差异具有统计学意义(χ2=65.685,P<0.001)。mSAS高分组(n=101)术后并发症发生率为40.6%,而mSAS低分组(n=87)术后并发症发生率为96.6%;对并发症进一步分析显示,菌血症、肺部感染、腹腔感染、切口并发症、腹腔出血以及肝衰竭在两组间差异有统计学意义(χ2值分别为15.196、52.245、48.409、5.556、11.087、17.772,P值均<0.05)。多因素回归分析显示,mSAS[优势比(OR)=0.026,95%可信区间(95%CI:0.007~0.099,P<0.001)、手术方式(OR=2.195,95%CI:1.070~4.500,P=0.032)、术前黄疸水平(OR=2.470,95%CI:1.376~4.434,P=0.002)]是影响肝门部胆管癌术后并发症发生的独立因素。mSAS与SAS预测肝门部胆管癌术后出现并发症的AUC分别为0.830(95%CI:0.768~0.880)和0.776(95%CI:0.710~0.834)。mSAS的最佳临界值为6.5,敏感度为96.6%,特异度为59.4%,准确度为76.6%。结论mSAS有助于预测肝门部胆管癌术后并发症的发生。     

Elderly patients undergoing major vascular surgery: risk factors and medication associated with risk reduction

This study assesses risk factors in elderly vascular surgery patients and to evaluate whether perioperative cardiac medication can reduce postoperative mortality rate. In a cohort study, 1693 consecutive patients > or =65 years undergoing major non-cardiac vascular surgery were preoperatively screened for cardiac risk factors and medication. During follow-up (median: 8.2 years), mortality was noted. Hospital mortality occurred in 8.1% and long-term mortality in 28.5%. In multivariate analysis, age, coronary artery disease, heart failure, cerebrovascular disease, renal failure and diabetes were significantly associated with increased hospital and long-term mortality. Perioperative aspirin (OR: 0.53, 95% confidence interval: 0.34-0.83), beta-blockers (OR: 0.32, 95% CI: 0.19-0.54) and statins (OR: 0.35, 95% CI: 0.18-0.68) were significantly associated with reduced hospital mortality. In addition, aspirin (HR: 0.65, 95% CI: 0.53-0.81), angiotensin-converting enzyme (ACE)-inhibitors (HR: 0.74, 95% CI: 0.59-0.92), beta-blockers (HR: 0.61, 95% CI: 0.48-0.76) and statins (HR: 0.65, 95% CI: 0.49-0.87) were significantly associated with reduced long-term mortality. Heterogeneity tests revealed a gradient decrease of mortality risk in patients from low to high age using statins (p=0.03). In conclusion, age is an independent predictor of hospital and long-term mortality in elderly patients undergoing major vascular surgery. Aspirin, ACE-inhibitors, beta-blockers and statins reduce long-term mortality risk. Especially the very elderly may benefit from statin therapy.