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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 28
| Issue : 2 | Page : 138-142 |
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The perioperative outcome in geriatric patients undergoing major gastrointestinal surgery
VR Anantha Krishna1, TU Shabeer Ali2, A Mohamad Safwan3
1 Department of Surgical Gastroenterology, Medical College and Hospital, Thiruvananthapuram, Kerala, India
2 Department of Surgical Gastroenterology, KIMSHEALTH Hospital, Thiruvananthapuram, Kerala, India
3 Department of General Surgery, KIMSHEALTH Hospital, Thiruvananthapuram, Kerala, India
| Date of Submission | 04-Dec-2022 |
| Date of Decision | 08-Dec-2022 |
| Date of Acceptance | 12-Dec-2022 |
| Date of Web Publication | 30-Jan-2023 |
Correspondence Address:
Dr. V R Anantha Krishna
Department of Surgical Gastroenterology, Medical College and Hospital, Thiruvananthapuram - 695 011, Kerala
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ksj.ksj_50_22
Background: The surgical impact on the 30-day mortality and morbidity in geriatric patients is a scarcely studied topic. The aims of this study were to identify the 30-day morbidity and mortality in geriatric patients undergoing major gastrointestinal surgery and to identify the risk factors associated with the same. Materials and Methods: A cross-sectional study was conducted on 93 patients at a tertiary care centre. Thirty-day morbidity was broadly grouped into wound, renal, cardiac, respiratory, psychiatric, neurologic complications and others. The complications were also graded into five based on the Clavien–Dindo classification. Data were analysed using appropriate statistical methods. Results: The 30-day mortality in our study was 3.2%. The 30-day overall morbidity was 58.06%. Grade 2 and above Clavien–Dindo complications were encountered in 25/93 patients – 26.9%. There was an increased risk of Grade 2 and above Clavien–Dindo surgical complications in patients who had prior history of falls, who had timed up and go test more than 14 s, who had significant weight loss, who were operated for malignant causes and those who underwent open surgeries. Majority of complications occurred in the 65–69-year age group. Patients operated for non-malignant causes had no post-operative complications in our study. Conclusion: Elective surgery is generally well tolerated by the elderly. Age should not be used as the only criterion when deciding suitability for surgery in this age group. The results of elective surgery in the elderly are in fact reproducibly good, especially in non-malignant causes.
Keywords: Major gastrointestinal surgery, perioperative assessment, post-operative complication
How to cite this article:
Anantha Krishna V R, Shabeer Ali T U, Safwan A M. The perioperative outcome in geriatric patients undergoing major gastrointestinal surgery. Kerala Surg J 2022;28:138-42 |
How to cite this URL:
Anantha Krishna V R, Shabeer Ali T U, Safwan A M. The perioperative outcome in geriatric patients undergoing major gastrointestinal surgery. Kerala Surg J [serial online] 2022 [cited 2023 Mar 24];28:138-42. Available from: http://www.keralasurgj.com/text.asp?2022/28/2/138/368608 |
| Introduction | |  |
In elderly patients, there is an increased use of physiologic reserves just to maintain normal homeostasis. There appears to be a lack of robust research on this topic, and strategies to reduce the impact of advancing age on surgical mortality and morbidity have yet to be fully explored. With the ageing population on the rise, healthcare providers need to be aware of the adverse impact that surgery has on older adults and develop pre-operative optimisational interventions and better perioperative management practices to offer the best possible care to prevent and reduce adverse outcomes. This can only be analysed through studies in this age group.
Our study analysed the perioperative outcome in the elderly 65 years and above undergoing major gastrointestinal (GI) surgeries and aimed to provide a further insight into the factors that contribute to the occurrence of perioperative morbidity/mortality in this so-called 'vulnerable' age group. This study also considered various factors to formulate a comprehensive perioperative geriatric management plan to better the care that is offered to this fastest-growing subset of the population, who have their own rights to be not denied the best of treatment available. The complications and death rates can also aid in ongoing quality improvement initiatives and may be helpful when counselling patients regarding abdominal operations.
| Materials and Methods | | |
The aim of the study was to identify the perioperative outcome in all geriatric patients undergoing major GI surgeries. We identified the 30-day morbidity and mortality and associated risk factors in the study population. It was a prospective cohort study from February 2020 to December 2021 of all patients above or equal to 65 years undergoing major GI surgery (duration more than 2 h) in a tertiary care centre. The following high-risk patients were excluded: patients who have disseminated cancer, having pre-operative mechanical ventilator dependence, having pre-operative renal failure (acute or requiring dialysis) or having pre-operative sepsis or emergency procedures.
Sample size was calculated using the formula/based on a similar study conducted by Bentrem et al. Patients undergoing upper GI tract (n = 4115), hepatobiliary or pancreatic (n = 3364) and colorectal (n = 17268) operations at 121 hospitals between 1 January 2005 and 31 December 2006 were examined.[1]
n = 82.
Patient information data were obtained through direct interview with the patients using questionnaires. Sociodemographic data such as age and occupation were collected from patients using standard questionnaires and kept confidential during the research. The basic ADLs, skills required to manage one's basic physical needs, including personal hygiene or grooming, dressing, toileting, transferring or ambulating, and eating were documented preoperatively.
Thirty-day morbidity was defined as any one of the following: superficial surgical site infection, deep wound infection including anastomotic leak, wound dehiscence, pneumonia, more than 48 h on ventilator, pulmonary embolism, reintubation, post-operative atelectasis, acute renal failure, progressive renal failure, urinary tract infection (UTI), dyselectrolytaemia, cerebrovascular accident (CVA), coma longer than 24 h, peripheral nerve injury, cardiac arrest, myocardial infarction, pulmonary oedema, arrhythmia, delirium, bleeding requiring >4-unit blood, deep venous thrombosis, systemic sepsis, prolonged ileus, readmission within 30 days after discharge and re-exploration. Intensive care unit (ICU) stay of more than 2 days, length of stay of more than 7 days and 3 weeks follow up as good/bad were also documented. The pre-operative risk factors contributing to the 30-day morbidity and mortality were also assessed. Patients were followed up for 30 days in hospital and as outpatients. Information regarding whether a post-operative complication occurred was obtained from patient hospital charts and office charts and by contacting the patient directly if needed.
The instrumental activities of daily living (IADLs) which include more complex activities related to the ability to live independently in the community such as managing finances and medications, food preparation, housekeeping and laundry were documented.
Patients were followed up in the hospital and for 30 days as outpatients. Information regarding whether a post-operative complication occurred was obtained by directly examining the patient and from patient hospital charts and electronic medical records (EMR). His/her pre-operative workup sheets were evaluated in detail by following up the investigations done and by going through the EMR notes.
Data collected were tabulated in MS Excel and analysed using SPSS version 20 for Windows (IBM, New Delhi 2020). Frequency, mean, standard deviation median and percentage, t-test, Chi-square test, Mann–Whitney test, binomial logistic regression, odds ratio with 95% confidence interval and P < 0.05 was considered statistically significant.
| Results | | |
Sixty-nine (74%) males and 24 (26%) females comprised the study. Majority (44%) of 41 patients belonged to the 65–69-year age group. Twenty-five (26.9%), 14 (15.1%) and 13 (14%) patients belonged to the 70–74-, 75–79- and more than 80-year age groups, respectively. Forty-five (48%) underwent Hepato pancreatico biliary (HPB) surgery, 41 (44%) underwent colorectal and 7 (8%) underwent upper GI surgery. Majority of surgeries (64, 69%) were laparoscopic and laparoscopic-assisted surgeries. Sixty-one (66%) surgeries were laparoscopic surgeries. Fifty-four (58%) cases were malignant. Twenty-nine (31%) patients had poor pre-operative nutritional status with body mass index (BMI) <18.5 and/or albumin <3.5 g/dl. Thirty (32%) patients were dependent with ADL/IADL <2. Nineteen (20%) patients had Clinical Frailty Score (CFS) >3. Forty-four (47%) patients had gait speed <1 m/s. 77 (83%) patients had Timed up and go test (TUG) <14s. Twelve (13%) patients reported prior history of falls. Fifty (54%) patients had pre-operative significant weight loss. Eighteen (19%) patients had Charlson Comorbidity Index <4.
Grade 2 and above Clavien–Dindo surgical complications occurred in 25/93 patients – 26.9%. There was an increased risk of Grade 2 and above Clavien–Dindo surgical complications in patients who had prior history of falls, who had timed up and go test more than 14 s, who had significant weight loss, who were operated for malignant causes and those who underwent open surgeries.
The most common post-operative complication was post-operative Surgical Site infection (SSI) and post-operative dyselectrolytaemia. Sixteen (17%) patients developed post-operative superficial surgical site infection and 9 (10%) developed deep wound infection including anastomotic leak. Eleven (12%) patients developed post-operative delirium. Seven (8%) patients developed post-operative arrhythmias and 1 (1%) patient developed post-operative pulmonary oedema. Sixteen (17%) patients developed post-operative dyselectrolytaemia, 5 (5%) had acute renal failure, 3 (3%) required re-catheterisation for retention and 2 (2%) patients had UTI. Six (6%) patients required prolonged ventilator support, 4 (4%) patients had post-operative atelectasis, 4 (4%) patients had pneumonia and 1 (1%) required reintubation. None of the patients had neurological complications.
Out of 93 patients, wound complications were seen in 12 patients (29.3%) among the age group between 65 and 59 years, 4 patients (16%) among the age group between 70 and 74 years, 5 patients (35.7%) among the age group between 75 and 79 years and 4 patients (30.8%) among the age group between 80 years or more, which are not statistically significant [Table 1].
Renal complications were seen in 12 patients (29.3%) among the age group between 65 and 59 years, 7 patients (28%) among the age group between 75 and 79 years, 4 patients (28.6%) among the age group between 75 and 79 years and 3 patients (23.1%) among the age group between 80 years or more, which are not statistically significant [Table 2].
Psychiatric complications were seen in 6 patients (14.6%) among the age group between 65 and 59 years, 3 patients (12%) among the age group between 75 and 79 years, 1 patient (7.1%) among the age group between 75 and 79 years and 1 patient (7.7%) among the age group between 80 years or more, which are not statistically significant [Table 3].
Cardiac complications were seen in 5 patients (12.2%) among the age group between 65 and 59 years, 1 patient (4%) among the age group between 75 and 79 years, 0 patient among the age group between 75 and 79 years and 2 patients (15.4%) among the age group between 80 years or more, which are not statistically significant [Table 4].
Six patients (14.6%) had bad 30-day follow-up among the age group between 65 and 69 years, 2 patients (8%) had bad 30-day follow-up among the age group between 70 and 74 years and 1 patient (7.1%) had bad 30-day follow-up among the age group between 65 and 69 years, which are not statistically significant [Table 5].
Fourteen patients (34.1%) in the age group between 65 and 69 years had ICU stay of more than 2 days, 3 patients (12%) in the age group between 70 and 74 years had ICU stay of more than 2 days, 3 patients (21.4%) in the age group between 75 and 79 years had ICU stay of more than 2 days and 15 patients (38.5%) in the age group between 80 years or more had ICU stay of more than 2 days, which are not statistically significant [Table 6]. | Table 6: Frequency of intensive care unit stay of more than 2 days with age group
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Nineteen patients (46.3%) in the age group between 65 and 69 years had length of stay of more than 7 days in hospital, 13 patients (52%) in the age group between 70 and 74 years had length of stay of more than 7 days in hospital, 8 patients (57.1%) in the age group between 75 and 79 years had length of stay of more than 7 days in hospital and 7 patients (53.8%) in the age group between 80 years or more had length of stay of more than 7 days in hospital, which are not statistically significant [Table 7].
| Discussion | | |
The 30-day mortality in our study population was around 3.2%. Moreover, the overall 30-day morbidity (which included Grade I–V Clavien–Dindo classification) was 58.06%.
Our results suggest that surgery in geriatric patients is not always benign as reflected by a 58.06% overall rate of post-operative complications. Grade 2 and above Clavien–Dindo surgical complications were encountered in 25/93 patients –26.9%.
The most common post-operative complication encountered in our study was post-operative SSI and post-operative dyselectrolytaemia. Age was not found to be a predictive factor for SSIs in our study. These findings were similar to the prospective case–control studies by Minutolo et al. and Agodi et al. regarding the surgical site infection in elderly versus younger patients undergoing abdominal surgeries. Their study reported no statistically significant differences between two groups in relation to age. However, in their study, no variables were confirmed as significant risk factors for SSI in older patients.[2],[3] This was also substantiated by another cohort study by Kaye et al. comprising 1,44,485 consecutive patients where surprisingly, at ages ≥65 years, increasing age independently predicted a decreased risk of SSI.[4]
The chance of having respiratory complications was found to be more in upper GI surgeries and those with CFS >3 in our study. This was found to be statistically significant and was comparable with the results of Cho et al. in gastrectomy patients ≥75 years of age.[5] Our study, however, failed to show any statistically significant association between respiratory complications and open surgeries.
El-Sharkawy et al. concluded that age-related pathophysiological changes in the handling of fluid and electrolytes make older adults undergoing surgery a high-risk group and an understanding of these changes will enable better management of fluid and electrolyte therapy in the older adult.[6] However, there was no statistically significant association with age and renal complications. The chances of having renal complications were found to be more in those with poor pre-operative nutritional status, those who underwent open surgeries and those with TUG test >14 s.
Liu et al. studied 547 patients aged above 80 years, with a history of CAD who underwent non-cardiac surgery, 19.4% of patients developed at least one post-operative cardiac complication and 2.7% of patients developed cardiac death. The risk factors were age ≥85 years and BMI ≥30 kg/m2.[7] Our study showed contrary results with cardiac complications occurring more in those with poor nutritional status. Cardiac complications were also found to be more in open surgeries, those with prior history of falls, those with TUG >14 s and those with poor nutritional status. This was found to be statistically significant.
In a retrospective study by Bai et al. who underwent non-cardiac surgery, ageing had no influence on the perioperative cardiac risk in patients without overt myocardial ischaemia or infarction.[8] This result was comparable to our study.
Lin et al. identified the relationship between frailty and post-operative outcomes in surgical population with a mean age of 75 and older, frailty was associated consistently with increased 30-day, 90-day and 1-year mortality, post-operative complications and length of stay.[9] Our study results showed a statistically significant association between frailty and prolonged stay.
Age was found to be a strong risk factor for post-operative delirium in the studies by Marcantonio et al. and Dyer et al.[10],[11] Our study, however, failed to show that age was a risk factor for POD.
The 30-day follow-up whether good/bad was not associated with age. In our study, good 30-day follow-up was seen in those who underwent laparoscopic surgeries.
The limitations of our study were the lack of a control group which means the young patients <65 years of age, which would have enabled a direct comparison of the study group in terms of RRs and Odds ratio, and the smaller sample size of 93 patients compared to conclusions drawn from studies from large databases. However, data collection due to shortage of elective cases during the COVID pandemic has to be taken into consideration.
It has also covered almost all abdominal surgeries; both laparoscopic and open procedures, both malignant and benign causes were taken into consideration which makes it more diverse. Analysing and comparing the results has been difficult, as there were different surgical procedures and indications grouped together.
The strengths of our study were that it was a prospective study and covered a very important and scarcely studied topic. As the population ages, there is an increased need to study the elderly population, recognise their needs and identify the factors which when modified can be used to improve their health as a whole. Most of the studies done on the elderly are from western populations and there is in fact a dire need to study the Indian population in this respect. Another was that our study had a short 30-day follow-up analysing the functional status of the patient with good/bad recovery which most studies lack.
We believe that this study shall instil enthusiasm for future research on formulating a myriad of new assessment tools to aid surgeons in risk-stratifying patients and planning for pre-and post-operative transdisciplinary interventions. This should pioneer a paradigm shift from a mortality and morbidity reduction–centric surgical management to an overall patient-centric level of care aimed at full functional recovery to pre-operative baseline for elderly adults undergoing major GI surgery.
| Conclusion | | |
Elective surgery is generally well tolerated by the elderly. Age should not be used as the only criterion when deciding suitability for surgery. The most common complications are wound complications with superficial and deep SSIs and renal complications in the form of dyselectrolytaemia. Healthcare providers should be aware of this scarcely studied topic on geriatric GI surgery and foster quality improvement initiatives.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Bentrem DJ, Cohen ME, Hynes DM, Ko CY, Bilimoria KY. Identification of specific quality improvement opportunities for the elderly undergoing gastrointestinal surgery. Arch Surg 2009;144:1013-20.  |
| 2. | Minutolo M, Blandino G, Lanteri R, Puleo S, Minutolo V. Surgical site infection in elderly patients. BMC Geriatr 2011;11:A37. |
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| 4. | Kaye KS, Schmit K, Pieper C, Sloane R, Caughlan KF, Sexton DJ, et al. The effect of increasing age on the risk of surgical site infection. J Infect Dis 2005;191:1056-62. |
| 5. | Cho GS, Kim W, Kim HH, Ryu SW, Kim MC, Ryu SY. Multicentre study of the safety of laparoscopic subtotal gastrectomy for gastric cancer in the elderly. Br J Surg 2009;96:1437-42. |
| 6. | El-Sharkawy AM, Sahota O, Maughan RJ, Lobo DN. The pathophysiology of fluid and electrolyte balance in the older adult surgical patient. Clin Nutr 2014;33:6-13. |
| 7. | Liu Z, Xu G, Xu L, Zhang Y, Huang Y. Perioperative cardiac complications in patients over 80 years of age with coronary artery disease undergoing noncardiac surgery: The incidence and risk factors. Clin Interv Aging 2020;15:1181-91. |
| 8. | Bai J, Hashimoto J, Nakahara T, Suzuki T, Kubo A. Influence of ageing on perioperative cardiac risk in non-cardiac surgery. Age Ageing 2007;36:68-72. |
| 9. | Lin HS, Watts JN, Peel NM, Hubbard RE. Frailty and post-operative outcomes in older surgical patients: A systematic review. BMC Geriatr 2016;16:157. |
| 10. | Marcantonio ER, Goldman L, Mangione CM, Ludwig LE, Muraca B, Haslauer CM, et al. A clinical prediction rule for delirium after elective noncardiac surgery. JAMA 1994;271:134-9. |
| 11. | Dyer CB, Ashton CM, Teasdale TA. Postoperative delirium. A review of 80 primary data-collection studies. Arch Intern Med 1995;155:461-5. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]
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