 
|
|
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Journal of the New Zealand Medical Association,
17-April-2003, Vol 116 No 1172
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
Major abdominal surgery in octogenarians
Saleh Abbas and Michael Booth
Ageing of the population presents an increasing demand on
the healthcare dollar. This is due to increasing costs of treatment, the
availability of more therapies and advances in technology that allow sicker and
older patients to survive major surgery. The surgeon is commonly faced with a
sick, elderly patient who requires an emergency operation. This situation
frequently requires a decision to be made accompanied by little information
about the patient and can, therefore, represent an ethical dilemma. Ten per cent
of surgical admissions at North Shore Hospital are patients of 80 years or over.
They present a challenge to the surgical team when a major surgical procedure is
required. Previous studies have shown that mortality rates in emergency
situations vary from 13–30%.1,2 There is
frequently a need for intensive care admission and prolonged hospital
stay.3
MethodsThis study examined the
immediate outcome and long-term survival of a group of patients of 80 years and
over who had major abdominal surgical operations at North Shore Hospital.
Long-term survival was compared with the New Zealand age-matched population
(survival data obtained from Statistics New Zealand).
Patients who underwent elective or emergency major abdominal surgery at North Shore Hospital over a two-year period, from 1 July 1997 to 1 July1999, were studied. No patients had trauma or vascular procedures, as these patients are treated elsewhere. The operating theatre database (GQL Software), surgical audit (Otago Surgical Audit) and patient files were reviewed. Demographics, clinical presentation, diagnosis, operative treatment and outcome were collected by review of medical records, theatre audit and surgical audit. Long-term survival data were collected by GPs, family members and patients themselves. ASA class was recorded for each patient at the time of the operation by the anaesthetist. Outcome parameters that were analysed included morbidity, in-hospital mortality, duration of ICU stay, post-operative hospital stay and long-term survival. Operative mortality was defined as death within 30 days of the operative procedure or in-hospital death in the instance of prolonged hospital stay. Morbidity was defined as any event that required diagnostic or therapeutic intervention, or resulted in prolonged hospital stay. Statistical analysis Analysis was performed using StatsDirect for Windows. Group contingency analysis was performed by chi-square test and Fisher exact test. Mann-Whitney test was used for non-parametric variables. Actuarial survival was calculated using Kaplan-Meier analysis and comparison between groups was performed using the log rank test. Logistic regression was used for categorical outcome analysis including the impact of demographics and clinical, emergency, comorbidity and operative intervention on post-operative mortality. ResultsPatient
demographics One hundred and eighty patients (17 lost to follow up) of 80
years or over had a major abdominal operation (Table 1). One hundred and fifteen
were females and 65 were males. Median age was 84 (range 80–97). Ninety
nine patients were aged between 80 and 84 years, and 81 were 85 years and over.
Emergency operations were performed on 100 patients and 80 patients had elective
procedures. One hundred and thirteen patients had ASA class 3 and higher at the
time of the operation. Median hospital stay was 12 (range 2–61)
days.
Operative treatment
The major operations performed are listed in Table 1.
Table 1. Patient demographics
Peri-operative outcome
Median post-operative stay was 12 days (range 2–61). There were 34
ICU admissions with a median stay of 4 days (average 0–30). Sixty patients
(33.3%) had complications. Overall, 30-day mortality was 19.4%. There was
significantly higher mortality in patients who had emergency operations than
those who had elective operations (29% vs 7.5%, p = 0.0026). Patients with ASA
class 4 and 5 had significantly higher mortality (46% and 33% respectively) than
ASA class 2 and 3 patients (8% and 13 %), p <0.0001. The difference in
mortality between ASA class 4 and 5 was not statistically significant; nor was
the difference between ASA class 2 and 3.
Simple logistic regression for factors affecting
peri-operative mortality showed ASA class 4 and 5 have a significant effect,
with odds ratio of 1.9 and 0.7, compared with ASA 2 and 3 (p <0.0001).
Emergency surgery was associated with a significantly higher peri-operative
mortality (OR 2.4, p = 0.0026). Operative procedure, age at the time of
operation and pre-operative diagnosis did not influence complications or
peri-operative mortality (Table 1).
Long-term survival
Median follow up was 31.5 months. At 30 months of follow up, 50% of these
patients were still alive. The median survival for patients of 80–84 years
was 32 months and for patients 85 years and over, 12 months, p = 0.011.This
included in-hospital mortality (Figure 1).
Figure 1. Survival by age group
 There was no significant difference in survival between
patients who had surgery for malignant disease (77 patients) and those who had
surgery for benign disease (88 patients). The median survival for the malignant
group was 11 months and for the benign group, 25 months, p = 0.37 (Figure
2).
Figure 2. Median survival in months: benign vs
malignant (p = 0.37)
 Long-term survival was significantly affected by the
presence of associated comorbidities. The median survival for patients in ASA
class 2 was 48 months, and for ASA class 3, 4 and 5, 23 months, 7 months and 3
months respectively (Figure 3, Table 2). However, having an emergency operation
did not adversely affect long-term survival compared with having an elective
operation.
Figure 3. Median survival by ASA class (ASA 2 has
better survival than other classes, p = 0.0003)
 Table 2. Survival by ASA class (163 patients followed
up)
Long-term survival of these patients was compared with the
New Zealand age-matched population (data obtained from life table analysis and
analysed using the log rank test). There was a significant difference: p
<0.0001. However, when we excluded patients who died in the peri-operative
period the long-term survival was similar (Figure 4).
Figure 4. Survival compared with age-matched
population, showing the upper and lower limits of 95%CI. Uppermost curve shows
survival of age-matched general population. (click here to
see larger version of Figure 4)
Fewer than 10% (17) of patients were lost to follow up.
Eleven of these were in the 80–84 age group. Seven had complications and
nine underwent acute procedures. Eight had colorectal procedures, six
adhesiolysis with or without bowel resection, two cholecystectomies and one
closure of a perforated duodenal ulcer. Eight were classified ASA 2, six ASA 3
and three ASA 4. The patients in this group appear to be representative of the
entire group, although relatively more ASA 2 patients were lost to follow up. It
is unlikely that the exclusion of this group from our data would have had any
impact on the reported long-term survival of either the emergency or elective
surgery patients as a whole (Figure 5).
Figure 5. Survival by elective or emergency operation
(p = 0.06)
 DiscussionThere is much evidence in the
literature to suggest that elderly patients do well after major abdominal
surgery.4–8 In the 1970s, patients over
70 were regarded as elderly and age was often used as an important criterion to
determine access for major surgery. Published reports often included those
patients over 65 and 70 in the ‘elderly’
group.4–8 As it became apparent that
these patients were doing well after major surgery, attention focused more on
patients over 80 years to see how well they respond to major surgery and how
this surgery affects their survival. This shift has become more pertinent as the
population ages.
Patients over 80 who have had colonic surgery have reported
mortality rates of 9–10%.4,9
Pancreaticoduodenectomy is also well tolerated in the elderly, with mortality
rates as low as 4%.8,10–12 Similarly,
major gastric resections have a published mortality of
9%.5 Even major hepatic resection in the
elderly carries mortality rates of
7–11%.13 It would, therefore, be
reasonable to say that elderly patients should not be denied major elective
abdominal surgery on age criteria alone.
Age may be regarded as a selection criterion for urgent or
emergency laparotomy.6 There is a significantly
higher mortality attached to this procedure – 29% in our series. However,
long-term survival is similar to the age-matched population once peri-operative
mortality figures are excluded. ASA status is also of predictive
value.6 No ASA 5 patient in our series survived
longer than three months. ASA 4 and 5 patients had a significantly higher
mortality than ASA 2 and 3 patients.
An 80-year-old female has a mean life expectancy of 9.2
years and an 80-year-old male, 7.2 years. An 85-year-old female has a mean life
expectancy of 6.6 years and a male of the same age, 5.3
years.14 Therefore, many elderly patients can
look forward to several more years of life.
Quality of life is a factor that is often difficult to
assess but is important when decisions regarding major surgery need to be made.
This study did not look at quality of life before or after surgery. However,
most clinicians faced with decisions regarding major surgery in the elderly do
take quality of life into consideration. It is often more difficult for the
surgeon and family to take the decision not to operate than to operate. New
palliative techniques such as colonic stenting, interventional radiology and
therapeutic endoscopy may reduce the need for major surgery and hence reduce the
number of difficult decisions to be made with regards to these
patients.
In summary, the decision to treat a sick, elderly patient
requires consideration of ASA status, quality of life and expectations of the
patients and family following surgery. For those patients who are prepared to
accept the risks of emergency surgery, surgery should not be denied on the basis
of age alone.
Author information:
Saleh Abbas, Surgical Registrar; Michael Booth, Upper GI Surgeon and
Endoscopist, North Shore Hospital, Auckland
Correspondence: Mr
Saleh Abbas, Department of Surgery, North Shore Hospital, 51A Francis street,
Takapuna, Auckland. Fax: (09) 377 9656; email: Salehabbas@clear.net.nz
References:
|
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| | Current
issue | Search journal |
Archived issues | Classifieds
| Hotline (free ads) Subscribe | Contribute | Advertise | Contact Us | Copyright | Other Journals |
|