Abstract
Background and purpose. The number of octogenarians requiring surgery increases constantly. Data regarding perioperative morbidity and mortality in octogenarians is limited. Our aim was to assess surgery-related complications in octogenarians, undergoing urological surgery.
Patients and methods. We prospectively collected data from octogenarians and a control group of younger patients undergoing an elective urological surgery in our institution. Recorded data included: age, gender, American Society of Anesthesiologists (ASA) score, co-morbidities, number of medications, operation extent, anaesthesia type, surgery duration and perioperative morbidity and mortality.
Results. Forty-seven octogenarians and 80 patients with a median age of 59 years (range 19–75) enrolled prospectively. Gender ratio, surgeries extent and median operative time were similar among groups. General anaesthesia was more prevalent in the control group. ASA classification and duration of hospitalization were significantly higher in octogenarians. The rate of intra-operative complications was significantly higher in the octogenarians group 6.38% versus 3.75% (p = 0.007), there was no significant difference in immediate post-operative and post-discharge complications among groups. One octogenarian patient died 2 days post-surgery, no death occurred in the control group.
Conclusions. Octogenarians have higher rate of intra-operative morbidity, leading to longer hospital stay. More experienced surgeons and anaesthetists should be involved in the operation; and careful surgical technique, tapered anaesthesia and higher level of post-operative monitoring should be applied for patients in this age.
Introduction
Age has been considered a risk factor for perioperative morbidity and mortality for decades, though data in that subject is limited. There is a worldwide trend towards an increased life expectancy. According to a publication of the World Health Organization, in 2050 more than 20% of population will be older than 60 years Citation[1]. The number of surgical procedures performed in these aged patients rises consequently. In an attempt to-reduce elderly patients' perioperative complications we implemented a preoperative preparation procedure in which all elderly patients scheduled for an elective or semi-elective surgery will be examined by the anaesthesiologist following their visit at the urology clinic. Patients with active or unbalanced disease were revaluated and treated by the appropriate specialist and only then approved for surgery.
The aim of our study was to assess morbidity and mortality in the elderly patients group following this preoperative preparation procedure.
Patients and methods
With the approval of the local ethics committee, we conducted a prospective study of elderly patients 80 years old and more, who underwent elective urology surgery in our institution between January and July 2007. As a control group we have recorded the data from all other patients older than 18 years and younger than 80 years who had elective urologic surgery during the last 3 weeks of the study.
All elderly patients in the study group had a meticulous preoperative evaluation as follows. The patient had a primary visit at the outpatient urology clinic and the type of surgery was agreed upon, while taking into account the patient's age and general condition Citation[2]. Thereafter the patient was examined by a senior anaesthesiologist in the pre-anaesthesia clinic, who focused on the problems characteristic of the geriatric patient Citation[3-5]. The anaesthesiologist determined the ASA classification, planned the type of anaesthesia, the degree of monitoring during the surgery, and the level of post-operative care, such as overnight stay in the intensive care unit (ICU). In some cases the anaesthesiologist recommended further evaluation by other specialists or demanded more tests. These patients were re-examined after the completion of the studies or balancing of their diseases, and only then approved for surgery. Most of the patients underwent this evaluation as outpatients. However, a few patients were hospitalized due to acute problems, such as urinary retention, or haematuria. The above mentioned evaluation was carried out in hospital and the surgery was performed on a semi-elective basis, after the completion of the evaluation. Throughout the study period the evaluation was completed before surgery in all elderly patients.
Parameters recorded were: age; gender; ASA score; presence of ischaemic heart disease (IHD), hypertension (HTN), diabetes (DM), pulmonary disease (PD); number of medications taken chronically; type of anaesthesia (local, regional, general, combined regional, and general); extent of the surgical procedure; duration of the surgeryand hospitalization; intra-operative, immediate post-operative and 30 days post-discharge from the hospital complications and mortality within 30 days from the operation ().
Table I. The extent of operation.
Comparison between the study and the control groups was performed using the Mann-Whitney rank sum test; comparison of proportions was performed using the Z test. P < 0.05 was considered statistically significant.
Results
The parameters recorded and the comparison between groups is summarized in .
Table II. Comparison of patients and surgery parameters of the study groups.
Table III. Comparison of patients who underwent major surgery.
Table IV. Comparison of patients who underwent intermediate surgery.
Table V. Comparison of patients who underwent minor operation.
During the study period 47 elderly patients (34 male, 13 female) with a median age of 82 years (range 80–95) were evaluated and underwent surgery in our department. The control group comprised 80 patients (51 male, 29 female) with a median age of 59 years (range 19–75). Age difference among groups was statistically significant. Male to female ratio between the groups was not significantly different.
Median ASA score was significantly higher in the elderly group, 3 versus 2 (p < 0.001). IHD, and HTN were more prevalent in the elderly group (46.8% versus 13.75%, p < 0.001; 82.9% versus 50%, p < 0.001, respectively). Also the median number of chronically taken medications was significantly higher in the elderly group 4 versus 1.5 (p < 0.001). Analysing the data with the stratification of the according to the extent of operation (minor, intermediate, and major) demonstrated that in the intermediate and major operations groups there was no difference regarding the prevalence of IHD, HTN, the number of medications taken and the ASA classification. Only patients undergoing minor surgery were significantly different in ASA classification and number of medications (, and ).
The proportions of minor, intermediate, and major operations were similar for both groups. The use of local, regional and combined anaesthesia was proportional in both groups; though in the control group a higher rate of general anaesthesia was administered (2.12 % versus 16.25%, p = 0.0031). Median operation time was similar for both groups (45 min).
Intra-operative complication rate was significantly higher in the elderly group, 6.38% versus 3.75%, p = 0.007. In the elderly group one female patient suffered from pneumothorax during upper calyces PCNL, which was drained with a chest tube. Her chest x-ray upon discharge was normal. One male patient had an excessive bleeding during retropubic prostatectomy (RPP), which required massive transfusion, packing and surgical re-evaluation in the following day. An additional male patient needed transfusion of two units of packed red blood cells (PC) transfused during RPP. In the control group one male patient had TUR syndrome which led to transient hyponathremia and confusion during transurethral resection of the prostate. He was treated conservatively with saline infusion and his symptoms subside within a few hours. One female patient developed pneumothorax during upper calyces PCNL, which was drained with a chest tube. An addditional female patient suffered from extravasation of irrigation fluid during PCNL, which was treated conservatively. None of these intra-operative complications led to intra-operative mortality.
The rate of in-hospital post-operative complications was not significantly different among groups (21.27% versus 13.75%). In the elderly group, one male patient died 2 days after cystoscopy which was performed under local anaesthesia; this patient had a history of stable IHD, HTN and Parkinson's disease. The procedure went uneventfully but he was hospitalized due to his restricted mobility condition, waiting for urodynamic study. During post-operative day 2 he developed myocardial infarction and did not survive resuscitation. An additional five patients had haemoglobin level lower than 10 mg/dl and were transfused based on clinical decision. All underwent RPP, one needed 1PC unit, two needed 2PC units and the one who bled extensively during the surgery received massive transfusion post-operatively. This patient was admitted to the ICU and also suffered from pneumonia that was treated with antibiotics. Two patients had transient arrhythmia both treated conservatively. Three other patients had fever, confusional state and chest pain without electrocardiogram (ECG) changes or elevated enzymes. Beside the single mortality neither of the above-mentioned complication led to patient death.
Duration of hospitalization was significantly longer in the elderly group, median in hospital stay was 3 (1–50) days vs. 1 (1–15) (p < 0.001) in the control group.
Thirty days post-discharge complications rate was not significantly different among groups. Complications were recorded in 7 (14.89%) patients in the elderly group versus 10 (12.5%) in the control group. Elderly group complications included transient haematuria (2 patients), urinary tract infection (2 patients), transient urinary retention (2 patients), and limb pain (1 patient). All complications were transient and managed conservatively. Control group complications included uro-sepsis (2 patients), urinary tract infection (3 patients), renal colic (4 patients) and transient elevation of creatinine levels (1patient). All these complications were transient and managed conservatively.
No post-discharge mortality was recorded in either group.
Discussion
Approximately 100 elective surgeries are performed in our department annually in octogenarians; another 100 procedures in patients 75–80 year old; and more than 100 procedures in patients 70–75 year old. These numbers increase persistently, parallel to the tendency in other western countries. Around 15–23% of all surgical activity will treat elderly patients, though it varies between the different surgical specialisms. Hamel et al. Citation[6] recorded the data from 123 centres during 1991–1999 and reported that of 5% of the operations were performed in patients older than 80 years. Among the 26,648 operation analysed, transurethral prostatectomy was the most prevalent (14%), the next most common procedures were hernia repair 7.5%, colectomy 6% and hip replacement 4.1%. Marusch et al. Citation[7] presented a multi-centre study of 19,080 colorectal operations, among them 23.4% were performed in patients older than 80 years. Mortality associated with anaesthesia and surgery is defined as death within 30 days of operation. Jin and Chung Citation[3] in their review article reported an overall 1.2% surgically related mortality for the general population compared with 5.8% for patients over 80 years of age. Another study reported 6.2% in hospital mortality within one month of surgery Citation[8]. In our study group we had a single surgically related mortality in the elderly group (2.1%), and no mortality in the control group. In this specific case the patient was operated on under local anaesthesia, hence his mortality most probably was not attributed to anaesthetic cause. The surgical procedure went smoothly and the post-operative period was uneventful until sudden and rapid deterioration began. His clinical symptoms, ECG results and biochemical findings led us to the diagnosis of acute myocardial infarction that caused his death.
The elderly population has not only higher mortality rate, but also a recognized higher rate of perioperative complications, minor as well as major Citation[9-13]. In our study, over all surgical complications recorded three were in the elderly group and three in the control group. The rate of intra-operative complications was significantly higher in the elderly. Analysing the type of complications in the elderly group revealed that all three complications were related to surgical technical issues and did not evolve from age-related issues or illness. Hamel et al. Citation[6],Citation[9] reported a perioperative complications rate of about 20%. Wth regard to bleeding, 1.5% of patients needed transfusion of more than 4 PC units (versus 4.2% in our study). The vascular and pulmonary complications reported by Hamel were: prolonged post-operative intubation and ventilation (2.8%), myocardial infarction (1%), cardiac arrest (2.1%), pulmonary oedema (1%), and cerebrovascular accidents (0.7%). None of these morbidities were recorded in our patients. Although this was a relatively small group, a very high percentage of the operated patients had history of IHD, HTN, and PD. The low rate of vascular and pulmonary complications could be attributed to pre-surgical thorough evaluation, and stabilization of those conditions in all patients. Regarding the extent of surgery and complication rate, there was no significant difference within the group; however, caution should be taken here as stratification reduces the number in each group.
The cornerstone of preoperative evaluation is ASA classification, which is a reflection of the severity of preoperative co-morbidities. It was already established in the geriatric population that high ASA classification increases the odds of developing any postoperative adverse events Citation[14],Citation[15]. Since elderly patients bear greater frequency of co-morbid conditions, they obviously have poorer outcome. This occurrence was found in our study as well: older patients had significantly higher ASA classification and took more medications. In order to determine whether age by itself is a risk factor for perioperative complication, one should separate age from co-morbidity, which is unfeasible. With aging, baseline functions of almost every organ undergo progressive decline resulting in a decreased physiologic reserve and inability to compensate for stress Citation[16]. Therefore the old-age population is a recognized high-risk group, with specific requirements.
In our study elderly patients had a significantly longer duration of hospitalization, with a median of 3 days versus 1 in the control group (p < 0.001). Polanczyk et al. Citation[17] reported a similar trend in hospital stays with a prolongation of a day or two in elderly patients. Elderly patients require more aggressive and costly perioperative care with intense monitoring as they are more vulnerable to decompensate perioperatively Citation[16]. Careful management results in reduced morbidity and mortality, reduced re-admission rate, improved outcome and is beneficial to both patient and healthcare system Citation[5],Citation[18].
Along with the aging population and the increasing age of surgical patients, the issue of perioperative complications and its costs gains importance. The limitation of the study is a relatively small number of patients limiting the statistical power, especially after the stratification according to the extent of surgery (see –). In our continuing study we will increase the number of participating patients and include surgeries of all medical disciplines.
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