Modified Frailty Index to Assess Risk in Elderly Patients Undergoing Distal Pancreatectomy: A Retrospective Single-Center Study

Background To compare the postoperative course of elderly patients (≥70 years) submitted to minimally invasive (MIDP) versus open distal pancreatectomy (ODP) and to evaluate if the modified Frailty Index (mFI) predicts the surgical course of elderly patients submitted to DP. Methods Data of patients aged ≥70 who underwent DP at a single institution between March 2011 and December 2019 were retrospectively retrieved. A 2:1 propensity score matching (PSM) was used to correct for differences in baseline characteristics. Then, postoperative complications were compared between the two groups (MIDP vs. ODP). Additionally, the entire cohort of DP elderly patients was stratified according to the mFI into three groups: non-frail (mFI = 0), mildly frail (mFI = 1/2), or severely frail (mFI = 3) and then compared. Results A total of 204 patients were analyzed. After PSM, 40 MIDP and 80 ODP patients were identified. The complications considered stratified homogenously between the two groups, with no statistically significant differences. The severity of the postoperative course increased as mFI did among the three groups regarding any complication (p = 0.022), abdominal collection (p = 0.014), pulmonary complication (p = 0.001), postoperative confusion (p = 0.047), Clavien-Dindo severity ≥3 events (p = 0.036), and length of stay (p = 0.018). Conclusions Elderly patients can be safely submitted to MIDP. The mFI identifies frail elderly patients more prone to develop surgical and non-surgical complications after DP.

Preoperative fluid management of the older adult patient with hip fracture

<p>Background While recommendations about the preoperative fluid management of the older adult hip fracture patient have been produced the evidence relating to postoperative outcomes is scant. Aim The aim of this study is, therefore, to explore the relationships between preoperative fluid management (PFM) - defined as timing to start of fluids (oral or intravenous) after admission, preoperative oral fluid rate, and timing of last preoperative oral fluids – and postoperative outcomes - defined as change in renal function (creatinine and GFR), new reported postoperative confusion, timing of discontinuation of postoperative intravenous fluids (IV), and length of stay (LOS). Method This observational study looked at 100 consecutive older adult patients admitted to a tertiary New Zealand hospital with traumatic hip fracture between March and September, 2012. Data was gathered regarding cohort demographics and in hospital events, including surgical details, alongside PFM and postoperative outcomes. Descriptive statistics, linear regression, independent t-tests, tests of equality, and multiple logistic regression were utilised to ascertain relationships between variables. Results Characteristics of the perioperative journey of 100 consecutive patients, with mean age of 85.2 yr (SD 6.6) and predominantly female (70%), presenting to CCDHB with a fragility hip fracture were itemised. High rates of co-morbidities were observed in this group, with 92% of patients having cardiac, pulmonary, vascular or renal co-morbidities, but with a mortality rate (2%) much lower than the literature would suggest might be expected. There was no substantiated statistically significant relationships observed between preoperative fluid management in this cohort and postoperative outcomes, but this may reflect limited power in this study. Conclusion These results provide useful data for planning services with regards management of the older adult hip fracture patient at CCDHB. In addition, the study has highlighted a number of clinical guidelines that might be more effectively promoted.</p>

Preoperative fluid management of the older adult patient with hip fracture

<p>Background While recommendations about the preoperative fluid management of the older adult hip fracture patient have been produced the evidence relating to postoperative outcomes is scant. Aim The aim of this study is, therefore, to explore the relationships between preoperative fluid management (PFM) - defined as timing to start of fluids (oral or intravenous) after admission, preoperative oral fluid rate, and timing of last preoperative oral fluids – and postoperative outcomes - defined as change in renal function (creatinine and GFR), new reported postoperative confusion, timing of discontinuation of postoperative intravenous fluids (IV), and length of stay (LOS). Method This observational study looked at 100 consecutive older adult patients admitted to a tertiary New Zealand hospital with traumatic hip fracture between March and September, 2012. Data was gathered regarding cohort demographics and in hospital events, including surgical details, alongside PFM and postoperative outcomes. Descriptive statistics, linear regression, independent t-tests, tests of equality, and multiple logistic regression were utilised to ascertain relationships between variables. Results Characteristics of the perioperative journey of 100 consecutive patients, with mean age of 85.2 yr (SD 6.6) and predominantly female (70%), presenting to CCDHB with a fragility hip fracture were itemised. High rates of co-morbidities were observed in this group, with 92% of patients having cardiac, pulmonary, vascular or renal co-morbidities, but with a mortality rate (2%) much lower than the literature would suggest might be expected. There was no substantiated statistically significant relationships observed between preoperative fluid management in this cohort and postoperative outcomes, but this may reflect limited power in this study. Conclusion These results provide useful data for planning services with regards management of the older adult hip fracture patient at CCDHB. In addition, the study has highlighted a number of clinical guidelines that might be more effectively promoted.</p>

Factors Associated With Postoperative Confusion and Prolonged Hospital Stay Following Deep Brain Stimulation Surgery for Parkinson Disease

BACKGROUND Several patient and disease characteristics are thought to influence DBS outcomes; however, most previous studies have focused on long-term outcomes with only a few addressing immediate postoperative course. OBJECTIVE To evaluate predictors of immediate outcomes (postoperative confusion and length of postoperative hospitalization) following deep brain stimulation surgery (DBS) in Parkinson disease (PD) patients. METHODS We conducted a retrospective study of PD patients who underwent DBS at our institution from 2006 to 2011. We computed the proportion of patients with postoperative confusion and those with postoperative hospitalization longer than 2 d. To look for associations, Fisher's exact tests were used for categorical predictors and logistic regression for continuous predictors. RESULTS We identified 130 patients [71% male, mean age: 63 ± 9.1, mean PD duration: 10.7 ± 5.1]. There were 7 cases of postoperative confusion and 19 of prolonged postoperative hospitalization. Of the 48 patients with tremors, none had postoperative confusion, whereas 10.1% of patients without tremors had confusion (P = .0425). Also, 10.2% of patients with preoperative falls/balance-dysfunction had postoperative confusion, whereas only 1.6% of patients without falls/balance-dysfunction had postoperative confusion (P = .0575). For every one-unit increase in score on the preoperative on-UPDRS III/MDS-UPDRS III score, the odds of having postoperative confusion increased by 10% (P = .0420). The following factors were noninfluential: age, disease duration, dyskinesia, gait freezing, preoperative levodopa-equivalent dose, number of intraoperative microelectrode passes, and laterality/side of surgery. CONCLUSION Absence of tremors and higher preoperative UPDRS III predicted postoperative confusion after DBS in PD patients. Clinicians’ awareness of these predictors can guide their decision making regarding patient selection and surgical planning.

Atlantoaxial Instability in Patients Older Than 70 Years: What Is the Outcome When Further Conservative Treatment Is Not an Option?

Objective We report on our experiences of navigated posterior C1–C2 spondylodesis in the elderly (≥ 70 years of age). Patients This retrospective cohort study evaluated all patients ≥ 70 years of age treated with navigated posterior spondylodesis C1-C2 (at the most to C3) from 2008 to 2015 with a minimum follow-up of 1 year. Minor and major complications within 30 days after surgery, patient outcome, and the rate of solid fusion in computed tomography were recorded. The follow-up over 1 year was conducted by outpatient examinations and via telephone interviews. Results Twenty-two patients with a mean age of 79.9 years (range: 71–91 years) were treated. Minor complications were mild pneumonia (18.2%), postoperative confusion (9.1%), and urinary tract infection (4.5%). Major complications were severe pneumonia (4.5%) and clinically asymptomatic vertebral artery injury (4.5%). The mortality rate was 13.6% (n = 3) within the first 30 days after surgery and 22.7% (n = 5) within 1 year. All deceased patients were > 85 years of age. Conclusion In our patient population, posterior spondylodesis was shown to be beneficial for patients > 70 years up to age ∼ 85 years. The mortality rate increased sharply in patients > 85 years. In these patients the indication for surgery should be critically evaluated.

Transgressing the Ventricular Wall During Subthalamic Deep Brain Stimulation Surgery for Parkinson Disease Increases the Risk of Adverse Neurological Sequelae

BACKGROUND: Deep brain stimulation (DBS) at the subthalamic nucleus (STN) is an effective treatment for the motor manifestations of advanced medically refractory Parkinson disease. Because of the medial location of the target, surgical trajectories to the STN may violate the ipsilateral lateral ventricle. OBJECTIVE: To determine whether violating the ventricle during STN DBS surgery is associated with postoperative confusion. METHODS: A retrospective chart review of all STN implantation procedures for Parkinson disease performed by 1 surgeon between January 2005 and September 2008 was performed. Postoperative magnetic resonance imaging was performed in all cases, and each scan was reviewed for evidence of ventricular wall violation. All charts were reviewed for postoperative confusion and/or increased length of hospital stay. RESULTS: A total of 145 leads were implanted in 81 patients over 102 admissions. Forty-three patients underwent contemporaneous bilateral lead implantation; 23 underwent unilateral implantation; and 18 underwent staged bilateral implantation. The cases of 8 patients were complicated by postoperative confusion and increased length of stay. Sixteen magnetic resonance imaging scans demonstrated evidence of ventricular wall violation including all 8 patients with postoperative confusion. The relative risk of having postoperative confusion after traversing the ventricle is 87 (P &lt; .001). CONCLUSION: Violating the ventricular system during STN DBS surgery correlated significantly with postoperative altered mental status and subsequent increased length of hospital stay. This finding may explain why cognitive complications are observed more frequently in Parkinson disease patients undergoing DBS at the STN compared with the internal globus pallidus.