International Journal of Surgery 13 (2015) 304e305
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Letter to the Editor
Correspondence to: “Predictors of in-hospital mortality amongst octogenarians undergoing emergency general surgery: A retrospective cohort study” Keywords: Emergency Surgery Mortality Morbidity DNR ASA Cardiovascular Pulmonary Risk
Dear Editor, We read the article written by Wilson et al. [1], with great interest. There have been various studies in the literature focusing on predictors of risk for emergency surgery in the geriatric population [2e4]. In this article, the authors collected data on patient demographics, post-operative morbidity and the relationship between the American Society of Anesthesiologists (ASA) scoring grade and in-hospital mortality. The ASA scoring grade is a useful, quick and easy tool to assess the emergency patient before operative intervention [5]. From a range of univariate analyses, the authors conclude that COPD was a significant risk predictor and should be used alongside the ASA scoring grade. The research performed here was useful in analysing statistically significant independent risk predictors, so the authors are applauded for their contribution. However, before their conclusion is universally accepted, we believe there ought to be several clarifications. Firstly, it is well known that an existing do not resuscitate (DNR) status of a patient pre-operatively is a significant risk factor for post-operative mortality and morbidity within a 30-day period [6,7]. The authors did not reflect on any statistics showing what proportion of their patient cohort had a known DNR status. Although there may be inconsistent implementation or meaning across hospitals of what comprises a DNR status, the UK General Medical Council guidelines state that it is when the risks of treatment after cardiopulmonary resuscitation (CPR) outweigh the clinical benefit and when ‘cardiac or respiratory arrest is an expected part of the dying process’ in an individual [8]. Scarborough et al. [6] compared the mortality risk of 25,558 elderly patients above the age of 65 and undergoing emergency surgery. They were divided per cohort of DNR (4.3%) and non-DNR (95.7%) patients. Although the pre-operative and intraoperative variables in both DOI of original article: http://dx.doi.org/10.1016/j.ijsu.2014.08.404. http://dx.doi.org/10.1016/j.ijsu.2014.11.055 1743-9191/© 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
cohorts were controlled, the post-operative mortality rate was significantly higher in DNR vs non-DNR patients (36.9% vs 22.3% respectively, p < 0.0001), despite similar post-operative complication rates. Whilst age may not necessarily be an independent predictor for the classification of DNR patients, studies have shown that DNR is likely to occur with increased age [7]; therefore there may be a higher number of DNR patients amongst octogenarians, as in this article by Wilson et al. [1]. Thus, having a higher proportion of potential DNR patients within this population age group is likely to place them at a higher mortality risk, which may affect management of the patient. Studies have also attempted to give plausible reasons for the excess mortality rates in DNR patients, suggesting decreased willingness of the patient to pursue aggressive treatment following major post-operative complications or refusal of surgeon to admit these patients into theatre [6,9]. Secondly, patients who are operated in emergency conditions have a much higher chance of further unplanned re-operations. A prospective study by Guevara et al. [10] showed a 1.79 crude relative risk (RR) of re-operation on emergency patients. Also the RR of mortality following re-operations was 8.94 (95% CI, 6.11e13.07). The literature seems to also support “re-operations” as an independent entity for mortality risk. It would have been interesting to know whether the seven patients who were readmitted into surgery within 30 days of discharge, survived after the consecutive post-operative phase. Therefore, a follow-up on these patients would be useful to allow accurate assessment for overall post-operative mortality/morbidity of in-hospital stay. Finally, the authors conclude that assessment of risk should be based solely on the ASA scoring grade and COPD. However, during the article, the authors mention ASA scoring grade several times as an independent significant predictor for mortality that is found in other studies [11e13]. Serejo et al. [14] reported a 4.5% prevalence of COPD compared to the 16% in this study which indicates demographic variation. The authors, Wilson et al. [1], stated that the ASA grade was too simple and subjective. Whilst we appreciate its easy use at the bedside, the results obtained between the relationships of high ASA scoring grade vs in-hospital mortality were inconclusive as recorded in Table 2 [1]. Of the patients who died in hospital, 67.1% had an ASA grade of 2e3, compared to the remaining 32.9% of patients who were graded ASA 4e5. With regards to COPD, it is difficult to judge which complication is more prevalent in a population, unless extensive studies are performed by groups of tertiary centres in their regional trusts. Furthermore, in a larger study conducted by Leung et al. [15], 544 patients aged >70yrs old were analysed for major post-operative adverse outcomes undergoing non-cardiac surgery. Here, they
Letter to the Editor / International Journal of Surgery 13 (2015) 304e305
established that the leading cause of adverse outcomes were cardiovascular complications (10.3%), neurological (7.7%) and pulmonary complications (5.5%). It is also worth noting the prevalence of heart failure where Kupari et al. [16] noted this as 8.2% in the octogenarians and this would be a useful variable to measure as a predictor of risk in the context of DNR. We also feel that the authors failed to include a number of confounding factors into their analyses, including body mass index (BMI), smoking status, previous DVT/PE and asthma. Some of these variables such as BMI and asthma have already been studied, showing a positive risk relationship to in-hospital mortality [14]. In conclusion, although the authors are to be praised for their research, further studies spanning their cohort of octogenarians across various tertiary centres are required, including data on DNR status and secondary end-points to follow-up of patients with consecutive re-operations. ASA grade is a useful tool for quick pre-operative risk stratification. Our suggestion would be to consider the use of ASA scoring grade alongside DNR vs non-DNR status information, a known respiratory complication (i.e. asthma/COPD status) and a known cardiac complication (i.e. heart failure status). Ultimately, further research in this area is needed to better predict the in-hospital mortality amongst octogenarians undergoing emergency general surgery. Ethical approval None required. Funding None.
[2] [3]
[4] [5] [6]
[7]
[8] [9]
[10]
[11] [12]
[13]
[14]
[15]
[16]
Author contribution
305
retrospective cohort study, Int. J. Surg. (2014) 1e5, http://dx.doi.org/ 10.1016/j.ijsu.2014.08.404 pii: S1743-9191(14)00889-9. K. Nishida, K. Okinaga, Y. Miyazawa, et al., Emergency abdominal surgery in patients aged 80 years and older, Jpn. J. Surg. 30 (2000) 22e27. A.M. Malik, A. Khan, K.A.H. Talpur, A.A. Laghari, Factors influencing morbidity and mortality in elderly population undergoing inguinal hernia surgery, J. Pak. Med. Assoc. 60 (1) (2010) 45e47. P. Svenningsen, T. Manoharan, N.B. Foss, et al., Increased mortality in the elderly after emergency abdominal surgery, Dan. Med. J. 61 (7) (2014) 1e4. E. Leung, K. McArdle, L.S. Wong, Risk-adjusted scoring systems in colorectal surgery, Int. J. Surg. 9 (2) (2011) 130e135. J.E. Scarborough, T.N. Pappas, The effect of do-not-resuscitate status on postoperative mortality in the elderly following emergency surgery, Adv. Surg. 47 (2013) 213e225. S.D. Adams, B.A. Cotton, C.E. Wade, et al., Do not resuscitate status, not age, affects outcomes after injury: an evaluation of 15,227 consecutive trauma patients, J. Trauma Acute Care Surg. 74 (5) (2013) 1327e1330. General Medical Council, Treatment and Care towards the End of Life: Good Practice in Decision Making, Good Medical Council, July 2010. P.J. Speicher, S.A. Lagoo-Deenadayalan, A.N. Galanos, T.N. Pappas, J.E. Scarborough, Expectations and outcomes in geriatric patients with donot-resuscitate orders undergoing emergency surgical management of bowel obstruction, JAMA Surg. 148 (1) (2013) 23e28. O.A. Guevara, J.A. Rubio-Romero, Al Ruiz-Parra, Unplanned reoperations: is emergency surgery a risk factor? A cohort study, J. Surg. Res. 182 (1) (2013) 11e16. I.J. Arenal, M. Bengoechea-Beeby, Mortality associated with emergency abdominal surgery in the elderly, Can. J. Surg. 46 (2) (2003) 111e116. D. Griner, A. Adams, C.A. Kotwall, et al., After-hours urgent and emergent surgery in the elderly: outcomes and prognostic factors, Am. Surg. 77 (8) (2011) 1021e1024. I. Rubinfeld, C. Thomas, S. Berry, et al., Octogenarian abdominal surgical emergencies: not so grim a problem with the acute care surgery model? J. Trauma 67 (5) (2009) 983e989. L.G.G. Serejo, FPd Silva-Junior, J.P.C. Bastos, et al., Risk factors for pulmonary complications after emergency abdominal surgery, Respir. Med. 101 (2007) 808e813. J.M. Leung, S. Dzankic, Relative importance of preoperative health status versus intraoperative factors in predicting postoperative adverse outcomes in geriatric surgical patients, J. Am. Geriatr. Soc. 49 (8) (2001) 1080e1085. M. Kupari, M. Lindroos, A.M. Iivanainen, et al., Congestive heart failure in old age: prevalence, mechanisms and 4-year prognosis in the Helskinki Ageing study, J. Intern Med. 241 (5) (1997) 387e394.
MOA drafted the final manuscript. YAO reviewed for logical reasoning of the final draft. AA revised it critically for important intellectual content.
Mohammed Omer Anwar*, Yasser Al Omran Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
Guarantor
Abdullatif Aydın MRC Centre for Transplantation, King's College London, King's Health Partners, London, United Kingdom
None. Conflicts of interest None. References [1] I.A.N. Wilson, M.P. Barrett, A. Sinha, S. Chan, Predictors of in-hospital mortality amongst octogenarians undergoing emergency general surgery: a
*
Corresponding author. Barts and the London School of Medicine and Dentistry, Garrod Building, Turner Street, Whitechapel, London SE1 9RT, United Kingdom. E-mail address: [email protected] (M.O. Anwar). 12 November 2014 Available online 19 December 2014
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Letter to the Editor
Correspondence to: “Predictors of in-hospital mortality amongst octogenarians undergoing emergency general surgery: A retrospective cohort study” Keywords: Emergency Surgery Mortality Morbidity DNR ASA Cardiovascular Pulmonary Risk
Dear Editor, We read the article written by Wilson et al. [1], with great interest. There have been various studies in the literature focusing on predictors of risk for emergency surgery in the geriatric population [2e4]. In this article, the authors collected data on patient demographics, post-operative morbidity and the relationship between the American Society of Anesthesiologists (ASA) scoring grade and in-hospital mortality. The ASA scoring grade is a useful, quick and easy tool to assess the emergency patient before operative intervention [5]. From a range of univariate analyses, the authors conclude that COPD was a significant risk predictor and should be used alongside the ASA scoring grade. The research performed here was useful in analysing statistically significant independent risk predictors, so the authors are applauded for their contribution. However, before their conclusion is universally accepted, we believe there ought to be several clarifications. Firstly, it is well known that an existing do not resuscitate (DNR) status of a patient pre-operatively is a significant risk factor for post-operative mortality and morbidity within a 30-day period [6,7]. The authors did not reflect on any statistics showing what proportion of their patient cohort had a known DNR status. Although there may be inconsistent implementation or meaning across hospitals of what comprises a DNR status, the UK General Medical Council guidelines state that it is when the risks of treatment after cardiopulmonary resuscitation (CPR) outweigh the clinical benefit and when ‘cardiac or respiratory arrest is an expected part of the dying process’ in an individual [8]. Scarborough et al. [6] compared the mortality risk of 25,558 elderly patients above the age of 65 and undergoing emergency surgery. They were divided per cohort of DNR (4.3%) and non-DNR (95.7%) patients. Although the pre-operative and intraoperative variables in both DOI of original article: http://dx.doi.org/10.1016/j.ijsu.2014.08.404. http://dx.doi.org/10.1016/j.ijsu.2014.11.055 1743-9191/© 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
cohorts were controlled, the post-operative mortality rate was significantly higher in DNR vs non-DNR patients (36.9% vs 22.3% respectively, p < 0.0001), despite similar post-operative complication rates. Whilst age may not necessarily be an independent predictor for the classification of DNR patients, studies have shown that DNR is likely to occur with increased age [7]; therefore there may be a higher number of DNR patients amongst octogenarians, as in this article by Wilson et al. [1]. Thus, having a higher proportion of potential DNR patients within this population age group is likely to place them at a higher mortality risk, which may affect management of the patient. Studies have also attempted to give plausible reasons for the excess mortality rates in DNR patients, suggesting decreased willingness of the patient to pursue aggressive treatment following major post-operative complications or refusal of surgeon to admit these patients into theatre [6,9]. Secondly, patients who are operated in emergency conditions have a much higher chance of further unplanned re-operations. A prospective study by Guevara et al. [10] showed a 1.79 crude relative risk (RR) of re-operation on emergency patients. Also the RR of mortality following re-operations was 8.94 (95% CI, 6.11e13.07). The literature seems to also support “re-operations” as an independent entity for mortality risk. It would have been interesting to know whether the seven patients who were readmitted into surgery within 30 days of discharge, survived after the consecutive post-operative phase. Therefore, a follow-up on these patients would be useful to allow accurate assessment for overall post-operative mortality/morbidity of in-hospital stay. Finally, the authors conclude that assessment of risk should be based solely on the ASA scoring grade and COPD. However, during the article, the authors mention ASA scoring grade several times as an independent significant predictor for mortality that is found in other studies [11e13]. Serejo et al. [14] reported a 4.5% prevalence of COPD compared to the 16% in this study which indicates demographic variation. The authors, Wilson et al. [1], stated that the ASA grade was too simple and subjective. Whilst we appreciate its easy use at the bedside, the results obtained between the relationships of high ASA scoring grade vs in-hospital mortality were inconclusive as recorded in Table 2 [1]. Of the patients who died in hospital, 67.1% had an ASA grade of 2e3, compared to the remaining 32.9% of patients who were graded ASA 4e5. With regards to COPD, it is difficult to judge which complication is more prevalent in a population, unless extensive studies are performed by groups of tertiary centres in their regional trusts. Furthermore, in a larger study conducted by Leung et al. [15], 544 patients aged >70yrs old were analysed for major post-operative adverse outcomes undergoing non-cardiac surgery. Here, they
Letter to the Editor / International Journal of Surgery 13 (2015) 304e305
established that the leading cause of adverse outcomes were cardiovascular complications (10.3%), neurological (7.7%) and pulmonary complications (5.5%). It is also worth noting the prevalence of heart failure where Kupari et al. [16] noted this as 8.2% in the octogenarians and this would be a useful variable to measure as a predictor of risk in the context of DNR. We also feel that the authors failed to include a number of confounding factors into their analyses, including body mass index (BMI), smoking status, previous DVT/PE and asthma. Some of these variables such as BMI and asthma have already been studied, showing a positive risk relationship to in-hospital mortality [14]. In conclusion, although the authors are to be praised for their research, further studies spanning their cohort of octogenarians across various tertiary centres are required, including data on DNR status and secondary end-points to follow-up of patients with consecutive re-operations. ASA grade is a useful tool for quick pre-operative risk stratification. Our suggestion would be to consider the use of ASA scoring grade alongside DNR vs non-DNR status information, a known respiratory complication (i.e. asthma/COPD status) and a known cardiac complication (i.e. heart failure status). Ultimately, further research in this area is needed to better predict the in-hospital mortality amongst octogenarians undergoing emergency general surgery. Ethical approval None required. Funding None.
[2] [3]
[4] [5] [6]
[7]
[8] [9]
[10]
[11] [12]
[13]
[14]
[15]
[16]
Author contribution
305
retrospective cohort study, Int. J. Surg. (2014) 1e5, http://dx.doi.org/ 10.1016/j.ijsu.2014.08.404 pii: S1743-9191(14)00889-9. K. Nishida, K. Okinaga, Y. Miyazawa, et al., Emergency abdominal surgery in patients aged 80 years and older, Jpn. J. Surg. 30 (2000) 22e27. A.M. Malik, A. Khan, K.A.H. Talpur, A.A. Laghari, Factors influencing morbidity and mortality in elderly population undergoing inguinal hernia surgery, J. Pak. Med. Assoc. 60 (1) (2010) 45e47. P. Svenningsen, T. Manoharan, N.B. Foss, et al., Increased mortality in the elderly after emergency abdominal surgery, Dan. Med. J. 61 (7) (2014) 1e4. E. Leung, K. McArdle, L.S. Wong, Risk-adjusted scoring systems in colorectal surgery, Int. J. Surg. 9 (2) (2011) 130e135. J.E. Scarborough, T.N. Pappas, The effect of do-not-resuscitate status on postoperative mortality in the elderly following emergency surgery, Adv. Surg. 47 (2013) 213e225. S.D. Adams, B.A. Cotton, C.E. Wade, et al., Do not resuscitate status, not age, affects outcomes after injury: an evaluation of 15,227 consecutive trauma patients, J. Trauma Acute Care Surg. 74 (5) (2013) 1327e1330. General Medical Council, Treatment and Care towards the End of Life: Good Practice in Decision Making, Good Medical Council, July 2010. P.J. Speicher, S.A. Lagoo-Deenadayalan, A.N. Galanos, T.N. Pappas, J.E. Scarborough, Expectations and outcomes in geriatric patients with donot-resuscitate orders undergoing emergency surgical management of bowel obstruction, JAMA Surg. 148 (1) (2013) 23e28. O.A. Guevara, J.A. Rubio-Romero, Al Ruiz-Parra, Unplanned reoperations: is emergency surgery a risk factor? A cohort study, J. Surg. Res. 182 (1) (2013) 11e16. I.J. Arenal, M. Bengoechea-Beeby, Mortality associated with emergency abdominal surgery in the elderly, Can. J. Surg. 46 (2) (2003) 111e116. D. Griner, A. Adams, C.A. Kotwall, et al., After-hours urgent and emergent surgery in the elderly: outcomes and prognostic factors, Am. Surg. 77 (8) (2011) 1021e1024. I. Rubinfeld, C. Thomas, S. Berry, et al., Octogenarian abdominal surgical emergencies: not so grim a problem with the acute care surgery model? J. Trauma 67 (5) (2009) 983e989. L.G.G. Serejo, FPd Silva-Junior, J.P.C. Bastos, et al., Risk factors for pulmonary complications after emergency abdominal surgery, Respir. Med. 101 (2007) 808e813. J.M. Leung, S. Dzankic, Relative importance of preoperative health status versus intraoperative factors in predicting postoperative adverse outcomes in geriatric surgical patients, J. Am. Geriatr. Soc. 49 (8) (2001) 1080e1085. M. Kupari, M. Lindroos, A.M. Iivanainen, et al., Congestive heart failure in old age: prevalence, mechanisms and 4-year prognosis in the Helskinki Ageing study, J. Intern Med. 241 (5) (1997) 387e394.
MOA drafted the final manuscript. YAO reviewed for logical reasoning of the final draft. AA revised it critically for important intellectual content.
Mohammed Omer Anwar*, Yasser Al Omran Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
Guarantor
Abdullatif Aydın MRC Centre for Transplantation, King's College London, King's Health Partners, London, United Kingdom
None. Conflicts of interest None. References [1] I.A.N. Wilson, M.P. Barrett, A. Sinha, S. Chan, Predictors of in-hospital mortality amongst octogenarians undergoing emergency general surgery: a
*
Corresponding author. Barts and the London School of Medicine and Dentistry, Garrod Building, Turner Street, Whitechapel, London SE1 9RT, United Kingdom. E-mail address: [email protected] (M.O. Anwar). 12 November 2014 Available online 19 December 2014
