Eightfold higher odds for mortality with high-risk emergency GI surgery in older adults
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Key takeaways:
- High-risk surgery had an eightfold increase in odds for death and a fourfold increase in odds for postoperative complications.
- Procedure risk had a threefold greater impact on complications than frailty status.
Although both patient frailty and type of procedure affected outcomes among adults older than 65 years undergoing emergency surgery, the level of procedure risk had a stronger link to adverse outcomes, according to researchers.
“We are seeing a lot more elderly patients in the emergency department with acute surgical problems that require a major operation,” study co-author Raul Coimbra, MD, PhD, FACS, surgeon-in-chief at Riverside University Health System and professor of surgery at Loma Linda University School of Medicine, said in a related American College of Surgeons press release. “And the outcomes for these individuals, compared to younger patients, are much worse.
“We need to counsel patients and their families about all the risks they are incurring when patients undergo a major emergency operation and be transparent about what to expect afterwards.”
In a retrospective cohort study published in Journal of the American College of Surgeons, Coimbra and colleagues used ACS’s National Surgical Quality Improvement Project database to define risk factors associated with adverse outcomes among 59,633 patients older than 65 years (mean age, 75 years; 54.9% women) who underwent emergency general surgery between 2018 and 2020.
Researchers stratified patients as non-frail (29.3%), frail (66.4%) and severely frail (4.3%), according to the validated Modified 5 Item Frailty Index, and also grouped them by procedure risk. Low-risk procedures included laparoscopic and open appendectomy and laparoscopic cholecystectomy (n = 25,157), while open cholecystectomy, open colectomy, laparoscopic colectomy, small bowel resection, perforated ulcer repair, lysis of adhesions and laparotomy were considered high-risk (n = 34,476).
Studied outcomes included 30-day mortality and surgical complications, failure to rescue, 30-day reoperation and unplanned readmission.
Study results showed frailty and procedure risk were associated with increased mortality, postoperative complications, failure to rescue and readmissions, although procedure risk had a “stronger association with relevant outcomes” compared with frailty alone.
Key findings include:
- The mortality rate for non-frail patients who underwent high-risk surgery was 7.1% vs. 0.2% for low-risk surgery, while frail and severely frail patients had mortality rates of 11.5% and 25.8%, respectively, and 1% and 4.1%.
- High-risk surgeries accounted for a fourfold increase in surgical complications vs. low-risk surgeries among non-frail patients, with similar findings for frail (10.8%-40.3%) and severely frail (19.4%-53.8%) patients.
- Non-frail patients who experienced surgical complications had a significantly higher failure-to-rescue rate of 15.7% following high-risk surgery compared with a rate of 1.2% following low-risk surgery. High-risk procedures resulted in a more than fourfold increase in failure-to-rescue rates among frail (21.3% vs. 5%) and severely frail (37.4% vs. 11.5%) patients.
- High-risk surgeries accounted for a three- to fourfold increase in reoperation, regardless of frailty.
- Readmission rate after high-risk surgery was 8.9% among non-frail patients vs. 3.9% after low-risk procedures, with a nearly twofold increase in rate reported among frail patients (11% vs. 5.8%) and similar findings for severely frail patients.
According to multivariate logistic regression, the odds for mortality after a high-risk surgery were 8.38 higher vs. a low-risk procedure, while the odds for developing a surgical complication were 4.79 higher. Procedure risk had a threefold greater impact on the development of a surgical complication than frailty status, researchers reported.
“The message from our study is that elderly patients should undergo surgical treatment when they first present with their disease,” Coimbra said in the release. “It should not be put off until complications develop to the point where an emergency operation is needed, because that emergency operation is the most significant risk for mortality and complications.”
Reference:
- Type of surgery and its risk level has significant impact on complications and death in elderly patients. https://www.facs.org/for-medical-professionals/news-publications/news-and-articles/press-releases/2024/type-of-surgery-and-its-risk-level-has-significant-impact-on-complications-and-death-in-elderly-patients/. Published April 25, 2024. Accessed May 7, 2024.
Perspective
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Diya Alaedeen, MD, FACS
Patients’ hesitation to be seen in our busy ED or doctors’ offices may be because they do not want to wait for hours or days, they are afraid of what the diagnosis may be or they are worried about the financial burdens of health care.
As a result, there is a general delay in the diagnosis and treatment of many surgical issues, especially among older patients. When a delay causes these surgical issues to present as emergencies, the required operations are often more complex and come with higher risks.
This study’s findings of an eightfold increase in the odds of death and a fourfold increase in postoperative complications should not be surprising to acute care surgeons caring for these patients.
These results should encourage a strong advocacy for expedited diagnosis and earlier care for these emergency surgical issues, especially in severely frail patients, who the study authors report have a one in four chance of death with complex high-risk emergency GI operations.
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