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Improving outcomes in elective surgery
S22
J O U RN A L OF GE RI A T RI C O NC OL O G Y 3 ( 2 01 2 ) S 1 0 –S2 5
As an example, there is no doubt that a 92-year old demented patient with prostate carcinoma, tongue carcinoma, hairy cell leukemia, and who is incapable of communicating and eating by himself, with no advanced directives would be considered frail; however, what if the family requests surgery? radiation therapy? chemotherapy? immunotherapy? Should the patient be denied modern therapeutic means on the basis of its obvious frailty? The question here remains unanswered. 1
Not all the biographies were available at time of printing.
doi:10.1016/j.jgo.2012.10.163
F29 Improving outcomes in elective surgery1 J.K. Dhesi. Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK With changes in demographics, in surgical and anaesthetic techniques and in patient expectations, increasing numbers of older people are undergoing elective surgery. Although it is well established that this group has much to gain in terms of morbidity and mortality, it is also recognised that older people remain more likely to ‘fail the pre-assessment’ (not have surgery) than younger people, and furthermore those who do have surgery have higher rates of post-operative complications. From a geriatrician's perspective, opportunities to improve outcomes after elective surgery are being missed. First, at the pre-assessment stage; the prevalent model is for the patient to be assessed by a surgical nurse or doctor, with no specific expertise in optimising the patient. This occurs despite the wealth of evidence demonstrating improved outcomes if comorbidities (such as anaemia, cardiac disease, respiratory disease, diabetes etc.) are appropriately assessed and treated. Second at the peri-operative stage, the anaesthetist sees the patient on the day of surgery, with limited information from the pre-assessment clinic, and is less likely to adjust peri-operative care to improve outcome in older patients. Third, at the postoperative stage, medical care is provided by junior surgical staff, with advice from on-call teams, lacking in expertise in management of older people with multiple comorbidities. Proactive care of older people undergoing surgery (POPS) provides an alternative model, with an elderly care team involved throughout the surgical journey. In this talk I will expand on this model and describe some of the interventions and benefits. 1
Methods: A perioperative protocol based on fast-track surgery principles and techincal modifications of the surgical techinque was applied to bladder cancer patient candidates for etherotopic bladder substitution. Our protocol included pre-, intra-, and post-operative interventions. The technical variations of the modified Indiana Pouch tecnique were focused on the intestinal anastomosis to restore bowel continuity, the ureterocolonic anastomoses, and the capacity of the reservoir. Results: From 2003 and 2010, 68 consecutive patients partecipated in the study. Two patients died due to surgical complications (2.9%). Overall, 24 of 68 patients experienced complications (35.3%). Surgery was needed under general anaesthesia for 7 patients (10.2%) and under local anaesthesia for 4 (5.9%). Medical complications were encountered in 13 of 68 patients (19.1%). According to Clavien grading, complications were grade 5 in 2 patients, grade 4 in 2 patients, grade 3b in 5 patients, grade 3a in 4 patients, grade 2 in 9 patients and grade 1b in 2 patients (see Table 1). A limitation of our series is that patients were recruited at a single urologic centre and were operated by a single surgeon. Findings need validation. Conclusions: Progress in the perioperative management of major surgery and technical refinements can contribute to reduced complications. In addition, the use of objective reporting tools will facilitate comparison of studies.
Table 1 Postoperative complications.
Not all the biographies were available at time of printing.
doi:10.1016/j.jgo.2012.10.164 1
Major surgical: pts n°
Clavien grade pts n°
Death 2 Dehiscence intestinal anastomosis 1 Jejunal cannula displacement 1 Uretero-colonic anastomosis stricture 1 Ureteral stone 1 Afferent ileal limb re-alignment 1
V2 III b 5
Minor surgical: Wound dehiscence 3 Stoma mucosal prolapse 1
III a 4
Major medical Myocardial infarction 1 Sepsis 1
IV 2
Minor medical Cl. Difficilis colitis 2 Urinary infection 1 Delirium 4 Failure to thrive 2 Permanent catheter 2 Total 24
II 9
Id2 Total 24
Not all the biographies were available at time of printing.
Pelvic Malignancies in Older Patients doi:10.1016/j.jgo.2012.10.165 F30 Surgical excision and recontruction for bladdder cancer1 Massimo Maffezzini. Department of Urology, E.O. Ospedali Galliera, Genova, Italy Purpose of the study: The population of patients aged 75 years , or more, has increased in the last decades. As a consequence, an increase of age related diseases as cancer and chronic illnesses is currently observed. As an example, about 35% of patient candidates to radical cystectomy at presentation have one or more co-morbidities putting the patients at increased risk of peri-operative complications. Our purpose was to reduce the complications of radical cystectomy and intestinal urinary reconstruction for bladder cancer.
F31 Pelvic malignancies in older patients: New drugs in the elderly?1 H. Boyle. Medecine department, Centre Léon Bérard, 28 rue Laënnec 69008 Lyon, France Pelvic tumours occur frequently in the elderly. Several new drugs have been developed in the last few years. Among them, there are new hormonal therapies for prostate cancer such as abiraterone acetate and enzalutamide.1,2 There are also new chemotherapy drugs such as cabazitaxel in prostate cancer,3 vinflunine in bladder cancer,4,5 pegylated liposomal doxorubicin6–8 and trabectidin in
J O U RN A L OF GE RI A T RI C O NC OL O G Y 3 ( 2 01 2 ) S 1 0 –S2 5
As an example, there is no doubt that a 92-year old demented patient with prostate carcinoma, tongue carcinoma, hairy cell leukemia, and who is incapable of communicating and eating by himself, with no advanced directives would be considered frail; however, what if the family requests surgery? radiation therapy? chemotherapy? immunotherapy? Should the patient be denied modern therapeutic means on the basis of its obvious frailty? The question here remains unanswered. 1
Not all the biographies were available at time of printing.
doi:10.1016/j.jgo.2012.10.163
F29 Improving outcomes in elective surgery1 J.K. Dhesi. Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK With changes in demographics, in surgical and anaesthetic techniques and in patient expectations, increasing numbers of older people are undergoing elective surgery. Although it is well established that this group has much to gain in terms of morbidity and mortality, it is also recognised that older people remain more likely to ‘fail the pre-assessment’ (not have surgery) than younger people, and furthermore those who do have surgery have higher rates of post-operative complications. From a geriatrician's perspective, opportunities to improve outcomes after elective surgery are being missed. First, at the pre-assessment stage; the prevalent model is for the patient to be assessed by a surgical nurse or doctor, with no specific expertise in optimising the patient. This occurs despite the wealth of evidence demonstrating improved outcomes if comorbidities (such as anaemia, cardiac disease, respiratory disease, diabetes etc.) are appropriately assessed and treated. Second at the peri-operative stage, the anaesthetist sees the patient on the day of surgery, with limited information from the pre-assessment clinic, and is less likely to adjust peri-operative care to improve outcome in older patients. Third, at the postoperative stage, medical care is provided by junior surgical staff, with advice from on-call teams, lacking in expertise in management of older people with multiple comorbidities. Proactive care of older people undergoing surgery (POPS) provides an alternative model, with an elderly care team involved throughout the surgical journey. In this talk I will expand on this model and describe some of the interventions and benefits. 1
Methods: A perioperative protocol based on fast-track surgery principles and techincal modifications of the surgical techinque was applied to bladder cancer patient candidates for etherotopic bladder substitution. Our protocol included pre-, intra-, and post-operative interventions. The technical variations of the modified Indiana Pouch tecnique were focused on the intestinal anastomosis to restore bowel continuity, the ureterocolonic anastomoses, and the capacity of the reservoir. Results: From 2003 and 2010, 68 consecutive patients partecipated in the study. Two patients died due to surgical complications (2.9%). Overall, 24 of 68 patients experienced complications (35.3%). Surgery was needed under general anaesthesia for 7 patients (10.2%) and under local anaesthesia for 4 (5.9%). Medical complications were encountered in 13 of 68 patients (19.1%). According to Clavien grading, complications were grade 5 in 2 patients, grade 4 in 2 patients, grade 3b in 5 patients, grade 3a in 4 patients, grade 2 in 9 patients and grade 1b in 2 patients (see Table 1). A limitation of our series is that patients were recruited at a single urologic centre and were operated by a single surgeon. Findings need validation. Conclusions: Progress in the perioperative management of major surgery and technical refinements can contribute to reduced complications. In addition, the use of objective reporting tools will facilitate comparison of studies.
Table 1 Postoperative complications.
Not all the biographies were available at time of printing.
doi:10.1016/j.jgo.2012.10.164 1
Major surgical: pts n°
Clavien grade pts n°
Death 2 Dehiscence intestinal anastomosis 1 Jejunal cannula displacement 1 Uretero-colonic anastomosis stricture 1 Ureteral stone 1 Afferent ileal limb re-alignment 1
V2 III b 5
Minor surgical: Wound dehiscence 3 Stoma mucosal prolapse 1
III a 4
Major medical Myocardial infarction 1 Sepsis 1
IV 2
Minor medical Cl. Difficilis colitis 2 Urinary infection 1 Delirium 4 Failure to thrive 2 Permanent catheter 2 Total 24
II 9
Id2 Total 24
Not all the biographies were available at time of printing.
Pelvic Malignancies in Older Patients doi:10.1016/j.jgo.2012.10.165 F30 Surgical excision and recontruction for bladdder cancer1 Massimo Maffezzini. Department of Urology, E.O. Ospedali Galliera, Genova, Italy Purpose of the study: The population of patients aged 75 years , or more, has increased in the last decades. As a consequence, an increase of age related diseases as cancer and chronic illnesses is currently observed. As an example, about 35% of patient candidates to radical cystectomy at presentation have one or more co-morbidities putting the patients at increased risk of peri-operative complications. Our purpose was to reduce the complications of radical cystectomy and intestinal urinary reconstruction for bladder cancer.
F31 Pelvic malignancies in older patients: New drugs in the elderly?1 H. Boyle. Medecine department, Centre Léon Bérard, 28 rue Laënnec 69008 Lyon, France Pelvic tumours occur frequently in the elderly. Several new drugs have been developed in the last few years. Among them, there are new hormonal therapies for prostate cancer such as abiraterone acetate and enzalutamide.1,2 There are also new chemotherapy drugs such as cabazitaxel in prostate cancer,3 vinflunine in bladder cancer,4,5 pegylated liposomal doxorubicin6–8 and trabectidin in