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Individual Components of Validated Screening Tools Predict Surgical Outcomes in a Geriatric Population
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ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS
cartilage. Dissection was then carried onto the cartilage itself and using a combination of bipolar energy (to reduce thermal spread) and endoscopic biopsy forceps, 30% of the circumference of the tracheal ring was resected. Care was taken to preserve the outer perichondrium. The specimen was sent for histological confirmation. Results: The operative time was less than 30 minutes. There were no intraoperative or post-operative complications. Histological evaluation using Trichrome stain demonstrated near total thickness excision of the tracheal cartilage layer, without the outer layer of perichondrium (Figure-1). Conclusions: Endoscopic segmental tracheal ring resection is a technically feasible procedure and can be performed with a standard therapeutic bronchoscope. Clinical Implications: This advanced tracheoplasty technique may be feasible in patients with benign tracheal stenosis who have failed more conventional endoscopic tracheoplasty. The addition of endobronchial ultrasound may add an additional layer of safety when performing this technique. Additional studies will be needed to study long-term outcomes. 24.18. Individual Components of Validated Screening Tools Predict Surgical Outcomes in a Geriatric Population. A. Kothari,1 T. Bretl,2 K. Block,2 T. L. Weigel1; 1University of Wisconsin School of Medicine and Public Health, Madison, WI; 2University of Wisconsin Hospitals and Clinics, Madison, WI Introduction: It has been estimated that by 2030 over 60% of the population will be over the age of 60, and as a result surgeons will more frequently be required to gauge the impact of surgery on older patients. No tool currently exists to easily allow surgeons to objectively quantify surgical risk in geriatric patients. In general medicine and family practice clinics, validated screening tools are used to predict a range of patient outcomes. They are lengthy and often require administration by a member of the clinical staff making them impractical in a high volume surgical setting. The Geriatric Depression Score and the NSI Nutritional Health Checklist are 15 and 10 question surveys, respectively. The goal of our prospective study was to determine if a single or combination of individual questions extracted from validated screens would have predictive value for surgical risk in geriatric patients with thoracic neoplasms. Methods: Patients 70 years old were recruited to participate in a prospective, IRB-approved study that involved the preoperative administration of a panel of eight validated functional and cognitive screening tests. As part of this panel, patients were given the Geriatric Depression Screen (GDS), Nutrition Screening Initiative Nutritional Health Checklist (NSI) and Mini Mental Status Exam (MMSE) in a preoperative clinic visit by a member of the surgical team trained in administration of the screening tools. Results: A total of 61 patients were analyzed and our accrual goal was met (19 with esophageal, 34 with lung, and 8 with metastatic lesions). Of patients entered into the study, thirty day and overall mortality was 1.6% (1/61) and 4.9% (3/61), respectively. The specific components of the MMSE did not show any significant relationships to any endpoints. The answer ‘‘Yes’’ to GDS question #2 (Have you dropped many of your activities and interests?) was positively correlated with having major complications post-operatively (CC .272, p 0.03). Patients who answered ‘‘Yes’’ to NSI question #1 (I have an illness or condition that made me change the kind or amount of food I eat.) or ‘‘Yes’’ to NSI question #9 (Without wanting to, I have lost or gained 10 lbs in the last 6 months.) were more likely to have extended length of stays than those who answered ‘No’ (NSI Q1: OR 3.59, p 0.03, 95% CI 1.16, 12.2; NSI Q9: OR 6.61, p 0.01, 95% CI 1.45, 48.1). Answering ‘‘Yes’’ to GDS Question #12 (Do you feel pretty worthless the way you are now?) increased the odds of discharge to a non-home location (OR 9.65, p 0.06, 95% CI 0.85, 110.2). Conclusions: Our data indicate that an abbreviated, rapid pre-surgical assessment can be developed for evaluating geriatric patients with thoracic malignancies using individual questions from previously validated screening tools. Using a combination of questions derived from the NSI Checklist and GDS can allow a member of the surgical team to estimate operative risk, length of stay and discharge destination enabling patients and
physicians to make more informed treatment choices. The questions identified by our study also suggest the importance of patient mindset (GDS Question 12), sudden life changes (GDS Question 2, NSI Question 1), and health changes (NSI Question 9) on post-operative outcomes. These results suggest the possibility of developing a simple, succinct set of questions which combines these considerations to use as a first-line risk stratification tool. Future study will focus on novel pre-operative screens that encourage use in high paced surgical settings. 24.19. Outcomes of Thoracoscopic Anatomic Resections in Patients with Limited Pulmonary Reserve. S. Kachare, T. Demmy, C. Nwogu, S. Yendamuri; State University of New York, Buffalo, NY Background: Preoperative pulmonary function tests are used to assess the operability of patients for either a lobectomy or pneumonectomy. Current guidelines for defining high risk patients (for thoracic surgery) based on these tests were developed in the era of open thoracotomy. We studied the outcomes of such high risk patients after Video-Assisted Thoracoscopic Surgery (VATS) resections to assess the performance of these guidelines. Methods: This is a single center, retrospective study to assess the post-operative mortality and morbidity of patients with limited pulmonary function who underwent lung resection surgery. The study looked at 59 patients (lobectomies ¼ 56; pneumonectomies ¼ 3) from 2001-2009 with either a predicted postoperative FEV1 (ppoFEV1) <40% and/or a predicted postoperative DLCO (ppoDLCO) < 40%. In these patients a combination of clinical assessment, split lung function
ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS
cartilage. Dissection was then carried onto the cartilage itself and using a combination of bipolar energy (to reduce thermal spread) and endoscopic biopsy forceps, 30% of the circumference of the tracheal ring was resected. Care was taken to preserve the outer perichondrium. The specimen was sent for histological confirmation. Results: The operative time was less than 30 minutes. There were no intraoperative or post-operative complications. Histological evaluation using Trichrome stain demonstrated near total thickness excision of the tracheal cartilage layer, without the outer layer of perichondrium (Figure-1). Conclusions: Endoscopic segmental tracheal ring resection is a technically feasible procedure and can be performed with a standard therapeutic bronchoscope. Clinical Implications: This advanced tracheoplasty technique may be feasible in patients with benign tracheal stenosis who have failed more conventional endoscopic tracheoplasty. The addition of endobronchial ultrasound may add an additional layer of safety when performing this technique. Additional studies will be needed to study long-term outcomes. 24.18. Individual Components of Validated Screening Tools Predict Surgical Outcomes in a Geriatric Population. A. Kothari,1 T. Bretl,2 K. Block,2 T. L. Weigel1; 1University of Wisconsin School of Medicine and Public Health, Madison, WI; 2University of Wisconsin Hospitals and Clinics, Madison, WI Introduction: It has been estimated that by 2030 over 60% of the population will be over the age of 60, and as a result surgeons will more frequently be required to gauge the impact of surgery on older patients. No tool currently exists to easily allow surgeons to objectively quantify surgical risk in geriatric patients. In general medicine and family practice clinics, validated screening tools are used to predict a range of patient outcomes. They are lengthy and often require administration by a member of the clinical staff making them impractical in a high volume surgical setting. The Geriatric Depression Score and the NSI Nutritional Health Checklist are 15 and 10 question surveys, respectively. The goal of our prospective study was to determine if a single or combination of individual questions extracted from validated screens would have predictive value for surgical risk in geriatric patients with thoracic neoplasms. Methods: Patients 70 years old were recruited to participate in a prospective, IRB-approved study that involved the preoperative administration of a panel of eight validated functional and cognitive screening tests. As part of this panel, patients were given the Geriatric Depression Screen (GDS), Nutrition Screening Initiative Nutritional Health Checklist (NSI) and Mini Mental Status Exam (MMSE) in a preoperative clinic visit by a member of the surgical team trained in administration of the screening tools. Results: A total of 61 patients were analyzed and our accrual goal was met (19 with esophageal, 34 with lung, and 8 with metastatic lesions). Of patients entered into the study, thirty day and overall mortality was 1.6% (1/61) and 4.9% (3/61), respectively. The specific components of the MMSE did not show any significant relationships to any endpoints. The answer ‘‘Yes’’ to GDS question #2 (Have you dropped many of your activities and interests?) was positively correlated with having major complications post-operatively (CC .272, p 0.03). Patients who answered ‘‘Yes’’ to NSI question #1 (I have an illness or condition that made me change the kind or amount of food I eat.) or ‘‘Yes’’ to NSI question #9 (Without wanting to, I have lost or gained 10 lbs in the last 6 months.) were more likely to have extended length of stays than those who answered ‘No’ (NSI Q1: OR 3.59, p 0.03, 95% CI 1.16, 12.2; NSI Q9: OR 6.61, p 0.01, 95% CI 1.45, 48.1). Answering ‘‘Yes’’ to GDS Question #12 (Do you feel pretty worthless the way you are now?) increased the odds of discharge to a non-home location (OR 9.65, p 0.06, 95% CI 0.85, 110.2). Conclusions: Our data indicate that an abbreviated, rapid pre-surgical assessment can be developed for evaluating geriatric patients with thoracic malignancies using individual questions from previously validated screening tools. Using a combination of questions derived from the NSI Checklist and GDS can allow a member of the surgical team to estimate operative risk, length of stay and discharge destination enabling patients and
physicians to make more informed treatment choices. The questions identified by our study also suggest the importance of patient mindset (GDS Question 12), sudden life changes (GDS Question 2, NSI Question 1), and health changes (NSI Question 9) on post-operative outcomes. These results suggest the possibility of developing a simple, succinct set of questions which combines these considerations to use as a first-line risk stratification tool. Future study will focus on novel pre-operative screens that encourage use in high paced surgical settings. 24.19. Outcomes of Thoracoscopic Anatomic Resections in Patients with Limited Pulmonary Reserve. S. Kachare, T. Demmy, C. Nwogu, S. Yendamuri; State University of New York, Buffalo, NY Background: Preoperative pulmonary function tests are used to assess the operability of patients for either a lobectomy or pneumonectomy. Current guidelines for defining high risk patients (for thoracic surgery) based on these tests were developed in the era of open thoracotomy. We studied the outcomes of such high risk patients after Video-Assisted Thoracoscopic Surgery (VATS) resections to assess the performance of these guidelines. Methods: This is a single center, retrospective study to assess the post-operative mortality and morbidity of patients with limited pulmonary function who underwent lung resection surgery. The study looked at 59 patients (lobectomies ¼ 56; pneumonectomies ¼ 3) from 2001-2009 with either a predicted postoperative FEV1 (ppoFEV1) <40% and/or a predicted postoperative DLCO (ppoDLCO) < 40%. In these patients a combination of clinical assessment, split lung function