- Email: [email protected]
Reply to: “Correspondence to: Predictors of in-hospital mortality amongst octogenarians undergoing emergency general surgery: A retrospective cohort study”
International Journal of Surgery 13 (2015) 306e307
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Letter to the Editor
Reply to: “Correspondence to: Predictors of in-hospital mortality amongst octogenarians undergoing emergency general surgery: A retrospective cohort study” Keywords: Emergency General surgery Mortality Octogenarian
We would like to thank the authors for their letter and we feel they raise some interesting points. We note the studies which show DNR status as a significant risk factor for post-operative mortality and morbidity [1,2]. DNR orders, in most cases, are implemented in individuals who are elderly and with multiple comorbidities. It follows that these patients present a high surgical risk. In practice the implementation of a DNR is based not only on physiological fitness but also on a complex interaction between emotional, cultural and institutional factors. These factors can be highly subjective and unquantifiable, thus rendering DNR status less useful as an objective, reproducible risk factor. We do, however, think this raises a much larger issue of attitudes of surgeons towards DNR orders and the use of DNR orders in the elderly emergency surgical patient. We note the number of DNR patients in the papers you cite are very low [1,2]. Perhaps in these patients with high and predictable mortality, we should encourage that DNR status be discussed routinely with the patient and their relatives prior to surgery and the upper limit of care determined pre-operatively by the consultant surgeon and anaesthetist. In response to the second point, seven of our cohort returned to theatre within 30 days. Five of these patients died within 30 days of their initial operation. The remaining two were alive at 12 months. Return to theatre was predictive of mortality in the univariate analysis, but not in the multivariate analysis. Unscheduled return to theatre has been identified as a risk factor by previous studies and we acknowledge that our findings here may have been limited by the relatively small sample size. Your correspondents make an interesting point about the variables considered in our analysis. Multiple variables were considered and we selected those most frequently observed within our patient group. Additionally these are the factors which surgeons in our centre were considering when assessing individual fitness for surgery. Although we did not consider previous PE and DVT and smoking status we did consider warfarin use and COPD which could be considered as surrogate markers. We agree that body mass index (BMI) may have been an DOI of original article: http://dx.doi.org/10.1016/j.ijsu.2014.11.055. http://dx.doi.org/10.1016/j.ijsu.2014.12.018 1743-9191/© 2015 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
interesting factor to include in our analysis. Ageing and obesity are both common in Western populations and are set to increase substantially in the near future. The relationship between obesity and ageing and the outcomes of emergency surgery remains unclear. Some studies suggest that a raised BMI does not increase mortality in elective and emergency general surgical patients [3] while others have shown higher mortality and morbidity in patients aged over 65 years with a raised BMI [4]. There is however little doubt that the management of the obese elderly patient is an emerging surgical challenge. We hope that our study provides a useful contribution to this important area of research and we encourage further discussion in this area. Ethical approval None required. Funding None. Author contribution Iain Wilson e Principal author. Michael Barrett e Editor. Ashish Sinha e Editor. Shirley Chan e Senior author. Conflicts of interest None.
References [1] 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. [2] 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. [3] J.T. Mullen, D.W. Moorman, D.L. Davenport, The obesity paradox. Body mass index and outcomes in patients undergoing nonbariatric general surgery, Ann. Surg. 250 (1) (2009) 166e172. [4] F.J. Yanque, J.M. Clements, D. Grauf, A.M. Merchant, Synergistic effect of age and body mass index on mortality and morbidity in general surgery, J. Surg. Res. 184 (1) (2013) 89e100.
Letter to the Editor / International Journal of Surgery 13 (2015) 306e307
Iain Wilson, Michael Barrett, Ashish Sinha, Shirley Chan* Department of General Surgery, Medway Maritime Hospital, Windmill Rd, Gillingham, Kent, ME7 5NY, UK *
Corresponding author.
307
E-mail address: [email protected] (S. Chan). 8 December 2014 Available online 3 January 2015
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Letter to the Editor
Reply to: “Correspondence to: Predictors of in-hospital mortality amongst octogenarians undergoing emergency general surgery: A retrospective cohort study” Keywords: Emergency General surgery Mortality Octogenarian
We would like to thank the authors for their letter and we feel they raise some interesting points. We note the studies which show DNR status as a significant risk factor for post-operative mortality and morbidity [1,2]. DNR orders, in most cases, are implemented in individuals who are elderly and with multiple comorbidities. It follows that these patients present a high surgical risk. In practice the implementation of a DNR is based not only on physiological fitness but also on a complex interaction between emotional, cultural and institutional factors. These factors can be highly subjective and unquantifiable, thus rendering DNR status less useful as an objective, reproducible risk factor. We do, however, think this raises a much larger issue of attitudes of surgeons towards DNR orders and the use of DNR orders in the elderly emergency surgical patient. We note the number of DNR patients in the papers you cite are very low [1,2]. Perhaps in these patients with high and predictable mortality, we should encourage that DNR status be discussed routinely with the patient and their relatives prior to surgery and the upper limit of care determined pre-operatively by the consultant surgeon and anaesthetist. In response to the second point, seven of our cohort returned to theatre within 30 days. Five of these patients died within 30 days of their initial operation. The remaining two were alive at 12 months. Return to theatre was predictive of mortality in the univariate analysis, but not in the multivariate analysis. Unscheduled return to theatre has been identified as a risk factor by previous studies and we acknowledge that our findings here may have been limited by the relatively small sample size. Your correspondents make an interesting point about the variables considered in our analysis. Multiple variables were considered and we selected those most frequently observed within our patient group. Additionally these are the factors which surgeons in our centre were considering when assessing individual fitness for surgery. Although we did not consider previous PE and DVT and smoking status we did consider warfarin use and COPD which could be considered as surrogate markers. We agree that body mass index (BMI) may have been an DOI of original article: http://dx.doi.org/10.1016/j.ijsu.2014.11.055. http://dx.doi.org/10.1016/j.ijsu.2014.12.018 1743-9191/© 2015 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
interesting factor to include in our analysis. Ageing and obesity are both common in Western populations and are set to increase substantially in the near future. The relationship between obesity and ageing and the outcomes of emergency surgery remains unclear. Some studies suggest that a raised BMI does not increase mortality in elective and emergency general surgical patients [3] while others have shown higher mortality and morbidity in patients aged over 65 years with a raised BMI [4]. There is however little doubt that the management of the obese elderly patient is an emerging surgical challenge. We hope that our study provides a useful contribution to this important area of research and we encourage further discussion in this area. Ethical approval None required. Funding None. Author contribution Iain Wilson e Principal author. Michael Barrett e Editor. Ashish Sinha e Editor. Shirley Chan e Senior author. Conflicts of interest None.
References [1] 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. [2] 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. [3] J.T. Mullen, D.W. Moorman, D.L. Davenport, The obesity paradox. Body mass index and outcomes in patients undergoing nonbariatric general surgery, Ann. Surg. 250 (1) (2009) 166e172. [4] F.J. Yanque, J.M. Clements, D. Grauf, A.M. Merchant, Synergistic effect of age and body mass index on mortality and morbidity in general surgery, J. Surg. Res. 184 (1) (2013) 89e100.
Letter to the Editor / International Journal of Surgery 13 (2015) 306e307
Iain Wilson, Michael Barrett, Ashish Sinha, Shirley Chan* Department of General Surgery, Medway Maritime Hospital, Windmill Rd, Gillingham, Kent, ME7 5NY, UK *
Corresponding author.
307
E-mail address: [email protected] (S. Chan). 8 December 2014 Available online 3 January 2015