Post on 13-Aug-2019
1
8/7/2014
Specific Problems in Surgery in the
Elderly
TAN Kok-Yang
MMed(Surg), FRCSE, FAMS
Head & Senior Consultant, Department of Surgery
Clinical Director, Geriatric Surgery Service
Khoo Teck Puat Hospital
KTPH Surgery. To deliver progressive and
collaborative surgical care with a passion for
safety and culture of compassion.
• Elderly population in Singapore growing
• 6.3% aged above 65 currently
• 25% by year 2030
(more than 1 million individuals)
Background
Problem with Elderly Surgical
Patients • High incidence of co-
morbidities
• Limited functional reserves
• Frequent acute surgical
problems resulting in
emergency situations
• Old Paris Hilton
Department of General Surgery
Physiological Issues in Elderly
Surgical Patients
Old Brad Pitt
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Ageing
• Declining physiologic reserves
• May not be adequate in acute illness or
surgical stress
Heart
• Reduced myocytes
• Increased collagen
• Decrease ventricular
compliance
• Autonomic tissue
changes
• Reduced max capacity
• ACS poorer outcomes
Respiratory
• Reduced chest wall
compliance
• Loss of elasticity and
collapse of small
airways
• Responses reduced
• Reduced protective
mechanism
• Prone to infection
Renal
• Capacity reduced
• Implications on
pharmacology
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8/7/2014
Others
• Nutrition
• Dementia
Significant heterogeneity not only in
physiologic alterations but also in
associated co-morbidity and life
expectancy
Problem of Risk Stratification
Department of Surgery
Khoo Teck Puat Hospital
Importance of Risk Stratification
• Building blocks to:
– Better decision making for
surgical indication and
planning
– Anticipatory perioperative
management
– Robust informed consent
Department of Surgery, Khoo Teck
Puat Hospital
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8/7/2014
Department of Surgery, Khoo Teck
Puat Hospital
What do we know on
Surgical Outcomes?
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8/7/2014
Factor Odds ratio 95% C.I. p
Elective operation 0.99
Tumour presenting with
complication
5.38 0.60 – 48.31 0.13
Cormorbid diabetes mellitus 4.41 0.66 – 29.42 0.12
Comorbid coronary artery disease 0.45 0.05 – 4.22 0.49
Comorbid heart failure 0.99
Preoperative haemoglobin 0.89 0.52 – 1.54 0.69
Preoperative serum albumin 1.26 0.38 – 4.26 0.70
Preoperative BUN 0.97 0.86 – 1.09 0.63
ASA score > 3 64.85 3.26 – 1290.92 0.01
Comorbidity index > 5 8.41 1.22 – 57.97 0.03
Surgical blood loss > 1000mls 13.58 1.01 – 181.76 0.05
Multivariate Analysis for Morbidity RiskConclusion
• Octogenarians undergoing major colorectal
resection have an acceptable perioperative
morbidity and mortality rate and survival rate
and should not be denied surgery based on
age alone.
• Comorbidity index scores and ASA scores are
useful tools to identify poor risk patients.
Quantification of comorbidities and
physiological status helps risks stratification
for surgery in a very heterogenous group of
patients
Department of Surgery, Khoo Teck
Puat Hospital
Quantification makeseasier comparisons
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8/7/2014
Tools for Pre-op Assessment
• ASA & Comorbidity index» Tan et al WJS 2006
» Tan et al Int J Colorectal Dis 2008
• POSSUM, CR-POSSUM
• Barthels functional status
• Conventional biochemical markers
• Alb
• Renal function
• FBC
ASA scoreASA Status Criteria
1 A normal healthy patient
2 A patient with mild systemic disease
3 A patient with severe systemic disease
4 A patient with severe systemic disease that is a
constant threat to life
5 A moribund patient who is note expected to
survive without the operation
6 A declared brain-dead patient whose organs are
being removed for donor purposes
Weighted Index of Comorbidity from Charlson Comorbidity Index
Condition Assigned Weight
Myocardial infarction 1
Congestive heart failure 1
Peripheral vascular disease 1
Cerebrovascular disease 1
Dementia 1
Chronic pulmonary disease 1
Connective tissue disease 1
Ulcer disease 1
Liver disease mild 1
Diabetes 1
Hemiplegia 2
Renal disease moderate or severe 2
Diabetes with end organ damage 2
Any malignancy 2
Leukemia 2
Malignant lymphoma 2
Liver disease. moderate or severe 3
Metastatic solid malignancy 6
AIDS 6
Physiological and Operative Severity
Score for the enUmeration of
Mortality and morbidity (POSSUM)
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Physiological Possum
1 2 4 8
Severity Score Minor Moderate (colectomies) Major (APR) Major +
Multiple
Procedures
1 2 >2
Blood Loss (mls) <100 101-500 501-999 >999
Contamination None Minor (serous) Local pus Free bowel content, pus or blood
Presence of Ca None Primary Nodal mets Distant mets
Mode of Surgery Elective Urgent Emergency (immediate <2hrs)
x = (0.16* physiologic score)+(0.19*operative score)-5.91Predicted Morbidity Rate = 1/(1+ e(-x))y = (0.13* physiologic score)+(0.16*operative score)-
7.04
Predicted Mortality Rate = 1/(1+ e(-y))
Operative Possum
Department of Surgery, Khoo Teck
Puat Hospital
One must have 3 or more of the following criteria to be frail
Male Female
Weight Loss Greater than 10lbs or 5% weight loss in the last year
15 foot Walk Time Height < 173
cm
>7 seconds Height < 159
cm
>7 seconds
Height >173 cm > 6 seconds Height >159 cm > 6 seconds
Grip Strength BMI < 24 < 29 BMI < 23 < 17
BMI 24.1 - 26 < 30 BMI 23.1 - 26 < 17.3
BMI 26.1 - 28 < 30 BMI 26.1 - 29 < 18
BMI > 28 < 32 BMI > 29 < 21
Physical Activity
(MLTA)
< 383 kcal / wk < 270 kcal / wk
Exhausation A score of 2 or 3 on either question on the CES-D*
*How often in the last week did you feel this way?
a) I felt that everything I did was an effort.
b) I could not get going.
0 = 1 day; 1 = 1–2 days; 2 = 3–4 days; 3 = more than 4 days
BMI = Body Mass Index;
MLTA = Minnesota Leisure Time Activity Questionnaire;
CES-D = Center for Epidemiologic Studies Depression Scale.
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M.R.C.P.Correlation with Major Complication
Risk 95% CI p
ASA > 3 1.048 0.323-3.400 0.938
WCIS > 5 1.424 0.426-4.759 0.564
Frail 3.467 1.113 – 10.795 <0.001
Major complication Yes No p
Mean Pred Mort 11.58 8.00 0.055
Department of General Surgery
Physical phenotype of frailty may reflect
reduced functional reserves and thus
intolerance to the trauma of major surgery
Health status at the time of
assessment
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8/7/2014
Department of Surgery, Khoo Teck
Puat Hospital
Assessment
Patient 2
Patient 1
Cancer
Patient 3
time
Health status
Treatment
Tan KY Ed. Colorectal Cancer in the Elderly, 2012
Retonaz et al in
Delivering Surgical Care to the Complex
Geriatric Patient
Comorbidity
FrailADL
dependent
• Identification of high risk patients
• Shift towards elective surgery
• Optimize comorbidities
through prehabilitation
• Transdisciplinary approach
• Attention to details
Getting Round These ProblemsTransdisciplinary Geriatric Surgery Service
• Surgeons
• Anaesthetists
• Geriatric Medicine Physicians
• Cardiologist
• Nurse Clinician
• Physiotherapist
• Dietitian
• Medical Social Worker
• Pharmacist
• Befriender
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DIETITIAN
SURGEON
PATIENT
Multidisciplinary Approach
Adhoc, uncoordinated care rendered to patients
not managed by Geriatric Surgery Service.
MSW PHYSIOTHERAPIST
ANAESTHETISTCARDIOLOGISTGERIATRICIAN
Department of Surgery, Khoo Teck
Puat Hospital
Dr. Tan Kok YangSurgeon Dr. Lawrence Tan
Geriatrician
Ms Adeline WeePharmacist
Dr. Naville ChiaAnaesthetist
WeilingBefriender
Tan Pei PeiMedical Social Worker
Dr. Edwin SeetAnaesthetist
Dr. Ong Hean YeeCardiologist
Amy VongDietitian
Dispenses of hierarchyHeightened communicationPatient-centricRole extension (improve one’s own discipline)
Role enrichment (understand other disciplines)Role expansion (interdisciplinary education)Role release (blurred boundaries)Role support (constant feedback and quality improvement)
Coordinated and less fragmented care
George TohDietitian
BarbaraPhysiotherapist
Phyllis TanNurse Clinician
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8/7/2014
Transdisciplinary Multi-level Risk Assessment Setting Goals
• Goals for Team
– Care plan
– Attention to details
• Goals for Patients
– Return of function
– Independence and QOL
vs Survival
Department of Surgery, Khoo Teck
Puat Hospital
OUTCOME STUDIES ON OLDER PATIENTS
UNDERGOING SURGERY ARE MISSING
THE MARK
Joyce Chee, Tan Kok Yang
Journal of American Geriatric
Society
JAGS Nov 2010; 58(11): 2238-40
GSS Step-wise Consenting Process
1• Consolidation of data of risk stratification and disease pathology
2• Patient education process on disease pathology
3• Transdisciplinary patient and family conference
4• Exploration of treatment goals in accordance to patient
5• Exploration of treatment options and setting treatment aims, risks and benefits
6• Obtain consensus on treatment strategy between patient, surgical team and family
7• Clear documentation of discussions
Department of Surgery, Khoo Teck
Puat Hospital
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8/7/2014
Components of Prehabilitation
• Education
• Optimisation of lung
function
• Mobilisation
• Muscle strengthening
• Nutrition
Prehabilitation
Selection Criteria
Prehabilitation Post Rehabilitation
Criteria Day
Rehabilitation
Centre
Home
Prehabilitation
Criteria Home
Rehabilitation
Inpatient
Rehabilitation
(AMKCH)
Charlson
Comorbidity
Index
>3 >3 Charlson
Comorbidity
Index
>3 >3
Frailty
Syndrome
Positive Positive Frailty
Syndrome
Positive Positive
Mobility Moderate Poor to
moderate
Peri-operative
complication(s)
requiring more
specific care
Negative Positive
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8/7/2014
Patient Education Materials
Prehab Education
Twice per week home visit
Barthels Index after 2 weeks
of prehabilitation :
71/100 from 65/100
Satisfied patient and family
reported overall improvement in functional
status.
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8/7/2014
Component Initial
Assessment
One Week after prehabilitation Two Weeks after
prehabilitation
Target
Education and
Compliance
Understand
disease and
indication for
surgery
Patient
understands
disease and
indication for
surgery
Yes � No � Patient
understands
disease and
indication for
surgery
Yes
�
No
�
Patient understands
disease and indication
for surgery
Knows what to
expect
Patient knows
what to expect
Yes � No � Patient knows
what to expect
Yes
�
No
�
Patient knows what to
expect
Preparation of
Operation
Patient knows
what to do
Yes � No � Patient knows
what to do
Yes
�
No
�
Patient knows what to
do
Weight Change
Current Weight: No Weight Loss � No Weight Loss � No Weight Loss Over
past 2 weeks
Weight Loss <5% � Weight Loss <5% �
Weight Loss >5�
Weight Loss >5�
Dietary Intake
Usual Intake: Achieved 100%
of dietary
requirement 5 in
7days
Yes � No � Achieved 100%
of dietary
requirement 5 in
7days
Yes
�
No
�
Achieved 100% of
dietary requirement 5
in 7days
050
100150200250300350400450500
Pre op 1st postop 2nd post op 3rd post op 4th post op 5th post op discharge
Dis
tan
ce (
m)
2/ 6MWT 2mwt 6mwt
05
101520253035404550
Fo
rce (
kg
)
Ankle Dorsiflexion ankle dorsiflexion Left
ankle dorsiflexion Right
02468
101214161820
no
. o
f re
ps
Chair riseChair rise
0
10
20
30
40
Pre op 1st postop 2nd post op 3rd post op 4th post op 5th post op discharge
Dis
tan
ce (
cm
)
Forward reachForward reach
0
5
10
15
20
Pre op 1st postop 2nd post op 3rd post op 4th post op 5th post op discharge
no
. o
f re
ps
Step Test Left step up Right step up
0
5
10
15
20
25
30
Pre op 1st postop 2nd post op 3rd post op 4th post op 5th post op discharge
Tim
e (
s)
TUG TUG
Department of Surgery, Khoo Teck
Puat Hospital
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8/7/2014
Intraoperative Care Planning
Anaesthesia
Hypothermia
Fluids
Tubes
Department of Surgery, Khoo Teck
Puat Hospital
01565605
Endoscopic Submucosal Dissection for Early Cancers
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8/7/2014
Postoperative
Department of Surgery, Khoo Teck
Puat Hospital
Post-operative
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8/7/2014
Early Mobilisation POD1 Anterior Resection and Partial
Cystectomy
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8/7/2014
Geriatric Surgery Service continue to provide home based rehabilitation after discharge to ensure preservation of functional state and quality of life as per premorbid.
Ability to perform self care with
minimal/no assistance.
Post Discharge Rehabilitation
Medication reconciliation at home after surgery
Activities of Daily Living
After surgery at 84 years old.
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8/7/2014
Friends of Geriatric Surgery Service at work
83 years old.Back to teaching Qi Gong
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8/7/2014
-18
-16
-14
-12
-10
-8
-6
-4
-2
0
2
4
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65
Patient no.
Collaborative Transdisciplinary
ApproachStandard Treatment
Patient no.
-4
-3
-2
-1
0
1
2
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63
Functional Outcomes of Elderly Adults who have
Undergone Major Colorectal Resections
• Wang Zhongkai, Tan Kok Yang
• Journal of American Geriatric
Society
• JAGS Dec 2013; 61(12): 2249-50
Mean follow-up of 91.2 months93.6% had Barthels Index not inferior to preoperative
score
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8/7/2014
Department of Surgery, Khoo Teck
Puat Hospital