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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 8  |  Issue : 2  |  Page : 47-53

Age versus American society of anesthesiologists–Examining 30-day mortality and morbidity in elderly patients undergoing colectomy from the American college of surgeons national surgical quality improvement program


1 Department of Surgery, University of Louisville, Louisville, KY, USA
2 Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA

Date of Web Publication27-Jun-2019

Correspondence Address:
Dr. Amy K Wise
Department of Surgery, University of Louisville, 500 S Preston St., Louisville, KY 40202
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/WJCS.WJCS_1_19

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  Abstract 


Background: As the percentage of the population that is elderly increases, colorectal operations performed in this age group are becoming more common. This study examined the use of the American Society of Anesthesiologists(ASA) Classification System(class) as a predictor of 30-day morbidity and mortality in patients≥90years old. Objective: The objective of this study was to evaluate the use of ASA classification in elderly patients undergoing colorectal surgery to determine whether it is an accurate predictor of perioperative risk. Design and Setting: This was a retrospective database review. Patients and Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried for all colectomies, coloproctectomies, and proctectomies performed from 2005 to 2009. Demographic and perioperative information including class and 30-day outcomes were assessed. Amultiple logistic regression model was used to calculate the odds of 30-day morbidity and mortality correlated with age, class procedure type (open vs. minimally invasive), and do not resuscitate (DNR)status. Main Outcome Measures: 30-day mortality and 30-day morbidity. Sample Size: The sample size included 73,974patients. Results: Atotal of 73,974patients were identified including 1276patients≥90years old. Across all patients, multiple logistic regression demonstrated higher odds of 30-day mortality with increase in class(P < 0.001, odds ratio[OR] 5.62), age(P < 0.001, OR 1.04), DNR status(P < 0.001, OR 3.01), and open procedures(P < 0.001, OR 2.60). Subgroup analysis of patients with class≤3 showed increase in 30-day mortality with increased age(P < 0.001, OR 1.05), class(P < 0.001, OR 3.87), DNR status(P < 0.001, OR 5.05), and open procedures(P < 0.001, OR 2.39). For patients ≥90 with class≤3, class was no longer correlated with 30-day mortality(P = 0.251) or morbidity(P = 0.236). Conclusions: In colorectal surgery patients, class is a validated predictor of morbidity and mortality. For the most elderly patients, class indicative of preoperative status of less than a constant threat to life(≤3) increasing class does not correlate with increased morbidity or mortality. Ongoing work is needed to define predictors of risk in these patients. Limitations: This is a retrospective study derived on data retrieved from a national database; we are limited to the preselected variables collected and the potential for missed or omitted patients.

Keywords: American Society of Anesthesiologists score, colectomy, elderly


How to cite this article:
Mongiu AK, Rumma RT, Wise AK, Farmer RW. Age versus American society of anesthesiologists–Examining 30-day mortality and morbidity in elderly patients undergoing colectomy from the American college of surgeons national surgical quality improvement program. World J Colorectal Surg 2019;8:47-53

How to cite this URL:
Mongiu AK, Rumma RT, Wise AK, Farmer RW. Age versus American society of anesthesiologists–Examining 30-day mortality and morbidity in elderly patients undergoing colectomy from the American college of surgeons national surgical quality improvement program. World J Colorectal Surg [serial online] 2019 [cited 2019 Dec 10];8:47-53. Available from: http://www.wjcs.us.com/text.asp?2019/8/2/47/261542




  Introduction Top


Colectomy is a common operation in the elderly, performed for benign and malignant disease, in both the elective and emergent settings. Colorectal cancer, estimated to account for 8% of all new cancer diagnoses in the United States for 2017, is a common cause of colectomy in the elderly. In addition, the overall incidence rate of colorectal cancer is significantly higher in individuals over80years of age when compared with those under 80.[1],[2] Combined with the expanding US population of adults over the age of 80, doubling by 2050, colorectal surgeons can expect to have an increasingly elderly population presenting for potential surgical intervention.[3]

Nonagenarians, the most elderly group, present a unique challenge for the colorectal surgeon. Residual life expectancy dwindles as we age. The 2015 Social Security Actuarial Tables indicate that while an 80-year-old male has an additional 8.2years life expectancy, this drops to 4years by age 90 and 2.8years by age 95.[4] Concomitantly, postoperative mortality and morbidity has been shown to increase with age.[5],[6] Surgical decision-making in this most elderly population, therefore, becomes a delicate balance between potential surgical outcomes and quality of remaining lifespan. Accurate determination of perioperative risk in this population allows us to best counsel our patients on the risks and benefits of undergoing colectomy. However, in the most elderly population, the best method of perioperative risk stratification is unclear.

Scoring patients based on physical condition before the administration of anesthesia is a widely enacted method of assessing preoperative risk. This method was first proposed in 1941[7] with a modified version published in 1961,[8] commonly referred to today as the American Society of Anesthesiologists classification(ASA class). Variations of this method have been widely adopted and have been validated as a predictive model for assessment of perioperative morbidity and mortality.[9],[10],[11] However, the ASA class does not include age or functional status when assessing perioperative risk. Functional status or similar measures of independence such as residence in a nursing home has been shown to be independent predictors of morbidity and mortality after surgery.[12],[13]

We queried The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database of patients undergoing laparoscopic and open colectomies in order to assess the relationship between age and ASA classification with 30-day morbidity and mortality in nonagenarians. We additionally examined the relationship between DNR status, surgical technique (open vs. laparoscopic), and case status(elective vs. emergent) with 30-day mortality and morbidity in this population.


  Patients and Methods Top


Data collection

The ACS NSQIP is a well-known, monitored, and validated database which collects 135 clinical variables on each(randomly selected and deidentified) patient including preoperative risk factors, demographic data, and 30-day postoperative mortality and morbidity.[11],[14] The ACS NSQIP database was queried for all colectomies, coloproctectomies, and proctectomies performed from 2005 to 2009. This included both elective and emergent cases and cases performed in both open and minimally invasive techniques. Patient demographic information and perioperative information including ASA score, as well as postoperative morbidity and mortality data were included in this dataset.

Outcomes and statistical analysis

The ACS NSQIP dataset from 2005 to 2009 was used for our analysis. We vetted the data using Data 14.0(StataCorp.2015. Stata Statistical Software: Release 14. College Station, TX, USA: StataCorp LP.) A multiple logistic regression model was used to calculate the odds of 30-day morbidity and mortality correlated with age, ASA score, procedure type (open vs. minimally invasive), and DNR status.


  Results Top


Patient demographics

Query of the 2005–2009 ACS-NSQIP dataset yielded a total of 76,103 colectomies, coloproctectomies, and proctectomies; 2129 were excluded due to incomplete data and generating a total cohort of 73,974patients. This included 62,395patients undergoing elective surgeries and 11,557patients undergoing emergent operations, and 66,875patients of all ages with ASA score≤3 (59,425 elective procedure patients). About 1276patients≥90years old underwent relevant operations(936 of which were elective). Of patients≥90years old, 946 had a preprocedural ASA score≤3, including 788 elective operations and 158 emergent operations. [Table1] lists demographics of the cohort. Morbidity was defined as the presence of any 1 out of 21 common morbidities occurring within 30days from the date of the primary operation[Table2].{Table1}{Table2}

Multiple logistic regression analysis

All ages, all American Society of Anesthesiologists class

Across all patients in the cohort, multiple logistic regression demonstrated that there was a statistically significant higher odds of 30-day mortality with a higher ASA score(P < 0.001, odds ratio[OR] 5.62), increased age(P < 0.001, OR 1.04), and DNR status(P < 0.001, OR 3.01), as well as open procedures(P < 0.001, OR 2.60). There was no difference in significance of outcomes when patients undergoing elective and emergent operations were analyzed separately. Independently, ASA class displayed the strongest odds of 30-day mortality with OR of 5.62. Similarly, when considering all patients, statistically significant odds of 30-day morbidity were demonstrated with ASA class(P < 0.001, OR 2.12), DNR status (P < 0.001, OR 1.33), and open procedures(P < 0.001, OR 1.94). However, age was not found to be correlated with 30-day morbidity in all patients(P = 0.017, OR 1.00) [Table 3].
Table 3: Surgical outcomes

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All ages, American Society of Anesthesiologists ≤3

Subgroup analysis of patients with ASA score≤3 was performed for both 30-day mortality and 30-day morbidity. In this subgroup, increased odds of 30-day mortality were correlated with age(P < 0.001, OR 1.05), ASA score(P < 0.001, OR 3.87), DNR status (P < 0.001, OR 5.05), and open procedures(P < 0.001, OR 2.39). Age was not predictive of 30-day morbidity in this subgroup(P = 0.836), but ASA score(P < 0.001, OR 1.76), DNR status(P < 0.001, OR 1.61), and open procedure(P < 0.001, OR 1.89) remained significantly correlated [Table 3].

Age>90, all American Society of Anesthesiologists class

We then focused our analysis on the cohort of patients aged≥90years old. When considering both elective and emergent cases, ASA class(P < 0.001, OR 3.05), DNR status(P = 0.001, OR 2.02), and open procedures(P < 0.001, OR 3.33) were strongly correlated with 30-day mortality, while only ASA class(P < 0.001, OR 1.89) and open procedures(P < 0.001, OR 1.79) correlated with higher odds of perioperative morbidity [Table 3].

Age>90, American Society of Anesthesiologists ≤3

Notably, when patients≥90years old with ASA Class≤3 were examined(n=946), only DNR status (P < 0.001, OR 4.1) and open procedures(P = 0.003, OR 2.84) were significantly correlated with higher odds of 30-day mortality. ASA score in these patients no longer correlated with 30-day mortality(P = 0.251). These findings remained consistent whether elective versus emergent operations were analyzed separately. For patients≥90years old with ASA score≤3 undergoing emergent operations, no variables significantly correlated with 30-day mortality. Only open procedures were noted to be significantly correlated with perioperative morbidity(P = 0.001, OR 1.85), unlike DNR status(P = 0.287) and ASA class(P = 0.236). For patients undergoing elective operations, only open procedures continued to be associated with increased morbidity(P = 0.004, OR 1.79). For emergent procedures in this subgroup, there were no significant correlations to 30-day morbidity [Table 3].

Thirty-day mortality

Thirty-day mortality was calculated for each decade from 50 to 90+. Astatistically significant increase in mortality was noted with each increasing decade of life. Notably, all comers in their 80's experienced an 11%, 30-day mortality following colectomy. This nearly doubled to 19.9% in patients aged >90. For patients aged 90 and greater, further analysis demonstrated a 10.2%, 30-day mortality in those with ASA Class1–3 compared with 35.7% in those ASA Class4–5(P< 0.001) [Table 4].
Table 4: Thirty-day mortality

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  Discussion Top


The definition of the elderly is shifting in the medical literature. In the 1920s, elective surgery in patients aged>50 was not advised.[15] However, advances in medicine have led to both longer life expectancies and increasingly aged patients presenting for both elective and emergent surgeries.[15],[16]

In the current practice, age as low as 55 is considered elderly in the trauma surgery literature.[17] However, in gastrointestinal surgery, there is evidence to suggest that an age>75 represents the beginning of the “very elderly,” and an increase in mortality is seen when these patients undergo major operations.[18] In our cohort, 30-day mortality nearly doubled in each decade over the 7th, going from 5.8% for those 70–79 to 11.1% for those 80–89, and 19.9% for those aged more than 90years. However, much of the excess mortality in nonagenarians in our cohort appears driven by ASA Class4–5patients which comprise roughly 25% cohort and sustained a 35.7%, 30-day mortality. By comparison, nonagenarians with ASA Class1–3 were noted to have a 10.2%, 30-day mortality, more in line with all comers in their 8thdecade.

The decision to offer operative intervention in the most elderly patients requires careful perioperative risk assessment and thoughtful selection of operative technique in combination with a clear discussion of the goals of care. The literature specific to nonagenarians undergoing colectomy is quite small, and for the most part, limited to small retrospective studies with<75patients.[19],[20],[21],[22],[23],[24] Larger studies combining octo-and nonagenarians can provide additional guidance; however, it may not be accurate to generalize outcomes for nonagenarians as being the same as octogenarians.[5],[25],[26],[27],[28],[29] Our study of 1276patients comprises the largest analysis dedicated to nonagenarians undergoing colectomy.

ASA class is widely used for preoperative risk assessment. It is additionally recorded in the ACS NSQIP database making it uncomplicated to assess a large national cohort without requiring further calculations. In our initial multivariate analysis, we unsurprisingly found ASA class to be highly correlated with 30-day mortality and morbidity when all ages and ASA classes were included. Subdivision of elective and emergent cases in this group did not change this correlation. Similarly, when we considered only patients>90years of age in all ASA classes, we continued to see strong correlation between ASA status and 30-day mortality and morbidity. Kassahun et al. published similar findings in their study of 80 nonagenarians undergoing a variety of thoracic and abdominal procedures.[30]

When we examined the overall makeup of ASA class in our entire cohort, we found that 90.4%(66,875/73,974) of all patients were ASA Class1–3. This dropped to 74.1%(946/1276) in nonagenarians. When we repeated our multivariate analysis on all ages of patients with ASA Class limited to 1–3, we continued to see a significant correlation between ASA class and 30-day mortality and morbidity. However, in nonagenarians, when we excluded patients with ASA Classes 4 and 5, we found that ASA status was no longer correlated with either 30-day morbidity or mortality. When we further examined elective and emergent subgroups, this did not change. Our results would, therefore, suggest that ASA classification is not an ideal metric for preoperatively risk stratifying the majority of nonagenarians who are not moribund or critically ill.

The modified Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity(POSSUM) and the colorectal modification CR-POSSUM are alternative risk stratification tools that have been studied in octo-and nonagenarians undergoing abdominal surgery.[31],[32],[33] Imaoka et al. showed that POSSUM and age-adjusted POSSUM(P-POSSUM) were accurate in protecting morbidity and mortality in nonagenarians undergoing emergency abdominal procedures in their series of 36patients.[32] However, both Gomes and Overstraeten found in their reviews of 204 and 286 octo-and nonagenarians undergoing colorectal surgical procedures, that neither POSSUM/P-POSSUM/CR-POSSUM were sufficiently accurate to be used in clinical application in their patient populations.[31],[33] Ultimately, more work is needed to define more accurate perioperative risk assessment tools aimed at the most elderly population undergoing colorectal surgery.

In our cohort, open surgery was strongly correlated with 30-day mortality and morbidity when all ages and either all ASA classes or ASA Class1–3 were evaluated. This result is consistent with other studies utilizing the ACS NSQIP data published by Senagore and Kannan who noted a higher incidence of 30-day morbidity patients undergoing open versus laparoscopic surgery, although Senagore noted those undergoing open surgery may have had higher preoperative risk factors.[34],[35] Neither study was limited to octo-and/or nonagenarians.

In our cohort of nonagenarians, however, open surgery was only significantly correlated with 30-day mortality, not morbidity. In addition, open surgery was no longer significantly correlated with 30-day mortality in nonagenarians with ASA Class1–3 undergoing emergency operations. The literature on outcomes after laparoscopic versus open colorectal surgery in octo-and nonagenarians remains limited, but small series has noted equivalent to slightly improved outcomes in both morbidity and mortality utilizing laparoscopic surgery in this population.[19],[28],[36]

The presence of a do not resuscitate order presents an understandable challenge to the operating surgeon when counseling any patient, much less a nonagenarian. DNR status was strongly correlated with 30-day mortality in all groups examined, excluding only those nonagenarians with ASA Class1–3 undergoing emergency surgery. It was not correlated with 30-day morbidity in nonagenarians in any group. Scarborough et al. found similar results in their propensity-matched cohort of patients aged>65 undergoing emergency abdominal surgery.[37],[38] They theorized that the excess mortality seen in the DNR group was more likely related to the patients' reluctance to undergo further aggressive treatments following a postoperative complication(based on a statistically lower rate of reoperation in the DNR group). Based on this, we would suggest that nonagenarians with a DNR in place presenting for elective colorectal surgery should be counseled of this increased risk and undergo a comprehensive goal of care discussion prior to surgery.

Limitations of the study

Our study has some notable limitations. It is a retrospective study derived on data retrieved from a national database. Although data collection in the ACS NSQIP database has been validated in multiple studies and ongoing monitoring of the data collection is in place, we are limited to the measured variables which have been preselected. Cases/patients were selected by CPT code, and there is the potential for cases to be miscoded or omitted in this process.


  Conclusion Top


The decision to offer operative intervention in the most elderly patients requires careful perioperative risk assessment and thoughtful selection of operative technique in combination with a clear discussion of the goals of care. Our results suggest that ASA classification is not an ideal metric for preoperatively risk stratifying the majority of nonagenarians who are not moribund or critically ill. Additional work is needed to stratify these patients appropriately so that we may best counsel our oldest patients prior to operative intervention.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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