Emergency abdominal surgery in the aged

Transcription

1 Br. J. Surg. Vol. 63 (1976) Emergency abdominal surgery in the aged RICHARD BLAKE AND JOHN LYNN* SUMMARY The results of 375 emergency abdominal operations in elderly patients over the age of 75 years are presented and discussed in detail. There has been a fourfold increase in the population over the age of 75 years in England and Wales during the 60-year period from 1911 to The overall mortality of these patients of 31.7per cent is unrelated to the age of the patient, but appears to be directly related to the severity of the surgical condition and to cardiorespiratory complications. Our approach to these problems is presented and discussed. THE widespread application of preventive medicine and improved medical resources in the twentieth century has resulted in an increase in the number of elderly people in our community. In certain areas this is accentuated by an influx of retired people. Bournemouth is such a retirement area as demonstrated by the 1971 census which showed a total population of with people over the age of 75 years (Office of Population Censuses and Surveys, 1973). This represents 10.5 per cent of the local population. In comparison with the national figures this is twice the average (Office of Population Censuses and Surveys, 1975). Because of the large numbers of elderly people in our local community we decided to study the results of emergency abdominal surgery in patients over the age of 75 years. Patients We have defined a case as an emergency if it was deemed deleterious to the patient to delay surgery until the next routine operating list. The age limit of 75 years was taken arbitrarily, as we considered anyone over the age of 75 years represented a geriatric patient. The cases were collected from the theatre operation registers and included both public and private patients who were admitted to the Royal Victoria Hospital, Bournemouth. During the 6)-year period from January 1969 to March 1975,392emergency abdominal operations were performed on patients over the age of 75 years. Of these, the case records were obtained for 375 operations, representing a retrieval rate of 95.7 per cent. Using a prepared pro forma, a retrospective examination of the notes was undertaken with regard to the patients age, sex, general clinical condition, details of operation, complications and mortality. A period of 30 days following operation was taken as an arbitrary figure in which morbidity and mortality resulting from surgery were considered likely to occur. Results A total of 375 patients satisfied the criteria for the study. The age range was years, with a mean age of 81.8 years. Table Z shows the frequency distribution of the patients in relation to age, with the mortality rates for the different age groups. Of the patients studied, 228 patients were female and 147 patients were male. Table ZZ shows the analysis of the cases according to diagnosis, with the respective mortality rates. Strangulated hernia There were 115 cases of strangulated hernia (30.7 per cent of all cases), of which 70 were femoral (57 females) 35 inguinal (34 males), 5 incisional, 4 para-umbilical and one obturator hernia. The mortality for strangulated femoral hernia was 17.1 per cent, but was slightly higher in those who underwent bowel resection, i.e. 4 deaths in 16 cases. In the 35 patients with strangulated inguinal hernia 5 deaths occurred (143 per cent). Twenty out of the 34 male patients in this group had pre-existing cardiac or pulmonary disease or both, and of the 5 patients who died, all had previous cardiac or pulmonary disease. Intestinal obstruction The next most common emergency was intestinal obstruction, with 103 cases (273 per cent of the total series). Of these, there were 60 cases with large bowel obstruction and 43 with small bowel obstruction. The cases of obstruction due to external hernia have been included in the group of strangulated hernias. Table ZZZ shows that most of the small bowel obstructions were due to adhesions, whilst the majority of large bowel obstructions were due to carcinoma (Table ZV). Acute appendicitis Thirty-four patients had acute appendicitis of whom 4 died. Twenty patients underwent laparotomy and appendicectomy and the 4 deaths occurred in this group. Of the remainder, 11 patients had appendicectomy via a grid-iron incision and 3 patients had drainage of an appendix abscess via a grid-iron incision. Haemorrhage from the gastro-intestinal tract Table Vshows the cause of bleeding in the 27 patients who underwent operation for haematemesis and melaena. Twelve deaths occurred, a mortality of 44.4 per cent. Eleven cases were due to bleeding duodenal ulcer and 13 to bleeding gastric ulcer. In 2 cases no cause for the haematemesis was found, and a blind Billroth I gastrectomy was undertaken. There * The Royal Victoria Hospital, Bournemouth. Present addresses: R. Blake, Dudley Road Hospital, Birmingham; J. Lynn, Westminster Hospital, London. 956

2 Emergency surgery in the aged Table I: FREQUENCY DISTRIBUTION IN RELATION TO AGE Age No. of No. of (at last birthday) cases deaths Mortality (%) Total Table 11: DISTRIBUTION OF CASES ACCORDING TO DIAGNOSIS No. of No. of Diagnosis cases deaths Mortality PA) Strangulated hernia Femoral Inguinal Others Intestinal obstruction Small bowel Large bowel Acute appendicitis Bleeding gastro-intestinal tract Perforation of stomach or duodenum Large bowel perforation Biliary tract disease Ruptured aortic aneurysm Mesenteric ischaemia of small bowel Miscellaneous Total was one case of massive melaena due to diverticular disease of the colon, and a left hemicolectomy was performed. Gastrectomy, either Polya or Billroth I, was carried out in 15 cases, with 8 deaths (53.3 per cent). Vagotomy, drainage procedures were performed in 11 cases, with 3 deaths (27.3 per cent). Perforations of the stomach and duodenum Twenty-two patients had perforation of the stomach or duodenum of which 13 were due to duodenal ulcer, 4 were due to gastric ulcer and there were 5 perforated gastric carcinomas. Eleven of the 13 perforated duodenal ulcers were treated by simple oversewing of the perforation with an omental patch, and 3 of these patients died. The remaining 2 had a vagotomy and Table 111: CAUSES OF SMALL BOWEL OBSTRUCTION Cause No. of cases No. of deaths Benign adhesions Carcinoma of caecum 3 1 Gallstone ileus 3 1 Volvulus 3 0 Carcinomatosis 2 0 Ischaemic stricture 1 0 In tussusception 1 1 Total (34.9%) Table IV: CAUSES OF LARGE BOWEL OBSTRUCTION No. of Operation No. of Cause cases performed deaths Carcinoma of right colon 7 Resection 4 2 (including transverse Colostomy 3 2 coion)* Carcinoma of left colon 35 Resection IS 5 (splenic flexure to Colostomy 20 5 rectum) only Sigmoid volvulus 6 Reduction 3 3 and fixation Resection 3 1 Carcinomatosis 4 3 Caecal volvulus 2 1 Miscellaneous 6 2 Total (40%) * Cases of carcinoma of the caecum have been included in Table III. Table V: CAUSES OF HAEMATEMESIS AND MELAENA No. of No. of Cause cases Ooeration deaths Duodenal ulcer 11 Gastrectomy 3 1 Vagotomy, drainage 8 2 Gastric ulcer 13 Gastrectomy 10 5 Vagotomy, drainage 3 1 None found 2 Gastrectomy 2' 2 Diverticular 1 Left hemicolectomy 1 1 disease of colon Total 27 Gastrectomy 15 8 (53.3%) Vagotomy, drainage 11 3 (27.3%) Overall mortality 444% pyloroplasty. In the 4 patients with perforated gastric ulcer one had a Billroth I gastrectomy and the remaining 3, all of whom died, had an oversewing of the perforation. Three of the 5 patients with perforated gastric carcinoma died. Perforation of the large bowel Twenty-two patients had perforation of the large bowel, of which 17 were due to diverticulitis, 2 were due to a stercoral ulcer and in 3 cases the cause was not determined. Most of the cases were treated by drainage and a proximal defunctioning colostomy (18 cases), 2 cases had a large bowel resection and 2 cases were managed with drainage only, without colostomy. There was a very high mortality (6 deaths in 7 patients) 957

3 Richard Blake and John Lynn Table VI: MISCELLANEOUS LAPAROTOMIES FOR ABDOMINAL PAIN No. of Procedure No. of Final diagnosis cases performed deaths Perforated ileum due 1 Perforation over- 1 to malignant sewn and biopsy lymphoma Perforated Meckel's 1 Diverticulectomy 0 diverticulum and appendicectomy Pseudo-obstruction of 1 Transverse 1 large bowel colostomy Acute pancreatitis 1 No procedure 1 Diverticular disease 1 Appendicectomy 0 of colon Urinary tract 2 Appendicectomy 1 0 infection No procedure 1 Ovarian cyst 1 Ovarian cystectomy 0 Fibroids of uterus 1 Hysterectomy and 0 oophorectomy Myocardial infarction I No procedure 1 No diagnosis made 3 No procedure 2 1 Appendicectomy 1 Total 13 5 Table VII: CAUSES OF DEATH IN 119 CASES WITHIN 30 DAYS OF SURGERY No. of Mortality deaths (%) Related to surgical condition Peritoneal sepsis and septicaemia Haemorrhage and shock Carcinomatosis Other causes Non-related conditions Bronchopneumonia and chest infection Heart failure Pulmonary embolus Myocardial infarction Cerebrovascular accident 2 I.I Other Cause undefined Total 119 Table VIII: COMPLICATIONS WITHIN 30 DAYS OF SURGERY IN 375 PATIENTS No. (%) Related to surgical condition Wound infection and sepsis Fistula Complete wound dehiscence Superficial wound dehiscence Haemorrhage Obstruction Ileus Non-related conditions Bronchopneumonia and chest infection Heart failure Urinary infection Urinary retention Myocardial infarction Pulmonary embolus Deep vein thrombosis Others Cerebrovascular accident in cases of frank faecal peritonitis, whereas there were 8 deaths in 15 patients who had a purulent peritonitis. Biliary tract disease There were 21 patients with acute gallbladder disease, representing 5.6 per cent of the total series. Included in this group were cases with biliary peritonitis due to a ruptured gallbladder and also patients with acute cholecystitis in whom perforation was considered imminent. The latter patients were operated on as emergencies after an initial period of conservative management. There were 9 patients with perforated gallbladder and biliary peritonitis, 5 patients with acute cholecystitis, 6 patients with empyema of the gallbladder and one patient with a volvulus of the gallbladder. Cholecystectomy was carried out in all except 2 cases of empyema where a cholecystostomy was performed. In addition 5 patients had an exploration of the common bile duct. Four patients died, a mortality of 19.0 per cent. Other cases There were 9 patients with a ruptured aortic aneurysm of whom only 2 survived operation. Nine patients had mesenteric emboli or thromboses with small bowel infarction, and 3 patients survived. Of these 3 survivors, all underwent small bowel resection: 2 for mesenteric venous thrombosis and one for mesenteric arterial embolus. A further 13 miscellaneous cases with the diagnoses are listed in Table VI. These cases include several where no significant pathology was found at laparotomy, although their abdominal signs were such as to warrant surgery. Two cases had a subsequent diagnosis of urinary tract infection made and one case had a myocardial infarction, the diagnosis being established following laparotomy. In 3 of these cases no diagnosis was established. Mortality and morbidity Tables VII and VIII show the causes of death and principal complications. The total number of deaths was 119, representing an overall mortality of 31.7 per cent. Fifty-one deaths (42-9 per cent) were due to cardiac and pulmonary complications following surgery, whilst a further 51 deaths (42.9 per cent) were directly related to the presenting surgical condition. The correlation coefficient, r, of mortality rates in relation to age (estimated from figures in Table I) is , demonstrating that there is no correlation between age and mortality in this group of patients. Discussion Increased expectation of life over the age of 75 years is reflected in a higher proportion of elderly people developing acute surgical conditions. There are more than 2+ million people in the United Kingdom (Office of Population Censuses and Surveys, 1975) over the age of 75 years, and nearly 4 million of these are over the age of 85 years. Compared with the National census of 1911 this represents nearly a fourfold increase in people over 75 years and more than a sixfold increase in people over 85 years. However, the 958

4 Emergency surgery in the aged total population from 191 I to 1971 only increased by one-third. We have arbitrarily defined 75 years of age as the criterion for a geriatric patient. Hanlon (1960) predicted 16 years ago that 75 or even 80 years of age would be considered as the onset of geriatric youth. The geriatric patient has a high incidence of coronary and peripheral vascular disease and often occult pulmonary disease as well, and complications resulting from these conditions account for a high mortality in the patients who undergo emergency surgery. Fiftyone patients (42.9 per cent) in this series died from bronchopneumonia, congestive cardiac failure, myocardial infarction and pulmonary embolus (Table VII). Cole (I 953) considered that peripheral vascular disease and cardiorespiratory disorders comprised a major factor in the mortality of geriatric patients. In a further 51 of our patients death was due to the nature and severity of the presenting surgical condition. Patients with gastro-intestinal perforation, haemorrhage from the gastro-intestinal tract or ruptured aortic aneurysm had a high mortality, and these conditions represent major problems in patients of this age group. Stahlgren (1961) showed that the mortality for all age groups is between two and three times greater for emergency surgery as compared with non-urgent surgery. Bonus and Dorsey (1965) reviewed their experience with 370 patients over the age of 75 years who had undergone surgery, and although there mere only 41 emergency cases, 24 per cent of these patients died compared with 5.8 per cent of the non-urgent cases. This represents more than a fourfold increase in mortality for emergency surgery compared with elective surgery. Therefore it would seem reasonable to advise elective surgery in elderly patients in conditions such as inguinal or femoral hernia, as the mortality is greatly increased if emergency surgery is undertaken. Age by itself is not a contraindication to surgery, and in our series of 375 patients who underwent emergency surgery there is no correlation between mortality and age. In the present series the most common abdominal surgical emergency in elderly patients was a strangulated hernia, representing 30.7 per cent of all the cases. This was followed by intestinal obstruction (27.5 per cent of the cases). This contrasts quite clearly with the situation in young people among whom acute appendicitis is far more common. Acute appendicitis only accounted for 9.1 per cent of the cases in our elderly patients. Similarly, Ponka et al. (1963), in a series of 200 patients over the age of 60 years, recorded only 16 patients (8.0 per cent) with acute appendicitis. In our cases of large bowel obstruction there was no significant difference in mortality between the cases treated by large bowel resection and those who had a colostomy only. This may be due to selection of cases, resection being undertaken in patients who were considered suitable. We would advocate the use of Hartmann s procedure for neoplasms of the descending and sigmoid colon. This procedure results in a onestage or at the most a two-stage operation, and the advantage is that there is no problem with leakage from an anastomosis and definitive surgery is undertaken at one operation. There is also no necessity for advising a second operation if the patient is not deemed fit. This clearly has advantages over a threestage procedure. There were 34 cases of acute appendicitis in this series with only 4 deaths, representing an 11.8 per cent mortality. This compares favourably with the series reported by Browne (1962) of 22 cases in the younger age group of 60 years and over, with a mortality of 13.6 per cent. In the larger series of Wolff and Hindman (1952) there was a 4.5 per cent mortality, but these patients were again in the younger age group of 60 years and over. In 22 patients over 70 years with acute appendicitis Herron et al. (1960) reported a mortality of 13.6 per cent. It must be emphasized that acute appendicitis in the elderly is a relatively uncommon condition. It is interesting that there were no deaths in the patients who were explored via a grid-iron incision, the 4 deaths occurring in those who underwent a laparotomy. The significance of this is difficult to assess, as the type of incision may well reflect the severity of the disease. Emergency surgery was performed in cases of acute cholecystitis and empyema of the gallbladder after an initial period of conservative treatment. Van der Linden and Sunzel (1970) have shown quite clearly that emergency biliary surgery is not in general associated with a high mortality. The mortality in the present series was 19.0 per cent in 21 patients with acute biliary tract disease. Herron et al. (1960) reported a mortality of 22.9 per cent in 61 patients over the age of 70 years with acute biliary tract disease who underwent emergency surgery compared with one of 7.8 per cent in 103 patients who underwent elective cholecystectomy. In a study of mortality rates in biliary tract surgery Glenn and Hays (1955) reported a mortality of 10.9 per cent in emergency biliary tract surgery as opposed to 4.4 per cent in elective surgery in patients over the age of 65 years. There is no doubt that in perforated gastric ulcer the best treatment, if the patient s condition permits, is a Billroth I gastrectomy. The alternative of oversewing the ulcer and a four-quadrant biopsy is unsatisfactory and the 3 patients in our series in whom this was done all died, whilst a fourth patient who had a Billroth I gastrectomy survived. The situation with a perforated duodenal ulcer is more complex. In the majority of cases simple oversewing of the perforation is suitable. However, in those with a long history of duodenal ulceration and evidence of pyloric stenosis vagotomy and excision of the ulcer mass anteriorly by including it in a pyloroplasty would seem to be the treatment of choice. The mortality for perforated duodenal ulcer was 23.1 per cent in 13 cases. Herron et al. (1960) quoted an overall mortality of 62 per cent for primary closure of perforated ulcer in patients over 70 years, and Tanner (1943) gave an identical figure for simple closure of perforated ulcer in elderly patients. In cases of bleeding gastric ulcer gastrectomy is the treatment of choice. The only exception to this would

5 Richard Blake and John LYM be on rare occasions where there is a very high ulcer on the lesser curve, when vagotomy and pyloroplasty with biopsy and oversewing of the ulcer would be more suitable. However, Duthie and Smith (1968) found that approximately 10 per cent of patients with gastric ulcer who underwent surgery had a malignant ulcer, which emphasizes the importance of considering gastric resection. The mortality in our series for bleeding gastric ulcer (46.2 per cent) is comparable to the findings of others. Herron et al. (1960) cited a mortality of 45 per cent for emergency gastrectomy in patients over the age of 70 years. However, Cocks et al. (1972) reported a 26 per cent mortality in 213 patients over 60 years who underwent emergency gastrectomy for bleeding gastric or duodenal ulcer. The situation with bleeding duodenal ulceration is more difficult and opinion is still divided as to whether it should be treated by vagotomy and pyloroplasty with under-running of the ulcer or by partial gastrectomy. It would appear that in this age group vagotomy, pyloroplasty of the ulcer is preferable to emergency gastrectomy, whichgenerally carries a higher mortality. Foster et al. (1965) reported a 46 per cent mortality for emergency gastrectomy in patients over 70 years of age, whereas the mortality for vagotomy, pyloroplasty of the ulcer was only 14 per cent. Likewise, Schiller (1970) recorded 25 deaths in 69 patients over the age of 60 years (36.2 per cent mortality) undergoing emergency Polya gastrectomy, compared with 5 deaths in 42 patients (1 1.9 per cent mortality) having emergency vagotomy and drainage. The small number of cases with bleeding duodenal or gastric ulcer in the present series (Table V) support these figures. Thus it appears that emergency gastrectomy for bleeding duodenal ulcer is to be avoided in elderly patients, and that vagotomy, pyloroplasty of the ulcer is the treatment of choice. In conclusion the results of 375 emergency abdominal operations in patients over the age of 75 years have been reviewed, and several important points have emerged from this large series of elderly patients. Despite their age two-thirds of all the patients were alive and well at 1 month following surgery. We feel that the overall mortality of 31.7 per cent is reasonable when it is considered that the mean age of the patients was over 80 years. However, age itself was found to bear no correlation to mortality. It appears that mortality is related to the severity and nature of the surgical condition and to the intolerance of elderly patients to cardiorespiratory complications. We have concluded that an aggressive attitude to diagnosis and management must be adopted, and that early definitive surgery is the ideal. Multiple staged operations are inadvisable since definitive surgery is delayed. This is particularly so in large bowel obstructions of the sigmoid colon, where we would advocate the use of a Hartmann s operation. We have been unable to make an assessment of the quality of life following emergency surgery. We feel that this series, although retrospective in nature, will provide an interesting basis for future prospective studies. Acknowledgements We would like to thank the consultant surgical staff of the Royal Victoria Hospital, Bournemouth, Messrs W. G. Q. Mills, R. C. Shepherd, J. E. Trapnell and R. H. Jago, for their help and encouragement in the preparation of this paper. We would also like to thank Miss B. K. Doggett and Mrs M. Palmer of the Records Department, and Miss J. Hall for her secretarial help. References BONUS R. L. and DORSEY J. M. (1965) Major surgery in the aged patient. A continuation study. Arch. Surg. 90, BROWNE H. J. (1962) Acute appendicitis in the aged. J. Zr. Med. Assoc. 51, COCKS J. R., DESMOND A. M., SWYNNERTON B. F. et al. (1972) Partial gastrectomy for haemorrhage. Gut 13, COLE w. H. (1953) Operability in the young and aged (Roswell Park Lecture). Ann. Surg. 138, DUTHIE H. L. and SMITH G. H. (1968) A comparison of vagotomy plus pyloroplasty with Billroth I gastrectomy in the treatment of gastric ulcer. J. R. CON. Surg. Edinb. 13, FOSTER J. H., HICKOK D. F. and DUNPHY J. E. (1965). Changing concepts in the surgical treatment of massive gastroduodenal haemorrhage. Ann. Surg. 161, GLENN F. and HAYS D. M. (1955) The age factor in the mortality rate of patients undergoing surgery of the biliary tract. Surg. Gynecol. Obstet. 100,ll-18. HANLON c. R. (1960) Preparation of geriatric patients for anesthesia and operation. JAMA 174, HERRON P. w., JESSEPH J. E. and HARKINS H. N. 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