The inflammatory response in surgical oncology: potential sequelae in elderly patients

Due to the ageing of society and increasing cancer incidence with ageing, surgery for elderly patients has, and will, become more and more common. Although elderly patients diagnosed with cancer may benefit from surgical treatment, they are more susceptible for adverse events than the young. During the last decades the role of a physiologic response in the development of postoperative complications (including cognitive impairment) has been suggested. During surgery tissue damage is inflicted, leading to the activation of the immune system. A tightly balanced reaction from the immune system is vital for recovery from trauma and surgery. However, a severe and prolonged inflammatory response might be detrimental and might be associated with postoperative complications. Although substantial progress has been made in recognizing and treating postoperative complications to improve the postoperative care, it remains unclear why and how especially the elderly are prone for the development of adverse outcomes and how the immune system plays a role. Therefore the aim of this thesis was to study the possible negative sequelae of the inflammatory response, and the inflammatory response itself, to surgery in elderly oncological patients with special interest in cognitive functioning. Identification of patients at increased risk of postoperative complications enables tailored treatment, ultimately leading to improved quality of care and improved postoperative outcomes in older oncological patients. Being able to preserve postoperative cognitive functioning for the oncological patients will enable them to lead an independent life after successful cancer treatment

The association of preoperative anxiety and depression with neurocognitive disorder following oncological surgery

Background: The proposed underlying mechanisms of anxiety and depression, and of postoperative neurocognitive disorder (NCD), each include immune system involvement. Therefore, the aims of this study were to investigate the incidence of postoperative NCD 3 months after surgery among oncological patients undergoing surgery and to evaluate the role of preoperative anxiety and depression. Method: A consecutive series of patients (age ≥ 18 years) undergoing surgery for the removal of solid tumors were included (n = 218). Cognitive performance was assessed preoperatively and at 3 months postoperatively. Preoperative anxiety and depression were evaluated using the Hospital Anxiety and Depression Scale. Results: NCD affected 12.3% of elderly patients (age ≥ 70 years, n = 57) at 3 months after surgery, with executive function mostly affected. By contrast, 8.4% of younger patients (age < 70 years, n = 107) were affected, with information processing speed mostly affected. Low educational attainment was a risk factor (OR, 6.0; 95% CI, 1.9–19.0) of overall NCD, whereas preoperative anxiety was associated with decline in the domain of executive function. Conclusion: Postoperative NCD is a complication of oncological surgery for all adults instead of the elderly only. Preoperative anxiety was associated with an increased risk of executive function decline, and low educational attainment was a key factor for overall NCD

Remote Home Monitoring of Older Surgical Cancer Patients:Perspective on Study Implementation and Feasibility

BACKGROUND: Remote home monitoring might fill the perceived surveillance gap after hospital discharge. However, it is unclear whether older oncologic patients will be able to use the required new digital technologies. The study aimed to assess the feasibility of postoperative remote home monitoring for this population. METHODS: This observational cohort study recruited patients aged 65 years or older scheduled for oncologic surgery. The study patients used a mobile application and activity tracker preoperatively until 3 months postoperatively. A subset of the patients used additional devices (thermometer, blood pressure monitor, weight scale) and completed electronic health questionnaires 2 weeks after hospital discharge. Feasibility was assessed by the study completion rate, compliance in using components of the information technology system, acceptability [Net Promotor Score (NPS)] and usability [System Usability Scale (SUS)]. The NPS score varied from - 100 to + 100. An SUS higher than 68 was considered above average. RESULTS: Of 47 participants (mean age, 72 years; range, 65-85 years), 37 completed a follow-up assessment, yielding a completion rate of 79%. Compliance in using the activity tracker (n = 41) occurred a median of 81 days [interquartile range (IQR), 70-90 days] out of 90 post-discharge days. Compliance in measuring vital signs and completing health questionnaires varied from a median of 10.5 days (IQR, 4.5-14.0 days) to 12 days (IQR, 5-14 days) out of 14 days. The NPS was + 29.7%, and the mean SUS was 74.4 ± 19.3. CONCLUSION: Older oncologic patients in the study considered postoperative home monitoring acceptable and usable. Once they consented to participate, the patients were compliant, and the completion rate was high

Association between anaesthesia-related factors and postoperative neurocognitive disorder:a post-hoc analysis

BACKGROUND: Postoperative neurocognitive disorder (pNCD) is common after surgery. Exposure to anaesthetic drugs has been implicated as a potential cause of pNCD. Although several studies have investigated risk factors for the development of cognitive impairment in the early postoperative phase, risk factors for pNCD at 3 months have been less well studied. The aim of this study was to identify potential anaesthesia-related risk factors for pNCD at 3 months after surgery.METHODS: We analysed data obtained for a prospective observational study in patients aged ≥ 65 years who underwent surgery for excision of a solid tumour. Cognitive function was assessed preoperatively and at 3 months postoperatively using 5 neuropsychological tests. Postoperative NCD was defined as a postoperative decline of ≥ 25% relative to baseline in ≥ 2 tests. The association between anaesthesia-related factors (type of anaesthesia, duration of anaesthesia, agents used for induction and maintenance of anaesthesia and analgesia, the use of additional vasoactive medication, depth of anaesthesia [bispectral index] and mean arterial pressure) and pNCD was analysed using logistic regression analyses. Furthermore, the relation between anaesthesia-related factors and change in cognitive test scores expressed as a continuous variable was analysed using a z-score.RESULTS: Of the 196 included patients, 23 (12%) fulfilled the criteria for pNCD at 3 months postoperatively. A low preoperative score on Mini-Mental State Examination (OR, 8.9 [95% CI, (2.8-27.9)], p &lt; 0.001) and a longer duration of anaesthesia (OR, 1.003 [95% CI, (1.001-1.005)], p = 0.013) were identified as risk factors for pNCD. On average, patients scored higher on postoperative tests (mean z-score 2.35[± 3.13]).CONCLUSION: In this cohort, duration of anaesthesia, which is probably an expression of the complexity of the surgery, was the only anaesthesia-related predictor of pNCD. On average, patients' scores on cognitive tests improved postoperatively.</p

The association between the inflammatory response to surgery and postoperative complications in older patients with cancer; a prospective prognostic factor study

BACKGROUND: Accurate prognostic biomarkers would substantially improve surgical planning and decisions making yet no studies have been reported exploring the inflammatory response in surgically treated older patients with cancer. The aim of this study was to explore inflammatory biomarkers as potential prognostic factors for postoperative complications within 30 days in older patients with cancer. METHOD: Patients 65 years and older undergoing surgery for removal of a solid malignant tumour were included in an observational cohort study. All complications occurring up to 30 days postoperatively were documented prospectively. Inflammatory markers were measured in plasma samples pre- and postoperatively: C-reactive protein (CRP), Interleukin-1 beta (IL-1β), IL-6, IL-10, IL-12, and Tumour necrosis factor-alpha (TNF-α). Associations between inflammatory markers and postoperative complications were explored using logistic regression analysis. RESULTS: Between July 2010 and April 2014, plasma samples of 224 patients were collected. Median age was 72 (65-89) years and 116 (51.8%) patients were female. Approximately half of the patients developed postoperative complications (49.6%) of whom 62 patients (55.9%) developed >1 complication. An independent prognostic effect was observed for the inflammatory biomarkers IL-6 and IL-10 for the occurrence of postoperative complications. CONCLUSION: The perioperative inflammatory response is associated with complications, independently from patient and surgical factors which are also associated with outcome. Research is warranted towards further exploration of the perioperative inflammatory response with the aim to improve perioperative care and outcome, and might help to improve surgical planning and decision making for older patients with cancer

Compromised intestinal integrity in older adults during daily activities:a pilot study

Abstract Background Malnutrition is a common and significant problem in older adults. Insight into factors underlying malnutrition is needed to develop strategies that can improve the nutritional status. Compromised intestinal integrity caused by gut wall hypoperfusion due to atherosclerosis of the mesenteric arteries in the aging gastrointestinal tract may adversely affect nutrient uptake. The presence of compromised intestinal integrity in older adults is not known. The aim of this study is to provide a proof-of-concept that intestinal integrity is compromised in older adults during daily activities. Methods Adults aged ≥75 years living independently without previous gastrointestinal disease or abdominal surgery were asked to complete a standardized walking test and to consume a standardized meal directly afterwards to challenge the mesenteric blood flow. Intestinal fatty acid-binding protein (I-FABP) was measured as a plasma marker of intestinal integrity, in blood samples collected before (baseline) and after the walking test, directly after the meal, and every 15 min thereafter to 75 min postprandially. Results Thirty-four participants (median age 81 years; 56% female) were included. Of the participants, 18% were malnourished (PG-SGA score ≥ 4), and 32% were at risk of malnutrition (PG-SGA score, 2 or 3). An I-FABP increase of ≥50% from baseline was considered a meaningful loss of intestinal integrity and was observed in 12 participants (35%; 8 females; median age 80 years). No significant differences were observed in either baseline characteristics, walking test scores, or calorie/macronutrient intake between the groups with and without a ≥ 50% I-FABP peak. Conclusion This study is first to indicate that intestinal integrity is compromised during daily activities in a considerable part of older adults living independently