Oncogeriatrics (part 1.). Frailty in older adults with cancer

About onehalf of cancer cases and two-thirds of cancer deaths occur in patients 65 years of age or older. Therefore, understanding the health status of an older patient is just as important as staging of the cancer.Frailty is a complex, multidimensional syndrome of increased vulnerability and loss of adaptive capacity/resistance to external stressors, resulting in an increased risk of adverse outcomes. Clinical presentation is non-specific: fatigue, unexplained weight loss, frequent infections, decline in physical mobility/balance/gait speed. Therefore, the routine format of preoperative investigations often does not allow for adequate frailty identification. There are two principal models of frailty: the phenotype model and the accumulation of deficits model. There is no consensus on an operational definition of frailty. However, it has been demonstrated that frailty, not chronological age, is the most important risk factor for poor outcome. Therefore, frailty identification should be obligatory before the beginning of the oncologic treatment

Oncogeriatrics (part 4.) Pre-operative assessment of elderly patients with cancer

Older patients comprise a highly heterogeneous group, and chronological age, comorbidities, or the type of surgical pro­cedure performed cannot adequately describe the risk of adverse post-operative outcomes. Therefore, current routine pre­-operative assessment also cannot adequately identify patients at risk. The Comprehensive Geriatric Assessment, the mean life expectancy and the treatment goals of a patient must be included in the pre-operative evaluation. The Comprehensive Geriatric Assessment helps to determine the primary status of an older patient, to diagnose frailty syndrome and to identify how to optimize a patient’s condition before surgery. Surgery is one of the primary triggers for disability in older patients. In this age group, being independent is more important than prolonging life. This is particularly true in patients with frailty syndrome, or decreased physiological reserves, which arise from cumulative deficits in several physiological systems and result in a diminished resistance to stressors. Therefore, a standardized pre-operative diagnostic approach, individualized surgical technique selection and tailored post-operative care are essential for successful treatment of elderly patients.Older patients comprise a highly heterogeneous group, and chronological age, comorbidities, or the type of surgical procedure performed cannot adequately describe the risk of adverse post-operative outcomes. Therefore, current routine pre-operative assessment also cannot adequately identify patients at risk. The Comprehensive Geriatric Assessment, the mean life expectancy and the treatment goals of a patient must be included in the pre-operative evaluation. The Comprehensive Geriatric Assessment helps to determine the primary status of an older patient, to diagnose frailty syndrome and to identify how to optimize a patient’s condition before surgery. Surgery is one of the primary triggers for disability in older patients. In this age group, being independent is more important than prolonging life. This is particularly true in patients with frailty syndrome, or decreased physiological reserves, which arise from cumulative deficits in several physiological systems and result in a diminished resistance to stressors. Therefore, a standardized pre-operative diagnostic approach, individualized surgical technique selection and tailored post-operative care are essential for successful treatment of elderly patients

Oncogeriatrics (part 2.). Normal and pathological ageing

There are two ageing processes, one physiological, also known as normal ageing, and that of pathological ageing, which depends on the occurrence of chronic diseases. The essence of the former is a gradual, progressive, and a very indivi­dual restriction of the organs’ functional reserve with age. The changes occur in all cells, tissues and systems and do not affect each organ at the same time, and the rate of change can vary between organs. Therefore, the chronological age alone cannot be the factor determining the terapeutic decisions, including surgical treatment. Among the elderly, there is a distinct situation where acute stress response associated with surgery is imposed on the otherwise ageing-related, reduced physiological reserves and the cumulative effect of any accompanying diseases. Standard preparation for surgery and routine perioperative management in such patients can lead to serious complications. In older persons, even mini­mal injury can exceed the body’s capacity to compensate, especially among those with frailty syndrome. It is critical to understand the physiological changes associated with ageing to better understand the differences in the management of these elderly patients

The need for culture swabs in laparoscopically treated appendicitis

INTRODUCTION: Appendicitis remains the most common cause of an acute abdomen. Obtaining intra-abdominal cultures is routine surgical practice. There are studies showing no efficacy of such procedures in cases where open appendectomies are performed. AIM: The goal of this study was to assess the need for obtaining intra-abdominal cultures during laparoscopic appendectomies. MATERIAL AND METHODS: Between 2007 and 2012, 369 patients were operated on with the diagnosis of histopathologically proven acute appendicitis. Sixty-two percent of them were operated on using laparoscopic techniques. The microbiological assessment was routinely done for the open procedures and in 42% of cases that underwent a laparoscopic operation. RESULTS: In 57% (134) the swabbing results were negative. Among 43% (102) of the patients with a positive result, Escherichia coli was isolated in 76.5% (78), Proteus mirabilis in 13.7% (14), Pseudomonas aeruginosa in 4.9% (5) and Citrobacter freundii in 4.9% (5). Five cases had bacteria resistant to the antibiotic given preoperatively (that is 4.9% of all positive cultures and 1.4% of all operated patients). However, these cases did not affect the incidence of postoperative complications. Consideration of the postoperative morbidity showed that there was no statistically significant difference between the laparoscopic group with and without intra-operative swabbing (p > 0.05). CONCLUSIONS: The postoperative patient outcome was more dependent on the pathology of the appendix than on the results of the microbiological assessment at the time of surgery. Hence, routine intra-operative cultures during laparoscopic appendectomies appear to have little value in patient management. Swabbing during laparoscopic procedures should be limited to only selected high-risk groups