Ben Eiseman

Redefining geriatric preoperative assessment using frailty, disability and co-morbidity.

Objectives:(1) Determine the relationship of geriatric assessment markers to 6-month postoperative mortality in elderly patients. (2) Create a clinical prediction rule using geriatric markers from preoperative assessment. Background:Geriatric surgery patients have unique physiologic vulnerability requiring preoperative assessment beyond the traditional evaluation of older adults. The constellation of frailty, disability and comorbidity predict poor outcomes in elderly hospitalized patients. Methods:Prospectively, subjects ≥65 years undergoing a major operation requiring postoperative intensive care unit admission were enrolled. Preoperative geriatric assessments included: Mini-Cog Test (cognition), albumin, having fallen in the past 6-months, hematocrit, Katz Score (function), and Charlson Index (comorbidities). Outcome measures included 6-month mortality (primary) and postdischarge institutionalization (secondary). Results:One hundred ten subjects (age 74 ± 6 years) were studied. Six-month mortality was 15% (16/110). Preoperative markers related to 6-month mortality included: impaired cognition (P < 0.01), recent falls (P < 0.01), lower albumin (P < 0.01), greater anemia (P < 0.01), functional dependence (P < 0.01), and increased comorbidities (P < 0.01). Similar statistical relationships were found for all 6 markers and postdischarge institutionalization. Logistic regression identified any functional dependence (odds ratio 13.9) as the strongest predictor of 6-month mortality. Four or more markers in any one patient predicted 6-month mortality with a sensitivity of 81% (13/16) and specificity of 86% (81/94). Conclusions:Geriatric assessment markers for frailty, disability and comorbidity predict 6-month postoperative mortality and postdischarge institutionalization. The preoperative presence of ≥4 geriatric-specific markers has high sensitivity and specificity for 6-month mortality. Preoperative assessment using geriatric-specific markers is a substantial paradigm shift from the traditional preoperative evaluation of older adults.

Postoperative delirium in the elderly: diagnosis and management

Delirium is a common but often undiagnosed complication in the elderly following a major operation. Recognizing the presentation of delirium and the criteria to establish the diagnosis of delirium will improve a clinician’s ability to detect this complication. Treating delirium with environmental, supportive, and pharmacologic interventions reduces the incidence and side effects of postoperative delirium. The purpose of this review is to describe the diagnosis and treatment of postoperative delirium.

Clinical indications and accuracy of gray scale ultrasonography in the patient with suspected biliary tract disease

One hundred patients with suspected biliary tract disease underwent gray scale cholecystosonography (GSCS) and had diagnostic confirmation by oral cholecystogram (OCG) and/or operation. Ultrasonography demonstrated the gallbladder in 94 of the 100 patients; 2 patients had had previous cholecystectomy and 3 of the 4 remaining patients had documented stones with no confirmation of a nonvisualizing OCG in the other patient. Among the 88 patients with OCG, GSCS findings correlated in 91 per cent (2 per cent false-positive; 7 per cent false-negative). Among the 43 operative patients, GSCS was proven correct in 91 per cent (no false positive; 9 per cent false-negative). Of 12 patients with jaundice GSCS correlated with operative findings in 75 per cent (no false-positive; 25 per cent false-negative). Diagnostic errors occurred in patients with very small biliary calculi, particularly when a single stone was impacted in the cystic duct. Failure to identify the gallbladder with ultrasound signifies probable cholelithiasis in the patient without previous cholecystectomy. On the basis of this experience, we conclude that (1) GSCS is most useful when jaundice or acute illness precludes conventional studies; (2) GSCS provides an inexpensive, quick, accurate means of diagnosing cholelithiasis with a very high specificity (97 per cent) and moderate sensitivity (88 per cent); and (3) GSCS is the optimal diagnostic procedure for evaluating the biliary tract in the acutely ill, jaundiced, vomiting, allergic, and/or pregnant patient.

Experimental cryoprobe production of intrahepatic portocaval shunt.

Abstract Experiments have been performed on 25 pigs creating a shunt through the liver substance between the portal vein and the vena cava. The technique involves passage of a small caliber (5 mm) probe via an incision in the portal vein to a major branch of the left hepatic vein. Directed toward a finger on the middle hepatic vein, a 9-mm diameter tunnel is created through 3 cm of liver tissue to the hepatic venous outflow tract. A rigid cryoprobe (−70°C) created a 9-mm diameter tunnel between the portal and hepatic veins through the substance of the liver. Six of 11 animals sacrificed between 5 and 56 days postoperatively had patent shunts; these unheparinized animals had normal portal pressures. The technique is designed ultimately to provide a relatively atraumatic method for creating an emergency portocaval shunt in patients with bleeding esophageal varices.

Reduction of splenic vascular resistance during perfusion by pluronic F68

Abstract Pluronic F68 (a nonionic surface-active agent) has been shown to decrease the vascular resistance in a series of 10 pig spleens perfused with human blood. Addition of Pluronic F68 produced a vascular resistance during heterologous perfusion comparable to that noted during homologous perfusion. In so doing it increased the duration of successful perfusion from 1 to 6 hours.

The role of electron microscopy in the management of surgical patients.

This report records a 12-month experience with 49 neoplasms submitted to the hospital pathologists for electron microscopic (EM) diagnosis as a part of routine clinical surgical practice. Twenty-five specimens were from a private community hospital and 24 from a university hospital. In 40 of 49 cases (82%), EM confirmed a tentative light microscopic (LM) diagnosis. In 11 of these 40 cases, EM provided a more specific histogenetic diagnosis than was possible by LM. In three cases (6%), EM corrected the original LM diagnosis. In two cases EM did not resolve a diagnostic dilemma. EM is a beneficial adjunct to the correct diagnosis of selected tumors. Although in general EM does not help differentiate benign from malignant tumors, it is helpful in identifying the cell of origin of poorly differentiated neoplasms. A more precise histogenetic diagnosis was judged to be clinically helpful in 56% of the cases studied in this experience. EM is a relatively inexpensive (115–250) and prompt (three to five days) adjunct to surgical care. It should be routinely available to the practicing surgeon for help in determining the cell type of confusing tumors. EM is no longer simply a research tool.

Gastric mucosal blood flow measurement

1. 1. Pertechnetate clearance (CTc) by the stomach before and after betazole stimulation was compared to regional measurements of gastric blood flow utilizing nuclide (Chromium-51 and Cerium-141) labeled microspheres in five piglets. 2. 2. Pertechnetate clearance closely correlated (correlation coefficient 0.926) with mucosal blood flow in the gastric corpus measured by the microsphere technique. Betazole increased blood flow in the corpus region by 100% but did not alter this relationship. Except in one experiment, microsphere blood flow valves in the antrum and fundus were unchanged by betazole and did not significantly correlate with pertechnetate clearance. 3. 3. Pertechnetate clearance appears to be a reliable method of determining gastric mucosal blood flow in experimental animals and may be considered as a noninvasive method for measuring such flow in humans.

Carbohydrate metabolism of the lung

Abstract Studies have been performed on 25 isolated perfused dog lungs quantitating glucose metabolism. In three additional experiments 14 C-glucose was employed. The lung actively metabolized 0.53–0.64 mg. glucose/gm./lung/hr. Studies of lung metabolism and techniques for their preservation should take into account its active metabolism of glucose.

In vitro challenge and antibody production of the ex vivo perfused spleen.

Summary Antigenic challenge with sheep red blood cells has been made to 16 pig spleens, 4 hours after excision and placement in an asanguinal perfusion system. Antibody-producing lymphocytes, both within the spleen and in the perfusate, were detected in increasing amounts for 3 days of perfusion. This is the first definite evidence that an isolated perfused organ can manufacture antibody-producing cells following primary antigenic stimulation in vitro.

Training foreign academicians in U.S. medical schools

Abstract Of 500 foreign medical graduates working as surgical research fellows in the U.S., an important few are within University hospitals shaping their careers to become academic surgeons overseas. A seminar program is described which acquaints potential foreign academicians with medical education and practice in this country. We have developed this program over the past 20 years to meet the need of our future teachers above and beyond their purely scientific interests.