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Background: Outcome data on the very elderly patients undergoing emergency general surgery (EGS) are sparse. We sought to examine short- and long-term mortality in the 80 plus years population following EGS., Methods: Using our institutional 2008-2018 EGS Database, all the 80 plus years patients undergoing EGS were identified. The data were linked to the Social Security Death Index to determine cumulative mortality rates up to 3 years after discharge. Univariate and multivariable logistic regression analyses were used to determine predictors of in-hospital and 1-year cumulative mortality., Results: A total of 385 patients were included with a mean age of 84 years; 54% were female. The two most common comorbidities were hypertension (76.1%) and cardiovascular disease (40.5%). The most common procedures performed were colectomy (20.0%), small bowel resection (18.2%), and exploratory laparotomy for other procedures (15.3%; e.g., internal hernia, perforated peptic ulcer). The overall in-hospital mortality was 18.7%. Cumulative mortality rates at 1, 2, and 3 years after discharge were 34.3%, 40.5%, and 43.4%, respectively. The EGS procedure associated with the highest 1-year mortality was colectomy (49.4%). Although hypertension, renal failure, hypoalbuminemia, hyperbilirubinemia, and elevated liver enzymes predicted in-hospital mortality, the only independent predictors of cumulative 1-year mortality were hypoalbuminemia (odds ratio, 2.17; 95% confidence interval, 1.10-4.27; p = 0.025) and elevated serum glutamic pyruvic transaminase (SGOT) level (odds ratio, 2.56; 95% confidence interval, 1.09-4.70; p = 0.029) at initial presentation. Patients with both factors had a cumulative 1-year mortality rate of 75.0%., Conclusion: More than half of the very elderly patients undergoing major EGS were still alive at 3 years postdischarge. The combination of hypoalbuminemia and elevated liver enzymes predicted the highest 1-year mortality. Such information can prove useful for patient and family counseling preoperatively., Level of Evidence: Prognostic, Level III.

Background: The decision to emergently operate on nonagenarian patients (NONAs) can be complex due to the uncertainty about outcomes and goals of care at this advanced age. We sought to study: (1) the outcomes and predictors of mortality for NONAs undergoing emergency general surgery (EGS) and (2) the accuracy of ACS-NSQIP mortality risk calculator in this special population., Methods: Using the 2007 to 2015 ACS-NSQIP database, we included all patients older than 90 years of age who underwent an emergent operation with a Current Procedural Terminology (CPT) code for "digestive system." Multivariable logistic regression analyses were performed to identify independent predictors of 30-day mortality. NONAs' mortality rates for different combinations of risk factors were also studied and compared to the ACS-NSQIP calculator-predicted mortality rates., Results: Out of a total of 4,456,809 patients, 4,724 NONAs were included. The overall 30-day patient mortality and morbidity rates were 21% and 45%, respectively. In multivariable analyses, several independent predictors of 30-day mortality were identified, including recent history of weight loss, history of steroid use, smoking, functional dependence, hypoalbuminemia and sepsis or septic shock. The mortality among NONAs with a history of steroid use and a recent history of weight loss was 100%. Similarly, the mortality of NONAs with recent history of weight loss who presented with preoperative septic shock was 93%. The ACS-NSQIP calculator significantly and consistently underestimated the risk of mortality in all NONAs undergoing EGS., Conclusion: Most NONAs undergoing EGS survive the hospital stay and the first 30 postoperative days, even in the presence of significant preexisting comorbidities. However, the combination of recent weight loss with either steroid use or septic shock nearly ensures mortality and should be used in the discussions with patients and families before a decision to operate is made. The ACS-NSQIP surgical risk calculator should be used with caution in these high-risk patients., Level of Evidence: Prognostic study, level III.

Background: The Emergency Surgery Score (ESS) was validated recently as an accurate and user-friendly post-operative mortality risk calculator specific for Emergency General Surgery (EGS). ESS is calculated by adding one to three integer points for each of 22 pre-operative variables (demographics, co-morbidities, and pre-operative laboratory values); increasing scores accurately and gradually predict higher mortality rates. We sought to evaluate whether ESS can predict the occurrence of post-operative infectious complications in EGS patients., Patients and Methods: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2007-2015, all EGS patients were identified by using the "emergent" ACS-NSQIP variable and a concomitant surgery Current Procedural Terminology code for "digestive system." Patients with any missing ESS variables or those who died within 72 hours from the surgical procedure were excluded. A composite variable, post-operative infection, was created and defined as the post-operative occurrence of one or more of the following: superficial, deep incisional or organ/space surgical site infection, surgical site disruption, pneumonia, sepsis, septic shock, or urinary tract infection. ESS was calculated for all included patients, and the correlation between ESS and post-operative infection was examined using c-statistics., Results: Of a total of 4,456,809 patients, 90,412 patients were included. The mean age of the population was 56 years, 51% were female, and 70% were white; 22% developed one or more post-operative infections, most commonly sepsis/septic shock (12.2%), surgical site infection (9%), and pneumonia (5.7%). The ESS gradually and consistently predicted infectious complications; post-operative infections developed in 7%, 24%, and 49% of patients with an ESS of 1, 5, and 10, respectively. The c-statistics for overall post-operative infection, post-operative sepsis/septic shock, and pneumonia were 0.73, 0.75, and 0.80, respectively., Conclusion: The ESS accurately predicts the occurrence of post-operative infectious complications in EGS patients and could be used for pre-operative clinical decision-making as well as quality benchmarking of infection rates in EGS.