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Design An observational cohort study conducted at a tertiary referral center for aortic surgery to describe the medical and surgical characteristics of patients assessed for abdominal aortic aneurysm repair and examine associations with 12-month outcome. Methods Patients with aortic aneurysms referred for discussion at the aortic multidisciplinary meeting (MDM). Data were collected via a prospectively maintained clinical database and included aneurysm characteristics, patient demographics, co-morbidities, geriatric syndromes, including frailty, management decision and 12-month mortality, both aneurysm-related and all-cause including cause of death. The operative and non-operative groups were compared statistically. Results 621 patients referred to aortic MDM; 292 patients listed for operative management, 141 patients continued on surveillance, 138 patients for non-operative management. There was a higher 12-month mortality rate in the non-operative group compared to the operative group (41% vs 7%, P = <0.001). In the non-operative group, 16 patients (29%) died of aneurysm rupture within 12 months, with 39 patients (71%) dying from other medical causes. Non-operatively managed patients were older, more likely to have cardiac and respiratory disease and more likely to be living with frailty, cognitive impairment and functional limitation, compared to the operative group. Conclusion This study shows that preoperative geriatric syndromes and increased comorbidity lead to shared decision to non-operatively manage asymptomatic aortic aneurysms. Twelve-month mortality is higher in the non-operative group with the majority of deaths occurring due to cause other than aneurysm rupture. These findings support the need for preoperative comprehensive geriatric assessment followed by multispecialty discussion and shared decision making. [ABSTRACT FROM AUTHOR]

Older adults constitute a large proportion of patients undergoing surgery and present with complexity, predisposing them to adverse postoperative outcomes. Inequalities exist in the provision of surgical care across the United Kingdom evidenced by increased waiting times in areas of social deprivation, a disparity in the provision of surgical care across geographic locations as well as a variation in the medical management of comorbidities in surgical patients. Addressing inequalities in the delivery of perioperative care for older adults necessitates a multi-faceted approach. It requires implementation of an evidence-based approach to optimisation of older surgical adults using Comprehensive Geriatric Assessment and optimisation methodology at scale, development of an age-attuned, flexible, transdisciplinary workforce, a restructuring of funding to commission services addressing the needs of the older surgical population and a change in culture and professional and public understanding of the needs of the older surgical patient. [ABSTRACT FROM AUTHOR]

Background: This is Part 2 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy (EL) using an Enhanced Recovery After Surgery (ERAS) approach. This paper addresses intra- and postoperative aspects of care. Methods: Experts in aspects of management of high-risk and emergency general surgical patients were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and Medline database searches were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Some ERAS® components covered in other guideline papers are outlined only briefly, with the bulk of the text focusing on key areas pertaining specifically to EL. Results: Twenty-three components of intraoperative and postoperative care were defined. Consensus was reached after three rounds of a modified Delphi Process. Conclusions: These guidelines are based on best available evidence for an ERAS® approach to patients undergoing EL. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies. [ABSTRACT FROM AUTHOR]

Frailty is common in the older population and is a predictor of adverse outcomes following emergency and elective surgery. Identification of frailty is key to enable targeted intervention throughout the perioperative pathway from contemplation of surgery to recovery. Despite evidence on how to identify and modify frailty, such interventions are not yet routine perioperative care. To address this implementation gap, a guideline was published in 2021 by the Centre for Perioperative Care and the British Geriatrics Society, working with patient representatives and all stakeholders involved in the perioperative care of patients with frailty undergoing surgery. The guideline covers all aspects of perioperative care relevant to adults living with frailty undergoing elective and emergency surgery. It is written for healthcare professionals, as well as for patients and their carers, managers and commissioners. Implementation of the guideline will require collaboration between all stakeholders, underpinned by an implementation strategy, workforce development with supporting education and training resources, and evaluation through national audit and research. The guideline is an important step in improving perioperative outcomes for people living with frailty and quality of healthcare services. This commentary provides a summary and discussion of the evidence informing the standards and recommendations in the published guideline. [ABSTRACT FROM AUTHOR]