Background: As the population ages, more older adults are presenting for surgery. Age-related declines in physiological reserve and functional capacity can result in frailty and poor outcomes after surgery. Hence, optimizing perioperative care in older patients is imperative. Enhanced Recovery After Surgery (ERAS) pathways and Minimally Invasive Surgery (MIS) may influence surgical outcomes, but current use and impact on older adults patients is unknown. The aim of this study was to provide evidence-based recommendations on perioperative care of older adults undergoing major abdominal surgery. Methods: Expert consensus determined working definitions for key terms and metrics related to perioperative care. A systematic literature review and meta-analysis was performed using the PubMed, Embase, Cochrane Library, and Clinicaltrials.gov databases for 24 pre-defined key questions in the topic areas of prehabilitation, MIS, and ERAS in major abdominal surgery (colorectal, upper gastrointestinal (UGI), Hernia, and hepatopancreatic biliary (HPB)) to generate evidence-based recommendations following the GRADE methodology. Result: Older adults were defined as 65 years and older. Over 20,000 articles were initially retrieved from search parameters. Evidence synthesis was performed across the three topic areas from 172 studies, with meta-analyses conducted for MIS and ERAS topics. The use of MIS and ERAS was recommended for older adult patients particularly when undergoing colorectal surgery. Expert opinion recommended prehabilitation, cessation of smoking and alcohol, and correction of anemia in all colorectal, UGI, Hernia, and HPB procedures in older adults. All recommendations were conditional, with low to very low certainty of evidence, with the exception of ERAS program in colorectal surgery. Conclusions: MIS and ERAS are recommended in older adults undergoing major abdominal surgery, with evidence supporting use in colorectal surgery. Though expert opinion supported prehabilitation, there is insufficient evidence supporting use. This work has identified evidence gaps for further studies to optimize older adults undergoing major abdominal surgery.

To investigate hospital-level variation in short-term laparoscopic colectomy outcomes among stage I-III elderly colon cancer patients. Surgical outcomes are associated with patient and surgeon characteristics. If outcomes are also impacted by the hospital where the surgery occurs, there is a hospital center effect (HCE). Surveillance, Epidemiology, and End Results (SEER)-Medicare data was used to identify stage I-III colon cancer patients treated with laparoscopic colectomies. Multilevel regressions were utilized to study potential HCE for length of stay (LOS), 30-day rehospitalization, and in-hospital mortality, adjusting for patient, surgeon, and hospital-level characteristics. To quantify HCE, we calculated the median instantaneous rate ratio (MIRR) for LOS and median odds ratio (MOR) for in-hospital mortality and 30-day rehospitalization. Sensitivity analyses were conducted for high volume/medical school affiliated hospitals and colorectal surgeons. The multilevel analyses based on 4617 patients from 465 hospitals documented statistically significant HCEs for LOS (MIRR = 1.35; P < 0.001) and in-hospital mortality (MOR = 1.69; P = 0.032), but no HCE for 30-day rehospitalization. Sensitivity analyses confirmed our findings. HCE was significant for LOS in all sensitivity analyses and was significant for in-hospital mortality for high volume/medical school affiliated hospitals. HCE exists for LOS and in-hospital mortality of laparoscopic colectomy, which suggests that the choice of hospital affects outcomes independently of other confounding variables. Reducing the variation in outcomes associated with HCE may improve the quality of cancer care.

The faecal occult blood test (FOBT) is the screening test validated for use in the National Health Service (NHS) Bowel Cancer Screening Programme (BCSP) after trials demonstrated a 16% reduction in colorectal cancer-specific mortality. FOBT is not validated for use outside the BCSP. The aim was to investigate the number of FOBTs performed outside of the NHS BCSP at a single centre. All FOBTs performed over 1 year were identified. Basic patient demographics, requesting physician and FOBT results were obtained. Referrals and outcomes of the investigation following the FOBT were collected. A total of 758 FOBTs were requested in 701 patients (352 female; median age 69; range 16-99). The majority (91%) were requested by general practitioners. A total of 515 out of 758 tests (68%) were performed in patients outside the NHS BCSP age range. Thirty-seven out of 86 positive FOBTs were investigated, diagnosing four rectal cancers and two polyps. Forty-nine out of 87 patients with a positive FOBT were not investigated further by the requesting physician or the test repeated. Of the remaining 672 FOBTs, 615 were negative and 57 were either incomplete or unsuitable for analysis. A total of 111 patients (18%) were referred to hospital and 105 of these had FOBT performed as part of the referral process. Our study demonstrates significant misuse of the FOBT outside the NHS BCSP. Inappropriate use leads to false positives and exposes patients to unnecessary risk. False negatives provide reassurance to patients who may have symptoms that should be investigated. The FOBT should not be available to physicians in either primary or secondary care and be restricted to NHS BCSP.