Commentary (Barden/Daly): Surgery in the Older Patient

The elderly population in the United States increased by a factor of 11 in the past century, while the under age 65 population tripled in that same period.[1] Given that the majority of cancers occur in patients over 65 years old, there is an increasing need for surgical interventions in the elderly.

Surgery in the Elderly

The article by Drs. Termuhlen and Kemeny is a timely and relevant review of several issues surrounding surgical oncologic care of elderly patients. The authors summarize recent data on the resection of breast, colorectal, pancreatic, and gastric cancer in elderly patients, as well as risk assessment and procedures for palliation. Unfortunately, most of the data regarding oncologic surgery in the elderly are derived from retrospective studies, as there is a paucity of randomized trials in this population.

Recent studies suggest that most postoperative morbidity and mortality is a function of the current physiologic state of the patient, not the patient’s chronologic age. Moreover, survival after the resection of malignancy is usually equivalent for older and younger patients when controlled for stage of disease. Elderly patients may present with more advanced disease, often requiring emergency surgery without time for adequate preparation. Thus, greater awareness in the medical community of the increased incidence of malignant disease in the elderly should result in improved screening and surveillance practices.

Fong and associates reported the results of surgery for elderly patients (age 70 years or more) undergoing liver or pancreatic resection for malignancy.[2] They found no significant differences in perioperative mortality, complication rate, hospital length of stay, or intensive care unit admission, compared to a younger cohort. The perioperative and long-term survival results were also similar for older and younger patients. The authors concluded that advanced chronologic age should not be regarded solely as a contraindication to liver or pancreatic resection in the elderly.

Cost-Effectiveness of Surgery in the Elderly

An important issue that was not addressed in the article is that of cost-effectiveness of surgical intervention in this population. Physicians are being asked to justify the expense of treating elderly patients because a rise in the number of operations performed in this age group will have an impact on overall health-care spending and allocation of medical resources.

One recent retrospective study evaluated the cost-effectiveness of coronary artery bypass graft surgery in patients over age 80 years.[3] Patients in the surgical cohort reported greater quality of life (equivalent to that of a 55-year-old person in the general population) and a greater 3-year survival than age-matched controls managed medically. The cost per quality-adjusted life year was approximately $10,000 greater for patients undergoing the bypass graft vs those being managed medically. Further studies of oncologic surgery and procedures are needed to justify major resections for malignancy in this population.

Preoperative Evaluations

The majority of all perioperative complications in elderly patients are cardiopulmonary. Therefore, identification of cardiac risk becomes increasingly important in the older population. Indeed, most of the concern in preparing elderly patients for surgery relates to their cardiac status, particularly prevention of perioperative myocardial infarction. The mortality of perioperative myocardial infarction is four times greater than when myocardial infarction is not associated with an operative procedure. Several risk assessment scales, such as the CRIS and Goldman risk criteria, have been shown to be predictive of cardiac mortality.

Assessment of physiologic status in preparation of the patient for surgery centers on the history and physical examination.[4] The review of symptoms may suggest comorbid conditions that should be investigated. Preoperative testing may include more extensive studies such as pulmonary function testing, arterial blood gas measurement, echocardiography, stress electrocardiography, and cardiac nuclear medicine testing.

Conclusions

The authors make several recommendations regarding how to better manage the elderly surgical patient preoperatively. A thorough medical evaluation is the cornerstone of preoperative optimization in these patients. Attention is directed to physiologic variables that may increase the risk of perioperative morbidity and mortality.

An important reminder also addressed by the authors is the need for increased awareness among members of the patient’s support systems, which play a larger role in postoperative care for older patients. Realistic discussions with patients and their families about advance directives as well as extension and/or quality of life postoperatively are equally paramount.

References:

1. US Bureau of the Census: Population Projections of the United States, byAge, Sex, Race and Hispanic origin: 1993-2050, Current population reports,P25-1104. US Government Printing Office, 1993.

2. Fong Y, Blumgart LH, Fortner JG, et al: Pancreatic or liver resection formalignancy is safe and effective for the elderly. Ann Surg 222:426-437, 1995.

3. Sollano JA, Rose EA, Williams, DL, et al: Cost-effectiveness of coronaryartery bypass surgery in octogenarians. Ann Surg 228:297-306, 1998.

4. Daly JM, Barie PS, Fahey TJ III: Preparation of the patient, in Baker RJ,Fischer JE (eds): Mastery of Surgery, 4th ed, pp 23-54. Philadelphia, LippincottWilliams & Wilkins, 2001.