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234 B. Eiseman
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Allies
Warfare with neighbors, as mentioned, is to be avoided, but
allies in peaceful negotiation should be cultivated by a newly
independent specialty. The most obvious ally for the geriatric surgeon are the geriatricians who themselves only recently
achieved their own independence. Even more powerful support, however, can come from those who pay the enormous
cost of geriatric health care. The two big payers are the government and health insurers. Once they are convinced that
geriatric surgical specialists are cost-effective, the war for
specialty survival is assured. Subsequent bloody battles may
be necessary, but independence will follow. Geriatric surgeons are well advised to improve and document their costeffectiveness.
Internal Stability
Independence inevitably creates temporary turbulence and
instability. Examples such as internal conflicts of the Sunnis
and Shias or the Tutsis and Hutus abound in foreign affairs.
The health care specialty equivalents are the internal disputes
among vascular surgeons or invasivist vs. noninvasivist gastroenterologists or cardiologists.
Founders of surgical geriatrics should promptly settle
self-destructive internal disputes among tribal leaders and
present a united front to professional competitors.
The Slippery Slope of Health Care
Specialization
Pioneer health care specialists routinely deny intent to
become involved in the complexities that characterize
administration of other new specialties. They inevitably fail
and so will surgical geriatricians who might as well resign
themselves to the frustrations and pangs of the required rites
of transition. Steps on this slippery slope are familiar. An
early manifestation is a web page, which now serves to
advertise a new faith and as did the church door for Martin
Luther. Subsequent steps include definition of training
requirements for the new specialty. Fellowships precede
specialty residencies which soon follow. This leads to
Residency Review Committees, formal requirements for
accreditation, an examination, one’s very own Board, a
Central Office, a Director and his or her staff, annual meetings and dues, and endless black-tie dinners and speeches.
Soon thereafter, a large multiauthored textbook appears.
A separate journal inevitably follows.
This formal professional minuet absorbs an unbelievable
amount of time, energy, and stress on one’s family but apparently is unavoidable.
Health Policy Decisions
Founders of geriatric surgery struggling for recognition can
benefit from realizing their unique opportunity to influence
US health-care policy at a moment when it is anticipating
significant change. The high cost, low societal and personal
yield of their patient population constitutes a particularly
vulnerable segment of health- care patients whose most costeffective care would be ideal for critical review and change
when our society is ready to include cost–benefit analysis in
the formulae dictating government reimbursement.
Involvement in such medical political pioneering by the
leadership in geriatric surgery would have enormous collateral benefit to this new specialty.
You are well launched and will thrive. You also predictably will resent future efforts of young whippersnappers who
will suggest further separation from your then established
authority.
Chapter 20
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Principles of Geriatric Surgery
Mark R. Katlic
With a few obvious exceptions, those of us who are
surgeons must become geriatric surgeons. The population
as a whole is aging, with the most explosive growth in the
over 85 year group, and the conditions that require surgery
(atherosclerosis, cancer, arthritis, prostatism, cataract, and
others) increase in incidence with increasing age. Improving
our care of the elderly surgical patient – the raison d’etre
of this book – will become progressively more important to
us all.
Admittedly, surgeons have always cared for the elderly,
but the definition of “elderly” has changed. A threshold of
50 years was chosen for the 167 patients described in a paper
in 1907 [1], and 20 years later influential surgeons still wrote
that elective herniorrhaphy in this age group was not warranted [2]. Now, though, we are performing complex operations in octogenarians, nonagenarians, and occasionally
centenarians [3–7]. In addition, the salutary results of such
surgery can even influence general sentiment about medical
care of the elderly. Linn and Zeppa’s study [8] of junior
medical students reported that the surgery rotation, in contrast to other clerkships, positively influenced the students’
attitudes about aging regardless of the students’ career
choices, as the elderly surgical patients were admitted and
treated successfully.
Surgery therefore has much to offer the geriatric patient,
but that patient must be treated with appropriate knowledge
and attention to detail. Discussions of physiologic changes
in the elderly and results of specific operations comprise the
bulk of this book and are not presented here. The author’s
quarter-century study in this area, in addition to caring for
an elderly thoracic oncology population, has led to a distillate of several general principles (Table 20.1) which are relevant to all who care for the aged. These principles are
worthwhile chiefly for propaedeutic purposes, as they can-
Ta b l e 20.1 Principles of geriatric surgery
I. The clinical presentation of surgical problems in the elderly may
be subtle or somewhat different from that in the general population. This may lead to delay in diagnosis
II. The elderly handle stress satisfactorily but handle severe stress
poorly because of lack of organ system reserve
III. Optimal preoperative preparation is essential, because of Principle
II. When preparation is suboptimal, the perioperative risk increases
IV. The results of elective surgery in the elderly are reproducibly
good; the results of emergency surgery are poor though still better
than nonoperative treatment for most conditions. The risk of
emergency surgery may be many times that of similar elective
surgery because of Principles II and III
V. Scrupulous attention to detail intraoperatively and perioperatively
yields great benefit, as the elderly tolerate complications poorly
(because of Principle II)
VI. A patient’s age should be treated as a scientific fact, not with
prejudice. No particular chronologic age, of itself, is a contraindication to operation (because of Principle IV)
M.R. Katlic (*)
Division of Thoracic Surgery,
Director, Regional Ambulatory Campus Geisinger Wyoming Valley
Medical Center, Wilkes-Barre, PA, USA
e-mail: mrkatlic@geisinger.edu
R.A. Rosenthal et al. (eds.), Principles and Practice of Geriatric Surgery,
DOI 10.1007/978-1-4419-6999-6_20, © Springer Science+Business Media, LLC 2011
235
236 M.R. Katlic
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Fi g u r e 20.1 Operative mortality
in the national Medicare
population has declined for some,
but not all, procedures. Adjusted
odds ratios (average change in
mortality) and 95% confidence
intervals for the 6-year period
1994–1999. Adjusted for age,
gender, race, comorbidities,
admission acuity, income, and
hospital volume (from Goodney
et al. [10], reprinted with
permission from Elsevier).
not apply to every patient or every clinical situation. Some
principles also apply to surgery in the young patient, but the
quantitative differences in the elderly are significant enough
to approach qualitative status. Risks of many emergency
operations in the young, for example, are indeed greater
than the risks of similar elective operations, but the differences are small compared with the threefold increase in the
elderly. With respect to these principles, the elderly need not
be treated as a separate species but perhaps as a separate
genus or order within the same larger group of surgical
candidates.
Although our results have generally improved over the
9], this improvement has not been universal [10]
years [
(Fig. 20.1), and emergency surgery is still risky (Fig. 20.2).
So, how do we do better?
Principle I: Clinical Presentation
The clinical presentation of surgical problems in the elderly
may be subtle or somewhat different from that in the general
population. This may lead to delay in diagnosis.
Fi g u r e 20.2 Decline in surgical mortality in elderly over time (emer-
gency always much higher) (from Thomas and Ritchie [9], with permission from Blackwell Publishing).
23720 Principles of Geriatric Surgery
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CASE STUDY
This brief case report illustrates several of the six
Principles of Geriatric Surgery outlined in this chapter.
An 88-year-old man was referred for evaluation and
treatment of a right lung mass. He had been a cigarette
smoker for 40 years but quit 25 years prior to evaluation.
He had fully recovered from a cerebrovascular accident
8 years before – playing golf several times each week,
had undergone inguinal herniorrhaphy, and took only
nifedipine. A chest radiograph ordered because of a nagging cough showed a hazy perihilar density that, on
computed tomogram (Fig. 20.3), proved to be a 4-cm
right lower lobe mass. His family physician told him
that he was too old for surgery, but he and his wife
wanted another opinion.
Examination showed a tall man with a strong regular
pulse and blood pressure 140/82 mmHg. Lungs were
clear, heart without murmur, abdomen benign. Computed
tomograms showed no adenopathy and no evidence of
metastatic disease. Pulmonary function was greater than
100% of predicted. Bronchoscopy was grossly and cytologically unremarkable. After a discussion of risks and
alternatives, he chose to undergo resection.
Right lower lobectomy was performed for what
proved to be a 3-cm squamous cell carcinoma with negative hilar and mediastinal nodes. Stapled vessel and
bronchial
closures were reinforced with sutures. Venous
compression stockings and monitoring of oxygen
saturation and cardiac rhythm were maintained overnight. He had an uncomplicated postoperative course.
He resumed golfing and social life. I saw the patient
and his wife of 70 years having dinner on Valentine’s
Day 1 month prior to his death from pneumonia, without
evidence of cancer, at an age of 92.
Fi g u r e 20.3 Computed tomogram of 88-year-old patient with right
lower lobe cancer.
Classic symptoms of appendicitis are present in a minority of
elderly patients, as few as 26% in Horattas’ series over
20 years [11] (Table 20.2). Rebound tenderness was present
in fewer than half the patients in another series [12] and
leukocytosis in only 42.9% in a third series [13]. Clouding the
picture further, objective tests may suggest alternative diagnoses: one in six patients has an elevated bilirubin and one in
four has signs of ileus, bowel obstruction, gallstones, or renal
calculus on abdominal radiographs [14]. Even astute diagnosis may not prevent perforation, present in 42–60% of elderly
patients despite operation within 24 h of symptom onset
[11, 13].
Biliary tract disease is the most common entity requiring
abdominal surgery in the elderly, yet the diagnosis is often
delayed. More than one-third of patients with acute cholecystitis are afebrile, one-fourth are nontender, and one-third
are without leukocytosis [15–17]. Cholangitis may appear
only as fever of unknown origin or as confusion [18].
Consequently, the elderly predominate in series of patients
with complications of biliary disease (gallbladder perforation, empyema, gangrene, gallstone ileus, and cholangitis) [19],
Ta b l e 20.2 Classic symptoms of appendicitis are present in a minority
of elderly patients, resulting in perforation despite expeditious operation
Twenty-year comparison and compilation
Characteristic
Classic presentation (19) 20% (36) 30%
Delayed presentation (>48 h) (32) 33% (36) 30% (68) 33%
Imaging
AAS (81) 84% (86) 76% (167) 80%
Sensitivity (22) 27% (22) 25% (44) 26%
CT (50) 44%
Sensitivity (45) 90%
Correct admitting diagnosis (49) 51% (52) 46% (101) 48%
Surgery within 24 h (80) 83% (97) 85% (177) 85%
Perforation (60) 72% (58) 51% (127) 61%
Complications (30) 32% (24) 21% (54) 26%
Those with perforation (25) 83% (15) 72% (40) 76%
Deaths (4) 4% (4) 4% (8) 4%
From Storm-Dickerson [11]. Reprinted with permission from Elsevier
1978–1988
(n = 96)
1988–1998
(n = 113)
1978–1998
(n = 209)
(55) 26%
and the complication may result in the first apparent
symptom [16, 20]. Saunders [21] reported that abdominal
pain was a less prominent symptom and that the bilirubin
238 M.R. Katlic
Symptoms
Number (%) of patients
p-value
Group A
(<65 years)
(n = 241)
Group B
(³65 years)
(n = 63)
Heartburn 209 (86) 45 (47) 0.001
Dysphagia 92 (38) 28 (35) 0.77
Regurgitation 113 (47) 46 (71) 0.001
Chest pain
97 (39) 18 (28) 0.13
Cough 89 (37) 42 (67) 0.001
Response to proton pump
inhibitors
a
70 75 0.53
Reprinted with permission from Tedesco [26] © 2006 Massachusetts
Medical Society. All rights reserved
a
Percentage of patients
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level was nearly double in elderly patients presenting with
bile duct carcinoma, compared with the findings in young
patients seen during the same time period.
Peptic ulcer disease may present as confusion, malaise,
anemia, or weight loss as opposed to pain [22]; even with
perforation pain may be absent or minimal. Rabinovici and
Manny [23] found a discrepancy between “severe intraoperative findings” and preoperative objective findings such as
heart rate (mean 88/min), temperature (37.2°C), and white
blood cell count (10,900/dl). Some have suggested that the
elderly and possibly their physicians become tolerant over
the years to abdominal pain, loss of energy, and other symptoms, resulting in a delay in diagnosis or an emergency
presentation. In Mulcahy’s [24] series of patients with
colorectal carcinoma, for example, elderly patients were
nearly twice as likely (18%) as younger patients (11%) to
present emergently. Elderly patients with perforated diverticulitis are three times more likely to have generalized
peritonitis at operation than young patients [25].
Gastroesophageal reflux disease in the elderly is less
likely to cause heartburn and more likely to cause regurgitation or cough (p = 001) [26]. In Pilotto’s study of 840 consecutive patients [27], typical heartburn/acid reflux, pain,
and indigestion were more likely in the young (p < 0.001);
older patients more often experienced dysphagia, anorexia,
anemia, or vomiting (p < 0.001 each) or weight loss (p < 0.007)
(Table 20.3).
Head and neck disease may also present differently in the
elderly. Sinusitis may lead to subtle signs such as delirium or
fever of unknown origin [28, 29]; and head and neck cancers
are less likely to be associated with smoking (p < 0.01) [30]
and alcohol use (p < 0.001) [30, 31]. Hyperparathyroidism is
more likely to cause dementia or skeletal complaints and less
likely to cause renal stones [32]. In Thomas and Grigg’s
series [33] of patients with carotid artery disease, stroke was
the most common indication for surgery in octogenarians
and was the least common indication in younger patients.
Unstable angina is as likely to present with dyspnea, nausea,
or diaphoresis as it is with classic chest pain [34].
Even the eureka moments that keep us energized as diagnosticians [35] may be “subtler and less electric” [36] in the
elderly.
The clinician who understands that classic presentations
of surgical disease occur in a minority of elderly patients will
maintain the high index of suspicion needed to minimize
delay in diagnosis.
Principle II: Lack of Reserve
The elderly handle stress satisfactorily but handle severe
stress poorly because of lack of organ system reserve.
Functional reserve may be considered the difference between
basal and maximal function (Fig. 20.4); it represents the
capacity to meet increased demands imposed by disease or
trauma. Although there is variability among individuals, this
organ system reserve inexorably declines in one’s 70s, 80s,
and 90s (Fig. 20.5). With excellent anesthetic and perioperative care, the aged patient may tolerate the stress of even
complex surgery – particularly if elective – but not the added
stress of exceptional or emergency surgery.
The elderly patient with lung cancer, like our case report
patient, can undergo routine pulmonary lobectomy with
results nearly indistinguishable from those of the general
population [37, 38], but the added stress of concomitant chest
wall resection leads to a disparate increase in risk. In Keagy’s
series [39], the one death and two of the three respiratory
a b l e 20.3 Symptoms of gastroesophageal reflux disease may be
T
different and more subtle in the elderly
Fi g u r e 20.4 Organ system functional reserve is the difference between
maximal function and basal function; reserve declines with age (reprinted
with permission from Muravchick [192], copyright Elsevier 2000).
23920 Principles of Geriatric Surgery
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Fi g u r e 20.5 Lack of reserve: with increasing age cardiac function is
maintained at rest but not under stress. Linear regression at rest and
during maximal cycle ergometry in healthy sedentary men (solid lines)
failures were in patients who underwent the en bloc chest
wall resection. An elderly patient, entering the operating
room with decreased chest wall compliance and strength and
decreased elastic recoil as a baseline, may tolerate lung
resection but lacks the reserve to tolerate an extended operation. Other researchers have reported increased mortality in
septuagenarians and octogenarians following pneumonectomy, especially right pneumonectomy or completion pneumonectomy [40–42].
On the other side of the spectrum, more limited procedures, such as video-assisted thoracic surgery, may decrease
stress further by preserving respiratory muscle strength [43–
46]. Yim [46] reported no deaths or pulmonary complica-
tions following thoracoscopic surgery in 22 patients over an
age of 75, 5 with major resections; and Jaklitsch et al. [44]
found decreased mortality, length of hospital stay, and postoperative delirium after 307 video-assisted procedures in
patients aged 65–90 compared with that associated with
open thoracotomy. Video-assisted pulmonary lobectomy in
half of a group of elderly lung cancer patients resulted in
fewer complications (p = 0.04) and decreased length of stay
(p < 0.001) compared with the half who underwent open
(thoracotomy) lobectomy [47]. Patel et al. [48] reported
shorter hospitalization and similar late outcomes following
endovascular thoracic aortic procedures in patients greater
than 75 years, compared with open procedures.
Left ventricular functional reserve assumes critical importance in elderly patients undergoing cardiac surgery. In general, results in the elderly diverge from those of young age
groups only in the worst functional classes. Bergus et al.
[49], for example, found that the length of stay following
aortic valve replacement was significantly longer (p < 0.05)
and women (dotted lines). All subjects are healthy, community-dwelling
volunteers screened to exclude hypertension and occult coronary artery
disease (reprinted with permission from Lakatta [193]).
in septuagenarians in New York Heart Association class IV
but not in class III, compared with patients under the age of
70. Patients over an age of 75 in Salomon’s large series [
50]
had significantly higher mortality after coronary artery
bypass grafting if they had suffered a myocardial infarction
less than 3 weeks preoperatively compared with more than
3 weeks (14.1 vs. 5.2%); there was much less difference in
patients younger than age 75 (3.5 vs. 2.3%). When patients
over an age of 70 undergo a third coronary reoperation, only
those in the worse Canadian Functional Class experience
increased mortality, an increase not seen in young patients in
a similar class [51]. Elayda et al. [52] reported that mortality
for isolated aortic valve replacement in patients over an age
of 80 was acceptable (5.2%), but addition of concomitant
procedures increased this figure significantly (27.7%).
Similar findings pertain to major abdominal surgery.
Fortner and Lincer [53] found that the increased number of
deaths among elderly patients undergoing hepatic resection
for liver cancer were nearly all in the extended-resection
group (i.e., extended right hepatectomy or trisegmentectomy), among whom 60% of deaths were due to hepatic
insufficiency. In another group of hepatic resections done for
metastatic colon cancer, where cirrhosis and functional
hepatic reserve are less important factors, there was no difference in mortality between young and old patients [
54].
Even the addition of common duct exploration to open cholecystectomy significantly increased mortality in the elderly
(3.5 vs. 1.8%, p < 0.05) [55]. For some oncology cases (e.g.,
gastric cancer and lung cancer), a more limited operation in
the elderly need not decrease survival [56–59].
The elderly can return to normal function after stressful
operations (such as colectomy and hepatectomy), but after
240 M.R. Katlic
100
(%)
100
(%)
50
50
0
MEP(% of preoperative level)
a
b
MEP(% of preoperative level)
0
12 4
After operation(weeks)
After operation(weeks)
12
12 412
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Fi g u r e 20.6 Return to activities of daily living after major surgery
(function returns rapidly after stressful operations but not the most
stressful, speaking to lack of reserve). From Lawrence et al. [60],
reprinted with permission from Elsevier.
the most stressful operations (such as Whipple pancreaticoduodenectomy) it will take longer [60] (Fig. 20.6).
With modern anesthetic and critical care management, an
elderly patient can tolerate the stress of even complex operations. However, if the most extended procedures are contemplated, a comprehensive preoperative evaluation of functional
reserve is recommended.
Principle III: Preoperative Preparation
Optimal preoperative preparation is essential because of
Principle II. When preparation is suboptimal the periopera-
tive risk increases.
A patient’s advanced age is immutable but some factors can
be improved preoperatively, with benefits in excess of those
to a younger patient. No universal threshold of blood hemoglobin applies to every patient, but correction of anemia and
dehydration do assume greater importance in the elderly
because of their general lack of reserve and particularly the
physiology of the aged heart and kidney. Among the predictors of an overall good postoperative course in Seymour’s
series of 288 elderly general surgery patients were a hemoglobin level of more than 11.0
depletion [61]. Contrary to this, Dzankic found that routine
blood testing in the elderly surgical patient rarely showed
abnormal results and even when abnormal did not correlate
with adverse postoperative outcome [62].
Few would argue that pulmonary problems are among the
most common perioperative complications in the elderly, in
part due to decreased respiratory muscle strength. Nomori
et al. [45] showed that following thoracotomy patients older
than 70 years experience significant reductions in both
maximum inspiratory and expiratory pressures, unlike their
younger counterparts; this effect persists for 12 weeks
g/dl and absence of volume
i g u r e 20.7 Postoperative changes in mean (a) maximum inspiratory
F
pressure (MIP, percent of preoperative level) and (b) maximum expiratory pressure (MEP, percent of preoperative level) following pulmonary
resection in 36 patients younger than 69 years (open circles) and 12
patients older than 70 years (closed circles). From Nomori et al. [45],
reprinted with permission from Elsevier).
(Fig. 20.7). Although few data exist to support the routine
use of preoperative pulmonary conditioning or rehabilitation, most authors strongly advocate smoking cessation [63]
and treatment of bronchitis and reactive airways disease such
as asthma [64, 65]. Prophylaxis against deep vein thrombosis
(DVT), clearly a risk in the elderly [66], and against pulmonary embolism should be routine [67].
The value of preoperative optimization of cardiac function (e.g., via placement of a pulmonary artery catheter)
is controversial. Some authors have shown clear benefit
[68], whereas others [69, 70], citing methodologic flaws in
24120 Principles of Geriatric Surgery
300
ab
160
140
120
100
80
60
40
20
0
250
200
Global
Chi
2
Global
Chi
2
Clinical ClinicalClinical +
Rest Echo
Clinical +
Rest Echo
Clinical +
Rest Echo +
DSE Ischemia
Clinical +
Rest Echo +
DSE Ischemia
150
100
50
0
p<0.0001
p<0.001
p<0.0001
p<0.0001
p<0.0001
p<0.01
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the former studies, reported no reduction in perioperative
morbidity or mortality. These studies do not include exceptionally high risk or very elderly patients, who could well
be helped by such treatment. Another unsettled issue concerns the value of aggressive preoperative screening for
coronary and carotid artery disease, particularly in patients
scheduled for peripheral vascular surgery. Leppo [71]
considered age over 70 years to be one of the several risk
factors (the others being a history of angina, congestive
heart failure, diabetes mellitus, prior myocardial infarction,
and ventricular ectopy) that should trigger further cardiac
assessment. Echocardiogram and dobutamine stress testing
have been shown to bear incremental value over clinical
evaluation [72] (Fig. 20.8).
There is some evidence that performance testing may
hold value. Maximal oxygen consumption (VO2 Max) tests
may not be readily available in all hospitals, but reasonable
surrogates – stair climbing [73, 74], shuttle walk [75], long
distance corridor walk [76], metabolic equivalent (MET) –
have been shown to correlate. Weinstein [77] reported prolonged length of stay following thoracic cancer surgery in
those patients with METs £4 (equating to calisthenics or
walking briskly). The International Society of Geriatric
Oncology has studied a standardized Preoperative Assessment
in Elderly Cancer Patient (PACE); postoperative complications were associated with poor preoperative performance
status and lower score on Instrumental Activities of Daily
Living but major complications correlated only with
American Society of Anesthesiologists (ASA) Physical
Status £2 [78] (Table 20.4). However, as Internullo et al.
recently concluded that “a practical and reliable individual
risk assessment tool is still lacking” [79].
Fi g u r e 20.8 Incremental value of echocardiogram and dobutamine
stress echocardiogram (DSE) over clinical evaluation for the prediction
of cardiac events (a) and all-cause mortality (b) in the elderly (from
T
a b l e 20.4 Univariate
association between components
of preoperative assessment of
cancer in the elderly (PACE)
with 30-day morbidity (any and
major complication) adjusted
for age, sex, type, and stage of
cancer and severity of surgery
Component of PACE
MMS abnormal (<24) 1.23 0.81–1.88 1.08 0.48–2.44
ADL dependent (>0) 1.41 0.95–2.10 1.87 0.95–3.69
IADL dependent (<8) 1.43 1.03–1.98 1.65 0.88–3.08
GDS depressed (>4) 1.30 0.93–1.81 1.69 0.93–3.08
BFI mod/severe fatigue (>3) 1.52 1.09–2.12 1.24 0.67–2.27
ASA abnormal (³2) 1.00 0.73–1.38 1.96 1.09–3.53
PS abnormal (>1) 1.64 1.07–2.52 1.97 0.92–4.23
Satariano’s index (1) 1.11 0.78–1.59 1.29 0.68–2.44
Satariano’s index (2+) 1.58 0.88–2.85 1.95 0.74–5.18
From Audisio [78]. Reprinted with permission from Elsevier
MMS mini mental status, ADL activities of daily living, IADL instrumental activities of daily living,
GDS geriatric depression scale, BFI brief fatigue inventory, ASA American society of anesthesi-
ologists physical status, PS eastern cooperative oncology group performance status
a
Bold italics represent significant relationship (p < 0.05)
Biagini et
Gerontological Society of America).
al. [72], reprinted with permission from the American
Any complication Major complication
a
RR
95% CI RR
a
95% CI
242 M.R. Katlic
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Preoperative antibiotics are not necessary for every type
of elective surgery, but researchers agree that advanced age
is a risk factor for nosocomial infection. Iwamoto et al. [80]
studied 4,380 patients who underwent general anesthesia for
thoracic, abdominal, or neurologic surgery and concluded
that advanced age is a risk factor for nosocomial pneumonia,
especially after thoracic surgery. Age greater than 70 years
has been shown to be a risk factor for both positive bile cultures (p < 0.001) [81] and septic complications of biliary sur-
gery compared with younger patients [82]; antibiotic
prophylaxis can reduce these complications [83].
Efforts to improve our elderly patients’ preoperative nutri-
tional state would seem desirable – even active, communitydwelling older adults manifest impaired recovery of strength
after major surgery [84] – but it is unclear how to do this. Low
levels of serum albumin, for example, correlate strikingly
with postoperative problems [85] (Fig. 20.9), but cannot be
improved to a great degree preoperatively. Souba [86]
reviewed the literature on nutritional support and concluded
that preoperative support should be reserved for severely malnourished patients scheduled to undergo major elective surgery and then should be provided for no more than 10 days.
In addition to those already cited, a number of surgeons
have attributed their improved results in elderly patients to
compulsive preoperative preparation. Bittner et al. [87]
believed that the significant decrease in mortality after total
Fi g u r e 20.9 Preoperative albumin level and major postoperative com-
plications (from Kudsk et al. [85], reprinted with permission from the
American Society for Parenteral and Enteral Nutrition).
gastrectomy in septuagenarians (32% in 1979 to 4.4% in
1996) was the result of standardized perioperative antibiotics, thromboembolic prophylaxis, “a systemic analysis of
risk factors and their thorough preoperative therapy,” and
nutritional support for the malnourished. Our presented
patient was neither anemic nor an active smoker; he received
preoperative antibiotics and perioperative DVT prophylaxis.
Hypovolemia is tolerated poorly by the elderly patient
and it must be corrected. Smoking should be stopped.
Treating other correctable aberrations such as anemia,
bronchitis, and hypertension preoperatively increases the
elderly patient’s chance for a smooth postoperative course.
Principle IV: Emergency Surgery
The results of elective surgery in the elderly are reproduc-
ibly good; the results of emergency surgery are poor though
still better than non-operative treatment for most conditions.
The risk of emergency surgery may be many times that of
similar elective surgery because of Principles II and III.
The results of elective surgery in the elderly are good,
frequently indistinguishable from the results in younger
counterparts [88–90]. Coyle [91] reported the results of
carotid endarterectomy in 79 octogenarians and summarized
the results of five other series (634 total patients); mortality
and morbidity were similar to those in a younger cohort.
Maehara et al. [92] had 0% operative mortality in 77 patients
over an age of 70 who underwent resection of gastric carcinoma, and Jougon’s [93] results for esophagectomy in 89
patients of age 70–84 years were identical to those in 451
younger patients. Our 88-year-old patient with lung cancer
could anticipate mortality and survival after pulmonary
lobectomy statistically identical to that of younger patients
with similar stage disease [64, 88, 94–96]. Identical operations performed emergently in the elderly, however, carry at
least a threefold (and as much as a tenfold) increased risk
[97] (Fig. 20.10). Keller [98], for example, reported 31%
morbidity and 20% mortality in 100 patients over an age of
70 who underwent emergency operations, which is significantly more (p < 0.0005) than the 6.8% morbidity and 1.9%
mortality following elective operation in 513 similar patients.
Elective cholecystectomy can be performed in young and old
patients with the risk of death approaching 0% [20, 99, 100];
the risk of mortality for emergency cholecystectomy increases
somewhat in the younger group (1–2%) but increases greatly
in the elderly (5–15%) [20]. Surgical priority clearly affects
cardiac surgery risk [101, 102]. Elective operative mortality
for colorectal surgery is as low as 1.5–3.0%, rising to over
20% for emergency operation [103, 104].
A patient’s advanced age therefore weighs in favor of
commencing rather than deferring needed elective surgery.
Fi g u r e 20.10 Elective vs. emergency surgery in the elderly (from
https://t.me/med1917
Thomas and Ritchie [
Publishing).
9], reprinted with permission of Blackwell
Principle V: Attention to Detail
Scrupulous attention to detail intraoperatively and perioperatively yields great benefit, as the elderly tolerate complications poorly (because of Principle II).
Perioperative blood loss is the bete noire of geriatric surgery,
as the elderly lack the responsive compensatory mechanisms
necessary to restore equilibrium. Fong et al. [54] reported that
the only independent predictor of postoperative complications in 138 patients over an age of 70 who underwent pancreatic resection was intraoperative blood loss exceeding 2 l.
This finding has been mirrored in reports from cardiac surgery and neurosurgery. Sisto et al. [105] reported that 6 of 23
octogenarian coronary bypass patients who required
reexploration for tamponade died; Logeais et al. [106] found
that reoperation for tamponade following aortic valve replacement placed the elderly patient at high risk for mortality
(p < 0.001). Hemostasis is exceptionally important in the
elderly craniotomy patient, possibly because the elderly brain
is less likely to expand to obliterate dead space. MauriceWilliams and Kitchen [107] reported that postoperative bleeding following resection of meningioma occurred in 20% of 46
elderly patients and 0% of 38 young patients (p < 0.05).
Meticulous surgical technique is important in any patient,
but it becomes crucial in those of advanced age. Anastomotic
leak after esophageal or gastric resection, a dreaded complication in any patient, embodies an exceptional risk of mortality in the elderly [108]; yet this complication can be minimized
by careful technique [109, 110]. Only one of Bandoh’s [111]
elderly patients who underwent gastrectomy for cancer experienced a leak, as did only 2 of 163 patients over an age of 70
in Bittner’s series [87]. Despite having significantly greater
preoperative comorbidity, the elderly patients undergoing
gastrectomy in Gretschel’s series experienced no greater
24320 Principles of Geriatric Surgery
postoperative morbidity [57]. The elderly cardiac surgery
patient may benefit from extra care when they have a calcified aorta (e.g., intraoperative ultrasound or modified
clamping and cannulation technique) or a fragile sternum
(e.g., additional or pericostal wires) [112]. Operative speed is
less important than technique: in Cohen’s series of 46 nonagenarians undergoing major procedures [7], the duration of
operation did not correlate with mortality.
Perioperative monitoring is more important in the elderly,
since they may manifest few signs or symptoms of impending problems (see Principle I above). Bernstein [113] credits
intensive hemodynamic monitoring in his lack of mortality
among 78 patients over an age of 70 who underwent abdominal aortic aneurysmectomy. Such monitoring and intensive
care were also emphasized by Alexander et al. [3], who
reported excellent results for 59 octogenarians having major
upper abdominal cancer operations, and by Lo [114] for 85
elderly patients undergoing adrenal surgery at the Mayo
Clinic. Giannice [115] credits attention to perioperative care
(DVT prophylaxis, antibiotics, monitoring, respiratory care,
pain management, and early mobilization) for his group’s
improved recent results in gynecologic oncology patients.
Our case report patient had reinforcement of vascular and
bronchial closures in addition to compulsive hemostasis and
minimization of parenchymal air leaks. He was monitored
postoperatively. If he had developed an atrial arrhythmia, it
would have been aggressively treated; if he had developed
tracheobronchial secretions, he would have promptly undergone therapeutic bronchoscopy.
We should continue to teach the surgical aphorism,
“Elderly patients tolerate operations but not complications”
(Table 20.5).
T
a b l e 20.5 Importance of postoperative complications in failure of
octogenarians to return to normal function following major abdominal
surgery
All cases Odds ratio 95% confidence interval
Emergency operation 2.7 0.99–7.24
ASA III or IV 1.0 0.29–3.56
Comorbidity index >5 1.8 0.48–6.66
Dependence on activities of
daily living
Preexisting cardiac disease 1.9 0.69–5.44
Preexisting chronic pulmonary
disease
Preexisting cerebrovascular
disease
Development of postoperative
complications
Elective cases only
Comorbidity index >5 11.2 1.08–116.26
Development of postoperative
complications
From Tan et
Science + Business Media
al. [108]. Reprinted with permission from Springer
1.8 0.42–7.73
2.0 0.54–7.47
2.0 0.43–9.06
24.5 3.08–194.88
10.6 3.08–194.88
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