Improving the Outcomes of Major Abdominal Surgery in Elderly Patients

Albert B Lowenfels, MD

Disclosures

November 22, 2005

Editorial Collaboration

Medscape &

Introduction

To discuss the growing challenge of surgery in the rapidly enlarging geriatric population, the American College of Surgeons together with The American Geriatrics Society sponsored a half-day session at the 91st Annual Clinical Congress held in San Francisco, California. The need for this special session arose because of the rapid increase in life span resulting from improved healthcare, which began in the 20th century.

James C. Thompson, Galveston, Texas, opened the session by pointing out that in the beginning of the 20th century, life expectancy was about 50 years; in contrast, by the end of the century, average life span in the United States was 75 years -- a gain of 25 years in a single century. Some specific figures are even more startling: There has been a 3-fold increase in patients older than age 70 and a 10-fold increase in persons over the age of 80. And at present, there are 50,000-60,000 persons over the age of 100 years, many of whom live independently. All of these statistics imply that taking care of elderly patients will become an increasingly important component of the surgeon's workload.

Dr. Thompson pointed out what many surgeons intuitively recognize: Elderly patients tolerate abdominal surgery and have reasonable postoperative mortality rates if there are no serious complications. Good results depend on careful preoperative evaluation, balancing the risks and benefits of surgery, attention to pain management, and avoidance of postoperative complications, such as postoperative delirium and pulmonary and cardiac complications.

Good communication with the patient is important. Talking to an elderly patient who has a severe hearing deficit can be a frustrating problem both for the surgeon and for the patient. In many instances, the reverse stethoscope maneuver can help: To apply this maneuver, place the stethoscope's earpieces in the patient's ears and talk into the stethoscope's diaphragm (Figure).

Figure 1. Communicating with a hearing-impaired elderly patient can often be improved with the reverse stethoscope method: Place the earpieces on the patient and talk into the diaphragm.
Vascular Surgery

K. Craig Kent, MD, FACS, New York, NY, discussed vascular surgery in geriatric patients, focusing on the new technique of endovascular grafts for managing aneurysms of the abdominal aorta (AAA). From 1980 to 2000, the mortality rates for conventional surgery for elective and emergency repair of aortic aneurysms had remained nearly constant at 5% and 50%, respectively. But over the past few years, the use of endografts, which can be inserted through a small groin incision without the necessity for a large abdominal incision, have become increasingly employed. During 2003 in New York State, a total of 1530 operations were performed for aortic aneurysms -- 932 (61%) were endovascular grafts. Mortality rates for elective AAA repair with endovascular surgery are surprisingly low -- 1.1% in 1995 and only .6% in 2003. The data suggest that patients treated with the new endovascular approach have the same number of comorbidities as patients treated with an open operation. Some centers are now beginning to use the endovascular approach for ruptured AAAs; preliminary reports suggest that mortality is lower than with the conventional open approach. As with many other surgical procedures, postoperative mortality is related to volume.

What are the drawbacks to the new endovascular procedures for AAA? The main complication is graft leakage at the site of internal fixation (endoleak), which can require additional surgery. Also, the graft can migrate from its original position. There are cost considerations as well, because the new prosthetic devices are more expensive than the conventional grafts. And finally, there is the quality-of-life problem. However, compared with patients with conventional grafts, those with endovascular grafts tend to have minimal pain and shortened hospital stays; they require much more careful follow-up -- including more frequent abdominal scans. About 30% of these patients will need an additional intervention during a 7-year follow-up period. Already randomized trials show that the early survival advantage of the endovascular approach disappears after 1 year.[1] So there is a trade-off between early benefit and late complications, making the procedure well-suited for elderly patients who are more interested in early results than in late complications.

Dr. Kent briefly discussed other abdominal vascular procedures that are suitable for the elderly. Renal and mesenteric artery stenosis can be effectively treated with stents and coils inserted into aneurysms involving small arteries, such as the splenic artery.

Rehabilitation

How long does it take for elderly patients to return to their preoperative functional status after major abdominal surgery? Valerie A. Lawrence, MD, Division of General Medicine, South Texas Veterans Health Care System, investigated this problem in a longitudinal study of 372 consecutive patients.[2] All patients were ≥ 60 years and had abdominal surgery requiring at least a 5-cm abdominal incision. Fifty-six percent of patients were men, and the mean age was 69.4 ± 6.4 years. The main types of operations were colectomy (38%), open AAA repair (24%), and ventral hernia repair (19%). Follow-up data were available for 88% of the study group. Data were collected on variables on functional status, such as the ability to get dressed, the ability to ambulate, grip strength, mental status, and depression scores. Some measures, such as dressing, the ability to rise from a chair, and walking, returned within a 6- to 12-week period. But to become fully functional (able to prepare meals, drive, and shop), it took 3-6 months. Hand grip strength, often considered a measure of overall body strength, was still diminished at 6 months.

The 2 factors having the most impact on postoperative functional status were (1) the preoperative physical status and (2) any serious postoperative complication. When asked what factors were most helpful to their recovery, patients reported that family and social support were most important. Other factors mentioned were having a positive outlook and medical advice, especially for walking.

The results of this unique research project suggest that recovering preoperative functional status after major abdominal surgery takes much longer than we generally recognize. How can we shorten the functional recovery period? One approach is "prehab" -- physical conditioning in the preoperative period -- which may hasten postoperative recovery, although would also delay surgery. Prehab is conceptually appealing but needs to be carefully explored before it can be recommended.

Infection and the Elderly Patient

Infections are a major concern for all hospitalized patients, but are especially dangerous for elderly persons. According to the Institute of Medicine, each year about 1 in 20 hospitalized patients will develop an infection, adding to a total of nearly 2 million infections. Of this total number, 16% are surgical site wound infections -- many of which are preventable.

Ronnie A. Rosenthal, MD, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, outlined some of the salient points related to infections and infection control in elderly surgical patients. Plotting the frequency of surgical site infections against age produces a "bell-shaped" curve: Infection rates are highest at age 74 years, but lower in younger and older individuals. The reasons for this unexpected distribution are unclear.

General risk factors for infection in elderly patients are known to include frailty, chronic undernutrition, reduced muscle mass, and poor dentition. Other more general factors common to all age groups are diabetes, aspiration, and the presence of an indwelling urinary catheter.

The extent of malnutrition can be estimated from the serum albumin: As serum albumin levels decrease, 30-day perioperative mortality increases.[3] Many elderly surgical patients are admitted from nursing homes where 25% to 60% of patients are likely to be malnourished. For elective operations, a program of nutritional supplementation prior to surgery may reduce the risk for sepsis and enhance postoperative recovery.[4]

Avoiding hypothermia is an additional potentially important factor in preventing wound infection, possibly because it blunts the normal inflammatory response.[5] Warming during abdominal surgery, in any case, is necessary for older patients with diminished muscle mass because body heat is largely derived from muscles.

Hyperglycemia is known to be associated with increased sepsis, suggesting that careful monitoring of glucose levels may be a way to reduce serious postoperative infections.

In a study of over 500 patients, insulin therapy designed to maintain glucose levels between 80-110 mg/dL significantly reduced hospital mortality, with the greatest benefit in critically ill patients with a proven focus of infection.[6] Careful control of glucose levels can play an important role in reducing the burden of infection in elderly surgical patients.

Dr. Rosenthal pointed out a few other factors leading to infection in geriatric patients. Swallowing is impaired in older patients -- especially after age 80. Impaired swallowing ability leads to increased aspiration of oral and/or gastric contents resulting in serious pulmonary infection. The problem is compounded if there is poor oral hygiene -- a frequent problem in older patients. Foley catheters are another well-recognized source of infection. Their prolonged use increases the likelihood of bacteriuria, so they should be removed as quickly as possible.

Cancer

Because cancer is so strongly age-related, as our population ages, cancer deaths have increased, whereas deaths from heart disease have decreased. The result has been that deaths from cancer are the major cause of mortality for most age groups, including the elderly.[7]

David H. Berger MD, Houston Center for Quality of Care and Utilization Studies, Baylor College of Medicine, Houston, Texas, discussed the cancer problem in geriatric patients, focusing on large bowel cancer -- one of the most common cancers in this age group. He estimated that by the year 2050, there will be 2.6 million patients diagnosed with cancer -- a 2-fold increase compared with 2000. Because the population is aging so rapidly, the number of cancers in patients aged 85 or older will be 4 times greater than at the present time.

In addition to the increased frequency of cancer in the elderly, there are age-related differences in treatment and outcome. For example, older patients are more likely to be diagnosed with late-stage disease or to never be staged if no surgery was performed. Five-year survival is reduced, although part of this reduction results from increased comorbidity from nonmalignant disease. A meta-analysis of surgery for colorectal cancer based on 34,194 patients concluded that patients aged 65 or older had an increased frequency of comorbid conditions, presented more often with later stages of cancer, were more likely to need emergency surgery, and were less likely to have curative surgery than younger patients. Nevertheless, surgery is generally worthwhile because the majority of patients survive for 2 years.

A final discussion point concerned screening for colorectal cancer in elderly people. Is it beneficial? The obvious benefit of detecting small, curable tumors must be weighed against complications, false-positive tests, and general anxiety. One report found that screening is likely to be useful if the patient's life expectancy is 5 or more years.[8]

Clifford Y. Ko, MD, The David Geffen School of Medicine at the University of California, Los Angeles, concluded the seminar by discussing quality indicators for abdominal surgery in elderly patients. Quality issues will become a vital concern for surgeons because we seem to be heading toward an individual "pay for performance" reimbursement scheme. Hospitals, insurance companies, and obviously patients all want and deserve high-quality surgery, so it is distressing to discover that patients receive only an estimated 55% of recommended healthcare.[9]

Key Points

Some of the key points brought up in the symposium and in the question period were:

  • Increased life expectancy along with the aging of the baby boomer generation will enlarge the group of elderly patients needing surgical care.

  • Elderly patients have acceptable survival rates after major abdominal surgery, but poorly tolerate complications. Good results are linked to a smooth, uneventful postoperative recovery.

  • Attention to details is critical. For example, attention to oral hygiene can reduce the frequency of pulmonary complications.

  • Beta blockers are extremely useful for elderly patients undergoing major noncardiac surgery. A meta-analysis documented a reduction of cardiac mortality from 12% to 2%.[10]

  • Tight control of glucose levels can reduce wound infection, but is labor-intensive.

Summary

Even though there is no recognized specialty of geriatric surgery, deciding when to or when not to operate on elderly patients can be complex, and requires careful explanation to the patient and the family. All available demographic estimates point to a rapid increase in the number of elderly patients, especially those patients > 85 years -- the frailest of all groups. Therefore, an increasing amount of the surgeon's time will be spent caring for elderly patients with abdominal conditions, such as cancer, biliary tract disease, and aortic aneurysms. Managing the frequent comorbid conditions that accompany these diseases, understanding the altered physiology, and supervising the recovery of these patients will require skill and precision.

References
  1. Blankensteijn JD, de Jong SE, Prinssen M, et al; Dutch Randomized Endovascular Aneurysm Management (DREAM) Trial Group. Two-year outcomes after conventional or endovascular repair of abdominal aortic aneurysms. N Engl J Med. 2005;352:2398-2405. Abstract

  2. Lawrence VA, Hazuda HP, Cornell JE, et al. Functional independence after major abdominal surgery in the elderly. J Am Coll Surg. 2004;199:762-772. Abstract

  3. Gibbs J, Cull W, Henderson W, et al. Preoperative serum albumin level as a predictor of operative mortality and morbidity: results from the National VA Surgical Risk Study. Arch Surg. 1999;134:36-42. Abstract

  4. Rosenthal RA. Nutritional concerns in the older surgical patient. J Am Coll Surg. 2004;199:785-791. Abstract

  5. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med. 1996;334:1209-1215. Abstract

  6. van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med. 2001;345:1359-1367. Abstract

  7. Jemal A, Ward E, Hao Y, Thun M. Trends in the leading causes of death in the United States, 1970-2002. JAMA. 2005;294:1255-1259. Abstract

  8. Walter LC, Covinsky KE. Cancer screening in elderly patients: a framework for individualized decision making. JAMA. 2001;285:2750-2766. Abstract

  9. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348:2635-2645. Abstract

  10. McGory ML, Maggard MA, Ko CY. A meta-analysis of perioperative beta blockade: what is the actual risk reduction? Surgery. 2005;138:171-179.

Suggested Reading
  • Berger DH, Roslyn JJ. Cancer surgery in the elderly. Clin Geriatr Med. 1997;13:119-141.

  • Etzioni DA, Liu JH, Maggard MA, Ko CY. The aging population and its impact on the surgery workforce. Ann Surg. 2003;238:170-177.

  • Hamel MB, Henderson WG, Khuri SF, Daley J. Surgical outcomes for patients aged 80 and older: morbidity and mortality from major noncardiac surgery. J Am Geriatr Soc. 2005;53:424-429.

  • Iversen LH, Pedersen L, Riis A, Friis S, Laurberg S, Sorensen HT. Age and colorectal cancer with focus on the elderly: trends in relative survival and initial treatment from a Danish population-based study. Dis Colon Rectum. 2005;48:1755-1763.

  • O'Connell JB, Maggard MA, Ko CY. Cancer-directed surgery for localized disease: decreased use in the elderly. Ann Surg Oncol. 2004;11:962-969.

  • O'Connell JB, Maggard MA, Liu JH, Etzioni DA, Ko CY. Are survival rates different for young and older patients with rectal cancer? Dis Colon Rectum. 2004;47:2064-2069.

  • Pofahl WE, Pories WJ. Current status and future directions of geriatric general surgery. J Am Geriatr Soc. 2003;51(suppl):S351-S354.

  • Rosenthal RA, Kavic SM. Assessment and management of the geriatric patient. Crit Care Med. 2004;32(suppl):S92-S105.

  • Surgery for colorectal cancer in elderly patients: a systematic review. Colorectal Cancer Collaborative Group. Lancet. 2000;356:968-974.

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