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Medical Meeting Reports

American College of Surgery Clinical Congress

October 10-15, 1999


SURGICAL ISSUES IN THE ELDERLY
font=>By Paul Recchia, Ph.D.

Moderators Brent Eastman, MD, and Ronnie Rosenthal, MD, led two sessions that together made up a full-day postgraduate course on surgical issues in the elderly.

Prevalence of Surgery on the Elderly

Ronnie A. Rosenthal, MD, extrapolated that in the next 50 years, the portion of the population over age 65 is expected to grow from the present 12.5% to 20%, or to nearly 80 million people. In 1980, 19% of patients undergoing operations in non-federally funded, short-stay hospitals were over age 65. By 1990, this portion had jumped to 29%. Persons in this age group are now estimated to account for 50% of the patients in general surgery practices.

Differences in the Physiology of the Elderly

Walter J. Pories, MD, explained that success measures in geriatric patients are promising: early mortality in 100 patients is only 3%; 2 year mortality is 25% due to anticoagulants; in-hospital deaths is 16%; actuarial survival at 1 year is 67% and post-surgery quality of life is far better. Nonetheless, he noted, it is more important to recognize: "The elderly are not just older adults!"

Surgery on geriatric patients must be carefully considered because the elderly are physiologically different. The elderly have their own special problems and issues: multi-system limitations of function, chronic diseases, malnutrition, medications and addictions, limited responses to injury, and social hindrance to recovery. The elderly may require adjustments in surgical judgment, variations in technical approaches, and greater requirements for support systems. Different operative complications are observed in the elderly: hypotension, hypothermia, respiratory problems, thromboembolism, mental disturbances, delirium, fluid and electrolyte imbalance, and malnutrition. All these differences require a different approach to treating the elderly, including: attention to detail in preoperative care taking note of subtle signals, and a meticulous workup because many elderly are overmedicated yet underfed. While many elderly patients have a high tolerance for major surgery, they often incur high morbidity and mortality from minor complications. As a result, the surgeon must be more attentive to post surgical complications in elderly patients.

Breast Cancer in Elderly Women

Monica Morrow, MD, discussed concern over a high rate of mastectomy and uniformly low 30-day postoperative mortality of elderly women. Multiple prospective randomized trials demonstrated that lumpectomy and radiotherapy (breast-conserving therapy; BCT) result in survival equivalent to that with mastectomy. In fact, nonrandomized studies suggest that rates of local recurrence after BCT are particularly low in older women. In spite of this, national patterns of care studies suggest that older women are significantly less likely than their younger counterparts to receive BCT. This is probably a reflection of physician bias, rather than patient preference, since studies in which older women are offered BCT indicate that they choose this option with the same frequency as their younger counterparts. However, the use of radiation therapy (RT) in the older age group reduced the local recurrence rate from 1.53/100 patient years to 0.19/100 patient years. Breast reconstruction is also rarely utilized in the elderly. Patients under age 60 were 7 times more likely than their older counterparts to undergo breast reconstruction. Finally, the failure to use adjuvant therapy when indicated is one of the most frequently identified problems in management of breast cancer in elderly women.

For professional correspondence, please contact Dr. Pories at pories@brody.med.ecu.edu or pories@aol.com, and Dr. Morrow at m-morrow@nwu.edu.

Ortho Biotech

Funded through an unrestricted educational grant by Ortho Biotech.



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