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Invited Critique
November 16, 2009

Surgery and Old Age: An Age Old QuestionComment on “Identification of Specific Quality Improvement Opportunities for the Elderly Undergoing Gastrointestinal Surgery”

Arch Surg. 2009;144(11):1020. doi:10.1001/archsurg.2009.65

Is advanced age a contraindication to a major operation? The literature is rife with reports that purport to show that even complex procedures may be carried out safely in elderly patients with otherwise limited comorbidities. The authors of this study mined the ACS-NSQIP database to directly address this question. They convincingly demonstrate that after controlling for other preoperative factors, age remains a strong independent predictor of morbidity and mortality after major gastrointestinal procedures. The increased risk with advancing age is largely attributable to differences in cardiac, pulmonary, and urologic complications, which suggests opportunities to improve the quality of surgical care in the elderly with measures beyond current initiatives directed at surgical site infection and deep venous thrombosis. Although multi-institutional databases are inherently limited by the consistency of data gathering, the greater sample size and the ability to sample experience across both academic and community centers are distinct advantages of this study. Indeed, it has tended to be the smaller, single-institution studies, often from tertiary or quaternary centers, that have advocated major operations in older persons. Such highly favorable reports should be interpreted with caution because of the probable presence of publication bias, and the results of those studies should not automatically be extrapolated to less experienced centers and surgeons. The ACS-NSQIP database provides a more real-world assessment of risk. Advancing age insidiously saps physiologic reserve, even in those individuals who have reached older age without apparent medical morbidity. Thus, surgeons should not assume that the risk of complications in the active octogenarian who shoots his or her age in golf are the same as in a healthy 60-year-old person. Although major surgical interventions in the elderly may not be contraindicated, there is nothing like an operation to make someone show their age.

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