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Correspondence and Brief Communications
January 1, 2006

No Nonagenarians Please!

Arch Surg. 2006;141(1):104. doi:10.1001/archsurg.141.1.104-a

I read with interest the article by Durward et al1 on the technically successful carotid endarterectomy procedures that they performed on the elderly. No doubt the group has considerable experience given the fact that they have operated on many patients, several of whom were over the age of 89. Based on their still limited experience in this specific subgroup, the authors claim that an operation should be considered for symptomatic patients in good clinical condition. It appears that this conclusion may need some tempering. In the accompanying critique, Mayer2 states that many surgeons may remain reluctant because of the high likelihood of comorbid conditions being present and also notes that one can only do so much with scarce health care resources. A simple cost-effectiveness analysis will show that because of the quite limited life expectancy, very little health may be gained in this subcategory of patients, whereas expenditures will be considerable. It is given that some strokes may be prevented, but what is actually gained by the operation? Any medical doctor should realize that this type of research is already unethical to begin with. It is a waste of valuable resources and patients are exposed to considerable risk and stand to gain nothing. This may be a rare example of the opposite of the frequently heard argument that a randomized clinical trial is unethical because too many subjects might be subjected to a supposedly inferior old treatment. I ask that readers please forget about this article and not waste future resources on the research question posed, or expose patients to unacceptable risk.

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