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Invited Critique
March 1, 2006

Laparoscopic Fundoplication in Elderly Patients With Gastroesophageal Reflux Disease—Invited Critique

Arch Surg. 2006;141(3):292. doi:10.1001/archsurg.141.3.292

Tedesco et al1 put forward a cogent argument for offering laparoscopic antireflux surgery to patients regardless of age. Their retrospective review of their own large database reveals some interesting and pertinent trends, including the finding that elderly patients (defined as those ≥65 years) were more likely to experience symptoms of regurgitation and cough than were younger patients. These symptoms do not respond as well to medical management as does the symptom of heartburn, so surgery is particularly appealing in this group. The authors assert that laparoscopic antireflux surgery is as safe in elderly patients as in the younger population, but is that correct? The outcomes reported in this article, including resolution of preoperative complaints, intraoperative complications, and postoperative complications of urinary retention, myocardial infarction, pneumonia, wound infection, and pleural effusion, were similar between age groups. Although the authors note that no patient in either group required admission to a skilled nursing facility after discharge, they do not specifically comment on cognitive function. We know that one quarter of patients 65 years or older experience delirium during hospitalization,2 and there is strong suspicion that this number underestimates the true rate.3 The long-term sequelae of postoperative delirium can be significant. If we extrapolate from the medical population, only one third of patients who experience delirium in the hospital will still live independently in the community 2 years later.4 Other studies have shown that the only predictor of postoperative cognitive dysfunction is age.5 As surgeons, we may be guilty of ascribing a little postoperative confusion to narcotics and preexisting mild dementia. If we do not look for it and define it as a postoperative complication, we may do our older patients a disservice. A higher degree of attention to postoperative mental changes and their long-term effects is needed before we can declare laparoscopic antireflux surgery to be as safe in elderly patients as in the younger population.

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