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Introduction
The aging of the world population is a serious issue for healthcare physicians, and most of all for surgeons, who are increasingly being asked to operate on patients who would absolutely not have been suitable for surgical treatment in the past few decades. Historically, chronological age has been considered the most important factor in the surgical decision-making process. However, unimaginable advances have been made in medical science making operative treatments feasible, even in very elderly patients, since surgery remains the cornerstone of the multimodal treatment of the vast majority of abdominal neoplastic diseases.
There are also many abdominal benign conditions that may require surgical treatment in the emergency setting (e.g., bowel perforation, acute appendicitis, bowel ischemia, acute cholecistitis) where surgery is the only option to save the patient’s life. In these situations, the decision-making process should be rapid and include clear communication with patients, caregivers and all staff members in order to clarify treatment goals, including a non-operative strategy when the risks outweigh the benefits. Thus, preoperative assessment (frailty, functional and cognitive limitations, malnutrition, comorbidities, poly-pharmacy, as well as social environment) plays a pivotal role in identifying elderly patients who could tolerate surgical treatment and potentially benefit from it.
When treatment decisions for frail patients are made, there are several questions that surgeons should consider: Is the patient going to die from the condition being evaluated for surgery? Is the patient able to tolerate the stress of surgery with reasonable postoperative risks? Is the treatment going to produce more benefit than harm? What is the patient’s life expectancy? What is the patient’s current quality of life and how will this change after surgery? (see also Chapter 9).
Elective Abdominal Surgery
In the twenty-first century, surgery is still the main strategy for treating a significant number of benign and malignant abdominal diseases. This is particularly relevant for the elderly population, accounting for the majority of elective surgical operations.
Despite surgery being often technically feasible, the postoperative course could be affected by substantial complications, including death. It is intuitive that morbidity and mortality rates in the elderly population are significantly higher than in younger patients, despite the surgery being performed in the elective setting.
As shown by multiple studies, septic complications occur more frequently in senior adults and more often lead to organ failure, mainly because of the patients’ more tenuous immune response.
For this reason, individualized perioperative treatment pathways, from admission to discharge, should be designed and put in place (see Chapter 22). An individualized treatment program starts with sharing the care strategy with patients, caregivers and all healthcare providers involved in the process.
Alternative, non-invasive treatments should always be discussed for both benign and malignant conditions, directing the care towards improving patients’ quality of life.
Prehabilitation (see Chapter 12) should always be offered to patients with a poor functional status who might strongly benefit from increasing their cardiovascular or pulmonary reserve (Minnella et al. 2017, Carli et al. 2017).
Several studies have highlighted that elderly patients are inappropriately discharged to postacute/rehabilitation facilities, even when functionally independent, with institutionalization leading to a progressive and irreversible decline. Innovative strategies to help patients return to their own homes after surgery are strongly advocated in order to enhance postoperative functional recovery rather than promote unrelenting dependency.
Gastric Procedures
Total and sub-total gastrectomy still represent the treatment of choice for gastric carcinoma. Several studies have demonstrated the feasibility of surgical procedures in senior adults with acceptable morbidity and mortality. Data regarding disease-specific survival are controversial when compared to younger patients; Takeshita et al. (2013) demonstrated that treatment results in elderly patients were comparable to those in non-elderly patients, while Kitamura et al. (1996) failed to demonstrate non-inferior survival in the elderly population undergoing surgery for gastric adenocarcinoma.
Cancer-specific long-term survival does not differ between older and younger patients, while overall survival is reduced in elderly patients (Biondi et al. 2012). Whenever possible, a radical resection (R0) with appropriate lymph node dissection (D2) is recommended, even in patients 70 years of age and older (Jeong et al. 2010). The effectiveness of surgical treatment (gastrectomy with radical lymphadenectomy) in patients aged 85 years and older was recently confirmed in a multicenter survey (Konishi et al. 2017).
Surgeons are frequently asked to take care of elderly patients with advanced symptomatic gastric cancer, presenting with bleeding or obstructing lesions; in these cases, a multidisciplinary approach is strongly advised in order to establish the best treatment option, balancing the benefit and the harm of surgical aggressiveness and medical non-operative treatments. In the case of unfit patients with extremely deteriorated conditions, palliative non-invasive procedures should always be considered. When gastric outlet obstruction due to a distal neoplastic mass is present in a frail patient, a minimally invasive palliative gastro-jejeunostomy (GJ) can be performed with limited risks. An endoscopic stenting (ES) procedure can also be considered as an alternative palliative treatment.
Hepato-biliary Procedures
Primary Liver Cancer
In developed countries, where hepatitis C virus (HCV) and alcohol abuse are widespread, the median age at the time of hepatocellular carcinoma (HCC) diagnosis is 60 years of age (McGlynn and London 2005). However, the current literature points out age-related differences in patterns of care (Mirici-Cappa et al. 2010), showing elderly individuals being more frequently treated with percutaneous procedures and less frequently with surgical resection, even if the feasibility of radical or effective HCC treatments was unaffected by advanced age. Hepatectomy for HCC is correlated with significant morbidity and mortality in the general population, and it is estimated to be higher in elderly patients. However, recent studies have demonstrated that selected senior adults may benefit from liver resection, even if overall survival is still found to be reduced in this sub-set of patients (Cucchetti et al. 2016).
Elderly patients affected by HCC having significant comorbidities, insufficient liver function or compromised performance status should be considered for non-surgical and less invasive procedures, such as radiation therapy, percutaneous radiofrequency ablation (RFA) or trans-catheter chemo-embolization (TACE) (Hung and Guy 2015).
The majority of patients with cholangiocarcinoma (CC) are diagnosed with advanced disease, and curative surgery is rarely possible, particularly in the elderly. Palliative care, including any biliary drainage procedure for jaundice or oncologic treatment (chemotherapy, radiation therapy), should have health-related quality of life as the primary clinical endpoint.
Colorectal Liver Metastasis
Current demographic trends will lead to an increasing number of elderly patients presenting with potentially resectable colorectal liver metastasis (CRLM). Since metastasis resection has become a potentially curable procedure in selected patients, efforts have been made to investigate its role in the elderly setting. However, there is still a critical lack of information regarding the management and long-term outcome of CRLM among elderly patients in routine clinical practice. A recent population-based retrospective cohort study conducted by Booth et al. (2015), enrolling 1310 elderly patients, concluded that surgical resection of CRLM is associated with a greater risk of postoperative mortality, despite less aggressive treatment. Although the long-term outcomes are inferior to those of younger patients, a notable proportion of elderly patients will have a substantial long-term survival benefit.
Once again, every decision should be individualized based on the natural history of the disease, with a better prognosis for metachronous single lesions, patient functional reserve and life expectancy. Non-surgical options should always be considered, since increasing experience is becoming available with procedures such as microwave/radiofrequency ablation, TACE and yttrium-90 resin microsphere radioembolization (Wong and Cooper 2016).
Pancreatic Procedures
Pancreatic ductal adenocarcinoma is probably the worst abdominal malignancy with a five-year overall survival rate of less than 5%. However, it has been demonstrated that patients who undergo a curative and radical resection with no local lymph nodes involved could reach a five-year survival rate of approximately 40%.
Recent studies have demonstrated that major pancreatic surgery for ductal adenocarcinoma of the pancreatic head is justified in elderly patients. With careful patient selection and perioperative management, elderly patients will have a similar long-term outcome, despite the higher rate of postoperative morbidity based on non-surgical complications. In fit elderly patients, the benefit of surgical resection does not decrease with age, and these patients can experience long-term survival and a good quality of life. In fact, once patients over 80 years of age surpass the two-year survival mark without cancer recurrence, their survival parallels that of their age-matched counterparts (Riall 2009).
Centralization and caseload are associated with better outcomes. A recent analysis from the Netherlands Cancer Registry, including 3420 senior adults affected by pancreatic adenocarcinoma, pointed out that elderly patients strongly benefit from centralization by undergoing pancreatico-duodenectomy in high-volume hospitals (van der Geest et al. 2016).
When curative resection is not possible or the patient is too frail to tolerate extensive surgery, strategies to palliate symptoms should always be considered in order to offer a better quality of life. In the case of jaundice, biliary drainage (endoscopic or percutaneous) should be considered, as well as palliative gastrojejeunostomy or endoscopic stenting for gastric outlet obstruction.
Colorectal Procedures
The incidence of colorectal cancer (CRC) is increasing and it is expected that the highest risk of being diagnosed will be between 70 and 85 years of age (Nederlands Cancer Registry).
Since long-term cancer-specific survival is not affected by patient age, every effort should be made to identify frail senior adults who may benefit from tailored perioperative strategies in order to improve their clinical pathway. In fact, there is robust evidence that senior colon cancer patients have a higher risk of mortality in the first postoperative year, mainly due to cardiovascular and pulmonary complications (Dekker et al. 2011).
Often elderly patients present with acute obstruction, mainly caused by cancers located in the left colon. Whenever possible, emergency surgery should be avoided due to its intrinsic higher complication rate. Bridge strategies, such as self-expandable metallic stents (SEMS), should be considered in order to stabilize the patient, planning surgery in an elective setting. However, current studies have failed to definitively demonstrate that SEMS in left-sided colonic obstruction are also effective in reducing stoma creation rate, especially in the elderly setting (Pirlet et al. 2011).
Several studies have pointed out that, even for rectal cancer, cancer-specific survival is not affected by patient age, while postoperative morbidities increase (Rutten et al. 2008).
Interestingly, functional results in elderly patients who underwent low anterior resection have been found not to be affected by patient age, except for those who underwent preoperative radiation therapy. For this reason, senior adults with optimal functional status should always be considered for sphincter-preserving surgery. In patients with a complete clinical response after chemo-radiation therapy, a “watch and wait” (Habr-Gama et al. 2004) strategy can be considered with caution. T1 cancers can be safely treated with trans-anal resections, taking advantage of the lower postoperative complication rate.
Ovarian Procedures
Complete cyto-reduction with adjuvant or neo-adjuvant chemotherapy has been established as the main treatment for advanced epithelial ovarian cancer. The peak incidence of ovarian cancer occurs at 61 years of age, which means that a large proportion of patients are elderly. Concerns are visibly raised when facing the evidence that elderly patients are likely to receive standard therapy less often, are less able to tolerate medical treatments and are often less optimally debulked (Cloven et al. 1999).
In fact, the surgical strategy used seems to impact outcomes, regardless of the immediate perioperative morbidity and mortality. Several studies have already pointed out the detrimental impact of a limited lymphadenectomy, independent of cyto-reductive surgery extension (Chan et al. 2007). Unfortunately, in a previous publication by Aletti et al. (2006), it was determined that the decision to perform lymph node assessment depends on the surgeon, low residual disease, ASA grade and the absence of carcinomatosis. Regrettably, once a lymphadenectomy has been decided upon, the main independent criterion for performing a complete lymphadenectomy vs. lymph node sampling was shown to be limited to patients under 65 years of age. More objective criteria have also been advocated by different authors, but the ultimate reality is that the surgical and medical management of ovarian cancer often requires extended and debilitating treatments in order to be effective.
Currently, no alternatives having a more limited impact but similar outcomes have been recommended to effectively treat ovarian cancer. On the other hand, it seems that, despite notable evidence regarding risk prediction, elderly women with ovarian cancer are precluded from the best available treatment merely because of their chronological age.
Emergency Surgery
Emergency surgery (see also Chapter 11) in the elderly population is a major burden for healthcare systems, since it represents up to 26% of all hospital admissions. Furthermore, mortality after emergency surgery increases with each decade, with a notable peak above 75 years of age in frail patients. It has been shown that emergency laparotomy is associated with a threefold increased risk of death compared to younger patients. “Common” emergent conditions, such as appendicitis and diverticulitis, can easily crack the fragile homeostasis of elderly patients.
Making a diagnosis in the acute setting is particularly challenging in senior adults. Conditions associated with cognitive impairment (cerebral-vascular accidents, dementia etc.) could create a breach in the communication of symptoms. Other comorbidities common in the elderly, such as diabetes and chronic vascular diseases can frequently mask symptoms related to urgent conditions. Indeed, elderly patients may have atypical abdominal pain or “hide” signs of intra-abdominal/systemic sepsis.
One of the keys, again, to a personalized approach, especially in an emergency situation, is communication. From the diagnostic pathway to the treatment, every step should be accurately planned, taking into consideration life expectancy and the patient’s desires, together with caregivers and family members. Communication should always be very straightforward and as clear as possible; once again, the preferred strategy is to avoid overtreatments and spare the patient a painful and life-shortening postoperative course. Non-operative treatments (CT-guided, endoscopic, percutaneous procedures) should always be considered in order to minimize the burden of care or to bridge the patient to an elective/more stable setting.
Open vs. Minimally Invasive Approach
Minimally invasive surgery (MIS) is safe and feasible in the elderly and should be pursued because it promotes faster functional recovery. For the purpose of this discussion, for the most part, the colorectal surgical field where MIS has been routinely used over the last two decades and where the greatest amount of literature has been produced in order to address its usefulness for senior adults will be referred to.
The goals of MIS are to obtain the same disease-related and functional outcomes of open surgery, while decreasing the surgical stress and, consequently, the associated morbidity and mortality.
One of the focuses of the use of MIS techniques is not only to promote the return of bowel function, expedite oral nutrition and reduce hospital stay, but also to facilitate functional recovery. Such abilities, such as a return to active life, and a return to independent living or bowel/urinary control, are particularly necessary in elderly patients, where reaching those goals often means the difference between the success or failure of an operation (Frasson et al. 2008). Frasson specifically focused on functional recovery after laparoscopic surgery, analyzing a large series of elderly and younger patients with colorectal disease randomly assigned to laparoscopic or open resection. The authors were able to show how laparoscopy in the elderly, even more than in younger patients, improves the preservation of functional status, permitting a higher rate of postoperative independence at discharge and faster postoperative recovery.
Recently, Li et al. (2016) “closed” the debate regarding the possible benefits of laparoscopic surgery in octogenarians by publishing a meta-analysis including 1066 laparoscopic and 1034 open colorectal resection. The result was that laparoscopy was safe and carried a lower risk of infectious complications, a shorter length of stay and a reduced incidence of postoperative ileus.
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