Emergency surgery in the elderly: the balance between function, frailty, fatality and futility

Abstract

Becoming old is considered a privilege and results from the socioeconomic progress and improvements in health care systems worldwide. However, morbidity and mortality increases with age, and even more so in acute onset disease. With the current prospects of longevity, a considerable number of elderly patients will continue to live with good function and excellent quality of life after emergency surgical care. However, mortality in emergency surgery may be reported at 15-30%, doubled if associated with complications, and notably higher in patients over 75 years. A number of risks associated with death are reported, and a number of scores proposed for prediction of risk. Frailty, a decline in the physiological reserves that may make the person vulnerable to even the most minor of stressful event, appears to be a valid indicator and predictor of risk and poor outcome, but how to best address and measure frailty in the emergency setting is not clear. Futility may sometimes be clearly defined, but most often becomes a borderline decision between ethics, clinical predictions and patient communication for which no solid evidence currently exists. The number and severity of other underlying condition(s), as well as the treatment alternatives and their consequences, is a complex picture to interpret. Add in the onset of the acute surgical disease as a further potential detrimental factor on function and quality of life – and you have a perfect storm to handle. In this brief review, some of the challenging aspects related to emergency surgery in the elderly will be discussed. More research, including registries and trials, are needed for improved knowledge to a growing health care challenge.

Perioperative medicine and mortality after elective and emergency surgery

“…But of greatest importance are age and comorbidity, both strongly associated with long-term deterioration due to frailty in the elderly, and both strongly associated with short and long-term mortality after surgery. 11,12 Frailty is a lack of resilience to stressors to physiological systems. Although there might be survival of the initial insult, the challenge to the body and organ systems may reveal previously unrecognised organ failure or trigger new physiological weakness.…”

“…17 The rate of high-risk patients with preexisting comorbidities is increasing in high-income countries and is related to demographic changes. 3,11 Adaptations of postoperative surveillance management are imperative, but may not need expensive ICU beds. Identification of index markers that trigger a priority for a higher level of care, IMC or ICU level, are needed.…”

Emergency Surgery for Colorectal Cancer in Patients Aged Over 90 Years: Review of the Recent Literature

“…Most probably this is related to the degree of severity of the patient at admission. Elderly people represent a heterogeneous group of patients, ranging from very fit to very frail individuals consequently with decreased physiological reserves, due to chronological age and biological changes, making these patients vulnerable to any stressful event [8][9] . There is a lack of studies evaluating early and late outcomes of emergency abdominal surgery in the cohort of patients aged over ninety years affected by colorectal cancer.…”

“…Recent retrospective studies [8] demonstrated that high ASA class is associated with high mortality following emergency surgery.…”

Transanal endoscopic operation for rectal cancer after neoadjuvant therapy

“…This vulnerability to a stressful event has been suggested as a risk predictor and is associated with substantial morbidity and mortality [15][16][17] .…”