Optimizing the management of elderly colorectal surgery patients

Abstract

With the ever increasing number of geriatric surgical patients, there is a need to develop efficient processes that address all of the potential issues faced by patients during the perioperative period. This article explores the physiological changes in elderly surgical patients and the outcomes achieved after major abdominal surgery. Perioperative management strategies for elderly surgical patients in line with the practices of the Geriatric Surgical Team of Alexandra Health, Singapore, are also presented. A coordinated transdisciplinary approach best tackles the complexities encountered in these patients.

Considerations for Geriatric Patients Undergoing Colorectal Surgery

“…Clinical cardiac risk factors include angina, prior MI, heart failure, stroke/TIA, renal dysfunction, and IDDM. Additionally, exercise tolerance, ambulatory EKG changes, echo changes demonstrating prior MI, valvular disease or left ventricular diastolic dysfunction, and positive stress test have also been associated with increased risk of peri-operative cardiac event [ 90 ]. As such, an EKG is required for patients with presence of cardiac risk factors prior to any surgical intervention.…”

“…Interestingly, there is minimal evidence to suggest pre-operative revascularization reduces risk in non-cardiac surgery. Instead of cardiac catheterization, beta-blockade, and statins pre-and peri-operatively are strongly recommended [ 90 ]. For patients with recent MI, risk of recurrent MI in all comers is over 30 % when surgery performed within fi rst month.…”

“…The surgeon should identify patients with pre-existing lung conditions and recent functional decline. In such patients, it is prudent to refer to pulmonary specialists for optimization through inhalers, incentive spirometry, mobilization, and other indicated treatments [ 90 ]. Risk factors requiring further work up include abnormal CXR, high ASA, abnormal respiratory exam, elevated Goldman Cardiac Risk Index [ 92 ] (Figure 65-3 ), and elevated Charlson comorbidity index [ 93 ].…”

“…Up to 25 % of elderly patients with COPD have an operative pulmonary complication, with mortality approaching 7 % [ 89 ]. In patients with history of tobacco abuse, smoking cessation for more than 6-8 weeks is recommended [ 90 ]. If patients pursue smoking cessation, duration needs to be greater than 2 months, otherwise risk of pulmonary complications is signifi cantly increased.…”

“…On adjusted analysis, hyperglycemia was independently associated with increased rates of sepsis, surgical site infection, reoperation, and increased LOS [ 96 ]. Allowing clear liquids until 2 h before a procedure, then providing a carbohydrate drink, has been associated with reducing the risk of insulin resistance, decreasing the likelihood of complications from hyperglycemia, and limiting signifi cant fl uid shifts that are so prevalent in dehydrated elderly colorectal patients [ 90 ]. Strict glucose management has been well established to improve peri-operative outcomes in surgical patients.…”