Of course, the aspects of anaesthesiology are important, and part of the preoperative preparations. Comprehensive geriatric assessment is, however, much more: The key is to determine the biological reserves - or biological age - of the individual elderly patient, which often differs from the chronological/calendar age. A 90 year old person may have the biological reserves/age of a 70 years old person, and vice versa. There are a number of publications from the above mentioned group of authors that describe CGA clearly, and which impact it has on outcomes in colorectal surgery in elderly patients. Frailty is one of the most important predictors of poor surgical outcome in elderly, and worthwhile to assess preoperatively. Knowledge about and implementation of these aspects would in my opinion define a geriatric colorectal surgical service.

no

 @Namir,

could you please give arguments?

I request all to explain the reasoning to support thier answer/view.

I run a surgical liaison service as a Prof of Geriatric Medicine.  I optimise patients, sort out post operative medicine and help with discharge planning.  The surgeons love me, the patients benefit and the hospital saves money.

The benefit of comprehensive geriatric assessment of older patients undergoing colorectal surgery for cancer has been clearly shown in this publication:

http://theoncologist.alphamedpress.org/content/early/2014/10/28/theoncologist.2014-0237

Thank you, Dr Körner, highly interesting. We are currently running a randomized study on comorbidity and postop mortality, would be interesting to hear more about your screening instrument. Will request your article ASAP. /HBR 

Is there a role of Geriatric Colorectal Surgery as a special service? The surgeon answer is obviously no because of the colorectal surgery in the elderly does not differ technically from that in younger patient, moreover, interventions on elderly are rising because there is an increasing of elderly patients that need surgery. Having said that, I feel the need for a particular anesthesiologic approach towards elderly patients. In this era of limited resources, the elderly patient that would require more intensive care, paradoxically, is the one more penalized for priorities that often is given to young patients. It's clear that this is the result of heavy choices well considered and the rest, the current health system must move toward a perspective of management of poor economic resources and sometimes the choices are very difficult .

Dear Dr Vasquez,

when looking solely at the technical aspects of surgery, there is, of course, no difference between younger and older patients, as surgeons never will accept to perform inferior surgery for one patient group compared to others. The important point of the question is that the feasibility of an operation is not an indication alone to perform the operation. Rather, it is important to identify the fit elderly who tolerates surgery, including possible complications, and the frail who does not. This is the aim of a comprehensive geriatric assessment, and well documented. While many octo- and nonagenarians wish to undergo surgery, others do not, depending on their life situation. Further, it is possible to make surgical choices to reduce the risk of complications, as to create a stoma and not an anastomosis. Finally, there are many possibilities to secure high quality of life by non-resectional procedures or self expanding metal stents combined with adequate palliative care. The main point of the question of geriatric colorectal surgery is to tailor the surgical treatment to the individual patient and his/her needs, or the individual treatment goal - I would like to call it personalised surgery.

Dear Dr. Hartwig Körner, I fully agree with what is stated about the surgical decision making, but this does not imply the need for a dedicated service for the colorectal surgery in elderly patients. Allow me to stress the fact that what makes the difference between young and older patients is the anesthesiologic approach, and not the surgical one.

Of course, the aspects of anaesthesiology are important, and part of the preoperative preparations. Comprehensive geriatric assessment is, however, much more: The key is to determine the biological reserves - or biological age - of the individual elderly patient, which often differs from the chronological/calendar age. A 90 year old person may have the biological reserves/age of a 70 years old person, and vice versa. There are a number of publications from the above mentioned group of authors that describe CGA clearly, and which impact it has on outcomes in colorectal surgery in elderly patients. Frailty is one of the most important predictors of poor surgical outcome in elderly, and worthwhile to assess preoperatively. Knowledge about and implementation of these aspects would in my opinion define a geriatric colorectal surgical service.

All post-operative patients can gain benefit from a CGA type approach- vascular surgeons, orthopaedic, colorectal, cardiothoracics are all operating on older patients now.   It's not simply surgical technique or anaesthetic choice-  rehabilitation, medication review, dealing with comorbidity, delirium etc etc become much more important in actually discharging the patient back to the community.  You can operate on the vast majority of older people- but you won't get the frailer ones home without good geriatric input.  

There is evidence to suggest that ortho-geriatric approach has better outcomes for vulnerable older people undertaking surgery and so such an approach might have similar benefits in other surgical specialities. It is a matter of volume I suppose and that such patients commonly have, or at clear risk of, developing geriatric syndromes. Also, they commonly present following a traumatic incident such as a fall and are likely to be poorly prepared for surgery.

 I think that there is another issue here that is alluded to by Hartwig and that is in providing patients with realistic evaluation of their individual risk of complications, both intra-operatively and post operatively when undergoing surgery. The risks for a frail older person are different to that of a younger person – or even a fitter older person. For people to make choices then they need to understand what the real risk is, quantified so that if the risk is 1% of something happening then if you are frail and have multimorbidity then the risk might actually be 25%; this might be more likely to engage patients in a different conversation. For that matter, do surgeons routinely identify what the risks are of developing such things as delirium post op for an older person? Generally, poorly identified and managed, such patients will experience lengthy stays in hospital, suffer other adverse events, be upsetting for families and can have significant longer term implications on morbidity and mortality. I suspect that many patients do not sign up for such outcomes when they consent for surgery.

The question is whether this is better managed with a geriatric surgical approach or should we expect services to be skilled in managing the specific care issues of vulnerable older people undergoing surgery in general. The key is in the assessment and understanding of an individual’s risk and proactively having things in place for when things do not go quite according to plan

I agee with Dr Vasquez not an other sub-division !

It is not the question to create another subdivision - it is more a matter of combining various existing services according to the patient's needs. If we can refer to a cardiologist or anaesthesiologist preoperatively, why not to a geriatrician? If we can discuss with oncologists in the MDT meeting, why shouldn't we be able to have the same communication with geriatrics? They can provide us with important knowledge that is needed when we discuss the treatment options for older patients. This is even important as to know about the individual treatment goal of the elderly, which may vary from the cure of disease to less aggressive treatment focusing to maintain best quality of life for the remaining life time. As surgeons treating more and more older people we will have to learn this approach if we want to do this successfully.

Thank you all for your valuable opinions and answers.

At my hosiptal, we have been running a very successful Transdisciplinary Geriatric Surgical Service since 2007.

Please read

 A collaborative transdisciplinary "geriatric surgery service" ensures consistent successful outcomes in elderly colorectal surgery patients. World J Surg. 2011 Jul;35(7):1608-14. doi: 10.1007/s00268-011-1112-9.

PubMed PMID: 21523500.

One of the important goals of surgery in elderly patients should be  to restore them to the preoperative functional status after surgery. It is no point to operate on an 80y old patient and render him dependent for the rest of his life. Our results have shown that if there is good pre-operative optimisation, good intra-operative and postoperative care in collaboration with anesthetist, geriatric physicians, physiotherapists, pharmacists, dietiticians and others, a majority of elderly patients have a good functional recovery.