The Holy Grail of Geriatric Surgery

Abstract

T he Holy Grail of Geriatric Surgery is a simple, reliable test to assess perioperative risk. Have the authors found it? It seems intuitive to most people, even most physicians, that advanced age increases operative risk; but is chronologic age itself really the culprit? We all know octogenarians who play vigorous tennis and others who cannot walk to the mailbox. Most of the possible tests to clarify risk in this highly variable group are surrogates of the standardized cardiopulmonary exercise test (CPET) that the authors studied. These surrogates, utilized because CPET is unavailable in some locales and unappealing in others, all suffer from one or more inadequacies, although some have been correlated with maximal oxygen consumption or surgical risk or even cancer survival: stair climbing, 6-Minute Walk Test, Long-Distance Corridor Walk, gait speed, Shuttle-Walk test, Timed Up-and-Go test, Braden scale, various frailty scales, Surgical Apgar Score, Charlson Comorbidity Index score, American Society of Anesthesiology (ASA) Physical Status Classification, and visceral assessment of an experienced surgeon. The Charlson Comorbidity Index, ASA Physical Status Classification, Braden scale, and several different frailty scales have all been shown to predict surgical risk but are not true tests of physiological fitness. The Surgical Apgar Score is calculated postoperatively rather than preoperatively. The walking tests and the Timed Up-and-Go test are simple but have not been extensively studied in surgical populations. Stair climbing, historically used most by thoracic surgeons and with decades of published results, has consistently come closest to mimicking the CPET.1,2 We have known for decades that cardiopulmonary fitness declines with age, even in elite athletes. The authors have shown that this phenomenon, admittedly associated with age, is more important than chronologic age itself in predicting risk.3 Thereby, they also have struck an indirect blow against “ageism,” prejudice based on chronologic age alone. In nearly 400 patients who underwent major open hepatobiliary and sarcoma operations, anaerobic threshold, at a level of 10 mL/kg/min, proved to be the best predictor, better than chronologic age. Age became important when fitness was poor but was unimportant when fitness was good. The study also shows that CPET is safe and even elderly patients with malignancy can complete the test (96% achieved anaerobic threshold). So, why not just administer the CPET to all elderly surgical patients? Access to the test and delays in surgery will remain issues. Cost is a major factor and not only cost to the payer. The patients and their caregivers will inevitably bear some cost in time and dollars. The decreased length of stay either in the hospital or in the intensive care unit shown in the present article accrues only to the least fit patients and may not apply to the United States, where one’s insurance policy and family issues may prolong stay beyond medical necessity. There is already proven overuse of cardiac stress testing in Medicare patients undergoing elective noncardiac surgery,4 and we will need to be selective in our use of the CPET. Parenthetically, the study begs the question, “What do we do when we discover reduced fitness preoperatively?” Although pulmonary rehabilitation before lung resection has been proven valuable in certain sets of high-risk patients, in general, studies of prehabilitation have shown equivocal results to date.5 Attempts to improve nutrition, medication use, and postdischarge care are admirable but even more speculative. I suspect that a well-defined patient population (eg, below anaerobic threshold or frail by criteria) given a discrete intervention (eg, brief, evidence-based prehabilitation) would show benefit from that intervention. Given our burgeoning elderly population, most of whom need surgery sometime, this is a ripe area for research. Many centers have shown excellent results, results equal to a younger population, in septugenarians, octogenarians, and even nonagenarians undergoing major operations such as esophagogastectomy, pancreaticoduodenectomy, and ascending aorta replacement. Better selection of patients may be a factor in their good results, but so may be the great attention to detail perioperatively. Gretschel et al,6 for example, showed that despite statistically increased comorbidities compared with a younger