lmproving outcomes in geriatric surgery:ls there more to the equation?

TO THE EDlTOR

The rise in geriatric surgery over the recent decade can be attributed to increased life expectancy,advances in surgical and anesthetic techniques coupled with improved socioeconomic conditions.In tandem with the population aging globally,the elderly are expected to make up almost half of Singapore’s population by 2050.

Veering[1]suggested that half of the population over the age of 65 will require some form of surgery at least once in their lives.Hence,the challenge of operating on elderly patients with increased perioperative risks seems an inevitable one.The literature has shown that elderly patients fare worse than their younger counterparts in terms of postoperative complications,morbidity and length of stay after both elective[2]and emergency surgeries[3,4].Therein explains the growing interest in optimizing postoperative outcomes for the elderly.

The idea of Death as the great leveler started during the Middle Ages (Biedermann 91), where Death was seen as a skeleton in picture depicting23 The Dance of Death (Biedermann 91). The death figure in this story seems to be a cross between the skeleton like death and the death from early medieval representations. There Death is seen as masculine: powerful, pitiless, omnipresent (Windling). The Grimms Death has feeble legs, but he strides.According to John Clute and John Grant, editors of The Encyclopedia24 of Fantasy, Death in literature is a Liminal Being who exists at the threshold of two states; this gives LBs both wisdom and the ability to instruct while also rendering25 them dangerous and uncanny (581).Return to place in story.

A myriad of studies has explored modifiable factors that adversely impact outcomes such as frailty and sarcopenia.The subsequent introduction of prehabilitation as a solution to mitigate frailty and sarcopenia was shown to be a protective strategy for postoperative complications in high-risk patients undergoing elective abdominal surgery[5].Multidisciplinary and multimodal programs catered for the elderly have also shown a reduction in length of hospital stay in our institute[6].Similarly,a systematic review by Bagnall

[7]demonstrated that elderly patients had fewer complications and shorter hospital stay when managed within an enhanced recovery after surgery program as compared to conventional care.In terms of emergency surgery,the National Emergency Laparotomy Audit has also reported improved outcomes in the elderly secondary to increased perioperative geriatrician input within their laparotomy pathway.

Last but not least,the adoption of a specialized geriatric surgical service promises to align team members to a common goal,promote productivity and communication and foster ownership to prevent fragmentation of elderly care[8].The aforementioned strategies may continue to improve conventional measurable outcomes in elderly patients undergoing surgery.However,it is of essence to understand that the process of recovery for the elderly commences at the time of diagnosis and does not cease until the patient has regained a functional capacity similar to his or her premorbid state and has integrated back to society[9].Lowered surgical mortality risk itself does not obviate the possibility of postoperative debilitation and loss of independence in the elderly.These intangible factors are important in the equation for geriatric surgery.

All authors declare no conflicts of interest.

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers.It is distributed in accordance with the Creative Commons Attribution NonCommercial(CC BYNC 4.0)license,which permits others to distribute,remix,adapt,build upon this work non-commercially,and license their derivative works on different terms,provided the original work is properly cited and the use is noncommercial.See: https://creativecommons.org/Licenses/by-nc/4.0/

While the growing interest and development in the field of geriatric surgery has been heartening,the greatest challenge remains in the sustainability of these efforts.Moving forward there should be more focus on dedicated geriatric services to facilitate holistic recovery of the elderly post major surgery.Regular audits and cross institutional collaboration are ways to ensure quality care for our elderly patients.

FOOTNOTES

Ma YJ

There was great joy and gladness between them all that night, but the next day, when the wedding was to take place, the Prince said, I must see what my bride can do

The decision to offer major surgery to the elderly should also be individualized to their premorbid function,comorbidities,personal wishes and considerations with regards to postoperative quality of life.Furthermore,multimodal programs such as the National Emergency Laparotomy Audit may overemphasize efficiency of processes given the time critical nature of the underlying etiology for emergency laparotomies.However,the geriatric surgical equation in the elderly surpasses the mere equation of “time to scan,time to surgery or length of stay.” Reasonable time should be given to address the wishes and concerns of the elderly and their families while deciding on major surgery.

Serene Si Ning Goh 0000-0003-4916-2142;Clement LK Chia 0000-0003-2248-9348.

Singapore

Goh SSN conceptualized and wrote the manuscript;Chia CLK conceptualized,vetted and approved the manuscript.

On subsequent trips through LaGuardia, Garth would inquire about Miles, and about six months later he asked us to help him contact the family. Garth was going to be performing in Kansas City and he wanted Miles to be his guest. Not only was Miles seated in the front row, but he and Garth also had a lengthy8 private meeting backstage after the performance.

Filipodia

In the morning Vasilissa dug a deep hole in the ground and buried the skull. Then she locked the house and set out to the village, where she went to live with an old woman who was poor and childless, and so she remained for many days, waiting for her father s return from the far-distant Tsardom.

Guo X

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