Complications and mortality in older surgical patients in Australia and New Zealand (the REASON study): a multicentre, prospective, observational study

We read with interest the results of the REASON study published by Story et al. [1]. We would like to commend them on their work in bringing to attention the mortality and morbidity associated with surgery in the older population. It is indeed true that surgeons will be increasingly faced with older patients in the future and there needs to be an in-depth understanding of the short-term and long-term outcomes of major surgery and anaesthesia on this patient cohort. Our team has previously published results from a national database on elective or planned colectomy in the elderly [2] and we are currently in the process of submitting our work in the emergency setting. Review of the literature reveals only a limited number of studies with a large sample size that have prospectively analysed outcomes in elderly patients undergoing major surgery. Moreover, large variation exists in peri-operative mortality rates observed amongst studies with smaller sample sizes. For example, in elective colorectal resection in the elderly, short-term (i.e. 30-day) mortality rates range from 3.1% to 13.3% [3– 5]. This represents a source of potential confusion to both surgeons and patients. In the current study, the authors report a 20% complication rate and 5% mortality at 30 days. These outcomes are generally consistent with the published literature. However, it may be necessary to look beyond short-term outcome measures in this elderly patient cohort. Importantly, significant morbidity is observed in elderly patients up to one year following surgery. In fact, we have demonstrated from a routinely collected English national database that significant mortality occurs amongst elderly patients following major, elective colonic resection after the initial 30-day period and up to one year [2]. Furthermore, it is likely that the impact of intermediate and late mortality will be exaggerated in elderly patients undergoing emergency surgery. Story et al. have shown that non-scheduled surgery has almost twice the risk of mortality when compared with planned or elective surgery [1]. Clear information regarding anticipated surgical outcome is essential to both surgeons and patients to enable informed decision-making. Even amongst patients who have survived the initial 30-day period, little is known regarding the quality of life and functional outcome achieved by survivors. Debate exists about whether it is the independent impact of advancing age or the greater presence of associated co-morbidities in this cohort that renders the elderly susceptible to complications and death. However, in the current study, our own evaluation of a national patient cohort and other large studies has found age to be an independent determinant of postoperative mortality [2, 5–7]. Pre-operative optimisation and intensive postoperative surveillance in high dependency care environments have been suggested as management strategies that may reduce this risk; however, these factors probably have limited bearing on the 1-year mortality. Rehabilitation programmes and close out-of-hospital monitoring by a broad multidisciplinary team involving both primary and secondary care may mitigate some of the late mortality risk inherent to major surgery amongst this population. Once again we thank the authors for their insightful contribution towards establishing meaningful outcome measures in the elderly patient undergoing major surgery.