The challenge of colorectal surgery in the elderly

The ageing population is a modern-day success story, but brings new challenges. Increased life expectancy has been accompanied by a corresponding demand for medical and surgical care. According to the U.S. Centre for Disease Control, more than a third of surgical procedures are now carried out in people over 65 years of age. The older patient poses an increased surgical challenge, with reduced physiological reserve, higher likelihood of comorbidity and ultimately greater cost of care. Recovery from ‘successful’ surgery may have mediumto long-term ramifications for quality of life, with loss of function and independence, and need for discharge to a care facility. Although scrupulous surgical care and timely intervention may expedite recovery and mitigate the sequelae of adverse events, complications are poorly tolerated. However, there is great physiologic variability in the older population, as demonstrated by Luo et al. and Duraes et al. in this edition of the Journal, and the published results in the elderly may not always support exclusion from surgery based on age. Attitudes towards surgery in older patients have changed, partly reflected in progressive adjustments in the definition of an elderly patient. In 1907, performing surgery on 50 year old patients was considered rash, and twenty years later, influential surgeons opined that elective herniorrhaphy in this age group was not warranted. Procedures previously considered high-risk in the elderly have now become commonplace in the over 65-year-old patient cohort. Minimally invasive colorectal surgery carries particular challenges in all age groups, and more-so in the elderly. One of the first groups in Australia to expand laparoscopic colectomy to the elderly were Stitz and colleagues in Brisbane. Concerns have predominantly centred on length of surgery compared with an open approach, particularly the duration of pneumoperitoneum and intraoperative cardiovascular and respiratory impact. These effects are, however, offset by the benefits reported in multiple publications such as the COLOR and COST trials. In this edition of the Journal, a metaanalysis by Luo et al. concludes that the positive short-term outcomes of laparoscopic colorectal surgery evident in the literature are also conferred to elderly patients. Despite these advantages, the ability to tolerate, recover and benefit from more complex colorectal procedures remains debatable. One such procedure is the ileal pouch-anal anastomosis (IPAA) for ulcerative colitis, carried out after proctocolectomy, which has been considered a contraindication in elderly patients due to a perceived higher incidence of postoperative morbidity and poor pouch function. Duraes et al. in this issue of the Journal, present the extensive Cleveland Clinic, Ohio experience with IPAA and challenge the claim that advanced age is a contraindication to the procedure. In patients operated on over a 36 year period they found advancing age did not increase major postoperative morbidity. Although pouch function was worse, with a higher incidence of faecal incontinence in patients over 60 years, quality of life was satisfactory in older patients and the authors do not recommend an age cut-off as a barrier to surgery. Functional outcome after colorectal surgery, and particularly after rectal excision with a restorative procedure such as IPAA, is extremely important. Ileal pouch function correlates closely with quality of life and since pelvic floor and anal sphincter physiology change with age, the capacity to compensate for poor pouch function is reduced in the elderly patient. Pouch function improves in the postoperative period with small bowel adaptation leading to colonic metaplasia of the pouch and proximal intestinal mucosal hyperplasia and the capacity for mucosal adaptation is not lost in the elderly. Although there are minor age-associated alterations in intestinal morphology, these do not impact nutrient or water uptake. Age does not preclude IPAA, but patients should be appropriately selected, taking into consideration patient expectations and anticipated functional outcomes. Alongside the large proportion of well elderly is a vulnerable subset of elderly patients who have frailty-related comorbidities. The frail elderly have become the focus of initiatives including multidisciplinary care teams, perioperative optimisation protocols, and ‘prehabilitation’. Prehabilitation has recently gained traction and has become a core tenet in the recently published practice guidelines of The American Society of Colon and Rectal Surgeons in the perioperative management of frail older patients. Prehabilitation programs consist of a multi-disciplinary and multi-modal approach focusing on nutritional supplementation, physical exercise regimens, pulmonary optimisation and psychosocial support. In elderly patients undergoing colorectal surgery, prehabilitation has been shown to significantly increase patients’ preand postoperative functional capacity, although these improvements in physical performance are yet to translate to notable reductions in postoperative morbidity. In future studies, it is hoped that by defining specific subgroups at risk, and standardising multimodal prehabilitation regimens, postoperative outcomes will improve. Ultimately, globally and in Australia, the population aged 65 and over is expanding. With continued advancements in the perioperative optimisation and procedural management of the elderly patient, we will witness an ongoing evolution in their suitability for major procedures such as an IPAA and laparoscopic colectomy.