Foregut Surgery—80 is the New 60?

With the advancement in modern medicine and improved patient care, clinicians are required nowadays to assess more patients in their 80’s and 90’s. when these patients are being considered for surgery—current research emphasizes that physiological age is more important than chronologic age during patient assessment for surgery.

As the global population ages, identification of physiological reserve in the perioperative period should be standardized and routinely performed by multidisciplinary teams lead by surgeons, anesthesiologists, and geriatricians as part of a comprehensive work-up in the elderly surgical candidate. Targetable risk factors should be identified (such as—pulmonary, renal, and cardiac functions; exercise capacity; extent of surgery; polypharmacy; nutrition; sleep and family support are only few examples of such factors) and methods should be utilized to optimize these risk-factors during the preoperative setting. Those factors should be preferably addressed with a well-planned, individualized treatment plan before surgery.

The obesity epidemy and modern life resulted in an increase in foregut-related pathologies, which, as a consequence, increased the surgical referral both for benign and malignant foregut diseases.

Taking together the aging population, and the increase in foregut pathologies, many foregut surgeons are facing Octo and nonagenarians’ referrals.

In this month edition of Journal of Laparoendoscopic and Advanced Surgical Techniques, we focused on some of the advancement in foregut surgery in the elderly.

Ben-Yehuda et al. reported their experience with gastrointestinal stromal tumor (GIST) resection in patients >75 years old. ¹ While having more emergent surgeries and more open resections compared with younger patients, octogenarians were having similar complication rate, demonstrating the superiority of proper patient care during and following surgery, highlighting the safety and feasibility of GIST resection in the elderly. With the hope that more patients will be offered timely surgical consultation followed by elective resections—more patients will be able to enjoy the benefits of minimally invasive resections like their younger counterparts. Similar findings were nicely demonstrated by Marom et al. who presented the safety and efficacy of minimally invasive giant hiatal hernia repair (>30% of stomach in the thoracic cavity) in nonagenarians and demonstrated a reduced length of hospital stay and morbidity when compared with medically treated matched patient group. ²

Tankel et al. described their outcomes following gastrectomy for cancer prior and following the implementation of their institute’s specific enhanced recovery after surgery pathways (ERAS) in nonagenarians. ³ In a well-matched group, Tankel’s team reported a reduced hospital stay with no differences in the incidence of postoperative complications or readmission to the hospital. This report joins the robust data accumulating on ERAS pathways that has been recommended and embraced by many surgical societies in majority of the surgical specialties and specifically pointing out the benefits of the use of ERAS following gastrectomy in the elderly.

Finally, Schiller et al. performed an extensive systematic review on esophagectomy in the older adult population. ⁴ Summarizing the results of 26 papers specifically on controversial topics such as the differences in endoscopic versus surgical resection of early esophageal cancer, the benefit of neoadjuvant treatments when compared with upfront surgery in the elderly and the outcomes of selected medical and radiation oncology regimens, the authors concluded that when appropriately selected and prepared, older patients can have survival benefit when offered esophagectomy.

The prolongation of life is one of the great medical and social miracles of the modern era. Advanced foregut surgery training programs improved significantly the implementation and use of minimally invasive surgical techniques and as a result the outcomes of surgeries for benign and malignant foregut pathologies. With proper patient selection and the proven benefit of prehabilitation, intraoperative patient management, postoperative care and rehabilitation we should not be afraid to offer extensive foregut surgery even to those in extremes of age. With proper selection, let it be that 80 is the new 60 for our patients in foregut surgery.