Abdominal surgery

The natural history of science is the study of the unknown. If you fear it you’re not going to study it and you’re not going to make any progress. Michael Ellis DeBakey (1908-2008) Introduction The aging of the world population is a serious issue for healthcare physicians, and most of all for surgeons, who are increasingly being asked to operate on patients who would absolutely not have been suitable for surgical treatment in the past few decades. Historically, chronological age has been considered the most important factor in the surgical decision-making process. However, unimaginable advances have been made in medical science making operative treatments feasible, even in very elderly patients, since surgery remains the cornerstone of the multimodal treatment of the vast majority of abdominal neoplastic diseases. There are also many abdominal benign conditions that may require surgical treatment in the emergency setting (e.g., bowel perforation, acute appendicitis, bowel ischemia, acute cholecistitis) where surgery is the only option to save the patient’s life. In these situations, the decision-making process should be rapid and include clear communication with patients, caregivers and all staff members in order to clarify treatment goals, including a non-operative strategy when the risks outweigh the benefits. Thus, preoperative assessment (frailty, functional and cognitive limitations, malnutrition, comorbidities, poly-pharmacy, as well as social environment) plays a pivotal role in identifying elderly patients who could tolerate surgical treatment and potentially benefit from it. When treatment decisions for frail patients are made, there are several questions that surgeons should consider: Is the patient going to die from the condition being evaluated for surgery? Is the patient able to tolerate the stress of surgery with reasonable postoperative risks? Is the treatment going to produce more benefit than harm? What is the patient’s life expectancy? What is the patient’s current quality of life and how will this change after surgery? (see also Chapter 9). Elective Abdominal Surgery In the twenty-first century, surgery is still the main strategy for treating a significant number of benign and malignant abdominal diseases. This is particularly relevant for the elderly population, accounting for the majority of elective surgical operations. Despite surgery being often technically feasible, the postoperative course could be affected by substantial complications, including death. It is intuitive that morbidity and mortality rates in the elderly population are significantly higher than in younger patients, despite the surgery being performed in the elective setting.