Who Thrives After Surgery?

Who Thrives After Surgery?

The New York Times, December 27th, 2010

Martin A. Makary, a surgeon and public health researcher at Johns Hopkins Hospital in Baltimore, had a long talk with a patient last week. The man had a tumor in his pancreas that was probably benign but might not be. Should Dr. Makary remove it? Or should the man have regular scans to see whether it grew?

“If you’re 25, the decision is easy — get rid of that risk,” Dr. Makary told me afterward. But this patient was 89.

Let’s pause for a moment to consider the changing surgical landscape. When Dr. Makary was in training, he recalled, surgeons were just starting to offer elective procedures to patients in their 70s. Now, with better techniques, safer anesthesia and, of course, more old people — half of all operations in the United States are performed on those over age 65.

“It’s become acceptable to do major procedures on very old patients,” he said. “We routinely do elective surgery on people in their 80s and 90s.”

That doesn’t mean it’s always a good idea, or that it’s easy to calculate the costs and benefits. How very old patients respond to surgery has proved unpredictable. “There are some people you worry won’t do well, and then they fly,” Dr. Makary said. “And some people you are confident will do well have a cascade of symptoms that lead to their demise or permanent disability — and everybody is shocked.”

Surgeons eyeball their patients all the time to try to evaluate whether they can recover well from the stress of an operation, but it’s an inexact science. “You can be thrown off by hair or teeth or wrinkles, things that don’t have much to do with physiologic reserve,” Dr. Makary said.

The usual tests surgeons use to try to predict how older patients will fare are crude, Dr. Makary added, mostly based on cardiovascular strength. And standard estimates of mortality and length of hospitalization for specific operations are all but useless for patients who might be 30 or 40 years older than the norm.

But thanks to a rather elegant piece of research by a Johns Hopkins team, recently published in The Journal of the American College of Surgeons, surgeons can give more informative answers when elderly patients in this situation, or their families, wonder what to do.

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