Joseph M., an 88-year-old Rockville resident, called his physician early one Saturday morning. He felt stabbing pain in his abdomen and was nauseous and weak. Within an hour, Joseph M. was admitted to George Washington University Hospital. The diagnosis: a perforated gastric ulcer.
Surgeons at the hospital consulted with his internist and learned that despite his advanced age, the patient was in good health with no underlying lung or cardiac problems. The proposed surgery was judged to be relatively safe and was performed immediately.
Ten days later, Mr. M. was able to leave the hospital and recuperate at home.
"Well-planned surgical procedures for elderly patients can be safe and are justifiable," conclude Drs. R. Benton Adkins and H. William Scott Jr., two surgeons from Vanderbilt University Medical Center in Nashville in a recent issue of the Southern Medical Journal. They base their conclusion on a controlled study of 85 operations on 75 patients more than 90 years old.
"In the study, post-operative mortality for this age group was only 2.3 percent in elective surgery ," they wrote in their paper. "Post-operative mortality in elective surgery in persons ranging in age from 29 to 49 years is 2.7 percent."
There have been numerous recent examples of safe surgery in elder statesmen, including major surgery to remove colon cancer from President Reagan, 74, artificial hip implants for Sen. Barry Goldwater (R-Ariz.), 76, and coronary artery bypass surgery for U.S. District Judge John J. Sirica, 81.
But Washington surgeons caution against too much enthusiasm for surgery in the elderly. While invasive procedures in this age group can be both successful and life-prolonging, they should not be attempted except as a last resort -- and with every attempt made to use limited anesthesia.
Local physicians also agree that it is better to use nonsurgical approaches when appropriate in treating the elderly. Noninvasive techniques can often provide a lower-risk alternative.
Even though the elderly body can survive the rigors of surgery, it is still more at risk for certain complications, especially when the surgery is performed on an emergency basis, when general anesthesia is used, and when the operation is a long one.
"Patients who require general anesthesia are subject to greater risk than patients who may be treated surgically with more limited anesthesia," says Dr. Robert Simmons, chief of cardio-thoracic surgery at Providence Hospital. "And the risk represented by general anesthesia escalates geometrically with patients suffering from complicating or chronic underlying disease."
Since elderly patients tend to suffer a higher incidence of lung and cardiac problems, they clearly fit into this increased risk category, Simmons says.
Emergency operations are more common among the elderly, Adkins and Scott concluded, and they also are more risky. Nine of the 11 deaths during their study occurred in patients who had emergency or urgent operations.
"Post-operative mortality for emergency surgery in older patients . . . was 45 percent," Adkins and Scott wrote. The average mortality rate for emergency surgery in persons under 65, except in accident victims and other cases of trauma, is less than 10 percent, according to the National Center for Health Statistics.
The operations most often performed on the elderly include genito-urinary procedures, gastro-intestinal procedures, repairs of hip fractures, eye operations, cancer surgery, heart pacemaker insertions, and brain and blood vessel procedures. Nearly all of these procedures, which Adkins and Scott estimate account for some 80 percent of all elderly surgery, require general anesthesia.
General anesthesia is more risky in the elderly because it is a kind of controlled poisoning of the body. Anesthesia acts on the brain by bringing on a sleep-like state. But in the elderly, it may overtax damaged or weakened lungs, stress the heart and circulatory system and lower the oxygen supply to other critical organs.
In a normal, healthy person, the rigors of anesthesia can be withstood well. In an older person, anesthesia could be metabolized more slowly and built up to lethal levels.
Although surgery in the elderly when using general anesthesia is risky, under certain circumstances such operations may be desirable.
According to Dr. Richard Flax, associate clinical professor of surgery at George Washington, the following criteria should be applied before any senior citizen considers surgery:
Can the disease or problem be treated nonsurgically? If so, is there any compelling reason to operate?
If a decision is made to operate, can local anesthesia be substituted for general anesthesia? More and more procedures, apparently, are being undertaken with local anesthesia.
If the disease or problem is either "urgent" or "emergent" and surgery offers life-saving hope, does the surgeon know the patient's medical history well enough to minimize the chances of running into complications -- either during or after surgery?
In certain instances, Flax says, conditions that would instantly call for surgery in a younger person might most prudently be treated without surgery in an older person. If a gall bladder stone, for instance, were not provoking an acute crisis, it would not be treated surgically in an older individual.
Breast cancer, which today is being treated with a diverse array of medical therapies, might not result in the surgical removal of the breast in an elderly woman. Instead, a more restrictive operation such as a lumpectomy might be performed.
Physicians and surgeons concurred that no one, regardless of age, should consider surgery except with careful consideration of the options.
The elderly also face post-operative complications. Dr. Edward Adelson, clinical professor of medicine at George Washington, says elderly patients are particularly prone to depression.
"The stress of surgery," Adelson says, "coupled with the alien hospital environment can cause significant distress to an elderly person. Surgeons and internists need to be particularly sensitive to the psychic needs of the elderly before initiating procedures."
Blood clots are another key complication, says Dr. Samuel Loube, also a clinical professor of medicine at George Washington. "During the recovery period, the bed-ridden patient is more vulnerable to circulatory problems -- and in the elderly, of course, such problems, if not anticipated, may be lethal."
On the positive side, however, Loube says techniques today for monitoring post-operative patients are vastly improved over those used even a decade ago. "Surgery for the elderly," he concludes, "can be as successful as for any other age group, providing that optimal care is available."