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SURGERY IN THE ELDERLY (ABOVE 80 YEARS) IN DEVELOPING NATIONS
Dr. P. S. Ramani
The life span is increasing. With advancement in medicine the health standards have significantly gone up. With advance in technology it is now possible to do a major surgery in elderly with minimally invasive techniques, giving more comfort to the patient, less pain, less morbidity, shorter hospital stay and early mobility.
All these features go a long way in achieving cure in many patients above the age of 80 years when they require a major surgery lasting anywhere between five to eight hours. I routinely do such surgeries in the city of Mumbai and last week I have operated two patients (83 and 88 years old) for PLIF surgery on the back, the operation lasting more than 5 hours in each case. Both of them were discharged from the hospital 3 days after surgery.
At this age certain additional precautions are mandatory.
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fig 1
Dr Ramani with the patient |
1. The Surgeon :
Besides routine preoperative protocol and looking after his/her medical problems the patient is by default checked by a Cardiologist and a Physician to check and give consent for surgery. Pulmonary function tests and coagulation profile are mandatory. The patient is also seen by the physiotherapist to teach him breathing exercises during the post operative period. He has to take extra care if patient is consuming drugs like ecosprin or clopidogrel. Social adversity and lack of affection for the elderly is significantly prevalent in our society. It may not be worth doing a major surgery if there is no family back up to support him in the post operative period as our social security is not well established.
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fig 2
MRI of
the spine |
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fig 3
X-ray showing
broken spine |
2. The Anesthetist :
He is aware of certain problems in the elderly. He knows that they have reduced physiological reserve. Several times elderly patients come with atypical presentations like electrolyte imbalance causing abnormal behavior or drowsiness. Many of such patients have co-morbid conditions and have to be taken care e.g. a patient of compression fracture in the spine can have associated prostate or breast cancer. They are also consuming a lot of medicines (poly–pharmacy). A proper itinerary of al the drugs have to be taken. (RAMPS).
3. During Surgery :
4. A dose of low molecular heparin in routinely given.
Proper positioning of the patient is very important to avoid pressure on the tissues and particularly legs to prevent blood clogging.
The surgeon must do meticulous dissection and achieve perfect haemostasis and avoid circumstances which can lead to embolism.
The anesthetist does more extensive monitoring and proper dose titration. He uses newer drugs which are short acting and stable haemodynamically so that after surgery the patient can be quickly woken up. The blood pressure is not lowered unduly ad it is maintained more nearer to his existing blood pressure.
Swings in blood pressure are avoided. Serum electrolytes are checked
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fig 5
Xray 1 shows
PLIF operation on spine |
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fig 6
X-ray 2 shows
PLIF operation on spine |
5. Post Operative Period :
Chest physiotherapy is started immediately. Inhalations are given regularly. Physiotherapy in bed for the legs and hands is started as soon as is possible preferably on the same day of operation in the evening. Patient is provided with Fluton pump for both legs to prevent deep vein thrombosis. Low molecular heparin is given for 48 hours. Constant vigil is maintained for 24 hours and haemoglobin and serum electrolytes are checked.
6. The Physiotherapist :
He is very important during the post operative period for chest physiotherapy, passive movements, early mobilization, gait training and breathing exercises followed by active permissible exercises.
I undertake surgery in the elderly (above 80 years) taking precautions as mentioned above to provide cure for the patient. Seen in the picture is Shri Appasaheb alias S. R. Patil , 88 years old, ex MLA and Chairman of Sugar factory in Kolhapur leaving the hospital 3 days after major surgery of PLIF on his back which had lasted 5 and half hours.
7. Need of the hour :
The attitude of the patient needs to be changed. Our society is conservative. They do not easily accept aggressive approach. The feeling in the society is such that even after 65 years they feel that he is old enough not to undergo any surgery. This attitude needs to be changed aggressively. Only last week I operated 2 patients one 83 years old and Appaasaheb 88 years old. Both undergoing surgery lasting more than 5 hours and both going home 3 days after surgery. In major cities in India it is now possible to undertake such surgeries where all the facilities as mentioned above are available and particularly where post operative care as discussed is assured.
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