© Borgis - Postępy Nauk Medycznych 11/2008, s. 768
The next issue of Postępy Nauk Medycznych/Progress in Medical Science includes a range of articles about problems in medicine, and in particular surgery of the aged. The population of people aged over 65 from the current level of 12.7% will reach 20% of the general world population in 2030. The over-85 age group has been growing rapidly; the number of persons aged 85 or above will increase 6-fold and will reach approximately 20 million in 2050. The treatment of people in advanced age in the USA already consumes approximately one third of the budget allotted for health protection. Doctors, and in particular surgeons, have to prepare themselves theoretically and practically for health care of people in advanced age. In this group of patients dominant are illnesses such as: cancers, diseases of the circulation and respiratory system, the consequences of atherosclerosis, diseases of the osseous and articular system, cataract, injuries, perforations within the alimentary system, senile dementia and metabolic diseases. Immunity impairment connected with age increases the risk of infections. Surgical treatment of patients in advanced age is difficult and expensive. These patients are burdened by numerous illnesses. Surgeons need to learn surgery of the aged. Operations should be of short duration, minimally invasive and bloodless. After surgery patients should be quickly rehabilitated in accordance with the principles of fast-track surgery.
The aims of conservative and surgical treatment of patients in advanced age are as follows:
1. prolong the average survival,
2. maintain dignity of life and self-satisfaction from prolonged life,
3. increase independence and self-reliance of people in advanced age,
4. bring relief from suffering, in particular eliminating pain; although usually it is not possible to cure the patient in advanced age, it is very important to provide palliative care improving the comfort of life.
Particularly important conclusions result from articles published in this issue of "Postępy Nauk Medycznych”. I shall mention them briefly. In elderly people lactose intolerance intensifies, intestinal carbohydrate absorption decreases, intestinal ischaemia connected with atheromatosis of the arteries and a decrease in cardiac output are more frequent, and intestinal calcium absorption decreases due to a decline of 1,25-dihydroxycholecalciferol synthesis in the kidneys.
The number of infections increases with age. Senescence has an influence on the pharmacokinetics and pharmacodynamics of drugs. The lower efficiency of the liver and kidneys causes a decrease of elimination of drugs in the organism. This has an influence on decreased drug requirements during operative procedures. In the pre- and post-operative period particular care is needed for the elderly with concomitant diseases of the heart and the respiratory system, with diabetes or for malnourished patients. Regional anaesthesia may be performed in patients qualified for a short-lasting operation. In elderly people postoperative complications, such as consciousness disorders, thromboembolic complications, and hypothermia, are more frequent. Peritonitis can have atypical, oligosymptomatic course. Diverticulitis and alimentary tract bleeding are more frequent. Double-balloon enteroscopy is especially useful in the diagnostics of small intestinal bleeding. Lower gastrointestinal haemorrhage should be initially treated non-invasively because most cases of bleeding stop spontaneously.
The most frequent cause of acute pancreatitis in very elderly people is cholelithiasis. Cholelithiasis is also the most frequent indication for operative treatment in the elderly. Colorectal carcinoma is the most common cancer in the group of patients above 75 years old. Diverticular disease of the intestine is a quantitatively important problem in elderly people. It concerns equally both men and women. Diverticula are most often located in the sigmoid. Computer tomography is the method of choice in the diagnosis of this disease. Diffuse peritonitis is more common in elderly people. Also, other complications, such as lower gastrointestinal tract bleeding, are more frequent in elderly people. They suffer from constipation, caused by the reduction of anal resting pressure and the loss of power of anal sphincter contraction. Per rectum examination is still the most important diagnostic method. Also examination of the intestinal passage time is often used. At the beginning saline cathartics and osmotic laxatives are used in the treatment of constipation. Surgery is an extremely rare treatment for constipation. It is still a very harmful procedure for the patient.
Prof. dr hab. med. Krzysztof Bielecki