SIOG 2014

Update on post-operative complications in older patients

Prof Kwok-Leung Cheung - Nottingham University, Nottingham, UK

What I have described in my talk about post-operative management would be when we should start. We can’t just teach someone to do an operation by taking them to the operating room; we’ve got to start early, and I was pleased to note that there was a talk before me talking about pre-operative preparation, and then the surgery and then post-operative care. So there are a few things which I have discovered through my literature review, in terms of updates in the last year or so, about factors that contribute to post-operative complications. They are age: when I say age in the context of SIOG the older old patients like the over-80s or even 90s. They are at higher risk of post-operative complications.

The second factor is one thing which has been looked at thoroughly in this meeting and also in last year’s literature about post-operative delirium which is an issue for the older patients. That tends to be intensified for patients who’ve got poor cognitive function before surgery, patients who are particularly older, patients who are having surgery of higher intensity in the sense of a more severe type of surgery, major operations and so forth.

Another thing is co-morbidity so the increase in number of co-morbidities, the extent as illustrated by different things, also contributes to significant post-operative complications. Lastly, which is something related to us is the intensity of surgery and the quality of surgery. So it tends to be more related to a visceral surgery rather than superficial surgery. So the more intense the surgery is, the more likely that post-operative complications tend to arise.

How do you balance the duties of a multidisciplinary team?

I think the important thing is you could look at this from the patient pathway perspective, so from the beginning at diagnosis. So what can you offer? Looking in the patient’s biological and geriatric perspectives what are the treatment options available? Is surgery the best option or is there an alternative, as I have alluded to in my previous talk. Then you decide, if surgery is going to be the best possible treatment option for this patient to start with, then you make a decision to act early to optimise the patient situation. By acting earlier I mean it starts pre-operatively and then you also decide whether that patient needs more intensive post-operative care. By intensive post-operative care it doesn’t necessarily mean intensive care as in putting a patient in an ITU but it could be some sort of personalised care, depending on the patient’s special needs or individualised needs. Because putting someone with potential delirium into an intensive care setting may not actually help.

What are the key messages for doctors regarding post-operative care?

I would say it would go back to the old dictum: the best surgeon is someone who knows when not to operate. So once you’ve decided to operate then you identify the high risk patients based on the factors that I have alluded to - age, cognitive function, comorbidities and intensity of surgery that you’re going to perform – then you act early to optimise the care of that group of high risk patients.