Introduction
Among the common cancers globally, gastrointestinal cancer comes fifth in position and is one of the leading reasons for death. There is an increasing prevalence of gastrointestinal cancers seen among the elderly population, as there is an increase in life expectancy. The peak is between 50 to 70 years of age. The management of this cancer can be quite challenging, with surgical resection being the only option most of the time. The current article intends to explore the surgical considerations in elderly patients, highlighting the importance of incorporating a comprehensive treatment approach.
What Is the Role of Age in Gastric Cancer?
Defining the elderly population is arbitrary. Generally, it is considered a population above 65 years of age. However, as life expectancy increases, the definition becomes highly variable. Humans undergo aging, a natural phenomenon that cannot be stopped. It brings about a significant decrease in mental and physical ability. Compared to the young self, elderly people feel reduced organ function and an increased sense of tiredness. Commonly, the respiratory and cardiovascular (heart) systems show decreased efficiency.
Gastrointestinal cancers pose a significant health challenge. Among the various risk factors, lifestyle changes contribute significantly to this. Helicobacter pylori infection, increased alcohol intake, high sodium consumption, and smoking are associated with increased risk. In this context, gastrointestinal cancer is presented differently in the elderly compared to young patients.
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Elderly patients have more medical comorbidities.
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They have more symptomatic diseases of advanced type.
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They have tumors of large size, multiple.
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The lymph node metastasis pattern is different.
Treatment includes surgery, chemotherapy, neoadjuvant chemotherapy, and chemoradiation. In the elderly, the choice of treatment becomes crucial, as its benefits and risks outweigh each other.
What Are the Surgical Considerations?
Whenever surgery is contemplated in the elderly, functional disabilities and associated comorbidities can further complicate the surgical procedure. The ability to recover quickly has also decreased. All this complicates and makes it complex. Aging brings about a decline in both mental and physical health, making them more vulnerable to surgical stress. A few important considerations include :
1. Pre-operative Assessment: Before any surgery is planned, a complete, thorough assessment of the patient’s overall health, associated comorbidities, and functional status is done. This assessment gauges whether the patient can withstand the stress of surgery. Patients often have more medical chronic conditions, such as diabetes, hypertension, and renal diseases, which can further complicate the surgical process and impact surgery and recovery. Consideration should be given to the cancer and the patient as a whole.
Numerous assessment tools are utilized to assess their cognitive, psychosocial, and strength aspects. Examples include the Clock drawing test, the geriatric depression scale, etc. Careful pre-assessment is done, as the elderly have more complications post-operatively.
2. Nutrition Support: The patient's nutrition intake is also checked, as malnutrition affects wound healing after surgery. Elderly cancer patients have shown significant malnutrition tendencies. Enteral or parenteral nutrition may be indicated where orally administered food calorie intake is insufficient. This is essential to optimizing recovery. A diet plan is to be chartered with the help of a qualified nutritionist considering other concomitant diseases. For example, a patient is to consume low-sugar nutritious food. Similarly, a hypertensive patient is to consume a low-sodium nutritious diet.
3. Surgical Procedure: The extent of resection depends mainly on the tumor stage and how much node is involved. A TNM classification for staging is used. Minimally invasive approaches are advocated to reduce this. Using laparoscopy and robotic surgery modes has shown less functional impairments and quicker recovery post-operatively. A gastrectomy is a complete abdominal operation. Partial or complete resection along with lymph nodes is considered based on extent. In the elderly, minimally invasive is generally practiced.
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Lymph Node Involvement: The extent of lymphadenectomy is also questioned. Extended D2 is generally avoided in the elderly as it is an extensive process. Fewer elderly patients undergo extended D2 lymphadenectomy, which is the actual standard of care. For this reason, researchers need more data to study this procedure.
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Pain Management: Care should be taken before prescribing medication, as elderly patients are more susceptible to adverse effects. A multiple-level pain management combining regional anesthesia techniques and prescribing medications can help minimize pain.
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Post-operative Monitoring: There is an increased risk of infections, delay in wound healing, and breathing issues after surgeries in the elderly population. Careful monitoring and prompt intervention in case of any event are necessary to address these complications.
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Palliative Care: In advanced cases, it is difficult to treat, and the focus is shifted to providing symptomatic relief. Surgery can also reduce symptoms and improve overall quality of life. Before taking up any mode of treatment, open and clear communication must be done with the patient and their family regarding their goals of treatment and care.
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Cognitive Decline: Post-operative cognitive decline is commonly seen after surgeries, and in the elderly, it is a critical factor. Various strategies must be undertaken to reduce this issue. Early mobilization, adopting a patient-centric approach, prescribing medications only when necessary, and regular cognitive assessments in all follow-up visits to be done.
4. Rehabilitation: All therapies to reduce the disability and increase functional outcomes must be started immediately. These include physical therapy, occupational therapy, and other rehabilitative services. Social support should also be provided through support groups catering to people going through a similar phase.
Conclusion
Exploring and choosing surgery as a treatment option for elderly patients needs a meticulous, patient-centered, individualized approach. Numerous challenges, such as aging, comorbidities, and functional limitations, must be considered, and a multidimensional collaborative approach must be considered. From careful pre-operative assessment to surgical procedures modified to lessen the post-operative issues, all these form a part of surgical considerations in the elderly. Post-operative monitoring is also crucial for uninterrupted healing. The concept of palliative care, particularly in advanced cases, stresses the importance of reducing the patient's symptoms without a definitive treatment. Open and clear communication is important to ensure the patient and doctor are on the same page. The journey to recovery is challenging, but careful consideration can make things easier.
