Geriatric surgery: a novel field of person-centered surgical care for the oldest-old

Dear Editor, Surgery is a medical and scientific field characterized by the high rigor of its techniques, methods, and outcomes across all age groups. Global surgery, supported by some manifestos from The Lancet Commission on Global Surgery, has proposed specific areas of work and objectives in response to the current demands and challenges of global health, involving surgery as a potential solution in the human disease process[1]. Some of these indicators, related to the density of surgical care teams, timely access to high-quality surgical services, perioperative mortality, and high health costs, are closely linked to the particularities of surgical care[1], such as interventions in longevity or extreme longevity, which have not been extensively studied previously. Contrary to the care of adults, in older persons, there is a transition in the life cycle that starting at age 80, is characterized by a notable acceleration of biological aging. This often correlates with the onset of age-related chronic diseases, loss of functional capacity, and other organic declines[2], which are traditional significant risk factors for perioperative and postoperative complications. However, biologically, an important finding has been described in the oldest-old (nonagenarians and centenarians)[3], suggesting that in this population, there is an inversion in the traditional predictors of overall morbidity and mortality, as functional capacity, specific health outcomes (frailty, sarcopenia, cognitive status, among others), and person-centered outcomes more accurately predict disability-free life expectancy and overall life expectancy compared to chronic diseases[2]. For this reason, some authors have suggested developing a specific surgical field focusing on the surgical care for older persons[4,5]. However, much of this proposal is concentrated on the population over 65 years old, when it should really consider those over 80 or 85 years old, where the organic and functional changes are more pronounced. Recent evidence has revealed the relationship between biological age and certain specific health outcomes[6]. In surgery, much remains to be investigated to transition from precision medicine to precision surgery, utilizing biomarkers of biological age and organic functioning to predict more accurately the biological response of a tissue, structure, or organ. Nonagenarians and centenarians serve as examples of successful biological aging models in humans, characterized by delayed biological aging that allows them to surpass standard life expectancy and even reach extreme ages with a good health phenotype[3]. Surgical care for this population would be a clear example of transitioning towards precision surgery, which considers biological age, rather than chronological age, as a predictor of surgical outcomes[7]. Currently, the number of randomized controlled trials and robust observational studies that have examined medium- and long-term surgical interventions and outcomes in extreme longevity is scarce, and even nonexistent in certain regions of the world. Therefore, many surgical decisions are made based on assumptions and extrapolations from recommendations for older persons in general[8], even though this analysis is flawed, given the arguments presented. In response to this scenario, it would be necessary to formally develop geriatric surgery programs[9], primarily focused on the surgical care of older persons with particularities, such as longevity and extreme longevity. This field should direct its attention toward person-centered surgical care, recognizing the multidimensional and multidirectional factors of aging[10], which involves proximal and distal influences that are not traditionally considered in surgical care. To address true knowledge gaps, it is important to critically and systematically evaluate the evidence through meta-research studies that determine the pluralism and medical relevance in geriatric surgery research[11-13]. New studies should be designed and directed to provide definitive answers to these issues. Given that this scenario has never been discussed before and recognizing the importance of the arguments presented, it is presumed that there is a significant bias in surgical research concerning older persons[14]. This bias should be carefully analyzed by decision-makers when interpreting and applying certain recommendations or results in surgical interventions for older persons.