Functional Outcomes in Elderly Adults Who Have Undergone Major Colorectal Surgery

The aging population is an increasing healthcare concern in developing countries worldwide, requiring the management of elderly adults within surgical disciplines. The high incidence of comorbidities, limited functional reserve, and frequency of acute surgical problems makes treating elderly adults a constant challenge.1-3 In the experience of the authors of the current letter, a dedicated collaborative transdisciplinary geriatric surgery service (GSS) has been able to achieve sustained outcomes for elderly adults undergoing colorectal surgery better than standard management.4 To objectively measure surgical outcome and capture the true postoperative status of older adults undergoing surgery, mortality and morbidity data alone do not suffice. Currently, surgical outcomes are typically measured using postoperative morbidity and mortality data alone, even among authors reporting postoperative outcome data in elderly. Only a minority of authors have insightfully included postoperative functional status as part of their surgical outcome.5-7 It is likely that functional status recovery is a better indicator of recovery after the trauma of surgery; it will be a failure if people are bed-bound after major surgery, even though they survived the operation. A prospective study was conducted to track the preoperative and postoperative functional status of elderly adults (≥75) undergoing major colorectal resections. All individuals were managed using a transdisciplinary collaborative approach by the GSS. Operative risk was quantified using the American Society of Anesthesiologists classification, which has previously been validated in other studies,8 and the weighted Charlson Comorbidity Index.9 Frailty was also assessed based on the widely accepted definition using the Fried criteria, as detailed in a previous study.10 Preoperative and postoperative functional status was measured prospectively using the modified Barthel Index. Preoperative functional status was measured based on individual's baseline function before the diagnosis of pathology that required surgery. Postoperative functional status was measured 6 weeks after surgery and then every 3 months. Failure to achieve a Barthel score similar to or higher than the preoperative score was defined as failure of functional recovery. This study included 47 consecutive individuals who underwent major colorectal resections in emergency and elective settings between 2007 and 2011. Mean patient age was 81.9. mean follow-up duration was 91.2 weeks (range 6–249 weeks). As demonstrated in Table 1 6 weeks after surgery, 83% (n = 39) of patients had a Barthel Index not inferior to their preoperative score. At a mean follow-up of 91.2 weeks (range 6–249 weeks), 93.6% (n = 44) had a Barthel Index not inferior to their preoperative score. Bivariate analysis revealed that failure of functional recovery was significantly more frequent in individuals whose comorbidity index score was 4 and above (P = .004) and those who were frail (P = .004). Close attention to functional outcome through a transdisciplinary surgical approach results in good medium-term functional outcomes after major colorectal surgery in elderly adults. Individuals with a high comorbidity index and those who are frail must be identified because they need further targeted interventions pre- and postoperatively to optimize a smooth return to their preoperative functional status. As defined by the World Health Organization, health is a state of physical, mental, and social well-being and not merely the absence of disease or infirmity. There is a rising trend toward self-reliant elderly adults for whom the absence of disease is regarded on equal terms as their functional ability and preservation of their physical and social independence. Decisions regarding surgical intervention and preoperative management targeted toward mortality and morbidity reduction alone is therefore insufficient in these individuals. It is therefore imperative to include functional outcome measurements as part of the pre- and postoperative assessment in elderly adults because it will be a true reflection of postoperative heath status in this group. Although many previous studies of elderly adults claimed that morbidity and mortality were acceptable after major colorectal resections in these individuals, there has been a lack of data documenting that these individuals truly returned to good health after surgery. With the increasing emphasis on geriatric surgery, compelled by an aging population in most developed countries, there are a myriad of new assessment tools to aid colorectal surgeons in risk stratifying patients and planing for pre- and postoperative transdisciplinary interventions. These should pioneer a paradigm shift from a mortality and morbidity reduction–centric surgical management to an overall patient-centric level of care aimed at full functional recovery to preoperative baseline for elderly adults undergoing colorectal surgery. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Wang: analysis and interpretation of data, preparation of manuscript. K.-Y. Tan: concept and design, acquisition of subjects and data, analysis and interpretation of data, preparation of manuscript. P. Tan: acquisition of subjects and data. Sponsor's Role: None.