Rethinking Perioperative Care in Older Adults: A Plea for Specialization

INTRODUCTION The aphorism “the operation was successful, but the patient died” highlights the gap between technical success and meaningful outcomes. Surgical care for older adults is shifting from a procedure-centered model toward a patient-centered framework emphasizing functional recovery, autonomy, and quality of life, driven by demographic, ethical, and scientific change.1 With increasing longevity and multimorbidity, surgeons are now routinely performing complex procedures in patients whose advanced age alone would have precluded surgery only a decade ago. Frailty, a measure of physiological, cognitive, and psychosocial reserves, is a superior determinant of recovery and long-term function than chronological age. These insights have shaped geriatric surgery as a distinct domain, exemplified by initiatives such as the American College of Surgeons Geriatric Surgery Verification Program and other subspecialty guidelines that standardize multidisciplinary care for older surgical patients. Modern practice increasingly requires balancing technical capability with patient priorities, integrating frailty-informed decision-making, prehabilitation, and multidisciplinary optimization into routine workflows. Surgical success extends beyond survival and complications to whether older adults regain dignity, independence, and a quality of life aligned with their goals. Surgical care for older adults has reached an inflection point warranting recognition of geriatric surgery as a distinct surgical discipline. THE EVOLUTION OF MODELS FOR COLLABORATION BETWEEN MEDICAL SPECIALTIES The evolution of collaboration in surgical care reflected the growing complexity of older adults and the recognition that no single discipline could fully address their needs. This complexity initially gave rise to a “consultation model”, in which surgeons retained primary responsibility, and could accept or disregard recommendations, often limiting meaningful integration of other expertise in the management of multimorbidity. As clinical knowledge expanded, a “disease management teams (DMTs) model,” such as tumor boards emerged. This promotes multidisciplinary decision-making while preserving professional boundaries, without integrating perioperative care across disciplines. More recently, a “co-management model”, particularly for older surgical patients, has emerged, with surgeons and geriatricians sharing responsibility for both decision-making and perioperative care, leading to improved outcomes in vulnerable populations. These developments mark a shift toward transdisciplinary care, emphasizing shared governance and patient-centered pathways, and underscoring that optimal outcomes for older surgical patients require coordinated, continuous care rather than isolated decision-making. REDEFINING SURGICAL SUCCESS For much of modern surgical history, success has been measured through clinical outcomes such as mortality, morbidity, and technical performance. However, these metrics do not reflect what matters most to many older adults, namely, maintaining independence, preserving cognitive and functional integrity, and the ability to return home. The question has shifted from “Did the operation go well? to “Did the patient recover meaningfully?.”2 Nonetheless, a recent systematic review of 103 studies evaluating abdominal surgery in older adults found that only 31 reported functional outcomes.3 Recognizing this gap requires surgeons to adopt a broader concept of benefit that encompasses not only anatomical correction or survival but also the likelihood of restoring function, minimizing postoperative decline, and supporting return to each patient’s preferred living environment.4 Patient-reported outcome measures (PROMs) provide a valuable complement to clinical data, capturing domains such as mobility, energy, social participation, pain, and overall well-being, elements not reliably reflected in conventional endpoints. Incorporating PROMs enhances communication, strengthens shared decision-making, and improves alignment between surgical plans and patient priorities. However, implementation remains uneven. Only 20%–37% of studies worldwide reported perioperative functional data, highlighting a global mismatch between clinical priorities and measurement practices.3 Patient-centered definitions of success reshape professional responsibility, requiring humility in assessing surgical appropriateness and close collaboration across disciplines. Surgical excellence must extend beyond technical metrics to include ethical commitment to shared decision-making and alignment with individual patient goals. Together, these developments reflect a cultural and ethical transformation within surgery, from surgeon-directed decision-making to a model grounded in shared professional responsibility, transdisciplinary collaboration, and value-based care. FROM PROCEDURE TO PROCESS: THE EMERGENCE OF PREHABILITATION AND INTEGRATED PERIOPERATIVE CARE Surgical care for older adults has shifted from a discrete event to a longitudinal, process-oriented journey in which outcomes depend on preoperative readiness as much as intraoperative care. Enhanced Recovery After Surgery pathways and comprehensive geriatric assessment exemplify this approach, emphasizing personalized optimization, multidisciplinary coordination, and recovery-focused care.5 Prehabilitation has become central to modern perioperative care. First described in 1946, the concept evolved to enhancing functional reserve before surgery to reduce complications and support recovery. Contemporary multimodal approaches incorporate exercise, nutrition, and psychological support. A recent meta-analysis associated prehabilitation with fewer postoperative complications, faster bowel recovery, and shorter hospital stays after colorectal cancer surgery.6 Adherence to prehabilitation remains variable, with systematic reviews identifying challenges among frail older adults and participants in home-based programs, demonstrating that postoperative benefits are greatest with high adherence.7,8 Contemporary reviews also caution that prehabilitation may inadvertently substitute for discussions of surgical appropriateness and patient priorities, emphasizing that it should complement, not replace, shared decision-making in older surgical candidates. Collectively, prehabilitation, Enhanced Recovery After Surgery principles, PROM-guided evaluation, and geriatric perioperative comanagement represent a paradigm shift from reactive, disease-centered care to proactive, patient-centered surgery focused on preserving autonomy, function, and quality of life in older adults. THE NEED FOR PROFESSIONAL EDUCATION AND TRAINING Traditional surgical training has emphasized technical skill and disease-specific knowledge, with mastery defined largely by operative proficiency and anatomical expertise. However, this framework insufficiently addresses the physiological, functional, cognitive, and psychosocial factors that shape outcomes in older adults, necessitating new competencies as surgical care increasingly incorporates frailty, multimorbidity, shared decision-making, and perioperative optimization. Embedding process-oriented, collaborative models into surgical care for older adults requires a fundamental evolution in surgical education. Training must extend beyond technical dexterity to include interdisciplinary collaboration, geriatric principles, and longitudinal care planning. Structured instruction in geriatric assessment, risk stratification, functional optimization, and goal-concordant communication is essential to align surgical care with older patients’ needs and values. Systematic reviews continue to demonstrate persistent gaps in training, with many trainees reporting inadequate preparation to manage frailty, polypharmacy, cognitive impairment, and postoperative functional decline.9 This underscores the need for competency-based curricula that integrate operative proficiency with the nontechnical skills required to care for medically complex older adults. Educational interventions such as simulation-based training, interprofessional learning, and structured mentorship have shown promise in improving understanding of geriatric principles and strengthening collaborative practice.10 Emerging models, including microlearning and AI-driven educational tools, offer promising adjuncts to traditional training by enhancing residents’ competencies in perioperative care for older adults. Developing a workforce capable of managing the complexity of older surgical patients is foundational to improving outcomes and advancing geriatric surgery toward recognition as a formal subspecialty. A PLEA FOR SPECIALIZATION As of 2025, geriatric surgery is not formally recognized as a distinct surgical subspecialty with dedicated board certification. However, the case for greater specialization has become increasingly compelling. Older adults comprise a rapidly growing segment of the surgical population, with perioperative risks shaped by physiological aging, multimorbidity, frailty, functional decline, and psychosocial vulnerability. These factors profoundly influence decision-making, recovery, and long-term outcomes, yet remain insufficiently addressed in traditional surgical training. Despite the high volume of procedures in this population, many surgeons lack structured preparation to manage the complexities of aging, highlighting a critical educational gap. Geriatric surgery should be viewed not as a rigid or singular model but rather as a spectrum of approaches, ranging from enhanced competencies and comanagement to focused certification and potential subspecialty recognition, allowing adaptation across healthcare systems. Given the marked heterogeneity of older adults, this field is defined less by procedures and more by patient-centered competencies, including frailty assessment and goal-concordant decision-making. In this sense, it functions as an integrative layer that complements, rather than replaces, disease-specific expertise. Advancing specialization in geriatric surgery would provide a clearer framework for competency development in comprehensive geriatric assessment, perioperative optimization, and interdisciplinary care. It would also reinforce collaboration across surgery, geriatrics, anesthesiology, rehabilitation, nursing, and social work, supporting a coordinated, patient-centered model of care. Defining such a field is inherently challenging, particularly across diverse international training systems. Each healthcare system reflects its own traditions, regulatory structures, educational pathways, and professional norms. Accordingly, geriatric surgery, whether conceptualized as a subspecialty, fellowship, or expertise-focused domain, must remain adaptable to local contexts while articulating globally relevant core competencies. Nonetheless, its evolution is already underway. Expanding evidence, international initiatives, and increasing clinical demand all point of its emergence as a necessary focus within modern surgical practice. Future directions should prioritize the educational and professional infrastructure required to support this evolution. This includes integrating geriatric principles into undergraduate medical education and surgical residency, expanding fellowship opportunities, and standardizing competencies in frailty assessment, multimorbidity management, and shared decision-making. Research priorities should emphasize prehabilitation, PROMs, and perioperative models tailored to the heterogeneity of older adults. At the systems level, policies and incentives must evolve to support care models that extend beyond traditional surgical metrics. We acknowledge that implementing a formal subspecialty presents real challenges, including workforce constraints, variability in training structures, and the tension between procedure-based certification and competency-based care. However, these barriers should not delay progress. Scalable and immediately actionable approaches include integrating geriatric principles into existing training, expanding quality improvement initiatives, and developing focused certification models. Importantly, there are clear parallels to other cross-cutting and population-focused domains, such as perioperative medicine, geriatric oncology, and palliative care, which similarly integrate specialized competencies across traditional specialty boundaries. These models demonstrate how structured expertise can evolve in response to increasing patient complexity, even in the absence of procedure-specific differentiation. These approaches are not competing alternatives, but complementary strategies toward a more responsive surgical system. CONCLUSIONS In conclusion, geriatric surgery has become an essential component of contemporary surgical care. Evidence suggests that frailty-based assessment, targeted prehabilitation, and interdisciplinary comanagement improve outcomes and promote functional recovery, shifting the definition of surgical success toward patient-centered goals, including the preservation of independence and quality of life. Recognition of geriatric surgery as a distinct subspecialty reflects this evolution but should be viewed within a broader flexible framework of adaptable and complementary care models. Whether through subspecialty development, enhanced training pathways, or integrated care models, the central aim remains the same: aligning surgical care with the needs, goals, and vulnerabilities of older adults.