Ageless surgeries

By DR CHA KAR HUEI

Can anyone be ever too old for ‘key-hole’ surgery?

More and more surgical operations are being performed using minimally-invasive methods. In layman terms, they are commonly known as “key-hole” surgeries.

Such surgical methods are also called “laparoscopic surgery” when applied to the abdomen, “thoracoscopic surgery” in the chest, or simply “endoscopic surgery” in other parts of body.

“Key-hole” surgery has revolutionised the way surgeons treat diseases and benefited patients in terms of post-operative complications, pain, and discomfort. Today, “key-hole” surgery can be done on almost any organ, such as the gallbladder, appendix, stomach, large and small intestines, uterus, ovary, liver, pancreas, spleen, kidney and adrenal glands, abdominal wall hernias, and even thyroid glands in the neck!

The question is: does this type of surgery suit all patients?

When “key-hole” surgery was first introduced, there was a lot of criticism regarding its longer procedural time, putting patients at unnecessary risk, especially elderly patients. Besides, there was also concern that the gases surgeons use to create space in the abdomen in order to do this type of surgery would put extra pressure on patients’ cardiovascular systems (ie straining their hearts). There was a case where a physician actually wanted the surgeon to do open surgery on his “fit” old patient because of these concerns despite knowing the clear advantages of laparoscopic surgery.

The notion that laparoscopic surgery takes a longer time to complete is no longer true. In Malaysia, more surgeons are using this method. The learning curve is steep, but many have scaled it competently, and are able to complete common operations such as appendix and gallbladder removals in the same amount of time taken by open surgery.

Therefore, older patients are not subjected to “prolonged surgery” as claimed. On the contrary, older patients will benefit from faster recovery time and less post-operative discomfort. For example, removal of the gallbladder through the open method will set a patient back three days in the hospital compared to one day if done laparoscopically. The pain associated with a bigger incision will require more pain medications and increases the risks of post-operative delirium (confusion) in older patients.

Furthermore, higher lung infection rates have been reported in open surgeries because patients were too worried to take deeper breaths due secondary to pain. Lung infection or pneumonia represents one of the most costly and dangerous complications.

After all these potential ordeals in the first few days post-operation, surgeons also have to worry about the higher risks of wound infection rate simply because the incision is bigger.

The second notion that laparoscopic surgery increases risk of cardiovascular complications also does not hold well in today’s practice of surgery and anesthesia. The increased abdominal pressure during surgery is negligible in otherwise old fit patients. It has been shown that an additional abdominal pressure of 12 to 15cm H2O does not cause clinically significant distress to an otherwise normal body.

If the marginal increase in pressure causes unwanted side-effects, such as respiratory embarrassment during surgery, then the patients probably are not fit for open surgery either. It just means that the patient’s health or reserve is so poor that general anesthesia may be contraindicated. In this type of patients, the risks and benefits of doing or not doing the operation will have to be discussed in detail between the attending surgeon and the patient.

Let’s take abdominal or groin hernia as another example. If a patient is too frail to undergo general anaesthesia, the better option will be an open operation under local anaesthesia. The main point here is general versus local anaesthesia for the patient rather than laparoscopic versus open surgery.

More often than not, the decision to do or not to do “key-hole” surgery depends on the extent of the disease, ie large or small tumour, and the skill and experience of the attending surgeon. It is very rare to have absolute contraindication for “key-hole” surgery anymore. A case too complicated for one surgeon may be a “routine” operation for another. Patients should always seek second opinions if in doubt.

When we age, the possibility that we need surgical intervention increases significantly. Apart from appendix, gallbladder and hernia operations, other common diseases such as cancers in the colon, stomach, kidney, etc, start to appear in our golden years. Fortunately, “key-hole” surgery has been proven feasible in the colon, stomach and kidney as well. The results are not inferior to standard open surgery in terms of oncologic (cancer) control and risks of recurrence. The added benefits are less pain, smaller incision, faster recovery, less blood transfusion, and shorter length of hospital stay.

There have been studies carried out that show older patients are less likely to receive surgical intervention compared to younger patients in cancer cases. This is despite the fact that doctors know the end results after surgery are the same for older and younger patients. Older patients have the same chance of achieving as good a result as the younger group. Hopefully more patients and doctors will be more receptive to surgical intervention in curable cancer cases with “key-hole” surgery.

One major obstacle to further popularising “key-hole” surgery in Malaysia is cost. It costs significantly more compared to open surgery, anywhere between 50 and 100% more. This includes the use of special instruments and higher technology set-up required by the hospital. For fee-paying patients, this added cost does burden the patient and family. For insured patients, insurance companies have so far had no problems with the use of such high technology procedures as long as it brings benefits to their clients.

Age alone should not be the reason not to do “key-hole” surgery. There are other more important issues to consider for older patients, such as, pre-existing medical problems, patients’ nutritional status, hydration status, and others. It is paramount for the surgeon to review all the available data before deciding what is the best for his patients.

Fortunately for us, the advancements of surgical techniques and anaesthesia care that have occurred in the past decade have minimised the risks of peri-operative death for most operations. While we are talking about “key-hole” surgery now, there are more exciting innovations in progress to minimise insults to our body in the name of curing diseases, such as the “natural orifice transluminal endoscopic surgery”, ie surgery through the mouth or other natural openings!

- THE STAR