Surgery News - November 2008 - (Page 21)

NOVEMBER 2008 • SURGERY NEWS ENDOCRINE SYSTEM 21 Older Age Alone Should Not Preclude Thyroid Surgery BY BRUCE JANCIN Else vier Global Medical Ne ws C H I C A G O — Octogenarians undergoing thyroid surgery experience a markedly increased rate of serious perioperative complications, compared with younger patients, according to Dr. Michal Mekel. “We as surgeons need to have better preoperative evaluation and risk stratification of patients over age 80 [years]. Furthermore, we need to improve our postoperative care, perhaps with involvement of a geriatric team,” said Dr. Mekel of Massachusetts General Hospital, in Boston. She presented a retrospective study involving 90 consecutive patients over age 80 years and 242 randomly selected 18- to 79year-olds. All of the patients underwent thyroid surgery at the hospital during the same recent period. Eighty percent of the octogenarians were women, Dr. Mekel reported at the annual meeting of the American Thyroid Association. The overall 30-day complication rate was 23.3% in octogenarians and 9.1% in ogists and surgeons. Earlier surgical intervention may be advised in those who are at higher risk for clinical progression— for example, those in whom goiter enlargement is predicted—before they develop comorbidities. On the other hand, follow-up strategies without surgery may be advised for those who are at low risk for cancer or disease progression but who have the highest risk for complications,” she said. The distribution of preoperative indications for surgery—a mix of benign dis- ease, suspected malignancy, and suspected follicular neoplasms—was similar in the octogenarians and younger patients. At final pathology, cancer was confirmed in 29% of patients over age 80 years and 35% of those who were younger, a nonsignificant difference. Session cochair Dr. Gerard M. Doherty took a somewhat sunnier view of the study outcomes than did Dr. Mekel, noting he’d consider the results of this 332patient series “outstanding,” even if it hadn’t included 90 octogenarians. These generally excellent outcomes are testimony to what can be accomplished through an institutional policy of careful preoperative risk assessment and administration of routine deep venous thrombosis prophylaxis, said Dr. Doherty, an ACS Fellow who is professor and head of general surgery at the University of Michigan, Ann Arbor. He added that these precautions should be coupled with preoperative initiation of β-blocker and statin protocols as indicated, based upon patient risk factors. ■ THE 30-DAY COMPLICATION RATE WAS 23.3% IN OCTOGENARIANS AND 9.1% IN YOUNGER PATIENTS, BUT NO DEATHS OCCURRED IN EITHER GROUP. controls. Moreover, most affected octogenarians had multiple complications. However, no deaths occurred in either group. Mean length of stay was 1.67 days in patients over age 80 years, compared with 1.23 days in the younger group. The most frequent complications in patients over age 80 years were cardiovascular; a total of 6.7% of octogenarians were affected. Pulmonary complications, occurring in 3.3%, were next most common in this group. Complications experienced only by the octogenarians included atrial fibrillation, other arrhythmias, heart failure, pneumonia, ischemic colitis, tracheostomy, urosepsis, blood transfusion, reintubation, and sternotomy-related wound infection secondary to resection of a large substernal goiter. In a multivariate analysis, comorbid respiratory conditions proved to be an independent risk factor for perioperative complications in patients over age 80 years, conferring a 9.9-fold increased risk. Female gender was associated with a 3.3-fold increased risk of perioperative complications in the elderly. Interestingly, advanced age was not an independent risk factor for serious complications. This finding underscores the point that while careful selection of elderly candidates for thyroid surgery is warranted, advanced biologic age is not a contraindication to surgery, Dr. Mekel emphasized. “As far as patient selection is concerned, this needs to be more carefully looked at in the octogenarians by both endocrinol-

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Surgery News - November 2008

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