This Month in Archives of Surgery FREE

This issue of the ARCHIVES contains a symposium on the surgery of aging organized by the editor, Claude H. Organ, Jr, with articles by his former and present resident staff.

The subject of transplantation is becoming more important because of expanding indications and great success. Three articles deal with various aspects of this intervention. The first of these by Randall et al is part of the theme issue, Surgery in the Aging. It is a review of transplantation in elderly patients, pointing out that there is no statistical difference in either patient or graft survival in adult recipients 60 years and younger. However, the data show a clear difference when patients older than 65 years are compared with younger patients.

The second article by Perez et al addresses allograft rejection and survival in regard to the presence of vascular cell adhesion molecule 1 (VCAM-1). Patients with low levels of VCAM-1 experienced less graft rejection, an independent predictor. Increased levels correlated with greater graft loss. Thus, assessmentation inflammatory status may be useful in optimizing immunosuppression therapy.

Third, Freise at al reviewed the records of 40 consecutive patients receiving a pancreas-kidney transplant. They found that the combination of thymoglobulin, mycophenolate mofetil, tacrolimus, and sero-limus for the maintenance of immunosuppression—with steroids used only while thymoglobulin was given—proved highly successful with extremely low rejection rates. Thus, newer immunosuppression protocols without steroid maintenance are possible with minimal rejection in the first 3 months and equivalent patient and graft survival rates compared with earlier protocols.

The characteristic changes that accompany aging appear to follow a regulated patterned program. This includes the effects of reactive oxygen species, various genetic programs, and genomic instability. Molecular processes that control aging may be numerous and interdependent. Further advances in DNA array chip technology may help in clarifying these complexities. As our understanding of nature advances, it carries the responsibility to use the knowledge wisely.

There are age-related alterations in the homeostatic mechanisms used to maintain electrolyte and water balance. Histologic examination of the aged kidney, avoidance of fluid deprivation or iatrogenic insult, and meticulous detail paid to salt and water balance, drug dosing, and choices are a few of the approaches that appear warranted.

The normal physiological changes associated with aging lead to diminished reserve. Patients of advanced age have the highest mortality rate within the adult surgical population. Perioperative stress produces great shifts in fluids, temperature, adrenergic activity, and pulmonary function. Careful postoperative treatment is advocated.

Elderly patients undergo proportionately more permanent fecal ostomy procedures with longer hospital stays, more complications, and higher mortality rates. However, eligible candidates should not be denied consideration for closure based on age alone.

Despite underlying comorbidities, elderly individuals tolerate laparoscopic procedures extremely well.