It ain’t the model year . . .


It ain’t the model year . . .

He was 94 years old and was in my office because his gallstones were becoming a problem. They had been diagnosed two years earlier when he had an ultrasound for an unrelated problem. At that time they were asymptomatic and he was correctly advised to do nothing unless they started to cause problems.

Three months before he came to see me, he started having intermittent pain in his right upper abdomen and some occasional nausea after eating ice cream. Two months later the episodes of pain had become worse and more frequent, almost daily. He went to the Emergency Room with one particularly bad episode. At that visit his labs (blood counts and chemistries) were normal and his pain subsided after some medication. He was given the name of a different surgeon and was discharged.

The surgeon he originally saw told him he was ‘too old’ for an operation and started him on a drug called Actigall to try to dissolve the stones.

Drug therapy for gallstones is a hit or miss proposition. Under the best of circumstances, the drug is 60% effective, takes six to eighteen months to work, does nothing to prevent or relieve the attacks of pain, and over 75% of those patients who successfully dissolve their stones will develop gallstones again within five years of stopping the drug. It may make sense in asymptomatic stones, but isn’t good therapy if the stones are causing trouble.

The man dutifully took the medication until it caused such severe diarrhea (a known side effect) that he became dehydrated and required admission to the hospital for IV fluids.

His family brought him to me because one of them sees the PA in the Primary Care practice where my wife works. The PA asked her advice and Michele gave them my name.

For 94, the man was in great shape. He took some low level antihypertensive medication and a baby aspirin daily, had no history of heart or lung disease, was thin and active, walking for exercise every day and managing his own affairs. He had family close by that could help him during his recovery. After meeting him, examining him and going over his medical records, I told him he needed an operation to remove his gallbladder. His response was “That’s why I’m here, Doc. When can we do it?”

There’s no absolute age limit for surgery. My oldest elective gallbladder surgery patient was 103 years old. Age contributes to surgical risk in a very real way. Physiologic reserves diminish with age and even minor insults may tip a patient over what my wife calls ‘The Ledge”.

Some people live on the edge of a steep physiologic ledge. They’re fine day to day, but fall hard when something challenges their reserves. There are usually some clues to this, though. Body habitus (too fat or too thin), the ability to climb a flight of stairs or walk over 100ft on level ground, engagement with current events or family activities, etc, all give you some clues as to how well a patient will tolerate surgery.

This gentleman had all good indicators. He had few medical problems, was engaged in the community and with his family, had great exercise tolerance and most important, had symptoms that significantly interfered with the activity he liked to pursue. We scheduled his surgery for the following week.

Was the other surgeon wrong to refuse to operate on this man? I can’t say. I don’t know his skill level or, more important, his experience with older patients. All surgeons have different tolerances for risk. Some of us are very safe surgeons because our risk tolerance is very low. These surgeons won’t take on difficult or higher risk patients. Perhaps they fear complications, or perhaps they just recognize their own limitations. I never criticize someone for declining a non-emergent operation on the grounds of unacceptable risk.

My own risk tolerance has its limits. I have refused to operate on people whose risk profile exceeded what I consider a reasonable level. But usually that is based on physiology rather than age alone. In most cases, age is not the sole limiting factor. One must take into account the disease process, the prognosis with and without surgery, and the patient’s own understanding of risks and benefits.

Many of my patients are over 90 years old. Our trauma unit regularly treats older patients. There is a 60+ initiative in the hospital system that tries to devise protocols for patients in the Medicare age range. We have recently begun to look at an 80+ initiative to recognize the different needs and risks of that increasingly common demographic.

My patient’s surgery went well. I kept him overnight in the hospital for safety sake, but found him walking on the ward the next morning when I made rounds. He went home that day and has done well since.

As my mentor and Chief, Dr. Ray Fletcher once told me, “It ain’t the model year, but the mileage that counts.”