VATS surgeons, already geriatric surgeons, can still improve

Video-assisted thoracoscopic surgery (VATS) surgeons are, with a few exceptions, geriatric surgeons. The conditions that we treat, such as lung and esophageal cancer, increase in incidence with increasing age; and our operating schedules routinely list septuagenarians and octogenarians. We learned from our teachers and mentors how to care for these older adults and, for the most part, we do it well.

However, neither we nor our mentors were ever offered explicit teaching about normal physiologic changes that occur with age, about the importance of more comprehensive preoperative evaluation, or about the benefit of multidisciplinary perioperative care. We may have called the most common postoperative complication in older adults, postoperative delirium, “sundowning”, and considered it almost routine and of little long-term consequence. Also, if we are truly treating this population well, why is its mortality and morbidity higher than the general population after VATS? Either we are not selecting our patients for surgery optimally or we are not compulsive enough in their postoperative care.

The point is, with increased knowledge about older adults and about principles of their surgical care, we can all do better. Hence here goes this special edition.

The aging of the population will be the greatest force affecting health care in our lifetime, greater overall than other forces such as smoking and obesity and social determinants of health and even coronavirus disease (COVID), all of which are also influenced by patient age. This force will not go away or even lessen, so we must deal with it. Some VATS surgeons have shown, in single-institution series, that they can achieve results in older adults equivalent to those in a younger cohort; we can learn from them. Either they are selecting their operative candidates better—and there is nothing wrong with that, as our goal is to do minimal harm—or they are caring for them better, or both.

Overall, we are doing better, and the results at these centers and others around the world argue against ageism, or prejudice based on chronologic age. There is such variability among individuals, variability which increases with each decade of chronologic age, that it makes more sense to consider physiologic age. In evaluating physiologic age, we have learned that it is important in older adults to look at cognition and frailty and function as well as heart and lung and kidney function. For the largest operations more extended evaluation, e.g., with VO²Max testing or echocardiography or cardiac stress or creatinine clearance, may be important, as the elderly manifest less functional reserve.

Therefore, let us learn from the experts in this special edition. We can then teach our residents, our students, and perhaps our own mentors how to do even better in caring for our older adult VATS patients.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Video-Assisted Thoracic Surgery for the series “VATS in Older Adults”. The article did not undergo external peer review.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://vats.amegroups.com/article/view/10.21037/vats-22-21/coif). The series “VATS in Older Adults” was commissioned by the editorial office without any funding or sponsorship. The author is Chair of the Standards and Verification Committee of the American College of Surgeons Geriatric Surgery Verification Program and was part of the program’s Core Development Group, and served as the unpaid Guest Editor of the series and serves as an unpaid editorial board member of Video-Assisted Thoracic Surgery from April 2022 to March 2024. The author has no other conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

Mark R. Katlic