Because obese people suffer higher rates of infection, they are more likely to be turned down for surgery.
Obese people, smokers and the frail elderly are increasingly being turned away from surgery because the risks outweigh the benefits for them, surgeons say.
There is also a growing feeling that people whose lives are coming to an end would be better off skipping major operations that could cause them more harm than good. It may also mean the difference between dying in hospital over a long period of time rather than dying comfortably at home.
A meeting of surgeons in Perth last week heard that while doctors are getting better at operating on the frail and critically ill, serious risks remain for the obese, smokers and elderly people whose cognitive functions are deteriorating along with their strength and mobility.
Perth bariatric surgeon Harsha Chandraratna said an increasing number of severely obese people were being told they had to lose weight before they could have surgery. In some cases, these people were lining up for weight-loss surgery, such as lap bands, to help them improve their fitness for other operations because they could not lose weight in other ways.
Dr Chandraratna said obese people suffered higher rates of infections and wound breakdowns after surgery, and that research suggested they had a five-fold increased risk of dying during major orthopedic surgery compared to people of a healthy weight.
“A one per cent risk of death becomes a five per cent risk of death,” he said at the Royal Australasian College of Surgeons’ annual scientific congress last week.
Mark Newman, director of cardiothoracic surgery at Sir Charles Gairdner Hospital in Perth, said smokers also had up to 15 times the risk of an infection or wound breakdown after surgery – a fact that should be taken into account if people wanted non-life saving procedures such as hip replacements and breast augmentations.
He said wound breakdowns were particularly problematic for plastic surgical procedures because it meant there was a high risk of a bad cosmetic result. For this reason, some surgeons declined to operate on people while they were still smoking.
“It’s not that we’re opposed to performing surgery because you’re a smoker and we think you’re bad and bringing this on yourself. It’s because the outcomes of the surgery are worse,” he said.
David Cooke, a general surgeon at Fiona Stanley Hospital in Perth, said smokers also struggled with kidney dialysis procedures. He said fistulas for dialysis – joining a vein and an artery together to make the blood vessel larger and stronger – failed six times more often in smokers, reducing their chance of effective treatment for kidney failure. “You can only do it four or five times and then you run out of veins,” he said.
David Bruce, a geriatrician and hospital administrator, said surgeons were increasingly dividing elderly people into the healthy and frail to assess their risks. The latter tend to have early signs of dementia and cognitive deficits, a slow gait, sedentary lifestyle, unexplained weight loss and poor grip strength in their hands. While their precise age was irrelevant, he said people who presented as frail carried much greater risks of not coming out of surgery well.
Dr Newman agreed, saying: “There are people in their 90s who you know will do well, or you get a pretty good idea they’ll do well … but there are many people in their late 70s who you think ‘I’m not going to touch you’.”
Dr Cooke said while most people feared death on the operating table, it was rare. “The far worse outcome is not to die on the table, but to survive and then spend two months in intensive care having festering wounds and mainly intubated, so they might as well be dead because they can’t talk. They may never recover,” he said.
“The aim now is to prolong life, not prolong death.”
Dr Newman said the size of the surgical procedure also mattered, causing different degrees of trauma.
“If you can perform operations endoscopically with small incisions, patients will do a lot better even if they’re frail,” he said.
“If you do a major open operation with large incisions, a large incision over about six centimetres seems to trigger a major trauma response. If you can keep a small wound, you can do all the things we do like put them on heart lung machines for two hours, but you need a small hole and people do much better.”