Br. J. Surg. 1992, Vol. 79, November, 1216-1 218
M. Rsrbaek-Madsen, G. Dupont*, K. Kristensen, T. Holm?, J. Ssrensen.$ and H. Dahgerg Departments of Surgery, Herning Central, * Holstebro Central, TRingkobing, 1Tarm and SLemvig Hospitals, Denmark Correspondence to: Dr M. Rsrbaek-Madsen. Storaavej 48, DK-7400 Herning, Denmark
General surgery in patients aged 80 years and older This study reviews 594 surgical admissions, of patients aged 80 years and older, to departments of general surgery during I year. Half of the patients were admitted as emergencies and 60 per cent underwent surgery. The operative mortality rate was 8 per cent and the overall mortality rate for all admissions 9 per cent. The number of complications and the mortality rate after surgery increased in emergency cases and in patients with coexisting disease. O f all admissions, 72 per cent were uncomplicated and in 70 per cent patients could be discharged directly home; such patients do not generally take up beds and are discharged as soon as medical care is no longer indicated. The number of admissions of patients over 80 years of age will increase by about 30 per cent during this decade and, unless additional resources are provided to meet this challenge, new standards must be considered f o r the distribution of resources and of indications for surgery in both young and old.
In most Western countries the number of people over the age of 80 years is increasing, both in absolute terms and as a proportion of the total population. It may be expected that demands for surgical care of the elderly will rise during the next decade. Few data are available on the amount of surgical care needed by this population and this study was undertaken to provide information on the present surgical provision required for this age group.
Patients and methods All patients aged >80 years admitted to the departments of general surgery (including urology) in the county of Ringkobing, Denmark, between 1 April 1989 and 31 March 1990 were included prospectively in the study. Owing to local arrangements, patients with vascular surgical diseases are admitted to the departments of orthopaedics and are thus not included. The population of the county is 267000, of whom 8400 (3 per cent) are aged 2 80 years; 50 per cent of the total population are male, but in octogenarians and older only 38 per cent are male. There are five departments of general surgery: three in local hospitals and two in regional central hospitals. Age, sex, and the dates of admission and discharge/death were recorded, in addition to the principal diagnosis on discharge, treatment while in hospital, complications and any significant concomitant disease. It was also recorded whether the patients were admitted as emergencies or in a planned fashion, and whether they were admitted from home or from another institution. Destination on discharge was noted. The county statistical department provided population statistics and numerical estimates of the composition of the population at the end of the decade.
Results Patients admitted During the study 434 patients were admitted on 594 occasions. A total of 85 patients were admitted twice, 20 three times, nine four times and two on more than four occasions. Women represented 41 per cent of patients, which means that 3 per cent of the total female population of this age group were admitted during 1 year compared with 8 per cent of men. If, however, sex-related diagnoses (prostatic and gynaecological disease, breast carcinoma) are excluded, the admission rate was 3 per cent for both sexes. The median age was 84 (range 8&99) years with no statistically significant difference between men and women. Emergencies comprised 50 per cent of admissions (Table I ) , a little more than the emergency admissions of the departments as a whole. Important coexisting disease was
1216
present in 51 per cent of patients, mostly ischaemic heart disease, chronic obstructive airway disease, or diabetes.
Length of hospital stay The median stay was 8 (range 1-62) days. In the same period the median stay for patients as a whole was 5 days. All patients were discharged at the conclusion of surgical management except for 12 (2 per cent) whose stay was prolonged by 2-24 (median 8) days because of temporary lack of suitable accommodation after discharge. Source of admissions Almost 75 per cent of patients were admitted from home, where they managed on their own, some with varying degrees of support from family or social services. A group of 17 per cent were admitted from nursing homes or homes for the elderly and 9 per cent from other hospital departments. On discharge, nearly 70 per cent of patients were able to return home. The proportion of those discharged to a nursing home was about the same as that admitted from such a source (Table 2). Cause of admissions Malignant disease was the reason for admission in 31 per cent of cases (Figures 1 and 2 ) . The majority of admissions in men were for urological, in particular prostatic, disease. Colorectal Table 1 Number of admissions Men
Women
Total
Emergency Planned
166 186
130 112
296 298
Total
352
242
594
Table 2 Source of admissions and destination of discharges Source or destination
Admissions from Discharges to source (YO) destination (YO)*
Home Nursing home Other hospital department
14 17 9
70 16 7
*A further 8 per cent died
0007-1323/92/11121&03
0 1992 Butterworth-Heinemann
Ltd
Surgery in the elderly:
t 8o
Table 4 Complications
t
Patients operated on
n
Upper Colorectal gastrointestinal
Urinary
Breast
Other
Figure 1 Causes of 185 admissions with a malignant diagnosis. 0, Men; 8 , women
2oo
M.Rsrbaek-Madsen et al.
t
Heart failure Apoplectic stroke Thromboernbolism Infection Pneumonia Septicaemia Urinary Wound Other Other Total
Patients not operated on
Total
40 2 2
15 0 0
55 2 2
26 2 39 9 3 38
4 4 8 1 21
30 6 47 9 4 59
t61
53
214
Patients not operated on
Total
0
Table 5 Causes of death Patients operated on
Ulcer Gallstone Appen- Colo- H e r n i a U r i n a r y O t h e r dicitis rectal
Figure 2 Causes of 409 admissions with a benign diagnosis. 0, Men; 8 , women
Table 3 Operations performed Operation Laparotomy Ulcer Gallbladder disease Appendicitis Colorectal disease Other Herniotomy Breast surgery TransuretKrai surgery Miscellaneous Total
Benign diagnosis
Malignant diagnosis
Total 94
13 7 6 8 17 31 2 94 59
0 0 0 40 3 0 18 34 26
31 20 128 85
237
121
358
Heart failure 19 Pneumonia 3 Renal failure 2 Pulmonary embolism 2 2 Apoplectic stroke Gastrointestinal 0 haemorrhage Septicaemia 0 Cachexia 1
7 0 4 0 0 4
26 3 6 2 2
3 4
3 5
29
22
51
Total
4
cations’ were also seen in patients for whom surgery was not indicated or contraindicated because of a ‘complication’ (Table 4 ) . Twice as many complications were seen in patients with coexisting complicating disease as in those without concomitant morbidity. Also, the frequency of complications after operation was 45 per cent in emergency cases compared with 23 per cent in cases of planned surgery. The most common complication was myocardial infarction or cardiac arrhythmia; in patients undergoing operation, pneumonia and other infectious complications predominated. Wound infection was seen in 3 per cent of patients, all after emergency surgery. Mortality
The overall mortality rate was 9 per cent (51 patients). The mortality rate ranged from zero of 107 patients with no complicating disease undergoing elective surgery to 20 of 97 emeigency cases (21 per cent) with important concomitant disease. There were 63 emergency operations in patients without complicating disease and the mortality rate was 6 per cent. Heart failure was by far the most common cause of death (Table 5 ) .Thromboembolic complications caused death in two patients (0.5 per cent). Of those who died, 49 per cent had a diagnosis of malignancy, compared with 31 per cent of all patients admitted. ~~
disease was the predominant diagnosis in women, 8 per cent of whom were admitted with carcinoma of the breast. Colorectal carcinoma was the cause of admission in 17 per cent of women but in only 6 per cent of men. However, excluding urological diagnoses, colorectal carcinoma accounted for 18 per cent of male admissions. Operations
During their hospital stay, 358 patients (60 per cent of admissions) underwent surgery. Of patients with a benign diagnosis, 58 per cent had an operation, while 66 per cent with malignant disease underwent surgery. Of 298 patients admitted electively, 76 per cent were operated on, compared with 54 per cent admitted as emergencies. Details of the operations performed are shown in Table 3. Complications
Of the 594 admissions, 72 per cent had no recorded complications. The remaining 165 patients had 214 complications (Table 4). Complications after operation occurred in 33 per cent of patients who underwent surgery, but ‘compli-
Br. J. Surg., Vol. 79, No. 11, November 1992
Discussion Surgery in the elderly carries a risk, but it should not be characterized by defeatism. The majority of patients are admitted for benign conditions and elective surgery can be carried out with an acceptable number of complications and a low mortality rate; 72 per cent of all admissions had no complications. It appears that morbidity and mortality after operation do not depend so much on age per se, but are related to the coincidental medical problems present before surgery. This has also been found in other studies’-3. In addition, emergency surgery further increases the risk of complications and death. It has been suggested that early surgical treatment
1217
Surgery in the elderly: M. Rsrbaek-Madsen et al.
is often advisable in the e l d e r l ~ ~as . ~the , risk of turning an elective operation into an emergency one, thereby adding to the probability of complications, is increased by delay. Efforts should be made to adjust and correct any concomitant disease before surgery, although this may be difficult in urgent cases. The complication and mortality rates in this study compare favourably with those of other studiesZs5~'. Half of the patients who died had malignant disease, and 20 per cent of these died not from complications but from cachexia. It is often assumed that elderly patients who no longer need inpatient medical or nursing care frequently take up beds longer than younger individuals. In other studies this has not been found to be the case6s8.9and the present study confirms this. Few patients stayed longer than medically indicated and, despite 70 per cent being discharged home, the median hospital stay was only 8 days. The median stay for patients admitted to the surgical departments as a whole was 5 days; in general the prolonged hospitalization of the elderly results from morbidity after surgery and is not related to social factors. The incidence of malignant disease increases dramatically with age" and one-third of admitted patients had cancer. Colorectal carcinoma in this age group has been reported to be slightly commoner in women than in menlo and this was confirmed in the present study. Most of the higher admission rate for men was for prostatic disease but, even if specific sex-related diagnoses are excluded, the admission rate in relation to the number and composition of octogenarians and older in the population was almost twice as high for men as for women. This means that men had multiple admissions more often than women. There is no obvious explanation for this difference. Estimates of the composition of the population of Ringkobing county suggest a 24 per cent increase in octogenarians and older during this decade, from 8400 in 1990 to 10400 in 2001. With an unchanged sex ratio and unaltered admission rates, there will be a corresponding rise in hospital admissions of patients over 80 years. This increase will certainly be noticeable, as estimates of the population under 80 years suggest little change. Furthermore, orthopaedic and vascular surgery were not included in the present study and the demands on these specialties are increasing, perhaps especially with respect to the elderly. A recent study in the UK' demonstrated the same tendency and the results are probably applicable to most countries of the Western world, both to those in which all hospitals are tax-financed non-payment public institutions (as in Denmark) and to those in which hospitals are subject to varying degrees of private enterprise.
1218
To meet this future challenge one or more of the following, demands must be met:
1. More resources must be made available. 2. Priority concerning certain groups of patients, certain diagnoses, or certain treatments must be decided. 3. More surgery must be performed on an outpatient basis. This may be difficult in elderly patients, half of whom are admitted as emergencies and more than half of whom have concomitant medical problems. 4. New treatments with lower morbidity rates, earlier recovery and reduced hospital stay must be developed. Laparoscopic and endoscopic surgery seem promising in this respect and may be particularly valuable in the treatment of the elderly. Further research in surgical methods, indications for and organization of surgery is warranted, and a comprehensive professional and political discussion concerning priority and distribution of resources is urgently needed.
References 1. Fenyo G. The elderly surgical patient. Opuscula Medica 1981; 26: 2-5. 2. Greenburg AG, Saik RP, Coyle JJ, Peskin GW. Mortality and gastrointestinal surgery in the aged. Arch Surg 1981; 116: 788-91. 3. Seymour DG, Vaz FG. Aspects of surgery in the elderly: preoperativemedical assessment.Br JHosp Med 1987;37: 102-12. 4. Nehme AE. Groin hernias in elderly patients. Am J Surg 1983; 146: 257-60. 5. Adkins RB, Scott HW. Surgical procedures in patients aged 90 years and older. South Med J 1984; 77: 1357-64. 6 . Sandell C, Bolin T. Kirurgi p i mycket gamla - analys av patienter over 85 i r p i en allmenkirurgisk klinik. Lakartidningen 1989; 86: 972-3. 7. Seymour DG, Pringle R. A new method of auditing surgical mortality rates: application to a group of elderly general surgical patients. BMJ 1982; 284: 153942. 8. Williams JH, Collin J. Surgical care of patients over eighty: a predictable crisis at hand. Br J Surg 1988; 7 5 : 371-3. 9. Seymour DG, Pringle R. Elderly patients in a surgical unit: do they block beds? BMJ 1982; 284: 1921-3. 10. Rosenthal RA, Chukwuogo N, Scalea TM. Abdominal surgery in the elderly. In: Katlic MR, ed. Geriatric Surgery; Comprehensive Care of the Elderly Patient. 1st ed. Baltimore: Urban and Schwarzenberg, 1990: 459-512. Paper accepted 8 May 1992
Br. J. Surg., Vol. 79, No. 11, November1992
M. Rsrbaek-Madsen, G. Dupont*, K. Kristensen, T. Holm?, J. Ssrensen.$ and H. Dahgerg Departments of Surgery, Herning Central, * Holstebro Central, TRingkobing, 1Tarm and SLemvig Hospitals, Denmark Correspondence to: Dr M. Rsrbaek-Madsen. Storaavej 48, DK-7400 Herning, Denmark
General surgery in patients aged 80 years and older This study reviews 594 surgical admissions, of patients aged 80 years and older, to departments of general surgery during I year. Half of the patients were admitted as emergencies and 60 per cent underwent surgery. The operative mortality rate was 8 per cent and the overall mortality rate for all admissions 9 per cent. The number of complications and the mortality rate after surgery increased in emergency cases and in patients with coexisting disease. O f all admissions, 72 per cent were uncomplicated and in 70 per cent patients could be discharged directly home; such patients do not generally take up beds and are discharged as soon as medical care is no longer indicated. The number of admissions of patients over 80 years of age will increase by about 30 per cent during this decade and, unless additional resources are provided to meet this challenge, new standards must be considered f o r the distribution of resources and of indications for surgery in both young and old.
In most Western countries the number of people over the age of 80 years is increasing, both in absolute terms and as a proportion of the total population. It may be expected that demands for surgical care of the elderly will rise during the next decade. Few data are available on the amount of surgical care needed by this population and this study was undertaken to provide information on the present surgical provision required for this age group.
Patients and methods All patients aged >80 years admitted to the departments of general surgery (including urology) in the county of Ringkobing, Denmark, between 1 April 1989 and 31 March 1990 were included prospectively in the study. Owing to local arrangements, patients with vascular surgical diseases are admitted to the departments of orthopaedics and are thus not included. The population of the county is 267000, of whom 8400 (3 per cent) are aged 2 80 years; 50 per cent of the total population are male, but in octogenarians and older only 38 per cent are male. There are five departments of general surgery: three in local hospitals and two in regional central hospitals. Age, sex, and the dates of admission and discharge/death were recorded, in addition to the principal diagnosis on discharge, treatment while in hospital, complications and any significant concomitant disease. It was also recorded whether the patients were admitted as emergencies or in a planned fashion, and whether they were admitted from home or from another institution. Destination on discharge was noted. The county statistical department provided population statistics and numerical estimates of the composition of the population at the end of the decade.
Results Patients admitted During the study 434 patients were admitted on 594 occasions. A total of 85 patients were admitted twice, 20 three times, nine four times and two on more than four occasions. Women represented 41 per cent of patients, which means that 3 per cent of the total female population of this age group were admitted during 1 year compared with 8 per cent of men. If, however, sex-related diagnoses (prostatic and gynaecological disease, breast carcinoma) are excluded, the admission rate was 3 per cent for both sexes. The median age was 84 (range 8&99) years with no statistically significant difference between men and women. Emergencies comprised 50 per cent of admissions (Table I ) , a little more than the emergency admissions of the departments as a whole. Important coexisting disease was
1216
present in 51 per cent of patients, mostly ischaemic heart disease, chronic obstructive airway disease, or diabetes.
Length of hospital stay The median stay was 8 (range 1-62) days. In the same period the median stay for patients as a whole was 5 days. All patients were discharged at the conclusion of surgical management except for 12 (2 per cent) whose stay was prolonged by 2-24 (median 8) days because of temporary lack of suitable accommodation after discharge. Source of admissions Almost 75 per cent of patients were admitted from home, where they managed on their own, some with varying degrees of support from family or social services. A group of 17 per cent were admitted from nursing homes or homes for the elderly and 9 per cent from other hospital departments. On discharge, nearly 70 per cent of patients were able to return home. The proportion of those discharged to a nursing home was about the same as that admitted from such a source (Table 2). Cause of admissions Malignant disease was the reason for admission in 31 per cent of cases (Figures 1 and 2 ) . The majority of admissions in men were for urological, in particular prostatic, disease. Colorectal Table 1 Number of admissions Men
Women
Total
Emergency Planned
166 186
130 112
296 298
Total
352
242
594
Table 2 Source of admissions and destination of discharges Source or destination
Admissions from Discharges to source (YO) destination (YO)*
Home Nursing home Other hospital department
14 17 9
70 16 7
*A further 8 per cent died
0007-1323/92/11121&03
0 1992 Butterworth-Heinemann
Ltd
Surgery in the elderly:
t 8o
Table 4 Complications
t
Patients operated on
n
Upper Colorectal gastrointestinal
Urinary
Breast
Other
Figure 1 Causes of 185 admissions with a malignant diagnosis. 0, Men; 8 , women
2oo
M.Rsrbaek-Madsen et al.
t
Heart failure Apoplectic stroke Thromboernbolism Infection Pneumonia Septicaemia Urinary Wound Other Other Total
Patients not operated on
Total
40 2 2
15 0 0
55 2 2
26 2 39 9 3 38
4 4 8 1 21
30 6 47 9 4 59
t61
53
214
Patients not operated on
Total
0
Table 5 Causes of death Patients operated on
Ulcer Gallstone Appen- Colo- H e r n i a U r i n a r y O t h e r dicitis rectal
Figure 2 Causes of 409 admissions with a benign diagnosis. 0, Men; 8 , women
Table 3 Operations performed Operation Laparotomy Ulcer Gallbladder disease Appendicitis Colorectal disease Other Herniotomy Breast surgery TransuretKrai surgery Miscellaneous Total
Benign diagnosis
Malignant diagnosis
Total 94
13 7 6 8 17 31 2 94 59
0 0 0 40 3 0 18 34 26
31 20 128 85
237
121
358
Heart failure 19 Pneumonia 3 Renal failure 2 Pulmonary embolism 2 2 Apoplectic stroke Gastrointestinal 0 haemorrhage Septicaemia 0 Cachexia 1
7 0 4 0 0 4
26 3 6 2 2
3 4
3 5
29
22
51
Total
4
cations’ were also seen in patients for whom surgery was not indicated or contraindicated because of a ‘complication’ (Table 4 ) . Twice as many complications were seen in patients with coexisting complicating disease as in those without concomitant morbidity. Also, the frequency of complications after operation was 45 per cent in emergency cases compared with 23 per cent in cases of planned surgery. The most common complication was myocardial infarction or cardiac arrhythmia; in patients undergoing operation, pneumonia and other infectious complications predominated. Wound infection was seen in 3 per cent of patients, all after emergency surgery. Mortality
The overall mortality rate was 9 per cent (51 patients). The mortality rate ranged from zero of 107 patients with no complicating disease undergoing elective surgery to 20 of 97 emeigency cases (21 per cent) with important concomitant disease. There were 63 emergency operations in patients without complicating disease and the mortality rate was 6 per cent. Heart failure was by far the most common cause of death (Table 5 ) .Thromboembolic complications caused death in two patients (0.5 per cent). Of those who died, 49 per cent had a diagnosis of malignancy, compared with 31 per cent of all patients admitted. ~~
disease was the predominant diagnosis in women, 8 per cent of whom were admitted with carcinoma of the breast. Colorectal carcinoma was the cause of admission in 17 per cent of women but in only 6 per cent of men. However, excluding urological diagnoses, colorectal carcinoma accounted for 18 per cent of male admissions. Operations
During their hospital stay, 358 patients (60 per cent of admissions) underwent surgery. Of patients with a benign diagnosis, 58 per cent had an operation, while 66 per cent with malignant disease underwent surgery. Of 298 patients admitted electively, 76 per cent were operated on, compared with 54 per cent admitted as emergencies. Details of the operations performed are shown in Table 3. Complications
Of the 594 admissions, 72 per cent had no recorded complications. The remaining 165 patients had 214 complications (Table 4). Complications after operation occurred in 33 per cent of patients who underwent surgery, but ‘compli-
Br. J. Surg., Vol. 79, No. 11, November 1992
Discussion Surgery in the elderly carries a risk, but it should not be characterized by defeatism. The majority of patients are admitted for benign conditions and elective surgery can be carried out with an acceptable number of complications and a low mortality rate; 72 per cent of all admissions had no complications. It appears that morbidity and mortality after operation do not depend so much on age per se, but are related to the coincidental medical problems present before surgery. This has also been found in other studies’-3. In addition, emergency surgery further increases the risk of complications and death. It has been suggested that early surgical treatment
1217
Surgery in the elderly: M. Rsrbaek-Madsen et al.
is often advisable in the e l d e r l ~ ~as . ~the , risk of turning an elective operation into an emergency one, thereby adding to the probability of complications, is increased by delay. Efforts should be made to adjust and correct any concomitant disease before surgery, although this may be difficult in urgent cases. The complication and mortality rates in this study compare favourably with those of other studiesZs5~'. Half of the patients who died had malignant disease, and 20 per cent of these died not from complications but from cachexia. It is often assumed that elderly patients who no longer need inpatient medical or nursing care frequently take up beds longer than younger individuals. In other studies this has not been found to be the case6s8.9and the present study confirms this. Few patients stayed longer than medically indicated and, despite 70 per cent being discharged home, the median hospital stay was only 8 days. The median stay for patients admitted to the surgical departments as a whole was 5 days; in general the prolonged hospitalization of the elderly results from morbidity after surgery and is not related to social factors. The incidence of malignant disease increases dramatically with age" and one-third of admitted patients had cancer. Colorectal carcinoma in this age group has been reported to be slightly commoner in women than in menlo and this was confirmed in the present study. Most of the higher admission rate for men was for prostatic disease but, even if specific sex-related diagnoses are excluded, the admission rate in relation to the number and composition of octogenarians and older in the population was almost twice as high for men as for women. This means that men had multiple admissions more often than women. There is no obvious explanation for this difference. Estimates of the composition of the population of Ringkobing county suggest a 24 per cent increase in octogenarians and older during this decade, from 8400 in 1990 to 10400 in 2001. With an unchanged sex ratio and unaltered admission rates, there will be a corresponding rise in hospital admissions of patients over 80 years. This increase will certainly be noticeable, as estimates of the population under 80 years suggest little change. Furthermore, orthopaedic and vascular surgery were not included in the present study and the demands on these specialties are increasing, perhaps especially with respect to the elderly. A recent study in the UK' demonstrated the same tendency and the results are probably applicable to most countries of the Western world, both to those in which all hospitals are tax-financed non-payment public institutions (as in Denmark) and to those in which hospitals are subject to varying degrees of private enterprise.
1218
To meet this future challenge one or more of the following, demands must be met:
1. More resources must be made available. 2. Priority concerning certain groups of patients, certain diagnoses, or certain treatments must be decided. 3. More surgery must be performed on an outpatient basis. This may be difficult in elderly patients, half of whom are admitted as emergencies and more than half of whom have concomitant medical problems. 4. New treatments with lower morbidity rates, earlier recovery and reduced hospital stay must be developed. Laparoscopic and endoscopic surgery seem promising in this respect and may be particularly valuable in the treatment of the elderly. Further research in surgical methods, indications for and organization of surgery is warranted, and a comprehensive professional and political discussion concerning priority and distribution of resources is urgently needed.
References 1. Fenyo G. The elderly surgical patient. Opuscula Medica 1981; 26: 2-5. 2. Greenburg AG, Saik RP, Coyle JJ, Peskin GW. Mortality and gastrointestinal surgery in the aged. Arch Surg 1981; 116: 788-91. 3. Seymour DG, Vaz FG. Aspects of surgery in the elderly: preoperativemedical assessment.Br JHosp Med 1987;37: 102-12. 4. Nehme AE. Groin hernias in elderly patients. Am J Surg 1983; 146: 257-60. 5. Adkins RB, Scott HW. Surgical procedures in patients aged 90 years and older. South Med J 1984; 77: 1357-64. 6 . Sandell C, Bolin T. Kirurgi p i mycket gamla - analys av patienter over 85 i r p i en allmenkirurgisk klinik. Lakartidningen 1989; 86: 972-3. 7. Seymour DG, Pringle R. A new method of auditing surgical mortality rates: application to a group of elderly general surgical patients. BMJ 1982; 284: 153942. 8. Williams JH, Collin J. Surgical care of patients over eighty: a predictable crisis at hand. Br J Surg 1988; 7 5 : 371-3. 9. Seymour DG, Pringle R. Elderly patients in a surgical unit: do they block beds? BMJ 1982; 284: 1921-3. 10. Rosenthal RA, Chukwuogo N, Scalea TM. Abdominal surgery in the elderly. In: Katlic MR, ed. Geriatric Surgery; Comprehensive Care of the Elderly Patient. 1st ed. Baltimore: Urban and Schwarzenberg, 1990: 459-512. Paper accepted 8 May 1992
Br. J. Surg., Vol. 79, No. 11, November1992
