Colorectal and GI Surgery for Older Adults

Podcast Transcript

Dr. Scott Steele: Butts and Guts, a Cleveland Clinic Podcast, exploring your digestive and surgical health from end to end.

Hi everyone, and welcome to another episode of Butts and Guts. I'm your host, Scott Steele, the Chair of Colorectal Surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. We're extremely pleased to have another member of my department here today, Dr. Joshua Sommovilla, who is a colorectal surgeon in Cleveland Clinic's Digestive Disease and Surgery Institute. We're going to talk something today that Josh is maybe one of the few colorectal surgeons in the world that has the background, which I'll let him tell you about, to touch on this topic, and that's colorectal surgery and GI surgery, essentially in older adults, and we'll get into a little bit about palliative in there as well. So, Josh, welcome to Butts and Guts.

Dr. Joshua Sommovilla: Thanks for having me. It's great being here.

Dr. Scott Steele: So, we always like to start out by asking you to give us a little bit about your background. Where are you from? Where'd you train, and how did it to come to the point that you're here at the Cleveland Clinic?

Dr. Joshua Sommovilla: I'm originally from Philadelphia, Pennsylvania, but I did the majority of my surgical training in St. Louis, Missouri. When I was in surgical, training. I became interested at the same time, both in the outcomes of surgery in older adults and in colorectal surgery. I ended up pursuing fellowship training in both of those things, so I ended up doing a colorectal surgery fellowship, and I did a palliative medicine fellowship before coming here to Cleveland, where I now specialize in doing colon surgery for all colorectal conditions, but focusing mainly on cancer, and also have started a palliative medicine practice within the Department of Colorectal Surgery.

Dr. Scott Steele: Josh also has done an additional training within our Weiss Center, looking at hereditary colorectal cancers, and hereditary neoplasia , and so three fellowships after a grueling residency at Wash U. Fantastic, and we're so glad to have you here. We've talked a lot about colorectal surgery on Butts and Guts, but can you share with our listeners, what are some of the most common colorectal or GI procedures that are performed on older adults?

Dr. Joshua Sommovilla: So, I think probably within colorectal surgery, the most common operation would be what we call a colectomy, which is removing the colon, ,which in older adults it's usually done for cancer. We do surgery for inflammatory bowel disease in older adults too, which is less common in older patients, but when we do it, it's usually a pretty serious undertaking. When I think of the more urgent surgeries that we sometimes perform, these are often for large bowel obstructions from cancer, or sometimes for diverticulitis. Both colonoscopy and upper endoscopy are also common procedures that we often perform in older adults, but these are less invasive procedures than the other I discussed.

Dr. Scott Steele: So Josh, we talk a lot about older adults, and we know that age is not only chronological, but also physiological. Can you talk a little bit about that? Then, what are some of the considerations that you take into account both pre and postoperatively when treating older patients?

Dr. Joshua Sommovilla: So, I think there's several important things to consider when we're evaluating older patients for surgery, and this starts with before surgery, but it also continues when we're planning out what we do in the operating room, and how we take care of patients afterwards. I think that one of the more important parts of our preoperative process is making sure that we have ways to identify the most vulnerable patients. So, some of the risk factors for older adults, when we're looking at risk factors for surgery, include having any kind of cognitive impairment, being malnourished, having difficulty swallowing, which can lead to aspiration problems, having an overall impaired functional status and being alcohol users. So, if we're able to identify an older adult that we think is high risk and vulnerable, we really have to do two things. First, we have to decide what we're going to do for their surgical problem.

Then, the second thing we have to do is decide how to optimize them. If it's okay, I wanted to take just a minute kind of talking about the first part, and how decision-making is different in a older population than a younger population. So, these patients often have more complicating factors in their health that are not directly related to their surgical problem, and sometimes these things are more life-threatening than their surgical problem itself. As specialists, we sometimes get used to having a problem-focused discussion with patients, focusing on the disease that they're seeing us for, or the procedure that we're thinking about doing. But for a lot of these patients and their families, we have to really exclusively discuss their overall health goals that incorporate more than the specific problem that there's seeing us for. So, this is the basis of what we call shared decision making, where we have to emphasize that there's a choice, and contextualize it into a patient's life.

So, if we think about a problem like a near obstructing colon cancer, there's a lot of different things that we could do for that. We could do a major surgery, where we remove that part of the colon. We might do a where we just create a stoma to create a diversion, to relieve the obstruction, but not remove the tumor, or we could do a less-invasive palliative procedure like placing a stent, or in some cases we could do no procedure at all, and provide what we call best supportive care. So, it's important to describe these choices to patients in a narrative way that emphasizes how it impacts different things that different patients prioritize differently. So, things like symptoms, functional independence, burden of care, their living situation, and obviously they're survival. So, these conversations can be hard, and they can take us out our comfort zone, where we're used to talking about diagnosis, pathophysiology or the technical aspects of a surgery.

So, in my practice, I find asking simple questions, like, what are you worried about, or what activities can you not imagine living without, or what treatments are you hoping to avoid? These types of questions can help open the door to getting the information to figure out what the best choices. There are communication tools that have been described, like the best case-worst case scenario tool, that can also be helpful in having some of these discussions. So, let's say, after this discussion, we decide to do surgery, and we identify a vulnerable patient that we're worried about might have complications. This is where it's really important to have a great team in place, and to individualize the treatment plan before surgery so that we can have the best outcome. So, we use the time that we have before surgery to prehabilitate a patient and get other people involved. So, depending on what the needs are, we might get a nutritionist, a rehab specialist, a geriatrician, a neurologist, a pharmacist, or a social worker to help optimize things, and plan and for after surgery.

Dr. Scott Steele: So, there's been recent advancements in surgical planning and treatment that can benefit older adults in their recovery time, including their quality of life, post-surgery. So, can you give any examples of these? Then, again, if there's any things that you see that particularly pertain to them, how do you go about incorporating that into their care?

Dr. Joshua Sommovilla: So, like some of the things I mentioned previously, if you identify a specific vulnerability, that gives you an area to focus on optimizing nutrition preoperatively, or doing what we call prehabilitation is becoming a big recent advance in surgery, where instead of getting rehab after surgery, you put patients on an exercise regimen, and get them in better shape before you do surgery. When we think about the procedures themselves, there are ways that you can plan a procedure to help improve outcomes for older adults after surgery. So, less invasive procedures might lead to reduced opioid use, less time in the hospital and improve outcomes and decrease the likelihood of delirium after surgery. So, preventing delirium is a major issue, because it's not just more common in these patients, but it can have profound long-term, negative effects. When we think about after surgery, it's really important that we create a postoperative environment that's good for older adults.

So, we have to recognize delirium early. We have to have patients room and we do here that really facilitates space for family and caregivers. This has been a challenge during COVID, because the visit limitations are more impactful for older patients. Then postoperatively, also, it's important to avoid certain medications in this patient population that might contribute to delirium, so things like opioids, benzodiazepines and some nausea medications that we commonly use in other patients. When we think about, if we take, for example, a patient with a large colon polyp, as we improve our surgical technology and our ability to do things like endoluminal surgery to avoid general anesthesia, to avoid inpatient hospital stay, these things can have a profound impact for older patients, and really improve their outcomes. Whereas, in the past, they'd be having a major operation, spending a few days in the hospital, potentially becoming delirious. We can really avoid a lot of these things by improving surgically the way that we do things.

Dr. Scott Steele: So, Truth or Myth: Colorectal cancer is very rare in people under the age of 50.

Dr. Joshua Sommovilla: This is definitely a myth. While it may have been true in the past, colorectal cancer is definitely, steadily increasing in the young population in recent years. So, people under the age of 50 make somewhere between 10 and 15% of the new colorectal cancer diagnoses that we see now, and this is expected to continue to rise over the next decade or two. So, for all these reasons, the US Preventative Services Task Force recently decreased the age of first colonoscopy screening to the age of 45. We're even seeing colorectal cancer in patients younger than this, so we're continually rethinking how we might change screening guidelines in the future. We're really careful to evaluate any symptoms, even in really young patients that in the past, we may have attributed to hemorrhoids or some other issues,

Dr. Scott Steele: Truth or Myth: After age 65 screening colonoscopy is no longer needed?

Dr. Joshua Sommovilla: This is also a myth. Despite what I just said about the rise of cancer in young patients, increasing age is still one of the biggest risk factors for colorectal cancer. So, right now we still recommend to continue colorectal cancer screening, at least until the age of 75. Then above the age of 75, it really becomes more individualized. It can still be beneficial for many patients even going into the eighties, but it really depends on what else is going on in their life. So, just giving a couple of examples, you could have a 76-year old patient, who has multiple other life-threatening health problems, and has never had a polyp on prior colonoscopies. For that person, it might not make sense to continue doing colonoscopy into their late seventies and eighties. But then you take an active, healthy 80-year old who's had several polyps on all their prior colonoscopies, but no other immediately life-threatening health illnesses. Those are people that you can continue to derive benefit from doing colonoscopy until a very late age.

Dr. Scott Steele: What can a patient expect in a visit with you or one of the colleagues here in our Department of Colorectal Surgery when they come in for, let's just choose an example, for a colon cancer?

Dr. Joshua Sommovilla: So, I think the first thing, they should assume that they're going to receive this world-class cancer care, and to treat their surgical or medical problem with all of our expertise, in the least invasive way possible. In addition to that, I think what really makes us unique is that we work as a team to utilize all the resources at our disposal here, to ensure that we're providing care and a treatment path that really meets the patient's overall goals, and allows for the best quality of life possible after that treatment's given.

Dr. Scott Steele: So, what's on the horizon, as far as additional research into colorectal surgery, colorectal cancer, to improve a patient's recovery time and quality of life after surgery?

Dr. Joshua Sommovilla: think in our field, the most exciting ongoing research right now are geared towards first treating rectal cancer non-operatively, and potentially avoiding surgery altogether, is going to make huge strides for some of these patients in terms of their quality of life if they're able to avoid surgery and still achieve a cure. When surgery is needed, continue to find endoscopic and minimally-invasive approaches to do surgery is also hugely important, and something we're continuing to develop. When I think of older adults specifically, and some of the things that we've been talking about, having optimized care bundles, both preoperatively and postoperatively to minimize complications and maximize return to a function as early as possible, are the really exciting things that I see on the horizon.

Dr. Scott Steele: So, I always like to take this time to get to know our guests a little bit better. So, what's your favorite sport?

Dr. Joshua Sommovilla: My favorite sport's amateur wrestling.

Dr. Scott Steele: Whoa. What, so what? Are we talking college, or are we talking WWE? What does that mean?

Dr. Joshua Sommovilla: No, I do like college a lot, but I prefer Olympic-style, which is slightly different. So, freestyle wrestling in the Olympics would probably be my first choice, and then college, which is called folkstyle, after that.

Dr. Scott Steele: Wow. Another first here on Butts and Guts. What's your favorite food?

Dr. Joshua Sommovilla: Pizza, unfortunately.

Dr. Scott Steele: What's your favorite movie?

Dr. Joshua Sommovilla: Oh, The Big Lebowski.

Dr. Scott Steele: Classic. Just a classic. So, you get one trip to go anywhere in the world. Where are you going?

Dr. Joshua Sommovilla: Japan.

Dr. Scott Steele: Any reason why?

Dr. Joshua Sommovilla: I've never been there. There's really beautiful cities with great food and some mountains that are really great for hiking, and could do all that stuff in one trip would be outstanding.

Dr. Scott Steele: Fantastic. So, give us a final take-home message for our listeners regarding colorectal surgery in older adults.

Dr. Joshua Sommovilla: So, in surgery, there's a devoted specialty to surgery in children, pediatric surgery. There's not the same thing for older patients, and they seem to kind of blend in seamlessly with the rest of our practice, but we really should think of them as a distinct patient population with different and comprehensive needs. So, if you're an older patient considering surgery, please make sure that your surgical providers are addressing your overall care needs and goals. If you're a surgeon, please make sure that you're considering all these comprehensive needs before you move ahead with doing surgery in a vulnerable patient population.

Dr. Scott Steele: That is sage wisdom there. So, to learn more about colorectal surgery and the various treatment options here at the Cleveland Clinic, please visit clevelandclinic.org/colorectalsurgery. That's clevelandclinic.org/colorectalsurgery, and to speak with a specialist in Digestive Disease and Surgery Institute, please call 216.444.7000. That's 216.444.7000.

And remember, it's important for you and your family to continue to receive medical care, regular checkups and screenings. Rest assured, here at the Cleveland Clinic, we're taking all the necessary precautions to sterilize our facilities, and protect our patients and caregivers.

Josh, thank you so much for joining us on Butts and Guts.

Dr. Joshua Sommovilla: Thank you for having me.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.