Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Postoperative complications in elderly patients and their significance for long-term prognosis David A. Story Introduction The relationship between the international phenomenon of an aging population and perioperative care is complex. On the one hand, we are challenged by offering advanced medical and surgical care to patients with increasing comorbidity up to and over 100 years old. On the other hand, some argue that ‘seventy is the new fifty’: many older patients are fit, have well controlled medical con- ditions, and lead active lives. In this review, I will examine recent work on the risk of complications and death following surgery for older patients. I will also examine some emerging strategies that attempt to reduce the risk for older patients and problems associated with assessing the risk. What is the risk? The largest available data set anywhere in the world is the National Surgical Quality Improvement Program (NSQIP) [1] developed by the Department of Veterans Affairs in the United States. This database has records of over 1 million patients, with around 100 thousand patients added each year [2]. In a study [3] from this database of 27 000 patients aged 80 years or more, the 30-day mortality after surgery was 8%, and 20% had at least one complication. The NSQIP data collection approach has been embraced by the American College of Surgeons (ACS) leading to data collection in hospitals other than Veterans’ hospitals, including private hospitals (ASC-NSQIP) in the United States [4]. In a single hospital study [4] in Virginia, of 1628 patients aged 70 years or more, 50% had at least one in-hospital com- plication and 5% died within 30 days of surgery. Another earlier study [5], on 367 patients aged 80 years or more from two hospitals in California, found an in-hospital mortality rate of 4.5% and a 25% complication rate. These findings from the United States are consistent with the studies from other countries. A recent study [6] from Singapore on 125 patients aged 80 years or more undergoing major abdominal surgery found a 6% 30-day mortality and 30–40% complication rate. In another recent paper [7  ] from our hospital, we studied 1100 patients aged 70 years or more undergoing noncardiac surgery at three University teaching hospitals in Melbourne, Australia. We found a 20% complication rate within 5 days Departments of Anaesthesia and Surgery, Austin Health, The University of Melbourne, Heidelberg, Victoria, Australia Correspondence to David Story, MBBS, BMedSci, MD, FANZCA, Joint Director of Research, Department of Anaesthesia, Austin Hospital, Heidelberg, Vic 3084, Australia Tel: +61 3 9496 5992; fax: +61 3 9496 3932; e-mail: David.Story@austin.org.au Current Opinion in Anaesthesiology 2008, 21:375–379 Purpose of review To outline perioperative risk factors for postoperative mortality in older patients, the relationship of these factors with long-term mortality, and to examine possible strategies to reduce mortality. Recent findings For patients aged 70 years and over 30-day mortality is about 6%, whereas 20% are likely to have at least one complication during their hospital stay. The mortality risk increases by 10% for every year after age 70. Mortality is also strongly associated with preoperative status and postoperative complications, particularly systemic inflammation and renal impairment. Unplanned postoperative intensive care unit admission is an important predictor for mortality. Requirement for postoperative vasopressors or inotropes is associated with 50% mortality in patients aged 80 years or more. Early postoperative complications are likely to be associated with an increased long-term (a year or more later) mortality. Strategies such as critical care outreach may decrease both 30-day and long-term mortality. Summary Strategies are needed to prevent, or at least adequately manage, complications in elderly patients. Agreed international definitions for risks and complications can help in assessing risks and benefits. Keywords complications, mortality, postoperative Curr Opin Anaesthesiol 21:375–379 ß 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins 0952-7907 0952-7907 ß 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins