The decision is not easy. One should remember that the life expectancy
of an 87 year old woman is about 10 years. This may sound incredible,
but it's true. Check any textbook on geriatrics (it is only 5-7 years
for an 85 years old man) Moreover, if the person is financially secure,
as it would be in a welfare state as Sweden, the quality of life is
excellent, at least in the eyes of the old themselves. Therefore the
age is not in itself a barrier for potentially curative surgery.
On the downside, the two previous major abdominal operations may make
the 3rd operation difficult. And obviously, the risks of any major
operation in an 87 years old are high, even if we assume that the lady
in question is otherwise fit. If she is not, than there is really no
I presume that by local excision PO does not talk about colonoscopic
removal, but a wedge resection with laparotomy. I would guess that in
expert hands, the added risk of TAC over wedge excision is marginal, as
the adhesions would have to be dealt with in any case. It may be a
technical decision that can only be made in situ.
It comes down to the following choices:
1. Curative operation (which must be total abdominal colectomy) with a
good chance of long term survival and increased risk of immediate death.
2. A smaller procedure (local excision) with poor chance of long term
survival and a somewhat lesser risk of immediate death;
3. Do nothing with no chance of cure, but no risk of immediate death.
While the choice between the first two could be a technical question,
the choice between these and the third is purely a value decision.
While we ought to make technical decisions for the patients, we cannot
make value decisions for them. We have to give them a accurate
assessment of the risks and benefits, and they should make the decision.
In this regard, we are not different from any other expert. Suppose I
bring in a plumber to fix your faucet. The plumber can use a silicone
gasket which costs say 10$ but will last 5 years, or a rubber gasket
which costs 5$ but will last only one year. The question now is not
which is better, but how I value 5$ vs. 10$ now. It is possible that I
can't afford the extra 5$ now. So it is up to me, not the plumber, to
decide, even though the silicone gasket is objectively a better choice.