Many recent developments in gastrointestinal surgery are of particular relevance to older people. They include new methods for the treatment or palliation of carcinoma, an increasing use of laparoscopic techniques (although the benefits of many of the approaches have yet to be proved in randomised controlled trials), and new treatments for non-malignant anal problems such as incontinence and prolapse.1-4 Meanwhile, the role of elective surgery in the field of peptic ulceration continues to decrease because of more effective medical treatments.1

The majority of research studies in the older surgical patient have confined their attention to the surgical ward, typically correlating the immediate preoperative risk factors with the immediate postoperative outcome.5 ,6 Although valuable insights can be gained from such studies, they are not considered further in the present review. Rather, it is argued here that we need to take a wider view of the referral and treatment process if our older patients are to benefit from the rapid developments that are occurring in gastrointestinal surgery. The first part of this review therefore considers the process by which older people with a gastrointestinal problem find their way (or fail to find their way) to appropriate surgical treatment. It is here that issues of equality of access and treatment are most likely to arise. The second part of the review argues that we need to improve the way that medical, surgical and anaesthetic services are organised so as to improve overall quality of care. For reasons of space, the biliary tract and pancreas have been excluded from the discussion.