Emergency laparoscopic surgery in the elderly and frail patient

✍ Scribed by Ferdinando Agresta (editor), Mauro Podda (editor), Fabio Cesare Campanile (editor), Carlo Bergamini (editor), Gabriele Anania (editor)

• Publisher: Springer
• Year: 2021
• Tongue: English
• Leaves: 340
• Category: Library

✦ Synopsis

The global population is aging rapidly, and as a result emergency abdominal surgery for acute abdomen in the elderly has become a global issue. Demographic changes in the population have also altered the profile of emergency abdominal surgery, with typical causes of acute abdomen in the elderly including acute cholecystitis, incarcerated hernia, bowel obstruction and appendicitis. In these patients, recovery from surgery is often complicated, leading to longer hospital stays compared with younger patients. Laparoscopy in the emergency setting is well established and offers a number of advantages over open surgical approaches, such as reduced postoperative pain, length of hospital stay and complication rates. While laparoscopic surgery for acute diverticulitis has become more widespread, in other conditions, like small bowel obstruction and perforated peptic ulcer, laparotomy is still used in about 70% of cases. Further, despite the urgent need for knowledge regarding surgical treatment of acute abdomen in the elderly, there is still a lack of evidence in this relevant clinical field.

This book analyzes the management strategies and critically evaluates the outcomes of laparoscopic emergency surgery for acute abdomen in the elderly according to the principles of evidence-based medicine. Discussing each topic clearly, and promoting the use of emergency laparoscopy in elderly patients, the book is intended for young general surgeons and surgeons in training with at least a basic knowledge of surgery for acute abdomen. It is also useful as a quick reference tool during on-call shifts.

✦ Table of Contents

Foreword
Preface
Contents
Part I: Generalities
1: How to Define an Elderly and Frail Patient?
1.1 How to Define Elderly?
1.2 How Often Do We Face an Elderly Patient in the General Population and Surgical Practice?
1.3 Should the Operative and Perioperative Approach Be Different in Elderly Patients?
1.4 How to Define Frailty?
1.5 How Often Can Do Face a Frail Patient in General Population and Surgical Practice?
1.6 How Does a Patient Become Frail?
1.7 Is an Older Patient Always Frail Too and Vice Versa?
1.8 What Is the Conceptual Difference Among Frailty, Multimorbidity, and Disability?
1.9 Are There Any Therapeutic Methods to Prevent, Contrast, or Treat the Frailty Process?
1.10 How Does Frailty Modify the Surgical Approach and Outcome?
References
2: Defining the Burden of Emergency General Surgery in the Elderly Today
2.1 Introduction
2.2 Older Patients and Emergency Surgery
2.2.1 Diagnostic and Therapeutic Challenges
2.2.2 Multidisciplinary Approach and Comprehensive Geriatric Assessment (CGA)
2.3 Screening and Assessment of Frailty in EGS
2.3.1 Frailty and EGS
2.3.2 Assessment of Frailty in EGS
2.4 Care Plan from Admission to Discharge
2.4.1 Clinical Assessment and Preoperative Optimization
2.4.2 Minimally Invasive Techniques in EGS in Elderly
2.5 Outcomes After EGS in Elderly
2.5.1 Acute Postoperative Monitoring
2.5.2 Cognitive Impairment
2.5.3 Loss of Independence and Recurrent Hospitalization
References
3: A Worldwide Overview of Emergency Laparoscopic Procedure in the Elderly
3.1 Introduction
3.2 Acute Calculous Cholecystitis (ACC)
3.3 Acute Appendicitis
3.4 Colorectal Cancer (CRC)
3.5 Acute Left-Side Colonic Diverticulitis (ALCD)
3.6 Small Bowel Obstruction
3.7 Perforated Peptic Ulcer
References
Appendix
4: The Economic Burden of Emergency Abdominal Surgery in the Elderly: What Is the Role of Laparoscopy?
4.1 Introduction
4.2 Emergency Surgery in the Elderly Patients
4.3 The Economic Burden
4.4 Common Postsurgery Consequences for Elderly
4.5 The Surgery Procedure Innovation
4.6 The Economic Impact of Emergency Abdominal Laparoscopic Surgery on the Elderly Patients
4.7 Concluding Remarks
References
5: Goals of Care in Emergency Abdominal Surgery in the Elderly and Frail Patient
5.1 Introduction
5.2 Frailty Degree and Preoperative Predictive Factors: Evaluation of Surgical Patient
5.3 What Kind of Procedure? Variables for Decision-Making Process
5.4 Goals of Care and Optimization of Therapeutic Management
5.4.1 Preoperative Conditions
5.4.2 Intraoperative Management
5.4.3 Postoperative Management
5.5 Complications in Frail and Elderly Patients
5.6 Conclusion
References
6: Wound Healing in Elderly and Frail Patients
6.1 Laparoscopy in the Elderly, Inflammatory Response, and Reduction of Complications in Emergency Surgery
6.2 Minimally Invasive Surgery in the Elderly and Choice of the Correct Surgical Incision
References
Part II: Surgery
7: Acute Cholecystitis
7.1 Introduction
7.2 Diagnosis
7.2.1 History and Physical
7.2.2 Systemic Signs of Inflammation
7.3 Should We Operate on Elderly and Frail Patients?
7.3.1 Does Advanced Age Increase the Risk for Surgery?
7.3.2 Is Age an Independent Risk Factor?
7.3.3 What Is the Risk of Not Operating?
7.3.3.1 Mortality and Morbidity
7.3.3.2 Recurrence and Readmission
7.4 Laparoscopic or Open Cholecystectomy in Advanced Age?
7.4.1 Could Open Surgery Be Advantageous?
7.5 Early or Delayed
7.5.1 Should we Delay Surgery in Elderly and Frail Patients?
7.6 Percutaneous Cholecystostomy
7.6.1 The Observational Studies
7.6.2 The Randomized Trials
7.7 Is a Tailored Approach Possible?
7.8 Conclusions
References
8: Cholangitis and Choledocholithiasis
8.1 Introduction
8.2 Choledocholithiasis
8.2.1 Diagnosis
8.2.2 Therapy
8.2.3 Is Cholecystectomy Necessary After CBD Clearance?
8.3 Acute Cholangitis
8.3.1 Diagnosis
8.3.2 Therapy
References
9: Gallstone Ileus
9.1 Introduction and Epidemiology
9.2 Clinical Presentation
9.3 Diagnosis
9.3.1 Abdominal X-ray
9.3.2 Computed Tomography (CT)
9.3.3 Abdominal Ultrasonography
9.3.4 Magnetic Resonance Imaging (MRI)
9.3.5 Esophagogastroduodenos copy
9.4 Treatment
9.5 Conclusions
References
10: Acute Pancreatitis Management in Elderly/Frail Patients
10.1 Introduction
10.2 Revised Atlanta Classification (RAC)
References
11: Acute Appendicitis
11.1 Introduction
11.1.1 Acute Appendicitis in the Elderly: The Scale of the Problem
11.1.2 Risk Factors for Perforation
11.1.3 Diagnostic Issues in Acute Appendicitis in the Elderly and Frail Patient
11.1.4 Timing of Appendectomy
11.1.5 Laparoscopic Appendectomy
11.1.5.1 Laparoscopic Appendectomy for Complicated Appendicitis with Phlegmon or Abscess
11.1.5.2 Technical Aspects
11.1.6 Risk Factors Predictive for Postoperative Morbidity Following Appendectomy
11.1.7 Nonoperative Treatment
11.1.7.1 The Risk of Missing Appendiceal Tumors
11.1.7.2 Interval Appendectomy
References
12: Non-specific Abdominal Pain
12.1 Definition and Epidemiology
12.2 Baseline Investigations
12.3 Imaging
12.4 Frailty Score
12.5 Management: Early Laparoscopy Versus Wait-and-See
12.6 Conclusions
References
13: Perforated Gastroduodenal Ulcer
13.1 Introduction
13.2 Clinical Presentation and Diagnostic Procedures
13.3 Management of the Patient
13.4 Selection of Patients for Surgery
13.5 Surgical Procedure
13.6 ERAS Programme
References
14: Gastric Outlet Obstruction in the Elderly
14.1 Introduction
14.2 Pathogenesis
14.3 Presentation and Workup
14.4 Goals of Palliative Intervention: Endoscopic and Surgical Management
14.5 Perioperative Care
14.6 Surgery
14.7 Laparoscopic Stomach Partitioning Gastrojejunostomy: Step-by-Step Technique
14.8 GOO for Acute Gastric Volvolus: A Surgical Emergency
14.9 Conclusion
References
15: Obstructing Colorectal Tumor
15.1 Introduction
15.2 Diagnostic Workup and Initial Care
15.3 Right-Sided Malignant Colonic Obstruction
15.4 Left-Sided Malignant Colonic Obstruction
15.4.1 Hartmann’s Procedure
15.4.2 Resection and Primary Anastomosis
15.4.3 Subtotal Colectomy
15.5 Bridging Strategies
15.5.1 Self-Expanding Metal Stent SEMS
15.5.2 Decompressing Stoma
15.5.3 Stent as a Bridge to Elective Surgery Versus Diverting Stoma as a Bridge to Surgery
15.6 Palliative Treatment
References
16: Acute Diverticulitis
16.1 Epidemiology in Elderly People
16.2 Surgery in Diverticulitis
16.3 Impact of Age over Treatment
16.4 Technical Considerations
16.4.1 Approach to Surgery: Laparoscopy or Laparotomy?
16.4.2 Colonic Resection: One-Stage or Two-Stage Procedure?
16.4.3 Laparoscopic Peritoneal Lavage
References
17: Small Bowel Obstruction
17.1 Introduction
17.2 Epidemiology
17.3 Pathophysiology
17.4 Clinical Presentation and Differential Diagnosis
17.5 Radiology
17.6 Management
17.7 Laparoscopic Surgical Strategy and Technique: Tips and Tricks
References
18: Incarcerated Inguinal and Crural Hernias
18.1 Incarcerated Inguinal and Crural Hernias
References
19: Incarcerated Incisional and Ventral Hernias in the Elderly and Frail Patient
19.1 Introduction
19.2 Pathophysiology
19.3 Diagnosis
19.4 Identification of the Presence of Incarceration
19.5 Preoperative Preparation
19.6 Laparoscopic Technique
19.7 Conclusions
References
20: Abdominal Trauma in the Elderly
20.1 Introduction
20.2 Changes in the Elderly
20.3 Mechanisms of Injury
20.4 Abdominal Trauma in the Elderly
20.5 Trauma Laparoscopy in the Elderly
20.6 Diagnostic Laparoscopy Technique
20.7 Anticoagulation
References
Further Reading
Guidelines
21: Laparoscopic Approach to Acute Mesenteric Ischemia in Elderly Patients
21.1 Introduction
21.2 Diagnostic Value of Laparoscopy in AMI
21.2.1 First-Look Exploration
21.2.2 Second-Look Exploration
21.3 The Role of Laparoscopy in the Treatment of AMI
References
22: Open Abdomen in the Elderly
22.1 Introduction
22.2 Technique
22.3 Results
References
23: Gynaecologic Emergencies
23.1 Introduction
23.2 Intra-abdominal Haemorrhage in the Elderly
23.3 Adnexal Torsion in Elderly
23.4 Traumatic Injuries and Cuff Dehiscence Post-hysterectomy
23.5 Pyometra Perforation
References
24: Bedside Laparoscopy in the Elderly and Frail Patient
24.1 Definition and Rationale for Use
24.2 History of Application
24.3 Advantages and Indications
24.4 Contraindications and Potential Adverse Effects
24.5 Results and Complications
24.6 Technique: Rules and Pitfalls
References
25: Emergency Video-Assisted Thoracoscopy in the Elderly
25.1 Introduction
25.2 Indications for Thoracoscopy
25.3 Hemothorax
25.4 Diaphragmatic Injury
25.5 Esophageal Perforation
25.6 Descending Necrotizing Mediastinitis
References
26: Palliative Surgery for Oncologic Elderly Patients in Emergency
26.1 Introduction
26.2 Epidemiology
26.3 Multidimensional Geriatric Evaluation in the Emergency Surgical Patient
26.4 An Overview of Palliative Cancer Surgery
26.5 Palliation for Colorectal Obstructions
26.6 Palliation for Gastric Cancer
26.7 Palliation for Pancreatic Cancer
References
27: Emergency Robotic Surgery for Acute Abdomen in the Elderly
27.1 Introduction
27.2 Robotic Surgery in the Emergency Setting
27.3 Robotic Surgery in Elderly Patients
27.4 Conclusions
References
Part III: Perioperative Care
28: Enhanced Recovery After Emergency Surgery in the Elderly
28.1 Introduction
28.2 Eras in Emergency and Frail Patients
28.3 Eras and Laparoscopy
References
29: Antibiotics in Emergency Abdominal Surgery in the Elderly
29.1 Introduction
29.2 The Management of Infections in Elderly People
29.3 Antibiotic Therapy in Elderly Patients
29.4 Elderly Patients and Antimicrobial Resistance
29.5 Conclusions
References
30: Imaging and Interventional Radiology in Emergency Abdominal Surgery in the Elderly
30.1 Imaging Approach to the Elderly Patients with Acute Abdominal Pain/Acute Abdomen
30.1.1 Abdominal Radiographs
30.1.1.1 Main Findings
30.1.1.2 Pros and Cons
30.1.2 Ultrasound
30.1.2.1 Main Findings
30.1.2.2 Pros and Cons
30.1.3 CT Scan
30.1.3.1 Pathological Findings
30.1.3.2 Pros and Cons
30.2 Role of Radiology in Patient Management
30.2.1 Acute Cholecystitis
30.2.2 Intestinal Diseases
30.2.2.1 Acute Appendicitis
30.2.3 Diverticulitis
30.2.4 Bowel Obstruction
30.2.5 Alimentary Tract Perforations
References
31: Anesthesia and Emergency Laparoscopy in the Elderly Patient
31.1 Physiology Considerations in the Elderly Patient
31.2 Laparoscopy and Organ and System Modification
31.3 Preoperative Care
31.4 Intraoperative Care
31.5 Anesthetic Technique
31.5.1 Premedication
31.5.2 Positioning on the Operating Table
31.5.3 Intraoperative Monitoring
31.6 General Anesthesia
31.6.1 Hypnotic Drugs and Anesthesia Induction
31.6.2 Opioid Analgesics
31.6.3 Dexmedetomidine
31.6.4 Neuromuscular Blocking Agents
31.7 Risk of Aspiration and Rapid Sequence Induction
31.8 Intraoperative Fluid Management
31.9 Regional Anesthesia Techniques
31.10 Postoperative Care
31.10.1 Pain Management
31.10.2 Postoperative Delirium
31.11 Conclusions
References
32: PONV and Pain Management
32.1 PONV
32.2 Pain Management
References
33: The Geriatrician Point of View
33.1 Introduction
33.2 Geriatric Patients: Clinical Characteristics
33.3 Establishing Goals of Care and Surgery
33.4 Preoperative Assessment: Risk Stratification
33.5 Postoperative Care and Prevention of Geriatric Complications
33.5.1 Function and Mobility Preservation
33.5.2 Delirium
33.5.3 Malnutrition
33.5.4 Postoperative Pain
33.5.5 Postoperative Pulmonary Complications
33.5.6 Postoperative Cardiovascular Complications
33.5.7 Urinary Tract Infection
33.5.8 Pressure Ulcers
33.6 Hospital Discharge and Continuity of Care
33.7 Conclusions
References
34: Perioperative Nutritional Management of Elderly Patients
34.1 Introduction
34.2 Preoperative Nutritional Screening and Assessment
34.3 Preoperative Nutritional Interventions
34.4 Intraoperative Strategies
34.5 Postoperative Nutritional Management
34.6 Post-discharge Follow-Up
References
35: Emergency Laparoscopy in the Elderly and Frail Patient: Perioperative Nursing Considerations
35.1 Introduction
35.2 Operative Nursing
35.3 Intraoperative Phase
35.4 Continuity of Care
35.5 Teamwork and Multidisciplinary
References
36: Shared Decision-Making at the End of Life
36.1 Introduction: The Age as a Decisional Criterion
36.2 The Ethical Value of Palliative Surgery at the End of Life (EOL)
36.3 Ethical Principles Governing Clinical Decisions at the EOL
36.4 “Shared Care Planning” as a Tool for Decision in EOL Setting
36.5 The Role of Clinical Ethics Consultation in Decision-Making
36.6 Concluding Remarks
References
37: Minimally Invasive Surgery in the Elderly and Frail Patient in the COVID-19 Era
References