Emergency laparoscopic surgery in the elderly and frail patient
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Emergency laparoscopic surgery in the elderly and frail patient
Ferdinando Agresta • Mauro Podda Fabio Cesare Campanile Carlo Bergamini • Gabriele Anania Editors Emergency laparoscopic surgery in the elderly and frail patient
Editors Ferdinando Agresta Mauro Podda Department of General Surgery Policlinico Universitario Duilio Casula ULSS2 Trevigiana del veneto AOU Cagliari, Department of Vittorio Veneto (TV) Emergency Surgery Italy Monserrato Italy Fabio Cesare Campanile General Surgery Carlo Bergamini Ospedale San Giovanni Department of Emergency Surgery Decollato - Andosilla AOU Careggi Civita Castellana, Viterbo Firenze Italy Italy Gabriele Anania UO di chirurgia Generale e Toracica AOU Ferrara Ferrara Italy ISBN 978-3-030-79989-2 ISBN 978-3-030-79990-8 (eBook) https://doi.org/10.1007/978-3-030-79990-8 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Thinking of our elders, from a professional, personal, and human point of view; taking into account our young people— the reason for our being professional, personal, and human; without forgetting us, with our frailties: professional, personal, and human.
Foreword Randomized clinical trials (RCTs) are the best way to assess the efficacy and/ or toxicity of a therapeutic product. They have been developed and refined particularly for clinical pharmacology. RCTs are seldom used for non- pharmacological interventions, and very rarely in surgery. Even when there is an improvement, it is hard to find scientific evidence to establish whether a surgical procedure is better than some other one, whether surgery that has achieved good results in adults is also effective in old people and is equally favorable in males and females. This kind of information is very important for supplementing a Health Therapeutic Assessment (HTA) and implementing the guidelines in various areas of surgery. However, the field of surgery is always very complex because the experi- ence and the manual skills of surgeons and their staff are of paramount impor- tance for the success of any intervention. This means that surgical RCTs must be multicentric in order to randomize the surgeons when comparing, for instance, two surgical procedures. It is even harder to achieve double blind- ness because the surgeons must be aware of the procedure, while the blind- ness should be mandatory for the patients. It is instead possible that the results of a surgical intervention are evaluated by surgeons who are not involved in that clinical trial. This book, written by Italian surgeons, sets out to define and discuss these problems in a specific field: laparoscopy in frail old people. The definition of frailty is particularly relevant for the Italian population. In fact, Italians top the lists for lifespan (81 and 85 years for males and females, respectively), but the drop lower when the healthy lifespan is considered because they often suffer one or more pathologies in the last part of their lives. Probably, scarce attention to good life styles is the main reason. Therefore, “classic” surgery could be contraindicated in such conditions while laparoscopy, being less invasive, may be tolerated better by frail old people. The authors of this book are convinced that only RCTs can give answers to a number of questions. Is the treatment urgent and necessary or could it be delayed? Some cases of acute appendicitis can avoid surgery because the infection could be cured by antibiotics. A recent study shows that obese dia- betics achieve the same results—loss of body weight—with a well-balanced diet or a gastric bypass. Most surgical knowledge is based on interventions in adults. Are they transferable to frail old people? Then too, if laparoscopy is really well vii
viii Foreword tolerated in old people, are the results acceptable? Results mean not only in the short term, but also with long enough follow-up to evaluate late or long- term side effects and relapses. All these questions in the various pathological areas call for RCTs to avoid “good intentions” translating to damage. We need to know what is better because we cannot accept that the age of patients and their frailty is a reason to avoid surgery or an excuse to limit them to non- surgical treatments. The possibility of organizing more RCTs in surgery depends essentially on the availability of adequate resources that national and European govern- ments will make available. This book gives them good reasons. Frail old people deserve attention! Silvio Garattini “Mario Negri” Institute for Pharmacological Research, Milan, Italy
Preface “Science is built of facts the way a house is built of bricks: but an accumula- tion of facts is no more science than a pile of bricks is a house”, wrote the mathematician Henri Poincare. However, as surgeons and doctors, we have to face and consider our own “facts”. We are ageing! This is the first fact. From a global perspective, it is esti- mated that the number of people over 65 years old will increase from 5234 million in 2010 to more than 1.5 billion in 2050 and, currently, about 33% of hospital stays and 41% of hospital costs are attributed to patients over 65 years old. As an example, more than 20% of the Italian population is over 65 years old and this percentage is expected to rise to 34% by 2050. Over the last 20 years, life expectancy in the country has increased from 78 to 80 years for men and from 84 to 85 years for women. About 20% of the elderly and 6% of the country’s total population are now over 80 years old. Second fact: when we think of the elderly, our first thought is chronic medical illness, but it is estimated that 21% of the total population over 60 will need surgery, compared to only 12% of people in the 45–60 age group. Third fact: we are all well aware of the advantages of laparoscopy in planned surgical procedures, which include elderly and frail patients. However, there are many doubts about emergencies: people over 70 who undergo an emergency laparotomy have a hospital mortality of 21.4%, and older patients, especially octogenarians, have worse outcomes with up to 44% mortality reported. Fourth fact: an ageing population will put greater financial pressure on elderly care systems. And in an era of budgetary restrictions, this has to be taken into careful consideration. Fifth fact: we continue to use the term “elderly” only in a chronological sense: 65 years old continues to be adopted as a threshold for old age. This can no longer be the case, just as it can no longer be just a number (age) to define a person's situation. That is why it is better to use and talk about, and define, frailty. Sixth fact: last but not least, it is no longer the time for the one-man show; surgeons cannot and must no longer ignore multidisciplinarity, especially in the medical profession. These are the facts. However, on their own, these facts are not science. ix
x Preface “… As doctors and surgeons, our mission is to treat patients to the best of our knowledge and expertise. The exponential knowledge eruption and the nearly daily skill-related technology advances in minimally invasive surgery make it more than ever mandatory that we, surgeons and doctors, humbly examine, analyze and objectively audit our own practice…we have to recog- nize and discard our acquired biases, and base our diagnostic procedures and surgical therapy on ‘hard’ evidence…” It is still correct, timeless, and contex- tual what Dr. Fingerhut wrote. So these were the ideas that led us to be the Editors of a book about the laparoscopic approach in emergencies in elderly and frail patients. We tried to work on it with a multitasking approach, involving not only surgeons but also anaesthetists, internists, nurses, and radiologists. As this is an indisputable fact, only together, we could try to summarize the facts in science. Without forgetting ethics! The idea for this book was born at the beginning of 2020, and in the mean- time another worrying fact has emerged, the SARS-CoV-2 (COVID-19) infection. There is no real evidence, especially regarding surgery, about this “worry- ing fact”. However, we could not overlook it, especially considering that our elderly were significantly affected during the first wave. On the contrary, in the second wave, younger people became frail. We have tried to answer the questions listed above, which we want to share with everyone. Perhaps “forcing” the meaning of the Aristotelian syllogism a bit: if the safety and efficacy profiles of laparoscopy in the elderly and frail patient have been confirmed, then it is even more true in the non-elderly and non-frail patient. Vittorio Veneto, Italy Ferdinando Agresta Monserrato, Italy Mauro Podda Civita Castellana, Italy Fabio Cesare Campanile Firenze, Italy Carlo Bergamini Ferrara, Italy Gabriele Anania
Contents Part I Generalities 1 How to Define an Elderly and Frail Patient?�������������������������������� 3 Ferdinando Agresta, Carlo Bergamini, Mauro Podda, Fabio Cesare Campanile, Gabriele Anania, Stefano Volpato, Alessandro Nobili, Gianluca Costa, Alessandro Puzziello, Francesco Corcione, and Gianluigi Melotti 2 Defining the Burden of Emergency General Surgery in the Elderly Today������������������������������������������������������������������������ 19 Elisa Cassinotti, Luigi Boni, and Ludovica Baldari 3 A Worldwide Overview of Emergency Laparoscopic Procedure in the Elderly������������������������������������������������������������������ 31 Giancarlo D’Ambrosio, Andrea Picchetto, Stefania La Rocca, Francesca De Laurentis, Laura Rossi, and Antonio Crucitti 4 The Economic Burden of Emergency Abdominal Surgery in the Elderly: What Is the Role of Laparoscopy? �������� 41 Emidia Vagnoni 5 Goals of Care in Emergency Abdominal Surgery in the Elderly and Frail Patient������������������������������������������������������ 53 Antonino Agrusa, Giuseppe Di Buono, Salvatore Buscemi, Francesco Saverio Latteri, Antonio Giuseppe Biondi, and Giorgio Romano 6 Wound Healing in Elderly and Frail Patients ������������������������������ 61 Valerio Caracino, Pietro Coletta, Piergaspare Palumbo, Simone Castiglioni, Diletta Frazzini, and Massimo Basti Part II Surgery 7 Acute Cholecystitis�������������������������������������������������������������������������� 73 Fabio Cesare Campanile, Monica De Angelis, Elisabetta Santucci, and Ilaria Vecchioni xi
xii Contents 8 Cholangitis and Choledocholithiasis���������������������������������������������� 87 Gennaro Perrone, Federica Gaiani, Andrea Morini, Mario Giuffrida, Gian Luigi de’ Angelis, Fausto Catena, and Fabio Cesare Campanile 9 Gallstone Ileus���������������������������������������������������������������������������������� 95 Irnerio Angelo Muttillo, Federico Coccolini, Biagio Picardi, Stefano Rossi, Edoardo Maria Muttillo, and Ferdinando Agresta 10 Acute Pancreatitis Management in Elderly/Frail Patients���������� 105 Angelo Iossa and Gianfranco Silecchia 11 Acute Appendicitis �������������������������������������������������������������������������� 111 Mauro Podda, Gaetano Poillucci, Chiara Gerardi, Nicola Cillara, Leonardo Montemurro, Giulia Russo, Massimo Carlini, and Adolfo Pisanu 12 Non-specific Abdominal Pain���������������������������������������������������������� 121 Riccardo Brachet-Contul, Lorenzo Cinti, Mario Junior Nardi, Salvatore Condurro, Paolo Millo, and Daniele Marrelli 13 Perforated Gastroduodenal Ulcer�������������������������������������������������� 129 Gabriele Anania, Alberto Campagnaro, Francesco Marchetti, Giuseppe Resta, and Roberto Cirocchi 14 Gastric Outlet Obstruction in the Elderly ������������������������������������ 141 Marcello Pisano, Corrado Gromo, Francesco Autuori, Antonio Lai, Federica Frongia, Giuseppe Esposito, Mauro Podda, and Francesco Balestra 15 Obstructing Colorectal Tumor�������������������������������������������������������� 153 Alberto Arezzo, Giacomo Lo Secco, Giovanni Distefano, Edoardo Forcignanò, and Mario Morino 16 Acute Diverticulitis�������������������������������������������������������������������������� 163 Monica Ortenzi, Sophie Williams, Amyn Haji, Roberto Ghiselli, and Mario Guerrieri 17 Small Bowel Obstruction���������������������������������������������������������������� 181 Carlo Alberto Ammirati, Marco Ettore Allaix, and Mauro Zago 18 Incarcerated Inguinal and Crural Hernias ���������������������������������� 187 Alberto Sartori, Umberto Bracale, Andrea Bianchin, Emanuele Pontecorvi, Jacopo Andreuccetti, Vania Silvestri, and Francesco Corcione 19 Incarcerated Incisional and Ventral Hernias in the Elderly and Frail Patient������������������������������������������������������ 197 Diego Cuccurullo, Carlo Sagnelli, Ernesto Tartaglia, and Giovanni D’Alterio
Contents xiii 20 Abdominal Trauma in the Elderly������������������������������������������������� 203 Francesco Virdis, Matthew Martin, Mansoor Khan, Isabella Reccia, Gaetano Gallo, Mauro Podda, and Salomone Di Saverio 21 Laparoscopic Approach to Acute Mesenteric Ischemia in Elderly Patients���������������������������������������������������������������������������� 215 Marco Milone, Anna D’Amore, Michele Manigrasso, and Bruno Amato 22 Open Abdomen in the Elderly�������������������������������������������������������� 221 Giovanni Bellanova, Simone Frassini, Stefania Cimbanassi, Osvaldo Chiara, Sergio Ribaldi, and Gregorio Tugnoli 23 Gynaecologic Emergencies�������������������������������������������������������������� 227 Emanuele Botteri, Giulia Montori, Luca Ansaloni, and Federico Coccolini 24 Bedside Laparoscopy in the Elderly and Frail Patient���������������� 235 Carlo Bergamini, Giovanni Alemanno, Alessio Giordano, Alessandro Bruscino, Gherardo Maltinti, Desiré Pantalone, Jacopo Martellucci, and Paolo Prosperi 25 Emergency Video-Assisted Thoracoscopy in the Elderly ������������ 245 Nicola Tamburini, Francesco D’Urbano, Pio Maniscalco, Francesco Quarantotto, Francesco Bagolini, Alessandro Bertani, and Giorgio Cavallesco 26 Palliative Surgery for Oncologic Elderly Patients in Emergency������������������������������������������������������������������������������������ 251 Nereo Vettoretto, Emanuele Botteri, Dhimiter Cuka, Alessandra Marengoni, and Giuseppe Romanelli 27 Emergency Robotic Surgery for Acute Abdomen in the Elderly������������������������������������������������������������������������������������ 259 Wanda Petz, Paolo Pietro Bianchi, Graziano Pernazza, and Graziano Ceccarelli Part III Perioperative Care 28 Enhanced Recovery After Emergency Surgery in the Elderly������������������������������������������������������������������������������������ 269 Ugo Elmore, Andrea Vignali, Giulia Maggi, Roberto Delpini, and Riccardo Rosati 29 Antibiotics in Emergency Abdominal Surgery in the Elderly������������������������������������������������������������������������������������ 275 Massimo Sartelli 30 Imaging and Interventional Radiology in Emergency Abdominal Surgery in the Elderly ������������������������������������������������ 281 Francesca Iacobellis, Gianluca Rasetto, Antonio Brillantino, Marco Di Serafino, Roberto Rizzati, and Luigia Romano
xiv Contents 31 Anesthesia and Emergency Laparoscopy in the Elderly Patient ���������������������������������������������������������������������� 291 Concezione Tommasino 32 PONV and Pain Management�������������������������������������������������������� 301 Roberta Monzani 33 The Geriatrician Point of View ������������������������������������������������������ 307 Stefano Volpato 34 Perioperative Nutritional Management of Elderly Patients���������������������������������������������������������������������������� 317 Nicolò Pecorelli, Maria Teresa Salvioni, Alessia Vallorani, and Giovanni Guarneri 35 Emergency Laparoscopy in the Elderly and Frail Patient: Perioperative Nursing Considerations ������������������������������������������ 327 Salvatore Casarano, Pierpaolo Pizzolante, and Dario Galati 36 Shared Decision-Making at the End of Life���������������������������������� 335 Antonio G. Spagnolo, Barbara Corsano, and Dario Sacchini 37 Minimally Invasive Surgery in the Elderly and Frail Patient in the COVID-19 Era���������������������������������������� 343 Emanuele Botteri, Alberto Sartori, Marco Giovenzana, Beatrice Giuliani, Giacomo Piatto, Andrea Balla, Fabio Cesare Campanile, Gabriele Anania, Mauro Podda, Alberto Arezzo, and Ferdinando Agresta
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