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

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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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