Principles and Practice of Geriatric Surgery

Preface to the Third Edition
Preface to the Second Edition
Preface to the First Edition
Contents
About the Editors
List of Section Editors
Contributors
Part I: Principles
	1 Principles of Geriatric Surgery
		Introduction
		Principle I: Clinical Presentation
		Principle II: Lack of Reserve
		Principle III: Preoperative Preparation
		Principle IV: Emergency Surgery
		Principle V: Attention to Detail
		Principle VI: Age is a Scientific Fact
		Conclusion
		References
	2 Defining Quality of Care
		Impact of the Aging Population
		Quality of Care in Surgery
		Quality of Care Definitions
		Cognitive Impairment
		Functional Status
		Frailty
		Medication Management
		Patient Goals and Preferences
		The Coalition for Quality in Geriatric Surgery (CQGS)
		Conclusion
		References
	3 Biology of Aging
		Geroscience and the Surgical Patient
		Immunosenescence and Inflammaging
		Hemostasis
		Delirium
		Cardiovascular
		Gastrointestinal
		Metabolic and Endocrine
		Renal
		Summary
		References
	4 Surgery in Centenarians
		Introduction
		History
		Case Studies
			Case 1
			Case 2
			Case 3
		Discussion
			Physiologic Changes in Centenarians
			Pathology in Centenarians
			Determinants of Extreme Longevity
			Selective Survival Hypothesis
		Supercentenarians
		Conclusions
		References
	5 Geriatric Syndromes
		Introduction
		Assessment of the Geriatric Surgical Patient
		Common Geriatric Syndromes in the Setting of Surgical Care
			Frailty
			Delirium
			Dementia
			Depression
		Falls
		Hearing Impairment
		Visual Impairment
		Urinary Incontinence
		Sleep Disorders
		Conclusion
		References
Part II: Preoperative Assessment
	6 Patient-Centered Surgical Decision Making
		Introduction
		Clinical Vignette
		What is Patient-Centered Decision Making?
		Barriers to Patient-Centered Decision Making
		Approach to Patient-Centered Decision Making in Geriatric Surgery
			Setting the Stage: Conveying Overall Prognosis and the Problem of Uncertainty
			Identify More than One Treatment Option and the Need to Work Together to Make a Decision
			Describe the Treatment Options
			Elicit Patient Values and Goals
			Make a Recommendation
		Conclusion
		References
	7 Frailty
		Introduction
		What Is Frailty?
		Limitations of Age (Superiority of Frailty Measurements)
		Pathophysiology
		Sarcopenia: Two Sides of the Same Coin
		Clinical Implementation of Frailty
		Frailty Index
		Frailty Score
		FI Versus FS
		Frailty and Kinesiology
		Preoperative Assessment
		Postoperative Outcomes
		Complications
		Length of Stay
		Discharge Disposition
		Hospital Resources
		Failure to Rescue
		Conclusion
		References
	8 Function and Prehabilitation
		Preoperative Assessment for Prehabilitation
			Exercise Tolerance
			Sarcopenia and Frailty
			Cognitive Assessment
			Nutritional Assessment
			Summary
		Prehabilitation to Enhance Postoperative Outcome
			Prehabilitation to Attenuate Deconditioning
			Literature on Surgical Prehabilitation
			Prehabilitation for the Frail Elderly Patient
			Duration of Prehabilitation
			Preoperative Exercise Activity to Enhance Functional Capacity
			Optimizing Prehabilitation with Nutrition
			Monitoring Prehabilitation
		Conclusions
		References
	9 Preoperative Cognitive Assessment in Older Adults
		Introduction
		The Aging Brain
		Cognitive Impairment and Dementia
		Preoperative Cognitive Screening
			Mini Mental State Examination (MMSE)
			Montreal Cognitive Assessment (MoCA)
			Mini-Cog
			General Practitioner Assessment of Cognition (GPCOG)
			Verbal Fluency Test
		Optimizing Patients with Cognitive Impairment
		Conclusion
		References
	10 Nutrition in the Geriatric Surgical Patient
		Clinical Vignette
		Introduction
		Factors Contributing to Geriatric Malnutrition
			Physiologic
			Psychologic
			Socioeconomic
		Nutritional Assessment of Geriatric Patients
			History and Physical Exam
			Subjective Global Assessment
			Biochemical Markers
				Albumin
				Transthyretin (Prealbumin) and C-Reactive Protein
				Other Biochemical Markers
			Body Composition and Anthropometric Measures
			Ultrasonography
			Anthropometry
			Sarcopenia and Frailty
			Functional Assessment
		Nutritional Assessment Scoring Systems
			Mini Nutritional Assessment
			GNRI
			MUST
			NRS 2002
		Impact of Nutrition on Outcomes
		Nutrition Optimization
			Energy Requirements in the Elderly
			Perioperative Nutrition Management
			Oral supplementation
			Enteral Nutrition
			Parenteral Nutrition
			Refeeding Syndrome
			``Prehabilitation´´
			Comprehensive Geriatric Assessment
		Conclusion
		References
	11 Medication-Related Problems in Surgical Patients
		Biology of Aging
		Drug Absorption
		Distribution
		Metabolism
			Pharmacogenomics and the Cytochrome P450 Enzymes
			Renal Elimination
		Medication-Related Problems in the Elderly
			Polypharmacy, Potentially Inappropriate Medications, and the Surgeon
				Preoperative Medication Therapy Management
		Medication Selection in Older Adults
		Medication Review and Reconciliation
		De-prescribing
		Specific Prescribing Issues
			Delirium
			Antipsychotics
			Antidepressants
			Anxiolytics
			Sedative/Hypnotics
			Pain Management
			Antihistamines
			Antibiotics
		Summary
		References
	12 Cancer in Older Adults
		Introduction
		Preoperative Considerations
			Life Expectancy
			Decision-Making Capacity
			Goals of Care
			Comprehensive Geriatric Assessment
		Treatment Approaches
			Planning and Sequencing of Care
			Surgical Therapy
			Radiation Therapy
			Systemic Therapy
				Specific Chemotherapy-Related Challenges
				Targeted Therapy and Immunotherapy
				Evaluation Prior to Systemic Therapy
		Disease-Specific Treatment Recommendations in Elderly Cancer Patients
			Breast Cancer
			Lung Cancer
			Colorectal Cancer
			Liver Cancer
			Prostate Cancer
			Bladder Cancer
			Ovarian Cancer
			Melanoma
		Conclusion
		References
	13 Diabetes in Older Adults
		Introduction
		Epidemiology, Pathophysiology, and Diagnosis of Diabetes
		Acute and Chronic Complications
			Acute Complications
			Chronic Complications
		Goals of Treatment in Older Adults
		Tools of Glucose Management
		Management of Glucose in the Hospital
		Conclusion
		References
	14 Cardiac Disease in Older Adults
		Introduction
		Afterload
		Preload
		Contractility
		Diastolic Function
		Cardiovascular Response to Exercise
		Age-Related Changes in Cardiovascular Function
		Treatment of Congestive Heart Failure
		Abnormal Left Ventricular Ejection Fraction
		Normal Left Ventricular Ejection Fraction
		Other Cardiovascular Disorders
		Aortic Valvular Disease
		Mitral Valvular Disease
		Conduction Defects
		Conclusions
		References
	15 Pulmonary Disease in the Older Adult
		Airways and Lung Parenchyma Lung Shape
		Conducting Airways
		Lung Parenchyma
		Mechanical Properties of the Lungs
		Changes in Lung Recoil Due to Surface Forces
		Changes in Structural Macromolecules
		Chest Wall
		Muscles of Respiration
		Control of Breathing
		Diminished Ventilatory Response to Hypercapnia
		Diminished Ventilatory Response to Hypoxia
		Diminished Occlusion Pressure Responses
		Respiratory Load Compensation and Dyspnea
		Pulmonary Circulation
		Pulmonary Function Tests
		Lung Volumes
		Airflow
		Gas Exchange
		Summary and Implications for Geriatric Surgery
		References
	16 Renal Disease in Older Adults
		Assessing Renal Function in the Older Surgical Patient
		Specific Concerns for the Older Patient with Kidney Disease Undergoing Surgery
			Volume Management
			Hypertension
			Hyperkalemia
			Metabolic Acidosis
		Preventive Strategies for Acute Kidney Injury in the Perioperative Period
			Ischemic Kidney Injury
			Avoiding Nephrotoxins
		Surgery in the Older Adult Patient with End-Stage Renal Disease on Dialysis
			Timing of Dialysis Prior to Surgery
			Protecting Vascular Access in Hemodialysis Patients
		References
	17 Traumatic Injury in Older Adults
		Introduction: Epidemiology of Injury in the Elderly
		The Impact of Altered Physiology and Comorbid Disease
		Changes in Physiology by Organ System
			Central Nervous System
			Cardiovascular
			Pulmonary
			Renal Disease
			Musculoskeletal
			Gastrointestinal
			Metabolic/Endocrine
			Immunology
		Common Injury Patterns in the Elderly
			Falls
			Motor Vehicle Collision
			Pedestrian-Motor Vehicle Collision
			Depression, Substance Abuse, and Suicide
			Burns
			Elder Abuse
		Management of the Elderly Injured Patient
			Triage
			Initial Management and Resuscitation
		Considerations for Specific Injuries in the Elderly
			Head Injuries
			Spinal Injuries
			Thoracic Injuries
			Abdomen/Pelvis Injuries
			Fractures
		Rehabilitation and Disposition
		Long-Term Outcome
		Injury Prevention
		Decision-Making Capability
		End of Life/Withdrawal of Treatment
		Conclusion
		Case Study
			Physical Exam
			Lab Work
			Radiographs
			Things to Consider
			Hospital Course
		References
	18 Ethical Issues in Older Adults
		Introduction
		Truth-Telling
		Informed Consent
		Assessment of Decisional Capacity
		Decision-Making for Incapacitated Patients (Table 6)
		DNR Orders in the Operating Room
		Confidentiality
		Limits to Autonomy and Choice (Futility)
		Prognostication
		Decisions Near the End of Life
		Conclusion
		References
	19 Legal Issues in Older Adults
		Introduction
		Medical Malpractice
			Duty/Standard of Care
			Breach of Duty
			Damage or Injury
			Causation
		Informed Consent
			Elements
				Voluntariness
				Knowledge or Information
				Decisional Capacity
			Exceptions to the Consent Requirement
			Documentation of Consent
			Advance Medical Planning
			Surrogate/Proxy Decision Making
				Advance Planning
				Guardianship
				Default Authority Statutes
				``Unbefriended´´ Patients
			Nonbeneficial Surgery
			Research Context
		Confidentiality
		Patient Safety and Risk Management
			Safety Checklists
			Hospital Credentialing
			Documentation
			Error Disclosure and Apology
		Conclusion
		References
	20 Physiologic Responses to Anesthesia in the Elderly
		Introduction
		A Patient
		Cardiovascular Implications of Anesthesia in the Elderly
			Cardiovascular Changes with Aging that Affect Anesthetic Physiology
				Left Ventricle Structure and Function
				Conduction Abnormalities
				Autonomic Responses
				Cardiac Disease
			The Interplay of the Aging Cardiovascular System and the Effects of Anesthesia
				Individual Anesthetic Drugs
				General Interactions of Cardiovascular Aging with Anesthetic Management
			Regional Anesthesia: Spinal and Epidural
		Pulmonary Implications of Anesthesia in the Elderly
			Pulmonary Changes with Aging that Affect Anesthetic Physiology
			The Interplay of the Aging Pulmonary System and the Effects of Anesthesia
			Regional Anesthesia and Pulmonary Implications
		Physiologic Response to Anesthesia in the Aging Nervous System
			Altered Pharmacodynamics
			Increased Susceptibility to Postoperative Delirium and Cognitive Dysfunction
		Renal Implications of Anesthesia in the Elderly
		Hepatic Implications of Anesthesia in the Elderly
		Endocrine Implications of Anesthesia in the Elderly
		Thermoregulation
		Anesthetic Drugs in Older Adults
			Pharmacokinetic Considerations
			Specific Anesthetic Drugs
				Anxiolytics
				Induction Agents
				Opioids
				Neuromuscular Blocking Agents
				Inhalational Agents
				Other
		Conclusion
		References
Part III: Perioperative Care
	21 Management of Acute Postoperative Pain in the Geriatric Patient
		Introduction
		Nociception Is Not Pain
			Pharmacodynamics/Pharmacokinetics, Organ Function, and Aging
		Perioperative Cognitive Impairment and Pain
			Perioperative Pain Management Planning
		Education, Counseling, and Forming a Plan
		Methods of Post-Op Pain Assessment
			Multimodal Therapy
		Systemic Pharmacologic Therapy
			Opioids
			Weak Opioids
			Strong Opioids
		Principles of Dosing and Delivery Methods
		Systemic Nonopioid Adjuvants
			Acetaminophen
			NSAIDs
			Gabapentinoids
			Ketamine
			Glucocorticoids
			α2-Agonists
			Antidepressants
		Regional Analgesic Techniques
			Neuraxial Analgesia
			Peripheral Perineural Analgesia
		Nonpharmacologic Therapies
		Transitioning to Outpatient Care
		Special Considerations
		The Elderly Chronic Pain Patient
		Addiction, Dependence, Tolerance, Pseudoaddiction
		Conclusion
		References
			Further Reading
	22 Postoperative Delirium
		Introduction
		Risk Factors for Postoperative Delirium
			Preoperative Factors
			Intraoperative Factors
			Postoperative Factors
		Features, Etiology, and Diagnosis of PD
			Features
			Etiology
			Diagnosis
			Treatment of PD
		Conclusion
		References
	23 Models of Care
		Introduction
		Complications of Older Hospitalized Patients
			Geriatric Care Model Objectives
			Educate Health Care Providers in Core Geriatric Principles
			Target Risk Factors for Complications
			Incorporate Patient (Family) Choices and Treatment Goals
			Employ Evidence-Based Interventions
			Promote Interdisciplinary Communication
			Emphasize Discharge Planning (or Transitional Care)
		Geriatric Models
		Geriatric Consultation Service
		The Community Aging in Place: Advancing Better Living for Elders (CAPABLE)
		Acute Care for the Elders (ACE) Units
			Nurses Improving the Care of Health System Elders (NICHE)
			The Hospital Elder Life Program (HELP)
			Transitional Care Models
		Surgical Specialty Models
			Orthogeriatric Models
			Surgical Onco-Geriatrics
			Other Surgical Specialties
		Conclusion
		References
	24 Nursing Issues in Older Adult Surgery Patients
		Complications of Older Hospitalized Patients
			Functional Decline
			Fall-Related Injury
			Undernutrition/Malnutrition
			Pressure Ulcers
			Urinary Tract Infection
			Delirium
		Geriatric Care Model Objectives
			Educate Health-Care Providers in Core Geriatric Principles
			Target Risk Factors for Complications
			Incorporate Patient (Family) Choices and Treatment Goals
			Employ Evidence-Based Interventions
			Promote Interdisciplinary Communication
			Emphasize Discharge Planning (or Transitional Care)
		Geriatric Models
			Geriatric Consultation Service
			Acute Care for the Elderly Units
			Nurses Improving the Care of Health System Elders
			The Hospital Elder Life Program
			Transitional Care Models
			New Specialty Models
		Conclusion
		References
	25 Intensive Care in Older Adult Surgery Patients
		Introduction
		Outcomes
		Delirium
			Evaluation
			Prevention
			Treatment
		Respiratory Failure
			Changes in Pulmonary Function Associated with Aging
			Management
		Shock
			Changes in the Cardiovascular System Associated with Aging
			Evaluation
			Management
		Acute Kidney Injury
			Changes in the Renal System Associated with Aging
			Evaluation
			Clinical Management
			Outcomes: Renal Replacement Therapy
		Nutrition
		Caring for Dying Patients
		Conclusion
		References
	26 Age, Frailty, and Impaired Wound Healing
		Introduction
		Pathophysiology of Chronic Wounds in the Aging and the Frail
		Management of Chronic Wounds in Frail Older Adults
			Risk Factors and Red Flags
			Functional and Cognitive Status Determination and Frailty Assessment
			Prognostication: Does This Wound Have the Potential to Heal in a Normal Time Frame?
			Promoting a Healing Environment
				Nutritional Support
				Risk Factor Modification
				Physical Rehabilitation
				Medication Debridement
			A Different Focus on the Wound That Will Not Heal
				Pain Management
				Discharge and Exudate Management
				Odor Control
				Hemostasis
		Financing Wound Care
		Clinical Vignette
		Conclusion: Putting It All Together
		References
Part IV: Outcomes and Transitions of Care
	27 Transitioning Care at Discharge
		Introduction
		Patients at Risk for Poor Care Transitions Following Surgery
			Multimorbidity
			Frailty
			Functional Deficits
			Low Health Literacy
			Inadequate Social Support
			Cognitive Impairment
		Interventions to Improve Care Transitions Before Hospital Discharge
			Assessment of Readmission Risk and Readiness for Discharge
			Education and Engagement of Patients and Their Caregivers
			Enhanced Discharge Planning
			Medication Management and Reconciliation
		Interventions to Improve Care Transitions Following Hospital Discharge
			Scheduled Early Follow-Up Visits with Healthcare Providers
			Home Visits
			Follow-Up Telephone Communication
			Home Telemonitoring
		Interventions to Improve Care Transitions Across Episode of Care
			Maintaining Continuity of Provider Care
			Care Transitions Navigators
		Bundled Care Models for Transitional Care
			Transitional Care Model
			Care Transitions Intervention
			Project RED
			Project BOOST
		Conclusion
		References
	28 Postoperative Recovery and Rehabilitation
		Introduction
		Functional Status
		Symptoms Status
		General Health Perception
		Quality of Life
		Risk Factors for Protracted Recovery
		Strategies for Optimizing Recovery
			Preoperative Care
				Comprehensive Geriatric Assessment
				Pre-habilitation
			Hospitalization
				Enhanced Recovery Pathways
				Multidisciplinary Intervention Team
				Hospital Elder Life Program (HELP)
				Proactive Care of Older People Undergoing Surgery (POPS)
				Acute Care for Elders (ACE)
				Geriatric Surgery Service (GSS)
			Post Hospital Care
				Rehabilitation
		Conclusion
		References
	29 Available Government and Community Resources for the Care of Older Adults
		Introduction
		Government Resources: Medicare and Medicaid
		Community Resources
		Conclusion
		References
	30 Outcomes of Surgery in Older Adults
		Introduction
		Surgical Outcomes in the Elderly Population
		Optimizing Surgical Outcomes for Elderly Patients: Best Practice Guidelines
			Special Considerations
				Assessment of Frailty
				Prehabilitation
				Postoperative Cognitive Decline
				Preexisting Do Not Resuscitate (DNR) and Failure to Rescue
			Specific Patient Populations
				The Nursing Home Patient
				Elderly Patients with Dementia
			Postoperative Care
				The Use of Enhanced Recovery Pathways in the Elderly
				Prevention of Postoperative Complications in the Elderly
		Conclusion
		References
	31 Surgery in the Frail Elderly: Nursing Home Patients
		Introduction
		Focusing Surgical Care on the Frail Elderly: Development of a Dedicated Consult Service for Nursing Home Patients
		Analysis of Data from the Geriatric Surgery Consult Service: Role of Dementia, Age, and Coronary Artery Disease in the Nursing...
			Case Examples
				Case 1
				Case 2
				Case 3
				Comment
			Development of a Second Geriatric Surgery Consult Service: Decubitus Care
		A Dedicated Surgical Service for Community Nursing Home: The Einstein College of Medicine Experience
		Population-Based Outcomes After Major Surgery in Nursing Home Residents
		Conclusions
		References
Part V: Specific Specialties
	32 Neurosurgery-Intracranial
		Introduction
		Traumatic Brain Injury
			Extra-Axial Hematomas
			Intracerebral/Subarachnoid Hemorrhage
			Fractures
			Penetrating Trauma
		Nontraumatic Vascular Lesions
			Aneurysms
			Vascular Malformations
			Stroke
			Amyloid Angiopathy
			Adverse Drug Reactions
			Sinus Thrombosis
		Infection
		Peripheral Nerve Injury
		Tumors
		Conclusions
		References
	33 Anatomic and Physiologic Changes in the Ears, Nose, and Throat
		Introduction
		The Aging Ear
			Auditory Anatomy and Physiology
				External Ear
				Middle Ear
				Cochlea
				Auditory Nerve
			Central Auditory Processing
			Auditory Function
			Clinical Implications
			Vestibular Anatomy and Physiology
			Vestibular Function
			Clinical Implications
		The Aging Nose
			Anatomy and Physiology
			Olfactory Function
			Clinical Implications
		The Aging Throat
			Anatomy and Physiology
			Aging Changes in Voice Function and Swallowing
				Voice Function
				Oropharyngeal Function
			Clinical Implications
		Conclusion
		References
	34 Cardiac Surgery in the Older Adult
		Introduction
		Characteristics of the Older Adult Undergoing Cardiac Surgery
		Pharmacokinetics and Pharmacodynamics in the Older Adult Undergoing Cardiac Surgery
			Age-Related Changes in Pharmacokinetics and Pharmacodynamics
			Cardiac Medications and Aging
		Preoperative Assessment of the Older Adult Undergoing Cardiac Surgery
			Frailty in the Cardiac Surgery Patient
			Strategies to Decrease Operative Risk
			Pre-habilitation
		Predictors of Perioperative Morbidity and Mortality
		Quality of Life Considerations
		Postoperative Complications
			General Postoperative Complications
				Major Bleeding, Transfusion, and Anemia
			Complications Germane to the Older Adult Undergoing Cardiac Surgery
			Postoperative Atrial Fibrillation
				Stroke
				Delirium
				Deep Sternal Wound Infection
		Nonsurgical Alternatives
			Transplantation and Mechanical Circulatory Support
		Strategies for Postoperative Follow-Up
		Conclusions
		References
	35 Vascular Surgery
		Introduction
		Perioperative Risk Factors and Anesthesia
		Peripheral Arterial Disease
			Noninvasive Imaging
			Invasive Imaging
			Decision for Intervention
			Endovascular Versus Open Surgical Revascularization
			Amputation
		Acute Limb Ischemia
		Extracranial Carotid Disease
			Management of the Symptomatic Patient
			Management of Asymptomatic Patient
			Endarterectomy Versus Stenting
		Aneurysm Disease
			Epidemiology and Clinical Presentation
			Decision to Intervene
			Open Versus Endovascular Repair
		Frailty
		Conclusion
		References
	36 Pulmonary Surgery for Malignant Disease in Older Adults
		Case Study
		Introduction
		Physiologic Changes of Age
		Preoperative Evaluation
			Cardiac Risk Assessment
			Pulmonary Risk Assessment
			Cognitive Assessment
			Geriatric Assessments
		Postoperative Care
		Non-small Cell Lung Cancer
			Stage at Presentation
			Histology
			Extent of Resection
		Pulmonary Carcinoid
		Surgical Resection for Pulmonary Metastases
		Treatment Patterns of Elderly Cancer Patients
		Case Reveal
		Conclusion
		References
	37 Benign and Malignant Diseases of the Prostate
		General Anatomical Considerations
		Benign Prostatic Hyperplasia
			Epidemiology
			Pathophysiology
			Diagnosis and Evaluation of Prostate Disease
			Treatment of Benign Prostatic Hyperplasia
				Alpha Blockers
				5-Alpha Reductase Inhibitors (5ARIs)
				Surgical Management of BPH
					Simple Prostatectomy
					Transurethral Incision of the Prostate (TUIP)
					Prostatic Urethral Lift (UroLift)
		Prostate Cancer
			Epidemiology
			Pathophysiology
			Diagnosis and Evaluation
				Prostate MRI
			Active Surveillance
			Treatment of Prostate Cancer
				Radical Prostatectomy
				Radiation Therapy
				Ablative Therapy for the Treatment of Localized Prostate Cancer
					Cryoablation
					High-Intensity Focused Ultrasound (HIFU)
			Prostate Summary
		Kidney Cancer
			Kidney Cancer Epidemiology and Etiology
				Natural History
			Management
			Radiologic Evaluation
			Treatment of Kidney Cancer
				Radical Nephrectomy
				Partial Nephrectomy
				Thermal Ablative Therapies
				Adjuvant Therapies for Localized RCC
				Management of Advanced RCC
		Bladder Cancer
			Diagnosis
			Natural History
				Non-muscle Invasive Bladder Cancer
				Muscle Invasive Bladder Cancer
				Radiologic Evaluation
			Treatment: Non-muscle Invasive Disease
				Intravesical Therapy
			Treatment: Muscle-Invasive Bladder Cancer
				Surgical Therapy
				Multimodality Therapy for Muscle Invasive Bladder Cancer
			Metastatic Bladder Cancer
		Conclusions
		References
	38 Gynecologic Disorders in the Older Woman
		Benign Gynecologic Conditions
			Introduction
			Menopause
			Lower Genital Tract
				Vulva
				Lichen Sclerosus
				Lichen Simplex Chronicus
				Lichen Planus
				Bartholin´s Cysts and Abscesses
				Vulvodynia
				Cervix
				Urogenital Atrophy and Vaginitis
				Genitourinary Syndrome of Menopause (GSM)
			Upper Genital Tract
				Uterus
				Endometrial Atrophy
				Endometrial Polyps
				Leiomyomas (Fibroids)
				Endometrial Hyperplasia and Cancer
				Ovary
		Urogynecologic Conditions
			Introduction
			Urethra
			Urethral Prolapse
			Urethral Caruncles
			Urethral Diverticulum
		Pelvic Floor Disorders
			Introduction
			Pelvic Organ Prolapse and Urinary Incontinence
			Treatment of POP and UI
			Nonsurgical Treatment of POP and UI
			Surgical Treatment of POP
			Surgical Treatment of Urinary Incontinence
			Fecal Incontinence
		Gynecologic Malignancies in the Older Woman
			Introduction
			Uterine Cancer
				Endometrial Adenocarcinomas
				Uterine Sarcomas
			Ovarian, Primary Peritoneal, and Fallopian Tube Cancers
			Cervical Cancer
			Vulvar Cancer
				Other Vulvar Malignancies
			Vaginal Cancer
		Research Involving Older Woman
		Conclusion
		References
	39 Anesthetic Management
		Introduction
		Preoperative Evaluation
			Intraoperative Management
				Anesthetic Goals
			Central Nervous System Management
			Cardiovascular System Management
			Respiratory System Management
			Temperature Management
			Stress Response to Surgery
			Controversies in Geriatric Anesthesia
		Postoperative Care of the Surgical Geriatric Patient
			Anesthesia Considerations for Postoperative Care in the Elderly Patient
			Organ Anatomy and Physiology
			Postoperative Pain Management
			In Patients with Renal Dysfunction
				In Patients with Hepatic Dysfunction
			Postoperative Complications in the Elderly Patient
			Long-Term Outcome in the Elderly Patient
		Putting All Together: The Geriatric Perioperative Surgical Home
		Conclusions
		References
	40 Skin Lesions and Pressure Ulcers
		Common Benign and Malignant Skin Lesions
		Basic Skin Anatomy
			Dermis
			Epidermal Appendages
		Skin Function
			Changes in the Skin Associated with Aging
		Epidermis
		Dermis
		Benign Epidermal Lesions
			Seborrheic Keratoses
		Epidermal Appendages
			Solar Lentigo (Senile Lentigo, Actinic Lentigo)
			Melanocytic Nevi (Moles)
		Benign Dermal Lesions
			Acrochordons (Skin Tags)
			Xanthelasma Palpebrarum (Eyelid Xanthomas)
			Sebaceous Hyperplasia
			Chondrodermatitis Nodularis Helicis
			Cherry Hemangioma (Campbell de Morgan Spots)
			Venous Lakes
		Premalignant Lesions
			Actinic Keratoses (Solar Keratoses)
			Actinic Cheilitis
			Leukoplakia
			Cutaneous Horn
			Bowen´s Disease (Squamous Cell Carcinoma In Situ)
			Lentigo Maligna (Hutchinson´s Freckle)
				Melanoma In Situ
		Malignant Lesions
			Squamous Cell Carcinoma
			Keratoacanthoma
			Basal Cell Carcinoma
			Melanoma
			Atypical Fibroxanthoma
			Merkel Cell Carcinoma
		Conclusions
		Discussion
		Pressure Sores in the Elderly
			Pathophysiology
			Evaluation
			Management
		Reduction of Pressure and Deleterious Extrinsic Factors
		Restoration of Nutrition and Other Wound-Promoting Intrinsic Factors
		Wound Care (Active Debridement and Regular Maintenance)
		Principles of Surgical Treatment
			Sacral Pressure Sores
		Ischial Pressure Sores
		Greater Trochanter Pressure Sores
		Foot Pressure Sores
		Postoperative Care
		Conclusions
		References
	41 Abdominal Wall Hernias in the Elderly
		Case Studies
			Case Study #1
				Background
				Management
			Case Study #2
				Background
				Management
		Introduction
		Special Considerations
		Groin Hernias
			Etiology and Distribution
			Diagnosis
			Emergency Repair
			Watchful Waiting Versus Elective Repair
			Anesthesia
			Surgical Treatment
				Suture Repair
				Synthetic Repair
				Laparoscopic Repair
			Bilateral Hernias
			Recurrence
			Inguinodynia
		Incisional Hernias
		Umbilical Hernias
		Richter´s Hernia
		Obturator Hernias
		Spigelian Hernias
		Conclusion
		References
	42 Benign Esophageal Diseases in the Elderly
		Gastroesophageal Reflux Disease
			Pathophysiology
			Clinical Presentation
			Diagnosis
			Treatment
		Nonsurgical Treatment
		Surgical Treatment
		Endoscopic Treatment
		Paraesophageal Hernia
			Case Study: Part 1
			Pathophysiology
			Clinical Presentation
			Diagnosis
			Treatment
			Case Study: Part 2
		Salient Points
		Esophageal Motility Disorders
		Achalasia
			Pathophysiology
			Clinical Presentation
			Diagnosis
			Treatment
		Nonsurgical Treatment
		Surgical Treatment
		Diffuse Esophageal Spasm
			Diagnosis
			Treatment
		Other Esophageal Motility Disorders
		Benign Tumors of the Esophagus
			Leiomyomas
			Fibrovascular Polyps
		Esophageal (Zenker´s) Diverticula
			Clinical Presentation and Diagnosis
			Treatment of Zenker´s Diverticula
				Surgical Treatment
		Endoscopic Treatment
		References
	43 Elderly Transplant Recipients
		Introduction
			The Elderly: Is It Age or Frailty or Both?
			What Can Be Done to Address Frailty?
				Transplantation in Elderly Patients: Criteria for Selection
			Justification of Transplant in Elderly End-Stage Renal Disease Patients
			Access to Transplantation for Seniors: The UNOS New Allocation Policy
			Selecting the Right Candidate: Evaluation Issues in the Elderly
		Organ Selection for the Elderly Transplant Candidate
			Liver Transplantation
			Kidney Transplantation
		The Older Living Donor: Should There Be an Upper Age Limit?
			Liver Transplantation
			Kidney Transplantation
		Immunosuppressive Strategies in Older Recipients
			Immunosenescence and Immunological Characteristics of the Elderly Recipient
			Risk and Challenges for Immunosuppression Considerations
			General Considerations for an Optimal Immunosuppressive Regimen
				Outcomes
		Conclusion
		References
	44 Benign and Malignant Tumors of the Liver
		Introduction
		Case Study
			Background
			Management
		Epidemiology of Liver Neoplasms
		Liver Surgery in the Elderly
		The Aging Liver
		Pre-op Evaluation and Prehabilitation
		Benign Liver Tumors
		Malignant Liver Tumors
		Hepatocellular Carcinoma
		Intrahepatic Cholangiocarcinoma
		Colorectal Cancer Metastasis
		Neuroendocrine Metastasis
		Conclusion
		References
	45 Benign and Malignant Neoplasms of the Exocrine Pancreas
		Introduction
		Epidemiology
		Risk Factors
			Percent of New Cases by Age Group
		Pathology
			Solid Tumors
			Cystic Tumors
			Precancerous Lesions
		Clinical Presentation
			History and Physical
			Laboratory Studies
		Management of Malignant Neoplasms
			Diagnosis and Staging
			Preparation for Operation
			Resection of Lesions of the Pancreatic Head
			Resection of Lesions of the Body and Tail
			Palliation
			Postop Care and Complications
			Chemotherapy/Radiation Therapy
			Long-Term Outcomes and Quality of Life
			Treatment Disparities in the Elderly
		Management of Benign and Premalignant Neoplasms
			Diagnosis
			Estimating the Malignant Potential
			Indications for Resection
			Resection
			Outcomes
		Conclusions
		References
	46 Colorectal Cancer in Elderly Patients: Considerations in Treatment and Management
		Introduction
		Case Study #1
		Case Study #2
		Epidemiology
			Incidence in Geriatric Patients
			Survival in Geriatric Patients
		Screening in Elderly Patients
		Clinical Presentation and General Treatment Considerations in Elderly Patients
			Emergency Surgery
			Metastatic Colorectal Cancer
		Concerns for Elective Colorectal Cancer Treatment in Geriatric Patients
			Geriatric Surgical Risk Assessment
			Enhanced Recovery Pathways
			Minimally Invasive Surgery
			The Volume-Outcome Relationship
			Sphincter Sparing Surgery for Rectal Cancer
			Colorectal Cancer and Inflammatory Bowel Disease
		Neoadjuvant and Adjuvant Therapy in the Elderly
			Neoadjuvant Chemoradiation Therapy for Rectal Cancer and Geriatric Patients
			Adjuvant Chemotherapy and Geriatric Patients
		Posttreatment Surveillance
		Conclusions
		References
	47 Gastric Cancer in the Elderly
		Introduction
		Epidemiology
		Risk Factors
		Anatomic Classification
		Histologic Classification
		Molecular Classification
		Presentation and Diagnosis
		Workup
		Geriatric Assessment
		Surgery
		Lymphadenectomy
		Minimally Invasive Surgery
		Staging
		Outcomes in the Elderly
		Perioperative Locoregional and Systemic Therapy
		Preoperative Chemoradiation Therapy
		Adjuvant Chemoradiation Therapy
		Perioperative Therapy
		Adjuvant Systemic Therapy
		Clinical Trials in the Elderly
		Advanced Disease
		Targeted Therapies
		Palliative Surgery
		Future Directions
		Conclusion
		Clinical Vignette 1
		Clinical Vignette 2
		References
	48 Esophageal Cancer in the Elderly
		Case Studies
			Patient 1
			Patient 2
		Introduction
		Treatment Options for Esophageal Cancer
		Conclusion
		References
	49 Breast Cancer in Elderly Women
		Introduction
		Epidemiology
		Screening
		Local Therapy of Breast Cancer
		Mastectomy
		Breast-Conserving Surgery in the Elderly
		Sentinel Lymph Node Biopsy
		Primary Endocrine Therapy as an Alternative Local Therapy
		Systemic Therapy
		Breast Cancer Survival and Patterns of Care in the Elderly
		Healthy Versus Frail Elderly Patients
		Conclusion
		Case Study
			Background
			Management
		References
	50 Small Bowel Obstruction in the Elderly
		Case Study 1
			Background
			Management
		Case Study 2
			Background
			Management
		Introduction
		Epidemiology
		Etiology-Specific Considerations in the Elderly
			Adhesions
			Malignancy
			Hernia
		Pathophysiology of SBO and Evaluation
		Clinical Features of SBO in the Elderly
		Diagnostic Considerations for the Elderly
		Initial Treatment
		Surgical Treatment: General Principles
		Laparoscopic Treatment of SBO
		Nonoperative Management
		Outcomes of Treatment of SBO
		Biological Barriers
		Conclusion
		References
	51 Ischemic Disorders of Small and Large Intestine
		Mesenteric Ischemia Vignettes
			Case Study: SMV Thrombosis
				Management
			Case Study: Mesenteric Ischemia
				Management
			Case Study: Mesenteric Ischemia
				Management
		Epidemiology
		Anatomy
		Imaging/Diagnosis
		Arterial Mesenteric Ischemia
			Acute Pathology
			Chronic Pathology
			Ischemic Colitis
			Venous Mesenteric Ischemia
			Nonocclusive Mesenteric Ischemia
		Treatment
			Preoperative Planning
			Open Surgery
			Embolectomy
			Bypass
			Endarterectomy
			Endovascular
		Conclusion
		References
	52 Benign Disease of Stomach and Duodenum
		Case #1
			Background
			Management
		Case #2
			Background
			Management
		Anatomy and Physiology of the Stomach and Duodenum
		Effect of Age on Physiology
		Perioperative Considerations in the Elderly Patient
		Peptic Ulcer Disease
			Epidemiology
			Pathophysiology
			Classification of Gastric Ulcers
			Etiology
				Helicobacter pylori
				Nonsteroidal Anti-inflammatory Drugs
				Zollinger-Ellison Syndrome
				Smoking
			Clinical Manifestations of Uncomplicated Peptic Ulcer Disease
			Medical Treatment for Uncomplicated Peptic Ulcer Disease
			Clinical Manifestations of Complicated Peptic Ulcer Disease
			Perforation
			Primary Closure Reinforced with Omental Patch
			Bleeding
			Surgical Treatment of Bleeding Gastric Ulcers
			Surgical Treatment of Bleeding Duodenal Ulcers
		Gastric Volvulus
		Gastric Outlet Obstruction
		Gastric Polyps
			Hyperplastic Polyps
			Fundic Gland Polyps
			Adenomatous Polyps
		Dieulafoy Lesion/Malformation
		Gastroparesis
			Etiology
			Clinical Manifestation
			Treatment
		Duodenal Diverticula
		Complications After Gastric Surgery
			Dumping Syndrome
			Postvagotomy Diarrhea
			Gastroparesis or Delayed Gastric Emptying
			Afferent Loop Syndrome
			Efferent Syndrome
			Duodenal Stump Leak
			Alkaline Gastritis
		Conclusion
		References
	53 Benign Disease of the Gallbladder and Pancreas in the Elderly
		Introduction
		Gallbladder
			Cholelithiasis
			Choledocholithiasis
			Gallstone Ileus
			Acute Cholecystitis
		Pancreas
			Pancreatitis
				Acute
				Chronic
			Conclusions
		Conclusion
		References
	54 Elderly Donors in Transplantation
		Cases for Contemplation
		Introduction
		Demographics
		Renal Transplantation
			Age-Dependent Changes in Kidney Function
			Deceased Donor
			Living Donor
				Choice of Older Donors for LDKT
				Encouraging Older Patients to Become Donors
			Summary
		Liver Transplantation
			Age-Dependent Changes in Liver Function
			Deceased Donor Liver Transplantation
			Living Donor Liver Transplantation
			Prognostic Scoring of Donor Organs
			Summary
		Improving Utilization of Organs from Older Donors
		Current Organ Allocation Policies
		Conclusion
		References
	55 Malignant Diseases of the Gallbladder and Bile Ducts
		Introduction
			Case Study Gallbladder Adenocarcinoma
				Background
				Management
			Case Study Perihilar Cholangiocarcinoma
				Background
				Management
		Gallbladder Malignancy
			Incidence
			Etiology
			Pathology and Staging
			Presentation and Diagnosis
				Clinical Presentation
				Radiological Evaluation
			Treatment
				Incidental Discovery
				Single Polyp
				Resection of T2 + Disease
			Outcomes
			Adjuvant Therapy
			Palliation
		Cholangiocarcinoma
			Incidence
			Etiology
			Pathology and Staging
				Klatskin and Distal Extrahepatic Cholangiocarcinoma
				Intrahepatic Cholangiocarcinoma
			Presentation and Diagnosis
				Klatskin and Distal Extrahepatic Cholangiocarcinoma
				Intrahepatic Cholangiocarcinoma
			Treatment
				Surgical Resection of Klatskin Tumor
				Surgical Resection of Distal Extrahepatic Cholangiocarcinoma
				Surgical Resection of Intrahepatic Cholangiocarcinoma
				Transplantation
				Chemoradiation Therapy
			Outcomes
			Unresectable Disease/Palliation
		Conclusion
		References
	56 Benign Colorectal Disease in the Elderly
		Case Study
			Background
			Management
		Introduction
		Constipation and Pelvic Floor Dysfunction
		Rectal Prolapse
			Colonic Pseudo-obstruction
		Stercoral Ulceration and Perforation
		Clostridium difficile Infection
		Volvulus
		Fecal Incontinence
		Conclusion
		References
	57 Diverticulitis and Appendicitis in the Elderly
		Introduction
		Diverticular Disease
			Case Study
		Background
			Etiology
			Epidemiology
				Pathogenesis
			Symptoms
			Diagnosis
		Management
			Prevention of Symptoms
			Uncomplicated Diverticulitis
			Surgical Technique for Elective Sigmoid Resection
			Robotic Surgery for Diverticulitis
			Emergent Surgery for Uncomplicated Diverticulitis
			Complicated Diverticular Disease
			Laparoscopic Lavage
			Right-Sided Diverticulitis
		Appendicitis
			Case Study
		Background
			Etiology
			Epidemiology
			Symptoms and Diagnosis
			Management
		Complicated Appendicitis: Differences Between Young and Old Patients
		Conclusion
		References
	58 Lower Gastrointestinal Bleeding in the Elderly
		Introduction
		Causes of Lower Gastrointestinal Bleeding in the Elderly
			Diverticulosis
			Colonic Angioectasias
			Colorectal Malignancy
			Colitis
			Anorectal Disease
		Assessment of Lower Gastrointestinal Bleeding in the Elderly
		Management of Lower Gastrointestinal Bleeding in the Elderly
		Conclusion
		References
	59 Hip Fracture
		Introduction
		Preoperative Care
		Surgical Treatment
		Postoperative Care
		System Improvements
		Clinical Vignettes
			Femoral Neck Fracture
			Intertrochanteric Fracture
			Atypical Hip Fracture
			Failed Screw Fixation
		Conclusion
		References
	60 Total Joint Replacement
		Introduction
		Total Hip Replacement
			History
			Indications
			Surgical Technique
			Implant Design
			Outcomes
			Complications
		Total Knee Replacement
			History
			Indications
			Surgical Technique
			Implant Design
			Outcomes
			Complications
		Minimally Invasive Surgery, Bundled Payments, and Changes in Joint Replacement
		Clinical Vignettes
			Vignette 1: Routine Total Hip Replacement
			Vignette 2: Complex Total Hip Replacement
			Vignette 3: Loose Total Hip Replacement
			Vignette 4: Primary Total Knee Replacement
			Vignette 5: Infected Total Knee Replacement
		Conclusion
		References
	61 Burns in the Older Adult
		Introduction
		Epidemiology
		Prognosis
		Frailty
		Acute Phase Response
			Inflamm-Aging/Immunosenescence
		Infection and Sepsis
			Infections
			Sepsis
		Long-Term Outcomes
		Conclusion
		References
Index