Cardiothoracic Surgery in the Elderly (eBook)

Cardiothoracic Surgeryin the Elderly 5
Foreword 9
Preface 13
Contents 15
Contributors 19
Part I:General Aspects of Care 27
Chapter 1: Invited Commentary 28
References 29
Chapter 2: The Epidemiology and Economics of Cardiothoracic Surgery in the Elderly 30
Introduction 30
Demographics: The Aging Population 30
A Data-Driven Approach 32
Historical Rates of Treatment 32
Forecasting Rates of Treatment 33
Determinants of Rates of Treatment 36
Epidemiologic Trends 37
Trends in Coronary Artery Disease (CAD) 37
Trends in Valvular Heart Disease 38
Trends in Lung Cancer 38
Outcomes of Cardiothoracic Surgery in Elderly Patients 40
Overuse and Underuse 40
Overuse 41
Underuse 41
Cardiologic Evaluation 41
Surgical vs. Nonsurgical Treatment 42
Improving the Appropriateness of Care 43
Payment Systems 43
Medical Technology 45
The Domestic Supply of Cardiothoracic Surgeons 46
Conclusion 47
Appendix 1: Cardiothoracic Surgical Procedures 48
References 48
Chapter 3: Principles of Geriatric Surgery 50
Principle I: Clinical Presentation 51
Principle II: Lack of Reserve 53
Principle III: Preoperative Preparation 54
Principle IV: Emergency Surgery 57
Principle V: Attention to Detail 57
Principle VI: Age Is a Scientific Fact 58
Conclusion 61
References 62
Chapter 4: Geriatric Models of Care 68
Introduction 68
Complications of Older Hospitalized Patients 68
Functional Decline 71
Fall-Related Injury 71
Under/Malnutrition 71
Pressure Ulcers 71
Urinary Tract Infection 71
Delirium 72
Geriatric Care Model Objectives 72
Geriatric Models 74
Transitional Care Models 78
New Specialty Models 78
Conclusion 78
References 79
Chapter 5: Delirium After Cardiac Surgery 82
Defining and Diagnosing Delirium 82
Distinction Between Delirium and Postoperative Cognitive Dysfunction 83
Pathophysiology of Delirium After Cardiac Surgery 83
Anticholinergic Burden 83
Inflammation 84
Large Neutral Amino Acids 84
Atherosclerosis and Blood–Brain Barrier Compromise 84
Preoperative Assessment for Delirium Risk 84
Assessment of Preoperative Cognitive Function 85
Assessment of Depression 85
Albumin 85
Age-Associated Risk Factors Associated with Delirium 85
Precipitating Factors for Delirium 85
Microemboli 86
Intraoperative Medication 86
Postoperative Medication 87
Metabolic Abnormalities 87
Postoperative Environment 87
Iatrogenic Events 87
Prevention of Delirium 87
Treatment of Delirium 88
Cerebral Imaging 88
Remove or Minimize Cognitively Active Medications 88
Pain Control 89
Management of Agitation Associated with Delirium 89
References 89
Chapter 6: Cardiac Rehabilitation in the Elderly 92
Definition of Cardiac Rehabilitation 92
Core Components of CR/Secondary Prevention Programs 93
Patient Assessment 93
Nutritional Counseling 93
Weight Management 94
Blood Pressure Management 94
Management of Diabetes Mellitus (DM) 94
Tobacco Cessation 94
Psychosocial Management 94
Physical Activity Counseling 94
Exercise Training 95
Performance Measures 95
Safety of CR 95
Efficacy of CR 96
Efficacy in Patients with MI, Stable Angina, and After CABG or PCI 96
Efficacy of CR in Heart Failure Patients 97
Efficacy in Patients Undergoing Valve Replacement Procedures 97
Efficacy in Patients Undergoing Cardiac Transplantation 98
Summary and Conclusions Regarding Efficacy 98
CR in the Elderly 98
Outcomes of CR in the Elderly 98
Morbidity and Mortality 98
Physical Fitness 99
Risk Factor Therapies 99
Psychosocial Disorders and QoL 99
Summary and Conclusions 100
References 100
Chapter 7: Legal Aspects of Geriatric Surgery 103
Introduction 103
Medical Malpractice 103
Elements of a Claim 104
Duty/Standard of Care 104
Breach of Duty 105
Damage or Injury 105
Causation 106
Informed Consent 106
Elements 106
Voluntariness 107
Information 107
Decisional Capacity 107
Surrogate Decision Making 108
Guardianship/Conservatorship 108
Durable Power of Attorney 109
Family Authority Statutes 109
Documentation of Patient or Surrogate Consent 109
Emergency Exception 109
Institutional Ethics Committees 110
Conclusion 110
References 110
Chapter 8: Ethical Issues in Cardiothoracic Surgery for the Elderly 112
Introduction 112
Further Considerations of Illness and Death in Old Age 115
Personhood 115
The Technology Pendulum 115
Rationing Health Care for the Elderly 115
Palliative Care 116
Other Palliative Care Options 116
Cardiothoracic Surgery in the Elderly 117
Heart Transplantation in the Elderly 119
Decision Making for the Elderly with Cardiothoracic Disease 120
Advance Directives and Proxy/Surrogate Decision Making 121
The Elderly as Research Subjects 122
The Nuremberg Code 122
The Declaration of Helsinki 123
The Belmont Report 123
The Elderly as Vulnerable Research Subjects 124
A Corollary Principle: Decisional Flexibility 124
References 125
Chapter 9: Acute Pain Control in Geriatric Patients After Cardiac and Thoracic Surgeries 127
Thoracic Pain Pathways 128
Pain Management Techniques for Thoracic Surgeries 130
Regional Analgesia 130
Epidural Analgesia 130
Other Regional Anesthetic Techniques 132
Intercostal Blocks 132
Extrapleural Analgesia 132
Interpleural Analgesia 133
Intravenous Opiates 133
Conversion from Morphine to Transdermal Fentanyl 134
Conversion from IV PCA to Control Release Oxycodone in the Postoperative Period 134
Other Analgesics 134
Analgesic Adjuvants 135
Alpha 2 Agonists 135
Cardiac Surgery 135
Wound Pump 136
Surgical Bra and Vest 137
Use of the Pillow 137
Heating Pad 137
Summary 138
References 138
Chapter 10: Palliative Care in the Elderly 142
Introduction 142
Why Palliative Care? 142
The Palliative Care Team 143
Indications for Palliative Care Referral 143
Clinical Scenarios 143
Case Scenario 1: Unstable Angina/Cardiomyopathy 144
Case Scenario 2: Post-Operative Multiple System Organ Failure 146
Case Scenario 3: Advanced Carcinoma of the Lung 148
Case Scenario 4: Cardiomyopathy and Delirium 151
Conclusion 153
References 153
Chapter 11: Cardiopulmonary Trauma in the Elderly 154
Introduction 154
Background 154
Thoracic Trauma 154
Physiologic Changes 154
Rib Fractures 155
Flail Chest 157
Pain Management 157
Complications 158
Blunt Aortic Injury 158
Sternal Fractures 161
Cardiac Contusion 161
Conclusion 161
References 162
Chapter 12: Imaging Features of the Normal Aging Chest 164
Introduction 164
Lung 164
Morphologic Changes 164
Apical Cap 165
Focal Fibrosis 166
Air Trapping 166
Benign Intrapulmonary Lymph Nodes/Perifissural Lymph Nodes (PFNS) 167
Mediastinum 168
Thymus 168
Mediastinal Lipomatosis 168
Aorta and Great Vessels 168
Diaphragm 172
Musculoskeletal 174
Conclusion 176
References 176
Chapter 13: Cardiac Imaging in the Elderly 178
Introduction 178
Cardiac Imaging Techniques 178
Echocardiography 178
Structural Imaging 178
Spectral Doppler 178
Color Flow Doppler 179
Nuclear Myocardial Perfusion Imaging 179
Technique 179
Safety 179
Indications 179
Cardiac Computed Tomography (CT) 180
Technique 180
Indications 180
Limitations 181
Cardiac Magnetic Resonance Imaging (CMR) 181
Indications 181
Ischemic Heart Disease 182
Ischemic Heart Disease Introduction 182
Echocardiography 183
SPECT Myocardial Perfusion Imaging 185
Multislice Computed Tomography and Magnetic Resonance Imaging 187
Congestive Heart Failure 188
Assessment of LV Systolic Function 189
Etiology of Systolic Heart Failure 189
Nuclear and ECHO for Viability 190
CMR for Viability 191
Diastolic Heart Failure (DHF) or “Heart Failure with Normal Ejection Fraction” (HFNEF) 192
Assessment of LV Filling Pressure 194
Valvular Heart Disease 194
Aortic Stenosis 195
Aortic Regurgitation 196
Mitral Stenosis 197
Mitral Regurgitation 198
Novel Valve Imaging Applications 201
Prosthetic Valves 201
Post Operative Cardiac Imaging 204
Postoperative LV Function 205
Pericardial Effusion and Cardiac Tamponade 205
Pericardial Constriction 206
CT for Assessing Bypass Grafts 209
Preoperative Planning for Redo Surgery 209
References 210
Part II:Physiologic Changes 214
Chapter 14: Invited Commentary 215
Chapter 15: Biology of Aging 216
Introduction 216
Aging-Related Biological Decline 216
Extension of Life Span by Caloric Restriction 216
Oxidative Stress and Macromolecular Damage 217
Posttranslational Protein Modification 218
Cell Proliferation and Telomere Function 218
Insulin-Signaling Pathway and Response to Intake of Nutrients 220
Other Long-Lived Mouse Mutants 220
Cell Death and Turnover 221
What Could All of This Have To Do with Cardiothoracic Surgery in the Elderly Human? 222
Human Relevance 222
Oxidative Stress 222
Cell Replacement 222
Insulin-Signaling 223
Caloric Restriction 223
References 223
Chapter 16: Hematologic Disorders in the Elderly 226
Introduction 226
Anemia in the Elderly 226
Nutritional Deficiencies 227
Vitamin B12 (Cobalamine) Deficiency 228
Folate Deficiency 229
Anemia of Chronic Inflammation 229
Anemia Due to Renal Insufficiency 230
Bone Marrow Dysfunction and Myelodysplasia 230
Thrombocytopenia and Platelet Dysfunction in the Elderly 230
Immune Thrombocytopenic Purpura 231
Coagulation Disorders and Thrombosis 232
Thrombosis in the Elderly 232
Heparin Induced Thrombocytopenia 234
References 235
Chapter 17: Anticoagulation in the Older Surgical Patient 239
Special Considerations for Anticoagulating Older Patients 239
Risk/Benefit Changes 239
Increased Thrombotic Risk in Older Adults 239
Increased Risk of Bleeding in Older Adults 240
Specific Contraindications for Chronic Oral Anticoagulation 240
Pharmacologic Changes 241
Dosing Considerations 241
Strategies to Reduce Bleeding Risk 242
Surgical Site 242
Gastrointestinal Bleeding 242
Intracranial Hemorrhage 243
Fall Risk in Older Adults 243
The Surgical Patient on Chronic Anticoagulation 243
High Thrombotic Risk Patients 243
Low Thrombotic Risk 246
Minor Surgical Procedures 247
Temporary Reversal of Chronic Anticoagulation for Urgent Surgery 247
IVC Filters 247
Specific Surgeries with Recommended Anticoagulation Initiation 248
Prosthetic Valve Implantation 248
Mechanical Valve Implantation 248
Bioprosthetic Valve Implantation 248
Cardiac Surgery 248
Vascular Surgery 249
Surgical Venothromboembolic Prophylaxis 249
General Issues 249
Perioperative Events Requiring Anticoagulation 250
New Onset or Recurrent Atrial Fibrillation 250
Myocardial Infarction 251
Left Ventricular Dysfunction 251
Venothromboembolic Treatment 251
Anticoagulation 251
Inferior Vena Cava Filters 252
Specific Anticoagulant Use in Older Patients 252
Heparins 252
Unfractionated Heparin 254
Low Molecular Weight Heparin 254
Heparin Induced Thrombocytopenia 254
Direct Thrombin Inhibitors 254
Fondaparinux 255
Combining Agents 255
Summary 255
References 256
Chapter 18: Medication Usage in Older Cardiothoracic Surgical Patients1 258
Biology of Aging 258
Drug Absorption 258
Distribution 260
Metabolism 260
First-Pass Metabolism and High Hepatic Extraction Ratio Drugs 260
Pharmacogenomics and the Cytochrome P450 Enzymes 261
Renal Elimination 261
Medication-Related Problems in the Elderly 262
Polypharmacy in Surgical Patients 262
General Principles of Prescribing 263
Specific Prescribing Issues 264
Delirium 264
Antipsychotics 265
Antidepressants 266
Anxiolytics 267
Sedative/Hypnotics 267
Pain Management 267
Antihistamines 268
Antibiotics 268
Summary 271
References 271
Chapter 19: Wound Healing in the Elderly 275
Introduction 275
The Three Stages of Wound Healing 276
Inflammatory Phase 276
Proliferative Phase 276
Remodeling Phase 276
The Aging Skin 277
Wound Healing and Aging 278
Mucosal Tissue and Aging 278
Wound Healing, Menopause and Hormones 280
Scar Formation and Aging 281
Myocardial Tissue Healing 281
Bone Repair and Aging 282
Lung Fibrosis and Aging 282
Angiogenesis and Tissue Oxygenation 283
Clinical Implications 283
References 284
Chapter 20: Pulmonary Changes in the Elderly 287
Structural and Functional Changes of the Respiratory System Associated with Normal Aging 287
Changes in Chest Wall Mechanics and Respiratory Muscle Performance 287
Changes in the Airways and Lung Parenchyma 288
Changes in Gas Exchange and Ventilation 289
Changes in the Pulmonary Vasculature 289
Physiologic Manifestation of Normal Aging in the Lung on Diagnostic Testing 290
Review of Parameters Obtained in Pulmonary Function Testing 290
Changes in Forced Spirometry Associated with Normal Aging 290
Changes in Lung Volumes Associated with Normal Aging 290
Changes in Measurements of Gas Transfer Associated with Normal Aging 291
Alterations in Exercise Capacity Associated with Normal Aging 292
Changes in Lung Host Defense Mechanisms Associated with Normal Aging and Vulnerability to Respiratory Infections 292
References 293
Chapter 21: Cardiac Changes in the Elderly 294
Afterload 294
Preload 296
Contractility 297
Diastolic Function 297
Cardiovascular Response to Exercise 299
Age-Related Changes in Cardiovascular Function 299
Treatment of Congestive Heart Failure 300
Abnormal Left Ventricular Ejection Fraction 300
Normal Left Ventricular Ejection Fraction 301
Cardiovascular Disease 301
Aortic Valve Disease 301
Mitral Valvular Disease 302
Conduction Defects 302
Conclusions 302
References 303
Chapter 22: Renal Changes in the Elderly 308
Introduction 308
Decrease in GFR (Senile Hypofiltration) 308
Clinical Consequences 310
Renal Vascular Changes 310
Clinical Consequences 311
Tubular Dysfunction 311
Sodium 311
Potassium 311
Clinical Consequences 312
Medullary Hypotonicity 312
Clinical Consequences 312
Tubular Frailty 312
Clinical Consequences 313
Obstructive Uropathy 313
Clinical Consequences 313
Conclusions 313
References 313
Chapter 23: Gastrointestinal and Liver Changes in the Elderly1 315
Introduction 315
The Esophagus 315
Anatomy 315
Physiology 316
Age Related Changes in the Phrenoesophageal Swallow Mechanism 316
Age Related Changes in Esophageal Contraction 317
The Stomach 318
Anatomy 318
Physiology 318
Gastric Acid Secretion and the Elderly 318
Aging and Gastric Emptying 319
Aging and Gastric Carcinogenesis 319
The Small Bowel 319
Anatomy 319
Physiology 319
Small Bowel Changes with Aging 319
The Large Intestine 320
Anatomy 320
Physiology 320
Age Related Changes in the Colon 320
The Liver and Hepatobiliary System 322
Liver Anatomy 322
Liver Physiology 322
Age Related Changes in Hepatic Function 323
Biliary Anatomy 324
Biliary Physiology 324
Biliary Function in the Elderly 324
Gallstone Pathogenesis 325
Cholesterol Gallstone Pathogenesis 325
Pigment Gallstone Pathogenesis 326
Lithogenic Factors in the Elderly 326
Pancreas 327
Anatomy 327
Physiology 328
Exocrine Function 328
Endocrine Function 328
Pancreatic Anatomy in the Elderly 329
Aging of the Exocrine Pancreas 330
Insulin Resistance in the Elderly 330
Glucagon 330
References 331
Chapter 24: Neurologic and Cognitive Changes in the Elderly 334
Introduction 334
A Brief History of Dementia 335
The Rediscovery of Alzheimer’s Disease and the Cholinergic Hypothesis 336
Alzheimer’s Disease and Dementia Today 337
The Clinical Evaluation of Cognitive Impairment in Older Adults 339
The History 339
The Examination 341
The Mental Status Exam 342
Level of Consciousness 342
Attention 342
Memory 343
Testing Recent Memory 343
Neocortical Function 344
Bedside Mental Status Examinations 344
The Remainder of the Neurological Examination 345
Cranial Nerves (CN) 345
Visual Fields (VF CN II)345
Visual Acuity (VA CN II)346
Extraocular Movements (EOMs CNs III, IV, VI)346
Facial Symmetry (CN VII) 346
Hearing (CN VIII) 346
Speech (CNs V, VII, IX, X See Also CN XII Below)347
Cervical Rotation (CN XI Sternocleidomastoid Muscles)347
Tongue (CN XII) 347
Motor 347
Strength 347
Proximal Extremity Strength 347
Distal Extremity Strength 347
Bulk 347
Tone 347
Deep Tendon Reflexes (DTRs) 348
Plantar Reflex 348
Sensory 348
Position 348
Light Touch 348
Coordination, Station and Gait 348
Gait 348
Postural Stability 349
Coordination 349
Involuntary, Uncontrolled, or Diminished Movements 349
Summary and Conclusions 350
References 350
Chapter 25: Hormonal Changes During and After Cardiac Surgery 352
Endocrine Changes During Aging 352
Changes in Pituitary-Gonadal Function During Aging in Men and Women 352
Changes in GH-IGF-1 Axis During Aging 353
Changes and Consequences of Altered Hypothalamus Pituitary Adrenal Axis During Aging 353
Changes and Consequences of Altered Hypothalamic-Pituitary-Thyroid Axis During Aging 353
Acute Hormonal Changes After Cardiac Surgery 354
Cardiac Surgery as a Model of Nonsurgical Critical Illness 354
Potential Mechanisms Underlying the Hormonal Response to Coronary Artery Bypass Grafting: The Role of Oxidative Stress and Inflammation 354
Changes in Thyroid Hormones After CABG 355
Observational Studies 355
Intervention Studies Using T3 in CABG 356
Adrenal Hormones and CABG 356
Changes in Cortisol and ACTH Levels After Cardiac Surgery 356
Changes in DHEA, DHEAS Levels After Cardiac Surgery 358
Changes in Sex Hormone Levels After Cardiovascular Surgery 358
Changes in GH-IGF-1 Levels After Cardiac Surgery 360
The Significance of Hormonal Changes in Young vs. Older Population 361
Duration of Hormonal Changes and Recovery to Baseline 362
Thyroid Hormones 362
Adrenal Hormones 362
Sex Hormones 362
GH-IGF-1 Axis 362
Possible Clinical Implications of Postsurgical Endocrine Changes: Adaptive Phenomenon or Therapeutic Targets? 363
References 363
Part III:Cardiac Surgery 369
Chapter 26: Invited Commentary 370
Chapter 27: Preoperative Evaluation and Preparation in the Elderly Cardiac Surgery Patient 372
Introduction 372
Nutritional Evaluation 372
Assessment of Risk for Delirium 373
Assessment of Disability 375
Advance Directives/Medical Proxy 375
Conclusion 376
References 376
Chapter 28: Cardiac Anesthesia in the Elderly 377
Preoperative Considerations 377
Neurological 377
Cardiovascular 377
Pulmonary 378
Renal 379
Endocrine 379
Fluid Balance 379
Induction of Anesthesia 379
Monitors 379
Drugs 381
Sedative Hypnotics 381
Opiates 382
Muscle Relaxants 382
Volatile Anesthetics 383
Maintenance of Anesthesia 383
Prebypass 383
Bypass 384
Separation from Bypass 384
Post Bypass 384
Postoperative Period 384
References 385
Chapter 29: Postoperative and Critical Care in the Elderly Cardiac Surgery Patient 387
Introduction 387
Operation-Specific Risk Factors 388
Renal Insufficiency 389
Gastrointestinal Complications 390
Neurologic Impairment 391
Pulmonary Care 392
Cardiovascular Management 394
Wound Complications 394
Cardiac Rehabilitation 395
References 397
Chapter 30: Surgery for Ischemic Coronary Disease in the Elderly1 399
Characteristics of the Elderly Cardiac Surgery Population 399
Predictors of Perioperative Morbidity and Mortality 401
Quality of Life 403
Possible Strategies to Decrease Operative Risk 404
Nonsurgical Alternatives 405
The New Era of Mechanical Circulatory Assist 406
Guidelines for Therapy in the Elderly Cardiac Surgery Patient 407
Conclusions 407
References 408
Chapter 31: Surgical Treatment of Aortic Valve Disease in the Elderly 410
Introduction 410
Nonsurgical Management 411
Surgical Technique of Conventional AVR 411
Preoperative Assessment 411
Intraoperative Technique 412
Postoperative Care 412
Predictive Models 414
Outcomes 414
In-Hospital Mortality 414
Mid- and Long-Term Survival 415
Quality of Life and Cost 416
Alternative to Sternotomy AVR 416
Left Ventricular Apex to Descending Aortic Conduits 416
Surgical Technique 416
Outcomes 417
Transcatheter Aortic Valve Implantation 418
Conclusions 420
References 420
Chapter 32: Surgical Treatment of Mitral Valve Disease in the Elderly 423
Introduction 423
Pathophysiology 424
Natural History 425
Assessment 425
Management 426
Medical Therapy 426
Surgical Treatment 426
Surgical Techniques 426
Mitral Valve Replacement 426
Mitral Valve Repair 427
Results of Surgery 430
Mitral Repair vs. Replacement in Elderly 430
Improved Outcomes 430
Survival 431
Others 431
Conclusion 431
References 432
Chapter 33: Surgical Treatment of Thoracic Aortic Disease in the Elderly 435
Cardiovascular Surgery in the Aging Population 435
Aneurysmal Disease of the Thoracic Aorta 435
Surgery of the Ascending Aorta and Aortic Arch 436
Surgery of the Descending and Thoracoabdominal Aorta 437
Penetrating Atherosclerotic Ulcers 438
Aortic Dissection Syndromes 438
Acute Type A Aortic Dissection 439
Acute Type B Aortic Dissection 440
Intramural Hematoma of the Thoracic Aorta 441
Endovascular Treatment of Thoracic Aneurysmal Disease 441
Palliative Care in Elderly Patients with Terminal Thoracic Aortic Condition 442
Conclusion 442
References 443
Chapter 34: Surgical Treatment of Pericardial Disease in the Elderly 445
Anatomy 445
Physiology 445
Pericardial Diseases 446
Acute Pericarditis 446
Constrictive Pericarditis 446
Pericardial Effusion and Acute Cardiac Tamponade 448
Pericardial Neoplasms 449
Postcardiac Surgery Injury Syndromes 449
References 449
Chapter 35: Pacemakers and Implantable Cardioverter Defibrillators in the Elderly 451
Introduction 451
Epidemiology of Pacemaker and Implantable Cardioverter Defibrillator Use 451
The Conventional Role of Pacemakers in the Elderly 452
Pacing for Non-Accidental Falls and Carotid Sinus Hypersensitivity 452
Technical Issues for Cardiac Rhythm Device Implantation in the Elderly, Including Risk of Device-Related Complications 453
Implantable Cardioverter Defibrillators in Elderly Patients 456
Appropriate Programming of Pacemakers and Defibrillators in Elderly Patients 458
Conclusions 458
References 458
Chapter 36: Heart Transplantation and Mechanical Assistance in the Elderly 461
Introduction 461
Heart Transplantation 462
Destination Therapy 465
Rematch 465
Heartmate II Destination Trial 466
Patient Selection for Destination Therapy 466
Certification 467
Conclusion 467
References 467
Part IV:Thoracic Surgery 469
Chapter 37: Invited Commentary 470
Chapter 38: Preoperative Evaluation and Preparation in the Elderly Thoracic Surgery Patient 471
Introduction 471
Indications for Surgery in the Older Patient 471
Traditional Preoperative Assessment Prior to Cardiothoracic Surgery 473
Pulmonary Risk and Evaluation 473
Cardiac Risk and Evaluation 474
Informed Consent and Capacity to Consent 475
Geriatric Assessment 475
Evaluation of Geriatric Assessment Prior to Cardiothoracic Surgery 475
Conclusion 477
References 477
Chapter 39: Thoracic Anesthesia in the Elderly 480
Introduction 480
Physiology and Risk Factors 481
Cardiovascular 481
Pulmonary 481
Hepatic 481
Renal 482
Nervous System 482
Temperature Regulation 482
Anesthesia 482
Inhaled Anesthetics 482
Hypnotics 483
Muscle Relaxants 483
Narcotics 483
Positioning 483
Comorbidity 483
Surgical Population 484
Anesthetic Management 485
Pain Control and Delirium 485
Summary 485
References 486
Chapter 40: Postoperative and Critical Care in the Elderly Thoracic Surgery Patient 488
Introduction 488
Cardiovascular Physiology 489
Pulmonary Physiology 489
Renal Physiology 490
Preoperative Assessment 491
Cardiac Evaluation 491
Pulmonary Evaluation 492
Intraoperative Approaches to Minimize Morbidity 493
Anesthesia 493
Minimally Invasive Operation 493
Outcomes 493
Pain Management 495
Neurocognitive Dysfunction 496
End-of-Life Issues 497
References 497
Chapter 41: Adjuvant Therapy for Lung Cancer in the Elderly 502
Introduction 502
Elderly-Specific Data 503
Neoadjuvant Therapy 505
Choice of Chemotherapy Regimen in the Elderly 505
Conclusions 506
References 507
Chapter 42: Pulmonary Surgery for Malignant Disease in the Elderly 509
Introduction 509
Lung Cancer Treatment in the Elderly 510
Case Study 510
Preoperative Evaluation 510
Functional and Performance Status 511
Cardiac Assessment and Perioperative Cardiac Management 511
Pulmonary Assessment 512
Nonsmall Cell Lung Cancer in the Elderly 512
Histology 512
Stage at Presentation 513
Surgical Planning 513
Surgical Approach 513
Extent of Resection 513
Advances in Technology and the Elderly 514
Recommended Treatment Algorithm 515
Pulmonary Carcinoid 516
Surgical Resection of Pulmonary Metastases 516
Postoperative Care 516
Conclusion 517
References 517
Chapter 43: Benign Thoracic Disease in the Elderly1 520
Introduction 520
Disease of the Chest Wall and Pleura 520
Mondor’s Disease 520
Lung Herniation 521
Pneumomediastinum 521
Kyphosis 521
Neoplastic Disease 522
Benign Lung Tumors 522
Epithelial Tumors 522
Papillomas 522
Sclerosing Hemangioma (Pneumocytoma) 522
Alveolar Adenoma 522
Type II Pneumocyte Papilloma 523
Mucous Gland Adenomas 523
Mucinous Cystadenoma 523
Mesenchymal Tumors 523
Hamartoma 523
Solitary Fibrous Tumor of the Lung 523
Clear Cell (Sugar Tumor) 523
Other Mesenchymal Tumors 523
Infectious and Rheumatologic Disease 524
Pneumonia 524
Empyema 524
Rheumatoid Pleural Effusions 525
Chronic Obstructive Pulmonary Disease in the Elderly 526
Summary 527
References 528
Chapter 44: Lung Transplantation in the Elderly 530
Introduction 530
Elderly Lung Transplant Recipients 530
Selection of Elderly Candidates for Lung Transplantation 532
Technical Considerations for Elderly Lung Transplant Recipients 534
Elderly Lung Transplant Donors 534
Considerations in the Allocation of Donor Lungs 535
Summary 535
References 536
Chapter 45: Esophageal Surgery for Malignant Disease in the Elderly 537
Histologic Classification, Location, and Incidence 538
Pathogenesis 539
Diagnosis 541
Staging 543
Analysis of Comorbidities and Medical Clearance 544
Therapy for Premalignant Disease 544
Therapy for Invasive Carcinoma 544
Surgery 544
Esophagectomy in the Elderly 547
Neoadjuvant Therapy 548
Surgery vs. Chemoradiation in the Elderly 549
Palliation 549
Radiation 549
Chemotherapy 550
Endoscopic Palliation 550
Stenting 550
Neodymium: Yttrium-Aluminum-Garnet Laser Fulguration 551
Photodynamic Therapy 551
References 551
Chapter 46: Esophageal Surgery for Benign Disease in the Elderly 554
Introduction 554
Pathophysiology of the Aging Esophagus 554
Dysphagia in the Elderly 555
Esophageal Motility in the Elderly Patient 555
Upper Esophageal Sphincter (UES) 555
Body of the Esophagus 556
Lower Esophageal Sphincter (LES) 556
Manometry in the Elderly Patient 556
Esophageal Surgery for Benign Esophageal Disorders 557
Paraesophageal Hernia/Hiatal Hernia 557
Gastroesophageal Reflux Disease (GERD) 559
Peptic Stricture 561
Barrett’s Esophagus 561
Achalasia 561
Diffuse Esophageal Spasm and Hypercontracting “Nutcracker” Esophagus 563
Esophageal Diverticula 564
Zenker’s Diverticulum 565
Epiphrenic Diverticulum 566
Summary 566
References 567
Chapter 47: Surgery for Mediastinal Disease in the Elderly 569
Thymoma and Thymic Carcinoma 569
Diagnosis 570
Pathology 571
Staging 572
Early Stage Thymoma 572
Operable or Potentially Operable Locally Advanced Thymoma 573
Post Induction Surgery 573
Prognosis 574
Substernal and Intrathoracic Goiters 574
Mediastinal Lymphoma 576
Posterior Mediastinal Neurogenic Tumors 577
References 577
Chapter 48: Surgery for Pleural Disease in the Elderly 580
Introduction 580
Air: Pneumothorax 580
Fluid: Pleural Effusions 581
Pleural Space Infections 582
Malignant Pleural Effusions 582
Methods of Pleurodesis 583
Chronic Drainage with Indwelling Catheters 584
Tumors of the Pleura 584
References 585
Chapter 49: Surgery for Chest Wall Disease in the Elderly 587
Indications 587
Preoperative Evaluation 587
Principles of Reconstruction 588
Management of Pleural Cavity 589
Management of Skeleton 589
Management of Soft Tissue 592
Muscle Transposition 592
Omental Transposition 593
Clinical Experience 594
Conclusion 595
References 595
Chapter 50: Surgery of the Trachea and Bronchi in the Elderly 597
Introduction 597
Anatomy of the Trachea 597
Airway Pathology 597
Tracheal and Bronchial Neoplasms 598
Airway Stenosis 600
Acquired Airway Esophageal Fistulae 600
Tracheobronchial Malacia and Saber-Sheath Trachea 601
Extrinsic Airway Compression 601
Preoperative Diagnostic Procedures 601
Anesthesia 602
Tracheostomy in the Elderly 602
Tracheal T-Tubes and Airway Stents 603
Laryngotracheal and Tracheal Resection for Airway Stenosis and Tumors 603
Resection and Reconstruction for Airway Esophageal Fistula 605
Carinal Reconstruction 606
Main and Lobar Bronchoplasty 608
Conclusion 608
References 609
Appendix A: Indices 610
Appendix B: Function 611
Appendix C: Physiologic 616
Appendix D: References 620
Index 621