Mark R. Katlic

Postoperative Delirium in Older Adults: Best Practice Statement from the American Geriatrics Society

Disclosure Information: Disclosures for the members of t Geriatrics Society Postoperative Delirium Panel are listed in Support: Supported by a grant from the John A Hartford Fou to the Geriatrics-for-Specialists Initiative of the American Geri (grant 2009-0079). This article is a supplement to the American Geriatrics Soci Practice Guidelines for Postoperative Delirium in Older Adu at the American College of Surgeons 100 Annual Clinic San Francisco, CA, October 2014.

American Geriatrics Society abstracted clinical practice guideline for postoperative delirium in older adults

The abstracted set of recommendations presented here provides essential guidance both on the prevention of postoperative delirium in older patients at risk of delirium and on the treatment of older surgical patients with delirium, and is based on the 2014 American Geriatrics Society (AGS) Guideline. The full version of the guideline, American Geriatrics Society Clinical Practice Guideline for Postoperative Delirium in Older Adults is available at the website of the AGS. The overall aims of the study were twofold: first, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the prevention of postoperative delirium in older adults; and second, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the treatment of postoperative delirium in older adults. Prevention recommendations focused on primary prevention (i.e., preventing delirium before it occurs) in patients who are at risk for postoperative delirium (e.g., those identified as moderate‐to‐high risk based on previous risk stratification models such as the National Institute for Health and Care Excellence (NICE) guidelines, Delirium: Diagnosis, Prevention and Management. Clinical Guideline 103; London (UK): 2010 July 29). For management of delirium, the goals of this guideline are to decrease delirium severity and duration, ensure patient safety and improve outcomes.

Clostridium septicum infection and malignancy.

Evidence mounts favoring the relationship, albeit unexplained, between Clostridium septicum infection and malignancy, particularly hematologic or intestinal malignancy. Seven patients with C. septicum gangrene or sepsis have been treated at the Massachusetts General Hospital in the years 1977–79. All of these patients have had associated malignant disease: four patients had colon adenocarcinomas, two patients had acute myeloblastic leukemias, and one patient had breast carcinoma. In six of the seven patients, the malignancy was in an advanced state; the breast carcinoma showed no evidence of recurrence after mastectomy, 17 years earlier. A bowel portal of entry is postulated in five patients. Despite prompt use of appropriate antibiotics, the only survivors were two of the four patients, who underwent early extensive debridement. These results suggest that, in the patient with C. septicum infection, malignancy should be sought; that, in the septic patient with known malignancy, C. septicum should be considered; and that, in the absence of external source in the patient with clostridial myonecrosis or sepsis, the cecum or distal ileum should be considered a likely site of infection. Increased awareness of this association between C. septicum and malignancy, and aggressive surgical treatment, may result in improvement in the present 50–70% mortality rate.

Principles and practice of geriatric surgery

PART I- GENERAL PRINCIPLES.- Section 1- Physiology of Aging.- Invited Commentary.- Cellular and Molecular Aging.- Cancer, Carcinogenesis and Aging.- Effects of Aging on Immune Function.- Hematological Changes, Anemia and Bleeding.- Invited Commentary.- Nutrition and Metabolism.- Wound Healing and Aging.- Frailty and Surgery in the Elderly.- Section 2 - Social/Societal Issues.- Invited Commentary.- Demography of Aging and Disability.- Economics of Providing Surgical Care to an Aging Population: Implications for the Surgical Workforce.- Defining Quality of Care in Geriatric Surgery.- Ethics in Clinical Practice.- Teaching Geriatrics to Surgeons.- Palliative Care and Decision Making at the End of Life.- Surgery in Centenarians.- The Effects of Advanced Age on Physician Performance.- Section 3- Perioperative Issues.- Invited Commentary.- Principles of Geriatric Surgery.- Geriatric Models of Care.- Preoperative Evaluation of the Older Surgical Patient.- Invited Commentary.- Physiologic Response to Anesthesia in the Elderly.- Choosing the Best Anesthetic Regimen.- Acute Perioperative Pain Management in Elderly Patients.- Drug Usage in Surgical Patients: Preventing Medication-Related Problems.- Invited Commentary.- Common Perioperative Complications in Older Patients.- Management and Outcomes of Intensive Care in the Geriatric Surgical Patient.- Care of the Injured Elderly.- Maximizing Postoperative Functional Recovery.- PART II SPECIFIC ISSUES.- Section 1- Endocrine System/Breast.- Invited Commentary.- Surgcial Disorders of the Thyroid in the Elderly.- Parathyroid Disorders in the Elderly.- Adrenal Tumors in Older Persons.- Benign Breast Disease in Elderly Women and Men.- Breast Cancer in Elderly Women.- Diabetes in the Elderly.- Section 2- Oral Cavity, Eyes, Ears, Nose and Throat.- Invited Commentary.- Changes in the Oral Cavity with Age.- Geriatric Ophthalmology.- Anatomic and Physiologic Changes of the Ears, Nose, and Throat.- Geriatric Dysphagia.- Head and Neck Cancer in the Elderly.- Section 3 - Respiratory System.- Invited Commentary.- Physiologic Changes in Respiratory Function.- Pulmonary Surgery for Malignant Disease in the Elderly.- Section 4 - Cardiovascular System.- Invited Commentaries.- Physiologic Changes in Cardiac Function with Age.- Risk Factor for Atherosclerotic Disease in the Elderly.- Cardiac Surgery.- Surgical Treatment of Vascular Occlusive Disease.- Natural History and Treatment of Extracranial Cerebrovascular Disease.- Natural History and Treatment of Aneurysms .- Section 5 - Gastrointestinal System.- Invited Commentary.- Physiologic Changes of the Gastrointestinal Track.- Benign Esophageal Disease.- Esophageal Cancer in the Elderly.- Benign Diseases of the Stomach and Duodenum.- Gastric Cancer in the Elderly.- Small Bowel Obstruction in Geriatric Patients.- Lower Gastrointestinal Bleeding in the Elderly.- Ishcemic Disorders of the Large and Small Bowel.- Inflammatory Bowel Disease.- Diverticulitis and Appendicitis in the Elderly.- Benign Colorectal Disease.- Neoplastic Diseases of the Colon and Rectum.- Abdominal Wall Hernia in the Elderly.- Section 6 - Hepatobiliary System.- Invited Commentary.- Hepatobiliary and Pancreatic Function: Physiologic Changes.- Benign Disease of the Gallbladder and Pancreas.- Malignant Diseases of the Gallbladder and Bile Ducts.- Benign and Malignant Neoplasms of the Exocrine Pancreas.- Benign and Malignant Tumors of the Liver.- Section 7- Urogenital System.- Invited Commentaries.- Change in Renal Function, Fluids and Electrolytes.- Urinary Incontinence.- Neoplasms of the Kidney, Ureters and Bladder.- Benign and Malignant Diseases of the Prostate.- Benign Gynecological Disorders in Older Women.- Gynecological Malignancies in the Elderly.- Section 8 - Nervous System.- Invited Commentary.- Effects of Aging on the Nervous System.- Geriatric Neurosurgical Emergencies.- Benign and Malignant Tumors of the Brain.- Spinal Disorders and Nerve Compression Syndromes.- Section 9- Musculoskeletal System and Soft Tissue.- Invited Commentary.- Physiologic Changes of the Bones and Soft Tissue with Age.- Benign and Malignant Lesions of the Skin in Old Age.- Surgical Management of Soft Tissue Sarcoma in the Geriatric Population.- Pressure Sores in the Elderly.- Orthopedic Trauma in the Elderly.- Treatment of Degenerative Joint Diseases.- Section 10- Transplantation.- Invited Commentary.- Elderly Donors in Transplantation.- Elderly Transplant Recipients

Video-Assisted Thoracic Surgery Utilizing Local Anesthesia and Sedation: 384 Consecutive Cases

BACKGROUND Video-assisted thoracic surgery (VATS) is usually performed with general anesthesia and endotracheal intubation. There are risks to such anesthesia and some operations may not require general anesthesia or intubation. We elected to study the safety and efficacy of VATS utilizing local anesthesia, sedation, and spontaneous ventilation. METHODS The medical records of all patients undergoing VATS utilizing local anesthesia and sedation at our systems three hospitals between June 1, 2002 and June 1, 2009 were retrospectively reviewed. The authors or residents under supervision performed all procedures. Unsuccessful attempts at this technique were eligible for inclusion but there were none. No patient was excluded based on age or comorbidity. All procedures were performed in the operating room with patients in full lateral position; no patient had endotracheal intubation or epidural or nerve block analgesia. RESULTS Three hundred fifty-three patients ranging in age from 21 to 100 years (mean 67 years) underwent 384 VATS operations: pleural biopsy-drainage with or without talc, 244; drainage of empyema, 74; lung biopsy, 40; evacuate hemothorax, 13; pericardial window, 7; drain lung abscess, 2; treat chylothorax, 2; treat pneumothorax, 1; and biopsy mediastinal mass, 1. No patient required intubation or conversion to thoracotomy. No patient required a subsequent biopsy for diagnosis; two patients required a subsequent procedure for empyema. There were 10 complications: cerebrovascular accident, 2; atrial fibrillation, 2; persistent air leak, 2; empyema, transient renal failure, transient respiratory failure, and urinary tract infection, 1 each. There were no deaths due to operation; within 30 days 9 patients died from underlying disease and 1 from overanticoagulation. CONCLUSIONS Video-assisted thoracic surgery utilizing local anesthesia-sedation is well tolerated, safe, and valuable for an increasing number of indications.

The surgical management of goiter: Part II. Surgical treatment and results†‡

Surgery for goiter embodies a unique challenge. Our objective is to provide a comprehensive analysis of cervical and substernal goiter data in two paired articles. This second article focuses on surgical management. The following null hypotheses regarding goiter excision have been tested: 1) there are no goiter‐associated risk factors for difficult intubation; 2) there are no predictive risk factors for recurrent laryngeal nerve injury (RLN) or postoperative hypocalcemia; 3) there is no difference in RLN injury with neural monitoring versus without.

ProvenCare lung cancer: A multi-institutional improvement collaborative

Geisingers ProvenCareTM Program (for elective coronary artery bypass surgery, total hip replacement, and others) has shown that the principles of reliability science, facilitated by a robust electronic health record and institutional commitment, allow the re‐engineering of complicated clinical processes. This eliminates unwarranted variation and promotes the completion of evidence‐based elements of care. It has not been established that ProvenCare can be generalized to other institutions. Now, under the auspices of the American College of Surgeons Commission on Cancer, ProvenCare has been adapted to a multi‐institutional collaborative for the care of the patient with resectable lung cancer. CA Cancer J Clin 2011.

Operative correction of pectus excavatum: an evolving perspective.

From 1949 to 1975, 220 children have undergone surgical reconstruction of pectus excavatum using a variety of operations on our Pediatric Surgical Service. The first 183 were previously reported and have had subsequent, careful followup evaluation. From 1970 to 1975, an identifiable group of 45 children had a standard operation, a modified Ravitch repair, with the addition of a three-point or tripod internal fixation technique for support of the sternum. These children have all obtained satisfactory reconstruction without prosthetic support of any kind. We have thus avoided the possible danger of foreign material within the chest and have obviated the need for another procedure to remove a supporting stent. The two groups have been analyzed and compared with respect to age distribution, postoperative complications and end results to see if we could detect any trends in the evolving management of children with this condition. The main indications for surgical correction remain cosmetic and postural. Specific trends which have emerged from our experience include an increased percentage of patients between 3 and 8 years of age (average 5.8 years); a decreased need for blood transfusion (10%); a near resolution of postoperative seromas with the use of substernal and subcutaneous suction drains; and in the last 45 children, a 100% excellent or acceptable result to date. We feel that age selection is an important factor in the improved operative result and in the emotional impact on these young patients. Eighty per cent of the children in the recent series were between 3 and 8 years of age at the time of repair. On the basis of this experience, we now feel confident in recommending our standardized operation for pectus excavatum at an elective age of 4 to 6 years.

The Surgical Management of Goiter: Part I. Preoperative Evaluation

Our overarching objective is to provide a comprehensive analysis of goiter data in two paired articles. This first article focuses on the preoperative evaluation. The following null hypotheses have been tested: 1) there is no correlation between goiter size and preoperative symptoms, 2) there is no correlation between preoperative neck imaging abnormalities and preoperative symptoms, and 3) there are no predictors for goiter recurrence.

Principles of Geriatric Surgery

The world population is aging and the conditions that require cardiothoracic surgery – atherosclerosis, lung and esophageal cancer, degenerative valve disease, dysrhythmia, and others – increase in incidence with increasing age. What do we know about surgery in the elderly that will help us improve our care of these conditions? Six general principles are useful for teaching purposes. These include the fact that the clinical presentation of surgical problems may be subtle or different from that of the general population; the elderly handle stress well but not severe stress due to lack of reserve; preoperative preparation and attention to detail are crucial; when these are lacking, as in emergency surgery, risk dramatically increases; and the results of elective surgery in the elderly are good and do not support prejudice against advanced age. Cardiothoracic surgeons must become students of the physiologic changes that occur with aging and, guided by these few principles, apply this knowledge to daily clinical care. We owe it to our elders to become good geriatric surgeons and in so doing we will become better surgeons to patients of all ages.