Michael E. Zenilman

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

Groin lymphorrhea complicating revascularization involving the femoral vessels

Seven (4%) of 193 patients developed lymphoceles in 8 (2%) of 316 groin wounds after 211 arterial reconstructive procedures. Included were 91 aortic, 15 extra-anatomic, and 105 infrainguinal revascularizations. Lymphoceles developed in otherwise uncomplicated wounds in 6 (8%) of 73 patients with oblique incisions and bilaterally in 1 (1%) of 120 patients with vertical incisions (p = 0.01). This difference may be related to the surgical technique, with increased lymphatic damage and inadequate wound closure in the oblique approach. No increased incidence of lymphorrhea was noted in those patients undergoing aortic reconstruction regardless of the type of incision used (p = 0.15), or when compared with patients who had undergone extra-anatomic or infrainguinal bypass (p = 0.14). Each lymphocele was persistent, and external fistulas spontaneously occurred in three. Diagnosis was based upon clinical awareness and the appearance of the groin mass. Conservative management was uniformly unsuccessful, and operative ablation of the lymph fistula and lymphocele proved to be definitive therapy.

Clinical Communities at Johns Hopkins Medicine: An Emerging Approach to Quality Improvement

BACKGROUND Clinical communities are an emerging approach to quality improvement (QI) to which several large-scale projects have attributed some success. In 2011 the Armstrong Institute for Patient Safety and Quality established clinical communities as a core strategy to connect frontline providers from six different hospitals to improve quality of care, patient safety, and value across the health system. CLINICAL COMMUNITIES: Fourteen clinical communities that presented great opportunity for improvement were established. A community could focus on a clinical area, a patient population, a group, a process, a safety-related issue, or nearly any health care issue. The collaborative spirit of the communities embraced interdisciplinary membership and representation from each hospital in each community. Communities engaged in team-building activities and facilitated discussions, met monthly, and were encouraged to meet in person to develop relationships and build trust. After a community was established, patients and families were invited to join and share their perspectives and experiences. ENABLING STRUCTURES: The clinical community structure provided clinicians access to resources, such as technical experts and safety and QI researchers, that were not easily otherwise accessible or available. Communities convened clinicians from each hospital to consider safety problems and their resolution and share learning with workplace peers and local unit safety teams. CONCLUSION The clinical communities engaged 195 clinicians from across the health system in QI projects and peer learning. Challenges included limited financial support and time for clinicians, timely access to data, limited resources from the health system, and not enough time with improvement experts.

Origin and control of gastrointestinal motility.

As a result of improved understanding of the origin and control of motility at both the whole organ and the cellular level, a scientific approach to the diagnosis and treatment (both medical and surgical) of motility disorders has evolved. Examples are present for all levels of the gastrointestinal tract. Manometric, myoelectric, and pharmacologic studies have elucidated the role of the lower esophageal sphincter and stomach in the pathogenesis of gastroesophageal reflux and determined the mechanism of successful medical and surgical treatment. Better evaluation of colorectal motility using colonic transit studies, pelvic floor radiography, and rectoanal manometrics has led to a better identification of both the etiology of severe constipation and patients who will have a successful surgical outcome. Studies of normal and abnormal gallbladder motility and responsiveness to hormonal stimulation have shed light on the cellular abnormalities in gallbladder myocytes that predispose to gallstone formation. Finally, since we have learned that certain surgical procedures affect motility in an adverse manner, a better basic understanding of gastrointestinal physiology has led to a better clinical understanding of the mechanism by which the changes occur and to the development of more directed physiologic operations. The classic example is seen in ulcer surgery, where the introduction of highly selective vagotomy instead of truncal vagotomy preserved antral innervation and decreased the incidence of postvagotomy complications. All these concepts and more are addressed in more detail in subsequent articles in this issue.

Geriatric surgery--evolution of a clinical community.

BACKGROUND We reviewed the current scientific data and opinions from thought leaders in the field of surgery in the elderly population and queried whether a new society should be formed. METHODS The science of geriatric surgery (GS) was reviewed, including topics scientific sessions focused on GS. A town hall meeting was held, which included geriatric surgical scholars. A survey was created to define the interest in GS as a specialty society was sent to surgical scholars. RESULTS As the volume of GS scholarly work has increased, the focus of geriatric science has migrated toward clinical studies on frailty and geriatric syndromes. Our town hall meeting outlined the need for a multidisciplinary GS team. Our survey documented more interest in multidisciplinary sessions at national meetings rather than a new, unique society. CONCLUSIONS GS as a discipline is a multidisciplinary practice. Our data suggest that this unique characteristic speaks to the development of a clinical community rather than an independent society.

Acute pancreatitis in aging animals: Loss of pancreatitis-associated protein protection?

AIM To investigate the effect of age on severity of acute pancreatitis (AP) using biochemical markers, histology and expression of the protective pancreatitis-associated proteins (PAPs). METHODS AP was induced via intraductal injection of 4% sodium taurocholate in young and old rats. Sera and pancreata were assayed at 24 h for the parameters listed above; we also employed a novel molecular technique to assess bacterial infiltration using polymerase chain reaction to measure bacterial genomic ribosomal RNA. RESULTS At 24 h after induction of AP, the pancreata of older animals had less edema (mean ± SE histologic score of young vs old: 3.11 ± 0.16 vs 2.50 ± -0.11, P < 0.05), decreased local inflammatory response (histologic score of stromal infiltrate: 3.11 ± 0.27 vs 2.00 ± 0.17, P < 0.05) and increased bacterial infiltration (174% ± 52% increase from sham vs 377% ± 4%, P < 0.05). A decreased expression of PAP1 and PAP2 was demonstrated by Western blotting analysis and immunohistochemical staining. There were no differences in serum amylase and lipase activity, or tissue myeloperoxidase or monocyte chemotactic protein-1 levels. However, in the most-aged group, serum C-reactive protein levels were higher (young vs old: 0.249 ± 0.04 mg/dL vs 2.45 ± 0.68 mg/dL, P < 0.05). CONCLUSION In older animals, there is depressed PAP expression related to a blunted inflammatory response in AP which is associated with worsened bacterial infiltration and higher C-reactive protein level; this may explain the more aggressive clinical course.

Closed claim review from a single carrier in New York: the real costs of malpractice in surgery and factors that determine outcomes

INTRODUCTION We postulated that a closed claim review of surgical cases would identify not only the quality of care elements but also factors that will predict successful legal outcomes. METHODS One hundred eighty-seven closed surgical cases from a single carrier, which insured physicians practicing in 4 university hospitals in New York State, were reviewed, cataloged, and analyzed. RESULTS Most suits occurred during midcareer and routine operations. Seventy-three percent of cases were won. The average payment and expenses per case were

A Model for Integrating Ambulatory Surgery Centers Into an Academic Health System Using a Novel Ambulatory Surgery Coordinating Council.

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Cardiopulmonary Resuscitation in Surgical Patients: Comment on “Cardiac Arrest Among Surgical Patients: An Analysis of Incidence, Patient Characteristics, and Outcomes in ACS-NSQIP”

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Modeling for the future: Too many POSSUMS?: Invited Commentary on Pelavski, et al. Am J Surg 2013;205:58-63

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