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390
S. Sandrucci
asymptomatic until the mass reaches a large size (often 15cm or greater). Symptoms
include a palpable mass, early satiety, abdominal discomfort, or occasionally a new
varicocele in men. Others may be incidental ndings during abdominal imaging for
other reasons.
Retroperitoneal sarcomas are distinct from other soft tissue sarcomas, in that
local recurrence, rather than distant metastasis, is the most common cause of
disease- specic mortality, accounting for 75% of deaths [21]. Extended surgical
resections, encompassing adjacent uninvolved organs, have been adopted by several
sarcoma centers with the aim of improving local control and patient outcomes [21,
22]. Compared to limited resections, extended resections have been shown to
improve oncological outcomes (60% of patients surviving 5years) with an acceptable perioperative morbidity.
Proper resection of RPS requires appreciation of the anatomic boundaries of the
tumor [23]. CT imaging should be reviewed to identify landmarks dening the
extent of the mass to determine which structures may be safely resected and which
ones cannot. The anterior margin of a RPS is generally the ipsilateral colon and
mesocolon, pancreas, liver, or stomach. The posterior margin is generally the psoas
and iliacus muscles inferiorly, the ipsilateral kidney and diaphragm superiorly, and
the ipsilateral ureter and gonadal vessels medially. However, this may vary from
tumor to tumor, and some or all of these structures could be anterior to the mass, in
which case they would constitute a portion of the anterior margin. The medial margin usually includes the spine and paraspinous muscles, the inferior vena cava (for
right-sided tumors), and the aorta (for left-sided tumors). The lateral margin is constituted by the lateral or ank musculoskeletal sidewall, although depending on the
size and location of the tumor, the kidney and/or colon could also border the lateral
portion of the mass. The superior margin is similarly dependent on the size and
location of the mass and may include the diaphragm on either side; the right lobe of
the liver, the duodenum, and the head/uncinate process of the pancreas for rightsided tumors; and pancreatic tail, spleen, and splenic vessels for left-sided tumors.
The inferior margin may include the iliopsoas muscle; the femoral nerve; the common, internal, and external iliac vessels; and the pelvic sidewall [21]. Clearly, the
size and specic location of the mass determine which of the many structures mentioned above constitute which specic margin.
In general, the ipsilateral kidney, colon and mesocolon, and at least a portion of
the psoas can be safely and relatively easily resected without much difculty.
Resection of the pancreatic tail and spleen can usually be performed with relatively
low short-term morbidity. Resection of other structures, including but not limited to
the aorta, inferior vena cava, iliac vessels, femoral nerve, diaphragm, duodenum,
pancreatic head or uncinate process, and liver, entails more signicant resections,
with ensuing greater morbidity [24].
The proportion of elderly patients that are t for extended resections at presentation and the outcomes of surgery in this age group is unknown. A surgical approach
is still potentially benecial in the elderly, as life expectancy is over 10years in
people of 75years of age of either sex and does not fall below 5years until beyond
the age of 85years [19].
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However, extended resections for retroperitoneal sarcoma are a substantial
undertaking. The proportion of patients treated nonoperatively is signicantly
higher in those aged over 65years, with no difference in the proportion of patients
presenting with unresectable disease between older and younger patients, due to
unsuitability to major surgical intervention for comorbidities or surgery refusal.
Perioperative morbidity has a threefold increase in patients over 65years, but perioperative mortality does not increase compared to younger patients, and no evidence
exists in identifying age as a prognostic factor [20, 25].
The location, rather than the absolute size, of retroperitoneal sarcomas is most
pertinent in determining resectability, with the median tumor size in patients unsuitable for surgery being on average smaller than those proceeding to operation. In
case of established renal insufciency, the tumor must be deemed to be inoperable,
as resection would necessitate a nephrectomy, which would likely render the patient
dialysis dependent. Renal replacement therapy has not been shown to improve survival in the elderly when comorbidities are taken into account, and the median survival of elderly patients on dialysis is approximately 3years [19, 24]. As such, it
becomes difcult to justify an extended resection that is likely to result in end-stage
renal failure, although these decisions should be made on a case-by-case basis.
The outcomes for patients managed nonoperatively are poor. The use of radiotherapy or chemotherapy is signicantly less common in patients older than
65years, likely reecting the proportion of patients unt for operative management.
Due to the lack of effective treatment options in this situation, the patient’s quality
of life should be paramount in treatment planning.
27.3 Adjuvant/Neoadjuvant Radiation
Therapy andChemotherapy
Postoperative chemo-/radiotherapy has no proven efcacy in retroperitoneal sarcomas [26].
Limb-sparing surgery generally relies on adjuvant/neoadjuvant radiation therapy
to minimize risk of local recurrence. The goal of radiation is to treat the margin to
minimize the risk of recurrence, not necessarily to reduce the size of the tumor per se.
Radiation therapy reduces the risk of local recurrence from greater than 30% to less
than 10% in most series, but does not impact distant failure or overall survival [27].
Radiation therapy may be delivered as external beam radiation therapy (EBRT)
or brachytherapy. EBRT may be delivered preoperatively or postoperatively.
Preoperative EBRT is associated with a doubling in the rate of wound complications
(35% vs. 17%) but importantly with a lower rate of late complications and tissue
brosis and better functional outcomes. Postoperative EBRT generally has higher
dose than preoperative EBRT.Brachytherapy may be delivered through afterloading
catheters placed across the tumor bed at the end of surgery. The goal of brachytherapy is to deliver additional radiation to a close margin (including neurovascular
structures) with minimal treatment to surrounding tissue, particularly when further
EBRT is no longer feasible. This can be a desirable option for older patients.
392
Approximately 25–50% of patients with extremity STS develop distant metastatic disease [28]. Those with large (>10cm), deep, high-grade STS may be considered for preoperative or postoperative chemotherapy, usually with active agents
such as doxorubicin and ifosfamide (response rates of 20–40% in patients with
metastatic disease). However, there are no consistently convincing data that such an
approach improves overall survival for most STS histologies, and cardiac and kidney toxicities make the majority of older patients unt for treatment.
Hyperthermic isolated limb perfusion (ILP) and infusion (ILI) have been investigated in several institutions as treatment for patients with locally advanced STS in
whom limb-sparing, function-sparing surgery may not be possible, but the associated high morbidity makes this treatment not advisable for geriatric patients [29].
S. Sandrucci
27.4 Histology-Specific Treatments
27.4.1 Atypical Lipomatous Tumor (ALT)/
Well-Differentiated Liposarcoma
This low-grade tumor, when arising in the extremity, has a relatively low rate of
recurrence, may not recur for quite some time, and has no risk of distant metastatic
spread and death, unless dedifferentiation occurs over its natural history.
Dedifferentiation, if it occurs, in fact entails a risk of metastatic spread as high as
20%. In contrast, low-grade locally recurrent ALT may grow slowly for years.
Therefore, such tumors arising in the extremity can be resected with a limited negative or even a positive margin especially when preserving limb function is an issue.
Radiographically, ALT may be difcult to distinguish from an intramuscular lipoma,
a benign entity which can also arise in deep muscle tissue. ALT/well-differentiated
liposarcoma is a more threatening neoplasm when located in the retroperitoneum
even in the absence of areas of dedifferentiation. In fact, local control is an issue at
this site, and patients often die of locoregional failure, without developing distant
metastases [2, 21].
27.4.2 Dermatofibrosarcoma Protuberans (DFSP)
DFSP is a supercial tumor which inltrates soft tissue for centimeters beyond the
obvious margins of the lesion and can recur locally following an inadequate resection. However, the more common variety of DFSP does not display metastatic
behavior. Therefore, the goal of surgery should be negative margins, often necessitating reconstruction by plastic surgery. When cosmesis or function preservation is
an issue, limited positive margins may be accepted, and a wider resection postponed
until DFSP locally recurs.
Since DFSP is usually a relatively supercial tumor, resection of muscle deep to
the tumor is not often necessary. Intraoperative frozen section margin analysis is not
generally helpful, as the surrounding fat rarely freezes well for analysis. Radiation
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therapy is not usually recommended. Approximately 5–10% of patients with DFSP
have a more aggressive brosarcomatous variant which may recur locally and
potentially spread. Those individuals should be treated as a “conventional” sarcoma
with more aggressive local therapy (including radiation) and followed with systematic imaging.
27.4.3 Myxofibrosarcoma
Myxobrosarcoma most commonly arises in the extremities of elderly individuals. It
demonstrates a 30% rate of local recurrence and 16% rate of distant recurrence [14].
Multiple local recurrences have been associated with eventual amputation. Therefore,
it is critical to pursue aggressive local therapy. Wide surgical margins (2–4cm radial
margins beyond the clinical boundaries of the palpable mass, especially in more
supercial tumors) should be the goal of surgery, which often requires complex
wound closure or ap reconstruction by a plastic and reconstructive surgeon, as well
as resection and reconstruction of vessels and/or nerves. Radiation therapy, either
preoperatively or postoperatively (described below), may be considered, though the
direct impact on this specic histology remains unknown.
27.4.4 Angiosarcoma
Scalp angiosarcomas are commonly multifocal, by both clinical examination and
CT or MRI imaging. As radical surgery (often requiring complex ap reconstructions) is possible but rarely curative even if margins are widely negative, it may be
reserved for patients who are experiencing problems with local control (bleeding
from a fungating tumor) or who only appear to have a solitary site of disease by both
clinical examination and imaging while undergoing systemic therapy. Angiosarcoma
is sensitive to systemic chemotherapy and to radiation therapy [2].
27.4.5 Radiation-Induced Sarcomas
Radiation-induced sarcomas are rare and include a variety of histological subtypes,
the most common of which are unclassied pleomorphic sarcoma, angiosarcoma,
malignant peripheral nerve sheath tumors, and leiomyosarcoma. Besides the intrinsic characteristics of each histological subtype, they are all characterized by a high
propensity to locally recur, given the difculty of obtaining clear margins. This is
due in part to the difculty in distinguishing tumor inltration of healthy tissues
from radiation-induced soft tissue changes around the tumor site and in part to the
discontiguous and multifocal involvement of tissue within the radiation eld. The
tumor should be excised with as much tissue around it as possible. This often if not
always requires reconstruction and coverage by a plastic surgeon and potentially a
more liberal policy of neurovascular resection and reconstruction. Systemic
394
S. Sandrucci
chemotherapy and re-irradiation are often considered, given the overall dismal
prognosis, though the use of the latter must be weighed with caution [2].
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Part VII
Trauma and Non Traumatic Emergencies
Trauma inGeriatric Age
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28
EmanueleRausa, FedericoCoccolini, GiuliaMontori,
Maria AgneseKelly, BaggiPaolo, DarioPiazzalunga,
CeciliaMerli, andLucaAnsaloni
28.1 Introduction
The denition of the word “elderly” is not one that has been universally agreed
though it is generally accepted that it pertains to a subset of population between 45
and 75years old [1]. People are living much longer worldwide. Currently, the population over 60years of age accounts for over 40 million persons in the United States.
Over the next 20years, the population over 65years of age is projected to double in
size, reaching 82.3 million (approximately 22% of the total population) by 2040 [2].
It is thought that the population over 65years of age will be the fastest growing
subset of population. As this population grows, so too will the need for healthcare
services and their costs. In 2008, despite the fact that the elderly constituted only
13% of the US population, they represented 40% of all hospitalized adults. The total
expenditure on health care reects these data; in fact, the elderly costs twice as
much as their younger counterparts (13.2% vs 6.6%, respectively) [3].
The Western lifestyle encourages old people to maintain their independence for as
long as possible. In 2014, there were 5709 people over 65 killed and an estimated
221,000 injured in motor vehicle trafc crashes. Older people made up 17 percent of
all trafc fatalities and 9% of all people injured in trafc crashes during the year [4].
However, physiological changes are natural and uncontrolled events that affect
compensatory mechanisms and cause them to become insufcient to adequately
E. Rausa • F. Coccolini • G. Montori • B. Paolo • D. Piazzalunga • L. Ansaloni (*)
Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital,
P.zza OMS 1, 24128 Bergamo, Italy
e-mail: lansaloni@asst-pg23.it
M.A. Kelly
Department of Colorectal Diseases, St. Vincent’s University Hospital, Elm Park,
Dublin, Ireland
C. Merli
Unit of Emergency Medicine, Papa Giovanni XXIII Hospital, Bergamo, Italy
© Springer International Publishing AG, part of Springer Nature 2018
A. Crucitti (ed.), Surgical Management of Elderly Patients,
https://doi.org/10.1007/978-3-319-60861-7_28
399
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E. Rausa et al.
react to injuries, illnesses, or surgery [5]. This physiological decline renders the
elderly prone to traumatic injuries in the course of their daily activities. Furthermore,
the higher comorbidities rate (66%) and preexisting home therapy may exacerbate
and complicate the trauma and the underlying physiological mechanism [6].
The trauma mechanism in the elderly is dissimilar to that in their younger counterparts. In young patients, road trauma is most prevalent (58.4%). Other predominant trauma mechanisms are recreation (15.4%) and violence (15.3%) [7].
Blunt trauma is the dominant mechanism in elderly patients (EPs) and makes up
more than 80% of all geriatric trauma [8]. Falls, which consist of a low-energy blunt
trauma, account for 70% of blunt trauma cases. EPs may be more inclined to fall
because of physiological change with aging and comorbidities affecting the musculoskeletal system and the brain causing tremor, rigidity, and dementia. Further blunt
trauma events are motor vehicle accidents (the second most common trauma mechanism), pedestrian struck, and burn injuries [9]. Finally, there are penetrating trauma
and suicide attempts. EPs account for 18% of all suicide deaths. Of note, domestic
abuse and assaults represent an underrated cause of trauma, with an estimated
25,886 elderly people treated in emergency departments for lacerations, contusions,
or fractures secondary to nonfatal assaults. It is estimated that roughly 85% of abuse
incidents involving the elderly are not reported [10].
Despite the steady increase in geriatric trauma admissions, specic guidelines
addressed toward the management of the geriatric have not been dened, and the
treatment remains challenging. Demetriades etal. showed a deciency in the proper
triaging of these trauma cases [11]. EPs, even if severely injured, were underrated
in 25% of cases. This bias results in a signicant delay in treatment. Statistics show
that 43% of patients who were considered hemodynamically stable were found to
have experienced cardiogenic shock, and 54% of these cases resulted in death [12].
Mortality among those patients was substantially reduced by employing “age over
70” as an activation code for the trauma team [11].
Given the well-established relationship between age, Injury Severity Score (ISS),
and mortality, a clear trauma classication at the presentation is essential as invasive
procedures in EPs are widely accepted in ISS>18, whereas in ISS<18, the indications need to be cautiously evaluated according to the risks and benets [13].
Due to a reduced physiological reserve, body reaction to a traumatic event is
poor in both the short and the long term. EPs who are hospitalized are likely to
develop a limitation in their daily abilities and functional status and need long-term
care. A poor pre-injury functional status is a strong predictor of an undesirable outcome [14]. It has been evaluated as even more relevant than the admitting diagnosis
in the short term (complications and in-hospital mortality) and the long term (posthospitalization mortality) [15].
Poor functional status at the baseline, an advanced age, and a high ISS result in
a longer hospital stay and increase the risk of developing nosocomial infections. As
shown by Labib etal., among all the nosocomial complications, respiratory complications are those that most increase the risk for in-hospital mortality [16]. Pracht
etal. showed that in patient groups aged between 65 and 74years of age, the risk of
mortality increases according to the number of comorbidities [17].
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Fleischman etal. show that age is a relevant predictor of long-term prognosis. In fact,
the risk of post-hospitalization mortality continues to go up until 6months post-trauma
in EPs [18]. Additionally, Davidson etal. stated that the risk of post- hospitalization mortality remains high over a 3-year post-trauma period (16%) [19]. EPs outcomes are
related to multiple signicant factors such as trauma mechanism, age, ISS, comorbidities (especially cardiovascular comorbidities), functional status at the baseline, and
home therapy [20]. In this context, as EPs are extremely frail and feeble, it would be
better to evaluate them more as individuals than as a cohort of patients.
28.2 The Physiology ofAging
Substantial physiological changes occur in aging and may affect the body’s response
to trauma.
In a trauma, the rst body reaction is the release of catecholamine hormones, in
order to raise blood pressure and provide more blood to muscles and brain. In EPs,
the cardiovascular system responds to this stimulation with a consistent delay [21].
Additionally, medications such as beta-blockers or diuretic medications may mitigate the hormones’ effect and exacerbate a forced status of hypotension and hypoperfusion in cases of blood loss. Figures which dene the “normal blood pressure” in
adults should be reconsidered in EPs. Heffernan etal. found that mortality increased
in EPs with a systolic blood pressure <110mmHg, whereas the same results were
obtained when the blood pressure was <95mmHg in younger counterparts [22].
The heart and vessels are stiff and thickened, causing a decreased compliance.
Body uid compartments are extremely narrow, and small changes among them
coincide with a massive change between hypovolemia and edema because cardiac
reserve is limited; atherosclerosis leads to poor vessel constriction, and the neurological system is slow in arousing the “ght or ight” response [23].
In a trauma, EPs may decompensate quickly because the respiratory reserve is
decreased as well. The loss in elasticity and arthritic process makes the rib cage
stiff, causing a reduction in the articular range of motion. Lungs, which are enclosed
in an inexible space, lose compliance, and the vital capacity decreases, while the
dead space increases. Additionally, the pulmonary tissue changes its pattern because
of brosis and the loss of collagen and because of chemicals and pollution in the
atmosphere. Hence, early intubation is recommended in patients with borderline
respiratory function [
The kidneys are less efcient in concentrating urine. Even temporary hypotension and hypoperfusion, radiological contrast, or nephrotoxic drugs represent a trigger for an acute kidney injury [25]. Aging acts on the musculoskeletal system,
decreasing the muscle mass and strength because fat or brous tissue replaces muscles. In addition, osteoporosis and arthritis decrease bone density and make EPs
susceptible to fracture, even in low-energy trauma [26].
Finally, another substantial physiological change is the loss of adequate thermoregulation. Even a modest trauma may easily make EPs hypothermic, resulting in a
worsening of coagulopathy, which then dramatically raises the risk of mortality [27].
24].
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