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3 Principles ofGeriatric Surgery
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https://doi.org/10.1016/j.jamcollsurg.
Perioperative Management
PiergasparePalumbo, MarcoScatizzi,
GiorgiaPrestigiacomo, andMaddalenaBaraghini
4.1 The Challenge ofAging inElderly Patients
In all the industrialized countries of the world, the elderly population is constantly
increasing, having reached about 13.4 million people overall and 22% in relative
terms, according to OMS data. Therefore, it represents the fastest increasing group
in the entire population, which is expected to double by 2050.
This aging population sets constant healthcare challenges that aim to ensure an
extended life expectancy and an improved quality of life.
Elderly patients have specic and different characteristics but in varying degrees,
thus constituting their typical fragility: they have multiple diseases (hematological,
hepatic, renal, cardiac, hypertension, diabetes mellitus, atherosclerosis, and chronic
obstructive pulmonary disease (COPD)), as well as cognitive-behavioral and psychological problems due to old age. These show atypical presentations of disease
and unstable homeostasis, which are accompanied by a high risk of complications
and trigger a cascade of vicious circles. Above all, as a result of an acute pathological event or a surgical treatment, elderly patients have a physiological reduction of
the functional reserve, in particular if this involves a long hospital stay or a rehospitalization. Consequently, there is a more pronounced risk of comorbidities and
complications. It is like conguring a permanent situation of disability and loss of
independence, which will inevitably affect the overall health.
4
P. Palumbo (*) • G. Prestigiacomo • M. Baraghini
Department of Surgical Sciences, “Sapienza”—University of Rome,
Viale del Policlinico, 155, 00161 Rome, Italy
Via Alessandro Serpieri, 13, 00197 Rome, Italy
e-mail: piergaspare.palumbo@uniroma1.it
M. Scatizzi
Chief Surgical Department, Usl 4 - Prato, Florence, Italy
Via Alessandro Serpieri, 13, 00197 Rome, 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_4
47
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P. Palumbo et al.
The ERAS (Enhanced Recovery After Surgery) method, a multimodal protocol
aimed at ensuring the most rapid possible postoperative recovery, keeps the degree
of elderly patient autonomy as close as possible to the previous level, limiting
stress and signicantly reducing the length of hospital stay and discharge and the
rate of complications and readmission. To provide optimal care while maintaining
high- quality standards and at the same time cope with the complexity of multiple
health conditions of the elderly patient, the obvious priority is to reconsider the
perioperative process starting with a careful analysis of the existing literature and
providing common guidelines for proper management of the surgical geriatric
patient.
In fact, by combining the latest available scientic evidence in the various disciplines that operate around the patient requiring major surgery, this method aims
to positively change the response in preserving the physiological functional
reserve.
4.2 The Pathophysiology ofSurgical Stress
4.2.1 The Metabolic Response toSurgery
Surgery, and especially major surgery, is an insult to the body comparable to the
intensity of the metabolic response to trauma or an extended burn.
The determining events are the result of the triggering of physiological compensation mechanisms which all together constitute the metabolic stress response to
surgery.
The essential purpose of this response is to make the functional reserves available, from which the substrates are required to adapt to the stressful situation, repair
damaged tissue, and protect the vital organs.
Three main events are identied, which act as a switch to all the other effects: the
activation of the hypothalamic-pituitary-adrenal axis, the action of the immune system, and the systemic inammatory response. They constitute the set of triggers that
massively mobilize hormones and second messenger molecules, causing a series of
cellular and metabolic changes in target organs. The result is a profound imbalance
with complete disruption of homeostasis.
The paraventricular nucleus (NPV) acts as a coordinating center for signals from
different brain areas devoted to the stress response. Its activation results in the secretion of corticotropin-releasing factor (CRF), which regulates the production of adrenocorticotropic hormone (ACTH), required for the production and release of
glucocorticoids from the adrenal cortex, the most important of which is cortisol.
Glucocorticoid hormones, in turn, exert signicant inuence on the immune system,
acting both against the humoral and cellular effector arms. In fact, they regulate the
production of interleukins, such as IL-1 and IL-6, interferon γ (IFNγ), and tumor
necrosis factor α (TNFα) by T helper cells 1 and 2.
The dialogue between the nervous and immune systems does not seem to be
conned to the hypothalamic-pituitary-adrenal axis. It extends potentially to the
entire central nervous system, particularly the frontal lobe and the limbic system
4 Perioperative Management
49
(hippocampus and amygdala), and determines some related events in inammatory
states and intense stress, such as the reduction of attention and interaction with
the environment. This connection represents a pathophysiological basis for understanding the etiology of delirium that is very frequent in elderly patients undergoing surgery.
4.2.2 Stress Hyperglycemia
The liver is a target organ of the stress response. In fact, the production of proinammatory cytokines and chemokines, catecholamines, and cortisol guides its
function in favor of a massive production of glucose.
Protein catabolism induced by cortisol also acts on muscle tissue, until “muscle
wasting”; this response leads to amino acid availability and increase hepatic gluconeogenesis. Also, the feedback mechanism responsible for the silencing of this
pathway is inhibited by the presence of large amounts of proinammatory
molecules.
The TNFα and the IL-1 are, in fact, engaged in various actions: to directly stimulate gluconeogenesis and liver glycogenolysis, to cause a downregulation of synthesis and exposure of the glucose transporter GLUT4 membrane, and to interfere with
insulin tyrosine kinase receptor signaling, repressing and thus triggering a resistance to the insulin response itself.
The result is an increase in hepatic glucose production and the onset of a marked
insulin resistance, clinically dened as “stress hyperglycemia.”
Hyperglycemia supports the inammatory response and oxidative stress, contributing to the emergence of a vicious cycle that feeds on itself.
It also establishes a switch in hepatic protein synthesis, which is diverted to produce acute phase proteins and immunoglobulins and albumin in disadvantage.
This mechanism is amplied in the elderly patient, who already has a pre- existing
condition of a depletion in protein stores and often of malnutrition.
This condition causes a reduction in oncotic pressure and the passage of uid
from the intravascular compartment to the interstitial, promoting a side effect of
edema, which in the geriatric patient involves the onset of respiratory, cardiovascular, infective, and immune complications and contributes to increased postoperative
morbidity and mortality. Moreover, the loss of protein is responsible for the state of
sarcopenia and of delay in healing the surgical wound.
In addition, a marked lipolysis occurs, with cleavage of the fat reserves in the
triglyceride which will take part, by increasing their blood concentration, in the
intensication of the inammatory response and the vicious circle described above,
adding to the deterioration of other signaling processes with a reduction of cellular
resistance to apoptosis.
Several studies also show that hyperglycemia and other stress-related disorders are associated at a statistically signicant rate with an increased risk of
perioperative adverse events, particularly in elderly patients with signicant
pre-existing comorbidities, and could therefore be considered predictive of
mortality.
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P. Palumbo et al.
In clinical practice, the increase in blood glucose concentration appears to be
related to the intensity of the surgical trauma and in major surgery can also record
postoperative levels equal to 10–12mmol/L.A glucose concentration higher than
7mmol/L, frequently found in patients undergoing abdominal surgery, appears to
be a predictor of mortality and the development of complications, and the patients
show an increase of 15 times in the incidence of associated infections and hospital
mortality.
The sudden and repeated uctuations are mainly associated with worse outcomes, due to the consequences induced in the endothelial and cellular level; oxidative stress, in fact, has less serious effects when exposure lasts longer than the
sudden exposure to high concentrations.
The elements that contribute to the onset of the state of insulin resistance in the
postoperative period were identied in preoperative fasting, postoperative pain, and
prolonged bed rest.
4.3 Risk Assessment intheElderly Patient
The “Elderly Multidimensional Assessment (EMA)” must be used in this specic
methodological approach, although it is not generally considered in the preoperative
stage. It aims to assess the patient’s geriatric functionality and status through performance measures, clinical data, laboratory, and also psychological and social
measures.
The EMA uses specic rating scales, which differ in relation to the investigated
areas. Several are validated and used in the international arena, including the Mini
Mental State Exam (MMSE), which investigates the cognitive functions exploring
temporal orientation, spatial, memory, and computing power. The Geriatric Depression
Scale (GDS) aims to detect specic aspects of depression in the elderly. Activities of
the Day Living (ADL) and Instrumental Activities of Day Living (IADL) reect the
elderly person’s needs in their daily life and thus provide an indirect estimate of functional autonomy and social measures. The Barthel Index (BI) and the Modied Rankin
Scale (MRS) are also commonly used for the assessment of disability. Finally, the
scale of Tinetti is used to evaluate balance, posture, and gait [1].
Risk assessment can also use tools such as the POSSUM (Physiological and
Operative Severity Score for the Enumeration of Mortality and Morbidity) score,
which is very useful in predicting the postoperative outcomes and is appropriate in
objectively evaluating the performance status of patients [2].
Finally, we need to apply a high degree of attention to the multiple comorbidities
present. Elderly patients with two or more comorbidities have a higher risk of perioperative mortality (4–16%) than those with a single pre-existing pathology, conrming fragility as a predictor of morbidity and mortality.
The progressive interweaving of these elements and their interaction results in
greater differentiation between patients and makes it difcult to nd a standard risk
assessment tool.
4 Perioperative Management
51
Score
Age (years)
Cardiac signs Normal Diuretic, digoxin
Chest radiograph Normal — Borderline
Respiratory history Normal Dyspnea on exertion Limiting
Chest radiograph Normal Mild chronic
Systolic blood
pressure (mmHg)
Pulse (beats/min) 50–80 81–100 101–120
Glasgow coma scale 15 12–14 9–11
Hemoglobin (g/dl) 13–16 11.5–12.9 10–11.4
White cell count
12
(×10
/l)
Blood urea (mmol/l)
Sodium (mmol/l)
Potassium (mmol/l) 3.5–5 3.2–3.4 2.9–3.1
Electrocardiogram Normal Atrial
COAD: Chronic obstructive airway disease
1 2 4
≤60
110–130 131–170
4–10 10.1–20
≤7.5
≥136
61-70
antianginal or antihypertensive therapy
obstructive airway
disease
100–109 90–99
40–49
16.1–17 17.1–18
3.1–4 <3
7.6–10 10.1–15
131–135 126–130
5.2–5.3 5.4–5.9
≥71
Peripheral
edema, warfarin
therapy
cardiomegaly
dyspnea (one
ight of stairs)
Moderate
COAD
≥171
≥20.1
brillation
(rate 60–90)
8
Raised jugular
venous pressure
Cardiomegaly
Dyspnea at rest
Fibrosis or
consolidation
<89
≥121
≤39
≤8
≤9.9
≥18.1
≥15.1
≤125
≤2.8
≥6
Any other
change
The POSSUM score (Copeland etal. [2]).
4.4 Eras Method
4.4.1 Rationale ofApplication
In recent years new topics in surgery and anesthesia have allowed demonstration of
improvements for postoperative recovery in medium-high complexity surgery
candidates.
The traditional care approach determines a signicant postoperative reduction in
functional capacity which can last up to several weeks.
In addition, in assessing the actual need and effectiveness of several standard
approaches such as mechanical intestinal preparation, excessive uid administration, and the prolonged use of the nasogastric tube, several studies have documented
the uselessness and the risks of delaying the reacquisition of normal feeding and
walking.
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P. Palumbo et al.
The usefulness of the ERAS protocol lies in the multimodal advanced management philosophy and perioperative route optimization, with the goal of limiting
surgical stress as a factor conditioning the duration of hospital stay and at the same
time restoring and supporting all those functions that enable rapid recovery of normal life activities of the patient, reducing the risk of complications and the hospital
readmission rate.
This method, therefore, aims to modify the physiological response to major surgery and has proven effective in reducing complications, demonstrating a decrease
in postoperative dysfunction in the geriatric patient and consequently greater
satisfaction.
However, despite encouraging data, such innovations in the management of the
surgical patient struggle to fully enter clinical practice because of cultural resistance
anchored to conventional procedures and organizational difculties.
4.5 The ERAS Protocol
Currently a single standardized protocol in any surgical procedure has yet been
dened; however, some key elements are recognized as part of a rehabilitation program advanced in most adopted protocols. In applying the ERAS method, however,
three common phases are recognized: the preoperative phase, the intraoperative
phase, and the postoperative phase.
Mid-thoracic epidural anesthesia/analgesia Preadmission counselling
No nasogastric tubes
Prevention of nausea and vomting
Avoidance of salt and water overload
Early removal of catheter
Early oral nutrition
Non-opioid oral
analgesia/NSAIDs
Early mobilization
Stimulation of gut motility
Audit of compliance
and outcomes
Fast-Track in Colorectal Surgery (Varadhan etal. [3]).
Postoperative Preoperative
ERAS
Intraoperative
Maintenance of normothermia (body warmer/warm intravenous fluids)
Mid-thoracic epidural anesthesia/analgesia
Fluid and carbohydrate loading
No prolonged fasting
No/selective bowel preparation
Antibiotic prophylaxis
Thromboprophylaxis
No premedication
Short-acting anesthetic
agents
No drains
Avoidance of salt and water overload
4 Perioperative Management
53
4.5.1 The Preoperative Phase
During the preoperative phase, counseling helps patients to better understand their
overall health status, to become aware of the benets and risks associated with the
procedures, and to weigh up expectations based on these elements, especially with
regard to pain treatment, the reacquisition of existing functionality, and other hurdles to be faced each postoperative day.
Therefore, the patient must have the opportunity to meet with all members of the
multidisciplinary team to discuss details of various aspects of their treatment and to
outline to the team members a complete picture of what they will face so that the
team will be ready to put in place resources to help them cope.
Elderly patients who have had major surgery are often burdened with important
comorbidities, which should be identied and treated to adequately limit their
effects. This will signicantly change the rate of occurrence of complications and
affect the postoperative course.
Uncontrolled diabetic patients with elevated glycated hemoglobin levels show a
more increased risk of major postoperative complications than patients with glucose
intolerance or those without diabetes. Similarly, patients with cardiac comorbidity,
COPD, and other homeostatic disorders have an increased risk of adverse events.
Although anemia is a condition often found in the elderly, it needs to be identied
and corrected before surgery. The anemic state in the preoperative period, in fact, is
closely associated with increased morbidity and postoperative mortality, so it can be
considered a predictor.
Malnutrition operates like other comorbidities to the establishment of an unfavorable condition to the body’s response to surgical stress and impairs the patient’s
general condition. It is characterized by a negative impact on outcome and requires
special attention to the correction of deciencies of essential nutrients.
The European Society of Parenteral and Enteral Nutrition (ESPEN) dened
severe nutritional risk patients as those who present with one or more of the following characteristics:
• Signicant weight loss (from 10 to 16%) in 6months
• BMI <18.5kg/m
2
• Serum albumin <30g/L
The ESPEN provides a screening questionnaire, the Nutritional Risk Screening,
for the evaluation and stratication of patients, similar to the Malnutrition Universal
Screening Tool (MUST); it identies malnourished adults, with elevated risk of
malnutrition or obesity based on a ve-step process. Both are easy to use in the
hospital setting.
Within the ERAS protocol, the achievement of a satisfactory nutritional state is
carried out by administration of nutritional supplements to patients, generally by
mouth or, if necessary, enterally. Scientic evidence supports preoperative nutrition
as it has shown that administration of glucose solutions before surgery is safe and
can have a positive effect on clinical outcomes, reducing the rate of complications
and the length of stay [4].
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P. Palumbo et al.
Further addition of nutritional support is represented by immunonutrition, a term
which denes the formula enriched with amino acids such as arginine and glutamine, unsaturated fatty acids, omega-3, vitamins, and minerals.
In conventional practice the preoperative fasting in its form “nihil per os”
(NPO) from midnight of the day before surgery is considered standard. This
recommendation is still very strong in clinical practice and is justied in the
attempt to prevent aspiration pneumonia. Several studies have disproved the claim
that fasting provides an “empty stomach,” conrming that during fasting the
stomach can secrete up to 50mL/h of gastric juice and thus highlighting the limits
of preoperative fasting and its potential harmfulness. The treatment provided by
the ERAS protocol consists of the administration of a preoperative carbohydrate
load (PCL) orally. The PCL causes a more rapid recovery of bowel function,
reducing the length of stay without causing any side effects. Several randomized
controlled trials (RCTs) show that the administration of the PCL will result in a
faster metabolic response in the postoperative period, a reduction of insulin resistance, and contained protein loss, with greater preservation of muscle functional
reserve. In fact, a Cochrane systematic review of 22 RCTs showed how fasting
from midnight does not reduce gastric contents and also does not reduce the rate
of complications of fasted patients compared to those who were allowed the
ingestion of solid foods up to 6h before the operation and clear liquids (water,
fruit juices without pulp, carbonated drinks, tea, and coffee) up to 2h before. The
advantage of the pathophysiological preoperative glucose load lies in increasing
the production of insulin which causes a cellular metabolism shift toward an anabolic state [5–7].
The traditional management of abdominal surgery candidate patients, in particular colorectal ones, provides for a complete mechanical cleaning of the colon with a
duration of one or more days in combination with a diet low in slag and to an intestinal antibiotic prophylaxis.
Mechanical preparation allows a signicant reduction in stool weight and, in
synergy with the antiseptic preparation, results in a reduction of 80–90% of the
colonic bacterial ora.
Recently, mechanical bowel preparation has been shown to be useless in multiple
randomized clinical trials and in a Cochrane review, since it involves dehydration
and electrolyte imbalances [
8, 9].
Both lead to a signicant reduction in muscle strength and exercise tolerance, as
well as weight loss; also, they determine an increase in hematocrit and hemodynamic alterations, increased plasma osmolarity with rising concentrations of urea,
and a falling of concentrations of calcium and potassium.
These results in elderly patients with several comorbidities lead to dangerous
postural hypotension, which may cause syncope and increase the risk of falls and
injuries.
Therefore, the utility of MBP is strongly challenged, and its avoidance does not
cause an increased incidence of anastomotic leakage or the risk of infection.
Undergoing surgery is usually a strong emotional stress. In traditional perioperative management, patients receive the administration of atropine and benzodiazepines
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