Katlic Cardiothoracic Surgery in the Elderly

1. Auflage 2011
ISBN: 978-1-4419-0892-6
Verlag: Springer
Format: PDF
Kopierschutz: 1 - PDF Watermark

E-Book, Englisch, 654 Seiten

Cardiothoracic Surgery in the Elderly: Evidence Based Practice is an important and timely book that reflects the thoughtful work of pioneers in geriatric surgery. It encompasses their knowledge related to geriatric surgery, and their reflections and guidance on the rapidly accumulating knowledge related to improving the health and surgical care of seniors.This book provides a scholarly review of the constantly expanding knowledge base about cardiovascular and thoracic surgery in seniors. The book follows a logical sequence covering general aspects of care, cardiac surgery and thoracic surgery. Chapters are focused on common, devastating and often missed complications of surgical care in the seniors. These include delirium, depression, pressure sores, functional losses, incontinence, volume depletion and asymptomatic or atypical complications -myocardial infarction, post-operative diarrhea, urinary track infections and pneumonia. Each is expertly reviewed. Strategies to help the surgeons and the surgical team anticipate, recognize and effectively prevent or manage such problems are discussed and the evidence basis for such strategies is provided.Cardiothoracic Surgery in the Elderly: Evidence Based Practice is particularly timely and the first to review the substantial body of knowledge that has been developed in recent years related to geriatric cardiothoracic surgical problems. It catalogs well the expanding knowledge basis for achieving successful surgical outcomes in the very old. It provides a most useful resources for cardiovascular thoracic surgeons in training and those already in practice.

Autoren/Hrsg.

Katlic, Mark R.

Inhaltsverzeichnis

1;Cardiothoracic Surgeryin the Elderly;5
1.1;Foreword;9
1.2;Preface;13
1.3;Contents;15
1.4;Contributors;19
1.5;Part I:General Aspects of Care;27
1.5.1;Chapter 1: Invited Commentary;28
1.5.1.1;References;29
1.5.2;Chapter 2: The Epidemiology and Economics of Cardiothoracic Surgery in the Elderly;30
1.5.2.1;Introduction;30
1.5.2.2;Demographics: The Aging Population;30
1.5.2.3;A Data-Driven Approach;32
1.5.2.4;Historical Rates of Treatment;32
1.5.2.5;Forecasting Rates of Treatment;33
1.5.2.6;Determinants of Rates of Treatment;36
1.5.2.7;Epidemiologic Trends;37
1.5.2.7.1;Trends in Coronary Artery Disease (CAD);37
1.5.2.7.2;Trends in Valvular Heart Disease;38
1.5.2.7.3;Trends in Lung Cancer;38
1.5.2.8;Outcomes of Cardiothoracic Surgery in Elderly Patients;40
1.5.2.9;Overuse and Underuse;40
1.5.2.9.1;Overuse;41
1.5.2.9.2;Underuse;41
1.5.2.10;Cardiologic Evaluation;41
1.5.2.11;Surgical vs. Nonsurgical Treatment;42
1.5.2.12;Improving the Appropriateness of Care;43
1.5.2.13;Payment Systems;43
1.5.2.14;Medical Technology;45
1.5.2.15;The Domestic Supply of Cardiothoracic Surgeons;46
1.5.2.16;Conclusion;47
1.5.2.17;Appendix 1: Cardiothoracic Surgical Procedures;48
1.5.2.18;References;48
1.5.3;Chapter 3: Principles of Geriatric Surgery;50
1.5.3.1;Principle I: Clinical Presentation;51
1.5.3.2;Principle II: Lack of Reserve;53
1.5.3.3;Principle III: Preoperative Preparation;54
1.5.3.4;Principle IV: Emergency Surgery;57
1.5.3.5;Principle V: Attention to Detail;57
1.5.3.6;Principle VI: Age Is a Scientific Fact;58
1.5.3.7;Conclusion;61
1.5.3.8;References;62
1.5.4;Chapter 4: Geriatric Models of Care;68
1.5.4.1;Introduction;68
1.5.4.2;Complications of Older Hospitalized Patients;68
1.5.4.2.1;Functional Decline;71
1.5.4.2.2;Fall-Related Injury;71
1.5.4.2.3;Under/Malnutrition;71
1.5.4.2.4;Pressure Ulcers;71
1.5.4.2.5;Urinary Tract Infection;71
1.5.4.2.6;Delirium;72
1.5.4.3;Geriatric Care Model Objectives;72
1.5.4.4;Geriatric Models;74
1.5.4.5;Transitional Care Models;78
1.5.4.6;New Specialty Models;78
1.5.4.7;Conclusion;78
1.5.4.8;References;79
1.5.5;Chapter 5: Delirium After Cardiac Surgery;82
1.5.5.1;Defining and Diagnosing Delirium;82
1.5.5.2;Distinction Between Delirium and Postoperative Cognitive Dysfunction;83
1.5.5.3;Pathophysiology of Delirium After Cardiac Surgery;83
1.5.5.3.1;Anticholinergic Burden;83
1.5.5.3.2;Inflammation;84
1.5.5.3.3;Large Neutral Amino Acids;84
1.5.5.3.4;Atherosclerosis and Blood–Brain Barrier Compromise;84
1.5.5.4;Preoperative Assessment for Delirium Risk;84
1.5.5.4.1;Assessment of Preoperative Cognitive Function;85
1.5.5.4.2;Assessment of Depression;85
1.5.5.4.3;Albumin;85
1.5.5.4.4;Age-Associated Risk Factors Associated with Delirium;85
1.5.5.5;Precipitating Factors for Delirium;85
1.5.5.5.1;Microemboli;86
1.5.5.5.2;Intraoperative Medication;86
1.5.5.5.3;Postoperative Medication;87
1.5.5.5.4;Metabolic Abnormalities;87
1.5.5.5.5;Postoperative Environment;87
1.5.5.5.6;Iatrogenic Events;87
1.5.5.6;Prevention of Delirium;87
1.5.5.7;Treatment of Delirium;88
1.5.5.7.1;Cerebral Imaging;88
1.5.5.7.2;Remove or Minimize Cognitively Active Medications;88
1.5.5.7.3;Pain Control;89
1.5.5.8;Management of Agitation Associated with Delirium;89
1.5.5.9;References;89
1.5.6;Chapter 6: Cardiac Rehabilitation in the Elderly;92
1.5.6.1;Definition of Cardiac Rehabilitation;92
1.5.6.2;Core Components of CR/Secondary Prevention Programs;93
1.5.6.2.1;Patient Assessment;93
1.5.6.2.2;Nutritional Counseling;93
1.5.6.2.3;Weight Management;94
1.5.6.2.4;Blood Pressure Management;94
1.5.6.2.5;Management of Diabetes Mellitus (DM);94
1.5.6.2.6;Tobacco Cessation;94
1.5.6.2.7;Psychosocial Management;94
1.5.6.2.8;Physical Activity Counseling;94
1.5.6.2.9;Exercise Training;95
1.5.6.3;Performance Measures;95
1.5.6.4;Safety of CR;95
1.5.6.5;Efficacy of CR;96
1.5.6.5.1;Efficacy in Patients with MI, Stable Angina, and After CABG or PCI;96
1.5.6.5.2;Efficacy of CR in Heart Failure Patients;97
1.5.6.5.3;Efficacy in Patients Undergoing Valve Replacement Procedures;97
1.5.6.5.4;Efficacy in Patients Undergoing Cardiac Transplantation;98
1.5.6.5.5;Summary and Conclusions Regarding Efficacy;98
1.5.6.6;CR in the Elderly;98
1.5.6.6.1;Outcomes of CR in the Elderly;98
1.5.6.6.1.1;Morbidity and Mortality;98
1.5.6.6.1.2;Physical Fitness;99
1.5.6.6.1.3;Risk Factor Therapies;99
1.5.6.6.1.4;Psychosocial Disorders and QoL;99
1.5.6.7;Summary and Conclusions;100
1.5.6.8;References;100
1.5.7;Chapter 7: Legal Aspects of Geriatric Surgery;103
1.5.7.1;Introduction;103
1.5.7.2;Medical Malpractice;103
1.5.7.2.1;Elements of a Claim;104
1.5.7.2.2;Duty/Standard of Care;104
1.5.7.2.3;Breach of Duty;105
1.5.7.2.4;Damage or Injury;105
1.5.7.2.5;Causation;106
1.5.7.3;Informed Consent;106
1.5.7.3.1;Elements;106
1.5.7.3.1.1;Voluntariness;107
1.5.7.3.1.2;Information;107
1.5.7.3.1.3;Decisional Capacity;107
1.5.7.3.1.4;Surrogate Decision Making;108
1.5.7.3.1.5;Guardianship/Conservatorship;108
1.5.7.3.1.6;Durable Power of Attorney;109
1.5.7.3.1.7;Family Authority Statutes;109
1.5.7.3.1.8;Documentation of Patient or Surrogate Consent;109
1.5.7.3.1.9;Emergency Exception;109
1.5.7.3.1.10;Institutional Ethics Committees;110
1.5.7.4;Conclusion;110
1.5.7.5;References;110
1.5.8;Chapter 8: Ethical Issues in Cardiothoracic Surgery for the Elderly;112
1.5.8.1;Introduction;112
1.5.8.2;Further Considerations of Illness and Death in Old Age;115
1.5.8.2.1;Personhood;115
1.5.8.2.2;The Technology Pendulum;115
1.5.8.2.3;Rationing Health Care for the Elderly;115
1.5.8.2.3.1;Palliative Care;116
1.5.8.2.4;Other Palliative Care Options;116
1.5.8.3;Cardiothoracic Surgery in the Elderly;117
1.5.8.3.1;Heart Transplantation in the Elderly;119
1.5.8.3.2;Decision Making for the Elderly with Cardiothoracic Disease;120
1.5.8.3.3;Advance Directives and Proxy/Surrogate Decision Making;121
1.5.8.4;The Elderly as Research Subjects;122
1.5.8.4.1;The Nuremberg Code;122
1.5.8.4.2;The Declaration of Helsinki;123
1.5.8.4.3;The Belmont Report;123
1.5.8.4.4;The Elderly as Vulnerable Research Subjects;124
1.5.8.5;A Corollary Principle: Decisional Flexibility;124
1.5.8.6;References;125
1.5.9;Chapter 9: Acute Pain Control in Geriatric Patients After Cardiac and Thoracic Surgeries;127
1.5.9.1;Thoracic Pain Pathways;128
1.5.9.2;Pain Management Techniques for Thoracic Surgeries;130
1.5.9.3;Regional Analgesia;130
1.5.9.3.1;Epidural Analgesia;130
1.5.9.3.2;Other Regional Anesthetic Techniques;132
1.5.9.3.2.1;Intercostal Blocks;132
1.5.9.3.2.2;Extrapleural Analgesia;132
1.5.9.3.2.3;Interpleural Analgesia;133
1.5.9.3.2.4;Intravenous Opiates;133
1.5.9.3.3;Conversion from Morphine to Transdermal Fentanyl;134
1.5.9.3.4;Conversion from IV PCA to Control Release Oxycodone in the Postoperative Period;134
1.5.9.4;Other Analgesics;134
1.5.9.4.1;Analgesic Adjuvants;135
1.5.9.4.1.1;Alpha 2 Agonists;135
1.5.9.5;Cardiac Surgery;135
1.5.9.5.1;Wound Pump;136
1.5.9.5.2;Surgical Bra and Vest;137
1.5.9.5.3;Use of the Pillow;137
1.5.9.5.4;Heating Pad;137
1.5.9.5.5;Summary;138
1.5.9.6;References;138
1.5.10;Chapter 10: Palliative Care in the Elderly;142
1.5.10.1;Introduction;142
1.5.10.2;Why Palliative Care?;142
1.5.10.3;The Palliative Care Team;143
1.5.10.4;Indications for Palliative Care Referral;143
1.5.10.5;Clinical Scenarios;143
1.5.10.5.1;Case Scenario 1: Unstable Angina/Cardiomyopathy;144
1.5.10.5.2;Case Scenario 2: Post-Operative Multiple System Organ Failure;146
1.5.10.5.3;Case Scenario 3: Advanced Carcinoma of the Lung;148
1.5.10.5.4;Case Scenario 4: Cardiomyopathy and Delirium;151
1.5.10.6;Conclusion;153
1.5.10.7;References;153
1.5.11;Chapter 11: Cardiopulmonary Trauma in the Elderly;154
1.5.11.1;Introduction;154
1.5.11.1.1;Background;154
1.5.11.1.2;Thoracic Trauma;154
1.5.11.1.3;Physiologic Changes;154
1.5.11.2;Rib Fractures;155
1.5.11.2.1;Flail Chest;157
1.5.11.2.2;Pain Management;157
1.5.11.2.3;Complications;158
1.5.11.3;Blunt Aortic Injury;158
1.5.11.4;Sternal Fractures;161
1.5.11.5;Cardiac Contusion;161
1.5.11.6;Conclusion;161
1.5.11.7;References;162
1.5.12;Chapter 12: Imaging Features of the Normal Aging Chest;164
1.5.12.1;Introduction;164
1.5.12.2;Lung;164
1.5.12.2.1;Morphologic Changes;164
1.5.12.2.2;Apical Cap;165
1.5.12.2.3;Focal Fibrosis;166
1.5.12.2.4;Air Trapping;166
1.5.12.2.5;Benign Intrapulmonary Lymph Nodes/Perifissural Lymph Nodes (PFNS);167
1.5.12.3;Mediastinum;168
1.5.12.3.1;Thymus;168
1.5.12.3.2;Mediastinal Lipomatosis;168
1.5.12.3.3;Aorta and Great Vessels;168
1.5.12.4;Diaphragm;172
1.5.12.5;Musculoskeletal;174
1.5.12.6;Conclusion;176
1.5.12.7;References;176
1.5.13;Chapter 13: Cardiac Imaging in the Elderly;178
1.5.13.1;Introduction;178
1.5.13.2;Cardiac Imaging Techniques;178
1.5.13.2.1;Echocardiography;178
1.5.13.2.1.1;Structural Imaging;178
1.5.13.2.1.2;Spectral Doppler;178
1.5.13.2.1.3;Color Flow Doppler;179
1.5.13.2.2;Nuclear Myocardial Perfusion Imaging;179
1.5.13.2.2.1;Technique;179
1.5.13.2.2.2;Safety;179
1.5.13.2.2.3;Indications;179
1.5.13.2.3;Cardiac Computed Tomography (CT);180
1.5.13.2.3.1;Technique;180
1.5.13.2.3.2;Indications;180
1.5.13.2.3.3;Limitations;181
1.5.13.2.4;Cardiac Magnetic Resonance Imaging (CMR);181
1.5.13.2.4.1;Indications;181
1.5.13.3;Ischemic Heart Disease;182
1.5.13.3.1;Ischemic Heart Disease Introduction;182
1.5.13.3.2;Echocardiography;183
1.5.13.3.3;SPECT Myocardial Perfusion Imaging;185
1.5.13.3.4;Multislice Computed Tomography and Magnetic Resonance Imaging;187
1.5.13.4;Congestive Heart Failure;188
1.5.13.4.1;Assessment of LV Systolic Function;189
1.5.13.4.2;Etiology of Systolic Heart Failure;189
1.5.13.4.3;Nuclear and ECHO for Viability;190
1.5.13.4.4;CMR for Viability;191
1.5.13.4.5;Diastolic Heart Failure (DHF) or “Heart Failure with Normal Ejection Fraction” (HFNEF);192
1.5.13.4.6;Assessment of LV Filling Pressure;194
1.5.13.5;Valvular Heart Disease;194
1.5.13.5.1;Aortic Stenosis;195
1.5.13.5.2;Aortic Regurgitation;196
1.5.13.5.3;Mitral Stenosis;197
1.5.13.5.4;Mitral Regurgitation;198
1.5.13.5.5;Novel Valve Imaging Applications;201
1.5.13.5.6;Prosthetic Valves;201
1.5.13.6;Post Operative Cardiac Imaging;204
1.5.13.6.1;Postoperative LV Function;205
1.5.13.6.2;Pericardial Effusion and Cardiac Tamponade;205
1.5.13.6.3;Pericardial Constriction;206
1.5.13.6.4;CT for Assessing Bypass Grafts;209
1.5.13.6.5;Preoperative Planning for Redo Surgery;209
1.5.13.7;References;210
1.6;Part II:Physiologic Changes;214
1.6.1;Chapter 14: Invited Commentary;215
1.6.2;Chapter 15: Biology of Aging;216
1.6.2.1;Introduction;216
1.6.2.2;Aging-Related Biological Decline;216
1.6.2.2.1;Extension of Life Span by Caloric Restriction;216
1.6.2.2.2;Oxidative Stress and Macromolecular Damage;217
1.6.2.2.3;Posttranslational Protein Modification;218
1.6.2.2.4;Cell Proliferation and Telomere Function;218
1.6.2.2.5;Insulin-Signaling Pathway and Response to Intake of Nutrients;220
1.6.2.2.6;Other Long-Lived Mouse Mutants;220
1.6.2.2.7;Cell Death and Turnover;221
1.6.2.3;What Could All of This Have To Do with Cardiothoracic Surgery in the Elderly Human?;222
1.6.2.3.1;Human Relevance;222
1.6.2.3.2;Oxidative Stress;222
1.6.2.3.3;Cell Replacement;222
1.6.2.3.4;Insulin-Signaling;223
1.6.2.3.5;Caloric Restriction;223
1.6.2.4;References;223
1.6.3;Chapter 16: Hematologic Disorders in the Elderly;226
1.6.3.1;Introduction;226
1.6.3.2;Anemia in the Elderly;226
1.6.3.2.1;Nutritional Deficiencies;227
1.6.3.2.2;Vitamin B12 (Cobalamine) Deficiency;228
1.6.3.2.3;Folate Deficiency;229
1.6.3.2.4;Anemia of Chronic Inflammation;229
1.6.3.2.5;Anemia Due to Renal Insufficiency;230
1.6.3.2.6;Bone Marrow Dysfunction and Myelodysplasia;230
1.6.3.3;Thrombocytopenia and Platelet Dysfunction in the Elderly;230
1.6.3.3.1;Immune Thrombocytopenic Purpura;231
1.6.3.4;Coagulation Disorders and Thrombosis;232
1.6.3.4.1;Thrombosis in the Elderly;232
1.6.3.4.2;Heparin Induced Thrombocytopenia;234
1.6.3.5;References;235
1.6.4;Chapter 17: Anticoagulation in the Older Surgical Patient;239
1.6.4.1;Special Considerations for Anticoagulating Older Patients;239
1.6.4.1.1;Risk/Benefit Changes;239
1.6.4.1.2;Increased Thrombotic Risk in Older Adults;239
1.6.4.1.3;Increased Risk of Bleeding in Older Adults;240
1.6.4.1.4;Specific Contraindications for Chronic Oral Anticoagulation;240
1.6.4.1.5;Pharmacologic Changes;241
1.6.4.1.5.1;Dosing Considerations;241
1.6.4.1.6;Strategies to Reduce Bleeding Risk;242
1.6.4.1.6.1;Surgical Site;242
1.6.4.1.6.2;Gastrointestinal Bleeding;242
1.6.4.1.6.3;Intracranial Hemorrhage;243
1.6.4.1.6.4;Fall Risk in Older Adults;243
1.6.4.2;The Surgical Patient on Chronic Anticoagulation;243
1.6.4.2.1;High Thrombotic Risk Patients;243
1.6.4.2.2;Low Thrombotic Risk;246
1.6.4.2.3;Minor Surgical Procedures;247
1.6.4.2.4;Temporary Reversal of Chronic Anticoagulation for Urgent Surgery;247
1.6.4.2.5;IVC Filters;247
1.6.4.3;Specific Surgeries with Recommended Anticoagulation Initiation;248
1.6.4.3.1;Prosthetic Valve Implantation;248
1.6.4.3.1.1;Mechanical Valve Implantation;248
1.6.4.3.1.2;Bioprosthetic Valve Implantation;248
1.6.4.3.2;Cardiac Surgery;248
1.6.4.3.3;Vascular Surgery;249
1.6.4.4;Surgical Venothromboembolic Prophylaxis;249
1.6.4.4.1;General Issues;249
1.6.4.5;Perioperative Events Requiring Anticoagulation;250
1.6.4.5.1;New Onset or Recurrent Atrial Fibrillation;250
1.6.4.5.2;Myocardial Infarction;251
1.6.4.5.3;Left Ventricular Dysfunction;251
1.6.4.5.4;Venothromboembolic Treatment;251
1.6.4.5.4.1;Anticoagulation;251
1.6.4.5.4.2;Inferior Vena Cava Filters;252
1.6.4.6;Specific Anticoagulant Use in Older Patients;252
1.6.4.6.1;Heparins;252
1.6.4.6.1.1;Unfractionated Heparin;254
1.6.4.6.1.2;Low Molecular Weight Heparin;254
1.6.4.6.1.3;Heparin Induced Thrombocytopenia;254
1.6.4.6.1.4;Direct Thrombin Inhibitors;254
1.6.4.6.1.5;Fondaparinux;255
1.6.4.6.1.6;Combining Agents;255
1.6.4.7;Summary;255
1.6.4.8;References;256
1.6.5;Chapter 18: Medication Usage in Older Cardiothoracic Surgical Patients1;258
1.6.5.1;Biology of Aging;258
1.6.5.1.1;Drug Absorption;258
1.6.5.1.2;Distribution;260
1.6.5.1.3;Metabolism;260
1.6.5.1.3.1;First-Pass Metabolism and High Hepatic Extraction Ratio Drugs;260
1.6.5.1.4;Pharmacogenomics and the Cytochrome P450 Enzymes;261
1.6.5.1.5;Renal Elimination;261
1.6.5.2;Medication-Related Problems in the Elderly;262
1.6.5.2.1;Polypharmacy in Surgical Patients;262
1.6.5.2.2;General Principles of Prescribing;263
1.6.5.2.3;Specific Prescribing Issues;264
1.6.5.2.3.1;Delirium;264
1.6.5.2.3.2;Antipsychotics;265
1.6.5.2.3.3;Antidepressants;266
1.6.5.2.3.4;Anxiolytics;267
1.6.5.2.3.5;Sedative/Hypnotics;267
1.6.5.2.3.6;Pain Management;267
1.6.5.2.3.7;Antihistamines;268
1.6.5.2.3.8;Antibiotics;268
1.6.5.3;Summary;271
1.6.5.4;References;271
1.6.6;Chapter 19: Wound Healing in the Elderly;275
1.6.6.1;Introduction;275
1.6.6.2;The Three Stages of Wound Healing;276
1.6.6.2.1;Inflammatory Phase;276
1.6.6.2.2;Proliferative Phase;276
1.6.6.2.3;Remodeling Phase;276
1.6.6.3;The Aging Skin;277
1.6.6.4;Wound Healing and Aging;278
1.6.6.5;Mucosal Tissue and Aging;278
1.6.6.6;Wound Healing, Menopause and Hormones;280
1.6.6.7;Scar Formation and Aging;281
1.6.6.8;Myocardial Tissue Healing;281
1.6.6.9;Bone Repair and Aging;282
1.6.6.10;Lung Fibrosis and Aging;282
1.6.6.11;Angiogenesis and Tissue Oxygenation;283
1.6.6.12;Clinical Implications;283
1.6.6.13;References;284
1.6.7;Chapter 20: Pulmonary Changes in the Elderly;287
1.6.7.1;Structural and Functional Changes of the Respiratory System Associated with Normal Aging;287
1.6.7.1.1;Changes in Chest Wall Mechanics and Respiratory Muscle Performance;287
1.6.7.1.2;Changes in the Airways and Lung Parenchyma;288
1.6.7.1.3;Changes in Gas Exchange and Ventilation;289
1.6.7.1.4;Changes in the Pulmonary Vasculature;289
1.6.7.2;Physiologic Manifestation of Normal Aging in the Lung on Diagnostic Testing;290
1.6.7.2.1;Review of Parameters Obtained in Pulmonary Function Testing;290
1.6.7.2.2;Changes in Forced Spirometry Associated with Normal Aging;290
1.6.7.2.3;Changes in Lung Volumes Associated with Normal Aging;290
1.6.7.2.4;Changes in Measurements of Gas Transfer Associated with Normal Aging;291
1.6.7.2.5;Alterations in Exercise Capacity Associated with Normal Aging;292
1.6.7.3;Changes in Lung Host Defense Mechanisms Associated with Normal Aging and Vulnerability to Respiratory Infections;292
1.6.7.4;References;293
1.6.8;Chapter 21: Cardiac Changes in the Elderly;294
1.6.8.1;Afterload;294
1.6.8.2;Preload;296
1.6.8.3;Contractility;297
1.6.8.4;Diastolic Function;297
1.6.8.5;Cardiovascular Response to Exercise;299
1.6.8.6;Age-Related Changes in Cardiovascular Function;299
1.6.8.7;Treatment of Congestive Heart Failure;300
1.6.8.7.1;Abnormal Left Ventricular Ejection Fraction;300
1.6.8.7.2;Normal Left Ventricular Ejection Fraction;301
1.6.8.8;Cardiovascular Disease;301
1.6.8.9;Aortic Valve Disease;301
1.6.8.10;Mitral Valvular Disease;302
1.6.8.11;Conduction Defects;302
1.6.8.12;Conclusions;302
1.6.8.13;References;303
1.6.9;Chapter 22: Renal Changes in the Elderly;308
1.6.9.1;Introduction;308
1.6.9.2;Decrease in GFR (Senile Hypofiltration);308
1.6.9.2.1;Clinical Consequences;310
1.6.9.3;Renal Vascular Changes;310
1.6.9.3.1;Clinical Consequences;311
1.6.9.4;Tubular Dysfunction;311
1.6.9.4.1;Sodium;311
1.6.9.4.2;Potassium;311
1.6.9.4.3;Clinical Consequences;312
1.6.9.5;Medullary Hypotonicity;312
1.6.9.5.1;Clinical Consequences;312
1.6.9.6;Tubular Frailty;312
1.6.9.6.1;Clinical Consequences;313
1.6.9.7;Obstructive Uropathy;313
1.6.9.7.1;Clinical Consequences;313
1.6.9.8;Conclusions;313
1.6.9.9;References;313
1.6.10;Chapter 23: Gastrointestinal and Liver Changes in the Elderly1;315
1.6.10.1;Introduction;315
1.6.10.2;The Esophagus;315
1.6.10.2.1;Anatomy;315
1.6.10.2.2;Physiology;316
1.6.10.2.3;Age Related Changes in the Phrenoesophageal Swallow Mechanism;316
1.6.10.2.4;Age Related Changes in Esophageal Contraction;317
1.6.10.3;The Stomach;318
1.6.10.3.1;Anatomy;318
1.6.10.3.2;Physiology;318
1.6.10.3.3;Gastric Acid Secretion and the Elderly;318
1.6.10.3.4;Aging and Gastric Emptying;319
1.6.10.3.5;Aging and Gastric Carcinogenesis;319
1.6.10.4;The Small Bowel;319
1.6.10.4.1;Anatomy;319
1.6.10.4.2;Physiology;319
1.6.10.4.3;Small Bowel Changes with Aging;319
1.6.10.5;The Large Intestine;320
1.6.10.5.1;Anatomy;320
1.6.10.5.2;Physiology;320
1.6.10.5.3;Age Related Changes in the Colon;320
1.6.10.6;The Liver and Hepatobiliary System;322
1.6.10.6.1;Liver Anatomy;322
1.6.10.6.2;Liver Physiology;322
1.6.10.6.3;Age Related Changes in Hepatic Function;323
1.6.10.6.4;Biliary Anatomy;324
1.6.10.6.5;Biliary Physiology;324
1.6.10.6.6;Biliary Function in the Elderly;324
1.6.10.6.7;Gallstone Pathogenesis;325
1.6.10.6.8;Cholesterol Gallstone Pathogenesis;325
1.6.10.6.9;Pigment Gallstone Pathogenesis;326
1.6.10.6.10;Lithogenic Factors in the Elderly;326
1.6.10.7;Pancreas;327
1.6.10.7.1;Anatomy;327
1.6.10.7.2;Physiology;328
1.6.10.7.3;Exocrine Function;328
1.6.10.7.4;Endocrine Function;328
1.6.10.7.5;Pancreatic Anatomy in the Elderly;329
1.6.10.7.6;Aging of the Exocrine Pancreas;330
1.6.10.7.7;Insulin Resistance in the Elderly;330
1.6.10.7.8;Glucagon;330
1.6.10.8;References;331
1.6.11;Chapter 24: Neurologic and Cognitive Changes in the Elderly;334
1.6.11.1;Introduction;334
1.6.11.2;A Brief History of Dementia;335
1.6.11.3;The Rediscovery of Alzheimer’s Disease and the Cholinergic Hypothesis;336
1.6.11.4;Alzheimer’s Disease and Dementia Today;337
1.6.11.5;The Clinical Evaluation of Cognitive Impairment in Older Adults;339
1.6.11.5.1;The History;339
1.6.11.5.2;The Examination;341
1.6.11.5.3;The Mental Status Exam;342
1.6.11.5.4;Level of Consciousness;342
1.6.11.5.5;Attention;342
1.6.11.5.6;Memory;343
1.6.11.5.7;Testing Recent Memory;343
1.6.11.5.8;Neocortical Function;344
1.6.11.5.9;Bedside Mental Status Examinations;344
1.6.11.5.10;The Remainder of the Neurological Examination;345
1.6.11.5.11;Cranial Nerves (CN);345
1.6.11.5.11.1;Visual Fields (VF; CN II)345
1.6.11.5.11.2;Visual Acuity (VA; CN II)346
1.6.11.5.11.3;Extraocular Movements (EOMs; CNs III, IV, VI)346
1.6.11.5.11.4;Facial Symmetry (CN VII);346
1.6.11.5.11.5;Hearing (CN VIII);346
1.6.11.5.11.6;Speech (CNs V, VII, IX, X; See Also CN XII Below)347
1.6.11.5.11.7;Cervical Rotation (CN XI; Sternocleidomastoid Muscles)347
1.6.11.5.11.8;Tongue (CN XII);347
1.6.11.5.12;Motor;347
1.6.11.5.12.1;Strength;347
1.6.11.5.12.1.1;Proximal Extremity Strength;347
1.6.11.5.12.1.2;Distal Extremity Strength;347
1.6.11.5.12.2;Bulk;347
1.6.11.5.12.3;Tone;347
1.6.11.5.12.4;Deep Tendon Reflexes (DTRs);348
1.6.11.5.12.4.1;Plantar Reflex;348
1.6.11.5.12.5;Sensory;348
1.6.11.5.12.6;Position;348
1.6.11.5.12.7;Light Touch;348
1.6.11.5.13;Coordination, Station and Gait;348
1.6.11.5.13.1;Gait;348
1.6.11.5.13.2;Postural Stability;349
1.6.11.5.13.3;Coordination;349
1.6.11.5.13.4;Involuntary, Uncontrolled, or Diminished Movements;349
1.6.11.6;Summary and Conclusions;350
1.6.11.7;References;350
1.6.12;Chapter 25: Hormonal Changes During and After Cardiac Surgery;352
1.6.12.1;Endocrine Changes During Aging;352
1.6.12.1.1;Changes in Pituitary-Gonadal Function During Aging in Men and Women;352
1.6.12.1.2;Changes in GH-IGF-1 Axis During Aging;353
1.6.12.1.3;Changes and Consequences of Altered Hypothalamus Pituitary Adrenal Axis During Aging;353
1.6.12.1.4;Changes and Consequences of Altered Hypothalamic-Pituitary-Thyroid Axis During Aging;353
1.6.12.2;Acute Hormonal Changes After Cardiac Surgery;354
1.6.12.2.1;Cardiac Surgery as a Model of Nonsurgical Critical Illness;354
1.6.12.2.2;Potential Mechanisms Underlying the Hormonal Response to Coronary Artery Bypass Grafting: The Role of Oxidative Stress and Inflammation;354
1.6.12.2.3;Changes in Thyroid Hormones After CABG;355
1.6.12.2.4;Observational Studies;355
1.6.12.2.5;Intervention Studies Using T3 in CABG;356
1.6.12.2.6;Adrenal Hormones and CABG;356
1.6.12.2.6.1;Changes in Cortisol and ACTH Levels After Cardiac Surgery;356
1.6.12.2.6.2;Changes in DHEA, DHEAS Levels After Cardiac Surgery;358
1.6.12.2.6.3;Changes in Sex Hormone Levels After Cardiovascular Surgery;358
1.6.12.2.6.4;Changes in GH-IGF-1 Levels After Cardiac Surgery;360
1.6.12.2.7;The Significance of Hormonal Changes in Young vs. Older Population;361
1.6.12.2.8;Duration of Hormonal Changes and Recovery to Baseline;362
1.6.12.2.8.1;Thyroid Hormones;362
1.6.12.2.8.2;Adrenal Hormones;362
1.6.12.2.8.3;Sex Hormones;362
1.6.12.2.8.4;GH-IGF-1 Axis;362
1.6.12.2.9;Possible Clinical Implications of Postsurgical Endocrine Changes: Adaptive Phenomenon or Therapeutic Targets?;363
1.6.12.3;References;363
1.7;Part III:Cardiac Surgery;369
1.7.1;Chapter 26: Invited Commentary;370
1.7.2;Chapter 27: Preoperative Evaluation and Preparation in the Elderly Cardiac Surgery Patient;372
1.7.2.1;Introduction;372
1.7.2.2;Nutritional Evaluation;372
1.7.2.3;Assessment of Risk for Delirium;373
1.7.2.4;Assessment of Disability;375
1.7.2.5;Advance Directives/Medical Proxy;375
1.7.2.6;Conclusion;376
1.7.2.7;References;376
1.7.3;Chapter 28: Cardiac Anesthesia in the Elderly;377
1.7.3.1;Preoperative Considerations;377
1.7.3.1.1;Neurological;377
1.7.3.1.2;Cardiovascular;377
1.7.3.1.3;Pulmonary;378
1.7.3.1.4;Renal;379
1.7.3.1.5;Endocrine;379
1.7.3.1.6;Fluid Balance;379
1.7.3.2;Induction of Anesthesia;379
1.7.3.2.1;Monitors;379
1.7.3.3;Drugs;381
1.7.3.3.1;Sedative Hypnotics;381
1.7.3.3.2;Opiates;382
1.7.3.3.3;Muscle Relaxants;382
1.7.3.3.4;Volatile Anesthetics;383
1.7.3.4;Maintenance of Anesthesia;383
1.7.3.4.1;Prebypass;383
1.7.3.4.2;Bypass;384
1.7.3.4.3;Separation from Bypass;384
1.7.3.4.4;Post Bypass;384
1.7.3.4.5;Postoperative Period;384
1.7.3.5;References;385
1.7.4;Chapter 29: Postoperative and Critical Care in the Elderly Cardiac Surgery Patient;387
1.7.4.1;Introduction;387
1.7.4.2;Operation-Specific Risk Factors;388
1.7.4.3;Renal Insufficiency;389
1.7.4.4;Gastrointestinal Complications;390
1.7.4.5;Neurologic Impairment;391
1.7.4.6;Pulmonary Care;392
1.7.4.7;Cardiovascular Management;394
1.7.4.8;Wound Complications;394
1.7.4.9;Cardiac Rehabilitation;395
1.7.4.10;References;397
1.7.5;Chapter 30: Surgery for Ischemic Coronary Disease in the Elderly1;399
1.7.5.1;Characteristics of the Elderly Cardiac Surgery Population;399
1.7.5.2;Predictors of Perioperative Morbidity and Mortality;401
1.7.5.3;Quality of Life;403
1.7.5.4;Possible Strategies to Decrease Operative Risk;404
1.7.5.5;Nonsurgical Alternatives;405
1.7.5.6;The New Era of Mechanical Circulatory Assist;406
1.7.5.7;Guidelines for Therapy in the Elderly Cardiac Surgery Patient;407
1.7.5.8;Conclusions;407
1.7.5.9;References;408
1.7.6;Chapter 31: Surgical Treatment of Aortic Valve Disease in the Elderly;410
1.7.6.1;Introduction;410
1.7.6.2;Nonsurgical Management;411
1.7.6.3;Surgical Technique of Conventional AVR;411
1.7.6.3.1;Preoperative Assessment;411
1.7.6.3.2;Intraoperative Technique;412
1.7.6.3.3;Postoperative Care;412
1.7.6.3.4;Predictive Models;414
1.7.6.3.5;Outcomes;414
1.7.6.3.5.1;In-Hospital Mortality;414
1.7.6.3.5.2;Mid- and Long-Term Survival;415
1.7.6.3.5.3;Quality of Life and Cost;416
1.7.6.4;Alternative to Sternotomy AVR;416
1.7.6.4.1;Left Ventricular Apex to Descending Aortic Conduits;416
1.7.6.4.2;Surgical Technique;416
1.7.6.4.3;Outcomes;417
1.7.6.5;Transcatheter Aortic Valve Implantation;418
1.7.6.6;Conclusions;420
1.7.6.7;References;420
1.7.7;Chapter 32: Surgical Treatment of Mitral Valve Disease in the Elderly;423
1.7.7.1;Introduction;423
1.7.7.2;Pathophysiology;424
1.7.7.3;Natural History;425
1.7.7.4;Assessment;425
1.7.7.5;Management;426
1.7.7.5.1;Medical Therapy;426
1.7.7.5.2;Surgical Treatment;426
1.7.7.5.3;Surgical Techniques;426
1.7.7.5.3.1;Mitral Valve Replacement;426
1.7.7.5.3.2;Mitral Valve Repair;427
1.7.7.6;Results of Surgery;430
1.7.7.6.1;Mitral Repair vs. Replacement in Elderly;430
1.7.7.6.2;Improved Outcomes;430
1.7.7.6.3;Survival;431
1.7.7.6.4;Others;431
1.7.7.7;Conclusion;431
1.7.7.8;References;432
1.7.8;Chapter 33: Surgical Treatment of Thoracic Aortic Disease in the Elderly;435
1.7.8.1;Cardiovascular Surgery in the Aging Population;435
1.7.8.2;Aneurysmal Disease of the Thoracic Aorta;435
1.7.8.2.1;Surgery of the Ascending Aorta and Aortic Arch;436
1.7.8.2.2;Surgery of the Descending and Thoracoabdominal Aorta;437
1.7.8.2.3;Penetrating Atherosclerotic Ulcers;438
1.7.8.3;Aortic Dissection Syndromes;438
1.7.8.3.1;Acute Type A Aortic Dissection;439
1.7.8.3.2;Acute Type B Aortic Dissection;440
1.7.8.3.3;Intramural Hematoma of the Thoracic Aorta;441
1.7.8.4;Endovascular Treatment of Thoracic Aneurysmal Disease;441
1.7.8.4.1;Palliative Care in Elderly Patients with Terminal Thoracic Aortic Condition;442
1.7.8.5;Conclusion;442
1.7.8.6;References;443
1.7.9;Chapter 34: Surgical Treatment of Pericardial Disease in the Elderly;445
1.7.9.1;Anatomy;445
1.7.9.2;Physiology;445
1.7.9.3;Pericardial Diseases;446
1.7.9.3.1;Acute Pericarditis;446
1.7.9.3.2;Constrictive Pericarditis;446
1.7.9.4;Pericardial Effusion and Acute Cardiac Tamponade;448
1.7.9.5;Pericardial Neoplasms;449
1.7.9.6;Postcardiac Surgery Injury Syndromes;449
1.7.9.7;References;449
1.7.10;Chapter 35: Pacemakers and Implantable Cardioverter Defibrillators in the Elderly;451
1.7.10.1;Introduction;451
1.7.10.2;Epidemiology of Pacemaker and Implantable Cardioverter Defibrillator Use;451
1.7.10.3;The Conventional Role of Pacemakers in the Elderly;452
1.7.10.4;Pacing for Non-Accidental Falls and Carotid Sinus Hypersensitivity;452
1.7.10.5;Technical Issues for Cardiac Rhythm Device Implantation in the Elderly, Including Risk of Device-Related Complications;453
1.7.10.6;Implantable Cardioverter Defibrillators in Elderly Patients;456
1.7.10.7;Appropriate Programming of Pacemakers and Defibrillators in Elderly Patients;458
1.7.10.8;Conclusions;458
1.7.10.9;References;458
1.7.11;Chapter 36: Heart Transplantation and Mechanical Assistance in the Elderly;461
1.7.11.1;Introduction;461
1.7.11.2;Heart Transplantation;462
1.7.11.3;Destination Therapy;465
1.7.11.4;Rematch;465
1.7.11.4.1;Heartmate II Destination Trial;466
1.7.11.4.2;Patient Selection for Destination Therapy;466
1.7.11.4.3;Certification;467
1.7.11.5;Conclusion;467
1.7.11.6;References;467
1.8;Part IV:Thoracic Surgery;469
1.8.1;Chapter 37: Invited Commentary;470
1.8.2;Chapter 38: Preoperative Evaluation and Preparation in the Elderly Thoracic Surgery Patient;471
1.8.2.1;Introduction;471
1.8.2.2;Indications for Surgery in the Older Patient;471
1.8.2.3;Traditional Preoperative Assessment Prior to Cardiothoracic Surgery;473
1.8.2.3.1;Pulmonary Risk and Evaluation;473
1.8.2.3.2;Cardiac Risk and Evaluation;474
1.8.2.4;Informed Consent and Capacity to Consent;475
1.8.2.5;Geriatric Assessment;475
1.8.2.5.1;Evaluation of Geriatric Assessment Prior to Cardiothoracic Surgery;475
1.8.2.6;Conclusion;477
1.8.2.7;References;477
1.8.3;Chapter 39: Thoracic Anesthesia in the Elderly;480
1.8.3.1;Introduction;480
1.8.3.2;Physiology and Risk Factors;481
1.8.3.2.1;Cardiovascular;481
1.8.3.2.2;Pulmonary;481
1.8.3.2.3;Hepatic;481
1.8.3.2.4;Renal;482
1.8.3.2.5;Nervous System;482
1.8.3.2.6;Temperature Regulation;482
1.8.3.3;Anesthesia;482
1.8.3.3.1;Inhaled Anesthetics;482
1.8.3.3.2;Hypnotics;483
1.8.3.3.3;Muscle Relaxants;483
1.8.3.3.4;Narcotics;483
1.8.3.3.5;Positioning;483
1.8.3.3.6;Comorbidity;483
1.8.3.4;Surgical Population;484
1.8.3.5;Anesthetic Management;485
1.8.3.6;Pain Control and Delirium;485
1.8.3.7;Summary;485
1.8.3.8;References;486
1.8.4;Chapter 40: Postoperative and Critical Care in the Elderly Thoracic Surgery Patient;488
1.8.4.1;Introduction;488
1.8.4.2;Cardiovascular Physiology;489
1.8.4.3;Pulmonary Physiology;489
1.8.4.4;Renal Physiology;490
1.8.4.5;Preoperative Assessment;491
1.8.4.5.1;Cardiac Evaluation;491
1.8.4.5.2;Pulmonary Evaluation;492
1.8.4.6;Intraoperative Approaches to Minimize Morbidity;493
1.8.4.6.1;Anesthesia;493
1.8.4.6.2;Minimally Invasive Operation;493
1.8.4.7;Outcomes;493
1.8.4.8;Pain Management;495
1.8.4.9;Neurocognitive Dysfunction;496
1.8.4.10;End-of-Life Issues;497
1.8.4.11;References;497
1.8.5;Chapter 41: Adjuvant Therapy for Lung Cancer in the Elderly;502
1.8.5.1;Introduction;502
1.8.5.2;Elderly-Specific Data;503
1.8.5.3;Neoadjuvant Therapy;505
1.8.5.4;Choice of Chemotherapy Regimen in the Elderly;505
1.8.5.5;Conclusions;506
1.8.5.6;References;507
1.8.6;Chapter 42: Pulmonary Surgery for Malignant Disease in the Elderly;509
1.8.6.1;Introduction;509
1.8.6.2;Lung Cancer Treatment in the Elderly;510
1.8.6.3;Case Study;510
1.8.6.4;Preoperative Evaluation;510
1.8.6.4.1;Functional and Performance Status;511
1.8.6.4.2;Cardiac Assessment and Perioperative Cardiac Management;511
1.8.6.4.3;Pulmonary Assessment;512
1.8.6.5;Nonsmall Cell Lung Cancer in the Elderly;512
1.8.6.5.1;Histology;512
1.8.6.5.2;Stage at Presentation;513
1.8.6.5.3;Surgical Planning;513
1.8.6.5.3.1;Surgical Approach;513
1.8.6.5.3.2;Extent of Resection;513
1.8.6.5.4;Advances in Technology and the Elderly;514
1.8.6.5.5;Recommended Treatment Algorithm;515
1.8.6.6;Pulmonary Carcinoid;516
1.8.6.7;Surgical Resection of Pulmonary Metastases;516
1.8.6.8;Postoperative Care;516
1.8.6.9;Conclusion;517
1.8.6.10;References;517
1.8.7;Chapter 43: Benign Thoracic Disease in the Elderly1;520
1.8.7.1;Introduction;520
1.8.7.2;Disease of the Chest Wall and Pleura;520
1.8.7.2.1;Mondor’s Disease;520
1.8.7.2.2;Lung Herniation;521
1.8.7.2.3;Pneumomediastinum;521
1.8.7.2.4;Kyphosis;521
1.8.7.3;Neoplastic Disease;522
1.8.7.3.1;Benign Lung Tumors;522
1.8.7.3.1.1;Epithelial Tumors;522
1.8.7.3.1.1.1;Papillomas;522
1.8.7.3.1.1.2;Sclerosing Hemangioma (Pneumocytoma);522
1.8.7.3.1.1.3;Alveolar Adenoma;522
1.8.7.3.1.1.4;Type II Pneumocyte Papilloma;523
1.8.7.3.1.1.5;Mucous Gland Adenomas;523
1.8.7.3.1.1.6;Mucinous Cystadenoma;523
1.8.7.3.1.2;Mesenchymal Tumors;523
1.8.7.3.1.2.1;Hamartoma;523
1.8.7.3.1.2.2;Solitary Fibrous Tumor of the Lung;523
1.8.7.3.1.2.3;Clear Cell (Sugar Tumor);523
1.8.7.3.1.2.4;Other Mesenchymal Tumors;523
1.8.7.4;Infectious and Rheumatologic Disease;524
1.8.7.4.1;Pneumonia;524
1.8.7.4.2;Empyema;524
1.8.7.4.3;Rheumatoid Pleural Effusions;525
1.8.7.5;Chronic Obstructive Pulmonary Disease in the Elderly;526
1.8.7.6;Summary;527
1.8.7.7;References;528
1.8.8;Chapter 44: Lung Transplantation in the Elderly;530
1.8.8.1;Introduction;530
1.8.8.2;Elderly Lung Transplant Recipients;530
1.8.8.3;Selection of Elderly Candidates for Lung Transplantation;532
1.8.8.4;Technical Considerations for Elderly Lung Transplant Recipients;534
1.8.8.5;Elderly Lung Transplant Donors;534
1.8.8.6;Considerations in the Allocation of Donor Lungs;535
1.8.8.7;Summary;535
1.8.8.8;References;536
1.8.9;Chapter 45: Esophageal Surgery for Malignant Disease in the Elderly;537
1.8.9.1;Histologic Classification, Location, and Incidence;538
1.8.9.2;Pathogenesis;539
1.8.9.3;Diagnosis;541
1.8.9.4;Staging;543
1.8.9.5;Analysis of Comorbidities and Medical Clearance;544
1.8.9.6;Therapy for Premalignant Disease;544
1.8.9.7;Therapy for Invasive Carcinoma;544
1.8.9.8;Surgery;544
1.8.9.9;Esophagectomy in the Elderly;547
1.8.9.10;Neoadjuvant Therapy;548
1.8.9.11;Surgery vs. Chemoradiation in the Elderly;549
1.8.9.12;Palliation;549
1.8.9.13;Radiation;549
1.8.9.14;Chemotherapy;550
1.8.9.15;Endoscopic Palliation;550
1.8.9.16;Stenting;550
1.8.9.17;Neodymium: Yttrium-Aluminum-Garnet Laser Fulguration;551
1.8.9.18;Photodynamic Therapy;551
1.8.9.19;References;551
1.8.10;Chapter 46: Esophageal Surgery for Benign Disease in the Elderly;554
1.8.10.1;Introduction;554
1.8.10.2;Pathophysiology of the Aging Esophagus;554
1.8.10.3;Dysphagia in the Elderly;555
1.8.10.4;Esophageal Motility in the Elderly Patient;555
1.8.10.4.1;Upper Esophageal Sphincter (UES);555
1.8.10.4.2;Body of the Esophagus;556
1.8.10.4.3;Lower Esophageal Sphincter (LES);556
1.8.10.5;Manometry in the Elderly Patient;556
1.8.10.6;Esophageal Surgery for Benign Esophageal Disorders;557
1.8.10.6.1;Paraesophageal Hernia/Hiatal Hernia;557
1.8.10.6.2;Gastroesophageal Reflux Disease (GERD);559
1.8.10.6.3;Peptic Stricture;561
1.8.10.6.4;Barrett’s Esophagus;561
1.8.10.6.5;Achalasia;561
1.8.10.6.6;Diffuse Esophageal Spasm and Hypercontracting “Nutcracker” Esophagus;563
1.8.10.7;Esophageal Diverticula;564
1.8.10.7.1;Zenker’s Diverticulum;565
1.8.10.7.2;Epiphrenic Diverticulum;566
1.8.10.8;Summary;566
1.8.10.9;References;567
1.8.11;Chapter 47: Surgery for Mediastinal Disease in the Elderly;569
1.8.11.1;Thymoma and Thymic Carcinoma;569
1.8.11.1.1;Diagnosis;570
1.8.11.1.2;Pathology;571
1.8.11.2;Staging;572
1.8.11.2.1;Early Stage Thymoma;572
1.8.11.2.2;Operable or Potentially Operable Locally Advanced Thymoma;573
1.8.11.2.3;Post Induction Surgery;573
1.8.11.3;Prognosis;574
1.8.11.4;Substernal and Intrathoracic Goiters;574
1.8.11.5;Mediastinal Lymphoma;576
1.8.11.6;Posterior Mediastinal Neurogenic Tumors;577
1.8.11.7;References;577
1.8.12;Chapter 48: Surgery for Pleural Disease in the Elderly;580
1.8.12.1;Introduction;580
1.8.12.2;Air: Pneumothorax;580
1.8.12.3;Fluid: Pleural Effusions;581
1.8.12.4;Pleural Space Infections;582
1.8.12.5;Malignant Pleural Effusions;582
1.8.12.6;Methods of Pleurodesis;583
1.8.12.7;Chronic Drainage with Indwelling Catheters;584
1.8.12.8;Tumors of the Pleura;584
1.8.12.9;References;585
1.8.13;Chapter 49: Surgery for Chest Wall Disease in the Elderly;587
1.8.13.1;Indications;587
1.8.13.2;Preoperative Evaluation;587
1.8.13.3;Principles of Reconstruction;588
1.8.13.4;Management of Pleural Cavity;589
1.8.13.5;Management of Skeleton;589
1.8.13.6;Management of Soft Tissue;592
1.8.13.7;Muscle Transposition;592
1.8.13.8;Omental Transposition;593
1.8.13.9;Clinical Experience;594
1.8.13.10;Conclusion;595
1.8.13.11;References;595
1.8.14;Chapter 50: Surgery of the Trachea and Bronchi in the Elderly;597
1.8.14.1;Introduction;597
1.8.14.2;Anatomy of the Trachea;597
1.8.14.3;Airway Pathology;597
1.8.14.4;Tracheal and Bronchial Neoplasms;598
1.8.14.5;Airway Stenosis;600
1.8.14.6;Acquired Airway Esophageal Fistulae;600
1.8.14.7;Tracheobronchial Malacia and Saber-Sheath Trachea;601
1.8.14.8;Extrinsic Airway Compression;601
1.8.14.9;Preoperative Diagnostic Procedures;601
1.8.14.10;Anesthesia;602
1.8.14.11;Tracheostomy in the Elderly;602
1.8.14.12;Tracheal T-Tubes and Airway Stents;603
1.8.14.13;Laryngotracheal and Tracheal Resection for Airway Stenosis and Tumors;603
1.8.14.14;Resection and Reconstruction for Airway Esophageal Fistula;605
1.8.14.15;Carinal Reconstruction;606
1.8.14.16;Main and Lobar Bronchoplasty;608
1.8.14.17;Conclusion;608
1.8.14.18;References;609
1.9;Appendix A: Indices;610
1.10;Appendix B: Function;611
1.11;Appendix C: Physiologic;616
1.12;Appendix D: References;620
1.13;Index;621