In the preface to this impressive and well-produced book, the editors state that their aim is not to describe a new surgical specialty, since most surgeons will soon need to be "geriatric surgeons," but to assemble a comprehensive account that will allow "all providers of healthcare to the elderly to understand the issues involved in choosing surgery as a treatment option for their patients."
The editors of any book about problems associated with the medical or surgical treatment of older people have to decide how much space to devote to their chosen subject and how much to devote to background information. The editors of Principles and Practice of Geriatric Surgery have adopted a two-part structure that works relatively well. Part 1, the first fifth of the book, is entitled "General Principles," and part 2, "Specific Issues in Geriatric Surgery," focuses on organ systems. A nice touch is the inclusion of a commentary at the beginning of each major section, in which a senior figure takes a broad look at major developments in the field.
Part 1 begins with chapters on cell and molecular aging, demography, carcinogenesis, immune function, and nutrition. Chapters on surgical topics follow, beginning with an excellent chapter in which Katlic identifies what he considers to be the six principles of geriatric surgery. Another impressive chapter draws together a large amount of information about the preoperative evaluation of the elderly patient undergoing surgery. Part 1 also contains the only chapter that deals specifically with anesthesia for geriatric surgery. The main shortcoming of this chapter is not its content but its brevity: it comprises only 13 of the 1053 pages of text in the book, and the index mentions only 7 other pages in which topics related to anesthesia are discussed. This is an important deficiency in a book that aims to be comprehensive.
Part 1 concludes with a section entitled "Ethical Considerations." The chapter on ethical principles is short, and a more detailed treatment, with illustrative case histories, would have been welcome. The chapter on rationing and cost effectiveness also contains useful discussions of ethics.
Part 2 of the book begins with two chapters on critical care and trauma and then discusses the various body systems. The "normal" aging of individual organs is described at the beginning of each section. Most of the authors of this part of the book avoided the temptation to give step-by-step accounts of surgical techniques. A particularly nice example of the balance that can be struck between the needs of the specialist and the needs of the nonspecialist reader is the chapter by Camacho et al. on cardiac surgery in the elderly. In a short chapter, the authors consider the characteristics of the elderly population undergoing cardiac surgery, predictors of adverse postoperative outcomes, quality of life, strategies to decrease the operative risk in older patients, and nonsurgical alternatives and offer general guidelines for therapy and referral. Similarly, most of the chapters on the gastrointestinal system discuss specific problems relevant to older patients while offering a broad enough view to enlighten those who are not specialists in surgery, anesthesia, or geriatric medicine.
In some instances, more information would have been welcome. For example, there is little detail about the surgical treatment of benign ear, nose, and throat conditions, and in the section on neurosurgery there is little mention of intracerebral emergencies, such as subdural hematoma, for which identification and early referral by nonspecialists are particularly important.
This is a useful book that deserves to do well. I hope that the editors and their publisher will have the stamina to make this the first of several editions, as it is clear that updated information about surgery in the elderly will be required to keep pace with this important field.
D. Gwyn Seymour, M.D.
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