Emergency presentation and mortality from colorectal cancer in the elderly

Adjuvant Chemotherapy Benefit in Elderly Stage II/III Colon Cancer Patients

Background

Studies providing more evidence to guide adjuvant chemotherapy decisions in elderly colon cancer patients are expected.

Methods

We obtained data from the Surveillance, Epidemiology and End Results (SEER) database between 2004 and 2012. Kaplan-Meier survival curves were constructed to calculate the cancer-specific survival (CSS) rate, and comparisons of survival difference between different subgroups were performed using the log-rank test. Multivariate Cox proportional hazards regression models were carried out to estimate hazard ratio (HR) and 95% confidence intervals (CIs) of different clinicopathological characteristics.

Results

In stage II colon cancer patients aged 70 years or older, the Kaplan-Meier survival analysis showed that the 5-year CSS rates of no chemotherapy and chemotherapy groups were 82.0% and 72.4%, respectively (P < 0.001). In stage III colon cancer patients aged 70 years or older, the Kaplan-Meier survival analysis showed that the 5-year CSS rates of no chemotherapy and chemotherapy groups were 50.7% and 61.3%, respectively (P < 0.001). Patients with chemotherapy receipt were independently associated with a 35.8% lower cancer-specific mortality rate (HR = 0.642, 95% CI: 0.620-0.665, P < 0.001) compared with those who did not receive chemotherapy.

Conclusions

Adjuvant chemotherapy should be considered during the treatment of stage III colon cancer patients aged 70 years or older, but the chemotherapy benefit in elderly stage II colon cancer is suboptimal.

Breast Cancer in Women Over 65 years- a Review of Screening and Treatment Options

Breast cancer is becoming increasingly prevalent in the women greater than 65 years of age. Most tumors are hormone receptor-positive in this group. Breast cancer screening recommendations for older women should be tailored based on life expectancy. Early stage breast cancer should be treated with conservative surgery followed by adjuvant endocrine therapy in HR+ patients. Primary endocrine therapy is a low-risk option for those with limited life expectancy. Adjuvant radiation therapy can be avoided in early stage, low-risk cancers. Evaluation should include comprehensive geriatric assessment. Treatment with less cytotoxic chemotherapy, HER-2 targeted therapies, and other biomarker-driven, molecularly targeted therapies should be sought whenever possible.

Time Trends in the Diagnosis of Colorectal Cancer With Obstruction, Perforation, and Emergency Admission After the Introduction of Population-Based Organized Screening

IMPORTANCE

Up to 30% of patients with a diagnosis of colorectal cancer (CRC) present as an emergency (an intestinal obstruction, perforation, or emergency hospital admission) (OPE). There are limited data about the association of organized, population-based colorectal cancer screening with the rate of emergency presentations.

OBJECTIVE

To examine the association of CRC screening with OPE at cancer diagnosis and time trends in the rate of OPE after the start of organized CRC screening using a highly sensitive fecal occult blood test.

DESIGN, SETTING, AND PARTICIPANTS

A historical cohort study was conducted among 1861 individuals 52 to 74 years of age with a diagnosis of CRC from January 1, 2007, to December 31, 2015, who lived in Winnipeg, Manitoba, a province with universal health care and an organized CRC screening program. Statistical analysis was performed from January 22, 2019, to February 26, 2020.

EXPOSURES

Variables included prior CRC screening, era of diagnosis, cancer stage at diagnosis, tumor site in the colon, area level mean household income, primary care continuity of care, and comorbidity.

MAIN OUTCOMES AND MEASURES

The primary outcomes were defined as an OPE. Logistic regression was used to evaluate factors associated with OPE at CRC diagnosis. Trends over time were calculated using Joinpoint Regression.

RESULTS

From 2007 to 2015, 1861 individuals 52 to 74 years of age (1133 men; median age, 65.1 years [interquartile range, 60.0-70.3 years]) received a diagnosis of CRC in Winnipeg. Most individuals had good continuity of care and moderate comorbidities. Overall, 345 individuals (18.5%) had an OPE. The rate of emergency hospital admissions decreased significantly from 2007 (the start of the organized, province-wide CRC screening program) to 2015 (annual change, -7.1%; 95% CI, -11.3% to -2.8%; P = .01). There was no change in the rate of obstructions or perforations or stage IV CRCs. Individuals who were up to date for CRC screening were significantly less likely to receive a diagnosis of an OPE (odds ratio, 0.38; 95% CI, 0.28-0.50; P < .001). The results were similar after adding emergency department visits and stage IV CRC at diagnosis to the outcome.

CONCLUSIONS AND RELEVANCE

This study suggests that the rate of emergency hospital admissions decreased over time for individuals who underwent CRC screening, but there was no change in the rate of obstructions and perforations. Individuals who were up to date for CRC screening were less likely to have a CRC diagnosis with an OPE.

Colon metal stents as a bridge to surgery had no significant effects on the perineural invasion: a retrospective study

Purpose

The long-term oncological effects of self-expandable metallic stent (SEMS) as a “bridge to surgery” are contradictory, and perineural invasion was supposed to be enhanced by the stenting. In this retrospective study, we compared the perineural invasion and the oncological outcomes between the stent as a bridge to surgery (SBTS)- and emergency surgery (ES)-treated patients to evaluate the results of stenting on the perineural invasion.

Methods

The clinical data of patients with acute intestinal obstruction caused by colorectal cancer from January 2013 to January 2017 were retrospectively collected. Forty-three patients underwent semi-elective curative resection after endoscopic SEMS insertion, and sixty-three underwent ES. The adverse events and long-term follow-up outcomes were assessed. The clinicopathological characteristics, perineural invasion rates, and survival rates were compared between the two patient groups.

Results

Stent insertion resulted in significantly lower stoma rate (32.6% vs 46%; P = 0.03), post-operative overall complication rate (11.6% vs 28.6%, P = 0.038), and total hospital stay (17.07 ± 5.544 days vs 20.48 ± 7.372 days, P = 0.042). Compared with the ES group, there was no significant increase in the incidence of peripheral invasion in the SBTS group (39.5% vs 47.6%, P = 0.411). No significant difference was noted in the survival rate and long-term prognosis between the SEMS and ES groups (P = 0.964). The technical success rate was 95.6%, and the clinical success rate was 97.7%.

Conclusions

Preoperative colon stenting was an effective transitional method for colorectal cancer patients with complete obstruction. Short-term stent implantation had no significant effect on perineural invasion in patients with CRC.

Comparative Age-Based Prospective Multi-Institutional Observations of 12,367 Patients Enrolled to the American College of Surgeons Oncology Group (ACOSOG) Z901101 Trials (Alliance)

BACKGROUND

The risk of surgery, particularly for older cancer patients with serious, extensive comorbidities, can make this otherwise curative modality precarious. Leveraging data from the American College of Surgeons Oncology Group, this study sought to characterize age-based comparative demographics, adverse event rates, and study completion rates to define how best to conduct research in older cancer patients.

METHODS

This study relied on clinical data from 21 completed studies to assess whether older patients experienced more grade 3 or worse adverse events and were more likely to discontinue study participation prematurely than their younger counterparts.

RESULTS

The study enrolled 12,367 patients. The median age was 60 years, and 36% of the patients were 65 years of age or older. Among 4008 patients with adverse event data, 1067 (27%) had experienced a grade 3 or worse event. The patients 65 years or older had higher rates of grade 3 or worse adverse events compared to younger patients [32% vs. 24%; odds ratio (OR), 1.5; 95% confidence interval (CI), 1.3-1.7; p < 0.0001]. This association was not observed in multivariate analyses. The study protocol was completed by 97% of the patients. No association was observed between age and trial completion (OR 0.8; 95% CI 0.7-1.1; p = 0.14). Only the older gastrointestinal cancer trial patients were less likely to complete their studies compared to younger patients (OR 0.50; 95% CI 0.30-0.70; p < 0.0001).

CONCLUSION

Despite higher rates of adverse events, the older patients typically completed the study protocol, thereby contributing relevant data on how best to render care to older cancer patients and affirming the important role of enrolling these patients to surgical trials.

Post-operative outcomes and predictors of mortality after colorectal cancer surgery in the very elderly patients

BACKGROUND

The frailty of the very elderly patients who undergo surgery for colorectal cancer negatively influences postoperative mortality. This study aimed to identify risk factors for postoperative mortality in octogenarian and nonagenarian patients who underwent surgical treatment for colorectal cancer.

METHODS

This is a single institution retrospective study. The primary outcomes were risk factors for postoperative mortality. The variables of the octogenarians and nonagenarians were compared by using t-test, chi-square test, and Fisher exact test. A multivariate logistic regression analysis was carried out on the combined cohorts.

RESULTS

we identified 319 octogenarians and 43 nonagenarians (N = 362) who underwent surgery for colorectal cancer at the Sant'Orsola-Malpighi university hospital in Bologna between 2011 and 2015. The 30-day post-operative mortality was 6% (N = 18) among octogenarians and 21% (N = 9) for the nonagenarians.The groups significantly differed in the type of surgery (elective vs. urgent surgery, p < 0.0001), ASA score (p = 0.0003) and rates of 30-day postoperative mortality (6% vs. 21%, p = 0.0003).In the multivariate analysis ASA > III (OR 2.37, 95% CI [1.43-3.93], p < 0,001), and urgent surgery (OR 2.17, 95% CI [1.17-4.04], p = 0.014) were associated to post-operative mortality. On the contrary, pre-operative albumin≥3.4 g/dL (OR 0.14, 95% CI [0.05-0.52], p = 0.001) was associated with a protective effect on postoperative mortality.

CONCLUSIONS

In the very elderly affected by colorectal cancer, preoperative nutritional status and pre-existing comorbidities, rather than age itself, should be considered as selection criteria for surgery. Preoperative improvement of nutritional status and ASA risk assessment may be beneficial for stratification of patients and ultimately for optimizing outcomes.

Clinical Effectiveness of Endoscopic Stent Placement in Treatment of Acute Intestinal Obstruction Caused by Colorectal Cancer

Background

Emergency endoscopic intestinal stenting has been applied with increasing frequency in colorectal cancer patients with acute intestinal obstruction. However, its clinical effectiveness as compared to emergency surgery remains controversial.

Material/Methods

The clinical data of 96 patients with acute intestinal obstruction caused by colorectal cancer from April 2012 to April 2018 were retrospectively collected. Statistical technique success rate, clinical success rate, operative time, average indwelling time of stent, complications, transition time to second-stage surgery, postoperative hospital stay, sputum rate, and postoperative infection rate were studied.

Results

Endoscopic colonoscopy was successfully performed in 94 patients. The success rate of stent placement was 97.9%, and the average operative time was 35 minutes (range, 25–85 minutes). Forty-two patients underwent stage I colectomy after relief of the obstruction. The average stent retention time was 7 days (range, 5–15 days). Two patients suffered from anastomotic infection. Their intestinal preparation time, hospital stay, fistula rate, and infection rate were lower than those of patients undergoing emergency operation for colon cancer intestinal obstruction. A total of 52 patients with colon cancer underwent palliative stent placement. Three patients had complications, including 1 case of stent displacement in the palliative care group and 2 cases with perforation in the bridge surgery group.

Conclusions

Emergency endoscopic placement of an intestinal stent is safe and effective in the treatment of patients with acute intestinal obstruction caused by colorectal cancer. It is also a safe and simple procedure for patients receiving advanced palliative treatment, which greatly improves their quality of life and is easy for patients’ families to accept.

Surgical approach and geriatric evaluation for elderly patients with colorectal cancer

This review aims to define the most appropriate surgical approach and geriatric evaluation for elderly patients with colorectal cancer (CRC). Surgery represents the main treatment for CRC, but elderly cancer patients still represent a challenge for the surgeon due to frequent comorbidities such as cardiovascular and pulmonary diseases, which increase operative risk as well as the risk of postoperative morbidity and mortality. Cancer patients with comorbidities show lower survival rates and quality of life, together with higher healthcare costs. There is also evidence that patients with comorbidities sometimes receive modified treatment, compromising optimal care. To optimize treatment, the approach to elderly cancer patients needs a multidisciplinary team to assess preoperative conditions, prevent post-surgical complications and improve outcome, especially for frail patients. Laparoscopic surgery for CRC shows a number of advantages compared to conventional surgery such as less postoperative pain, rapid return to prior activities and a decrease in costs. Recent studies confirm that laparoscopic procedures could be performed safely on both older and younger patients with no difference compared with open surgery as regards morbidity or length of hospital stay.

Is bridge to surgery stenting a safe alternative to emergency surgery in malignant colonic obstruction: a meta-analysis of randomized control trials

BACKGROUND

Despite studies showing superior results in terms of reduced stoma rate and higher primary anastomosis rate, the safety of bridge to surgery stenting (BTS stent) for left-sided malignant colonic obstruction, especially in oncological terms, remains a concern.

AIM

The aim of this meta-analysis was to evaluate whether BTS stent is a safe alternative to emergency surgery (EmS).

METHODS

Randomized control trials (RCTs) comparing BTS stent and EmS for left-sided colonic obstruction caused by primary cancer of the colon, up to Sep 2018, were retrieved from the Pubmed, Embase database, clinical trials registry of U. S. National Library of Medicine and BMJ and Google Search.

RESULTS

There were seven eligible RCTs, involving a total of 448 patients. Compared to EmS, BTS stent had a significantly lower risk of overall complications (RR = 0.605; 95% CI 0.382-0.958; p = 0.032). However, the overall recurrence rate was higher in the BTS stent group (37.0% vs. 25.9%; RR = 1.425; 95% CI 1.002-2.028; p = 0.049). BTS stent significantly increased the risk of systemic recurrence (RR = 1.627; 95% CI 1.009-2.621; p = 0.046). This did not translate into a significant difference in terms of 3-year disease-free survival or 3-year overall survival.

CONCLUSION

BTS stent is associated with a lower rate of overall morbidities than EmS. However, BTS stent was associated with a greater chance of recurrence, especially systemic recurrence. Clinicians ought to be aware of the pros and cons of different interventions and tailor treatments for patients suffering from left-sided obstructing cancer of the colon.

Early and Late Outcome after Surgery for Colorectal Cancer Elective versus Emergency Surgery

Aims and Background

Emergency surgery for colorectal cancer is associated with a higher postoperative morbidity and mortality rate and a poor long-term outcome compared with elective surgery. The aim of the present study was to compare early and late outcome after elective and emergency surgery for malignant colorectal cancer, looking for the principal determinants of a worse outcome after emergency colorectal surgery.

Methods

A retrospective study of 236 patients presenting with colorectal cancer over an 8-year period was undertaken. Of these, 118 presented as emergencies, whereas 118 patients, well matched for age, sex, site of tumor and TNM admitted as elective, were included in the study. Data reviewed included postoperative mortality and morbidity and long-term outcome.

Results

The 30-day operative mortality rate was significantly higher in the emergency group than in the electively treated group (11.9% versus 3.4%, P<0.01). The higher mortality rate was observed in the perforation group. The 30-day operative morbidity was higher in the emergency group (27.1% versus 12.7%, P <0.05). Anastomotic failure was a serious complication: following primary resection, we observed 4 non-fatal (5.4%) and two fatal (2.7%) anastomotic leaks after 74 primary anastomoses. Among emergency-treated patients, the procedures characterized by the highest percentage of postoperative complications were three-stage resections (63.6%). The 5-year survival rate was greater after elective surgery (59% versos 39%).

Conclusions

The early and long-term outcome following emergency colorectal surgery was significantly lower than that after elective surgery. Although medical complications in patients with end-stage cancer played an important role, surgical failures still had an important impact on outcome.

The "ick" Factor Matters: Disgust Prospectively Predicts Avoidance in Chemotherapy Patients

BACKGROUND

Chemotherapy can be physically and psychologically demanding. Avoidance and withdrawal are common among patients coping with these demands.

PURPOSE

This report compares established emotional predictors of avoidance during chemotherapy (embarrassment; distress) with an emotion (disgust) that has been unstudied in this context.

METHODS

This report outlines secondary analyses of an RCT where 68 cancer patients undergoing chemotherapy were randomized to mindfulness or relaxation interventions. Self-reported baseline disgust (DS-R), embarrassment (SES-SF), and distress (Distress Thermometer) were used to prospectively predict multiple classes of avoidance post-intervention and at 3 months follow-up. Measures assessed social avoidance, cognitive and emotional avoidance (IES Avoidance), as well as information seeking and treatment adherence (General Adherence Scale).

RESULTS

Repeated-measures ANOVAs evaluated possible longitudinal changes in disgust and forward entry regression models contrasted the ability of the affective variables to predict avoidance. Although disgust did not change over time or vary between groups, greater disgust predicted greater social, cognitive, and emotional avoidance, as well as greater information seeking. Social avoidance was predicted by trait embarrassment and distress predicted non-adherence.

CONCLUSIONS

This report represents the first investigation of disgust's ability to prospectively predict avoidance in people undergoing chemotherapy. Compared to embarrassment and distress, disgust was a more consistent predictor across avoidance domains and its predictive ability was evident across a longer period of time. Findings highlight disgust's role as an indicator of likely avoidance in this health context. Early identification of cancer patients at risk of deleterious avoidance may enable timely interventions and has important clinical implications (ACTRN12613000238774).

Laparoscopic versus open colectomy for obstructing right colon cancer: A systematic review and meta-analysis

BACKGROUND

Hemicolectomy is the treatment of choice for intestinal obstruction from right colon cancer. This review compares the laparoscopic vs open access in hemicolectomy for patients with right colon cancer.

METHODS

A systematic review and meta-analysis of clinical studies published after January 2017 was performed according to the Prisma guidelines. The study has been recorded on the Prospero register (CRD42016044108).

RESULTS

Five studies were included for review. Only one anastomotic leak was reported in conventional open anastomosis group (1.9%) and none of the studies included in the meta-analysis reported re-operations during the first 30 postoperative days. The 30-day postoperative mortality did not differ between the two groups. The length of incision, blood loss, early mobilization after surgery, the 30-day postoperative overall complication rate and hospital length of stay were significantly shorter in the laparoscopic group. The difference in the duration of procedure was statistically significant in favor of the open group. The number of dissected lymph nodes, the overall survival at 5 years and time to flatus were described only in one study, without any significant difference. Finally, none of the trials reported any information concerning differences in the costs between the two techniques.

CONCLUSIONS

The better outcomes described in this study achieved with laparoscopy, must be interpreted with caution because of the small number of patients involved, the selection and publication bias and the low level of evidence of the analysed trials. Indeed, the advantages of a minimally invasive approach, which have been demonstrated by the present meta-analysis, should encourage the use of laparoscopy also in emergency setting.

Investigation of clinicopathological parameters in emergency colorectal cancer surgery: a study of 67 patients

INTRODUCTION

The aim of the present study was to establish, having adjusted for case mix, the size of the differences in postoperative mortality and 5-year survival between patients presenting as an emergency with evidence of obstruction and perforation and the association of clinicopathological factors with mortality (bivariate analyses).

MATERIAL AND METHODS

The study included 67 patients who presented with colorectal cancer (CRC) between 2009 and 2013 in Iran. The mean age of the patients was 59.7 years. Of the 67 patients, 37 (55.22%) were male and 30 (44.77%) were female. Certain parameters that correlated with CRC and surgical treatment were investigated.

RESULTS

Our results showed that 46 (68.65%) patients had obstruction, while perforation was observed in 21 (31.34%) cases. Among the patients with obstruction, obstruction of the right colon was observed in 29 (43.28%) cases. There was no significant difference in mortality rate between right and left colonic obstruction. Based on the bivariate analyses, our findings showed that death of patients was significantly related to tumor grade (p = 0.02) and TNM staging (p = 0.026), but no association was found between other parameters and death, including age, sex, and tumor site.

CONCLUSIONS

Compared with patients who undergo elective surgery for colon cancer, those who present as an emergency with evidence of obstruction or perforation have higher postoperative mortality rates and poorer cancer-specific survival. Also, colorectal cancer patients with emergency surgery showed aggressive histopathology and an advanced stage.

Octogenarian patients with colorectal cancer: Characterizing an emerging clinical entity

AIM

To characterize colorectal cancer (CRC) in octogenarians as compared with younger patients.

METHODS

A single-center, retrospective cohort study which included patients diagnosed with CRC at the age of 80 years or older between 2008-2013. A control group included consecutive patients younger than 80 years diagnosed with CRC during the same period. Clinicopathological characteristics, treatment and outcome were compared between the groups. Fisher’s exact test was used for dichotomous variables and χ² was used for variables with more than two categories. Overall survival was assessed by Kaplan-Meier survival analysis, with the log-rank test. Cancer specific survival (CSS) and disease-free survival were assessed by the Cox proportional hazards model, with the Fine and Gray correction for non-cancer death as a competing risk.

RESULTS

The study included 350 patients, 175 patients in each group. Median follow-up was 40.2 mo (range 1.8-97.5). Several significant differences were noted. Octogenarians had a higher proportion of Ashkenazi ethnicity (64.8% vs 47.9%, P < 0.001), a higher rate of personal history of other malignancies (22.4% vs 13.7%, P = 0.035) and lower rates of family history of any cancer (36.6% vs 64.6%, P < 0.001) and family history of CRC (14.4% vs 27.3%, P = 0.006). CRC diagnosis by screening was less frequent in octogenarians (5.7% vs 20%, P < 0.001) and presentation with performance status (PS) of 0-1 was less common in octogenarians (71% vs 93.9%, P < 0.001). Octogenarians were more likely to have tumors located in the right colon (45.7% vs 34.3%, P = 0.029) and had a lower prevalence of well differentiated histology (10.4% vs 19.3%, P = 0.025). They received less treatment and treatment was less aggressive, both in patients with metastatic and non-metastatic disease, regardless of PS. Their 5-year CSS was worse (63.4% vs 77.6%, P = 0.009), both for metastatic (21% vs 43%, P = 0.03) and for non-metastatic disease (76% vs 88%, P = 0.028).

CONCLUSION

Octogenarians presented with several distinct characteristics and had worse outcome. Further research is warranted to better define this growing population.

Surgical Management of Complicated Colon Cancer

The management of complicated colon cancer (locally invasive, obstructed, or perforated cancers) can pose diagnostic and therapeutic challenges to surgical management. Adherence to traditional surgical oncologic principles must often be balanced with the patients' clinical presentation and other parameters. While the goal of an R0 (no residual microscopic disease) resection must always be kept in mind, situations sometimes arise which can make this difficult to achieve. Recognition of complicated disease and availability of varied therapeutic modalities is important to ensure favorable patient outcomes. This review will discuss the surgical management of complicated colon cancer, with special focus on locally advanced disease.

Emergency laparotomy in octogenarians: A 5-year study of morbidity and mortality

AIM: To determine the morbidity and mortality associated with emergency laparotomy for a clinically acute abdomen in patients aged ≥ 80 years.

METHODS: In this retrospective audit, octogenarians undergoing emergency laparotomy between 1st January 2005 and 1^st January 2010 were identified using the Galaxy Theatre System. Patients undergoing abdominal surgery through groin crease incisions or Lanz or Gridiron incisions were excluded. Also simple appendectomies were excluded. All patients were aged 80 years or more at the time of their surgery. Data were obtained using casenote review with a standardised proforma to determine patient age, American Society of Anesthesiologists (ASA) grade, indications for surgery, early (within 30 d) and late (after 30 d) complications, mortality and length of stay. Data were inserted into a Microsoft Excel spreadsheet and analysed.

RESULTS: One hundred patients were identified from the database (Galaxy) as having undergone emergency laparotomy. Of those, 55 underwent the procedure for intestinal procedures and 37 for secondary peritonitis. There was a 2:1 female predominance; average age 85 and ASA grade 3. Bowel resection was required in 51 out of the 100 patients and 22 (43%) died. Other procedures included appendicectomy, adhesiolysis, repair of AAA graft leak and colostomies for the pathological process resulting in an acute abdomen. Twelve of 100 patients (12%) suffered intra-operative complications, including splenic and bowel-serosal tears. Seventy patients (70%) had postoperative complications including myocardial infarction, wound infection, haematoma and sepsis. Overall mortality was 45/100 patients (45%). The major causes of death were sepsis (19/45 patients, 42%), underlying cancer (13/45 patients, 29%); with others including bowel obstruction (2/45 patients, 4%), myocardial and intestinal ischaemia and dementia.

CONCLUSION: Emergency laparotomy in octogenarians carries a significant morbidity and mortality. In particular, surgery requiring bowel resection has higher mortality than without resection.

Curative colorectal resections in patients aged 80 years and older: clinical characteristics, morbidity, mortality and risk factors

BACKGROUND

The management of colorectal cancer in the elderly presents unique challenges. The objective of this study was to determine outcomes following curative colorectal resection in patients aged 80 years and older.

PATIENTS AND METHODS

Study design is retrospective. Data were extracted from the university hospital database and medical records of patients aged 80 years and older operated between April 2004 and December 2009. Intervention was curative colorectal resection. Main outcome measures include postoperative morbidity, mortality and individual risk factors associated with them.

RESULTS

Three hundred fifty-eight patients (43.8% males, age = 84 ± 3 years) were included; 72.6% received elective surgery. A significantly higher complication rate and 30 day, 1 year and 4 year mortality were present for emergency operations compared to elective (p < 0.001). One-year survival was 65.0% for elective resections and 55.1% for emergency. At 4 years of follow-up, survival was 49.2% for the elective vs. 27.6% for emergency. The American Society of Anesthesiologists (ASA) score is the only factor associated with the 30-day mortality at the multivariate analysis (p < 0.01), Dukes staging with overall mortality (p < 0.005), sex and mode of the operation with major complications (p < 0.05). A limitation of the study is that is retrospective.

CONCLUSIONS

The highest mortality rates following colorectal surgery in the elderly are in the early postoperative period, especially for emergency operations and patients with significant comorbidities. However, the 1-year survival following elective curative resection for colorectal cancer approaches 65 %. ASA score and modality of the operation (elective vs. emergency) impacted on postoperative mortality and morbidity and could be used to select patients with more favourable outcomes.

Use of the high dependency unit, increased consultant involvement and reduction in adverse events in patients who die after colorectal cancer surgery

AIM

We prospectively audited adverse events for surgical patients with colorectal cancer who died under surgical care to test the hypothesis that increased critical care and consultant input could be associated with a reduction in adverse events.

METHOD

Patients with a diagnosis of colorectal cancer who died under surgical care in Scotland from 1996 to 2005 underwent peer review audit using established methodologies through the Scottish Audit of Surgical Mortality.

RESULTS

In the 10-year study period, 3029 patients with colorectal cancer, mean age 76 (13-105) years, died under surgical care, of whom 80% had presented as an emergency admission. Operative intervention was performed in 1557 (51%) patients of whom 1030 (34%) patients had a resection of the cancer. The annual number of patients dying after a cancer resection decreased significantly (P = 0.009). Significant decreases in adverse events were noted over time with a 67% fall in adverse events relating to critical care (P = 0.009), a 37% fall for surgical care (P = 0.04) and a significant increase in consultant anaesthetist and consultant surgeon input, but there was a 9% increase in delay as an adverse event (P = 0.006). The documented anastomotic leakage rate in patients who died increased from 8% in 1996 to 19% in 2005 (P = 0.016).

CONCLUSION

The number of patients dying with colorectal cancer after surgery has decreased in recent years. Adverse events in these patients have significantly reduced over a decade with increased consultant involvement although there is the potential for further improvement.

Predicting risk of death in general surgery patients on the basis of preoperative variables using American College of Surgeons National Surgical Quality Improvement Program data

OBJECTIVES

To use the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database to develop an accurate and clinically meaningful preoperative mortality predictor (PMP) for general surgery on the basis of objective information easily obtainable at the patient's bedside and to compare it with the preexisting NSQIP mortality predictor (NMP).

METHODS

Data were obtained from the ACS NSQIP Participant Use Data File (2005 to 2008) for current procedural terminology codes that included open pancreas surgery and open/laparoscopic colorectal, hernia (ventral, umbilical, or inguinal), and gallbladder surgery. Chi-square analysis was conducted to determine which preoperative variables were significantly associated with death. Logistic regression followed by frequency analysis was conducted to assign weight to these variables. PMP score was calculated by adding the scores for contributing variables and was applied to 2009 data for validation. The accuracy of PMP score was tested with correlation, logistic regression, and receiver operating characteristic analysis.

RESULTS

PMP score was based on 16 variables that were statistically reliable in distinguishing between surviving and dead patients (p < 0.05). Statistically significant variables predicting death were inpatient status, sepsis, poor functional status, do-not-resuscitate directive, disseminated cancer, age, comorbidities (cardiac, renal, pulmonary, liver, and coagulopathy), steroid use, and weight loss. The model correctly classified 98.6% of patients as surviving or dead (p < 0.05). Spearman correlation of the NMP and PMP was 86.9%.

CONCLUSION

PMP score is an accurate and simple tool for predicting operative survival or death using only preoperative variables that are readily available at the bedside. This can serve as a performance assessment tool between hospitals and individual surgeons.

Nonelective colon cancer resections in elderly patients: results from the dutch surgical colorectal audit

AIMS

The aim of the study was to assess which factors contribute to postoperative mortality, especially in elderly patients who undergo emergency colon cancer resections, using a nationwide population-based database.

METHODS

6,161 patients (1,172 nonelective) who underwent a colon cancer resection in 2010 in the Netherlands were included. Risk factors for postoperative mortality were investigated using a multivariate logistic regression model for different age groups, elective and nonelective patients separately.

RESULTS

For both elective and nonelective patients, mortality risk increased with increasing age. For nonelective elderly patients (80+ years), each additional risk factor increased the mortality risk. For a nonelective patient of 80+ years with an American Society of Anesthesiologists score of III+ and a left hemicolectomy or extended resection, postoperative mortality rate was 41% compared with 7% in patients without additional risk factors.

CONCLUSIONS

For elderly patients with two or more additional risk factors, a nonelective resection should be considered a high-risk procedure with a mortality risk of up to 41%. The results of this study could be used to adequately inform patient and family and should have consequences for composing an operative team.

Elderly patients with colon cancer have unique tumor characteristics and poor survival

BACKGROUND

The incidence of colon cancer increases with age, and colon cancer predominantly affects individuals >65 years old. However, there are limited data regarding clinical and pathologic factors, treatment characteristics, and survival of older patients with colon cancer. The objective of this study was to determine the effects of increasing age on colon cancer.

METHODS

Patients diagnosed with colon cancer between 1988 and 2006 were identified through the Los Angeles County Cancer Surveillance Program, in Southern California. Patients were stratified into 4 age groups: 18-49, 50-64, 65-79, and ≥80 years. Clinical and pathologic characteristics and disease-specific and overall survival were compared between patients from different age groups.

RESULTS

A total of 32,819 patients were assessed. Patients aged 18 to 49 and 65 to 79 years represented the smallest and largest groups, respectively. A near equal number of males and females were diagnosed with colon cancer in the 3 youngest age groups, whereas patients who were ≥80 years old were more commonly white and female. Tumor location was different between groups, and the frequency of larger tumors (>5 cm) was greatest in youngest patients (18-49 years). The oldest patients (≥80 years) were administered chemotherapy at the lowest frequency, and disease-specific and overall survival rates decreased with increasing age.

CONCLUSIONS

This investigation demonstrates that older age is associated with alterations in clinical and pathologic characteristics and decreased survival. This suggests that the phenotype of colon cancer and the efficacy of colon cancer therapies may be dependent on the age of patients.

Short-term outcome following elective laparoscopic colorectal cancer resection in octogenarians and nonagenarians

AIM

The 30-day outcome after laparoscopic resection for cancer in patients over the age of 80 years was studied.

METHOD

An electronic database was used to identify patients over 80 years who underwent laparoscopic bowel resection between December 2000 and October 2009 at three UK laparoscopic colorectal training units. Patients who required abdominoperineal excision of the rectum were excluded.

RESULTS

In all, 173 patients (80 men) of median age 84 (80-93) years were identified. American Society of Anesthesiologists (ASA) grades were ASA 1, 14; ASA 2, 87; ASA 3, 68; and ASA 4, 4. Median body mass index was 26 (14-45) kg/m(2). Thirteen (7.5%) patients were converted to open surgery. The major causes for conversion were bleeding and adhesions. Thirty-three major complications occurred in 21 (12%) patients. Ten (5.8%) required readmission after discharge for complications giving a total of 17.8% of patients with complications. The median hospital stay was 5 (1-37) days. Three (1.7%) patients died within 30 days of surgery.

CONCLUSION

This study confirms that laparoscopic large bowel resection is safe and beneficial in a population over 80 years. It has low morbidity and mortality and a shortened hospital stay. Octogenarians should not be denied major laparoscopic bowel surgery based on age alone.

Long-term outcome following surgery for colorectal cancers in octogenarians: a single institution's experience of 204 patients

BACKGROUND

The incidence of colorectal cancer in elderly patients is likely to increase with an aging population. The aims of this study are to review our experience in the surgical management of octogenarians with colorectal cancers and to identify factors that influence the short-term and long-term outcomes.

METHODS

A retrospective review of all octogenarians who underwent surgery for colorectal cancer from December 2002 to October 2008 was performed.

RESULTS

We identified 204 patients with a median age of 84 years (range, 80-97 years). The majority of patients had an American Society of Anesthesiologists score ≥3 (n = 142, 69.6%) and a Charlson Comorbidity Index of ≤3 (n = 128, 62.7%). Emergency surgery was performed in 83 (40.7%) patients. Left-sided malignancy was seen in 138 patients (67.6%). Most of the patients had either stage II (n = 75, 36.8%) or III (n = 69, 33.8%) diseases. The 30-day mortality rate was 16.2% (n = 33). After multivariate analysis, the independent variables predicting worse perioperative complications and death were age >85 years old, emergency surgery, and Charlson Comorbidity Index >3. The median follow-up for the 171 remaining patients was 27 months (range, 2-92 months). The 30-day readmission rate was 2.9% (n = 5). Thirty-one (21.2%) of 146 patients who survived curative surgery developed recurrent disease. Seventy (34.3%) patients died from various etiologies after their first 30 days postoperatively (60% cancer-specific with median survival of 15 months and 40% noncancer-related with median survival of 14 months). Overall and disease-free survivals were adversely affected in patients with advanced malignancy and in those with severe perioperative complications.

CONCLUSIONS

Surgery for octogenarians with colorectal cancers is associated with significant morbidity and mortality rates which are associated with advanced age, emergency surgery, and Charlson Comorbidity Index >3. Long-term survival is dependent on the stage of the malignancy and the presence of severe perioperative complications.

Stenting of the colon in patients with malignant large bowel obstruction: a local experience

PURPOSE

There is an increasing evidence base to support the use of self-expanding metallic gastrointestinal stents. In patients with colorectal cancer, they are used as a bridge to surgery and for palliation. The purposes of this study are to assess technical success, clinical outcome, complication rate and patency following colonic stent insertion in patients with colonic cancer at a local level and to compare our results with the current evidence base.

METHODS

A retrospective, two-centre study was conducted. Twenty-seven patients were included over a 5-year period. Six patients had undergone stent insertion as a bridge to surgery, and 21 had the procedure for palliation.

RESULTS

Initial technical success was achieved in 26 of 27 patients (96%). Of these 26 patients, clinical success was achieved in 24 patients (92%). Five patients (21%) suffered from stent re-occlusion, and one patient (4%) suffered from stent migration. There was one case (4%) of procedure-related perforation. Of the 19 palliative patients in whom clinical success was achieved, 17 (89%) were alive at 30 days, 13 (68%) at 90 (53%) days and 10 at 180 days. Average stent patency was 195 days.

CONCLUSION

WallFlex® self-expanding metallic gastrointestinal stents are a safe and effective means of alleviating obstructive symptoms in patients with colonic cancer requiring palliative treatment or as a bridge to surgery. Our data suggest that although a small percentage of patients are affected by stent re-occlusion, this does not contribute to premature mortality. They improve quality of life in palliative care patients as well as reducing premature morbidity and mortality caused by emergency surgery.

Impact of age on outcome after colorectal cancer surgery in the elderly - a developing country perspective

BACKGROUND

Colorectal cancer (CRC) is a major source of morbidity and mortality in the elderly population and surgery is often the only definitive management option. The suitability of surgical candidates based on age alone has traditionally been a source of controversy. Surgical resection may be considered detrimental in the elderly solely on the basis of advanced age. Based on recent evidence suggesting that age alone is not a predictor of outcomes, Western societies are increasingly performing definitive procedures on the elderly. Such evidence is not available from our region. We aimed to determine whether age has an independent effect on complications after surgery for colorectal cancer in our population.

METHODS

A retrospective review of all patients who underwent surgery for pathologically confirmed colorectal cancer at Aga Khan University Hospital, Karachi between January 1999 and December 2008 was conducted. Using a cut-off of 70 years, patients were divided into two groups. Patient demographics, tumor characteristics and postoperative complications and 30-day mortality were compared. Multivariate logistic regression analysis was performed with clinically relevant variables to determine whether age had an independent and significant association with the outcome.

RESULTS

A total of 271 files were reviewed, of which 56 belonged to elderly patients (≥ 70 years). The gender ratio was equal in both groups. Elderly patients had a significantly higher comorbidity status, Charlson score and American society of anesthesiologists (ASA) class (all p < 0.001). Upon multivariate analysis, factors associated with more complications were ASA status (95% CI = 1.30-6.25), preoperative perforation (95% CI = 1.94-48.0) and rectal tumors (95% CI = 1.21-5.34). Old age was significantly associated with systemic complications upon univariate analysis (p = 0.05), however, this association vanished upon multivariate analysis (p = 0.36).

CONCLUSION

Older patients have more co-morbid conditions and higher ASA scores, but increasing age itself is not independently associated with complications after surgery for CRC. Therefore patient selection should focus on the clinical status and ASA class of the patient rather than age.

Age at death of patients with colorectal cancer and the effect of lead-time bias on survival in elective vs emergency surgery

AIM

Colorectal cancer survival depends on stage at presentation, and current strategies aim for improvements through early detection. Previous studies have demonstrated improved survival from diagnosis but not increased life expectancy. While lead-time bias may account for variations in known prognostic indicators and also influence screening programmes, only age at death provides a true representation of the effectiveness of an intervention. We aimed to compare age at death for patients with colorectal cancer presenting on an emergency or elective basis.

METHOD

Patients presenting with colorectal cancer (2000-2006) were entered into a prospective database (analysis 1 December 2008). Fields included age at death, emergency/elective presentation, palliative/curative intent and disease stage.

RESULTS

One thousand six hundred and fifty patients (922 men) were identified. Elective patients presented younger than emergency patients (67.9 vs 70.6 years; P < 0.005). Dukes B patients presented older than Dukes D (P = 0.02). Mortality was 41% at time of analysis; no difference was seen in mean age at death between emergency and elective presentation (72.8 vs 72.0 years; P = 0.379) or palliative and curative intent (72.0 vs 72.5 years; P = 0.604).

CONCLUSION

Colorectal cancer is common in a population where actuarial life expectancy is limited. Current colorectal cancer early detection strategies may improve cancer-specific survival by increasing lead-time bias but do not influence overall life expectancy.

Earlier diagnosis and treatment of symptomatic bowel cancer: can it be achieved and how much will it improve survival?

AIM

To determine current delays in diagnosis and treatment of bowel cancer, when and why they occur, and what effect they have on survival.

METHOD

A detailed review of the literature based on the development of the GP referral guidelines in 2000.

RESULTS

There is no evidence of a reduction in the delay to diagnosis and treatment of bowel cancer over the last 60 years. There is no strong theoretical basis for a benefit from earlier diagnosis of symptomatic bowel cancer and this is consistent with observational studies.

CONCLUSION

Campaigns to earlier diagnose bowel cancer will not be successful unless new strategies are developed. There is substantial evidence that earlier diagnosis of symptomatic bowel cancer will not improve survival in the majority of patients. However as excessive delays still occur in some patients it is reasonable to continue to aim to diagnose and treat all bowel cancer within 6 months of the onset of symptoms with an overall median of 3-4 months.

Emergency first presentation of colorectal cancer predicts significantly poorer outcomes: a review of 356 consecutive Irish patients

PURPOSE

Colorectal cancer commonly presents first as an emergency and is likely to be complicated by bowel obstruction/perforation requiring more difficult procedures, with poorer outcomes. Analysis of all of the procedures performed on patients diagnosed in Wexford General Hospital, Ireland, during the period 2000 to 2006 was carried out to validate this hypothesis in our western European population.

METHODS

Retrospective analysis of a prospectively maintained database of patient demographics, diagnosis, procedures, and mode of presentation (elective, emergency) was undertaken.

RESULTS

A total of 356 patients with colorectal cancer underwent 498 procedures during the years 2000 to 2006. Eighty-four emergency endoscopies and 100 emergency bowel resections were performed. Obstructive lesions were more likely to require emergency resection (P < 0.001). Median survival time for patients treated electively was 82 months vs. 59 months for patients treated on an emergency basis.

CONCLUSIONS

Of all colonic resections, 34 percent were carried out as emergencies and were significantly more likely to be complicated by obstruction or perforation (P < 0.001). Emergency resections were associated with a significantly poorer perioperative mortality and five-year survival rate (P < 0.001). Forty-one percent of colorectal cancers diagnosed at endoscopy were first seen emergently. These data raise concerns regarding public awareness of colorectal cancer and resource allocation and reemphasize the need for a national colorectal screening program.

Retrospective analysis of pre- and peri-operative imaging in confirmed proximal colonic cancers--possible implications for screening flexible sigmoidoscopy

OBJECTIVE

Faecal occult blood testing is being introduced for population screening in the United Kingdom. Flexible sigmoidoscopy may provide a viable alternative. The outcomes of the flexible sigmoidoscopy trial are awaited but the most obvious disadvantage is that only the lower third of the colon is examined and proximal pathology cannot be excluded. The relationship between proximal pathology and distal findings at flexible sigmoidoscopy is uncertain. The aim of this study was to determine the incidence of distal neoplasia in patients with confirmed proximal cancers of the colon.

METHOD

All confirmed proximal colonic cancers (defined as those proximal to the splenic flexure) were identified from a database of pathology specimens at a single centre between January 1999 and August 2006. A retrospective analysis of preoperative and peri-operative mucosal imaging (contrast enema, colonoscopy and CT colonography) was conducted to identify any distal neoplasia in these patients.

RESULTS

A total of 348 patients were identified. Pre- or peri-operative mucosal imaging was identified in 231 (66%) and 49 (21%) had distal neoplasia. Nineteen (8%) of these patients would have gone on to have a colonoscopy based on the UK flexible sigmoidoscopy trial protocol and 92% of the cohort would not have had a colonoscopy.

CONCLUSION

Nearly 80% of confirmed proximal cancers in our series did not have any demonstrable distal neoplasia. Only 8% of our cohort would have proceeded to colonoscopy. A very significant number of proximal cancers would not have been detected.

Outcome of right colectomy for cancer in octogenarians

BACKGROUND

Colorectal cancer is one of the commonest malignancies in the elderly and, as such, is a major cause of morbidity and mortality. There is no consensus yet if age itself is a risk factor for adverse outcome after colectomy. The aims of the study were to evaluate the impact of age on operative results of right colectomy for cancer and to define factors that influence the postoperative mortality in octogenarians.

METHODS

Data of all patients who underwent right colectomy for colon cancer between January 2001 and December 2006 were collected retrospectively. Patients were divided into two groups: those who were 80 years and older and those who were less than 80 years old. Analysis included patients' demographics, comorbidities, American Society of Anesthesiologists class, functional status, mode of presentation, stage of disease, length of hospital stay, postoperative morbidity, and mortality.

RESULTS

A total of 124 consecutive patients with right colon cancer were operated. Control group included 84 patients less than 80 year old. Study group included 40 patients 80 years or older. In Cox multivariate regression analysis, poor functional status and emergent surgery were independent factors for postoperative mortality.

CONCLUSIONS

There was no significant difference in the outcome of elective right colectomy between elderly patients and their younger counterparts. Operative mortality of emergency surgery was significantly higher in octogenarians. Emergent setting and poor functional status are major risk factors for postoperative mortality.

Rectal cancer surgery in the elderly: analysis of consecutive 158 patients with stage III rectal cancer

BACKGROUND

It is difficult to establish a clear-cut indication for rectal surgery in elderly patients because of greater risk. We tried to clarify the factors associated with the short-term and long-term outcomes between elderly and younger patients.

MATERIALS AND METHODS

We clarified the potential predictors of the cancer-related and disease-free survivals after surgery, the factors associated with the elderly, preoperative comorbid conditions, and postoperative complications in 158 patients with stage III rectal cancer who underwent surgery, including 33 elderly patients (>or=75 years) and 125 younger patients (<75 years).

RESULTS

An old age and macroscopic types 3 and 4 were independent poor prognostic factors of cancer-related survival, whereas the disease-free survival of the younger patients was not longer than for the elderly patients. Interestingly, the survival rate in the elderly patients with recurrence was shorter than that in the younger patients. Histopathological type except well differentiated and without chemotherapy were significant tumor characteristics associated with the elderly patients. On preoperative comorbid conditions, elderly patients have more cardiovascular diseases than younger patients, whereas there were no significant differences in the postoperative complications.

CONCLUSION

Strength of the adjuvant and intensive therapies after recurrence may contribute to gain long-term survival in the elderly rectal cancer patients.

Prediction of postoperative mortality in elderly patients with colorectal cancer

PURPOSE

This study was designed to develop a model for predicting postoperative mortality in elderly patients undergoing surgery for colorectal cancer.

METHODS

This multicenter study was conducted by using routinely collected clinical data, assessing patients older than aged 80 years, with 30-day operative mortality as the primary end point. Data were collected from The Association of Coloproctology of Great Britain and Ireland database, encompassing 8,077 newly diagnosed colorectal cancer patients undergoing resectional surgery in 79 hospitals between April 2000 to March 2002, The Association of Coloproctology Malignant Bowel Obstruction Study, encompassing 1,046 patients with malignant bowel obstruction in 148 hospitals, between April 1998 to March 1999, and The Wales-Trent audit, encompassing 3,522 newly diagnosed colorectal cancer patients, between July 1992 to June 1993. A multilevel logistic regression model was developed to adjust for case-mix and to accommodate the variability of outcomes between the three study populations. The model was internally validated using a Bayesian resampling technique and tested using measures of discrimination, calibration, and subgroup analysis.

RESULTS

A total of 2,533 patients satisfied the inclusion criteria, with a 30-day mortality of 15.6 percent. Multivariate analysis identified the following independent risk factors: age (odds ratio for 85-90, 90-95, >95 vs. 80-85 = 1.1, 1.8, 2.9), American Society of Anesthesiology grade (odds ratio for Grade III, IV vs. I-II = 2.7, 6.1), operative urgency (odds ratio for emergency vs. elective = 1.9), no cancer excision vs. resection (odds ratio = 1.2), and metastatic disease (odds ratio for metastases vs. no metastases = 1.9). The model offered adequate discrimination (area under receiver operator curve = 0.732) and excellent agreement between observed and predicted outcomes during eight colorectal procedures (P = 0.885).

CONCLUSIONS

The elderly colorectal cancer model can accurately estimate 30-day mortality in patients older than aged 80 years undergoing surgery for colorectal cancer. Because the mortality can be considerable, this may have important implications when determining management for this group of patients.

Risk factors for obstruction, perforation, or emergency admission at presentation in patients with colorectal cancer: a population-based study

OBJECTIVES

Previous studies have shown that patients newly diagnosed with colorectal cancer (CRC) requiring emergency admission to hospital or those presenting with obstruction or perforation (defined here as OPE) have advanced disease. The objective was to conduct a population-based study among persons with a new diagnosis of CRC to identify factors associated with OPE in Ontario.

METHODS

We analyzed data from the following databases: Canadian Institute for Health Information (CIHI), the Ontario Health Insurance Plan (OHIP), and the Registered Persons Database (RPDB). We identified all individuals > or = 20 yr of age with a new diagnosis of CRC (ICD-9 codes 153.0-153.4, 153.6-154.1) during 1996-2001 and defined the first admission for CRC as the index admission. We excluded those who received chemotherapy, radiotherapy, or palliative care prior to the index admission. We identified those with concomitant obstruction (ICD-9 code 560.9), perforation (ICD-9 code 569.8), or who were classified as emergency admission (referred to as OPE). Adjusted risk of OPE was calculated using logistic regression analysis.

RESULTS

Between 1996 and 2001, we identified 41,356 persons with CRC, of whom 53.5% were men. In logistic regression analysis, female sex and low income were significantly associated with OPE, after adjusting for differences in age, cancer site, previous large bowel evaluation, comorbidity, having a regular source of primary care, and year of diagnosis. For men the adjusted odds ratio (OR) for OPE was 0.93 (95% confidence interval (CI) 0.88-0.99), and for the highest-income quintile the adjusted OR was 0.78 (95% CI 0.72-0.85).

CONCLUSION

Among persons with a new diagnosis of CRC in Ontario, women and those who are poor are more likely to present with obstruction, perforation, or emergency admission to hospital. Population-based CRC screening is needed to address these adverse outcomes.

The impact of age on post-operative outcomes of colorectal cancer patients undergoing surgical treatment

Background

the purpose of study was to evaluate the impact of age on outcomes in colorectal cancer surgery.

Methods

patients on hospital database treated for colorectal cancer during the period 1995 – 2002 were divided into two groups: Group 1 – patients of 75 years or older (n = 154), and Group 2 – those younger than 75 years (n = 532).

Results

In Group 1, for colon cancers, proximal tumors were significantly more common (23% vs. 13.5%, p < 0.05), complicated cases were more frequent (46 % vs. 33%, p = 0.002), bowel obstruction more common at presentation (40% vs. 26.5%, p = 0.001), and more frequent emergency surgery required (24% vs. 14%, p = 0.003). Postoperative overall morbidity was higher in the elderly group, but with no differences in surgical complications rate. Overall 5 year survival was 39% vs. 55% (p = 0.0006) and cancer related 5 year survival was 44% vs. 62% (p = 0.0006). Multivariate Cox analysis showed that age was not an independent risk factor for postoperative mortality.

Conclusion

Preoperative complications and co-morbidities, more advanced disease, and higher postoperative nonsurgical complication rates adversely affect postoperative outcomes after surgery for colorectal cancer in the elderly.

The impact of the risk factor "age" on the early postoperative results of surgery for colorectal carcinoma and its significance for perioperative management

The risks and benefits of surgery for colorectal cancer in old patients have not been unequivocally defined. The present investigation was carried out in 309 hospitals as a prospective multicenter study. In the period between 1 January 2000 and 31 December 2001, a total of 19,080 patients were recruited for the study; 16,142 (84.6%) patients were younger than 80 years (<80) and 2932 (15.4%) were 80 years and older (> or =80). Significant differences between the age groups were observed for general postoperative complications (22.3% for <80 years; 33.9% for > or =80). Specific postoperative complications were identical in both groups. Overall, significantly elevated morbidity and mortality rates were found with increasing age (morbidity: 33.9% vs. 43.5%; mortality: 2.6% vs. 8.0%). The distribution of tumor stages revealed a significantly higher percentage of locally advanced tumors in the older age group (stage II: 28.0% vs. 34.4%). In contrast, no increase in metastasizing tumors was found in the older age group (stage IV: 17.4% vs. 14.1%). Logistic regression showed that, in concert with a number of other parameters, age is a significant influencing factor on postoperative morbidity and mortality. The increase in postoperative morbidity and mortality rates associated with aging is a result of the increase in general postoperative complications, in particular, pneumonia and cardiovascular complications. Age as such does not represent a contraindication for surgical treatment. The short-term outcome and quality of life are of overriding importance for the geriatric patient.

Ventajas y peculiaridades del abordaje laparoscópico en el anciano

Both the age of the population and anesthetic and surgical techniques are advancing. Currently, 40% of surgical activity is performed in patients older than 65 years, who present a higher surgical risk than younger patients. The aim of treatment in the elderly is to provide the best possible quality of life, even though this represents a surgical challenge because of associated comorbidity and reduced cardiopulmonary reserve. From the moment at which laparotomy becomes an increased stress in the elderly, laparoscopic surgery can be particularly advantageous in this population. Therefore, minimally invasive surgery may have a greater impact in these individuals than in younger patients in reducing postoperative pain, cardiorespiratory complications, hospital stay, and recovery time before resuming physical activity. The recent advances in anesthesia, together with improved patient selection and perioperative cardiac care, and the general adoption of minimally invasive access have enabled more complex gastrointestinal procedures to be performed in the elderly. The factors that could influence the development of this type of approach in the elderly, as well as the precautions that should be taken, should be further analyzed.

Colorectal cancer presenting as surgical emergencies

Colorectal Cancer (CRC) is a major cause of cancer morbidity and mortality. Surgery is considered the first line therapy for CRC, and is generally encountered by many surgeons under elective conditions. Unfortunately, colorectal cancer may present acutely as a surgical emergency. These conditions include, but are not limited to perforation, hemorrhage, and obstruction. The presentation of a patient with these conditions can lead to higher morbidity and mortality. The choice of operation depends mainly on the site of the disease (left-sided versus right-sided), the patient's physical condition, nutritional status, and age. The treatment for right-sided lesions is a right hemicolectomy. However, treatment of left-sided lesions is still undecided. There are many therapeutic options such as primary or staged resections, Hartman's procedure, subtotal colectomy, or colostomy. Other therapies involve non-operative techniques such as laser therapy, colonic stenting, emergency endoscopy, and comfort measures.

Colon resection in elderly patients: comparison of data of a single surgical department with collective data from the Czech Republic

Colorectal cancer is predominantly a disease of elderly people, since over 70% of cases occur in those aged 65 years or older. Clinicians have to frequently decide whether major surgery is justified in elderly patients with a limited life expectancy. Our retrospective study was aimed to compare outcomes of primary surgery for colorectal cancer in the elderly patient population. The evaluated data were collected from the 1st Department of Surgery, Charles University, and from all over the Czech Republic. Patients were divided into three groups: the young-old (21-59 years), the older-old (60-69 years), and the oldest-old (>69 years) patients. In the collective data the youngest and the oldest groups differ significantly in the rate of early postoperative complications (12.3% versus 17.6%, p<0.001). The number of complications associated with the emergency procedures was twice as high compared to elective surgery in all groups (p<0.001). There was no correlation between age and length of hospital stay in the single surgery department. These data suggest that major oncology procedures may be undertaken in older patients in whom operative risk is reasonable, with acceptable rates of complications.

Preoperative Assessment of Surgical Risk in Oncogeriatric Patients

Cancer is a prevalent disease in our aging population; however, few oncologists are familiar with caring for oncogeriatric patients. Surgery is presently the treatment of choice for most solid tumors, but it is frequently delivered in a suboptimal way in this patient subsetting. Undertreatment is often justified with the concern of an unsustainable toxicity, while overtreatment can be related to the lack of knowledge in optimizing preoperative risk assessment. To draw new light on this issue, several surgeons presented their series, providing hard evidence that surgical options can be offered to the elderly with cancer, with only a limited postoperative mortality and morbidity. As it is likely that much of these data suffer from selection bias, we concentrated on Comprehensive Geriatric Assessment (CGA), which can add substantial information on the functional assessment of elderly cancer patients. A validated instrument such as the CGA allows a comparison of series, predicting short-term surgical outcomes more precisely, and offers appropriate information when consenting elderly patients. Preoperative Assessment of Cancer in the Elderly is a prospective international study conceived and launched to outline the fitness of elderly surgical patients with malignant tumors. This paper reports on preliminary results and analysis from the ongoing study.

Temporal trends in new diagnoses of colorectal cancer with obstruction, perforation, or emergency admission in Ontario: 1993-2001

OBJECTIVES

Previous studies have shown that patients newly diagnosed with colorectal cancer requiring emergency admission to hospital or presenting with obstruction or perforation (defined here as OPE) have advanced disease. None of these studies, however, has evaluated temporal trends in these adverse outcomes, which may reflect screening failures. We evaluated temporal trends in the proportion of Ontario patients with a new diagnosis of colorectal cancer and OPE.

METHODS

Data were obtained from four sources: the Ontario Cancer Registry (OCR); the Canadian Institute for Health Information (CIHI) database, which contains diagnostic information on all patients discharged from hospitals; the Ontario Health Insurance Plan (OHIP) database, which records all physician claims in Ontario; and the Registered Persons Database, which contains demographic information on all Ontario residents covered under OHIP. We calculated the proportion of patients (>/=20 yr) with a new diagnosis of colorectal cancer recorded in CIHI who presented with OPE between 1993 and 2001. These patients were assigned to one of three cohort years: 1993-1995, 1996-1998, or 1999-2001. Those who received chemotherapy, radiotherapy, or palliative care before their first admission to hospital were excluded. We repeated the analysis using the number of OPE patients identified from CIHI in the numerator, and the number of patients (>/=20 yr) with a new diagnosis of colorectal cancer recorded in the OCR in the denominator. Adjusted risk of OPE was calculated using a logistic regression model.

RESULTS

Between 1993 and 2001, 59,670 patients with a new diagnosis of colorectal cancer were recorded in the CIHI database and 54,103 in the OCR. The proportion of these patients with OPE recorded in the CIHI decreased significantly over time: 23.8% (95% CI = 23.2-24.4%) during 1993-1995, 19.4% (95% CI = 18.8-20.0%) during 1996-1998, and 18.1% (95% CI 17.6-18.6%) during 1999-2001 (a 24% relative decrease over time). The relative decrease calculated from OCR data was similar. The adjusted relative decrease in the proportion of patients with OPE during 1993-2001 was 31%.

CONCLUSIONS

Much greater emphasis on screening is needed since approximately 20% of patients with a new diagnosis of colorectal cancer in 1999-2001 presented with OPE.

Outcomes in elderly patients following surgery for colorectal cancer in the veterans affairs health care system

AIM

To compare 30-day and 5-year mortality in elderly vs. younger patients following surgical resection for colorectal cancer.

METHODS

A cohort study of patients admitted to VA hospitals with a new diagnosis of colorectal cancer who underwent surgical resection between October 1990 and September 2000. Cumulative survival rates (30-day and 5-year) were calculated from Kaplan-Meier estimates and adjusted risks of death were estimated using Cox proportional hazards models.

RESULTS

We identified 34,888 individuals with a new diagnosis of colorectal cancer between October 1990 and September 2000, of whom 22 633 (65%) underwent surgical resection. The 30-day mortality following resection for rectal and colon cancer, respectively, for patients <65 years was 2.1 and 2.8% compared with 4.9 and 5.6% for those > or =65 years. The 5-year cumulative survival for rectal and colon cancer for patients <65 years was 54.0 and 57.6% compared with 44.5 and 46.6% for those > or =65 years. In patients > or =65 years with rectal or colon cancer, after adjustment, 30-day mortality was 2 times greater and 5-year mortality was 1 times greater than in younger patients.

CONCLUSIONS

Older age is an independent predictor of increased short-term and long-term mortality following surgery in patients with rectal and colon cancer.

Emergency surgery for colonic cancer in a defined population

Background

The aim of this study was to identify risk factors in emergency surgery for colonic cancer in a large population and to investigate the economic impact of such surgery.

Methods

Data from the colonic cancer registry (1997–2001) of the Uppsala/Örebro Regional Oncological Centre were analysed and classified by hospital category. Some 3259 patients were included; 806 had an emergency and 2453 an elective procedure. Data for calculating effects on health economy were derived from a national case-costing register.

Results

Patients who had emergency surgery had more advanced tumours and a lower survival rate than those who had an elective procedure (5-year survival rate 29·8 versus 52·4 per cent; P &lt; 0·001). There was a stage-specific difference in survival, with poorer survival both for patients with stage I and II tumours and for those with stage III tumours after emergency compared with elective surgery (P &lt; 0·001). Emergency surgery was associated with a longer hospital stay (mean 18·0 versus 10·0 days; P &lt; 0·001) and higher costs (relative cost 1·5 (95 per cent confidence interval 1·4 to 1·6)) compared with elective surgery. The duration of hospital stay was the strongest determinant of cost (r2 = 0·52, P &lt; 0·001).

Conclusion

Emergency surgery for colonic cancer is associated with a stage-specific increase in mortality rate.

Evaluating operative risk in colorectal cancer surgery: ASA and POSSUM-based predictive models

OBJECTIVE

To review two predictive models, based on the American Society of Anaesthesiologists (ASA) and the Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (POSSUM)-used for estimating postoperative mortality in patients, undergoing surgery for colorectal disease, in the UK.

METHODS

Data was derived from three multicentre, UK-based studies involving a total of 16,006 patients with malignant or non-malignant bowel pathologies. Data sources were: The Colorectal-POSSUM (CR-POSSUM) Study population, comprising 6883 patients undergoing colorectal surgery in 15 UK hospitals between 1993 and 2001; The Association of Coloproctology of Great Britain and Ireland (ACPGBI) Colorectal Cancer (CRC) Database, encompassing 8077 newly diagnosed CRC patients, undergoing surgical resections in 79 hospitals, between April 2000 and March 2002; The ACPGBI Malignant Bowel Obstruction (MBO) Study, encompassing 1046 patients with MBO in 148 hospitals, treated between April 1998 and March 1999. Multifactorial logistic regression analyses were used to adjust for case-mix, identify risk factors for in-hospital/30-day operative mortality and to accommodate the variability of outcomes between hospitals.

RESULTS

In the ACPGBI CRC study, 7374 patients had surgery, 6622(89.8%) a major bowel resection and 1465(19.9%) emergency surgery. Nine hundred and eighty-nine (94.6%) patients with MBO had surgery and 854(86.3%) underwent bowel resection. In the CR-POSSUM study, of the 6790(98.6%) patients undergoing surgery, 3451(50.8%) had a major colorectal resection, including 2107(31.0%) as an emergency. The operative mortality was 7.5% for the ACPGBI CRC study, 15.7% for patients with MBO and 5.7% for patients in the CR-POSSUM study. When tested, the predictive models showed good discrimination, with an area under the receiver-operator characteristic curve of 77.5% for the ACPGBI CRC, 80.1% for the MBO and 89.8% for the CR-POSSUM.

CONCLUSIONS

Prediction of postoperative death can be made by the clinician using simple, numerical, tables derived from the ACPGBI CRC, MBO and CR-POSSUM models. The models can be used in everyday practice for pre-operative counselling of patients and their carers, as a part of the process of informed consent. They may also be used to compare the outcomes between multidisciplinary CRC teams.

Expression level of Wnt signaling components possibly influences the biological behavior of colorectal cancer in different age groups

Advancing of age apparently influences the behavior of colorectal cancer (CRC). The pattern of activation and expression of Wnt target genes may influence the behavior of the cancer. In the present study, the level of activation of some elements of Wnt signaling was evaluated and correlated with the patient's age and clinicopathological characteristics of the tumor. Beta-catenin and c-Myc mRNA expressions were evaluated by semiquantitative real-time PCR, and subcellular localization of the beta-catenin protein was evaluated by immunohistochemistry. Patients aged 70-84 tended to have locally advanced disease more frequently than younger patients. The same group of patients also more frequently had high nuclear expression of beta-catenin protein and higher expression of c-Myc mRNA. Beta-catenin mRNA had a rather constant expression with advancing of age. High nuclear expression of beta-catenin and high expression of c-Myc were apparently also correlated with locally advanced disease. We concluded that the level of Wnt signaling activation might influence the behavior of the disease in different age groups.

Changing practices for diagnosis and treatment of colorectal cancer in calvados: 1990-1999

AIM

Two consensus conferences on management of colorectal cancer were conducted in France during the last ten Years: one regarding rectal cancers in 1994 and the other regarding colonic cancer in 1998. In the present study, we examined data collected in a local gastrointestinal cancer registry to investigate changes in management practices for colorectal cancer in a well-defined population seen between 1990 and 1999.

METHODS

The study population consisted of 3 135 patients with colorectal cancer diagnosed in Calvados (an administrative district in northern France) from 1990 to 1999. Two periods were defined: P1=1990-1994 and P2=1995-1999. Multivariate logistic regression analysis was performed.

RESULTS

No trends in stage of disease at diagnosis or rate of surgical resection were observed. For patients with cancer of the rectum, the rate of sphincter preservation increased significantly from 65.6% in P1 to 72.3% in P2, in men and in all patients under the age of 75 Years. For patients with cancer of the colon, the number of resection specimens with at least eight examined lymph nodes increased from 50.7% in P1 to 60.2% in P2. This trend predominated in university centers; for rectal cancer patients it was significant only in university centers. Prescription of adjuvant chemotherapy for stage III colonic cancer increased significantly: 41.4% in P1 and 52.5% in P2. No changes in prescription of adjuvant radiotherapy for rectal cancer were observed, irrespective of the stage at diagnosis. The proportion of patients managed in university centers decreased significantly over time from 30.5% in P1 to 27.6% in P2, with a corresponding increase in private clinics.

CONCLUSION

Most of the trends observed during the study period began before the consensus conference guidelines were Issued. The consensus guidelines appear to have influenced management practices mainly in university centers, while the majority of patients are managed in non-university centers.