Safety of bowel resection for colorectal surgical emergency in the elderly

Emergency Surgery for Obstructive Colon Cancer in Elderly Patients: Results of a Multicentric Cohort of the French National Surgical Association

BACKGROUND

Although elderly patients constitute most of the patients undergoing surgery for obstructed colon cancer, available data in the literature are very limited.

OBJECTIVE

The purpose of this study was to assess the management and outcomes of elderly patients treated for obstructed colon cancer.

DESIGN

This was a multicenter, retrospective cohort study.

SETTINGS

Between 2000 and 2015, 2325 patients managed for an obstructed colon cancer in member centers of the French National Surgical Association were identified. Data were collected by each center on a voluntary basis after institutional approval. Bowel obstruction was defined clinically and confirmed by imaging.

PATIENTS

Three age groups were defined, including patients <75 years, 75 to 84 years, and ≥85 years.

MAIN OUTCOME MEASURES

Postoperative and oncologic results in elderly patients with an obstructed colon cancer were measured. Relative survival was calculated as the ratio of the overall survival with the survival that would have been expected based on the corresponding general population.

INTERVENTIONS

A total of 302 patients (13%) underwent colonic stent insertion, and 1992 (87%) underwent surgery as emergency procedure.

RESULTS

A total of 2294 patients were analyzed (<75 y, n = 1200 (52%); 75-84 y, n = 650 (28%); and ≥85 y, n = 444 (20%)). Elderly patients were more likely to be women (p < 0.0001), to have proximal colon cancer (p < 0.0001), and to have a higher incidence of comorbidities (p < 0.0001). The use of colonic stent or the type of surgery was identical regardless of age. In patients with resected colon cancer, elderly patients had less stage IV disease (p < 0.0001). The absence of tumor resection (p < 0.0001) and definitive stoma rate increased with age (p < 0.0001). Postoperative mortality and morbidity were significantly higher in elderly patients (p < 0.0001), but surgical morbidity was similar across age groups (p = 0.60). Postoperative morbidity was correlated to the 6-month mortality rate in elderly (p < 0.0001). Overall and disease-free survivals were significantly lower in more elderly patients (p < 0.0001) but relative survival was not (p = 0.09).

LIMITATIONS

It is quite difficult to know how to interpret these data as a whole, given the inherent bias in the study population, lack of ability to stratify by performance status, and long study period duration.

CONCLUSIONS

Elderly patients have high morbidity with lower survival in the highest age ranges of elderly subgroups. These data should be considered when deciding on an operative approach. See Video Abstract at http://links.lww.com/DCR/A964.

Preoperative Colonic Decompression With Decompression Tube Insertion Versus Stent Insertion in Patients With Malignant Left Colonic Obstruction

PURPOSE

To compare the clinical effectiveness of preoperative colonic decompression (PCD) performed with stent or decompression tube insertion in patients with malignant left colonic obstruction (MLCO).

MATERIALS AND METHODS

Between September 2014 and September 2018, 63 patients with MLCO underwent PCD (decompression tube: 35; stent: 28) in our center. Elective surgery was performed for patients with clinical success of PCD.

RESULTS

The rates of technical success for PCD with tube and stent insertion were 91.4% (32/35) and 96.4% (27/28), respectively (P=0.773). Clinical success rates for PCD with tube and stent insertion were 90.6% (29/32) and 85.2% (23/27), respectively (P=0.811). Tumor resection with primary anastomosis was performed in all patients with clinical success in both groups. No significant differences were found between 2 groups regarding the duration of surgery and rates of postoperative complications.

CONCLUSION

Decompression tube and stent insertion had similar effectiveness for PCD in patients with MLCO.

Surgical Oncology and Geriatric Patients

Geriatric medicine is a growing field filled with complicated patients who are susceptible to developing cancer. Surgical oncology is expanding while adapting to the increasing elderly population and creating novel treatment regimens for this group of patients. This article reviews surgical oncology in elderly patients and addresses surgical optimization, management of several cancer subtypes, surgical advances in minimally invasive surgery, and ethical considerations.

Clinical application of transanal ileal tube placement using X-ray monitoring

Colorectal cancer, which includes colon and rectal cancer, is a common digestive tract tumor. Although surgery is the primary form of treatment, there are a number of drawbacks, including patients experiencing considerable pain and high cost. The present study was undertaken to examine the clinical value of transanal ileal tube placement under X-ray monitoring. Thirty-six cases of left colon obstruction presenting to our hospital between July 2011 and February 2014, underwent transanal ileal tube placement using a single-curve catheter guided by a guidewire under X-ray monitoring. An ileal tube was successfully inserted into 32 patients. Clinical symptoms were alleviated effectively within 48 h. Indwelling catheter decompression time was 4–9 days with an average of 5.61 days. In two cases, the colon guidewire perforated into the abdominal cavity. Repeated exploration resistance of the guidewire and catheter indicated stenosis at this position owing to obstruction. In conclusion, transanal placement of the ileal tube through X-ray monitoring is capable of effectively alleviating the symptoms of ileus. Thus, this constitutes a safe, effective, and economical method that is acceptable to patients.

Comparison between metallic stent and transanal decompression tube for malignant large-bowel obstruction

BACKGROUND

The short-term safety and efficacy of a self-expandable metallic colonic stent (SEMS) insertion followed by elective surgery, "bridge to surgery (BTS)", for malignant large-bowel obstruction (MLBO) have been well described comparing with emergency surgery. The aim of this study was to compare short-term outcomes of endoscopic decompression using a SEMS versus a transanal decompression tube (TDT).

MATERIALS AND METHODS

From January 2005 to November 2014, a total of 101 patients with MLBO underwent surgery at our single institution were retrospectively identified. Among them, 73 patients who underwent preoperative complete insertion of a decompression device (TDT, n = 45; SEMS, n = 28) were finally included in this study. Six patients with incomplete insertion of a decompression device (TDT, n = 5; SEMS, n = 1) were also excluded. The primary endpoints of this study were the postoperative morbidity and mortality rates. The secondary endpoints were decompression-related outcomes. Additionally, propensity score matched (PSM) analysis was conducted in short-term outcomes between the groups.

RESULTS

The SEMS group had significantly higher proportion of right-sided tumor and bigger tumor size compared with those of the TDT group. The SEMS group had a significantly higher proportion of patients who underwent laparoscopic surgery, and consequently, a longer surgical duration than did the TDT group. Higher rates of insertion failure and perforation were recognized in the TDT group than in the SEMS group (10.0% versus 3.6% and 8.9% versus 0.0%, respectively), although these differences were not statistically significant (P = 0.406 and 0.291, respectively). The two groups showed similar occurrences of anastomotic leakage, bowel obstruction, overall complications, and mortality. Compared with the TDT group, the SEMS group had a significantly lower rate of surgical site infection (24.4% versus 3.6%, respectively; P = 0.023 and P = 0.025 after PSM) and a shorter length of hospital stay (median, 21 d [interquartile range, 18-29 d] versus 38 d [interquartile range, 28-45 d], respectively; P = 0.015 and P = 0.003 after PSM). Solid food intake after decompression and preoperative temporary discharge occurred only in the SEMS group.

CONCLUSIONS

Preoperative SEMS insertion for MLBO is effective with at least equivalent short-term outcomes and superior preoperative quality of life compared with decompression using TDT.

Feasibility of Preoperative Chemotherapy With or Without Radiation Therapy in Localized Soft Tissue Sarcomas of Limbs and Superficial Trunk in the Italian Sarcoma Group/Grupo Español de Investigación en Sarcomas Randomized Clinical Trial: Three Versus Five Cycles of Full-Dose Epirubicin Plus Ifosfamide

PURPOSE

We report on feasibility of preoperative chemotherapy with or without radiation therapy (RT) in the context of a phase III randomized clinical trial involving localized, high-risk, soft tissue sarcomas.

PATIENTS AND METHODS

Of 321 eligible patients, 161 were randomly assigned to three preoperative cycles of epirubicin 120 mg/m(2) plus ifosfamide 9 g/m(2), and 160 were randomly assigned to three preoperative plus two postoperative cycles. Among them, 303 patients were included in this analysis; 169 were male and 134 were female, with a median age of 48 years (range, 15 to 79 years). One hundred fifty-two patients received concurrent RT preoperatively at a total dose of 44 to 50 Gy. Preoperative chemotherapy-related hematologic toxicity and early postoperative complications were reported. The influence of RT, age, and sex on hematologic grade 3 or 4 toxicities and wound complications was analyzed. Chemotherapeutic dose intensity (DI) was analyzed.

RESULTS

Among the patients, 61.4%, 22.4%, and 23.8% experienced, grade 4 leucopenia, grade 3 or 4 anemia, and grade 3 or 4 thrombocytopenia, respectively. Respective rates were 66.4%, 24.3%, and 31.6% when RT was added preoperatively, and 56.3%, 20.5%, and 15.9% when preoperative chemotherapy was administered alone. Patient age affected grade 3 or 4 thrombocytopenia. Grade 4 leucopenia and grade 3 or 4 anemia presented 2.5 times more frequently in female patients than in male patients. Wound complications were observed in 13.5% of patients: 17% with preoperative RT and 10% without. Chemotherapeutic DI was greater than 90%, even in patients receiving preoperative RT and in patients age 65 years or older.

CONCLUSION

This preoperative chemotherapy is feasible and can also be proposed for selected elderly patients. Grade 3 or 4 hematologic toxicity was common, but DI was excellent. Concurrent preoperative RT is safe, although an increased rate of grade 4 thrombocytopenia and limited increase in wound complications may be observed.

Colorectal cancer with intestinal perforation - a retrospective analysis of treatment outcomes

Aim of the study

Colorectal cancer (CRC) is one of the leading cause of death in European population. It progresses without any symptoms in the early stages or those clinical symptoms are very discrete. The aim of this study was a retrospective analysis of treatment outcomes in patients with colorectal cancer complicated with intestinal perforation.

Material and methods

A retrospective analysis of patients urgently operated upon in our Division of General Surgery, because of large intestine perforation, from February 1993 to February 2013 has been made. Results were compared with a group of patients undergoing the elective surgery for colorectal cancer in the same time and Division.

Results

Intestinal perforation occurred more often in males (6.52% vs. 6.03%), patients with mucous component in histopathological examination (9.09% vs. 6.01%) and with clinicaly advanced CRC. Patients treated because of perforation had a five-fold higher 30 day mortality rate (9.09% vs. 1.83%), however long-term survival did not differ significantly in both groups. After resectional surgery in 874 patients an intestinal anastomosis was made. Anastomotic leakage was present in 23 (2.6%) patients. This complication occurred six-fold more frequently in a group of patients operated upon because of intestinal perforation (12.20% vs. 2.16%).

Conclusions

In patients with CRC complicated with perforation of the colon in a 30-day observation significantly higher rate of complications and mortality was shown, whereas there was no difference in distant survival rates.

Colorectal cancer treatment in octogenarians: elective or emergency surgery?

Background

The purpose of this research was to assess the characteristics of octogenarian patients with colorectal cancer and compare specific outcomes due to different types of surgical procedures used to treat the disease.

Methods

A total of 346 octogenarian patients undergoing surgery for colorectal cancer between April 2000 and April 2010 were retrospectively assessed according to elective (n = 261) or emergent (n = 85) admission group. The two groups were compared for clinical variables, surgical procedures, morbidity and mortality, ICU admission, length of hospital stay and overall survival.

Results

The two groups had similar comorbidities. The emergent group had a more advanced Dukes’ stage, higher American Society of Anesthesiologists grading, lower anastomosis rate (40.2 vs 80.1%), higher stoma rate (30.6 vs 9.6%), more complications (71.8 vs 43.3%), nine days longer length of hospital stay and higher (82.4% vs 36.4%) ICU admission rate. Overall mortality was 9.5%, with a higher mortality rate in the emergent group (30.6%) than the elective group (3.1%).

Conclusions

Octogenarians who undergo elective colorectal cancer surgery have better results than those requiring emergent surgery, but both are quite acceptable and we recommend surgical intervention should not be delayed.

The outcome of self-expanding metal stents in elderly patients

Background and Objectives:

Emergency surgery for large bowel obstruction is associated with high morbidity and mortality rates, especially in elderly patients. Colonic self-expanding metal stents may provide temporary relief of obstructions and enable preoperative evaluation. The aim of this retrospective study was to assess the clinical outcomes of emergency stenting in elderly patients with large bowel obstructions.

Methods:

Between 1997 and 2010, patients presenting with large bowel obstructions were treated predominantly with self-expanding metal stent insertion. Clinical data, including age, site of obstruction, success rate, and surgery and mortality rates, were collected. Patients were divided into 3 groups (I, II, and III) according to age: <69, 70 to 79, or >80 years.

Results:

One hundred thirty-two consecutive patients underwent stent implantation, with a mean age of 72.1 years (range, 28–95 years). Similar diversity of sex, indication, and stricture location was found. There were no significant differences in clinical success (88.7%, 73.8%, and 78.4%, P = .16) and stent-related mortality (2.1%, 3.3%, and 3.6%, P = 1.00). Similar rates of stoma creation were also found (59.3%, 46.7%, and 60.0%, P = .76). In contrast, rates of surgery were lower in older patients (50.9%, 38.1%, and 13.5%, P = .0013), and mortality during the same admission was significantly higher in patients >70 years of age (4.0%, 15.0%, and 22.2%, P = .027). Kaplan-Meier 30-day survival curves for the 3 groups showed a trend toward earlier death among patients >70 years of age.

Conclusions:

This study demonstrates that stenting provides similar success rates in all age groups but is associated with higher mortality rates in older patients.

Factors associated with mortality risk for malignant colonic obstruction in elderly patients

BACKGROUND

Acute colonic obstruction is the most common complication of colorectal cancer (CRC) in elderly patients. Medical treatment has been associated with higher perioperative morbidity and mortality rates. There is a need for identification of elderly CRC patients who will do poorly so that results can be improved. The purpose of this study is to assess the 30-day outcome of elderly patients undergoing malignant colonic obstruction procedures and identify the associated factors of mortality.

METHODS

A review of 233 elderly patients who received medical procedures for malignant colonic obstruction between April 2000 and April 2012 was conducted. Data regarding clinical variables, surgical procedures and outcomes, complications, and mortality were studied. Univariate and logistic regression analyses were performed on mortality risk factors.

RESULTS

Patients had a mean age of 78.2 years (range 70-95). A total of 126 (54.1%) patients were classified ASA III and above. Eighty (34.3%) patients had right-sided colonic obstruction. In the 153 (65.7%) patients with left-sided colonic obstruction, 40 patients received self-expandable metallic stent (SEMS) treatment and 193 patients received surgery. A total of 62.2% (n = 145) patients had post operation complications. The overall 30-day mortality was 24.5% (n = 57). ASA grading, peritonitis and Dukes staging were independent risk factors for mortality.

CONCLUSIONS

Medical procedures in elderly patients with malignant colonic obstruction are associated with significant complications and mortality. Identifying these high-risk patients and treating promptly may improve outcomes. SEMS treatment provides a useful alternative to surgical intervention.

Assessment of solid cancer treatment feasibility in older patients: a prospective cohort study

PURPOSE

To assess solid cancer treatment feasibility in older patients.

METHODS

Between 2007 and 2010, 385 consecutive elderly patients (mean age: 78.9 ± 5.4 years; 47.8% males) with solid malignancies referred to two geriatric oncology clinics were included prospectively. We recorded feasibility of first-line chemotherapy (planned number of cycles in patients without metastases and three to six cycles depending on tumor site in patients with metastases), surgery (patient alive 30 days after successfully performed planned surgical procedure), radiotherapy (planned dose delivered), and hormonal therapy (planned drug dose given), and we recorded overall 1-year survival.

RESULTS

Main tumor sites were colorectal (28.6%), breast (23.1%), and prostate (10.9%), and 47% of patients had metastases. Planned cancer treatment was feasible in 65.7% of patients with metastases; this proportion was 59.0% for chemotherapy, 82.6% for surgery, 100% for radiotherapy, and 85.2% for hormonal therapy. In the group without metastases, feasibility proportions were 86.8% overall, 72.4% for chemotherapy, 95.7% for surgery, 96.4% for radiotherapy, and 97.9% for hormonal therapy. Factors independently associated with chemotherapy feasibility were good functional status defined as Eastern Cooperative Oncology Group performance status <2 (p < .0001) or activities of daily living >5 (p = .01), normal mobility defined as no difficulty walking (p = .01) or no fall risk (p = .007), and higher creatinine clearance (p = .04).

CONCLUSION

Feasibility rates were considerably lower for chemotherapy than for surgery, radiotherapy, and hormonal therapy. Therefore, utilization of limited geriatric oncology resources may be optimized by preferential referral of elderly cancer patients initially considered for chemotherapy to geriatric oncology clinics.

Treatment of colorectal cancer in older patients

Colorectal cancer (CRC) largely affects older individuals; almost half of cases occur in patients >75 years old. The incidence increases with advancing age, doubling every 7 years in patients aged ≥50 years. The medical and societal burdens of CRC will probably worsen over the coming decades as the number of older individuals (>70) continues to grow. No evidence-based guidelines are available for this age group, as older patients with CRC are generally excluded from randomized clinical trials and the fit ones who are recruited are not representative of the general elderly population. When feasible, surgery is the most successful treatment option for eradicating the primary lesion, as well as any metastases. The operative risk under elective conditions is not markedly different in older than in younger patients; however, the acute setting is to be avoided as it is associated with high operative death rates. Well-selected older patients can tolerate chemotherapy, but benefits need to be balanced against potentially limited life expectancy and reduced quality of life. The use of combination chemotherapy is an area of much controversy, but this treatment should not necessarily be withheld because of the age of the patient. Careful monitoring of toxicities and early intervention is essential in older patients undergoing chemotherapy.

Poor 1-year survival in elderly patients undergoing nonelective colorectal resection

BACKGROUND

Colorectal resection in elderly patients is associated with significant morbidity and mortality, especially in an emergency setting.

OBJECTIVES

This study aims to quantify the risks associated with nonelective colorectal resection up to 1 year after surgery in elderly patients.

DESIGN

This is a population-based observational study.

SETTING

Data were obtained from the Hospital Episode Statistics database.

POPULATION

All patients aged 70 years and older who underwent a nonelective colorectal resection in an English National Health Service Trust hospital between April 2001 and March 2008 were included.

MAIN OUTCOME MEASURES

: The primary outcomes measured were 30-day in hospital mortality, 365-day mortality, unplanned readmission within 28 days of discharge, and duration of hospital stay.

RESULTS

During the study period, 36,767 nonelective colorectal resections were performed in patients aged ≥ 70 years in England. Patients were classified into 3 age groups: A (70-75 years), B (76-80 years), and C (>80 years). Thirty-day mortality was 17.0%, 23.3%, and 31.0% in groups A, B, and C (p < 0.001). The overall 30-day medical complication rate was 33.7%, and the reoperation rate was 6.3%. Cardiac and respiratory complications were significantly higher in group C (22.2% and 18.2%, p < 0.001). Mortality in Group C was 51.2% at 1-year postsurgery. Advanced age was an independent determinant of mortality in risk-adjusted regression analyses.

LIMITATIONS

This is a retrospective analysis of a prospective database. Stage of disease at presentation, severity of complications, and cause of death cannot be ascertained from this database.

CONCLUSIONS

In this population-based study, half of all English patients aged over 80 years undergoing nonelective colorectal resection died within 1 year of surgery. Further research is required to identify perioperative and postdischarge strategies that may improve survival in this vulnerable cohort.

Octogenarians: an increasing challenge for acute care and colorectal surgeons. An outcomes analysis of emergency colorectal surgery in the elderly

AIM

Emergency surgery is associated with higher mortality rates, especially in elderly patients presenting with emergent colorectal disease. The aim of this study was to determine the outcomes in elderly patients following emergency colorectal resection, with particular focus on octogenarians who presented a sixfold higher mortality rate with respect to other patients.

METHOD

This study examined 355 patients who underwent surgery at an Emergency Department for complications of colorectal disease between January 2007 and December 2009. Morbidity and mortality were analyzed on the basis of patients' characteristics and presentation. Univariate and logistic regression analyses were performed on morbidity and mortality risk factors.

RESULTS

Two-hundred and fifteen patients of > 65 years of age were included, 93 of whom were ≥ 80 years of age. The global mortality rate was 16%. In patients ≥ 80 years of age the mortality rate was 30%. The difference in mortality rate between patients < 80 years of age vs patients ≥ 80 years of age was 24%. In resected patients ≥ 80 years of age, American Society of Anesthesiology grade, colonic ischaemia, neurological comorbidity and anastomotic dehiscence were identified as independent risk factors in both univariate and logistic regression analyses. The morbidity rate was approximately 17%, and no significant difference in morbidity was found between the two groups.

CONCLUSION

The results of this study show that fitness status and micro vascular impairment impact significantly on mortality in the elderly, particularly in octogenarians. Although the outcomes observed were compatible with the literature, the six fold higher mortality rate observed in the most elderly patients identifies a group for which death prevention is best achieved with aggressive resuscitation and intensive postoperative care, rather than timing of surgery.

The impact of age on outcome after surgery for colorectal adenocarcinoma

INTRODUCTION

The incidence of colorectal cancer (CRC) increases with age. The aim of this study was to investigate the impact of age and age-related factors on post-operative mortality and survival following CRC resections.

METHODS

A prospectively collected database of 459 CRC resections was analysed.

RESULTS

The mean age of the patients was 70 years (range: 25-95 years) and 54% were male. The relative proportion of female patients increased with age so that for patients aged over 77 more women were treated than men. The probability of undergoing an emergency resection (25%) did not change with age. In older patients the proportion of rectal cancers resected decreased and the proportion of hemicolectomies and Hartmann's operations performed increased. The 30-day mortality rate was 4% after elective and 11% after emergency resections. Most deaths were caused by medical complications, reflecting increased co-morbidity in the elderly. Post-operative mortality was 1% in patients under the age of 59. This increased by 3 percentage points every 10 years after elective resections and by 8 percentage points every 10 years after emergency resections. CRC-specific survival was independent of age whereas overall survival decreased so the likelihood of dying from CRC decreased with age: at age 50 half the deaths were from CRC, at age 70 a third and at age 80 a quarter.

CONCLUSIONS

CRC stage and the probability of presenting as an emergency did not change with age but older patients were more likely to be female and have colon cancer. Post-operative mortality progressively increased with age. Most deaths were caused by medical complications, reflecting increased co-morbidity. Older patients were less likely to die from CRC.

Principles of surgical oncology in the elderly

Elderly patients constitute the largest group in oncologic medical practice, despite the fact that in solid cancers treated operatively, many patients are denied standard therapies and where such decision making is based solely on age. The “natural” assumptions that we have are often misleading; namely, that the elderly cannot tolerate complex or difficult procedures, chemotherapy, or radiation schedules; that their overall predictable medical health determines survival (and not the malignancy); or that older patients typically have less aggressive tumors. Clearly, patient selection and a comprehensive geriatric assessment is key where well-selected cases have the same cancer-specific survival as younger cohorts in a range of tumors as outlined including upper and lower gastrointestinal malignancy, head and neck cancer, and breast cancer. The assessment of patient fitness for surgery and adjuvant therapies is therefore critical to outcomes, where studies have clearly shown that fit older patients experience the same benefits and toxicities of chemotherapy as do younger patients and that when normalized for preexisting medical conditions,that older patients tolerate major operative procedures designed with curative oncological intent. At present, our problem is the lack of true evidence-based medicine specifically designed with age in mind, which effectively limits surgical decision making in disease-based strategies. This can only be achieved by the utilization of more standardized, comprehensive geriatric assessments to identify vulnerable older patients, aggressive pre-habilitation with amelioration of vulnerability causation, improvement of patient-centered longitudinal outcomes, and an improved surgical and medical understanding of relatively subtle decreases in organ functioning, social support mechanisms and impairments of health-related quality of life as a feature specifically of advanced age.

Self-expanding metallic stents drainage for acute proximal colon obstruction

AIM: To clarify the usefulness of the self-expanding metallic stents (SEMS) in the management of acute proximal colon obstruction due to colon carcinoma before curative surgery.

METHODS: Eighty-one colon (proximal to spleen flex) carcinoma patients (47 males and 34 females, aged 18-94 years, mean = 66.2 years) treated between September 2004 and June 2010 for acute colon obstruction were enrolled to this study, and their clinical and radiological features were reviewed. After a cleaning enema was administered, urgent colonoscopy was performed. Subsequently, endoscopic decompression using SEMS placement was attempted.

RESULTS: Endoscopic decompression using SEMS placement was technically successful in 78 (96.3%) of 81 patients. Three patients’ symptoms could not be relieved after SEMS placement and emergent operation was performed 1 d later. The site of obstruction was transverse colon in 18 patients, the hepatic flex in 42, and the ascending colon in 21. Following adequate cleansing of the colon, patients’ abdominal girth was decreased from 88 ± 3 cm before drainage to 72 ± 6 cm 7 d later, and one-stage surgery after 8 ± 1 d (range, 7-10 d) was performed. No anastomotic leakage or postoperative stenosis occurred after operation.

CONCLUSION: SEMS placement is effective and safe in the management of acute proximal colon obstruction due to colon carcinoma, and is considered as a bridged method before curative surgery.

Analysis of 230 cases of emergent surgery for obstructing colon cancer--lessons learned

PURPOSE

We aimed to identify prognostic factors affecting clinical outcomes in emergent primary resection.

METHODS

A retrospective analysis of prospectively acquired data of 230 consecutive emergent patients between August 1994 and January 2005 were evaluated in this study. Sixty-nine patients applied with right colon obstruction and 161 patients with left. Resection and primary anastomosis was carried out in 128 patients and resection and stoma in 102 patients. The patients were divided into two cohorts: patients who developed poor outcome within 30 days after surgery and those who did not.

RESULTS

Major morbidity or mortality were reported in 60 (26.1%) patients. Analysis revealed that the most important prognostic factors for poor outcome were American Anesthesiology Association (ASA) grade ≥3, Acute Physiology and Chronic Health Evaluation II (APACHE II) score ≥11, age >60 years, presence of peritonitis, and surgery during on-call hours. Age >60 years and on-call surgery were determinant factors in right-sided obstructions, whereas ASA grade ≥3, APACHE II score ≥11, and presence of peritonitis were determinant factors in left-sided obstructions.

CONCLUSIONS

All these factors but the timing of the operation emphasize the pivotal role of the patient's physiological condition on admission. Accurate preoperative evaluation might predict the clinical outcome and help in establishing the most appropriate treatment.

Current management of diverticular disease of the colon

The medical treatment plays the first role in the vast majority of cases. Severe acute diverticulitis requires hospitalization and supporting care with intravenous fluids and antibiotics such as ciprofloxacin and metronidazole. Emergency operative intervention is necessary if complication occurs. Laparoscopic surgery has a well-defined place and such colectomy has been gaining, nowadays, more popularity.

Emergency colorectal resections in Asian octogenarians: factors impacting surgical outcome

PURPOSE

The population in developing countries is aging and the number of octogenarians is expected to increase in the future at an alarmingly fast rate. This paper evaluates the surgical outcomes of emergency colorectal resections among Asian octogenarians.

METHODS

We conducted a retrospective review of all octogenarians and older, who had an emergency colorectal resection performed between February 1996 to December 2001.

RESULTS

Fifty-eight emergency colorectal resections were performed in patients with a median age of 83 years. The indications for surgery were colorectal cancer (74%) and complicated diverticular disease (12%). The most common presentation was an intestinal obstruction (72%). Fifty-one (88%) of the patients had comorbidities. Forty-five percent of patients had an American Society of Anesthesiologists (ASA) score of I and II, while 55% had a score of III and IV. Consultants performed 53% of the procedures. The mean surgical time was 156 min. Hartmann's procedure was the most common procedure performed (43%). There were 16 (28%) mortalities. The postoperative morbidity was 81%. The only factor impacting outcome was a high ASA score of III and IV. The median length of stay was 17.5 (range 3-108) days.

CONCLUSIONS

The mortality and morbidity of emergency colorectal resections among Asian octogenarians are high and can be predicted by their ASA status.

Endoscopic decompression using a transanal drainage tube for acute obstruction of the rectum and left colon as a bridge to curative surgery

OBJECTIVE

The aim of this study was to clarify the usefulness of the management of acute left colon and rectum obstruction because of colorectal carcinoma using a transanal ileus drainage tube before curative surgery.

METHOD

Forty-six patients (24 males and 22 females, aged 24-94 years, mean = 56.2) treated between September 2005 and March 2007 for acute left colon and rectal obstruction were identified in a colorectal obstruction database, and their clinical and radiological features were reviewed. After a cleaning enema was administered, urgent colonoscopy was performed. Subsequently, endoscopic decompression using a ileus tube was attempted.

RESULTS

Endoscopic decompression using the ileus tube was technically successful in 45 of 46 patients (97.8%). Perforation occurred in one patient 3 days later and emergent operation was performed. The site of obstruction was the rectum in 15 patients, the sigmoid colon in 18, the descending colon in 13. Following adequate cleansing of the colon, patients' abdominal girth were decreased from 91 +/- 4 cm before drainage to 82 +/- 2 cm 7 days later, and one-stage surgery after 8 +/- 1 days (SD; range 7-10 days) were performed. No anastomotic leakage or postoperative stenosis occurred after operation.

CONCLUSION

Management of acute left colon and rectum obstruction because of colorectal carcinoma using the ileus tube was found to be effective and safe, considered as a bridged method before curative surgery.

Direct hemoperfusion with polymyxin-B-immobilized fiber columns improves septic hypotension and reduces inflammatory mediators in septic patients with colorectal perforation

PURPOSE

Although some studies have reported favorable effects of direct hemoperfusion with polymyxin-B-immobilized fiber columns (PMX) for the treatment of septic shock, few studies have demonstrated the efficacy of PMX in studies with a uniform case definition and without any other blood purification techniques.

MATERIALS AND METHODS

Fifty-two patients with severe sepsis or septic shock secondary to colorectal perforation were treated with PMX. Hemodynamic alterations and plasma concentrations of endotoxin, interleukin (IL)-1beta, IL-1 receptor antagonist (IL-1Ra), IL-6, IL-8, and IL-10 were evaluated following PMX treatment.

RESULTS

We observed a significant reduction in plasma endotoxin in the nonsurvivors immediately after PMX treatment compared to before treatment. Systolic blood pressure was markedly increased and circulating levels of IL-1beta, IL-1Ra, and IL-8 were significantly reduced during a 2-h interval of PMX.

CONCLUSIONS

Our findings suggested that PMX treatment appears to adsorb endotoxin and also modulates circulating cytokine during a 2-h interval of direct hemoperfusion in septic patients with such condition.

Treatment of advanced colorectal cancer in the elderly

The recent improved survival in advanced colorectal cancer, owing in a large part to advances in adjuvant treatment, has mainly been reported in studies of younger patient groups. Less is known about outcome in elderly patients, the fastest growing cohort of cancer patients. The antimetabolite capecitabine used sequentially or concomitantly with the topoisomerase 1 inhibitor irinotecan or the DNA cross linking agent oxaliplatin are now considered to be the standard first line chemotherapy regime. The role of surgery in advanced colorectal cancer in the elderly is restricted to the relief of bowel obstruction and where appropriate resection of hepatic metastasis. Advanced chronological age has not been shown to be a contraindication to the consideration of these interventions. Indeed, chronological age alone does not provide sufficient guidance when considering the appropriateness of any palliative treatment regime in the elderly.

Surgical management of oncogeriatric patients

Major changes are taking place at a great pace in modern medicine, and surgical oncologists are at the forefront when new skills are to be tested and implemented. Perhaps the most significant change we are facing relates to the aging of our population, with most solid tumors presenting at age 70 years (+/- 5 years). The demographics and epidemiological details are covered in the appropriate sections of this special issue, but it is important to realize how such a shift influences our day-to-day practice. These principally are occurring in improved anesthetic care, minimally invasive surgery, nonoperative therapies, risk assessment, and quality-of-life estimates.