Emergency presentation and mortality from colorectal cancer in the elderly

Evaluation of POSSUM and P-POSSUM scoring systems in patients undergoing colorectal surgery

BACKGROUND

The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and Portsmouth POSSUM (P-POSSUM) equations were derived from a heterogeneous general surgical population and have been used successfully as audit tools to provide risk-adjusted operative mortality rates. Their applicability to high-risk emergency colorectal operations has not been established.

METHODS

POSSUM variables were recorded for 1017 patients undergoing major elective (n = 804) or emergency (n = 213) colorectal surgery in ten hospitals. Subgroup analysis was performed to investigate the predictive capability of POSSUM and P-POSSUM in emergency and elective surgery and in patients in different age groups.

RESULTS

The overall operative mortality rate was 7.5 per cent (POSSUM-estimated mortality rate 8.2 per cent; P-POSSUM-estimated mortality rate 7.1 per cent). In-hospital deaths increased exponentially with age. Both scoring systems overpredicted mortality in young patients and underpredicted mortality in the elderly (P < 0.001). Death was underpredicted by both systems for emergency cases, significantly so at a simulated emergency caseload of 47.9 per cent (P < 0.05).

CONCLUSION

There is a lack of calibration of POSSUM and P-POSSUM systems at the extremes of age and high emergency workload. This has important implication in clinical practice, as consultants with a high emergency workload may seem to underperform when these scoring systems are applied. Recalibration or remodelling strategies may facilitate the application of POSSUM-based systems in colorectal surgery.

Is there ageism in oncology?

OBJECTIVE

To use routine data to explore age-related decision making in the hospital management of colorectal cancer.

DESIGN

Retrospective analysis of linked Scottish cancer registry and hospital discharge data for colorectal cancer.

SETTING

All Scottish general hospitals.

PARTICIPANTS

All patients on the Scottish colorectal cancer registry 1992-6 (n = 15,299).

MAIN RESULTS

Histological verification was used to indicate the "gold standard" of investigation. Definitive surgery and chemotherapy were used as indicators of treatment received. After adjusting for demographic factors, tumour sub-site, co-morbidity and route of first admission, increasing age was associated with markedly decreased rates of histological verification, surgery and chemotherapy. It is still not possible to be sure whether there is ageism in the management of older patients with colorectal cancer. However, the rate of histological verification fell markedly with increasing age, making it questionable whether decisions to treat were based on best clinical practice at the time. Differences observed between this study and clinical trial data may represent the margin of ageism between everyday clinical practice and controlled conditions.

CONCLUSIONS

The value of this analysis lies in the fact that the data come from routine clinical practice rather than special studies. The improved content of Scottish cancer register and the ability to link it to hospital care provides a useful baseline for monitoring adherence to clinical guidelines.

Rectal cancer surgery in patients more than 80 years of age

BACKGROUND

This retrospective study aimed to compare the prognosis for rectal cancer in patients more than 80 years old with that observed in younger patients.

METHODS

Patients operated on for a rectal adenocarcinoma, from 1980 to 1998, were divided into two groups: group 1 (>80 years, n = 92); group 2 (<80 years, n = 276).

RESULTS

There were significant differences between the two groups with regard to the sex ratio, the American Society of Anesthesiologists (ASA) classification, the emergency presentation, and the curative operation rate. The operative mortality rate was 8% in group 1, 4% in group 2 (P = 0.26). The overall 5-year survival rate was 35% in group 1, 53% in group 2 (P = 0.0004). In patients operated on for cure, the cancer-specific 5-year survival rate was 50% in group 1, 59% in group 2 (P = 0.08).

CONCLUSIONS

The prognosis for rectal cancer in patients over 80 years is not significantly different from that of younger patients. Surgery should not be restricted on the basis of age.

Major colorectal cancer resection should not be denied to the elderly

AIMS

Adjuvant therapy after surgery for colorectal cancer is often denied to the elderly for various reasons. This study was to determine morbidity and mortality risk after surgery in the elderly and whether this is affected by adjuvant therapy.

METHODS

Data were collected prospectively and entered on a database for all patients undergoing resection of colorectal cancer between January 1994 and July 2000. A total of 304 patients were included, 65 aged 80 years and over.

RESULTS

There were 84 deaths, 21 (30%) in the over 80s, and 63 (26%) in the under 80s (P=0.51). The 'in-hospital' mortality was 10.1% in the over 80s and 3.8% in the under 80s (P=0.056). In the over 80s the colon was more affected than the rectum (P=0.002). The over 80s were less likely to be offered adjuvant therapy, 7.2% vs 42.1% (P<0.001). The 5 year survival (all-cause mortality) in the over 80s was 58.5% and 47.6% in the under 80s (P=0.25). Cox's regression analysis of all patients identified the following factors to be independently related to overall survival: age>80 years, post-operative leak, increasing Dukes stage and distant recurrence of disease.

CONCLUSION

This study has demonstrated that surgery should not be denied to elderly patients with colorectal cancer as despite a higher post-operative morbidity and mortality rate and with the absence of adjuvant therapy, favourable long-term outcome can be achieved by resectional surgery alone.

Obstructing colonic cancer: failure and survival patterns over a ten-year follow-up after one-stage curative surgery

BACKGROUND

Large-bowel cancers that present as obstructing lesions have a poor prognosis. However, little is known of the reasons for the dismal survival and of failure patterns after potentially curative treatment.

METHOD

An observational study and multivariate analysis were conducted to identify determinants of survival and to compare recurrence patterns between obstructing and nonobstructing tumors after primary resection and anastomosis as curative treatment.

RESULTS

Over a period of ten years (1980-1989), 528 patients with colonic cancer were treated at one institution. The cancer was obstructing in 179 cases and nonobstructing in 349. One-stage primary resection and anastomosis as curative treatment were performed in 107 obstructed and 256 nonobstructed patients. Three hundred thirty-six potentially cured survivors (94 in the former group and 242 in the latter) were followed for a median of 55 months. During follow-up, local recurrence occurred in 37 patients (12 obstructed (12.8 percent) and 25 nonobstructed (10.4 percent), P = 0.44) and metastatic disease in 68 (25 obstructed (27.6 percent) and 43 nonobstructed (17.8 percent), P = 0.029). Multivariate analysis of survival showed that age over 70 years, Dukes stage, histologic grade, and recurrence were the only prognostic factors. No statistically significant determinant turned out for local recurrence, whereas at multivariate analysis for metastatic and overall relapse, Dukes stage, positive nodes, and obstruction remained independent prognostic factors.

CONCLUSIONS

After one-stage emergency curative treatment, patients presenting with obstructing tumors of the colon have a smaller survival probability than that of patients with nonobstructing lesions. Local recurrence pattern is similar between groups. Conversely, obstruction, along with pathologic stage and positive nodes, carries a significantly higher risk of metastatic tumor recurrence and death.

Surgery for colorectal cancer in elderly patients: a systematic review. Colorectal Cancer Collaborative Group

BACKGROUND

The effectiveness of surgery for colorectal cancer depends on it being carried out safely, which allows most patients to return to productive lives, with an improved postoperative life expectancy, or at least one that is not diminished by the surgery. Because colorectal cancer is a major cause of morbidity and mortality in elderly people, we have examined how the outcomes of surgery in elderly patients differ from those in younger patients.

METHODS

We did a systematic review of published and aggregate data provided by investigators. Studies were identified by computerised and manual searches of published and unpublished reports, scanning references, and contacting investigators. Within each study, outcomes for patients aged 65-74 years, 75-84 years, and 85+ years were expressed in relation to those aged less than 65 years.

FINDINGS

From 28 independent studies, and a total of 34,194 patients, we found that elderly patients had an increased frequency of comorbid conditions, were more likely to present with later-stage disease and undergo emergency surgery, and less likely to have curative surgery than younger patients. The incidence of postoperative morbidity and mortality increased progressively with advancing age. Overall survival was reduced in elderly patients, but for cancer specific survival age-related differences were much less striking.

INTERPRETATION

The relation between age and outcomes from colorectal cancer surgery is complex and may be confounded by differences in stage at presentation, tumour site, pre-existing comorbidities, and type of treatment received. However, selected elderly patients benefit from surgery since a large proportion survive for 2 or more years, irrespective of their age.

A retrospective analysis of palliative colonic stent placement in an elderly population

OBJECTIVE

Self-expanding metal stents (SEMS) have added a new dimension to the management of colonic malignant obstruction. We present our experience of palliative colonic stent insertion in a group of patients unsuitable for surgery.

PATIENTS AND METHODS

Since 1995 11 patients (median age 82 years) with strictures of the rectosigmoid region underwent SEMS placement at this Hospital. The indications for stent placement were large bowel obstruction (n=6), overflow incontinence (n=4) and faecal fistula (n=1). The selection criteria included five patients with disseminated disease and six who were deemed unfit for surgery. SEMS insertion was performed under fluoroscopic control in all patients, and colonoscopic assistance was required in four patients where fluoroscopy alone failed.

RESULTS

SEMS placement was successful in nine patients with resulting bowel decompression and immediate symptomatic relief, but failed in two patients. Where SEMS placement was unsuccessful, the stricture was impassable in one instance and in the other the patient withdrew consent. Stent migration occurred in three out of nine patients. The median survival time after stent placement was 5 months; one patient is still alive at 14 months.

CONCLUSION

SEMS placement resulted in the successful palliation of symptoms in patients with obstructive lesions deemed unfit for surgery-however, it is not always successful and there are complications.

How should patients 80 years of age or older with colorectal carcinoma be treated? Long-term and short-term outcome and postoperative cytokine levels

PURPOSE

The aim of this study was to determine how extensive resection affects operative morbidity, mortality, and long-term survival in elderly patients with colorectal cancer.

METHODS

A total of 119 patients 80 years of age or older were given a diagnosis of colorectal carcinoma at our hospital between 1985 and 1997. Eleven patients who did not undergo surgery were excluded. The remaining 108 patients underwent laparotomy and were reviewed. Serum levels of interleukin-6 were measured perioperatively in 22 patients to assess the degree of operative stress.

RESULTS

Potentially curative resection was performed in 64 (88.9 percent) of the 72 patients in the active performance status group and 13 (36.1 percent) of the 36 patients in the sedentary performance status group (P < 0.001). The in-hospital mortality rate was 8.3 percent in group the active performance status group and 38 percent in the sedentary performance status group (P = 0.007). Patients in the sedentary performance status group and those who underwent emergency operations had higher levels of IL-6 than patients in the active performance status group or those who underwent elective operations.

CONCLUSIONS

Preoperative performance status, operative curability, and tumor stage have a significant impact on outcome in patients with colorectal cancer who are 80 years of age or older. Knowledge of early postoperative response of IL-6 is useful in predicting postoperative mortality and morbidity in this subgroup of patients.

Treatment of colorectal cancer in patients aged over 75

Colorectal cancer is a common malignancy which is occurring with increasing incidence in the elderly. As the age of the population increases so the importance of this malignancy will gradually increase. In addition a high proportion of elderly patients present with intestinal obstruction secondary to colorectal cancer and therefore the management of intestinal obstruction in the elderly becomes an important surgical consideration. This review discusses the management of colorectal cancer in patients over the age of 75 in both the elective and emergency situations with particular reference to screening, surgical management and the use of adjuvant therapy.

Outcome after proctectomy for rectal cancer in Department of Veterans Affairs Hospitals: a report from the National Surgical Quality Improvement Program

OBJECTIVE

To define risk factors that predict adverse outcomes after proctectomy for cancer in Department of Veterans Affairs Medical Centers.

SUMMARY BACKGROUND DATA

Accurate presurgical assessment of the risk of perioperative complications and death is important in planning surgical therapy.

METHODS

The National VA Surgical Quality Improvement Program contains prospectively collected and extensively validated data on >287,000 patients. All patients undergoing proctectomy for rectal cancer from 1991 to 1995 who were registered in this data base were selected for study. Independent variables examined included 68 presurgical and 12 intraoperative clinical risk factors; dependent variables were 21 specific adverse outcomes. Stepwise logistic regression analysis was used to construct models predicting 30-day morbidity rates for each of the 10 most common complications and the 30-day mortality rate.

RESULTS

Five hundred ninety-one patients were identified; 467 (79%) underwent abdominoperineal resection and 124 (21%) were treated with sphincter-saving procedures. Thirty percent of patients had one or more complications after proctectomy. Prolonged ileus, urinary tract infection, pneumonia, and deep wound infection were the most frequently reported complications. The 30-day mortality rate was 3.2% (19 deaths). For most complications, 30-day mortality rates were significantly higher for patients with complications than for those without. Thirty-day mortality rates for several complications exceeded 50%: cardiac arrest requiring cardiopulmonary resuscitation, deep venous thrombosis or thrombophlebitis, coma lasting >24 hours, acute renal failure, cerebrovascular accident, and pulmonary embolism. Four presurgical factors predicted a high risk of 30-day mortality in the logistic regression analysis: elevated blood urea nitrogen level, impaired sensorium, low serum albumin concentration, and partial thromboplastin time < or =25 seconds.

CONCLUSIONS

Mortality rates after proctectomy in VA hospitals are comparable to those reported in other large series. Most postsurgical complications are associated with an increased 30-day mortality rate. Elevated presurgical blood urea nitrogen level, impaired sensorium, low serum albumin concentration, and partial thromboplastin time < or =25 seconds predict a high risk of 30-day mortality.

Curative surgery for colorectal cancer: long-term results and life expectancy in the elderly

PURPOSE

The long-term prognosis after curative surgery for colorectal cancer was evaluated in relation to age and life expectancy as a possible basis for assessing the risk to benefit ratios in the elderly.

METHODS

Data relating to 1,256 patients operated on from 1976 to 1994 were stored in a computer database prospectively from 1987. Patients were subdivided into four age groups (A = <60 years; B = 60-69; C = 70-79; D = > or =80). Distribution of general contraindications to curative surgery was examined. In the 869 patients who underwent curative treatment (A = 206; B = 256; C = 289; D = 118), distribution of tumor stage and elective/emergency surgery and the operative mortality rate were evaluated. Crude and age-corrected survival curves were calculated in 794 patients. The median crude survival of each group was related by gender and tumor stage to demographic life expectancy, assuming as "relative median survival index" the ratio between the two values.

RESULTS

General contraindications to curative surgery increased significantly with age. The operative mortality rate was higher in Group D than in Groups A, B, plus C over the total series (P < 0.001) and in both elective (P < 0.001) and emergency surgery (P < 0.05). Intergroup analysis of long-term survival rates showed significant differences between "crude" (P = 0.0057) but not age-corrected (P = 0.66) curves. The relative median survival index increased with age, up to approximately 1 in the local stages of Groups C and D.

CONCLUSIONS

To evaluate long-term results, elderly patients should be compared with unaffected, same-age subjects. Because the risks may be very high, the surgical policy in the elderly should be carefully weighed and related to life expectancy and actual results.

Duration of colorectal cancer symptoms and survival: the effect of confounding clinical and pathological variables

The relationship between symptom duration and long-term survival following colorectal cancer is complex, and a number of factors may influence the length of time from onset of symptoms of cancer diagnosis. We prospectively studied 777 consecutive colorectal cancer patients to determine the association between symptom duration and survival independent of other clinical and pathological features. We used survival curves, the logrank test and Cox's proportional hazards model to assess possible changes in relative risk of death with increasing symptom duration, without making any a priori assumptions. We found that symptom duration shortened with advanced tumour stage (P < 0.0006) and was also shorter for patients presenting with bowel obstruction (P < 0.0001). Univariate survival analysis showed that long-term survival increased consistently with symptom duration (P < 0.001). However, when the effect of tumour stage and bowel obstruction were accounted for in a multivariate analysis, no decrease in the relative risk of death was seen as symptom duration increased. The addition of other variables to the proportional hazards model such as age, sex or tumour site did not further influence the risk function form of symptom duration. Our results suggest that early diagnosis of colorectal cancer should remain our goal when assessing patients with suggestive gastrointestinal symptoms.

Elective surgery for gastrointestinal tumours in the elderly

The geriatric population is expanding and clinical decision-making is often complicated by the effects of ageing. Age should not be the only parameter considered when addressing medical problems. Elderly subjects have been denied surgery because of their presumed higher mortality and morbidity. The present review summarises the physiology of the aged and discusses operative risks, mortality and morbidity rates as well as therapeutic results for the different gastrointestinal sites when affected by cancer. Reports on surgical treatments are revisited and compared to the same procedures delivered to younger patients in the context of the ethical issue of offering the best care to every patient. Elective operations by surgical oncologists are found to be safe with the exception of major liver resections. Complication rates and mean hospital stay do not differ between the two age groups provided the procedure is conducted with the best-known technique in expert hands. A drop in operative morbidity has occurred in the past three decades. Several investigators have emphasised the marked increase in morbidity and mortality experienced by elderly patients when undergoing emergency procedures. Associated diseases have to be properly assessed, as the elderly have a frail physiological balance with a reduced capacity for recovery from traumatic events including major surgical procedures. Careful preoperative evaluation, intraoperative conduct and postoperative care are presently achieved in almost every major hospital. Good clinical practice is based on the balance between probability of cure and toxic effects. Treatment of the elderly should no longer be based on untested beliefs and personal opinions. The elderly should be accrued for prospective clinical evaluation and should not be denied optimal surgical treatment.

Colon cancer in the elderly: evidence for major improvements in health care and survival

Time trends in therapeutic approaches and in the prognosis of colon cancer for patients aged 75 years and above have been investigated in comparison with corresponding trends for younger patients using a population-based series of 2089 colon cancer patients diagnosed between 1976 and 1990 in the Côte-d'Or area (478,000 inhabitants), Burgundy, France. Significant progress has been achieved in the management of patients with colon cancer in both age groups, but trends have been more noticeable in patients aged 75 years and above. In the elderly, the proportion of cancers limited to the digestive tract wall showed a 3-year average increase of 2.8% (P = 0.02) and the frequency of curative surgery an average increase of 8.6% (P < 0.001), so that it was performed in 80% of cases in the last 3-year period. Operative mortality decreased by 2.5% between 3-year periods (P < 0.004). Crude 5-year survival rates in elderly patients increased from 15% in the 1976-78 period to 29% in the 1985-87 period (P < 0.001), the corresponding figures being 36% and 44% (P > 0.10) in younger patients.

Audit of outcome of major surgery in the elderly

The clinical outcome of 152 patients aged 65 years or over who were referred to the author's institute between August 1990 and August 1991 with certain specified gastrointestinal malignancies and acute, life-threatening abdominal conditions, were audited concurrently. Two groups were considered: patients aged 65-79 years and those over 80 years. The mortality rate within 30 days of surgery was 14 per cent in both age groups, although significantly fewer patients aged over 80 years (35 of 54) were considered suitable for surgery than in the 65-79 years age group (84 of 98) (0.01 > P > 0.001). Morbidity after operation and cost of treatment were not significantly different between the two groups. Two years after surgery 40 per cent of the patients aged over 80 years and 58 per cent of those aged 65-79 years were alive. Quality of life in these survivors was good with 85 per cent of those aged over 80 years living at home and 72 per cent fit enough to undertake light work.

The influence of age on resection rates and postoperative mortality in 6457 patients with colorectal cancer

Due to the ageing of the general population, the proportion of elderly patients with colorectal cancer has increased. In a registry-based study, we evaluated the influence of age and other variables on resection rates and operative risk. Resection rates and postoperative mortality rates (30-day) were analysed in 6457 patients with colorectal cancer, diagnosed from 1985 through 1992 in hospitals connected to the Rotterdam Cancer Registry. Overall, 87% of the patients underwent resection but resection rates were lower for patients older than 89 years (67%) and for patients with rectal cancer (83%). The postoperative mortality rate was 1% for patients younger than 60 years and steadily increased with age. For patients 80 years and older the operative risk was 10%. According to multivariate analysis gender, age, subsite and stage were defined as independent prognostic factors. In view of the lack of alternatives, elderly patients with colorectal cancer should not be denied surgery on account of chronological age alone. Even in patients over 90 years of age resections can be performed with acceptable risk.

Long-term outcome following curative surgery for malignant large bowel obstruction

This study determined whether the long-term outcome of patients with obstructing colorectal cancer could be related to conventional pathological prognostic variables or to other clinical, operative or histological features. Ninety-eight patients with bowel obstruction who had undergone potentially curative surgery and survived the postoperative period were studied. Features related to poor long-term outcome after a median follow-up of 5 years included bowel perforation at initial operation (P = 0.007), advanced tumour stage (P < 0.001), poor tumour differentiation (P = 0.02), mucin production by tumour (P = 0.004) and the presence of vascular (P = 0.08) and neural (P = 0.004) invasion. Outcome was not significantly related to the seniority of the operating surgeon (P = 0.52), even when this was adjusted for potentially confounding variables (adjusted hazard rate ratio for trainee surgeons 1.4 (95 per cent confidence interval 0.9-2.4), P = 0.16). Conventional prognostic features may help to identify the majority of patients with obstructed colorectal cancer at high risk of tumour recurrence and death.

Which kind of surgery in elderly people for colorectal cancer?

Colo-rectal cancers are of high incidence in elderly patients. Different clinical features and the peculiar behavior of the tumor may influence surgical results and should be considered in the decision making, when the surgeon has to decide whether to perform radical gut resection or less straining palliative procedures. In a retrospective study, 102 large bowel cancer patients are analyzed submitted to surgery in the period 1989-1994. Patients were divided in two age classes: Group A: above 70 years of age, 45 cases (44.2%); Group B: under 70 years of age, 57 cases (55.8%). Emergency surgery procedures were necessary in 35 patients (34.4%), 20 cases (57%) in Group A and 15 cases (43%) in Group B. Radical resections could be performed in 25 (37%) old patients, 67% of the cases underwent a curative resection. Perioperative mortality and surgical complication rates were significantly higher in Group A than in Group B. The technical and biological difficulties in performing radical curative resections, the high complication rates and the occurrence of negative results of treatments provide a reason for careful evaluation of the risk/benefit ratio in older patients, where less straining palliative therapies may sometimes offer similar results.

The outcome of surgery for colorectal cancer in the elderly: a 12-year review from the Trafford Database

In this database study of 882 patients with colorectal cancer, elderly patients are of poor physical status on admission and are more likely to be either completely inoperable or require urgent surgery. The operative mortality rate is higher and hospital stay is likely to be longer. However, if the elderly patient is fit for surgery, survives for more than 30 days and a curative resection performed, the 5-year survival and post-operative complication rates are as good as those patients in the younger age groups.

Risk factors in patients presenting as an emergency with colorectal cancer

Of 905 patients with colorectal cancer admitted to a single district general hospital, 272 (30 per cent) were admitted as emergencies. Emergency patients had more advanced tumours (Dukes stage B and C 96 per cent versus 88 per cent of those admitted electively, P < 0.006), a shorter history (median 3 versus 11 weeks, P < 0.0001), were less likely to be fully ambulatory (44 versus 80 per cent, P < 0.0001) and more likely to have abdominal pain (74 versus 51 per cent, P < 0.001) and vomiting (40 versus 10 per cent, P < 0.0001). More emergency patients were given stomas (56 versus 35 per cent, P < 0.0001) and died in hospital (19 versus 8 per cent, P < 0.0001). Of those who survived to be discharged, patients admitted as an emergency spent longer in hospital (median stay 16 versus 13 days, P < 0.0001) and had a poorer overall 5-year survival rate (29 versus 39 per cent, P = 0.0001). Emergency patients were significantly older (median 74 versus 72 years, P = 0.04) and much more likely to be widowed (41 versus 27 per cent, P = 0.0002) than those admitted for elective surgery. If the personal and resource disaster of emergency colorectal cancer admission is to be reduced, screening strategies targeted by demographic characteristics require investigation.

Prognosis of elderly patients with large bowel cancer

The effect of age on the presentation, diagnosis, management and survival of patients with colorectal cancer was studied prospectively in 512 patients admitted to a single institution. In all, 225 patients were aged 70 years or more and 287 less than 70 years. Older patients had a significant excess of emergency presentations (18 versus 11 per cent). Methods of diagnosis, proportion of curative operations performed, stage and histological grade were similar in the two age groups. The postoperative mortality rate was 6 per cent in the elderly group and 3 per cent in younger patients. The postoperative mortality rate rose to 15 and 12 per cent respectively in those undergoing emergency surgery. The relative 5-year survival rate standardized for age and sex was 52 per cent for older patients and 45 per cent for younger patients; for those undergoing curative surgery it was 68 and 59 per cent respectively. The behaviour of colorectal carcinoma changes little with age and, allowing for population mortality, age has no effect on the long-term survival of elderly patients with large bowel cancer.

Advanced colorectal neoplasia in the high-risk elderly patient: is surgical resection justified?

A review of the perioperative morbidity and mortality and long-term survival in elderly and high-risk patients with colorectal neoplasia was undertaken. Elderly high-risk patients with localized disease were compared with those with advanced disease. Over a five-year period, 82 high-risk (at least one major organ system disease), or elderly (age > or = 70 years) patients underwent an operation for colorectal neoplasia. Overall, 43 of 82 (52 percent) had advanced disease (obstruction, perforation, hemorrhage, or metastatic disease), while 39 of 82 (48 percent) had localized disease. The mean age of all patients was 78.2 years. Preoperative comorbid diseases included: coronary atherosclerosis, 59 (72 percent); previous myocardial infarction, 17 (21 percent); previous arrhythmia, 10 (12 percent); emphysema, 32 (39 percent); renal failure, 6 (7 percent); and cirrhosis, 3 (4 percent). At the time of surgery, 26 patients (32 percent) had metastatic disease. Six patients (7 percent) died in the perioperative period. The presence of advanced neoplasia did not significantly affect 30-day mortality. There was no difference in major morbidity between patients operated on for localized and for advanced disease. The mean actuarial 18-month survival was less for patients with advanced disease (P < 0.05). Sixty-eight patients (83 percent) are alive at a follow-up of 17.7 +/- 29 months postoperatively. The morbidity and mortality associated with resection of colorectal neoplasia in high-risk elderly patients are acceptable even in the presence of advanced disease. In select patients, resection offers the best palliation and may improve the quality of remaining life.

Elective versus emergency surgery for patients with colorectal cancer

A prospective study of 570 patients presenting with colorectal cancer over a 6-year period was undertaken. Of these, 363 were admitted electively and 207 presented as emergencies. The outcome following elective admission was more favourable than after emergency admission. In the elective group the proportion of resected tumours was greater (77 versus 64 per cent, P less than 0.001), the operative mortality rate lower (9 versus 19 per cent, P less than 0.001) and the 5-year disease-related survival rate higher (37 versus 19 per cent, P less than 0.001). These differences may relate to the greater resection rates in the elective situation. Results of surgical intervention might be improved if emergency colorectal operations were undertaken by surgeons with more experience of this type of surgery.

Results of colectomy in elderly patients with colon cancer, based on Medicare claims data

Currently available estimates of outcomes following colon resection in elderly patients with colon cancer are based on series collected at academic medical centers. We used Medicare Part A claims and enrollment records of a 5% nationally random sample of elderly Medicare beneficiaries from 1983 to 1985 to estimate how patient age and sex affected perioperative mortality and 1- and 2-year survival rates among elderly patients undergoing a colon resection procedure for colon cancer. Among the 5,586 individuals in our data set, the overall perioperative mortality rate was 5.0%, ranging from 3.3% in beneficiaries 66 to 69 years of age to 9.3% in those 85 years of age and older. Men had a 31% higher perioperative mortality rate than women (5.8% versus 4.4%, p less than 0.05). The overall postoperative survival rates at 1 and 2 years were 72% and 63%, respectively, decreasing with increasing age, but were similar in men and women. This analysis provides age- and sex-specific estimates of outcomes following surgery for elderly patients with colon cancer that are more precise and have more potential for generalization than those that were available previously.

Colorectal carcinoma over 30 years at one hospital: no evidence for a shift to the right

Many recent reports in the North American literature have documented an increase in the ratio of proximal to distal colorectal cancers with an increase in right-sided lesions. In order to assess trends in the distribution of large bowel carcinoma at our hospital we reviewed the files of 1553 patients who presented with primary colorectal carcinoma over a 30-year period. Thirty-nine percent of patients were over 70 years old and 51% were in the 50-69 year age group. Seventy five percent of the carcinomas were left-sided, 22% right-sided and caecal carcinomas accounted for 18%. This distribution varied only slightly over the study period. Left-sided lesions were more common in males (55%: p less than 0.005), and right-sided lesions were more common in females (57%: p less than 0.005). Caecal carcinoma was more common in patients over 69 years old than in younger patients (p less than 0.001). In elderly females (greater than 69 years) 30% of colorectal carcinomas occurred in the caecum. These findings may have important implications for the investigation of patients with suspected colorectal disease or for screening programmes.

Colorectal cancer in patients over 80 years of age

Between January 1, 1973, and December 31, 1986, 1,734 patients underwent colorectal resections for carcinoma. Patients were divided into two groups: Group I included 163 patients aged greater than or equal to 80 years on first presentation; Group II comprised 1,571 patients aged less than 80 years. The total perioperative mortality rates for the elderly and young group were 15.3 percent and 5 percent, respectively (P less than 0.001). The surgical mortality rates after elective operations in Groups I and II were 7.4 and 4.5 percent, respectively, and were not statistically different. Emergency surgery was associated with a significantly higher incidence of perioperative deaths at any age (P less than 0.001). In the elderly group, most deaths (88 percent) resulted from complications of coexisting medical disorders or thromboembolic complications. The 5-year survival for the young and elderly group were 46.2 percent and 35 percent, respectively (P less than 0.05). However, excluding patients dying from nonmalignant disease, the 5-year survival rate did not differ significantly between the two groups of patients (49.5 percent vs. 41.2 percent).

[Morbidity and mortality after elective resections of colorectal cancers]

There are few actual published results about morbidity and mortality after elective resection of colorectal cancer. Out of 596 patients with colorectal cancer, the medical records of 492 who had been prepared preoperatively according to our predefined standards and electively operated on, were analysed. We studied the results of morbidity and mortality and their association with preexisting conditions and preoperative complications. We found that 50% of our patients had preexisting conditions and that 18.7% had preoperative complications (obstruction, ileus, infections). The rate of general postoperative complications was 30.5%. While for pneumonia (13%) there was age and sex relation, for urinary infection (12.7%) there was only sex relation. We were able to reduce urinary infections by half (5.7%), by using a suprapubic catheter. 11.4% of our patients had local complications (anastomotic leakage 2%, ileus 2.2%, bleeding 1.6%, fistula 1.2%). These were neither dependent on age or sex, nor on preoperative complications or preexisting conditions. Mortality within 30 days was 2% and overall mortality was 2.6%. Our results show that careful diagnosis and treatment of preexisting conditions, bowel preparation and an improvement in operating techniques can all lead to improved results after elective resection.

Prospective, randomized trial of the biofragmentable anastomosis ring. The BAR Investigational Group

A randomized trial was undertaken to compare the biofragmental anastomotic ring (BAR) with conventional intraperitoneal colorectal anastomotic techniques. Patients were randomized into one of two schemes: BAR versus sutured or BAR versus stapled anastomosis. There were 782 patients entered into the study and 283 patients (36%) had a sutured anastomosis, 104 patients (13%) had a stapled anastomosis, and 395 (51%) had the BAR. Comparison of the BAR with combined suture and stapled controls revealed no significant differences in wound complication, abscess rate, bleeding, anastomotic leaks, ileus, obstruction, or deaths. There were no differences in return of bowel function, return to normal diet, or hospital stay. Intraoperative difficulties occurred in 46 BAR patients (17%), and this was significantly higher (p less than 0.001) than for sutured (3%) but not for stapled anastomoses (11%). The occurrence of these problems did not adversely effect the outcome. The data suggest that the BAR is a safe, satisfactory alternative to sutured or stapled colorectal anastomoses.

Ampullary carcinoma in patients under 50 years of age with a poor prognosis

Clinicopathologic features of 145 Japanese patients with ampullary carcinoma were compared among three age groups. The 145 patients were divided into three groups by the patient's age at the time of operation; there were 24 patients in group I (younger) aged less than or equal to 50 years, 99 in group II (ordinary) aged 51-69, and 22 in group III (elderly) aged greater than or equal to 70. The three groups showed no significant difference in sex, icterus, duration of icterus, size of the tumor, year of operation, macroscopic type, histopathologic type, tumor margin, lymphatic permeation, venous invasion, or pancreatic invasion. The survival curve of group I was worse than those of groups II and III. Multivariate regression analysis using 11 prognostic variables failed to reveal that the age of the patient at the time of operation was an independent factor. The younger patients aged less than or equal to 50 fared worse than the elderly patients aged greater than or equal to 70, because the group I tumors included a significantly greater number of advanced ampullary carcinoma with more frequent perineural invasion than did the group III tumors.

Malignant left-sided large bowel obstruction managed by subtotal/total colectomy

Of 60 patients presenting with acute obstructing carcinoma of the left colon, 49 underwent immediate resection either by radical subtotal/total colectomy (31 patients, group I) or by radical segmental resection (18 patients, group II) of whom three had immediate anastomosis after on-table bowel irrigation and 15 had a planned staged procedure. The operative mortality rate was 3 per cent in group I and 11 per cent in group II (not a statistically significant difference). However, substantial differences were found for major morbidity (6 versus 44 per cent in groups I and II respectively; P less than 0.01) and mean length of hospital stay (17 days in group I versus 35 days in group II; P less than 0.05). All three patients who had on-table lavage developed anastomotic leaks which necessitated a second operation to form a stoma. Six patients (19 per cent) in group I required antidiarrhoeal medication in the immediate postoperative period. However, subsequent improvement in stool frequency was noted in all patients. It is concluded that subtotal/total colectomy is an acceptable means of managing patients with obstructing carcinoma of the left colon in that it is associated with a low morbidity and mortality rate and good functional results.

Surgery for carcinoma of the colon in people aged 75 years and older

From January 1976 to June 1986, 154 patients (75 men and 79 women) who were 75 years of age or older were admitted for the surgical treatment of a colonic cancer. The mean age was 80.7 years. Patients were divided into two groups: 66 patients, between 75 and 80 years of age, were in Group I; 88 patients, 80 years of age and older, were in Group II. One hundred and forty-three patients (93%) were operated on and a resection was carried out in 125 patients (87%). The overall post-operative mortality rate was 12% (Group I: 5%; Group II: 17%; p less than 0.02). The actuarial survival rate of patients operated on was 32 +/- 8% at 3 years and 26 +/- 8% at 5 years (Group I: 37%; Group II: 17%). In both groups the survival rate was closely related to the extent of the disease according to Dukes classification. These results suggest that in the 75-80 year group age alone should no longer be considered a major risk factor for immediate surgical outcome. In patients aged 80 and older, the results are worse but it is not advanced age per se which influences mortality, rather the physiologic status of the patient.

Abdominal pain: a surgical audit of 1190 emergency admissions

In an audit of 1190 emergency admissions with abdominal pain (1166 patients) in a general surgical unit, the diagnosis was non-specific abdominal pain (NSAP) in 415 (35 per cent), acute appendicitis in 200 (17 per cent) and intestinal obstruction in 176 (15 per cent). The largest number of admissions occurred in the age groups 10-29 years (31 per cent) and 60-79 years (29 per cent). Surgical operations were performed in 551 patients (47 per cent) and there was a 16 per cent incidence of unnecessary appendicectomy (22 per cent in the age group 20-29 years). Fifty-one deaths resulted in a 30-day hospital mortality rate of 4.4 per cent and a perioperative mortality rate of 8 per cent. The mortality rate increased significantly in patients aged greater than or equal to 60 years, and patients aged 80-89 years had a perioperative mortality rate of 20 per cent. The causes of perioperative death included laparotomy for inoperable disease (28 per cent), ruptured abdominal aortic aneurysm (23 per cent), perforated peptic ulcer (16 per cent) and colonic resections (14 per cent). The perioperative mortality rates for ruptured aneurysm and perforated ulcer were 71 and 23 per cent respectively. The duration of inpatient stay increased significantly with the age of the patients, including those with NSAP. The results of the study indicate a need to review the methods of management of ruptured aortic aneurysm and perforated peptic ulcer, the methods of diagnosis of appendicitis, particularly in young females, and the factors that determine the duration of stay of patients suffering from NSAP.

Obstructing carcinomas of the colon

A series of 908 cases of colonic carcinoma has been analysed to elucidate reasons for the poor prognosis in obstructing colonic cancer. Complete obstruction was present in 148 cases (16.3 per cent), 280 cases (30.8 per cent) had partial obstruction and 480 (52.8 per cent) presented without obstruction. There were fewer Dukes' A tumours in those with complete obstruction (P less than 0.005) and greater numbers of advanced tumours (P less than 0.0005) compared with those without obstruction. This is reflected in a lower curative resection rate of 50.7 per cent in those with obstruction compared with 70.6 per cent in those without obstruction (P less than 0.001). However, after curative resection there was no significant difference in the distribution of tumour stage. Patients with complete obstruction showed a higher incidence of recurrence (P less than 0.01) after curative resection, consequent to an increased incidence of local recurrence (P less than 0.02). Five-year cancer-specific survival for the total series was decreased from 59.1 per cent in patients without obstruction to 31.8 per cent in those with complete obstruction (P less than 0.001). After curative resection there was also a significant reduction in survival (P less than 0.001). It is concluded that completely obstructing colonic cancers are more aggressive than other colonic cancers.

Factors influencing mortality after curative resection for large bowel cancer in elderly patients

Mortality rates from the Large Bowel Cancer Project are presented with special reference to patients older than 70 years. The in-hospital mortality rate among those who underwent curative resection for colorectal carcinoma was 7%. Unlike long-term prognosis, which is influenced by pathological features, in-hospital mortality is influenced largely by clinical factors. Age was an adverse factor (78% of deaths occurred among those aged over 70, who formed 46% of the study population), as was obstruction or perforation. 55% of deaths were due to cardiopulmonary complications. Educating patients to seek treatment early, careful preoperative assessment and postoperative monitoring of cardiopulmonary function, and, in selected patients, use of local treatments rather than wide resections may help to reduce mortality in elderly patients.

Surgery for colorectal cancer in elderly patients--a comparison with younger adult patients

Between 1972 and 1986, 668 patients without familial polyposis coli underwent surgery for colorectal cancer at the National Kyushu Cancer Center. Among these, there were 85 patients aged 75 years and older, and 39 patients aged 39 years and younger. The older patients tended to have a higher frequency of less advanced disease (stage I-III) and the progression of cancer in the older patients appeared to be relatively mild. The operative mortality rate of the older patients was as low as 1.2 per cent, which was almost identical to that of the younger adults (0 per cent), being 16.7 per cent for emergency operations, whereas it was 0 per cent for elective operations. The five-year survival curve of the older patients with curative resections was significantly better than that of those with noncurative resections. There was no significant difference in the cancer-related five-year survival curves between the older and younger patients with curative resections. Surgery for colorectal cancer in elderly patients should therefore not be restricted on the basis of chronological age alone.

Prognosis of colorectal cancer in the elderly

The prognosis of colorectal cancer in the elderly was examined in a study of 306 consecutive patients. The patients were divided into two groups: Group 1 included 171 patients of average age 77 years (range 70-97); Group 2 comprised 135 patients of average age 59 years (range 22-69). There was no significant difference between the two groups with regard to the mode of presentation, the location and Duke's classification of the tumours, the incidence of palliative operations, and the perioperative mortality. The surgical mortality rates in Group 1 were 6 per cent overall, 4 per cent after elective operations, and 16 per cent after emergency surgery; the corresponding mortality rates for Group 2 were 3 per cent, 1 per cent, and 20 per cent. Emergency surgery was associated with a significantly higher incidence of perioperative death at any age (P less than 0.001) and most deaths resulted from complications of coexisting medical disorders or thrombo-embolic complications. Crude actuarial 5-year survival curves showed an increased death rate in Group 1 after 18 months and a significantly lower 5-year survival (P less than 0.05) but the age-corrected survival curves for the two groups were not significantly different, and it was concluded that the prognosis for colorectal cancer in the elderly is not significantly different from that of younger patients.

Resection for colorectal cancer in the very old: are the risks too high?

Altogether 277 consecutive patients aged 70 or more who were admitted for resection of colorectal cancer between 1975 and 1985 were studied. The postoperative complications and mortality in the 175 patients aged 70-79 were compared with those in the 102 patients aged 80 or more. The overall mortality was 11%. Mortality was significantly higher after resection in the older age group even when deaths from widespread malignancy were excluded from the analysis. After curative resection mortality was 2% (2/120) in the younger group and 7% (4/60) in the older group, but after palliative resection of tumours with local or distant spread mortality was significantly higher, at 21% (9/44) and 38% (12/32), respectively. An equal but high proportion of patients in both age groups suffered major complications, but complications caused significantly more deaths in the older group. The length of stay in hospital was not significantly different between the age groups. Patients should not be denied resection of a colorectal cancer because of age alone, especially if a curative operation is possible. The increased risk of death from major complications, particularly after palliative resection, should, however, be taken into account when an operation on patients over 80 is being considered.

Outcome of colorectal cancer

The outcome of 454 patients who presented with colorectal carcinoma during a 16 year period is reviewed: 54 per cent were males, 58 per cent were aged more than 60 and 10 per cent had an emergency admission, 42 per cent of tumours occurred in the rectum. A curative resection was possible in 68 per cent. Postoperative mortality was 7 per cent. The overall crude 5-year survival was 41 per cent. The mortality from local recurrence was significantly higher in rectal (11.7 per cent) than in colonic cancer (8.8 per cent; P less than 0.01). The rate of recurrence and metastases was higher in patients with low rectal cancer than in patients with cancer of the middle and the upper rectum (P less than 0.01). Distant metastases were the cause of death in 94 per cent of the patients who had a Miles' operation for cancer of the middle rectum, whereas local recurrence was responsible for late mortality in 80 per cent of patients who underwent an anterior resection. No difference in 5-year survival was found in the restorative and in the excisional group.