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

Implantation of a new enteral stent in obstructive colorectal cancer using interventional radiology in patients over 70 years of age

Introduction

Colorectal cancer is the second leading cause of death due to cancer in Poland. The traditional approach to treat patients included a surgical procedure. Irrespective of the surgical method being used, surgical treatment of malignant colorectal obstruction is associated with prolonged hospitalisation, and the postoperative mortality rate is approximately 5–11%. Due to these problems, more interest has been shown in less invasive methods. Prosthesis implantation is a leading endoscopic method used currently in palliative or preoperative treatment.

Aim

To compare the results of implantation of traditional stents with the results of implantation of an own stent using minimally invasive methods.

Material and methods

Left-sided colon obstruction due to cancer was an indication for transplantation. All patients were aged over 70 years and had serious concomitant diseases. The control group included 50 patients with colorectal cancer who received traditional stents in the period 2009–2011. Our stent covers only the internal length of a tumour. It is not equipped with anti-migration flares. To minimize the risk of migration it has a system of hooks that are responsible for permanent anchorage of the stent within the tumour mass.

Results

Implantation technical and clinical success defined as effective decompression of intestinal obstruction was 100% in both groups. There were 2 cases of stent migration in the control group.

Conclusions

It is possible to achieve a secure surgical anastomosis after intestinal decompression. Stent implantation is fast and safe thanks to the positioning system that was used. The use of labelled hooks is a secure anti-migration solution.

The survival gap between middle-aged and elderly colon cancer patients. Time trends in treatment and survival

AIMS

For several types of cancer, including colon cancer, the survival gap between middle-aged patients and elderly patients widened between 1988 and 1999 in Europe. The aim of our study was to describe treatments and compare survival rates over time (1991-2005) between middle-aged (<65 years), aged (65-74 years) and elderly (≥ 75 years) colon cancer patients in the mid-western part of the Netherlands to assess whether this survival gap further increased.

METHODS

All 8926 patients with invasive colon cancer diagnosed between 1991 and 2005 were selected from the Comprehensive Cancer Centre West. Relative survival was calculated. Relative Excess Risks of death (RER) were estimated using a multivariable generalized linear model with a Poisson distribution.

RESULTS

There were no significant changes in the treatment for stage I and II colon. Patients with stage III and IV more often received chemotherapy over time (from 9.6% to 54.3% and from 7.5% to 44.2% for all ages, respectively), while less stage IV patients were operated on (from 73.1% to 55.2%). Relative 5-year survival increased significantly for middle-aged patients (RER = 0.97, 95%CI = 0.95-0.98, p < 0.001), borderline significantly (RER = 0.98, 95%CI = 0.97-0.99, p = 0.05) for elderly patients and not significantly for aged patients (RER = 0.99, 95%CI = 0.97-1.00, p = 0.08) after adjustment for sex, age, grade, stage, and treatment.

CONCLUSIONS

The survival gap earlier found by the EUROCARE is confirmed for the mid-western part of the Netherlands, even after adjustment for age, sex, grade, stage and treatment. However, present study does not show an increase in the survival gap between middle-aged and elderly patients.

Long-term outcome after operative intervention for rectal cancer in patients aged over 80 years: analysis of 9,501 patients

INTRODUCTION

Perceptions of poor outcome may detract caregivers from offering standard therapies to patients over 80 years who have been diagnosed with rectal cancer. We evaluate the effect of operative intervention on their survival.

METHODS

Demographics, tumor characteristics, treatment, and survival for patients over 80 years with rectal and rectosigmoid cancer from 1993 to 2002 in the Surveillance, Epidemiology and End Results Program of the National Cancer Institute were examined. Survival was determined by using the Kaplan-Meier method. Patients who underwent operation (Group A) were compared with those who did not undergo surgery (Group B). Fisher's exact, chi-squared, analysis of variance, and log-rank tests were used as appropriate, and P < 0.05 was considered statistically significant.

RESULTS

A total of 9,501 patients (19 percent) were aged older than 80 years. Mean age was 85 years, and median survival was 24 months. Stage of disease was unknown for 2,915 patients. Median survival was 58, 53, 39, 27, and 5 months for Stages 0 (n=163), I (n=1,878), II (n=1,796), III (n=1,536), and IV (n=1,213), respectively. A total of 6,900 patients (81 percent) underwent surgery. Median survival for operated patients was significantly longer for all stages (36 vs. 5 months, P < 0.00001), Stage 0 (60 vs. 7 months, P < 0.01), Stage I (55 vs. 11 months, P < 0.0001), Stage II (41 vs. 13 months, P < 0.0001), Stage III (28 vs. 14 months, P < 0.05), and Stage IV (8 vs. 3 months, P < 0.0001). For patients with rectal cancer, local therapy also significantly improved median survival compared with nonoperated patients (P < 0.0001).

CONCLUSIONS

Operative intervention provides sustained benefit in terms of survival to patients aged >80 years with rectal cancer at all stages who are assessed to be a good operative risk. Age older than 80 years should not detract surgeons from offering optimal therapy to good-risk 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.

Colorectal surgery in the elderly: an audit of surgery in octogenarians

BACKGROUND

Morbidity and mortality rates are higher in elderly compared to younger patients undergoing colorectal cancer surgery. This study was undertaken to see whether this finding applied to all colorectal surgery in the elderly and if so to try to identify the determining factors.

METHODS

All patients undergoing colorectal surgery between 1975 and 1990 were entered into a computerized database. Patients were divided into two groups, those less than 80 years (< 80) and those 80 years and more (80+), and compared with regard to the type of surgery performed, the patient's race, the seniority of the surgeon, the patient's disease, the operation performed and the postoperative morbidity and mortality. In addition, patients undergoing major resectional surgery and patients undergoing colorectal cancer surgery were compared separately.

RESULTS

Of 2011 admissions, 88 were for patients of 80+. The male to female admission rate was 1:0.79 in the < 80 group and 1:1.25 in the 80+ group. More surgical procedures were performed by consultants in older patients. More emergency admissions were for 80+ patients. Rectal, sigmoid and right colonic pathology was more common in the elderly. Very few elderly patients were admitted with minor anorectal problems. Rectal prolapse and colorectal cancer were the commonest causes for admission in octogenarians. There were more pulmonary and cardiovascular postoperative complications in 80+ patients. Urinary tract infections were also more common. The postoperative mortality rate was higher in older patients (7.9 vs 1.4%). Four hundred and sixty-two patients underwent major resectional surgery and 45 were 80+. Surgery for diverticular disease was more frequent in younger patients (13.4 vs 2.2%) and cancer surgery in older patients (93.3 vs 70.5%). The postoperative mortality rate was higher in the elderly (11.1 vs 3.6%). Three hundred and thirty-six major resections were for cancer and 42 were 80+. Emergency surgery was performed more commonly in the older group (38.1 vs 14.9%). The rate of advanced disease seemed to be similar in both groups. The postoperative death rate was higher in the elderly (11.9 vs 3.4%).

CONCLUSIONS

Elderly patients were more likely to die from cardiopulmonary problems after surgical interventions than either from their primary disease or from the surgery undertaken for it. Good postoperative cardiopulmonary support should thus be provided for all such patients.

Colorectal cancer in patients over 75 years of age--determinants of outcome

Two hundred and two consecutive patients with colorectal cancer, aged 75 years or older, diagnosed between 1980 and 1990, were followed up from the date of diagnosis until their death or until October 1994. Of these, 194 underwent some type of surgery, in 151 cases elective and in 43 emergency. The peri-operative mortality rate was 10.8% and the overall 5-year survival rate 28%. The ASA score was a predictor for both peri-operative mortality and survival. Peri-operative mortality was significantly increased among patients who had palliative operations, and those with post-operative complications and blood transfusions. Overall survival was worse for patients with absence of blood in the stools or absence of anaemia, for patients who lived in institutions pre-operatively, and for patients with advanced tumour stages. We conclude that the survival rate in elderly patients with colorectal cancer is acceptable after surgery. Old age is not a risk factor per se for peri-operative mortality or poor prognosis, and should not disqualify a person from operation.

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.

Preoperative assessment of older adults

Caring for older patients who need surgery presents challenging medical situations. The clinical paradigm involves identifying coexisting disease, defining the urgency of the intervention, and predicting postoperative complications based on the type of surgery planned. The prime function of the medical consultant is searching for correctable medical conditions. The consultant must carefully identify coexisting and comorbid conditions. Emergency surgery should be avoided, if possible, by elective planning. The risk of surgery varies with the procedure. Non-body cavity surgery, with the exception of hip fracture repair, is usually tolerated well. Age is a risk factor for surgery, but coexisting disease is more important than age alone. The net effect of improvements in surgical outcome advances the age at which surgical risk becomes prohibitive.

Preoperative evaluation and postoperative surveillance for patients with colorectal carcinoma

As the understanding of the biology of carcinoma of the colon and rectum increases and the effectiveness of adjuvant therapy for patients with such carcinoma improves, preoperative staging of disease has assumed an increasingly important role. The rationale and specifics of preoperative evaluation and the role, rationale, and controversies regarding postoperative surveillance after curative resection of colorectal carcinoma are discussed.

Prognostic factors in colorectal cancer

The prognostic power of the extent of tumour invasion is indisputable; Dukes' classification has repeatedly been proven to be strongly correlated with patient survival. Modifications have led only to confusion, resulting in caution being required in the classification of patients with Dukes' A tumours. In the UK, the American tumour node metastasis and Australian clinicopathological systems are frequently considered too complex for routine clinical use. Meanwhile, Jass's classification may be complicated by observer variation between pathologists, and recent evidence suggests that it offers no advantage over that of Dukes. All the conventional staging systems also fail to take the skill of the surgeon into account when determining outcome. Attempts at quantifying tumour structure have not heralded the expected major advance. For instance, the expense and uncertain prognostic value of tumour DNA content assessed by flow cytometry are likely to restrict widespread use of this technique. It may soon be possible, however, to provide optimum treatment for patients based on individual tumour doubling times. Classification using knowledge of how a small number of cells in the tumour have the ability to invade locally, enter blood vessels and metastasize would also provide important prognostic information on which treatment could be based. Until then, the ease of use and high prognostic power of Dukes' classification ensure that, after 60 years, it is still the 'gold standard' against which all other prognostic classifications in colorectal cancer should be assessed.