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

Mortality and Survival after Surgical Treatment of Colorectal Cancer in Patients Aged over 80 Years

OBJECTIVE

The purpose of this study was to identify the clinical factors and tumor characteristics that predict the outcome of colorectal cancer patients aged >80 years.

MATERIALS AND METHODS

The data of 186 patients aged >80 years with colorectal cancer were collected from a computer database, and the variables were analyzed by both uni- and multivariate analyses.

RESULTS

The 30-day mortality was 4% and the 90-day mortality 10%. The 1-year survival was 76%, and 27 (61%) of the 44 deaths were unrelated to cancer. The overall 5-year survival was 36%, the median survival 38 months, and the cancer-specific survival 40%. The recurrence rate after radical surgery was 22% and it was not affected by age. Kaplan-Meier estimates indicated that age, number of underlying diseases, radical operation, Union for International Cancer Control stage of the tumor, tumor size, number of lymph nodes involved, venous invasion, and recurrent disease were significant predictors of survival, but in the Cox regression model, only radical operation and venous invasion were independent prognostic factors for survival.

CONCLUSIONS

After good surgical selection, low early mortality and acceptable long-term survival can be achieved even in the oldest old patients with colorectal cancer. However, low early mortality seems to underestimate the effects of surgery during the first postoperative year.

The Use of the Enhanced Recovery After Surgery (ERAS) Protocol in Patients Undergoing Laparoscopic Surgery for Colorectal Cancer – A Comparative Analysis of Patients Aged above 80 and below 55

Age is one of the principal risk factors for colorectal adenocarcinoma. To date, older patients were believed to achieve worse treatment results in comparison with younger patients due to reduced vital capacity. However, papers have emerged in recent years which confirm that the combination of lap-aroscopy and postoperative care based on the ERAS protocol improves treatment results and may be particularly beneficial also for elderly patients.

was to compare the outcomes of laparoscopic surgery for colorectal cancer in combination with the ERAS protocol in patients aged above 80 and below 55.

. The analysis included patients aged above 80 and below 55 undergoing elective laparoscopic colorectal resection for cancer at the 2

Group 1 comprised 34 patients and group 2, 43 patients. No differences were found between both groups in terms of gender, BMI, tumour progression or surgical parameters. Older patients typically had higher ASA scores. No statistically significant differences were found with regard to the length hospital stay following surgery (5.4 vs 7 days, p=0.446481), the occurrence of complications (23.5% vs 37.2%, p=0.14579) or hospital readmissions (2.9% vs 2.4%). The degree of compliance with the ERAS protocol in group 1 and 2 was 85.2% and 83.0%, respectively (p=0.482558). Additionally, recovery parameters such as tolerance of oral nutrition (82.4% vs 72.1%, p=0.28628) and mobilisation (94.1% vs 83.7%, p=0.14510) within 24 hours of surgery did not differ among the groups. However, a smaller proportion of older patients required opioids in comparison with younger patients (26.5% vs 55.8%, p=0.00891).

Similar levels of compliance with the ERAS protocol may be achieved among patients aged ≥80 and younger patients. When laparoscopy is combined with the ERAS protocol, age does not seem to be a significant factor that could account for worse utcomes. Therefore, older patients should not be excluded from perioperative care based on ERAS principles.

Risk factors for vertical incomplete resection in endoscopic submucosal dissection as total excisional biopsy for submucosal invasive colorectal carcinoma

PURPOSE

Endoscopic submucosal dissection (ESD) for colorectal tumor is a minimally invasive treatment. Histologic information obtained from the entire ESD specimen is important for therapy selection in submucosal invasive colorectal carcinoma (SMca). This study aimed to identify risk factors for vertical incomplete resection (vertical margin-positive [VM+]) when ESD was performed as total excisional biopsy for SMca.

METHODS

From June 2003 through December 2011, 78 SMca cases were resected by ESD at Hiroshima University Hospital. Patient and tumor characteristics, intraoperative variables, and histopathology were compared between the VM+ group and the vertical complete resection (vertical margin-negative) group. The ability of magnifying endoscopy (ME) and endoscopic ultrasonography (EUS) to predict VM+ was assessed.

RESULTS

ESD resulted in VM+ in eight cases (10.3 %), with a greater percentage invading to a depth of ≥2,000 vs. <2,000 μm (P = 0.047). Severe submucosal fibrosis was found in five of the eight cases (62.5 %, P = 0.017). Poor differentiation was seen at the deepest invasive portion in six cases (75.0 %), and two of six cases had an invasion depth <2,000 μm. Of 39 EUS cases, 36 not showing deep invasion close to the muscularis propria were completely resected by ESD.

CONCLUSIONS

Submucosal fibrosis and poor differentiation at the deepest invasive portion may be risk factors for VM+ in colorectal ESD for tumors with submucosal deep invasion. ME plus EUS is more likely to help determine whether ESD is indicated as complete total excisional biopsy for SMca.

Surgical treatment of colorectal cancer in patients aged over 80 years

PURPOSE

The aim of this study was to identify the clinical factors and tumour characteristics that predict the outcome in patients older than 80 years with colorectal cancer.

PATIENTS AND METHODS

One hundred and four patients with colorectal cancer aged over 80 years were identified from a computer database, and their clinical variables were analysed by both univariate and multivariate analyses.

RESULTS

All 104 patients underwent resective surgery, 87% radical and 13% palliative resection. Postoperative mortality was 5%, being associated with a number of coexisting diseases and the presence of postoperative complications, especially anastomotic leakage. The cumulative 5-year survival was 33%, the median survival was 31 months and the cancer-specific 5-year survival was 36%. The recurrence rate after radical surgery was 30%, being 13%, 25%, 44% and 100% in the Union for International Cancer Control stages I, II, III and IV. Kaplan-Meier estimates indicated that age, number of underlying diseases, radicality of operation, Dukes' staging, size of tumour, number of lymph node metastasis, metastasised disease, venous invasion and recurrent disease were significant predictors of survival, but in the Cox regression model, only venous invasion was an independent prognostic factor of survival.

CONCLUSIONS

Low mortality and acceptable survival can be achieved even in very elderly patients with colorectal cancer. Venous invasion is an independent predictor of survival.

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

Clinicopathological features of colorectal cancer in patients over 70 years of age

OBJECTIVE

The aim was to identify the clinical factors and tumor characteristics that predict mortality and survival in patients older than 70 years with colorectal adenocarcinoma.

MATERIAL AND METHODS

One hundred and ninety-four patients with colorectal cancer aged over 70 years were identified from a computer database and their clinical variables were analyzed by both univariate and multivariate analyses.

RESULTS

All patients underwent resective surgery, 79% radical and 21% palliative resection, and postoperative mortality was 6% being associated with the presence of postoperative complications, especially anastomotic leakage. The cumulative 5-year survival was 38%, the median survival 35 months, and the cancer-specific 5-year survival 48% and this did not differ significantly between the age groups. The recurrence rate after radical surgery was 30%, being 12, 22, 56, and 100% in Dukes classes A, B, C, and D. Kaplan-Meier estimates indicated that gender, Dukes staging, grade of tumor, number of lymph node metastasis, venous invasion, and recurrent disease were significant predictors of survival, but in the Cox regression model, only venous invasion and recurrent disease were independent prognostic factors of survival.

CONCLUSIONS

Low mortality and acceptable survival can be achieved in elderly patients with colorectal cancer. Venous invasion and recurrent cancer are independent predictors of survival.

Systemic cytokine response after emergency and elective surgery for colorectal carcinoma

BACKGROUND

Systemic cytokines (SC) are accepted mediators of host immune response. It is debated if long-term survival is influenced by emergency presentation of colorectal cancer, and the role of immunitary response is still unknown. The aim of this prospective study was to compare the SC response after emergency resection with that after elective resections of colorectal carcinoma.

MATERIALS AND METHODS

One hundred six consecutive subjects with colorectal cancer were submitted to emergency (complete bowel obstruction; EMS, n = 50) or elective resection (ELS, n = 56) of the tumour. Sera were collected before surgery and at appropriate time points afterward and assayed for interleukin-1beta (IL-1beta), tumour necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6) and C-reactive protein (CRP). Five-year survival was analysed according to Kaplan-Meier test. The Cox proportional hazard model was used for the multivariate analysis.

RESULTS

Pre-operative levels of IL-1beta, IL-6 and CRP were statistically higher in the EMS group. Levels of TNF-alpha were not elevated after surgery and there was no difference between the groups. Five-year survival was significantly lower in the EMS group (p < 0.05).

CONCLUSIONS

Immunitary response, as reflected by SC, was better after elective resection than after emergency resection of colorectal carcinoma and this difference may have implication in the long-term survival.

Colorectal surgery in octogenarian patients--outcomes and predictors of morbidity

INTRODUCTION

Surgery for elderly patients pose a constant challenge. This study aims to review the outcome and find predictors of adverse outcome in octogenarians undergoing major colorectal resection for cancer.

METHODS

A review of 121 octogenarians who underwent colorectal cancer surgery between September 1992 and May 2008 was performed. Comorbidities were quantified using the weighted Charlson Comorbidity Index and ASA classification. CR-POSSUM scores and ACPGBI scores and the predicted mortality rates were calculated. Outcome measures were morbidity rates and 30-day mortality rates.

RESULTS

The patients had a mean age of 83.5 years (range, 80-99). The mean index of comorbidity was 3.1 (2-7) and 12.5% of patients were classified ASA III and above. The mean predicted mortality rate based on CR-POSSUM and ACPGBI scoring models were 11.2% and 5.4% respectively. The overall observed morbidity rate was 30.7% and 30-day mortality was 1.6. Factors found on bivariate analysis to be significantly associated with an increased risk of morbidity were tumor presenting with complication, comorbid coronary heart disease, serum urea levels, ASA classification > or =3 and comorbidity index 3 of 5 > or = 5. Multivariate analysis revealed the latter two factors to be independent predictors of morbidity.

CONCLUSION

Octogenarians undergoing major colorectal resection have an acceptable perioperative morbidity and mortality rate and survival rate and should not be denied surgery based on age alone. Comorbidity index scores and ASA scores are useful tools to identify poor risk patients.

Which Octogenarians Do Poorly After Major Open Abdominal Surgery in Our Asian Population?

BACKGROUND

As the elderly population grows and surgeons are faced with more octogenarians, there is a need to know how our Asian patients fair after major surgery.

METHODS

A retrospective review of 125 octogenarians who underwent major abdominal surgery between January 1997 and September 2003 was performed. Preoperative condition was assessed using a weighted index of comorbidity used in Charlson Comorbidity Index and classification of patients according to the American Society of Anaesthesiologists (ASA). Outcome was measured as to whether complications developed, 30-day mortality and whether there was return to premorbid function.

RESULTS

The patients had a mean age of 84.6 years (range: 80-106). Nearly half (48.8%, n = 61) the cases were emergency cases. The median index of comorbidity was 3, and 29.6% of patients were classified either ASA III or IV. The operations were mostly stomach, small bowel or large bowel resection. Multivariate analysis revealed that emergency operations were associated with significantly increased odds of morbidity. The overall 30-day mortality was 5.6%, being only 4.7% for elective cases, despite high morbidity rates. ASA classification, comorbidity index >5, development of acute coronary syndrome and anastomotic leakage were found on multivariate analysis to significantly increase the odds of mortality. For elective cases, 82.8% of patients were able to return to their premorbid functional status. Development of complications and comorbidity index >5 were found to predict failure of its occurrence. Low serum albumin and haemoglobin and renal impairment were also predictors of adverse outcome.

CONCLUSIONS

Efforts to improve outcome in geriatric surgery patients should emphasize a shift of attitude towards elective surgery rather than doing emergency operations when complications occur and also target the optimization of predictors of adverse outcome. Octogenarians should not be denied elective surgery.

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

Background

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

Methods

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

Results

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

Conclusion

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

Laparoscopy in patients over 60 years old: a prospective, randomized evaluation of laparoscopic versus open adnexectomy

OBJECTIVE

To compare objective and subjective parameters of surgical stress following laparoscopic and open adnexectomy in patients older than 60 years old.

STUDY DESIGN

Twenty patients with a benign ovarian tumour were prospectively randomized to undergo adnexectomy by a laparoscopic or an open surgical procedure. Measurements included C-reactive protein; interleukin-6 before, during, and after surgery; intensity and duration of postoperative pain; and complications and recovery period. Statistical analysis consisted of analysis of variance and a Mann-Whitney U test.

RESULTS

The levels of the interleukin-6 and C-reactive protein differed significantly between the 2 operative procedures (P = .013) in favor of the laparoscopic approach. The laparoscopic approach was associated with a reduction in operative morbidity, postoperative pain, analgesic requirement, and recovery period.

CONCLUSIONS

Minimally invasive surgery is of particular benefit to elderly patients if there is a plan in place for appropriate staging and treatment by laparotomy for malignancy. It should be the first choice and may help to reduce postoperative complications.

Should patients over 85 years old be operated on for colorectal cancer?

BACKGROUND

The aim of this study is to evaluate risk factors for mortality, morbidity, and long-term survival in very old patients with colorectal cancer compared with old patients.

METHODS

Patients operated on with colorectal cancer aged 75 years old or older were divided into 2 groups: Group A (75-84 years, n = 93) and Group B (>or=85, n = 21).

RESULTS

The serum albumin level, oxygen pressure in arterial blood gases, and forced expiratory volume in 1 second in Group B were significantly lower than in Group A, respectively (P = 0.0094, 0.0264, 0.0363). Pulmonary complications were developed significantly more frequently in Group B than in Group A (P = 0.0019). Group B had a significantly higher mortality rate than Group A (P = 0.0477). There was no significant difference between the 2 groups in the 2- and 5-year survival rates.

CONCLUSIONS

Very old patients with colorectal cancer should not be denied surgery on account of chronological age alone, although the perioperative risks for the very old are very high.