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Cathomas M, Taha A, Kunst N, Burri E, Vetter M, Galli R, Rosenberg R, Heigl A. Adherence to enhanced recovery after surgery (ERAS) in older adults following colorectal resection. J Geriatr Oncol 2024; 15:102062. [PMID: 39270426 DOI: 10.1016/j.jgo.2024.102062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 06/28/2024] [Accepted: 08/31/2024] [Indexed: 09/15/2024]
Abstract
INTRODUCTION Enhanced recovery after surgery (ERAS) is an established pathway to improve short-term outcomes in colorectal surgery. It is unclear whether the efficacy, feasibility, and safety of the ERAS protocol are similar in older and younger patients. The study examined adherence to the ERAS protocol and identified factors leading to deviations in older patients. MATERIALS AND METHODS Patients undergoing colorectal resection were prospectively included in the ERAS protocol between 2019 and 2022. The cohort was stratified according to age and ERAS adherence score. The patients were compared regarding clinical short-term follow-up (30 days). Univariate and multivariate analyses were performed using the statistical program R (version 4.1.2). RESULTS During the study period, 414 patients were recruited, including 132 patients (31.9 %) aged ≥75 years. The cohort of older adults showed significantly higher American Society of Anesthesiologists (ASA) scores III/IV (57.8 % vs. 81.8 %; p < 0.001) and more frequently malignant diseases (45.9 % vs. 64.1 %; p < 0.001), but a lower body mass index (26.7 vs. 24.4; p < 0.001). Furthermore, older adults achieved significantly lower adherence to the ERAS protocol in the postoperative phase (84.6 % vs. 80.1 %; p = 0.003) and experienced a longer median length of hospital stay (6 vs. 8 days; p < 0.001). The differences identified were increased change of body weight on postoperative day 1, delayed removal of a urinary catheter, and shorter duration of mobilization on postoperative days 2 and 3 (p < 0.05). However, in the multivariate analysis, emergency and open surgery as well as severe complications, but not age, were elicited as independent predictive factors for lower adherence to the ERAS protocol postoperatively. DISCUSSION Adherence to the postoperative ERAS requirements appears to be lower in older patients, although age alone was not an independent factor in our multivariate analysis and therefore not responsible for a lower adherence to the postoperative ERAS protocol after colorectal resection. This difference underlines the importance of interdisciplinary teamwork in daily practice to achieve optimal postoperative results, especially in older adults.
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Affiliation(s)
- Marionna Cathomas
- Department of Surgery, Cantonal Hospital Baselland, Liestal, Switzerland.
| | - Anas Taha
- Department of Surgery, Cantonal Hospital Baselland, Liestal, Switzerland
| | - Nicole Kunst
- Department of Surgery, Cantonal Hospital Baselland, Liestal, Switzerland
| | - Emanuel Burri
- Department of Gastroenterology and Hepatology, Medical University Clinic, Cantonal Hospital Baselland, Liestal, Switzerland
| | - Marcus Vetter
- Department of Oncology and Hematology, Cantonal Hospital Baselland, Liestal, Switzerland
| | - Raffaele Galli
- Department of Surgery, Cantonal Hospital Baselland, Liestal, Switzerland
| | - Robert Rosenberg
- Department of Surgery, Cantonal Hospital Baselland, Liestal, Switzerland
| | - Andres Heigl
- Department of Surgery, Cantonal Hospital Baselland, Liestal, Switzerland
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Kryzauskas M, Bausys A, Kuliavas J, Bickaite K, Dulskas A, Poskus E, Bausys R, Strupas K, Poskus T. Short and long-term outcomes of elderly patients undergoing left-sided colorectal resection with primary anastomosis for cancer. BMC Geriatr 2021; 21:682. [PMID: 34876049 PMCID: PMC8650566 DOI: 10.1186/s12877-021-02648-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 11/16/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The proportion of elderly colorectal cancer (CRC) patients requiring surgery is increasing. Colorectal resection for left-sided cancers is the most controversial as the primary anastomosis or end-colostomy and open or minimally invasive approaches are available. Therefore, this study was conducted to investigate the short- and long-term outcomes in elderly patients after resection with primary anastomosis for left-sided CRC. METHODS The cohort study included left-sided colorectal cancer patients who underwent resection with primary anastomosis. The participants were divided into non-elderly (≤75 years) and elderly (> 75 years) groups. Short- and long-term postoperative outcomes were investigated. RESULTS In total 738 (82%) and 162 (18%) patients were allocated to non-elderly and elderly groups, respectively. Minimally invasive surgery (MIS) was less prevalent in the elderly (42.6% vs 52.7%, p = 0.024) and a higher proportion of these suffered severe or lethal complications (15.4% vs 9.8%, p = 0.040). MIS decreased the odds for postoperative complications (OR: 0.41; 95% CI: 0.19-0.89, p = 0.038). The rate of anastomotic leakage was similar (8.5% vs 11.7%, p = 0.201), although, in the case of leakage 21.1% of elderly patients died within 90-days after surgery. Overall- and disease-free survival was impaired in the elderly. MIS increased the odds for long-term survival. CONCLUSIONS Elderly patients suffer more severe complications after resection with primary anastomosis for left-sided CRC. The risk of anastomotic leakage in the elderly and non-elderly is similar, although, leakages in the elderly seem to be associated with a higher 90-day mortality rate. Minimally invasive surgery is associated with decreased morbidity in the elderly.
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Affiliation(s)
- Marius Kryzauskas
- Clinic of Gastroenterology, Nephrourology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.
| | - Augustinas Bausys
- Clinic of Gastroenterology, Nephrourology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Centre for Visceral Medicine and Translational Research, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Justas Kuliavas
- Clinic of Gastroenterology, Nephrourology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | | | | | - Eligijus Poskus
- Clinic of Gastroenterology, Nephrourology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Rimantas Bausys
- Clinic of Gastroenterology, Nephrourology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Kestutis Strupas
- Clinic of Gastroenterology, Nephrourology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Tomas Poskus
- Clinic of Gastroenterology, Nephrourology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
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Sevak S, Gregoir T, Wolthuis A, Albert M. How can we utilize local excision to help, not harm, geriatric patients with rectal cancer? Eur J Surg Oncol 2020; 46:344-348. [PMID: 31983488 DOI: 10.1016/j.ejso.2019.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 09/12/2019] [Accepted: 12/13/2019] [Indexed: 01/24/2023] Open
Abstract
A majority of the morbidity and mortality burden of rectal cancer is distributed within the geriatric age group. Current surgical and medical treatment modalities pose significant challenges in treating complications specifically in the already pre-disposed senior population with baseline dysfunction. This chapter reviews the work-up, management, current data and oncologic outcomes of treating rectal cancer in the senior adult.
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Affiliation(s)
- Shruti Sevak
- Center for Colon and Rectal Surgery, AdventHealth, Orlando, FL, USA.
| | - Tine Gregoir
- Department of Abdominal Surgery, University Hospital Leuven, Herestraat 48, 3000, Leuven, Belgium
| | - Albert Wolthuis
- Department of Abdominal Surgery, University Hospital Leuven, Herestraat 48, 3000, Leuven, Belgium
| | - Matthew Albert
- Center for Colon and Rectal Surgery, AdventHealth, Orlando, FL, USA
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Suhool A, Moszkowicz D, Cudennec T, Vychnevskaia K, Malafosse R, Beauchet A, Julié C, Peschaud F. Optimal oncologic treatment of rectal cancer in patients over 75 years old: Results of a strategy based on oncogeriatric evaluation. J Visc Surg 2018; 155:17-25. [PMID: 29503170 DOI: 10.1016/j.jviscsurg.2017.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Few data are available on the management of elderly rectal cancer patients, and especially on the ability to provide optimal oncological treatment. The aim of this study was to determine the feasibility and results of multimodality treatment for rectal cancer in patients 75years and older after simplified comprehensive geriatric assessment (CGA) according to Balducci score. METHODS We reviewed the charts of elderly patients who underwent surgery for localized middle or low rectal cancer. Patients were classified into three CGA groups depending on their functional reserve, comorbidities, geriatric syndromes, and life expectancy. RESULTS Neoadjuvant therapy was discussed for 27 patients (47%), but only 56% of them were treated, including 8, 7, and 1 patient from CGA groups 1, 2, and 3, respectively. Fifty-three patients (93%) underwent sphincter-preserving surgical resection and four patients underwent abdominoperineal resection (7%). Postoperative complications were observed in 21 patients (37%). The postoperative complication rate was correlated non-significantly with age (<85years: 40.6%; ≥85years: 57.1%; P=0.3), and with the CGA (P=0.64). In total, 10 patients (18%) had definitive colostomy, including five anastomotic leakages (9%), and one incontinence (2%). The total rate of sphincter preservation was 82% (n=47). The risk of secondary definitive colonic stoma formation was not correlated with CGA (group 1: 14%; group 2/3: 16%; P=0.8). Estimated OS at five years was 52%. CONCLUSIONS After routine geriatric assessment, elderly rectal cancer patients have good rates of sphincter conservation and acceptable morbidity/mortality.
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Affiliation(s)
- A Suhool
- Service de chirurgie digestive, oncologique et metabolique, hôpital Ambroise-Paré, AP-HP, 92100 Boulogne-Billancourt, France
| | - D Moszkowicz
- Service de chirurgie digestive, oncologique et metabolique, hôpital Ambroise-Paré, AP-HP, 92100 Boulogne-Billancourt, France; UVSQ, université Paris-Saclay, UFR des sciences de la santé Simone Veil, 78180 Montigny-Le-Bretonneux, France
| | - T Cudennec
- Service de gériatrie, hôpital Ambroise-Paré, AP-HP, 92100 Boulogne-Billancourt, France
| | - K Vychnevskaia
- Service de chirurgie digestive, oncologique et metabolique, hôpital Ambroise-Paré, AP-HP, 92100 Boulogne-Billancourt, France; UVSQ, université Paris-Saclay, UFR des sciences de la santé Simone Veil, 78180 Montigny-Le-Bretonneux, France
| | - R Malafosse
- Service de chirurgie digestive, oncologique et metabolique, hôpital Ambroise-Paré, AP-HP, 92100 Boulogne-Billancourt, France
| | - A Beauchet
- Service de biostatistiques, hôpital Ambroise-Paré, AP-HP, 92100 Boulogne-Billancourt, France
| | - C Julié
- UVSQ, université Paris-Saclay, UFR des sciences de la santé Simone Veil, 78180 Montigny-Le-Bretonneux, France; Service d'anatomo-pathologie, hôpital Ambroise-Paré, AP-HP, 92100 Boulogne-Billancourt, France
| | - F Peschaud
- Service de chirurgie digestive, oncologique et metabolique, hôpital Ambroise-Paré, AP-HP, 92100 Boulogne-Billancourt, France; UVSQ, université Paris-Saclay, UFR des sciences de la santé Simone Veil, 78180 Montigny-Le-Bretonneux, France.
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Muralee M, Singh R, Mathew AP, Cherian K, Chandramohan K, Augustine P, Roshni S, Ahamed I. Radical Treatment of Rectal Cancer in Elderly Is Feasible than Feared: Results from a Tertiary Care Centre. Indian J Surg Oncol 2017; 8:479-483. [PMID: 29203977 DOI: 10.1007/s13193-017-0659-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 04/20/2017] [Indexed: 11/24/2022] Open
Abstract
The thought of subjecting an elderly patient with rectal cancer to protocol-based neoadjuvant chemoradiation (NACTRT), surgery and adjuvant chemotherapy is sought with fear due to their multiple comorbidities and impaired functional status associated with the process of ageing. Hence, many a times the treatment is compromised and it is a fact that this subgroup of patients is underrepresented in most of the clinical trials. This study was aimed at analysing the perioperative and oncologic outcomes after protocol-based treatment of rectal cancer in the elderly patients, defined here as those with age ≥70 years. Prospective analysis of medical records of rectal cancer patients was done who were ≥70 years of age and were diagnosed and treated at Regional Cancer Centre (RCC), Thiruvanathapuram from 2008 to 2012. In this 5-year period, a total of 339 rectal cancer patients underwent surgery as part of multimodality treatment with curative intent. Of them, 75 patients were ≥70 years of age. Half of them had one or more comorbidities (54%) and majority were locally advanced at presentation (77%). Forty-seven (62%) cases received NACTRT and all of them tolerated RT dose (50.4 Gy) without modification. Anterior resection (AR) was performed in 48 (64%) and abdominoperineal resection (APR) in remaining. Diverting stoma was made in four; of which three remained permanent. Two colostomies were performed for delayed leaks. Three patients (4%) died within 30 days due to leak, sepsis and cardiopulmonary causes. Two thirds (49/75) received adjuvant chemotherapy (ACT) but only 55% of them (27/49) could complete all the cycles without dose modification. The median survival was 28 months. The 3-year disease-free survival (DFS) and overall (OS) were 80.1 and 83.9%, respectively. There were 11 distant recurrences including two locoregional recurrences. The morbidity and mortality of multimodality therapy is reasonable to proceed with radical treatment with curative intent in the elderly patients with rectal cancer.
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Affiliation(s)
- Madhu Muralee
- Division of Surgical Oncology, Regional Cancer Centre, 11, Thiruvananthapuram, Kerala India
| | - Rajesh Singh
- Division of Surgical Oncology, Regional Cancer Centre, 11, Thiruvananthapuram, Kerala India
| | - Arun Peter Mathew
- Division of Surgical Oncology, Regional Cancer Centre, 11, Thiruvananthapuram, Kerala India
| | - Kurian Cherian
- Division of Surgical Oncology, Regional Cancer Centre, 11, Thiruvananthapuram, Kerala India
| | - K Chandramohan
- Division of Surgical Oncology, Regional Cancer Centre, 11, Thiruvananthapuram, Kerala India
| | - Paul Augustine
- Division of Surgical Oncology, Regional Cancer Centre, 11, Thiruvananthapuram, Kerala India
| | - S Roshni
- Division of Radiation Oncology, Regional Cancer Centre, 11, Thiruvananthapuram, Kerala India
| | - Iqbal Ahamed
- Division of Surgical Oncology, Regional Cancer Centre, 11, Thiruvananthapuram, Kerala India
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Couwenberg AM, de Beer FSA, Intven MPW, Burbach JPM, Smits AB, Consten ECJ, Schiphorst AHW, Wijffels NAT, de Roos MAJ, Hamaker ME, van Grevenstein WMU, Verkooijen HM. The impact of postoperative complications on health-related quality of life in older patients with rectal cancer; a prospective cohort study. J Geriatr Oncol 2017; 9:102-109. [PMID: 29032962 DOI: 10.1016/j.jgo.2017.09.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 08/01/2017] [Accepted: 09/21/2017] [Indexed: 01/11/2023]
Abstract
OBJECTIVES As result of the aging population and increasing rectal cancer incidence, more older patients undergo treatment for rectal cancer. This study compares treatment course, postoperative complications, and quality of life (QOL) between older and younger patients with rectal cancer and evaluates the impact of postoperative complications on QOL in the elderly. MATERIALS AND METHODS Patients with rectal cancer participating in a prospective colorectal cancer cohort and referred for radiotherapy between 2013 and 2016 were included. QOL was assessed with the cancer questionnaire of the European Organisation for Research and Treatment of Cancer (EORTC QLQ-C30) before treatment and at three, six, and twelve months. Outcomes were compared between older patients (≥70years) and younger patients (<70years) and stratified by presence of postoperative complications. RESULTS In total, 115 (33%) older patients and 230 (67%) younger patients were included. Compared to younger patients, older patients underwent significantly more often short-course radiation with delayed surgery (6.1% and 19.1% respectively) and less often chemoradiation (62.6% and 39.1% respectively), and were more likely to undergo a Hartmann procedure with permanent stoma (3.5% and 13.0% respectively) instead of sphincter-sparing surgery (43.9% and 29.6% respectively). Postoperative complication rates were similar (38.5% in older patients versus 34.7% in younger patients). Older patients had worse physical functioning at six and twelve months after diagnosis compared to younger patients. Presence of postoperative complications had a significant stronger impact on physical- and role functioning in older patients. CONCLUSION Older patients undergo more often a tailored treatment approach for rectal cancer than younger patients. With this tailored approach, similar postoperative complication rates and QOL are achieved. However, postoperative complications have a larger negative impact on physical- and role functioning in older patients which indicates a need for better prediction of postoperative complications in the elderly.
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Affiliation(s)
- Alice M Couwenberg
- Department of Radiation-Oncology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Fleur S A de Beer
- Department of Radiation-Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Martijn P W Intven
- Department of Radiation-Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Anke B Smits
- Department of Surgery, St. Antonius Ziekenhuis, Nieuwegein, The Netherlands
| | - Esther C J Consten
- Department of Surgery, Meander Medisch Centrum, Amersfoort, The Netherlands
| | | | - Niels A T Wijffels
- Department of Surgery, Zuwe Hofpoort Ziekenhuis, Woerden, The Netherlands
| | | | - Marije E Hamaker
- Department of Geriatric Medicine, Diakonessenhuis, Utrecht, The Netherlands
| | | | - Helena M Verkooijen
- Imaging Division, University Medical Center Utrecht, Utrecht, The Netherlands
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Abstract
This study aimed to assess perioperative morbidity and mortality in elderly patients following colorectal cancer resection and to investigate risk factors for postoperative complications. This study reviewed 697 consecutive patients who underwent elective colorectal cancer resection between 2005 and 2013 at our institution. Patients were divided into 3 groups according to their age: ≤74 (n = 420), 75 to 89 (n = 261), and ≥90 years (n = 16). Clinical findings, morbidity, and mortality were compared among these groups. Univariate and multivariate logistic regression analyses were performed with clinically relevant variables for the complications that increased with aging. Postoperative delirium and pneumonia showed significant increases with aging. There were no significant differences in mortality and morbidity among the 3 groups, except for the 2 aforementioned diseases. Multiple logistic regression analysis showed that dementia and laparoscopic surgery were independent determinants of postoperative delirium and that age and American Society of Anesthesiologists (ASA) score were independent risk factors for postoperative pneumonia. Dementia, high ASA score, and age were the risk factors for higher postoperative morbidity in elderly patients. Our results demonstrated the effectiveness of laparoscopic surgery for the prevention of postoperative delirium after colorectal resection.
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Manceau G, Hain E, Maggiori L, Mongin C, Prost À la Denise J, Panis Y. Is the benefit of laparoscopy maintained in elderly patients undergoing rectal cancer resection? An analysis of 446 consecutive patients. Surg Endosc 2016; 31:632-642. [PMID: 27317029 DOI: 10.1007/s00464-016-5009-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Accepted: 05/27/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Several studies showed that age is significantly associated with impaired outcomes after open colorectal surgery. However, very few data exist on laparoscopic rectal cancer surgery in elderly patients. The aim of this study was to assess operative results of laparoscopic rectal cancer surgery according to age. METHODS From 2005 to 2014, 446 consecutive patients who underwent laparoscopic rectal cancer resection were identified from a prospective database. Five groups were defined: age <45 (n = 44), 45-54 (n = 80), 55-64 (n = 166), 65-74 (n = 95) and ≥75 years (n = 61). RESULTS Elderly patients presented significantly higher ASA score (p = 0.004), higher Charlson comorbidity index (p < 0.0001) and more frequent cardiovascular, pulmonary (p < 0.0001) and neurological (p = 0.03) comorbidities. Overall postoperative morbidity rate was similar between groups (34-35-37-43-43 %, p = 0.70). Medical morbidity slightly increased with age (14-9-14-19-26 %, p = 0.06), but there was no significant difference regarding clinical anastomotic leakage, surgical morbidity, major morbidity (Dindo ≥3), cardiopulmonary complications and length of hospital stay. In multivariate analysis, age was not an independent factor for postoperative morbidity, unlike ASA score ≥3 (p = 0.039), neoadjuvant radiotherapy/chemoradiotherapy (p = 0.034) and operative time ≥240 min (p = 0.013). CONCLUSIONS This study showed that laparoscopic rectal cancer resection might safely be performed irrespective of age.
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Affiliation(s)
- Gilles Manceau
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Denis Diderot University (Paris VII), 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - Elisabeth Hain
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Denis Diderot University (Paris VII), 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - Léon Maggiori
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Denis Diderot University (Paris VII), 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - Cécile Mongin
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Denis Diderot University (Paris VII), 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - Justine Prost À la Denise
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Denis Diderot University (Paris VII), 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - Yves Panis
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Denis Diderot University (Paris VII), 100 Boulevard du Général Leclerc, 92110, Clichy, France.
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Bissolati M, Orsenigo E, Staudacher C. Minimally invasive approach to colorectal cancer: an evidence-based analysis. Updates Surg 2016; 68:37-46. [DOI: 10.1007/s13304-016-0350-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 02/20/2016] [Indexed: 12/13/2022]
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Singh J, Stift A, Brus S, Kosma K, Mittlböck M, Riss S. Rectal cancer surgery in older people does not increase postoperative complications--a retrospective analysis. World J Surg Oncol 2014; 12:355. [PMID: 25418609 PMCID: PMC4258037 DOI: 10.1186/1477-7819-12-355] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 11/06/2014] [Indexed: 02/06/2023] Open
Abstract
Background Rectal cancer surgery in the older population remains a highly controversial topic. The present study was designed to assess whether older patients had an increased risk for postoperative complications after rectal resection for malignancies. Methods Consecutive patients (n =627), who underwent rectal cancer resection at a single institution, were included in the study and analyzed retrospectively. Short-term complications were compared between patients ≥80 years (n =55) and <80 years (n =572). Additionally, predictive factors for postoperative complications were analyzed. Results The older aged group showed a significantly higher rate of co-morbidities compared to controls, in terms of cardiovascular and pulmonary diseases (P =0.002, P =0.006). In older patients, a Hartmann’s procedure and transanal endoscopic microsurgery (TEM) were performed most frequently (P <0.0001). The overall complication rate was 39% (n =244) (medical: n =59 (9%), surgical: n =185 (30%)), including 24 (44%) complications in the older aged group (medical: n =6 (11%), surgical: n =18 (33%)). Notably, the incidence of surgical and medical complications showed no significant difference between patients and controls (P =0.58, P =0.69). Neurological and cardiovascular disorders were associated with an increased risk for a eventful postoperative course in the older aged group (P =0.03, P =0.04). Conclusions Rectal cancer resection can be performed safely in selected older patients. Age itself should not be considered as a risk factor for postoperative complications.
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Affiliation(s)
| | | | | | | | | | - Stefan Riss
- Department of Surgery, Medical University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria.
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11
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Stornes T, Wibe A, Romundstad PR, Endreseth BH. Outcomes of rectal cancer treatment--influence of age? Int J Colorectal Dis 2014; 29:825-34. [PMID: 24798628 DOI: 10.1007/s00384-014-1878-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/18/2014] [Indexed: 02/04/2023]
Abstract
PURPOSE To evaluate how age influences the selection to different treatment modalities for rectal cancer and how these differences in approach affect the short- and long-term outcomes. METHODS A single-center cohort of all 837 rectal cancer patients diagnosed between 1994 and 2006 was analyzed. Patients <75, 75-79, 80-84, and >85 years were compared. RESULTS Treatment for cure was judged possible for 80.8, 77.9, 74.6, and 65.3 % of the four age groups (p = 0.02), and radiochemotherapy was given to 22.9, 19.3, 10.2, and 2 % of the same groups (p = 0.001). Local resection was performed for 3.7, 14.7, 13.6, and 24.5 % (p < 0.001) and anterior resection for 66.6, 54.1, 56.8, and 49 % (p < 0.001). The 5-year rates of local recurrence were 5.3, 8.3, 12.8, and 22.3 % (p < 0.001), and overall survival was 70, 54, 45.9, and 29.8 % in the four groups treated with curative intent (p < 0.001). Relative survival was 76.4, 72.6, 72.9, and 72.3 % (ns). CONCLUSIONS Age caused treatment to be modified; there was less surgery for patients over 85 years, less radiochemotherapy over 80 years, and less major radical surgery over 75 years. This strategy resulted in more local recurrences among the elderly, although no certain effect on relative survival was observed.
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Affiliation(s)
- T Stornes
- Department of Surgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, 7006, Norway,
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Comparative outcomes of rectal cancer surgery between elderly and non-elderly patients: a systematic review. Lancet Oncol 2013. [PMID: 23182193 DOI: 10.1016/s1470-2045(12)70378-9] [Citation(s) in RCA: 112] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Elderly people represent almost all patients diagnosed with and treated for rectal cancer, and this trend is likely to become more apparent in the future. Surgical management and treatment decisions for this disease are becoming increasingly complex, but only a few reports deal specifically with older patients. In this systematic review, we provide an overview of published studies of outcomes after curative surgery for rectal cancer in elderly people (>70 years). We identified 48 studies providing information about postoperative results, survival, surgical approach, stoma formation, functional results, and quality of life after rectal resection for cancer. We found that advanced chronological age should not, by itself, exclude patients from curative rectal surgery or from other surgical options that are available for younger patients. Although overall survival is lower in elderly patients than in younger patients, cancer-specific survival does not decrease with age. However, the level of evidence for most studies was weak, emphasising the need for high-quality clinical trials for this population.
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Abstract
BACKGROUND As the population ages, an increasing number of elderly persons will undergo surgery for rectal cancer. The use of sphincter-sparing surgery in frail older adults is controversial. OBJECTIVE The aim of this study was to examine mortality and bowel function after proctectomy in nursing home residents. DESIGN This is a retrospective cohort study. SETTING This investigation was conducted in nursing homes in the United States contracted with the Center for Medicare and Medicaid Services. PATIENTS Nursing home residents age 65 and older undergoing proctectomy for rectal cancer (2000-2005) were included. MAIN OUTCOME MEASURES The primary outcomes measured were fecal incontinence and the 1-year mortality rate. RESULTS Operative mortality was 18% after proctectomy with permanent colostomy and 13% after sphincter-sparing proctectomy (adjusted relative risk, 1.25 (95% CI 0.90-1.73), p = 0.188). One-year mortality was high: 40% after sphincter-sparing proctectomy and 51% after proctectomy with permanent colostomy (adjusted hazard ratio 1.32 (95% CI 1.09-1.60), p = 0.004). After sphincter-sparing proctectomy, 37% of residents were incontinent of feces. Residents with the poorest functional status (Minimum Data Set-Activities of Daily Living quartile 4) were significantly more likely to be incontinent of feces than residents with the best functional status (Minimum Data Set-Activities of Daily Living quartile 1) (76% vs 13%, adjusted relative risk 3.28 (95% CI 1.74- 6.18), p= 0.0002). Fecal incontinence was also associated with dementia (adjusted relative risk 1.55 (95% CI 1.15-2.09), p = 0.004) and renal failure (adjusted relative risk 1.93 (95% CI 1.10-3.38), p = 0.022). LIMITATIONS Measures of fecal incontinence in nursing home registries are not as well studied as those commonly used in clinical practice. CONCLUSIONS Sphincter-sparing proctectomy in nursing home residents is frequently associated with postoperative fecal incontinence and should be considered only for continent patients with good functional status.
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Varpe P, Huhtinen H, Rantala A, Grönroos J. Patient's age should not play a key role in clinical decisions on surgical treatment of rectal cancer. Aging Clin Exp Res 2010; 22:42-6. [PMID: 20305366 DOI: 10.1007/bf03324814] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND AIMS Recent advances in surgical techniques and adjuvant treatments have decreased morbidity and mortality in patients with rectal cancer. The aim of this study was to clarify the effects of aging on the choice, feasibility and safety of various treatment modalities in patients with rectal cancer. PATIENTS AND METHODS During 2003-2006, a total of 274 rectal cancers were diagnosed at Turku University Central Hospital. Patient and tumor characteristics, treatment modalities chosen, and complications were recorded, and patients were followed up prospectively for 1-3 years after treatment. Patients were then divided into two groups: under 75 (n=181) and 75 years or older (n=93) at the moment of diagnosis. Patient data in the two age groups were analysed and compared with each other. RESULTS Of the total of 274 patients with rectal cancer, 243 (89%) underwent surgery. The percentage of patients operated was higher (p=0.03) in the younger (92%) than in the older group (83%). The main reasons for non-operative or palliative treatment were severe concomitant diseases and metastasized cancer. Preoperative radiation therapy was given more often (p<0.01) to young (72%) than old (27%) patients. With these selections, there was no difference in 30-day postoperative mortality (1% vs 1%, ns) or postoperative complications (22% vs 34%, ns) between two groups. CONCLUSION With preoperative selection, patients over 75 with rectal cancer are suitable for major surgery, as morbidity and mortality rates are comparable to those in younger patients.
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Ferenschild FTJ, Dawson I, de Wilt JHW, de Graaf EJR, Groenendijk RPR, Tetteroo GWM. Total mesorectal excision for rectal cancer in an unselected population: quality assessment in a low volume center. Int J Colorectal Dis 2009; 24:923-9. [PMID: 19488771 PMCID: PMC2699389 DOI: 10.1007/s00384-009-0732-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/13/2009] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The aim of this study was to review the results and long-term outcome after total mesorectal excision (TME) for adenocarcinoma of the rectum in an unselected population in a community teaching hospital. MATERIALS AND METHODS Between 1996 and 2003, 210 patients with rectal cancer were identified in our prospective database, containing patient characteristics, radiotherapy plans, operation notes, histopathological reports, and follow-up details. An evaluation of prognostic factors for local recurrence, distant metastases, and overall survival was performed. RESULTS The mean age at diagnosis was 69 years (range 40-91 years). A total of 145 patients were treated by anterior rectal resection; 65 patients had to undergo an abdominoperineal resection (APR). Anastomotic leakage rate was 5%. Postoperative mortality was 3%. After a median follow-up of 3.6 years, the local recurrence-free rate in patients with microscopically complete resections was 91%. The 5-year overall survival rate was 58%. An increased serum carcinoembryonic antigen, an APR, positive lymph nodes, and an incomplete resection all significantly influenced the 5-year overall survival and local recurrence rate. In a multivariate analysis, age was the most important prognostic factor for overall survival. CONCLUSIONS Patients with rectal cancer can safely be treated with TME in a community teaching hospital and leads to a good overall survival and an excellent local control. In patients aged above 80, treatment-related mortality is an important competitive risk factor, which obscures the positive effect of modern rectal cancer treatment.
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Affiliation(s)
- Floris T. J. Ferenschild
- Department of Surgery, IJsselland Hospital, P.O. Box 690, 2900 AR Capelle aan den IJssel, The Netherlands
| | - Imro Dawson
- Department of Surgery, IJsselland Hospital, P.O. Box 690, 2900 AR Capelle aan den IJssel, The Netherlands
| | - Johannes H. W. de Wilt
- Department of Surgical Oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, The Netherlands
| | - Eelco J. R. de Graaf
- Department of Surgery, IJsselland Hospital, P.O. Box 690, 2900 AR Capelle aan den IJssel, The Netherlands
| | - Richard P. R. Groenendijk
- Department of Surgery, IJsselland Hospital, P.O. Box 690, 2900 AR Capelle aan den IJssel, The Netherlands
| | - Geert W. M. Tetteroo
- Department of Surgery, IJsselland Hospital, P.O. Box 690, 2900 AR Capelle aan den IJssel, The Netherlands
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Brisinda G, Vanella S, Cadeddu F, Civello IM, Brandara F, Nigro C, Mazzeo P, Marniga G, Maria G. End-to-end versus end-to-side stapled anastomoses after anterior resection for rectal cancer. J Surg Oncol 2009; 99:75-9. [PMID: 18985633 DOI: 10.1002/jso.21182] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIMS Sphincter-saving procedures for resection of mid and, in some cases, of distal rectal tumors have become prevalent as their safety have been established. Increased anastomotic leak rate, associated with the type of anastomosis and the distance from the anal verge, has been reported. To compare surgical outcomes of end-to-end and end-to-side anastomosis after anterior resection for T1-T2 rectal cancer. METHODS During the study period, a total of 298 rectal cancer patients were treated. Patients with T1-T2 rectal cancer (i.e., tumor level < or =15 cm from the anal verge) fit for surgery were asked to participate in the study. Patients were randomized to receive either an end-to-end anastomosis or an end-to-side anastomosis using the left colon. Surgical results and complications were recorded. RESULTS Seventy-seven patients were randomized. Thirty-seven end-to-end anastomoses and 40 end-to-side anastomoses were performed. Anastomotic leakage after end-to-end anastomosis was 29.2%, while after end-to-side anastomosis was 5% (P = 0.005). In the end-to-end group 11 patients had anastomotic leaks: nine patients needed a re-intervention with colostomy creation subsequently closed in seven cases. Two patients of the end-to-side group experienced anastomotic leakage and were successfully treated conservatively. CONCLUSIONS Regarding postoperative surgical complications, end-to-side anastomosis is a safe procedure.
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Affiliation(s)
- Giuseppe Brisinda
- Department of Surgery, Catholic University Hospital Agostino Gemelli, Rome, Italy.
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Rutten HJT, den Dulk M, Lemmens VEPP, van de Velde CJH, Marijnen CAM. Controversies of total mesorectal excision for rectal cancer in elderly patients. Lancet Oncol 2008; 9:494-501. [PMID: 18452860 DOI: 10.1016/s1470-2045(08)70129-3] [Citation(s) in RCA: 219] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The cornerstone of treatment for rectal cancer is resectional treatment according to the principles of total mesorectal excision (TME). However, population-based registries show that improvements in outcome after resectional treatment occur mainly in younger patients. Furthermore, 6-month postoperative mortality is significantly increased in elderly patients (> or = 75 years of age) compared with younger patients (< 75 years of age). Several confounding factors, such as treatment-related complications and comorbidity, are thought to be responsible for these disappointing findings. Thus, major resectional treatment is not advantageous for all older patients with rectal cancer. However, the Dutch TME trial showed a good response to a short course of neoadjuvant radiotherapy in elderly patients. Biological responses to cancer treatment seem to change with age, and, therefore, individualised cancer treatments should be used that take into account the heterogeneity of ageing. For elderly patients who retain a good physical and mental condition, treatment that is given to younger patients is deemed appropriate, whereas for those with diminished physiological reserves and comorbid conditions, alternative treatments that keep surgical trauma to a minimum and optimise the use of radiotherapy might be more suitable.
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Affiliation(s)
- Harm J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, Netherlands.
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Short-and long-term outcomes of surgery for diffuse peritonitis in patients 80 years of age and older. Surg Today 2008; 38:413-9. [DOI: 10.1007/s00595-007-3658-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2007] [Accepted: 08/20/2007] [Indexed: 11/27/2022]
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Ong ES, Alassas M, Dunn KB, Rajput A. Colorectal cancer surgery in the elderly: acceptable morbidity? Am J Surg 2008; 195:344-8; discussion 348. [PMID: 18222410 DOI: 10.1016/j.amjsurg.2007.12.022] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2007] [Revised: 12/14/2007] [Accepted: 12/14/2007] [Indexed: 12/13/2022]
Abstract
BACKGROUND Because of the increase in the geriatric population, an increasing number of elderly patients are being treated for colorectal cancer. The purpose of this study was to evaluate perioperative morbidity and mortality in this population. METHODS A retrospective chart review was performed for patients 80 years of age or older who underwent surgery for colorectal cancer (1993-2006). RESULTS Ninety patients were identified, with a median age of 84 years. More than 90% presented with symptoms; the remaining were diagnosed by screening colonoscopy. Emergent surgery was required in 10%. The morbidity rate was 21% and the overall 30-day mortality rate was 1.1%. Morbidity was higher in patients who required surgery emergently. CONCLUSIONS Despite advanced age, the majority of patients in this study did well. Postoperative morbidity was higher than in the general population, but we believe it was acceptably low in most patients. Colorectal surgery appears to be safe in most elderly patients.
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Affiliation(s)
- Evan S Ong
- Department of Surgical Oncology, Roswell Park Cancer Institute, Elm and Carlton St., Buffalo, NY 14263, USA
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Tan E, Tilney H, Thompson M, Smith J, Tekkis PP. The United Kingdom National Bowel Cancer Project – Epidemiology and surgical risk in the elderly. Eur J Cancer 2007; 43:2285-94. [PMID: 17681782 DOI: 10.1016/j.ejca.2007.06.009] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2007] [Revised: 06/13/2007] [Accepted: 06/20/2007] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To evaluate the epidemiology and risk of surgery in the treatment of colorectal cancer in the elderly. METHODS Patients undergoing colorectal cancer surgery were identified from the Association of Coloproctology of Great Britain and Ireland (ACPGBI) bowel cancer database, comprising 47,455 patients treated over a 5-year period. Demographic characteristics and outcomes were compared between patients aged <75 and those 75 or above. The primary endpoint was 30-day mortality. Secondary endpoints were the length of hospital stay, abdominoperineal excision (APER) rates and lymph node harvest. RESULTS Elderly patients were likely to be female and have higher American Society of Anaesthesiology (ASA) grade, while Dukes' stage was lower. They underwent surgery less often (81% versus 88%, p<0.001), but more frequently needed urgent or emergency procedures (p<0.001) and non-excisional surgery (7.7% versus 6.6%, p<0.001). Operative mortality was significantly higher for the older age group (10.6% versus 3.8%, p<0.001), and their median length-of-stay was 2 days longer (p<0.001). Mortality has improved over time for elderly patients with ASA grade III, and Dukes' stage A and D disease, but not for other subgroups. CONCLUSION Significant differences in the demographic characteristics and operative risk-factors between under-75s, and those aged 75 or above exist. These variations are reflected in the inferior outcomes experienced by elderly patients.
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Affiliation(s)
- Emile Tan
- Imperial College, Department of Biosurgery & Surgical Technology, 10th Floor, QEQM, St. Mary's Hospital, Praed Street, London W2 1NY, UK
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Lee JM, Kim HC, Park IJ, Kim DD, Yu CS, Kim JC. The Characteristics of Colorectal Cancer in Patients Older than 80 Years. JOURNAL OF THE KOREAN SOCIETY OF COLOPROCTOLOGY 2007. [DOI: 10.3393/jksc.2007.23.6.490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Jae Myeong Lee
- Department of Surgery, University of Ulsan College of Medicine and Colorectal Clinic, Asan Medical Center, Seoul, Korea
| | - Hee Cheol Kim
- Department of Surgery, University of Ulsan College of Medicine and Colorectal Clinic, Asan Medical Center, Seoul, Korea
| | - In Ja Park
- Department of Surgery, University of Ulsan College of Medicine and Colorectal Clinic, Asan Medical Center, Seoul, Korea
| | - Dae Dong Kim
- Department of Surgery, University of Ulsan College of Medicine and Colorectal Clinic, Asan Medical Center, Seoul, Korea
| | - Chang Sik Yu
- Department of Surgery, University of Ulsan College of Medicine and Colorectal Clinic, Asan Medical Center, Seoul, Korea
| | - Jin Cheon Kim
- Department of Surgery, University of Ulsan College of Medicine and Colorectal Clinic, Asan Medical Center, Seoul, Korea
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