Optimal Assessment of Frailty Predicts Postoperative Complications in Older Patients with Colorectal Cancer Surgery

Frailty is a Risk Factor for Postoperative Complications in Older Adults with Lumbar Degenerative Disease: A Prospective Cohort Study

Objective

Frailty, representing the physiological reserve and tolerance of the body, serves as a crucial evaluation index of the overall status of the older adults. This study aimed to investigate the prevalence of preoperative frailty and its impact on postoperative outcomes among older adults with lumbar degenerative disease in China.

Patients and Methods

In this prospective study, a total of 280 patients aged 60 and above, diagnosed with lumbar degenerative disease and scheduled for surgical intervention were enrolled. The prevalence of frailty pre-surgery was evaluated using the Tilburg Frailty Indicator (TFI) and the modified Frailty Index 11 (mFI-11). The primary outcome was postoperative complication within 30 days post-surgery. The secondary outcomes were the length of hospital stay, hospital costs, reoperation within 30 days post-surgery and unplanned readmission within 30 days post-discharge. Both univariable and multivariable logistic regression were employed to screen and identify the risk factors predisposing patients to postoperative complications.

Results

A total of 272 older adults were included in the study ultimately. The frailty detection rates of TFI and mFI-11 were 15.8% (43/272) and 10.7% (29/272) respectively. Thirty-four patients (12.5%) encountered complications. Significantly elevated rates of complications, prolonged hospital stays, increased hospital costs, and heightened readmission rates were observed in the frail group compared to the non-frail group (P<0.05). Univariable analysis showed that the potential factors related to complications are TFI, mFI-11 and albumin. Multivariable logistic regression revealed that TFI was an independent risk factor for postoperative complications (OR=5.371, 95% CI: 2.338-12.341, P < 0.001).

Conclusion

Frailty was an independent predictor of postoperative complications in older adults undergoing lumbar fusion surgery. Frailty assessment should be performed in such patients to improve preoperative risk stratification and optimize perioperative management strategies.

Frailty and Cancer Prognosis

PURPOSE OF REVIEW

This review aims to summarize the current evidence regarding the prognostic role of frailty in older patients diagnosed with cancer and to explore the evidence regarding its prognostic implications in cancer survivors.

RECENT FINDINGS

Frailty has been consistently associated with mortality/overall survival, postoperative complications, short- and long-term postoperative mortality, length of stay, among other adverse health-related outcomes in several oncological contexts. The possible association between frailty and treatment toxicity has been less explored, however most studies suggest frailty is a predictor of treatment induced toxicity. In addition, in cancer survivors, frailty is a risk factor for cardiovascular disease, incident type 2 diabetes mellitus, mortality, altered cognitive performance and increased symptom severity. Due to its usefulness in establishing prognosis and informing treatment decision making, it is expected that frailty screening and assessment will continue to gain popularity as part of the pretreatment evaluation of older patients with cancer.

Functional Outcomes after Abdominal Surgery in Older Adults - How concerned are we about this?

Amidst trends of a rapidly ageing population with better surgical outcomes for geriatric patients, it is imperative to consider outcome measures beyond mortality and morbidity rates. In fact, the preservation of one's postoperative function has been cited as a key priority for older adults and is a crucial determinant of postoperative independence and survival. This review aims to examine the prevalence of perioperative function reporting amongst older surgical patients undergoing elective major abdominal surgery for cancer. We systematically reviewed studies from inception to December 2023 for studies which focused on the outcomes of older surgical patients undergoing elective major abdominal surgery for cancer. Relevant citations were screened (title, abstract and full article review) based on the inclusion and exclusion criteria. 103 studies were included, of which only 31 studies consisting of 20885 participants reported perioperative function. While the nominal number of studies which report perioperative function has been on a steady rise since 2018, the proportion of studies which do so remains low. Postoperative function is three times less likely to be reported than preoperative function, suggesting that functional recovery is not sufficiently assessed. This suggests that there is still a poor uptake of functional recovery as an outcome measure amongst surgeons, and any increase in perioperative function reporting is likely due to the increased administration of frailty assessments. These findings should urge greater efforts in quantifying and enabling functional recovery to improve the clinical outcomes and quality of care for older surgical patients.

Geriatric Assessment in Colorectal Surgery: A Systematic Review

INTRODUCTION

The prevalence of colorectal surgery among older adults is expected to rise due to the aging population. Geriatric conditions (e.g., frailty) are risk factors for poor surgical outcomes. The goal of this systematic review is to examine how current literature describes geriatric assessment interventions in colorectal surgery and associated outcomes.

METHODS

Systematic searches of Ovid MEDLINE, Cochrane Library, CINAHL, Embase, and Web of Science were completed. Review was performed according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines and prospectively registered in PROSPERO, the international prospective register of systematic reviews in health and social care. All cohort studies and randomized trials of adult colorectal surgery patients where geriatric assessment was performed were included. Geriatric assessment with/without management interventions were identified and described.

RESULTS

Seven-hundred ninety-three studies were identified. Duplicates (197) were removed. An additional 525 were excluded after title/abstract review. After full-text review, 20 studies met the criteria. Reference list review increased final total to 25 studies. All 25 studies were cohort studies. No randomized clinical trials were identified. Heterogeneous assessments were organized into geriatrics domains (mind, mobility, medications, matters most, and multi-complexity). Incomplete evaluations across geriatric domains were performed with few studies describing the use of assessments to impact management decisions.

CONCLUSIONS

There are no randomized trials assessing the impact of geriatric assessment to tailor management strategies and improve outcomes in colorectal surgery. Few studies performed assessments to evaluate the geriatric domain matters most. These findings represent a gap in evidence for the efficacy of geriatric assessment and management strategies in colorectal surgical care.

Predictive value of the G8 screening tool for postoperative complications in older adults undergoing cancer surgery: A systematic review and meta-analysis

INTRODUCTION

Older adults with cancer who are being considered for cancer surgery are heterogenous, with variation in their physical, mental, and social baselines and risk of postoperative complications. Due in part to the complex nature of this population, the optimal preoperative evaluation method is not clearly defined. In this study we investigated whether geriatric-8 (G8), a screening tool for older patients with cancer that determines the need for a full geriatric assessment, is suitable for assessing the risk of postoperative complications in this population being considered for surgery.

MATERIALS AND METHODS

Studies that enrolled older patients undergoing cancer surgery and compared prevalence of postoperative complications in G8 "high" (≥15) patients and G8 "low" (<15) patients were identified using PubMed and EMBASE. A meta-analysis was conducted to calculate the risk ratio of postoperative complication rate. Postoperative mortality was systematically reviewed.

RESULTS

Eleven studies published between 2017 and 2022 were included in our analysis with a total of 2,691 older patients who underwent various types of cancer surgery and were characterized by their G8 scores: 1,255 G8 high (≥15) patients and 1,436 G8 low (<15) patients. G8 low patients had a significantly higher prevalence of postoperative complications than G8 high patients (risk ratio [95% confidence interval]: 1.56 [1.18-2.07], p = 0.002, I2 = 79%).

DISCUSSION

G8 can be an effective and efficient preoperative tool to assess risk of postoperative complications in older adults undergoing cancer surgery and identify potential need for further evaluation of an individual's risk with a comprehensive geriatric assessment.

Impact of frailty on short-term postoperative outcomes in patients undergoing colorectal cancer surgery: A systematic review and meta-analysis

BACKGROUND

Colorectal cancer is a major global health challenge that predominantly affects older people. Surgical management, despite advancements, requires careful consideration of preoperative patient status for optimal outcomes.

AIM

To summarize existing evidence on the association of frailty with short-term postoperative outcomes in patients undergoing colorectal cancer surgery.

METHODS

A literature search was conducted using PubMed, EMBASE and Scopus databases for observational studies in adult patients aged ≥ 18 years undergoing planned or elective colorectal surgery for primary carcinoma and/or secondary metastasis. Only studies that conducted frailty assessment using recognized frailty assessment tools and had a comparator group, comprising nonfrail patients, were included. Pooled effect sizes were reported as weighted mean difference or relative risk (RR) with 95% confidence intervals (CIs).

RESULTS

A total of 24 studies were included. Compared with nonfrail patients, frailty was associated with an increased risk of mortality at 30 d (RR: 1.99, 95%CI: 1.47-2.69), at 90 d (RR: 4.76, 95%CI: 1.56-14.6) and at 1 year (RR: 5.73, 95%CI: 2.74-12.0) of follow up. Frail patients had an increased risk of any complications (RR: 1.81, 95%CI: 1.57-2.10) as well as major complications (Clavien-Dindo classification grade ≥ III) (RR: 2.87, 95%CI: 1.65-4.99) compared with the control group. The risk of reoperation (RR: 1.18, 95%CI: 1.07-1.31), readmission (RR: 1.70, 95%CI: 1.36-2.12), need for blood transfusion (RR: 1.67, 95%CI: 1.52-1.85), wound complications (RR: 1.49, 95%CI: 1.11-1.99), delirium (RR: 4.60, 95%CI: 2.31-9.16), risk of prolonged hospitalization (RR: 2.09, 95%CI: 1.22-3.60) and discharge to a skilled nursing facility or rehabilitation center (RR: 3.19, 95%CI: 2.0-5.08) was all higher in frail patients.

CONCLUSION

Frailty in colorectal cancer surgery patients was associated with more complications, longer hospital stays, higher reoperation risk, and increased mortality. Integrating frailty assessment appears crucial for tailored surgical management.

Nomogram for predicting prolonged postoperative ileus after laparoscopic low anterior resection for rectal cancer

BACKGROUND

Prolonged postoperative ileus (PPOI) is a common complication after colorectal surgery that increases patient discomfort, hospital stay, and financial burden. However, predictive tools to assess the risk of PPOI in patients undergoing laparoscopic low anterior resection have not been developed. Thus, the purpose of this study was to develop a nomogram to predict PPOI after laparoscopic low anterior resection for rectal cancer.

METHODS

A total of 548 consecutive patients who underwent laparoscopic low anterior resection for mid-low rectal cancer at a single tertiary medical center were retrospectively enrolled between January 2019 and January 2023. Univariate and multivariate logistic regression analysis was performed to analyze potential predictors of PPOI. The nomogram was constructed using the filtered variables and internally verified by bootstrap resampling. Model performance was evaluated by receiver operating characteristic curve and calibration curve, and the clinical usefulness was evaluated by the decision curve.

RESULTS

Among 548 consecutive patients, 72 patients (13.1%) presented with PPOI. Multivariate logistic analysis showed that advantage age, hypoalbuminemia, high surgical difficulty, and postoperative use of opioid analgesic were independent prognostic factors for PPOI. These variables were used to construct the nomogram model to predict PPOI. Internal validation, conducted through bootstrap resampling, confirmed the great discrimination of the nomogram with an area under the curve of 0.738 (95%CI 0.736-0.741).

CONCLUSIONS

We created a novel nomogram for predicting PPOI after laparoscopic low anterior resection. This nomogram can assist surgeons in identifying patients at a heightened risk of PPOI.

Elective colorectal cancer surgery in nonagenarians and postoperative outcomes

OBJECTIVES

The population of very elderly patients is increasing, and nonagenarians have significantly higher mortality rates and poorer rates of survival than younger patients. Meanwhile, recent studies have shown colorectal cancer surgery in nonagenarian patients to be feasible regarding postoperative outcomes. This retrospective study aims to evaluate the postoperative outcomes of nonagenarians in the latest clinical settings.

METHODS

Consecutive nonagenarian patients who underwent elective colorectal cancer surgery between 2018 and 2020 retrospectively enrolled (Trial registration number: UMIN000046296 on December 7th, 2021). Clinicopathological data and short-term postoperative outcomes were collected for statistical analysis.

RESULTS

This study included 81 nonagenarian patients (31 males, 50 females). Postoperative complications occurred in 21 patients (25.9%), and 3 patients died within 90 days (3.7%). Multivariate analysis revealed prognostic nutritional index was a significant predictor of postoperative complications (OR 2.99, 95% CI 0.78-9.10, P = 0.048), and performance status ≥ 3 could be an independent risk factor of 90-day mortality (HR 32.30, 95% CI 3.20-326.10, P = 0.032).

CONCLUSIONS

Short-term outcomes after surgical treatment for nonagenarian patients with colorectal cancer were acceptable. Low prognostic nutritional index was closely related to postoperative complications and poor performance status could also lead to 90-day mortality. In aging populations, risk stratification to prevent poorer postoperative outcomes in nonagenarian patients is needed.

Nomogram for prediction of prolonged postoperative ileus after colorectal resection

BACKGROUND

Prolonged postoperative ileus (PPOI) is a major complication in patients undergoing colorectal resection. The aim of this study was to analyze the risk factors contributing to PPOI, and to develop an effective nomogram to determine the risks of this population.

METHODS

A total of 1,254 patients with colorectal cancer who underwent radical colorectal resection at Fujian Cancer Hospital from March 2016 to August 2021 were enrolled as a training cohort in this study. Univariate analysis and multivariate logistic regressions were performed to determine the correlation between PPOI and clinicopathological characteristics. A nomogram predicting the incidence of PPOI was constructed. The cohort of 153 patients from Fujian Provincial Hospital were enrolled as a validation cohort. Internal and external validations were used to evaluate the prediction ability by area under the receiver operating characteristic curve (AUC) and a calibration plot.

RESULTS

In the training cohort, 128 patients (10.2%) had PPOI after colorectal resection. The independent predictive factors of PPOI were identified, and included gender, age, surgical approach and intraoperative fluid overload. The AUC of nomogram were 0.779 (95% CI: 0.736-0.822) and 0.791 (95%CI: 0.677-0.905) in the training and validation cohort, respectively. The two cohorts of calibration plots showed a good consistency between nomogram prediction and actual observation.

CONCLUSIONS

A highly accurate nomogram was developed and validated in this study, which can be used to provide individual prediction of PPOI in patients after colorectal resection, and this predictive power can potentially assist surgeons to make the optimal treatment decisions.

Frailty affects prognosis in patients with colorectal cancer: A systematic review and meta-analysis

Background

The prevalence of colorectal cancer has remained high. Most patients have already developed into the middle and advanced stage when they are diagnosed with colorectal cancer, and a small number of them are accompanied by metastasis. In recent years, frailty has been recognized as an important factor affecting the prognosis of colorectal cancer. The aim of this study was to assess the value of frailty on prognosis in patients with colorectal cancer after treatment.

Method

We systematically searched PubMed, Embase, Web Of Science databases up until March2022. A total of 18 studies were retrieved that met the inclusion criteria, including 9 prospective studies and 9 retrospective studies. Frailty screening tools, proportion of frail patients, and outcomes of colorectal cancer patients after treatment were recorded.

Result

18 studies were included with a total of 352,535 participants. Regardless of differences in frailty screening and treatment approaches, outcomes for frailty patients were less favorable in all studies. Compared with the non-frail group, the frail group had higher mortality, more serious complications, more postoperative blood transfusions and delirium, and more support outside the home.

Conclusion

Although there is no uniform standard for frailty screening, assessing the frailty of colorectal cancer patients is of great significance for predicting prognosis of patients after treatment.

Short-term outcomes of colorectal cancer surgery in older patients: a novel nomogram predicting postoperative morbi-mortality

PURPOSE

To analyze short-term outcomes of curative-intent cancer surgery in all adult patients diagnosed with colorectal cancer undergoing surgery from January 2010 to December 2019 and determine risk factors for postoperative complications and mortality.

METHODS

Retrospective study conducted at a single tertiary university institution. Patients were stratified by age into two groups: < 75 years and ≥ 75 years. Primary outcome was the influence of age on 30-day complications and mortality. Independent risk factors for postoperative adverse events or mortality were analyzed, and two novel nomograms were constructed.

RESULTS

Of the 1486 patients included, 580 were older (≥ 75 years). Older subjects presented more comorbidities and tumors were located mainly in right colon (45.7%). After matching, no between-group differences in surgical postoperative complications were observed. The 30-day mortality rate was 5.3% for the older and 0.8% for the non-older group (p < 0.001). In multivariable analysis, the independent risk factors for postoperative complications were peripheral vascular disease, chronic pulmonary disease, severe liver disease, postoperative transfusion, and surgical approach. Independent risk factors for 30-day mortality were age ≥ 80 years, cerebrovascular disease, severe liver disease, and postoperative transfusion. The model was internally and externally validated, showing high accuracy.

CONCLUSION

Patients aged ≥ 75 years had similar postoperative complications but higher 30-day mortality than their younger counterparts. Patients with peripheral vascular disease, chronic pulmonary disease, or severe liver disease should be informed of higher postoperative complications. But patients aged ≥ 80 suffering cerebrovascular disease, severe liver disease, or needing postoperative transfusion should be warned of significantly increased risk of postoperative mortality.

The effect of prehabilitation on the postoperative outcomes of patients undergoing colorectal surgery: A systematic review and meta-analysis

Study objective

Prehabilitation is analogous to marathon training and includes preoperative preparation for exercise, as well as nutrition and psychology. However, evidence-based recommendations to guide prehabilitation before colorectal surgery are limited. We aimed to evaluate the effect of prehabilitation on the postoperative outcomes of patients undergoing colorectal surgery.

Design

This study is a systematic review and meta-analysis.

Methods

The PubMed, Embase, and Cochrane databases were searched for studies reporting the effect of prehabilitation strategies versus standard care or rehabilitation in patients undergoing colorectal surgery. The primary outcomes were overall postoperative complications and length of hospital stay (LOS), and the secondary outcome was functional capacity (measured using the 6-min walk test [6MWT]) at 4 and 8 weeks after surgery.

Main results

Fifteen studies with 1,306 participants were included in this meta-analysis. The results showed no significant reduction in the number of overall postoperative complications (risk ratio = 1.02; 95% confidence interval [CI] = 0.79–1.31; p = 0.878) or LOS (standardized mean difference = 0.04; 95% CI = −0.11 to 0.20; p = 0.589) in patients who underwent colorectal surgery with or without prehabilitation strategy. Additionally, there were no significant differences in the functional capacity estimated using the 6MWT at 4 and 8 weeks postoperatively.

Conclusions

Prehabilitation did not significantly affect the number of postoperative complications, LOS, or functional capacity of patients undergoing colorectal surgery. Whether prehabilitation should be recommended deserves further consideration.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=290108, identifier CRD42021290108

Frailty and surgical outcomes in gastrointestinal cancer: Integration of geriatric assessment and prehabilitation into surgical practice for vulnerable patients

As life expectancy increases, the older population continues to grow rapidly, resulting in increased requirement for surgery for older patients with gastrointestinal cancer. Older individuals represent a heterogeneous group in terms of physiological reserves, co-morbidity, cognitive impairment, and disability. Owing to the lack of treatment guidelines for vulnerable patients with gastrointestinal cancer, these patients are more likely to be at risk of undertreatment or overtreatment. Hence, the identification of frail patients with gastrointestinal cancer would improve cancer treatment outcomes. Although there is no standardized geriatric assessment tool, a growing body of research has shown associations of frailty with adverse postoperative outcomes and poor prognosis after resection of gastrointestinal tract and hepatobiliary-pancreatic cancers. Emerging evidence suggests that prehabilitation, which includes exercise and nutritional support, can improve preoperative functional capacity, postoperative recovery, and surgical outcomes, particularly in frail patients with gastrointestinal cancer. We reviewed major geriatric assessment tools for identification of frail patients and summarized clinical studies on frailty and surgical outcomes, as well as prehabilitation or rehabilitation in gastrointestinal tract and hepatobiliary-pancreatic cancers. The integration of preoperative geriatric assessment and prehabilitation of frail patients in clinical practice may improve surgical outcomes. In addition, improving preoperative vulnerability and preventing functional decline after surgery is important in providing favorable long-term survival in patients with gastrointestinal cancer. Further clinical trials are needed to examine the effects of minimally invasive surgery, and chemotherapy in frail patients with gastrointestinal cancer.

What is related to postoperative outcome of frail status in elective colorectal cancer surgery?

Background

The population affected by colorectal cancer is growing, and there is an increasing need for prevention of functional decline following treatment. We proposed that the Kihon Checklist published by the Japanese Ministry of Health, Labor, and Welfare would be an appropriate means of frailty assessment for prediction of postoperative complications in older patients with colorectal cancer. This prospective cohort study aims to identify the factors influencing postoperative frailty.

Methods

We prospectively enrolled consecutive patients with colorectal cancer and aged ≥ 65 year (N = 500) between May 2017 and December 2018. Eligible patients were assessed with the Kihon Checklist prior to surgery and 30 days after surgery. The main measures were variables related to postoperative change in view of frail status.

Results

According to the Kihon Checklist questionnaire, 164 patients were frail preoperatively and 172 patients were frail postoperatively, whereas 38 patients changed from "nonfrail" before surgery to postoperative "frail." Overall complications were counted in 97 patients (19.4%), and 5 patients died. Performance status ≥ 2, history of laparotomy, open surgery, complication, ostomy creation, and delirium were significantly associated with changing postoperative "frail" (P = .014, P = .023, P = .006, P < .001, P = .023, and P = .024, respectively). In multivariate analysis, independent related factors of changing postoperative "frail" were complication (odds ratio 2.69, 95% confidence interval 1.19–6.09, P = .018) and ostomy creation (odds ratio 2.32, 95% confidence interval 1.01–5.33, P = .047).

Conclusion

The Kihon Checklist questionnaire could identify the factors related to postoperative change of frailty status in older patients with colorectal cancer. This cohort concluded that whether postoperative complication occurred or not was closely associated with perioperative change of frailty status.

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Our prospective cohort study examined the factor influencing postoperative frailty in older patients with colorectal cancer by Kihon Checklist questionnaire.

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The importance of this study is that postoperative complication and ostomy creation were significantly associated with postoperative change of frailty status.

The prevalence and prognostic value of frailty screening measures in patients undergoing surgery for colorectal cancer: observations from a systematic review

Introduction

Frailty is a complex multifactorial syndrome characterised by a significant increase in vulnerability and worsened health outcomes. Despite a range of proposed frailty screening measures, the prevalence and prognostic value of frailty in patients undergoing surgery for colorectal cancer is not clear.

Aim

The aim of this present review was to examine the use of commonly employed frailty screening measures in patients undergoing surgery for colorectal cancer.

Methods

A systematic search of PubMed and Medline was carried out to identify studies reporting the use of frailty screening tools or measures in patients undergoing surgery for colorectal cancer. The screening measure used and prevalence of frailty within the population were recorded. Outcomes of interest were the incidence of post-operative complications, 30-day mortality and overall survival.

Results

Of the 15 studies included (n = 97, 898 patients), 9 studies were retrospective and included patients aged 70 years or older (n = 96, 120 patients). 5 of 12 studies reported that frailty was independently associated with the incidence of post-operative complications. There was also evidence that frailty was independently associated with 30-day mortality (1 of 4 studies, n = 9, 252 patients) and long-term survival (2 of 3 studies, n = 1, 420 patients).

Conclusions

Frailty was common in patients with colorectal cancer and the assessment of frailty may have prognostic value in patients undergoing surgery. However, the basis of the relationship between frailty and post-operative outcomes is not clear and merits further study.

Perioperative and oncologic outcomes in young and octogenarian patients with colorectal cancer: a comparison at the extremes

INTRODUCTION

In colorectal cancer (CRC), surgical outcomes in the young (< 50) and octogenarian populations are believed to be poor due to an aggressive phenotype in the former, and increased frailty in the latter. Given that age-related effects are inversely related between groups, we compared short- and long-term outcomes of young and octogenarian patients with CRC to determine the dominance of one age-related factor over another.

METHODS

A prospectively collected database from 2015 to 2020 of all CRC was analyzed. Cases were divided into metastatic and non-metastatic groups.

RESULTS

Among non-metastatic cases, there were 34 young and 113 octogenarian patients. Mean CEA was higher among octogenarians (11.2 vs 32.8 units/ml; p = 0.041). Octogenarians suffered from more comorbidities than younger counterparts, with increased rates of postoperative UTI (3.3% vs 10.3%; p = 0.246) and pneumonia (3.1% vs 8.8%; p = 0.331). There was no increased rate of reintervention or Clavien-Dindo scores. We noticed a statistically significant higher proportion of extramural vascular invasion (EMVI) (8.8% vs 32.3%; p = 0.003) among the young. When excluding octogenarians who had declined surgery, Kaplan-Meier analysis showed no difference in disease-free (p = 0.290) or overall survival (p = 0.111). Among metastatic cases, there were 21 young and 19 octogenarian patients. Young patients were treated more aggressively with chemotherapy (55.6% vs 12.5%; p = 0.040). There was however no difference in overall survival between groups (p = 0.610).

CONCLUSIONS

Octogenarians may have more comorbidities, but can achieve similar surgical outcomes with younger patients. There is no reason to suspect a more aggressive phenotype in younger patients.

Multidisciplinary management of elderly patients with rectal cancer: recommendations from the SICG (Italian Society of Geriatric Surgery), SIFIPAC (Italian Society of Surgical Pathophysiology), SICE (Italian Society of Endoscopic Surgery and new technologies), and the WSES (World Society of Emergency Surgery) International Consensus Project

BACKGROUND AND AIMS

Although rectal cancer is predominantly a disease of older patients, current guidelines do not incorporate optimal treatment recommendations for the elderly and address only partially the associated specific challenges encountered in this population. This results in a wide variation and disparity in delivering a standard of care to this subset of patients. As the burden of rectal cancer in the elderly population continues to increase, it is crucial to assess whether current recommendations on treatment strategies for the general population can be adopted for the older adults, with the same beneficial oncological and functional outcomes. This multidisciplinary experts' consensus aims to refine current rectal cancer-specific guidelines for the elderly population in order to help to maximize rectal cancer therapeutic strategies while minimizing adverse impacts on functional outcomes and quality of life for these patients.

METHODS

The discussion among the steering group of clinical experts and methodologists from the societies' expert panel involved clinicians practicing in general surgery, colorectal surgery, surgical oncology, geriatric oncology, geriatrics, gastroenterologists, radiologists, oncologists, radiation oncologists, and endoscopists. Research topics and questions were formulated, revised, and unanimously approved by all experts in two subsequent modified Delphi rounds in December 2020-January 2021. The steering committee was divided into nine teams following the main research field of members. Each conducted their literature search and drafted statements and recommendations on their research question. Literature search has been updated up to 2020 and statements and recommendations have been developed according to the GRADE methodology. A modified Delphi methodology was implemented to reach agreement among the experts on all statements and recommendations.

CONCLUSIONS

The 2021 SICG-SIFIPAC-SICE-WSES consensus for the multidisciplinary management of elderly patients with rectal cancer aims to provide updated evidence-based statements and recommendations on each of the following topics: epidemiology, pre-intervention strategies, diagnosis and staging, neoadjuvant chemoradiation, surgery, watch and wait strategy, adjuvant chemotherapy, synchronous liver metastases, and emergency presentation of rectal cancer.