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Moro-Valdezate D, Martín-Arévalo J, Ferro-Echevarría Ó, Pla-Martí V, García-Botello S, Pérez-Santiago L, Gadea-Mateo R, Tarazona N, Roda D, Roselló-Keränen S, Espí-Macías A. Short-term outcomes of colorectal cancer surgery in older patients: a novel nomogram predicting postoperative morbi-mortality. Langenbecks Arch Surg 2022; 407:3587-3597. [PMID: 36129528 DOI: 10.1007/s00423-022-02688-1] [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: 07/24/2022] [Accepted: 09/15/2022] [Indexed: 10/14/2022]
Abstract
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.
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Affiliation(s)
- David Moro-Valdezate
- Colorectal Surgery Unit, Department of General and Digestive Surgery, INCLIVA Biomedical Research Institute, Hospital Clínico Universitario de Valencia, Av. Blasco Ibáñez, 17, 46010, Valencia, Spain. .,Department of Surgery, University of Valencia, Valencia, Spain.
| | - José Martín-Arévalo
- Colorectal Surgery Unit, Department of General and Digestive Surgery, INCLIVA Biomedical Research Institute, Hospital Clínico Universitario de Valencia, Av. Blasco Ibáñez, 17, 46010, Valencia, Spain.,Department of Surgery, University of Valencia, Valencia, Spain
| | | | - Vicente Pla-Martí
- Colorectal Surgery Unit, Department of General and Digestive Surgery, INCLIVA Biomedical Research Institute, Hospital Clínico Universitario de Valencia, Av. Blasco Ibáñez, 17, 46010, Valencia, Spain.,Department of Surgery, University of Valencia, Valencia, Spain
| | - Stephanie García-Botello
- Colorectal Surgery Unit, Department of General and Digestive Surgery, INCLIVA Biomedical Research Institute, Hospital Clínico Universitario de Valencia, Av. Blasco Ibáñez, 17, 46010, Valencia, Spain.,Department of Surgery, University of Valencia, Valencia, Spain
| | - Leticia Pérez-Santiago
- Colorectal Surgery Unit, Department of General and Digestive Surgery, INCLIVA Biomedical Research Institute, Hospital Clínico Universitario de Valencia, Av. Blasco Ibáñez, 17, 46010, Valencia, Spain
| | - Ricardo Gadea-Mateo
- Colorectal Surgery Unit, Department of General and Digestive Surgery, INCLIVA Biomedical Research Institute, Hospital Clínico Universitario de Valencia, Av. Blasco Ibáñez, 17, 46010, Valencia, Spain
| | - Noelia Tarazona
- Department of Medical Oncology, INCLIVA Biomedical Research Institute, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Desamparados Roda
- Department of Medical Oncology, INCLIVA Biomedical Research Institute, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Susana Roselló-Keränen
- Department of Medical Oncology, INCLIVA Biomedical Research Institute, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Alejandro Espí-Macías
- Colorectal Surgery Unit, Department of General and Digestive Surgery, INCLIVA Biomedical Research Institute, Hospital Clínico Universitario de Valencia, Av. Blasco Ibáñez, 17, 46010, Valencia, Spain.,Department of Surgery, University of Valencia, Valencia, Spain
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2
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Diers J, Baum P, Lehmann K, Uttinger K, Baumann N, Pietryga S, Hankir M, Matthes N, Lock JF, Germer CT, Wiegering A. Disproportionately high failure to rescue rates after resection for colorectal cancer in the geriatric patient population - A nationwide study. Cancer Med 2022; 11:4256-4264. [PMID: 35475597 DOI: 10.1002/cam4.4784] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 04/07/2022] [Accepted: 04/16/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Colorectal cancer incidence increases with patient age. The aim of this study was to assess, at the nationwide level, in-hospital mortality, and failure to rescue in geriatric patients (≥ 80 years old) with colorectal cancer arising from postoperative complications. METHODS All patients receiving surgery for colorectal cancer in Germany between 2012 and 2018 were identified in a nationwide database. Association between age and in-hospital mortality following surgery and failure to rescue, defined as death after complication, were determined in univariate and multivariate analyses. RESULTS Three lakh twenty-eight thousands two hundred and ninety patients with colorectal cancer were included of whom 77,287 were 80 years or older. With increasing age, a significant relative increase in right hemicolectomy was observed. In general, these patients had more comorbid conditions and higher frailty. In-hospital mortality following colorectal cancer surgery was 4.9% but geriatric patients displayed a significantly higher postoperative in-hospital mortality of 10.6%. The overall postoperative complication rate as well as failure to rescue increased with age. In contrast, surgical site infection (SSI) and anastomotic leakage (AL) did not increase in geriatric patients, whereas the associated mortality increased disproportionately (13.3% for SSI and 29.9% mortality for patients with AI, both p < 0.001). Logistic regression analysis adjusting for confounders showed that geriatric patients had almost five-times higher odds for death after surgery than the baseline age group below 60 (OR 4.86; 95%CI [4.45-5.53], p < 0.001). CONCLUSION Geriatric patients have higher mortality after colorectal cancer surgery. This may be partly due to higher frailty and disproportionately higher rates of failure to rescue arising from postoperative complications.
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Affiliation(s)
- Johannes Diers
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany
| | - Philip Baum
- Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
| | - Kai Lehmann
- Department of General, Visceral and Vascular Surgery, Charité University Hospital Berlin Campus Benjamin Franklin, Berlin, Germany
| | - Konstatin Uttinger
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany
| | - Nikolas Baumann
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany
| | - Sebastian Pietryga
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany
| | - Mohammed Hankir
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany
| | - Niels Matthes
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany
| | - Johann F Lock
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany.,Comprehensive Cancer Centre Mainfranken, University of Würzburg Medical Centre, Würzburg, Germany
| | - Armin Wiegering
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany.,Comprehensive Cancer Centre Mainfranken, University of Würzburg Medical Centre, Würzburg, Germany.,Department of Biochemistry and Molecular Biology, University of Würzburg, Würzburg, Germany
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3
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Skorus U, Rapacz K, Kenig J. The significance of comorbidity burden among older patients undergoing abdominal emergency or elective surgery. Acta Chir Belg 2021; 121:405-412. [PMID: 32873179 DOI: 10.1080/00015458.2020.1816671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Comorbidities may cause complications in perioperative care and affect treatment outcomes of older patients. The study aim was to analyse comorbidity burdens with respect to their predictive power in outcome prediction in elderly qualified for abdominal elective or emergency surgery. METHODS Consecutive patients undergoing major abdominal surgery between 2010 and 2017 at a secondary referral hospital were included in the retrospective study, for a total of 1586 patients. To explain the relationship between the comorbidity types and 30-day mortality and morbidity logistic regression analysis was performed. Morbidity was assessed using the Clavien-Dindo Score. Major complications were defined as a C-D score ≥ 3. We also presented the data concerning need for reoperation and ICU admission. RESULTS 85.9% of patients had at least one comorbidity. In the group of emergency patients age and number of comorbidities were independent risk factors of 30-day mortality and major morbidity. In elective patients age, dementia (OR:3.52; 95%CI:1.35-9.20) and kidney disease (OR:1.64; 95%CI:1.04-2.57) were found to be independent risk factors of 30-day postoperative mortality. Age (1.04; 95%CI:1.00-1.08) and heart disease (OR:1.30, 95%CI:1.04-1.63) were found to be independent risk factors of 30-day major morbidity. CONCLUSIONS In patients undergoing elective surgery 30-day mortality and morbidity was associated with age. 30-day mortality, but not morbidity was associated with kidney disease and dementia. 30-day morbidity, but not mortality, was associated with heart disease.
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Affiliation(s)
- Urszula Skorus
- Department of General, Oncologic and Geriatric Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Kamil Rapacz
- Department of General, Oncologic and Geriatric Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Jakub Kenig
- Department of General, Oncologic and Geriatric Surgery, Jagiellonian University Medical College, Krakow, Poland
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Park H, Parys S, Tan J, Entriken F, Hodder R. Post-operative outcomes in the elderly following colorectal cancer surgery. ANZ J Surg 2020; 91:387-391. [PMID: 33089941 DOI: 10.1111/ans.16394] [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: 08/16/2020] [Revised: 10/01/2020] [Accepted: 10/04/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Despite the prevalence of colorectal cancer in the elderly, there has been a lack of recent studies examining surgical outcomes in these patients. Post-operative outcomes of colorectal cancer surgeries in those aged 80 and above will be compared to those younger than 80. METHODS A retrospective study was conducted of adults receiving surgical resections at a single tertiary centre for colorectal cancer diagnosed between January 2017 and December 2019. Patient demographics, mode of presentation, tumour demographics, operative data and post-operative outcomes were investigated. RESULTS Of the 326 patients included, 56 were aged 80 and above. Older patients were more likely to be female (P = 0.02), present with surgical emergencies or from other workup rather than through screening (P = 0.002), have more locally advanced cancers (P = 0.009) and receive less neoadjuvant therapy (P = 0.016). Despite this, they had comparable outcomes to those younger than 80 in terms of length of stay (P = 0.21) and rates of complications including mortality (P = 0.67). CONCLUSION With appropriate patient selection and management, elderly patients can achieve comparable post-operative outcomes to their younger counterparts.
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Affiliation(s)
- Hyerin Park
- Colorectal Surgery Unit, Department of Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Simon Parys
- Colorectal Surgery Unit, Department of Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Jonathan Tan
- Colorectal Surgery Unit, Department of Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Fiona Entriken
- Colorectal Surgery Unit, Department of Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Rupert Hodder
- Colorectal Surgery Unit, Department of Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
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Rausei S, Pappalardo V, Ceresoli M, Catena F, Sartelli M, Chiarugi M, Kluger Y, Kirkpatrick A, Ansaloni L, Coccolini F. Open abdomen management for severe peritonitis in elderly. Results from the prospective International Register of Open Abdomen (IROA): Cohort study. Int J Surg 2020; 82:240-244. [PMID: 32891828 DOI: 10.1016/j.ijsu.2020.08.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/09/2020] [Accepted: 08/11/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Analyzing the data of the International Register of Open Abdomen (IROA), the feasibility of open abdomen treatment has been demonstrated at every age. This new analysis on the IROA database investigates the risk factors for mortality in elderly patients treated with open abdomen for intra-abdominal infection. METHODS Data were derived from the IROA, a prospective observational international cohort study that enrolled patients treated with open abdomen worldwide. A univariate analysis of potential risk factors was performed. Inclusion criteria were patients older than 65 years and treated with open abdomen for intra-abdominal infection. End point was overall mortality, calculated within 30 days after open abdomen management, after 1-month and 1-year follow-up. RESULTS A total of 116 patients was analyzed with mean age of 76 ± 7 years. Definitive closure was achieved in 93 patients (93/116, 80.2%) for a mean open abdomen duration of 5.0 ± 5.0 days. Complicated patients were 101 (101/116, 87.1%) for a total of 201 complications. Overall, 62 out of 116 patients (53.4%) died: 23 patients (23/62, 37.1%) during open abdomen management, 29 patients (46.8%) within 30 days after abdominal closure, 9 patients (14.5%) after 1-month follow-up, and 1 patient (1.6%) after 1-year follow-up. Age did not affect mortality (75 ± 6 years in alive patients versus 77 ± 7 years in dead patients, p = 0.773). Definitive abdominal closure was the most important factor to prevent mortality. CONCLUSIONS This study confirmed that age alone cannot be considered a determinant for death, even in elderly patients managed with open abdomen for severe intra-abdominal infection.
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Affiliation(s)
- Stefano Rausei
- Department of Surgery, ASST Valle Olona, Gallarate, Varese, Italy.
| | | | - Marco Ceresoli
- Emergency and General Surgery Department, University of Milan-Bicocca, Milan, Italy
| | - Fausto Catena
- General Surgery Department, Ospedale Maggiore, Parma, Italy
| | - Massimo Sartelli
- General and Emergency Surgery, Macerata Hospital, Macerata, Italy
| | - Massimo Chiarugi
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Andrew Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
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6
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Dogrul RT, Dogrul AB, Konan A, Caglar O, Sumer F, Caliskan H, Kizilarslanoglu MC, Kilic MK, Balci C, Arik G, Aycicek GS, Ozsurekci C, Halil M, Cankurtaran M, Yavuz BB. Does Preoperative Comprehensive Geriatric Assessment and Frailty Predict Postoperative Complications? World J Surg 2020; 44:3729-3736. [PMID: 32737555 DOI: 10.1007/s00268-020-05715-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND The influence of preoperative comprehensive geriatric assessment and frailty on postoperative morbidity, mortality, delirium were examined. METHODS A total of 108 patients were evaluated. The Katz Index of Independence in Activities of Daily Living (ADL), the Lawton Brody Instrumental Activities of Daily Living Scale (IADL), the Mini-Nutrition Assessment test (MNA), the Mini-Mental State Examination (MMSE), Yesavage Geriatric Depression Scale (GDS) were performed. Fried Criteria were used to assess physical frailty. We used the Physiological and Operative Severity Scores for the Enumeration of Mortality and Morbidity score (POSSUM), the American Society of Anesthesiologists Score (ASA), and the Charlson Comorbidity Index (CCI) to determine the risk of postoperative morbidity and mortality. Assessment Test for Delirium (4AT) was applied for detection of delirium. RESULTS The median age was 71 years (min-max: 65-84). IADL (p = 0.032), MNA (p = 0.01), MMSE scores (p = 0.026) were found to be significantly lower in patients with morbidity. POSSUM physiology score (p = 0.005), operative score (p = 0.015) and CCI (p = 0.029) were significantly higher in the patients with morbidity. Patients developed morbidity were found to be more frail (p < 0.001). The patients with delirium were found to have lower IADL (p = 0.049) and MMSE scores (p = 0.004), higher POSSUM physiology score (p = 0.005) and all of them were frail. It was found that frailty (OR = 23.695 95% CI: 6.912-81.231 p < 0.001), POSSUM operative score (OR:1.118 95% CI: 1.021-1.224 p = 0.016) and preoperative systolic blood pressure (OR:0.937%95 CI: 0.879-0.999 p = 0.048) were independently related factors for postoperative morbidity. CONCLUSION In our study, CGA and frailty in preoperative period were found to be indicators for postoperative morbidity and delirium.
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Affiliation(s)
- Rana Tuna Dogrul
- Division of Geriatrics, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, 06100, Ankara, Turkey.
| | - Ahmet Bulent Dogrul
- Department of General Surgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Ali Konan
- Department of General Surgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Omur Caglar
- Department of Orthopedics and Traumatology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Fatih Sumer
- Division of Geriatrics, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, 06100, Ankara, Turkey
| | - Hatice Caliskan
- Division of Geriatrics, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, 06100, Ankara, Turkey
| | - Muhammet Cemal Kizilarslanoglu
- Division of Geriatrics, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, 06100, Ankara, Turkey
| | - Mustafa Kemal Kilic
- Division of Geriatrics, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, 06100, Ankara, Turkey
| | - Cafer Balci
- Division of Geriatrics, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, 06100, Ankara, Turkey
| | - Gunes Arik
- Division of Geriatrics, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, 06100, Ankara, Turkey
| | - Gozde Sengul Aycicek
- Division of Geriatrics, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, 06100, Ankara, Turkey
| | - Cemile Ozsurekci
- Division of Geriatrics, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, 06100, Ankara, Turkey
| | - Meltem Halil
- Division of Geriatrics, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, 06100, Ankara, Turkey
| | - Mustafa Cankurtaran
- Division of Geriatrics, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, 06100, Ankara, Turkey
| | - Burcu Balam Yavuz
- Division of Geriatrics, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, 06100, Ankara, Turkey
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7
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Lopez-Lopez V, Gómez-Ruiz AJ, Eshmuminov D, Cascales-Campos PA, Alconchel F, Arevalo-Perez J, Robles Campos R, Parrilla Paricio P. Surgical oncology in patients aged 80 years and older is associated with increased postoperative morbidity and mortality: A systematic review and meta-analysis of literature over 25 years. Surg Oncol 2019; 33:81-95. [PMID: 32561103 DOI: 10.1016/j.suronc.2019.12.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 11/19/2019] [Accepted: 12/18/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND The study aim is to analyze the evolution over the last 25 years of the results reported after abdominal oncological surgery in patients aged 80 years of age and older. The primary endpoint was morbidity and mortality in this group of patients; the secondary endpoint was overall survival. METHODS A systematic search strategy was used to browse through Medline/PubMed, EMBASE, Scopus, ClinicalTrials.gov, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials using a combination of standardized index terms. Studies published between 1997 and 2017 were selected. Only those studies that showed morbidity and mortality after digestive and hepatobiliary tract oncological surgery in individuals aged 80 years and older were included. The PROSPERO registration number is CRD42018087921. PRISMA and MOOSE guidelines were applied. RESULTS A total of 79 studies were included, categorized by origin of malignancy: esophageal (7), stomach (26), liver (4), pancreas (19), and colorectal (23). Compared with the non-elderly group, the elderly group had similar esophageal morbidity with higher mortality (RR 2.51, 1.50 to 4.21; P = 0.0005); higher gastric morbidity (RR 1.25, 1.09 to 1.43; P = 0.001), and mortality (RR 2.51, 1.81 to 3.49; P = 0.0001); similar liver morbidity and mortality; higher pancreatic morbidity (RR 1.17, 1.03 to 1.33; P = 0.02) and mortality (RR 2.37, 1.86 to 3.03; P < 0.00001); and similar colorectal morbidity with higher mortality (RR 4.44, 1.91 to 10.32; P = 0.005). CONCLUSION Oncological surgery of most abdominal visceral tumors is associated with increased morbidity and mortality in patients older than 80 years.
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Affiliation(s)
- V Lopez-Lopez
- Virgen de La Arrixaca Clinic and University Hospital, IMIB, Murcia, Spain
| | - A J Gómez-Ruiz
- Virgen de La Arrixaca Clinic and University Hospital, IMIB, Murcia, Spain.
| | - D Eshmuminov
- Department of Surgery, Swiss HPB and Transplantation Centre, University Hospital Zurich, Zurich, Switzerland
| | | | - F Alconchel
- Virgen de La Arrixaca Clinic and University Hospital, IMIB, Murcia, Spain
| | - J Arevalo-Perez
- Memorial Sloan Kettering Cancer Center. Radiology Departament, New York, USA
| | - R Robles Campos
- Virgen de La Arrixaca Clinic and University Hospital, IMIB, Murcia, Spain
| | - P Parrilla Paricio
- Virgen de La Arrixaca Clinic and University Hospital, IMIB, Murcia, Spain
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8
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Abstract
The aging population is an increasing healthcare concern in developing countries. In Singapore, 25% of the local population are expected to be older than 65 years old by 2030. Colorectal cancer (CRC) is ranked third most diagnosed cancers worldwide with up to 1.8 million new cases diagnosed in 2018. 60% of newly diagnosed CRC are among patients who are 70 years or older and hence majority of these patients will invariably face challenges with frailty and multiple comorbidities that require appropriate assessment and stratification. The standard of care in patients with stage I or II CRC is surgery with curative intent. For patients with stage III CRC, upfront surgical resection of tumor along with adjuvant chemotherapy is the internationally recommended treatment approach. As for those patients with metastatic disease, they are usually managed within a multidisciplinary team and considered for surgical resection if deemed feasible. Elderly patients are mostly burdened with frailty, functional dependency and existing co-morbidities, all of which are predictors of early postoperative mortality and morbidity in patients with CRC. This article thus aims to review existing evidence to discuss the intricate decision-making process for the surgical management of elderly patient with CRC.
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Affiliation(s)
- Rhan Chaen Chong
- Department of General Surgery, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Marc Weijie Ong
- Department of General Surgery, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Kok Yang Tan
- Department of General Surgery, Khoo Teck Puat Hospital, Singapore, Singapore
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9
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Novello M, Mandarino FV, Di Saverio S, Gori D, Lugaresi M, Duchi A, Argento F, Cavallari G, Wheeler J, Nardo B. Post-operative outcomes and predictors of mortality after colorectal cancer surgery in the very elderly patients. Heliyon 2019; 5:e02363. [PMID: 31485540 PMCID: PMC6716468 DOI: 10.1016/j.heliyon.2019.e02363] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 01/18/2019] [Accepted: 08/21/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The frailty of the very elderly patients who undergo surgery for colorectal cancer negatively influences postoperative mortality. This study aimed to identify risk factors for postoperative mortality in octogenarian and nonagenarian patients who underwent surgical treatment for colorectal cancer. METHODS This is a single institution retrospective study. The primary outcomes were risk factors for postoperative mortality. The variables of the octogenarians and nonagenarians were compared by using t-test, chi-square test, and Fisher exact test. A multivariate logistic regression analysis was carried out on the combined cohorts. RESULTS we identified 319 octogenarians and 43 nonagenarians (N = 362) who underwent surgery for colorectal cancer at the Sant'Orsola-Malpighi university hospital in Bologna between 2011 and 2015. The 30-day post-operative mortality was 6% (N = 18) among octogenarians and 21% (N = 9) for the nonagenarians.The groups significantly differed in the type of surgery (elective vs. urgent surgery, p < 0.0001), ASA score (p = 0.0003) and rates of 30-day postoperative mortality (6% vs. 21%, p = 0.0003).In the multivariate analysis ASA > III (OR 2.37, 95% CI [1.43-3.93], p < 0,001), and urgent surgery (OR 2.17, 95% CI [1.17-4.04], p = 0.014) were associated to post-operative mortality. On the contrary, pre-operative albumin≥3.4 g/dL (OR 0.14, 95% CI [0.05-0.52], p = 0.001) was associated with a protective effect on postoperative mortality. CONCLUSIONS In the very elderly affected by colorectal cancer, preoperative nutritional status and pre-existing comorbidities, rather than age itself, should be considered as selection criteria for surgery. Preoperative improvement of nutritional status and ASA risk assessment may be beneficial for stratification of patients and ultimately for optimizing outcomes.
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Affiliation(s)
- Matteo Novello
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), S.Orsola- Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Francesco Vito Mandarino
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), S.Orsola- Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Salomone Di Saverio
- Department of Surgery, Carlo Alberto Pizzardi Maggiore Hospital, Largo Nigrisoli 2, Bologna, Italy
- Colorectal Unit, Addenbrookes Hospital University of Cambridge, Cambridge, United Kingdom
| | - Davide Gori
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Marialuisa Lugaresi
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), S.Orsola- Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Alessandro Duchi
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), S.Orsola- Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Francesca Argento
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), S.Orsola- Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Giuseppe Cavallari
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), S.Orsola- Malpighi Hospital, University of Bologna, Bologna, Italy
| | - James Wheeler
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Bruno Nardo
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), S.Orsola- Malpighi Hospital, University of Bologna, Bologna, Italy
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Richards CR, Steele SR, Lustik MB, Gillern SM, Lim RB, Brady JT, Althans AR, Schlussel AT. Safe surgery in the elderly: A review of outcomes following robotic proctectomy from the Nationwide Inpatient Sample in a cross-sectional study. Ann Med Surg (Lond) 2019; 44:39-45. [PMID: 31312442 PMCID: PMC6610645 DOI: 10.1016/j.amsu.2019.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 06/04/2019] [Accepted: 06/04/2019] [Indexed: 12/13/2022] Open
Abstract
Background As our nation's population ages, operating on older and sicker patients occurs more frequently. Robotic operations have been thought to bridge the gap between a laparoscopic and an open approach, especially in more complex cases like proctectomy. Methods Our objective was to evaluate the use and outcomes of robotic proctectomy compared to open and laparoscopic approaches for rectal cancer in the elderly. A retrospective cross-sectional cohort study utilizing the Nationwide Inpatient Sample (NIS; 2006-2013) was performed. All cases were restricted to age 70 years old or greater. Results We identified 6740 admissions for rectal cancer including: 5879 open, 666 laparoscopic, and 195 robotic procedures. The median age was 77 years old. The incidence of a robotic proctectomy increased by 39%, while the open approach declined by 6% over the time period studied. Median (interquartile range) length of stay was shorter for robotic procedures at 4.3 (3-7) days, compared to laparoscopic 5.8 (4-8) and open at 6.7 (5-10) days (p < 0.01), while median total hospital charges were greater in the robotic group compared to laparoscopic and open cases ($64,743 vs. $55,813 vs. $50,355, respectively, p < 0.01). There was no significant difference in the risk of total complications between the different approaches following multivariate analysis. Conclusion Robotic proctectomy was associated with a shorter LOS, and this may act as a surrogate marker for an overall improvement in adverse events. These results demonstrate that a robotic approach is a safe and feasible option, and should not be discounted solely based on age or comorbidities.
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Affiliation(s)
- Carly R. Richards
- Department of Surgery, Tripler Army Medical Center, Honolulu, HI, United States
- Corresponding author. 1 Jarrett White Road, Honolulu, HI, 96859, United States.
| | - Scott R. Steele
- Department of Colon & Rectal Surgery, Cleveland Clinic Foundation, Cleveland, OH, United States
| | - Michael B. Lustik
- Department of Clinical Investigations, Tripler Army Medical Center, Honolulu, HI, United States
| | - Suzanne M. Gillern
- Department of Surgery, Tripler Army Medical Center, Honolulu, HI, United States
| | - Robert B. Lim
- Department of Surgery, Tripler Army Medical Center, Honolulu, HI, United States
| | - Justin T. Brady
- Department of Surgery, University Hospitals Case Medical Center, Cleveland, OH, United States
| | - Ali R. Althans
- Department of Surgery, University Hospitals Case Medical Center, Cleveland, OH, United States
| | - Andrew T. Schlussel
- Department of Surgery, Madigan Army Medical Center, Tacoma, WA, United States
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Strombom P, Widmar M, Keskin M, Gennarelli RL, Lynn P, Smith JJ, Guillem JG, Paty PB, Nash GM, Weiser MR, Garcia-Aguilar J. Assessment of the Value of Comorbidity Indices for Risk Adjustment in Colorectal Surgery Patients. Ann Surg Oncol 2019; 26:2797-2804. [PMID: 31209671 DOI: 10.1245/s10434-019-07502-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND PURPOSE Comorbidity indices (CIs) are widely used in retrospective studies. We investigated the value of commonly used CIs in risk adjustment for postoperative complications after colorectal surgery. METHODS Patients undergoing colectomy without stoma for colonic neoplasia at a single institution from 2009 to 2014 were included. Four CIs were calculated or obtained for each patient, using administrative data: Charlson-Deyo (CCI-D), Charlson-Romano (CCI-R), Elixhauser Comorbidity Score, and American Society of Anesthesiologists classification. Outcomes of interest in the 90-day postoperative period were any surgical complication, surgical site infection (SSI), Clavien-Dindo (CD) grade 3 or higher complication, anastomotic leak or abscess, and nonroutine discharge. Base models were created for each outcome based on significant bivariate associations. Logistic regression models were constructed for each outcome using base models alone, and each index as an additional covariate. Models were also compared using the DeLong and Clarke-Pearson method for receiver operating characteristic (ROC) curves, with the CCI-D as the reference. RESULTS Overall, 1813 patients were included. Postoperative complications were reported in 756 (42%) patients. Only 9% of patients had a CD grade 3 or higher complication, and 22.8% of patients developed an SSI. Multivariable modeling showed equivalent performance of the base model and the base model augmented by the CIs for all outcomes. The ROC curves for the four indices were also similar. CONCLUSIONS The inclusion of CIs added little to the base models, and all CIs performed similarly well. Our study suggests that CIs do not adequately risk-adjust for complications after colorectal surgery.
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Affiliation(s)
- Paul Strombom
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Maria Widmar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Metin Keskin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Renee L Gennarelli
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Patricio Lynn
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - J Joshua Smith
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jose G Guillem
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Philip B Paty
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Garrett M Nash
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Martin R Weiser
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Julio Garcia-Aguilar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Seow-En I, Tan WJ, Dorajoo SR, Soh SHL, Law YC, Park SY, Choi GS, Tan WS, Tang CL, Chew MH. Prediction of overall survival following colorectal cancer surgery in elderly patients. World J Gastrointest Surg 2019; 11:247-260. [PMID: 31171956 PMCID: PMC6536886 DOI: 10.4240/wjgs.v11.i5.247] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 05/09/2019] [Accepted: 05/23/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND With advanced age and chronic illness, the life expectancy of a patient with colorectal cancer (CRC) becomes less dependent on the malignant disease and more on their pre-morbid condition. Justifying major surgery for these elderly patients can be challenging. An accurate tool demonstrating post-operative survival probability would be useful for surgeons and their patients.
AIM To integrate clinically significant prognostic factors relevant to elective colorectal surgery in the elderly into a validated pre-operative scoring system.
METHODS In this retrospective cohort study, patients aged 70 and above who underwent surgery for CRC at Singapore General Hospital between 1 January 2005 and 31 December 2012 were identified from a prospectively maintained database. Patients with evidence of metastatic disease, and those who underwent emergency surgery or had surgery for benign colorectal conditions were excluded from the analysis. The primary outcome was overall 3-year overall survival (OS) following surgery. A multivariate model predicting survival was derived and validated against an equivalent external surgical cohort from Kyungpook National University Chilgok Hospital, South Korea. Statistical analyses were performed using Stata/MP Version 15.1.
RESULTS A total of 1267 patients were identified for analysis. The median post-operative length of stay was 8 [interquartile range (IQR) 6-12] d and median follow-up duration was 47 (IQR 19-75) mo. Median OS was 78 (IQR 65-85) mo. Following multivariate analysis, the factors significant for predicting overall mortality were serum albumin < 35 g/dL, serum carcinoembryonic antigen ≥ 20 µg/L, T stage 3 or 4, moderate tumor cell differentiation or worse, mucinous histology, rectal tumors, and pre-existing chronic obstructive lung disease. Advanced age alone was not found to be significant. The Korean cohort consisted of 910 patients. The Singapore cohort exhibited a poorer OS, likely due to a higher proportion of advanced cancers. Despite the clinicopathologic differences, there was successful validation of the model following recalibration. An interactive online calculator was designed to facilitate post-operative survival prediction, available at http://bit.ly/sgh_crc. The main limitation of the study was selection bias, as patients who had undergone surgery would have tended to be physiologically fitter.
CONCLUSION This novel scoring system generates an individualized survival probability following colorectal resection and can assist in the decision-making process. Validation with an external population strengthens the generalizability of this model.
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Affiliation(s)
- Isaac Seow-En
- Department of Colorectal Surgery, Singapore General Hospital, Singapore 169608, Singapore
| | - Winson Jianhong Tan
- Department of General Surgery, Sengkang General Hospital, Singapore 544886, Singapore
| | | | - Sharon Hui Ling Soh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Yi Chye Law
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Soo Yeun Park
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, Kyungpook National University School of Medicine, Daegu 702-210, South Korea
| | - Gyu-Seok Choi
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, Kyungpook National University School of Medicine, Daegu 702-210, South Korea
| | - Wah Siew Tan
- Department of Colorectal Surgery, Singapore General Hospital, Singapore 169608, Singapore
| | - Choong Leong Tang
- Department of Colorectal Surgery, Singapore General Hospital, Singapore 169608, Singapore
| | - Min Hoe Chew
- Department of General Surgery, Sengkang General Hospital, Singapore 544886, Singapore
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14
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Weerink LBM, Gant CM, van Leeuwen BL, de Bock GH, Kouwenhoven EA, Faneyte IF. Long-Term Survival in Octogenarians After Surgical Treatment for Colorectal Cancer: Prevention of Postoperative Complications is Key. Ann Surg Oncol 2018; 25:3874-3882. [PMID: 30244418 PMCID: PMC6245105 DOI: 10.1245/s10434-018-6766-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Indexed: 12/13/2022]
Abstract
Background Whether to treat octogenarians with colorectal cancer (CRC) in the same manner as younger patients remains a challenging issue. The purpose of this study was to analyse postoperative complications and long-term survival in a consecutive cohort of octogenarians who were surgically treated for CRC. Methods Octogenarians with primary CRC suitable for curative surgery between January 2008 and December 2011 were included. Data about comorbidities, tumour stage, and complications were retrospectively collected from patient files. Data about survival were retrieved with use of the Dutch database for persons and addresses. To identify factors associated with severe postoperative complications and postoperative survival, logistic regression analyses, and Cox regression analyses were performed. Odds ratios and hazard ratios (HR) with 95% confidence intervals (CI) were estimated. Results In a series of 108 octogenarians, median age was 83 years (range 80–94 years). Median follow-up was 47 (range 1–107) months. Major postoperative complications occurred in 25% of the patients. No risk factors for development of severe postoperative complications could be identified. The 30-day mortality was 7%; 1- and 5-year mortality was 19% and 56%, respectively. Overall median survival was 48 months: 66 months in patients without complications versus 13 months in patients with postoperative complications. Postoperative complications were most predictive of decreased survival (HR 3.16; 95% CI 1.79–5.59), even including tumour characteristics, comorbidity, and emergency surgery. Conclusions Long-term survival in octogenarians deemed fit for surgery is reasonably good. Prevention of major postoperative complications could further improve clinical outcome.
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Affiliation(s)
- Linda B M Weerink
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands. .,Department Surgery, Hospital Group Twente, Almelo, The Netherlands.
| | - Christina M Gant
- Department Surgery, Hospital Group Twente, Almelo, The Netherlands
| | - Barbara L van Leeuwen
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Geertruida H de Bock
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Ian F Faneyte
- Department Surgery, Hospital Group Twente, Almelo, The Netherlands
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Xue DD, Cheng Y, Wu M, Zhang Y. Comprehensive geriatric assessment prediction of postoperative complications in gastrointestinal cancer patients: a meta-analysis. Clin Interv Aging 2018; 13:723-736. [PMID: 29731614 PMCID: PMC5927346 DOI: 10.2147/cia.s155409] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Gastrointestinal cancer is an age-associated disease, and geriatric patients are mostly likely to suffer from postoperative complications. Some studies indicated that comprehensive geriatric assessment (CGA) could predict postoperative complications in gastrointestinal cancer patients. However, the evidence is mixed. Objective This study aimed to conduct a meta-analysis to identify the effectiveness of CGA for predicting postoperative complications in gastrointestinal cancer patients. Methods The Joanna Briggs Institute Library, Cochrane Library, PubMed, Embase, Web of Science, CINAHL Complete and four Chinese databases were searched for studies published up to March 2017. Two reviewers independently screened literature, extracted data and assessed the quality of included studies. RevMan5.3 was used for meta-analysis or only descriptive analysis. Results Six studies were included, with 1,037 participants in total. In all, 13 components of CGA were identified, among which comorbidity (Charlson Comorbidity Index [CCI] ≥3; odds ratio [OR]=1.31, 95% CI [1.06, 1.63], P=0.01), polypharmacy (≥5 drugs/day; OR=1.30, 95% CI [1.04, 1.61], P=0.02) and activities of daily living (ADL) dependency (OR=1.69, 95% CI [1.20, 2.38], P=0.003) were proven relevant to the prediction of postoperative complications. No conclusive relationship was established between instrumental activities of daily living (IADL) dependency (OR=1.18, 95% CI [0.73, 1.91], P=0.51), Mini-Mental State Examination (MMSE; OR=1.13, 95% CI [0.91, 1.41], P=0.27), potential malnutrition (OR=1.07, 95% CI [0.87, 1.31], P=0.54), malnutrition (OR=1.26, 95% CI [0.80, 1.99], P=0.32), Geriatric Depression Scale (GDS; OR=1.18, 95% CI [0.90, 1.55], P=0.24) and postoperative complications. Conclusion Comorbidity (CCI ≥3), polypharmacy (≥5 drugs/day) and ADL dependency were predictive factors for postoperative complications in gastrointestinal cancer patients; the results of other geriatric instruments were not conclusive, pointing to insufficient studies and requirement of more original investigations.
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Affiliation(s)
- Dan-Dan Xue
- Nursing Department, Huadong Hospital Affiliated to Fudan University, Shanghai, People's Republic of China.,School of Nursing, Fudan University, Shanghai, People's Republic of China
| | - Yun Cheng
- Nursing Department, Huadong Hospital Affiliated to Fudan University, Shanghai, People's Republic of China
| | - Mei Wu
- School of Nursing, Fudan University, Shanghai, People's Republic of China
| | - Yan Zhang
- Department of General Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai, People's Republic of China
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Castellví Valls J, Borrell Brau N, Bernat MJ, Iglesias P, Reig L, Pascual L, Vendrell M, Santos P, Viso L, Farreres N, Galofre G, Deiros C, Barrios P. Resultados de morbimortalidad en cáncer colorrectal en paciente quirúrgico frágil. Implementación de un Área de Atención al Paciente Quirúrgico Complejo. Cir Esp 2018; 96:155-161. [DOI: 10.1016/j.ciresp.2017.09.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 09/15/2017] [Accepted: 09/25/2017] [Indexed: 12/11/2022]
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Duraes LC, Stocchi L, Steele SR, Kalady MF, Church JM, Gorgun E, Liska D, Kessler H, Lavryk OA, Delaney CP. The Relationship Between Clavien-Dindo Morbidity Classification and Oncologic Outcomes After Colorectal Cancer Resection. Ann Surg Oncol 2017; 25:188-196. [PMID: 29116488 DOI: 10.1245/s10434-017-6142-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Limited data on the relationship between postoperative complications (POCs) after colorectal cancer resection and oncologic outcomes are available. We hypothesized that the increased severity of POCs is associated with progressively worse oncologic outcomes. METHODS Patients with pathological stages I-III colorectal adenocarcinoma undergoing elective curative resection in a single institution between 2000 and 2012 were identified from a prospectively collected database. The severity of POCs was determined using the Clavien-Dindo classification, and oncologic outcomes were assessed. RESULTS Of 2266 patients, 669 (30%) had at least one POC. POCs were not associated with pathologic stage (p = 0.58) or use of adjuvant therapy (p = 0.19). With a mean follow-up of 5.3 years, POCs were associated with decreased 5-year overall survival (OS) (60% vs. 77%, p < 0.001), disease-free survival (DFS) (53% vs. 70%, p < 0.001), cancer-specific survival (CSS) (81% vs. 87%, p < 0.001), and increased overall recurrence rates (19% vs. 15%, p = 0.008). Increasing Clavien-Dindo scores from I to IV was significantly associated with progressively decreasing OS (71, 64, 60, 22%, p < 0.001), DFS (65, 58, 51, 19%, p < 0.001), CSS (88, 77, 79, 74%, p < 0.001), and increasing recurrence rates (12, 20, 26, 18%, p = 0.002). Multivariate analysis confirmed POCs as an independent factor associated with decreased OS [hazard ratio (HR) 0.63, 95% CI 0.52-0.76], DFS (HR 0.64, 95% CI 0.54-0.76), CSS (HR 0.73, 95% CI 0.56-0.97), and increased recurrence rates (HR 1.36, 95% CI 1.02-1.80). CONCLUSIONS POCs are associated with adverse oncologic outcomes, with increasing effect with higher Clavien-Dindo score. Efforts to reduce both the incidence and severity of complications should result in improved oncologic outcomes.
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Affiliation(s)
- Leonardo C Duraes
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Luca Stocchi
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Matthew F Kalady
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - James M Church
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Emre Gorgun
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - David Liska
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Hermann Kessler
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Olga A Lavryk
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Conor P Delaney
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
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Duraes LC, Stocchi L, Dietz D, Kalady MF, Kessler H, Schroeder D, Remzi FH. The Disproportionate Effect of Perioperative Complications on Mortality within 1 Year After Colorectal Cancer Resection in Octogenarians. Ann Surg Oncol 2016; 23:4293-4301. [DOI: 10.1245/s10434-016-5445-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Lee YH, Oh HK, Kim DW, Ihn MH, Kim JH, Son IT, Kang SI, Kim GI, Ahn S, Kang SB. Use of a Comprehensive Geriatric Assessment to Predict Short-Term Postoperative Outcome in Elderly Patients With Colorectal Cancer. Ann Coloproctol 2016; 32:161-169. [PMID: 27847786 PMCID: PMC5108662 DOI: 10.3393/ac.2016.32.5.161] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 10/07/2016] [Indexed: 11/21/2022] Open
Abstract
Purpose This study was conducted to identify the effectiveness of a preoperative comprehensive geriatric assessment (CGA) for predicting postoperative morbidity in elderly patients who underwent surgery for colorectal cancer. Methods Elderly patients (≥70 years old) who underwent surgery for colorectal cancer at a tertiary hospital in Korea were identified, and their cases were analyzed using data from a prospectively collected database to establish an association between major postsurgical complications and 'high-risk' patient as defined by the CGA. Results A total of 240 patients, with a mean age of 76.7 ± 5.2 years, were enrolled. Ninety-five patients (39.6%) were classified as "high-risk" and 99 patients (41.3%) as having postoperative complications. The univariate analysis indicated that risk factors for postoperative complications were age, American Society of Anesthesiologists physical status classification, serum hemoglobin, carcinoembryonic antigen, cancer stage, and "high-risk" status. The multivariable analyses indicated that "high-risk" status (odds ratio, 2.107; 95% confidence interval, 1.168–3.804; P = 0.013) and elevated preoperative carcinoembryonic antigen (odds ratio, 2.561; 95% confidence interval, 1.346–4.871, P = 0.004) were independently associated with postoperative complications. A multivariable analysis of the individual CGA domains indicated that high comorbidities and low activities of daily living were significantly related with postoperative complications. Conclusion A preoperative CGA indicating "high-risk" was associated with major postoperative complications in elderly patients who underwent surgery for colorectal cancer. Thus, using the CGA to identify elderly colorectal-cancer patients who should be given more care during postoperative management may be clinically beneficial.
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Affiliation(s)
- Yoon Hyun Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Heung-Kwon Oh
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Duck-Woo Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Myong Hoon Ihn
- Department of Surgery, Soonchunhyang University Gumi Hospital, Gumi, Korea
| | - Jee Hyun Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Il Tae Son
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sung Il Kang
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Gwang Il Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Soyeon Ahn
- Division of Statistics, Medical Research Collaborating Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sung-Bum Kang
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
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Simkens GA, Verwaal VJ, Lemmens VE, Rutten HJ, de Hingh IH. Short-term outcome in patients treated with cytoreduction and HIPEC compared to conventional colon cancer surgery. Medicine (Baltimore) 2016; 95:e5111. [PMID: 27741129 PMCID: PMC5072956 DOI: 10.1097/md.0000000000005111] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is an extensive procedure with considerable morbidity. Since only few hospitals perform CRS + HIPEC, this might lead to confounded outcomes between hospitals when audited. This study aims to compare outcomes between peritoneally metastasized (PM) colon cancer patients treated with CRS + HIPEC and patients undergoing conventional colon surgery. Furthermore, the impact of CRS + HIPEC on the risk of postoperative complications will be assessed, probably leading to better insight into how to report on postoperative outcomes in this distinct group of patients undergoing extensive colon surgery.All patients with primary colon cancer who underwent segmental colon resection in a tertiary referral hospital between 2011 and 2014 were included in this prospective cohort study. Outcome after surgery was compared between patients who underwent additional CRS + HIPEC treatment or conventional surgery.Consequently, 371 patients underwent surgery, of which 43 (12%) underwent CRS + HIPEC. These patients were younger and healthier than patients undergoing conventional surgery. Tumor characteristics were less favorable and surgery was more extensive in CRS + HIPEC patients. The morbidity rate was also higher in CRS + HIPEC patients (70% vs 41%; P < 0.001). CRS + HIPEC was an independent predictor of postoperative complications (odds ratio 6.4), but was not associated with more severe postoperative complications or higher treatment-related mortality.Although patients with colonic PM undergoing CRS + HIPEC treatment were younger and healthier, the postoperative outcome was worse. This is most probably due to less favorable tumor characteristics and more extensive surgery. Nevertheless, CRS + HIPEC treatment was not associated with severe complications or increased treatment-related mortality. These results stress the need for adequate case-mix correction in colorectal surgery audits.
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Affiliation(s)
- Geert A. Simkens
- Department of Surgical Oncology, Catharina Hospital, Eindhoven, The Netherlands
| | - Vic J. Verwaal
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Valery E. Lemmens
- Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
- Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Harm J. Rutten
- Department of Surgical Oncology, Catharina Hospital, Eindhoven, The Netherlands
| | - Ignace H. de Hingh
- Department of Surgical Oncology, Catharina Hospital, Eindhoven, The Netherlands
- Correspondence: Ignace H. de Hingh, Catharina Hospital Eindhoven, Department of Surgical Oncology, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands (e-mail: )
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Shalaby M, Di Lorenzo N, Franceschilli L, Perrone F, Angelucci GP, Quareisma S, Gaspari AL, Sileri P. Outcome of Colorectal Surgery in Elderly Populations. Ann Coloproctol 2016; 32:139-43. [PMID: 27626024 PMCID: PMC5019966 DOI: 10.3393/ac.2016.32.4.139] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 07/23/2016] [Indexed: 12/13/2022] Open
Abstract
Purpose The aim of this study is to investigate the impact of age on short-term outcomes after colorectal surgery in terms of the 30-day postoperative morbidity and mortality rates. Methods The subjects for the study were patients who had undergone colorectal surgery. Patients were divided into 2 groups according to age; groups A and B patients were ≥80 and <80 years old of age, respectively. Both groups were manually matched for body mass index, American Society of Anesthesiologists score, Charlson Comorbidity Index and procedure performed. Results A total of 200 patients, 91 men (45.5%) and 109 women (54.5%), were included in this retrospective study. These patients were equally divided into 2 groups. The mean ages were 85 years in group A (range, 80 to 104 years) and 55.3 years in group B (range, 13 to 79 years). The overall 30-day postoperative mortality rate was 1% of total 200 patients; both of these 2 patients were in group A. However, this observation had no statistical significance. No intraoperative complications were encountered in either group. The overall 30-day postoperative morbidity rate was 27% (54 of 200) for both groups. The 30-day postoperative morbidity rates in groups A and B were 28% (28 of 100) and 26% (26 of 100), respectively. However, these differences between the groups had no statistical significance importance. Conclusion Age alone should not be considered to be more of a contraindication or a worse predictor than other factors for the outcome after colorectal surgery on elderly patients.
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Affiliation(s)
- Mostafa Shalaby
- Department of General Surgery, UOC B, Policlinico Tor Vergata, University of Rome Tor Vergata, Rome, Italy
| | - Nicola Di Lorenzo
- Department of General Surgery, UOC B, Policlinico Tor Vergata, University of Rome Tor Vergata, Rome, Italy
| | - Luana Franceschilli
- Department of General Surgery, UOC B, Policlinico Tor Vergata, University of Rome Tor Vergata, Rome, Italy
| | - Federico Perrone
- Department of General Surgery, UOC B, Policlinico Tor Vergata, University of Rome Tor Vergata, Rome, Italy
| | - Giulio P Angelucci
- Department of General Surgery, UOC B, Policlinico Tor Vergata, University of Rome Tor Vergata, Rome, Italy
| | - Silvia Quareisma
- Department of General Surgery, UOC B, Policlinico Tor Vergata, University of Rome Tor Vergata, Rome, Italy
| | - Achille L Gaspari
- Department of General Surgery, UOC B, Policlinico Tor Vergata, University of Rome Tor Vergata, Rome, Italy
| | - Pierpaolo Sileri
- Department of General Surgery, UOC B, Policlinico Tor Vergata, University of Rome Tor Vergata, Rome, Italy
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Adachi T, Hinoi T, Kinugawa Y, Enomoto T, Maruyama S, Hirose H, Naito M, Tanaka K, Miyake Y, Watanabe M. Lower body mass index predicts worse cancer-specific prognosis in octogenarians with colorectal cancer. J Gastroenterol 2016; 51:779-87. [PMID: 26660524 DOI: 10.1007/s00535-015-1147-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 11/09/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND High body mass index (BMI) is a risk factor for colorectal cancer. However, the prognostic impact of BMI and other factors may differ between elderly and younger colorectal cancer patients. We analyze here prognostic factors in the surgical management of octogenarians with colorectal cancer and clarify the prognostic impact of BMI. METHODS Cox regression analysis and propensity score methods were used to retrospectively examine the association of BMI with mortality in 1613 octogenarian patients who underwent curative surgery for stage 0-III colorectal cancer. RESULTS In the Cox regression analysis, lower BMI (<18.5 kg/m(2); p = 0.001), age ≥83 years (p = 0.008), American Society of Anesthesiology class ≥3: (p = 0.001), performance status ≥2 (p = 0.003), Union for International Cancer Control (UICC) stage ≥III (p = 0.001), and postoperative adverse events (p = 0.001) were independently associated with decreased overall survival. Lower BMI (p = 0.001) and UICC stage ≥III (p = 0.001) were independently associated with decreased cancer-specific survival. After covariate adjustment, lower BMI was a risk factor for overall [hazard ratio (HR) 1.62; 95 % confidence interval (CI) 1.26-2.05; p = 0.0004] and cancer-specific survival (HR 2.00; 95 % CI 1.39-2.87; p = 0.0038) compared with normal BMI (18.5-24.9 kg/m(2)). CONCLUSIONS Lower BMI is significantly and independently associated with increased mortality risk in octogenarians who undergo curative surgery for colorectal cancer. Lower BMI should be used for prognosis assessment in octogenarians with colorectal cancer.
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Affiliation(s)
- Tomohiro Adachi
- Department of Gastroenterological and Transplant Surgery Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Takao Hinoi
- Department of Gastroenterological and Transplant Surgery Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Yusuke Kinugawa
- Department of Colon and Rectal Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Toshiyuki Enomoto
- Department of Surgery, Toho University, Ohashi Medical Center, Tokyo, Japan
| | - Satoshi Maruyama
- Department of Surgery, Niigata Cancer Center Hospital, Niigata, Japan
| | - Hajime Hirose
- Department of Surgery, Kinan Hospital, Wakayama, Japan
| | - Masanori Naito
- Department of Surgery, Kitasato University, School of Medicine, Sagamihara, Kanagawa, Japan
| | - Keitaro Tanaka
- Department of General and Gastroenterological Surgery, Osaka Medical College, Osaka, Japan
| | - Yasuhiro Miyake
- Department of Surgery, Nishinomiya Municipal Central Hospital, Nishinomiya, Hyougo, Japan
| | - Masahiko Watanabe
- Department of Surgery, Kitasato University, School of Medicine, Japan Society of Laparoscopic Colorectal Surgery, Sagamihara, Kanagawa, Japan
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The effect of a postoperative quality improvement program on outcomes in colorectal surgery in a community hospital. Int J Colorectal Dis 2016; 31:1603-9. [PMID: 27385205 PMCID: PMC4989010 DOI: 10.1007/s00384-016-2619-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim of this study was to evaluate whether implementation of a comprehensive quality improvement program was associated with improved outcomes in patients undergoing oncological colorectal surgery in a non-academic, non-referral community hospital. METHODS The quality improvement program (QIP) was introduced in January 2011 and consisted of the following interventions: (1) avoidance of postoperative nonsteriodal anti-inflammatory drugs; (2) normovolemia was pursued pre- and postoperatively; (3) non-resectional surgery if possible, in patients over 80 with ASA 3 or 4 classification; and (4) a standardized, postoperative surveillance protocol was introduced, with CRP determination day 2 and 4, and if necessary subsequent abdominal CT with rectal contrast to reduce delay in diagnosis of complications. From a prospectively maintained database of 488 patients undergoing colorectal surgery between 2009 and 2014, postoperative outcomes of patients operated before and after implementation of the program were compared. RESULTS The severe complication rate (Clavien-Dindo >3b) decreased significantly (25.0 vs. 13.7 %; p < .001) after implementation of the QIP program. The mortality rate dropped from 8.7 to 2.6 % (p = .003). The percentage of anastomotic leakage was 9.6% before QIP implementation and 4.2% after (p = .013). Median length of hospital stay decreased from 9 (IQR 5-19) to 7 days (IQR 4-12) (p < .001). Multivariate analyses showed that surgery after implementation of the program was a strong independent predictor for less major complications (OR 0.54, 95 % CI 0.32-0.88). CONCLUSIONS A significant decrease in major complications and mortality was observed after introduction of a relative simple quality improvement program.
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Stornes T, Wibe A, Endreseth BH. Complications and risk prediction in treatment of elderly patients with rectal cancer. Int J Colorectal Dis 2016; 31:87-93. [PMID: 26298183 DOI: 10.1007/s00384-015-2372-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/13/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE The primary aim of this study was to characterise complications, identify predictors of postoperative morbidity and mortality and to evaluate existing risk prediction models in elderly rectal cancer patients. METHODS An observational single-centre study of 330 consecutive patients >75 years treated in 1994-2006. Analyses were performed by age group: 75-79 years, 80-85 years and >85 years. RESULTS Total observed in-hospital morbidity was 48.7 %. In multivariate analysis, age (OR 1.04, 95 % CI 1.01-1.08, p = 0.04), ASA grade ≥ 3 (p = 0.01), acute presentation (OR 1.67, 95 % CI 1.2-13.2, p = 0.02) and major surgery (APR OR 3.72, 95 % CI 1.37-10.15, p = 0.01, LAR OR 2.98, 95 % CI 1.14-7.79, p = 0.03, Hartmann OR 5.46, 95 % CI 1.60-19.28, p = 0.02) were independent risk factors for postoperative morbidity. The 30-day mortality was 6.3, 6.4 and 14.3 % (p = 0.146) in the three age groups, and the 100-day mortality was 8.7, 10.1 and 22.2 % (p = 0.03), respectively. ASA group 3 (OR 6.21, 95 % CI 4.39-27.69, p = 0.017), ASA group 4 (OR 32.6, 95 % CI 5.12-207.75, p < 0.001) and acute presentation (OR 6.48, 95 % CI 1.62-25.99, p = 0.008) increased the risk of 100-day mortality. The Physiological and Operative Severity Score for enUmeration of Mortality and Morbidity (POSSUM) observed/estimated (O/E) ratio for morbidity was 1.05. For 30-day mortality, the colorectal POSSUM (Cr-POSSUM) O/E ratio was 0.74, Surgical Risk Scale 0.61 and the Association of Coloproctology of Great Britain and Ireland (ACPGBI) mortality model 0.63, and for 100-day mortality, ratios were 1.12, 0.91 and 0.95, respectively. CONCLUSION In this series, age increased the risk of in-hospital morbidity and 100-day mortality. Cr-POSSUM, SRS and ACPGBI overestimated 30-day mortality but predicted 100-day mortality with a high degree of accuracy. POSSUM correctly predicted in-hospital morbidity.
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Affiliation(s)
- T Stornes
- Department of Surgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, N-7006, Norway.
| | - A Wibe
- Department of Surgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, N-7006, Norway.,Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - B H Endreseth
- Department of Surgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, N-7006, Norway.,Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
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Schmidt M, Eckardt R, Scholtz K, Neuner B, von Dossow-Hanfstingl V, Sehouli J, Stief CG, Wernecke KD, Spies CD. Patient Empowerment Improved Perioperative Quality of Care in Cancer Patients Aged ≥ 65 Years - A Randomized Controlled Trial. PLoS One 2015; 10:e0137824. [PMID: 26378939 PMCID: PMC4574984 DOI: 10.1371/journal.pone.0137824] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Accepted: 08/20/2015] [Indexed: 12/21/2022] Open
Abstract
Purpose This randomized controlled, clinical prospective interventional trial was aimed at exploring the effect of patient empowerment on short- and long-term outcomes after major oncologic surgery in elderly cancer patients. Methods This trial was performed from February 2011 to January 2014 at two tertiary medical centers in Germany. The study included patients aged 65 years and older undergoing elective surgery for gastro-intestinal, genitourinary, and thoracic cancer. The patients were randomly assigned to the intervention group, i.e. patient empowerment through information booklet and diary keeping, or to the control group, which received standard care. Randomization was done by block randomization in blocks of four in order of enrollment. The primary outcome were 1,postoperative length of hospital stay (LOS) and 2. long-term global health-related quality of life (HRQoL) one year postoperatively. HRQoL was assessed using the EORTC QLQ C30 questionnaire. Secondary outcomes encompassed postoperative stress and complications. Further objectives were the identification of predictors of LOS, and HRQoL at 12 months. Results Overall 652 patients were included. The mean age was 72 ± 4.9 years, and the majority of patients were male (68.6%, n = 447). The ^median of postoperative length of stay was 9 days (IQR 7–14 day). There were no significant differences between the intervention and the control groups in postoperative LOS (p = 0.99) or global HRQoL after one year (women: p = 0.54, men: p = 0.94). While overall complications and major complications occurred in 74% and 24% of the cases, respectively, frequency and severity of complications did not differ significantly between the groups. Patients in the intervention group reported significantly less postoperative pain (p = 0.03) than the control group. Independent predictors for LOS were identified as severity of surgery, length of anesthesia, major postoperative complications, nutritional state, and pre-operative physical functional capacity measured by the Timed Up and Go-test by multiple robust regressions. Conclusion Patient empowerment through information booklet and diary keeping did not shorten the postoperative LOS in elderly onco-surgical patients, but improved quality of care regarding postoperative pain. Postoperative length of stay is influenced by pre-operative nutritional state, pre-operative functional impairment, severity of surgery, and length of anesthesia. Trial Registration Clinicaltrials.gov. Identifier NCT01278537
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Affiliation(s)
- Maren Schmidt
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitaetsmedizin Berlin, Berlin, Germany
| | - Rahel Eckardt
- Charité Research Group on Geriatrics, Charité- Universitaetsmedizin Berlin, Berlin, Germany
| | - Kathrin Scholtz
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitaetsmedizin Berlin, Berlin, Germany
| | - Bruno Neuner
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitaetsmedizin Berlin, Berlin, Germany
| | - Vera von Dossow-Hanfstingl
- Department of Anesthesiology, University Hospital Munich-Grosshadern, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Jalid Sehouli
- Department of Gynecology, European Competence Center of Ovarian Cancer, Charité Campus Virchow-Klinikum, Charité- Universitaetsmedizin Berlin, Berlin, Germany
| | - Christian G. Stief
- Department of Urology, University Hospital Munich-Grosshadern, Ludwig-Maximilians-University Munich, Munich, Germany
| | | | - Claudia D. Spies
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitaetsmedizin Berlin, Berlin, Germany
- * E-mail:
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Effects of laparoscopic surgery on the patterns of death in elderly colorectal cancer patients: competing risk analysis compared with open surgery. Surg Today 2015; 46:422-9. [DOI: 10.1007/s00595-015-1171-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 03/12/2015] [Indexed: 02/07/2023]
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Gomes A, Rocha R, Marinho R, Sousa M, Pignatelli N, Carneiro C, Nunes V. Colorectal surgical mortality and morbidity in elderly patients: comparison of POSSUM, P-POSSUM, CR-POSSUM, and CR-BHOM. Int J Colorectal Dis 2015; 30:173-9. [PMID: 25430595 DOI: 10.1007/s00384-014-2071-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/12/2014] [Indexed: 02/04/2023]
Abstract
PURPOSE This study aims to compare the predictive value of POSSUM, P-POSSUM, CR-POSSUM and CR-BHOM in colorectal surgical mortality and morbidity in patients over 80 years old. METHODS This is a retrospective observational longitudinal study. A total of 991 patients who underwent major colorectal surgery between 2008 and 2012 in a secondary hospital in Portugal were screened, and 204 who were over 80 years old were included. Subgroup analysis was performed for malignant/benign disease and emergent/elective surgery. The main outcome measure was 30-day postoperative mortality and morbidity with Clavien-Dindo classification ≥ 2. RESULTS Of the 204 patients included in this study, 155 had malignant disease, and 65 underwent emergent procedures. Overall average age was 84.3 ± 3.9 years (range 80-100). Overall surgical mortality and morbidity were 18.6% (n = 38) and 52.4% (n = 87), respectively. Expected mortality followed the order P-POSSUM<CR-POSSUM<CR-BHOM (p < 0.001), and expected morbidity followed the order POSSUM<CR-BHOM (p < 0.001) in all groups. All scores were higher in the emergent surgery group compared with elective surgery (p < 0.05). All scores had sensitivity below 60%. Physiology scores were higher among patients with surgical mortality (p < 0.05), with no differences in operative scores. CONCLUSIONS In our population, CR-POSSUM was the best predictor of surgical mortality. POSSUM and P-POSSUM underestimated surgical mortality and morbidity, and CR-BHOM overestimated surgical mortality, being however the best predictor of morbidity. Nevertheless, none of the scores showed sufficient discriminatory power to have clinical application value. Moreover, our results suggest that, in elderly patients, it is the patient's health status and not the type of surgery that is mainly responsible for the surgical outcome.
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Affiliation(s)
- António Gomes
- B Surgery Department, Hospital Prof. Doutor Fernando Fonseca, Estrada IC-19, 2720-276, Amadora, Portugal,
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Ming-Gao G, Jian-Zhong D, Yu W, You-Ben F, Xin-Yu H. Colorectal cancer treatment in octogenarians: elective or emergency surgery? World J Surg Oncol 2014; 12:386. [PMID: 25519055 PMCID: PMC4302045 DOI: 10.1186/1477-7819-12-386] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2014] [Accepted: 12/03/2014] [Indexed: 01/25/2023] Open
Abstract
Background The purpose of this research was to assess the characteristics of octogenarian patients with colorectal cancer and compare specific outcomes due to different types of surgical procedures used to treat the disease. Methods A total of 346 octogenarian patients undergoing surgery for colorectal cancer between April 2000 and April 2010 were retrospectively assessed according to elective (n = 261) or emergent (n = 85) admission group. The two groups were compared for clinical variables, surgical procedures, morbidity and mortality, ICU admission, length of hospital stay and overall survival. Results The two groups had similar comorbidities. The emergent group had a more advanced Dukes’ stage, higher American Society of Anesthesiologists grading, lower anastomosis rate (40.2 vs 80.1%), higher stoma rate (30.6 vs 9.6%), more complications (71.8 vs 43.3%), nine days longer length of hospital stay and higher (82.4% vs 36.4%) ICU admission rate. Overall mortality was 9.5%, with a higher mortality rate in the emergent group (30.6%) than the elective group (3.1%). Conclusions Octogenarians who undergo elective colorectal cancer surgery have better results than those requiring emergent surgery, but both are quite acceptable and we recommend surgical intervention should not be delayed.
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Affiliation(s)
- Guo Ming-Gao
- Department of Surgery, The Shanghai Sixth People's Hospital, Shanghai Jiaotong University, Yishan Road 600, 200233 Shanghai, China.
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What is the effect of advanced age and comorbidity on postoperative morbidity and mortality after musculoskeletal tumor surgery? Clin Orthop Relat Res 2014; 472:3971-8. [PMID: 25138472 PMCID: PMC4397778 DOI: 10.1007/s11999-014-3889-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Accepted: 08/07/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although the elderly population is increasing rapidly, little information is available regarding how the risk of postoperative mortality and morbidity increases when combined with age and comorbidity burden in patients undergoing musculoskeletal tumor surgery. QUESTIONS/PURPOSES We evaluated the effect of age and comorbidity burden on the (1) postoperative complication rate and (2) in-hospital mortality rate after musculoskeletal tumor surgery. METHODS We identified 5716 patients undergoing musculoskeletal tumor surgery during 2007 to 2012 using a Japanese national inpatient database. Logistic regression analyses were performed to examine the relationships of various factors with the rates of mortality and morbidity. RESULTS The postoperative complication rate (6.7%) was associated with male sex (p = 0.033), age 80 years or older (p = 0.001), tumor located in the lower extremity (p = 0.001) or trunk (p = 0.019), Charlson Comorbidity Index of 4 or greater (p < 0.001), blood transfusion (p < 0.001), and duration of anesthesia of 240 minutes or longer (p < 0.001). The in-hospital mortality (0.8%) was related to the Charlson Comorbidity Index of 4 or greater (p < 0.001), blood transfusion (p < 0.001), and high hospital volume (p = 0.016). The morbidity (21.6%; OR, 3.29; p < 0.001) and mortality (4.1%; OR, 5.95; p < 0.001) in patients 80 years or older with a Charlson Comorbidity Index of 4 or greater was increased three and six times, respectively, compared with patients 64 years or younger with no comorbidity. CONCLUSIONS We found that age and comorbidity burden together greatly increased the risk of morbidity and mortality. Our study showed quantitative evidence that will assist physicians in assessing perioperative risk accurately and provide a more informative explanation to elderly patients undergoing musculoskeletal tumor surgery. LEVEL OF EVIDENCE Level IV, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.
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Inflammatory markers as predictors of postoperative adverse outcome in octogenarian surgical patients: an observational prospective study. Cir Esp 2014; 93:166-73. [PMID: 25443149 DOI: 10.1016/j.ciresp.2014.08.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Revised: 08/08/2014] [Accepted: 08/25/2014] [Indexed: 11/20/2022]
Abstract
INTRODUCTION The value of inflammatory proteins, interleukin-6 and alpha-1-acid glycoprotein as prognostic factors in elderly people undergoing surgery has not been determined yet. OBJECTIVE To know whether preoperatively determined inflammatory markers may predict the postoperative outcome of elderly patients undergoing surgery. A scoring system for predicting postoperative morbidity was assessed. METHODS Hospital-based observational prospective study, with geriatric surgical patients. Preoperative determination of following data: age, gender, scheduled or urgent operation, comorbid diseases, malignancy, physical, mental and nutritional profile. Biochemical markers of inflammation, C Reactive Protein, interleukin-6, and alpha-1-acid glycoprotein were also studied. Preoperative data and postoperative complications were recorded. Binary logistic regression analysis was used to obtain a morbidity risk prediction model. RESULTS A total of 225 patients were included. Fifty-five patients (24.4%) had postoperative complications, with a mortality rate of 5.3%. Binary logistic regression analysis showed an independent relation between morbidity and the variables malignancy, alpha-1-acid glycoprotein and interleukin-6. The risk (R) of postoperative morbidity adjusted by age was calculated. The model showed a 22.2% sensitivity, 94.8% specificity, and a percentage of correct classification of 78.3%. The area under the ROC curve was 0.781 (95% CI: 0.703-0.858). CONCLUSIONS An age-adjusted equation for predicting 30-day morbidity that included malignancy, serum IL-6 and alpha 1-acid glycoprotein levels may be useful for risk assessment in octogenarian surgical patients.
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Marventano S, Grosso G, Mistretta A, Bogusz-Czerniewicz M, Ferranti R, Nolfo F, Giorgianni G, Rametta S, Drago F, Basile F, Biondi A. Evaluation of four comorbidity indices and Charlson comorbidity index adjustment for colorectal cancer patients. Int J Colorectal Dis 2014; 29:1159-69. [PMID: 25064390 DOI: 10.1007/s00384-014-1972-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/16/2014] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Cancer survival is related not only to primary malignancy but also to concomitant nonmalignant diseases. The aim of this study was to investigate the prognostic capacity of four comorbidity indices [the Charlson comorbidity index (CCI), the Elixhauser method, the National Institute on Aging (NIA) and National Cancer Institute (NCI) comorbidity index, and the Adult Comorbidity Evaluation-27 (ACE-27)] for both cancer-related and all-cause mortality among colorectal cancer patients. A modified version of the CCI adapted for colorectal cancer patients was also built. METHODS The study population comprised 468 cases of colorectal cancer diagnosed between 1 January 2000 and 31 December 2010 at a community hospital. Data were prospectively collected and abstracted from patients' clinical records. Kaplan-Meier method and multivariate logistic regression models were performed for survival and risk of death analysis. RESULTS Only moderate or severe renal disease [hazard ratio (HR) 2.71, 95% confidence interval (CI) 1.11-6.63] and AIDS (HR 3.27, 95% CI 1.23-8.68) were independently associated with cancer-specific mortality, with a population attributable risk of 5.18 and 4.36%, respectively. For each index, the highest comorbidity burden was significantly associated with poorer overall survival (NIA/NCI: HR 2.14, 95% CI 1.14-4.01; Elixhauser: HR 1.98, 95% CI 1.09-1.42; ACE-27: HR 1.78, 95% CI 1.07-1.23; CCI: HR 1.68, 95% CI 1.05-1.42) and cancer-specific survival. The modified version of the CCI resulted in a higher predictive power compared with other indices studied (cancer-specific mortality HR = 2.37, 95% CI 1.37-4.08). CONCLUSIONS The comorbidity assessment tools provided better prognostic prevision of prospective outcome of colorectal cancer patients than single comorbid conditions.
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Affiliation(s)
- Stefano Marventano
- Department "G. F. Ingrassia," Section of Hygiene and Public Health, University of Catania, Catania, Italy
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Dekker JWT, Gooiker GA, Bastiaannet E, van den Broek CBM, van der Geest LGM, van de Velde CJ, Tollenaar RAEM, Liefers GJ. Cause of death the first year after curative colorectal cancer surgery; a prolonged impact of the surgery in elderly colorectal cancer patients. Eur J Surg Oncol 2014; 40:1481-7. [PMID: 24985723 DOI: 10.1016/j.ejso.2014.05.010] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Revised: 04/06/2014] [Accepted: 05/13/2014] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The 1-year mortality after colorectal cancer surgery is high and explains age related differences in colorectal cancer survival. To gain better insight in its etiology, cause of death for these patients was studied. METHODS All 1924 patients who had a resection for stage I-III colorectal cancer from 2006 to 2008 in the Western region of the Netherlands were identified. Data were merged with cause of death data from the Central Bureau of Statistics Netherlands. To calculate excess mortality as compared to the general population, national data were used. RESULTS Overall 13.2% of patients died within the first postoperative year. One-year mortality increased with age. It was as high as 43% in elderly patients that underwent emergency surgery. In 75% of patients, death was attributed to the colorectal cancer. In 25% of all patients, registered deaths were attributed to postoperative complications. Elderly patients with comorbidity more frequently died due to complications (p < 0.01). Death of other causes was similar to background mortality according to age group. CONCLUSION In the presently studied cohort of patients that died within one year of surgery, cause of death was predominantly attributed to colorectal cancer. However, because it is not to be expected that in this cohort the number of deaths from recurrences is very high, the excess 1-year mortality indicates a prolonged impact of the surgery, especially in elderly patients. Therefore, in these patients we should focus on limiting the physiological impact of the surgery and be more involved in the post-hospital period.
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Affiliation(s)
- J W T Dekker
- Leiden University Medical Center, Department of Surgery, Leiden, The Netherlands; Reinier de Graaf Gasthuis, Department of Surgery, Delft, The Netherlands.
| | - G A Gooiker
- Leiden University Medical Center, Department of Surgery, Leiden, The Netherlands
| | - E Bastiaannet
- Leiden University Medical Center, Department of Surgery, Leiden, The Netherlands
| | - C B M van den Broek
- Leiden University Medical Center, Department of Surgery, Leiden, The Netherlands
| | - L G M van der Geest
- Comprehensive Cancer Centre the Netherlands (CCCNL), Utrecht, The Netherlands
| | - C J van de Velde
- Leiden University Medical Center, Department of Surgery, Leiden, The Netherlands
| | - R A E M Tollenaar
- Leiden University Medical Center, Department of Surgery, Leiden, The Netherlands
| | - G J Liefers
- Leiden University Medical Center, Department of Surgery, Leiden, The Netherlands
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Guo MG, Feng Y, Liu JZ, Zheng Q, Di JZ, Wang Y, Fan YB, Huang XY. Factors associated with mortality risk for malignant colonic obstruction in elderly patients. BMC Gastroenterol 2014; 14:76. [PMID: 24735084 PMCID: PMC3998070 DOI: 10.1186/1471-230x-14-76] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Accepted: 04/11/2014] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Acute colonic obstruction is the most common complication of colorectal cancer (CRC) in elderly patients. Medical treatment has been associated with higher perioperative morbidity and mortality rates. There is a need for identification of elderly CRC patients who will do poorly so that results can be improved. The purpose of this study is to assess the 30-day outcome of elderly patients undergoing malignant colonic obstruction procedures and identify the associated factors of mortality. METHODS A review of 233 elderly patients who received medical procedures for malignant colonic obstruction between April 2000 and April 2012 was conducted. Data regarding clinical variables, surgical procedures and outcomes, complications, and mortality were studied. Univariate and logistic regression analyses were performed on mortality risk factors. RESULTS Patients had a mean age of 78.2 years (range 70-95). A total of 126 (54.1%) patients were classified ASA III and above. Eighty (34.3%) patients had right-sided colonic obstruction. In the 153 (65.7%) patients with left-sided colonic obstruction, 40 patients received self-expandable metallic stent (SEMS) treatment and 193 patients received surgery. A total of 62.2% (n = 145) patients had post operation complications. The overall 30-day mortality was 24.5% (n = 57). ASA grading, peritonitis and Dukes staging were independent risk factors for mortality. CONCLUSIONS Medical procedures in elderly patients with malignant colonic obstruction are associated with significant complications and mortality. Identifying these high-risk patients and treating promptly may improve outcomes. SEMS treatment provides a useful alternative to surgical intervention.
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Affiliation(s)
- Ming-gao Guo
- Department of Surgery, Shanghai Jiaotong University Affiliated The Six People's Hospital, 200233 Shanghai, China.
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Huisman MG, van Leeuwen BL, Ugolini G, Montroni I, Spiliotis J, Stabilini C, de’Liguori Carino N, Farinella E, de Bock GH, Audisio RA. "Timed Up & Go": a screening tool for predicting 30-day morbidity in onco-geriatric surgical patients? A multicenter cohort study. PLoS One 2014; 9:e86863. [PMID: 24475186 PMCID: PMC3901725 DOI: 10.1371/journal.pone.0086863] [Citation(s) in RCA: 121] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 12/18/2013] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE To determine the predictive value of the "Timed Up & Go" (TUG), a validated assessment tool, on a prospective cohort study and to compare these findings to the ASA classification, an instrument commonly used for quantifying patients' physical status and anesthetic risk. BACKGROUND In the onco-geriatric surgical population it is important to identify patients at increased risk of adverse post-operative outcome to minimize the risk of over- and under-treatment and improve outcome in this population. METHODS 280 patients ≥70 years undergoing elective surgery for solid tumors were prospectively recruited. Primary endpoint was 30-day morbidity. Pre-operatively TUG was administered and ASA-classification was registered. Data were analyzed using multivariable logistic regression analyses to estimate odds ratios (OR) and 95% confidence intervals (95%-CI). Absolute risks and area under the receiver operating characteristic curves (AUC's) were calculated. RESULTS 180 (64.3%) patients (median age: 76) underwent major surgery. 55 (20.1%) patients experienced major complications. 50.0% of patients with high TUG and 25.6% of patients with ASA≥3 experienced major complications (absolute risks). TUG and ASA were independent predictors of the occurrence of major complications (TUG:OR 3.43; 95%-CI = 1.14-10.35. ASA1 vs. 2:OR 5.91; 95%-CI = 0.93-37.77. ASA1 vs. 3&4:OR 12.77; 95%-CI = 1.84-88.74). AUCTUG was 0.64 (95%-CI = 0.55-0.73, p = 0.001) and AUCASA was 0.59 (95%-CI = 0.51-0.67, p = 0.04). CONCLUSIONS Twice as many onco-geriatric patients at risk of post-operative complications, who might benefit from pre-operative interventions, are identified using TUG than when using ASA.
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Affiliation(s)
- Monique G. Huisman
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- * E-mail:
| | - Barbara L. van Leeuwen
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Isacco Montroni
- Department of Surgery, S. Orsola Malpighi Hospital, Bologna, Italy
| | - John Spiliotis
- Department of Surgery, Metaxa Cancer Hospital, Piraeus, Greece, and Regional University Hospital of Patras, Patras, Greece
| | - Cesare Stabilini
- Department of Surgery, San Martino University Hospital, Genua, Italy
| | | | - Eriberto Farinella
- Department of Surgery, S. Maria Hospital, Perugia, Italy, and Luton & Dunstable Hospital, Luton, United Kingdom
| | - Geertruida H. de Bock
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Riccardo A. Audisio
- Department of Surgery, University of Liverpool St. Helens Teaching Hospital, St. Helens, United Kingdom
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Identifying important predictors for anastomotic leak after colon and rectal resection: prospective study on 616 patients. Ann Surg 2013; 257:108-13. [PMID: 22968068 DOI: 10.1097/sla.0b013e318262a6cd] [Citation(s) in RCA: 213] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The purpose of this study was to identify patient, clinical, and surgical factors that may predispose patients to anastomotic leak (AL) after large bowel surgery. BACKGROUND Anastomotic leak is still one of the most devastating complications following colorectal surgery. Knowledge about factors predisposing patients to AL is vital to its early detection, decision making for surgical time, managing preoperative risk factors, and postoperative complications. METHODS This was a prospective observational, quality improvement study in a cohort of 616 patients undergoing colorectal resection in a single institution with the main outcome being AL within 30 days postoperatively. Some of the predictor variables were age, sex, Charlson Comorbidity Index (CCI), radiation and chemotherapy, immunomodulator medications, albumin, preoperative diagnoses, surgical procedure(s), surgical technique (laparoscopic vs open), anastomotic technique (staple vs handsewn), number of major arteries ligated at surgery, surgeon's experience, presence of infectious condition at surgery, intraoperative adverse events, and functional status using 36-Item Short Form General Health Survey. RESULTS Of the 616 patients, 53.4% were female. The median age of the patients was 63 years and the mean body mass index was 25.9 kg/m. Of them, 80.3% patients had laparoscopic surgery and 19.5% had open surgery. AL occurred in 5.7% (35) patients. In multivariate analysis, significant independent predictors for leak were anastomoses less than 10 cm from the anal verge, CCI of 3 or more, high inferior mesenteric artery ligation (above left colic artery), intraoperative complications, and being of the male sex. CONCLUSIONS Multiple risk factors exist that predispose patients to ALs. These risk factors should be considered before and during the surgical care of colorectal patients.
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Use of different comorbidity scores for risk-adjustment in the evaluation of quality of colorectal cancer surgery: Does it matter? Eur J Surg Oncol 2012; 38:1071-8. [DOI: 10.1016/j.ejso.2012.04.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Revised: 04/04/2012] [Accepted: 04/29/2012] [Indexed: 11/18/2022] Open
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Bamboat ZM, Kinnier C, Dursun A, Ferrone CR, Shellito PC, Berger DL, Bordeianou L. Short-term outcomes in obese patients after colectomy for adenocarcinoma at a bariatric center. J Gastrointest Surg 2012; 16:1923-8. [PMID: 22847573 DOI: 10.1007/s11605-012-1978-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Accepted: 07/17/2012] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Obesity (body mass index ≥30) is associated with worse outcomes after colon cancer surgery. Most research, however, has been performed outside bariatric centers of excellence. We sought to determine the relationship between obesity and outcomes after colon cancer resection when performed at a center with bariatric expertise. METHODS We performed a retrospective review of 245 consecutive patients undergoing elective colectomy for adenocarcinoma at a single institution from 2008 to 2009. Body mass index, major and minor postoperative complications, tumor characteristics, lymph node yield, type of resection, and operating times were determined. RESULTS Complication rates, operative times, and lymph node counts were all similar between the two weight groups. Obese patients had similar tumor characteristics at all stages when compared with nonobese patients. On multivariate analysis, obesity did not correlate with tumor size, tumor differentiation, or presence of lymphovascular or perineural invasion. CONCLUSION We conclude that obese patients undergoing colon cancer resection at a bariatric center of excellence have similar tumor characteristics and equivalent short-term outcomes as do nonobese patients.
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Affiliation(s)
- Zubin M Bamboat
- Massachusetts General Hospital, Division of Gastrointestinal Surgery, Colon and Rectal Surgery Program, Harvard Medical School, 15 Parkman Street, WAC 460, Boston, MA 02114, USA
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Herrera-Gómez A, Orozco C, Ruíz-Molina JM, Téllez-Palacios D, Ortega-Gutiérrez C, Namendys-Silva SA. [Colorectal surgery in patients over 65 years of age]. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2012; 77:119-24. [PMID: 22883155 DOI: 10.1016/j.rgmx.2012.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Accepted: 04/21/2012] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is a limited functional reserve in patients over 65 years of age which is conducive to more frequent postoperative complications. Disease extension at the time of diagnosis (clinical stage) and complete tumor resection are two independent risk factors that have a direct influence on survival. AIMS To describe the factors that influence morbidity and mortality in patients over 65 years of age after colorectal surgery. MATERIAL AND METHODS A retrospective, observational, descriptive study was carried out within the time frame of January 2004 and December 2009 on 105 colon cancer patients after colorectal surgery. They were divided into two groups, one under 65 years of age and the other over 65 years of age, in order to compare preoperative comorbidity, as well as morbidity and mortality 30 days after surgery. RESULTS Of the 105 patient total (53,3%), 56 were ≤ 65 years of age. There were complications in 42,8% of the patients, and those of early and less severe presentation were the most frequent; late complications were more frequent in patients ≤ 65 vs > 65 years of age (16,0% vs 10,2%). Overweight (BMI > 25 kg/m(2)) was observed in 35,0% of the study population. Patients > 65 years of age had fewer comorbidities. The most common causes of reintervention were anastomosis dehiscence and postoperative hemorrhage. Mortality in the group was 6,6% and sepsis was the most frequent cause of death. CONCLUSIONS Colorectal surgery in patients over 65 years of age has an acceptable complication frequency and a low mortality rate. Our results suggest that patients older than 65 years of age be treated with the same prospects for cure as younger patients.
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Affiliation(s)
- A Herrera-Gómez
- Subdirección de Cirugía, Instituto Nacional de Cancerología, México DF, México. herrera
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Tan KK, Koh FHX, Tan YY, Liu JZ, Sim R. Long-term outcome following surgery for colorectal cancers in octogenarians: a single institution's experience of 204 patients. J Gastrointest Surg 2012; 16:1029-36. [PMID: 22258874 DOI: 10.1007/s11605-011-1818-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2011] [Accepted: 12/28/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND The incidence of colorectal cancer in elderly patients is likely to increase with an aging population. The aims of this study are to review our experience in the surgical management of octogenarians with colorectal cancers and to identify factors that influence the short-term and long-term outcomes. METHODS A retrospective review of all octogenarians who underwent surgery for colorectal cancer from December 2002 to October 2008 was performed. RESULTS We identified 204 patients with a median age of 84 years (range, 80-97 years). The majority of patients had an American Society of Anesthesiologists score ≥3 (n = 142, 69.6%) and a Charlson Comorbidity Index of ≤3 (n = 128, 62.7%). Emergency surgery was performed in 83 (40.7%) patients. Left-sided malignancy was seen in 138 patients (67.6%). Most of the patients had either stage II (n = 75, 36.8%) or III (n = 69, 33.8%) diseases. The 30-day mortality rate was 16.2% (n = 33). After multivariate analysis, the independent variables predicting worse perioperative complications and death were age >85 years old, emergency surgery, and Charlson Comorbidity Index >3. The median follow-up for the 171 remaining patients was 27 months (range, 2-92 months). The 30-day readmission rate was 2.9% (n = 5). Thirty-one (21.2%) of 146 patients who survived curative surgery developed recurrent disease. Seventy (34.3%) patients died from various etiologies after their first 30 days postoperatively (60% cancer-specific with median survival of 15 months and 40% noncancer-related with median survival of 14 months). Overall and disease-free survivals were adversely affected in patients with advanced malignancy and in those with severe perioperative complications. CONCLUSIONS Surgery for octogenarians with colorectal cancers is associated with significant morbidity and mortality rates which are associated with advanced age, emergency surgery, and Charlson Comorbidity Index >3. Long-term survival is dependent on the stage of the malignancy and the presence of severe perioperative complications.
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Affiliation(s)
- Ker-Kan Tan
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
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Assessment for frailty is useful for predicting morbidity in elderly patients undergoing colorectal cancer resection whose comorbidities are already optimized. Am J Surg 2011; 204:139-43. [PMID: 22178483 DOI: 10.1016/j.amjsurg.2011.08.012] [Citation(s) in RCA: 163] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2011] [Revised: 07/10/2011] [Accepted: 08/04/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND The clinical syndrome of frailty identified through the assessment of weight loss, gait speed, grip strength, physical activity, and physical exhaustion has been used to identify patients with reduced reserves. We hypothesized that frailty is useful in predicting adverse outcomes in optimized elective elderly colorectal surgery patients. METHODS A prospective study was conducted at 2 centers (Singapore and Japan). All patients over 75 years of age undergoing colorectal resection were assessed for the presence of the syndrome of frailty. All these patients had already had their comorbidities optimized for surgery. The outcome measure was postoperative major complications (defined as Clavien-Dindo type II and above complications). RESULTS Eighty-three patients were studied from February 2008 to April 2010. The mean age was 81.5 years (range 75-93 years). The mean comorbidity index was 3.37 (range 0-11). Twenty-six (31.3%) patients were an American Society of Anesthesiologists (ASA) score of 3 and above. Chi-square analysis revealed that the odds ratio of postoperative major complications was 4.083 (95% confidence interval, 1.433-11.638) when the patient satisfied the criteria for frailty. Albumin <35, ASA >3, comorbidity index >5, and Physiologic and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) scores were not predictive of postoperative major complications. CONCLUSIONS Preliminary findings show that frailty is a potent adjunctive tool of predicting postoperative morbidity. Frailty can be used to identify elderly patients needing further optimization before major surgery.
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Khan MR, Bari H, Zafar SN, Raza SA. Impact of age on outcome after colorectal cancer surgery in the elderly - a developing country perspective. BMC Surg 2011; 11:17. [PMID: 21849062 PMCID: PMC3175436 DOI: 10.1186/1471-2482-11-17] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Accepted: 08/17/2011] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Colorectal cancer (CRC) is a major source of morbidity and mortality in the elderly population and surgery is often the only definitive management option. The suitability of surgical candidates based on age alone has traditionally been a source of controversy. Surgical resection may be considered detrimental in the elderly solely on the basis of advanced age. Based on recent evidence suggesting that age alone is not a predictor of outcomes, Western societies are increasingly performing definitive procedures on the elderly. Such evidence is not available from our region. We aimed to determine whether age has an independent effect on complications after surgery for colorectal cancer in our population. METHODS A retrospective review of all patients who underwent surgery for pathologically confirmed colorectal cancer at Aga Khan University Hospital, Karachi between January 1999 and December 2008 was conducted. Using a cut-off of 70 years, patients were divided into two groups. Patient demographics, tumor characteristics and postoperative complications and 30-day mortality were compared. Multivariate logistic regression analysis was performed with clinically relevant variables to determine whether age had an independent and significant association with the outcome. RESULTS A total of 271 files were reviewed, of which 56 belonged to elderly patients (≥ 70 years). The gender ratio was equal in both groups. Elderly patients had a significantly higher comorbidity status, Charlson score and American society of anesthesiologists (ASA) class (all p < 0.001). Upon multivariate analysis, factors associated with more complications were ASA status (95% CI = 1.30-6.25), preoperative perforation (95% CI = 1.94-48.0) and rectal tumors (95% CI = 1.21-5.34). Old age was significantly associated with systemic complications upon univariate analysis (p = 0.05), however, this association vanished upon multivariate analysis (p = 0.36). CONCLUSION Older patients have more co-morbid conditions and higher ASA scores, but increasing age itself is not independently associated with complications after surgery for CRC. Therefore patient selection should focus on the clinical status and ASA class of the patient rather than age.
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Affiliation(s)
- Muhammad Rizwan Khan
- Department of Surgery, Aga Khan University & Hospital, Stadium Road, Karachi - 74800, Pakistan.
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Outcomes of damage control laparotomy with open abdomen management in the octogenarian population. ACTA ACUST UNITED AC 2011; 70:616-21. [PMID: 21610351 DOI: 10.1097/ta.0b013e31820d19ed] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Controversy surrounds the role of abbreviated laparotomy and open abdomen (OA) in the octogenarian population in the acute care surgery model based on concern that the initial insult, combined with its sequelae, is beyond the physiologic reserve of these patients. As the population ages further, this dilemma will arise more frequently, requiring the analysis of futility or utility of OA in this demographic. METHODS The institutional review board approval was obtained to analyze retrospectively patients aged 80 years or older with OA from 1997 to 2009. Univariate, multivariate, and Kaplan-Meier analyses were used to evaluate the effects that demographics, comorbidities, and clinical factors had on in-hospital mortality and overall survival. RESULTS Sixty-seven patients (32 men and 35 women) were identified. Acute general surgery (including vascular procedures) was the most common indication for laparotomy (94%) with trauma a distant second (6%). Early definitive closure was obtained in 52% of patients with a 34% planned ventral hernia rate. Overall complication rate was 62% and overall in-hospital mortality was 37%. Multivariate analysis revealed congestive heart failure (odds ratio, 11.4; 95% confidence interval, 1.01-128.03) and acute renal failure (odds ratio, 11.8; 95% confidence interval, 2.00-69.12) correlated with in-hospital mortality. Of those surviving to hospital dismissal, 2-year survival was 66% with a 17-month median follow-up (range, 1-125 months). CONCLUSION There is utility in octogenarians undergoing aggressive surgical management that requires OA. These patients have high mortality rates, but long-term survival can be better than their peers with other chronic diseases if they survive the surgical insult. Patient selection should be based on preexisting comorbidities such as congestive heart failure and the development of acute renal failure. Despite the adequate long-term survival, most patients will leave the hospital with a hernia.
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A Collaborative Transdisciplinary “Geriatric Surgery Service” Ensures Consistent Successful Outcomes in Elderly Colorectal Surgery Patients. World J Surg 2011; 35:1608-14. [DOI: 10.1007/s00268-011-1112-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Predictive value of POSSUM and ACPGBI scoring in mortality and morbidity of colorectal resection: a case-control study. J Gastrointest Surg 2011; 15:294-303. [PMID: 20936370 PMCID: PMC3035786 DOI: 10.1007/s11605-010-1354-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2010] [Accepted: 09/17/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Preoperative risk prediction to assess mortality and morbidity may be helpful to surgical decision making. The aim of this study was to compare mortality and morbidity of colorectal resections performed in a tertiary referral center with mortality and morbidity as predicted with physiological and operative score for enumeration of mortality and morbidity (POSSUM), Portsmouth POSSUM (P-POSSUM), and colorectal POSSUM (CR-POSSUM). The second aim of this study was to analyze the accuracy of different POSSUM scores in surgery performed for malignancy, inflammatory bowel diseases, and diverticulitis. POSSUM scoring was also evaluated in colorectal resection in acute vs. elective setting. In procedures performed for malignancy, the Association of Coloproctology of Great Britain and Ireland (ACPGBI) score was assessed in the same way for comparison. METHODS POSSUM, P-POSSUM, and CR-POSSUM predictor equations for mortality were applied in a retrospective case-control study to 734 patients who had undergone colorectal resection. The total group was assessed first. Second, the predictive value of outcome after surgery was assessed for malignancy (n = 386), inflammatory bowel diseases (n = 113), diverticulitis (n = 91), and other indications, e.g., trauma, endometriosis, volvulus, or ischemia (n = 144). Third, all subgroups were assessed in relation to the setting in which surgery was performed: acute or elective. In patients with malignancy, the ACPGBI score was calculated as well. In all groups, receiver operating characteristic (ROC) curves were constructed. RESULTS POSSUM, P-POSSUM, and CR-POSSUM have a significant predictive value for outcome after colorectal surgery. Within the total population as well as in all four subgroups, there is no difference in the area under the curve between the POSSUM, P-POSSUM, and CR-POSSUM scores. In the subgroup analysis, smallest areas under the ROC curve are seen in operations performed for malignancy, which is significantly worse than for diverticulitis and in operations performed for other indications. For elective procedures, P-POSSUM and CR-POSSUM predict outcome significantly worse in patients operated for carcinoma than in patients with diverticulitis. In acute surgical interventions, CR-POSSUM predicts mortality better in diverticulitis than in patients operated for other indications. The ACPGBI score has a larger area under the curve than any of the POSSUM scores. Morbidity as predicted by POSSUM is most accurate in procedures for diverticulitis and worst when the indication is malignancy. CONCLUSION The POSSUM scores predict outcome significantly better than can be expected by chance alone. Regarding the indication for surgery, each POSSUM score predicts outcome in patients operated for diverticulitis or other indications more accurately than for malignancy. The ACPGBI score is found to be superior to the various POSSUM scores in patients who have (elective) resection of colorectal malignancy.
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Tan KY, Konishi F, Tan L, Chin WK, Ong HY, Tan P. Optimizing the management of elderly colorectal surgery patients. Surg Today 2010; 40:999-1010. [PMID: 21046496 DOI: 10.1007/s00595-010-4354-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Accepted: 04/28/2010] [Indexed: 12/20/2022]
Abstract
With the ever increasing number of geriatric surgical patients, there is a need to develop efficient processes that address all of the potential issues faced by patients during the perioperative period. This article explores the physiological changes in elderly surgical patients and the outcomes achieved after major abdominal surgery. Perioperative management strategies for elderly surgical patients in line with the practices of the Geriatric Surgical Team of Alexandra Health, Singapore, are also presented. A coordinated transdisciplinary approach best tackles the complexities encountered in these patients.
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Affiliation(s)
- Kok-Yang Tan
- Geriatric Surgery Service, Alexandra Health, Khoo Teck Puat Hospital, 90 Yishun Central, 768828, Singapore, Singapore
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Which elements of a comprehensive geriatric assessment (CGA) predict post-operative complications and early mortality after colorectal cancer surgery? J Geriatr Oncol 2010. [DOI: 10.1016/j.jgo.2010.06.001] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Richards CH, Leitch FE, Horgan PG, McMillan DC. A systematic review of POSSUM and its related models as predictors of post-operative mortality and morbidity in patients undergoing surgery for colorectal cancer. J Gastrointest Surg 2010; 14:1511-20. [PMID: 20824372 DOI: 10.1007/s11605-010-1333-5] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Accepted: 08/12/2010] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) model and its Portsmouth (P-POSSUM) and colorectal (CR-POSSUM) modifications are used extensively to predict and audit post-operative mortality and morbidity. This aim of this systematic review was to assess the predictive value of the POSSUM models in colorectal cancer surgery. METHODS Major electronic databases, including Medline, Embase, Cochrane Library and Pubmed were searched for original studies published between 1991 and 2010. Two independent reviewers assessed each study against inclusion and exclusion criteria. All data was specific to colorectal cancer surgery. Predictive value was assessed by calculating observed to expected (O/E) ratios. RESULTS Nineteen studies were included in final review. The mortality analysis included ten studies (4,799 patients) on POSSUM, 17 studies (6,576 patients) on P-POSSUM and 14 studies (5,230 patients) on CR-POSSUM. Weighted O/E ratios for mortality were 0.31 (CI 0.31-0.32) for POSSUM, 0.90 (CI 0.88-0.92) for P-POSSUM and 0.64 (CI 0.63-0.65) for CR-POSSUM. The morbidity analysis included four studies (768 patients) on POSSUM with a weighted O/E ratio of 0.96 (CI 0.94-0.98). CONCLUSIONS P-POSSUM was the most accurate model for predicting post-operative mortality after colorectal cancer surgery. The original POSSUM model was accurate in predicting post-operative complications.
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Affiliation(s)
- Colin Hewitt Richards
- University Department of Surgery, Faculty of Medicine-University of Glasgow, Royal Infirmary, Glasgow G4 0SF, UK.
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Tan KY, Konishi F, Kawamura YJ, Maeda T, Sasaki J, Tsujinaka S, Horie H. Laparoscopic colorectal surgery in elderly patients: a case-control study of 15 years of experience. Am J Surg 2010; 201:531-6. [PMID: 20605135 DOI: 10.1016/j.amjsurg.2010.01.024] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2009] [Revised: 08/09/2009] [Accepted: 01/05/2010] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The aim of this study was to review the impact of age (≥75 years) on the short-term outcomes of laparoscopic colorectal surgery. METHODS Three hundred seventy-nine patients under 70 years of age and 91 patients 75 years and older were analyzed. Quantification of comorbidities was performed using the Charlson Weighted Comorbidity Index. Outcome measures were postoperative complications and 30-day mortality. RESULTS There was no difference in the occurrence of postoperative complications between the younger and older patients. Bivariate analysis revealed that patient age was not a risk factor of major complications (odds ratio = 1.2; 95% confidence interval, .6-2.3). Although bivariate analysis revealed that older age had a statistically significant odds ratio for 30-day mortality (odds ratio = 12.8; 95% confidence interval, 1.3-125.4), multivariate analysis revealed that it was a weighted comorbidity index score of 5 or more (P = .02) and long operative time (P = .01) that were independent predictors of 30-day mortality and not age per se. CONCLUSIONS Age is not an independent predictor of morbidity and mortality in laparoscopic colorectal cancer surgery.
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Affiliation(s)
- Kok-Yang Tan
- Department of Surgery, Saitama Medical Centre, Jichi Medical School, Omiyaku, Saitamashi, Japan
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Comprehensive geriatric assessment can predict complications in elderly patients after elective surgery for colorectal cancer: a prospective observational cohort study. Crit Rev Oncol Hematol 2009; 76:208-17. [PMID: 20005123 DOI: 10.1016/j.critrevonc.2009.11.002] [Citation(s) in RCA: 297] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2009] [Revised: 11/04/2009] [Accepted: 11/11/2009] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To examine the association between the outcomes of a pre-operative comprehensive geriatric assessment (CGA) and the risk of severe post-operative complications in elderly patients electively operated for colorectal cancer. METHODS One hundred seventy-eight consecutive patients ≥ 70 years electively operated for all stages of colorectal cancer were prospectively examined. A pre-operative CGA was performed, and patients were categorized as fit, intermediate, or frail. The main outcome measure was severe complications within 30 days of surgery. RESULTS Twenty-one patients (12%) were categorized as fit, 81 (46%) as intermediate, and 76 (43%) as frail. Eighty-three patients experienced severe complications, including three deaths; 7/21 (33%) of fit patients, 29/81 (36%) of intermediate patients and 47/76 (62%) of frail patients (p=0.002). Increasing age and ASA classification were not associated with complications in this series. CONCLUSION CGA can identify frail patients who have a significantly increased risk of severe complications after elective surgery for colorectal cancer.
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