Validation of risk assessment scoring systems for an audit of elective surgery for gastrointestinal cancer in elderly patients: an audit

Effect of Heptaflourane Inhalation and Anesthesia Induction on Hemodynamics of Elderly Patients Undergoing Elective Gastrointestinal Tumor Surgery

Gastrointestinal stromal tumors (GISTs) are rare malignancies that begin in specific cells in the GI tract’s (also known as the digestive tract’s) wall. The microenvironment of gastrointestinal cancers has gotten a lot of interest in the last decade. There are various obstacles connected with providing care to individuals with gastrointestinal cancers, especially the elderly. The physiological reserves of elderly individuals are generally depleted, and comorbidities might limit treatment options and increase problems. Surgeons and anesthesiologists must be aware of the measures that must be used while dealing with this fragile population. Anesthesia is a term that refers to the use of drugs to alleviate pain during the surgery and other treatments. Anesthesia is crucial to a patient’s successful treatment and recovery. To induce and maintain general anesthesia in the operating room, inhalation anesthetics (isoflurane, halothane, nitrous oxide, sevoflurane, and desflurane, the most commonly used agents in practice today) are utilized. Inhalation anesthetics are drugs used to give general anesthesia for surgery in the operating room. Anesthetics have the potential to cause substantial cardiac depression as well as hemodynamic instability. In this study, we propose the SBWOA (spark bumper whale optimization algorithm), which is used to assess the patient’s risk before surgery. The entire experiment was run through Matlab simulations.

Sarcopenia estimation using psoas major enhances P-POSSUM mortality prediction in older patients undergoing emergency laparotomy: cross-sectional study

INTRODUCTION

Emergency laparotomy is a considerable component of a colorectal surgeon's workload and conveys substantial morbidity and mortality, particularly in older patients. Frailty is associated with poorer surgical outcomes. Frailty and sarcopenia assessment using Computed Tomography (CT) calculation of psoas major area predicts outcomes in elective and emergency surgery. Current risk predictors do not incorporate frailty metrics. We investigated whether sarcopenia measurement enhanced mortality prediction in over-65 s who underwent emergency laparotomy and emergency colorectal resection.

METHODS

An analysis of data collected prospectively during the National Emergency Laparotomy Audit (NELA) was conducted. Psoas major (PM) cross-sectional area was measured at the L3 level and a ratio of PM to L3 vertebral body area (PML3) was calculated. Outcome measures included inpatient, 30-day and 90-day mortality. Statistical analysis was conducted using Mann-Whitney, Chi-squared and receiver operating characteristics (ROC). Logistic regression was conducted using P-POSSUM variables with and without the addition of PML3.

RESULTS

Nine-hundred and forty-four over-65 s underwent emergency laparotomy from three United Kingdom hospitals were included. Median age was 76 years (IQR 70-82 years). Inpatient mortality was 21.9%, 30-day mortality was 16.3% and 90-day mortality was 20.7%. PML3 less than 0.39 for males and 0.31 for females indicated significantly worse outcomes (inpatient mortality 68% vs 5.6%, 30-day mortality 50.6% vs 4.0%,90-day mortality 64% vs 5.2%, p < 0.0001). PML3 was independently associated with mortality in multivariate analysis (p < 0.0001). Addition of PML3 to P-POSSUM variables improved area under the curve (AUC) on ROC analysis for inpatient mortality (P-POSSUM:0.78 vs P-POSSUM + PML3:0.917), 30-day mortality(P-POSSUM:0.802 vs P-POSSUM + PML3: 0.91) and 90-day mortality (P-POSSUM:0.79 vs P-POSSUM + PML3: 0.91).

CONCLUSION

PML3 is an accurate predictor of mortality in over-65 s undergoing emergency laparotomy. Addition of PML3 to POSSUM appears to improve mortality risk prediction.

Post-operative outcomes and predictors of mortality after colorectal cancer surgery in the very elderly patients

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.

Predicting and Preventing Postoperative Outcomes

Complications after colorectal surgery are common. Given the frequency of postoperative complications and their implications on quality of life, it is important to know how to predict and prevent the complications that we encounter. This article aims to provide ways to predict and prevent postoperative complications in colorectal surgery. Here, we review the predictive models, American College of Surgeons National Surgery Quality Improvement Program risk calculator and Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity on their practicality and usefulness. Additionally, this review summarizes nonmodifiable and modifiable risk factors in colorectal surgery, which are important for surgeons to understand to minimize and attempt to avoid postoperative complications as well as providing ways to optimize patients preoperatively. Thus, this review will provide information to surgeons to predict and prevent postoperative complications, how to optimize patients preoperatively and ultimately to help reduce their occurrence.

Outcomes of surgery in patients aged ≥90 years in the general surgical setting

Introduction An increasing proportion of the population is living into their nineties and beyond. These high risk patients are now presenting more frequently to both elective and emergency surgical services. There is limited research looking at outcomes of general surgical procedures in nonagenarians and centenarians to guide surgeons assessing these cases. Methods A retrospective analysis was conducted of all patients aged ≥90 years undergoing elective and emergency general surgical procedures at a tertiary care facility between 2009 and 2015. Vascular, breast and endocrine procedures were excluded. Patient demographics and characteristics were collated. Primary outcomes were 30-day and 90-day mortality rates. The impact of ASA (American Society of Anesthesiologists) grade, operation severity and emergency presentation was assessed using multivariate analysis. Results Overall, 161 patients (58 elective, 103 emergency) were identified for inclusion in the study. The mean patient age was 92.8 years (range: 90-106 years). The 90-day mortality rates were 5.2% and 19.4% for elective and emergency procedures respectively (p=0.013). The median survival was 29 and 19 months respectively (p=0.001). Emergency and major gastrointestinal operations were associated with a significant increase in mortality. Patients undergoing emergency major colonic or upper gastrointestinal surgery had a 90-day mortality rate of 53.8%. Conclusions The risk for patients aged over 90 years having an elective procedure differs significantly in the short term from those having emergency surgery. In selected cases, elective surgery carries an acceptable mortality risk. Emergency surgery is associated with a significantly increased risk of death, particularly after major gastrointestinal resections.

[The POSSUM: a good scoring system for predicting mortality in elderly patients undergoing emergency surgery?]

Introduction

Le POSSUM (Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity) est un score prédictif de mortalité qui est largement utilisé en chirurgie aortique élective et abdominale. Le but de notre étude est une validation du POSSUM chez le sujet âgé (>70 ans) opéré pour une urgence digestive. Nous nous proposons d'étudier les meilleurs seuils du POSSUM, composé d'un score physiologique et d'un score opératoire, pour prédire la mortalité dans cette population.

Méthodes

Il s'agit d'une étude rétrospective analytique de type cas témoin à partir d'une série de 291 patients d'âge ≥ 70 ans opérés pour une urgence digestive. Ces patients étaient répartis en deux groupes comportant 50 patients chacun. Le groupe "DC": patients décédés en post opératoire immédiat et le Groupe témoin "SURV" choisis par tirage au sort. Nous avons analysé la fiabilité du POSSUM pour prédire la mortalité et la morbidité. Par la suite, nous avons établi des courbes de ROC pour définir les seuils qui donnent le meilleur couple sensibilité/spécificité.

Résultats

Le score physiologique, le score opératoire et les taux de morbidité et mortalité prédits par POSSUM et la mortalité prédit par P-POSSUM représentaient des facteurs prédictifs de mortalité (P <0,0001). Les valeurs seuils du score physiologique et du score opératoire qui donnent le meilleur couple sensibilité/spécificité, étaient respectivement de 23 et 15.

Conclusion

Prédire la mortalité permet de cibler la prise en charge et d'informer le patient et sa famille des risques encourus.

Implications for determining the optimal treatment for locally advanced rectal cancer in elderly patients aged 75 years and older

Patients were excluded if they were older than 75 years of age in most clinical trials. Thus, the optimal treatment strategies in elderly patients with locally advanced rectal cancer (LARC) are still controversial. We designed our study to specifically evaluate the cancer specific survival of four subgroups of patients according to four different treatment modalities: surgery only, radiation (RT) only, neoadjuvant RT and adjuvant RT by analyzing the Surveillance, Epidemiology, and End Results (SEER)-registered database. The results showed that the 5-year cancer specific survival (CSS) was 52.1% in surgery only, 27.7% in RT only, 70.4% in neoadjuvant RT and 60.4% in adjuvant RT, which had significant difference in univariate log-rank test (P < 0.001) and multivariate Cox regression (P < 0.001). Thus, the neoadjuvant RT and surgery may be the optimal treatment pattern in elderly patients, especially for patients who are medically fit for the operation.

Skilled nursing facility placement in hospitalized elderly patients with colon cancer

BACKGROUND

The current study sought to determine predictive risk factors and inpatient resource utilization associated with discharge to skilled nursing facility (SNF) in hospitalized elderly patients with colon cancer.

MATERIALS AND METHODS

Inpatient data from U.S. community hospital discharges from 2003 to 2011 was analyzed in a retrospective cohort study using the Healthcare Cost and Utilization Project, National Inpatient Sample (HCUP-NIS). Subjects included hospitalized postoperative colon cancer patients over age of 65 (N = 98,797).

RESULTS

The proportion of elderly colon cancer patients discharged to a SNF increased by 16.67% from 2003 to 2011 (18-21%). Elderly patients discharged to a SNF had increased hospitalization costs (+$10,293.70, p < 0.01) compared to elderly colon cancer patients discharged home. Hospitalization predictive risk factors associated with SNF placement include age above 75 (OR, 4.07; 95% CI, 3.90, 4.25; p < 0.01), paralysis (OR, 3.60; 95% CI, 3.06-4.23; p < 0.01), length of stay (LOS) 10 days or more (OR, 3.00; 95% CI, 2.88-3.13; p < 0.01), psychoses (OR, 2.91; 95% CI, 2.56-3.32; p < 0.01), and neurological disorders (OR, 2.34; 95% CI, 2.17-2.52; p < 0.01).

CONCLUSIONS

Despite increased costs and worse clinical outcomes associated with SNF placement, over 40% increase of hospital discharge to SNF should be anticipated from this population over the next 20 years. Neurologic and psychiatric comorbidities have significantly negative clinical impacts and increase the likelihood of colon cancer patients' discharge to a SNF.

Predictors of postoperative complications in elderly and oldest old patients with gastric cancer

BACKGROUND

The incidence of gastric cancer has been increasing among elderly persons in Japan. This study aimed to clarify risk factors for postoperative complications in oldest old patients with gastric cancer.

METHODS

One-hundred ninety patients more than 75 years old with gastric cancer underwent gastrectomy between 2000 and 2011. Patients were classified into two groups: group A included 29 patients who were 85 years or older (oldest old patients), and group B included 161 patients who were 75-84 years of age. Perioperative parameters associated with complications were compared in each group.

RESULTS

The preoperative estimated glomerular filtration rate was significantly lower in group A (p = 0.03). The two groups significantly differed in performance status (p = 0.018). Patients in group A received a lesser extent of lymph node dissection and had fewer lymph nodes excised. As a result, the duration of the operation was significantly shorter in group A. There were no significant differences in the frequency or grade of total complications or mortality between the two groups. Operative hemorrhage (>300 ml) and Hiroshima POSSUM (predicted morbidity risk >40) were risk factors in both groups A and B; the risk factors of preoperative serum albumin level and prognostic nutritional index (PNI) were specific to group A.

CONCLUSIONS

Adjustments to the extent of surgery among oldest old patients most likely reduces the incidence of postoperative complications in this group. Preoperative serum albumin level and PNI are significant predictors of postoperative complications in oldest old patients with gastric cancer.

Colorectal surgical mortality and morbidity in elderly patients: comparison of POSSUM, P-POSSUM, CR-POSSUM, and CR-BHOM

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.

Predicting postoperative mortality after colorectal surgery: a novel clinical model

AIM

The aim of this study was to develop and externally validate a clinically, practical and discriminative prediction model designed to estimate in-hospital mortality of patients undergoing colorectal surgery.

METHOD

All consecutive patients who underwent elective or emergency colorectal surgery from 1990 to 2005, at the Zaandam Medical Centre, The Netherlands, were included in this study. Multivariate logistic regression analysis was performed to estimate odds ratios (ORs) and 95% confidence intervals (CIs) linking the explanatory variables to the outcome variable in-hospital mortality, and a simplified Identification of Risk in Colorectal Surgery (IRCS) score was constructed. The model was validated in a population of patients who underwent colorectal surgery from 2005 to 2011 in Barcelona, Spain. Predictive performance was estimated by calculating the area under the receiver operating characteristic curve.

RESULTS

The strongest predictors of in-hospital mortality were emergency surgery (OR = 6.7, 95% CI 4.7-9.5), tumour stage (OR = 3.2, 95% CI 2.8-4.6), age (OR = 13.1, 95% CI 6.6-26.0), pulmonary failure (OR = 4.9, 95% CI 3.3-7.1) and cardiac failure (OR = 3.7, 95% CI 2.6-5.3). These parameters were included in the prediction model and simplified scoring system. The IRCS model predicted in-hospital mortality and demonstrated a predictive performance of 0.83 (95% CI 0.79-0.87) in the validation population. In this population the predictive performance of the CR-POSSUM score was 0.76 (95% CI 0.71-0.81).

CONCLUSIONS

The results of this study have shown that the IRCS score is a good predictor of in-hospital mortality after colorectal surgery despite the relatively low number of model parameters.

Predicting postoperative morbidity following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CS+HIPEC) with preoperative FACT-C (Functional Assessment of Cancer Therapy) and patient-rated performance status

BACKGROUND

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CS+HIPEC) is associated with significant perioperative morbidity. One goal of our ongoing patient-reported health-related quality of life (HRQoL) program is to describe the prognostic value of HRQoL measures for predicting postoperative morbidity and mortality following CS+HIPEC.

METHODS

A retrospective analysis of a prospectively collected clinical database for all patients treated for peritoneal carcinomatosis and who participated in our patient-reported HRQoL program from 2001 to 2011 was done. Patients completed the Functional Assessment of Cancer Therapy questionnaire plus the colon symptom subscale, in addition to the Eastern Cooperative Oncology Group (ECOG) performance status rating prior to CS+HIPEC. The trial outcome index (TOI), a specific measure of function, symptoms, and physical well being of the patient, was analyzed. The TOI is a combination of the physical and functional well being subscales + the colon-specific subscale of the FACT-C.

RESULTS

Of 855 patients, 387 (45.2 %) participated in the HRQoL trials. Mean age was 53.3 years, and 213 (55 %) were female versus 174 (45 %) males. There were 240 patients (62 %) who had a complication versus 147 (38 %) who had no complication. A 30-day mortality rate of 7.7 % (30) was documented. Patients who suffered a 30-day postoperative mortality demonstrated a lower mean preoperative score in the FACT-C TOI 52.7 versus 61.7; P < 0.001. Independent predictors of 30-day mortality on multivariate analysis included TOI (0.05), age (0.001), and smoking (0.001). Patients with a higher TOI score were less likely to suffer a mortality (95 % CI 0.9-1.0, P = 0.05). Patients with a higher emotional well being (EWB) score were less likely to suffer a complication 0.9 (95 % CI 0.87-1.0, P = 0.04). Other independent predictors of postoperative morbidity included diabetic status (P = 0.05), ECOG performance status (0.001), and gender (0.02).

CONCLUSIONS

Preoperative HRQoL, as measured by FACT-C and ECOG performance status and added to traditional factors, helps predict postoperative morbidity and mortality following CS+HIPEC.

Preoperative frailty and quality of life as predictors of postoperative complications

BACKGROUND

Prediction of postoperative complications has been based on assessing comorbidities. However, the evaluation of these comorbidities has not consistently identified those at higher risk of complications, primarily due to the inability to assess how these comorbidities affect functional status. We hypothesized that preoperative functional measures of patients' health status can predict postoperative complications.

METHODS

A sample of patients undergoing general surgical operations were reviewed for age, gender, diagnosis (for severity), operations (for complexity), number of comorbidities, preoperative frailty (as determined by the Canadian Study of Health and Ageing Frailty Index), preoperative quality of life (as determined by the SF-36), occurrence of postoperative complications, number of postoperative complications, and severity of complications. Data were analyzed by linear and multiple logistic regression analyses, and the Mann-Whitney U test.

RESULTS

Two hundred and twenty-six patients were evaluated, average age 61 ± 13 years, 47% male patients. Frailty Index (FI) correlated with number of comorbidities (r = 0.61, P < 0.001), and all of the domains of the SF-36. Patients who had postoperative complications had higher median preoperative FI than those would did not [0.075 (IQR 0.046-0.118) vs. 0.059 (IQR 0.045-0.089), P = 0.007]. Multiple logistic regression analysis demonstrated that operation complexity, FI, and the role-emotional domain were associated with and increased risk of postoperative complications, whereas the bodily pain domain was associated with a lower risk of postoperative complications.

CONCLUSIONS

This study demonstrates that preoperative functional status as measured by FI and SF-36 may help identify patients at higher risk of postoperative complications. In our ageing population, use of such measures may help in better patient selection.

Usefulness of POSSUM physiological score for the estimation of morbidity and mortality risk after elective abdominal aortic aneurysm repair in Japan

BACKGROUND

The Physiological and Operative Severity Score for enUmeration of Mortality and morbidity (POSSUM), which consists of a physiological score (PS) and an operative severity score, is useful in determining the risk profile for patients with abdominal aortic aneurysms in Western countries, but no information is available on the use of this method in Japan.

METHODS AND RESULTS

A retrospective cohort study involving 225 patients was performed, and the prognostic factors for morbidity and in-hospital mortality including POSSUM were investigated. The morbidity rate was 26%. On univariate analysis age, renal disease, hemoglobin, albumin, operation time, blood loss and PS were significantly different. On multivariate analysis PS was significantly different. Using receiver operating characteristic (ROC) analysis, PS had an area under the curve (AUC) of 0.712 and the best cut-off point was 18. The in-hospital mortality rate was 2.2%. On univariate analysis renal disease, albumin and PS were significantly different, and on multivariate analysis PS was significantly different. On ROC analysis PS had an AUC of 0.921 and the best cut-off point was 22.

CONCLUSIONS

PS was the only independent risk factor for morbidity and in-hospital mortality. Further studies may be required to develop a risk-scoring system.

Optimizing the management of elderly colorectal surgery patients

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.

A systematic review of POSSUM and its related models as predictors of post-operative mortality and morbidity in patients undergoing surgery for colorectal cancer

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.

An evaluation of morbidity and mortality in oncologic gastric surgery with the application of POSSUM, P-POSSUM, and O-POSSUM

OBJECTIVE

Evaluation of surgical results observed in oncologic gastric surgery with reference to estimation of risks through POSSUM (Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity), P-POSSUM (Portsmouth POSSUM), and O-POSSUM (regression model based on the POSSUM and P-POSSUM, especially designed for gastric and esophagus surgery).

METHODS

A prospective follow-up of a cohort of 106 consecutive patients, gastrectomized because of gastric cancer. The variables studied were: age, sex, technical surgery, American Society of Anesthesiologists (ASA) score, the Charlson comorbidity index, morbidity, and mortality.

RESULTS

From January 2004 to April 2008, 131 patients were operated on for gastric neoplasia. Of these, 28 patients were excluded: 5 because of nonstandard gastrectomy, 17 because of staging laparoscopy or unresectable cancer after laparotomy, and 3 because of palliative gastroenteroanastomosis; 106 patients were included. We performed 38 total gastrectomies, 65 distal gastrectomies, 2 esophagogastrectomies, and 1 proximal gastrectomy. The mean age was 68 years (standard deviation (SD) = 12.1; range, 34-85 years). Associated comorbidity (Charlson) was 5.4 (SD = 2.7; range, 2-16); ASA 1 at 1.9%; ASA 2 at 36.8%; ASA 3 at 43.4%; and ASA 4 at 17.9%. Expected morbidity, according to POSSUM was 46.7%; observed morbidity was 50.5%. Morbidity ratio observed/expected was 1.08. Expected mortality, according to POSSUM = 13%, according to P-POSSUM = 4.9%, and according to O-POSSUM = 12.1%. Observed mortality was 7.8%. Mortality ratio observed/expected according to POSSUM, P-POSSUM, O-POSSUM was 0.6, 1.6, and 0.6, respectively. Morbidity results were within the confidence interval of the POSSUM estimation. Our results show lower mortality than the POSSUM and the O-POSSUM estimation (P < 0.001) and higher mortality regarding P-POSSUM estimation (P < 0.001).

CONCLUSIONS

The control systems of risk allow us continuous evaluation of our results and objective comparison to other teams. Compared with the POSSUM scoring systems, our series showed quality improvement (morbidity and mortality) over time.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Survival of elderly rectal cancer patients not improved: analysis of population based data on the impact of TME surgery

INTRODUCTION

The incidence of rectal cancer is highest in elderly patients. However, these patients are often underrepresented in randomised studies. Therefore, it is not clear whether results of rectal cancer studies are equally applicable to both elderly and younger patients. In this paper, the Dutch Total Mesorectal Excision (TME) study is revisited, focused on patients aged 75 years and above. The rectal cancer databases of the Comprehensive Cancer Centres (CCC) South and West were combined to analyse the effect of the TME-study in three different periods: before (1990-1995), during (1996-1999) and after (2000-2002) the trial.

RESULTS

Implementation of preoperative radiotherapy, as investigated in the TME trial, and the introduction of TME surgery resulted in improved 5 year survival during the subsequent periods, in patients younger than 75 years, of 60% (1990-1995) to 67% (1996-1999) and 70% (2000-2002) (log rank p<0.0001). The older patients did not improve and remained at 41%, 40% and 43% at 5 years in the respective periods. Furthermore, mortality during the first 6-month period after treatment is significantly raised compared to younger patients: 14% in the elderly, compared to 3.9% in the younger TME-study patient (p<0.0001 X2). In the CCC database these figures were confirmed at 16% and 3.9% (p<0.0001 X2).

CONCLUSION

Overall survival was not improved in the elderly rectal cancer patient after introduction of preoperative radiotherapy and TME-surgery. Non-cancer related mortality is a significant problem in the first 6 months after surgery.