Colorectal Cancer Surgery in the Very Elderly: Nonagenarians

EAES/SAGES evidence-based recommendations and expert consensus on optimization of perioperative care in older adults

BACKGROUND

As the population ages, more older adults are presenting for surgery. Age-related declines in physiological reserve and functional capacity can result in frailty and poor outcomes after surgery. Hence, optimizing perioperative care in older patients is imperative. Enhanced Recovery After Surgery (ERAS) pathways and Minimally Invasive Surgery (MIS) may influence surgical outcomes, but current use and impact on older adults patients is unknown. The aim of this study was to provide evidence-based recommendations on perioperative care of older adults undergoing major abdominal surgery.

METHODS

Expert consensus determined working definitions for key terms and metrics related to perioperative care. A systematic literature review and meta-analysis was performed using the PubMed, Embase, Cochrane Library, and Clinicaltrials.gov databases for 24 pre-defined key questions in the topic areas of prehabilitation, MIS, and ERAS in major abdominal surgery (colorectal, upper gastrointestinal (UGI), Hernia, and hepatopancreatic biliary (HPB)) to generate evidence-based recommendations following the GRADE methodology.

RESULT

Older adults were defined as 65 years and older. Over 20,000 articles were initially retrieved from search parameters. Evidence synthesis was performed across the three topic areas from 172 studies, with meta-analyses conducted for MIS and ERAS topics. The use of MIS and ERAS was recommended for older adult patients particularly when undergoing colorectal surgery. Expert opinion recommended prehabilitation, cessation of smoking and alcohol, and correction of anemia in all colorectal, UGI, Hernia, and HPB procedures in older adults. All recommendations were conditional, with low to very low certainty of evidence, with the exception of ERAS program in colorectal surgery.

CONCLUSIONS

MIS and ERAS are recommended in older adults undergoing major abdominal surgery, with evidence supporting use in colorectal surgery. Though expert opinion supported prehabilitation, there is insufficient evidence supporting use. This work has identified evidence gaps for further studies to optimize older adults undergoing major abdominal surgery.

Laparoscopic and robotic surgery for colorectal cancer in older patients: a systematic review and meta-analysis

INTRODUCTION

As life expectancy has been increasing, older patients are becoming more central to the healthcare system, leading to more intensive care use and longer hospital stays. Nevertheless, advancements in minimally invasive surgical techniques offer safe and effective options for older patients with colorectal diseases. This study aims to provide comprehensive evidence on the role of minimally invasive surgery in treating colorectal diseases in older patients.

MATERIAL AND METHODS

All articles directly compared the minimally invasive approach with open surgery in patients aged ≥65 years. The present metanalysis took 30-day complications as primary outcomes. Length of hospital stay, readmission, and 30-day mortality were also assessed, as secondary outcomes. Further subgroup analyses were carried out based on surgery setting, lesion features, and location.

RESULTS

After searching the main databases, 84 articles were included. Evaluation of 30-day complications rate, length of hospital stay, and 30-day mortality significantly favored minimally invasive approaches. The outcome readmission did not show any significant difference.

CONCLUSIONS

The current metanalysis demonstrates clear advantages of minimally invasive techniques over open surgery in colorectal procedures for older patients, particularly in reducing complications, mortality, and hospitalization. This suggests that prioritizing these techniques, based on available expertise and facilities, could improve outcomes and quality of care for older patients undergoing colorectal surgery.

Elective colorectal cancer surgery in nonagenarians and postoperative outcomes

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Factors affecting the post-operative outcomes in patients aged over 80 following colorectal cancer surgery

PURPOSE

In 2019, in Australia, there were 500,000 people aged 85 and over. Traditionally, clinicians have adopted the view that surgery is not desirable in this cohort due to increasing perioperative risk, perceived minimal clinical benefit, and shortened life expectancy. This cohort study is aimed at investigating postoperative outcomes from elective and non-elective colorectal cancer surgery in patients aged 80 and over.

METHODS

A retrospective analysis was conducted on patients from 2010 to 2020 on a prospectively maintained colorectal database. Patients aged over 80 who underwent surgical resection for colorectal cancer were reviewed. Oncological characteristics, short-term outcomes, overall survival, and relapse-free survival rates were analysed.

RESULTS

A total of 832 patients were identified from the database. Females comprised 55% of patients aged 80 and above. The median age was 84 for octogenarians and 92 for nonagenarians. Most patients were ASA 2 (212) or ASA 3 (501). ASA 3 and 4 and stage III pathology were associated with higher postoperative complications. Fifty percent of over 80 s and 37% of over 90 s were surgically discharged to their own home. Overall survival at 30, 180, and 360 days and 5 years was 98.1%, 93.1%, 87.2%, and 57.2% for the over 80 s and 98.1%, 88.9%, 74.9%, and 24.4% for the over 90 s.

CONCLUSION

Our results demonstrate that surgical treatment of older patients is safe with acceptable short-, medium-, and long-term survival. Nonetheless, efforts are needed to reduce the rates of complications in older patients, including utilisation of multi-disciplinary teams to assess the optimal treatment strategy and postoperative care.

Surgery for T4 Colorectal Cancer in Older Patients: Determinants of Outcomes

Background: This study aimed to compare the outcomes of older and younger patients with T4 colorectal cancer (CRC) treated with surgery. Methods: Consecutive patients with T4 CRC treated surgically at Henri Mondor Hospital between 2008 and 2016 were retrospectively analyzed in age subgroups (1) 50−69 years and (2) ≥70 years for overall and relative survival. The multivariable analyses were adjusted for adjusted for age, margin status, lymph node involvement, CEA level, postoperative complications (POC), synchronous metastases, and type of surgery. Results: Of 106 patients with T4 CRC, 57 patients (53.8%) were 70 years or older. The baseline characteristics were generally balanced between the two age groups. Older patients underwent adjuvant therapy less commonly (42.9 vs. 57.1%; p = 0.006) and had a longer delay between surgery and chemotherapy (median 40 vs. 34 days; p < 0.001). A higher trend for POC was reported among the older patients but did not impact the survival outcomes. After adjusting for confounding factors, the overall survival was shorter among the older patients (HR = 3.322, 95% CI 1.49−7.39), but relative survival was not statistically correlated to the age group (HR = 0.873, 95% CI 0.383−1.992). Conclusions: Older patients with CRC were more prone to severe POC, but age did not impact the relative survival of patients with T4 colorectal cancer. Older patients should not be denied surgery based on age alone.

Modern Cardiac Surgical Outcomes in Nonagenarians: A Multicentre Retrospective Observational Study

Background

There have been multiple recent advancements in the selection, optimisation and management of patients undergoing cardiac surgery. However, there is limited data regarding the outcomes in nonagenarians, despite this cohort being increasingly referred for these interventions. The objective of this study was to describe the patient characteristics, management and outcomes of a cohort of nonagenarians undergoing cardiac surgery receiving contemporary peri-operative care.

Methods

After receiving ethics approval, we conducted a retrospective observational study of nonagenarians who had undergone cardiac surgery requiring a classic median sternotomy. All operative indications were included. We excluded patients who underwent transcatheter aortic valve implantation (TAVI), and surgery on the thoracic aorta via an endovascular approach (TEVAR). Patients undergoing TEVAR often have the procedure done under sedation and regional blocks with local anesthetic solution. There is no open incision and these patients do not require cardiopulmonary bypass. We also excluded patients undergoing minimally invasive mitral valve surgery via a videoscope assisted approach. These patients do not have a median sternotomy, have the procedure done via erector spinae block, and often are extubated on table. Data were collected from four hospitals in Victoria, Australia, over an 8-year period (January 2012–December 2019). The primary objective was to assess 6-month mortality in nonagenarian patients undergoing cardiac surgery and to provide a detailed overview of postoperative complications. We hypothesized that cardiac surgery in nonagenarian patients would be associated with a 6-month postoperative mortality <10%. As a secondary outcome, we hypothesized that significant postoperative complications (i.e., Clavien Dindo Grade IIIb or greater) would occur in > 30% of patients.

Results

A total of 12,358 adult cardiac surgery patients underwent surgery during the study period, of whom 18 nonagenarians (0.15%) fulfilled inclusion criteria. The median (IQR) [min-max] age was 91.0 years (90.0:91.8) [90–94] and the median body mass index was 25.0 (kg/m²) (22.3:27.0). Comorbidities, polypharmacy, and frailty were common. The median predicted mortality as per EuroSCORE-II was 6.1% (4.1:14.5). There were no cases of intra-operative, in-hospital, or 6-month mortality. One (5.6%) patient experienced two Grade IIIa complications. Three (16.7%) patients experienced Grade IIIb complications. Three (16.7%) patients had an unplanned hospital readmission within 30 days of discharge. The median value for postoperative length of stay was 11.6 days (9.8:17.6). One patient was discharged home and all others were discharged to an inpatient rehabilitation facility.

Conclusion

In this selected, contemporary cohort of nonagenarian patients undergoing cardiac surgery, postoperative 6-month mortality was zero. These findings support carefully selected nonagenarian patients being offered cardiac surgery (Trials Registry: https://www.anzctr.org.au/ACTRN12622000058774.aspx).

Outcomes of colorectal cancer surgery in nonagenarian patients: a multicenter retrospective study

Background

The use of surgery in patients with colorectal cancer (CRC) aged ≥90 years remains controversial. This study aimed to evaluate the short-term postoperative and long-term oncologic outcomes of CRC surgery in patients within this age group.

Methods

A total of 151 consecutive nonagenarian patients who underwent CRC surgery were included from 3 different hospitals. The Comprehensive Complication Index (CCI) was used to grade postoperative complications. Univariate and multivariate analyses were conducted to identify factors associated with CCI and overall survival (OS).

Results

The patients had a mean age of 92.8 years (standard deviation ±1.9 years). Forty-six patients (30.5%) underwent emergency surgery, and 105 patients (69.5%) underwent elective surgery. The postoperative complications rate was 66.2% (100/151), and the mean CCI was 26.3 (±30.8). Twenty-three patients (15.2%) died postoperatively, and the perioperative mortality rates for elective surgery and emergency surgery were 7.6% (8/105) and 32.6% (15/46), respectively (P<0.001). The 1-, 3-, and 5-year survival rates were 77.5%, 53.9%, and 38.6%, respectively. Multivariate analysis revealed emergency surgery and American Society of Anesthesiologists (ASA) score to be predictors of postoperative complications. Advanced tumor stage, palliative surgery, ASA score ≥4, and CCI >17 were associated with poor OS.

Conclusions

CRC surgery should not be denied to nonagenarian patients. Surgical treatment can be performed with acceptable morbidity and mortality, and achieves long-term survival in a select group.

Short- and long-term survival after curative resection for colorectal cancer in nonagenarian patients

BACKGROUND/OBJECTIVE

With increased life expectancy, the incidence of colorectal cancer in oldest-old patients has been rising. Advanced age is a risk factor for adverse outcomes after surgery. This study aimed to evaluate the short- and long-term outcomes of curative resection for colorectal cancer in nonagenarians.

METHODS

Patients who had undergone curative resection for colorectal cancer (CRC) at Stage I to III from January 2010 to December 2019 were included. Cases of emergent surgery were excluded. The clinical characteristics were documented retrospectively, and factors affecting the long-term outcome were analyzed using multivariate analysis.

RESULTS

Fifty patients met the selection criteria. Most of them were women (58.0%), and the median age was 92 years. Among these patients, 29 (58.0%) had a poor performance status (ASA-PS≥3). Laparoscopic surgery was performed in 42.0% of the patients, and 50% of the patients had postoperative complications classified as Clavien-Dindo grade 2 or severer, including 3 patients (6.0%) with grade 3 disease. No postoperative mortality occurred. The 30-day, 180-day, 1-year, 3-year and 5-year survival rates were 100%, 80.4%, 71.0%, 46.3%, and 33.8%, respectively. Multivariate analysis showed that a preoperative poor performance status (ASA-PS≥3) (HR: 3.067; 95% CI: 1.220-7.709; p = 0.017) was an independent prognostic factor for OS.

CONCLUSION

Curative elective resections for CRC in nonagenarians were performed safely without postoperative mortality. The preoperative performance status was significantly associated with OS after curative elective resection of colorectal cancer in nonagenarians. Our results suggest that excellent long-term outcomes can be achieved in a selected group with a good performance status.

Surgical outcomes following colorectal cancer resections in patients aged 80 years and over: results from the Australia and New Zealand Binational Colorectal Cancer Audit

AIM

The primary aim was to compare the 30-day morbidity and mortality in patients aged ≥80 years undergoing surgery for colorectal cancer with those aged <80 years. The secondary aim was to identify independent outcome predictors.

METHOD

This was a retrospective study of patients undergoing surgery for colorectal cancer between January 2007 and February 2018. Patients were divided into those <80 years and those ≥80 years at the time of surgery. Data had been collected prospectively by the Australasian Binational Colorectal Cancer Audit and included patient demographics, site and stage of tumour, comorbidity, operative details, American Society of Anesthesiologists score (ASA), pathological staging, 30-day mortality and morbidity (medical and surgical). Univariate and multivariate analyses were used to identify predictors of 30-day morbidity and mortality.

RESULTS

During the study period, 4600 out of 20 463 (22.5%) patients were ≥80 years. They had a greater 30-day mortality after both colonic (97/2975 [3.3%] vs. 66/7010 [0.9%], P < 0.001) and rectal resections (50/1625 [3.1%] vs. 36/9006 [0.4%], P < 0.001) compared with younger patients. They also had an increased length of stay (colon cancer, 9 vs. 7 days; rectal cancer, 10 vs. 8 days; P < 0.001) and medical complications (colon cancer, 23.5% vs. 12.7%; rectal cancer, 25.2% vs. 11.2%; P < 0.001). Surgical complications were equivalent. Age ≥80 years was not an independent predictor of 30-day morbidity or mortality. Patients ≥80 years who were ASA 2/3 and had rectal cancer seemed to fare worse in terms of 30-day mortality (ASA 2, 22%, 95% CI 9%-36%, P < 0.001; ASA 3, 11%, 95% CI 4%-19%, P< 0.001).

CONCLUSIONS

Postoperative morbidity and mortality are significantly greater in patients ≥80 years undergoing colorectal cancer surgery. Any recommendation for surgery in this age group should take into account patient comorbidity and not be based on age alone.

Outcomes of Surgical and Nonsurgical Treatment for Colorectal Cancer in Nonagenarian Patients

PURPOSE

This study is aimed to evaluate the clinical outcomes of surgical treatment for nonagenarian patients with colorectal cancer.

METHODS

This retrospective single-center study included patients diagnosed with colorectal cancer at the age of ≥90 years between 2004 and 2018. Patient demographics were compared between the operation and nonoperation groups (NOG). Perioperative outcomes, histopathological outcomes, and postoperative complications were evaluated. Overall survival was analyzed using Kaplan-Meier methods and log-rank test.

RESULTS

A total of 31 patients were included (16 men and 15 women), and the median age was 91 (range: 90-96) years. The number of patients who underwent surgery and who received nonoperative management was 20 and 11, respectively. No statistical differences in baseline demographics were observed between both groups. None of these patients were treated with perioperative chemotherapy or radiotherapy. Surgery comprised 18 (90.0%) colectomies and 2 (10.0%) transanal excisions. Short-term (≤30 days) and long-term (31-90 days) postoperative complications occurred in 7 (35.0%) and 4 (20.0%) patients, respectively. No complications needed reoperation, such as anastomosis leakage or bleeding. No postoperative mortality occurred within 30 days: 90-day postoperative mortality occurred in two patients (10.0%), respectively. The median overall survival of the operation group was 31.6 (95% confidence interval: 26.7-36.5) and that of NOG was 12.5 months (95% CI: 2.4-22.6) (P = 0.012).

CONCLUSION

Surgical treatment can be considered in carefully selected nonagenarian patients with colorectal cancer in terms of acceptable postoperative morbidity, with better overall survival than the nonsurgical treatment.

Rectum versus colon: should malignant polyps be treated differently?

BACKGROUND

The management of malignant colorectal polyps removed at endoscopy remains controversial with patients either undergoing surgical resection or regular endoscopic surveillance. Lymph node (LN) metastases occur in 6-16% of patients with malignant polyps. This study assessed the rate of LN metastases in patients undergoing surgical resection for malignant polyps removed endoscopically to determine if there is a difference in the rate of LN metastases between colonic and rectal polyps.

METHODS

A retrospective review of a prospectively maintained database was performed from 2010 to 2018. All patients who underwent surgical resection following endoscopic removal of a malignant colorectal polyp were reviewed. Clinical data including patient demographics and tumour characteristics were examined.

RESULTS

A total of 177 patients underwent surgical resection in the study period. The median age at diagnosis was 65 years (range 22-88 years) with females comprising 52% of the patient cohort (n = 92/177). Polyps were located in the colon in 60.5% of cases with the remainder located in the rectum. The median number of LN harvested was 14 (range 0-44) with malignant LN (including a mesenteric tumour deposit) identified in 8.5% of resection specimens (n = 15/177). Malignant LNs were retrieved in 5.5% of right-sided tumours, 5.6% of left-sided tumours and 12.9% of rectal tumours (P = 0.090).

CONCLUSION

A small proportion of patients with malignant polyps removed endoscopically will have LN metastases. The results of this study suggest that the tumour location might be a useful predictive marker; however, a further study with increased patient numbers is required to properly establish this finding.

Care of the Geriatric Colorectal Surgical Patient and Framework for Creating a Geriatric Program: A Compendium From the 2019 American Society of Colon and Rectal Surgeons Annual Meeting

Supplemental Digital Content is available in the text.

Australasian ACPGBI risk prediction model for 30-day mortality after colorectal cancer surgery

BACKGROUND

Postoperative mortality after colorectal cancer surgery varies across hospitals and countries. The aim of this study was to test the Association of Coloproctologists of Great Britain and Ireland (ACPGBI) models as predictors of 30-day mortality in an Australian cohort.

METHODS

Data from patients who underwent surgery in six hospitals between 1996 and 2015 (CRC data set) were reviewed to test ACPGBI models, and patients from 79 hospitals in the Bi-National Colorectal Cancer Audit between 2007 and 2016 (BCCA data set) were analysed to validate model performance. Recalibrated models based on ACPGBI risk models were developed, tested and validated on a data set of Australasian patients.

RESULTS

Of 18 752 patients observed during the study, 6727 (CRC data set) and 3814 (BCCA data set) were analysed. The 30-day mortality rate was 1·1 and 3·5 per cent in the CRC and BCCA data sets respectively. Both the original and revised ACPGBI models overestimated 30-day mortality for the CRC data set (observed to expected (O/E) ratio 0·17 and 0·21 respectively). Their ability to correctly predict mortality risk was poor (P < 0·001, Hosmer-Lemeshow test); however, the area under the curve for both models was 0·88 (95 per cent c.i. 0·85 to 0·92) showing good discriminatory power to classify 30-day mortality. The recalibrated original model performed well for calibration and discrimination, whereas the recalibrated revised model performed well for discrimination but not for calibration. Risk prediction was good for both recalibrated models. On external validation using the BCCA data set, the recalibrated models underestimated mortality risk (O/E ratio 3·06 and 2·98 respectively), whereas both original and revised ACPGBI models overestimated the risk (O/E ratio 0·48 and 0·69). All models showed similar good discrimination.

CONCLUSION

The original and revised ACPGBI models overpredicted risk of 30-day mortality. The new Australasian calibrated ACPGBI model needs to be tested further in clinical practice.

Colorectal cancer surgery in selected nonagenarians is relatively safe and it is associated with a good long-term survival: an observational study

Background

Advanced age is a risk factor for colorectal cancer, and very elderly patients often need to be surgically treated. This study aimed to analyze the outcomes of a cohort of nonagenarian patients operated on for colorectal cancer.

Methods

Observational study conducted on a cohort of 40 nonagenarian patients, who were treated surgically for colorectal cancer between 2000 and 2018 in our institution. Clinical data, ASA score, Charlson Comorbidity Index, Surgical Mortality Probability Model, tumor characteristics, and nature and technical features of the surgical procedure, were recorded. The Comprehensive Complication Index (CCI) and survival time after the procedure were recorded as outcome variables. Univariate and multivariate analyses were performed in order to define risk factors for postoperative complications and long-term survival.

Results

Out of the 40 patients, 13 (32.5%) were men, 27 (67.5%) women, and mean age 91.6 years (SD ± 1.5). In 24 patients (60%), surgery was elective, and in 16 patients (40%), surgery was emergent. Curative surgery with intestinal resection was performed in 34 patients (85%). In 22 patients (55%), intestinal continuity was restored by performing an anastomosis. The median CCI was 22.6 (IRQ 0.0–42.6). Operative mortality was 10% (4 patients). Cumulative survival at 1, 3, and 5 years was 70%, 47%, and 29%, respectively. In multivariate analysis, only the need for transfusion remained as an independent prognostic factor for complications (p = 0.021) and TNM tumor stage as a significant predictor of survival (HR 3.0, CI95% 1.3–7.2).

Conclusions

Colorectal cancer surgery is relatively safe in selected nonagenarian patients and may achieve long-term survival.

Outcomes of colorectal cancer surgery in the nonagenarians: 20-year result from a tertiary center

Background

There is a foreseeable trend that life expectancy is on the rise in many parts of the world. More and more patients will present with colorectal cancer at extreme old age and advanced age is a well-known risk factor for adverse outcomes after surgery. The aim of this study is to evaluate the outcomes of colorectal cancer surgery in patients aged 90 or above.

Method

A retrospective analysis of consecutive patients aged 90 or above who underwent operations for colorectal cancer between January 1996 and December 2015 was performed. The primary outcomes were the complications rate, 30-day and 180-day mortality rates.

Results

A total of 57 patients were included in the analysis. The majority of them were women (64.9%). The median age was 92 years. Most of the surgery was of curative intent (77.2%), performed under elective setting (57.9%) and with open approach (78.9%). 36.8% of patients had postoperative complications, with pneumonia being the commonest. The 30-day and 180-day mortality rate was 7 and 31.6% respectively. History of ischemic heart disease and surgery under emergency setting were predictors of postoperative complications. Pneumonia, preoperative leukocytosis and Charlson comorbidity score ≥ 9 were predictors of 180-day mortality. The one and two-year survival rate for elective surgery was 69.7 and 54.5% respectively.

Conclusion

The outcomes of colorectal cancer surgery for nonagenarians could be favorable in a selected group of patients. Future study on better risk profiling and ways to improve outcomes is warranted.

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.

Emergency Surgery for Obstructive Colon Cancer in Elderly Patients: Results of a Multicentric Cohort of the French National Surgical Association

BACKGROUND

Although elderly patients constitute most of the patients undergoing surgery for obstructed colon cancer, available data in the literature are very limited.

OBJECTIVE

The purpose of this study was to assess the management and outcomes of elderly patients treated for obstructed colon cancer.

DESIGN

This was a multicenter, retrospective cohort study.

SETTINGS

Between 2000 and 2015, 2325 patients managed for an obstructed colon cancer in member centers of the French National Surgical Association were identified. Data were collected by each center on a voluntary basis after institutional approval. Bowel obstruction was defined clinically and confirmed by imaging.

PATIENTS

Three age groups were defined, including patients <75 years, 75 to 84 years, and ≥85 years.

MAIN OUTCOME MEASURES

Postoperative and oncologic results in elderly patients with an obstructed colon cancer were measured. Relative survival was calculated as the ratio of the overall survival with the survival that would have been expected based on the corresponding general population.

INTERVENTIONS

A total of 302 patients (13%) underwent colonic stent insertion, and 1992 (87%) underwent surgery as emergency procedure.

RESULTS

A total of 2294 patients were analyzed (<75 y, n = 1200 (52%); 75-84 y, n = 650 (28%); and ≥85 y, n = 444 (20%)). Elderly patients were more likely to be women (p < 0.0001), to have proximal colon cancer (p < 0.0001), and to have a higher incidence of comorbidities (p < 0.0001). The use of colonic stent or the type of surgery was identical regardless of age. In patients with resected colon cancer, elderly patients had less stage IV disease (p < 0.0001). The absence of tumor resection (p < 0.0001) and definitive stoma rate increased with age (p < 0.0001). Postoperative mortality and morbidity were significantly higher in elderly patients (p < 0.0001), but surgical morbidity was similar across age groups (p = 0.60). Postoperative morbidity was correlated to the 6-month mortality rate in elderly (p < 0.0001). Overall and disease-free survivals were significantly lower in more elderly patients (p < 0.0001) but relative survival was not (p = 0.09).

LIMITATIONS

It is quite difficult to know how to interpret these data as a whole, given the inherent bias in the study population, lack of ability to stratify by performance status, and long study period duration.

CONCLUSIONS

Elderly patients have high morbidity with lower survival in the highest age ranges of elderly subgroups. These data should be considered when deciding on an operative approach. See Video Abstract at http://links.lww.com/DCR/A964.

Clinical characteristics and treatment propensity in elderly patients aged over 80 years with colorectal cancer

BACKGROUND/AIMS

Elderly patients (≥ 80 years) with colorectal cancer (CRC) tend to avoid active treatment at the time of diagnosis despite of recent advances in treatment. The aim of this study was to determine treatment propensity of elderly patients aged ≥ 80 years with CRC in clinical practice and the impact of anticancer treatment on overall survival (OS).

METHODS

Medical charts of 152 elderly patients (aged ≥ 80 years) diagnosed with CRC between 1998 and 2012 were retrospectively reviewed. Patients' clinical characteristics, treatment modalities received, and clinical outcome were analyzed.

RESULTS

Their median age was 82 years (range, 80 to 98). Of 152 patients, 148 were assessable for the extent of the disease. Eighty-two of 98 patients with localized disease and 28 of 50 patients with metastatic disease had received surgery or chemotherapy or both. Surgery was performed in 79 of 98 patients with localized disease and 15 of 50 patients with metastatic disease. Chemotherapy was administered in only 24 of 50 patients with metastatic disease. Patients who received anticancer treatment according to disease extent showed significantly longer OS compared to untreated patients (localized disease, 76.2 months vs. 15.4 months, p = 0.000; metastatic disease, 9.9 months vs. 2.6 months, p = 0.001). Along with anticancer treatment, favorable performance status (PS) was associated with longer OS in multivariate analysis of clinical outcome.

CONCLUSION

Elderly patients aged ≥ 80 years with CRC tended to receive less treatment for metastatic disease. Nevertheless, anticancer treatment in patients with favorable PS was effective in prolonging OS regardless of disease extent.

[The Short-term Outcome and Safety of Laparoscopic Colorectal Cancer Resection in Very Elderly Patients]

Background/Aims

Due to the recent increase in elderly population, laparoscopic surgery is more frequently performed in the elderly. This study aimed to compare the short-term outcomes of laparoscopic colorectal cancer surgery between the very elderly group (VEG), categorized as those with age over 80 years and the elderly group (EG), categorized as those with age 65 to 79 years.

Methods

We retrospectively compared 48 very elderly patients with 96 elderly patients (1:2 matched) who underwent laparoscopic resection for colorectal cancers at our institution between March 2010 and December 2014. The clinicopathologic parameters, surgical characteristics and short term outcomes were compared.

Results

There was no statistically significant difference in clinicopathologic characteristics between VEG and EG. Postoperative pain score (7 points vs. 6 points, p=0.264), time to first flatus (3 days vs. 3 days, p=0.335), hospital stay (15 days vs. 16.5 days, p=0.361), complication rates (47.9% vs. 26.0%, p=0.147) and major complication rate (25% vs. 20.8%, p=0.681) were not statistically different between the two groups. Before surgery, VEG had higher rate of neurologic underlying disease, such as dementia or cerebrovascular disease, than EG (25.0% vs. 7.3%, p=0.007).

Conclusions

There was no significant difference in the clinicopathologic characteristics, short-term outcomes, and complication rates for laparoscopic colorectal resection between VEG and EG, except delirium. Age over 80 years may be relevant for the application of laparoscopic colorectal cancer resection.