Can elderly patients with colorectal cancer tolerate planned surgical treatment? A practical approach to a common dilemma

AIM

Analysing the effectiveness of a surgical procedure is mandatory in every modern health-care system. The aging of the population stresses the need for a good standard of care. This study tests the hypothesis that porthsmouth-physiologic operative severity score for enumeration of morbidity and mortality (P-POSSUM) and colorectal-POSSUM (CR-POSSUM) would be useful clinical auditing tools in colorectal cancer surgery for aged patients.

METHOD

One hundred and seventy-seven consecutive patients over 70 years of age underwent emergency or elective surgery from January 2003 to December 2005. Demographic, clinical and surgical information, score systems' prediction, complications and 30-day mortality data were prospectively entered in a comprehensive database. The observed over expected morbidity and mortality rate was calculated.

RESULTS

Thirty-day observed mortality was 10.3% (19/177) while P-POSSUM and CR-POSSUM expected mortality were, respectively, 11.21% (P = NS) and 13.08% (P = NS). Overall observed morbidity was 42.7%, P-POSSUM prediction was 59.3% (P = 0.002). Morbidity and mortality data were analysed for specific subgroups of patients (resection and anastomosis/resection and stoma/palliative; emergency/elective).

CONCLUSION

P-POSSUM and CR-POSSUM are useful tools to predict mortality in elderly patients. P-POSSUM significantly overestimated the risk of complications. A more accurate tool for preoperative assessment for aged patients is probably needed to predict the post-surgical outcome.

Sarcomatoid anaplastic carcinoma of the small bowel in cardiac transplant bearer

Sarcomatoid carcinoma is a rare form of primitive carcinoma of the small bowel; it is considered a variant of adenocarcinoma, histologically characterized by a typical biphasic pattern with epithelial- and mesenchymal-like cells. Twenty-one cases have been described in the literature, presenting as small bowel obstructions (twenty cases) or superior vena cava syndrome (one case). The authors report the case of a 56 year-old man on immunosuppressive therapy for a heart transplant, who underwent surgery after a history of repeated episodes of melena, anemization and bowel obstruction. The operation brought to light an intraluminal occlusive mass in the distal ileum, associated with other intraluminal neoplasms of different sizes throughout the small bowel. No evidence of mesenteric adenopathies or hepatic metastases were found. Histological examination and immunohistochemical stain showed an anaplastic sarcomatoid carcinoma. The tumor cells showed strong positivity for cytokeratin and vimentin, and negativity for CD117 and CD34, as well as for all other characteristic markers of mesenchymal tumors. Early diagnosis is usually very difficult, due to the lack of any stereotyped clinical expression and the difficult to study the small bowel. Small-bowel barium follow-through or video capsule endoscopy can be helpful. In most cases, an emergency surgical operation is performed without a clear preoperative diagnosis. The case report is completed by a review of the literature.