World Journal of Colorectal Surgery

Transcription

1 World Journal of Colorectal Surgery Volume 4, Issue Article 1 Surgical Management of Colorectal Cancer In Nonagenarian Patients Yair Edden Shlomo Yellinek Oded Olsha Joseph Alberton Petachia Reissman Shaare Zedek Medical Center, Jerusalem, Israel, yair edden@yahoo.com Shaare Zedek Medical Center, Jerusalem, Israel Shaare Zedek Medical Center, Jerusalem, Israel Shaare Zedek Medical Center, Jerusalem, Israel Shaare Zedek Medical Center, Jerusalem, Israel Copyright c 2014 The Berkeley Electronic Press. All rights reserved.

2 Surgical Management of Colorectal Cancer In Nonagenarian Patients Yair Edden, Shlomo Yellinek, Oded Olsha, Joseph Alberton, and Petachia Reissman Abstract Background: Comparable to the trend worldwide, the population in Israel is rapidly aging. This tendency affects many aspects of medicine and surgery as well as national health care policy. Similar to the general population, older patients require various and often complex surgical interventions. However, the surgical and the peri-operative management of nonagenarian patients (age 90 to 99) is still infrequent and has not been thoroughly investigated. Methods: All nonagenarian surgical patients admitted over a period of 12 years who underwent a surgical procedure for colorectal cancer are included in this study. Patient s demographics, comorbidities, indications, type of surgery (emergency or elective) complications and mortality were evaluated. Results: Of 952 patients aged 90 years or older treated in our department, 200 (21.5%) underwent a surgical procedure of whom 35 (17.5%) had surgery for colorectal cancer. Thirty-one patients (91%) had comorbid conditions such as hypertension (48%), ischemic heart disease (23%), congestive heart failure (23%), atrial fibrillation (20%), chronic renal failure (14%), diabetes mellitus (6%) and morbid obesity (3%). Sixteen patients (46%) required emergency surgery. Surgical procedures included right hemicolectomy 21 patients (60%), left hemicolectomy 4 patients (11%) and low anterior resection 1 patient (3%). Five patients (14%) died within 30 days of surgery. Two patients (6%) required reoperation. Complications occurred in 11 (31%) patients and included pulmonary edema (n=4), prolonged ileus (n=1) and cardiac arrhythmia (n=4) but did not include an anastomotic leak. The thirty surviving patients (85%) were discharged at a median of 8 days (range 0-29). Conclusions: Surgical management of colorectal cancer in nonagenarians is associated with acceptable rates of morbidity and mortality. This population should not be denied definitive surgical intervention in both the elective and the emergent setting. KEYWORDS: Nonagenarians; Colorectal cancer

3 Edden et al.: Surgical Management of Colorectal Cancer In Nonagenarian Patients 1 Introduction Over the last century the world's population has become older. Since 1900, the percentage of elderly Americans aged over 65 has more than tripled (from 4.1% in 1900 to 13.3% in 2011). As the population's size has increased, the absolute number has risen over thirteen times from 3.1 million to 41.4 million. By the year 2040 one out of five Americans is expected to be part of the elderly population. Simultaneously, as longevity extends, the oldest component of the elderly population, age more than 85 years, is becoming substantial. This segment of the population is expected to triple from 5.7 million in 2011 to 14.1 million in 2040 [1, 2]. The Israeli population conforms to this global trend. The Israeli Bureau of Statistics published a long range population projection in The report projects that the segment of the population age over 80 years will rise to 34% of the elderly population in 2034 [3]. Surgical care of elderly and, in particular, very elderly patients may be challenging [4]. Complicated co-morbidities, previous surgical interventions and frailty as well as ethical difficulties are only a part of the complex range of concerns. The accumulated information in the English literature is limited, with very few series addressing the outcomes of surgical procedures performed for colorectal cancer in the nonagenarian population [5, 6]. The aim of this study was to assess the characteristics and the outcome of nonagenarian patients who underwent elective and emergency procedures for colorectal cancer. Patients and Methods After IRB approval a constantly updated database was retrospectively analyzed for the period from 2001 to The details of all patients 90 years and older who underwent surgery for colorectal cancer were retrieved. Co-morbid conditions, indications for surgery, post-operative course, complications and mortality were analyzed. Results Over a 12 year period, 952 patients aged 90 years and older were admitted to the department of surgery. More than 21% (n=200) underwent a surgical intervention. Seventeen percent (n=35) were operated for colorectal cancer of whom 54% (n=19) had elective surgery and 46% (n=16) had an emergent procedure. In 37% (n=13) of the patients, surgery was electively scheduled with intention for cure. Produced by The Berkeley Electronic Press, 2014

4 2 World Journal of Colorectal Surgery Vol. 4, Iss. 2 [2014], Art. 1 While in other cases both elective and emergent patients underwent surgery in order to alleviate symptoms such bleeding, obstruction, or pain. The median age was 92 (range ), 42% were females (n=15). Thirty one patients (91%) had comorbid conditions such as hypertension (48%), ischemic heart disease (23%), congestive heart failure (23%), atrial fibrillation (20%), chronic renal failure (14%), diabetes mellitus (6%), and morbid obesity (3%). The American Society of Anesthesiology Physical Status Classification (ASA) of surgical risk of the operated patients is reported in Table 1. The various surgical procedures carried out on these patients are detailed in Table 2. Five patients (14%) underwent a laparoscopic procedure. Five patients (14%) died within 30 days, 2 patients (11%) following an elective procedure and 3 patients (19%) after emergent surgery. Two patients (6%) had a complication necessitating a second operation: one suffered from deep wound infection and underwent wound debridement, and the other one underwent repair of wound dehiscence. Both patients were initially operated on emergently. Interestingly, none of the 26 patients who had a bowel resection and anastomosis developed a leak. An additional 9 patients (35%) had other post-operative complications detailed in Table 3. Only 7 patients (20%) required admission to the Intensive Care Unit (ICU) after surgery. The median length of stay in the ICU was 3 days (range 1-7). Only 2 elective patients (10%) were admitted to the ICU post operatively compared to 5 patients (33%) who were admitted to the ICU following an emergency operation. The median overall length of stay was 8 days (range 0-29). For elective patients, the median length of stay was 7 days (range 0-25) and for emergent patients, 8 days (range 5-29). Pathology results based on TNM scoring system are detailed on Table 4. Five patients died during the initial hospitalization (Table 1). Twenty-two patients (73%) of the 30 who survived the surgical procedure and hospitalization were discharged home for further convalescence. Eight other patients (27%) were transferred to rehabilitation or a nursing care facility. Nine patients (26%) were known to be alive at the time this study was compiled. Six of the patients who were discharged were lost to follow up, and their fate is unknown. For the 15 patents who are known to have died after discharge, the median post-operative survival rate was 18 months (range 3-67). Discussion As a significant proportion of the population is aging, the medical community is facing a major challenge. Not only is the segment of population age over 65 years constantly growing, but within it, the elderly portion of old patients, over 85 years

5 Edden et al.: Surgical Management of Colorectal Cancer In Nonagenarian Patients 3 old, is growing rapidly [1-2]. Accordingly, the need for surgical care of the elderly population is becoming more and more frequent. Interventions that were not even deemed feasible in the past due to the patient's chronological age and limited life expectancy are commonly performed safely today with acceptable outcomes [2, 4, 5]. In this study we focused on nonagenarian patients. Our registry revealed that although infrequent, almost 100 patients in this age group were admitted electively and emergently to the department of general surgery each year. One out of 5 of those patients had surgery. The current study found that nonagenarian patients can undergo various surgical procedures in different settings with acceptable mortality and morbidity rates, especially when taking into consideration the number and nature of the comorbid conditions with which they present. In our population of patients age up to 89 years, median length of stay was 9 days (range 3-44). This is longer than the length of stay for nonagenarians who had median length of stay 8 days (range 0-29). This might be explained by the increased mortality, with death possibly occurring more rapidly, and possible preference for less complex procedures in patients age 90 years and over. It is the authors belief that what today seems like reaching the limits of what is appropriate in the treatment of nonagenarians will undoubtedly become an everyday occurrence in the near future. Major surgery for older patients with its unique clinical, ethical and social aspects should therefore be seriously addressed. Several papers have discussed the issue of surgery in the elderly population [4-12]. Naturally, reports addressing nonagenarian exclusively are limited. Evidencebased recommendations are not available for this age group, as older patients with colorectal cancer are generally excluded from randomized clinical trials. However, the operative risk under elective conditions is not markedly different in older than in younger patients [8]. Pinto et al. described an experience with a cohort of 199 octogenarian patients who underwent elective colon resections. The mean age of this series was 84.3 years. The overall mortality rate was 3% and the major complications rate was 6% [10]. From published data about octogenarians combined with data from our study a few conclusions can be reached. Major elective and emergent abdominal procedures in nonagenarian patients have increased in the western world over the last decades and minimally invasive surgery is accomplished safely in this age group. This trend is expected to become even more significant in the near future [8, 11, 12]. Although many older patients have substantial co-morbid conditions Produced by The Berkeley Electronic Press, 2014

6 4 World Journal of Colorectal Surgery Vol. 4, Iss. 2 [2014], Art. 1 and a considerable medical and surgical history, the surgical outcomes are within acceptable limits [6-8]. Limitations of this study, in addition to its retrospective nature, include small size due to the small number of patients in this age group. The proportion of patients with colorectal cancer who refused surgical treatment or who were initially referred by their primary care physician to medical or palliative care is also uncertain. Strengths of this study include the availability of detailed information on the oldest population treated in our department, a group of patients which has not received attention in the past as a distinct cohort. Conclusions Nonagenarians are becoming an increasing proportion of our patient population. Patients need not be denied surgical treatment solely because of advanced age. Appropriate planning together with reconciliation of expectations of patients, families and staff is warranted in order to accomplish optimal results. As surgeons, we have to make the appropriate changes, preparations and adjustments for the treatment of the elderly population with their special needs and comorbidities.

7 Edden et al.: Surgical Management of Colorectal Cancer In Nonagenarian Patients 5 Table 1. ASA score and in hospital mortality for 35 nonagenarians undergoing surgery for colorectal cancer. ASA score n (%) Death during initial hospitalization (%) I 1 (3) 0 II 8 (22) 0 III 19 (55) 4 (11) IV 7 (20) 1 (3) Table 2. Surgical procedures carried out for 35 nonagenarians for colorectal cancer. Type of surgery n (%) Right hemicolectomy 21 (60) Left hemicolecotmy 4 (12) Diverting enterostomy 4 (12) Segmental colectomy 4 (12) Low Anterior Resection 1 (2) Trans-anal excision 1 (2) Produced by The Berkeley Electronic Press, 2014

8 6 World Journal of Colorectal Surgery Vol. 4, Iss. 2 [2014], Art. 1 Table 3. Post-operative complications of 35 nonagenarians undergoing surgery for colorectal cancer. Complication n (%) Respiratory 6 (17) Surgical site infection 6 (17) Renal failure 4 (11) Cardiac ischemia/ arrhythmias 4 (11) Delirium 2 (6) Wound dehiscence 1 (3) Prolonged ileus 1 (3) Table 4. TNM stages of 35 nonagenarians undergoing surgery for colorectal cancer. TNM stage n (%) 0 1 (3) I 5 (14) II 14 (40) III 14 (40) IV 1 (3)

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10 8 World Journal of Colorectal Surgery Vol. 4, Iss. 2 [2014], Art Management and survival of colorectal cancer in the elderly in population-based studies. Faivre J, Lemmens VE, Quipourt V, Bouvier AM. Eur J Cancer Oct; 43(15): Laparoscopic Resection for Colorectal Cancer Improves Short-term Outcomes in Very Elderly Colorectal Cancer Patients. Hatakeyama T, Nakanishi M, Murayama Y, Komatsu S, Shiozaki A, Kuriu Y, Ikoma H, Ichikawa D, Fujiwara H, Okamoto K, Ochiai T, Kokuba Y, Otsuji E. Surg Laparosc Endosc Percutan Tech Dec;23(6):