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Outcome of Colonic Surgery in Elderly Patients with Colon Cancer

Outcome of Colonic Surgery in Elderly Patients with Colon Cancer Hindawi Publishing Corporation Journal of Oncology Volume 2010, Article ID 865908, 5 pages doi:10.1155/2010/865908 Clinical Study Outcome of Colonic Surgery in Elderly Patients with Colon Cancer 1 1 1 1 2 E. Hermans, P. M. van Schaik, H. A. Prins, M. F. Ernst, P. J. L. Dautzenberg, and K. Bosscha Department of Surgery, Jeroen Bosch Hospital, Nieuwstraat 54, 5211’s-Hertogenbosch, The Netherlands Department of Geriatrics, Jeroen Bosch Hospital, Nieuwstraat 54, 5211’s-Hertogenbosch, The Netherlands Correspondence should be addressed to P. M. van Schaik, p.m.vanschaik@umcutrecht.nl Received 9 December 2009; Revised 27 March 2010; Accepted 12 April 2010 Academic Editor: Francis Seow-Choen Copyright © 2010 E. Hermans et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction. Colonic cancer is one of the most commonly diagnosed malignancies and most often occurs in patients aged 65 years or older. Aim. To evaluate the outcome of colonic surgery in the elderly in our hospital and to compare five-year survival rates between the younger and elderly patients. Methods. 207 consecutive patients underwent surgery for colon cancer. Patients were separated in patients younger than 75 and older than 75 years. Results. Elderly patients presented significantly more (P< .05) as a surgical emergency, had a longer duration of admission and were more often admitted to the ICU (P< .01). Also, elderly patients had significant more co-morbidities, especially cardiovascular pathology (P< .01). Post-operative complications were seen more often in the elderly, although no significant difference was seen in anastomotic leakage. The five-year survival rate in the younger group was 62% compared with 36% in the elderly (P< .05). DFS was 61% in the younger patients compared with 32% in the elderly (P< .05). Conclusion. Curative resection of colonic carcinoma in the elderly is well tolerated and age alone should not be an indication for less aggressive therapy. However, the type and number of co-morbidities influence post-operative mortality and morbidity. 1. Introduction Therefore, curative surgery of colonic cancer in elderly patients is debatable, especially in the very elderly patients, Colonic cancer is one of the most commonly diagnosed who have limited prospects of survival. Some authors malignancies in men and women in developed countries. promote extensive surgery, including multistage procedures, The disease rarely occurs before age of 40 and the risk of as performed in younger patients [5, 6]; others promote less colonic cancer is the highest around age of 70. Seventy-five aggressive surgery [7, 8]. percent of colon tumors are found in patients aged 65 years The aim of this study was to evaluate the outcome of or older [1]. colonic surgery in the elderly in our hospital to determine The incidence of colonic cancer has increased in the last the best treatment strategy in this patient category. decades. With the increase of age in the general population in developed countries the next future decades, the number of elderly patients who present with this disease will increase 2. Patients and Methods [2]. Unfortunately, most elderly patients who develop colonic cancer also have significant other comorbidities such In the period January 1999–January 2004, 207 consecutive as cardiovascular and pulmonary diseases, which increase patients underwent surgery for stages I–III colonic cancer. the operative risk and the risk of postoperative morbidity Patients with rectal cancer and patients that presented with and mortality [3]. Other factors that contribute to poor distant metastases were excluded. All patients were separated outcome of surgery in the elderly are delayed presentation into two groups, one group with patients younger than 75 and more advanced disease [4]. years and one group with patients older than 75 years. 2 Journal of Oncology Table 1: Patient and tumor characteristics. Table 2: Comorbidity. <75 year % >75 year % P-value Comorbidity <75 years % >75 years % P-value No. of patients 133 64% 74 36% Other malignancy 13 10% 9 12% NS Emergency setting 11 9% 16 22% P< .05 COPD 12 9% 10 13% NS Location of tumor Cardiovascular 33 25% 36 49% P< .01 Right hemicolon 58 44% 41 55% NS CVA 7 5% 3 4% NS Left hemicolon 22 17% 6 8% NS DVT 0 0% 1 1% NS Sigmoid 49 36% 25 34% NS Hypertension 10 8% 11 14% NS Double tumor 4 3% 2 3% NS DM 15 11% 8 11% NS Invasion depth Other 5 4% 9 12% P< .05 T1 8 6% 1 1% NS rheumatoid arthritis, hyperthyroidism, hypothyroidism, and scleroder- mia. T2 21 16% 11 15% NS T3 87 65% 51 69% NS T4 17 13% 12 15% NS were operated upon in an emergency setting, none of them Dukes’ classification had symptoms a month prior to operation. A 12 9% 8 11% NS No differences were found in tumor location, depth of invasion, or Dukes’ stage. B 60 45% 35 47% NS Patients’ characteristics and tumor features are summa- C 61 46% 31 42% NS rized in Table 1. The mean number of days of admittance to the hospital in the elderly group was 16.5 days [range 2–68]. The mean This separation was based on several other publications number of days of admittance to the ICU was 2.3 days [range concerning this subject [2, 9–11]. 0–38]. In the group <75 years the mean number of days of The following data were collected for each patient: admittance was 14.9 days [4–84], and the mean number of gender, age, location, and characteristics of the tumour, days of admittance to the ICU was 1.3 [0–30] (P< .01). Forty type of operation, duration of admittance, ICU admittance, percent of the elderly patients had to be admitted to the ICU comorbidity, complications, type of ileostomy/colostomy, compared with 18% in the younger group (P< .01). disease-free survival, and overall survival. Elderly patients more often presented with significant Comorbidity was classified according to an adapted comorbidity (Table 2) especially more cardiovascular pathol- version of Charlson et al. and was divided into previous ogy (P< .05) and demential syndrome (P< .01). Also, malignancies, COPD, cardiovascular disease, cerebrovascular elderly patients presented significantly more often with more disease, hypertension, diabetes, and other [12]. than one type of comorbidity according to the Charlson Followup was conducted according to the criteria of the classification (P< .05) when compared with the younger Dutch Cancer Centre recommendations. patients. Statistical analyses were performed using SPSS 13.0 Table 3 shows the performed types of surgery. These did (SPSS, Chicago, Ill, USA). Mann-Whitney U test was not significantly differ between the elderly and the younger performed to establish significance between the number of patients. In total 5 subtotal colectomies were performed, days of admittance in both groups. Chi-square test was one in an elderly patient, who had a large tumour in the performed to determine significance in nonparametric vari- sigmoid and a blow-out of the cecum. The other 4 subtotal ables. Kaplan-Meier curves were used in the disease-free sur- colectomies were performed in young patients with Lynch’s vivaland overallsurvival.P< .05 was found to be significant. Syndrome (HNPCC). In 85% of the elderly patients and in 86% of the younger 3. Results patients, a primary anastomosis was made. No significant Seventy-four of 207 patients (36%) were 75 years or older difference was found in the number and types of ileo- and when operated upon, male: female 30 : 44. The mean age of colostomies. the elderly patients was 80 years [range 75–100] compared Complications were seen in 32 younger patients (24%) with a mean age of 62 years in the group < 75 years [range andin37elderly patients (50%)(P< .01). No difference was 38–74]. Sixteen of 74 (22%) patients presented as a surgical found in major complications as anastomotic leakage, fascia emergency and were operated upon within 24 hours after dehiscence, or intraabdominal abscesses. presentation. Significant however was the higher number of pneu- In the younger group, 11 patients (9%) presented as a monias, wound infections, and minor complications (i.e., surgical emergency (P< .05). urinary tract infection, and electrolyte disturbances) in the In the elderly group thirteen patients (81%) had abdom- elderly group (P< .05). Also, the number of deliriums inal complaints for less than 3 weeks. was significantly higher in the elderly group (P< .01). In the other 3 patients there was serious patient delay Complications are listed in Table 4. because all had significant complaints for more than 6 weeks The in-hospital mortality was 16% (12 patients) in the and refused to seek medical care. In the younger patients that elderly and 5% (6 patients) in the younger group (P< .01). Journal of Oncology 3 Table 3: Type of operation and stomata. Type of operation < 75 years % >75 years % P-value Ileocecal resection 3 2% 3 4% NS Hemicolectomy right 56 42% 36 49% NS Transversum resection 2 1% 2 3% NS Hemicolectomy left 18 15% 6 8% NS Sigmoidresection 35 26% 16 22% NS Anteriorresection 13 10% 7 9% NS Subtotal colectomy 4 3% 1 1% NS Double resection 2 1% 3 4% NS Stomata 0 2 5 6 8 10 No. of primary 115 86% 63 85% NS anastomoses Figure 1: Kaplan-Meier 5-year overall-survival curve. Blue solid Total no. of stomata 18 14% 11 15% NS line for patients > 75 years and green solid line for patients < 75 End ileostomy 2 10% 1 9% NS years. End colostomy 9 50% 4 36% NS Loop ileostomy 6 21% 3 27% NS Significant however was the number of deaths during 5- Loop colostomy 1 5% 3 27% NS year followup which were not (colonic) cancer related, in the 3 patients with sigmoidresection and ileocecalresection because of younger group 4/51 versus 12/36 in the elderly (P< .01). danger of blow-out cecum, 2 hemicolectomy left and right because of Only 6 patients in the elderly group received adjuvant doubletumor. chemotherapy (8%), while 33 patients were qualified for adjuvant therapy. In the younger group 40 patients (30%) Table 4: Complications. received adjuvant therapy, while 68 patients were qualified. <75 years % >75 years % P-value Besides age, the main reason not to give adjuvant treatment Total no. of was a low Karnovsky index. 32 24% 32 43% P< .01 DFS was 61% in the younger patients compared with complications 32% in the elderly (P< .05). Anastomotic leakage 7 5% 4 5% NS Fascia dehiscention 5 4% 2 3% NS 4. Discussion Pneumoniae 5 4% 10 14% P< .05 Intraabdominal Surgical resection remains the core in curative treatment 5 4% 0 0% NS abscesses for colonic cancer. Due to the steadily expansion of the elder population in the industrialized world, surgeons will Delerium 21 16% 28 38% P< .01 be confronted with more and more elderly patients. Woun dinfection 1 1% 6 8% P< .05 In a systematic review, which was published in the Lancet Ileus 6 5% 6 8% NS in 2000, it is demonstrated that in elderly patients less often Minor complications 6 5% 10 14% P< .05 a resection of the tumour is performed than in younger In-hospital mortality 6 5% 12 16% P< .01 patients [9]. However, studies have shown that age alone is not a significant prognostic factor in survival after colonic surgery The mean age of the patients that died in the elderly group [13, 14]. was84years and67years in the youngergroup. Therefore, it is better to speak of biological age rather Of all elderly patients that died, 5 died of sepsis and than chronological age when assessing risk factors for multiple organ failure, 3 due to pneumonia or respiratory surgery, which focuses more on the overall condition of the failure, 2 due to myocardial infarction, and 1 due to a patient. high gastrointestinal bleeding. In the younger patients, 3 Because treatment options in colonic cancer increase, died of sepsis and 2 due to respiratory failure. A palliative recent literature shows a decrease in resection rate between resection was performed in 2 patients, each in one group. elderly and younger patients [15]. Unfortunately, these 2 patients were in such worse condition Specific problems related with elderly patients are, as that they died after prolonged ICU admittance. The five- mentioned earlier, a significant higher number of comorbidi- year survival rate of patients, who were treated with curative ties, prolonged in-hospital stay, and a delayed or emergency resection, was 62% in the younger group compared with presentation. In our study 77% of the elderly had at time of 36% in the elderly (P< .05) (Figure 1). When corrected surgery one or more types of comorbidity. This corresponds for cancer-related survival, the 5-year survival rate was 63% with other studies, which report an incidence of 70%–85% versus 42% (NS). [16, 17]. 4 Journal of Oncology Most patients in the elderly group were classified as ASA [5] T. T. Irvin, “Prognosis of colorectal cancer in the elderly,” British Journal of Surgery, vol. 75, no. 5, pp. 419–421, 1988. III. [6] T. Wobbes, “Carcinoma of the colon and rectum in geriatric It is well documented that emergency surgery is related patients,” Age and Ageing, vol. 14, no. 6, pp. 321–326, 1985. with a higher mortality rate than elective surgery [18, 19]. [7] A. G. Greenburg, R. P. Saik, and D. Pridham, “Influence of age When we compare 5-year survival between the patients on mortality of colon surgery,” American Journal of Surgery, that were operated in an emergency setting with the patients vol. 150, no. 1, pp. 65–70, 1985. who were operated electively, there was a significant differ- [8] V. Violi, N. Pietra, M. Grattarola, et al., “Curative surgery for ence in 5-year survival (39% versus 56%) (P< .01). colorectal cancer: long-term results and life expectancy in the In-hospital stay did not significantly differ between the elderly,” Diseases of the Colon and Rectum,vol. 41, no.3,pp. two groups. This is remarkable because of the high number 291–298, 1998. of postoperative complications (pneumonias, cardiovascular [9] “Colorectal cancer collaberative group surgery for colorectal problems, and deliriums) in the elderly group. Delirium is a patients in elderly patients: a systematic review,” Lancet, vol. known, serious complication with high incidence in elderly 356, pp. 968–974, 2000. patients. It increases the chance of other complications, a [10] P. G. Alley, “Surgery for colorectal cancer in elderly patients,” longer duration of admittance, worse recovery (physically Lancet, vol. 356, no. 9234, p. 956, 2000. and mentally), and a higher mortality [20, 21]. [11] J. Faivre, V. E. P. P. Lemmens, V. Quipourt, and A. M. Bouvier, In our study, we found significantly more deliriums in “Management and survival of colorectal cancer in the elderly in population-based studies,” European Journal of Cancer, vol. elderly patients. In a study, which recently took place in our 43, no. 15, pp. 2279–2284, 2007. clinic, to determine the incidence of delirium after elective [12] M. E. Charlson, P. Pompei, K. L. Ales, and C. R. MacKenzie, abdominal surgery, an incidence of 24% was found as well as “A new method of classifying prognostic comorbidity in a higher mortality rate [22]. longitudinal studies: development and validation,” Journal of The incidence of delirium in our study was 23%. Chronic Diseases, vol. 40, no. 5, pp. 373–383, 1987. The type of surgery also did not differ between the two [13] S. Avital, H. Kashtan, R. Hadad, and N. Werbin, “Survival groups. In both groups the same percentage of ileo- or of colorectal carcinoma in the elderly: a prospective study of colostomies was performed. In a study done by Lemmens colorectal carcinoma and a five-year follow-up,” Diseases of the et al. it was demonstrated that elderly patients with comor- Colon and Rectum, vol. 40, no. 5, pp. 523–529, 1997. bidity were treated less aggressively and therefore had worse [14] H. Spivak, D. V. Maele, I. Friedman, and M. Nussbaum, survival [23]. “Colorectal surgery in octogenarians,” Journal of the American Remarkable in followup was that 33% of the patients that College of Surgeons, vol. 183, no. 1, pp. 46–50, 1996. died in the elderly group died of noncolonic cancer-related [15] A. M. Bouvier, G. Launoy, C. Lepage, and J. Faivre, “Trends in causes which could be linked to preoperative comorbidities. the management and survival of digestive tract cancers among patients aged over 80 years,” Alimentary Pharmacology and In the younger group this was only 8%. After correction Therapeutics, vol. 22, no. 3, pp. 233–241, 2005. for colonic cancer-related 5-year survival, no significant [16] W. E. Wise Jr., A. Padmanabhan, D. M. Meesig, M. W. Arnold, difference could be found between the two groups. P. S. Aguilar, and W. R. C. Stewart, “Abdominal colon and rectal operations in the elderly,” Diseases of the Colon and 5. Conclusion Rectum, vol. 34, no. 11, pp. 959–963, 1991. [17] S. D. Fitzgerald,W.E.Longo,G.L.Daniel, andA.M.Vernava Curative resection of colonic carcinoma in the elderly is III, “Advanced colorectal neoplasia in the high-risk elderly well tolerated and age alone should not be an indication patient: is surgical resection justified?” Diseases of the Colon for less aggressive therapy. However, the type and number and Rectum, vol. 36, no. 2, pp. 161–166, 1993. of comorbidities influence postoperative mortality and mor- [18] C. S. McArdle and D. J. Hole, “Emergency presentation of bidity. Treatment of these comorbidities prior to surgery may colorectal cancer is associated with poor 5-year survival,” influence postoperative outcome. British Journal of Surgery, vol. 91, no. 5, pp. 605–609, 2004. [19] P. G. Setti Carraro, M. Segala, B. M. Cesana, and G. Tiberio, References “Obstructing colonic cancer: failure and survival patterns over a ten-year follow-up after one-stage curative surgery,” Diseases [1] R. T. Greenlee, M. B. Hill-Harmon, T. Murray, and M. Thun, of the Colon and Rectum, vol. 44, no. 2, pp. 243–250, 2001. “Cancer statistics,” Ca-A Cancer Journal for Clinicians, vol. 51, [20] K.-I. Aizawa, T. Kanai, Y. Saikawa, et al., “A novel approach no. 1, pp. 15–36, 2001. to the prevention of postoperative delirium in the elderly after [2] J. T. Makela, H. Kiviniemi, and S. Laitinen, “Survival after gastrointestinal surgery,” Surgery Today, vol. 32, no. 4, pp. 310– operations for colorectal cancer in patients aged 75 years or 314, 2002. over,” European Journal of Surgery, vol. 166, no. 6, pp. 473–479, [21] R. J. A. Van Wensen, P. L. J. Dautzenberg, H. L. Koek, J. G. Olsman, and K. Bosscha, “Delirium after a fractured hip in [3] M. F. De Marco, M. L. G. Janssen-Heijnen, L. H. van der more than one-third of the patients,” Nederlands Tijdschrift Heijden, and J. W. W. Coebergh, “Comorbidity and colorectal voor Geneeskunde, vol. 151, no. 30, pp. 1681–1685, 2007. cancer according to subsite and stagea population-based study,” European Journal of Cancer, vol. 36, no. 1, pp. 95–99, [22] B. Koebrugge, H. L. Koek,R.J.A.van Wensen,P.L.J. Dautzenberg, and K. Bosscha, “Delirium after abdominal [4] N.A.Scott, J. Jeacock, andR.D.Kingston,“Risk factorsin surgery at a surgical ward with a high standard of delirium care: incidence, risk factors and outcomes,” Digestive Surgery, patients presenting as an emergency with colorectal cancer,” British Journal of Surgery, vol. 82, no. 3, pp. 321–323, 2005. vol. 26, no. 1, pp. 63–68, 2009. Journal of Oncology 5 [23] V. E. P. P. Lemmens, M. L. G. Janssen-Heijnen, C. D. G. W. Verheij, S. Houterman, O. J. Repelaer Van Driel, and J. W. W. Coebergh, “Co-morbidity leads to altered treatment and worse survival of elderly patients with colorectal cancer,” British Journal of Surgery, vol. 92, no. 5, pp. 615–623, 2005. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Oncology Pubmed Central

Outcome of Colonic Surgery in Elderly Patients with Colon Cancer

Journal of Oncology , Volume 2010 – Jun 13, 2010

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Pubmed Central
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Copyright © 2010 E. Hermans et al.
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1687-8450
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10.1155/2010/865908
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Abstract

Hindawi Publishing Corporation Journal of Oncology Volume 2010, Article ID 865908, 5 pages doi:10.1155/2010/865908 Clinical Study Outcome of Colonic Surgery in Elderly Patients with Colon Cancer 1 1 1 1 2 E. Hermans, P. M. van Schaik, H. A. Prins, M. F. Ernst, P. J. L. Dautzenberg, and K. Bosscha Department of Surgery, Jeroen Bosch Hospital, Nieuwstraat 54, 5211’s-Hertogenbosch, The Netherlands Department of Geriatrics, Jeroen Bosch Hospital, Nieuwstraat 54, 5211’s-Hertogenbosch, The Netherlands Correspondence should be addressed to P. M. van Schaik, p.m.vanschaik@umcutrecht.nl Received 9 December 2009; Revised 27 March 2010; Accepted 12 April 2010 Academic Editor: Francis Seow-Choen Copyright © 2010 E. Hermans et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction. Colonic cancer is one of the most commonly diagnosed malignancies and most often occurs in patients aged 65 years or older. Aim. To evaluate the outcome of colonic surgery in the elderly in our hospital and to compare five-year survival rates between the younger and elderly patients. Methods. 207 consecutive patients underwent surgery for colon cancer. Patients were separated in patients younger than 75 and older than 75 years. Results. Elderly patients presented significantly more (P< .05) as a surgical emergency, had a longer duration of admission and were more often admitted to the ICU (P< .01). Also, elderly patients had significant more co-morbidities, especially cardiovascular pathology (P< .01). Post-operative complications were seen more often in the elderly, although no significant difference was seen in anastomotic leakage. The five-year survival rate in the younger group was 62% compared with 36% in the elderly (P< .05). DFS was 61% in the younger patients compared with 32% in the elderly (P< .05). Conclusion. Curative resection of colonic carcinoma in the elderly is well tolerated and age alone should not be an indication for less aggressive therapy. However, the type and number of co-morbidities influence post-operative mortality and morbidity. 1. Introduction Therefore, curative surgery of colonic cancer in elderly patients is debatable, especially in the very elderly patients, Colonic cancer is one of the most commonly diagnosed who have limited prospects of survival. Some authors malignancies in men and women in developed countries. promote extensive surgery, including multistage procedures, The disease rarely occurs before age of 40 and the risk of as performed in younger patients [5, 6]; others promote less colonic cancer is the highest around age of 70. Seventy-five aggressive surgery [7, 8]. percent of colon tumors are found in patients aged 65 years The aim of this study was to evaluate the outcome of or older [1]. colonic surgery in the elderly in our hospital to determine The incidence of colonic cancer has increased in the last the best treatment strategy in this patient category. decades. With the increase of age in the general population in developed countries the next future decades, the number of elderly patients who present with this disease will increase 2. Patients and Methods [2]. Unfortunately, most elderly patients who develop colonic cancer also have significant other comorbidities such In the period January 1999–January 2004, 207 consecutive as cardiovascular and pulmonary diseases, which increase patients underwent surgery for stages I–III colonic cancer. the operative risk and the risk of postoperative morbidity Patients with rectal cancer and patients that presented with and mortality [3]. Other factors that contribute to poor distant metastases were excluded. All patients were separated outcome of surgery in the elderly are delayed presentation into two groups, one group with patients younger than 75 and more advanced disease [4]. years and one group with patients older than 75 years. 2 Journal of Oncology Table 1: Patient and tumor characteristics. Table 2: Comorbidity. <75 year % >75 year % P-value Comorbidity <75 years % >75 years % P-value No. of patients 133 64% 74 36% Other malignancy 13 10% 9 12% NS Emergency setting 11 9% 16 22% P< .05 COPD 12 9% 10 13% NS Location of tumor Cardiovascular 33 25% 36 49% P< .01 Right hemicolon 58 44% 41 55% NS CVA 7 5% 3 4% NS Left hemicolon 22 17% 6 8% NS DVT 0 0% 1 1% NS Sigmoid 49 36% 25 34% NS Hypertension 10 8% 11 14% NS Double tumor 4 3% 2 3% NS DM 15 11% 8 11% NS Invasion depth Other 5 4% 9 12% P< .05 T1 8 6% 1 1% NS rheumatoid arthritis, hyperthyroidism, hypothyroidism, and scleroder- mia. T2 21 16% 11 15% NS T3 87 65% 51 69% NS T4 17 13% 12 15% NS were operated upon in an emergency setting, none of them Dukes’ classification had symptoms a month prior to operation. A 12 9% 8 11% NS No differences were found in tumor location, depth of invasion, or Dukes’ stage. B 60 45% 35 47% NS Patients’ characteristics and tumor features are summa- C 61 46% 31 42% NS rized in Table 1. The mean number of days of admittance to the hospital in the elderly group was 16.5 days [range 2–68]. The mean This separation was based on several other publications number of days of admittance to the ICU was 2.3 days [range concerning this subject [2, 9–11]. 0–38]. In the group <75 years the mean number of days of The following data were collected for each patient: admittance was 14.9 days [4–84], and the mean number of gender, age, location, and characteristics of the tumour, days of admittance to the ICU was 1.3 [0–30] (P< .01). Forty type of operation, duration of admittance, ICU admittance, percent of the elderly patients had to be admitted to the ICU comorbidity, complications, type of ileostomy/colostomy, compared with 18% in the younger group (P< .01). disease-free survival, and overall survival. Elderly patients more often presented with significant Comorbidity was classified according to an adapted comorbidity (Table 2) especially more cardiovascular pathol- version of Charlson et al. and was divided into previous ogy (P< .05) and demential syndrome (P< .01). Also, malignancies, COPD, cardiovascular disease, cerebrovascular elderly patients presented significantly more often with more disease, hypertension, diabetes, and other [12]. than one type of comorbidity according to the Charlson Followup was conducted according to the criteria of the classification (P< .05) when compared with the younger Dutch Cancer Centre recommendations. patients. Statistical analyses were performed using SPSS 13.0 Table 3 shows the performed types of surgery. These did (SPSS, Chicago, Ill, USA). Mann-Whitney U test was not significantly differ between the elderly and the younger performed to establish significance between the number of patients. In total 5 subtotal colectomies were performed, days of admittance in both groups. Chi-square test was one in an elderly patient, who had a large tumour in the performed to determine significance in nonparametric vari- sigmoid and a blow-out of the cecum. The other 4 subtotal ables. Kaplan-Meier curves were used in the disease-free sur- colectomies were performed in young patients with Lynch’s vivaland overallsurvival.P< .05 was found to be significant. Syndrome (HNPCC). In 85% of the elderly patients and in 86% of the younger 3. Results patients, a primary anastomosis was made. No significant Seventy-four of 207 patients (36%) were 75 years or older difference was found in the number and types of ileo- and when operated upon, male: female 30 : 44. The mean age of colostomies. the elderly patients was 80 years [range 75–100] compared Complications were seen in 32 younger patients (24%) with a mean age of 62 years in the group < 75 years [range andin37elderly patients (50%)(P< .01). No difference was 38–74]. Sixteen of 74 (22%) patients presented as a surgical found in major complications as anastomotic leakage, fascia emergency and were operated upon within 24 hours after dehiscence, or intraabdominal abscesses. presentation. Significant however was the higher number of pneu- In the younger group, 11 patients (9%) presented as a monias, wound infections, and minor complications (i.e., surgical emergency (P< .05). urinary tract infection, and electrolyte disturbances) in the In the elderly group thirteen patients (81%) had abdom- elderly group (P< .05). Also, the number of deliriums inal complaints for less than 3 weeks. was significantly higher in the elderly group (P< .01). In the other 3 patients there was serious patient delay Complications are listed in Table 4. because all had significant complaints for more than 6 weeks The in-hospital mortality was 16% (12 patients) in the and refused to seek medical care. In the younger patients that elderly and 5% (6 patients) in the younger group (P< .01). Journal of Oncology 3 Table 3: Type of operation and stomata. Type of operation < 75 years % >75 years % P-value Ileocecal resection 3 2% 3 4% NS Hemicolectomy right 56 42% 36 49% NS Transversum resection 2 1% 2 3% NS Hemicolectomy left 18 15% 6 8% NS Sigmoidresection 35 26% 16 22% NS Anteriorresection 13 10% 7 9% NS Subtotal colectomy 4 3% 1 1% NS Double resection 2 1% 3 4% NS Stomata 0 2 5 6 8 10 No. of primary 115 86% 63 85% NS anastomoses Figure 1: Kaplan-Meier 5-year overall-survival curve. Blue solid Total no. of stomata 18 14% 11 15% NS line for patients > 75 years and green solid line for patients < 75 End ileostomy 2 10% 1 9% NS years. End colostomy 9 50% 4 36% NS Loop ileostomy 6 21% 3 27% NS Significant however was the number of deaths during 5- Loop colostomy 1 5% 3 27% NS year followup which were not (colonic) cancer related, in the 3 patients with sigmoidresection and ileocecalresection because of younger group 4/51 versus 12/36 in the elderly (P< .01). danger of blow-out cecum, 2 hemicolectomy left and right because of Only 6 patients in the elderly group received adjuvant doubletumor. chemotherapy (8%), while 33 patients were qualified for adjuvant therapy. In the younger group 40 patients (30%) Table 4: Complications. received adjuvant therapy, while 68 patients were qualified. <75 years % >75 years % P-value Besides age, the main reason not to give adjuvant treatment Total no. of was a low Karnovsky index. 32 24% 32 43% P< .01 DFS was 61% in the younger patients compared with complications 32% in the elderly (P< .05). Anastomotic leakage 7 5% 4 5% NS Fascia dehiscention 5 4% 2 3% NS 4. Discussion Pneumoniae 5 4% 10 14% P< .05 Intraabdominal Surgical resection remains the core in curative treatment 5 4% 0 0% NS abscesses for colonic cancer. Due to the steadily expansion of the elder population in the industrialized world, surgeons will Delerium 21 16% 28 38% P< .01 be confronted with more and more elderly patients. Woun dinfection 1 1% 6 8% P< .05 In a systematic review, which was published in the Lancet Ileus 6 5% 6 8% NS in 2000, it is demonstrated that in elderly patients less often Minor complications 6 5% 10 14% P< .05 a resection of the tumour is performed than in younger In-hospital mortality 6 5% 12 16% P< .01 patients [9]. However, studies have shown that age alone is not a significant prognostic factor in survival after colonic surgery The mean age of the patients that died in the elderly group [13, 14]. was84years and67years in the youngergroup. Therefore, it is better to speak of biological age rather Of all elderly patients that died, 5 died of sepsis and than chronological age when assessing risk factors for multiple organ failure, 3 due to pneumonia or respiratory surgery, which focuses more on the overall condition of the failure, 2 due to myocardial infarction, and 1 due to a patient. high gastrointestinal bleeding. In the younger patients, 3 Because treatment options in colonic cancer increase, died of sepsis and 2 due to respiratory failure. A palliative recent literature shows a decrease in resection rate between resection was performed in 2 patients, each in one group. elderly and younger patients [15]. Unfortunately, these 2 patients were in such worse condition Specific problems related with elderly patients are, as that they died after prolonged ICU admittance. The five- mentioned earlier, a significant higher number of comorbidi- year survival rate of patients, who were treated with curative ties, prolonged in-hospital stay, and a delayed or emergency resection, was 62% in the younger group compared with presentation. In our study 77% of the elderly had at time of 36% in the elderly (P< .05) (Figure 1). When corrected surgery one or more types of comorbidity. 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Published: Jun 13, 2010

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