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Emergency Surgery for Colon Cancer in the Aged

Emergency Surgery for Colon Cancer in the Aged Abstract Background: The prognosis of colon cancer is poorest in cases of emergency presentation of this disease in the elderly. The high rate of clinical mortality in this group of patients has made it necessary to devise a specific therapeutic approach. Objective: To define the therapeutic approach used for colon cancer in the elderly. Design: A retrospective study. Setting: A secondary referral center. Patients: Ninety-nine patients with colon carcinoma that first became clinically manifested in an emergency situation were examined retrospectively. The patients had been treated from 1986 through 1995. All patients were older than 70 years. A total of 74 patients showed clinical manifestation of a colon carcinoma with an ileus, while 10 patients had tumor perforation. A further 15 patients had a perforation proximal to an obstructing tumor. Main Outcome Measures: Clinical lethality, surgical procedure, risk of comorbidity, and multiple organ system failure. Results: Any increase in comorbidity was associated with a higher clinical lethality, which was especially true for the lungs, heart, and kidney, and also for diabetes. In 44.4% of the patients with a significantly higher comorbidity (P=.04) and a more advanced tumor stage (P<.001), the tumor was left in situ during the primary surgical intervention. Patients who survived after staged resection had an even higher comorbidity at first presentation when compared with patients who survived after primary resection (P=.02). However, the comorbidity of deceased patients who were supposed to undergo staged resection did not differ significantly from the comorbidity of those who underwent primary resection (P=.70). The clinical lethality in patients who were managed by stoma only or by bypass anastomosis was markedly higher than that in patients who underwent primary resection (59.0% vs 43.6%). The significantly highest postoperative mortality rate was recorded in patients who underwent primary resection after colonic perforation (74%) (P=.03),while the significantly lowest postoperative mortality rate was recorded in patients who underwent primary resection after tumor obstruction (28%) (P<.001). Postoperative failure of the lungs and heart and kidney failure requiring hemodialysis were associated with significantly higher clinical mortality rates (P<.001 to P=.004). Postoperative complications occurred in 28 (28.3%) of the patients. However, rupture of the anastomosis was observed in only 2 of these patients. Generalized disease was associated with a significantly higher rate of postoperative complications (P=.04), which was especially true for pneumonia (P=.003). However, no effect on survival was found for patients with Dukes disease stage D. Conclusions: The lower mortality rate following primary resection is achieved by preselection of patients. The preselection is such that patients in poor general condition who have tumors in advanced stages are not treated by resection. The significantly (P=.03) highest postoperative mortality rate in patients who underwent primary resection after tumor perforation reflects the necessity of resection in those cases regardless of higher comorbidity. In an emergency situation, initial minimal surgery followed by staged resection is a feasible alternative to treat aged patients with a higher comorbidity and an intraoperatively established greater spread of tumor. This procedure permits delayed radical resection at the lowest rate of clinical mortality for this age group and is especially suitable for frail, aged patients in poor condition. The advantages of staged resection can be demonstrated by the fact that more patients with a higher comorbidity survive. The poor physiological adaptability of elderly patients limits their ability to compensate for postoperative organ failure and adds the risk of comorbidity. Hence, these 2 factors are associated with poor prognosis in this age group.Arch Surg. 1997;132:1032-1037 References 1. Herfarth C, Runkel N. Chirurgische Standards beim primären Coloncarcinom . Chirurg . 1994;65:514-523. 2. Hermanek P Jr, Wiebelt H, Riedl S, Staimmer D, Hermanek P. Langzeitergebnisse der chirurgischen Therapie des Coloncarcinoms . Chirurg . 1994;65:287-297. 3. Jatzko G, Lisborg P, Wette V. Improving survival rates for patients with colorectal cancer . Br J Surg . 1992;79:588-591.Crossref 4. Payne JE, Chapuis PH, Pheils MT. Surgery for large bowel cancer in people aged 75 years and older . Dis Colon Rectum . 1986;29:733-737.Crossref 5. Boyd JB, Bradford B, Watne AL. Operative risk factors of colon resection in the elderly . Ann Surg . 1980;192:743-746.Crossref 6. Walsh TH. Audit of outcome of major surgery in the elderly . Br J Surg . 1996;83: 92-97.Crossref 7. Arnaud JP, Schloegel M, Oilier JC, Adloff M. Colorectal cancer in patients over 80 years of age . Dis Colon Rectum . 1991;34:896-898.Crossref 8. Umpleby HC, Bristol JB, Rainey JB, Williamson RCN, Chir M. Survival of 727 patients with single carcinomas of the large bowel . Dis Colon Rectum . 1981;27: 803-810.Crossref 9. Goris RJ, te Boekhorst TP, Nuytinck JK, Gimbrere JS. Multiple-organ failure: generalized autodestructive inflammation? Arch Surg . 1985;120:1109-1115.Crossref 10. Koperna T, Schulz F. Prognosis and treatment of peritonitis: do we need new scoring systems? Arch Surg . 1996;131:180-186.Crossref 11. Anderson JH, Hole D, McArdle CS. Elective versus emergency surgery for patients with colorectal cancer . Br J Surg . 1992;79:706-709.Crossref 12. Deutsch AA, Zelikovski A, Sternberg A, Reiss R. One-stage subtotal colectomy with anastomosis for obstructing carcinoma of the left colon . Dis Colon Rectum . 1983;26:227-230.Crossref 13. Fielding LP, Stewart-Brown S, Blesovsky L. Large-bowel obstruction caused by cancer: a prospective study . BMJ . 1979;2:515-517.Crossref 14. Hermanek PJ Jr, Schweiger M, Gall FP. Das colorectale Carcinom als chirurgischer Notfall . Langenbecks Arch Chir . 1985;366:461-465.Crossref 15. Jatzko G, Lisborg P, Wette V, Pertl A, Horn M, Wiercinski J. Der chirurgische Notfalleingriff bei akuten Dickdarmerkrankungen . Zentralbl Chir . 1992;117:589-594. 16. Leitman IM, Sullivan JD, Brams D, De Cosse JJ. Multivariate analysis of morbidity and mortality from the initial surgical management of obstruction carcinoma of the colon . Surg Gynecol Obstet . 1992;174:513-518. 17. Nespoli A, Ravizzini C, Trivella M, Segala M. The choice of surgical procedure for peritonitis due to colonic perforation . Arch Surg . 1993;128:814-818.Crossref 18. Runkel NS, Schlag P, Schwarz V, Herfarth C. Outcome after emergency surgery for cancer of the large intestine . Br J Surg . 1991;78:183-188.Crossref 19. Smithers BM, Theile DE, Cohen JR, Evans EB, Davis NC. Emergency right hemicolectomy in colon carcinoma: a prospective study . Aust N Z J Surg . 1986;56: 749-752.Crossref 20. Vigder L, Tzur N, Huber M, Mahagna M, Amir I. Management of obstructive carcinoma of the left colon: comparative study of staged and primary resection . Arch Surg . 1985;120:825-828.Crossref 21. White CM, Macfie J. Immediate colectomy and primary anastomosis for acute obstruction due to carcinoma of the left colon and rectum . Dis Colon Rectum . 1985;28:155-157.Crossref 22. Kaufman Z, Eiltch E, Dinbar A. Completely obstructive colorectal cancer . J Surg Oncol . 1989;41:230-235.Crossref 23. Riedl S, Wiebelt H, Bergmann U, Hermanek P Jr. Postoperative Komplikationen und Letalität in der chirurgischen Therapie des Coloncarcinoms . Chirurg . 1995; 66:597-606. 24. Waldron RP, Donovan IA, Drumm J, Mottram SN, Tedman S. Emergency presentation and mortality from colorectal cancer in the elderly . Br J Surg . 1986: 73:214-216.Crossref 25. Waldron RP, Donovan IA. Mortality in patients with obstructing colorectal cancer . Ann R Coll Surg Engl . 1986;68:219-221. 26. Phillips RKS, Hittinger R, Fry JS, Helding LP. Malignant large bowel obstruction . Br J Surg . 1985;72:296-302.Crossref 27. Beckman EN, Gathright JB, Ray JE. A potentially brighter prognosis for colon carcinoma in the third and fourth decades . Cancer . 1984;54:1478-1481.Crossref 28. Green JB, Timmcke AE, Mitchell WT, Hicks TC, Gathright JB, Ray JE. Mucinous carcinoma: just another colon cancer? Dis Colon Rectum . 1993;36:49-54.Crossref 29. Kashtan H, Werbin N, Aladjem D, Barak Y, Wiznitzer T. Right and left colon carcinoma: a retrospective comparative study . J Surg Oncol . 1987;35:245-248.Crossref 30. Reifferscheid M, Fass J, Hartung R, Mittermayer C. Besondere Aspekte des Rechtscoloncarcinoms . Langenbecks Arch Chir . 1987;371:193-200.Crossref 31. Mendes da Costa PR, Lurquin P. Gastrointestinal surgery in the aged . Br J Surg . 1993:80:329.Crossref 32. Turunen MJ, Peltokallio P. Surgical results in 657 patients with colorectal cancer . Dis Colon Rectum . 1983;26:606-612.Crossref 33. Dellinger EP, Wertz MJ, Meakins JL, et al. Surgical infection stratification system for intra-abdominal infection . Arch Surg . 1985;120:21-29.Crossref 34. Ohmann C, Wittmann DH, Wacha H, and the Peritonitis Study Group. Prospective evaluation of prognostic evaluation of prognostic scoring systems in peritonitis . Eur J Surg . 1993;159:267-274. 35. Wahl W, Minkus A, Junginger T. Prognostisch relevante Faktoren bei der intra-abdominalen Infektion . Langenbecks Arch Chir . 1992;377:237-243. 36. Barthlen W, Bartels H, Busch R, Siewert JR. Prognosefaktoren bei der diffusen Peritonitis . Langenbecks Arch Chir . 1992;377:89-93.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Surgery American Medical Association

Emergency Surgery for Colon Cancer in the Aged

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Publisher
American Medical Association
Copyright
Copyright © 1997 American Medical Association. All Rights Reserved.
ISSN
0004-0010
eISSN
1538-3644
DOI
10.1001/archsurg.1997.01430330098018
Publisher site
See Article on Publisher Site

Abstract

Abstract Background: The prognosis of colon cancer is poorest in cases of emergency presentation of this disease in the elderly. The high rate of clinical mortality in this group of patients has made it necessary to devise a specific therapeutic approach. Objective: To define the therapeutic approach used for colon cancer in the elderly. Design: A retrospective study. Setting: A secondary referral center. Patients: Ninety-nine patients with colon carcinoma that first became clinically manifested in an emergency situation were examined retrospectively. The patients had been treated from 1986 through 1995. All patients were older than 70 years. A total of 74 patients showed clinical manifestation of a colon carcinoma with an ileus, while 10 patients had tumor perforation. A further 15 patients had a perforation proximal to an obstructing tumor. Main Outcome Measures: Clinical lethality, surgical procedure, risk of comorbidity, and multiple organ system failure. Results: Any increase in comorbidity was associated with a higher clinical lethality, which was especially true for the lungs, heart, and kidney, and also for diabetes. In 44.4% of the patients with a significantly higher comorbidity (P=.04) and a more advanced tumor stage (P<.001), the tumor was left in situ during the primary surgical intervention. Patients who survived after staged resection had an even higher comorbidity at first presentation when compared with patients who survived after primary resection (P=.02). However, the comorbidity of deceased patients who were supposed to undergo staged resection did not differ significantly from the comorbidity of those who underwent primary resection (P=.70). The clinical lethality in patients who were managed by stoma only or by bypass anastomosis was markedly higher than that in patients who underwent primary resection (59.0% vs 43.6%). The significantly highest postoperative mortality rate was recorded in patients who underwent primary resection after colonic perforation (74%) (P=.03),while the significantly lowest postoperative mortality rate was recorded in patients who underwent primary resection after tumor obstruction (28%) (P<.001). Postoperative failure of the lungs and heart and kidney failure requiring hemodialysis were associated with significantly higher clinical mortality rates (P<.001 to P=.004). Postoperative complications occurred in 28 (28.3%) of the patients. However, rupture of the anastomosis was observed in only 2 of these patients. Generalized disease was associated with a significantly higher rate of postoperative complications (P=.04), which was especially true for pneumonia (P=.003). However, no effect on survival was found for patients with Dukes disease stage D. Conclusions: The lower mortality rate following primary resection is achieved by preselection of patients. The preselection is such that patients in poor general condition who have tumors in advanced stages are not treated by resection. The significantly (P=.03) highest postoperative mortality rate in patients who underwent primary resection after tumor perforation reflects the necessity of resection in those cases regardless of higher comorbidity. In an emergency situation, initial minimal surgery followed by staged resection is a feasible alternative to treat aged patients with a higher comorbidity and an intraoperatively established greater spread of tumor. This procedure permits delayed radical resection at the lowest rate of clinical mortality for this age group and is especially suitable for frail, aged patients in poor condition. The advantages of staged resection can be demonstrated by the fact that more patients with a higher comorbidity survive. The poor physiological adaptability of elderly patients limits their ability to compensate for postoperative organ failure and adds the risk of comorbidity. Hence, these 2 factors are associated with poor prognosis in this age group.Arch Surg. 1997;132:1032-1037 References 1. Herfarth C, Runkel N. Chirurgische Standards beim primären Coloncarcinom . Chirurg . 1994;65:514-523. 2. Hermanek P Jr, Wiebelt H, Riedl S, Staimmer D, Hermanek P. Langzeitergebnisse der chirurgischen Therapie des Coloncarcinoms . Chirurg . 1994;65:287-297. 3. Jatzko G, Lisborg P, Wette V. Improving survival rates for patients with colorectal cancer . Br J Surg . 1992;79:588-591.Crossref 4. Payne JE, Chapuis PH, Pheils MT. Surgery for large bowel cancer in people aged 75 years and older . Dis Colon Rectum . 1986;29:733-737.Crossref 5. Boyd JB, Bradford B, Watne AL. Operative risk factors of colon resection in the elderly . Ann Surg . 1980;192:743-746.Crossref 6. Walsh TH. Audit of outcome of major surgery in the elderly . Br J Surg . 1996;83: 92-97.Crossref 7. Arnaud JP, Schloegel M, Oilier JC, Adloff M. Colorectal cancer in patients over 80 years of age . Dis Colon Rectum . 1991;34:896-898.Crossref 8. Umpleby HC, Bristol JB, Rainey JB, Williamson RCN, Chir M. Survival of 727 patients with single carcinomas of the large bowel . Dis Colon Rectum . 1981;27: 803-810.Crossref 9. Goris RJ, te Boekhorst TP, Nuytinck JK, Gimbrere JS. Multiple-organ failure: generalized autodestructive inflammation? Arch Surg . 1985;120:1109-1115.Crossref 10. Koperna T, Schulz F. Prognosis and treatment of peritonitis: do we need new scoring systems? Arch Surg . 1996;131:180-186.Crossref 11. Anderson JH, Hole D, McArdle CS. Elective versus emergency surgery for patients with colorectal cancer . Br J Surg . 1992;79:706-709.Crossref 12. Deutsch AA, Zelikovski A, Sternberg A, Reiss R. One-stage subtotal colectomy with anastomosis for obstructing carcinoma of the left colon . Dis Colon Rectum . 1983;26:227-230.Crossref 13. Fielding LP, Stewart-Brown S, Blesovsky L. Large-bowel obstruction caused by cancer: a prospective study . BMJ . 1979;2:515-517.Crossref 14. Hermanek PJ Jr, Schweiger M, Gall FP. Das colorectale Carcinom als chirurgischer Notfall . Langenbecks Arch Chir . 1985;366:461-465.Crossref 15. Jatzko G, Lisborg P, Wette V, Pertl A, Horn M, Wiercinski J. Der chirurgische Notfalleingriff bei akuten Dickdarmerkrankungen . Zentralbl Chir . 1992;117:589-594. 16. Leitman IM, Sullivan JD, Brams D, De Cosse JJ. Multivariate analysis of morbidity and mortality from the initial surgical management of obstruction carcinoma of the colon . Surg Gynecol Obstet . 1992;174:513-518. 17. Nespoli A, Ravizzini C, Trivella M, Segala M. The choice of surgical procedure for peritonitis due to colonic perforation . Arch Surg . 1993;128:814-818.Crossref 18. Runkel NS, Schlag P, Schwarz V, Herfarth C. Outcome after emergency surgery for cancer of the large intestine . Br J Surg . 1991;78:183-188.Crossref 19. Smithers BM, Theile DE, Cohen JR, Evans EB, Davis NC. Emergency right hemicolectomy in colon carcinoma: a prospective study . Aust N Z J Surg . 1986;56: 749-752.Crossref 20. Vigder L, Tzur N, Huber M, Mahagna M, Amir I. Management of obstructive carcinoma of the left colon: comparative study of staged and primary resection . Arch Surg . 1985;120:825-828.Crossref 21. White CM, Macfie J. Immediate colectomy and primary anastomosis for acute obstruction due to carcinoma of the left colon and rectum . Dis Colon Rectum . 1985;28:155-157.Crossref 22. Kaufman Z, Eiltch E, Dinbar A. Completely obstructive colorectal cancer . J Surg Oncol . 1989;41:230-235.Crossref 23. Riedl S, Wiebelt H, Bergmann U, Hermanek P Jr. Postoperative Komplikationen und Letalität in der chirurgischen Therapie des Coloncarcinoms . Chirurg . 1995; 66:597-606. 24. Waldron RP, Donovan IA, Drumm J, Mottram SN, Tedman S. Emergency presentation and mortality from colorectal cancer in the elderly . Br J Surg . 1986: 73:214-216.Crossref 25. Waldron RP, Donovan IA. Mortality in patients with obstructing colorectal cancer . Ann R Coll Surg Engl . 1986;68:219-221. 26. Phillips RKS, Hittinger R, Fry JS, Helding LP. Malignant large bowel obstruction . Br J Surg . 1985;72:296-302.Crossref 27. Beckman EN, Gathright JB, Ray JE. A potentially brighter prognosis for colon carcinoma in the third and fourth decades . Cancer . 1984;54:1478-1481.Crossref 28. Green JB, Timmcke AE, Mitchell WT, Hicks TC, Gathright JB, Ray JE. Mucinous carcinoma: just another colon cancer? Dis Colon Rectum . 1993;36:49-54.Crossref 29. Kashtan H, Werbin N, Aladjem D, Barak Y, Wiznitzer T. Right and left colon carcinoma: a retrospective comparative study . J Surg Oncol . 1987;35:245-248.Crossref 30. Reifferscheid M, Fass J, Hartung R, Mittermayer C. Besondere Aspekte des Rechtscoloncarcinoms . Langenbecks Arch Chir . 1987;371:193-200.Crossref 31. Mendes da Costa PR, Lurquin P. Gastrointestinal surgery in the aged . Br J Surg . 1993:80:329.Crossref 32. Turunen MJ, Peltokallio P. Surgical results in 657 patients with colorectal cancer . Dis Colon Rectum . 1983;26:606-612.Crossref 33. Dellinger EP, Wertz MJ, Meakins JL, et al. Surgical infection stratification system for intra-abdominal infection . Arch Surg . 1985;120:21-29.Crossref 34. Ohmann C, Wittmann DH, Wacha H, and the Peritonitis Study Group. Prospective evaluation of prognostic evaluation of prognostic scoring systems in peritonitis . Eur J Surg . 1993;159:267-274. 35. Wahl W, Minkus A, Junginger T. Prognostisch relevante Faktoren bei der intra-abdominalen Infektion . Langenbecks Arch Chir . 1992;377:237-243. 36. Barthlen W, Bartels H, Busch R, Siewert JR. Prognosefaktoren bei der diffusen Peritonitis . Langenbecks Arch Chir . 1992;377:89-93.Crossref

Journal

Archives of SurgeryAmerican Medical Association

Published: Sep 1, 1997

References

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