Colorectal Surgery & Preoperative Risk in the

Elderly

1st Geneva International Scientific Day on Senior Visceral Surgery

RA Audisio, MD, FRCSUniversity of Liverpool UK

Gerontography

http://www.worldmapper.org/index.html

People >80 (2000, projections for 2030 and 2050)US Census Bureau & National Institute on Aging report1

Age-specific colon ca. - Japan

Ann Oncol. 1997 Apr;8(4):317-26Elective surgery for gastrointestinal tumours in the elderlyAudisio RA, et al.

Authors age n. pts op. † % 5yr surv %_______________________________________________________________________Jensen, Hermanek, Waldron, Umpley,Irvin, Brown, > 70 2,834 12 (1-29) 48 (26-52)Katshan, Mulcahy

Payne, Bader,Raab, Kingston > 75 990 10 (7-14) 46 (31-50)

Arnad, Sunouchi > 80 150 20 41

older patients can be operated

good long-term cancer outcomes

slightly increased short-term outcomes

selection bias

Evidence of under-management:

NJ Turner BMJ 1999

under-staging

Tekkis et al ACPGBI CRC study 2002

lymph node positivity with age

lymph node harvest with age

Tekkis et al ACPGBI CRC study 2003

assessing frailty

Definition of frailty is crucial in:

Designing Clinical Studies/Trials

Consenting patient

Individualising treatment

Predicting outcome

Comparing series

life expectancy

n./severity of comorbidities

CGA – MGA – screening tools

“rule of thumb”

ASA - POSSUM

Patients’ selection

the Rule of ThumbSurgical assessment was highly

accurate…

lack of consistency

…but not reproducible

Life expectancy tables

consistency in advise to treatmentmean 68.6% (range 30.9% - 91.6%)

Life expectancy tables

Prevalence of comorbidity across the age spectrum

Piccirillo JF. Crit Rev Onc Hem 2008

Comorbidity is prognostically most important in situations where the prognostic impact of the tumour is small.

Comorbidity

Read WL. JCO 2004

Conversely, where the tumour is advanced or aggressive and the prognosis is poor, comorbidity information is less important.

Age & co-morbiditiesare NOT

independent risk factors for operative mortality

• Comorbidities & Functional Status are independent

• Correlation between PS & ADL/IADL is moderate

• Patients with comorbidities do not have a higher risk of developing complications

Comorbidities

Extermann M. JCO 1998Repetto L. JCO 2002Lemmens V. WJSO 2006

POSSUM & P-POSSUM

observed † POSSUM † P-POSSUM † overall 7.5% 8.2% 7.1%elective 3.2% 4.6% 3.8%emergency 23.4% 16.7% 19.5%

<50yrs 0.5% 3.3% 2.6%50-59yrs 2.7% 6.1% 3.6%60-69yrs 5.3% 7.5% 6.2%70-79yrs 8.6% 11.8% 9.7%>80yrs 22.0% 12.4% 12.3%

PP Tekkis et al.BJS 2003;90:340

POSSUM & P-POSSUMPP Tekkis et al.

BJS 2003;90:340

complications (any & major) by severity of surgery stratified

by age group

010203040506070

70-74 75-79 80+ 70-74 75-79 80+ 70-74 75-79 80+

Severity of surgery

Major Any

Mod/ intermediate Major Complex major

Type of complication

Age group:

% with complications

multivariate analysis(Cox Regression)

Component of PACE RR* 95%CI

30 days Morbidity

BFI mod/severe fatigue (>3) 1.46 1.18-2.13

IADL dependent (<8) 1.36 1.04-2.05

Hospital stay

ADL dependent (>0) 2.00 1.37-2.92

PACE: probability of complications andn. deranged components

0

10

20

30

40

50

60

70

% w

ith

at lea

st 1

mor

bidi

ty

0 1 2 3

Functional Health StatusPerformance Status (PS)Mini mental State (MMS)

Brief Fatigue Inventory (BFI)Activities of Daily Living (ADL)

Geriatric Depression Scale (GDS)Instrumental activities of daily living (IADL)

Quick toolsVES-13

GFI“up & go”

Prospective series of consenting (MMS >18) elderly (>70 yrs) surgical cancer patients

PREOP

End Points30-day mortality & morbidity

n. of specialists involved

Frailty & Surgical Practice:Unbiased selection

Comparison of surgical outcomesConsenting & treatment planning

Tackling comorbiditiesIndividualised care

Improved survival (?)

personal tips

Per-operativelyMinimise blood lossesCareful anaesthetics

Post-operativelyNo NGTPrompt mobilizationEarly post-operative oral feeding

Pre-operativelyAvoid acute settingPrevention chest infections with positive

pressure chest physiotherapyOptimize nutritional statusNo bowel preparationSupra-pubic catheter (♂)

Surgery:

“If you can do it,it does not mean itneeds to be done”

TME – Total Mesorectal Excision

TME in the elderlyCancer Registry Data: 1,508pt >75yrs

Rutten HJT. Lancet Onc 2008

excessive operative death

Rutten HJT. Lancet Onc 2008

“… the effectiveness of TME surgery in the overall population cannot be simply derived from findings of studies involving a younger age group.”

Assessing Frailty in Surgical Practice

Understanding patient’s needs

Consenting & treatment planning

Tackling comorbidities

Individualising care

Improving survival & QoL