Complicated colorectal cancer in nonagenarian patients: is it better not to perform anastomosis in emergency?

Abstract

BACKGROUND: Colorectal cancer (CRC) is predominantly a disease of elderly people. Cancer in nonagenarian patients presents an ethical dilemma for surgeons and oncologists, and management of this group of patients in emergency for complicated CRC is debated. Presently described is retrospective study reporting experience of 6 departments of emergency surgery with management of nonagenarian patients sent to emergency surgery for CRC complications. METHODS: Data concerning patients aged over 90 years hospitalized from January 2011 to June 2015 in 6 departments of emergency surgery for complicated CRC were retrospectively analyzed. Data were collected in a dedicated database. Statistical analysis was conducted using IBM software SPSS 22 (IBM Corp., Armonk, NY, USA); statistical significance was set at p=0.05. RESULTS: In the period of study,19 patients aged over 90 underwent surgery in emergency department for complicated CRC. Of the total, 52.63% were female, with sex ratio F:M of 1.11:1. Mean age was 92.52 years (range: 90-97 years; SD 1.49). Preoperative assessment of surgical risk was made using American Society of Anesthesiologists (ASA) score. There was no statistically significant difference in terms of in-hospital mortality between patients with ASA score ≤ 3 and patients with an ASA score >3. Primary anastomosis was performed in 6 of 19 patients (31.57%), all of whom had right-side colon cancer. Diverting stoma was created for 12 of 19 patients (63.15%). There was a statistically significant difference in incidence of postoperative complications between patients with right-side colon cancer and patients with left-side colon cancer (p=0.0498). Mean length of hospital stay was 12.78 days (range: 2-31 days; SD 6.31). In-hospital mortality rate was 21.05% (n=4). At follow up, overall survival was 47.36% (n=9). CONCLUSION: Elective surgery is the best way to manage CRC in all patients affected. Emergency surgery for CRC complications in patients over 90 is feasible with careful preoperative selection and evaluation of the patient. One-stage surgery is the best choice, in selected patients. Two-and three-stage surgery is indicated in case of peritonitis, for frail patients, for hemodynamically unstable patients. If there is high risk of anastomotic leakage, decompressive stoma is suggested as bridge to elective surgery, and in advanced neoplastic disease, as palliative procedure. In emergency setting, diverting stoma is a good surgical option in nonagenarian patients to decrease surgical risk, morbidity, and mortality; however, clinical randomized controlled trials are necessary to confirm this.

Does intestinal anastomosis in resection of colon cancer have a significant impact onto early postoperative outcome and long-term survival?

“…This finding is in line with those of De Simone et al. [ 19 ]. In a retrospective study, the authors found that patients with a more disadvantageous general condition (measured semiquantitatively by “American Society of Anesthesiologists” score) and acute symptoms benefit from a shorter operating time due to ostomy creation and avoidance of the more complication-prone anastomosis placement.…”

A two-step surgery and a multidisciplinary approach in a centenarian patient with an acute presentation of right colon cancer

“…However, in the last decades CRC has been growingly increased in very old age subjects who are characterized by clinical conditions such as multimorbidity, cognitive impairment, malnutrition and frailty. Similarly, in the present case of a vulnerable centenarian patient with a cancer related obstruction of the right colon, the presence of hemodynamic instability, anemia, hypoalbuminemia and high inflammation had discouraged this recommended surgical approach because for the higher risk of anastomotic leakage, one of the most severe complications after colorectal surgery due to its associated higher morbidity and mortality [20].…”

Indications and Complications of Stoma Formations in Emergency Surgery

“…Anastomosis after emergency surgeries shows a higher rate of anastomic leakage than elective surgery [8] . Decompressive stoma during emergency surgery is a bridge to elective surgery and also decreases morbidity and mortality in patients with high risk of anastomotic leakage [9] . For all these reasons, surgeons are not prejudiced about stoma opening in emergency operations.…”