Effects of the combination of blood transfusion and postoperative infectious complications on prognosis after surgery for colorectal cancer. Danish RANX05 Colorectal Cancer Study Group

BACKGROUND: The frequency of postoperative infectious complications is significantly increased in patients with colorectal cancer receiving perioperative blood transfusion. It is still debated, however, whether perioperative blood transfusion alters the incidence of disease recurrence or otherwise affects the prognosis. METHODS: Patient risk variables, variables related to operation technique, blood transfusion and the development of infectious complications were recorded prospectively in 740 patients undergoing elective resection for primary colorectal cancer. Endpoints were overall survival (n = 740) and time to diagnosis of recurrent disease in the subgroup of patients operated on with curative intention (n = 532). The patients were analysed in four groups divided with respect to administration or not of perioperative blood transfusion and development or non-development of postoperative infectious complications. RESULTS: Overall, 19 per cent of 288 non-transfused and 31 per cent of 452 transfused patients developed postoperative infectious complications (P< 0.001). The median observation period was 6.8 (range 5.4-7.9) years. In a multivariate analysis, risk of death was significantly increased among patients developing infection after transfusion (n = 142) compared with patients receiving neither blood transfusion nor developing infection (n = 234): hazard ratio 1.38 (95 per cent confidence interval (c.i.) 1.05-1.81). Overall survival of patients receiving blood transfusion without subsequent infection (n = 310) and patients developing infection without preceding transfusion (n = 54) was not significantly decreased. In an analysis of disease recurrence the combination of blood transfusion and subsequent development of infection (hazard ratio 1.79 (95 per cent c.i. 1.13-2.82)), localization of cancer in the rectum and Dukes classification were independent risk factors. CONCLUSION: Blood transfusion per se may not be a risk factor for poor prognosis after colorectal cancer surgery. However, the combination of perioperative blood transfusion and subsequent development of postoperative infectious complications may be associated with a poor prognosis.     

Emergency presentation and mortality from colorectal cancer in the elderly

We have assessed the influence of age on the mode of presentation and perioperative mortality in 1033 patients with colorectal cancer. There were 522 patients (51 per cent) over 70 years (group I) and 511 patients (49 per cent) under 70 (group II). In group I, 301 patients (58 per cent) were admitted as emergencies compared with only 222 (43 per cent) in group II (P less than 0.001). Perioperative mortality was especially high in the elderly emergencies, 38 per cent, compared with 18 per cent for elective operations. Of the patients presenting as emergencies in either age group 66 per cent had localized "potentially curable' disease. The incidence of colorectal cancer is highest in the elderly. A larger number of these elderly patients present as emergencies and die from the consequences of complications of localized disease. Earlier diagnosis by pre-symptomatic screening is therefore especially desirable in these old patients.     

Major elective surgery for vascular disease in patients aged 80 or more: perioperative (30-day) outcomes

Although major vascular surgery is performed with increasing frequency in elderly people, the impact of age on outcomes is uncertain. We evaluated the perioperative (30-day) outcomes for patients who underwent major elective vascular operations under general or peripheral anesthesia in their eighties and nineties in a 14-year period. Data for all consecutive 3,060 patients (456 of them > or years old) who underwent 3,314 elective vascular surgery procedures were prospectively entered into a computerized vascular registry. Detailed information was collected on patients' preoperative status, type of procedure and anesthesia, perioperative outcomes, and predictors of perioperative outcomes. The end points of the study were perioperative death and main surgical complications. Perioperative all-cause mortality rates varied across operations and were higher in elderly than in younger patients (1.4% vs. 0.2%, P = 0.014) after abdominal surgery (2.4% vs. 0.1%, P = 0.006) and especially after abdominal aortic aneurysm repair (2.8% vs. 0%, P = 0.035). In the elderly cohort, the mortality rate was <1% for almost 60% of all operations. In logistic regression analysis, only preoperative hypertension (odds ratio [OR] = 72.5, 95% confidence interval [CI] 9.4-557.6), congestive heart failure (OR = 16.5, 95% CI 2.3-115.9), and perioperative cardiac (OR = 20.7, 95% CI 1.6-273.8) and pulmonary (OR = 41.7, 95% CI 7.9-218.9) complications were associated with a higher 30-day death risk. In this series, perioperative outcomes were not influenced by the type of elective surgical procedure. Though overall mortality after major vascular surgery was higher in patients > or 80 years old, age per se was not an independent factor of a higher perioperative mortality risk or fatal and nonfatal complications.     

Importance of the First Postoperative Year in the Prognosis of Elderly Colorectal Cancer Patients

Background

Elderly colorectal cancer patients have worse prognosis than younger patients. Age-related survival differences may be cancer or treatment related, but also due to death from other causes. This study aims to compare population-based survival data for young (<65 years), aged (65–74 years), and elderly (≥75 years) colorectal cancer patients.

Methods

All patients operated for stage I–III colorectal cancer between 1991 and 2005 in the western region of The Netherlands were included. Crude survival, relative survival, and conditional relative survival curves, under the condition of surviving 1 year, were made for colon and rectal cancer patients separately. Furthermore, 30-day, 1-year, and 1-year excess mortality data were compared.

Results

A total of 9,397 stage I–III colorectal cancer patients were included in this study. Crude survival curves showed clear survival differences between the age groups. These age-related differences were less prominent in relative survival and disappeared in conditional relative survival (CRS). Only in stage III disease did elderly patients have worse CRS than young patients. Furthermore, significant age-related differences in 30-day and 1-year excess mortality were found. Thirty-day mortality vastly underestimated 1-year mortality for all age groups.

Conclusions

Elderly colorectal cancer patients who survive the first year have the same cancer-related survival as younger patients. Therefore, decreased survival in the elderly is mainly due to differences in early mortality. Treatment of elderly colorectal cancer patients should focus on perioperative care and the first postoperative year.     

Abdominal pain: a surgical audit of 1190 emergency admissions

In an audit of 1190 emergency admissions with abdominal pain (1166 patients) in a general surgical unit, the diagnosis was non-specific abdominal pain (NSAP) in 415 (35 per cent), acute appendicitis in 200 (17 per cent) and intestinal obstruction in 176 (15 per cent). The largest number of admissions occurred in the age groups 10-29 years (31 per cent) and 60-79 years (29 per cent). Surgical operations were performed in 551 patients (47 per cent) and there was a 16 per cent incidence of unnecessary appendicectomy (22 per cent in the age group 20-29 years). Fifty-one deaths resulted in a 30-day hospital mortality rate of 4.4 per cent and a perioperative mortality rate of 8 per cent. The mortality rate increased significantly in patients aged greater than or equal to 60 years, and patients aged 80-89 years had a perioperative mortality rate of 20 per cent. The causes of perioperative death included laparotomy for inoperable disease (28 per cent), ruptured abdominal aortic aneurysm (23 per cent), perforated peptic ulcer (16 per cent) and colonic resections (14 per cent). The perioperative mortality rates for ruptured aneurysm and perforated ulcer were 71 and 23 per cent respectively. The duration of inpatient stay increased significantly with the age of the patients, including those with NSAP. The results of the study indicate a need to review the methods of management of ruptured aortic aneurysm and perforated peptic ulcer, the methods of diagnosis of appendicitis, particularly in young females, and the factors that determine the duration of stay of patients suffering from NSAP.     

Management of symptomatic gallstones in the elderly

In a study of 544 patients with symptomatic gallstones 158 subjects were aged greater than 70 years. Elderly patients had a significantly higher incidence of emergency presentation, jaundice, cholangitis, ductal stones, biliary drainage procedures, and acute complications requiring urgent or emergency surgery (P less than 0.001); they had more than twice the incidence of postoperative complications in comparison with patients aged less than 70 years. There was an increased perioperative mortality in the elderly (1.3 per cent after cholecystectomy and 2.9 per cent after bile duct exploration, P = 0.039). Conservative treatment in 11 per cent of elderly patients resulted in no mortality due to gallstones, but 3 of 17 patients had recurrent biliary symptoms. It was estimated that 38 per cent of the bile duct explorations in the elderly might have been avoided by referral for endoscopic sphincterotomy, but surgical treatment of gallstones in the district general hospital is relatively safe and specialist referral should be considered only in the relatively small number of 'high risk' cases.     

Surgery for colorectal cancer in elderly patients —A comparison with younger adult patients—

Between 1972 and 1986, 668 patients without familial polyposis coli underwent surgery for colorectal cancer at the National Kyushu Cancer Center. Among these, there were 85 patients aged 75 years and older, and 39 patients aged 39 years and younger. The older patients tended to have a higher frequency of less advanced disease (stage I–III) and the progression of cancer in the older patients appeared to be relatively mild. The operative mortality rate of the older patients was as low as 1.2 per cent, which was almost identical to that of the younger adults (0 per cent), being 16.7 per cent for emergency operations, whereas it was 0 per cent for elective operations. The five-year survival curve of the older patients with curative resections was significantly better than that of those with noncurative resections. There was no significant difference in the cancer-related five-year survival curves between the older and younger patients with curative resections. Surgery for colorectal cancer in elderly patients should therefore not be restricted on the basis of chronological age alone.     

Surgery for colorectal cancer in elderly patients--a comparison with younger adult patients

Between 1972 and 1986, 668 patients without familial polyposis coli underwent surgery for colorectal cancer at the National Kyushu Cancer Center. Among these, there were 85 patients aged 75 years and older, and 39 patients aged 39 years and younger. The older patients tended to have a higher frequency of less advanced disease (stage I-III) and the progression of cancer in the older patients appeared to be relatively mild. The operative mortality rate of the older patients was as low as 1.2 per cent, which was almost identical to that of the younger adults (0 per cent), being 16.7 per cent for emergency operations, whereas it was 0 per cent for elective operations. The five-year survival curve of the older patients with curative resections was significantly better than that of those with noncurative resections. There was no significant difference in the cancer-related five-year survival curves between the older and younger patients with curative resections. Surgery for colorectal cancer in elderly patients should therefore not be restricted on the basis of chronological age alone.     

Outcome analysis of patients undergoing colorectal resection for emergent and elective indications

Despite advances in perioperative care and operative techniques, urgent colorectal operations are associated with higher morbidity and mortality. To evaluate our rate of complications in elective and urgent colorectal operations, we performed retrospective chart review of 209 consecutive patients who underwent colorectal resection between 1998 and 2002 at Harbor-UCLA Medical Center. One hundred, forty-three (71%) patients underwent elective colorectal resection. A total of 19 (13.3%) complications occurred in the elective group, compared with 24 (38.1%) in the urgent group (P = 0.003). Both right-sided and left-sided operations were associated with higher incidence of complications when performed urgently. Wound infection occurred in 7.7 per cent of patients undergoing an elective operation and 14.3 per cent in an urgent setting (P = 0.21). Intra-abdominal abscess occurred in 1.4 per cent of patients undergoing elective operation, compared with 11.1 per cent in the urgent operation group. Four (1.9%) patients developed wound dehiscence, 1 in elective and 3 in the urgent group (P = 0.09). Anastomotic leak occurred in 1.9 per cent of patients, 2 in each group (P = 0.6). There were six deaths, 3 in elective and 3 in urgent cases (P = 0.4). Urgent operation of the colon and rectum is associated with higher incidence of complications. Both right- and left-sided resections have a higher complication rate when performed in a nonelective setting.     

Evaluation of POSSUM and P-POSSUM scoring systems in patients undergoing colorectal surgery

BACKGROUND: The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and Portsmouth POSSUM (P-POSSUM) equations were derived from a heterogeneous general surgical population and have been used successfully as audit tools to provide risk-adjusted operative mortality rates. Their applicability to high-risk emergency colorectal operations has not been established. METHODS: POSSUM variables were recorded for 1017 patients undergoing major elective (n = 804) or emergency (n = 213) colorectal surgery in ten hospitals. Subgroup analysis was performed to investigate the predictive capability of POSSUM and P-POSSUM in emergency and elective surgery and in patients in different age groups. RESULTS: The overall operative mortality rate was 7.5 per cent (POSSUM-estimated mortality rate 8.2 per cent; P-POSSUM-estimated mortality rate 7.1 per cent). In-hospital deaths increased exponentially with age. Both scoring systems overpredicted mortality in young patients and underpredicted mortality in the elderly (P < 0.001). Death was underpredicted by both systems for emergency cases, significantly so at a simulated emergency caseload of 47.9 per cent (P < 0.05). CONCLUSION: There is a lack of calibration of POSSUM and P-POSSUM systems at the extremes of age and high emergency workload. This has important implication in clinical practice, as consultants with a high emergency workload may seem to underperform when these scoring systems are applied. Recalibration or remodelling strategies may facilitate the application of POSSUM-based systems in colorectal surgery.     

高龄患者心脏围手术期手术风险分析

目的 探讨高龄心脏病患者围手术期特点及心脏手术的风险。方法 选取2007年1月－2011年6月不同类型心脏手术病人255例,分为A组（≥70岁）55例,B组（＜70岁）200例。分析两组间病人术前危险因素、手术策略及围术期监护的特点,对比两组间术后并发症及预后。结果 术前危险因素中,原发性高血压、急性冠脉综合征、肾功能不全在A组占比例显著高于B组（P<0.05）, EuroSCORE评分A组(5.56±2.26)高于B组(2.14±2.21, P<0.001）。术中体外循环时间A组(102.61±38.36min)显著短于B组(119.66±47.57min, P<0.05）, 主动脉阻断时间A组(63.57±27.08min)显著短于B组(79.46±35.29min, P<0.05）。术后A组肺部感染发生率,急性肾损伤发生率,呼吸机使用时间,ICU停留时间均高于B组（P<0.05）; 术后脑梗塞发生率,心律失常发生率,总引流量,血管活性药物使用情况及住院死亡率两组间无显著差异。结论 准确识别高龄患者围术期危险因素,制定个性化策略,缩短体外循环时间,积极预防并正确处理围术期并发症,可有效降低高龄患者群体心脏手术的风险。     

“快通道”外科理念指导下腹腔镜手术治疗老年结直肠癌的临床研究

目的:比较"快通道"外科指导下腹腔镜手术与单纯应用腹腔镜手术及应用"快通道"外科理念的常规开腹手术治疗65岁以上老年结直肠癌患者的有效性、安全性,评估"快通道"外科理念联合腹腔镜手术促进老年结直肠癌患者术后恢复的协同作用。方法:将94例65岁以上老年结直肠癌患者随机分为开腹(open surgery,OP)组、开腹+快通道(open surgery plus fast-track surgery,OPFT)组、腹腔镜(laparoscopy surgery,LAP)组及腹腔镜+快通道(laparoscopy surgery plus fast-track surgery,LAPFT)组。比较患者基线特征、手术效果、术后安全性指标。结果:LAP组与LAPFT组在术中出血量、术后排气时间、术后排便时间、术后阿片类镇痛药物使用时间方面均优于OP组、OPFT组(P0.05),而手术时间明显延长(P0.01)。OPFT组术后首次排便时间、术后阿片类镇痛药物使用时间、住院时间短于OP组(P0.05)。LAP组、LAPFT组术后切口感染率明显低于OP组、OPFT组(P0.01),其他并发症发生率及术后30 d内死亡率各组相比差异无统计学意义(P0.05)。结论:对于老年结直肠癌患者,腹腔镜术中应用"快通道"外科指导的围手术期处理可加快术后康复且不增加术后短期并发症发生率,是安全、有效的治疗措施。     

Outcome of Surgery for Lung Cancer in Young and Elderly Patients

Purpose It has been suggested that lung cancer follows a more aggressive course and has a poorer prognosis in young patients than in elderly patients. We conducted this study to determine whether the basal characteristics and survival of young patients undergoing surgical resection of lung cancer differ from those of elderly patients.Methods Eighty patients who underwent surgery for lung cancer at our hospital between 1989 and 2004 were divided into two groups according to age. Group 1 comprised 50 patients aged 45 years or younger and group 2 comprised 30 patients aged 70 years or older. The patients’ medical records were reviewed with respect to age, gender, histological diagnosis, coexisting diseases, smoking history, postoperative staging, type of operation, and postoperative morbidity, mortality, and survival results.Results The average ages were 40.2 ± 3.77 years (range, 29–45 years) in group 1 and 72.2 ± 2.53 years (range, 70–80 years) in group 2. The incidence of postoperative complications was significantly higher in group 2 (P = 0.02). However, the 5-year survival rates for patients who underwent surgery for non-small cell lung cancer did not differ between groups 1 and 2, at 33.3% versus 21.3%, respectively (P = 0.09).Conclusions The incidence of adenocarcinoma was higher in the young patients, whose prognosis was slightly better than that of the elderly patients. Coexisting diseases and postoperative complications were the major factors that adversely affected the prognosis of the elderly patients.     

Impact of surgeon volume and specialization on short-term outcomes in colorectal cancer surgery

BACKGROUND: Several studies have shown a relationship between surgeon volume and outcomes in colorectal cancer surgery. The aim of this study was to determine the impact of surgeon volume and specialization on primary tumour resection rate, restoration of bowel continuity following rectal cancer resection, anastomotic leakage and perioperative mortality. METHODS: The Northern Region Colorectal Cancer Audit Group conducts a population-based audit of patients with colorectal cancer managed by surgeons. This study examined 8219 patients treated between 1998 and 2002. Outcomes were modelled using multivariate logistic regression analysis. RESULTS: Tumour resection was performed in 6949 (93.8 per cent) of 7411 patients. High-volume surgeons with an annual caseload of at least 18.5 (odds ratio (OR) 1.53 (95 per cent confidence interval (c.i.) 1.10 to 2.12); P = 0.012) and colorectal specialists (OR 1.42 (95 per cent c.i. 1.06 to 1.90); P = 0.018) were more likely to perform elective sphincter-saving rectal surgery. In elective surgery, the risk of perioperative death was lower for high-volume surgeons (OR 0.58 (95 per cent c.i. 0.44 to 0.76); P < 0.001), but this was not the case in emergency surgery. CONCLUSION: High-volume surgeons had lower perioperative mortality rates for elective surgery, and were more likely to use restorative rectal procedures.     

Geriatric colon cancer

Two hundred twenty-six patients eighty years of age or older were seen over a twelve year period, and 156 underwent surgery. These patients tolerated surgery well when complications were avoided. The five year absolute survival rate was 22.4 per cent, and the corresponding age corrected figure was 53.3 per cent. On the basis of this analysis, the prognosis of elderly patients with colorectal cancer is more favorable than of the young. Considering that these patients may have an otherwise reasonable life expectancy, it seems justified to resect the colorectal cancer and to expect a rewarding survival rate.     

The operative risk factors of cholelithiasis in the elderly

A total 725 patients with cholelithiasis were divided into three groups according to age, and the risk factors and morbidity rates compared. Group 1 consisted of those aged younger than 49 years, group 2 of those aged between 50 to 69 years, and group 3 of those aged over 70 years. In group 3, the incidence of caliculi in the common bile duct was significantly higher than in the other two groups (p<0.05), and therefore, choledochotomy accompanying cholecystectomy was performed more often in this group (p<0.01). The rate of complications related to calculi and the presence of underlying disease were also higher in this group than in the two younger groups (p<0.05), as were preoperative abnormal liver or renal function tests, anemia and hypoproteinemia (p<0.05). The rate of positive bile cultures in group 3 was 75.6 per cent which was again significantly higher than in groups 1 and 2 (p<0.01). Postoperative complications appeared in 14.3 per cent of the group 3 patients, which was not statistically higher than in group 2 (9.7 per cent), but the percentages of both groups 2 and 3 were high compared to the 4.3 per cent of group 1 (p<0.01). The rates of complications directly attributable to the surgical procedures were 2.0 per cent in group 1, 4.8 per cent in group 2, and 5.1 per cent in group 3 with no significant differences between the three groups. There was no increase in the technical problems associated with the surgical procedures performed on the elderly patients and thus, if the operative risks are precisely evaluated and treated cautiously elderly patients should tolerate surgery for cholelithiasis well.     

Study of common bile duct exploration and endoscopic sphincterotomy in a consecutive series of 438 patients

The outcome of 438 consecutive patients who had exploration of the common bile duct and/or endoscopic sphincterotomy (ES) in a 5-year period was reviewed. Patients were analysed according to four groups: 59 patients had planned ES followed by surgery resulting in 14 major complications (23.7 per cent) including 3 deaths (5.1 per cent) (group 1); 248 patients had surgery alone with 21 major complications (8.5 per cent) including 10 deaths (4.0 per cent) (group 2); 114 patients with gallbladder in situ underwent ES alone with 22 major complications (19.3 per cent) including 9 deaths (7.9 per cent) (group 3); 17 patients with remote cholecystectomy also had ES alone with 3 major complications (17.6 per cent) including 3 deaths (17.6 per cent) (group 4). There was no difference in mortality between the groups. Compared with group 2, major complications were significantly higher in group 1 (chi 2 = 11.0, d.f. = 1, P less than 0.001) and in group 3 (chi 2 = 8.6, d.f. = 1, P less than 0.003). Patients in group 3, however, were significantly older than those in groups 1 and 2, and the former also had higher medical and total risk factor scores than the latter (all P less than 0.001). The results indicate that routine pre-operative ES is of questionable value. ES alone is justified in elderly high risk patients; mortality in this group might be reduced by improved management of post-ES complications.     

Hernia repair in elderly patients

Background This study evaluates a 5-year experience of the management of the most frequent abdominal wall hernias in an elderly population. Methods From April 1990 to December 1995, 231 inguinal, 12 femoral and seven umbilical hernias were repaired in 221 patients (mean age 74 (range 66–93) years). Concomitant diseases were present in 157 patients, A mesh repair was performed with ‘tension-free’ or ‘plug’ techniques in all but 23 inguinal and two femora! hernia repairs, in which the Bassini or Shouldice procedures were adopted. Ten emergency hernia repairs were performed for strangulation. A total of 232 operations, including four emergency hernia repairs, were carried out under local anaesthesia. Results There was no perioperative mortality. Acute intestinal bleeding occurred 2 days after surgery in a patient with colonic diverticular disease. Urinary retention occurred once following emergency hernia repair under general anaesthesia and twice after elective hernia repair under local anaesthesia. Local complications included four scrotl haematomas (2 per cent), three wound infections (1 per cent) and one case of orchitis with atrophy after repair of a recurrent hernia. There was one recurrence after a Bassini repair and one after Shouldice inguinal herniorrhaphy. No recurrence was observed after mesh repair. Conclusion Local anaesthetic mesh hernia repair is safe and effective in elderly patients. Age should be no bar to elective hernia repair. This policy should avoid the complications of emergency operation.     

Complications of biliary surgery

Procedures on the gallbladder and extrahepatic biliary tract were the most frequently performed operations in a series of 1500 consecutive abdominal operations done in community hospitals. The operative mortality rate for elective cholecystectomy was 0.3 per cent. The complication rate was 21.4 per cent for cholecystectomy. Patients requiring emergency cholecystectomy had significantly more urinary tract and intra-abdominal problems than those patients who underwent surgery electively. Operative cholangiography was performed during 20.3 per cent of the elective cholecystectomies. There were no biliary tract complications among the cholecystectomy patients who had cholangiography. When this study was not performed, 1.5 per cent of the patients had postoperative bile duct problems. Older surgeons (greater than 60 years of age) and high volume surgeons (greater than 300 cases/year) were significantly less likely to employ cholangiography. The mortality rate for elective common duct exploration was 4.4 per cent, with a complication rate of 60 per cent. There was a 13.3 per cent incidence of retained stones after choledochotomy, though this problem was readily managed by percutaneous extraction through the T-tube tract. Complex biliary tract procedures were performed electively without mortality, though the complication rate for these procedures was 35.3 per cent. Two-thirds of the patients undergoing complex biliary tract operations on an emergency basis died. Board certified general surgeons had the same mortality and complication rates for cholecystectomy as well as common bile duct exploration. Noncertified surgeons had significantly more intraabdominal complications after complex biliary tract procedures compared to their board certified colleagues.