Colorectal cancer in the elderly: which surgical approach?

Single-operator case studies of 135 patients undergoing surgery for colon rectal carcinoma (CRC) between June 2004 and April 2008 in our Institute. Patients were divided into two groups (A: < 70 years old, n = 44, - = 27 U = 17, B: ≥ 70 years old, n = 91, - = 49 U = 42) and were compared clinical, pathological and surgical data. In particular, were analyzed age range and average age, ASA score, post-operative complications (major and minor), mortality at 30 days. Surgical procedure with radical intent (R0) was achieved in 41 (93%) and 76 (83%) patients respectively in group A and B; Given the more than double the number in group B than in group A is easy to imagine that for equal numbers in both groups might have observed an almost equal R0 resections in both groups; Despite the uneven number of groups A and B, it was noted that age is not a factor in determining the surgical therapeutic strategy in the CRC, as well as the clinical conditions of patients.     

Revision hip surgery in the elderly: Is it worthwhile?

We prospectively analyzed the outcome in 103 consecutive patients undergoing revision hip replacement, dividing the patients into 2 groups according to their age at the time of surgery. There were 45 patients aged 75 years or older and 58 patients aged younger than 75 years. The results of revision hip replacement in terms of pain relief, functional improvement, and patient satisfaction did not differ between the 2 groups. There was a significantly higher death rate among the elderly patients (13.3% versus 1.7%; P = .0202) and a significantly higher rate of dislocation (20% versus 1.7%; P = .0019). We conclude that revision hip replacement is an effective operation in the elderly, but that patient and surgeon must be aware of the risks that such surgery entails.     

Is surgery the best treatment for elderly gastric cancer patients?

As the elderly population increases, the number of patients with gastric cancer has also been increasing. Elderly people have various preoperative problems such as malnutrition, high frequency of comorbidities, decreased performance status, and dementia. Furthermore, when surgery is performed, high postoperative complication rates and death from other diseases are also concerns. The goal of surgery in the elderly is that short-term outcomes are comparable to those in nonelderly, and long-term outcomes reach life expectancy. Perioperative problems in the elderly include: (1) Poor perioperative nutritional status; (2) Postoperative pneumonia; and (3) Psychological problems (dementia and postoperative delirium). Malnutrition in the elderly has been reported to be associated with increased postoperative complications and dementia, pointing out the importance of nutritional management. In addition, multidisciplinary team efforts, including perioperative respiratory rehabilitation, preoperative oral care, and early postoperative mobilization programs, are effective in preventing postoperative pneumonia. Furthermore, there are many reports on the usefulness of laparoscopic surgery for the elderly, and we considered that minimally invasive surgery would be the optimal treatment after assessing preoperative risk.     

Treatment strategies in elderly breast cancer patients: Is there a need for surgery?

BackgroundThe aim of this study was to determine the role of surgery in elderly patients with breast cancer.MethodsBetween 1999 and 2009, 153 consecutive women, ≥80 years old with breast cancer were treated at our hospital. Surgically and non-surgically treated patients were compared with respect to characteristics and survival.ResultsTreatment was surgical in 102 patients (67%). The non-surgically treated patients were older than surgically treated patients, had more co-morbidity and were more often diagnosed with a clinically T3/T4 tumour and distant metastasis. Patients not receiving surgery, had an 11% overall survival rate at 5-year versus 48% in surgically treated patients (P < 0.001). Independent factors for survival were clinical N0 status, M0 status at presentation and surgery.ConclusionOne in three patients of 80 years and older did not have surgical treatment for breast cancer. Patient not treated surgically are older, have more severe co-morbidity and are diagnosed with more advanced disease than patients who underwent surgery.The selection of patients, who have a poor prognosis, is made on clinical grounds not measurable with a common co-morbidity survey. Better and evidence-based selection criteria for surgical and non-surgical treatment in these patients are needed.     

Colorectal cancer in the young: a possible role for immune surveillance?

Background: Younger patients with colorectal cancer (CRC) generally have better survival in spite of worse clinical and pathological features.

Methods: Twenty-six patients under 50 years operated for primary CRC were enrolled and matched 1:2:2 according to stage, tumor site and gender with 52 patients from 50 to 70 years and 52 patients over 70 years old.

Results: Patients under 50 years had a significantly longer overall, cancer specific and disease free survival (p?=?.001, p?=?.007 and p?=?.05, respectively). However, they had more frequently lymphovascular invasion (p?=?.006) and they more frequently developed metachronous CRC at follow-up (p?=?.03). Nevertheless, preoperative lymphocytes blood count/white blood count (LBC/WBC) ratio inversely correlated with age at operation (rho?=??.21, p?=?.04) and it predicted CRC recurrence with an accuracy of 70%, p?p?p?=?.0001 and p?=?.01, respectively).

Conclusions: Patients under 50 years had a significantly longer survival with a higher LBC/WBC ratio. These results could suggest a possible role of immunosurveillance in neoplastic control.     

Major surgery in lung cancer in elderly patients? Risk factors analysis and long-term results

BACKGROUND: In the Oncological Thoracic Surgery Department of the Istituto Nazionale Tumori of Milan a retrospective study was performed on lung cancer patients 70 years old or more with the aim of evaluate the role of surgical treatment and to analyse long-term results. METHODS: In our Institute from January 1988 to December 1993, 151 lung cancer patients 70 years old or more underwent surgery for lung cancer. One hundred and twenty-six of them (83%) were males and 25 were females (17%), the average age was 73.09+/-2.91 years (median: 77; range: 70-82). All the subjects were completely staged preoperatively. In order to establish operability criteria, we considered some selection parameters. Patients general conditions were evaluated using Karnofsky score accepting only the ones with 70% or more for surgery, all the cases performed cardio-respiratory functional evaluation. Patients with: a) FEV1 <60% of predicted value or FEV1 <1 l; b) PaO2 <60 mmHg e PaCO2 >40 mmHg were excluded from surgery. RESULTS: The operations performed were: 23 pneumonectomies, 6 bilobectomies, 93 lobectomies, 13 segmentectomies and 16 wedge resections. Eight cases were submitted to thoracectomy in association to pulmonary resection. Peroperative mortality was 3% and morbidity was 10%. Histological examination showed 69 adenocarcinomas, 65 squamous carcinomas, 4 large cells carcinomas, 4 typical carcinoids, 5 small cells carcinomas, 2 mucoepidermal carcinomas and 2 adenosquamous carcinomas. Eighty-six patients were classified at stage I, 38 at stage II, 24 at stage III and 3 at stage IV (multifocal disease). The actuarial 4-years global survival predicted with Kaplan Meier method was 40%, in particular it was 75% for stage I patients. CONCLUSIONS: In case of resectable primary pulmonary neoplasm, surgery represents the first choice therapy; patient's age doesn't seem to be an absolute contraindication, but it has to be evaluated with biological and not with age criteria. Using adequate selection criteria, it's possible to obtain, in patients older than 70 years, long-term survivals that don't seem to differ from global survivals.     

Emergent and elective colon surgery in the extreme elderly: do the results warrant the operation?

With the elderly population rising continuously, surgeons are increasingly confronted by the dilemma of operative management in these patients, which frequently encompasses end-of-life issues. Increasing age and emergent surgery are known risk factors for poor outcomes in colon surgery. The purpose of this study is to delineate differences in outcomes between emergent and elective colon surgery and identify risk factors that can guide the surgeon in caring for the extreme elderly (age 80 years or older). From 2001 to 2006, a retrospective review of the resident database at Greenville Hospital System identified 104 extreme elderly patients who underwent colon surgery (65 elective, 39 emergent). Comparing elective and emergent operations, results showed substantial differences in morbidity (20% vs 51.2%, P < 0.001), 30-day mortality rate (7.7% vs 30.7%, P < 0.005), and length of stay (13.6 days vs 21.6 days, P < 0.004). Percentage of patients discharged to home was significantly less in the emergent group (13% vs 59%, P < 0.001). Evaluation of the emergent surgery group revealed male gender, history of smoking, and ischemic changes on pathologic examination were statistically significant risk factors for failure of surgery. As a result of the high-risk nature of emergent colon operations in the extreme elderly, it is important that surgeons carefully assess the benefits in relation to the risks and functional outcomes of surgery when planning patient care and providing informed consent.     

Locally-advanced prostate cancer in the elderly: should we revisit our treatment paradigms?

Prostate cancer (PCa) represents the most common malignancy in adult males with an estimated number of 280 000 newly diagnosed cases only in the United States in 2015.1 Due to the introduction of PSA in clinical practice, the majority of the patients are currently diagnosed with organ-confined and sometimes indolent disease. However, a nonnegligible proportion of individuals are still diagnosed with locally-advanced tumors. In their recently published article, Bekelman et al.2 focused on elderly patients with locally-advanced PCa in the attempt to determine the best treatment approach in this patient category, and concluded that, even in these individuals, androgen deprivation therapy (ADT) plus radiotherapy (RT) may confer a survival benefit relative to ADT alone. The importance of the current article resides in the fact that it focuses on a patient population that has not been, or has been only scarcely, included in previous studies on the same topic.The survival benefit of RT plus ADT versus ADT alone in patients with locally-advanced PCa has been recently demonstrated by two randomized controlled trials (RCTs).3,4 Specifically, Widmark et al. recruited 875 patients from 47 Scandinavian centers who were randomized to receive either ADT or ADT plus RT.3 Inclusion criteria for this study were age ≤75 and a life expectancy ≥10 years. According to this trial, the 10-year cancer-specific mortality rate was 23.9% in the ADT group relative to 11.9% in the ADT plus RT group. The same study demonstrated a slightly higher, but still acceptable, proportion of urinary, rectal and sexual problems in the latter group of patients. Similarly, Warde et al.4 evaluated the outcomes of 1205 individuals randomly assigned to be treated either with ADT or with ADT plus RT. Patients aged ≤80 years and with an Eastern Cooperative Oncology Group performance status between 0 and 2 were included. At 7 years, an 8% overall survival benefit was observed in the ADT plus RT group relative to patients receiving ADT alone. As in the previous study, gastrointestinal toxicities were most frequent in the ADT plus RT group.While both of these RCTs represent well-designed and well-conducted studies supporting the effectiveness of ADT plus RT in locally-advanced PCa, their strict inclusion criteria may limit the applicability of their findings to the general population. To overcome this issue and provide further evidences supporting the role of ADT plus RT in patients with high-risk PCa, Bekelman et al.2 used a population-based (SEER-Medicare) dataset to extrapolate three different groups of patients with locally-advanced PCa diagnosed between 1995 and 2007: (1) the RCT cohort (n = 12.924), consisting of patients selected according to the same inclusion criteria defined by the two previously cited studies; (2) the elderly cohort (n = 14.340), consisting of men aged between 76 and 85 years with locally-advanced PCa; (3) the screen-detected cohort (n = 4277), consisting of patients aged between 65 and 85 years with high-risk clinically undetectable disease. Besides standard survival analysis, the authors also adopted two statistical methodologies, namely the propensity score approach and instrumental variable analysis in order to adjust for possible confounders. In all of the three scenarios (unadjusted, propensity-score and instrumental variable adjusted), ADT plus RT resulted in a significant increase both in cancer-specific and overall mortality rates as compared to ADT alone. Interestingly, the survival benefit was observed not only in the RCT cohort, but also in the elderly and in the screen-detected ones. In consequence, this study provides evidences to expand the indications for ADT plus RT also to these patients. This is even more important when considering that, despite the potential survival benefits, older patients with locally-advanced PCa are less likely to receive local therapies relative to their younger counterparts.5However, while the population-based nature of this study may support the generalizability of its findings, it also represents a potential limitation that should be taken into account when interpreting the results. As correctly stated by the authors, several important data, such as total PSA and radiation dose/field, were missing. The retrospective nature of the dataset along with the risk of a misclassification bias also represents a limitation. In addition, no information was provided regarding the toxicities of ADT plus RT versus ADT alone and whether differences in the rate of side effects existed between the three groups. Finally, the oncological outcomes and morbidities of ADT plus RT in locally-advanced PCa should also be compared to those of radical prostatectomy with or without adjuvant RT, especially in carefully selected patients with a life expectancy ≥10 years.In conclusion, the study by Bekelman et al.2 adds important evidences regarding the oncological effectiveness of ADT plus RT relative to ADT alone in locally-advanced PCa even in older individuals. However, the clinical applicability of their findings should be further corroborated by prospective randomized trials focusing on this patient category.     

Does obesity affect the results of lumbar decompressive spinal surgery in the elderly?

The prevalence of obesity among the population is increasing, including in many elderly people. The purpose of this study was to evaluate whether lumbar spinal surgery in elderly patients with different body mass indices influences pain, satisfaction rate, and activities of daily living. Two hundred ninety-eight elderly patients (older than 65 years), 153 women and 145 men, who had decompressive laminectomy, discectomy, or combinations of these procedures during 1990 to 2000 were followed up. Indications for surgery included limitation in doing activities of daily living, severe pain, or both. The patients were classified into one of four categories in terms of their body mass index. The operative parameters, pain reduction, satisfaction rate, and activities of daily living using the Barthel index were assessed. The more obese patients were younger, tended to be female, and were more symptomatic. All four groups of patients had reduction in pain, improvement in activities of daily living, and were satisfied with the operation. Our data suggest that it is reasonable to operate on patients who are elderly and obese and who have lumbar symptoms, with the appropriate indications.     

Neck of femur fractures in the elderly: Does every hour to surgery count?

ObjectivesTo determine if early surgery before 12 h confers a survival or length of stay benefit for patients with neck of femur (NOF) fractures.DesignRetrospective review of prospectively collected data.SettingDistrict general hospital.Patients1913 patients aged over 60 admitted with a fractured NOF who underwent surgery between 2011 and 2015. Mean age was 83.9 years. 73.7% were female.InterventionPatients had surgery for fractured NOF with data collected on demographics, mortality and length of stay.Main outcome measurementsData collected included gender, age, ASA grade, fracture anatomy, surgery, time to surgery, days spent in acute hospital and rehabilitation settings and 30-day mortality. Statistical analysis was used to identify independent predictors of mortality and length of stay.Results30-day mortality was 6.1% and the mean hospitalisation time was 13 ± 11.3 days for the acute hospital and 20.2 ± 17.2 days for the trust. Operations were performed at a mean of 23.8 ± 14.8 h after presentation. Age, gender, ASA grade and type of fracture were independent predictors of either mortality or length of stay. Timing of surgery had an association with mortality but this only reached statistical significance at 24 h.In line with previous studies we analysed time to surgery in 12 h blocks. We also used logistic regression, recognizing time as a continuous variable, which revealed that every hour of delay to surgery increased the mortality risk by 1.8%.ConclusionsWhile every hour of delay increased mortality risk, the association with mortality only became statistically significant when delaying over 24 h. This supports a pragmatic approach, with surgery as soon as medically possible without a race to theatre.Level of evidenceLevel III retrospective cohort study.     

Can the Surgical Apgar Score predict morbidity and mortality in general orthopaedic surgery?

Purpose

The Surgical Apgar Score (SAS) is a simple tally based on intra-operative heart rate, blood pressure and blood loss; it predicts 30-day major postoperative complications and mortality in different surgical fields, but no validation has been performed in general orthopaedic surgery.

Methods

A prospective assessment of the SAS in 723 consecutive patients undergoing major and intermediate orthopaedic procedures was performed in an 18-month period. The SAS was calculated immediately after surgery, and the occurrence of major complications or death was registered within a 30-day follow-up.

Results

Thirty-seven patients had ≥1 complication (5.12 %). The complication rate did not augment as the score decreased (SAS 9–10 = 6.56 %; SAS 7–8 = 2.62 %; SAS 5–6 = 7.21 %; SAS ≤4 = 10.2 %), the relative risk did not augment as the score decreased and the likelihood ratio did not increase with decreasing SAS values, except in the subgroup of patients undergoing spine surgery. The C-statistic was 0.59 (95 % confidence interval 0.48–0.69), a weak discriminatory value. Using a threshold of 7 to define high-risk and low-risk patients, the SAS allowed risk stratification only for spine surgery.

Conclusions

The SAS does not predict 30-day major complications and death in patients undergoing general orthopaedic surgery, but it is useful in the subgroup of patients undergoing spine surgery.     

Quality of life in rectal cancer surgery:What do the patient ask?

Rectal cancer surgery has dramatically changed with the introduction of the total mesorectal excision (TME), which has demonstrated to significantly reduce the risk of local recurrence. The combination of TME with radiochemotherapy has led to a reduction of local failure to less than 5%. On the other hand, surgery for rectal cancer is also impaired by the potential for a significant loss in quality of life. This is a new challenge surgeons should think about nowadays: If patients live more, they also want to live better. The fight against cancer cannot only be based on survival, recurrence rate and other oncological endpoints. Patients are also asking for a decent quality of life. Rectal cancer is probably a paradigmatic example: Its treatment is often associated with the loss or severe impairment of faecal function, alteration of body anatomy, urogenital problems and, sometimes, intractable pain. The evolution of laparoscopic colorectal surgery in the last decades is an important example, which emphasizes the importance that themes like scar, recovery, pain and quality of life might play for patients. The attention to quality of life from both patients and surgeons led to several surgical innovations in the treatment of rectal cancer: Sphincter saving procedures, reservoir techniques (pouch and coloplasty) to mitigate postoperative faecal disorders, nerve-sparing techniques to reduce the risk for sexual dysfunction. Even more conservative procedures have been proposed alternatively to the abdominal-perineal resection, like the local excisions or transanal endoscopic microsurgery, till the possibility of a wait and see approach in selected cases after radiation therapy.     

Are we undertreating rectal cancer in the elderly? An epidemiologic study

OBJECTIVE: To better understand the reasons for decreased survival rates in elderly patients with rectal cancer by performing an epidemiologic evaluation of age-related differences in treatment and survival. SUMMARY BACKGROUND DATA: The incidence of rectal cancer increases with older age, and localized disease can be curatively treated with stage-appropriate radical surgery. However, older patients have been noted to experience decreased survival. METHODS: Patients with localized rectal adenocarcinoma were identified in the Surveillance, Epidemiology, and End Results database (1991-2002). Cancer-specific survival by age, sex, surgery type, tumor grade, lymph node status, and use of radiation therapy was evaluated using univariate and multivariate regression analysis. RESULTS: We identified 21,390 patients who met the selection criteria. The median age was 68 years. Each half-decade increase in age > or =70 years was associated with a 37% increase in the relative risk (RR) for cancer-related mortality (RR = 1.37; 95% confidence interval [CI], 1.33-1.42); decreased receipt of cancer-directed surgery (odds ratio [OR] = 0.56; 95% CI, 0.36-0.63); more local excision and less radical surgery (OR = 0.76; 95% CI, 0.72-0.81); less radiotherapy (OR = 0.64; 95% CI, 0.61-0.67); and greater likelihood of N0 pathologic stage classification (OR = 1.10; 95% CI, 1.05-1.15) (P < 0.0001 for each factor). The effect of age on cancer-specific mortality persisted in multivariate analysis with each half-decade increase in age > or =70 years resulting in a 31% increase in cancer-specific mortality (RR = 1.31; 95% CI, 1.25-1.36; P < 0.0001). CONCLUSIONS: In elderly patients, rectal cancer is characterized by decreased cancer-related survival rates that are associated with less aggressive treatment overall and decreased disease stages at presentation. Investigation into the reasons for these treatment differences may help to define interventions to improve cancer outcomes.     

The first 50s: can we achieve acceptable results in vestibular schwannoma surgery from the beginning?

Objective  

Vestibular schwannoma surgery requires a profound knowledge of anatomy and long-standing experience of surgical skull base techniques, as patients nowadays requests high-quality results from any surgeon. This educes a dilemma for the young neurosurgeon as she/he is at the beginning of a learning curve. The presented series should prove if surgical results of young skull base surgeons are comparable respecting carefully planned educational steps.