SURGERY FOR COLO-RECTAL CANCER: ADEQUACY OF NODAL STAGING IN AN EMERGENCY SETTING.

Background: It is a commonly held belief that in emergency surgery is not rare an inadequate lymphadenectomy resulting in pathologically understaged or indeterminate staging of the patient. Consequently some patients may not receive a necessary adjuvant chemotherapy or be subjected to unnecessary therapy. Methods: From September 2011 to May 2015, 483 patients were admitted in our Unit with the diagnosys of colo-rectal cancer. Four-hundred and fifty-five underwent to radical resection and were enrolled in this study. One-hundred and fifty-seven patients (35%) required an emergency operation (Group 1) and 298 (65%) had elective surgery (Group 2). Patients information were entered into a database: age and sex, tumor site, type of resection, laparoscopic versus open approach, stage, number of nodes and adequacy of lymph-node harvest (adequacy >= 12 lymph-nodes harvested). Statistical analysis was performed with SPSS v13; significance was defined as p< 0,05. Results: In Group 1, tumor sites were: right-sided 46%, left sided 45% and 9 % rectum. In Group 2, tumor sites were right-sided 38%, left sided 31% and 31 % rectum. These differences were statistically significant. The number of nodes harvested was similar in the two groups (Group 1: 18,3\ub19,2 nodes; Group 2: 18,7\ub110,1 nodes, p=0,97). The adequacy of lymph node harvest was 95% in Group 1 and 89% in Group 2. Thus the adequacy of lymphadenectomy was better in Group 1, however these differences were not statistically significant (p=0,60). The number of nodes harvested and the adequacy of lymphadenectomy were not influenced by the type of surgical approach (laparoscopic versus open surgery). Group 1 patients had a more advanced cancer stage (stage III/IV 47,1% vs. 36,0%, p=0,0006), but the need for enlarged resection was not significantly different in the two groups. Conclusions: Our data didn\u2019t show significant differences in nodes harvesting in emergency colo-rectal surgery compared to elective surgery. Adequacy of lymphadenectomy is comparable in the two settings

EMERGENCY COLO-RECTAL SURGERY IN PATIENTS OVER EIGHTY.

Background: Today average life expectancy in Western Countries has reached 80 years. At the same time, colorectal cancer (CCR) ranks first on both cancer incidence and related mortality. Therefore we face the problem of treating colorectal cancer occurring in elderly patients. Over the last years, there has been growing evidence in the literature that to this population should be offered life-prolonging radical surgeries. The aim of this study is to assess the clinical features and postoperative outcomes in 80 years old and older patients treated for colorectal cancer. We focused on safety (complication rates and operative mortality) and oncological results (radical excision and number of lymph nodes isolated). Methods: From September 2011 to May 2015, 483 resections for CCR with curative intent were performed; 16 explorative laparotomy and 12 trans-anal resection were excluded. Four hundred and fifty-five patients were enrolled: 307 of them were younger than 80 years and 168 patients were 80 years old or older. Patients\u2019 demographic, clinical and histopathological parameters, as well as intra- and perioperative results were analysed. Statistical analysis was performed with SPSS v13.0; significance was defined as p < 0.05. Results: Significant differences between the two groups were observed regarding comorbidities (p<0.001), cardio-vascular comorbidities and chronic renal failure in particular, emergency presentation (p<0.001), intraoperative blood transfusions (p=0.015), laparoscopic approach (p=0.002) and mortality (p<0.001). No differences were observed between the two groups regarding the number of radical resection and number of lymph nodes isolated. However, multivariate logistic regression analysis showed that advanced geriatric age ( 6580 years old) is an independent predictor of mortality (p=0.003 OR 4.756) but not an independent predictor of morbidity (p=0.669 OR 1.109); in particular, advanced geriatric age, emergency presentation and intraoperative blood transfusions are predictive of mortality; instead the presence of cardio-vascular comorbidities and emergency presentation, are independent predictor factors of morbidity. Conclusion: Old age ( 6580) as such does not represent a contraindication for CCR surgical treatment though associated with an increased risk of postoperative morbidity and mortality. In our opinion, patients who are appropriately evaluated and selected might have a favourable prognosis after undergoing colorectal resection

Impact of octogenarians on surgical outcome in colorectal cancer

Aim Colorectal cancer's (CRC) incidence occupies the second place among malignant tumours in men and the third place in women. The aging of the population raises new questions on the management of CRC in octogenarian patients. The objective of this study was to assess the influence of age ( 6580) on treatment and surgical outcome of colorectal cancer. Method In the period between October 1995 and April 2014, a total of 1397 patients underwent emergency and elective surgical interventions for CRC; the first group (Group-Older \u2013 GO) was composed of 291 patients 80 years or older (20.9%, of which 46.4% were male). The second group (Group-Younger \u2013 GY) included 1106 patients younger than 80 years (79,1%, 57.7% males). Results Significant differences between the two groups were observed regarding sex (p\ua0=\ua00.001), number of comorbidities (p\ua0=\ua00.001), ASA classification (p\ua0<\ua00.001), emergency presentation (p\ua0<\ua00.001), site of tumor (p\ua0=\ua00.010), need of intraoperative blood transfusions (p\ua0<\ua00.001), 30-days mortality (p\ua0<\ua00.001), 90-days mortality (p\ua0<\ua00.001) and morbidity in accordance with Clavien-Dindo classification (p\ua0<\ua00.001). When combining both elective and emergency procedures, multivariate logistic regression analysis showed that advanced age ( 6580 years old) was an independent predictor factor of 30-days mortality (p\ua0=\ua00.023, OR\ua0=\ua02.23) and morbidity (p\ua0=\ua00.088, OR\ua0=\ua01.31), while it was not predictive of 90-days mortality. When considering only elective colorectal surgery, octogenarian age was not found to be a predictive factor of 30-day and 90-day mortality, but predictive of postoperative morbidity. Conclusion Old age ( 6580) does not represent a contraindication to CRC elective surgical treatment, in emergency procedures it is associated with an increased risk of postoperative morbidity and mortality

EMERGENCY COLO-RECTAL SURGERY IN PATIENTS OVER EIGHTY.

Introduction: Today average life expectancy in Western Countries has reached 80 years. At the same time, colorectal cancer (CRC) ranks first on both cancer incidence and related mortality. Therefore we face the problem of treating colorectal cancer occurring in elderly patients. Over the last years, there has been growing evidence in the literature that this population should be offered life-prolonging radical surgeries. The aim of the study is to assess clinical features and postoperative outcomes in 80 years old and older patients treated for CRC. We focused on safety (complication rates and operative mortality) and oncological results (radical excision and number of isolated lymph nodes). Methods: From September 2011 to May 2015, 455 resections for CRC with curative intent were performed: 148 patients were over 80 years old (GroupA), 307 patients were younger than 80 years (GroupB). Patients\u2019 demographic, clinical and histo-pathological parameters, as well as intra- and perioperative results were analysed. Results: In GroupA 72 patients underwent emergency procedures (49%) and 76 underwent elective procedures (51%); conversely in GroupB 85 patients underwent emergency procedures (53%) and 76 underwent elective procedures (47%), respectively (p<0.001). Significant differences between the two groups were observed regarding comorbidities, cardio-vascular comorbidities and chronic renal failure in particular, emergency presentation, intraoperative blood transfusions, laparoscopic approach and mortality (p<0.001). No differences were observed between the two groups regarding the number of radical resection and number of lymph nodes isolated. However, multivariate logistic regression analysis showed that advanced geriatric age ( 6580 years old) is an independent predictor of mortality (p=0.003 OR 4.756) but not an independent predictor of morbidity (p=0.669 OR 1.109); in particular, old age, emergency presentation (EP) and intraoperative blood transfusions are predictive of mortality; instead the presence of cardio-vascular comorbidities and EP, are independent predictor factors of morbidity. Conclusion: Old age ( 6580) as such does not represent a contraindication for CRC surgical treatment though associated with an increased risk of postoperative morbidity and mortality, above on emergency procedures In our opinion it is advisable to reduce emergency procedures with multidisciplinary methods such as stenting in CRC obstruction as a bridge to surgery

GOSAFE - Geriatric Oncology Surgical Assessment and Functional rEcovery after Surgery:early analysis on 977 patients

Objective: Older patients with cancer value functional outcomes as much as survival, but surgical studies lack functional recovery (FR) data. The value of a standardized frailty assessment has been confirmed, yet it's infrequently utilized due to time restrictions into everyday practice. The multicenter GOSAFE study was designed to (1) evaluate the trajectory of patients' quality of life (QoL) after cancer surgery (2) assess baseline frailty indicators in unselected patients (3) clarify the most relevant tools in predicting FR and clinical outcomes. This is a report of the study design and baseline patient evaluations. Materials & Methods: GOSAFE prospectively collected a baseline multidimensional evaluation before major elective surgery in patients (≥70 years) from 26 international units. Short−/mid−/long-term surgical outcomes were recorded with QoL and FR data. Results: 1003 patients were enrolled in a 26-month span. Complete baseline data were available for 977(97.4%). Median age was 78 years (range 70–94); 52.8% males. 968(99%) lived at home, 51.6% without caregiver. 54.4% had ≥ 3 medications, 5.9% none. Patients were dependent (ADL 20 s (5.2%) or ASAIII-IV (48.8%). Major comorbidities (CACI > 6) were detected in 36%; 20.9% of patients had cognitive impairment according to Mini-Cog. Conclusion: The GOSAFE showed that frailty is frequent in older patients undergoing cancer surgery. QoL and FR, for the first time, are going to be primary outcomes of a real-life observational study. The crucial role of frailty assessment is going to be addressed in the ability to predict postoperative outcomes and to correlate with QoL and FR

ERAS program adherence-institutionalization, major morbidity and anastomotic leakage after elective colorectal surgery: the iCral2 multicenter prospective study

Background Enhanced recovery after surgery (ERAS) programs influence morbidity rates and length of stay after colorectal surgery (CRS), and may also impact major complications and anastomotic leakage rates. A prospective multicenter observational study to investigate the interactions between ERAS program adherence and early outcomes after elective CRS was carried out. Methods Prospective enrolment of patients submitted to elective CRS with anastomosis in 18 months. Adherence to 21 items of ERAS program was measured upon explicit criteria in every case. After univariate analysis, independent predictors of primary endpoints [major morbidity (MM) and anastomotic leakage (AL) rates] were identified through logistic regression analyses including all significant variables, presenting odds ratios (OR). Results Institutional ERAS protocol was declared by 27 out of 38 (71.0%) participating centers. Median overall adherence to ERAS program items was 71.4%. Among 3830 patients included in the study, MM and AL rates were 4.7% and 4.2%, respectively. MM rates were independently influenced by intra- and/or postoperative blood transfusions (OR 7.79, 95% CI 5.46-11.10; p &lt; 0.0001) and standard anesthesia protocol (OR 0.68, 95% CI 0.48-0.96; p = 0.028). AL rates were independently influenced by male gender (OR 1.48, 95% CI 1.06-2.07; p = 0.021), intra- and/or postoperative blood transfusions (OR 4.29, 95% CI 2.93-6.50; p &lt; 0.0001) and non-standard resections (OR 1.49, 95% CI 1.01-2.22; p = 0.049). Conclusions This study disclosed wide room for improvement in compliance to several ERAS program items. It failed to detect any significant association between institutionalization and/or adherence rates to ERAS program with primary endpoints. These outcomes were independently influenced by gender, intra- and postoperative blood transfusions, non-standard resections, and standard anesthesia protocol

Predicting Functional Recovery and Quality of Life in Older Patients Undergoing Colorectal Cancer Surgery: Real-World Data From the International GOSAFE Study

PURPOSE The GOSAFE study evaluates risk factors for failing to achieve good quality of life (QoL) and functional recovery (FR) in older patients undergoing surgery for colon and rectal cancer.METHODS Patients age 70 years and older undergoing major elective colorectal surgery were prospectively enrolled. Frailty assessment was performed and outcomes, including QoL (EQ-5D-3L) recorded (3/6 months postoperatively). Postoperative FR was defined as a combination of Activity of Daily Living &gt;= 5 + Timed Up &amp; Go test &lt;20 seconds + MiniCog &gt;2.RESULTS Prospective complete data were available for 625/646 consecutive patients (96.9%; 435 colon and 190 rectal cancer), 52.6% men, and median age was 79.0 years (IQR, 74.6-82.9 years). Surgery was minimally invasive in 73% of patients (321/435 colon; 135/190 rectum). At 3-6 months, 68.9%-70.3% patients experienced equal/better QoL (72.8%-72.9% colon, 60.1%-63.9% rectal cancer). At logistic regression analysis, preoperative Flemish Triage Risk Screening Tool &gt;= 2 (3-month odds ratio [OR], 1.68; 95% CI, 1.04 to 2.73; P = .034, 6-month OR, 1.71; 95% CI, 1.06 to 2.75; P = .027) and postoperative complications (3-month OR, 2.03; 95% CI, 1.20 to 3.42; P = .008, 6-month OR, 2.56; 95% CI, 1.15 to 5.68; P = .02) are associated with decreased QoL after colectomy. Eastern Collaborative Oncology Group performance status (ECOG PS) &gt;= 2 is a strong predictor of postoperative QoL decline in the rectal cancer subgroup (OR, 3.81; 95% CI, 1.45 to 9.92; P = .006). FR was reported by 254/323 (78.6%) patients with colon and 94/133 (70.6%) with rectal cancer. Charlson Age Comorbidity Index &gt;= 7 (OR, 2.59; 95% CI, 1.26 to 5.32; P = .009), ECOG &gt;= 2 (OR, 3.12; 95% CI, 1.36 to 7.20; P = .007 colon; OR, 4.61; 95% CI, 1.45 to 14.63; P = .009 rectal surgery), severe complications (OR, 17.33; 95% CI, 7.30 to 40.8; P &lt; .001), fTRST &gt;= 2 (OR, 2.71; 95% CI, 1.40 to 5.25; P = .003), and palliative surgery (OR, 4.11; 95% CI, 1.29 to 13.07; P = .017) are risk factors for not achieving FR.CONCLUSION The majority of older patients experience good QoL and stay independent after colorectal cancer surgery. Predictors for failing to achieve these essential outcomes are now defined to guide patients' and families' preoperative counseling

Quality of life in older adults after major cancer surgery: the GOSAFE international study

Abstract Background Accurate quality of life (QoL) data and functional results after cancer surgery are lacking for older patients. The international, multicenter Geriatric Oncology Surgical Assessment and Functional rEcovery after Surgery (GOSAFE) Study compares QoL before and after surgery and identifies predictors of decline in QoL. Methods GOSAFE prospectively collected data before and after major elective cancer surgery on older adults (≥70 years). Frailty assessment was performed and postoperative outcomes recorded (30, 90, and 180 days postoperatively) together with QoL data by means of the three-level version of the EuroQol five-dimensional questionnaire (EQ-5D-3L), including 2 components: an index (range = 0-1) generated by 5 domains (mobility, self-care, ability to perform the usual activities, pain or discomfort, anxiety or depression) and a visual analog scale. Results Data from 26 centers were collected (February 2017-March 2019). Complete data were available for 942/1005 consecutive patients (94.0%): 492 male (52.2%), median age 78 years (range = 70-95 years), and primary tumor was colorectal in 67.8%. A total 61.2% of all surgeries were via a minimally invasive approach. The 30-, 90-, and 180-day mortality was 3.7%, 6.3%, and 9%, respectively. At 30 and 180 days, postoperative morbidity was 39.2% and 52.4%, respectively, and Clavien-Dindo III-IV complications were 13.5% and 18.7%, respectively. The mean EQ-5D-3L index was similar before vs 3 months but improved at 6 months (0.79 vs 0.82; P &lt; .001). Domains showing improvement were pain and anxiety or depression. A Flemish Triage Risk Screening Tool score greater than or equal to 2 (odds ratio [OR] = 1.58, 95% confidence interval [CI] = 1.13 to 2.21, P = .007), palliative surgery (OR = 2.14, 95% CI = 1.01 to 4.52, P = .046), postoperative complications (OR = 1.95, 95% CI = 1.19 to 3.18, P = .007) correlated with worsening QoL. Conclusions GOSAFE shows that older adults’ preoperative QoL is preserved 3 months after cancer surgery, independent of their age. Frailty screening tools, patient-reported outcomes, and goals-of-care discussions can guide decisions to pursue surgery and direct patients’ expectations