Aim To investigate the efficacy and safety of  the single-step surgery  in elderly patients with obstructive colorectal cancer.

Methods  All patients who underwent single-step surgery and primary anastomosis for obstructive colorectal cancer in the period between January 2012 December 2017 were evaluated in this study.  The patients were divided into two groups: younger than 65 (Group Young) and  older than 65 (Group Old). Demographic data, American Society of  Anesthesiologists scores (ASA) scores, comorbidities, preoperative albumin levels, type of surgery, postoperative morbidity and mortality, pathological stages, and overall survival rates were investigated. 

Results  A total of 89 patients were included: 49 (54%) were older than 65 (Group Old).  In Group Old, the mean age was 75 (65-97), of which 28 (58.3%) were males. There were 41 patients younger than 65 (Group Young) with the mean age of 52.6 (41-64 years of age), of which 21 (51.2%) were males. There was no difference between groups according to albumin level. There was no statistical difference between two groups  according to tumour localization, pathological stage and type of surgery, as well as according to surgical complications.  The median overall survival rate was 11 months in both groups (0-66) (p=0.320). 

Conclusion Meticulous preparation of older patients (correction of anaemia, electrolyte levels and pH ) paves the road for successful surgeries, including single-step resection and primary anastomosis

Ahmet Seker

Hasan Fehmi Kucuk

Levent Kaptanoglu

Metin Kement

Nejdet Bildik

Onder Altin

Selcuk Kaya

Yunus Emre Altuntas

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83ORIGINAL ARTICLEAre the single-step resection and primary anastomosis suitable for obstructıve colorectal patients in older cases?Selcuk Kaya1, Onder Altin1, Yunus Emre Altuntas1, Metin Kement2, Levent Kaptanoglu2, Ahmet Seker1, Nejdet Bildik1, Hasan Fehmi Kucuk1 1Department of General Surgery, Kartal Research and Education Hospital, 2Department of General Surgery, School of Medicine, Bahce-sehir University; Istanbul, Turkey Corresponding author:Selcuk KayaDepartment of General Surgery, Kartal Research and Education HospitalIstanbul, TurkeyPhone: +90 505 230 5952;Fax: +90 216 3520083E-mail: selcukkaya_36@hotmail.comORCI ID: https://orcid.org/0000-0001-5729-9742Original submission:22 June 2018;Revised submission:10 August 2018;Accepted:15 August 2018.doi: 10.17392/971-19Med Glas (Zenica) 2019; 16(1):83-87ABSTRACTAim To investigate the efficacy and safety of  the single-step sur-gery  in elderly patients with obstructive colorectal cancer.Methods  All patients who underwent single-step surgery and primary anastomosis for obstructive colorectal cancer in the peri-od between January 2012 December 2017 were evaluated in this study.  The patients were divided into two groups: younger than 65 (Group Young) and  older than 65 (Group Old). Demographic data, American Society of  Anesthesiologists scores (ASA) scores, comorbidities, preoperative albumin levels, type of surgery, posto-perative morbidity and mortality, pathological stages, and overall survival rates were investigated. Results  A total of 89 patients were included: 49 (54%) were older than 65 (Group Old).  In Group Old, the mean age was 75 (65-97), of which 28 (58.3%) were males. There were 41 patients younger than 65 (Group Young) with the mean age of 52.6 (41-64 years of age), of which 21 (51.2%) were males. There was no difference between groups according to albumin level. There was no statisti-cal difference between two groups  according to tumour localizati-on, pathological stage and type of surgery, as well as according to surgical complications.  The median overall survival rate was 11 months in both groups (0-66) (p=0.320). Conclusion Meticulous preparation of older patients (correction of anaemia, electrolyte levels and pH ) paves the road for succe-ssful surgeries, including single-step resection and primary ana-stomosis. Key words: anastomosis, colorectal surgery, surgicalMedicinski Glasnik, Volume 16, Number 1, February 201984INTRODUCTIONMajority of patients suffering from colorectal cancer were diagnosed in advanced ages and about 30% of these cases were admitted with mechanical obstruction.  Unfortunately, there is limited data in the literature about feasibility of single step surgery  with primary anastomosis in elderly patients with obstructive colorectal cancer (CRC) (1,2). Obstructive tumours are usually presented in more advanced stages. Sep-sis, dehydration, hemodynamic instability and malnutrition remain major obstacles for succe-ssful surgical management of these patients  (3). Although, recent advances in technology such as colonic stents and laser applications give us the opportunity to create gastrointestinal system continuity, a significant number of the patients are not suitable for these conservative approaches (3,4). In right sided colonic malignancies with ob-struction general surgical approach is usually single-step resection and anastomosis, howe-ver, there is no consensus for left sided tumours (5). In practice, there are four current surgical approaches for the patients with left sided ob-structive tumour: loop colostomy/ ileostomy without resection (2/3 step approach), primary resection and Hartman procedure , resection with primary anastomosis (single step surgery), and in selected cases and centres conservative approaches (stent or laser) for palliation (brid-ge to surgery) (5). Most surgeons did not prefer single-step surgery because of an increasing risk of anastomosis leak secondary to co-morbidities and malnutrition, especially in elderly patients (1). According to the literature, Hartmann pro-cedure is still the most performed surgical pro-cedure in elderly patients with obstructive left sided colorectal cancer (1). Unfortunately, in majority of these patients, colostomies cannot be closed, therefore they have to live with per-manent stomas, and in such cases the quality of life is generally measured very low (1).  Howe-ver, some researchers reported very successful outcomes even in elderly patients, who un-derwent single-step surgery (6). Aim of this present study was to investigate the efficacy and safety of  the single-step surgery  in elderly patients with obstructive colorectal cancer.PATIENTS AND METHODPatients and study designAll patients who underwent single step surgery and primary anastomosis for obstructive colo-rectal cancer in the Department of General Sur-gery of Kartal Research and Education Hospi-tal, Istanbul, Turkey between January 2012 and December 2017 were retrospectively evaluated. The exclusion criteria were patients with mental disability and patients with another malignancy. The patients were divided into two groups accor-ding to the age: younger than 65 (Group Young) and patients ≥65 (Group Old). Demographic data, the American Society of Anesthesiologists scores (ASA) score, comorbidities, preoperati-ve albumin level, type of surgery, postoperative morbidity and mortality, pathological stage, and overall survival rate were investigated.  Postope-rative mortality was defined as deaths within a period of one month following surgeries. The study was approved by the Kartal Research and Education Hospital’s Ethics Committee.MethodsIn our clinic, all patients received nasogastric tu-bes for decompression and foley catheters for uri-nary status. Personalized fluid resuscitation was applied  with careful attention. Central venous catheter was placed and central venous pressure was measured. Plain abdominal graphies, whole abdominal CT scan and colonoscopy were utili-zed for diagnosis. For colonoscopy examination, fleet enemas was used. Manual decompression was applied for intestinal decompression before single-step resection and primary anastomosis. All patients received single dose 1 gr ceftriaxon and 500 metronidazol, preoperatively, and antibiotics treatment continued for a week. The American Society of Anesthesiologists sco-res (7) were evaluated by members of our anae-sthesia team. It is a physical status classification system calculated prior to surgery: ASA I - a nor-mal healthy patient; ASA II - a patient with mild systemic disease; ASA III- a patient with severe systemic disease; ASA IV - a patient with severe systemic disease that is a constant threat to life; ASA V- a moribund patient who is not expected to survive without the operation; ASA VI - dec-lared brain-death patient whose organs are being removed for donor purposes.85Kaya et al. Primary anastomosis in old patientsStatistical analysis Data were collected using paper/pencil instru-ments by the surgeon and entered into a computer by statistical staff. Parameters were evaluated for predictive significance by independent t-tests for continuous variables χ2 test for categorical varia-bles. A difference was considered as statistically significant with p<0.05.RESULTS A total of 89 patients were included in this study, of which 49 (54%) were older than 65 (Group Old).  In the Group Old, the mean age was 75 (range 65-97) years, of which 28 (58.3%) were males. There were 41 (46%) patients younger than 65 years (Group Young) with the mean age of 52.6 (range 41-64); 21 (51.2%) were males. There was no difference in either groups accor-ding to gender (p=0.501). The patients in Gro-up Old had  significantly higher ASA score (p=0.004) than those in Group Young. Also, co-morbidities were  significantly higher in Group Old  (p=0.337). Most frequent additional disease was hypertension in both groups (p=0.337).  In five (12.2%) patients in the Group Old albumin level lower than 3 g/dL was found and 12 (25%) in the Group Young ( p= 0.220) (Table 1). There was no statistical difference between two groups relating to tumour localization, patholo-gical stage and type of surgery (p>0.05 for all comparisons) (Table 2).No (%) of patients in the group Characteristic <65 years (n=41)≥ 65 years (n=48)pGender 0.501Female 20 (48.8) 20 (41.7)Male 21 (51.2) 28 (58.3)Serum albumin level (g/dL) 0.2203> 5 (12.2) 12 (25.0)3 ≤ ~ < 3.5 21 (51.2) 22 (45.8)3.5 ≤ ~ < 4.0 13 (31.7) 14 (29.2)4.0 ≤ 2 (4,9) 0Additional diseases 0.337Hypertension 10 (24.4) 22 (45.8)Diabetes 8 (19.5) 12 (25.0)Heart failure 0 6 (12.5)Asthma 0 4 (8.3)KOAH 0 4 (8.3)CLD 1 (2.4) 1 (2.1)CRF 1 (2.4) 2 (4.2)ASA score 0.004II 13 (31.7) 5 (10.4)III 27 (65.9) 33 (68.8) IV 1 (2.4) 10 (20.8)Table 1. Patient characteristics according to age groupsKOAH, chronic obstructive pulmonary disease; CLD, chronic liver disease; CRF, chronic renal failure; ASA, American Society of  AnesthesiologistNo (%) of the patients in the group Characteristic <65 (n=41) ≥ 65 (n=48) PLocalizationRight colon 19 (46.3) 17 (35.4)Left colon 22 (53.7) 31 (64.6)StageII 12 (29.3) 21 (43.8)III 14 (34.1) 16 (33.3)IV 15 (36.6) 11 (22.9)Type of surgeryRight colectomy 22 (53.7) 22 (45.8)Left colectomy 2 (4.9) 8 (16.7)Anterior resection 17 (41.5) 14 (29.2)Segmental resection 0 1 (2.1) Subtotal colectomy 0 3 (6.3)Table 2. Tumour localization, stage and type of surgeryNo (%) of the patients in the grouppType of morbidity <65 (n=41) ≥ 65 (n=48)LocalSurgical site infection 11 (26.8) 13 (27.1) 0.979Anastomosis leak 3 (7.3) 4 (8.3) 0.859Intra-abdominal bleeding 0 1 (2.1) 0.353Intra-abdominal infection 2 (4.9) 1 (2.1) 0.467Elongated ileus 6 (14.6) 7 (14.6) 0.995Evisceration 2 (4.9) 3 (6.3) 0.483SystematicRespiratoryRespiratory failure 5 (12.2) 9 (18.8) 0.397Pulmonary emboli 0 1 (2.1) -Pneumonia 0 1 (2.1) -CardiacMyocardial infarction 1 (2.4) 0 -RenalAcute renal failure 5 (12.2) 9 (18.8) 0.910 Deep venous thrombosis 1 (2.4) 0 -Table 3. Surgical and systematic postoperative morbidityASA, American Society of  AnesthesiologistThe most frequent postoperative complication was surgical site infection in both groups (26.8% v. 27.1%; p=0.979 ). A rate of anastomosis le-aks was 7.3% in the Group Old and 8.3% in the Group Young (p=0.859) (p=0.689, 0.653). Res-piratory and renal failures were most detected systemic complications in both groups, 12.2% v. 18.8%, respectively (Table 3).  The rate of postoperative early mortality was 2.3 % (n=1) in the Group Young and 8.3% (n=4)  in the Group Old (p=0.229). The median overall survival rate was 11 months in both groups (ran-ge 0-66) with no statistical significance (p=0.320) (Table 4.).Medicinski Glasnik, Volume 16, Number 1, February 201986DISCUSSIONUsually, majority of colorectal patients admitted with the obstruction are in advanced ages with comorbidities (8). Currently, the majority of lite-rature reviews urgent colorectal cancer patients with comorbidities who received stomas (9-11). If appropriate preoperative preparations are per-formed, single-step resection and primary ana-stomosis can be safely applied with low mortality and morbidity rates in even elderly patients (12). Patients admitted for obstructive colorectal can-cer require preoperative intestinal decompression for successful resection and anastomosis. Manual decompression and irrigation of colon (on-table lavage) can be safely applied. Studies comparing both methods conclude that manual decompressi-on is simple and can be done within a short peri-od of time. There is no difference between both methods (13,14). We applied manual decompre-ssion to all patients. To define synchronous tu-mours via colonoscopic examinations is highly difficult, manual decompression may be helpful to overcome this situation. We faced systemic complications more than local in cases with high ASA scores. The same reports can be found in the literature (15). In our study preoperative statistical difference between both groups according to ASA score was not de-tected following surgeries, in relation with local and systemic complications. Age should not be a contraindication for resection and anastomosis. Iversen et al. reported mortality as 22% in ob-structive colorectal cancer cases (16). According to the literature postoperative mortality is rela-ted to comorbidities and ASA score more than age (17-20). In our study short time results were excellent for resection and anastomosis. Total mortality rate was 5.6%. Application of Hartmann procedure due to high risk of anastomosis leak carry risk of permanent stomas with low quality of life (1). There is no randomized study comparing resection and Har-tman procedure. There is no difference between two surgeries according to mortality and mor-bidity (5). Advances in surgical techniques and preoperative supportive therapies give us the opportunity for successful operations. Primary resection and anastomosis can be safely applied. In our study, mortality rates and the number of anastomosis leaks were significantly lower than in other studies in the literature review (12,21). We believe in experienced hands, dedicated to colorectal surgery, who should do these type of surgeries. In specialized units for colorectal sur-gery like those in our, institution resection and anastomosis should be the choice of treatment. Single step-resection and anastomosis have excellent results within a short period of time. However, reports on long-term results indicate high numbers of mortality in older cases (22-24). We believe that shortage of long-term survival is related to high numbers of Stage 3 and 4 patients. In conclusion, meticulous preparation of older patients (correction of anaemia, electrolyte levels and pH) paves the road for successful surgeri-es, including single-step resection and primary anastomosis. This type of surgery can be safely applied with low mortality and morbidity rates. Older patients will not receive permanent stomas. Age should not play a major role in planning type of surgery. Curative resections should be done by experienced surgeons without hesitation. Despite the absence of screening and chemotherapy regi-mens in older patients, they should receive effec-tive surgical procedures. FUNDINGNo specific funding was received for this study. TRANSPARENCY DECLARATIONConflicts of interest: None to declare.<65 (n=41) ≥ 65 (n=48) pGender 0.300Female 1 2Male 0 2Stage 0.620II 0 1III 0 1IV 1 2ASA score 0.371I-II 0 0III 1 2IV 0 2 Total 1 4 0.229Table 4. Characteristics of mortality cases87Kaya et al. Primary anastomosis in old patientsREFERENCES1. Yang Z, Wang L, Kang L, Xiang J, Peng J, Cui J, Huang Y, Wang J. Clinicopathologic characteristics and outcomes of patients with obstructive colorectal cancer. J Gastrointest Surg  2011; 15:1213-22. 2. Morton DG, Fielding JW. Surgery for colonic can-cer. In: Bleiberg H, Rougier P, Wilke H-J, Eds. Ma-nagement of Colorectal Cancer. London: Martin Dunitz 1998; 84.3. Tekkis PP, Kinsman R, Thompson MR, Stamatakis JD. 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Are the single-step resection and primary anastomosis suitable for obstructıve colorectal patients in older cases?

Are the single-step resection and primary anastomosis suitable for obstructıve colorectal patients in older cases?

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