Post-operative outcomes in the elderly following colorectal cancer surgery

SAVE OFFLINE

ORIGINAL ARTICLE ANZJSurg.com

Post-operative outcomes in the elderly following colorectal cancer surgery Hyerin Park

, Simon Parys, Jonathan Tan, Fiona Entriken and Rupert Hodder

Colorectal Surgery Unit, Department of Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia

Key words aged, 80 and over, colorectal neoplasms, colorectal surgery, morbidity, post-operative complications. Correspondence Ms Hyerin Park, Colorectal Surgery Unit, Department of Surgery, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, WA, 6009, Australia. Email: [email protected] H. Park BBioMedSc; S. Parys MBBS, FRACS; J. Tan MD; F. Entriken BSc, MNurs; R. Hodder MBBS, FRACS. Accepted for publication 4 October 2020. doi: 10.1111/ans.16394

Abstract Background: Despite the prevalence of colorectal cancer in the elderly, there has been a lack of recent studies examining surgical outcomes in these patients. Post-operative outcomes of colorectal cancer surgeries in those aged 80 and above will be compared to those younger than 80. Methods: A retrospective study was conducted of adults receiving surgical resections at a single tertiary centre for colorectal cancer diagnosed between January 2017 and December 2019. Patient demographics, mode of presentation, tumour demographics, operative data and post-operative outcomes were investigated. Results: Of the 326 patients included, 56 were aged 80 and above. Older patients were more likely to be female (P = 0.02), present with surgical emergencies or from other workup rather than through screening (P = 0.002), have more locally advanced cancers (P = 0.009) and receive less neoadjuvant therapy (P = 0.016). Despite this, they had comparable outcomes to those younger than 80 in terms of length of stay (P = 0.21) and rates of complications including mortality (P = 0.67). Conclusion: With appropriate patient selection and management, elderly patients can achieve comparable post-operative outcomes to their younger counterparts.

Introduction In Australia, colorectal cancer is the third most common type of malignancy.1 The majority of these cases occur in older people, with those older than 74 having an incidence triple to that of those who are 50–74 years old.2 With increasing life expectancies, the importance of colorectal cancer in the elderly is only expected to increase.3 Despite this, there has been a lack of consensus on treating colorectal cancer in the elderly.4 Surgery remains a cornerstone of treatment, but older people have generally been viewed as highrisk surgical candidates as they are more likely to have emergency presentations, late-stage disease and comorbidities.4 The effect of these factors on outcomes following surgery in the elderly has been unclear, and this problem has been compounded by the paucity of studies that are reflective of current management practices.5,6 To examine the impact of recent advances in peri-operative and operative care, this study will compare postoperative outcomes in those aged 80 and above to those younger than 80 years.

© 2020 Royal Australasian College of Surgeons

Methods A retrospective study was conducted of adults receiving surgery for colorectal malignancy diagnosed between January 2017 and December 2019 at a single tertiary unit. Inclusion criteria were all patients with colon and/or rectum malignancy aged 18 years and above who received surgery as part of their treatment. Exclusion criteria included patients receiving palliative care, chemoradiotherapy only, local resections of low rectal tumours, appendiceal neoplasms and polypectomies. Data analysed included patient demographics (age, gender and mode of presentation), pathological data (stage of cancer, use of neoadjuvant therapy and completeness of resection), treatment (type of operation, including use of laparoscopic surgery) and follow-up data (length of stay, post-operative complications and 30-day mortality). Complications were classified using the Clavien– Dindo classification with minor complications defined as Clavien– Dindo grade I or II while major complications were defined as Clavien–Dindo grade III or IV. Data were collected into Microsoft Excel (Redmond, WA, USA) and statistical analysis was performed using analysis of variance and chi-squared contingency table with P < 0.05 being defined as significant. The study was granted

ANZ J Surg (2020)

Park et al.

2

approval by the Sir Charles Gairdner Hospital Quality Improvement Activity Audit Committee (reference number 33560).

Results A total of 361 patients with colorectal malignancy were initially identified. After applying inclusion and exclusion criteria, a total of 326 patients remained. The majority of exclusions (n = 28) consisted of patients who underwent only chemotherapy with palliative intent. These excluded patients were split proportionately between groups with 6.6% of those aged 80 and above and 8.1% of those younger than 80 receiving only palliative chemotherapy. Of the included patients, those aged 80 and above (n = 56) had an average age of 85 (range 80–94). Of those younger than 80 (n = 270), the average age was 63 (range 21–79). Those aged 80 and above were more likely to be female compared to those younger than 80 (56% versus 35%, P = 0.02). Older patients were also less likely to present from screening (9% versus 28%) or mild symptoms (41% versus 43%) and more likely to present with surgical emergencies (20% versus 8.5%) or from workup from other investigations (22% versus 15%), which was significant (P < 0.01). This is presented in Figure 1. In terms of pathology, older patients were more likely to have a higher T stage (P < 0.01),

but a comparable N stage (P = 0.59). This is summarized in Table 1. This higher rate of locally advanced tumours is in keeping with the previously mentioned lower screening and higher emergency presentation rates. Older patients were less likely to receive neoadjuvant chemotherapy (5.6% versus 18.5%, P = 0.02) compared to their younger counterparts. Despite more locally advanced tumours, older patients were still just as likely to receive a complete resection (96.4% versus 97.4%, P = 0.86). The type of operation was compared between the groups and is summarized in Table 2 and Figure 2. In the elderly, laparoscopic surgeries were performed less frequently (57% versus 69%) and defunctioning stoma formation was only more frequent (7% versus 3%). In addition, the elderly received right-sided resections more frequently (55% versus 33%), left-sided resections less frequently (60% versus 34%) and subtotal/total colectomies at a similar frequency (3.5% versus 4%). The post-operative outcomes of the two groups were comparable. Length of stay was comparable for the older (average 14 days, range 4–70) and younger (average 12 days, range 4–69) groups (P = 0.21). Likewise, the rates of complications were comparable between the older and younger groups in terms of overall complications (41% versus 36%) and major complications (8.9% versus 8.9%) (P = 0.67). These are summarized in Table 3 and Figure 3. There were three cases of 30-day post-operative mortality, all in the under 80-year-old group. Causes of post-operative mortality are detailed in Table S1.

Discussion

Fig 1. Mode of presentation in those aged younger than 80 ( ) and those aged 80 and above ( ).

Colorectal cancer is more commonly a disease of the elderly and, in developed nations, the elderly population is growing.5 In Australia over the past 20 years, the number of people aged 85 and above increased by 117%, which was significantly higher than the 35% increase in the general population over the same time period.7 With an increasing elderly population, understanding the impact of surgical interventions in the elderly is becoming more important.

Table 1 Patient and tumour characteristics Age ≥80 years

P-value

167 (62%) : 103 (38%)

25 (45%) : 31 (55%)

0.02

75 (28%) 116 (43%) 23 (9%) 41 (15%)

5 (9%) 23 (41%) 11 (20%) 12 (21%)

0.002

45 (17%) 42 (16%) 102 (38%) 64 (24%)

4 (7%) 5 (9%) 22 (39%) 20 (36%)

0.009

142 (53%) 75 (28%) 37 (14%)

27 (48%) 15 (27%) 9 (16%)

0.59

Age