Advertisement

Medical and Surgical Management of Colorectal Cancer Emergencies in Elderly Patients

  • Filippo Landi
  • Eloy EspinEmail author
Chapter
Part of the Hot Topics in Acute Care Surgery and Trauma book series (HTACST)

Abstract

The incidence of CRC increases sharply with age. Complicated CRC is a predominant disease in elderly patients. Emergency presentation in the elderly is associated with higher rates of advanced disease. Risk of emergency admission is closely linked to advanced age, comorbidities, and well-identified socioeconomic factors. Colorectal resection for CRC in the elderly is a procedure that is frequently performed in an emergency situation and with important pre-existing comorbidity and reduced physiologic reserve. Complicated right-sided colon cancer is the most frequent indication for nonelective colorectal resection in the octogenarian. Frequently, in the setting of obstruction, perforation, or bleeding, colectomy is a lifesaving treatment and is associated with postoperative mortality up to 48% and morbidity up to 77%. Morbidity and mortality increase with age, comorbidities, and physical frailty. Elderly CRC patients undergoing resection have a greatly increased 1-year mortality risk, as well as worst mid- and long-term survival compared to elective patients of the same age. Chronological age should not be a contraindication for radical surgery, and a curative resection should be performed whenever allowed by disease stage or patient physical status. Palliative treatment may be necessary in up to a third of over 80 patients with complicated cancer.

Keywords

Colorectal cancer Elderly patient Oldest old Emergency colorectal surgery Emergency presentation Nonelective colorectal resection 

Abbreviations

CC

Colon cancer

CRC

Colorectal cancer

ECR

Emergency colorectal resection

EP

Emergency presentation

GI

Gastrointestinal

mFI

Modified frailty index

MM

Morbidity and mortality

RC

Rectal cancer

References

  1. 1.
    Cao B, Bray F, Beltran-Sanchez H, Ginsburg O, Soneji S, Soerjomataram I. Benchmarking life expectancy and cancer mortality: global comparison with cardiovascular disease 1981–2010. BMJ. 2017;357:j2765.CrossRefGoogle Scholar
  2. 2.
    Neuman HB, O’Connor ES, Weiss J, Loconte NK, Greenblatt DY, Greenberg CC, et al. Surgical treatment of colon cancer in patients aged 80 years and older: analysis of 31,574 patients in the SEER-Medicare database. Cancer. 2013;119(3):639–47.CrossRefGoogle Scholar
  3. 3.
    Soto-Ortiz L, Brody JP. Similarities in the age-specific incidence of colon and testicular cancers. PLoS One. 2013;8(6):e66694.CrossRefGoogle Scholar
  4. 4.
    Rutten HJ, den Dulk M, Lemmens VE, van de Velde CJ, Marijnen CA. Controversies of total mesorectal excision for rectal cancer in elderly patients. Lancet Oncol. 2008;9(5):494–501.CrossRefGoogle Scholar
  5. 5.
    Ebell MH, Thai TN, Royalty KJ. Cancer screening recommendations: an international comparison of high income countries. Public Health Rev. 2018;39:7.CrossRefGoogle Scholar
  6. 6.
    Berkowitz Z, Hawkins NA, Peipins LA, White MC, Nadel MR. Beliefs, risk perceptions, and gaps in knowledge as barriers to colorectal cancer screening in older adults. J Am Geriatr Soc. 2008;56(2):307–14.CrossRefGoogle Scholar
  7. 7.
    Renzi C, Lyratzopoulos G, Card T, Chu TP, Macleod U, Rachet B. Do colorectal cancer patients diagnosed as an emergency differ from non-emergency patients in their consultation patterns and symptoms? A longitudinal data-linkage study in England. Br J Cancer. 2016;115(7):866–75.CrossRefGoogle Scholar
  8. 8.
    Comber H, Sharp L, de Camargo Cancela M, Haase T, Johnson H, Pratschke J. Causes and outcomes of emergency presentation of rectal cancer. Int J Cancer. 2016;139(5):1031–9.CrossRefGoogle Scholar
  9. 9.
    Govaert JA, Govaert MJ, Fiocco M, van Dijk WA, Tollenaar RA, Wouters MW, et al. Hospital costs of colorectal cancer surgery for the oldest old: a Dutch population-based study. J Surg Oncol. 2016;114(8):1009–15.CrossRefGoogle Scholar
  10. 10.
    Wallace D, Walker K, Kuryba A, Finan P, Scott N, van der Meulen J. Identifying patients at risk of emergency admission for colorectal cancer. Br J Cancer. 2014;111(3):577–80.CrossRefGoogle Scholar
  11. 11.
    Askari A, Malietzis G, Nachiappan S, Antoniou A, Jenkins J, Kennedy R, et al. Defining characteristics of patients with colorectal cancer requiring emergency surgery. Int J Colorect Dis. 2015;30(10):1329–36.CrossRefGoogle Scholar
  12. 12.
    Rabeneck L, Paszat LF, Li C. Risk factors for obstruction, perforation, or emergency admission at presentation in patients with colorectal cancer: a population-based study. Am J Gastroenterol. 2006;101(5):1098–103.CrossRefGoogle Scholar
  13. 13.
    Geraghty J, Shawihdi M, Devonport E, Sarkar S, Pearson MG, Bodger K. Reduced risk of emergency admission for colorectal cancer associated with the introduction of bowel cancer screening across England: a retrospective national cohort study. Colorectal Dis. 2018;20(2):94–104.CrossRefGoogle Scholar
  14. 14.
    Aquina CT, Becerra AZ, Xu Z, Boscoe FP, Schymura MJ, Noyes K, et al. Nonelective colon cancer resection: a continued public health concern. Surgery. 2017;161(6):1609–18.CrossRefGoogle Scholar
  15. 15.
    Scott NA, Jeacock J, Kingston RD. Risk factors in patients presenting as an emergency with colorectal cancer. Br J Surg. 1995;82(3):321–3.CrossRefGoogle Scholar
  16. 16.
    Xu Z, Becerra AZ, Aquina CT, Hensley BJ, Justiniano CF, Boodry C, et al. Emergent colectomy is independently associated with decreased long-term overall survival in colon cancer patients. J Gastrointest Surg. 2017;21(3):543–53.CrossRefGoogle Scholar
  17. 17.
    Mothes H, Bauschke A, Schuele S, Eigendorff E, Altendorf-Hofmann A, Settmacher U. Surgery for colorectal cancer in elderly patients: how can we improve outcome? J Cancer Res Clin Oncol. 2017;143(9):1879–89.CrossRefGoogle Scholar
  18. 18.
    Heriot AG, Tekkis PP, Smith JJ, Cohen CR, Montgomery A, Audisio RA, et al. Prediction of postoperative mortality in elderly patients with colorectal cancer. Dis Colon Rectum. 2006;49(6):816–24.CrossRefGoogle Scholar
  19. 19.
    Amri R, Bordeianou LG, Sylla P, Berger DL. Colon cancer surgery following emergency presentation: effects on admission and stage-adjusted outcomes. Am J Surg. 2015;209(2):246–53.CrossRefGoogle Scholar
  20. 20.
    Oliphant R, Mansouri D, Nicholson GA, McMillan DC, Horgan PG, Morrison DS, et al. Emergency presentation of node-negative colorectal cancer treated with curative surgery is associated with poorer short and longer-term survival. Int J Colorect Dis. 2014;29(5):591–8.CrossRefGoogle Scholar
  21. 21.
    Ming-Gao G, Jian-Zhong D, Yu W, You-Ben F, Xin-Yu H. Colorectal cancer treatment in octogenarians: elective or emergency surgery? World J Surg Oncol. 2014;12:386.CrossRefGoogle Scholar
  22. 22.
    Goldvaser H, Katz Shroitman N, Ben-Aharon I, Purim O, Kundel Y, Shepshelovich D, et al. Octogenarian patients with colorectal cancer: characterizing an emerging clinical entity. World J Gastroenterol. 2017;23(8):1387–96.CrossRefGoogle Scholar
  23. 23.
    Cuffy M, Abir F, Audisio RA, Longo WE. Colorectal cancer presenting as surgical emergencies. Surg Oncol. 2004;13(2–3):149–57.CrossRefGoogle Scholar
  24. 24.
    Baer C, Menon R, Bastawrous S, Bastawrous A. Emergency presentations of colorectal cancer. Surg Clin N Am. 2017;97(3):529–45.CrossRefGoogle Scholar
  25. 25.
    Winner M, Mooney SJ, Hershman DL, Feingold DL, Allendorf JD, Wright JD, et al. Incidence and predictors of bowel obstruction in elderly patients with stage IV colon cancer: a population-based cohort study. JAMA Surg. 2013;148(8):715–22.CrossRefGoogle Scholar
  26. 26.
    Bakker IS, Snijders HS, Grossmann I, Karsten TM, Havenga K, Wiggers T. High mortality rates after nonelective colon cancer resection: results of a national audit. Colorect Dis. 2016;18(6):612–21.CrossRefGoogle Scholar
  27. 27.
    Tabola R, Mantese G, Cirocchi R, Gemini A, Grassi V, Boselli C, et al. Postoperative mortality and morbidity in older patients undergoing emergency right hemicolectomy for colon cancer. Aging Clin Exp Res. 2017;29(Suppl 1):121–6.CrossRefGoogle Scholar
  28. 28.
    Arezzo A, Passera R, Lo Secco G, Verra M, Bonino MA, Targarona E, et al. Stent as bridge to surgery for left-sided malignant colonic obstruction reduces adverse events and stoma rate compared with emergency surgery: results of a systematic review and meta-analysis of randomized controlled trials. Gastrointest Endosc. 2017;86(3):416–26.CrossRefGoogle Scholar
  29. 29.
    Mizrahi H, Geron N, Parker MC. The outcome of self-expanding metal stents in elderly patients. J Soc Laparoendosc Surg. 2014;18(3):e2014.00038.CrossRefGoogle Scholar
  30. 30.
    Iversen LH, Bulow S, Christensen IJ, Laurberg S, Harling H, Danish Colorectal Cancer Group. Postoperative medical complications are the main cause of early death after emergency surgery for colonic cancer. Br J Surg. 2008;95(8):1012–9.CrossRefGoogle Scholar
  31. 31.
    McGillicuddy EA, Schuster KM, Davis KA, Longo WE. Factors predicting morbidity and mortality in emergency colorectal procedures in elderly patients. Arch Surg. 2009;144(12):1157–62.CrossRefGoogle Scholar
  32. 32.
    Congiusta DV, Palvannan P, Merchant AM. The impact of frailty on morbidity and mortality following open emergent colectomies. Biomed Res Int. 2017;2017:5126452.CrossRefGoogle Scholar
  33. 33.
    Felli E, Brunetti F, Disabato M, Salloum C, Azoulay D, De’angelis N. Robotic right colectomy for hemorrhagic right colon cancer: a case report and review of the literature of minimally invasive urgent colectomy. World J Emerg Surg. 2014;9:32.CrossRefGoogle Scholar
  34. 34.
    Clere-Jehl R, Schaeffer M, Vogel T, Kiesmann M, Pasquali JL, Andres E, et al. Upper and lower gastrointestinal endoscopies in patients over 85 years of age: risk-benefit evaluation of a longitudinal cohort. Medicine. 2017;96(44):e8439.CrossRefGoogle Scholar
  35. 35.
    Edelman DA, Sugawa C. Lower gastrointestinal bleeding: a review. Surg Endosc. 2007;21(4):514–20.CrossRefGoogle Scholar
  36. 36.
    Vallribera F, Landi F, Espin E, Sanchez JL, Jimenez LM, Marti M, et al. Laparoscopy-assisted versus open colectomy for treatment of colon cancer in the elderly: morbidity and mortality outcomes in 545 patients. Surg Endosc. 2014;28(12):3373–8.CrossRefGoogle Scholar
  37. 37.
    Landi F, Vallribera F, Rivera JP, Bertoli P, Armengol M, Espin E. Morbidity after laparoscopic and open rectal cancer surgery: a comparative analysis of morbidity in octogenarians and younger patients. Colorect Dis. 2016;18(5):459–67.CrossRefGoogle Scholar
  38. 38.
    Pirrera B, Vaccari S, Cuicchi D, Lecce F, De Raffele E, Via BD, et al. Impact of octogenarians on surgical outcome in colorectal cancer. Int J Surg. 2016;35:28–33.CrossRefGoogle Scholar
  39. 39.
    Turrentine FE, Wang H, Simpson VB, Jones RS. Surgical risk factors, morbidity, and mortality in elderly patients. J Am Coll Surg. 2006;203(6):865–77.CrossRefGoogle Scholar
  40. 40.
    McIsaac DI, Moloo H, Bryson GL, van Walraven C. The association of frailty with outcomes and resource use after emergency general surgery: a population-based cohort study. Anesth Analg. 2017;124(5):1653–61.CrossRefGoogle Scholar
  41. 41.
    Obeid NM, Azuh O, Reddy S, Webb S, Reickert C, Velanovich V, et al. Predictors of critical care-related complications in colectomy patients using the National Surgical Quality Improvement Program: exploring frailty and aggressive laparoscopic approaches. J Trauma Acute Care Surg. 2012;72(4):878–83.CrossRefGoogle Scholar
  42. 42.
    Vermillion SA, Hsu FC, Dorrell RD, Shen P, Clark CJ. Modified frailty index predicts postoperative outcomes in older gastrointestinal cancer patients. J Surg Oncol. 2017;115(8):997–1003.CrossRefGoogle Scholar
  43. 43.
    Buettner S, Wagner D, Kim Y, Margonis GA, Makary MA, Wilson A, et al. Inclusion of sarcopenia outperforms the modified frailty index in predicting 1-year mortality among 1,326 patients undergoing gastrointestinal surgery for a malignant indication. J Am Coll Surg. 2016;222(4):397–407.CrossRefGoogle Scholar
  44. 44.
    Rangel EL, Rios-Diaz AJ, Uyeda JW, Castillo-Angeles M, Cooper Z, Olufajo OA, et al. Sarcopenia increases risk of long-term mortality in elderly patients undergoing emergency abdominal surgery. J Trauma Acute Care Surg. 2017;83(6):1179–86.CrossRefGoogle Scholar
  45. 45.
    Schlichtemeier S, Logaraj A, Gill AJ, Engel A. Colorectal cancer resection in the Australian nonagenarian patient. Colorectal Dis. 2017;19(3):243–50.CrossRefGoogle Scholar
  46. 46.
    Kolfschoten NE, Wouters MW, Gooiker GA, Eddes EH, Kievit J, Tollenaar RA, et al. Nonelective colon cancer resections in elderly patients: results from the dutch surgical colorectal audit. Digest Surg. 2012;29(5):412–9.CrossRefGoogle Scholar
  47. 47.
    Modini C, Romagnoli F, De Milito R, Romeo V, Petroni R, La Torre F, et al. Octogenarians: an increasing challenge for acute care and colorectal surgeons. An outcomes analysis of emergency colorectal surgery in the elderly. Colorectal Dis. 2012;14(6):312–8.CrossRefGoogle Scholar
  48. 48.
    De Simone B, Coccolini F, Ansaloni L, Tarasconi A, Baiocchi G, Vettoretto N, et al. Complicated colorectal cancer in nonagenarian patients: is it better not to perform anastomosis in emergency? Turk J Trauma Emerg Surg. 2017;23(1):15–22.Google Scholar
  49. 49.
    Dekker JW, Gooiker GA, Bastiaannet E, van den Broek CB, van der Geest LG, van de Velde CJ, et al. Cause of death the first year after curative colorectal cancer surgery; a prolonged impact of the surgery in elderly colorectal cancer patients. Eur J Surg Oncol. 2014;40(11):1481–7.CrossRefGoogle Scholar
  50. 50.
    Dekker JW, van den Broek CB, Bastiaannet E, van de Geest LG, Tollenaar RA, Liefers GJ. Importance of the first postoperative year in the prognosis of elderly colorectal cancer patients. Ann Surg Oncol. 2011;18(6):1533–9.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Colorectal Surgery Unit, General Surgery ServiceHospital Universitari Vall d’Hebron, Universitat Autonoma de Barcelona (UAB)BarcelonaSpain

Personalised recommendations