Emergency surgery for colon cancer in the aged

T. Koperna, M. Kisser and F. Schulz
Department of General Surgery, Hospital Lainz, Vienna, Austria.

BACKGROUND: The prognosis of colon cancer is poorest in cases of emergency presentation of this disease in the elderly. The high rate of clinical mortality in this group of patients has made it necessary to devise a specific therapeutic approach. OBJECTIVE: To define the therapeutic approach used for colon cancer in the elderly. DESIGN: A retrospective study. SETTING: A secondary referral center. PATIENTS: Ninety-nine patients with colon carcinoma that first became clinically manifested in an emergency situation were examined retrospectively. The patients had been treated from 1986 through 1995. All patients were older than 70 years. A total of 74 patients showed clinical manifestation of a colon carcinoma with an ileus, while 10 patients had tumor perforation. A further 15 patients had a perforation proximal to an obstructing tumor. MAIN OUTCOME MEASURES: Clinical lethality, surgical procedure, risk of comorbidity, and multiple organ system failure. RESULTS: Any increase in comorbidity was associated with a higher clinical lethality, which was especially true for the lungs, heart, and kidney, and also for diabetes. In 44.4% of the patients with a significantly higher comorbidity (P = .04) and a more advanced tumor stage (P < .001), the tumor was left in situ during the primary surgical intervention. Patients who survived after staged resection had an even higher comorbidity at first presentation when compared with patients who survived after primary resection (P = .02). However, the comorbidity of deceased patients who were supposed to undergo staged resection did not differ significantly from the comorbidity of those who underwent primary resection (P = .70). The clinical lethality in patients who were managed by stoma only or by bypass anastomosis was markedly higher than that in patients who underwent primary resection (59.0% vs 43.6%). The significantly highest postoperative mortality rate was recorded in patients who underwent primary resection after colonic perforation (74%) (P = .03), while the significantly lowest postoperative mortality rate was recorded in patients who underwent primary resection after tumor obstruction (28%) (P < .001). Postoperative failure of the lungs and heart and kidney failure requiring hemodialysis were associated with significantly higher clinical mortality rates (P < .001 to P = .004). Postoperative complications occurred in 28 (28.3%) of the patients. However, rupture of the anastomosis was observed in only 2 of these patients. Generalized disease was associated with a significantly higher rate of postoperative complications (P = .04), which was especially true for pneumonia (P = .003). However, no effect on survival was found for patients with Dukes disease stage D. CONCLUSIONS: The lower mortality rate following primary resection is achieved by preselection of patients. The preselection is such that patients in poor general condition who have tumors in advanced stages are not treated by resection. The significantly (P = .03) highest postoperative mortality rate in patients who underwent primary resection after tumor perforation reflects the necessity of resection in those cases regardless of higher comorbidity. In an emergency situation, initial minimal surgery followed by staged resection is a feasible alternative to treat aged patients with a higher comorbidity and an intraoperatively established greater spread of tumor. This procedure permits delayed radical resection at the lowest rate of clinical mortality for this age group and is especially suitable for frail, aged patients in poor condition. The advantages of staged resection can be demonstrated by the fact that more patients with a higher comorbidity survive. The poor physiological adaptability of elderly patients limits their ability to compensate for postoperative organ failure and adds the risk of comorbidity. Hence, these 2 factors are associated with poor prognosis in this age group.