EMERGENCY-SURGERY FOR COLON-CANCER IN THE AGED

Background: The prognosis of colon cancer is poorest in cases of emerg ency presentation of this disease in the elderly. The high rate of cli nical mortality in this group of patients has made it necessary to dev ise a specific therapeutic approach. Objective: To define the therapeu tic approach used for colon cancer in the elderly. Design: A retrospec tive study. Setting: A secondary referral center. Patients: Ninety-nin e patients with colon carcinoma that first became clinically manifeste d in an emergency situation were examined retrospectively. The patient s had been treated from 1986 through 1995. All patients were older tha n 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 t umor. Main Outcome Measures: Clinical lethality, surgical procedure, r isk of comorbidity, and multiple organ system failure. Results: Any in crease 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 com orbidity (P=.04) and a more advanced tumor stage (P<.001), the tumor w as left in situ during the primary surgical intervention. Patients who survived after staged resection had an even higher comorbidity at fir st 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 u nderwent primary resection (59.0% vs 43.6%). The significantly highest postoperative mortality rate was recorded in patients who underwent p rimary resection after colonic perforation (74%) (P=.03),while the sig nificantly lowest postoperative mortality rate was recorded in patient s who underwent primary resection after tumor obstruction (28%) (P<.00 1). Postoperative failure of the lungs and heart and kidney failure re quiring hemodialysis were associated with significantly higher clinica l mortality rates (P<.001 to P=.004). Postoperative complications occu rred in 28 (28.3%) of the patients. However, rupture of the anastomosi s was observed in only 2 of these patients. Generalized disease was as sociated with a significantly higher rate of postoperative complicatio ns (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 posto perative mortality rate in patients who underwent primary resection af ter tumor perforation reflects the necessity of resection in those cas es regardless of higher comorbidity. In an emergency situation, initia l minimal surgery followed by staged resection is a feasible alternati ve to treat aged patients with a higher comorbidity and an intraoperat ively established greater spread of tumor. This procedure permits dela yed radical resection at the lowest rate of clinical mortality for thi s age group and is especially suitable for frail, aged patients in poo r condition. The advantages of staged resection can be demonstrated by the fact that more patients with a higher comorbidity survive. The po or physiological adaptability of elderly patients limits their ability to compensate for postoperative organ failure and adds the risk of co morbidity. Hence, these 2 factors are associated with poor prognosis i n this age group.