**3. Outcome of elective surgery in the older patient**

There is no consensus about the optimal surgical management of older people with colorectal cancer, whose fitness varies from very fit to very frail individuals.

#### *Surgery for Colorectal Cancer in Older People DOI: http://dx.doi.org/10.5772/intechopen.111510*

This population is undertreated compared with younger patients, with a comparatively lower percentage of patients being operated on. Older cancer patients are recruited less often to clinical trials than younger patients and are therefore underrepresented in publications about cancer treatment [26].

Surgical risk stratification remains one of the most important aspects in the management of older patients [27]. Age is associated with an increased mortality following elective colorectal resection, with a mortality of up to 15.6% in patients who are older than 80 years of age. Patients with higher levels of comorbidities are expected to have significantly higher rates of complications, longer hospital stays, and mortality [28].

The American Society of Anaesthetists (ASA) score is the most commonly used parameter to compare comorbidities in younger and older patients. Whereas Vironen et al. [29] and Li et al., [30] concluded that there were multiple interobserver errors in computing the ASA scores, and therefore ASA scores were considered to be of limited in use for surgical patients, other studies concluded otherwise. Significant differences in the ASA scores between the younger and older groups were shown by Symeonidis et al. [31], Khan et al., [32], Marusch et al. [33], and Gurevitch et al. [34].

Symeonidis et al. showed that there was a significant difference in mortality rate for those having an ASA score of two or more when compared to those with a lower ASA score [31]. This paper also correlated an increased postoperative mortality rate to a higher TNM score. On the other hand, Vironen et al. [29] demonstrated that when comparing two groups over and under 75 years of age, but with similar ASA scores, there was no significant difference in postoperative mortality. In this case, the postoperative mortality rate was shown to be low throughout, no matter the ASA score. It seems that there was considerable interobserver inconsistency of classification, making the ASA score too imprecise to use with regards to making a treatment decision.

Schwandner et al. [35] included 298 patients who had undergone laparoscopic or laparoscopic-assisted procedures for colorectal surgery. The morbidity in patients above 70 years of age and that in patients below 70 years of age showed no statistically significant difference. Also, two patients above 70 years of age died versus one patient below that age. They concluded 'if preoperative assessment of comorbid conditions and perioperative care was ensured, laparoscopic procedures were shown to be safe options in the elderly. The outcome of laparoscopic colorectal surgery in patients older than 70 years is similar to that noted in younger patients. Advanced age is no contraindication for laparoscopic colorectal surgery.' Tan et al. [36] studied 727 patients with an age of 70 years and over who underwent laparoscopic and open colorectal cancer surgery. The 30-day mortality was significantly lower in the laparoscopic arm compared to open colectomy (1.3 vs. 4.6%). Laparoscopic colectomy was deemed safe in older patients and not associated with a higher morbidity.

Ong et al. [37] included 90 patients who were 80 years of age or older and who had undergone colorectal cancer surgery. A morbidity of 21% and a 30-day mortality of 1.1% were reported. Basili et al. [38] reported their experience with 248 patients who had undergone colorectal cancer surgery. Patients were divided into four age groups: less than 65 years, 66 to 74 years, 75 to 84 years, and more than 85 years of age. The 30-day mortalities were 0% for under 75 years of age, and 6% and 7%, respectively, for patients with ages from 75 to 84 years and those older than 85 years. However, none of these results was significant.

In a large multicenter prospective observational study in Germany on 16,142 patients who were younger than 80 years of age and 2932 who were 80 years of age or older, Marusch et al. [33] reported an overall morbidity of 35.4% with

a significant difference (p < 0.001) between patients less than 80 years of age (33.9%) and those more than 80 years of age (43.5%). Significant differences were also found between the morbidity for emergency surgery (p < 0.001) and that for elective surgery (p < 0.001). The 30-day postoperative mortality rate also differed significantly (p < 0.001), 2.1% and 7.2% for those less than 80 years of age and those more than 80 years of age, respectively. Despite these significant results, they concluded that age alone should not be a limitation for surgery.

In a recent retrospective study by Shalaby et al. [39], the outcome of colorectal cancer surgery between two groups of patients was compared. The mean ages were 85 years in group A (range, 80 to 104 years) and 55.3 years in group B (range, 13 to 79 years). Both groups were manually matched for body mass index, ASA score, Charlson Comorbidity Index, and procedure performed. The overall 30-day postoperative mortality rate was 1% of total 200 patients, both of these two patients were in group A. However, this observation had no statistical significance. No intraoperative complications were encountered in either group. The 30-day postoperative morbidity rates in groups A and B were 28 and 26%, respectively. However, these differences between the groups were not statistically significant.

Marusch et al. [33] demonstrated a significant difference (p < 0.001) in the postoperative mortality rate between the groups (in this case, cohort 1 was under 65, cohort 2 was 65–79 and cohort 3 was over 80 years old). The differences were significant in both emergency (p = 0.004) and elective surgery (p < 0.001). The tumor stage differed significantly between the cohorts, which may be a reason for the increased mortality in the older age groups.

Andereggen et al. [40] demonstrated a postoperative mortality rate of 5% and a 67% 5-year survival, with 57% of deaths occurring in this period being unrelated to cancer. This was similar to the 60% 5-year survival shown by Vironen et al. [29]. Hermans et al. [41] demonstrated a mortality rate of 16% in those over 75 years and 5% in those under 75 years (p < 0.01), and between the two groups, there were no significant differences in comorbidities except for cardiovascular problems, which were more prevalent in the elderly group (p < 0.01, with 49% of all patients in the elderly group and 25% of all patients in the younger group having cardiovascular problems).

Gurevitch et al. [34] also found a significant difference in postoperative mortality between the younger and older groups (p < 0.01), though the cutoff age, in this case, was 80. In this study, emergency surgery was also considered, and there was a higher risk of postoperative mortality in the emergency setting (p < 0.001). Poor functional status, as well as the ASA score, was assessed in this case and there was a significant difference (p < 0.05) of 8% in the under 80 cohort and 32% in the over 80 cohort. Symeonidis et al. [31] showed that more elderly patients presented for emergency surgery when compared to younger patients (29.7 vs. 15.7%), p < 0.001). Hermans et al. [41] demonstrated a 22% emergency presentation in the over 75 age group and a 9% emergency presentation in the younger age group (p < 0.05) thus concurring with the conclusion of Symeonidis et al.. On the other hand, Khan et al. [32] noted that although 17.9% of the elderly group presented as an emergency when compared to 12.1% of the younger group, the difference was not significant (p = 0.25).

Leong et al. [42, 43] demonstrated increased morbidity and mortality rates following emergency surgery in the older colorectal cancer patients. The crude mortality rate was 27.5%. The most common cause of death was pneumonia, causing 38% of deaths. Other causes included sepsis and acute myocardial infarction, each causing 19% of deaths. A high ASA score was associated with a higher mortality (p = 0.04), and in this study, 52.5% of patients had an ASA score of III or IV. With regards to postoperative morbidity, 81% of total patients presented with

postoperative complications. Pneumonia was once again the commonest complication (38%), followed by wound infection (16% of complications). Renal impairment, prolonged ileus, and fluid overload each caused 14% of total complications. In this study, it was also shown that Duke's staging had no impact on the mortality (p = 0.48) or morbidity (p = 0.51).

Li et al. [30], using the Score of the Association of Coloproctology of Great Britain and Ireland (ACPGBI), showed that ACPGBI scores showed a higher concordance between predicted probability of postoperative mortality and the actual postoperative outcome than ASA scores. Roscio et al. used the Charlson comorbidity index (CCI) where a score of more than three was associated with twice the mortality rate of those scoring less than three. Mamidanna et al. [44] found that there was a significant difference in the mortality rate between patients younger and older than 75 (p < 0.01), and the rate was related to the presence of comorbidities.

With regards to the incidence of local postoperative complications, such as surgical site infections, in the older patient, the overall incidence was similar to a younger age group. In fact, Khan et al. [32] showed that when comparing the incidence of local postoperative complications in elective surgery, there was no difference (p = 0.39). However, systemic complications were higher in the older age group (p < 0.05), and higher ASA scores, as well as the tumor site, had a predictive effect on postoperative complications. In fact, those with an ASA score of two or higher were 2.9 times more likely to have systemic complications (CI 1.30–6.25). Older patients have the same rate of postoperative complications as younger patients with similar clinical status. Symeonidis et al. [31] demonstrated that while elderly patients demonstrated an increased morbidity (p = 0.002), this was dependent on their previous health status as shown by the ASA score and tumor stage.

Vironen et al. [29] studied patients with ASA scores one or two and compared them with patients of ASA score three or four. The overall complication rate was not significantly different between these two groups (p = 0.07). They also found no significant difference in the complication rates between those under 75 and those older than 75 (p = 0.31) with similar ASA scores. On the other hand, Marusch et al. [33] found significant differences in risk factors between the cohorts (cohort 1 was under 65, cohort 2 was 65–79, and cohort 3 was over 80 years old) (p < 0.001) when it came to preoperative risk factors such as cardiovascular or pulmonary conditions, or diabetes mellitus. Intraoperative complication rates did not differ significantly between the cohorts, but they differed in the case of systemic complications. General complications following emergency surgery also differed between age groups (p = 0.002). Local postoperative complications, such as anastomotic leaks, wound infection, and postoperative ileus, were significantly different for both emergency (p = 0.006) and elective surgery (p < 0.001) between the age groups. Gurevitch et al. [34] also found that when considering general postoperative complications there were no significant differences between the age groups, though there were significant differences in the presence of comorbidities and ASA scores between the cohorts (both p = 0.0001). However, certain general complications, such as pulmonary, cardiovascular, and urinary tract infections, were more common in the elderly. This was also demonstrated by Hermans et al. [41], who recorded significantly higher rates of wound infections, cases of pneumonia, urinary tract infections, and electrolyte disturbances in the over 75 age group (p < 0.05). However, unlike the study conclusions of Gurevitch et al., Hermans et al. demonstrated a significant difference in complications between younger (32%) and older (50%) age groups (p < 0.01).

Law et al. [45] found that the complication rate following elective surgery did not differ significantly in older and younger patients (36.8 vs. 30.1%, p = 0.141), but the ASA score was related to the morbidity of patients (p = 0.042). The concomitant medical diseases were also highly related to the morbidity (p = 0.033). Jin et al. [46] also demonstrated a significant differences in ASA scores between patients over and under 75, with 42.7% of the younger age group with a score of 2 or more, and 77.8% of the older age group with an ASA score of 2 or more (p = 0.01). They also found a significant difference in the BMI, with younger patients having a higher BMI than older patients p = 0.035.

Older patients who are deemed to be clinically and biochemically optimized for surgery may still have poor outcomes. As discussed earlier, the concept of frailty can be used to identify patients who require further investigation before surgery. Patients with a high frailty score had a higher risk of developing major complications. Decreased survival in older (more than 75 years) patients after surgery has mainly been attributed to differences in early mortality [47–49]. The rate of cardiovascular complications increases significantly with age. Pulmonary complications are also twice as common. Postoperative complications are more severe in older patients [50–53]. The occurrence of a complication was associated with a significantly increased risk of mortality at 6 months. Dekker et al. noted that the overall 6-month mortality was four times higher in older patients than in younger patients (14 *vs.* 3.3%; *P <* 0.0001) as was the 1-year mortality rate (20.1 *vs.* 5.1%) [54]. Older patients with colorectal cancer who survived the first postoperative year, however, had the same overall cancer-related survival as younger patients.

These results, therefore, confirm that the emphasis should be on survival and minimizing postoperative complications during the first postoperative year. These aims are achieved by the use of prehabilitation programs. These programs help correct malnutrition and optimize cardiovascular and pulmonary function [55].

#### **4. Outcome of emergency surgery in the older patient**

Emergency surgery should be avoided if possible. The presence of obstruction or perforation increases the perioperative mortality rate in older patients. Several studies show the correlation between advanced age, mortality, and emergent surgery. Kurian et al. [56] reported a postoperative 30-day mortality rate of 28% in emergency surgery compared to only 5% in elective surgery. Morse et al. [57] found similar outcomes in patients older than 80 years in open surgery for colonic cancer. Similarly, the results of the study by Louis et al. [58] found a close correlation between advanced age, high ASA grade, and emergency surgery. A study by Zerib et al. found that no patient with an ASA grade of three or more survived an emergency colectomy more than 6 months [59]. Modini et al. [60] reported a six-fold higher 30-day postoperative mortality in older patients more than 80 years of age when compared to younger patients. Basili et al. and McGillicuddy et al. noted that although morbidity and mortality rates in older patients could be similar to that of younger patients in elective surgery, these rates could be up to nine times higher in cases of emergency surgery [38, 61]. Patients over 70 years of age after emergency surgery have been shown to have a higher rate of postoperative myocardial infarction, and this complication is associated with a six-fold increase in postoperative mortality. Other common complications are pulmonary failure, acute renal failure, and sepsis; anastomotic leakage also occurred more frequently in older patients after emergency colorectal surgery and presented a significant association with postoperative mortality [62–64].

A feasible alternative management to emergency surgery for colonic obstruction could be the endoscopic placement of stents, especially in acute left-sided colonic obstruction. These self-expanding metallic stents alleviate obstruction and allow

the clinician to optimize the patient's clinical condition. In some cases, subsequent elective surgery may take place. Stents are, however, associated with a risk of colonic perforation and bleeding [65].
