Colorectal cancer(CRC)in the elderly is extremely common but only a few clinicians are familiar with the complexity of issues which present in the geriatric population.In this phase of the life ...cycle,treatment is frequently suboptimal.Despite the fact that,nowadays,older people tend to be healthier than in previous generations,surgical undertreatment is frequently encountered.On the other hand,surgical overtreatment in the vulnerable or frail patient can lead to unacceptable postoperative outcomes with high mortality or persistent disability.Unfortunately,due to the geriatric patient being traditionally excluded from randomized controlled trials for a variety of factors(heterogeneity,frailty,etc.),there is a dearth of evidence-based clinical guidelines for the management of these patients.The objective of this review was to summarize the most relevant clinical studies available in order to assist clinicians in the management of CRC in the elderly.More than in any other patient group,both surgical and non-surgical management strategies should be carefully individualized in the elderly population affected by CRC.Although cure and sphincter preservation are the primary goals,many other variables need to be taken into account,such as maintenance of cognitive status,independence,life expectancy and quality of life.
Purpose of Review
The goal of this manuscript is to present new and thought-provoking information related to the surgical care of older patients. We focused on four main areas including ...communication, surgical pathways, the care of emergency surgery patients, and functional recovery and quality of life. We sought to answer how these areas have evolved, affecting the care of older patients.
Recent Findings
Older patients with cancer present particular challenges in relation to communication, goals, surgical treatment, and post-surgical outcomes. Communication should be clear early and during the treatment course. A multidisciplinary, multimodality, multi-phase pathway can be utilized to improve the postoperative outcomes of older patients with cancer. Functional recovery and quality of life can and should be measured in this population.
Summary
Communication is complicated in cancer patients, which is made more complex with advancing age. Communication is the cornerstone of the treatment of older patients. Future research should focus on interventions to improve communication and measure quality of life and functional recovery metrics.
To determine the predictive value of the "Timed Up & Go" (TUG), a validated assessment tool, on a prospective cohort study and to compare these findings to the ASA classification, an instrument ...commonly used for quantifying patients' physical status and anesthetic risk.
In the onco-geriatric surgical population it is important to identify patients at increased risk of adverse post-operative outcome to minimize the risk of over- and under-treatment and improve outcome in this population.
280 patients ≥70 years undergoing elective surgery for solid tumors were prospectively recruited. Primary endpoint was 30-day morbidity. Pre-operatively TUG was administered and ASA-classification was registered. Data were analyzed using multivariable logistic regression analyses to estimate odds ratios (OR) and 95% confidence intervals (95%-CI). Absolute risks and area under the receiver operating characteristic curves (AUC's) were calculated.
180 (64.3%) patients (median age: 76) underwent major surgery. 55 (20.1%) patients experienced major complications. 50.0% of patients with high TUG and 25.6% of patients with ASA≥3 experienced major complications (absolute risks). TUG and ASA were independent predictors of the occurrence of major complications (TUG:OR 3.43; 95%-CI = 1.14-10.35. ASA1 vs. 2:OR 5.91; 95%-CI = 0.93-37.77. ASA1 vs. 3&4:OR 12.77; 95%-CI = 1.84-88.74). AUCTUG was 0.64 (95%-CI = 0.55-0.73, p = 0.001) and AUCASA was 0.59 (95%-CI = 0.51-0.67, p = 0.04).
Twice as many onco-geriatric patients at risk of post-operative complications, who might benefit from pre-operative interventions, are identified using TUG than when using ASA.
Recurrent diverticulitis after elective surgery Giulio, Mari; Gaia, Santambrogio; Andrea, Costanzi ...
International journal of colorectal disease,
10/2022, Letnik:
37, Številka:
10
Journal Article
Recenzirano
Purpose
Elective sigmoid resection is proposed as a treatment for symptomatic diverticular disease for the possible improvement in quality of life achievable. Albeit encouraging results have been ...reported, recurrent diverticulitis is still a concern deeply affecting quality of life. The aim of this study is to determine the rate of recurrent diverticulitis after elective sigmoid resection and to look for possible perioperative risk factors.
Methods
Patients who underwent elective resection for DD with at least a 3-year follow-up were included. Postoperative recurrence was defined as left-sided or lower abdominal pain, with CT scan-confirmed findings of diverticulitis.
Results
Twenty of 232 (8.6%) patients developed CT-proven recurrent diverticulitis after elective surgery. All the 20 recurrent diverticulitis were uncomplicated and did not need surgery. Eighty-five percent of the recurrences occurred in patients with a preoperative diagnosis of uncomplicated DD, 70% in patients who had at least 4 episodes of diverticulitis, and 70% in patients with a history of diverticulitis extended to the descending colon. Univariate analysis showed that recurrence was associated with diverticulitis of the sigmoid and of the descending colon (
p
= 0.04), with a preoperative diagnosis of IBS (
p
= 0.04) and with a longer than 5 years diverticular disease (
p
= 0.03). Multivariate analysis was not able to determine risks factors for recurrence.
Conclusion
Our study showed that patients with a preoperative diagnosis of IBS, diverticulitis involving the descending colon, and a long-lasting disease are more likely to have recurrent diverticulitis. However, these variables could not be assumed as risk factors.
This manuscript centers on what surgeons, patients, and hospital administrations want and need to know about the crucial role of functional recovery and patients’ reported outcome measure, above all ...in the elderly population. From all angles, it is clear that elderly patients are unique and their cancer care should be individualized and approached in a multidisciplinary fashion. Evaluation of patient fitness to undergo surgery should be undertaken in the elective and emergent settings. If patients are deemed fit for treatment, they should be offered the appropriate treatment, regardless of their age. This includes proceeding with surgery and/or chemotherapy and utilizing minimally invasive techniques, when appropriate. In addition, quality of life should be a priority in the care of elderly patients and patient-reported outcomes should be assessed and reported.
Abstract
Background
Enhanced Recovery After Surgery (ERAS) represents the standard of care in colorectal surgery. Among ERAS items, early removal of urinary catheter (UC) is considered a key issue, ...though adherence to this specific item still varies among centers. UC placement allows for monitoring of post-operative urinary output but relates to an increased risk of urinary tract infection (UTI), reduced mobility, and patient’s discomfort. Several studies investigated the role of early UC removal specifically looking at the rate of acute urinary retention (AUR) but most of them were retrospective, single-center, underpowered, cohort studies. The main purpose of this study is to compare the rate of AUR after immediate (at the end of the surgery) versus early (within 24 h from the completion of surgery) removal of UC in patients undergoing minimally invasive colonic resection (MICR). The secondary outcomes focus on goals that could be positively impacted by the immediate removal of the UC at the end of the surgery. In particular, the rate of UTIs, perception of pain, time-to-return of bowel and physical functions, postoperative complications, and length of hospital stay will be measured.
Methods
This is a prospective, randomized, controlled, two-arm, multi-center, study comparing the rate of AUR after immediate versus early removal of UC in patients undergoing MICR. The investigators hypothesize that immediate UC removal is non-inferior to 24-h UC removal in terms of AUR rate. Randomization is at the patient level and participants are randomized 1:1 to remove their UC either immediately or within 24 h from the completion of surgery. Those eligible for inclusion were patients undergoing any MICR with an anastomosis above the peritoneal reflection. Those patients who need to continue urinary output monitoring after the surgery will be excluded. The number of patients calculated to be enrolled in each group is 108 based on an expected AUR rate of 3% for the 24-h UC removal group and considering acceptable an AUR of 9% for the immediate UC removal group.
Discussion
The demonstration of a non-inferiority of immediate versus 24-h removal of UC would call into question the usefulness of urinary drainage in the setting of MICR.
Trial registration
ClinicalTrials.gov
NCT05249192. Prospectively registered on February 21, 2022.
Medical students represent a primary target for tobacco cessation training. This study assessed the prevalence of medical students' tobacco use, attitudes, clinical skills, and tobacco-related ...curricula in two countries, the US and Italy, with known baseline disparities in hopes of identifying potential corrective interventions.
From September to December 2013, medical students enrolled at the University of Bologna and at Brown University were recruited via email to answer survey questions assessing the prevalence of medical students' tobacco use, attitudes and clinical skills related to patients' smoking, and elements of medical school curricula related to tobacco use.
Of the 449 medical students enrolled at Brown and the 1426 enrolled at Bologna, 174 Brown students (38.7%) and 527 Bologna students (36.9%) participated in this study. Italian students were more likely to smoke (29.5% vs. 6.1%; p<0.001) and less likely to receive smoking cessation training (9.4% vs. 80.3%; p<0.001) than their American counterparts, even though the majority of students in both countries desired smoking cessation training (98.6% at Brown, 85.4% at Bologna; p<0.001). Additionally, negative beliefs regarding tobacco usage, the absence of formal training in smoking cessation counseling, and a negative interest in receiving specific training on smoking cessation were associated with a higher risk of not investigating a patient's smoking status during a routine history and not offering tobacco cessation treatment to patients.
Medical curricula on tobacco-related health hazards and on smoking cessation should be mandatory in order to reduce smoking among medical students, physicians, and patients, thereby improving tobacco-related global health.
Nipple discharge (ND) is a common symptom seen in breast cancer clinics. The primary aim of this study was to identify preoperative risk factors for breast cancer in patients with pathologic ND. The ...secondary aim was to assess the clinical and pathological effectiveness of physical examination, galactography, cytological examination of the discharge, selective duct excision and ductoscopy. All patients operated on between 1975 and 2008 who presented with ND as their only symptom was analyzed. Discharge's characteristics, cytological data and galactography reports were recorded. The relationship between each individual finding and the risk of breast cancer was calculated. For each diagnostic tool, the sensitivity, specificity and complication rates were calculated and compared. Nine-hundred-fifteen patients underwent selective duct excision. Two-hundred-nineteen patients (23.9%) were found to be affected by carcinoma. In 100/330 (30.3%) patients with bloody discharge and in 42/239 (17.6%) patients with serous secretion cancer was detected (P = 0.004, P = 0.013, respectively). Patients with sero-sanguinous or coloured discharge had the same risk of cancer as the population analyzed (23.9%, P = NS). Galactographic finding of irregular stenosis seemed to be associated with a higher risk of cancer (P = 0.0001). Cytological findings C5 and C4 were associated with cancer (P = 0.001). Selective duct excision showed highest sensitivity and specificity. In conclusion, the well established role of bloody secretion is confirmed. The supposed benign aetiology of serous, coloured or sero-sanguinous discharge is questionable. The high specificity of the cytological exam justifies routine examination of the ND. Selective duct excision can be considered as the diagnostic gold-standard.
Objective： Cancer is one of the most common diagnoses in elderly patients. Of all types of abdominal cancer, colorectal cancer（CRC） is undoubtedly the most frequent. Median age at diagnosis is ...approximately 70 years old worldwide. Due to the multiple comorbidities affecting elderly people, frailty evaluation is very important in order to avoid over- or undertreatment. This pilot study was designed to investigate the variables capable of predicting the long-term risk of mortality and living situation after surgery for CRC.Methods： Patients with 70 years old and older undergoing elective surgery for CRC were prospectively enrolled in the study. The patients were preoperatively screened using 11 internationally-validated-frailty-assessment tests. The endpoints of the study were long-term mortality and living situation. The data were analyzed using univariate Cox proportional-hazard regression analysis to verify the predictive value of score indices in order to identify possible risk factors.Results： Forty-six patients were studied. The median follow-up time after surgery was 4.6 years（range, 2.9-5.7 years） and no patients were lost to follow-up. The overall mortality rate was 39%. Four of the patients who survived（4/28, 14%） lost their functional autonomy. The preoperative impaired Timed Up and Go（TUG）, Eastern Cooperative Group Performance Status（ECOG PS）, Instrumental Activities of Daily Living（IADLs）, Vulnerable Elders Survey（VES-13） scoring systems were significantly associated with increased long term mortality risk.Conclusion： Simplified frailty-assessing tools should be routinely used in elderly cancer patients before treatment in order to stratify patient risk. The TUG, ECOG-PS, IADLs and VES-13 scoring systems are potentially able to predict long-term mortality and disability. Additional studies will be needed to confirm the preliminary data in order to improve management strategies for oncogeriatric surgical patients.
To investigate the rate of laparoscopic colectomies for colon cancer using registries and population-based studies. To provide a position paper on mini-invasive (MIS) colon cancer surgery based on ...the opinion of experts leader in this field.
A systematic review of the literature was conducted using PRISMA guidelines for the rate of laparoscopy in colon cancer. Moreover, Delphi methodology was used to reach consensus among 35 international experts in four study rounds. Consensus was defined as an agreement ≥75.0%. Domains of interest included nosology, essential technical/oncological requirements, outcomes and MIS training.
Forty-four studies from 42 articles were reviewed. Although it is still sub-optimal, the rate of MIS for colon cancer increased over the years and it is currently >50% in Korea, Netherlands, UK and Australia. The remaining European countries are un-investigated and presented lower rates with highest variations, ranging 7–35%. Using Delphi methodology, a laparoscopic colectomy was defined as a “colon resection performed using key-hole surgery independently from the type of anastomosis”. The panel defined also the oncological requirements recognized essential for the procedure and agreed that when performed by experienced surgeons, it should be marked as best practice in guidelines, given the principles of oncologic surgery be respected (R0 procedure, vessel ligation and mesocolon integrity).
The rate of MIS colectomies for cancer in Europe should be further investigated. A panel of leaders in this field defined laparoscopic colectomy as a best practice procedure when performed by an experienced surgeon respecting the standards of surgical oncology.
PDF
