PURPOSE: Comorbid conditions affect the risk of adverse outcomes after surgery, but the magnitude of risk has not previously been quantified using multivariate statistical methods and prospectively collected data. Identifying factors that predict results of surgical procedures would be valuable in assessing the quality of surgical care. This study was performed to define risk factors that predict adverse events after colectomy for cancer in Department of Veterans Affairs Medical Centers. METHODS: The National Veterans Affairs Surgical Quality Improvement Program contains prospectively collected and extensively validated data on more than 415,000 surgical operations. All patients undergoing colectomy for colon cancer from 1991 to 1995 who were registered in the National Veterans Affairs Surgical Quality Improvement Program database were selected for study. Independent variables examined included 68 preoperative and 12 intraoperative clinical risk factors; dependent variables were 21 specific adverse outcomes. Stepwise logistic regression analysis was used to construct models predicting the 30-day mortality rate and 30-day morbidity rates for each of the ten most frequent complications. RESULTS: A total of 5,853 patients were identified; 4,711 (80 percent) underwent resection and primary anastomosis. One or more complications were observed in 1,639 of 5,853 (28 percent) patients. Prolonged ileus (439/5,853; 7.5 percent), pneumonia (364/5,853; 6.2 percent), failure to wean from the ventilator (334/5,853; 5.7 percent), and urinary tract infection (292/5,853; 5 percent) were the most frequent complications. The 30-day mortality rate was 5.7 percent (335/5,853). For most complications, 30-day in-hospital mortality rates were significantly higher for patients with a complication than for those without. Thirty-day mortality rates exceeded 50 percent if postoperative coma, cardiac arrest, a pre-existing vascular graft prosthesis that failed after colectomy, renal failure, pulmonary embolism, or progressive renal insufficiency occurred. Preoperative factors that predicted a high risk of 30-day mortality included ascites, serum sodium >145 mg/dl, “do not resuscitate” status before surgery, American Society of Anesthesiologists classes III and IV OR V, and low serum albumin. CONCLUSIONS: Mortality rates after colectomy in Veterans Affairs hospitals are comparable with those reported in other large studies. Ascites, hypernatremia, do not resuscitate status before surgery, and American Society of Anesthesiologists classes III and IV OR V were strongly predictive of perioperative death. Clinical trials to decrease the complication rate after colectomy for colon cancer should focus on these risk factors.
Cancer is a prevalent disease in our aging population; however, few oncologists are familiar with caring for oncogeriatric patients. Surgery is presently the treatment of choice for most solid tumors, but it is frequently delivered in a suboptimal way in this patient subsetting. Undertreatment is often justified with the concern of an unsustainable toxicity, while overtreatment can be related to the lack of knowledge in optimizing preoperative risk assessment. To draw new light on this issue, several surgeons presented their series, providing hard evidence that surgical options can be offered to the elderly with cancer, with only a limited postoperative mortality and morbidity. As it is likely that much of these data suffer from selection bias, we concentrated on Comprehensive Geriatric Assessment (CGA), which can add substantial information on the functional assessment of elderly cancer patients. A validated instrument such as the CGA allows a comparison of series, predicting short-term surgical outcomes more precisely, and offers appropriate information when consenting elderly patients. Preoperative Assessment of Cancer in the Elderly is a prospective international study conceived and launched to outline the fitness of elderly surgical patients with malignant tumors. This paper reports on preliminary results and analysis from the ongoing study.
The Surgical Endoscopy Service has been aggressively evaluating gastrointestinal symptoms with colonoscopy and screening asymptomatic patients with flexible sigmoidoscopy in hopes of finding early curable colorectal cancers. The purpose of this study was to compare the stages of colorectal cancers resected during the 18-month period prior to (Pre-SES) and during the first 18 months (Post-SES) after the creation of the Surgical Endoscopy Service. In addition, the yield of lesions that would have been obtained by depending upon patient symptoms or occult blood testing were determined. A total of 361 colonoscopies were performed Pre-SES and 874 colono-scopies Post-SES; 26 patients underwent resection of colorectal cancers Pre-SES and 32 Post-SES. Whereas early colorectal cancers (Dukes' A and B1) were found in only three patients (12%) Pre-SES period, early cancers were found in 13 (41%) Post-SES. Doubling the number of colonoscopies produced a fourfold increase in the number of early lesions. Furthermore, disseminated cancers (D lesions) dropped from 19% Pre-SES to 3% Post-SES. Among the total 58 patients, 43% of the A lesions and 40% of the B1 lesions were asymptomatic. Even more alarming, 86% of the A lesions, 50% of the B1, lesions, 31% of the B2 lesions, and 14% of the C2 lesions were occult blood negative. Indeed, only the D lesions were uniformly occult blood positive. This study demonstrates that aggressive colonoscopy detects early colorectal cancers. Moreover, patient symptoms or occult blood testing will fail to indicate the majority of early colorectal cancers.
