title: Complicated colorectal cancer in nonagenarian patients: is it better not to perform anastomosis in emergency?
abstract: BACKGROUND
  Colorectal cancer (CRC) is predominantly a disease of elderly people. Cancer in nonagenarian patients presents an ethical dilemma for surgeons and oncologists, and management of this group of patients in emergency for complicated CRC is debated. Presently described is retrospective study reporting experience of 6 departments of emergency surgery with management of nonagenarian patients sent to emergency surgery for CRC complications.
  
  
  METHODS
  Data concerning patients aged over 90 years hospitalized from January 2011 to June 2015 in 6 departments of emergency surgery for complicated CRC were retrospectively analyzed. Data were collected in a dedicated database. Statistical analysis was conducted using IBM software SPSS 22 (IBM Corp., Armonk, NY, USA); statistical significance was set at p=0.05.
  
  
  RESULTS
  In the period of study, 19 patients aged over 90 underwent surgery in emergency department for complicated CRC. Of the total, 52.63% were female, with sex ratio F:M of 1.11:1. Mean age was 92.52 years (range: 90-97 years; SD 1.49). Preoperative assessment of surgical risk was made using American Society of Anesthesiologists (ASA) score. There was no statistically significant difference in terms of in-hospital mortality between patients with ASA score ≤ 3 and patients with an ASA score >3. Primary anastomosis was performed in 6 of 19 patients (31.57%), all of whom had right-side colon cancer. Diverting stoma was created for 12 of 19 patients (63.15%). There was a statistically significant difference in incidence of postoperative complications between patients with right-side colon cancer and patients with left-side colon cancer (p=0.0498). Mean length of hospital stay was 12.78 days (range: 2-31 days; SD 6.31). In-hospital mortality rate was 21.05% (n=4). At follow up, overall survival was 47.36% (n=9).
  
  
  CONCLUSIONS
  Elective surgery is the best way to manage CRC in all patients affected. Emergency surgery for CRC complications in patients over 90 is feasible with careful preoperative selection and evaluation of the patient. One-stage surgery is the best choice, in selected patients. Two- and three-stage surgery is indicated in case of peritonitis, for frail patients, for hemodynamically unstable patients. If there is high risk of anastomotic leakage, decompressive stoma is suggested as bridge to elective surgery, and in advanced neoplastic disease, as palliative procedure. In emergency setting, diverting stoma is a good surgical option in nonagenarian patients to decrease surgical risk, morbidity, and mortality; however, clinical randomized controlled trials are necessary to confirm this.
authors.affiliation: Department of Emergency Surgery, University Hospital of Parma, Parma-Italy. desimoneb@hotmail.it.
authors.forename: Belinda
authors.initials: B
authors.lastname: De Simone
authors.forename: Federico
authors.initials: F
authors.lastname: Coccolini
authors.forename: Luca
authors.initials: L
authors.lastname: Ansaloni
authors.forename: Antonio
authors.initials: A
authors.lastname: Tarasconi
authors.forename: Gianluca
authors.initials: G
authors.lastname: Baiocchi
authors.forename: Nereo
authors.initials: N
authors.lastname: Vettoretto
authors.forename: Peggy
authors.initials: P
authors.lastname: Joly
authors.forename: Marianne
authors.initials: M
authors.lastname: Ferron
authors.forename: Alessandro
authors.initials: A
authors.lastname: Pozzo
authors.forename: Lionel
authors.initials: L
authors.lastname: Charre
authors.forename: Salomone
authors.initials: S
authors.lastname: Di Saverio
authors.forename: Josephine Andrea
authors.initials: JA
authors.lastname: Napoli
authors.forename: Ferdinando
authors.initials: F
authors.lastname: Agresta
authors.forename: Massimo
authors.initials: M
authors.lastname: Sartelli
authors.forename: Fausto
authors.initials: F
authors.lastname: Catena
mesh_terms: D000369:Aged, 80 and over; D000714:Anastomosis, Surgical / Q000009:adverse effects / Q000706:statistics & numerical data; D015179:Colorectal Neoplasms / Q000601:surgery*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D015994:Incidence; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D011183:Postoperative Complications / Q000453:epidemiology*; D012189:Retrospective Studies