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19 Colorectal Cancer Management in Older Adults: Use of Geriatric Assessment…
https://t.me/medicina_free
Quality
of
evidence
Low
associated with long-term
outcome and
perioperative morbidity
- geriatric sum score is
- intermediate or high risk
data
associated with
scores were associated with
lower perioperative OS
- sum scores were
Low
identify patients at higher
risk for postoperative
complications
- frailty screening can
postoperative
complications
with G8 under 15 and/or
4GMST less than 1m/s
- higher complication rate
Moderate
alter the treatment plan in
colorectal cancer
- geriatric consultation can
impairments
− 93% had geriatric
− 69% were referred for
High
increase the number of
- geriatric interventions
‘more intensive
treatment option’
interventions included
older CRC patients
medication changes,
completing adjuvant
chemotherapy and can
improve mobility and
nutritional therapy, and
physiotherapy
- more interventional
illness burden.
patients completed
chemotherapy than control
- QoL and morbidity
improved in
interventional patients
decreased in
- burden of disease
227
interventional patients
assessment
- geriatric risk factor
undergoing elective
colorectal cancer surgery
Study design Patients Measure Results Conclusion
Retrospective 550 patients over age 70
Study
Souwer
[10]
-G8 score
-4MGST score
of age undergoing elective
colorectal cancer surgery
Retrospective 149 patients over 69years
Bessems
[11]
-geriatric consultation
168 patients over 59years
of age with colorectal
cancer referred for
Prospective
cohort
Verweij
[12]
-CGA-based intervention - Most common
geriatric consultation
adjuvant or rst-line
− 142 patients receiving
Randomized
phase III trial
Lund
[13]
palliative chemotherapy
under 14 were
randomized to CGA-
based interventions or
- patients with G8 score
standard care
228
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J. L. Roberson and N. M. Saur
Personal View
The multidimensional CGA, typically performed by geriatricians, is the gold standard for assessing frailty and can provide important insight and treatment guidance
in the perioperative setting in patients with colorectal cancer. However, as a limited
resource, only a minority of surgeons are able to collaborate with geriatricians [14,
15]. Therefore, it is imperative that surgeons familiarized themselves with the com-
ponents of a CGA and collaborate with geriatricians whenever possible. The main
domains of a CGA, for surgeons’ reference, are functional assessment, cognitive
assessment, evaluation of comorbidities, and nutrition assessment.
At the crux of creating a treatment plan for an older adult with colorectal cancer,
however, is aligning patient goals with possible outcomes. While maintaining independence and a desire to die at home are common health priorities among seniors,
both medical and surgical interventions can result in complications requiring further
invasive procedures, ICU admissions, or hasten an in-hospital death [16]. Therefore,
in the elective, outpatient setting, the provider should elicit a patient’s goals of care
and identify factors that inuence their quality of life through the process of shared
decision making [17]. A variety of communication aids have been developed for
elective surgery that help with information exchange and mutual decision making.
Specically, one question prompt list (QPL) encourages discussions to cover three
main areas: (1) Should I have surgery? (2) What should I expect if everything goals
well? And (3) What happens if things go wrong? [18] These types of questions
change the focus of the ofce visits from specic technical details to instead patient
goals and possible outcomes and, combined with the overall clinical assessment,
can help guide towards treatment for oncologic cure versus palliation.
To assist surgeons in this endeavor, the American College of Surgeons (ACS)
Geriatric Surgery Task Force has launched the Geriatric Surgery Verication
Program. The goal of this program is to support all hospitals, regardless of size and/
or resources, in caring for older adults with surgical diagnoses. The ACS has identied four phases of care of special importance, acknowledging that the ultimate goal
is to preserve functional independence and prioritize quality of life: (1) goals of care
and decision making, (2) cognitive function and prevention of delirium, (3) maintenance of function and mobility, and (4) nutrition and hydration optimization [19].
Looking forward and outside of the outpatient encounter, inpatient geriatric
comanagement for surgical patients has been shown to decrease perioperative complications. Specically, within vascular surgery, prospectively enrolled patients
with an inpatient surgical procedure were compared in a pre-post fashion following
implementation of formal comanagement. The post-group saw a signicant reduction in hospital-acquired geriatric syndromes such as delirium as well as cardiac and
infective complications [20].
With an aging population, it is the responsibility of the surgeon to be comfortable
caring for older adults, crafting care plans congruent with a patient’s goals, and
consulting with geriatricians. If proceeding with surgery, there are a variety of
assessments and interventions that can ultimately improve perioperative outcomes
and assist the patient in achieving their health goals.
19 Colorectal Cancer Management in Older Adults: Use of Geriatric Assessment…
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229
References
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2017;67:177–93.
2. Walter LC, Covinsky KE.Cancer screening in elderly patients: a framework for individualized
decision making. JAMA. 2001;285:2750–6.
3. Saur NM, Montroni I, Shahrokni A, Kunitake H, Potenti FM, Goodacre RC, Davis BR, Carli
F.Care of the geriatric colorectal surgical patient and framework for creating a geriatric program:
a compendium from the 2019 American society of colon and rectal surgeons annual meeting.
Dis Colon Rectum. 2020;63(11):1489–95. https://doi.org/10.1097/DCR.0000000000001793.
PMID: 32947418; PMCID: PMC7547896
4. Shahrokni A, Alexander K. The age of talking about age alone is over. Ann Surg Oncol.
2019;26:12–4.
5. Lawler M, Selby P, Aapro MS, Duffy S.Ageism in cancer care. BMJ. 2014;348:g1614.
6. Aparicio T, Canouï-Poitrine F, Caillet P, François E, Cudennec T, Carola E, Albrand G, Bouvier
AM, Petri C, Couturier B, Phelip JM, Bengrine-Lefevre L, Paillaud E.Treatment guidelines of
metastatic colorectal cancer in older patients from the French Society of Geriatric Oncology
(SoFOG). Dig Liver Dis. 2020;52(5):493–505. https://doi.org/10.1016/j.dld.2019.12.145.
Epub 2020 Feb 3
7. Antonio M, Saldaña J, Carmona-Bayonas A, Navarro V, Tebé C, Nadal M, Formiga F, Salazar
R, Borràs JM. Geriatric assessment predicts survival and competing mortality in elderly
patients with early colorectal cancer: can it help in adjuvant therapy decision-making?
Oncologist. 2017;22(8):934–43. https://doi.org/10.1634/theoncologist.2016- 0462. Epub 2017
May 9. PMID: 28487465; PMCID: PMC5553962
8. Li M, Schulte N, Elting F, Winkler EC, Hetjens S, Berger AK, Zschäbitz S, Hofmann J,
Hofmann J, Hilbertz L, Kuhn M, Khakzar C, Jesenofsky R, Betge J, Zhan T, Belle S, Ebert
MP, Härtel N.Sequential geriatric assessment in older patients with colorectal cancer during
chemotherapy: subgroup analysis of a prospective, multicenter study EpiReal 75. Oncol Res
Treat. 2022;45(11):670–80. https://doi.org/10.1159/000525101. Epub 2022 Jun 8
9. Decoster L, Vanacker L, Kenis C, Prenen H, Van Cutsem E, Van Der Auwera J, Van Eetvelde
E, Van Puyvelde K, Flamaing J, Milisen K, Lobelle JP, De Grève J, Wildiers H.Relevance
of geriatric assessment in older patients with colorectal cancer. Clin Colorectal Cancer.
2017;16(3):e221–9. https://doi.org/10.1016/j.clcc.2016.07.010. Epub 2016 Aug 8
10. Souwer ETD, Hultink D, Bastiaannet E, Hamaker ME, Schiphorst A, Pronk A, van der Bol
JM, Steup WH, Dekker JWT, Portielje JEA, van den Bos F.The prognostic value of a geriatric risk score for older patients with colorectal cancer. Ann Surg Oncol. 2019;26(1):71–8.
https://doi.org/10.1245/s10434- 018- 6867- x. Epub 2018 Oct 25. PMID: 30362061; PMCID:
PMC6338720
11. Bessems SAM, Konsten JLM, Vogelaar JFJ, Csepán-Magyar R, Maas HAAM, van de Wouw
YAJ, Janssen-Heijnen MLG.Frailty screening by Geriatric-8 and 4-meter gait speed test is feasible and predicts postoperative complications in elderly colorectal cancer patients. J Geriatr
Oncol. 2021;12(4):592–8. https://doi.org/10.1016/j.jgo.2020.10.012. Epub 2020 Nov 4
12. Verweij NM, Souwer ETD, Schiphorst AHW, Maas HA, Portielje JEA, Pronk A, van den
Bos F, Hamaker ME. The effect of a geriatric evaluation on treatment decisions for older
patients with colorectal cancer. Int J Color Dis. 2017;32(11):1625–9. https://doi.org/10.1007/
s00384- 017- 2883- 8. Epub 2017 Sep 20
13. Lund CM, Vistisen KK, Olsen AP, Bardal P, Schultz M, Dolin TG, Rønholt F, Johansen JS,
Nielsen DL.The effect of geriatric intervention in frail older patients receiving chemotherapy
for colorectal cancer: a randomised trial (GERICO). Br J Cancer. 2021;124(12):1949–58.
https://doi.org/10.1038/s41416- 021- 01367- 0. Epub 2021 Apr 7. PMID: 33828260; PMCID:
PMC8185087
14. Korc-Grodzicki B, Holmes HM, Shahrokni A.Geriatric assessment for oncologists. Cancer
Biol Med. 2015;12:261–74.
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15. Kottek A, Bates T, Spetz MJ.The roles and value of geriatricians in healthcare teams: a landscape analysis. UCSF Health Workforce Research Center on Long-Term Care; 2017. Accessed
15 Oct 2019. https://healthworkforce.ucsf.edu/sites/healthworkforce.ucsf.edu/les/REPORT_
Geriatricians_Lit_FINAL.pdf.
16. Ballou JH, Brasel KJ.Palliative care and geriatric surgery. Clin Geriatr Med. 2019;35(1):35–44.
https://doi.org/10.1016/j.cger.2018.08.004. Epub 2018 Sep 28
17. Kon AA, Davidson JE, Morrison W, etal. Shared decision making in ICUs: an American college of critical care medicine and American Thoracic Society policy statement. Crit Care Med.
2016;44(1):188–201.
18. Steffens NM, Tucholka JL, Nabozny MJ, Schmick AE, Brasel KJ, Schwarze ML.Engaging
patients, health care professionals, and community members to improve preoperative decision
making for older adults facing high-risk surgery. JAMA Surg. 2016;151(10):938–45. https://
doi.org/10.1001/jamasurg.2016.1308. PMID: 27368074; PMCID: PMC5071104
19. Ma M, Zhang L, Rosenthal R, Finlayson E, Russell MM.The American College of surgeons
geriatric surgery verication program and the practicing colorectal surgeon. Semin Colon
Rectal Surg. 2020;31(4):100779. https://doi.org/10.1016/j.scrs.2020.100779. Epub 2020 Oct
2. PMID: 33041604; PMCID: PMC7531280
20. Thillainadesan J, Aitken SJ, Monaro SR, Cullen JS, Kerdic R, Hilmer SN, Naganathan
V. Geriatric comanagement of older vascular surgery inpatients reduces hospital-acquired
geriatric syndromes. J Am Med Dir Assoc. 2022;23(4):589–595.e6. https://doi.org/10.1016/j.
jamda.2021.09.037. Epub 2021 Oct 29
J. L. Roberson and N. M. Saur
Colon Cancer intheSplenic Flexure:
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Which Operation?
HimaniBhatt andKellieMathis
Introduction
Adenocarcinoma of the colon is the fourth most common cancer worldwide, and
tumor location within the splenic exure is rare, occurring in less than 10% of cases.
Splenic exure cancers (SFC) have been anatomically dened as cancers located
within 10cm in either direction from the left upper quadrant maximal bend of the
colon or alternatively as a cancer located between the distal 1/3 of the transverse
colon and the proximal 1/3 of the descending colon [1–3]. Embryologically, the
splenic exure is located between the nal portion of the midgut and the starting
portion of the hindgut, and it is supplied by both superior mesenteric and inferior
mesenteric arteries. This dual vasculature and lymphatic drainage has led to uncertainty about the most appropriate extent of resection for SFCs. Understanding the
complex anatomy and embryology of the splenic exure is important to determine
the optimal surgical approach for a SFC [3].
SFCs have a less favorable prognosis compared to other colon locations, often
present at an advanced stage, have a high metastatic potential, have a high incidence
of bowel obstruction, and are associated with a higher rate of lymph node positivity
[4, 5]. The reason for these poor outcomes is not entirely understood. Multiple operations have been described for SFC including extended right hemicolectomy with
an ileocolic anastomosis (and sometimes referred to as subtotal colectomy), left
hemicolectomy with a colorectal anastomosis, segmental colectomy with a colocolonic anastomosis, and a total colectomy with an ileorectal anastomosis. The
20
H. Bhatt · K. Mathis (*)
Department of Surgery, Mayo Clinic, Rochester, MN, USA
e-mail: Bhatt.himani@mayo.edu; Mathis.kellie@mayo.edu
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
K. Umanskiy, N. Hyman (eds.), Difcult Decisions in Colorectal Surgery,
Difcult Decisions in Surgery: An Evidence-Based Approach,
https://doi.org/10.1007/978-3-031-42303-1_20
231
232
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H. Bhatt and K. Mathis
literature is limited on consensus for the best approach to treat SFCs and consists of
only retrospective and heterogenous data from single institutions, making generalizable recommendations difcult. In this chapter we aim to provide a thorough literature review to collate an evidence-based optimal surgical approach for SFC
resection.
Methods
An extensive literature review of several databases was conducted on May 18, 2022.
The databases included: Ovid MEDLINE(R) and Epub Ahead of Print, In-Process
& amp; Other Non-Indexed Citations, and Daily, Ovid EMBASE, Ovid Cochrane
Central Register of Controlled Trials, Ovid Cochrane Database of Systematic
Reviews, and Scopus. Controlled vocabulary supplemented with keywords like:
“left colic exure”, “splenic exure“, “transverse colon”, “Adenomatous polyposis”, “Familial polyposis”, “colorectal or bowel* or colon*”, “left colic exure”,
“splenic exure“, “transverse colon”, “cancer* or neoplasm* or tumor* or tumour*
or carcinoma* or adenocarcinoma* or carcinogenes*”, “extended right colectomy*”, “extended right hemicolectomy*”, “extended right hemi-colectomy*”,
“right extended colectomy*”, “right extended hemicolectomy*”, “right extended
hemi-colectomy*”, “left colectomy*”, “left hemicolectomy*”, “left hemicolectomy*”. Directed searches of the references from the primary articles were
also performed to look for additional relevant articles. Results from observational
studies and metanalyses were found. We found that all the relevant observational
studies were already incorporated in the metanalyses and thus, we only included
these meta-analyses in this review. Search was limited to: [1] Articles only in
English, [2] Articles published in last 5years [3] Articles related to splenic exure
cancer resection, and [4] Full text articles. See PICO information in Table20.1. The
Final 3 Metanalysis studies were reviewed in detail and their results are presented
in the Table20.2.
Table 20.1 PICO table
Patient population
Patients with
splenic exure
cancer
Intervention Comparators
Extended right/
subtotal colectomy
Left/segmental
colectomy
Outcomes
Perioperative outcome, overall
survival, disease free survival
20 Colon Cancer intheSplenic Flexure: Which Operation?
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Study
Quality
Total
number
Low
of
patients ERH LH STC SC Outcomes
956 353 361 242 No difference between
ERH, LH and SC in
terms of postoperative
morbidity and mortality,
Low
lymph node yield and
cancer survival.
for the curative
resection of splenic
2734 596 928 109 928 SC, LH, ERH and STC
Low
exure tumors provide
similar survival.
569 132 437 No difference in ERH
233
or LC
Table 20.2 Summary of 3 Metanalyses Included in this Review
Number of
Studies
7 retrospective
Type of
study
Systematic
Year Country Timeline
2020 UK 1946 to
Author
Hajibandeh
studies
review and
meta-
2020
etal.
analysis
10 retrospective
studies
Network
meta-
August
Wang etal. 2021 China up to
analysis
2020
12 retrospective
studies (6
comparative, 6
case series)
Systematic
review and
meta-
analysis
2016
2017 France 1990 to
Martınez-Pe
rez etal.
ERH Extended right hemicolectomy LH Left hemicolectomy SC Segmental colectomy, STC Subtotal colectomy
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H. Bhatt and K. Mathis
Results
Extensive literature review yielded 3 meta-analysis studies that matched our search
criteria. We found no prospective or randomized control trials published to date.
The studies included in the meta-analysis were all retrospective in nature leaving us
with low quality evidence.
This study included a total of 3264 non-overlapping subjects, but variable numbers of patients were included in each individual comparison.
Intra-Operative Outcomes
The intra-operative outcomes of interest include operative time, margin status, success of the anastomosis, the number of lymph nodes harvested, and minimally invasive surgery (MIS) use.
Extended Right Hemicolectomy vs Left Hemicolectomy
When comparing extended right hemicolectomy with left hemicolectomy,
Hajibandeh etal., found no difference in operative times, rate of R0 resection, or the
proportion of patients who had more than 12 LNs harvested. They did report that
ERH resulted in a higher number of total lymph nodes harvested as compared to LH
[xed effects model: MD 3.52, 95% CI 2.14, 4.89; P<0.00001; low heterogeneity
(I2=43%); high GRADE certainty of evidence] [6]. Wang etal., reported a higher
rate of primary anastomosis in the ERH group compared to the LH group [7].
Martinez Perez etal., found no differences in LN retrieval, R0 resection between
ERH and LH [8].
Extended Right Hemicolectomy vs Segmental Colectomy
Hajibandeh etal., found no difference in rate of R0 resection, total number of LNs
harvested, or the proportion of patients who had more than 12 LNs harvested.
Operative times were signicantly longer in the ERH group compared to segmental
colectomy [6]Wang etal., found a higher rate of ileus in the ERH group compared
to segmental colectomy (OR=4.2, 95% CI 1.3–18.0, P=0.019: low heterogeneity
(I2=14.8%) [7].
Segmental Colectomy vs Left Hemicolectomy
Hajibandeh etal., found no difference in rate of R0 resection, total number of LNs
harvested, or the proportion of patients who had more than 12 LNs harvested.
Operative times were signicantly longer in the left hemicolectomy group compared to segmental colectomy [6].
In the ACS NSQIP study, there were no differences in the proportion of patients
with <12 LNs. 73% of all cases were done with an MIS technique. Patients in the
segmental colectomy group had shorter operative times compared to left hemicolectomy [2].
20 Colon Cancer intheSplenic Flexure: Which Operation?
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235
Direct Comparison of4 Techniques: Subtotal Colectomy, Extended
Right Hemicolectomy, Left Hemicolectomy
andSegmental Colectomy
Wang etal., reported no difference in rate of minimally invasive technology use or
proportion of patients with >12 LNs harvested [7].
Post-Operative Outcomes/Morbidity
The postoperative outcomes reported include postoperative mortality, total complication rate, severe complication rate, anastomotic leak, ileus, need for reoperation,
and length of hospital stay.
Extended Right Hemicolectomy Versus Left Hemicolectomy
Hajibandeh etal., found no statistical difference in total postoperative complications [xed effects model: OR 1.16, 95% CI 0.83, 1.63; P=0.37; low heterogeneity
(I2=0%); high GRADE certainty of evidence], severe complications [xed effects
model: OR 0.69, 95% CI 0.43, 1.12; P=0.13; low heterogeneity (I2=28%); high
GRADE certainty of evidence], wound infection [xed effect model: OR 0.63, 95%
CI _0.14, 2.80; P=0.55; low heterogeneity (I2=0%); low GRADE certainty of
evidence], pancreatic stula [xed effects model: OR 1.00, 95% CI 0.06, 16.85;
P = 1.00; very low GRADE certainty of evidence], and intra-abdominal abscess
[xed effects model: OR 2.08, 95% CI 0.18, 24.41; P= 0.56; very low GRADE
certainty of evidence]. They also found no difference in anastomotic leak rates,
mortality, ileus, need for reoperation and length of hospital stay [6]. Martinez Perez
etal., found no differences in operative times, anastomotic leaks, postop complications [8].
Extended Right Hemicolectomy vs Segmental Colectomy
Hajibandeh etal., found no statistical difference in total postoperative complications, anastomotic leak, severe complications, mortality, need for reoperation, or
length of hospital stay. They did report a higher rate of postoperative ileus in in the
ERH group compared to segmental colectomy [6].
Segmental Colectomy vs Left Hemicolectomy
Hajibandeh etal., found no statistical difference in total postoperative complications, anastomotic leak, severe complications, mortality, need for reoperation, or
length of hospital stay [6]. In the ACS-NSQIP study, there was no difference in
major morbidity rates [2].
Direct Comparison of4 Techniques: Subtotal Colectomy, Extended
Right Hemicolectomy, Left Hemicolectomy
andSegmental Colectomy
Wang, etal. reported no difference in need for reoperation, anastomotic leak, or
mortality [7].
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H. Bhatt and K. Mathis
Laparoscopic Techniques (all Operations Combined) Versus
Open Technique
Martinez Perez found no difference in postoperative complication rates comparing
patients undergoing MIS surgery versus open surgery. The time to tolerance of an
oral diet and the length of hospital stay both favored the laparoscopic group [8].
Survival Outcomes
All studies showed no differences in overall survival or disease-free survival among
all comparisons. Survival outcomes were reported as 5year outcomes in Hajibandeh
etal., and Wang et al., studies [6, 7]. Wang etal., also reported no differences in
local recurrence rates or distant recurrence rates [7].
Recommendation
After an in-depth review of the surgical literature for management of splenic exure
adenocarcinoma, there is no consensus for a “best” operation. All operations,
including extended right hemicolectomy, left hemicolectomy, segmental colectomy,
and subtotal colectomy, have similar post-operative outcomes and no differences in
long-term oncologic outcomes. Two surveys about surgeons’ choice regarding SFC
resection approach yielded different outcomes, where one favored ERH at 63% [9]
and the other favored SC for 70% [10]. Therefore, the surgical care of each patient
with splenic exure adenocarcinoma should be individualized.
A principle of colon cancer surgery is to base the extent of resection on the lymphovascular drainage of the region where the tumor is located [11]. This is where
some of the uncertainty stems from with splenic exure cancers as the lymphovascular drainage is not clear cut and predictable. Advocates of the ERH believe that
lymph nodes along the middle colic proper should be removed in addition to those
around the left colics while advocates of left hemicolectomy or segmental colectomy believe that left colic lymph node excision is sufcient. A clinical trial by
Vasey etal., was conducted on 30 patients to assess the lymphatic drainage of SFC
using scintigraphic mapping intraoperatively. It demonstrated that lymphatic ow
was usually directed towards the left colic pedicle (96% of patients) followed by the
left branch of the middle colic and the inferior mesenteric artery [12]. Watanabe
etal., injected peritumoral indocyanine green at the time of laparoscopy for splenic
exure adenocarcinoma and found that the left colic basin was dominant in most
and one patient had ow along the left branch of the middle colic [13]. Additionally,
there was uorescence along the inferior mesenteric vein in multiple patients [12,
13]. Both left hemicolectomy and segmental colectomy ligate the left branch of the
middle colic and the left colic vessels, so either operation would allow sufcient
lymph node resection in the vast majority.
A signicant number of patients with SFCs will present with obstruction and
require urgent operations. In these cases, there may be signicant dilation of the
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