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6 Preoperative Evaluation inColorectal Patients
107
liver dysfunction, although all these proteins can be useful
when followed as trends over time.
Similarly, sarcopenia has been investigated as a factor in
preoperatively assessing risk for postoperative morbidity and
mortality. This variable is generally measured using psoas
muscle cross-sectional area on CT or MRI, generally at the
lumbar vertebra (L3) and normalizing for patient height. A
recent study evaluated 350 patients undergoing colorectal
surgery for malignancy at a tertiary care center. Of these,
nearly a third were found to be sarcopenic. Sarcopenia was
associated with a signicantly increased length of stay
(13days vs. 7 days; p <0.01) and 1-year mortality (13.9%
vs. 0.9%, p<0.01). Sarcopenia was also associated with a
signicant increased risk of any complication (85.2% vs.
34.5%, p < 0.01) and of major complications (30.4% vs.
8.9%, p<0.01) [72]. Preoperative identication of these sarcopenic malnourished patients affords the surgical team an
opportunity to prehabilitate the patient with improved nutritional support and exercise regimen leading to an improved
anabolic state. This is aimed with a goal of improved perioperative physiological status and risk mitigation.
Inammatory bowel disease, intestinal obstruction, large
tumors, stulizing diseases, and patients with diarrhea are
often unable to sustain themselves orally due to a poor appetite or resultant abdominal bloating and pain. This limits the
ability to intervene preoperatively, particularly when considering utilizing the enteral route. Options include oral nutritional supplements (standard or immunonutrition) or feeding
via nasoenteric feeding tubes. Total parenteral nutrition
(TPN) can be used if central intravenous access is obtained,
an appropriate formula is prescribed (1.5g protein per kilogram and 25kcal per kilogram), and tight glycemic control
is maintained (serum blood sugars <150g/dL).
Unfortunately, the use of preoperative nutrition has not
been well studied in the malnourished GI surgery patient
populations. A recent Cochrane review [73] highlights this
paucity of evidence and the reality that many of the studies
are outdated, with only two trials evaluating the administration of enteral nutrition (years 1992 and 2009) including
only 120 participants and a high risk of bias. Neither study
showed any difference in primary outcomes. The three studies that evaluated preoperative parenteral nutrition (years
1982, 1988, and 1992) showed a signicant reduction in
postoperative complications, predominantly in malnourished
patients.
Solid Organ Transplant Recipients
The introduction of novel, more effective immunosuppression regimens has resulted in improved long-term survival
after solid organ transplant. Over 150,000 patients in the
USA are living with functional kidney transplants, and this
number is on the rise. It is increasingly common for surgeons
to encounter transplant patients in their practice, in both the
elective and emergency settings. The vast majority of these
patients are maintained on chronic immunosuppressive regimens. These agents are generally continued throughout the
perioperative and early postoperative period in order to minimize the risk of rejection. Many patients are now on life-long
chronic immunosuppressive agents. It is therefore essential
that surgeons familiarize themselves with the more commonly used immunosuppressive agents and their effect on
wound and anastomotic healing and subsequent impact on
perioperative outcomes. Coordination of care with the transplant team is necessary prior to elective surgery.
The newer immunosuppressive agents, sirolimus and
everolimus, which belong to the drug class known as inhibitors of the mammalian target of rapamycin (mTOR), have
been shown to negatively impact healing of surgical wounds.
mTOR is a cytoplasmic kinase that is essential for cell
growth and proliferation [74]. Inhibition of lymphocyte proliferation despite stimulation results in immunosuppression.
This same mechanism is also responsible for inhibition of
the wound healing process. In a prospective trial of 123
patients randomized to receive either sirolimus or tacrolimus
on postoperative day 4 after kidney transplant, Dean etal.
found a signicantly higher rate of wound-related complications (including supercial site infection and incisional hernias) in the sirolimus cohort compared to those receiving
tacrolimus (47% vs. 8%, P < 0.0001) [75]. This data has
prompted clinicians to replace mTOR inhibitors with tacrolimus for 6weeks prior to elective surgery. Whenever possible, non-operative management may be prudent in patients
on chronic immunosuppression. Patients who are on therapy
status post-transplant are more likely to require emergency
operation and more likely to have a stoma created, whether
or not restoration of intestinal continuity is achieved at the
index operation. These patients similarly have an increased
mortality rate when compared to patients who have not
undergone solid organ transplants and are on immunosuppression [76]. Traditionally, patients who were immunocompromised had been recommended to undergo early elective
resection for diverticulitis. However, this is no longer the
case and should be addressed on an individual basis.
Substance Abuse
All surgical patients should be asked about their use of tobacco,
alcohol, and street drugs. A large database study from 2002
determined that 7.6% of Americans had a substance abuse disorder within the prior year (95% CI 6.6–8.6%) [77]. The surgeon must also recognize narcotic dependency and use of
prescription opioids that are not medically indicated. It is
important for surgeons to make patients feel comfortable in
answering these questions honestly and accurately. It is never
safe to simply assume that a particular patient does not t the
expected prole of an “alcoholic” or “drug addict.” Substance
abuse has been shown to affect the elderly [78], as well as
108
R. G. Landmann and T. D. Francone
highly functional individuals with families and careers [79]. It
is therefore critical to screen all patients preoperatively in
order to minimize perioperative risk.
Alcohol
Alcoholism has been shown to be associated with a number
of different perioperative complications in a dose-dependent
manner. Large studies have demonstrated that alcoholism is
associated with surgical site and other infections, cardiopulmonary complications, and also correlates with longer hospital stay, increased rates of ICU stay, and increased rates of
reoperation [80, 81]. The AUDIT-C questionnaire is a validated screening tool that can be used by the clinician to identify patients at high risk for perioperative complications [82].
A randomized controlled trial of 41 patients with alcoholism
(dened as consumption >60g ethanol per day) undergoing
elective colorectal surgery demonstrated that abstinence
1 month preoperatively was associated with fewer cardiac
complications, including myocardial ischemia (23% vs.
85%, P<0.05) and arrhythmias (33% vs. 86%, P<0.05), as
well as overall decreased complication rate (31% vs. 74%,
P=0.02) [83]. It is unknown what the optimal alcohol-free
interval is prior to elective surgery, in terms of maximizing
risk reduction, although the trial investigators recommend
3–8weeks, highlighting the importance of intensive counseling and monitoring of these patients during this interval [83].
Tobacco
Smoking has been shown in multiple studies to increase perioperative pulmonary risk, as well as risk of wound infections, neurologic complications, and ICU admission [84].
The best way to minimize this risk is to encourage patients to
quit smoking prior to elective surgery. Previously it was felt
that smoking cessation less than 8weeks preoperatively was
associated with a paradoxical increase in pulmonary complications, possibly due to a compensatory increase in secretions. This has now been disproven in multiple large studies.
A large trial of 522 smokers undergoing gastric cancer surgery compared risk of postoperative pulmonary complications between three groups: (1) active smokers or those who
quit less than 2weeks prior to surgery, (2) those who quit
4–8 weeks prior, and (3) those who quit 8 or more weeks
prior to surgery. The odds ratios for postoperative pulmonary
complications were 2.92 for group 1 (95% CI 1.45–5.90),
0.98 for group 2 (0.28–3.45), and 1.42 for group 3 (0.66–
3.05) [85]. Therefore, the recommendation is to encourage
smoking cessation, regardless of the timing of surgery,
although ideally surgery can be planned for at least 4weeks
from the “quit date.”
Opioids
There are many different types of patients with chronic opioid dependence, including abusers of street drugs such as
heroin; abusers of prescription-only opioids; patients with
prior history of opioid abuse, maintained on long-acting
agents such as methadone; and patients on long-term narcotics prescribed for a chronic medical condition. Overall, prescription opioid use is on the rise in the USA and therefore
this is being encountered by the surgeon with increasing frequency [86]. For all patients on narcotics, the surgeon should
always ask preoperatively what the indication is, how long
they have been taking it, side effects (such as constipation),
whether there is a plan to wean off the drug, and who has
been prescribing it. The patient’s responses should be corroborated with the prescribing physician and/or medical
record. Regardless of whether it is warranted for an underlying condition, opioid dependency will result in increased
narcotic requirements perioperatively. Whenever possible, it
is helpful to involve the acute pain management service preoperatively in order to provide the best perioperative pain
management. Non-narcotic adjunct therapies can be considered, including thoracic epidural catheters, transversus abdominus plane (TAP) blocks, and drugs such as ketorolac
(Toradol), acetaminophen, and gabapentin (Neurontin).
Preoperatively, a clear plan should be made with the patient
and the clinician who has been prescribing chronic opioids
regarding postoperative pain management following hospital
discharge, particularly who will be prescribing and for how
long. This is instrumental in avoiding concerns in the outpatient setting with overprescribing and relapse.
Other Illicit Drugs
All patients undergoing elective surgery should be screened
for the use of illicit drugs– not just “street drugs” but also
other prescription-only drugs, such as benzodiazepines, that
are not medically indicated. For patients requiring elective
surgery, intensive efforts should be made to encourage cessation prior to planned surgery. This requires clear communication with the patient’s primary care physician and/or
psychiatrist. Discussion of individual drugs is beyond the
scope of this chapter; however, additional information is well
summarized in this 2014 reference from the anesthesia literature [87].
Consideration ofSpecic Perioperative
Medication Management
Immunosuppressive Agents
When reviewing the literature on patients with diverticulitis
on immunosuppression, there was an increased rate of emergent operation (40%) with index presentation compared to
the general population (10–25%). On Biondo’s review, the
only variable associated with higher risk of surgery was
chronic corticosteroid therapy, and this was likely attributed
6 Preoperative Evaluation inColorectal Patients
109
to the masking of clinical symptoms of sepsis and delay in
presentation and diagnosis. Consequently, morbidity was
higher in the immunosuppressed patients (30.7%), despite a
very high success rate with non-operative management
(60.7%) of all patients presenting with acute diverticulitis.
Mortality was 6.9% and this was in patients with severe
comorbidities that precluded surgical management. Overall,
there was a low recurrence rate, and similar to patients not on
immunosuppression. Recurrent episodes were primarily
related to the initial severity index. Recurrence was signicantly higher (5×) and predominantly noted in patients with
chronic renal failure or collagen vascular disease (~36%),
and for this reason, careful consideration for elective sigmoid resection may be justied in this select cohort [88].
Corticosteroids have been shown to impair wound healing in both animal models and clinical studies. In animal
models, corticosteroids have been shown to alter multiple
independent signaling pathways, impairing all three phases
of wound healing: inammatory, proliferative, and remodeling. Clinical studies have also demonstrated a higher rate of
anastomotic complications in patients on chronic steroids
[89]. A prospective study performed in the 1980s specically
evaluated the risk of steroids in Crohn’s patients and demonstrated in multivariate analysis that corticosteroids were
associated with an increased overall postoperative complication rate in Crohn’s patients undergoing surgery involving
bowel anastomosis (15.4% vs. 6.7%; p=0.03) [90]. One of
the largest studies looking at anastomotic leak (AL) in
colorectal patients included 250 left-sided resections with
anastomosis. The overall anastomotic leak rate was 7.5%.
When patients were administered corticosteroids, either
perioperatively or on long term, the multivariate model concluded that corticosteroid use increased the risk for AL by
more than seven times (OR, 7.52; standard error, 4.47;
P=0.001; 95% CI, 2.35–24.08) [91]. A meta-analysis evalu-
ating the risk of corticosteroids on colorectal anastomotic
integrity that included 9564 patients from 12 studies demonstrated an overall leak rate of 6.77% (95% CI 5.48–9.06)
compared to 3.26% (95% CI 2.94–3.58) in the noncorticosteroid group [92]. In ulcerative colitis, doses greater
than 4 mg/day led to a statistically signicant increase in
complication. Similarly, in the Crohn’s Therapy, Resource,
Evaluation and Assessment Tool (TREAT), corticosteroids
were shown to slightly increase the infectious complications
(OR 2.21) [92].
In addition, corticosteroids impact wound healing and are
a risk factor for the development of supercial and deep surgical site infections and have even been shown to impact
postoperative mortality [74]. Another more recent metaanalysis on the effect of corticosteriods in the setting of
ulcerative colitis and ileal pouch anastomotic complications
demonstrated equivocal results [93]. Ultimately, this understanding allows the surgeon to better counsel the patient
regarding possible postoperative complications, wean steroids during the preoperative period when possible, and
make decisions in the operating room (such as the decision
to create diverting stoma and wound closure) to optimize
patient outcomes. Current recommendations state that
patients who are on greater than 20mg of prednisone daily,
on steroids for greater than 2 months duration, and/or combined immunosuppression with biologics within 12 weeks
are at highest risk for septic complications. In these patients,
recommendations are to delay pouch creation or other anastomosis (consider modied 2- vs. 3-stage procedures), divert
in the setting of, or delay, anastomosis, and wean steroids to
less than or equal to 20mg of prednisone daily for 2weeks.
Immunomodulators, including azathioprine and
6- mercaptopurine, are used in both Crohn’s disease and
ulcerative colitis to maintain steroid-induced remission.
These drugs often take 3–4months until clinical benet is
apparent and have infrequent but serious side effects such as
leucopenia, liver function abnormalities, pancreatitis, and
lymphoma. A retrospective study of 417 operations involving bowel anastomoses for Crohn’s disease demonstrated no
difference in the rate of anastomotic complications for
patients on immunomodulators (10% vs. 14%; p = 0.263)
[75, 94]. Similar to the studies above, they also found that in
multivariate analysis, corticosteroids (preoperative prednisolone 20mg or more) was a predictor of anastomotic complication (OR 0.355, 95% CI 0.167–0.756; p = 0.007).
Accordingly, these medications may be continued until surgery in some cases.
Biologic agents, including iniximab (Remicade), adalimumab (Humira), and cetolizumab (Cimzia), are chimeric
monoclonal antibodies that target tumor necrosis factor, a
proinammatory cytokine that has been shown to be elevated
in inamed tissue of IBD patients. Biological and immunological agents, including iniximab, have been demonstrated
to induce remission and control symptoms in patients with
moderate-to-severe Crohn’s and Ulcerative Colitis. Other
biologic agents are more targeted in their behavior and mechanism of action: ustekinumab – anti-IL12/IL23; natalizumab –
selective GI-specic anti-adhesion molecules(MadCAM-1);
tofacitinib – JAK (Janus kinase) inhibitors - prevent STAT
translocation, gene transcription, and lower cytokine production; vedolizumab – humanized monoclonal antibody to α4β7
integrin specic to GI endothelial cells blocking T-cell migration to inamed GI tissue, also critical for anastomotic healing. With more widespread use of biologic agents in other
inammatory conditions such as rheumatoid arthritis and
psoriasis, surgeons are seeing a larger percentage of patients
on these agents perioperatively. Critically, though many of
these newer agents are more selective in their mechanism and
site of action, they also have the paradoxical effect on inhibiting the pathways necessary for appropriate anastomotic
wound healing. Krane etal. performed a retrospective analysis
110
R. G. Landmann and T. D. Francone
of 518 patients with IBD undergoing elective laparoscopic
bowel resection, of which 142 patients were on preoperative
iniximab [95]. There was no difference in the rate of anastomotic leak, which was overall low in both groups (2.1% with
iniximab versus 1.3% without; p = 0.81). A signicantly
higher percentage of the patients on iniximab were also on
steroids, 73.9% vs. 58.8%, p= 0.006, and still this did not
impact anastomotic leak rate. A recent meta-analysis by
Wong evaluated anti-TNF agents and postoperative outcomes
in Crohn’s disease. Though there was signicant conicting
and controversial results secondary to heterogeneity in the trials, there was a consistent increase in infection complications
by approximately 20% (OR 1.5) [96].
Similarly, when evaluating postoperative outcomes with
ileal pouch anal anastomoses and the effects that anti-TNF
biologic agents have, there was a split on the effect of these
agents and adverse pouch-related and infectious complications [93]. Other studies at institutions with high volumes of
inammatory bowel disease and patients on biologics similarly supported an increase in infectious complications, OR
3.5 (anastomotic leaks p = 0.02, pouch specic complications p=0.01, other infectious complications p<0.01, and
postoperative sepsis, OR 13.8) [97].
A more recent study reviewed 3860 patients undergoing
colectomy for Crohn’s disease from the NSQIP database.
When investigating steroids and/or biologics within 30 days
of elective colectomy, multivariate analysis concluded that
immunosuppression led to statistically signicant increases
in infectious complications (OR 1.25; 95% CI 1.03–1.52),
overall SSI (OR 1.40; 95% CI 1.13–1.74), organ space SSI
(OR 1.47; 95% CI 1.09–1.98), and anastomotic leak (OR
1.41; 95% CI 1.02–2.25) [98].
Vedolizumab is a humanized monoclonal antibody to
α4β7 integrin specic to GI endothelial cells. This agent
results in blocking of T-cell migration to inamed GI tissue.
This same pathway and migration, however, are also critical
for anastomotic healing. When investigating vedolizumab
and SSI rate in surgical IBD patients, vedolizumab was demonstrated to increase all postoperative complications more so
than when compared to anti-TNF agents or no treatment at
all. Vedolizumab use within 12 weeks independently predicted 30-day postoperative SSI [99].
Most recently, the PUCCINI trial investigating risk factors for postoperative infection in patients with IBD was
completed and recently published. This group concluded that
preoperative use of anti-TNF drugs, as determined by history
or by drug levels, was not an independent factor for postoperative infections. When evaluating surgical site infection,
there was no statistically signicant increase with preoperative TNF use within 12weeks of surgery (P= 0.92) or if
there was any detectable TNF level (p=0.513). The results
were similar when investigating any infectious complication
(p= 0.80 and 0.985, respectively). Interestingly, no differ-
ences were seen with steroid use or preoperative use of other
immunosuppressive agents [100, 101].1 One of the biggest
arguments against the ndings in this study was that the
group looked at any use within 12weeks preoperatively. This
window was signicantly outside the 3× multiple of the biological agents half-life, with only 1.5% of the concentration
bioavailable. This concentration would have no effect on any
tissue and could not be expected to cause any effect on outcomes. Similarly, the study contradicts many other ndings
of the deleterious effect of corticosteroids on postoperative
complications.
Overall, the current literature is quite conicting and controversial in their ndings. Biologics have signicantly
improved medical management of IBD, though without a
signicant reduction in role of surgery. While delaying
necessity for surgery (particularly in UC), this comes at a
cost of increased malnourishment and chronic illness of
patients. Biologics have been shown to adversely impact
wound healing and increase the risk of postop infectious and
surgical complications. Though newer GI-specic therapies
may resolve many of these issues, most surgeons and highvolume IBD centers prefer to hold these agents for the equivalent of 3.5 half-lives (6–8weeks for most anti-TNFa agents,
12weeks for vedolizumab) prior to major abdominal surgery
[95]. Additionally, steroids should be weaned to 20mg of
prednisone daily and sustained for a minimum of 2weeks
preoperatively. Temporarily diverting stoma should be considered when unable to optimize these medical therapies
preoperatively.
Chemotherapy
Through a myriad of mechanisms, the nal
common pathway of cytotoxic chemotherapy is induction of
cell death during the otherwise rapid proliferation and growth
phase of neoplastic cells. Ideally this effect is minimized in
nontumor cells, including healing anastomoses. Large studies have attempted to evaluate the overall effect of neoadjuvant and adjuvant chemotherapy on the rate of anastomotic
leak, and there have been conicting results. In a recent
single- center study of 797 patients with a single anastomosis, Lucan etal. determined in multivariate analysis that preoperative chemotherapy was one of the strongest independent
risk factors for anastomotic leak, with an odds ratio of 2.85
(95% CI 1.21–6.73, P=0.017) [101]. Morse etal. performed
a similar study of 682 patients with intestinal anastomoses
over a 5-year period and determined in bivariate analysis that
chemotherapy (administered within 6 weeks of the operation) was not a risk factor for anastomotic leak.
Nash published a series of 131 patients with diverticulitis
in the setting of chemotherapy. Severity of symptoms was
not associated with recent chemotherapy administration.
1
Cohen etal. [100].
6 Preoperative Evaluation inColorectal Patients
111
However, chemotherapy patients were more likely to recur
with more severe disease, more likely to undergo emergent
surgery (75.0% vs. 23.5%, p = 0.03), more likely to be
diverted (100.0% vs. 25.0%, p=0.03), more likely to incur a
postoperative complication (100% vs. 9.1%, p< 0.01) following interval resection. These patients also were found to
have a signicantly increased overall mortality, with a lower
median survival (3.4 years) (median survival not reached in
non-chemotherapy patients). In summary, the group found
that nonoperative management of diverticulitis was very successful in patients receiving chemotherapy and should be
pursued. Though recurrent diverticulitis was not more common in cancer patients on chemotherapy, it was more likely
to be complicated and led to surgery in the select cohort. The
group also concluded that the interval of colon resection
after a single episode of diverticulitis was not routinely indicated and that, indeed, chemotherapy can safely be resumed
in most patients after acute diverticulitis episodes had
resolved with medical management [102].
Biondo also published their review on the effects of immunosuppression in the setting of diverticulitis. Chronic corticosteroid therapy was associated with higher rates of emergency
surgery. Recurrence was highest during the rst year after the
index episode, suggesting the need for appropriate surveillance. The need for emergency surgery for recurrence is comparable to that in the general population, and elective surgery
in immunosuppressed patients should be individually indicated according to persistence of symptoms or early recurrences. Contrary to prior guidelines, and appropriately
redirecting future practice parameters, Biondo concluded that
prophylactic colectomy in immunosuppressed patients with
diverticulosis cannot be recommended [88].
Bevacizumab (Avastin) is a humanized monoclonal antibody, which targets vascular endothelial growth factor A
(VEGF-A) and is thought to work in solid tumors by restricting neoangiogenesis, which is necessary for tumor growth. It
is the rst of the antiangiogenic drugs to be approved for
rst-line treatment of metastatic colorectal cancer and is also
used for other solid tumors including breast, kidney, ovarian,
and lung cancers. Bevacizumab is associated with increased
incidence of postoperative complications, including impaired
wound healing and anastomotic leak.
Consequently, phase II and III studies of bevacizumab for
colorectal cancer excluded patients who underwent major
surgery within the previous 28 days [103–105]. Yoshioka
et al. retrospectively evaluated 78 patients with resectable
advanced or metastatic colorectal cancer who received neoadjuvant bevacizumab prior to surgical resection (this
included 46 rectal resections and 4 colectomies) [106].
Overall median interval from last bevacizumab dose to surgery was 9weeks; anastomotic leaks occurred in six patients,
four of which required re-laparotomy. The mean interval
from surgery to diagnosis of anastomotic leak was 15.8days
(range 4–34days). Although the authors did not document
mean in-hospital length of stay, presumably most of the leaks
occurred after discharge. In multivariate analysis, primary
colorectal anastomosis was the only independent predictive
risk factor for major postoperative complications (OR 8.285;
P=0.013). Interestingly, the interval from last bevacizumab
dose to surgery was not an independent risk factor for postoperative complications. Bevacizumab has also been associated with late anastomotic complications [106].
Unsurprisingly, other newer antiangiogenic drugs have also
been implicated in the development of anastomotic leak,
including pazopanib and aibercept in small series and case
reports [107]. As with most chemotherapy agents, current
recommendations are to hold these antiangiogenic agents for
at least 6weeks before major surgery. Intestinal anastomosis
and/or proximal diversion should be carefully considered
due to the signicant complication and leak rate.
Newer checkpoint inhibitors (anti-PD/PD-L1 immunotherapy) such as prembolizumab, nivolumab, or ipilimumab
have been increasingly used in the armamentarium for
colorectal and other diseases. In rare instances, urgent intestinal operation may be required. Though no specic intestinal surgical studies have been performed, other studies
investigating bladder resections and conduit reconstruction
in patients on pembrolizumab found that the morbidity rate
was acceptable (69%>= Clavien-Dindo grade 2 complication) with no mortality appreciated [108]. Similarly, when
evaluating safety and feasibility of lung surgery following
immunotherapy, though the operations were technically
challenging, signicant morbidity appeared to be rare (32%),
with encouraging postoperative disease-free survival [109].
Preoperative Assessment intheElderly
Historically, advancing age has been utilized as a risk factor
in predicting adverse perioperative outcomes in patients like
other factors such as emergency surgery, ASA, and preoperative comorbidities, for instance, COPD or morbid obesity. As
such, prior risk stratication models such as Colorectal
Physiologic and Operative Severity Score for enumeration or
Mortality and Morbidity (CR-POSSUM) [110, 111] and
National Surgery Quality Improvement Program (NSQIP)
Morbidity and Mortality Risk Calculator [112] utilize chronological age as a variant predictor of adverse perioperative
outcomes. However, chronologic age has been shown to be a
poor reection of the functional, physical, and cognitive
decline a patient may experience in their elder years. This
poses a difcult challenge for today’s surgeons as most surgeries in the United States are performed on patients older
than the age of 65. Thus, most persons facing surgery are
elderly, underlying the importance of appropriate preoperative evaluation of this patient population.
112
R. G. Landmann and T. D. Francone
Dening theElderly
The older population is a heterogeneous group with varying
levels of health status. Commonly used predictors of postoperative complications are not tailored to the geriatric population. For example, the American Society of Anesthesiology
classication is determined by a subjective estimate of organ
system disease and likelihood of survival, while the Lee and
Eagle Criteria account for cardiac function only. Growing
evidence demonstrates that these models are limited in predicting perioperative risk since they do not account for the
diverse levels of physiologic reserves in the older surgical
patients.
The term “frailty” has been increasingly recognized as a
surrogate for decreased physiologic reserve in the elder population. There is a lack of consensus on a standard denition
of frailty in the literature, although it continues to evolve. It
has been described as several phenotypes associated with the
dysregulation of multiple physiologic systems. The two most
utilized phenotypes include phenotypic frailty which
includes assessment of physical activity, muscle strength,
and energy level [113], while decit-driven phenotype
includes assessment of nutrition, cognition, medical condition, and functional decline [114].
Assessing Frailty
A multidimensional comprehensive geriatric assessment
(CGA) is considered the gold standard for assessing frailty
by geriatricians. The CGA generally includes a compilation
of validated tools to assess comorbidity, functional status
(including ability to live at home), physical performance,
cognitive impairment, psychological status, nutritional
status, medication review, and social support (Table 6.9)
Table 6.9 A comprehensive geriatric assessment (CGA) should be
a key part of the treatment approach for all older cancer patients
[115, 116]
Domain Measures
Functional
status
Comorbidity Physical Health Section (OARS Subscale) [162]
Cognition Blessed Orientation-Memory-Concentration Test
Psychological Hospital Anxiety and Depression Scale
Social
Functioning
Social Support MOS Social Support Survey: Emotional/
Nutrition (1) Body Mass Index [170]
(1) Activities of Daily Living (Subscale of MOS
Physical Health) [161]
(2) Instrumental Activities of Daily Living
(Subscale of the OARS) [162]
(3) Karnofsky Performance [163]
(4) Timed Up and Go [164]
(5) Number of Falls in Last 6Months [165]
[166]
[167–169]
MOS Social Activity Limitations Measure [161]
Information & Tangible Subscales [161, 170]
(2) % Unintentional Weight Loss in Last
6 Months [171, 172]
[115, 116]. On the whole, the benets of a CGA include prolongation of life and prevention of hospitalizations and
admissions to adult living facilities [117–120], prevention of
geriatric syndromes such as delirium and falls [121, 122],
prevention of cognitive decline [123], and detection of
unsuspected conditions that may affect cancer treatment in
more than 50% of patients aged 70 or over [124].
Complete Geriatric Assessment
Several studies have demonstrated the ability of CGA to predict surgical outcomes in the elder population [125, 126].
Early studies include a Norwegian study by Kristjansson
etal. [127] in which the CGA was predictive of surgical morbidity in 178 elderly colorectal cancer patients with a median
age of 80. This study is consistent with previous work identifying frailty as a predictor of surgical outcomes. Robinson
and colleagues used seven frailty characteristics (Time Up
and Go, Katz score, Mini-Cog, Charleston Index, anemia,
poor nutrition, and geriatric syndrome of falls) to dene frail,
pre-frail, and non-frail individuals. Of the 201 patients who
underwent major cardiac or colorectal procedures, frailty was
independently associated with increased postoperative complications, prolonged hospital stay, and higher 30-day readmission rates [125]. More recently, a 2015 systemic review
evaluated six studies on CGA and surgical outcomes in the
geriatric oncology population. All studies included were prospective, cohort design and utilized validated questionnaires
with data collected prior to surgery. Primary outcomes
included 30-day postoperative complications (POC), mortality, and discharged to a non-home institution. Deciencies in
instrumental activities of daily living (iADL), activities of
daily living (ADL), fatigue, cognition, frailty, and cognitive
impairment were associated with increased postoperative
complications. Although there were no CGA predictors for
postoperative mortality, frailty, deciencies in iADL, and
depression were found to be predictive of discharge to a nonhome institution. Major complications happen more frequently in patients with cognitive impairment, iADL, and
activities of daily living (ADL). Interestingly, age was not
associated with complication rates [128]. Similarly, a study
by Shahrokin etal. evaluating 980 oncogeriatric patients aged
75 years or older demonstrated association between CGA
decits and 6-month mortality after stratication for multiple
variables. Of note, ASA classication was not associated with
6-month mortality while each additional impairment identied on the CGA was associated with a 40% increase in the
risk of a 6-month postoperative mortality [129].
Frailty Scores
Although comprehensive geriatric assessment is the most
consistent in predicting outcomes in the geriatric population,
a full CGA can take several hours to complete and may not
be feasible in a busy surgical practice. Shorter more efcient
6 Preoperative Evaluation inColorectal Patients
113
Table 6.10 Frailty score has been described as an age-associated
decline in ve domains: shrinking, weakness, exhaustion, low physical
activity, and slow walking speed [113]
Domain Denition
Shrinking
Decreased grip
strength
Exhaustion Response to questions about effort and
Low physical
activity
Slowed
walking speed
Adapted from Makary 2010 [126]
Unintentional weight loss ≥10pounds in the last
year
Patient squeezed a hand-held dynamometer
(strength measurement was adjusted for BMI and
gender)
motivation
Survey about leisure time activities
Speed at which patient could walk 15feet
geriatric assessments have been developed to address the
time constraints during acute evaluations, while demonstrating their ability to be as effective as the CGA in predicting
postoperative complications [130–132]. In 2001, Fried etal.
characterized frailty as an age-associated decline in ve
domains (Table6.10): shrinking, weakness, exhaustion, low
physical activity, and slow walking speed. The denition was
instrumental in providing the framework to help dene this
challenging population [113]. In 2010, Makary and colleagues used the Fried criteria to establish the Hopkins’
Frailty Score, which demonstrated that the frailty was a
potentially useful tool in predicting poor outcomes in the
elderly surgical population. Frailty was prospectively measured in 594 patents (aged 65years or older who presented
for elective major and minor surgeries). Patients scoring 4–5
were classied as frail, 2–3 were intermediately frail, and
0–1 were non-frail. Utilizing multiple logistic regression,
frailty was shown to be independently associated with the
development of postoperative complications (OR 2.54; 95%
CI 1.12–5.77), length of stay (OR 1.69; 95% CI 1.28–2.23)
and discharge to a skilled or assisted living facility after previously living at home (20.48; 95% CI5.54–75.68). In addition, when combined with other current risk assessment
models such as ASA and Lee and Eagle scores, assessing
frailty improved their predictive power [126].
In 2012, the American College of Surgeons recognized
the importance of a CGA in the preoperative evaluation of
elder patients. The American College of Surgeons NSQIP
and American Geriatric Society collaborated to create best
practices guidelines for the perioperative care of geriatric
surgical patients. In addition to conducting a complete history and physical, the authors recommended evaluations of
preoperative domains which included problems specic to
elderly individuals. These domains are very similar if not the
same domains included in the CGA discussed above and
include cognitive impairment, frailty, poly-pharmacy, risk of
malnutrition, and lack of family or social support. A pro-
Table 6.11 Preoperative workup for geriatric patients undergoing
colorectal surgery
Cardiac assessment
I.Patients with active cardiac conditions require cardiology
assessment and workup
II.Patients with over two clinical risk factors require heart rate
management, but do not need cardiac testing unless results will
change operative management
III.Patients undergoing low risk surgery, more than 3 METs, or
fewer than 3 clinical risk factors may proceed with surgery
Pulmonary assessment
IV.Encourage smoking patients to quit more than 8weeks postop,
although 4weeks may be long enough in some studies
V.Aggressive management of COPD and asthma
VI.Routine CXR and PFTs not indicated
Diabetes and glucose assessment
VII.Obtain baseline glucose level
VIII.Obtain baseline BUN and creatinine
Nutritional assessment
IX.Patients with BMI <18 or unintentional weight loss over 10% in
6months require evaluation by a registered dietician
X.Preoperative nutritional
Anemia and hematologic assessment
XI.Obtain baseline hemoglobin and hematocrit
Cognitive assessment
All patients require adequate history from patient and family
member
All patients require cognitive assessment (Mini-Cog)
All patients require anxiety/depression assessment
All patients require assessment of alcohol use, identication of
possible abuse
All patients require evaluation of decision-making capacity to
ensure informed consent
Any new ndings, or worsening of existing ndings, require further
evaluation by appropriate geriatrician or mental health care provider
Laboratory and noninvasive testing
Unless previously indicated above, routine CBC, BMP, PT/PTT,
EKG, CXR are not required
posed checklist was drafted for surgeons across all specialties to utilize in the evaluation of a surgical geriatric patient;
however, translating the information into predicting clinical
outcomes remained challenging (Table6.11) [133].
Composite indexes obtained from retrospective analysis of
large national data spaces are more frequently being utilized
to adequately assess the elder population in the preoperative
setting, given they are considered quick and simple tools. One
example is the modied frailty index (mFI) which was developed utilizing the American College of Surgeons National
Surgical Quality Improvement Program (NSQIP) database
[134]. This screening tool is favored among multiple surgical
disciplines because it is based on easily identiable relevant
patient characteristics which can be extracted using a straighforward history and physical examination. It consists of 11
variables each of which corresponds to one point. The mFI
has been shown to predict the 30-day readmission, major
complications, wound complications, failure to adhere to
enhance recovery protocols, discharge to non-home facilities,
and mortality for surgical patients [135–137]. The risk analy-
114
R. G. Landmann and T. D. Francone
sis index (RAI) is another composite index frequently used to
predict outcomes and surgical patients. It consists of a
14-question survey which evaluates domains such as ADLs
and cognitive decline along with more standard factors such
as age, sex, and medical comorbidities. Initial studies by Hall
et al. demonstrated the RAI to predict prolonged length of
stay, out of ICU admission, discharged to nursing home, and
mortality [138, 139].
Improving the preoperative evaluation of the elderly surgical patient to assess frailty is the rst step in improving
surgical outcomes in this heterogeneous, complex population. Preoperative assessments should not only be designed
for early detection and treatment of surgical medical complications but should also be aimed at identifying at-risk individuals with modiable risk factors in which targeted therapy
may improve their outcomes. This sets the stage for the
increasing interest in evaluating the impact of prehabilitation
on the elderly population undergoing surgical intervention.
Cognitive Dysfunction andDelirium
Cognitive dysfunction is common in elderly patients, with
rates between 5% and 15% in the general population but as
high as 60% in high-risk groups [140]. The degree of dysfunction can vary between severe, otherwise known as
dementia, and mild cognitive impairment (MCI). With MCI,
the level of impairment is not severe enough to interfere with
independent function [141, 142]. Both forms of cognitive
dysfunction have been shown to be associated with worse
surgical outcomes. Multiple studies have implicated both
MCI and dementia as high-risk factors for postoperative
delirium.
The American College of Surgeons and American Society
of Geriatrics have advocated for the use of the MiniCog preoperatively to detect MCI [143]. The MiniCog screening test
is a 3-minute instrument that can increase the detection of
cognitive impairment in older adults. It consists of two components: a 3-item recall test for memory and a simply scored
clock drawing test. Other tests include the Self-Administered
Gerocognitive Examination (SAGE) which was developed
by Scharre etal. [144]. It is a 12-item examination that is
self-administered to detect MCI and early dementia in geriatric patients.
Delirium is the one of the most common postoperative
complications in the elderly. It has been dened as a documented change in mental status characterized by reduced
environmental awareness and attention disturbance. In a prospective analysis of patients aged over 70, undergoing
abdominal surgery, the overall incidence of delirium was
60% with a 30-day mortality of 20% in those patients. In
fact, 40% of patients had three or four risk factors for delirium [145]. In the Hospital Elder Life Program, focus and
Table 6.12 Pre- and perioperative risk factors associated with
increased risk of postoperative occurrence of delirium
Preoperative
Dementia
Age [20]
Malnutrition [145]
Cognitive impairment [155]
Visual impairment [155]
Dehydration [20]
Immobilization [20]
Polypharmacy [20]
Severe illness [155]
Perioperative
Poor uid status [145]
Poor glycemic control >150mg/dL
Metabolic derangements [20, 145]
Uncontrolled pain (PCA necessary to improve delirium in elderly
patients) [155]
Addition of more than 4 new medications [145]
Bladder catheters [145]
Serum urea nitrogen to creatinine ratio >17 [155]
Prolonged bed rest
Physical restraints [145]
management of six factors reduced delirium: visual impairment, hearing impairment, cognitive impairment, sleep
deprivation, immobility, and dehydration (Table 6.12).
Treatment should not utilize medications as rst-line therapy. Instead, avoidance of triggers, reorientation, massage,
relaxing music, and one-on-one care with family are recommended. If medication is required, Haldol should be initially
be considered and the clinician should refrain from restraints
except in the most severe cases [146].
Prehabilitation
Increasing utilization of preoperative screening tools, such
as mFI, in the geriatric population has resulted in further
awareness of elders at risk for functional decline not only
from a physical aspect but also from a nutritional and psychological status. These factors may be considered modiable in which improvement may shift outcomes in a positive
direction for this high-risk population. For this reason, there
has been a concurrent in interest in developing preventive
strategies to restore the functional capacity after surgery,
reducing the clinical impact of reduced functional capacity.
Prehabilitation is a multidisciplinary intervention focused on
utilizing the perioperative period to optimize the patient to
prevent or diminish the surgery-related stress leading to
functional decline and its consequences. The multimodal
approach includes exercise training, nutritional therapy, and
anxiety reduction strategies [147].
Although the body of evidence is growing regarding prehabilitation, standardized consensus denition of
rehabilitation remains lacking. And as such, there is signi-
6 Preoperative Evaluation inColorectal Patients
115
cant variation in the reported types of interventions and the
recommended types of interventions, frequency, and duration [148–152]. Duration of intervention may vary between
5 days and 6 weeks and may occur at the patient’s home,
rehabilitation center, and outpatient or inpatient physiotherapy units. It is no surprise that all trials included exercises
and elements of rehabilitation to improve the functional
capacity and physiologic reserve.
Exercise
The goal of a prehabilitation program is to identify those
with modiable risk by assessing with screening tools for
specic conditions and intervening prior to surgery. Based
on the growing body of literature, exercise has been shown
to be the main component. Programs focus on the ability
of exercise to deliver a physiologic stress that causes an
adaptive response in all organs and tissues and as such
improve the ability of the body to withstand incoming
stress for surgery. Training programs often utilize the three
main categories of exercise (aerobic, resistance, and exibility training) to complement each other and lead to a
comprehensive functional outcome improvement [153].
Majority of programs demonstrated improvement in physical performance after undergoing a rehabilitation program.
Screening tools that identify patients with decreased performance status include the ACS NSQIP surgical risk calculator along with a revised cardiac risk index. Performance
status and functional capacity are often expressed and
metabolic equivalents (METs) as described earlier in this
chapter [16, 21].
Nutrition
Malnourishment affects between 2% and 32% of elderly,
and that’s among the “healthy” geriatric population. In hospitalized elderly patients, prevalence of malnourishment is
between 1% and 83% [154, 155]. There is a sixfold increased
risk of complications in malnourished elderly patients [21],
which may be further amplied in the setting of gastrointestinal cancer. Further, poor preoperative nutritional status
was independently associated with postoperative delirium
and mortality in elderly patients. Therefore, optimization of
nutritional status and enhancement of protein metabolism
are paramount [145]. Nutritional screening tools can be
used to properly identify the presence of undernutrition or
the risk of developing undernutrition to select patients for
nutritional therapy. Screening tools may include tools such
as Subjective Global Assessment (SGA) Nutritional Risk
Screening 2002 or Mini Nutritional Assessment (MNA)
[154]. The nutritional intervention should be multimodal
but individualized to the patient focusing on ensuring the
patient (1) meets the energy requirements of daily expenditure, maintains energy stores, and promotes physiologic
metabolic processes; (2) maintains a high protein diet; and
(3) receives a balanced meal with adequate intake and proportion of all macronutrients.
Psychosocial Therapy
Physiologic stress of surgery is not only entirely related to
the trauma of the surgery itself but can also be related to the
psychological distress caused to the patient. Preoperative
anxiety and depression have been shown to have a negative
impact not only in quality life but also in wound healing,
infection rates, length of stays, and adherence to medical
treatments [153]. The psychological component of a multimodal rehabilitation program is aimed at reducing anxiety
symptoms and distress with cognitive behavioral therapy.
Interventions may include educational sessions to improve
knowledge about surgery, relaxation, and imagery techniques such as passive breathing exercises, meditation skills,
and guided imagery [156].
Outcomes
In theory, prehabilitation programs should mitigate surgical
complications in high-risk individuals such as elders; however, currently there is little evidence to support this. Several
studies have investigated the effect of prehabilitation on
postoperative complications with only one study by Waite
et al. demonstrating a signicant impact on complications
with a decrease in overall complications by 30% and severe
complications by 20% in those patients awaiting cardiac surgery [157]. Reports vary on the effective prehabilitation with
regard to mortality and length of stay. Most of the literature
demonstrate no difference in mortality between those who
undergo prehab and those who do not, except for the study
by Waite etal. who demonstrated signicant decrease in both
30-day mortality and 3-month mortality. Majority of the literature also demonstrate no difference between the length of
stay and discharged institutionalization with no difference
between the two groups. One study by Mazzola etal. demonstrated a trend toward reduced length of stay, while Waite
etal. demonstrated a signicant decrease in the length of stay
for those undergoing prehab [150, 157].
Carli et al. performed a randomized trial evaluating the
effectiveness of prehabilitation (versus rehabilitation) specically on frail patients undergoing colorectal surgery for
cancer [158]. In a cohort with a mean age of 78years and
with almost 80% of patients undergoing minimally invasive
surgery, there was no difference in the primary outcome
measure, 30-day Comprehensive Complications Index, or
secondary outcome measures (30-day overall and severe
complications, primary and total length of hospital stay,
30-day emergency department visits and hospital readmissions, recovery of walking capacity, and patient-reported
outcome measures).
116
R. G. Landmann and T. D. Francone
A recent systematic review of 5921 patients undergoing
prehabilitation was recently published. Thirty-ve studies
(n=3402) on patients undergoing major abdominal surgery
were included. Only 45 studies compared the impact of prehabilitation versus no prehabilitation on postoperative outcomes (abdominal, n = 26; cardiothoracic, n =19), but in
those studies, patient’s receiving prehabilitation for major
abdominal surgery had signicantly lower rates of overall
complications (n= 10, odds ratio: 0.61, condence interval
95%: 0.43–0.86, P=0.005), pulmonary (n=15, odds ratio:
0.41, condence interval 95%: 0.25–0.67, P< 0.001), and
cardiac complications (n = 4, odds ratio: 0.46, condence
interval 95%: 0.22–0.96, P=0.044) [159].
Conclusion
Preoperative assessment of the colon and rectal surgical
patient remains the rst critical step in appropriate decisionmaking and improving outcomes. A keen understanding of
various medical therapies being utilized and their effects on
wound and anastomotic healing and resultant septic complications is critical in the timing of and preparation for procedures. Attention to patient’s other physiological organ systems
(cardiac, pulmonary, renal, endocrine, nutrition and metabolism, and immunologic) and alterations in normal function is
necessary for perioperative optimization to enhance the ability of the patients to tolerate the operation and also recover
with minimal morbidity and improved long- term function. In
some cases, timing of interventions may necessitate judicious
delay to optimize the surgical and medical milieu of the
patient. Special consideration is necessitated in the elderly,
given the multiple domains involved in dening this complex
population, particularly as prehabilitation for frailty has demonstrated signicant benets in improving surgical outcomes.
Preoperative assessments, with multidisciplinary input,
should be designed at early detection, stratication, and optimization to mitigate medical morbidity and minimize or
eliminate surgical complications. These should be a component of a robust enhanced recovery protocol that incorporates
early mobilization, narcotic- sparing multimodal pain management, and discharge planning.
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