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Paris, 4th November 2011
S i l U d tS i l U d tSurgical UpdatesSurgical Updates
Riccardo A Audisio, MD, FRCSUniversity of Liverpool - UK
treatment goals for older patients
Maximize/maintain potential life span
Maintain dignity of life, maximize self-esteem
Maximize independent function, minimize dependence
Relieve suffering (pain)Relieve suffering (pain)
When cure is not be possible palliation/comfort When cure is not be possible, palliation/comfort are just as important
CRC Oldest Olds & Surgical Risk 9,070 surgical pts >70yrs (4,162 >80yrs)
higher dependency, ASA, comorbidity ratelower albumin, drinking/smoking habit
longer hospital staymore minor & major post-op. complications
more operative deathsmore operative deaths
Pancreatic cancer - SEER 1992-2005Medicare >66yrs: 9 553ptsMedicare >66yrs: 9,553pts
20 29 0 1/100 00020-29yrs: 0,1/100,000>80yrs: 87.2/100,000
increasing age ~ less surgeryg g g y81%<70yrs vs 45%>85yrs
even for patients with no comorbidities
11% increase in resection rate/yeary
operative mortality is decreasing2-yr survival rates:resected 35%35%unresected 7%
“it is important pts understand it is important pts understand the risk of mortality as well asythe significant advantage of
surgical resection”
Impact of age on decision making for liver surgeryECOG not varying with age (p=0.08)for liver surgeryECOG not varying with age (p 0.08)
% patient’s preference to physician’s f f i d ith preference for surgery increased with age
(29% vs 50%)
Retrospective study 220 pts; 75>yrs receiving Radical Cystectomy
Developed a nomogram that provides i di id li d i k t f 90 d i lindividualised risk-esteem of 90-day survival
Mortality rate is high (10-15%) in this group y g ( ) g pand the nomogram allows offering
individualised treatment
Albumin is a strong predictor of post-Albumin is a strong predictor of post-operative mortality
CardioPulmonary Exercise Testing (CPE )(CPEx)
Formal assessment of maximum oxygen Formal assessment of maximum oxygen consumption during exercise (VO2 max)
Cohort studies and a meta-analysis report the association of low VO2 max and ‘high the association of low VO2 max and high risk’ lung resection
Studies are under-powered: mortality rate for lobectomy averages 2% (largest study
Anaesthesia TF @ SIOGon 422pts had 15 deaths)
CPEx68 ‘very high risk’ patients (FEV1 <900 ml and VO2 max <15/ml/kg/min) operated: / / g/ ) p1pt died (30 days) + 3pts died (in hosp)
These operated patients had more than double the median survival compared pwith the non-operated patients (36.0 months vs 15.8 months, p<0.001)p )
Denying patients with ‘prohibitive risk’ y g p pmay be against their best interests
Anaesthesia TF @ SIOG
risk prediction & decision making processfor SURGICAL patients:for SURGICAL patients:
CGAvs
GFI - VES13 - TUG
>300 patients entered
median age 76yrs
tests are predictive - some is better…
quick screening tools in clinical practice
slow gait speed confers 2-3 fold increase mortality or major morbidityincrease mortality or major morbidity
69pts >70yrs High-grade prostate ca. treated with robotic radical prostatectomy
operative time: 175 minutes (IQR: 136.8 –202.5)
bl d l 150 (IQR 100 200)blood loss: 150cc (IQR: 100–200)
4 complications (5.8%): 2 leaks and 2 ileus
postoperative stay: 1day (all pts<3 days)
biochemical recurrence: 12pts (17.4%)
biochemical DFS: 91% at 12mos (86% at 36mos)
good functional outcomes at 26.2mosRobotic RP safe and feasible
Good oncologic/functional outcomes
g
Good oncologic/functional outcomesChronological age not a contraindication
SEER (2001-2005)17 638pts >66yrs stage I-II NSCLC 17,638pts >66yrs stage I-II NSCLC
to compare areas of high vs low rates of curative surgerycurative surgery
High rates Low rates
resection rates 79% 63%
1 yr mortality 18% 23%1-yr mortality 18% 23%
1-yr cancer 12% 17%
Higher rates of surgery associate to improved i l
mortality
survivalNeed to identify and reduce barriers to surgery
Tailored TreatmentTailored Treatment
Neoadjuvant chemo-RT offers an excellent i d f t it t thi window of opportunity to this purpose
PRE-ABILITATION: correction of anemia, dehydration, malnourishment, depression…
Optimized patient’s conditions, as p p ,highlighted by frailty assessment tools, to
reduce complications, mortality & hospital p , y pstay
Surgery in the Elderly