t ud sils urgical updatest ud sils urgical updates riccardo a audisio, md, frcs university of...

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