t ud sils urgical updatest ud sils urgical updates riccardo a audisio, md, frcs university of...
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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
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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
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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
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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
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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”
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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)
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% patient’s preference to physician’s f f i d ith preference for surgery increased with age
(29% vs 50%)
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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
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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)
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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
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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…
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quick screening tools in clinical practice
slow gait speed confers 2-3 fold increase mortality or major morbidityincrease mortality or major morbidity
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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
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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
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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
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Surgery in the Elderly