As the age structure of our population is aging, the number of elderly patients is gradually increasing, so the treatment of elderly patients is becoming more and more important. With the growth of age, the function and structural state of various organs in the whole body are in progressive decline, gradually entering the compensated or decompensated state, the reserve capacity and immune function of the body are low, and the response to stressful situations such as disease, infection and trauma is slow, and there are many coexisting diseases, which often manifest themselves in the perioperative period as rapid progress of lesions, many postoperative complications, easy deterioration and high morbidity and mortality rate.
1.Clinical data
1.1 General data
Sixty-three cases of elderly colon and rectal cancer surgery patients aged 65 years or older with complete data were collected between 1997 and 2000. There were 29 male cases and 34 female cases. 30 cases were aged 65-69 years, 26 cases were aged 70-79 years, and 7 cases were aged 80 years or above. There were 40 cases of colon cancer and 23 cases of rectal cancer. 1 case of Dukes stage A0, 1 case of stage A1, 4 cases of stage A2, 22 cases of stage B, 13 cases of stage C1, 6 cases of stage C2, and 16 cases of stage D.
1.2 Coexisting diseases
Most of the elderly patients had other coexisting diseases. 39 cases (61.9%) had coexisting diseases in this group. See Table 1. There were 13 cases with 2 coexisting diseases and 10 cases with 3 or more coexisting diseases.
1.3 Treatment
All 63 cases in this group were treated with surgery. There were 14 cases of emergency surgery, 49 cases of elective surgery, 16 cases of intraoperative placement of portal vein or laparoscopic pump, 8 cases of combined organ resection, including 5 cases of partial hepatectomy, 1 case of cholecystectomy, 1 case of partial resection of the descending muscular layer of duodenum, and 1 case of partial vagotomy.
1.4 Results
Thirty-six cases in this group had different degrees of postoperative complications, accounting for 55.6% of the total number of cases in the group. The complications were shown in Table 3. 4 cases died after surgery (within 1 month after surgery, including 2 cases of emergency surgery and 2 cases of elective surgery), with a mortality rate of 6.3%. One of them died of MSOF, one of them died of myocardial infarction, and two of them died of ARDS.
2. Discussion
Elderly patients with colon and rectal cancer have a variety of factors, such as slow response of the body, light spontaneous symptoms, atypical symptoms, and often obscure signs, which cause patients to be in advanced stages when they are seen, and most of them have developed to different degrees of intestinal obstruction, with 36 cases in this group and only 6 cases in Dukes A stage. The number and severity of coexisting diseases is another characteristic of this group of patients, which is as high as 61.9% in this group.
The most common diseases were mainly coronary heart disease, hypertension, chronic bronchitis, emphysema, pulmonary infection, hypoproteinemia, urinary tract diseases, and diabetes mellitus. Thus, the postoperative survival rate is not only related to the type and stage of the tumor, but also closely related to the choice of surgical approach and the effectiveness of the prevention and treatment of coexisting diseases in the perioperative period.
The choice of surgical treatment plan should be based on the patient’s condition, comprehensive estimation of the necessity and risk of surgery, solving the main conflicts, prolonging life and improving quality of life, shortening the operation time as much as possible, and using new technologies and materials such as anastomosis. At the same time, radical surgery must not be abandoned because of advanced age and coexisting diseases.
Perioperative management can make a considerable number of patients who cannot tolerate radical surgery tolerate radical surgery. As long as timely and reasonable prevention and treatment of coexisting diseases are carried out, the chance of radical surgery can be improved, and 65% (41 cases) of radical surgery were performed in this group. In order to improve the postoperative survival rate, the key lies in the treatment of coexisting diseases and postoperative complications during the perioperative period.
Cardiovascular disease is one of the most common coexisting diseases. For these patients, we should shorten the operation time as much as possible, reduce injury, avoid blood pressure fluctuation, and ensure myocardial oxygen and blood supply. Intraoperative and postoperative monitoring of ECG, blood pressure, blood oxygen, urine volume, central venous pressure, etc. should be closely monitored, and timely management should be made according to changes in the condition.
There were 14 patients with coexisting hypertensive disease in this group, including 5 cases of class I, 4 cases of class II and 5 cases of class III. All of them used antihypertensive drugs before surgery, generally to about 18.7/12kpa, and the antihypertensive drugs were used until the morning of surgery, especially for patients with grade I coexisting cardiovascular and cerebrovascular damage, diabetes mellitus, and grade II and III patients. Cases in which the preoperative blood pressure lowering does not reach the target should be treated according to the following principles.
(1) Postpone surgery for elective surgery with blood pressure >24/14.7kpa.
(2) After treatment in the ward, the expected level has been approached, but on the morning of the operation day to the operating room >24/14.7kpa, such as <26.7/14.7kpa without cerebral and cardiovascular symptoms, generally can be injected with a small amount of rapid-acting antihypertensive drugs, and wait for the blood pressure to fall to a level close to normal before starting surgery.
(3) Emergency surgery, blood pressure >24/14.7kpa If the risk to the patient from delayed surgery exceeds that of hypertension, surgery is performed under close monitoring, applying antihypertensive drugs to maintain blood pressure at about 18.7/12kpa, avoiding dramatic fluctuations in blood pressure, and continuing to monitor blood pressure with antihypertensive drugs after surgery. There was no case of cerebral infarction, cerebral hemorrhage or other serious postoperative complications in this group.
Patients with combined coronary artery disease are highly susceptible to acute myocardial infarction, severe arrhythmias and heart failure during the perioperative period, and the operative mortality rate is significantly higher than that of general patients. Myocardial infarction usually occurs within 1 week after surgery, especially within 3 days after surgery, so the main points of postoperative treatment are to prevent the imbalance between myocardial oxygen supply and oxygen demand, to give sufficient oxygen, and to correct water-electrolyte disorders, especially hypokalemia.
One case in this group had symptoms of transient precordial discomfort and chest tightness half a month before surgery, ECG: ischemic ST-T changes, and myocardial infarction occurred one week after surgery, which led to death, and the lesson is profound. Since the symptoms of postoperative infarction are often not obvious, about 21%-37% are painless type, when unexplained hypotension, dyspnea, cyanosis, arrhythmia or signs of heart failure suddenly occur, all of them should be taken seriously, and ECG and myocardial enzyme spectrum and other examinations should be made immediately so as to make correct diagnosis and treatment in time.
Drugs for coronary artery disease, such as ß-blockers, calcium antagonists and nitrates, should be used routinely until the morning of surgery to prevent imbalance of myocardial oxygen supply and consumption due to sudden discontinuation of the drugs. Aspirin and disulfiram should be discontinued 7-10 days before surgery to prevent increased postoperative bleeding [2]. Patients with heart failure should, in principle, be operated only after 3-4 weeks of heart failure control, but in patients with acute intestinal obstruction, the degree of heart failure should be weighed against the urgency of surgery, and surgery should be performed after active control of heart failure if the condition permits.
In patients without intestinal obstruction, heart failure should be controlled first. Angiotensin-converting enzyme inhibitors (ACEI), diuretics, digitalis, etc. should be stopped 12 hours before surgery, and intravenous administration of drugs such as cetiran, dobutamine, dobutamine, etc. should be used. In this group, there were two cases of preoperative coexisting heart failure, one of which was sigmoid colon cancer causing cecum perforation and total peritonitis, which was treated briefly and operated urgently, and died of MSOF after surgery. the other case was treated preoperatively for nearly 3 weeks, and interventional chemotherapy was administered once, and no serious complications occurred after surgery.
The postoperative pulmonary complications such as pulmonary atelectasis, pulmonary infection, asthma, etc. are significantly increased and ARDS can occur in severe cases due to poor thoracic elasticity, weak respiratory muscle contraction, thinning of alveolar wall and reduced lung capacity and lung volume in elderly patients. Oxygen supply, use antibiotics and hormones, and use ventilator mechanical ventilation as soon as respiratory failure occurs. There were as many as 15 cases of postoperative pulmonary complications in this group, and 2 of them died of ARDS.
Diabetes mellitus is a common coexisting disease in elderly patients, and there were 7 cases in this group, including 5 cases of type I diabetes mellitus and 2 cases of type II diabetes mellitus. It is especially easy to miss the diagnosis of occult diabetes, and one patient in this group had severe hyperglycemia after surgery, although fasting blood sugar was normal before surgery. Thus, where
(1) with symptoms of diabetes mellitus, fasting blood glucose ≥ 7.84 mmol/L or random blood glucose ≥ 11.2 mmol/L
(2) With or without symptoms of diabetes mellitus, repeated fasting blood glucose ≥7.84mmol/L
(3) With or without symptoms of diabetes mellitus, 1-hour and 2-hour blood glucose ≥ 11.2 mmol/L after oral administration of 75 grams of glucose should be considered as diabetes mellitus.
For type II diabetes mellitus, oral hypoglycemic drugs should be stopped 2~3 days before surgery and replaced by insulin therapy, and for type I diabetes mellitus, the dosage and route of insulin should also be adjusted according to the needs of the disease before surgery to control blood glucose and urine sugar to the ideal level: blood glucose around 7.2~8.9mmol/L and urine sugar +~-. And the blood glucose is constantly monitored during and after the operation, insulin is continued, and the ratio of glucose to insulin is constantly adjusted so that the blood glucose level is controlled to about 6.7~11.2mmol/L and urine sugar (+).
For emergency surgery, there should be several hours of preparation, first enter isotonic saline, and adjust the insulin dosage according to the measured blood glucose results. At the same time, in order to prevent ketoacidosis, potassium, phosphorus and acidosis should be corrected in a timely manner. There was no case of ketoacidosis in this group.
For patients with hypoproteinemia, exogenous human albumin should be supplemented in a timely manner after surgery to prevent the occurrence of anastomotic fistula. One patient in this group had a preoperative liver function Child grade C, which was not supplemented in time after surgery due to financial reasons, resulting in the occurrence of anastomotic fistula.
The use of perioperative antibiotics should follow the principles of broad-spectrum, high-efficiency, and short-term. For elective surgery, they should be started 30 minutes before surgery and generally used for 3 to 5 days after surgery to avoid long-term abuse. Sedman et al. concluded that the rate of perioperative infections in general surgery patients is about 10%, but in our group, it was as high as 38%, with 24 cases, and the sites of infection included respiratory system, urinary system, abdominal cavity, incision, etc. Considering that our group was contaminated surgery and related to the weak immune function of the elderly and the combination of diabetes mellitus, etc. This group was considered to be contaminated surgery and related to the weak immune function of the elderly and the combination of diabetes.