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Outcomes After Rectal Cancer Surgery in Elderly Nursing Home Residents

Finlayson, Emily M.D., M.S.1,2; Zhao, Shoujun M.D., Ph.D.2; Varma, Madhulika G. M.D.2

doi: 10.1097/DCR.0b013e318267bfe3
Original Contribution: Colorectal/Anal Neoplasia

BACKGROUND: As the population ages, an increasing number of elderly persons will undergo surgery for rectal cancer. The use of sphincter-sparing surgery in frail older adults is controversial.

OBJECTIVE: The aim of this study was to examine mortality and bowel function after proctectomy in nursing home residents.

DESIGN: This is a retrospective cohort study.

SETTING: This investigation was conducted in nursing homes in the United States contracted with the Center for Medicare and Medicaid Services.

PATIENTS: Nursing home residents age 65 and older undergoing proctectomy for rectal cancer (2000–2005) were included.

MAIN OUTCOME MEASURES: The primary outcomes measured were fecal incontinence and the 1-year mortality rate.

RESULTS: Operative mortality was 18% after proctectomy with permanent colostomy and 13% after sphincter-sparing proctectomy (adjusted relative risk, 1.25 (95% CI 0.90–1.73), p = 0.188). One-year mortality was high: 40% after sphincter-sparing proctectomy and 51% after proctectomy with permanent colostomy (adjusted hazard ratio 1.32 (95% CI 1.09–1.60), p = 0.004). After sphincter-sparing proctectomy, 37% of residents were incontinent of feces. Residents with the poorest functional status (Minimum Data Set-Activities of Daily Living quartile 4) were significantly more likely to be incontinent of feces than residents with the best functional status (Minimum Data Set-Activities of Daily Living quartile 1) (76% vs 13%, adjusted relative risk 3.28 (95% CI 1.74– 6.18), p= 0.0002). Fecal incontinence was also associated with dementia (adjusted relative risk 1.55 (95% CI 1.15–2.09), p = 0.004) and renal failure (adjusted relative risk 1.93 (95% CI 1.10–3.38), p = 0.022).

LIMITATIONS: Measures of fecal incontinence in nursing home registries are not as well studied as those commonly used in clinical practice.

CONCLUSIONS: Sphincter-sparing proctectomy in nursing home residents is frequently associated with postoperative fecal incontinence and should be considered only for continent patients with good functional status.

1 Phillip R. Lee Institute of Health Policy Studies, University of California, San Francisco, California

2 Department of Surgery, University of California, San Francisco, California

Funding/Support: Work on this study was funded in part by a National Institute on Aging/Paul B. Beeson Clinical Scientist Development Award in Aging (5K08AG028965).

Financial Disclosures: None reported.

The views expressed in this article are those of the authors and do not necessarily represent those of the National Institute on Aging and American Federation for Aging.

Correspondence: Emily Finlayson, M.D., M.S., Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, 3333 California St, Suite 265, San Francisco, CA 94118. E-mail:

© The ASCRS 2012