Outcomes after rectal cancer surgery in elderly nursing home residents.

Abstract

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. The aim of this study was to examine mortality and bowel function after proctectomy in nursing home residents. This is a retrospective cohort study. This investigation was conducted in nursing homes in the United States contracted with the Center for Medicare and Medicaid Services. Nursing home residents age 65 and older undergoing proctectomy for rectal cancer (2000-2005) were included. The primary outcomes measured were fecal incontinence and the 1-year mortality rate. 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). Measures of fecal incontinence in nursing home registries are not as well studied as those commonly used in clinical practice. 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.