高龄结直肠癌肝转移Ⅰ期手术切除患者的围手术期处理

给老年肠癌的围手术期一个科学的护理围手术期是围绕手术的一个全过程，从病人决定接受手术治疗开始，到手术治疗直至基本康复，包含手术前、手术中及手术后的一段时间，具体是指从确定手术治疗时起，直到与这次手术有关的治疗基本结束为止，时间约在术前5－7天至术后7－12天。

老年人大肠癌的围手术期处理我国大肠癌发病率居肿瘤的第三位。

随着年龄的增高，人各系统功能在不断下降，同时多伴有心、肺、肾、肝等重要脏器疾病，再加之麻醉、手术耐受性差，增加了手术治疗及术后管理难度及危险性。

因此，重视老年人大肠癌围手术期的处理，是降低术后并发症率和死亡率的关键。

在手术之前应该做好术前准备及对病情和心、肺、肾等重要脏器功能的评估。

如果病人有一些顽固性的疾病，建议在术前先服用人参皂苷Rh2等保健类的中药，帮助患者巩固元气，平安度过手术。

应对患者作恰当细致的思想工作，消除其恐惧、烦躁或消沉情绪，使其配合治疗，树立战胜疾病的信心。

老年肠癌患者术后清醒之后应该注意以下几点：1、呼吸、循环系统监测与处理：( 1)持续心电监测: 老年人术后常出现房颤、早搏和心动过速，经给氧、止痛后多能自行恢复。

若无效或出现其他心律紊乱时，应请心内科医师会诊处理。

( 2)如脉率120次/m in，能除外由高热、脱水、缺氧及感染引起者属心功能不全，可酌情使用洋地黄制剂。

( 3) 间断低流量湿化吸氧，氧气流量以4 ~ 6L /m in为佳，若经鼻给氧不能纠正低氧血症时，可用呼吸机输氧。

病情严重或有呼吸窘迫综合征者，宜用呼吸机纠正低氧血症。

( 4 )持续监测CVP和尿量，避免发生血容量不足、过量及心功能不全。

2、防止并发症：术后协助老年人尽早活动，以减少尿潴留及下肢静脉栓塞等并发症。

鼓励和帮助病人主动咳嗽、咳痰、翻身，经常叩背，必要时给予雾化吸入，以防肺部并发症。

如痰多、咳痰无力时，可导管吸痰，必要时行气管切开，预防窒息、肺部感染及肺不张。

应避免过量输液，以防肺水肿及诱发心力衰竭。

高龄结、直肠癌病人并存病的围手术期护理摘要】总结60例高龄结、直肠癌病人并存病的围术期护理体会。

针对高龄结、直肠癌病人并存疾病术前、术中、术后实施相应的护理措施，有效地预防和减少了手术并发症和死亡率的发生，提高了手术成功率和治愈率。

【关键词】高龄结、直肠癌围手术期护理结肠癌和直肠癌简称为结、直肠癌或大肠癌，在我国结、直肠癌是前五位常见的恶性肿癌之一，发病年龄多在中年以上。

目前高龄结、直肠癌病人日趋增多，且大多数存在并存病。

我科从2003年1月至2007年6月共收治70岁以上有并存病的结、直肠癌病人60例，我们对60例患者采取了针对性的围手术期护理措施，取得了满意的临床效果，现介绍如下：1 临床资料1.1一般资料本组60例，男34例，女26例，年龄70～88岁，平均73.8岁。

均行手术治疗，Hartmann手术6例，Miles术9例，Dixon术9例，左半结肠切除12例，右半结肠切除13例，横结肠切除3例，姑息性手术8例。

1.2并存病本组60例均有并存病的存在，其中合并1种并存后的9例(15％)2种的37例(62％)3种以上的14例(23％)，包括心脏病34例，高血压病21例，糖尿病15例，呼级系统疾病13例，肾功能异常3例，低蛋白血症38例，贫血24例。

1.3术后并发症与转归术后出现并发症17例，其中心功能不全2例，肺部感染4例，切口感染9例，切口裂开1例，肠瘘1例，痊愈59例，死亡1例。

2 讨论高龄结、直肠癌病人各组织器官功能减退，并存疾病给手术增加了一定的风险，因此，如何做好围手术期护理至关重要。

2.1并存心血管疾病的围手术期护理心血管疾病是最常见的并存病，主要有高血压、冠心病、心律失常等，故高龄病人围手术期应做好如下护理。

2.1.1术前①做心电图，24小时动态心电图，超声心电图，胸部x线摄片，了解心脏的病变和功能状态，心功能不全者积极内科治疗。

②详细询问病史，心肌梗死发作1～2个月内不宜手术，至少稳定6个月后才能手术，但癌症病人应限制手术。

Chemotherapy delivery for resected colorectal cancer liver metastases:Management and outcomes in routine clinicalpracticeA.Krishnamurthy a ,J.Kankesan b ,X.Wei a ,S.Nanji b ,c ,J.J.Biagi b ,C.M.Booth a ,b ,d ,*aDivision of Cancer Care and Epidemiology,Queen’s University Cancer Research Institute,Queen’s University,Kingston,CanadabDepartment of Oncology,Queen’s University,Kingston,Canada cDepartment of Surgery,Queen’s University,Kingston,CanadadDepartment of Public Health Sciences,Queen’s University,Kingston,CanadaAccepted 25August 2016Available online 17September 2016AbstractBackground :International guidelines recommend peri-operative chemotherapy for patients with resectable colorectal cancer liver metasta-ses (CRCLM).Chemotherapy delivery in routine practice is not well described.Methods :All cases of CRC who underwent resection of LM in 2002e 2009were identified using the population-based Ontario Cancer Reg-istry.Electronic treatment records identified chemotherapy delivered within 16weeks before or after hepatectomy.All pathology reports were reviewed to describe extent of LM.Modified Poisson regression was used to evaluate factors associated with chemotherapy delivery.Cox proportional hazards model and propensity score analysis were used to explore the association between post-operative chemotherapy and cancer-specific (CSS)and overall (OS)survival.Results :We identified 1310patients.Sixty-two percent of cases (815/1310)received peri-operative chemotherapy;25%(200/815)pre-operative,45%(366/815)post-operative,and 31%(249/815)pre-and post-operative.Utilization of chemotherapy increased over time from 51%in 2002(57/112)to 73%in 2009(157/216,p <0.001).Fifty-four percent of patients received FOLFOX,41%FOLFIRI,and 10%5-FU monotherapy.Factors that were independently associated with greater utilization of post-operative chemotherapy included younger age (p <0.001),female sex (p ¼0.050),shorter disease-free interval (p ¼0.006),and no prior adjuvant chemotherapy (p <0.001).Utilization of chemotherapy varied substantially across geographic regions (from 24%to 71%,p ¼0.001).Post-operative chemotherapy was associated with improved CSS (HR 0.58,95%CI 0.44e 0.76)and OS (HR 0.49,95%CI 0.38e 0.61);results were consistent in propen-sity score analysis.Conclusion :Utilization of chemotherapy for resected CRCLM in routine practice has evolved with emerging evidence.Post-operative chemotherapy is associated with improved survival in the general population.Ó2016Elsevier Ltd,BASO ~The Association for Cancer Surgery,and the European Society of Surgical Oncology.All rights reserved.Keywords:Colon cancer;Chemotherapy;Surgery;Liver metastases;Quality of care;Outcomes research;Knowledge translationIntroductionSurgical resection of colorectal cancer liver metastases (CRCLM)has become standard practice and is associatedwith long-term survival in w 30e 50%of patients.1e 3Chemotherapy for CRCLM can be given in three different settings:1)downstaging chemotherapy to convert unresect-able disease;2)post-operative “pseudoadjuvant”chemo-therapy;and 3)peri-operative chemotherapy given to patients with resectable disease before and after surgery.The evidence in support of chemotherapy comes from clin-ical trials that have shown improved progression-free*Corresponding author.Division of Cancer Care and Epidemiology,Queen’s University Cancer Research Institute,10Stuart Street,Kingston,ON,K7L 3N6,Canada.Fax:þ1(613)5336794.E-mail address:boothc@ (C.M.Booth)./10.1016/j.ejso.2016.08.0220748-7983/Ó2016Elsevier Ltd,BASO ~The Association for Cancer Surgery,and the European Society of Surgical Oncology.All rightsreserved.Available online at ScienceDirectEJSO 43(2017)364e 371survival.4e6No Level I evidence has compared a peri-operative approach(i.e.before and after surgery)to a post-operative“pseudoadjuvant”approach.While guidelines universally recommend chemotherapy for patients with resectable CRCLM2,7e9this is based on evidence from clinical trials that enrolled patients from high volume institutions.Chemotherapy delivery and effec-tiveness has not been described in routine practice.This is important as it known that results from clinical trials and high volume centres may not apply to the general popula-tion.10,11To address these gaps in knowledge we undertook a population-based study of patients with resected CRCLM to describe chemotherapy delivery and outcomes in routine practice.MethodsStudy design and populationThis is a population-based,retrospective cohort study to describe utilization of chemotherapy and outcome of re-sected CRCLM in the Canadian province of Ontario.On-tario has a population of approximately13.5million people and a single-payer universal health insurance pro-gram.The study population included all patients with CRC who underwent liver resection during2002e2009. To identify the study cohort we used the Ontario Cancer Registry to identify all incident cases of colorectal adeno-carcinoma with liver resection during2002e2009.Extent of liver metastases was not available in the existing data sources;for this reason we obtained surgical pathology re-ports for all cases.The study was approved by the Research Ethics Board of Queen’s University.Data sources and linkageThe Ontario Cancer Registry(OCR)is a passive, population-based cancer registry that captures diagnostic and demographic information on at least98%of all inci-dent cases of cancer in the province of Ontario.12The OCR also provides information about vital status and cause of death.Records of hospitalization from the Canadian Institute for Health Information(CIHI)provided informa-tion about surgical interventions;these records are known to be complete.13Provincial physician billing records from the Ontario Health Insurance Plan(OHIP),treatment records[Activity Level Reporting(ALR)]from regional cancer centres,and provincial records of chemotherapy de-livery[New Drug Funding Program(NDFP)and Ontario Drug Benefits(ODB)]were used to identify chemotherapy utilization.These datasets were linked using unique en-coded identifiers and analysed at the Institute of Clinical and Evaluative Sciences(ICES).Surgical pathology reports were obtained from the OCR.A team of trained data ab-stractors reviewed the pathology reports and entered information about extent of disease and surgical procedure into an electronic database.Measures and outcomesIndicators of the socioeconomic status(SES)of the com-munity in which patients resided at diagnosis were linked as described previously.14Quintiles(Q)of the median household income were based on the household income dis-tribution for the full province of Ontario.Q1represents the communities where the poorest20%of the Ontario popula-tion resided.Geographic regions reflect the catchment areas for Ontario’s regional cancer centres.14Co-morbidity was classified using the Charlson Index modified for administra-tive data.15Pre-operative chemotherapy was defined as chemotherapy given within16weeks before resection of CRCLM;post-operative chemotherapy was defined as treatment initiated within16weeks after surgery for CRCLM.Cancer-specific(CSS)and overall survival(OS) were measured from resection of CRCLM.To account for possible cause of death miscoding,CSS included death from any plete information about vital status in the OCR was available up to December31,2012;cause of death was available up to December31,2010.Analyses of factors associated with treatment and chemotherapy comparative effectiveness were restricted to patients who did not receive pre-operative chemotherapy. This was done for two reasons.First,administrative data sources do not distinguish between downstaging chemo-therapy for unresectable disease and peri-operative chemo-therapy delivered to patients with resectable disease. Second,the extent of liver metastases(i.e.size and number of lesions)would not be reliably known from surgical pa-thology reports.Because these factors are known to be strongly associated with both chemotherapy utilization and outcome,subsequent analyses would be substantially limited by unmeasured confounding.Because the survival measure began before the chemo-therapy exposure window ended(i.e.at16weeks)our re-sults were vulnerable to immortal person-time bias whereby patients dying during the exposure window have a lower chance of receiving treatment;this would artifi-cially worsen survival of the no chemotherapy group.16 We therefore excluded patients dying within16weeks of surgery from survival analyses.Statistical analysisComparisons of proportions between study groups were made using the chi-square test.CSS and OS were deter-mined using the Kaplan e Meier method.Factors associated with post-operative chemotherapy were evaluated using modified Poisson regression.Factors associated with CSS/ OS were evaluated using the Cox proportional hazards regression model.To control for confounding variables when exploring the association between ACT and survival,365A.Krishnamurthy et al./EJSO43(2017)364e371we also employed the propensity score technique in the Cox proportional hazards model.The propensity scores al-lowed us to create five propensity strata.Survival of pa-tients treated with ACT was compared to those without ACT within each stratum using a Cox proportional hazards model;a summary HR combining the results across quin-tiles was calculated.17Results were considered statistically significant at p-value <0.05.All analyses were performed using SAS version 9.3(SAS Institute,Cary,NC).Results Study populationAs shown in Fig.1,linked administrative datasets iden-tified 1711potentially eligible patients who underwentsurgical resection of CRCLM during 2002e 2009;after applying study eligibility criteria the study population included 1310patients.Table 1describes the cohort characteristics.Chemotherapy practice patternsSixty-two percent of cases (815/1310)received peri-operative chemotherapy.Among these cases,25%(200/815)received pre-operative chemotherapy,45%(366/815)received post-operative chemotherapy,31%(249/815)received both.Utilization of peri-operative chemotherapy increased over the study period from 51%(57/112)in 2002to 73%(157/216)in 2009(p <0.001).This overall increase was driven primarily by increase in utilization of pre-operative treatment (from 7%to 16%,p <0.001)andAll CRC diagnosed 1996-2009N= 87179CRC cases with Liver Resection2002-2009 N= 1829Excluded cases N=99 Histology N=35Time from Dx to Surgery N=64CRC cases with Liver Resection and no HPB Primary CancerN= 1810Potential resected CRCLM CasesN=1711Excluded cases with another HPB primary cancer N=19 Liver cancer N=17 Biliary Cancer N=0 Pancreas Cancer N=2No Liver Resection N=85350Pathology report not identified N=268Potential CasesN=1443Pathology report not consistent with resected CRCLM N=133Study PopulationN=1310Figure 1.Identification of patients with colorectal cancer who underwent resection of liver metastases in Ontario 2002e 2009.366 A.Krishnamurthy et al./EJSO 43(2017)364e 371combined pre-/post-operative chemotherapy(from7%to 23%,p<0.001).Over time there was a small decrease in utilization of post-operative chemotherapy alone(from 37%to34%,p¼0.160).Chemotherapy regimens were identified for67%(548/ 815)of cases(Supplemental eTable1).Overall,54% (294/548)of patients received FOLFOX,41%(225/548) received FOLFIRI,and10%(57/548)received5-FU mono-therapy.Other regimens were used in2%(13/548)of cases. Overall,11%(63/548)of patients received bevacizumab. From2002to2009there was an increase in utilization of FOLFOX[from0%(0/27)to64%(66/103),p<0.001)], a decrease in5-FU monotherapy[from52%(14/27)to 6%(6/103),p<0.001],and a decrease in use of FOLFIRI [from48%(13/27)to35%(36/103),p<0.001].The me-dian number of cycles delivered was6in the pre-operative setting and7in the post-operative setting.Factors associated with chemotherapy utilizationFactors associated with utilization of post-operative chemotherapy utilization are summarized in Table2.Pa-tients who received any chemotherapy within16weeks before liver resection(n¼449)were excluded from this analysis.Factors that were independently associated with greater utilization of post-operative chemotherapy included younger age(p<0.001),female sex(p¼0.050),shorter disease-free interval(p¼0.006),and no prior adjuvant chemotherapy(p<0.001).Utilization of chemotherapy varied substantially across geographic regions(from24% to71%,p¼0.001).OutcomesAmong all cases post-operative mortality at30days and 90days was2%and3%respectively.Five year CSS and OS of all cases was46%and44%respectively.Among pa-tients treated with peri-operative FOLFOX5year CSS and OS was53%and50%respectively;30and90day mortal-ity was4%and5%.Factors associated with long-term survival among those patients who did not receive pre-operative chemotherapy are shown in Table3.CSS and OS were associated with age,co-morbidity,disease-free interval,and extent of liver metastases.Post-operative chemotherapy was associated with improved CSS(HR0.58,95%CI0.44e0.76)and OS (HR0.49,95%CI0.38e0.61).This result was consistent in propensity score analysis[CSS HR0.61(95%CI 0.46e0.82);OS HR0.51,(95%CI0.40e0.65)] (Supplemental eTable2).DiscussionIn this study we report utilization of chemotherapy and outcomes among patients with resected CRCLM in routine clinical practice.Several importantfindings have emerged. First,practice has evolved with emerging evidence with a temporal increase in chemotherapy utilization and a shift towards FOLFOX as the preferred regimen.Second, chemotherapy delivery varies widely by geographic region. Third,long-term survival of patients treated with peri-operative chemotherapy in routine practice is comparable to outcomes achieved in clinical trials and from high vol-ume centres.Finally,our results suggest that among those patients who do not receive pre-operative therapy,chemo-therapy after liver resection is associated with improved survival.Temporal trends in chemotherapy utilization and regi-mens used among patients with resected CRCLM in routineTable1Characteristics of patients treated with surgical resection of colorectal can-cer liver metastases in Ontario2002e2009(n¼1310).Patient-relatedAge(years)Median age63<65710(54%) 65e74414(32%) 75þ186(14%) SexMale810(62%) Female500(38%) SES by quintile b1221(17%) 2293(22%) 3270(21%) 4258(20%) 5262(20%) Charlson co-morbidity score01020(78%) 1194(15%) 2þ96(7%) Disease-relatedTiming of hepatic resection a0e6mos456(37%) 7e12mos243(20%) 13e24mos313(25%) 24þmos219(18%) Extent of diseaseMean number lesions c 2.1Mean size largest lesion d 4.2 Involved surgical margin e108(8%) Treatment-relatedExtent of surgical resection fMinor(<3segments)444(34%) Major( 3segments)838(64%) Peri-operative chemotherapyPre-op200(15%) Post-op366(28%) Both249(19%) None495(38%) a Only reported for the n¼1231cases with an identified date of primary CRC resection.b SES data not available for6cases,Quintile1¼poorest communities.c Number lesions not stated for51cases.d Lesion size not stated for52cases.e Margin status not stated for41cases.f Extent of surgical resection not stated for28cases.367A.Krishnamurthy et al./EJSO43(2017)364e371practice are not well described.To our knowledge,Mayo et al.have reported the only other population-based study.18 Using linked data from Medicare and the Surveillance, Epidemiology,and End Results(SEER)registry program in the US,chemotherapy utilization rates during 2003e2006were16%before surgery,47%after surgery, and10%before and after surgery;chemotherapy regimens were not described.In our previous report of temporal trends in surgery for CRCLM in1994e2008we found that chemotherapy utilization increased substantially from 44%(1994e1999),to52%(2000e2004),to65% (2005e2009,p<0.001).3This earlier report was limited by the lack of information pertaining to chemotherapy regimen;nor did we have details regarding extent of liver metastases.Accordingly,we were unable to describe fac-tors associated with practice or outcome.Temporal trends in chemotherapy delivered are consis-tent with the evolution of evidence in this context.The ENG(n¼129)and FFCD(n¼173)clinical trials were both reported in2002and suggested a non-significant trend in favour of post-operative5-FU monotherapy.19,20In2007, Nordlinger presented the results of the EORTC trial that randomized364patients with resectable CRCLM to FOL-FOX before and after surgery versus surgery alone5; chemotherapy was associated with improved PFS.In 2005two pivotal RCTs from Europe showed that FOLFIRI did not improve outcomes in the adjuvant setting for stage III colon cancer compared to5-FU monotherapy.21,22The lack of added benefit to FOLFIRI in the setting of resected CRCLM was subsequently confirmed in a RCT reported by Ychou et al.,in2009.23Accordingly,as evidence evolved clinicians moved from5-FU and FOLFIRI towards FOL-FOX and a combined pre-/post-operative approach.Short-term post-operative mortality in routine practice is higher than reported in clinical trials.Post-operative mor-tality in the pivotal EORTC trial of peri-operative FOLFOX was<1%versus4%in our cohort.5However,five year OS in the EORTC study was remarkably similar to our cohort at51%and50%respectively.24Our study provides insight into the effectiveness of post-operative chemotherapy for patients with resected CRCLM. Weiser and colleagues published a meta-analysis in2010(8 trials,n¼1174)that evaluated the efficacy of chemo-therapy in patients with resected CRCLM.Systemic chemotherapy was associated with improved relapse-free survival(HR0.77,95%CI0.67e0.88)and a trend towards improved OS(HR0.74,95%CI0.53e1.04).In Mitry’s combined analysis of the ENG and FFCD trials there wasa trend towards improved progression-free survival(HR0.76,95%CI0.57e1.00)and OS(HR0.76,95%CI 0.55e1.05).4The most recent results from Nordlinger’s EORTC trial show a trend towards improved PFS(HR 0.81,95%CI0.64e1.02)among all patients and a signifi-cant improvement in PFS among eligible patients(HR 0.78,95%CI0.61e0.99).There was no improvement in OS(HR0.88,95%CI0.68e1.14);although the trial was not powered for this analysis.24The biologic rationale for peri-operative chemotherapy in resectable CRCLM is to eradicate occult micrometasta-ses;this concept is analogous to stage III colon cancerTable2Factors associated with post-operative chemotherapy among patientstreated with surgical resection of colorectal cancer liver metastases in On-tario2002e2009who did not receive pre-operative chemotherapy(n¼861).Co-variate%Any chemo Multivariate analysisRR(95%CI)pPatient-relatedAge,years<0.001<65years(n¼435)52%Ref65e74years(n¼279)37%0.70(0.58e0.84)75þyears(n¼147)26%0.46(0.34e0.64)Sex0.050Male(n¼533)40%RefFemale(n¼328)46% 1.17(1.00e1.37)SES by quintile b0.3391(n¼164)41% 1.12(0.86e1.47)2(n¼198)45% 1.22(0.94e1.57)3(n¼167)45% 1.16(0.90e1.50)4(n¼169)41%0.96(0.74e1.26)5(n¼159)39%RefCharlson score0.1200(n¼651)45%Ref1þ(n¼210)34%0.84(0.66e1.06)Disease-relatedTiming of hepatic resection a0.0060e6mos(n¼290)61%0.95(0.74e1.22)7e12mos(n¼99)27%0.60(0.42e0.86)13e24mos(n¼244)32%0.80(0.61e1.05)24þmos(n¼177)38%RefMean number lesions c0.8051(n¼483)42%Ref>1(n¼349)43% 1.02(0.87e1.20)Mean size largest lesion d0.176<5cm(n¼562)45%Ref5þcm(n¼269)39%0.88(0.72e1.06)Treatment-relatedPrevious chemotherapy f<0.001Yes(n¼446)30%0.54(0.43e0.66)No(n¼415)56%RefSystem-relatedRegion e0.001A(n¼412)40%RefB(n¼98)34%0.81(0.60e1.10)C(n¼57)54% 1.43(1.11e1.84)D(n¼54)24%0.55(0.31e0.97)E(n¼14)71% 1.65(1.17e2.32)F(n¼10)40%0.85(0.31e2.34)G(n¼55)36%0.95(0.67e1.34)H(n¼129)50% 1.27(1.02e1.59)a Date of primary resection not available for51cases.b SES data not available for<6cases.c Lesion number not stated for29cases.d Lesion size not stated for30cases.e Region data not available for32cases.f Previous chemotherapy is defined as any chemotherapy within72months before liver resection but not within16weeks before liverresection.368 A.Krishnamurthy et al./EJSO43(2017)364e371for which efficacy of adjuvant chemotherapy is well estab-lished.Meta-analyses in stage III colon cancer have re-ported a 30%relative reduction in the risk of death with adjuvant chemotherapy.25,26The evidence in support of chemotherapy for CRCLM is substantially weaker.The re-sults of our study suggest that post-operative chemotherapy is associated with a meaningful improvement in survival.These results are consistent with other non-randomized data reported by high volume centres 27e 29where HRs for OS associated with chemotherapy range from 0.42to 0.75.Our study has several methodologic limitations that war-rant comment.The study population was identified using linked administrative health databases.While the Ontario Cancer Registry and the Canadian Institute for Health In-formation datasets are known to be consistent and com-plete,12,13it is possible that our results may be biased by mis-classification.While the study data describe general as-pects of treatment and outcome for all patients,detailed in-formation related to stage of primary cancer,carcinoembryonic antigen level,chemotherapy dose/cycles,Table 3Factors associated with cancer-specific and overall survival among patients treated with surgical resection of colorectal cancer liver metastases in Ontario 2002e 2009who did not receive pre-operative chemotherapy (N ¼829).a Co-variateCancer-specific survival Overall survival 5year CSSMultivariate analysis 5year OSMultivariate analysis HR (95%CI)p HR (95%CI)p Patient-related Age,years0.0180.005<65years (n ¼428)56%Ref55%Ref65e 74years (n ¼267)50% 1.23(0.92e 1.63)48% 1.14(0.90e 1.45)75þyears (n ¼134)37% 1.62(1.16e 2.27)31%1.61(1.21e2.14)Sex0.9640.579Male (n ¼512)51%Ref49%RefFemale (n ¼317)51% 1.01(0.77e 1.31)49%1.06(0.85e 1.33)SES by quintile c0.4910.5721(n ¼157)46% 1.18(0.78e 1.77)48% 1.23(0.87e 1.74)2(n ¼191)49% 1.16(0.79e 1.72)46% 1.27(0.91e 1.76)3(n ¼161)49% 1.41(0.95e 2.08)48% 1.30(0.93e 1.82)4(n ¼162)54% 1.08(0.71e 1.63)51% 1.15(0.81e 1.62)5(n ¼154)55%Ref53%RefCharlson co-morbidity score <0.001<0.0010(n ¼629)55%Ref53%Ref1(n ¼200)36%1.68(1.27e2.23)35%1.52(1.20e 1.94)Disease-relatedTiming of hepatic resection b 0.0210.1000e 6mos (n ¼281)48% 1.64(1.14e 2.36)49% 1.44(1.07e 1.94)7e 12mos (n ¼94)52% 1.89(1.20e 2.95)49% 1.38(0.94e 2.02)13e 24mos (n ¼235)49% 1.54(1.07e 2.22)46% 1.35(1.00e 1.82)24þmos (n ¼170)56%Ref53%RefMean number lesions d0.0060.0031(n ¼471)56%Ref53%Ref>1(n ¼333)46% 1.43(1.11e 1.86)45%1.40(1.13e 1.75)Mean size largest lesion e0.0110.001<5cm (n ¼546)55%Ref54%Ref5þcm (n ¼254)40% 1.43(1.09e 1.89)37%1.47(1.16e 1.85)Surgical margin f0.5090.205Margin Positive (n ¼63)38% 1.17(0.73e 1.87)38% 1.28(0.87e 1.88)Margin Negative (n ¼730)53%Ref51%RefTreatment-relatedExtent of surgical resection g0.1080.090Minor (n ¼279)47%Ref47%RefMajor (n ¼531)53%0.79(0.60e 1.05)50%0.82(0.65e 1.03)Post-op chemotherapy <0.001<0.001Yes (n ¼365)59%0.58(0.44e 0.76)60%0.49(0.38e 0.61)No (n ¼464)45%Ref40%Refa Cases that died within 16weeks of surgery are excluded to account for immortal time bias.b Date of primary resection not available for 49cases.c SES not available for <6cases.d Number lesions not stated for 25cases.e Lesion size not stated for 29cases.f Margin status not stated for 36cases.gExtent of surgical resection not stated for 19cases.Minor resection is defined as <3segments;major resection is defined as 3segments.369A.Krishnamurthy et al./EJSO 43(2017)364e 371and performance status is not available.Our chemotherapy records may also be incomplete for patients younger than 65years who receive capecitabine via private insurance plans.It is possible that other unmeasured confounders may have contributed to the observed survival benefit with chemotherapy.The fact that the effect size observed in our study and other retrospective reports27e29is of larger magnitude than the relevant clinical trials suggests that at least some of the observed effect is due to confounding. However,even in the setting of persistent residual con-founding,the observed effect size is large enough that we believe these results support the effectiveness of chemo-therapy in routine practice.Our results are made more convincing based on the fact that we observe a large treat-ment effect for CSS which may be less prone to the effect of additional co-morbidity than OS.Moreover,ourfindings were consistent using propensity score methodology which may further reduce bias from unmeasured confounders.30 Because our analysis of effectiveness was limited to those patients who did not receive pre-operative chemotherapy, the results do not provide insight into the optimal timing chemotherapy delivery.Despite these limitations,in addition to the very large sample size,a major strength of the current study is the fact that by virtue of the Ontario Cancer Registry our study population includes all cases of resected CRCLM and is therefore unselected.By including the entire population it is possible to minimize referral and selection bias that af-fects institution-based observational studies.31The observed difference in chemotherapy delivery across regions,within a health program that provides single-payer universal health insurance,warrants mention. It is possible that this practice variation may have decreased after publication of the Cancer Care Ontario practice guide-line in2013.9If substantial regional variation persists, further work in knowledge translation would be required to understand barriers and enablers of optimal care.In summary,utilization of peri-operative chemotherapy for resected CRCLM has increased over time and practice has shifted in response to emerging evidence from clinical trials.Outcomes achieved in routine practice are compara-ble to results of RCTs.Our data support the use of post-operative chemotherapy among patients with resected CRCLM.FundingDr.Booth is supported as a Canada Research Chair in Population Cancer Care.This work was also supported by the Canada Foundation for Innovation and Queen’s Univer-sity Department of Surgery.DisclosureThe authors report no conflicts of interest.AcknowledgementsParts of this material are based on data and information provided by Cancer Care Ontario.However,the analysis, conclusions,opinions and statements expressed herein are those of the authors and not necessarily those of Cancer Care Ontario.This study was supported by the Institute for Clinical Evaluative Sciences(ICES),which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care(MOHLTC).The opinions,results and conclusions re-ported in this paper are those of the authors and are indepen-dent from the funding sources.No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred.Dr.Booth had full access to all the data in the study and takes responsibility for the integrity of the data and the ac-curacy of the data analysis.Appendix A.Supplementary dataSupplementary data related to this article can be found at /10.1016/j.ejso.2016.08.022. References1.Clancy TE,Meyerhardt JA.Perioperative chemotherapy for colorectalcancer liver metastases.Oncology(Williston Park)2013;27(11): 1088–90.2.Schmoll HJ,Van Cutsem E,Stein A,et al.ESMO Consensus Guide-lines for management of patients with colon and rectal cancer.A personalized approach to clinical decision making.Ann Oncol2012;23(10):2479–516.3.Booth CM,Nanji S,Wei X,Biagi JJ,Krzyzanowska MK,Mackillop WJ.Surgical resection and peri-operative chemotherapy for colorectal cancer liver metastases:a population-based study.Eur J Surg Oncol2016;42(2):281–7.4.Mitry E,Fields AL,Bleiberg H,et al.Adjuvant chemotherapy afterpotentially curative resection of metastases from colorectal cancer:a pooled analysis of two randomized trials.J Clin Oncol2008;26(30): 4906–11.5.Nordlinger B,Sorbye H,Glimelius B,et al.Perioperative chemo-therapy with FOLFOX4and surgery versus surgery alone for resect-able liver metastases from colorectal cancer(EORTC Intergroup trial40983):a randomised controlled ncet2008;371(9617): 1007–16.6.Wieser M,Sauerland S,Arnold D,Schmiegel W,Reinacher-Schick A.Peri-operative chemotherapy for the treatment of resectable liver me-tastases from colorectal cancer:a systematic review and meta-analysis of randomized trials.BMC Cancer2010;10:309.7.van de Velde CJ,Boelens PG,Borras JM,et al.EURECCA colorectal:multidisciplinary management:European consensus conference colon &rectum.Eur J Cancer2014;50(1):1.e1–1.e34.work,N.C.C.NCCN guidelines colon cancer2015.9.Gallinger S,Biagi JJ,Fletcher GG,Nhan C,Ruo L,McLeod RS.Liverresection for colorectal cancer metastases.Curr Oncol2013;20(3): e255–65.10.Booth CM,Tannock IF.Randomised controlled trials and population-based observational research:partners in the evolution of medical ev-idence.Br J Cancer2014;110(3):551–5.11.Meyer RM.Generalizing the results of cancer clinical trials.J ClinOncol2010;28(2):187–9.370 A.Krishnamurthy et al./EJSO43(2017)364e371。

浅析高龄结直肠癌患者围手术期并存病的处理【摘要】目的：浅析高龄结直肠癌患者围手术期并存病的处理体会。

方法：对我院5年间收治98例70岁以上结直肠癌手术患者的临床资料进行回顾性分析。

结果：98例患者中并存心肺疾病者59例，糖尿病者18例，贫血者34例，低蛋白血症者10例，肝肾功能异常者8例，腔隙性脑梗塞者6例。

术后并发症主要有肺内感染、心律失常、心肌梗塞、急性胃粘膜病变、切口感染、脑梗塞、下肢深静脉血栓形成、尿储留、肠梗阻、吻合口漏、肺栓塞等。

其中围手术期死亡2例。

结论：高龄结直肠癌患者围手术期积极、正确、严密、合理的处理对加强手术安全性，提高手术成功率，减少并发症发生率，降低死亡率，改善预后至关重要。

【关键词】结直肠癌；高龄；围手术期；并存病【中图分类号】r735.3 【文献标识码】a 【文章编号】1004-7484（2012）09-0456-02随着医疗条件的改善，生活水平的提高，世界人口老龄化的增多，我国人均寿命也日渐提高，高龄结直肠癌患者随之增多。

因此缜密正确的术前评估，合理有效的围手术期处理对减少术后并发症、改善预后具有重要的临床意义。

现将我院2006年10月～2011年10月间收治的98例70岁以上的高龄结直肠癌患者围手术期的临床资料进行回顾性分析。

1临床资料1.1一般资料：本组98例，其中男58例，女40例；年龄70—94岁，平均78，2岁。

并存病：高血压病18例，冠心病16例，心律失常9例。

慢性支气管炎肺气肿16例。

糖尿病18例，腔隙性脑梗塞6例，贫血34例，低蛋白血症10例，肝肾功能异常8例。

术后并发症：肺内感染20例，心肌梗塞6例，心律失常16例，肺栓塞2例，急性胃粘膜病变16例，脑梗塞4例，下肢深静脉血栓形成8例，切口感染12例，切口裂开3例，呼吸功能衰竭2例，尿储留6例，吻合口漏4例，肠梗阻5例。

其中围手术期死亡2例（心梗和肺栓塞各1例）。

肿瘤部位：直肠癌52例，结肠癌46例。