Risk factors of preoperative complications after colorectal surgery in elderly and relationship between postoperative complications and long-term survival

Risk factors of preoperative complications after colorectal surgery in elderly and relationship between postoperative complications and long-term survival | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Risk factors of preoperative complications after colorectal surgery in elderly and relationship between postoperative complications and long-term survival Manabu Sato, Akihiro Kobayashi, Koichiro Kubo, Yoshihiro Morimoto, and 10 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6798855/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The potential risk factors of postoperative complications after colorectal surgeries in elderly and the impact of postoperative complications on long-term survival are in issue. This study aimed to identify the potential risk factors for postoperative complications and analyze the effect of postoperative complications on long-term survival. Methods A total of 258 patients of ≥ 80 years of age underwent surgery for colorectal cancer. We divided the patients into two groups: namely, a group without postoperative complications (Group A) and a group with postoperative complications (Group B). The independent risk factors of postoperative complications were evaluated in a multivariate analysis. We also compared the overall survival after CRC surgery between Group A and B. Furthermore, the survival was compared with respect to the number of potential risk factors estimated according to a multivariate analysis. Results The multivariate analysis revealed that POSSUM morbidity ≥ 60.6, and E-PASS SSS ≥ -0.09 were independent risk factors for postoperative complications. Survival curves showed that the survival rate of Group A was significantly lower than that of Group B. The survival analysis of differences in three groups showed a significant difference between them. Conclusion POSSUM morbidity and E-PASS SSS were investigated as potential risk factors for postoperative complications after CRC surgery in the elderly. The prognosis of patients with postoperative complications is worse than that of patients without complications. Preoperative management of the general condition and less-invasive surgery may therefore be important to avoid postoperative complications and achieve a long-term survival. Colorectal cancer postoperative complications elderly survival Figures Figure 1 Figure 2 Introduction Colorectal cancer (CRC) is the most common cancer, accounting for approximately 10% of all newly diagnosed cancers and cancer-related deaths worldwide( 1 , 2 ). Currently, the proportion of elderly patients has increased, and 60% of new CRC cases are diagnosed in patients older than 65 years of age( 1 , 3 – 5 ). The median age of CRC newly diagnosed CRC is 67 years, and the median age at death is 72 years( 1 ). Several studies have reported that the rate of CRC surgery in elderly patients is lower than that in younger patients, suggesting that surgery is associated with a high risk of postoperative complications and death in elderly patients( 6 ). Frailty, characterized by a reduction in physiologic reserves and susceptibility to adverse consequences after stress, is established as an independent syndrome due to aging and comorbidity related to postoperative outcomes( 7 ). Several reports have discussed the risk factors for postoperative complications of CRC surgery. These reports have shown that frailty, comorbidity, sarcopenia, and American Society of Anesthesiologists-Physical Status (ASA) are potential risk factors for postoperative complications ( 7 – 11 ). This suggests that a decline in the general condition of elderly patients may be related to postoperative complications. However, there are few comparative discussions on individual potential risk factors, so more useful predictors of postoperative complications after CRC surgery remain unclear. Elderly patients with CRC often have frailty or many comorbidities. However, the relationship between aging and long-term survival after CRC surgery remains unclear. Frailty and comorbidities in elderly patients with CRC may increase the risk of non-cancer death or obscure cancer signs, leading to a delayed diagnosis( 9 ). Meanwhile, It has also been reported that frailty in elderly patients with CRC does not affect the long-term outcomes( 7 ). Several reports have shown that complications after CRC surgery result in poor long-term outcomes( 12 , 13 ). However, the impact of postoperative complications on long-term survival after CRC surgery in the elderly is rare and measurable. The present study aimed to identify potential risk factors for postoperative complications after CRC surgery in the elderly and analyze the effect of postoperative complications on long-term survival. The relationship between the identified potential risk factors and long-term survival was also analyzed. Patients and methods A total of 258 patients of ≥ 80 years of age underwent surgery for colorectal cancer at Chiba-Nishi General Hospital between April 2016 and March 2023. All patients were diagnosed with colorectal adenocarcinoma based on a pathological examination. We constructed a database retrospectively from data collected during surgery for colorectal cancer in our hospital, including clinical characteristics, postoperative complications, and survival during the follow-up period. The background factors of surgery for colorectal cancer (sex, age, comorbidity, morbidity, and tumor staging) were obtained from our database. We assessed the severity of postoperative complications according to the Clavien-Dindo classification. In our study, the patients were divided into two groups those with Grade ≤ I postoperative complications were classified into Group A and those with Grade ≥ II postoperative complications were classified into Group B, and analyzed to identify risk factors for morbidity. A univariate analysis was performed to identify risk factors for postoperative complications. A multivariate analysis using factors extracted from the univariate analysis to identify independent risk factors for postoperative complications. We also compared the overall survival after CRC surgery between Group A and B. Furthermore, the survival was compared among three groups, including patients with no risk factor, those with one factor, and those with two factors. The following factors were included in the analysis to identify independent risk factors for postoperative morbidity: ASA, Eastern Cooperative Oncology Group Performance Status (ECOG-PS), Systemic Inflammatory Response Syndrome (SIRS), Physiological and Operative Severity Score for the Evaluation of Mortality and Morbidity (POSSUM; physiological score (PS), operative severity score (OS), morbidity) (Table 1)( 14 ), Estimation of Physiology Ability and Surgical Stress (E-PASS; PRS, SSS, and CRS)(Table 2)( 15 ), and tumor staging. The threshold values of continuous data were determined using receiver operating characteristic (ROC) curves. Fisher’s exact test was used to analyze categorical data. A logistic regression analysis was used for the multivariate analysis to identify independent postoperative risk factors. Overall survival was estimated using the Kaplan–Meier curve. The log-rank test was used to analyze survival. P values of < 0.05 were considered to indicate statistical significance. All statistical analyses were performed using R (ver. 3.5.2, The R Foundation for Statistical Computing). Results Short-term outcomes A total of 258 colorectal cancer patients of ≥ 80 years of age underwent surgery during the 6-year study period. The study included 137 males (53.1%) and 121 females (46.9%). A total of 227 patients (88.0%) had comorbidities, including hypertension, cardiovascular disease, diabetes mellitus, and neurogenic and mental disorders. The remaining 31 patients (12.0%) had no comorbidities (Table 3). A total of 132 patients (51.2%) had right-sided colon cancer and 126 patients (48.4%) had left-sided colorectal cancer. A total of 204 patients (93.1%) underwent radical resection, whereas the remaining 37 patients (14.3%) underwent resection and stoma construction. Sixteen patients (6.2%) underwent stoma construction alone, and 1 patient underwent bypass surgery (0.4%). The rate of stoma construction in left-sided tumors was significantly higher than that in right-sided tumors ( P < 0.05) (Table 4). Sixty-seven patients (26.0%) experienced grade ≥ 2 postoperative complications. There were 12 cases of surgical infectious complications, including anastomotic leakage (n = 5) and intra-abdominal abscesses (n = 7). Intraoperative iatrogenic injury occurred in 4 cases. Pulmonary and cardiac complications were noted in 20 cases and 5 cases, respectively. Urinary tract infection occurred in 15 cases. There were 3 cases of in-hospital death. The causes of death in these cases included cerebral infarction (n = 1), septic shock and renal failure (n = 1), and rapid tumor growth (n = 1) (Table 5). In accordance with our analysis of postoperative complications, the univariate analysis showed statistically significant differences between Groups A and B in ASA, SIRS, POSSUM (PS, OS, morbidity), and E-PASS (PRS, SSS, and CRS). The multivariate analysis revealed that POSSUM morbidity ≥ 60.6, and E-PASS SSS ≥ -0.09 were independent risk factors for postoperative complications. The odds ratios of POSSUM morbidity and SSS were 3.59 and 11.80, respectively (Table 6). Survival analysis We analyzed the correlation between the occurrence of postoperative complications and the prognosis. The survival rate of Group A was significantly lower than that of Group B (P = 0.022). The three-year survival rate in cases with complications was worse than that in cases without complications (64.7% vs. 81.9%). The five-year survival in cases with complications was also worse than that in cases without complications (51.7% vs. 73.0%) (Fig. 1 ). We analyzed the correlation between potential risk factors for postoperative complications and the prognosis. As mentioned above, the potential risk factors for postoperative complications were POSSUM morbidity ≥ 60.6, and E-PASS SSS ≥ -0.09. Patients were divided into three groups based on their number of risk factors. The Kaplan–Meier survival curves of the three groups showed a significant difference between them (P < 0.05). The three-year survival rates of the groups with no, one, and two factors were 83.2%, 75.3%, and 43.6%, respectively. The post-hoc test showed a significant difference between cases with no factors and those with two factors (P < 0.05) (Fig. 2 ). Discussion The present study investigated potential risk factors for postoperative complications after CRC surgery in elderly patients and analyzed the effect of postoperative complications and potential risk factors on long-term survival. This study showed that POSSUM morbidity ≥ 60.6, and E-PASS SSS ≥ -0.09, were potential risk factors for postoperative complications. The safety of surgery in elderly patients with CRC is one of the main concerns. CRC is largely diagnosed in old age, when frailty and comorbidity are common( 4 , 9 , 16 , 17 ). If postoperative complications occur after CRC surgery in elderly patients, their general condition usually worsens because of frailty and comorbidity. Several reports have discussed postoperative complications after CRC surgery in elderly patients. The previously reported incidence of postoperative complications was 10–30%( 4 , 11 , 18 , 19 ). It has also been reported that elderly patients show a higher rate of postoperative complications. The common complications included surgical and nonsurgical complications( 1 , 6 , 16 ). In elderly patients, non-surgical complications, such as pulmonary, cardiac, or urinary complications are common( 8 , 16 ). This is suspected to be a risk factor for postoperative complications following CRC surgery. The association between postoperative complications and long-term survival is an important issue. The present study showed the impact of postoperative complications after CRC surgery on the long-term survival of elderly patients. Several reports have shown that postoperative complications after CRC surgery in elderly patients are associated with a poor postoperative prognosis( 8 , 12 , 13 , 20 ). Warps et al. reported that 5-year overall survival with postoperative complications after CRC surgery was worse than in cases without complications( 13 ). The hazard ratio of the multivariate analysis for non-surgical complications was 1.489 for colon cancer and 1.456 for rectal cancer. Other studies have shown that postoperative complications after CRC surgery are significantly associated with long-term survival. However, most studies have targeted all generations, and not been limited to elderly patients. Kim et al. showed that, based on a multivariate analysis, the occurrence of postoperative complications was a significant prognostic factor for one-year mortality( 8 ). The association between complications and long-term survival and the association between the number of potential risk factors and long-term survival indicated the significance of reducing the risk of postoperative complications. Identifying potential risk factors for postoperative complications before CRC surgery may help avoid these complications. Many studies have investigated potential risk factors for postoperative complications after CRC surgery in elderly patients. Some reports have identified both surgical and nonsurgical complications as potential risk factors. Frailty, sarcopenia, lifestyle habits (smoking), nutritional disorder, comorbidities (cardiovascular, respiratory, renal, cerebrovascular), geriatric syndrome, ASA, and blood test parameters (hemoglobin, albumin) were identified as non-surgical risk factors for postoperative complication in these studies( 1 , 4 , 6 – 11 , 21 – 24 ). POSSUM morbidity was identified as a potential risk factor for postoperative morbidity. The POSSUM score includes a physiological score (PS) that is calculated based on 12 preoperative physiological variables, and an operative severity score (OS), which is calculated based on 6 operative variables( 14 ). Old age (≥ 71 years) markedly increases the POSSUM PS and morbidity. Other preoperative complications are affected by age. This means that old age itself may be a risk factor for postoperative complications, and that improvement of preoperative physical conditions is more important in elderly patients than in younger patients. The POSSUM morbidity score and EPASS SSS contain factors associated with surgical invasion (operating time, procedure, blood loss, operative severity, etc.) ( 14 , 25 ). Surgical invasion during CRC surgery in the elderly was also associated with postoperative complications. The open surgical approach, performance of combined surgery, and increased intraoperative blood loss have been reported as potential risk factors for surgical invasion in CRC surgery( 8 , 11 , 17 , 21 , 26 , 27 ). Given the present findings regarding POSSUM morbidity and E-PASS SSS as potential risk factors, these factors may be used to predict and prevent postoperative complications. To prevent postoperative complications in elderly patients, it is important to improve these scores, which is equivalent to improving the preoperative condition and reducing the invasiveness of CRC surgery. There are several methods for preoperative CRC surgery. In terms of POSSUM PS, blood pressure, pulse rate, hemoglobin, white blood cell count, plasma urea, sodium, and potassium levels are relatively easy to improve with appropriate medication, infusion, blood transfusion, and antibiotics. Cardiac or pulmonary impairments are frequently observed in elderly patients, and are not easy to improve. If these impairments are severe, the possibility of surgery and its indications should be discussed. Impairment of operative scores is difficult in the preoperative term. One of the methods for improving the operative score is to avoid emergency surgery. Bridging to surgery after placement of a self-expandable metallic stent (SEMS) is recognized as a treatment strategy for obstructive CRC( 28 ). Patients require urgent decompression to prevent severe abdominal distension, perforation, electrocyte imbalance, sepsis, and even death( 29 ). Ma et al. reported that patients with CRC who underwent SEMS had a lower incidence of early complications, lower incidence of 30-day mortality, stoma formation rate, and shorter hospital stays than patients with CRC who underwent primary surgery( 29 ). SEMS can avoid urgent surgery, and there is sufficient time to improve the general condition in the interval before curative surgery for CRC. If an elderly patient has severe frailty, many comorbidities, or a poor surgical condition, a non-operative management strategy after SEMS may be a useful option to prevent early complications and a poor prognosis after CRC surgery. Minimally invasive surgery (MIS) is also a method for improving operative scores. Laparoscopic and robotic surgery for CRC is preferred over open surgery because of reduced blood loss, shorter duration of postoperative ileus, improved pulmonary function, and reduced postoperative complications( 30 ). In our hospital, almost all CRC surgeries for elderly patients are performed with MIS, and MIS may contribute to a more favorable prognosis among elderly patients undergoing CRC surgery. The present study was associated with some limitations. This was a retrospective study that used information obtained from the operation database in our hospital. In addition, the procedures were performed by different operators. However, all operators had seven or more years of surgical experience in our institution; therefore, the heterogeneity was likely small. Conclusion In the present study, POSSUM morbidity and E-PASS SSS were investigated as potential risk factors for postoperative complications after CRC surgery in the elderly. The prognosis of patients with postoperative complications is worse than that of patients without complications. Preoperative management of the general condition and less-invasive surgery may be important to avoid postoperative complications and achieve long-term survival. Abbreviations CRC Colorectal cancer ASA American Society of Anesthesiologists-Physical Status ECOG-PS Eastern Cooperative Oncology Group Performance Status SIRS Systemic Inflammatory Response Syndrome POSSUM Physiological and Operative Severity Score for the Evaluation of Mortality and Morbidity PS Physiological score OS Operative severity score E-PASS Estimation of Physiology Ability and Surgical Stress ROC Receiver operating characteristic SEMS Self-expandable metallic stent MIS Minimally invasive surgery Declarations Ethics approval and consent to participate This study was submitted and approved by The Tokushukai Group Ethics Committee (TGE01727-025). Due to the retrospective design of this study, the requirement for informed consent was waived. Consent for publication Not applicable. Availability of data and materials No datasets were generated or analysed during the current study. Competing interests The authors declare no competing interests. Funding This study was conducted without any financial support. Authors' contributions Manabu Sato: Conceptualization; Methodology; Software; Data curation; Investigation; Formal analysis; Writing-original draft; Writing-review and editing. Akihiro Kobayashi: Conceptualization; Data curation; Resources; Project administration; supervision. Koichiro Kubo: Conceptualization; Data curation; Resources. Yoshihiro Morimoto: Conceptualization; Writing-review and editing. Nobuyoshi Yamazaki: Conceptualization; Writing-review and editing. Ryosuke Kobayashi: Conceptualization; Writing-review and editing. Fumitake Suzuki: Conceptualization; Writing-review and editing. Daichi Asai: Conceptualization; writing-review and editing. Naohiro Tomita: Conceptualization; Writing- review and editing. Kazuki Hayashi; Conceptualization; Writing- review and editing. Noriko Yamada; Writing- review and editing. Masaki Kakimoto; Writing- review and editing. Kei Hasegawa; Writing- review and editing. Kenji Ogata: Validation; Supervision. Acknowledgements We would like to thank Japan Medical Communication (www.japan-mc.co.jp) for the English language editing. References González-Senac NM, Mayordomo-Cava J, Macías-Valle A, Aldama-Marín P, Majuelos González S, Cruz Arnés ML, et al. Colorectal Cancer in Elderly Patients with Surgical Indication: State of the Art, Current Management, Role of Frailty and Benefits of a Geriatric Liaison. Int J Environ Res Public Health. 2021;18(11):6072. Dekker E, Tanis PJ, Vleugels JLA, Kasi PM, Wallace MB. Colorectal cancer. Lancet Lond Engl. 2019;394(10207):1467–80. Itatani Y, Kawada K, Sakai Y. Treatment of Elderly Patients with Colorectal Cancer. BioMed Res Int. 2018;2018:2176056. Fagard K, Leonard S, Deschodt M, Devriendt E, Wolthuis A, Prenen H, et al. 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Int J Colorectal Dis. 2024;39(1):148. Vilsan J, Maddineni SA, Ahsan N, Mathew M, Chilakuri N, Yadav N et al. Open, Laparoscopic, and Robotic Approaches to Treat Colorectal Cancer: A Comprehensive Review of Literature. Cureus 15(5):e38956. Tables Tables 1 to 6 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1.xlsx Table2.xlsx Table3.xlsx Table4.xlsx Table5.xlsx Table6.xlsx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6798855","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":470232452,"identity":"f80f95ff-3871-4cfe-be47-f5cedd114aad","order_by":0,"name":"Manabu 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05:08:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6798855/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6798855/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84817375,"identity":"a0c0c6ca-0b87-4454-8405-a43b86f231d6","added_by":"auto","created_at":"2025-06-17 15:49:07","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":26221,"visible":true,"origin":"","legend":"\u003cp\u003eOverall survival estimates, according to the presence or absence of Clavien–Dindo grade ≥ 2 postoperative complications after CRC surgery.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-6798855/v1/b88dec9acdd9eeb8246a3bad.png"},{"id":84817377,"identity":"99994536-113c-4c59-a45c-6cb702e3f6ff","added_by":"auto","created_at":"2025-06-17 15:49:07","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":27518,"visible":true,"origin":"","legend":"\u003cp\u003eOverall survival estimates, according to the number of potential risk factors for postoperative complications after CRC surgery.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-6798855/v1/6339ed6ca8fa66b03df7d0a0.png"},{"id":90794929,"identity":"a7f6d5d6-7fab-4c1b-ae1e-08fd5b5b1c5a","added_by":"auto","created_at":"2025-09-08 08:47:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":592053,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6798855/v1/2aaaf200-77d7-43a9-9eae-853e74d01363.pdf"},{"id":84817376,"identity":"5de62e48-ead3-4f6b-94ed-df1a2a399086","added_by":"auto","created_at":"2025-06-17 15:49:07","extension":"xlsx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":12307,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-6798855/v1/b00fbf5d23a6e2a2a5104a88.xlsx"},{"id":84817378,"identity":"9baff31a-a1db-49f8-a886-86a4b87210b0","added_by":"auto","created_at":"2025-06-17 15:49:07","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":10477,"visible":true,"origin":"","legend":"","description":"","filename":"Table2.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-6798855/v1/a98ddfe8426803552d45ee2a.xlsx"},{"id":84817380,"identity":"0be56229-2353-4e76-b48f-eb6f93f4795e","added_by":"auto","created_at":"2025-06-17 15:49:07","extension":"xlsx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":11257,"visible":true,"origin":"","legend":"","description":"","filename":"Table3.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-6798855/v1/9f915b3f490319c3881295fc.xlsx"},{"id":84817383,"identity":"bf9baa69-b497-420e-bdee-b184ffaae1c9","added_by":"auto","created_at":"2025-06-17 15:49:07","extension":"xlsx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":9888,"visible":true,"origin":"","legend":"","description":"","filename":"Table4.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-6798855/v1/6f4577313ee9730348936f79.xlsx"},{"id":84817384,"identity":"8f550434-d494-4818-af51-79ff474cc357","added_by":"auto","created_at":"2025-06-17 15:49:07","extension":"xlsx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":11389,"visible":true,"origin":"","legend":"","description":"","filename":"Table5.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-6798855/v1/db07f56189f9162d900bcbd8.xlsx"},{"id":84817389,"identity":"6f04bcf3-bbbe-44f8-97c1-8ca720d64e4a","added_by":"auto","created_at":"2025-06-17 15:49:07","extension":"xlsx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":11598,"visible":true,"origin":"","legend":"","description":"","filename":"Table6.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-6798855/v1/aa2dda0e3231125c6ba89ee8.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Risk factors of preoperative complications after colorectal surgery in elderly and relationship between postoperative complications and long-term survival","fulltext":[{"header":"Introduction","content":"\u003cp\u003eColorectal cancer (CRC) is the most common cancer, accounting for approximately 10% of all newly diagnosed cancers and cancer-related deaths worldwide(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Currently, the proportion of elderly patients has increased, and 60% of new CRC cases are diagnosed in patients older than 65 years of age(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The median age of CRC newly diagnosed CRC is 67 years, and the median age at death is 72 years(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSeveral studies have reported that the rate of CRC surgery in elderly patients is lower than that in younger patients, suggesting that surgery is associated with a high risk of postoperative complications and death in elderly patients(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Frailty, characterized by a reduction in physiologic reserves and susceptibility to adverse consequences after stress, is established as an independent syndrome due to aging and comorbidity related to postoperative outcomes(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSeveral reports have discussed the risk factors for postoperative complications of CRC surgery. These reports have shown that frailty, comorbidity, sarcopenia, and American Society of Anesthesiologists-Physical Status (ASA) are potential risk factors for postoperative complications (\u003cspan additionalcitationids=\"CR8 CR9 CR10\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). This suggests that a decline in the general condition of elderly patients may be related to postoperative complications. However, there are few comparative discussions on individual potential risk factors, so more useful predictors of postoperative complications after CRC surgery remain unclear.\u003c/p\u003e \u003cp\u003eElderly patients with CRC often have frailty or many comorbidities. However, the relationship between aging and long-term survival after CRC surgery remains unclear. Frailty and comorbidities in elderly patients with CRC may increase the risk of non-cancer death or obscure cancer signs, leading to a delayed diagnosis(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Meanwhile, It has also been reported that frailty in elderly patients with CRC does not affect the long-term outcomes(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Several reports have shown that complications after CRC surgery result in poor long-term outcomes(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). However, the impact of postoperative complications on long-term survival after CRC surgery in the elderly is rare and measurable.\u003c/p\u003e \u003cp\u003eThe present study aimed to identify potential risk factors for postoperative complications after CRC surgery in the elderly and analyze the effect of postoperative complications on long-term survival. The relationship between the identified potential risk factors and long-term survival was also analyzed.\u003c/p\u003e"},{"header":"Patients and methods","content":"\u003cp\u003eA total of 258 patients of \u0026ge;\u0026thinsp;80 years of age underwent surgery for colorectal cancer at Chiba-Nishi General Hospital between April 2016 and March 2023. All patients were diagnosed with colorectal adenocarcinoma based on a pathological examination. We constructed a database retrospectively from data collected during surgery for colorectal cancer in our hospital, including clinical characteristics, postoperative complications, and survival during the follow-up period.\u003c/p\u003e \u003cp\u003eThe background factors of surgery for colorectal cancer (sex, age, comorbidity, morbidity, and tumor staging) were obtained from our database.\u003c/p\u003e \u003cp\u003eWe assessed the severity of postoperative complications according to the Clavien-Dindo classification. In our study, the patients were divided into two groups those with Grade\u0026thinsp;\u0026le;\u0026thinsp;I postoperative complications were classified into Group A and those with Grade\u0026thinsp;\u0026ge;\u0026thinsp;II postoperative complications were classified into Group B, and analyzed to identify risk factors for morbidity. A univariate analysis was performed to identify risk factors for postoperative complications. A multivariate analysis using factors extracted from the univariate analysis to identify independent risk factors for postoperative complications.\u003c/p\u003e \u003cp\u003eWe also compared the overall survival after CRC surgery between Group A and B. Furthermore, the survival was compared among three groups, including patients with no risk factor, those with one factor, and those with two factors.\u003c/p\u003e \u003cp\u003eThe following factors were included in the analysis to identify independent risk factors for postoperative morbidity: ASA, Eastern Cooperative Oncology Group Performance Status (ECOG-PS), Systemic Inflammatory Response Syndrome (SIRS), Physiological and Operative Severity Score for the Evaluation of Mortality and Morbidity (POSSUM; physiological score (PS), operative severity score (OS), morbidity) (Table\u0026nbsp;1)(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), Estimation of Physiology Ability and Surgical Stress (E-PASS; PRS, SSS, and CRS)(Table\u0026nbsp;2)(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), and tumor staging.\u003c/p\u003e \u003cp\u003eThe threshold values of continuous data were determined using receiver operating characteristic (ROC) curves. Fisher\u0026rsquo;s exact test was used to analyze categorical data. A logistic regression analysis was used for the multivariate analysis to identify independent postoperative risk factors. Overall survival was estimated using the Kaplan\u0026ndash;Meier curve. The log-rank test was used to analyze survival. P values of \u0026lt;\u0026thinsp;0.05 were considered to indicate statistical significance. All statistical analyses were performed using R (ver. 3.5.2, The R Foundation for Statistical Computing).\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eShort-term outcomes\u003c/h2\u003e \u003cp\u003eA total of 258 colorectal cancer patients of \u0026ge;\u0026thinsp;80 years of age underwent surgery during the 6-year study period. The study included 137 males (53.1%) and 121 females (46.9%). A total of 227 patients (88.0%) had comorbidities, including hypertension, cardiovascular disease, diabetes mellitus, and neurogenic and mental disorders. The remaining 31 patients (12.0%) had no comorbidities (Table\u0026nbsp;3).\u003c/p\u003e \u003cp\u003eA total of 132 patients (51.2%) had right-sided colon cancer and 126 patients (48.4%) had left-sided colorectal cancer. A total of 204 patients (93.1%) underwent radical resection, whereas the remaining 37 patients (14.3%) underwent resection and stoma construction. Sixteen patients (6.2%) underwent stoma construction alone, and 1 patient underwent bypass surgery (0.4%). The rate of stoma construction in left-sided tumors was significantly higher than that in right-sided tumors (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;4).\u003c/p\u003e \u003cp\u003eSixty-seven patients (26.0%) experienced grade\u0026thinsp;\u0026ge;\u0026thinsp;2 postoperative complications. There were 12 cases of surgical infectious complications, including anastomotic leakage (n\u0026thinsp;=\u0026thinsp;5) and intra-abdominal abscesses (n\u0026thinsp;=\u0026thinsp;7). Intraoperative iatrogenic injury occurred in 4 cases. Pulmonary and cardiac complications were noted in 20 cases and 5 cases, respectively. Urinary tract infection occurred in 15 cases. There were 3 cases of in-hospital death. The causes of death in these cases included cerebral infarction (n\u0026thinsp;=\u0026thinsp;1), septic shock and renal failure (n\u0026thinsp;=\u0026thinsp;1), and rapid tumor growth (n\u0026thinsp;=\u0026thinsp;1) (Table\u0026nbsp;5).\u003c/p\u003e \u003cp\u003eIn accordance with our analysis of postoperative complications, the univariate analysis showed statistically significant differences between Groups A and B in ASA, SIRS, POSSUM (PS, OS, morbidity), and E-PASS (PRS, SSS, and CRS). The multivariate analysis revealed that POSSUM morbidity\u0026thinsp;\u0026ge;\u0026thinsp;60.6, and E-PASS SSS \u0026ge; -0.09 were independent risk factors for postoperative complications. The odds ratios of POSSUM morbidity and SSS were 3.59 and 11.80, respectively (Table\u0026nbsp;6).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurvival analysis\u003c/h3\u003e\n\u003cp\u003eWe analyzed the correlation between the occurrence of postoperative complications and the prognosis. The survival rate of Group A was significantly lower than that of Group B (P\u0026thinsp;=\u0026thinsp;0.022). The three-year survival rate in cases with complications was worse than that in cases without complications (64.7% vs. 81.9%). The five-year survival in cases with complications was also worse than that in cases without complications (51.7% vs. 73.0%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eWe analyzed the correlation between potential risk factors for postoperative complications and the prognosis. As mentioned above, the potential risk factors for postoperative complications were POSSUM morbidity\u0026thinsp;\u0026ge;\u0026thinsp;60.6, and E-PASS SSS \u0026ge; -0.09. Patients were divided into three groups based on their number of risk factors. The Kaplan\u0026ndash;Meier survival curves of the three groups showed a significant difference between them (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The three-year survival rates of the groups with no, one, and two factors were 83.2%, 75.3%, and 43.6%, respectively. The post-hoc test showed a significant difference between cases with no factors and those with two factors (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study investigated potential risk factors for postoperative complications after CRC surgery in elderly patients and analyzed the effect of postoperative complications and potential risk factors on long-term survival. This study showed that POSSUM morbidity\u0026thinsp;\u0026ge;\u0026thinsp;60.6, and E-PASS SSS \u0026ge; -0.09, were potential risk factors for postoperative complications.\u003c/p\u003e \u003cp\u003eThe safety of surgery in elderly patients with CRC is one of the main concerns. CRC is largely diagnosed in old age, when frailty and comorbidity are common(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). If postoperative complications occur after CRC surgery in elderly patients, their general condition usually worsens because of frailty and comorbidity. Several reports have discussed postoperative complications after CRC surgery in elderly patients. The previously reported incidence of postoperative complications was 10\u0026ndash;30%(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). It has also been reported that elderly patients show a higher rate of postoperative complications. The common complications included surgical and nonsurgical complications(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). In elderly patients, non-surgical complications, such as pulmonary, cardiac, or urinary complications are common(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). This is suspected to be a risk factor for postoperative complications following CRC surgery.\u003c/p\u003e \u003cp\u003eThe association between postoperative complications and long-term survival is an important issue. The present study showed the impact of postoperative complications after CRC surgery on the long-term survival of elderly patients. Several reports have shown that postoperative complications after CRC surgery in elderly patients are associated with a poor postoperative prognosis(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Warps et al. reported that 5-year overall survival with postoperative complications after CRC surgery was worse than in cases without complications(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The hazard ratio of the multivariate analysis for non-surgical complications was 1.489 for colon cancer and 1.456 for rectal cancer. Other studies have shown that postoperative complications after CRC surgery are significantly associated with long-term survival. However, most studies have targeted all generations, and not been limited to elderly patients. Kim et al. showed that, based on a multivariate analysis, the occurrence of postoperative complications was a significant prognostic factor for one-year mortality(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe association between complications and long-term survival and the association between the number of potential risk factors and long-term survival indicated the significance of reducing the risk of postoperative complications. Identifying potential risk factors for postoperative complications before CRC surgery may help avoid these complications. Many studies have investigated potential risk factors for postoperative complications after CRC surgery in elderly patients. Some reports have identified both surgical and nonsurgical complications as potential risk factors. Frailty, sarcopenia, lifestyle habits (smoking), nutritional disorder, comorbidities (cardiovascular, respiratory, renal, cerebrovascular), geriatric syndrome, ASA, and blood test parameters (hemoglobin, albumin) were identified as non-surgical risk factors for postoperative complication in these studies(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR7 CR8 CR9 CR10\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan additionalcitationids=\"CR22 CR23\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). POSSUM morbidity was identified as a potential risk factor for postoperative morbidity. The POSSUM score includes a physiological score (PS) that is calculated based on 12 preoperative physiological variables, and an operative severity score (OS), which is calculated based on 6 operative variables(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Old age (\u0026ge;\u0026thinsp;71 years) markedly increases the POSSUM PS and morbidity. Other preoperative complications are affected by age. This means that old age itself may be a risk factor for postoperative complications, and that improvement of preoperative physical conditions is more important in elderly patients than in younger patients.\u003c/p\u003e \u003cp\u003eThe POSSUM morbidity score and EPASS SSS contain factors associated with surgical invasion (operating time, procedure, blood loss, operative severity, etc.) (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Surgical invasion during CRC surgery in the elderly was also associated with postoperative complications. The open surgical approach, performance of combined surgery, and increased intraoperative blood loss have been reported as potential risk factors for surgical invasion in CRC surgery(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGiven the present findings regarding POSSUM morbidity and E-PASS SSS as potential risk factors, these factors may be used to predict and prevent postoperative complications. To prevent postoperative complications in elderly patients, it is important to improve these scores, which is equivalent to improving the preoperative condition and reducing the invasiveness of CRC surgery. There are several methods for preoperative CRC surgery. In terms of POSSUM PS, blood pressure, pulse rate, hemoglobin, white blood cell count, plasma urea, sodium, and potassium levels are relatively easy to improve with appropriate medication, infusion, blood transfusion, and antibiotics. Cardiac or pulmonary impairments are frequently observed in elderly patients, and are not easy to improve. If these impairments are severe, the possibility of surgery and its indications should be discussed.\u003c/p\u003e \u003cp\u003eImpairment of operative scores is difficult in the preoperative term. One of the methods for improving the operative score is to avoid emergency surgery. Bridging to surgery after placement of a self-expandable metallic stent (SEMS) is recognized as a treatment strategy for obstructive CRC(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Patients require urgent decompression to prevent severe abdominal distension, perforation, electrocyte imbalance, sepsis, and even death(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Ma et al. reported that patients with CRC who underwent SEMS had a lower incidence of early complications, lower incidence of 30-day mortality, stoma formation rate, and shorter hospital stays than patients with CRC who underwent primary surgery(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). SEMS can avoid urgent surgery, and there is sufficient time to improve the general condition in the interval before curative surgery for CRC. If an elderly patient has severe frailty, many comorbidities, or a poor surgical condition, a non-operative management strategy after SEMS may be a useful option to prevent early complications and a poor prognosis after CRC surgery.\u003c/p\u003e \u003cp\u003eMinimally invasive surgery (MIS) is also a method for improving operative scores. Laparoscopic and robotic surgery for CRC is preferred over open surgery because of reduced blood loss, shorter duration of postoperative ileus, improved pulmonary function, and reduced postoperative complications(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). In our hospital, almost all CRC surgeries for elderly patients are performed with MIS, and MIS may contribute to a more favorable prognosis among elderly patients undergoing CRC surgery.\u003c/p\u003e \u003cp\u003eThe present study was associated with some limitations. This was a retrospective study that used information obtained from the operation database in our hospital. In addition, the procedures were performed by different operators. However, all operators had seven or more years of surgical experience in our institution; therefore, the heterogeneity was likely small.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn the present study, POSSUM morbidity and E-PASS SSS were investigated as potential risk factors for postoperative complications after CRC surgery in the elderly. The prognosis of patients with postoperative complications is worse than that of patients without complications. Preoperative management of the general condition and less-invasive surgery may be important to avoid postoperative complications and achieve long-term survival.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCRC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eColorectal cancer\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eASA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAmerican Society of Anesthesiologists-Physical Status\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eECOG-PS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEastern Cooperative Oncology Group Performance Status\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSIRS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSystemic Inflammatory Response Syndrome\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePOSSUM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePhysiological and Operative Severity Score for the Evaluation of Mortality and Morbidity\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePhysiological score\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOperative severity score\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eE-PASS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEstimation of Physiology Ability and Surgical Stress\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eROC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eReceiver operating characteristic\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSEMS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSelf-expandable metallic stent\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMIS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMinimally invasive surgery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was submitted and approved by The Tokushukai Group Ethics Committee (TGE01727-025). Due to the retrospective design of this study, the requirement for informed consent was waived.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo datasets were generated or analysed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted without any financial support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eManabu Sato: Conceptualization; Methodology; Software; Data curation; Investigation; Formal analysis; Writing-original draft; Writing-review and editing. Akihiro Kobayashi: Conceptualization; Data curation; Resources; Project administration; supervision. Koichiro Kubo: Conceptualization; Data curation; Resources. Yoshihiro Morimoto: Conceptualization; Writing-review and editing. Nobuyoshi Yamazaki: Conceptualization; Writing-review and editing. Ryosuke Kobayashi: Conceptualization; Writing-review and editing. Fumitake Suzuki: Conceptualization; Writing-review and editing. Daichi Asai: Conceptualization; writing-review and editing. Naohiro Tomita: Conceptualization; Writing- review and editing. Kazuki Hayashi; Conceptualization; Writing- review and editing. Noriko Yamada; Writing- review and editing. Masaki Kakimoto; Writing- review and editing. Kei Hasegawa; Writing- review and editing. \u0026nbsp;Kenji Ogata: Validation; Supervision.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank Japan Medical Communication (www.japan-mc.co.jp) for the English language editing.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGonz\u0026aacute;lez-Senac NM, Mayordomo-Cava J, Mac\u0026iacute;as-Valle A, Aldama-Mar\u0026iacute;n P, Majuelos Gonz\u0026aacute;lez S, Cruz Arn\u0026eacute;s ML, et al. Colorectal Cancer in Elderly Patients with Surgical Indication: State of the Art, Current Management, Role of Frailty and Benefits of a Geriatric Liaison. Int J Environ Res Public Health. 2021;18(11):6072.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDekker E, Tanis PJ, Vleugels JLA, Kasi PM, Wallace MB. Colorectal cancer. Lancet Lond Engl. 2019;394(10207):1467\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eItatani Y, Kawada K, Sakai Y. Treatment of Elderly Patients with Colorectal Cancer. BioMed Res Int. 2018;2018:2176056.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFagard K, Leonard S, Deschodt M, Devriendt E, Wolthuis A, Prenen H, et al. The impact of frailty on postoperative outcomes in individuals aged 65 and over undergoing elective surgery for colorectal cancer: A systematic review. J Geriatr Oncol. 2016;7(6):479\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShinji S, Yamada T, Matsuda A, Sonoda H, Ohta R, Iwai T, et al. Recent Advances in the Treatment of Colorectal Cancer: A Review. J Nippon Med Sch Nippon Ika Daigaku Zasshi. 2022;89(3):246\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoselli C, Cirocchi R, Gemini A, Grassi V, Avenia S, Polistena A, et al. Surgery for colorectal cancer in elderly: a comparative analysis of risk factor in elective and urgency surgery. Aging Clin Exp Res. 2017;29(Suppl 1):65\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbdelfatah E, Ramos-Santillan V, Cherkassky L, Cianchetti K, Mann G. High Risk, High Reward: Frailty in Colorectal Cancer Surgery is Associated with Worse Postoperative Outcomes but Equivalent Long-Term Oncologic Outcomes. Ann Surg Oncol. 2023;30(4):2035\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim YW, Kim IY. Factors associated with postoperative complications and 1-year mortality after surgery for colorectal cancer in octogenarians and nonagenarians. Clin Interv Aging. 2016;11:689\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoakye D, Rillmann B, Walter V, Jansen L, Hoffmeister M, Brenner H. Impact of comorbidity and frailty on prognosis in colorectal cancer patients: A systematic review and meta-analysis. Cancer Treat Rev. 2018;64:30\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTrejo-Avila M, Bozada-Guti\u0026eacute;rrez K, Valenzuela-Salazar C, Herrera-Esquivel J, Moreno-Portillo M. Sarcopenia predicts worse postoperative outcomes and decreased survival rates in patients with colorectal cancer: a systematic review and meta-analysis. Int J Colorectal Dis. 2021;36(6):1077\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShiraishi T, Ogawa H, Ozawa N, Suga K, Komine C, Shibasaki Y, et al. Risk and Protective Factors for Postoperative Complications in Elderly Patients With Colorectal Cancer. Anticancer Res. 2022;42(2):1123\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHashimoto S, Hamada K, Sumida Y, Araki M, Wakata K, Kugiyama T, et al. Postoperative Complications Predict Long-term Outcome After Curative Resection for Perforated Colorectal Cancer. Vivo Athens Greece. 2021;35(1):555\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWarps AK, Tollenaar R, a. EM, Tanis PJ, Dekker JWT. Dutch ColoRectal Audit. Postoperative complications after colorectal cancer surgery and the association with long-term survival. Eur J Surg Oncol J Eur Soc Surg Oncol Br Assoc Surg Oncol. 2022;48(4):873\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCopeland GP, Jones D, Walters M. POSSUM: A scoring system for surgical audit. Br J Surg. 1991;78(3):355\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaga Y, Ikei S, Ogawa M. Estimation of physiologic ability and surgical stress (E-PASS) as a new prediction scoring system for postoperative morbidity and mortality following elective gastrointestinal surgery. Surg Today. 1999;29(3):219\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVacante M, Cristaldi E, Basile F, Borz\u0026igrave; AM, Biondi A. Surgical approach and geriatric evaluation for elderly patients with colorectal cancer. Updat Surg. 2019;71(3):411\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKirchhoff P, Dincler S, Buchmann P. A multivariate analysis of potential risk factors for intra- and postoperative complications in 1316 elective laparoscopic colorectal procedures. Ann Surg. 2008;248(2):259\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShang W, Yuan W, Liu R, Yan C, Fu M, Yang H, et al. Factors contributing to the mortality of elderly patients with colorectal cancer within a year after surgery. J Cancer Res Ther. 2022;18(2):503\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhao FQ, Jiang YJ, Xing W, Pei W, Liang JW. The safety and prognosis of radical surgery in colorectal cancer patients over 80 years old. BMC Surg. 2023;23(1):45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAoyama T, Oba K, Honda M, Sadahiro S, Hamada C, Mayanagi S, et al. Impact of postoperative complications on the colorectal cancer survival and recurrence: analyses of pooled individual patients\u0026rsquo; data from three large phase III randomized trials. Cancer Med. 2017;6(7):1573\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKochi M, Hinoi T, Niitsu H, Ohdan H, Konishi F, Kinugasa Y, et al. Risk factors for postoperative pneumonia in elderly patients with colorectal cancer: a sub-analysis of a large, multicenter, case-control study in Japan. Surg Today. 2018;48(8):756\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTokunaga R, Sakamoto Y, Nakagawa S, Miyamoto Y, Yoshida N, Oki E, et al. Prognostic Nutritional Index Predicts Severe Complications, Recurrence, and Poor Prognosis in Patients With Colorectal Cancer Undergoing Primary Tumor Resection. Dis Colon Rectum. 2015;58(11):1048\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLoogman L, de Nes LCF, Heil TC, Kok DEG, Winkels RM, Kampman E, et al. The Association Between Modifiable Lifestyle Factors and Postoperative Complications of Elective Surgery in Patients With Colorectal Cancer. Dis Colon Rectum. 2021;64(11):1342\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUgolini G, Ghignone F, Zattoni D, Veronese G, Montroni I. Personalized surgical management of colorectal cancer in elderly population. World J Gastroenterol WJG. 2014;20(14):3762\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaga Y, Wada Y, Takeuchi H, Kimura O, Furuya T, Sameshima H, et al. Estimation of physiologic ability and surgical stress (E-PASS) for a surgical audit in elective digestive surgery. Surgery. 2004;135(6):586\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi ZW, Shu XP, Wen ZL, Liu F, Liu XR, Lv Q, et al. Effect of intraoperative blood loss on postoperative complications and prognosis of patients with colorectal cancer: A meta\u0026ndash;analysis. Biomed Rep. 2023;20(2):22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLuo W, Wu M, Chen Y. Laparoscopic versus open surgery for elderly patients with colorectal cancer: a systematic review and meta-analysis of matched studies. ANZ J Surg. 2022;92(9):2003\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKanaka S, Yamada T, Matsuda A, Uehara K, Shinji S, Yokoyama Y, et al. Short-term and three-year long-term outcomes of laparoscopic surgery versus open surgery for obstructive colorectal cancer following self-expandable metallic stent placement: a meta-analysis. Surg Endosc. 2024;38(10):5514\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMa B, Ren T, Cai C, Chen B, Zhang J. Palliative procedures for advanced obstructive colorectal cancer: a systematic review and meta-analysis. Int J Colorectal Dis. 2024;39(1):148.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVilsan J, Maddineni SA, Ahsan N, Mathew M, Chilakuri N, Yadav N et al. Open, Laparoscopic, and Robotic Approaches to Treat Colorectal Cancer: A Comprehensive Review of Literature. Cureus 15(5):e38956.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 6 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Colorectal cancer, postoperative complications, elderly, survival","lastPublishedDoi":"10.21203/rs.3.rs-6798855/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6798855/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe potential risk factors of postoperative complications after colorectal surgeries in elderly and the impact of postoperative complications on long-term survival are in issue. This study aimed to identify the potential risk factors for postoperative complications and analyze the effect of postoperative complications on long-term survival.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA total of 258 patients of \u0026ge;\u0026thinsp;80 years of age underwent surgery for colorectal cancer. We divided the patients into two groups: namely, a group without postoperative complications (Group A) and a group with postoperative complications (Group B). The independent risk factors of postoperative complications were evaluated in a multivariate analysis. We also compared the overall survival after CRC surgery between Group A and B. Furthermore, the survival was compared with respect to the number of potential risk factors estimated according to a multivariate analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe multivariate analysis revealed that POSSUM morbidity\u0026thinsp;\u0026ge;\u0026thinsp;60.6, and E-PASS SSS \u0026ge; -0.09 were independent risk factors for postoperative complications. Survival curves showed that the survival rate of Group A was significantly lower than that of Group B. The survival analysis of differences in three groups showed a significant difference between them.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003ePOSSUM morbidity and E-PASS SSS were investigated as potential risk factors for postoperative complications after CRC surgery in the elderly. The prognosis of patients with postoperative complications is worse than that of patients without complications. Preoperative management of the general condition and less-invasive surgery may therefore be important to avoid postoperative complications and achieve a long-term survival.\u003c/p\u003e","manuscriptTitle":"Risk factors of preoperative complications after colorectal surgery in elderly and relationship between postoperative complications and long-term survival","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-17 15:49:02","doi":"10.21203/rs.3.rs-6798855/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"23864df7-e04f-4f23-90e9-d196ef12e402","owner":[],"postedDate":"June 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-08T08:39:15+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-17 15:49:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6798855","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6798855","identity":"rs-6798855","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}