Outcomes After Rectal Cancer Surgery in Elderly Nursing Home Residents

BACKGROUND: As the population ages, an increasing number of elderly persons will undergo surgery for rectal cancer. The use of sphincter-sparing surgery in frail older adults is controversial. OBJECTIVE: The aim of this study was to examine mortality and bowel function after proctectomy in nursing home residents. DESIGN: This is a retrospective cohort study. SETTING: This investigation was conducted in nursing homes in the United States contracted with the Center for Medicare and Medicaid Services. PATIENTS: Nursing home residents age 65 and older undergoing proctectomy for rectal cancer (2000-2005) were included. MAIN OUTCOME MEASURES: The primary outcomes measured were fecal incontinence and the 1-year mortality rate. RESULTS: Operative mortality was 18% after proctectomy with permanent colostomy and 13% after sphincter-sparing proctectomy (adjusted relative risk, 1.25 (95% CI 0.90-1.73), p = 0.188). One-year mortality was high: 40% after sphincter-sparing proctectomy and 51% after proctectomy with permanent colostomy (adjusted hazard ratio 1.32 (95% CI 1.09-1.60), p = 0.004). After sphincter-sparing proctectomy, 37% of residents were incontinent of feces. Residents with the poorest functional status (Minimum Data Set-Activities of Daily Living quartile 4) were significantly more likely to be incontinent of feces than residents with the best functional status (Minimum Data Set-Activities of Daily Living quartile 1) (76% vs 13%, adjusted relative risk 3.28 (95% CI 1.74- 6.18), p= 0.0002). Fecal incontinence was also associated with dementia (adjusted relative risk 1.55 (95% CI 1.15-2.09), p = 0.004) and renal failure (adjusted relative risk 1.93 (95% CI 1.10-3.38), p = 0.022). LIMITATIONS: Measures of fecal incontinence in nursing home registries are not as well studied as those commonly used in clinical practice. CONCLUSIONS: Sphincter-sparing proctectomy in nursing home residents is frequently associated with postoperative fecal incontinence and should be considered only for continent patients with good functional status.