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The Surgeon, Journal of the Royal Collegesof Surgeons of Edinburgh and Ireland

www.thesurgeon.net

Colonoscopy in the octogenarian population: Diagnostic andsurvival outcomes from a large series of patients

Shakeeb Khan*, Jamil Ahmed, Michael Lim, Anwar Owais, Clare McNaught,Karl Mainprize, Sathish Babu, Ian Renwick, John MacFie, Charles Mitchell

The Combined Gastroenterology Research Unit, Scarborough Hospital, Woodlands Drive, Scarborough, Yorkshire YO12 6QL, United Kingdom

a r t i c l e i n f o

Article history:

Received 15 June 2010

Received in revised form

3 August 2010

Accepted 8 September 2010

Available online 12 November 2010

Keywords:

Colonoscopy

Octogenarians

Colorectal cancer

CT colonoscopy

* Corresponding author. Tel.: þ44 01723 3681E-mail address: Shakeeb.a.khan@gmail.c

1479-666X/$ e see front matter ª 2010 RoyalSurgeons in Ireland. Published by Elsevier Ldoi:10.1016/j.surge.2010.09.003

a b s t r a c t

Objective: Our aim was to audit the diagnostic and survival outcomes of colonoscopy in

octogenarians and to determine if it confers any survival benefit.

Methods: A review of a prospectively maintained database over a two year period between

October 2005 and September 2007 was undertaken. Data on numerous outcome variables

and survival were collected and analysed. Categorical variables were compared using the

Chi-square test. KaplaneMeier survival curves were constructed and log rank test were

used to compare survival curves.

Results: There were 1905 patients, of which 289 (15%) were over the age of 80 years. Caecal

intubation was significantly lower in octogenarians when compared with young patients

(239/289, (82%) vs. 1411/1616 (88%), p ¼ 0.025). The most common reason for failure to

intubate the caecum was presence of stenosing pathology in distal bowel (octogenarians

46% (23 out of 50 failed intubations) vs. young 23% (49 out of 205 failed intubations),

p ¼ 0.002). A greater proportion of octogenarians had poor bowel preparation when

compared with the young (20% vs. 13%, p ¼ 0.001). Significantly more pathology was

detected in octogenarians (72% vs. 59%, p ¼ 0.001). Forty-four (15.2%) octogenarians were

found to have malignancy. Of these, only 23 (52%) underwent subsequent surgery. Median

survival of octogenarians who had surgery was not statistically better (31 (IQR 12e38)

months vs. 16 (IQR 5-31) months, p ¼ 0.10) than those who did not.

Conclusion: Colonoscopy is safe in octogenarians and provides a high yield. Our results

suggest that it does not appear to result in any survival benefit. However, to establish this,

further research with larger cohorts and longer follow-up periods would be required.

ª 2010 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and

Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.

Introduction a higher likelihood of pathology, the perceived benefits of

Colonoscopy is considered the investigation of choice for

colonic pathology.1 It is however, associated with a small but

significant risk of serious complications particularly in

the elderly.2e5 Further, although elderly patients have

11; fax: þ44 01723 354031om (S. Khan).College of Surgeons of Ed

td. All rights reserved.

performing colonoscopy are debatable particularly if patients

have significant co morbidity. The advent of alternative less

invasive techniques for imaging the colon such as CT colo-

nography also means that the role of colonoscopy in the

elderly is now less clear.

.

inburgh (Scottish charity number SC005317) and Royal College of

t h e s u r g e on 9 ( 2 0 1 1 ) 1 9 5e1 9 9196

There are no guidelines as to the age when initial colono-

scopicevaluationof thebowelshouldcease.TheBritishSociety

ofGastroenterology (BSG), theAssociation of Coloproctologists

in the United Kingdom (ACPGBI) and the American Society for

Gastrointestinal Endoscopy (ASGE) have published guidelines

on the indications and standards of colonoscopy, but make no

recommendations as regards age limits for index colonoscopy

for suspected colorectal cancer.6,7

The aim of this study was three-fold. Firstly, to audit the

diagnostic yield of colonoscopy in patients above the age of 80

by comparing caecal intubation rates (CIR), quality of bowel

preparation and complications to those less than 80 years in

age. Secondly, in order to identify if colonoscopy was appro-

priate in the elderly, we followed up a cohort of patients above

the age of 80 with colonoscopically detected cancers and

examined their rates of survival. Lastly, to provide recom-

mendations on colonoscopy in the elderly, we suggest an

algorithm for the investigation of these patients.

Materials and methods

Patients

This was a review of prospectively collected data for all colo-

noscopies performed over a two year period between October

2005 and September 2007. Data on patient demographics,

quality of bowel preparation, caecal intubation rate (CIR),

diagnostic yield, tolerance of the procedure and complications

were gathered. Levels of sedation and comfort were recorded

on a Likert scale that ranged between 1 and 4. On the scale, 1

was most comfortable and well sedated; while 4 was least

comfortable and least sedated. Quality of bowel preparation

was graded as ‘good’, ‘satisfactory’ or ‘poor’. Patients were

divided into two groups e octogenarians (above the age of 80)

or non-octogenarians (below the age of 80).

Colonoscopy

All colonoscopies were performed by consultant gastrointes-

tinal physicians and surgeons, specialist registrars in training

or an endoscopy nurse. The colon was prepared using two

doses of Picolax� given 8 hourly apart. Colonoscopy was per-

formed using Olympus� instruments and sedation was ach-

ieved with midazolam or fentanyl or a combination of both.

All colonoscopic findings were recorded on Endoscribe�, an

automated computer software and transferred to a secure

Microsoft Excel� database for analysis.

Table 1 e Reasons behind incompletion of colonoscopy.

Youngn¼ 205(%)

Octogenariann¼ 50(%)

P value

Pathology encountered 49(23.9) 23(46.0) 0.002

Poor bowel preparation 40(19.5) 13(26.0) 0.410

Discomfort 44(21.4) 3(6.0) 0.020

Looping 49(23.9) 3(6.0) 0.008

Excess blood 2(0.9) 1(2.0) 0.540

Patient request 12(5.7) 3(6.0) 0.160

Others 9(4.3) 4(8.0) 0.04

Statistics

Datawereanalysedusinga standard statistical package (SPSS�

for Windows, Version 11, Chicago, IL). Categorical variables

were compared using the Chi-square test. KaplaneMeier

survival curveswereconstructedand log rank testwereused to

compare survival curves. A p value of less than 0.05 was

considered significant.

Results

Patients

There were 1905 patients of which 1034 (54%) were female.

Mean age of the study population was 67 (IQR 56-76) years.

Two hundred and eighty nine patients (15%) were over the age

of 80.

Caecal intubation

The overall CIR in our study population was 86 percent and it

was significantly lower in octogenarians when compared with

young patients (239/289, (82%) vs. 1411/1616 (88%), p ¼ 0.025).

Conversely, caecal intubation was not possible in 50 octoge-

narians and in 205 young. The most common reason for

failure to intubate the caecumwas stenosing pathology which

prevented intubation of proximal bowel. Stenosing pathology

prevented intubation of the caecum in a greater proportion of

octogenarians when compared with young patients (46% (23

out of the 50 failed intubations) vs. 23% (49 out of the 205 failed

intubations), p ¼ 0.002). Other reasons for failure were poor

bowel preparation (octogenarians 26% (13/50) vs. young 20%

(40/205), p ¼ 0.410), looping of the scope (octogenarians 6% (3/

50) vs. young 24% (49/205), p ¼ 0.008) and patient discomfort

(octogenarians 6% (3/50) vs. young 21% (44/205), p ¼ 0.020).

Further details are listed in Table 1.

Bowel preparation

Bowel preparation was recorded as good or satisfactory in 85

percent of patients within the study population. However,

a greater proportion of patients in the octogenarian group had

poor bowel preparation when compared with the young (20%

vs. 13%, p ¼ 0.001).

Colonoscopic yield

Significantly more pathology was detected in octogenarians

when compared with young patients (72% vs. 59%, p ¼ 0.001).

Colorectal cancers were more likely to be detected in octoge-

narians when compared with young patients (15.2% vs. 6.4%,

p¼ 0.001). Table 2 lists the range of pathology detected in both

groups of patients.

Table 2 e Pathology detected on colonoscopy.

Pathology YoungN ¼ 1616(%)

OctogenarianN ¼ 289(%)

P value

Pathology detected 949 (58.7) 207 (71.6) 0.001

Benign 429 (26.5) 102 (35.2) 0.003

Diverticulosis 238 (14.6) 80 (27.7)

Diverticulitis 1 (0.06) 3 (1.0)

Haemorrhoids 10 (0.6) 1 (0.3)

Colitis 154 (9.5) 10 (3.5)

Angiodysplasia 7 (0.4) 1 (0.3)

Other benign 19 (1.2) 7 (2.4)

Polyps 417 (25.8) 61 (21.1) 0.130

Malignant 103 (6.4) 44 (15.2) 0.001

Colon Cancer 61 (3.8) 25 (8.6)

Rectal Cancer 41 (2.5) 19 (6.6)

Multiple Cancer 1 (0.06) 0 (0)

t h e s u r g e on 9 ( 2 0 1 1 ) 1 9 5e1 9 9 197

Comfort levels

The levels of sedation and comfortwere similar in both groups

of patients.

Complications

Complications were uncommon in this series. One non-octo-

genarian patient had a perforation which was treated surgi-

cally. Three patients (one octogenarian) had bleeding after

endomucosal resection. These presented in the early period

and patients underwent repeat colonoscopy with injection

and/or endolooping of the offending lesion.

Follow-up of octogenarian patients

Median survival for the entire group was 31 (IQR 16-48)

months. Fig. 1 shows the KaplaneMeier survival curves for the

overall octogenarian population who had colonoscopy.

Median survival for octogenarians who were found to have

Follow-up (months)

6050403020100

1.2

1.0

.8

.6

.4

.2

0.0

-.2

Survival

Censored

lavivrus evitalumu

C

Fig. 1 e Overall survival data for octogenarians who had

colonoscopy.

benign disease on colonoscopy was greater than those who

were found to have malignant disease (34 (IQR 28-40) vs. 26

(IQR 6-33) months, p-value ¼ 0.01).

Of the 44 octogenarians who were found to have malig-

nancy, 15 (34%) had significant medical co morbidity which

precluded any form of surgery. The remaining 29 (66%) octo-

genarians who were found to have malignancy were staged.

Twenty-three were found to have resectable disease and were

therefore considered for curative surgery. This meant that 21

(48%) octogenarians could not have surgery for their colorectal

cancer. Median survival for octogenarians who had surgery

was not statistically better (31 (IQR 12e38) months vs. 16 (IQR

5-31) months, p ¼ 0.10). Fig. 2 shows the KaplaneMeier

survival curves for octogenarians who did and did not have

surgery for their colorectal cancer.

Discussion

This studyexamined the safety, diagnostic yield andoutcomes

after colonoscopy in octogenarians. We had initially thought

that colonoscopy would prove to be more hazardous in the

elderly and that age would prove to be a relative contraindi-

cation to colonoscopy. In fact colonoscopywas better tolerated

in the elderly and was not associated with higher rates of

complications when compared with younger patients.

Not surprisingly, colorectal cancer was diagnosed more

frequently in the elderly (15.2% vs. 6.4%, p ¼ 0.001). But

although colonoscopy in octogenarians had a high diagnostic

yield, a large proportion of elderly patients (48%) were not

suitable for curative surgery. Moreover, elderly patients with

potentially curative surgery did not survive longer than those

who were not surgically treated.

The rate of incomplete colonoscopies in our study was

higher in octogenarians than younger patients (18% vs. 12%,

p ¼ 0.025). This was comparable to previous publications in

which it varied between 77% and 90%.8e10 We found that

obstructing pathology and less frequently, inadequate bowel

preparation were the main reasons for incomplete colonos-

copies in octogenarians. Interestingly, technical factors such

looping of the instrument and patient discomfort were less

common than in the young. These findings suggest that

although colonoscopy can be safely performed in the elderly,

one in five will have a suboptimal investigation because of

incomplete evaluation of the large bowel.

Because of these limitations, other modalities of investi-

gation such as CT colonography (CTC) may be better in the

elderly since this allows evaluation of the whole of the large

bowel.11 In recent studies, CTC has been shown to have

a sensitivity and specificity of around 90% in detecting polyps

greater than 10 mm in size.12,13 A recent meta-analysis

showed that its sensitivity for detecting colorectal cancer was

96% and the sensitivity and specificity of detecting polyps

greater than 10 mm in size was 93% and 97% respectively.14

Although the sensitivity and specificity of CTC are reduced

for medium (6e9 mm) and small (less than 6 mm) sized

polyps,15 the clinical consequence of missing such insignifi-

cant pathology in elderly patients is likely to be minimal.

Moreover, CTC is non-invasive and does not require sedation;

thereby minimising the risks of serious complications. In

Follow up (months)

50403020100

lavivrus evitalumu

C1.2

1.0

.8

.6

.4

.2

0.0

Surgery

yes

yes-censored

no

no-censored

Fig. 2 e Comparison of survival data in octogenarians who

had surgery vs. who did not.

Octogenarians: Assess fitness for

surgery

Not fit

Colonoscopy

Malignant Polyps Malignant

Surgery

Tagged CT colonography

Consider therapeutic colonoscopy

Surgery if fit Palliative care if not fit

Incomplete exam

Fit

Fig. 3 e Suggested algorithm for investigation of bowel

symptoms in those above the age of 80.

t h e s u r g e on 9 ( 2 0 1 1 ) 1 9 5e1 9 9198

a survey of centres performing virtual colonoscopy in the UK,

Burling and colleagues found the rate of serious complications

to be as low as 0.08%.16 In addition, with the development of

tagged stool techniques for virtual colonoscopy, the need to

perform bowel cleansing gets obviated and the specificity and

sensitivity of CTC are further improved.17e20 This is again

particularly attractive in the elderly who are more prone to

have complications due to bowel preparation.

The indication for colonoscopy in octogenarians is further

reduced if surgery is either not possible or unnecessary.

Although the advent of modern surgical and anaesthetic

practices such as laparoscopic surgery and enhanced recovery

pathways, have improved the outcomes of surgery in the

elderly,21e24 it is still associatedwith a higher risk ofmorbidity

and mortality.25 In our study, almost half (48%) of the octo-

genarians found to have colorectal cancer were not offered

surgical resection due to associated co-morbidities or

advanced disease. Our data suggest that curative surgery did

not confer any additional advantage in terms of improved

overall median survival.

As one in five elderly patients have incomplete colonos-

copies and only one in two elderly patients are suitable

candidates for surgery, we suggest a change in clinical prac-

tice in an octogenarian population. In our view only those

patients considered fit for surgical intervention should

undergo colonoscopy as first choice investigation for colonic

disease, with CTC or barium enema (depending upon local

resources) reserved for those in whom colonoscopy was

incomplete. All others, if investigation is deemed appropriate,

should have a tagged CTC (Fig. 3).

This study has a few limitations. Although our period of

follow-up is relatively short (maximumof4years),wehavestill

demonstrated that mortality is high in octogenarians irre-

spective of whether or not they have surgery. However our

methodology did not allow separation of cancer related

mortality fromall causemortality.Wedidnot relate diagnostic

outcome to the experience of the endoscopist. For practical

purposes, we did not distinguish between metaplastic,

pseudopolyps and adenomatous polyps because we were

studying diagnostic and surgical outcomes from invasive

cancer in octogenarians.

In conclusion, although colonoscopy is safe in octogenar-

ians and whilst malignancy is commonly detected, it is often

incomplete becauseof obstructingpathology. Curative surgery

is possible in only a small proportion of these patients. We

suggest therefore that tagged CTC should be the initial inves-

tigation in this age group, particularly when they are frail and

unfit for surgery.

Author disclosures

Mr. Khan, Mr. Lim, Mr. Ahmed, Mr. Owais, Ms. McNaught,

Mr. Mainprize, Dr. Babu, Dr. Renwick, Prof. MacFie and

Dr. Mitchell do not have any conflicts of interest or financial

disclosures to make.

Acknowledgements

We thank Sister S. Clarke and Sister A. Hopper and all other

endoscopy staff for their help in collecting data.

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