The aging population represents one of the most important medical challenges of this century. Colorectal Cancer (CRC) is the most common malignancy in the elderly. Age implies a reduced life expectancy and limited tolerance to stress. Careful evaluation of comorbidities is recommended before all treatment in order to minimize morbidity and mortality. The study tests the hypothesis that P-POSSUM (Porthsmouth-Physiologic Operative Severity Score for enUmeration of Morbidity & Mortality) and CR-POSSUM (ColoRectal Physiologic Operative Severity Score for enUmeration of Morbidity & Mortality) would be useful clinical auditing tools in colorectal cancer surgery for aged patients.
Methods: 177 consecutive CRC patients over 70 years of age who underwent emergency or elective surgery were prospectively entered in a comprehensive database from January 2003 to December 2005. Demographic information, disease severity, type of surgery, P-POSSUM and CR-POSSUM scores, detailed follow-up with a survey of 29 complications and 30 day mortality data were collected. The observed over expected morbidity and mortality rate was calculated.
Results: 99 patients (56%) were operated on urgently and 78 electively (44%). Mean age was 80.3 years (range 70-95). 75 patients had advanced disease (stage III and IV). In 36 patients a palliative procedure (without bowel resection) was performed; 113 patients underwent bowel resection with anastomosis while in 28 patients a stoma was created. All data with observed over expected morbidity and mortality rate are illustrated in the Table.
Conclusions: Our data confirm that surgical treatment for CRC in elderly people is associated with a significant risk of morbidity and mortality. P-POSSUM and CR-POSSUM are useful tools for predicting mortality in elderly patients. P-POSSUM significantly overestimated the risk of complications in every subgroup of patients. A more accurate tool for pre-operative assessment of elderly patients is probably needed to predict the post-surgical outcome. Quality of life assessment and other functional parameters should be considered in personalising treatment.

Subgroups	Pts	Expected Morbidity P-POSSUM	Observed Morbidity	P*	Expected Mortality CR-POSSUM	Expected Mortality P-POSSUM	Observed Mortality	P* CR-POSSUM/P-POSSUM
Resection and anastomosis	113	55.3%	38.9%	<0.05	11.3%	9.9%	9 (7.9%)	<0.05/n.s.
Resection and stoma	28	64.1%	46.4%	<0.05	15.8%	14.3%	2 (7.1%)	<0.05/n.s.
Palliative	36	67.9%	50%	<0.05	16.6%	12.7%	8 (22.2%)	<0.05/<0.05
Emergency	99	71.1%	48.5%	<0.05	18.1%	16.3%	14 (14.1%)	<0.05/n.s.
Elective	78	44.2%	34.6%	<0.05	6.6%	4.7%	5 (6.4%)	n.s./<0.05
Total	177	59.3%	42.4%	<0.05	13.1%	11.2%	19 (10.7%)	<0.05/n.s.

*Fisher's exact test