Advanced age--indication or contraindication for laparoscopic colorectal surgery?

Predictors of perioperative morbidity in elderly patients undergoing colorectal cancer resection

AIM

Colorectal cancer resection in the elderly may be associated with significant morbidity. This study aimed to assess perioperative morbidity in elderly patients undergoing colorectal cancer resection and to investigate risk factors for postoperative complications.

MATERIALS AND METHODS

Consecutive patients aged ≥ 75 years undergoing colorectal cancer resection with curative intent between January 2014 and December 2021 at our institution were included. We evaluated risk factors for postoperative complications, length of hospital stays (LOS), 30-day readmission, and 90-day mortality rates.

RESULTS

A total of 843 patients underwent colorectal cancer resection during the study period, of whom 202 patients were 75 years or older. Advanced age was associated with postoperative complications (Clavien-Dindo score > 3b, p = 0.001). Sarcopenia, preoperative plasma albumin < 3.5 g/dL, and open and urgent surgery were significantly correlated with major complications (p = 0.015, p = 0.022, p = 0.003, and p < 0.001, respectively). LOS was longer in elderly patients with a modified 5-item Frailty Index (5-mFI) ≥ 2 and low preoperative serum albumin levels, as well as following open surgery (p = 0.006, p = 0.001 and p < 0.001, respectively). Sarcopenia and preoperative plasma albumin < 3.5 g/dL were predictors for 90-day mortality (p = 0.004 and p > 0.001).

CONCLUSION

Advanced age, sarcopenia, preoperative hypoalbuminemia, 5-mFI ≥ 2, and open or urgent surgery may serve as predictors for postoperative morbidity in the elderly population.

Association of robotic surgery with early discharge, readmission, and complications in elective colectomy: an analysis of NSQIP data from 2012 to 2021

Background Early discharge (ED) after colectomy has become a target outcome for multiple reasons, but the factors associated with ED are not well characterized. This study investigated the factors associated with ED and evaluated the impact of ED on overall outcome. Methods Data from ACS-NSQIP were used to identify patients who underwent non-emergent colectomy from 2012 to 2021. ED was defined as length of stay ≤ 2 days. Unpaired t-tests, chi-square tests and adjusted multivariate logistic regression modeling were used to estimate associated factors for ED. Bounceback readmission was defined as readmission within 7 days of discharge. Results In this cohort of 282,490 patients, 43,137 (15.3%) met the criteria for ED. Robotic colectomy (OR 14.35; 95% CI [13.63-15.12]) was more strongly associated with ED than any other patient characteristic, including laparoscopic colectomy (6.82 [6.51-7.14], ref open colectomy). ED vs. non-ED patients had lower rates of 30-day (5.84 vs. 10.37%, p < 0.01) and bounceback (3.56 vs. 5.75%, p < 0.01) readmissions, overall complications (5.65 vs. 18.63%, p < 0.01) and post-discharge complications (4.21 vs. 7.49%, p < 0.01). Conclusions Robotic surgery was the variable most strongly associated with ED, with greater odds of ED compared to both laparoscopic and open colectomy. Patients who had ED after robotic surgery had lower rates of complications and readmission compared to non-ED patients.

A Personalized Approach to Radical Cystectomy Can Decrease Its Complication Rates

The aim of this study was to assess the influence of a patient’s general status on perioperative morbidity and mortality after radical cystectomy, and to assess which of the used scales is best for the prediction of major complications. The data of 331 patients with muscle-invasive bladder cancer, who underwent radical cystectomy, were analyzed. The general status was assessed according to the American Society of Anesthesiologists (ASA), Charlson Comorbidity Index (CCI), Eastern Cooperative Oncology Group (ECOG), and Geriatric-8 (G-8) scales. Complications were classified according to the Clavien–Dindo classification system. In a group of patients with the highest complication rate according to the Clavien–Dindo scale, (i) statistically more patients rated high according to the ASA and ECOG scales, (ii) patients had significantly higher CCI scores (minor complications (I-II), and (iii) there were significantly more patients rated as frail with G8—predominantly those with 11 points or fewer in the scale. A patient’s general status should be assessed before the start of therapy because patients with a high risk of death or serious complications (evaluated with any rating scale) should be offered conservative treatment. None of the scales can describe the risk of cystectomy, because the percentage of patients with major complications among those who achieved worse score results on any scale was not significantly different from the percentage of patients with major complications in the general group.

Special Considerations for Colorectal Surgery in the Elderly IBD Patient

PURPOSE OF REVIEW

We sought to understand the key aspects to optimize in the perioperative period when treating an elderly surgical patient with inflammatory bowel disease.

RECENT FINDINGS

Addressing preoperative polypharmacy, frailty, and nutrition is important in the elderly population. Understanding intraoperative principles of oncologic risk and pouch formation and the advantages of laparoscopy are key. Postoperative-enhanced recovery pathways and VTE prophylaxis are essential for high-quality care. Preoperative, perioperative, and postoperative factors can greatly impact elderly patients' surgical outcomes.

Enhanced Recovery Program for Colorectal Surgery: a Focus on Elderly Patients Over 75 Years Old

BACKGROUND

An enhanced recovery after surgery (ERAS) protocol can effectively improve perioperative outcomes in surgical patients by reducing complication rates and hospital stay. However, its application in elderly patients has yielded contradictory results. The aim of this study was to evaluate surgical outcomes in a cohort of elderly patients undergoing colorectal resection in our unit before and after the introduction of ERAS.

METHODS

From 328 patients undergoing colorectal surgery in our unit over a 2-year period (2015-2016), 114 patients ≥ 75 years of age were selected. The patients were categorized according to perioperative treatment as pre-ERAS and ERAS patients (respectively, 53 vs 61 patients), and the groups were compared for statistical purposes. Outcome measures included length of hospital stay, recovery of bowel functions, oral feeding, postoperative complications, and readmissions. Compliance with the ERAS protocol was also measured.

RESULTS

Groups were homogeneous for all the clinical-surgical variables, with the sole exception of the Charlson index, which was more severe in the ERAS group (p = 0.012). Compared with control patients, ERAS patients reported improved functional recovery (time to first flatus, stool, and oral feeding; p < 0.001). Hospital stay was reduced in ERAS patients overall and by side of resection, excluding rectal procedures. No differences were observed regarding postoperative complications. Of note, an optimal adherence to the protocol was reported, with 79% of items respected.

CONCLUSIONS

ERAS can be considered safe in elderly patients undergoing colorectal surgery with a high comorbidity index, providing a reduction in hospital stay and improving short-term postoperative outcomes. Finally, the protocol application was feasible, with a high adherence to the items in this subset of patients.

Laparoscopic Resection of Colorectal Cancer in Elderly Patients

Aims and background

Aging of the population and a longer life expectancy have led to an increased number of elderly patients presenting with colorectal cancer and searching for treatment. The aim of the study was to assess the effects of age on the outcome of laparoscopic colorectal surgery for cancer at a single department.

Methods

Perioperative outcome of patients ≥75 years old undergoing laparoscopic colorectal surgery between June 2005 and January 2009 for colorectal cancer were compared with findings in younger patients.

Results

The analysis considered 134 patients <75 years and 82 patients ≥75 years of age. There was a significant difference in perioperative risk factors, as reflected by different ASA scores and a significantly higher postoperative ‘medical’ morbidity, but ‘surgical’ morbidity was similar in the two groups and remained low.

Discussion

Surgical morbidity rate was not affected by age. Cardiovascular and pulmonary comorbid conditions were mainly responsible for the higher morbidity rate reported in the elderly patients, although advanced age, per se, should not be considered a contraindication to laparoscopic colorectal surgery for cancer. Free full text available at www.tumorionline.it

The Expression of TLR2 and TLR3 in Sertoli Cells of Azoospermic Patients

Objective

Toll-like receptors (TLRs) on Sertoli cells are thought to have essential roles in sperm protection. This study was conducted to investigate the expression of TLR2 and TLR3 in Sertoli cells of men with azoospermia.

Materials and Methods

In this experimental study, testicular biopsies were taken from ten azoospermic men. Following enzymatic dissociation, the samples were moved to lectin coated petri dishes. After a few passages, all cells were cultivated and Seroli cells were sorted by flow cytometry. To confirm Sertoli cell purification, alkaline phosphatase activity (ALP) and immunohistochemistry assays were employed. The expression of TLR2 and TLR3 at the transcript and protein levels was examined with real-time quantitative reverse transcription-polymerase chain reaction (RT-QPCR) and western blot, respectively.

Results

Isolation, purification and cultivation of human Sertoli cells were performed successfully. Efficacy of purification of Sertoli cells by fluorescence-activated cell sorting (FACS) sorter was ~97%. The type of cultured cells was confirmed by vimentin and follicle-stimulating hormone (FSH) receptor markers. Furthermore, the existence of anti- Müllerian hormone in culture was confirmed. RT-PCR showed that both genes were expressed in Sertoli cells. Consistently, proteins of both were also expressed in Sertoli cells. Moreover, QPCR showed that the relative expression of TLR3 transcripts was significantly higher than TLR2 in Sertoli cells. Although both genes are expressed in fibroblast cells, their level of expression was significantly lower than in Sertoli cells.

Conclusion

This study confirmed expression of TLR2 and TLR3 in human Sertoli cells. This may be an indicator of their roles in developing immunity against pathogens as well as allo- and auto-antigens or viral antigens in seminiferous tubules.

Outcome of Colorectal Surgery in Elderly Populations

Purpose

The aim of this study is to investigate the impact of age on short-term outcomes after colorectal surgery in terms of the 30-day postoperative morbidity and mortality rates.

Methods

The subjects for the study were patients who had undergone colorectal surgery. Patients were divided into 2 groups according to age; groups A and B patients were ≥80 and <80 years old of age, respectively. Both groups were manually matched for body mass index, American Society of Anesthesiologists score, Charlson Comorbidity Index and procedure performed.

Results

A total of 200 patients, 91 men (45.5%) and 109 women (54.5%), were included in this retrospective study. These patients were equally divided into 2 groups. The mean ages were 85 years in group A (range, 80 to 104 years) and 55.3 years in group B (range, 13 to 79 years). The overall 30-day postoperative mortality rate was 1% of total 200 patients; both of these 2 patients were in group A. However, this observation had no statistical significance. No intraoperative complications were encountered in either group. The overall 30-day postoperative morbidity rate was 27% (54 of 200) for both groups. The 30-day postoperative morbidity rates in groups A and B were 28% (28 of 100) and 26% (26 of 100), respectively. However, these differences between the groups had no statistical significance importance.

Conclusion

Age alone should not be considered to be more of a contraindication or a worse predictor than other factors for the outcome after colorectal surgery on elderly patients.

Clinical outcomes of the very elderly undergoing enhanced recovery programmes in elective colorectal surgery

Introduction Enhanced recovery programmes (ERPs) have been shown to improve short-term outcomes after major colorectal surgery. Benefits of the ERP in patients who are very elderly (VE) are less well understood. We aimed to evaluate the role of the ERP in the VE population, which for the purpose of this study was defined as any patient aged 75 years or over. Methods A prospectively compiled database was used to identify all patients aged ≥75 years who underwent elective colorectal resection in our unit between January 2011 and September 2012. These data were analysed to study the short-term outcomes in these patients and compared with those of patients aged <75 years. Results Overall, 352 patients underwent elective surgery during this period; 106 were identified as VE. The median length of stay (LOS) in the VE group was 7 days (5 days in non-VE group; p=0.002). Two-thirds (62%) underwent laparoscopic surgery. The median LOS of VE patients undergoing laparoscopic surgery was 6 days (11 days for open surgery; p=0.003). A third (33%) of the VE cohort was discharged by day 5. Of these patients, 85% underwent laparoscopic surgery. There was no statistical difference in overall complication rates (VE vs non-VE). Conclusions Accepting that some VE patients may stay in hospital for longer, this study supports our current policy of including everyone in the ERP regardless of age. Patients undergoing laparoscopic surgery appear to benefit, with a shorter LOS. Further large scale trials are required to support the results of this study and to identify long-term outcomes.

Is laparoscopic surgery really effective for the treatment of colon and rectal cancer in very elderly over 80 years old? A prospective multicentric case-control assessment

BACKGROUND

To evaluate the effectiveness of laparoscopic surgery (LCS) for colon and rectal cancer in the very elderly over 80 years old.

METHODS

We performed a prospective multicentric analysis comparing patients over 80 years (Group A) and patients between 60 and 69 years (Group B) undergoing LCS for cancer from January 2008 to December 2013. Colon and rectal cancers were analyzed separately. Comorbidity and complications were classified using the Charlson comorbidity index (CCI) and the Clavien-Dindo system, respectively. Oncological parameters included tumor-free margins, number of lymph nodes harvested and circumferential resection margin.

RESULTS

Group A included 96 and 33 patients, and Group B 220 and 82 for colon and rectal cancers, respectively. Groups were similar except for ASA score and CCI, as expected. There was no significant difference in operative time [colon; rectum] (180[IQR 150-200] vs 180[150-210] min; NS-180[160-210] vs 180[165-240] min; NS), estimated blood loss (50[25-75] vs 50[25-120] mL; NS-50[0-150] vs 50[25-108.7] mL; NS) and conversion rate (2.1 vs 2.7 %; NS-3.0 vs 2.4 %; NS). Timing of first stool (3[2-3.25] vs 3[2-5] dd; NS-3[2-4] vs 3[2-5] dd; NS), length of stay (7[6-8] vs 7[6-8] dd; NS-8[8-9] vs 8[7-9] dd; NS) and readmission rate (1.0 vs 0.45 %; NS-6.1 vs 1.2 %; NS) were similar. Tumor-free margins were appropriate, and positivity of CRM is poor (6.1 vs 4.9; NS). We did not record significant differences in complications rate (47.9 vs 43.6 %; NS-63.6 vs 52.4 %; NS).

CONCLUSIONS

Laparoscopic surgery is effective for the treatment of colorectal cancer even in the very elderly. Age is not a risk factor or a limitation for LCS.

Colorectal resection in nonagenarians: effectiveness of laparoscopic surgery

INTRODUCTION

The number and proportion of elderly persons in the general population have been increasing. Inevitably, the incidence of colorectal carcinoma has also increased. Although substantial evidence indicates that surgery is well tolerated in patients 80 years or older, studies in nonagenarians are not well documented.

METHODS

Consecutive nonagenarians and octogenarians who underwent elective laparoscopic-assisted colectomy (LAC) from September 2009 through October 2011 were studied. Data on medical history, ASA score, details of operations, and postoperative events were collected.

RESULTS

LAC was performed in nine nonagenarians and seven octogenarians. There were no complications related to laparoscopy. No patient required conversion from LAC to an open procedure or died postoperatively. Peristalsis was confirmed and oral intake was initiated on postoperative days 2.6 and 2.7, respectively.

CONCLUSIONS

Laparoscopic surgery is considered an extremely useful treatment for very old patients because it has a low risk of postoperative complications, even in the presence of pre-existing diseases. We conclude that LAC may be indicated in nonagenarians.

Are there any differences between age groups regarding colorectal surgery in elderly patients?

BACKGROUND

Surgical procedures with curative or palliative intentions in subjects aged over 70 represent a colorectal surgical challenge due to the issue they raise: Benefits versus increased morbidity. In this study, we proposed to compare the impact of surgery with the surgical intervention short-term results and analyze the factors that may influence these results in elderly age groups.

METHODS

We retrospectively analyzed a database containing information about patients who underwent colorectal surgery from January 2008 to December 2013 at the Baskent University Istanbul Research Hospital and the Okmeydani Training and Research Hospital.

RESULTS

A total of 265 patients were enrolled and analyzed in this retrospective study. Of these patients operated during the study period, 110 were between 60 and 69 years of age (group 1), 99 were between 70 and 79 years of age and 56 were older than 80 years of age. In total, there were 138 (52%) men and 127 (48%) women that underwent colorectal surgery. Intraoperative complications did not differ between group 1 and group 2, group 2 and group 3; however, some differences were observed between group 1 and group 3 (p = 0.001). Systemic complications were more frequent in group 3 than in groups 1 (p = 0.039) and 2 (p = 0.002). Furthermore, there were no significant systemic complication differences between groups 1 and 2. The mean length of postoperative hospital stay was 9.91 ± 2.65 days in the first group, 9.38 ± 2.44 days in the second group and 11.8 ± 4.35 days in the third group.

CONCLUSION

Colon surgery for both malignant and non-malignant diseases can be performed safely in different elderly age groups; thus, age should not be considered as an obstacle in elderly patients undergoing colorectal resection.

Long-term outcome of robotic-assisted laparoscopic rectopexy for full-thickness rectal prolapse in elderly patients

AIM

Full-thickness rectal prolapse is common in the elderly, but there are no particular practice guidelines for its surgical management. We evaluated retrospectively the perioperative and long-term clinical results and function in elderly and younger patients with complete rectal prolapse after robotic-assisted laparoscopic rectopexy (RALR).

METHOD

Seventy-seven patients who underwent RALR between 2002 and 2010 were divided into Group A (age < 75 years, n = 59) and Group B (age > 75 years, n = 18). Operative time, intra- and postoperative complications, length of hospital stay, short-term and long-term outcomes, recurrence rate and degree of satisfaction were evaluated.

RESULTS

There was no significant difference between the groups regarding operation time, conversion, morbidity or length of hospital stay. At a median follow-up of 51.8 (5-115) months, there was no difference in the improvement of faecal incontinence, recurrence and the degree of satisfaction.

CONCLUSION

Robotic-assisted laparoscopic rectopexy is safe in patients aged over 75 years and gives similar results to those in patients aged < 75 years.

Day-case laparoscopic ventral rectopexy: an achievable reality

AIM

Laparoscopic ventral rectopexy (LVR) is a non-resectional technique for selected patients with full-thickness rectal prolapse and obstructed defaecation syndrome. Despite its challenges, LVR can be performed with relatively minimal patient trauma thus creating the potential for same-day discharge. Our aim was to assess the safety of day-case LVR and identify factors associated with same-day discharge.

METHOD

Data were prospectively collected on all patients (n = 120) from June 2008 to October 2011. Variables included demographics, perioperative details and postoperative course. Primary outcome was length of stay and secondary outcome was symptom improvement at the latest outpatient follow-up. Patients discharged the same day after LVR were compared with those who stayed overnight or longer.

RESULTS

Indications included rectocele and internal prolapse (47%), full-thickness rectal prolapse (44%) and other (9%). Mean operative time was 97 min, same-day discharge occurred with 23% (n = 27) and 67% (n = 80) were discharged on postoperative day 1. In terms of complications, 89% had none, 8% minor and 3% major, including one 24-h readmission for pain. Logistic regression identified younger age (P = 0.054) and private insurance status (P < 0.001) as being significantly associated with same-day discharge. Although surgical indication (P < 0.001), no prior hysterectomy (P = 0.012) and use of biological mesh (P = 0.012) had significant association they were probably confounded by age.

CONCLUSION

In selected patients with rectal prolapse or obstructed defaecation, same-day discharge after LVR is feasible and safe. Our analysis identified quicker discharge in the private system with younger patients. Nevertheless, in unselected patients 90% were discharged by the first operative day.

Minimally invasive surgery for colorectal cancer: quality of life and satisfaction with care in elderly patients

BACKGROUND

The purpose of this multicentric prospective study was to evaluate postoperative HRQL and satisfaction with care after laparoscopic colonic resection for colorectal cancer in elderly patients.

METHODS

A total of 116 patients were enrolled in this study: 33 patients older than age 70 years had laparoscopic colectomy, whereas 24 had open colectomy; 44 patients younger than age 70 years had laparoscopic colectomy and 15 of them had open colectomy. The patients answered to three questionnaires about generic (EORTC QLQ C30) and disease-specific quality of life (EORTC CR29) and about treatment satisfaction (EORTC IN-PATSAT32). Nonparametric tests and forward stepwise multiple regression analysis were used for statistical analysis.

RESULTS

One month after surgery, global quality of life (QL2 item) was significantly impaired in elderly patients who had laparoscopic colectomy compared with younger patients who had the same operation (p = 0.003). Similarly, role function (RF), physical function (PF), emotional function (EF), cognitive function (CF), and social function (SF) were impaired in elderly patients who had laparoscopic colectomy compared with younger patients (p < 0.001, p < 0.001, p = 0.013, p < 0.001, p = 0.01, respectively). Fatigue (FA), sleep disturbances (SL), appetite loss (AP), and dyspnea (DY) affected the quality of life of these patients more than younger patients (p < 0.001, p = 0.055, p = 0.051, and p = 0.003, respectively).

CONCLUSIONS

Elderly patients undergoing laparoscopic colectomy for cancer experience less postoperative local complications than elderly patients undergoing open colectomy. Nevertheless, in the first postoperative month, these patients experience a worse global quality of life than younger patients undergoing the same operation with impairment of all the functions and the presence of fatigue, sleep disturbances, appetite loss, and dyspnea.

Safety and feasibility of a laparoscopic colorectal cancer resection in elderly patients

Purpose

The aim of this study is to assess the effects of age on the short-term outcomes of a laparoscopic resection of colorectal cancer in elderly (≥75 years old), as compared with younger (<75 years old), patients.

Methods

A retrospective analysis of patients who underwent laparoscopic surgery for colorectal cancer between January 2007 and December 2009 was performed. There were two groups: age <75 years old (group A) and age ≥75 years old (group B). The perioperative outcomes between group A and group B were compared.

Results

The study included 824 patients in group A and 92 patients in group B. The body mass index (BMI) and the American Society of Anesthesiologists (ASA) score were significantly different between group B and group A (BMI: 22.5 vs. 23.5, P = 0.002; ASA score: 1.88 vs. 1.48, P = 0.001). Mean operating times were similar between the groups (325.4 minutes vs. 351.6 minutes, P = 0.07). We observed a higher overall complication rate in group B than in group A (12.0% vs. 6.2%, P = 0.047), but the number of severe complications of Accordion Severity Classification ≥3 (those that required an invasive procedure) was not significantly different between the two groups (6.5% vs. 3.4%, P = 0.142). There was no significant difference in the length of hospital stay (13.0 days vs. 12.0 days, P = 0.053).

Conclusion

Although the elderly patients had a significantly higher overall postoperative complication rate, no significant difference was seen in either the number of severe complications of Accordion Severity Classification ≥3 or in the length of hospital stay. A laparoscopic colorectal cancer resection in elderly patients, especially those aged 75 years or older, is safe and feasible.

Early outcomes of colon laparoscopic resection in the elderly patients compared with the younger

BACKGROUND

The aim of this study was to define any benefits in terms of early outcome for laparoscopic colectomy in patients over 75 years old (OP) compared with the outcomes of a younger populations (YP).

METHODS

Forty elderly patients undergoing laparoscopic colectomy for colorectal cancer between 2007-2011 were studied, the patients are divided for gender, age, year of surgery, site of cancer, and comorbidity on admission and compared with 40 younger patients.

RESULTS AND DISCUSSION

Mean (standard deviation) age was 81.3 in OP and 68.3 YP Conversion rate was the same between the two groups. There was no difference in operative mean time . The overall mortality rate was 0% percent. The surgical morbidity rate was the same but there was an increased in cardiologic e bronchopneumonia complications in older population. Patients treated with laparoscopic approach had a faster recovery of bowel function and a significant reduction of the mean length of hospital stay not age related. Laparoscopy allowed a better preservation of postoperative independence status.

CONCLUSIONS

Laparoscopic colectomy for cancer in elderly patients is safe and beneficial including preservation of postoperative independence and a reduction of length of hospital stay.

Outcome analysis of elderly patients undergoing laparoscopic resection rectopexy for rectal prolapse

PURPOSE

For treatment of rectal prolapse, abdominal approaches are generally offered to younger patients, whereas perineal, less invasive procedures are considered more beneficial in the elderly. The aim of this study was to analyze whether laparoscopic resection rectopexy (LRR) is suitable for older patients.

PATIENTS/METHODS

Patients who received LRR for rectal prolapse were selected from a prospective laparoscopic colorectal surgery database. Perioperative and long-term outcome were compared between patients <75 years old (group A) and ≥75 years old (group B).

RESULTS

Of 154 patients, 111 were in group A and 43 in group B. There was one conversion that occurred in group B. Overall mortality rate was 1.3% (n = 2). Both patients were in group B (group B, 4.7%; p = 0.079). Differences in major and minor complications between the groups were not significant. Rates of improvement for incontinence were 62.7% (group A) and 66.7% (group B; p = 0.716); for constipation, the rates were 78.9% (group A) and 73.3% (group B; p = 0.832). All recurrences occurred in group A (n = 10; overall, 10.3%; group A, 13%). After exclusion of patients who had previously received perineal prolapse surgery, recurrence rate was 3.3% overall (group A, 4.3%).

CONCLUSIONS

This study supports the benefits of LRR for rectal prolapse in elderly patients. Age per se is not a contraindication for LRR. Elderly patients encounter complications slightly more frequently (although not statistically significant) than younger patients. Therefore, a very careful patient selection in the elderly is of paramount importance. However, the long-term outcome does not seem to differ between younger and elderly patients.

Cost Analysis of Laparoscopic versus Open Colectomy in Patients with Colon Cancer: Results from a Large Nationwide Population Database

Laparoscopic colectomy (LC) is a safe and reliable option for patients with colon cancer. This study examined factors associated with LC use and cost differences between LC and open colectomy (OC). Using the Cost & Utilization Project National Inpatient Sample database (2008), patients with colon cancer undergoing elective LC or OC were selected. Chi square and Mann-Whitney tests were used to assess differences between LC and OC. Logistic and multiple regression analysis was used to determine variables associated with LC and predictors of cost. All analysis was weighted. A total of 63,950 patients were identified (LC 8.1%, OC 91.9%). The majority was female (52.7%), white (61.4%), using Medicare (61.1%), and had surgery performed at a large (64.2%), nonteaching (56.9%), urban (87.3%) hospital in the South (37.7%). Mean age was 70 years. On unadjusted analysis, LC was associated with a lower mortality rate (1.7 vs 2.4%), fewer complications (18.9 vs 27.1%), shorter length of stay (5 vs 7 days), and lower total charges ($41,971 vs $43,459, all P < 0.001). LC is a less expensive but less popular surgical option for colon cancer. Stage, race, Charlson score, teaching status, location, and hospital size influence the use of a laparoscopic approach. LC is associated with fewer complications and decreased mortality which contribute to its lower cost as compared with OC.

Outcomes of laparoscopic surgery for colorectal cancer in elderly patients

Laparoscopic colorectal surgery appears to be feasible and safe in elderly patients with increased comorbidity.

Objective:

To evaluate the short-term outcomes of laparoscopic colorectal surgery for cancer in the elderly compared with younger patients.

Methods:

We retrospectively considered a consecutive unselected series of 159 patients who underwent elective laparoscopic procedures for colorectal cancer at our institution between January 2007 and December 2009. Of these patients, 101 (63.5%) were ≤70 years of age (Group A), and 58 (36.5%) were >70 (Group B). Operative steps and instrumentation were standardized. Demographics, disease-related, operative, and short-term data were analyzed for each group, and an appropriate statistical comparison was made. Comorbidity was quantified by using the Charlson Comorbidity Index.

Results:

We reviewed right colectomies (29.5%), left colectomies (44.7%), rectal resections (19.5%), and other procedures (6.3%). There was no significant difference in sex ratio, body mass index, American Society of Anesthesiology score, type of surgical procedures, and tumor stage between Group A and Group B. A statistically higher comorbidity according to the Charlson index characterized Group B (2.2 vs 3.8; P=.034). Median operative time (228±78.1min vs 224.3±97.6min; NS), estimated blood loss (50.0±94.8mL vs 31.2±72.7mL; NS), conversion rate (2.0% vs 1.7%; NS), and timing to canalization (4.5±1.7dd vs 4.4±1.3dd; NS) were statistically comparable in both Groups. Group B was associated with a significantly longer length of hospital stay compared with Group A (8.1±2.8dd vs 10.8±6.6dd; P<.01) There was no statistically significant difference in major postoperative complications (3.8% vs 3.4%; NS), reoperations (0.9% vs 1.7%; NS), and 30-day mortality (0% vs 1.7%; NS).

Conclusions:

Laparoscopic colorectal surgery appears feasible and safe in elderly patients with increased comorbidity.

Alvimopan for the management of postoperative ileus after bowel resection: characterization of clinical benefit by pooled responder analysis

Background

A pooled post hoc responder analysis was performed to assess the clinical benefit of alvimopan, a peripherally acting mu-opioid receptor (PAM-OR) antagonist, for the management of postoperative ileus after bowel resection.

Methods

Adult patients who underwent laparotomy for bowel resection scheduled for opioid-based intravenous patient-controlled analgesia received oral alvimopan or placebo preoperatively and twice daily postoperatively until hospital discharge or for 7 postoperative days. The proportion of responders and numbers needed to treat (NNT) were examined on postoperative days (POD) 3–8 for GI-2 recovery (first bowel movement, toleration of solid food) and hospital discharge order (DCO) written.

Results

Alvimopan significantly increased the proportion of patients with GI-2 recovery and DCO written by each POD (P < 0.001 for all). More patients who received alvimopan achieved GI-2 recovery on or before POD 5 (alvimopan, 80%; placebo, 66%) and DCO written before POD 7 (alvimopan, 87%; placebo, 72%), with corresponding NNTs equal to 7.

Conclusions

On each POD analyzed, alvimopan significantly increased the proportion of patients who achieved GI-2 recovery and DCO written versus placebo and was associated with relatively low NNTs. The results of these analyses provide additional characterization and support for the overall clinical benefit of alvimopan in patients undergoing bowel resection.

Laparoscopic resection of colorectal cancer: matched comparison in elderly and younger patients

BACKGROUND

Several studies have addressed the issue of the feasibility of laparoscopic colorectal surgery in elderly patients, usually by choosing an arbitrary cut-off age limit, and retrospectively evaluating patient outcomes. The aim of this study was to assess the effects of age on the outcome of laparoscopic colorectal surgery for cancer in a single department, by comparing younger and older patients, matched by ASA score and type of operation.

METHODS

The perioperative outcome of patients ≥75 years old who underwent laparoscopic colorectal surgery for cancer between June 2005 and January 2009 were compared with findings in younger patients, matched by ASA score and type of operation.

RESULTS

The study included 100 patients, fifty <75 years old (Group A) and fifty ≥75 (Group B) years old. There were 18 right hemicolectomies, 16 left hemicolectomies, 4 anterior resections, 9 low anterior resections, 2 Miles' operations and 1 segmental resection in each group. We observed a significantly higher overall morbidity rate among elderly patients than among younger patients (24 vs. 8%).

CONCLUSIONS

Short-term results after laparoscopic colorectal surgery for cancer in patients ≥75 years old reveal that they have higher postoperative risk compared to their younger counterparts, even when matched by ASA score and type of operation. It suggests that although advanced age, per se, is not a contraindication, it is a risk for patients who undergo laparoscopic colorectal surgery for cancer. This surgery in elderly patients should be performed by experienced surgeons in specialized centers to keep postoperative risk to a minimum.

[Laparoscopic surgery in colorectal tumors]

The minimally invasive technique, by means of the undoubted advantages of the method, has become fully accepted in the surgical treatments of the most benign and functional diseases. Today it has been proven that the laparoscopic technique is safely usable also in the surgical treatment of colorectal tumors. The authors, analyzing their own and the international experiences, present the laparoscopic surgical treatment of colorectal tumors. Seventy-four patients were treated with laparoscopic-assisted colorectal intestinal resection in the Department of Surgery of the University of Szeged between January 1, 2005 and December 31, 2008. The surgical indication was neoplastic colorectal lesion in 40 cases. The average age of them was 64 years (from 36 to 89 years). Four patients belonged to the risk group of ASA I, 11 patients to ASA II, 24 to ASA III, and one to ASA IV. Twenty-six patients underwent rectosigmoideal resection, 2 had rectal exstirpation, 9 had right hemicolectomy and one had left hemicolectomy. There were no surgical or postoperative complications. Four conversions and in one case a reoperation occurred due to adhesion ileus. The startup of the passage (2.4 days, on average) and the possibility of nourishing per os were significantly shortened. The histological processes of specimens justified tumor-free oral, aboral and circumferential resection in all cases. Summarizing our own and international experiences it can be stated that the laparoscopic surgeries performed due to colorectal tumors are safe, and are also appropriate with respect to oncosurgery. There are a number of benefits for the patients mainly in the early postoperative period (faster recovery, shorter hospitalization) and their long-term survival results are good as well.

Laparoscopic colectomy in octogenarians and nonagenarians: a preferable option to open surgery?

OBJECTIVES

To determine if laparoscopic colectomy is safer and more effective than open colectomy in patients older than 80 years of age.

METHODS

An operating room database of all colectomies performed on patients >or=80 years, from January 2002 to September 2007, was analyzed retrospectively. Data reviewed included type of operation, type of resection, length of procedure, length of stay (LOS), estimated blood loss, American Society of Anesthesiologists (ASA) grade, diagnosis, complications, mortality rates, and discharge destination, with p-values <0.05 considered significant.

RESULTS

One hundred thirty-nine patients underwent open procedures (Open group) during the study period versus 150 patients who underwent laparoscopic procedures (Lap group). Of the Lap group, 15 patients were converted to open cases. Forty-four patients from the Open group were excluded from the analysis as they were treated emergently, leaving 95 patients in the Open group. The mortality for open procedures was significantly higher at 9/95 (9.4%), compared with 3/150 (2%) following laparoscopic procedures (p = 0.0132). LOS was significantly longer for open procedures (11.16 days) versus laparoscopic procedures (7.11 days), p = 0.0001. Open procedures were associated with an increased risk of postoperative ileus (p < 0.02). The Open group had a higher likelihood of discharge to a nursing facility (43/87) than the Lap group (33/147), p < 0.0001. There were no significant differences in the length of procedure, estimated blood loss and postoperative complications.

CONCLUSIONS

Laparoscopic colectomy is a safer option that offers an improved outcome compared with open colectomy in elderly patients. Significant improvements in LOS, mortality rates, and discharge destination were observed.

Australasian Laparoscopic Colon Cancer Study shows that elderly patients may benefit from lower postoperative complication rates following laparoscopic versus open resection

BACKGROUND

A retrospective analysis of age-related postoperative morbidity in the Australia and New Zealand prospective randomized controlled trial comparing laparoscopic and open resection for right- and left-sided colonic cancer is presented.

METHODS

A total of 592 eligible patients were entered and studied from 1998 to 2005.

RESULTS

Data from 294 patients who underwent laparoscopic and 298 who had open colonic resection were analysed; 266 patients were aged less than 70 years and 326 were 70 years or older (mean(s.d.) 70.3(11.0) years). Forty-three laparoscopic operations (14.6 per cent) were converted to an open procedure. Fewer complications were reported for intention-to-treat laparoscopic resections compared with open procedures (P = 0.002), owing primarily to a lower rate in patients aged 70 years or more (P = 0.002). Fewer patients in the laparoscopic group experienced any complication (P = 0.035), especially patients aged 70 years or above (P = 0.019).

CONCLUSION

Treatment choices for colonic cancer depend principally upon disease-free survival; however, patients aged 70 years or over should have rigorous preoperative investigation to avoid conversion and should be considered for laparoscopic colonic resection.

REGISTRATION NUMBER

NCT00202111 (http://www.clinicaltrials.gov).

Short-term outcomes of laparoscopic rectal surgery for primary rectal cancer in elderly patients: is it safe and beneficial?

PURPOSE

The role of laparoscopic resection in management of rectal cancer is still controversial. The purpose of this study was to evaluate whether laparoscopic rectal resection for rectal cancer could be safely performed in elderly patients.

METHODS

Forty-four elderly patients (> or =75 years) undergoing laparoscopic rectal resection (group A) were compared with 228 younger patients (<75 years) undergoing laparoscopic rectal resection (group B) and 43 elderly patients (> or =75 years) undergoing open rectal resection (group C).

RESULTS

The American Society of Anesthesiologists' status was significantly higher in group A than in group B. Operative procedure, operating time, and estimated blood loss were comparable, and overall postoperative complications did not differ significantly between groups A and B (13.6% vs. 11.8%). Operating time was longer (256 vs. 196 min), but estimated blood loss was significantly less (25 vs. 241 ml) in group A than in group C. The rate of postoperative complications was lower (13.6% vs. 25.6%) in group A than in group C, but the difference was not statistically significant. Time to flatus (1.3 vs. 3.7 days), time to liquid diet (2.2 vs. 7.0 days), and hospital stay (19 vs. 22 days) were significantly shorter in group A than in group C.

CONCLUSIONS

Laparoscopic rectal resection for elderly patients can be safely performed with similar postoperative outcomes as in younger patients and may have advantages in terms of faster gastrointestinal recovery and shorter length of hospital stay compared with open surgery.

Laparoscopic vs open colectomy for colon cancer: results from a large nationwide population-based analysis

PURPOSE

Laparoscopic colectomy has only recently become an accepted technique for the treatment of colon cancer. We sought to analyze factors that affect the type of resection performed and associated outcomes from a large nationwide database.

METHODS

All admissions with a primary diagnosis of colon cancer undergoing elective resection were selected from the 2003 and 2004 Nationwide Inpatient Samples. Multiple linear and logistic regression analyses were used to compare outcome measures and identify independent predictors of a laparoscopic approach.

RESULTS

We identified 98,923 admissions (mean age 69.2 years). They were predominately Caucasian (81%), had localized disease (63%), had private insurance (56%), and had surgery performed in urban hospitals (87%). Laparoscopic resection was performed in 3,296 cases (3.3%) and was associated with a lower complication rate (18% vs 22%), shorter length of stay (6 vs 7.6 days), decreased need for skilled aftercare (5% vs 11%), and lower mortality (0.6% vs 1.4%, all P<0.01). There was no significant difference in the total hospital charges between the groups ($34,685 vs $34,178, P=0.19). Independent predictors of undergoing laparoscopic resection were age<70 (odds ratio [OR]=1.2, P<0.01), national region (Midwest OR=1.9, West OR=2.0, P<0.01), and lower disease stage (OR=2.5, P<0.01). Ethnic category and insurance status showed no significant association with operative method (P>0.05).

CONCLUSIONS

Laparoscopy for colon cancer is associated with improved outcomes in unadjusted analysis and similar charges compared to open resection. We found no influence of race or payer status on the utilization of a laparoscopic approach.

Alvimopan accelerates gastrointestinal recovery after bowel resection regardless of age, gender, race, or concomitant medication use

BACKGROUND

Postoperative ileus is a transient cessation of bowel motility that occurs after bowel resection (BR). Alvimopan, a peripherally acting mu-opioid receptor antagonist accelerated gastrointestinal (GI) recovery in 5 randomized, double-blind, phase III postoperative ileus trials.

METHODS

Individual covariates (age, gender, race) were assessed separately using Cox proportional hazards models that included the main effects of treatment and covariate factor. Time-to-GI recovery (GI-3 [first toleration of solid food and first bowel movement or flatus]; GI-2 [first toleration of solid food and first bowel movement]) for patients who underwent open laparotomy for BR in the absence of epidural anesthesia and received alvimopan (12 mg) or placebo was analyzed within subgroups (age, gender, race, concomitant medication use) using Cox proportional hazards models to generate hazard ratios (HRs). P values were calculated with the Wald chi2 test.

RESULTS

Elderly (>or=65 years), male, and nonwhite patients achieved GI-3 recovery later than younger (<65 years), female, and white patients (HR > 1 and P < .05 for all). Overall, alvimopan (12 mg) accelerated GI-3 recovery by 12 hours and GI-2 recovery by 17 hours compared with placebo. Within subgroups, regardless of covariate effect, patients who received alvimopan (12 mg) achieved GI-2 and GI-3 recovery sooner than patients who received placebo (HR > 1 and P < .05 for all).

CONCLUSIONS

These post hoc analyses support that alvimopan (12 mg) accelerates GI recovery across various patient populations.

Laparoscopic colorectal surgery in elderly patients: a matched case-control study in 178 patients

BACKGROUND

We conducted a prospective case-matched study to compare outcomes of laparoscopic colorectal surgery in elderly (>or= 70 years) and younger (< 70 years) patients.

STUDY DESIGN

Among 506 consecutive patients who underwent 536 colorectal resections supervised by 1 colorectal surgeon (YP), 75 elderly patients (>or= 70 years)were matched with 103 younger patients (< 70 years), according to gender, body mass index, pathology, and surgical procedure. Postoperative mortality and morbidity were defined as in-hospital deaths and complications.

RESULTS

One hundred seventy-eight patients (95 men and 83 women) underwent laparoscopic colorectal resection for colorectal carcinoma (40%) or benign diseases (60%). Laparoscopic surgical procedures included left colectomy (43%), rectal resection (34%), right colectomy (12%), subtotal colectomy (6%), and rectopexy (5%). Cardiopulmonary comorbidities were significantly more frequent in elderly compared with young patients (80% versus 33%, p < 0.001). Mean operating times were similar between elderly and young patients (244+/-89 minutes versus 242+/-80 minutes, NS). Thirty-two patients (18%, 16 in each group) required conversion to laparotomy. There was no mortality. Overall postoperative complications were comparable between groups (32% versus 26%, NS). Sixteen patients (9%, 5 elderly and 11 young) required reoperation. Mean hospital stay was comparable between groups (11+/-8 days versus 10+/-9 days, NS).

CONCLUSIONS

This large case-matched study suggested that laparoscopic colorectal surgery may be proposed in elderly patients, with similar postoperative outcomes as this surgery has in young patients, despite significantly more frequent cardiorespiratory comorbidities.

Considerations on the learning curve for laparoscopic colorectal surgery: a view from the bottom

INTRODUCTION

Those who have surmounted the learning curve for laparoscopic colorectal resection state that considerable numbers of highly selected cases should comprise a department's early experience to ensure reliability of technique before routine implementation. The objective of this study was to determine how this advice may interrupt case flow.

METHODS

Details on all colorectal operations performed in a single institution over a 4-year period were gleaned from a prospectively maintained database. Patient profiles were scrutinised to identify how the application of various published exclusion criteria would impact upon the theoretical completion rates of our proposed learning curve.

RESULTS

In total, 317 colorectal resections were performed; 259 operations were for adenocarcinoma (including 100 rectal tumours) while 58 were for benign disease. Of those with malignancy, 25(10%) were obese, 61(24%) had previous intra-abdominal surgery, while 52(20%) were aged over 80 years and 60(23%) were ASA (3/4). Strictest exclusion criteria would halve the number of cases to be commenced laparoscopically. A specialist registrar rotating through the department would have case exposure cut from a mean of 33 to 11 in 6 months under this regimen. Prioritising benign cases in the initial experience as has been recommended by certain groups would mean that, at most, 1.2 cases would be performed every 4 weeks during the learning period.

CONCLUSION

Although our caseload seems sufficient to allow the acquisition of expertise in a timely fashion, procedural flow would be markedly interrupted by stringent pre-selection. A low threshold for initiating the procedure laparoscopically seems a pragmatic way of ensuring departmental confidence through familiarity.

Do elderly patients benefit from laparoscopic colorectal surgery?

BACKGROUND

The steadily increasing age of the population mandates that potential benefits of new techniques and technologies be considered for older patients.

AIM

To analyze the short-term outcomes of laparoscopic (LAP) colorectal surgery in elderly compared to younger patients, and to patients who underwent laparotomy (OP).

METHODS

A retrospective analysis of patients who underwent elective sigmoid colectomies for diverticular disease or ileo-colic resections for benign disorders; patients with stomas were excluded. There were two groups: age < 65 years (A) and age >or= 65 years (B). Parameters included demographics, body mass index (BMI), length of operation (LO), incision length (LI), length of hospitalization (LOS), morbidity and mortality.

RESULTS

641 patients (M/F - 292/349) were included between July 1991 and June 2006; 407 in group A and 234 in group B. There were significantly more LAP procedures in group A (244/407 - 60%) than in group B (106/234 - 45%) - p = 0.0003. Conversion rates were similar: 61/244 (25%) in group A, and 25/106 (24%) in group B (p = 0.78). There was no difference in LO between the groups in any type of operation. LOS was shorter in patients in group A who underwent OP: 7.1 (3-17) days versus 8.7 (4-22) days in group B (p <0.0001), and LAP: 5.3 (2-19) days versus 6.4 (2-34) days in group B (p = 0.01). In both groups LOS in the LAP group was significantly shorter than in OP group. There were no significant differences in major complications or mortality between the two groups; however, the complication rates in the OP groups were significantly higher than in LAP and CON combined (p = 0.003).

CONCLUSIONS

Elderly patients who undergo LAP have a significantly shorter LOS and fewer complications compared to elderly patients who undergo OP. Laparoscopy should be considered in all patients in whom ileo-colic or sigmoid resection is planned regardless of age.

Clinical advantages of laparoscopic colorectal cancer surgery in the elderly

BACKGROUND AND AIMS

Elderly patients have a high incidence of colorectal cancer, which may be associated with increased morbidity and mortality due to complex comorbidity and diminished cardiopulmonary reserves. The aims of this study were to compare the outcomes of laparoscopic colorectal cancer surgery with those observed in traditional open surgery in patients aged over 70 years.

METHODS

Between January 2003 and October 2004, 51 patients aged over 70 years with colorectal cancer, who underwent laparoscopic surgery (LAP group), were evaluated and compared with 102 controls (also over 70 years old) treated by traditional open surgery (OPEN group) in the same period. All patients were evaluated with respect to the American Society of Anesthesiologists (ASA) classification, surgery-related complications, and postoperative recovery.

RESULTS

No surgery-related death was observed in the LAP group, whereas two deaths occurred in the OPEN group for severe post-operative pulmonary infection and anastomotic leak, respectively. No pneumoperitoneum-related complications were observed in the LAP group; 2 (3.9%) patients required conversion to open surgery, because of the unexpectedly bulky tumor and severe adhesions in the abdominal cavity. With the increase in patients' age, increased ASA classification was observed. No significant differences were observed in gender, Dukes' staging or types of procedures between LAP and OPEN groups. The overall morbidity in the LAP group was significantly less than that of the OPEN group [17.6% (9/51) vs 37.3% (38/102), p=0.013]. Mean blood loss, time to flatus passage, and time to semi-liquid diet in the LAP group were significantly shorter than those of the OPEN group (90.7+/-49.9 vs 150.3+/-108.7 ml, 2.4+/-1.2 vs 3.5+/-2.9 d, 5.0+/-1.8 vs 5.9+/-1.2 d, respectively, p<0.05). No significant differences were observed in terms of mean operation time or hospital stay between LAP and OPEN groups.

CONCLUSION

Laparoscopic colorectal cancer surgery in elderly patients with colon cancer has clinically significant advantages over traditional open surgery, and appears to be the ideal surgical choice for the elderly.

Laparoscopic colectomy in the elderly: when is too old?

To date, there is little literature regarding the impact of laparoscopic colectomy in the elderly population (i.e., patients older than 70 years) as the vast majority of studies regarding laparoscopic colectomy have evaluated younger patients (younger than 65 years). It is unknown whether elderly patients garner the same benefits from laparoscopic colectomy that younger patients have been shown to receive. As a result, there may be a reluctance to offer laparoscopy to elderly patients. The majority of the reports suggest that laparoscopic colectomy in the elderly is safe and provides the same benefits as laparoscopic colectomy in a younger population. Although an elderly population does not return to the work force, the benefits in the elderly population are related to a return to independence more often than after conventional surgery without an increase in hospital costs. Based on the current literature, one may never be too old to have a laparoscopic colectomy.

[Meta-analysis on minimally invasive surgical therapy of sigmoid diverticulitis]

The bowel diverticulitis is a complication of diverticulosis, occuring in 35% patients in 20 years after diagnosis. The study purpose was analysis of the results published in world literature.

METHOD

Double blind electronic search of several databases using key words: diverticulitis, laparoscopy.

RESULTS

11 studies with 415 patients that satisfy the criteria were selected. AGE: 62.7 + 14.2. Hinchey stadiums: I, IIa i IIb of these 44% I and 28% IIa i Iib each. Operative time: 197.4 +/- 49.6 min. Conversions: 11.7 +/- 10.1 (0 - 38.9%). Protective stoma: 5.5%. Bowel sounds: 2.3 - 3.2 postoperative day. Oral feeding: 2.6-5 postoperative day. Hospitalization: 6.1 2.1 dana. Anastomotic dehiscence: 2.8%, wound infection: 7.3%, iatrogen rectum perforation with stapler: 3.3%, bleeding: 3.5%, ileus: 4.4%, reoperation rate: 4.7%.

CONCLUSION

Sigmoid resection with or without a protective "loop" ileostomy is technically feasable by minimally invasive surgical technique, with an acceptable ratio of benefits and complications.

Laparoscopic vs. open colectomies in octogenarians: a case-matched control study

PURPOSE

The aim of this study was to define any benefits in terms of early outcome for laparoscopic colectomy in patients over 80 years old compared with open colectomy.

METHODS

Sixty-one patients undergoing laparoscopic colectomy for colorectal cancer were matched to 61 open colectomy patients for gender, age, year of surgery, site of cancer, and comorbidity on admission. Independence status on admission and at discharge from the hospital was also evaluated.

RESULTS

Mean (standard deviation) age was 82.3 (3.5) years in the laparoscopy group and 83.1 (3.3) years in the open group. Conversion rate was 6.1 percent. Operative time was 49 minutes longer in the laparoscopy group (P = 0.001). The overall mortality rate was 2.4 percent. The morbidity rate was 21.5 percent in the laparoscopy group and 31.1 percent in the open group (P = 0.30). Patients in the laparoscopy group had a faster recovery of bowel function (P = 0.01) and a significant reduction of the mean length of hospital stay (9.8 vs. 12.9 days for the open group, P = 0.001). Laparoscopy allowed a better preservation of postoperative independence status compared with the that of the open group (P = 0.02).

CONCLUSION

Laparoscopic colectomy for cancer in octogenarians is safe and beneficial including preservation of postoperative independence and a reduction of length of hospital stay.

Laparoscopic surgery in the old patient: do indications and outcomes differ?

BACKGROUND AND AIMS

In view of the increasing numbers of old and very old people in the general population, we evaluated the short-term outcomes of laparoscopic colorectal surgery for differences between younger and older patients.

METHODS

A total of 4,823 patients with complete data sets from a prospective, clinical observational multicentre study initiated by the "Laparoscopic Colorectal Surgery Study Group" were analysed for this investigation.

RESULTS

Of the patients, 909 (18.8%) were older and 3,914 (81.2%) younger than 75 years. In the older patient group, malignant disease was a significantly more common indication for surgery. As was expected, the rate of general complications (pneumonia, cardiopulmonary problems, urinary tract infection) was significantly higher in the older patient group with its greater prevalence of preoperative comorbidity, but there no differences in terms of intraoperative or postoperative surgical complications or conversion rate between the groups.

CONCLUSION

The higher rate of postoperative complications resulting from preoperative comorbidity in the older patients makes it necessary that the indication for surgery be established with care. In view of the advantages of the laparoscopic approach with regard to the postoperative course, the preferential use of laparoscopy for the treatment of colorectal problems requiring surgery in older patients should receive serious consideration.

Predictors of Duration of Postoperative Hospital Stay in Patients Undergoing Advanced Laparoscopic Surgery

The expansion of the indications for laparoscopic surgery to include high-risk patient, acute and malignant pathology, and more complex procedures may prolong the hospital stay. Cox multiple stepwise regression analysis model was employed to determine independent predictors of prolonged postoperative hospital stay (more than 3 days) following advanced laparoscopic procedures among 10 variables. Some 130 patients had undergone advanced laparoscopic surgical procedures between November 2000 and August 2003. The median postoperative hospital stay was 3 days (interquartile range 2-5), and 81 patients (62.3%) were discharged within 3 days of surgery. The independent predictors of prolonged postoperative hospital stay were ASA score of 3 or 4 (odds ratio [OR] = 4.610, P = 0.0002) and preoperative hospital stay (OR = 0.151 per day, P = 0.001). Independent predictors of duration of preoperative hospital stay were emergency admission to hospital (OR = 9.516, 95% CI 5.770-13.261, P < 0.0001) and an underlying malignant pathology (OR = 7.948, 95% CI 3.623-12.273, P = 0.0004). Advanced laparoscopic surgery is associated with a short postoperative hospital stay in the majority of patients. Prolongation of the postoperative hospital stay (more than 3 days) may be expected if the patient had been in the hospital with an acute or malignant disease for more than 6 days prior to surgery and in patients with high comorbidity. The duration of surgery has no impact on the duration of the postoperative hospital stay.

Laparoscopic TME: better vision, better results?

One of the most controversial discussions on laparoscopic surgery deals with the question of whether to apply this technique to malignant disease and specifically to rectal cancer. The four major issues are the adequacy of oncologic resection, recurrence rates and patterns, long-term survival and quality of life. There is evidence, from nonrandomized studies, suggesting that margins of excision and lymph node harvest achieved laparoscopically reached comparable results to those known from conventional open resection. Our own experience of laparoscopic surgery on rectal cancer is based on 52 patients treated with curative intent. Focusing on the postoperative long-term run, we gained the following results: The median age of patients was 66.7 years and ranged from 42-88. Anastomotic leakage was seen in 6.1% of cases. In a median follow-up of 48 months (36-136), we reached an overall 3-year survival rate of 93% and a 5-year survival rate of 62%. Local recurrence was 1.9%, distant metastasis occurred in 11.5% of cases. We saw no port-site metastasis. To evaluate functional results following laparoscopic surgery a matched pair analysis was carried out. Matching of patients after laparoscopic and conventional open surgery was performed according to sex, age, type of resection, time period of surgery, and stage of disease classified by UICC. Regarding bladder and sexual dysfunction, using the EORTC QLQ CR38 score we found no statistical significant difference between the examined groups. As far as can be seen, laparoscopic surgery in rectal carcinoma may achieve the same or, in selected patients, even better results than open surgery. However, at present no published study has shown much evidence. Many more studies are necessary to define the place of laparoscopic technique in rectal cancer surgery, regarding appropriate selection of patients and evaluating adjuvant or neoadjuvant treatment in combination with the laparoscopic approach.

Laparoscopic resection of colon Cancer: Consensus of the European Association of Endoscopic Surgery (EAES)

BACKGROUND

The European Association of Endoscopic Surgery (EAES) initiated a consensus development conference on the laparoscopic resection of colon cancer during the annual congress in Lisbon, Portugal, in June 2002.

METHODS

A systematic review of the current literature was combined with the opinions, of experts in the field of colon cancer surgery to formulate evidence-based statements and recommendations on the laparoscopic resection of colon cancer.

RESULTS

Advanced age, obesity, and previous abdominal operations are not considered absolute contraindications for laparoscopic colon cancer surgery. The most common cause for conversion is the presence of bulky or invasive tumors. Laparoscopic operation takes longer to perform than the open counterpart, but the outcome is similar in terms of specimen size and pathological examination. Immediate postoperative morbidity and mortality are comparable for laparoscopic and open colonic cancer surgery. The laparoscopically operated patients had less postoperative pain, better-preserved pulmonary function, earlier restoration of gastrointestinal function, and an earlier discharge from the hospital. The postoperative stress response is lower after laparoscopic colectomy. The incidence of port site metastases is <1%. Survival after laparoscopic resection of colon cancer appears to be at least equal to survival after open resection. The costs of laparoscopic surgery for colon cancer are higher than those for open surgery.

CONCLUSION

Laparoscopic resection of colon cancer is a safe and feasible procedure that improves short-term outcome. Results regarding the long-term survival of patients enrolled in large multicenter trials will determine its role in general surgery.