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

Practical considerations for colorectal cancer screening in older adults

Recent guidelines recommend that colorectal cancer (CRC) screening after age 75 be considered on an individualized basis, and discourage screening for people over 85 due to competing causes of mortality. Given the heterogeneity in the health of older individuals, and lack of data within current guidelines for personalized CRC screening approaches, there remains a need for a clearer framework to inform clinical decision-making. A revision of the current approach to CRC screening in older adults is even more compelling given the improvements in CRC treatment, post-treatment survival, and increasing life expectancy in the population. In this review, we aim to examine the personalization of CRC screening cessation based on specific factors influencing life and health expectancy such as comorbidity, frailty, and cognitive status. We will also review screening modalities and endoscopic technique for minimizing risk, the risks of screening unique to older adults, and CRC treatment outcomes in older patients, in order to provide important information to aid CRC screening decisions for this age group. This review article offers a unique approach to this topic from both the gastroenterologist and geriatrician perspective by reviewing the use of specific clinical assessment tools, and addressing technical aspects of screening colonoscopy and periprocedural management to mitigate screening-related complications.

Age and comorbidities do not affect short-term outcomes after laparoscopic rectal cancer resection in elderly patients. A multi-institutional cohort study in 287 patients

Postoperative complications and mortality rates after rectal cancer surgery are higher in elderly than in non-elderly patients. The aim of this study is to evaluate whether, like in open surgery, age and comorbidities affect postoperative outcomes limiting the benefits of a laparoscopic approach. Between April 2011 and July 2020, data of 287 patients with rectal cancer submitted to laparoscopic rectal resection from different institutions were collected in an electronic database and were categorized into two groups: < 75 years and ≥ 75 years of age. Perioperative data and short-term outcomes were compared between these groups. Risk factors for postoperative complications were determined on multivariate analysis, including age groups and previous comorbidities as variables. Seventy-seven elderly patients had both higher ASA scores (p < 0.001) and cardiovascular disease rates (p = 0.02) compared with 210 non-elderly patients. There were no significative differences between groups in terms of overall postoperative complications (p = 0.3), number of patients with complications (p = 0.2), length of stay (p = 0.2) and death during hospitalization (p = 0.9). The only independent variables correlated with postoperative morbidity were male gender (OR 2.56; 95% CI 1.53-3.68, p < 0.01) and low-medium localization of the tumor (OR 2.12; 75% CI 1.43-4.21, p < 0.01). Although older people are more frail patients, short-term postoperative outcomes in patients ≥ 75 years of age were similar to those of younger patients after laparoscopic surgery for rectal cancer. Elderly patients benefit from laparoscopic rectal resection as well as non-elderly patient, despite advanced age and comorbidities.

Impact of laparoscopic approach on the short-term outcomes of elderly patients with colorectal cancer: a nationwide Italian experience

INTRODUCTION

The laparoscopic approach is increasingly adopted in colorectal cancer surgery; however, its role in elderly patients is controversial. We sought to examine the relationship between age and short-term outcomes following laparoscopic surgery for colorectal cancer (CRC).

METHODS

Data of patients 65 + years old who underwent laparoscopic surgery for CRC between 2002 and 2014 were retrieved from the administrative National Italian Hospital Discharge Dataset. Patients were divided into three age categories (65-74, 75-84, and 85  +). The impact of age on length of stay, 30-day readmission, in-hospital mortality, and postoperative complications was evaluated.

RESULTS

During the study period, 47,704 patients underwent laparoscopic surgery for CRC. The median postoperative length of stay was 9 days, and 30-day readmission and in-hospital mortality were 4.4% and 0.9%, respectively. Age was found to be an independent risk factor of prolonged length of stay and increased in-hospital mortality. With respect to patients in 65-74 years age category, patients aged 75-84 years and those aged 85 + years had a higher risk of complications (OR 1.43, 95% CI 1.36-1.50, and OR 2.00, 95% CI 1.83-2.17, respectively). However, no statistically significant association was found between age and anastomotic leakage or surgical site infection (p = 0.29, and p = 0.58, respectively).

CONCLUSIONS

In patients with CRC who underwent laparoscopic surgery, age was found to be an independent risk factor for prolonged length of stay, in-hospital mortality, and global postoperative complications. These findings should be considered when planning laparoscopic surgery in elderly patients.

Minimizing the impact of colorectal surgery in the older patient: The role of minimally invasive surgery in the geriatric population

With an aging population comes a greater incidence of colorectal cancer and a corresponding need for surgical resection in the geriatric population. This heterogeneous group of patients may benefit from multidisciplinary pre-operative evaluation and optimization, prehabilitation, enhanced recovery protocols, and a minimally invasive approach to resection. Concerns regarding the ability of the older patient to tolerate the physiologic demands of pneumoperitoneum have not been validated. Conversely, these vulnerable patients may experience a greater reduction in morbidity than their younger counterparts through the use of minimally invasive techniques.

Does an extreme age (≥80 years) affect outcomes in patients after liver cancer surgery? A meta-analysis

BACKGROUND

Increasing global life expectancy has resulted in a greater demand for cancer surgery in aged patients. However, whether extreme age causes poorer clinical outcomes remains unclear. This meta-analysis aimed to evaluate the impact of extreme age (≥80 years) on outcomes in patients after liver cancer surgery.

METHODS

A systematic search was performed to enrol relevant studies. Data were analysed using fixed-effects or random-effects models. Eight retrospective studies involving 253 participants older than 80 years were included.

RESULTS

Compared with younger patients, patients of extreme age (≥80 years) who had undergone curative liver cancer surgery experienced less operating time and blood loss (both P < 0.0001); a larger size (weighted mean difference = 0.48 cm, 95% confidence interval (CI) 0.08-0.87 cm; P = 0.02) and more advanced stage of hepatocellular carcinoma (risk ratio (RR) = 1.20, 95% CI 1.04-1.39; P = 0.01); a higher overall morbidity (RR = 1.24, 95% CI 1.05-1.47; P = 0.01); and more post-operative ileus (POI) (RR = 3.45, 95% CI 1.03-11.56; P = 0.04), delirium (RR = 3.04, 95% CI 1.36-6.78; P = 0.007) and cardiovascular events (RR = 6.17, 95% CI 2.79-13.60; P < 0.00001). No significant difference was noted in overall (hazard ratio (HR) = 1.15, 95% CI 0.87-1.53; P = 0.32) or disease-free (HR = 0.96, 95% CI 0.75-1.24; P = 0.77) survival.

CONCLUSION

Although an extreme age may not be a contraindication for undertaking liver cancer surgery, it may cause more morbidity. Perioperative intervention should be considered for prevention and early treatment of POI, delirium and cardiovascular events.

Identification of factors predictive of postoperative morbidity and short-term mortality in older patients after colorectal carcinoma resection: A single-center retrospective study

OBJECTIVES

The aim of this study is to investigate the effect of age on patient outcome after colorectal carcinoma (CRC) resection in patients over 65 years of age.

METHODS

This study included patients aged 65 years and older who underwent CRC resection between 2003 and 2013 at a single-center institution. Patients were divided into two groups: Group A (65-74 years old) and Group B (≥75 years old).

RESULTS

Multivariable logistic analysis of 415 patients revealed serum albumin levels on the third postoperative day (POD) (Odds Ratio (OR), 0.44; 95% CI, 0.21-0.94; P = 0.03) and C-reactive protein (CRP) levels (OR, 1.05; 95% CI, 1.00-1.01; P = 0.04) in patients with colon cancer as predictive factors for morbidity. In addition, the multivariable logistic analysis revealed serum albumin levels (OR, 0.27; 95% CI, 0.08-0.87; P = 0.03) in patients with rectal cancer as predictive factors for morbidity. The multivariate Cox Proportional Hazards Model identified re-intervention for colon cancer (Hazard Ratio (HR), 4.57; 95% CI, 1.36-15.4 P = 0.01) and for rectal cancer (HR, 11.8; 95% CI, 1.08-129 P = 0.04) as a predictive factor for 30-day mortality. Serum albumin level on the third POD was predictive of 30-day mortality (HR, 0.30; 95% CI, 0.13-0.71; P = 0.01) and of 1-year mortality (HR, 0.34; 95% CI, 0.17-0.66; P < 0.01) in patients with colon cancer.

CONCLUSION

Age is not predictive of postoperative morbidity and mortality in patients with CRC. Serum albumin levels on the third POD can predict morbidity and mortality for colon and rectal carcinoma in older patients undergoing colorectal resections.

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

Long-term outcomes and propensity score matching analysis: rectal cancer resection for patients with elevated preoperative risk

BACKGROUND

It is still controversial about the treatment strategy for rectal cancer patients with elevated operative risk and elder rectal cancer patients.

METHODS

This study presented a retrospective single center experience in rectal cancer proctectomy for high operative risk patients. High operative risk patient was defined as Cr-POSSUM > 5% combined with associated risk factors. 220 in 1477 consecutive patients met the inclusion criteria.

RESULTS

132 patients were selected (66:66) after propensity score matching. The total complication rate between conventional open rectal resection (71 %) and laparoscopic surgery (41%) was significantly different (p = 0.0005). There is a significantly positive correlation between open surgery and advanced Dindo Classification (p = 0.02). Cr-POSSUM is positively correlated with Dindo Classification (p = 0.01). There was no significant difference in survival rate among stage I∼II, different age groups or different Cr-POSSUM score sub-groups. However, stage III-IV tumor patients in laparoscopic group experienced improved overall survival rate. (p < 0.0001). For patients with preoperative pulmonary or renal disease, patients in laparoscopic group also had better long term prognosis (p = 0.03, p = 0.049).

CONCLUSIONS

The results demonstrate the potential advantages of laparoscopic rectal cancer resection for high operative risk patients, especially for the patients with preoperative respiratory or renal disease and stage III cancer.

Impact of octogenarians on surgical outcome in colorectal cancer

AIM

Colorectal cancer's (CRC) incidence occupies the second place among malignant tumours in men and the third place in women. The aging of the population raises new questions on the management of CRC in octogenarian patients. The objective of this study was to assess the influence of age (≥80) on treatment and surgical outcome of colorectal cancer.

METHOD

In the period between October 1995 and April 2014, a total of 1397 patients underwent emergency and elective surgical interventions for CRC; the first group (Group-Older - GO) was composed of 291 patients 80 years or older (20.9%, of which 46.4% were male). The second group (Group-Younger - GY) included 1106 patients younger than 80 years (79,1%, 57.7% males).

RESULTS

Significant differences between the two groups were observed regarding sex (p = 0.001), number of comorbidities (p = 0.001), ASA classification (p < 0.001), emergency presentation (p < 0.001), site of tumor (p = 0.010), need of intraoperative blood transfusions (p < 0.001), 30-days mortality (p < 0.001), 90-days mortality (p < 0.001) and morbidity in accordance with Clavien-Dindo classification (p < 0.001). When combining both elective and emergency procedures, multivariate logistic regression analysis showed that advanced age (≥80 years old) was an independent predictor factor of 30-days mortality (p = 0.023, OR = 2.23) and morbidity (p = 0.088, OR = 1.31), while it was not predictive of 90-days mortality. When considering only elective colorectal surgery, octogenarian age was not found to be a predictive factor of 30-day and 90-day mortality, but predictive of postoperative morbidity.

CONCLUSION

Old age (≥80) does not represent a contraindication to CRC elective surgical treatment, in emergency procedures it is associated with an increased risk of postoperative morbidity and mortality.

Is the benefit of laparoscopy maintained in elderly patients undergoing rectal cancer resection? An analysis of 446 consecutive patients

BACKGROUND

Several studies showed that age is significantly associated with impaired outcomes after open colorectal surgery. However, very few data exist on laparoscopic rectal cancer surgery in elderly patients. The aim of this study was to assess operative results of laparoscopic rectal cancer surgery according to age.

METHODS

From 2005 to 2014, 446 consecutive patients who underwent laparoscopic rectal cancer resection were identified from a prospective database. Five groups were defined: age <45 (n = 44), 45-54 (n = 80), 55-64 (n = 166), 65-74 (n = 95) and ≥75 years (n = 61).

RESULTS

Elderly patients presented significantly higher ASA score (p = 0.004), higher Charlson comorbidity index (p < 0.0001) and more frequent cardiovascular, pulmonary (p < 0.0001) and neurological (p = 0.03) comorbidities. Overall postoperative morbidity rate was similar between groups (34-35-37-43-43 %, p = 0.70). Medical morbidity slightly increased with age (14-9-14-19-26 %, p = 0.06), but there was no significant difference regarding clinical anastomotic leakage, surgical morbidity, major morbidity (Dindo ≥3), cardiopulmonary complications and length of hospital stay. In multivariate analysis, age was not an independent factor for postoperative morbidity, unlike ASA score ≥3 (p = 0.039), neoadjuvant radiotherapy/chemoradiotherapy (p = 0.034) and operative time ≥240 min (p = 0.013).

CONCLUSIONS

This study showed that laparoscopic rectal cancer resection might safely be performed irrespective of age.

Factors associated with postoperative complications and 1-year mortality after surgery for colorectal cancer in octogenarians and nonagenarians

Purpose

To identify the factors affecting 30-day postoperative complications and 1-year mortality after surgery for colorectal cancer in octogenarians and nonagenarians.

Methods

Between 2005 and 2014, a total of 204 consecutive patients aged ≥80 years who underwent major colorectal surgery were included.

Results

One hundred patients were male (49%) and 52 patients had American Society of Anesthesiologists (ASA) score ≥3 (25%). Combined surgery was performed in 32 patients (16%). Postoperative complications within 30 days after surgery occurred in 54 patients (26%) and 30-day mortality occurred in five patients (2%). Independent risk factors affecting 30-day postoperative complications were older age (≥90 years, hazard ratio [HR] with 95% confidence interval [CI] =4.95 [1.69−14.47], P=0.004), an ASA score ≥3 (HR with 95% CI =4.19 [1.8−9.74], P=0.001), performance of combined surgery (HR with 95% CI =3.1 [1.13−8.46], P=0.028), lower hemoglobin level (<10 g/dL, HR with 95% CI =7.56 [3.07−18.63], P<0.001), and lower albumin level (<3.4 g/dL, HR with 95% CI =3.72 [1.43−9.69], P=0.007). An ASA score ≥3 (HR with 95% CI =2.72 [1.15−6.46], P=0.023), tumor-node-metastasis (TNM) stage IV (HR with 95% CI =3.47 [1.44−8.39], P=0.006), and occurrence of postoperative complications (HR with 95% CI =4.42 [1.39−14.09], P=0.012) were significant prognostic factors for 1-year mortality.

Conclusion

Patient-related factors (older age, higher ASA score, presence of anemia, and lower serum albumin) and procedure-related factors (performance of combined surgical procedure) increased postoperative complications. Avoidance of 30-day postoperative complications may decrease 1-year mortality.

Challenge or opportunity: outcomes of laparoscopic resection for rectal cancer in patients with high operative risk

This study investigated the impact of laparoscopic rectal cancer resection for patients with high operative risk, which was defined as American Society of Anesthesiology (ASA) grades III and IV. This study was conducted at a single center on patients undergoing rectal resection from 2006 to 2010. After screening by ASA grade III or IV, 248 patients who met the inclusion criteria were identified, involving 104 open and 144 laparoscopic rectal resections. The distribution of the Charlson Comorbidity Index was similar between the two groups. Compared with open rectal resection, laparoscopic resection had a significantly lower total complication rate (P<.0001), lower pain rate (P=.0002), and lower blood loss (P<.0001). It is notable that the two groups of patients had no significant difference in cardiac and pulmonary complication rates. Thus, these data showed that the laparoscopic group for rectal cancer could provide short-term outcomes similar to those of their open resection counterparts with high operative risk. The 5-year actuarial survival rates were 0.8361 and 0.8119 in the laparoscopic and open groups for stage I/II (difference not significant), as was the 5-year overall survival rate in stage III/IV (P=.0548). In patients with preoperative cardiovascular or pulmonary disease, the 5-year survival curves were significantly different (P=.0165 and P=.0210), respectively. The cost per patient did not differ between the two procedures. The results of this analysis demonstrate the potential advantages of laparoscopic rectal cancer resection for high-risk patients, although a randomized controlled trial should be conducted to confirm the findings of the present study.

Personalized surgical management of colorectal cancer in elderly population

Colorectal cancer (CRC) in the elderly is extremely common but only a few clinicians are familiar with the complexity of issues which present in the geriatric population. In this phase of the life cycle, treatment is frequently suboptimal. Despite the fact that, nowadays, older people tend to be healthier than in previous generations, surgical undertreatment is frequently encountered. On the other hand, surgical overtreatment in the vulnerable or frail patient can lead to unacceptable postoperative outcomes with high mortality or persistent disability. Unfortunately, due to the geriatric patient being traditionally excluded from randomized controlled trials for a variety of factors (heterogeneity, frailty, etc.), there is a dearth of evidence-based clinical guidelines for the management of these patients. The objective of this review was to summarize the most relevant clinical studies available in order to assist clinicians in the management of CRC in the elderly. More than in any other patient group, both surgical and non-surgical management strategies should be carefully individualized in the elderly population affected by CRC. Although cure and sphincter preservation are the primary goals, many other variables need to be taken into account, such as maintenance of cognitive status, independence, life expectancy and quality of life.

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.

Comparative outcomes of rectal cancer surgery between elderly and non-elderly patients: a systematic review

Elderly people represent almost all patients diagnosed with and treated for rectal cancer, and this trend is likely to become more apparent in the future. Surgical management and treatment decisions for this disease are becoming increasingly complex, but only a few reports deal specifically with older patients. In this systematic review, we provide an overview of published studies of outcomes after curative surgery for rectal cancer in elderly people (>70 years). We identified 48 studies providing information about postoperative results, survival, surgical approach, stoma formation, functional results, and quality of life after rectal resection for cancer. We found that advanced chronological age should not, by itself, exclude patients from curative rectal surgery or from other surgical options that are available for younger patients. Although overall survival is lower in elderly patients than in younger patients, cancer-specific survival does not decrease with age. However, the level of evidence for most studies was weak, emphasising the need for high-quality clinical trials for this population.

Postoperative morbidity after fast-track laparoscopic resection of rectal cancer

AIM

Analysis was carried out of the nature and chronological order of early complications after fast-track laparoscopic rectal surgery with a view to optimizing the short-time outcome of rectal cancer surgery.

METHOD

A total of 102 consecutive patients who underwent elective fast-track laparoscopic rectal cancer surgery were analysed prospectively from the Danish Colorectal Cancer Database supplemented by data from the medical records. We studied in detail the nature and chronological order of postoperative morbidity and reason for prolonged stay (> 5 days).

RESULTS

Twenty-five patients (25%) had one or more complications. Surgical complications occurred in 19 patients, while six patients had medical complications as the primary event. Fifteen patients underwent reoperation, three died, and eight were readmitted within 30 days. The median length of stay was 5 days (range 2-42).

CONCLUSION

Postoperative morbidity remains a significant problem in the fast-track era, even in experienced surgical hands. Our results suggest that besides improvement of surgical technique further improvement of outcome lies in early recognition and proper treatment of complications and the perioperative optimization of organ function.

Elective colonic surgery for cancer in the elderly: an investigation into postoperative mortality in English NHS hospitals between 1996 and 2007

BACKGROUND

This study was primarily aimed to quantify perioperative mortality risk in elderly patients undergoing elective colonic resectional surgery. In addition, the safety of minimally invasive colonic surgery in this patient group was evaluated.

METHODS

All patients aged > 75 undergoing elective colonic resection for colorectal malignancy between 1996 and 2007 in English NHS hospitals were included from the Hospital Episode Statistics (HES) dataset.

RESULTS

Between the study dates, 28,746 patients > 75 years underwent elective colonic resection. The national annual number of colonic excisions carried out amongst elderly patients increased from 2188 patients in 1996/7 to 3240 patients in 2006/7. Following adjustment for gender, comorbidity and surgical approach, advancing age was an independent predictor for 30-day mortality (OR 2.47 for patients aged 85-89 vs 75-79, P < 0.001). Use of laparoscopy was a significant predictor of reduced perioperative mortality (OR 0.56, P = 0.003) once adjusted for advancing age, gender and comorbidity. Comparison of 30-day and 1-year postoperative mortality following elective colonic resection in patients aged 90 revealed a large excess of patients dying outside of the immediate perioperative period (10.1% and 26.2% for proximal cancers, respectively; 12.9% and 36.1% for distal colonic resections, respectively).

CONCLUSIONS

Advancing age is an independent risk factor for postoperative death in elderly patients undergoing elective colonic resection for cancer. The risk of death in the elderly is extremely high and surgical decision-making should incorporate the mortality risk that occurs outside the immediate perioperative period. In this national series, patients selected for a laparoscopic procedure were at lower risk of perioperative death than those undergoing the conventional approach.

How reliable is laparoscopic colorectal surgery compared with laparotomy for octogenarians?

BACKGROUND

Due to the current increased longevity in the elderly population and the increased size of that population, major abdominal intervention is more frequently performed among octogenarians. This study aimed to compare the surgical and postoperative outcomes of laparoscopic colorectal resections with those of open surgery in the octogenarian population.

METHODS

Retrospective analysis based on a prospectively maintained database of octogenarians who underwent laparoscopic or open elective colorectal resections from 2001 to 2008 was performed. Diagnosis, comorbidities, operative data, and early postoperative complications are analyzed in this report.

RESULTS

Colon resection was performed for 199 octogenarians, using laparotomy for 116 patients (group 1) and laparoscopic surgery for 83 patients (group 2). The mean age was 84.3 years for the laparotomy patients and 84.7 years for the laparoscopic patients. The American Society of Anesthesiology (ASA) scores was comparable between groups 1 and 2. Colorectal adenoma was the most common indication for surgery in both groups: for 77.6% of the group 1 patients and 54.2% of the group 2 patients. Right colectomy was the most frequently performed operation in group 2: for 57.8% of the group 2 patients and 31% of the group 1 patients (p = 0.0003). Open resections had a higher mean blood loss in both group 1 (286 ml) and group 2 (152 ml) (p = 0.0002), and more patients required intraoperative transfusions (p = 0.005) despite similar operative times. The conversion rate in the laparoscopic group was 25.3%. The patients in the laparoscopic group had less morbidity, both overall and clinically, than the open group (p < 0.05). The median hospital stay was 8 days in group 1 and 6 days in group 2 (p = 0.0065). The rate of major surgical complications was similar in the two groups of patients: 6% in group 1 and 4.8% in group 2. The reoperation rate was 2.6% in group 1 and 3.6% in group 2 (p > 0.05). The mortality rate was 3.4% in group 1 and 2.4% in group 2.

CONCLUSIONS

Laparoscopic colorectal resection was effective and safe for octogenarians, with less blood loss and faster postoperative recovery. The morbidity rate is lower than for traditional laparotomy.

Postoperative complications in elderly patients with colorectal cancer: comparison of open and laparoscopic surgical procedures

BACKGROUND

Surgery is associated with higher morbidity and mortality rates in elderly patients with colorectal cancer compared with younger patients. The aim of this study was to examine preoperative evaluation for selecting operative procedure in elderly patients with colorectal cancer.

METHODS

The study of all patients who underwent open surgery (OS) or laparoscopically assisted surgery (LAS) for colorectal cancer from January 2004 to December 2007 were aged > or =71 years. Preoperative evaluation, operative factors, morbidity, and mortality were analyzed by the Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity (POSSUM) and Prognostic Nutritional Index (PNI).

RESULTS

A total of 129 patients were included in this study. Fifty-one patients underwent OS, and LAS was performed on 78 patients. The morbidity rate was 51.3% (40 patients) for the OS group and 23.5% (12 patients) for the LAS group. Three LAS patients (5.9%) subsequently required OS. One LAS patient died postoperatively. There were significant differences in the Operative Severity Score (OSS) in POSSUM and PNI, but not Physiologic Score (PS) in POSSUM, between the two groups. In the OS group, there were significant differences in PS, OSS, and PNI between those with or without complications, whereas in the LAS group, OSS, but not PS or PNI, was significantly lower in those without than in those with complications.

CONCLUSIONS

Compared with OS, LAS is associated with a lower incidence of complications in elderly patients with colorectal cancer. The nutritional status correlated with postoperative complications in the OS group.

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.

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).

Laparoscopic versus open colectomy for patients with American Society of Anesthesiology (ASA) classifications 3 and 4: the minimally invasive approach is associated with significantly quicker recovery and reduced costs

BACKGROUND

Conceivably, the benefits of earlier recovery associated with a minimally invasive technique used in laparoscopic colectomy (LC) may be amplified for patients with comorbid disease. The dearth of evidence supporting the safety of laparoscopy for these patients led to a comparison of outcomes between LC and open colectomy (OC) for patients with American Society of Anesthesiology (ASA) classifications 3 and 4.

METHODS

Data for all ASA 3 and 4 patients who underwent elective LC were reviewed from a prospectively maintained laparoscopic database. The patients who underwent LC were matched with OC patients by age, gender, diagnosis, year, and type of surgery. Estimated blood loss, operation time, time to return of bowel function, length of hospital stay, readmission rate, and 30-day complication and mortality rates were compared using chi-square, Fisher's exact, and Wilcoxon tests as appropriate. A p value <0.05 was considered statistically significant.

RESULTS

In this study, 231 LCs were matched with 231 OCs. The median age of the patients was 68 years, and 234 (51%) of the patients were male. There were 44 (19%) conversions from LC to OC. More patients in the OC group had undergone previous major laparotomy (5 vs. 15%; p < 0.001). Estimated blood loss, return of bowel function, length of hospital stay, and total direct costs were decreased in the LC group. Wound infection was significantly greater with OC (p = 0.02). When patients with previous major laparotomy were excluded, the two groups had similar overall morbidity. The other benefits of LC, however, persisted.

CONCLUSION

The findings show that LC is a safe option for patients with a high ASA classification. The LC approach is associated with faster postoperative recovery, lower morbidity rates, and lower hospital costs than the OC approach.

Laparoscopic resection for colorectal cancer in octogenarians: results in a decade

OBJECTIVES

This study was designed to evaluate the results of laparoscopic resection for colorectal cancer in octogenarians.

METHODS

Patients aged 80 years or older who underwent elective laparoscopic resection for colorectal cancer from July 1, 1996 to June 30, 2006 were recruited for analysis, with the following exceptions: 1) patients who did not give informed consent; 2) unfit for operative treatment; 3) presented as surgical emergencies; 4) multiple previous abdominal operations; or 5) locally advanced tumors. Operating time, blood loss, length of hospital stay, mortality and morbidities, including anastomotic dehiscence, pulmonary and wound sepsis, disease recurrence, and patient survival were used to measure outcome.

RESULTS

During a ten-year period, laparoscopic colorectal cancer resection was attempted in 101 octogenarians. The median age was 83 (range, 80-95) years and 45 patients were males. The median operating time was 110 (range, 60-245) minutes, with a median blood loss of 50 (range, 0-1,000) ml. Conversion was required in only one case with a leakage rate of 3.3 percent. The overall morbidity and operative mortality rate were 17 and 3 percent, respectively. With a median follow-up of 24 (range, 0-102) months, 22 patients developed recurrence, with 8 of those still surviving. The overall five-year survival is 51 percent.

CONCLUSIONS

Our experience confirms that laparoscopic colorectal cancer resection in selected octogenarians is safe and feasible. Aside from the obvious short-term benefits, the long-term oncologic outcomes are favorable.

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.