Effects of laparoscopic surgery on the patterns of death in elderly colorectal cancer patients: competing risk analysis compared with open surgery

Laparoscopic and robotic surgery for colorectal cancer in older patients: a systematic review and meta-analysis

INTRODUCTION

As life expectancy has been increasing, older patients are becoming more central to the healthcare system, leading to more intensive care use and longer hospital stays. Nevertheless, advancements in minimally invasive surgical techniques offer safe and effective options for older patients with colorectal diseases. This study aims to provide comprehensive evidence on the role of minimally invasive surgery in treating colorectal diseases in older patients.

MATERIAL AND METHODS

All articles directly compared the minimally invasive approach with open surgery in patients aged ≥65 years. The present metanalysis took 30-day complications as primary outcomes. Length of hospital stay, readmission, and 30-day mortality were also assessed, as secondary outcomes. Further subgroup analyses were carried out based on surgery setting, lesion features, and location.

RESULTS

After searching the main databases, 84 articles were included. Evaluation of 30-day complications rate, length of hospital stay, and 30-day mortality significantly favored minimally invasive approaches. The outcome readmission did not show any significant difference.

CONCLUSIONS

The current metanalysis demonstrates clear advantages of minimally invasive techniques over open surgery in colorectal procedures for older patients, particularly in reducing complications, mortality, and hospitalization. This suggests that prioritizing these techniques, based on available expertise and facilities, could improve outcomes and quality of care for older patients undergoing colorectal surgery.

EAES/SAGES evidence-based recommendations and expert consensus on optimization of perioperative care in older adults

BACKGROUND

As the population ages, more older adults are presenting for surgery. Age-related declines in physiological reserve and functional capacity can result in frailty and poor outcomes after surgery. Hence, optimizing perioperative care in older patients is imperative. Enhanced Recovery After Surgery (ERAS) pathways and Minimally Invasive Surgery (MIS) may influence surgical outcomes, but current use and impact on older adults patients is unknown. The aim of this study was to provide evidence-based recommendations on perioperative care of older adults undergoing major abdominal surgery.

METHODS

Expert consensus determined working definitions for key terms and metrics related to perioperative care. A systematic literature review and meta-analysis was performed using the PubMed, Embase, Cochrane Library, and Clinicaltrials.gov databases for 24 pre-defined key questions in the topic areas of prehabilitation, MIS, and ERAS in major abdominal surgery (colorectal, upper gastrointestinal (UGI), Hernia, and hepatopancreatic biliary (HPB)) to generate evidence-based recommendations following the GRADE methodology.

RESULT

Older adults were defined as 65 years and older. Over 20,000 articles were initially retrieved from search parameters. Evidence synthesis was performed across the three topic areas from 172 studies, with meta-analyses conducted for MIS and ERAS topics. The use of MIS and ERAS was recommended for older adult patients particularly when undergoing colorectal surgery. Expert opinion recommended prehabilitation, cessation of smoking and alcohol, and correction of anemia in all colorectal, UGI, Hernia, and HPB procedures in older adults. All recommendations were conditional, with low to very low certainty of evidence, with the exception of ERAS program in colorectal surgery.

CONCLUSIONS

MIS and ERAS are recommended in older adults undergoing major abdominal surgery, with evidence supporting use in colorectal surgery. Though expert opinion supported prehabilitation, there is insufficient evidence supporting use. This work has identified evidence gaps for further studies to optimize older adults undergoing major abdominal surgery.

Long-term outcomes in elderly patients after elective surgery for colorectal cancer within an ERAS protocol: a retrospective analysis

PURPOSE

The number of elderly patients with a diagnosis of colorectal cancer (CRC) is increasing. Considering short life expectancy and multiple comorbidities, surgery may not always be the best treatment option.

METHODS

We included all consecutive patients aged 80 years and older who underwent elective resection for CRC following Enhanced Recovery after Surgery (ERAS) protocol between January 2011 and May 2021. The primary endpoint was overall survival, secondary endpoints were 30-day morbidity, and the rate of return to pre-operative living conditions 3 months after surgery.

RESULTS

Ninety-four patients were included. Mean age was 84.6 ± 3.6 years, 49 patients (52%) were female. Most patients (77.6%) were ASA score ≥ 3. Laparoscopic resections were performed in 85 patients (90.4%), involving 69 (73.4%) colonic and 25 (26.6%) rectal resections. A stoma was constructed in 22 patients (23%), and reversed in 12 (54.5%). Twenty-two patients (23.4%) experienced a Clavien-Dindo ≥ 3 complication, and 2 patients (2.1%) died. The median length of hospital stay was 8 (interquartiles: 6-15) days. Sixty-six patients (70.2%) were discharged home directly and 26 (27.7%) to rehabilitation or postacute care institutes. At three months after surgery, eighty-two patients (96.5%) returned to their pre-operative living conditions directly or after short-term rehabilitation. Mean follow-up was 53 ± 33 months, estimated 5-year overall survival was 60.3% (95%CI 49.5-71.1%), and disease-free survival was 86.3% (95%CI 78.1-94.4%).

CONCLUSIONS

Our study suggests that elderly patients undergoing elective surgery have a high potential to return to preoperative living conditions and good overall- and disease-free survivals, despite significant postoperative morbidity.

Decreasing Postoperative Pulmonary Complication Following Laparoscopic Surgery in Elderly Individuals with Colorectal Cancer: A Competing Risk Analysis in a Propensity Score-Weighted Cohort Study

Simple Summary

As the effect of laparoscopic surgery on elderly patients with colorectal cancer (CRC) remains unclear, this propensity score–weighted cohort study revealed that laparoscopic surgery is a favorable method for elderly patients with CRC than open surgery in terms of less pulmonary-related postoperative morbidity and mortality, less hospital stay and similar oncological outcomes.

Abstract

Advanced age is a risk factor for major abdominal surgery due to a decline in physical function and increased comorbidities. Although laparoscopic surgery provides good results in most patients with colorectal cancer (CRC), its effect on elderly patients remains unclear. This study aimed to compare the short- and long-term outcomes between open and laparoscopic surgeries in elderly patients with CRC. Total 1350 patients aged ≥75 years who underwent curative resection for stage I–III primary CRC were enrolled retrospectively and were divided into open surgery (846 patients) and laparoscopy (504 patients) groups. After propensity score weighting to balance an uneven distribution, a competing risk analysis was used to analyze the short-term and long-term outcomes. Postoperative mortality rates were lower in the laparoscopy group, especially due to pulmonary complications. Postoperative hospital stay was significantly shorter in the laparoscopy group than in the open surgery group. Overall survival, disease-free survival, and competing risk analysis showed no significant differences between the two groups. Laparoscopic surgery for elderly patients with CRC significantly decreased pulmonary-related postoperative morbidity and mortality in this large cohort study. Laparoscopic surgery is a favorable method for elderly patients with CRC than open surgery in terms of less hospital stay and similar oncological outcomes.

Long-term outcomes of laparoscopic surgery in elderly patients with colorectal cancer: A single institutional matched case-control study

INTRODUCTION

The number of elderly patients with colorectal cancer has gradually increased. Laparoscopic colorectal surgery is widely used to approach colorectal cancer. The aim of this study was to evaluate long-term outcomes in octogenarians who underwent laparoscopic colorectal surgery for colorectal cancer.

METHODS

This study included 158 patients aged 80 or over who underwent surgery for colorectal cancer between 2010 and 2015. We compared long-term outcomes of a laparoscopic colorectal surgery group with those of an open colorectal surgery group by propensity score matching equalizing factors that could affect prognosis such as prognostic nutritional index and Charlson comorbidity index score.

RESULTS

Forty-eight pairs were selected after propensity score matching. The cancer-specific 5-year survival rate was 97.1% in the laparoscopic colorectal surgery group and 87.6% in the open colorectal surgery group (P = .17). The overall 5-year survival rate was 77.3% in the laparoscopic colorectal surgery group and 73.9% in the open colorectal surgery group (P = .32). The 5-year recurrence-free survival rate was 95.1% in the laparoscopic colorectal surgery group and 85.4% in the open colorectal surgery group (P = .14).

CONCLUSION

Laparoscopic colorectal surgery for octogenarians with colorectal cancer achieves similar oncological outcomes to open colorectal surgery and should be considered as a treatment option.

Should we resect colorectal cancer in patients over the age of 85?

BACKGROUND

The prevalence of colorectal cancer in the elderly is rising, with increasing numbers of older patients undergoing surgery. However, there is a paucity of information on the surgical outcomes and operative techniques used in this population.

AIM

To evaluate the post-operative outcomes for patients ≥ 85 years old following colorectal cancer resection as well as evaluating the outcomes of laparoscopic resection of colorectal cancer in patients over 85.

METHODS

Patients who underwent colorectal cancer resection at our institution between January 2010 and December 2018 were included. The study was divided into two parts. For part one, patients were divided into two groups based on age: Those age ≥ 85 years old (n = 48) and those aged 75-84 years old (n = 136). Short term surgical outcomes and clinicopathological features were compared using appropriate parametric and non-parametric testing. For part two, patient’s over 85 years old were divided into two groups based upon operative technique: Laparoscopic (n = 37) vs open (n = 11) colorectal resection. Short-term post-operative outcomes of each approach were assessed.

RESULTS

The median length of stay between patients over 85 and those aged 75-85 was eight days, with no statistically significant difference between the groups (P = 0.29). No significant difference was identified between the older and younger groups with regards to severity of complications (P = 0.93), American Society of Anaesthesiologists grading (P = 0.43) or 30-d mortality (2% vs 2%, P = 0.96). Patients over 85 who underwent laparoscopic colorectal resection were compared to those who underwent an open resection. The median length of stay between the groups was similar (8 vs 9 d respectively) with no significant difference in length of stay (P = 0.18). There was no significant difference in 30-d mortality rates (0% vs 9%, P = 0.063) or severity of complication grades (P = 0.46) between the laparoscopic and open surgical groups.

CONCLUSION

No significant short term surgical differences were identified in patients ≥ 85 years old when compared to those 75-85 years old. There is no difference in short term surgical outcomes between laparoscopic or open colorectal resections in patients over 85.

The clinical features, management, and survival of elderly patients with colorectal cancer

Background

As the population ages, the number of elderly patients with colorectal cancer is increasing year by year. However, older people have rarely been the focus of studies on colorectal cancer. Therefore, in the present study, we aimed to carry out a retrospective analysis of this patient subgroup.

Methods

A retrospective study of clinical data of patients aged over 80 years who died from colorectal cancer in our hospital between 1993 and 2020 was performed. Logistic regression, the Kaplan-Meier method, and a multivariate Cox proportional hazards model were used to analyze the overall survival and treatment outcomes of the patients.

Results

A total of 87 patients were included in the study. The overall median survival was 45 months. In most patients, the primary lesion was located in the right colon. One-quarter of the patients refused to accept any treatment. Patients with stage IV tumors, who accounted for the largest proportion of the study population, displayed a higher rate of abandoning treatment than did patients of other stages. Almost all patients with stages II and III accepted surgery. Patients who underwent surgery to treat their colorectal cancer had longer survival than those who did not.

Conclusions

Old age should not be a reason for giving up treatment for colorectal cancer. The treatment of colorectal cancer patients aged 80 years and above requires individualized evaluation and more aggressive treatment to achieve greater benefits.

Long-term results of a randomized study comparing open surgery and laparoscopic surgery in elderly colorectal cancer patients (Eld Lap study)

BACKGROUND

We reported favorable short-term results of laparoscopic surgery in a randomized study comparing open and laparoscopic surgery for elderly patients with colorectal cancer (CRC). The purpose of this study is to clarify the long-term outcomes of the laparoscopic surgery for elderly patients with CRC.

METHODS

The inclusion criteria were ≥ 75 years, adenocarcinoma, ≤ T4a, M0 and elective surgery. The patients were randomly allocated to open or laparoscopic surgery according to the tumor location. The survival rates, recurrence and reasons for death were compared.

RESULT

One hundred patients (right colon 43, left colon 28, rectum 29) were included in each group. Eight patients who underwent open surgery and 2 patients who underwent laparoscopic surgery were excluded from the analysis because of metastatic diseases and other malignancies found during the operations. One hundred ninety patients (98 open, 98 laparoscopic) were analyzed. There was no difference in the backgrounds excluding more patients with vascular invasion in the laparoscopic rectal cancer. There were no differences in the 5-year overall survival rate (open vs. laparoscopic; 78.9% vs. 82.1%, p = 0.638), 5-year disease-free survival rate (70.5% vs. 62.8%, p = 0.276), 5-year recurrence-free survival rate (76.1% vs. 72.1%, p = 0.419), or 5-year cancer-specific survival rate (86.1% vs. 80.5%, p = 0.208). No differences in survival were detected in the analyses of stage and tumor location. There was no significant difference in the overall recurrence rate or recurrence site. However, distant lymph node metastases and local recurrences were more common after laparoscopic surgery than after open surgery. There was no difference in the cause of death. More than half of the patients died from other diseases in both groups (57.9% vs. 52.6%, p = 0.765).

CONCLUSION

Laparoscopic surgery showed similar long-term results compared to open surgery in elderly patients with CRC. Laparoscopic surgery is an effective surgical procedure for elderly patients with CRC.

Clinical outcomes of preoperative chemoradiotherapy in octogenarian with locally advanced rectal cancer

The number of elderly patients who receive surgical treatment for rectal cancer has gradually increased with aging of the population. In recent years, preoperative chemoradiotherapy, followed by surgical treatment, has been widely used for treating patients with locally advanced rectal adenocarcinoma. The aim of the present study was to evaluate if preoperative chemoradiotherapy is efficacious and safe for the treatment of rectal cancer in patients older than 80 years. A total of 293 patients with rectal cancer, who received preoperative chemoradiotherapy from 2007 to 2017, were studied. Comorbidities and the short- and long-term outcomes in elderly patients (aged ≥80 years old) were investigated and compared to younger patients. The elderly group comprised of 17 patients (5.8%). Pulmonary disease was the most common comorbidity (23.5%). No significant difference between the two groups regarding the rate of completeness of chemoradiotherapy was detected (P=0.26). Curative resection was performed in 14 patients in the elderly group and 252 patients in the younger group. Among 7 patients from both groups who could not receive curative resection due to their poor general condition, 4 patients had decreased lower respiratory function due to pneumonia (3 patients) or chronic obstructive pulmonary disease (1 patient). Morbidity and mortality rates were similar in elderly and younger groups (35.7% vs. 27.0%, 0% vs. 0%, respectively; P=0.54, P=1.00). No significant difference was found regarding recurrence between the two groups (P=1.00). To conclude, preoperative chemoradiotherapy in elderly patients with rectal cancer is safe and well tolerated.

Long-term outcomes of laparoscopy vs. open surgery for colorectal cancer in elderly patients: A meta-analysis

The long-term outcome of laparoscopic surgery for geriatric patients with colorectal cancer remains unclear due to decreased functional reserves and increased medical comorbidities. A meta-analysis was performed in the present study to compare the long-term outcome between laparoscopy and laparotomy. Randomized controlled trials and comparative studies regarding laparoscopy vs. open surgery for colorectal cancer in elderly patients were searched in Pubmed, Embase, and Cochrane library between inception and April 20, 2017. The methodological quality of the cohort studies was evaluated using the Newcastle-Ottawa Scale. The meta-analysis was performed using Stata v12.0 software. Eight cohort studies were enrolled in the meta-analysis. Laparoscopic surgery was associated with a higher 3-year survival rate compared with open surgery [risk ratio (RR), 0.74; 95% confidence interval (CI), 0.61–0.90; P=0.003]. No significant difference was identified between laparoscopy and laparotomy regarding the 5-year survival rate (RR, 0.93; 95% CI, 0.78–1.11, P=0.424). The results of the meta-analysis indicated that the use of laparoscopic surgery on geriatric patients with colorectal cancer should be increased due to more improved long-term outcomes. All the studies included in the meta-analysis were case-control studies with selection bias and other confounding factors. Thus, larger sample sizes and multicenter randomized controlled trials are required to further validate the use of laparoscopic surgery as the preferred therapeutic option for elderly patients with colorectal cancer.

Safety of laparoscopic surgery for colorectal cancer in patients over 80 years old: a propensity score matching study

PURPOSES

To establish the safety of laparoscopic-assisted colorectal resection for colorectal cancer in elderly patients aged ≥80 years.

METHODS

Data were obtained from a chart review of patients who underwent colorectal cancer resection between 2009 and 2014 in Kochi Medical School. The effect of patient age on the extent of lymph node dissection and operative safety was assessed by comparing the short-term results of elderly patients with those of younger patients after propensity score matching.

RESULTS

Of a total of 506 patients with colorectal cancer, 398 underwent laparoscopic surgery and 23% of these patients were aged ≥80 years old. The elderly patients tended to have poorer general condition and larger tumors, although no significant differences were found in tumor invasion, lymph node metastasis, or synchronous distant metastasis between the groups. After adjustment for preoperative factors, we noted that the elderly patients tended to undergo less aggressive surgical resection (P = 0.01). Further analysis after including surgical factors for propensity score matching revealed a similar rate of complications in the two groups (24 vs. 25%, respectively; P = 0.85), and similar postoperative death rates and length of postoperative hospital stay.

CONCLUSION

The findings of the present study demonstrate that laparoscopic surgery for colorectal cancer should not be avoided based on simply the age of the patient.

Short-Term Outcomes of Colorectal Resection for Cancer in Elderly in the Era of Enhanced Recovery

BACKGROUND AND AIMS

Early rehabilitation protocols should be assessed in elderly. We aimed to study the outcomes of colorectal surgery and the observance of the modalities of an early rehabilitation protocol in patients over 80 years.

MATERIAL AND METHODS

All consecutive patients who underwent surgery for colorectal cancer in our center over a 19-month period were included. All of these patients were managed using the same early rehabilitation protocol. Patients older than 80 were compared to younger patients.

RESULTS

A total of 173 patients were included and 36 were ≥80 years (20.8%). Patients aged ≥80 years had a significantly higher ASA score and were operated on in emergency. In the peroperative period, patients aged ≥80 years were more likely to undergo laparotomy than patients <80 years in univariate analysis (p = 0.048), but in multivariate analysis, the choice for a laparoscopy was influenced by ASA score ≤2 (odds ratio = 3.55, 95% confidence interval = 1.67-7.58) and emergency surgery (odds ratio = 0.18, 95% confidence interval = 0.06-0.50). In the postoperative period, peristalsis stimulation and vascular catheter ablation were significantly better followed in Group 1 (p = 0.012 and 0.031). However, in multivariate analysis, age was not significantly associated with these parameters. Peristalsis stimulation was influenced by ASA score ≥2 (odds ratio = 4.27, 95% confidence interval = 1.18-15.37) and vascular catheter ablation was also influenced by ASA score ≤2 (odds ratio = 2.63, 95% confidence interval = 1.33-5.21). Emergency surgery had a strong trend to influence these parameters (p = 0.08).

CONCLUSION

Although age or comorbidities may affect observance for certain modalities such as chewing gum use and vascular catheter ablation, an early rehabilitation protocol can be used after colorectal cancer surgery in patients ≥80 years old, where it would improve functional results and postoperative outcomes.

The short-term outcomes of laparoscopic multivisceral resection for locally advanced colorectal cancer: our experience of 39 cases

PURPOSE

Laparoscopic surgery for locally advanced colorectal cancer suspected of direct invasion to adjacent organs or structures remains controversial because of its high conversion rate, inadequate oncologic clearance and surgical outcomes. This study retrospectively evaluated the short-term outcomes of laparoscopic multivisceral resection for colorectal cancer and investigated the factors influencing conversion to open surgery.

METHODS

Between 2010 and 2015, 39 patients who underwent laparoscopic multivisceral resection for colorectal cancer intraoperatively suspected of direct invasion to adjacent organs or structures were included. The conversion rate, resection margin status, surgical results, and morbidity and mortality rates were evaluated. We also investigated the factors influencing conversion.

RESULTS

The conversion rate was 28 %. The resection margin was negative in all cases. The median operative time was 247 min, and the median blood loss was 80 ml. The postoperative mortality rate was 0 %, and the morbidity rate was 28 %; complications of Grade 3 or more were observed in 2 patients (5 %). The factors influencing conversion were ≥2 adherent organs (p = 0.028) and clinical suspicion of direct invasion to adjacent organs (cT4b) (p = 0.076).

CONCLUSION

Laparoscopic multivisceral resection for colorectal cancer intraoperatively suspected of direct invasion to adjacent organs or structures is feasible in selected patients. Conversion is more likely with ≥2 adherent organs and cT4b.

Safety and efficacy of an "enhanced recovery after surgery" protocol for patients undergoing colon cancer surgery: a multi-institutional controlled study

PURPOSE

The aim of this multi-institutional study was to prospectively evaluate the safety and efficacy of an enhanced recovery after surgery (ERAS) protocol for colonic surgery.

METHODS

The subjects of this study were 320 patients with an American Society of Anesthesiologists (ASA) grade I or II physical status. Patients underwent elective open or laparoscopic colonic resection or high anterior resection between April 2011 and January 2014 at one of six institutions. Three hospitals implemented an ERAS protocol (n = 159), and three administered conventional care (n = 161). The primary outcome measure was the surgical complication rate.

RESULTS

Most operations, irrespective of group, were performed laparoscopically. The incidence of a surgical complication was 17.0 % in the ERAS group vs. 16.1 % in the conventional group (P = 0.842), in which several non-surgical complications also arose. Oral food intake was implemented earlier for the ERAS group vs. the conventional group, after a median (range) of 1 (1-31) vs. 3 (1-9) days for the ERAS vs. conventional care groups, respectively (P < 0.001). The median length of postoperative hospital stay was reduced by 5.5 days for the ERAS group, being 8.5 (5-41) vs. 14 (7-56) days for the ERAS vs. conventional care groups, respectively (P < 0.001).

CONCLUSION

This multi-institutional controlled study clearly demonstrated that an ERAS protocol was efficient, without increasing the complication risk.

Systematic review of laparoscopic vs open surgery for colorectal cancer in elderly patients

AIM: To verify the safety and validity of laparoscopic surgery for the treatment of colorectal cancer in elderly patients.

METHODS: A meta-analysis was performed of a systematic search of studies on an electronic database. Studies that compared laparoscopic colectomy (LAC) in elderly colorectal cancer patients with open colectomy (OC) were retrieved, and their short and long-term outcomes compared. Elderly people were defined as 65 years old or more. Inclusion criteria were set at: Resection of colorectal cancer, comparison between laparoscopic and OC and no significant difference in backgrounds between groups.

RESULTS: Fifteen studies were identified for analysis. LAC was performed on 1436 patients, and OC performed on 1810 patients. In analyses of short-term outcomes, operation time for LAC was longer than for OC (mean difference = 34.4162, 95%CI: 17.8473-50.9851, P < 0.0001). The following clinical parameters were lower in LAC than in OC: Amount of estimated blood loss (mean difference = -93.3738, 95%CI: -132.3437 to -54.4039, P < 0.0001), overall morbidity (OR = 0.5427, 95%CI: 0.4425-0.6655, P < 0.0001), incisional surgical site infection (OR = 0.6262, 95%CI: 0.4310-0.9097, P = 0.0140), bowel obstruction and ileus (OR = 0.6248, 95%CI: 0.4519-0.8638, P = 0.0044) and cardiovascular complications (OR = 0.4767, 95%CI: 0.2805-0.8101, P = 0.0062). In analyses of long-term outcomes (median follow-up period: 36.4 mo in LAC, 34.3 mo in OC), there was no significant difference in overall survival (mean difference = 0.8321, 95%CI: 0.5331-1.2990, P = 0.4187) and disease specific survival (mean difference = 1.0254, 95%CI: 0.6707-1.5675, P = 0.9209). There was also no significant difference in the number of dissected lymph nodes (mean difference = -0.1360, 95%CI: -4.0553-3.7833, P = 0.9458).

CONCLUSION: LAC in elderly colorectal cancer patients had benefits in short-term outcomes compared with OC except operation time. The long-term outcomes and oncological clearance of LAC were similar to that of OC. These results support the assertion that LAC is an effective procedure for elderly patients with colorectal cancer.