Feasibility and Outcomes of Surgical Therapy in Very Elderly Patients With Colorectal Cancer

Five-year survival in laparoscopically operated colorectal cancer patients based on own material: A comparison of risk factors

<b>Introduction:</b> The laparoscopic method is a treatment method with proven effectiveness. In 2008, we started treating patients with this method. We present treatment results in unselected patients. This is a retrospective observation.<b>Aim:</b> The present article demonstrates the results of a 5-year postoperative follow-up in a group of patients who underwent laparoscopic colorectal surgery. We also assessed the importance of basic risk factors such as tumor stage, age, gender, type of complication, and conversion requirement for the survival of patients.<b>Material and methods:</b> In total, 212 patients with colon or rectal cancer were subjected to a standard laparoscopic procedure. In the case of rectal and sigmoid tumors, a mini-laparotomy was performed in the left iliac fossa. In the case of right hemicolectomy, an anastomosis was created above the abdominal walls. The results were statistically processed. As many as 80% (171) of patients were followed up.<b>Results:</b> Overall survival was 66.08%, while cancer-related survival - 61.4%. The cancer recurrence rate was 21.47%. In a multivariate analysis: assuming the same age of diagnosis, an increase in tumor stage by one category according to Dukes causes a 102.532-fold increase in the risk of death within the first 5 years after surgery.<b>Conclusions:</b> The results of laparoscopic colorectal cancer treatment in our material are similar to those reported in the literature. The most important prognostic factor for the long-term survival of patients in our material was the stage of cancer.

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.

Assessing and managing frailty in emergency laparotomy: a WSES position paper

Many countries are facing an aging population. As people live longer, surgeons face the prospect of operating on increasingly older patients. Traditional teaching is that with older age, these patients face an increased risk of mortality and morbidity, even to a level deemed too prohibitive for surgery. However, this is not always true. An active 90-year-old patient can be much fitter than an overweight, sedentary 65-year-old patient with comorbidities. Recent literature shows that frailty-an age-related cumulative decline in multiple physiological systems, is therefore a better predictor of mortality and morbidity than chronological age alone. Despite recognition of frailty as an important tool in identifying vulnerable surgical patients, many surgeons still shun objective tools. The aim of this position paper was to perform a review of the existing literature and to provide recommendations on emergency laparotomy and in frail patients. This position paper was reviewed by an international expert panel composed of 37 experts who were asked to critically revise the manuscript and position statements. The position paper was conducted according to the WSES methodology. We shall present the derived statements upon which a consensus was reached, specifying the quality of the supporting evidence and suggesting future research directions.

Short-term and long-term outcomes after laparoscopic surgery for elderly patients with colorectal cancer aged over 80 years: a propensity score matching analysis

PURPOSE

There has been an increase in the percentage of elderly patients with colorectal cancer (CRC). However, few studies have reported the short- and long-term outcomes of laparoscopic surgery for elderly patients with CRC aged over 80 years.

METHODS

This study included 529 patients who underwent laparoscopic resection for clinical stage 0-III CRC at Kobe University Hospital between January 2010 and December 2018. Propensity score matching (PSM) was used to create balanced cohorts of the elderly (aged ≥ 80, n = 113) and the non-elderly (aged < 80, n = 113). Their clinical outcomes were compared after PSM.

RESULTS

After matching, carcinoembryonic antigen (CEA) level was higher in the non-elderly group, and adjuvant chemotherapy was less frequently employed in the elderly group. D3 dissection was performed more frequently and the number of the harvested lymph nodes tended to be larger in the non-elderly group. There was no significant difference in the rates of postoperative complications, reoperation within 30 days, and 30-day mortality between the groups. The 5-year relapse-free survival rate was not statistically different between the two groups (77.3% for the non-elderly vs. 62.7% for the elderly, p = 0.13). The multivariate analyses for the whole cohort showed that the factors of sex, tumor location, operation time, and conversion to open surgery, but not the age, were significant predictors of postoperative complications.

CONCLUSION

Laparoscopic surgery for colorectal cancer patients aged over 80 years is technically and oncologically safe.

Clinical and oncologic outcomes of laparoscopic versus open surgery in elderly patients with colorectal cancer: a retrospective multicenter study

BACKGROUND

Laparoscopic surgery is commonly used in elderly patients over 80 years old. The purpose of this study was to compare the perioperative and oncologic outcomes between laparoscopic surgery and open surgery in elderly patients with colorectal cancer.

METHODS

We retrospectively analyzed the medical records of patients aged ≥ 80 years who underwent curative resection of colorectal cancer at six Hallym University-affiliated hospitals. The perioperative outcomes and oncologic outcomes were compared between laparoscopic and open surgery RESULTS: Of 294 elderly patients, 104 (35.3%) underwent open surgery and 190 (64.7%) underwent laparoscopic surgery. The postoperative hospital stay (P = 0.019) and time to soft diet (P = 0.009) were shorter in the laparoscopic group than in the open group. Postoperative complications were less frequent in the laparoscopic group than in the open group (P < 0.001), including wound infection (P = 0.005), ileus (P = 0.005), and pneumonia (P = 0.001). The 3-year overall survival (OS) (P = 0.982) and recurrence-free survival rates (RFS) (P = 0.532) were similar in both groups. In multivariable analyses, positive lymph node status was the only independent factor associated with OS (P = 0.019) and RFS (P = 0.012). Laparoscopic surgery was not associated with OS (P = 0.874) and RFS (P = 0.772).

CONCLUSION

Laparoscopic surgery offers several perioperative advantages over open surgery and similar long-term oncological outcomes for elderly patients with colorectal cancer. Therefore, we suggest that laparoscopic surgery can be safely performed for the treatment of elderly patients (≥ 80 years old) with colorectal cancer.

Short-Term Outcome of Laparoscopic Surgery in Elderly Colorectal Cancer Patients

We aimed to evaluate the short-term outcome of colorectal resection in very elderly patients, aged 85 years or older. As the population ages, the number of elderly patients with colorectal cancer (CRC) is increasing in Japan. At this time, it is unclear whether or not laparoscopic colorectal resection is safe for this very elderly patient population. From January 2005 to November 2014, a total of 20 patients aged 85 years or older underwent laparoscopic colorectal resection at Osaka University Hospital. Pre- and postoperative clinical data and outcomes were collected retrospectively. There were no intraoperative or postoperative deaths. In 2 cases, the laparoscopic procedure was converted to open surgery. Postoperative complications occurred in 6 patients. Two patients developed an infection at the surgical site. Among the 4 patients who underwent low anterior resection (LAR), 2 experienced postoperative anastomotic leakage. Two other patients developed a lung infection and urinary tract infection, respectively. Laparoscopic colectomy for very elderly patients with CRC appears to involve tolerable risk. However, special caution is advisable for patients who may undergo LAR.

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.

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.

Indications for laparoscopic surgery for older rectal cancer patients with comorbidities

PURPOSE

Given the lack of safety studies concerning laparoscopic surgery for rectal cancer in patients ≥ 80 years old with comorbidities, we sought to investigate this in the current study.

METHODS

Between 2012 and 2019, 24 patients ≥ 80 years old underwent laparoscopic surgery for rectal cancer without preoperative treatment. These patients were divided into those with [comorbidity(+) group, n = 13] and without [comorbidity(-) group, n = 11] comorbidities. The preoperative nutritional status and ASA classification, postoperative complications, time to oral diet, and length of hospital stay were evaluated in each group.

RESULTS

In the comorbidity(+)/comorbidity(-) groups, the average age was 85.9/84.1 years old, respectively. The major comorbidities were heart disease including atrial fibrillation and valvular disorder. The average PNI and CONUT scores in the comorbidity(+)/comorbidity(-) groups were 44.7/44.2 an 3.1/2.2, respectively. Planned surgical procedures were completed in all patients. Postoperative complications occurred in 2/3 cases in the comorbidity(+)/comorbidity(-) groups, respectively, and the average time to oral diet was 3.8/3.7 days, while the average length of hospitalization after surgery was 15.2/16.5 days, respectively. In the comorbidity(+) group, there was no exacerbation of comorbidities in any cases.

CONCLUSION

The safety of laparoscopic surgery is acceptable among older rectal cancer patients with comorbidities.

Robotic vs laparoscopic right colectomy - the burden of age and comorbidity in perioperative outcomes: An observational study

BACKGROUND

Several studies have shown the safety, feasibility and oncologic adequacy of robotic right hemicolectomy (RRH). Laparoscopic right hemicolectomy (LRH) is considered technically challenging. Robotic surgery has been introduced to overcome this technical limitation, but it is related to high costs. To maximize the benefits of such surgery, only selected patients are candidates for this technique. In addition, due to progressive aging of the population, an increasing number of minimally invasive procedures are performed on elderly patients with severe comorbidities, who are usually more prone to post-operative complications.

AIM

To investigate the outcomes of RRH vs LRH with regard to age and comorbidities.

METHODS

We retrospectively analyzed 123 minimally invasive procedures (68 LRHs vs 55 RRHs) for right colon cancer or endoscopically unresectable adenoma performed in our Center from January 2014 until September 2019. The surgical procedures were performed according to standardized techniques. The primary clinical outcome of the study was the length of hospital stay (LOS) measured in days. Secondary outcomes were time to first flatus (TFF) and time to first stool evacuation. The robotic technique was considered the exposure and the laparoscopic technique was considered the control. Routine demographic variables were obtained, including age at time of surgery and gender. Body mass index and American Society of Anesthesiologists physical status were registered. The age-adjusted Charlson Comorbidity Index (ACCI) was calculated; the tumor-node-metastasis system, intra-operative variables and post-operative complications were recorded. Post-operative follow-up was 180 d.

RESULTS

LOS, TFF, and time to first stool were significantly shorter in the robotic group: Median 6 [interquartile range (IQR) 5-8] vs 7 (IQR 6-10.5) d, P = 0.028; median 2 (IQR 1-3) vs 3 (IQR 2-4) d, P < 0.001; median 4 (IQR 3-5) vs 5 (IQR 4-6.5) d, P = 0.005, respectively. Following multivariable analysis, the robotic technique was confirmed to be predictive of significantly shorter hospitalization and faster restoration of bowel function; in addition the dichotomous variables of age over 75 years and ACCI more than 7 were significant predictors of hospital stay. No outcomes were significantly associated with Clavien-Dindo grading. Sub-group analysis demonstrated that patients aged over 75 years had a longer LOS (median 6 -IQR 5-8- vs 7 -IQR 6-12- d, P = 0.013) and later TFF (median 2 -IQR 1-3- vs 3 -IQR 2-4- d, P = 0.008), while patients with ACCI more than 7 were only associated with a prolonged hospital stay (median 7 -IQR 5-8- vs 7 -IQR 6-14.5- d, P = 0.036).

CONCLUSION

RRH is related to shorter LOS when compared with the laparoscopic approach, but older age and several comorbidities tend to reduce its benefits.

How can we utilize local excision to help, not harm, geriatric patients with rectal cancer?

A majority of the morbidity and mortality burden of rectal cancer is distributed within the geriatric age group. Current surgical and medical treatment modalities pose significant challenges in treating complications specifically in the already pre-disposed senior population with baseline dysfunction. This chapter reviews the work-up, management, current data and oncologic outcomes of treating rectal cancer in the senior adult.

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.

Safety of Laparoscopic Oncologic Resection in Elderly Patients with Colorectal Cancer: A Multicenter Retrospective Study Based on Perioperative Short-Term Outcomes

Objectives: Over the last century, unthinkable goals have been achieved in health care and medical sciences, leading to longer life expectancy. Although cancer affects all ages, it disproportionately targets older individuals. Thus, surgical oncologists are confronted with increasing numbers of older patients presenting with multiple chronic conditions. We intended to investigate the safety of oncologic resection in older patients with colorectal cancer (CRC) based on perioperative outcomes. Materials and Methods: We retrospectively collected and analyzed data from older patients (>85 years) who underwent curative resection for stage II or III CRC between January 2007 and August 2017 at four hospitals (St. Vincent's Hospital, Incheon St. Mary's Hospital, Seoul St. Mary's Hospital, and Yeouido St. Mary's Hospital). Results: A total of 140 patients were enrolled in this study. The mean age was 87.1, the mean stay in the intensive care unit after surgery was 1.6 ± 3.8 days, and the mean postoperative hospital stay was 10.5 ± 3.8 days, D3 lymph node dissection was performed in 67.0% of patients, and D2 lymph node dissection was performed in 33.0%. Postoperative complications occurred in 38 patients (27.9%). In the univariate analysis, the risk factors for postoperative complications were the omission of mechanical bowel preparation (P = .039) and open surgery (P = .031). Conclusions: Oncologic resection in selected older patients with CRC might be a relatively safe treatment option. In particular, a laparoscopic approach might be a safer surgical method than open surgery in older patients with CRC.

Prediction of overall survival following colorectal cancer surgery in elderly patients

BACKGROUND

With advanced age and chronic illness, the life expectancy of a patient with colorectal cancer (CRC) becomes less dependent on the malignant disease and more on their pre-morbid condition. Justifying major surgery for these elderly patients can be challenging. An accurate tool demonstrating post-operative survival probability would be useful for surgeons and their patients.

AIM

To integrate clinically significant prognostic factors relevant to elective colorectal surgery in the elderly into a validated pre-operative scoring system.

METHODS

In this retrospective cohort study, patients aged 70 and above who underwent surgery for CRC at Singapore General Hospital between 1 January 2005 and 31 December 2012 were identified from a prospectively maintained database. Patients with evidence of metastatic disease, and those who underwent emergency surgery or had surgery for benign colorectal conditions were excluded from the analysis. The primary outcome was overall 3-year overall survival (OS) following surgery. A multivariate model predicting survival was derived and validated against an equivalent external surgical cohort from Kyungpook National University Chilgok Hospital, South Korea. Statistical analyses were performed using Stata/MP Version 15.1.

RESULTS

A total of 1267 patients were identified for analysis. The median post-operative length of stay was 8 [interquartile range (IQR) 6-12] d and median follow-up duration was 47 (IQR 19-75) mo. Median OS was 78 (IQR 65-85) mo. Following multivariate analysis, the factors significant for predicting overall mortality were serum albumin < 35 g/dL, serum carcinoembryonic antigen ≥ 20 µg/L, T stage 3 or 4, moderate tumor cell differentiation or worse, mucinous histology, rectal tumors, and pre-existing chronic obstructive lung disease. Advanced age alone was not found to be significant. The Korean cohort consisted of 910 patients. The Singapore cohort exhibited a poorer OS, likely due to a higher proportion of advanced cancers. Despite the clinicopathologic differences, there was successful validation of the model following recalibration. An interactive online calculator was designed to facilitate post-operative survival prediction, available at http://bit.ly/sgh_crc. The main limitation of the study was selection bias, as patients who had undergone surgery would have tended to be physiologically fitter.

CONCLUSION

This novel scoring system generates an individualized survival probability following colorectal resection and can assist in the decision-making process. Validation with an external population strengthens the generalizability of this model.

Transanal endoscopic micro-surgery in elderly and very elderly patients: a safe option? Observational study with prospective data collection

BACKGROUND

Although the incidence of colorectal cancer increases with the patient's age, the elderly continue to be less likely to be scheduled for surgery. Transanal endoscopic micro-surgery (TEM) is a surgical alternative to total mesorectal excision (TME) in early stage rectal cancer and/or in selected patients that could decrease morbidity and mortality rates in this group of patients. Our main objective is to assess the safety and feasibility of TEM in elderly (75-84 years) and very elderly (≥ 85 years) patients.

METHODS

Observational study was conducted with prospective data collection of all consecutive patients who underwent TEM between April 2004 and January 2017. Patients were assigned to groups according to age. Descriptive and comparative analyses between groups were performed.

RESULTS

We analyzed 693 patients, 429 patients < 75 years (61.9%), 220 patients between the ages of 75 and 84 (31.7%), and 44 patients ≥ 85 years old (6.3%). The tendency in our series is to increase comorbidities with age. Palliative or consensus intent was more frequently performed in elderly (10.5%, 34/220), and very elderly (45.4%, 20/44), compared with the youngest (6.3%, 27/429), (p < 0.001). Global morbidity presented an increasing trend related to age from 20.3% in < 75 years, to 25.9% in elderly and 34.1% in very elderly. Surgical complications were recorded in 18.5% (128/693) of patients with no significant differences between groups. The most common one was rectal bleeding 16.1% (111/693). Significant differences were found in non-surgical complications, recorded in 7.3% (16/220) in the elderly, and 15.9% (7/44) in the group above 84 years (p = 0.013).

CONCLUSIONS

TEM presents acceptable morbidity rates mainly due to non-surgical-related adverse effects in elderly and very elderly patients and may be a feasible and safe alternative in this population in both curative and non-curative indications.

Clinical characteristics and treatment propensity in elderly patients aged over 80 years with colorectal cancer

BACKGROUND/AIMS

Elderly patients (≥ 80 years) with colorectal cancer (CRC) tend to avoid active treatment at the time of diagnosis despite of recent advances in treatment. The aim of this study was to determine treatment propensity of elderly patients aged ≥ 80 years with CRC in clinical practice and the impact of anticancer treatment on overall survival (OS).

METHODS

Medical charts of 152 elderly patients (aged ≥ 80 years) diagnosed with CRC between 1998 and 2012 were retrospectively reviewed. Patients' clinical characteristics, treatment modalities received, and clinical outcome were analyzed.

RESULTS

Their median age was 82 years (range, 80 to 98). Of 152 patients, 148 were assessable for the extent of the disease. Eighty-two of 98 patients with localized disease and 28 of 50 patients with metastatic disease had received surgery or chemotherapy or both. Surgery was performed in 79 of 98 patients with localized disease and 15 of 50 patients with metastatic disease. Chemotherapy was administered in only 24 of 50 patients with metastatic disease. Patients who received anticancer treatment according to disease extent showed significantly longer OS compared to untreated patients (localized disease, 76.2 months vs. 15.4 months, p = 0.000; metastatic disease, 9.9 months vs. 2.6 months, p = 0.001). Along with anticancer treatment, favorable performance status (PS) was associated with longer OS in multivariate analysis of clinical outcome.

CONCLUSION

Elderly patients aged ≥ 80 years with CRC tended to receive less treatment for metastatic disease. Nevertheless, anticancer treatment in patients with favorable PS was effective in prolonging OS regardless of disease extent.

Treatment of Elderly Patients with Colorectal Cancer

Colorectal cancer (CRC) is one of the leading causes of cancer-related deaths worldwide. As society ages, the number of elderly patients with CRC will increase. The percentage of patients with right-sided colon cancer and the incidence of microsatellite instability are higher in elderly than in younger patients with CRC. Moreover, the higher incidence of comorbid diseases in elderly patients indicates the need for less invasive treatment strategies. For example, care should be taken in performing additional surgery after endoscopic submucosal dissection for elderly patients with high-risk T1 CRC. Minimally invasive surgery, such as laparoscopic colectomy, would be preferable for elderly patients with CRC. Chemotherapy for elderly patients requires careful monitoring for adverse events. The aim of this review is to summarize the clinicopathological features of CRC in elderly patients, optical surgical strategies, including endoscopic and laparoscopic resection, and chemotherapeutic strategies, including postoperative adjuvant chemotherapy and systemic chemotherapy for unresectable CRC.

Systematic Review and Meta-Analysis of Liver Resection for Colorectal Metastases in Elderly Patients

BACKGROUND

This systematic review and meta-analysis evaluated the short- and long-term outcomes of liver resection for colorectal liver metastases (CRLM) in elderly patients.

METHODS

A PubMed, EMBASE, and Cochrane Library search was performed from January 1995 to April 2017, for studies comparing both short- and long-term outcomes in younger and elderly patients undergoing liver resection for CRLM.

RESULTS

Eleven studies comparing patients aged <70 years with patients aged >70 years and 4 studies comparing patients aged <75 years with patients aged >75 years were included. Postoperative morbidity was similar in patients aged >70 years (27 vs. 30%; p = 0.35) but higher in patients aged >75 years (21 vs. 32%; p = 0.001). Postoperative mortality was higher in both patients aged >70 years (2 vs. 4%; p = 0.01) and in patients aged >75 years (1 vs. 6%; p = 0.02). Mean 5-year overall survival was lower in patients aged >70 years (40 vs. 32%; p < 0.001) but equal in patients aged >75 years (42 vs. 32%; p = 0.06).

CONCLUSION

Although postoperative morbidity and mortality were increased with higher age, liver resection for CRLM seems justified in selected elderly patients.

[The Short-term Outcome and Safety of Laparoscopic Colorectal Cancer Resection in Very Elderly Patients]

Background/Aims

Due to the recent increase in elderly population, laparoscopic surgery is more frequently performed in the elderly. This study aimed to compare the short-term outcomes of laparoscopic colorectal cancer surgery between the very elderly group (VEG), categorized as those with age over 80 years and the elderly group (EG), categorized as those with age 65 to 79 years.

Methods

We retrospectively compared 48 very elderly patients with 96 elderly patients (1:2 matched) who underwent laparoscopic resection for colorectal cancers at our institution between March 2010 and December 2014. The clinicopathologic parameters, surgical characteristics and short term outcomes were compared.

Results

There was no statistically significant difference in clinicopathologic characteristics between VEG and EG. Postoperative pain score (7 points vs. 6 points, p=0.264), time to first flatus (3 days vs. 3 days, p=0.335), hospital stay (15 days vs. 16.5 days, p=0.361), complication rates (47.9% vs. 26.0%, p=0.147) and major complication rate (25% vs. 20.8%, p=0.681) were not statistically different between the two groups. Before surgery, VEG had higher rate of neurologic underlying disease, such as dementia or cerebrovascular disease, than EG (25.0% vs. 7.3%, p=0.007).

Conclusions

There was no significant difference in the clinicopathologic characteristics, short-term outcomes, and complication rates for laparoscopic colorectal resection between VEG and EG, except delirium. Age over 80 years may be relevant for the application of laparoscopic colorectal cancer resection.

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.

Colorectal cancer surgery in the very elderly patient: a systematic review of laparoscopic versus open colorectal resection

INTRODUCTION

Colorectal cancer is the second most common cause of death from neoplastic disease in men and third in women of all ages. Globally, life expectancy is increasing, and consequently, an increasing number of operations are being performed on more elderly patients with the trend set to continue. Elderly patients are more likely to have cardiovascular and pulmonary comorbidities that are associated with increased peri-operative risk. They further tend to present with more locally advanced disease, more likely to obstruct or have disseminated disease. The aim of this review was to investigate the feasibility of laparoscopic colorectal resection in very elderly patients, and whether there are benefits over open surgery for colorectal cancer.

METHODS

A systematic literature search was performed on Medline, Pubmed, Embase and Google Scholar. All comparative studies evaluating patients undergoing laparoscopic versus open surgery for colorectal cancer in the patients population over 85 were included. The primary outcomes were 30-day mortality and 30-day overall morbidity. Secondary outcomes were operating time, time to oral diet, number of retrieved lymph nodes, blood loss and 5-year survival.

RESULTS

The search provided 1507 citations. Sixty-nine articles were retrieved for full text analysis, and only six retrospective studies met the inclusion criteria. Overall mortality for elective laparoscopic resection was 2.92% and morbidity 23%. No single study showed a significant difference between laparoscopic and open surgery for morbidity or mortality, but pooled data analysis demonstrated reduced morbidity in the laparoscopic group (p = 0.032). Patients undergoing laparoscopic surgery are more likely to have a shorter hospital stay and a shorter time to oral diet.

CONCLUSION

Elective laparoscopic resection for colorectal cancer in the over 85 age group is feasible and safe and offers similar advantages over open surgery to those demonstrated in patients of younger ages.

Long-term outcomes of colorectal endoscopic submucosal dissection in elderly patients

BACKGROUND AND AIMS

The safety and efficacy of endoscopic submucosal dissection (ESD) in elderly patients remain unclear. The aim of this study is to clarify the short- and long-term outcomes of colorectal ESD in elderly patients.

PATIENTS AND METHODS

A total of 482 consecutive patients with 501 colorectal lesions treated with ESD from February 2005 to December 2013 were retrospectively reviewed. Patients were divided into two groups: an elderly group (≥ 75 years of age) and a non-elderly group (< 75 years of age). Short-term outcomes of interest were procedure time, complication rate, hospital stay, en bloc resection rate, and non-curative resection rate. Long-term outcomes of interest were disease-specific survival, and overall survival rates in the elderly group (51 patients) and non-elderly group (92 patients) were also analyzed.

RESULTS

No significant differences were observed between the groups with respect to short-term outcomes. Two patients in each group required emergency surgery. Of the patients who underwent non-curative resection, 7/12 (58%) in the elderly group and 15/23 (65%) in the non-elderly group underwent additional surgery. The 5-year disease-specific survival rates in the elderly and non-elderly groups were both 100%, and the corresponding 5-year overall survival rates were 86.3 and 93.5%, respectively (p = 0.026).

CONCLUSIONS

Short-term outcomes after colorectal ESD were equivalent in both groups, and all patients showed favorable long-term outcomes. Considering the benign prognosis of lesions resected with ESD, preoperative screening of comorbidities is essential to improve overall survival.

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.

Short- and long-term outcomes of laparoscopic surgery for colorectal cancer in the elderly: A prospective cohort study

BACKGROUND

The aim of this study was to evaluate the safety and validity of laparoscopic colorectal surgery for elderly patients. We compared the short and long-term postoperative outcomes of laparoscopic colorectal surgery in patients aged ≥75 years (elderly patients; EP) and <75 years (relatively younger patients; RP).

METHODS

Clinicopathological data and short- and long-term outcomes after laparoscopic surgery for colorectal cancer were compared between the EP (n = 53) and RP groups (n = 155).

RESULTS

In the EP group, patients with American Society of Anesthesiologists score II (p = 0.047) and medical comorbidity rate (EP vs RP: 83.0% vs 56.8%, p < 0.001), especially for cardiovascular disease (64.2% vs 37.5%, p < 0.001) and diabetes mellitus (20.8% vs 9.7%, p = 0.044), were significantly higher than those in the RP group. Regarding the clinical characteristics, the ratio of right colectomy (50.9% vs 25.3%, p < 0.001) and pathological tumor grade T4 (18.9% vs 7.7%, p = 0.044) were significantly higher in the EP group. There was no significant difference in the variation of pathological stage between the two groups. In the postoperative course, there were no significant differences regarding short-term postoperative outcomes between the EP and RP groups, including that for timing of oral diet tolerance (3.9 days vs 3.5 days, p = 0.073), first flatus (2.3 days vs 2.0 days, p = 0.636), first bowel movement (3.3 days vs 3.7 days, p = 0.153), ambulation after surgery (1.7 days vs 1.5 days, p = 0.081), postoperative hospital stay (10.5 days vs 10.8 days, p = 0.469), and incidence of postoperative complications (20.8% vs 15.5%, p = 0.385), respectively. Regarding the long-term outcomes, there were no significant differences in recurrence-free survival (RFS) (5-year RFS, 74.0% vs 85.2%, p = 0.091) and overall survival (OS) (5-year OS, 81.8% vs 90.1%, p = 0.112) between the two groups.

CONCLUSION

Laparoscopic colorectal surgery in elderly patients was safe and well-tolerated in comparison with the relatively younger patients.

Laparoscopic colorectal resection versus open colorectal resection in octogenarians: a systematic review and meta-analysis of safety and efficacy

Octogenarians are more often viewed as high-risk surgical candidates. This increased risk is attributed to an age-related decline in physical function and reserve capacity coupled with the presence of various underlying diseases. There are no current guidelines or consensus on the optimal treatment strategy for this cohort of complex patients. The aim of this systematic review and meta-analysis was to compare the efficacy and safety of laparoscopic colorectal resection versus open colorectal resection in octogenarians. The meta-analysis was conducted following all aspects of the Cochrane Handbook for Systematic Reviews and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A systematic literature review was carried out using the following databases: MEDLINE, Embase, PubMed, the Cochrane Library, Google Scholar and OVID. Only studies comparing outcome of laparoscopic and open colorectal resections in the elderly population (≥80 years) were selected. The data collected included the patient demographics, interventions, observed outcome and sources of bias. When performing the statistical analysis, we used the odds ratio for categorical variables and the weighted mean difference for continuous variables. The results of this systematic review and pooled analysis demonstrated the safety and potential benefits of laparoscopic colorectal resection in octogenarians. LC can reduce the length of hospital stay, intraoperative blood loss, time to return of normal bowel function, and incidence of postoperative pneumonia, wound infection, and postoperative ileus.

Colorectal cancer screening and surveillance in the elderly: updates and controversies

Colorectal cancer is common worldwide, and the elderly are disproportionately affected. Increasing age is a risk factor for the development of precancerous adenomas and colorectal cancer, thus raising the issue of screening and surveillance in older patients. Elderly patients are a diverse and heterogeneous group, and special considerations such as comorbid medical conditions, functional status and cognitive ability play a role in deciding on the utility of screening and surveillance. Colorectal cancer screening can be beneficial to patients, but at certain ages and under some circumstances the harm of screening outweighs the benefits. Increasing adverse events, poorer bowel preparation and more incomplete examinations are observed in older patients undergoing colonoscopy for diagnostic, screening and surveillance purposes. Decisions regarding screening, surveillance and treatment for colorectal cancer require a multidisciplinary approach that accounts not only for the patient’s age but also for their overall health, preferences and functional status. This review provides an update and examines the challenges surrounding colorectal cancer diagnosis, screening, and treatment in the elderly.

Do the advantages of a minimally invasive approach remain in complex colorectal procedures? A nationwide comparison

BACKGROUND

Since the introduction of laparoscopic colectomy, experience and technology continue to improve. Although accepted for many colorectal conditions, its use and outcomes in complex procedures are less understood.

OBJECTIVE

The purpose of this work was to compare the perioperative outcomes of laparoscopic transverse colectomy and total abdominal colectomy (study group) with an open approach (comparative group) and the more established laparoscopic right, left, and sigmoid colectomies (control group).

DESIGN

This was a retrospective review of the Nationwide Inpatient Sample (2008-2011) of all patients undergoing elective right, left, sigmoid, total, or transverse colectomy as identified by International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes. Risk-adjusted 30-day outcomes were assessed using regression modeling accounting for patient characteristics, comorbidities, and surgical procedures.

SETTINGS

The study included a national sample from a population database.

PATIENTS

There were 45,771 admissions: 2946 in the study group, 36,949 in the control group, and 5876 in the open comparative group.

MAIN OUTCOME MEASURES

Mortality was the primary outcome. Secondary outcomes included in-hospital complications, length of stay, and hospital charges.

RESULTS

The patients were predominantly white (73%), had private insurance (64%), and underwent surgery at urban centers (92%). Mortality was similar between the study and control groups (0.42% vs 0.51%; p = 0.52), with a higher complication rate in the study group (19% vs 14%; p < 0.01). The study group was also associated with a lower mortality rate compared with the open group (0.51% vs 2.20%; p < 0.01), which remained consistent after adjusting for covariates (OR, 0.38 [95% CI, 0.20-0.71]; p < 0.01). The study group had fewer complications overall compared with the open group (19% vs 27%; p < 0.01) and a shorter median length of stay (4.6 vs 6.3 days; p < 0.01).

LIMITATIONS

This was a retrospective study using an administrative database.

CONCLUSIONS

A laparoscopic approach for total abdominal and transverse colectomies has similar mortality rates and slightly higher complications than the more established laparoscopic colectomy procedures and improved perioperative outcomes when compared with an open technique (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A178).

Preoperative functional health status may predict outcomes after elective colorectal surgery for malignancy

BACKGROUND

Several studies suggest that preoperative functional health status (FHS) affects postoperative outcomes after ventral hernia repair, hepatic resections, and infrainguinal by-pass surgery. However, little is known about the proficiency of FHS in terms of preoperative outcome prediction of patients who undergo elective resection for colorectal cancer.

METHODS

All patients who underwent elective colorectal resections for malignancy between 2005 and 2009 were identified from the American College of Surgeons National Surgical Quality Improvement Program. We classified patients into three groups according to their preoperative FHS: independent (IND), partially dependent (PDN), and totally dependent (TDN). Multivariable techniques were used to evaluate the impact of FHS on postoperative outcomes. Outcomes of laparoscopic and open procedures in patients with dependent FHS were also compared.

RESULTS

In total, 25,591 patients included (94.2% IND, 5.1% PDN, and 0.71% TDN). Surgical, infectious, pulmonary, cardiovascular, renal, neurological complications, and mortality rate showed a linear progression that paralleled a decline in preoperative FHS of the patients (p < 0.05). Laparoscopic technique was associated with better outcomes in terms of reduced length of total hospital stay, decreased infectious complication rate, and mortality with comparable operating time in patients with dependent (PDN and TDN) FHS (p < 0.05).

CONCLUSIONS

Functional health status may predict postoperative outcomes after colorectal cancer surgery. A detailed preoperative evaluation, providing an optimization period before surgery if necessary, and increased utilization of laparoscopic technique may improve outcomes after elective colorectal resections for malignancy in patients who are partially or TDN.

Colorectal cancer of the elderly

OPINION STATEMENT

Colorectal cancer (CRC) disproportionately affects the elderly. Older age is a strong risk factor for both the development of precancerous adenomas and CRC, thus raising the issue of screening and surveillance in older patients. However, screening and surveillance decisions in the elderly can be complex and challenging. Elderly patients are a diverse and heterogeneous group and special considerations such as co-morbid medical conditions, functional status, and cognitive ability play a role in one's decisions regarding the utility of screening and surveillance. Such considerations also play a role in factors related to screening modalities, such as colonoscopy, as well as CRC treatment options and regimens. This review addresses many of the unique factors associated with CRC of the elderly and critically examines many of the controversies and challenges surrounding CRC in older patients.