Is colorectal surgery beyond the age of 80 still feasible with acceptable mortality? An analysis of the predictive value of CR-POSSUM and life expectancy after hospital discharge

Immunological changes and recovery-related factors in older patients with colon cancer: A pilot trial

INTRODUCTION

Immunity in older patients with colon cancer differs from that in younger patients. Specifically, concerns regarding postoperative recovery and immunity have prompted the development of personalized treatment options for older patients with colon cancer. This study aimed to assess the differences in immunological factor-related parameters and postoperative recovery between patients aged ≥70 years and < 70 years.

MATERIAL AND METHODS

This pilot study included 75 patients who underwent surgical resection for colon cancer between September 2023 and February 2024 at Asan Medical Center, Seoul, Korea. Patients were divided into two age groups: ≥70 years and < 70 years. The clinicopathological features associated with recovery, and the association among recovery, immunological factors, and clinical characteristics were analyzed. The EuroQol-5 Dimensions-3 questionnaire scores, which reflect the subjective perspectives of patients, were also compared between the two groups.

RESULTS

There were 29 patients in the ≥70 years group and 46 patients in the <70 years group. The ≥70 years group exhibited significantly higher IL-6 levels than the <70 years group both preoperatively (6.71 vs. 4.27, P = 0.04) and on postoperative day 21 (POD#21) (13.49 vs. 2.94, P = 0.03). The average NK cell counts were consistently higher in the ≥70 years group across all time points: preoperatively (24.54 vs. 13.87, P < 0.001), POD#3 (24.32 vs. 15.39, P < 0.001), and POD#21 (33.04 vs. 22.47, P < 0.001). While a greater proportion of patients in the ≥70 years group had below-average preoperative EQ-5D levels, this difference was not statistically significant (20.7 % vs. 17.4 %, P = 0.96).

DISCUSSION

Immunological factors, such as IL-6 levels and the number of natural killer cells, did not diminish in patients aged ≥70 years. Furthermore, postoperative recovery was not prolonged in this group.

Risk of Life-Threatening Complications After Colorectal Cancer Surgery: A Japanese Multicenter Study

PURPOSE

As the population ages, more surgeries are being performed on patients in poor general condition. Such patients are at greater risk of life-threatening postoperative complications and perioperative mortality.

METHODS

This multicenter study investigated 4164 consecutive patients who underwent colorectal surgery between 2016 and 2023. Patients were divided into those who experienced life-threatening complications (LT group, n = 31) and those who did not (no-LT group, n = 4133). Clinical features were compared between groups.

RESULTS

Thirty-one patients (0.7%) experienced life-threatening complications. Age was higher (80 years vs. 71 years, p = 0.011), body mass index was lower (19.7 kg/m2 vs. 22.0 kg/m2, p < 0.001), poor performance status (performance status ≥ 3) was more frequent (54.8% vs. 10.4%, p < 0.001), and open surgery was more frequent (25.8% vs. 9.0%, p < 0.001) in the LT group. Multivariate analysis revealed high age (odds ratio 2.268, 95% confidence interval 1.079-4.763; p = 0.030), poor performance status (odds ratio 7.714, 95% confidence interval 3.622-11.251; p < 0.001) and open surgery (odds ratio 1.792, 95% confidence interval 1.205-6.799; p = 0.016) as independent predictors of life-threatening complications.

CONCLUSION

Patients with a risk of life-threatening complications should be given a detailed preoperative description of the risks, and indications and approaches to surgery should be thoroughly examined.

OUP accepted manuscript

Background

As the outcome of modern colorectal cancer (CRC) surgery has significantly improved over the years, however, renewed and adequate risk stratification for mortality is important to identify high-risk patients. This population-based study was conducted to analyse postoperative outcomes in patients with CRC and to create a risk model for 30-day mortality.

Methods

Data from the Dutch Colorectal Audit were used to assess differences in postoperative outcomes (30-day mortality, hospital stay, blood transfusion, postoperative complications) in patients with CRC treated from 2009 to 2017. Time trends were analysed. Clinical variables were retrieved (including stage, age, sex, BMI, ASA grade, tumour location, timing, surgical approach) and a prediction model with multivariable regression was computed for 30-day mortality using data from 2009 to 2014. The predictive performance of the model was tested among a validation cohort of patients treated between 2015 and 2017.

Results

The prediction model was obtained using data from 51 484 patients and the validation cohort consisted of 32 926 patients. Trends of decreased length of postoperative hospital stay and blood transfusions were found over the years. In stage I–III, postoperative complications declined from 34.3 per cent to 29.0 per cent (P < 0.001) over time, whereas in stage IV complications increased from 35.6 per cent to 39.5 per cent (P = 0.010). Mortality decreased in stage I–III from 3.0 per cent to 1.4 per cent (P < 0.001) and in stage IV from 7.6 per cent to 2.9 per cent (P < 0.001). Eight factors, including stage, age, sex, BMI, ASA grade, tumour location, timing, and surgical approach were included in a 30-day mortality prediction model. The results on the validation cohort documented a concordance C statistic of 0.82 (95 per cent c.i. 0.80 to 0.83) for the prediction model, indicating good discriminative ability.

Conclusion

Postoperative outcome improved in all stages of CRC surgery in the Netherlands. The developed model accurately predicts postoperative mortality risk and is clinically valuable for decision-making.

Laparoscopic Surgery for Colorectal Cancer in Super-Elderly Patients: A Single-Center Analysis

BACKGROUND

Super-elderly patients with colorectal cancer are being encountered with increasing frequency in Japan. Laparoscopic surgery is considered a less invasive surgery in these patients; however, it is difficult to conduct controlled clinical trials in this super-elderly population. This study assessed the feasibility and safety of laparoscopic colorectal surgery in patients over 85 years old.

MATERIALS AND METHODS

Open and laparoscopic surgeries for colorectal cancer in super-elderly patients (aged 85 y and older) were performed under general anesthesia in a single medical center. Records were retrospectively reviewed, and the clinicopathologic features of each patient and the surgical time and outcomes were recorded and analyzed.

RESULTS

Records of colorectal surgery were reviewed for 108 super-elderly patients. Twenty-six open surgeries and 82 laparoscopic surgeries were performed. The mean operation times were 215 and 228 minutes in open and laparoscopic surgeries, respectively. Intraoperative bleeding in laparoscopic surgery was lesser than that in open surgery. There were 2 cases with major postoperative complications in open surgery, and mortality occurred in one case within 1 month after surgery. No major complications were observed in laparoscopic surgery. In survival analysis, disease-free survival did not differ between the 2 groups. The oldest patient was a man aged 102 years and 6 months who underwent laparoscopic anterior resection with lymph node dissection.

CONCLUSION

Laparoscopic surgery in super-elderly patients with colon cancer is feasible and safe. The authors report the success of laparoscopic colectomy for rectosigmoid colon cancer in the oldest known patient and the positive outcomes of laparoscopic colectomy in super-elderly patients.

Outcomes of laparoscopic surgery for pT3/pT4 colorectal cancer in young vs. old patients

BACKGROUND

Laparoscopy for locally advanced colorectal cancer is not standardized yet and its potential risks and benefits in elderly patients are still under debate. The aim of this study was to evaluate clinical and oncologic results of laparoscopic surgery for pT3/pT4 lesions in both old and young people.

METHODS

Between 2006 and 2015, 115 patients aged <70 years and 112 patients aged ≥70 years underwent elective laparoscopic surgery for pT3/pT4 colorectal cancer presenting without distant metastasis at the Department of General Surgery, Trieste. Characteristics of the study populations, including demographic, operative and tumor features, were prospectively collected and short-term and long-term clinical, pathologic and oncologic outcomes were retrospectively analyzed.

RESULTS

No difference was found in terms of tumor features, type and duration of surgery, and quality of resection. Old patients were found to have significantly higher rates of conversion (P=0.02) and postoperative mortality(P=0.03), whereas postoperative complications and reintervention rates - although higher in the elderly - did not differ on statistical analysis (P=0.13 and P=0.19, respectively). Local and distant recurrence rates were not statistically different between the two groups (P=0.64 and P=0.34, respectively). Adjuvant chemotherapy was more frequently offered to young people (P<0.001), who were considered significantly healthier than old ones (P<0.001). Overall survival was significantly lower among the elderly (P=0.001), but 5-year disease-free survival did not differ between the two groups (P=0.09).

CONCLUSIONS

Laparoscopic surgery for locally advanced lesions is feasible, but old patients present an increased risk of conversion and postoperative morbidity and mortality, which may alter long-term outcomes determining an apparent decrease in survival.

Successful laparoscopic treatment of advanced rectal cancer in an extremely elderly man (101 years and 9 months)

An extremely elderly man (age, 101 years and 9 months) visited our hospital because of recurrent and worsening anal bleeding. Type 2 rectal cancer was found in his rectum during colonoscopy. He did not have any severe coexisting diseases and had not suffered any episodes of dementia. Laparoscopy-assisted anterior resection combined with D2 lymph node dissection was performed with minimal bleeding. The operation time was 128 min. The patient suffered mild reflux pneumonia on postoperative day 6 and was administered additional antibiotics. He recovered within 2 days. He was discharged on postoperative day 17, at which point he was able to walk.