Laparoscopic complete mesocolic excision with D3 lymph node dissection for right colon cancer in elderly patients

Complete mesocolic excision (CME) with D3 lymph node dissection is considered an oncological surgery for right colon cancer. However, there is still controversy for extensive oncological surgery in elderly patients. The aim of this study is to evaluate the safety and oncological outcomes of laparoscopic CME with D3 lymph node dissection for right colon cancer in elderly patients. Patients who underwent laparoscopic right colectomy, from 2004 to 2014, were divided into Groups A (age ≥ 70 years, n = 80) or B (age < 70 years, n = 127). Short and long-term outcomes were analysed. Basic demographics and short-term surgical outcomes were similar between groups. Among pathological outcomes, the mean number of harvested lymph nodes was significantly less in Group A. Adjuvant chemotherapy refusal rate was significantly higher in Group A. Overall and recurrence-free survival were similar between groups. We found laparoscopic CME with D3 lymph node dissection is a safe and feasible surgical option for right colon cancer in elderly patients.

Baseline anaemia increases locally advanced rectal cancer mortality in older patients undergoing preoperative chemoradiation

PURPOSE

The median diagnosis age of rectal cancer (RC) is 70 years old. The standard of care for locally advanced RC (LARC) is preoperative chemoradiation (CRT) followed by surgery. Anaemia is a frequent condition in older patients but is not a pure consequence of ageing.

METHODS

The patients aged 65 years or over, with clinical stage II/III LARC, and treated with preoperative concurrent CRT were retrospectively reviewed. Baseline haemoglobin (Hb) levels were collected.

RESULTS

One hundred and seven patients enrolled in this study, but 17 were excluded in relation with treatment disruption. Fifty-seven (63.3%) males and 33 (36.7%) females completed preoperative CRT whose median age at diagnosis was 73. Twenty-five (27.8%) patients presented with anaemia at rectal cancer diagnosis, and median Hb was 13.5 g/dL (IQR = 1.45) and 11.2 g/dL (IQR = 1.35), for non-anaemic and anaemic patients, respectively. For the enrolled older population, only 2 patients reported acute grade 3 toxicity. Baseline anaemia tended to decrease the LARC-free interval and was associated with a significantly higher hazard of all-cause and LARC mortality, approximately 5 times (HR = 5.25; 95% CI 1.48-18.66) and 10 times (HR = 10.09; 95% CI 2.40-42.48), respectively. Patients older than 75 presented a significantly negative impact on overall survival (OS) and LARC-specific survival (HR = 6.20, 95% CI 2.00-19.22; and HR = 7.61, 95% CI 2.08-27.87, respectively). Conversely, no significant impact was found for age-adjusted Charlson comorbidity index on OS, LARC-specific survival and LARC-free interval.

CONCLUSIONS

Overall and LARC-specific survival were significantly lower for the baseline anaemic older patients and for those aged 75 years or over.

Short-term outcomes following single-port laparoscopic surgery in elderly patients with colon cancer compared with younger patients

Surgeons are increasingly being faced with the challenge of treating elderly patients with colon cancer. The present study therefore aimed to compare the short-term outcomes of single-port laparoscopic surgery (SILS) for elderly patients with colon cancer (≥70 years) with those in younger patients (41-69 years; control group). Among 100 patients with colorectal cancer who had been treated with single-port laparoscopic surgery between January 2011 and December 2014, 56 (56.0%) were ≥70 years of age. The results of treatment and short-term outcomes in the elderly group (n=56) were retrospectively compared with the younger patients in the control group (n=44). The sex distribution, body mass index, history of prior surgery and the American Society of Anesthesiologists physical status classification were similar between the groups. Onodera's prognostic nutritional index demonstrated significant differences between the elderly and control groups (38.3 vs. 49.8; P<0.05). No significant differences were observed in the mean length of surgery (219.5±73.5 vs. 201.4±76.5 min; P=0.43), estimated blood loss (32.2±74.5 vs. 36.1±90.2 ml; P=0.10), postoperative complications (10.9 vs. 7.1%; P=0.78), length of postoperative hospital stay (9.6±12.5 vs. 7.3±3.0 days; P=0.23) or number of harvested lymph nodes (21.8±24.3 vs. 22.5±11.3; P=0.87) between the elderly and control groups. In conclusion, the results of the present study demonstrate that SILS may be carried out feasibly in elderly patients with colon cancer.

Laparoscopic surgery for colorectal cancer in patients over 80 years of age: the morbidity outcomes

Purpose

The aim of this study was to compare the outcomes between patients under 60 years of age and older patients over 80 years of age who underwent laparoscopic colorectal surgery with colorectal cancer.

Methods

A retrospective analysis of 519 colorectal patients who underwent laparoscopic colorectal surgery for colorectal adenocarcinoma between January 2007 and December 2012 was collected and categorized into 2 groups of patients, those under 60 years of age (n = 404) and those over 80 years of age (n = 115).

Results

The group of patients over 80 years of age had a significantly higher ASA physical status classification (P < 0.001), more preoperative comorbidities (P < 0.001), had a tendency towards more tumors in a colonic location (P = 0.034), and more advanced American Joint Committee on Cancer TNM stage (P = 0.001). A higher proportion of right hemicolectomy and abdominoperineal resection was performed and more transfusions were required in the group of patients over 80 years of age (P = 0.002 and P = 0.001, respectively). There were no significant differences in operative time, conversion rate, resection margins, and numbers of harvested lymph nodes, hospital stay, and morbidity between the 2 groups. No postoperative mortality was found in the present study. The 3-year DFS for over 80 years age group and under 60 years age group were 73.5% and 73.9%, respectively (P = 0.770).

Conclusion

Laparoscopic colorectal surgery was effective and safe for elderly patients over 80 years of age and resulted in postoperative outcomes similar to those in younger patients. The postoperative morbidity after laparoscopic colorectal cancer surgery was not increased in over 80 years of age.

Single-port versus multi-port laparoscopic surgery for colon cancer in elderly patients

The safety of single-incision laparoscopic surgery (SLS) in elderly patients with colorectal cancer has not been established. The aim of the current study was to compare the outcomes of SLS and multi-port laparoscopic surgery (MLS) and to assess the feasibility of SLS in colorectal cancer patients aged ≥70 years. A retrospective case-control study of colon cancer patients undergoing elective surgical intervention between 2011 and 2014 was conducted. A total of 129 patients with colon cancer underwent surgery and were included in the analysis. Data regarding patient demographics, surgical variables, oncological outcomes and short-term outcomes were evaluated for statistical significance to compare MLS (n=79) and SLS (n=50) in colon cancer patients. No significant differences were observed in patient characteristics. No case required re-admission within 30 days post surgery. The mean surgery times were similar for the MLS and SLS groups when cases with left and right hemicolectomies were combined (207.7 and 215.9 min, respectively; P=0.47). In addition, overall perioperative outcomes, including blood loss, number of lymph nodes harvested, size of the surgical margin and complications, were similar between these groups. Thus, we suggest that SLS can be performed safely in elderly patients with colon cancer.

Age Over 80 is a Possible Risk Factor for Postoperative Morbidity After a Laparoscopic Resection of Colorectal Cancer

Purpose

With extended life expectancy, the mean age of patients at the time of diagnosis of colorectal cancer and its treatment, including radical resection, is increasing gradually. We aimed to evaluate the impact of age on postoperative clinical outcomes after a laparoscopic resection of colorectal cancers.

Methods

This is a retrospective review of prospectively collected data. Patients with primary colorectal malignancies or premalignant lesions who underwent laparoscopic colectomies between January 2009 and April 2013 were identified. Patients were divided into 6 groups by age using 70, 75, and 80 years as cutoffs: younger than 70, 70 or older, younger than 75, 75 or older, younger than 80, and 80 or older. Demographics, pathological parameters, and postoperative clinical outcomes, including postoperative morbidity, were compared between the younger and the older age groups.

Results

All 578 patients underwent a laparoscopic colorectal resection. The overall postoperative complication rate was 21.1% (n = 122). There were 4 cases of operative mortality (0.7%). Postoperative complication rates were consistently higher in the older groups at all three cutoffs; however, only the comparison with a cutoff at 80 years showed a statistically significant difference between the younger and the older groups.

Conclusion

Age over 80 is a possible risk factor for postoperative morbidity after a laparoscopic resection of colorectal cancer.

Outcome of laparoscopic versus open resection for rectal cancer in elderly patients

BACKGROUND

Laparoscopic colorectal resection has been gaining popularity over the past two decades. However, studies about laparoscopic rectal surgery in elderly patients with long-term oncologic outcomes are limited. In this study, we evaluated the short-term and long-term outcomes of laparoscopic and open resection in patients with rectal cancer aged ≥ 70 y.

METHODS

From 2007-2012, a total of 294 consecutive patients with rectal cancer from a single institution were included, 112 patients undergoing laparoscopic rectal resection were compared with 182 patients undergoing open rectal resection.

RESULTS

Seven (6.3%) patients in the laparoscopic group required conversion to open surgery. The two groups were well balanced in terms of age, gender, body mass index, American society of anesthesiologists scores, site, and stage of the tumors. Laparoscopic surgery was associated with significantly longer median operating time (220 versus 200 min; P = 0.005), less estimated blood loss (100 versus 150 mL; P < 0.001), a shorter postoperative hospital stay (8 versus 11 d), lower overall postoperative complication rate (15.2% versus 26.4%; P = 0.025), wound-related complication rate (7.14% versus 17.03%; P = 0.015), less need of blood transfusion (8.04% versus 16.5%; P = 0.038), and surgical intensive care unit after surgery (12.5% versus 22.0%; P = 0.042) when compared with open surgery. Mortality, quality of surgical specimen, lymph nodes harvested, positive distal, and circumferential margin rate were not significantly different between two groups. The estimated 3-y survival rates were similar between two groups.

CONCLUSIONS

Laparoscopic rectal surgery is safe and feasible in patients >70 y and is associated with better short-term outcomes when compared with open surgery.

the outcome of single-incision laparoscopic right colectomy for colon carcinoma in the elderly

PURPOSE

Surgeons are increasingly being faced with the problem of treating elderly colon cancer patients. The purpose of this study was to elucidate the feasibility of single-incision laparoscopic surgery for these patients.

METHODS

Among 34 right colon cancer patients treated with single-incision laparoscopic surgery procedure between August 2010 and September 2011, 9 (26.5%) were aged 80 or over. The results of treatment in this elderly group were compared retrospectively with those in 10 younger colon cancer patients (age, 59 to 67 y; control group, 29.5%).

RESULTS

The sex distribution, body mass index, and the tumor location were similar between the groups. The elderly had a higher incidence of preoperative risk factors (77.7% vs. 40.0%; P=0.17). However, operative time and estimated blood loss were similar and postoperative complications had not occurred in both groups.

CONCLUSIONS

We believe that single-incision laparoscopic colectomy can be carried out safely in elderly patients with colon cancer.

Is 30-day mortality an appropriate measure of risk in elderly patients undergoing elective colorectal resection?

AIM

The study aimed to define mortality in the elderly following elective colorectal resection and to identify the most meaningful postoperative period to report mortality rates in this group of patients.

METHOD

A systematic review was undertaken to identify studies that reported on mortality in the elderly following elective colorectal resection. Searches of MEDLINE, Embase and PubMed databases were carried out by two independent reviewers and the results were collated. Two reviewers conducted literature searches independently and the third reviewer acted as an arbiter in case of discordance.

RESULTS

Two-hundred and thirty-six studies published in 2000 or later were identified in the search. Studies were excluded if they included emergency surgery, included patients receiving surgery before 1995, or did not comment on mortality in an elderly age group. Seventeen studies were finally included in the review. Thirty-day or postoperative mortality rates varied from 0 to 13.3%. Short-term mortality was low in elderly patients selected for minimal access surgery. National population and registry observational audits reported higher short-term mortality rates than most small case series or cohort studies. One national audit demonstrated that a significant mortality risk persists for up to 1 year after surgery.

CONCLUSION

Historical case series suggest that 30-day mortality following colorectal resection in the elderly is low. The reliability of 30-day mortality measures to reflect surgical success in this cohort is, however, questionable as a significant proportion of patients die in the months following surgery.

Influence of comorbidity and age on 1-, 2-, and 3-month postoperative mortality rates in gastrointestinal cancer patients

BACKGROUND

Studies on the impact of comorbidity and age on postoperative outcome after gastrointestinal tumor resection are scarce. In this study we investigated the impact of comorbidity and age on 30-, 60-, and 90-day mortality after resection of esophageal, gastric, periampullary, colon, and rectal cancer.

METHODS

The study included 8,583 patients recorded in the population-based Netherlands Cancer Registry, regions Eindhoven (Eindhoven Cancer Registry) and Mid and South Limburg, who underwent resection for cancer stage I-III. Patients were diagnosed between 2005 and 2010. Age was categorized as <65, 65-74, and ≥75 years.

RESULTS

Comorbidity was present in more than two-thirds (n = 5,910) of patients. The 30-day mortality rates ranged from 0.5 % for rectal cancer patients <65 years to 12.8 % for gastric cancer patients ≥75 years. Patients with comorbidity who underwent esophageal tumor resection had the highest mortality rates, ranging from 8.4 % for 30-day to 12.0 % for 90-day mortality, while rectal cancer patients had the lowest rates, that is, 4.3-6.4 %, respectively. In multivariable analyses, cardiac disease (odds ratio [OR] = 1.74, 95 % confidence interval [95 % CI] = 1.32-2.30), vascular disease (OR = 1.41, 95 % CI = 1.02-1.95) and previous malignancies (OR = 1.38, 95 % CI = 1.02-1.86) in colon cancer, and cardiac disease (OR = 1.81, 95 % CI = 1.10-2.98) and vascular disease (OR = 1.95, 95 % CI = 1.11-3.42) in rectal cancer were associated with the highest 30-day mortality.

CONCLUSIONS

Postoperative mortality extends beyond 30 days. Comorbidity and older age are associated with early postoperative mortality after gastrointestinal cancer resection. Underlying comorbidity should be identified preoperatively with attention to patients' specific needs to optimally attenuate risk prior to surgery. A less aggressive treatment approach may well be considered in these groups.

Principles of surgical oncology in the elderly

Elderly patients constitute the largest group in oncologic medical practice, despite the fact that in solid cancers treated operatively, many patients are denied standard therapies and where such decision making is based solely on age. The “natural” assumptions that we have are often misleading; namely, that the elderly cannot tolerate complex or difficult procedures, chemotherapy, or radiation schedules; that their overall predictable medical health determines survival (and not the malignancy); or that older patients typically have less aggressive tumors. Clearly, patient selection and a comprehensive geriatric assessment is key where well-selected cases have the same cancer-specific survival as younger cohorts in a range of tumors as outlined including upper and lower gastrointestinal malignancy, head and neck cancer, and breast cancer. The assessment of patient fitness for surgery and adjuvant therapies is therefore critical to outcomes, where studies have clearly shown that fit older patients experience the same benefits and toxicities of chemotherapy as do younger patients and that when normalized for preexisting medical conditions,that older patients tolerate major operative procedures designed with curative oncological intent. At present, our problem is the lack of true evidence-based medicine specifically designed with age in mind, which effectively limits surgical decision making in disease-based strategies. This can only be achieved by the utilization of more standardized, comprehensive geriatric assessments to identify vulnerable older patients, aggressive pre-habilitation with amelioration of vulnerability causation, improvement of patient-centered longitudinal outcomes, and an improved surgical and medical understanding of relatively subtle decreases in organ functioning, social support mechanisms and impairments of health-related quality of life as a feature specifically of advanced age.