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Ammirati CA, Passera R, Beltrami E, Peluso C, Francis N, Arezzo A. Laparoscopic and robotic surgery for colorectal cancer in older patients: a systematic review and meta-analysis. MINIM INVASIV THER 2024; 33:253-269. [PMID: 38946054 DOI: 10.1080/13645706.2024.2360094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 04/21/2024] [Indexed: 07/02/2024]
Abstract
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.
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Affiliation(s)
| | - Roberto Passera
- Nuclear Medicine Division, Department of Medical Sciences, AOU Città della Salute e della Scienza di Torino, University of Turin, Torino, Italy
| | - Elsa Beltrami
- Department of Surgical Sciences, University of Turin, Torino, Italy
| | - Chiara Peluso
- Department of Surgical Sciences, University of Turin, Torino, Italy
| | - Nader Francis
- Department of Colorectal Surgery, Yeovil District Hospital Foundation Trust, Yeovil, UK
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Turin, Torino, Italy
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Keller DS, Curtis N, Burt HA, Ammirati CA, Collings AT, Polk HC, Carrano FM, Antoniou SA, Hanna N, Piotet LM, Hill S, Cuijpers ACM, Tejedor P, Milone M, Andriopoulou E, Kontovounisios C, Leeds IL, Awad ZT, Barber MW, Al-Mansour M, Nassif G, West MA, Pryor AD, Carli F, Demartines N, Bouvy ND, Passera R, Arezzo A, Francis N. EAES/SAGES evidence-based recommendations and expert consensus on optimization of perioperative care in older adults. Surg Endosc 2024; 38:4104-4126. [PMID: 38942944 PMCID: PMC11289045 DOI: 10.1007/s00464-024-10977-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Accepted: 05/30/2024] [Indexed: 06/30/2024]
Abstract
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.
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Affiliation(s)
- Deborah S Keller
- Department of Digestive Surgery, University of Strasbourg, Strasbourg, FR, USA
| | - Nathan Curtis
- Surgical Unit, Dorset County Hospital, Dorchester, Dorset, UK
| | | | | | - Amelia T Collings
- Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Hiram C Polk
- Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Francesco Maria Carrano
- Department of General and Minimally Invasive Surgery, Busto Arsizio Circolo Hospital, ASST-Valle Olona, Varese, Italy
| | - Stavros A Antoniou
- Department of General Surgery, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Nader Hanna
- Department of Surgery, Queen's University, Kingston, ON, Canada
| | | | - Sarah Hill
- Department of Surgery, The University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Anne C M Cuijpers
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Patricia Tejedor
- Department of Colorectal Surgery, University Hospital Gregorio Marañón, Madrid, Spain
| | - Marco Milone
- Department of Clinical and Surgical Gastrointestinal Diseases, University of Naples "Federico II", Via Pansini 5, Naples, Italy
| | - Eleni Andriopoulou
- Department of Surgery, Hellenic Red Cross Korgialeneio Benakeio NHS, Athens, Greece
| | - Christos Kontovounisios
- Department of Surgery and Cancer, Imperial College London, Chelsea and Westminster Campus and the Royal Marsden Hospital, London, UK
| | - Ira L Leeds
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Ziad T Awad
- Department of Surgery, University of Florida, Jacksonville, FL, USA
| | - Meghan Wandtke Barber
- Department of Surgery, The University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Mazen Al-Mansour
- Department of Surgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - George Nassif
- Department of Colorectal Surgery, AdventHealth, Orlando, FL, USA
| | - Malcolm A West
- Cancer Sciences Unit, Faculty of Medicine, University of Southampton, Southampton, UK
- Complex Cancer and Exenterative Service, University Hospitals Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, Perioperative and Critical Care Theme, University of Southampton, Southampton, UK
| | - Aurora D Pryor
- Long Island Jewish Medical Center and System Chief for Bariatric Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Great Neck, NY, USA
| | - Franco Carli
- Department of Anesthesia, Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada
| | | | - Nicole D Bouvy
- Innovative Surgical Techniques, Endoscopic and Endocrine Surgery, Department of Surgery, Maastricht University Medical Center, Amsterdam, Netherlands
| | - Roberto Passera
- Division of Nuclear Medicine, University of Torino, Turin, Italy
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Turin, Italy
| | - Nader Francis
- Department of Surgery, Yeovil District Hospital, Higher Kingston, Yeovil, UK.
- The Griffin Institute, Northwick Park and St Mark's Hospital, Y Block, Watford Rd, Harrow, HA1 3UJ, UK.
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Chern YJ, You JF, Cheng CC, Jhuang JR, Yeh CY, Hsieh PS, Tsai WS, Liao CK, Hsu YJ. Decreasing Postoperative Pulmonary Complication Following Laparoscopic Surgery in Elderly Individuals with Colorectal Cancer: A Competing Risk Analysis in a Propensity Score-Weighted Cohort Study. Cancers (Basel) 2021; 14:cancers14010131. [PMID: 35008295 PMCID: PMC8750692 DOI: 10.3390/cancers14010131] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 12/21/2021] [Accepted: 12/25/2021] [Indexed: 01/05/2023] Open
Abstract
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.
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Affiliation(s)
- Yih-Jong Chern
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Branch, No. 5, Fu-Hsing St., Kuei-Shan, Taoyuan 33305, Taiwan; (Y.-J.C.); (J.-F.Y.); (C.-C.C.); (C.-Y.Y.); (P.-S.H.); (W.-S.T.); (C.-K.L.)
- School of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
| | - Jeng-Fu You
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Branch, No. 5, Fu-Hsing St., Kuei-Shan, Taoyuan 33305, Taiwan; (Y.-J.C.); (J.-F.Y.); (C.-C.C.); (C.-Y.Y.); (P.-S.H.); (W.-S.T.); (C.-K.L.)
- School of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
| | - Ching-Chung Cheng
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Branch, No. 5, Fu-Hsing St., Kuei-Shan, Taoyuan 33305, Taiwan; (Y.-J.C.); (J.-F.Y.); (C.-C.C.); (C.-Y.Y.); (P.-S.H.); (W.-S.T.); (C.-K.L.)
- School of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
| | - Jing-Rong Jhuang
- Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei City 10055, Taiwan;
| | - Chien-Yuh Yeh
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Branch, No. 5, Fu-Hsing St., Kuei-Shan, Taoyuan 33305, Taiwan; (Y.-J.C.); (J.-F.Y.); (C.-C.C.); (C.-Y.Y.); (P.-S.H.); (W.-S.T.); (C.-K.L.)
- School of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
| | - Pao-Shiu Hsieh
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Branch, No. 5, Fu-Hsing St., Kuei-Shan, Taoyuan 33305, Taiwan; (Y.-J.C.); (J.-F.Y.); (C.-C.C.); (C.-Y.Y.); (P.-S.H.); (W.-S.T.); (C.-K.L.)
- School of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
| | - Wen-Sy Tsai
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Branch, No. 5, Fu-Hsing St., Kuei-Shan, Taoyuan 33305, Taiwan; (Y.-J.C.); (J.-F.Y.); (C.-C.C.); (C.-Y.Y.); (P.-S.H.); (W.-S.T.); (C.-K.L.)
- School of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
| | - Chun-Kai Liao
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Branch, No. 5, Fu-Hsing St., Kuei-Shan, Taoyuan 33305, Taiwan; (Y.-J.C.); (J.-F.Y.); (C.-C.C.); (C.-Y.Y.); (P.-S.H.); (W.-S.T.); (C.-K.L.)
- School of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
| | - Yu-Jen Hsu
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Branch, No. 5, Fu-Hsing St., Kuei-Shan, Taoyuan 33305, Taiwan; (Y.-J.C.); (J.-F.Y.); (C.-C.C.); (C.-Y.Y.); (P.-S.H.); (W.-S.T.); (C.-K.L.)
- School of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
- Correspondence:
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Son IT, Kim JY, Kim MJ, Kim BC, Kang BM, Kim JW. Clinical and oncologic outcomes of laparoscopic versus open surgery in elderly patients with colorectal cancer: a retrospective multicenter study. Int J Clin Oncol 2021; 26:2237-2245. [PMID: 34453641 DOI: 10.1007/s10147-021-02009-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 08/09/2021] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Il Tae Son
- Department of Surgery, Hallym Sacred Heart Hospital, Hallym University College of Medicine, Anyang, 445-907, Republic of Korea
| | - Jeong Yeon Kim
- Department of Surgery, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 40, Sukwoo-Dong, Hwaseong, Gyeonggi, 445-170, Republic of Korea
| | - Min Jeong Kim
- Department of Surgery, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, 445 Gil-1-dong, Gangdong-gu, Seoul, 134-701, Republic of Korea
| | - Byung Chun Kim
- Department of Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 948-1, 1, Shingil-ro, Yeongdeungpo-gu, Seoul, 150-950, Republic of Korea
| | - Byung Mo Kang
- Department of Surgery, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, 200-950, Republic of Korea
| | - Jong Wan Kim
- Department of Surgery, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 40, Sukwoo-Dong, Hwaseong, Gyeonggi, 445-170, Republic of Korea.
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Exarchou K, Patel S, Barrow H, Lunevicius R, Arthur JD. Laparoscopic Surgery Is Safe and Beneficial in True Functional High-Risk Patients with Colorectal Cancer: Utilization of Cardiopulmonary Exercise Test. J Laparoendosc Adv Surg Tech A 2020; 30:1194-1203. [PMID: 32352879 DOI: 10.1089/lap.2020.0170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Patients with colorectal cancer deemed to be high-risk may be denied an elective laparoscopic resection due to subjective reasons. A comparison of the 30-day outcomes in true functional high-risk patients who underwent either open or laparoscopic colorectal resection was undertaken. Materials and Methods: A retrospective cohort of all functional high-risk patients as assessed by cardiopulmonary exercise test between July 2015 and April 2018 were identified. Anaerobic threshold of <11 mL/kg/minute was used as a physiologic indicator to determine a high-risk patient. Adherence to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) was ensured. P values were computed via two-sided Fisher's exact test, and the exact Mann-Whitney U-test. Forest plots for relative risks with 95% confidence intervals were displayed on a log scale. Results: One hundred forty-six patients were identified as high-risk. Outcomes demonstrated a trend to laparoscopic benefit in all Clavien-Dindo grades of postoperative complications, but especially in severe complications of grades 3-4 (3.5% versus 10.2%). Readmissions demonstrated a trend to laparoscopic surgery benefit (7% versus 11.8%), as did mortality (1.7% versus 3.4%). The rate of surgery-site complications was higher after open surgery (42.1% versus 22.4%, P = .0201). Wound infections were observed more frequently after open surgery (12.5% versus 1.72%, P = .0280). The estimated risk of all-grade complications was significantly higher after open anterior rectal resection (63.0% versus 29.6%, P = .0281) and there was significantly shorter stay after laparoscopic right colectomy (5 v. 7 days, P = .0490). Conclusions: Laparoscopic approach for colorectal resections in high-risk patients is safe and beneficial compared to open surgery, especially in patients undergoing laparoscopic resection of the rectum and right colon.
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Affiliation(s)
- Klaire Exarchou
- Department of General Surgery, Liverpool University Hospitals NHS Foundation Trust, Aintree University Hospital, University of Liverpool, Liverpool, United Kingdom
| | - Shaneel Patel
- Department of General Surgery, Liverpool University Hospitals NHS Foundation Trust, Aintree University Hospital, University of Liverpool, Liverpool, United Kingdom
| | - Hannah Barrow
- Department of General Surgery, Liverpool University Hospitals NHS Foundation Trust, Aintree University Hospital, University of Liverpool, Liverpool, United Kingdom
| | - Raimundas Lunevicius
- Department of General Surgery, Liverpool University Hospitals NHS Foundation Trust, Aintree University Hospital, University of Liverpool, Liverpool, United Kingdom
| | - James D Arthur
- Department of General Surgery, Liverpool University Hospitals NHS Foundation Trust, Aintree University Hospital, University of Liverpool, Liverpool, United Kingdom
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Völkel V, Draeger T, Schnitzbauer V, Gerken M, Benz S, Klinkhammer-Schalke M, Fürst A. Surgical treatment of rectal cancer patients aged 80 years and older—a German nationwide analysis comparing short- and long-term survival after laparoscopic and open tumor resection. Eur J Surg Oncol 2019; 45:1607-1612. [DOI: 10.1016/j.ejso.2019.05.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 02/28/2019] [Accepted: 05/08/2019] [Indexed: 12/27/2022] Open
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Laparoscopic-assisted colorectal surgery benefits visceral obesity patients: a propensity-matched analysis. Eur J Gastroenterol Hepatol 2019; 31:786-791. [PMID: 31150364 DOI: 10.1097/meg.0000000000001423] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND We aimed to determine the safety and effectiveness of laparoscopic-assisted surgery (LAS) in visceral obesity patients with colorectal cancer (CRC). PATIENTS AND METHODS We retrospectively collected the clinical data of consecutive patients who underwent colorectal surgery for CRC between August 2014 and July 2018. The third lumbar vertebra visceral fat area was measured to diagnose visceral obesity. One-to-one propensity score matching was performed to compare the short-term outcomes between the open surgery (OS) and LAS in visceral obesity patients. Univariate and multivariate analyses were performed to evaluate the risk factors of postoperative complications. RESULTS A total of 280 visceral obesity patients were included in this study with 140 patients for each group. Compared with the OS group, the LAS group had more lymph nodes harvested, longer surgical duration, and shorter postoperative hospital stay. The overall incidence of complications in OS was significantly higher than LAS (32.1 vs. 20.0%, P=0.021). Multivariate analysis revealed that age of at least 65 years (odds ratio: 1.950, 95% confidence interval: 1.118-3.403; P=0.019) was an independent risk factor for postoperative complications, whereas LAS (odds ratio: 0.523, 95% confidence interval: 0.302-0.908; P=0.021) was a protective factor. CONCLUSION LAS in visceral obesity patients with CRC was a safer and less invasive alternative than open surgery, with fewer complications within the first 30 days postoperatively.
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