The dark side of laparoscopic surgery for colorectal cancer patients aged 75 years or older

Sijunzi decoction granules for the treatment of advanced refractory colorectal cancer: study protocol for a multicenter, randomized, double-blind, placebo-controlled trial

Background

Colorectal cancer (CRC) ranks among the most common gastrointestinal cancers globally, with both its incidence and mortality rates showing an upward trend. In particular, the 5-year survival rate for stage IV CRC patients is only 14%. Conventional treatments such as chemotherapy and immunotherapy can lead to drug resistance, exacerbate gastrointestinal function damage, and induce immunosuppression. Sijunzi decoction (SJZD), as a fundamental formula of Traditional Chinese medicine (TCM), has been demonstrated to confer distinct advantages in treatment of CRC. Therefore, we designed this trial to explore the efficacy of SJZD for the treatment of advanced refractory CRC.

Methods

A multicenter, randomized, double-blind, placebo-controlled trial is being conducted to assess the effectiveness of SJZD combined with standard therapy for treating advanced refractory CRC. Patients with advanced CRC will be recruited and randomly allocated to either the SJZD treatment group or the placebo group in a 1:1 ratio. Both groups will receive standard treatment. The intervention period will last for 6 months, with follow-up assessments every 8 to 10 weeks. Progression-free survival (PFS) is the main outcome measure. And the secondary outcomes contain duration of disease control (DDC), overall survival (OS), completion rate of chemotherapy, incidence of treatment-related adverse events, quality of survival scale score for tumor patients and changes in spleen deficiency patient-reported outcome (PRO) scores following the intervention.

Expected outcomes

To the best of our knowledge, this trial marks the first clinical investigation into the therapeutic potential of SJZD for managing advanced refractory CRC. The primary aim of this study is to provide robust clinical evidence to support the integration of TCM with Western medicine in the treatment of advanced refractory CRC.

Trial registration

The trial was registered at Chinese Clinical Trial Registry, http://www.chictr.org.cn (Registration No: ChiCTR2200065434); Date: 2022-11-04.

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.

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

Simple Summary

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

Abstract

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

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.

Laparoscopic Surgery Is Safe and Beneficial in True Functional High-Risk Patients with Colorectal Cancer: Utilization of Cardiopulmonary Exercise Test

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.

Laparoscopic-assisted colorectal surgery benefits visceral obesity patients: a propensity-matched analysis

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.