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

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.

Role of Age as a Predictor of Major Complications After Elective Surgery for Ulcerative Colitis

BACKGROUND

The incidence of ulcerative colitis (UC) in the elderly population is increasing. The aim of this study was to assess the degree to which age and other factors increase the risk of developing major complications in patients undergoing elective surgery for UC.

METHODS

Using the ACS-NSQIP database from 2016 to 2020, patients undergoing elective surgery for UC were divided into four categories: younger than 30, 30-49, 50-69, and 70 or older. A composite outcome was created including major complications and multivariable analysis was performed to identify factors associated with composite major complications.

RESULTS

5946 patients diagnosed with ulcerative colitis who underwent elective surgery were included in the analysis. 14.1% of all patients developed a major complication. For patients with UC, factors associated with the development of a major complication were age 50-69 (OR 1.31, P = .034), male sex (OR 1.38, P < .001), Black race (OR 1.47, P = .049), dependent status (OR 2.06, P = .028), hypoalbuminemia (OR 1.92, P < .001), preoperative steroid treatment (OR 1.27, P = .038), preoperative transfusion (OR 1.91, P < .001), open surgical approach (OR 1.44, P = .002), and partial colectomy (OR 1.51, P = .007). Specifically in patients aged 70 or older, hypoalbuminemia (OR 3.20, P < .001) and preoperative transfusion (OR 2.78, P = .019) were associated with a major complication.

CONCLUSION

Age is a risk factor for the development of a major complication in UC patients undergoing elective surgery. However, it is not the only risk factor nor is it the one that increases the risk the most.

Regional variations and deprivation are linked to poorer access to laparoscopic and robotic colorectal surgery: a national study in England

BACKGROUND

Laparoscopic and now robotic colorectal surgery has rapidly increased in prevalence; however, little is known about how uptake varies by region and sociodemographics. The aim of this study was to quantify the uptake of minimally invasive colorectal surgery (MIS) over time and variations by region, sociodemographics and ethnicity.

METHODS

Retrospective analysis of routinely collected healthcare data (Clinical Practice Research Datalink linked to Hospital Episode Statistics) for all adults having elective colorectal resectional surgery in England from 1 January 2006 to 31 March 2020. Sociodemographics between modalities were compared and the association between sociodemographic factors, region and year on MIS was compared in multivariate logistic regression analysis.

RESULTS

A total of 93,735 patients were included: 52,098 open, 40,622 laparoscopic and 1015 robotic cases. Laparoscopic surgery surpassed open in 2015 but has plateaued; robotic surgery has rapidly increased since 2017, representing 3.2% of cases in 2019. Absolute differences up to 20% in MIS exist between regions, OR 1.77 (95% CI 1.68-1.86) in South Central and OR 0.75 (95% CI 0.72-0.79) in the North West compared to the largest region (West Midlands). MIS was less common in the most compared to least deprived (14.6% of MIS in the most deprived, 24.8% in the least, OR 0.85 95% CI 0.81-0.89), with a greater difference in robotic surgery (13.4% vs 30.5% respectively). Female gender, younger age, less comorbidity, Asian or 'Other/Mixed' ethnicity and cancer indication were all associated with increased MIS.

CONCLUSIONS

MIS has increased over time, with significant regional and socioeconomic variations. With rapid increases in robotic surgery, national strategies for procurement, implementation, equitable distribution and training must be created to avoid worsening health inequalities.

Age-related variations in colon and rectal cancer: An analysis of the national cancer database

BACKGROUND

Characteristics of colorectal diseases may vary according to the patient's age. By using a large national database, we assessed age-related differences in characteristics and treatments of colorectal cancer and to evaluate the influence of age on outcomes.

METHOD

Retrospective cohort analysis of all patients who underwent surgical resection for colorectal cancer in the US National Cancer Database between 2005 and 2019. Patients were divided into 3 age groups: young age onset (<50 years), middle age group (50-79 years), and very old (≥80 years). Differences in tumor characteristics among groups were assessed. The main outcomes were clinical and treatment characteristics and short-term mortality.

RESULTS

In total, 662,102 patients with colon cancer and 114,460 with rectal cancer were included-36.1% of young patients with colon cancer presented with metastatic disease. Older patients underwent open surgery more often and received chemotherapy and radiation therapy less often than did the other 2 groups regarding disease stage. Very old patients, compared to middle-aged and young patients, had longer hospitalization and significantly higher rates of 30-day mortality after colon (7.6% vs 2.4% vs 0.7%; P < .001) and rectal (5.9% vs 1.3% vs 0.3%; P < .001) cancer surgery and higher 90-day mortality after colon (12.9% vs 4.6% vs 1.7% P < .001) and rectal (10.3% vs 2.6% vs 0.7%; P < .001) cancer surgery.Older patients had significantly shorter overall survival than the other 2 groups, regardless of pathologic stage, Charlson -Deyo comorbidity score, or tumor side.

CONCLUSION

Significant age-related disparities in characteristics, treatments, and outcomes of colorectal cancer were found in this study. Recognizing these differences can be the first step toward reducing age-related treatment differences.

Predictors for surgical site infection in patients undergoing therapeutic or prophylactic intra-abdominal onlay mesh (IPOM) implantation in clean and contaminated surgical fields

BACKGROUND

Prophylactic intra-abdominal onlay mesh (IPOM) implantation has been shown to reduce the rate of fascial dehiscence and incisional hernia. However, surgical site infection (SSI) in presence of an IPOM remains a concern. The aim of this study was to assess predictors for SSI following IPOM placement in hernia and non-hernia abdominal surgery in clean and contaminated surgical fields.

METHODS

Observational study including patients undergoing IPOM placement at a Swiss tertiary care hospital 2007-2016. IPOM implantation was performed in hernia and non-hernia elective and emergency abdominal surgery, including contaminated and infected surgical fields. The incidence of SSI was prospectively assessed by Swissnoso according to CDC criteria. The effect of disease- and procedure-related factors on SSI was assessed in multivariable regression analysis, adjusting for patient-related factors.

RESULTS

A total of 1072 IPOM implantations were performed. Laparoscopy was performed in 415 patients (38.7%), laparotomy in 657 patients (61.3%). SSI occurred in 172 patients (16.0%). Superficial, deep, and organ space SSI were found in 77 (7.2%), 26 (2.4%), and 69 (6.4%) patients, respectively. Multivariable analysis revealed emergency hospitalization (OR 1.787, p = 0.006), previous laparotomy (1.745, p = 0.029), duration of operation (OR 1.193, p < 0.001), laparotomy (OR 6.167, p < 0.001), bariatric (OR 4.641, p < 0.001), colorectal (OR 1.941, p = 0.001), and emergency (OR 2.510, p < 0.001) surgery, wound class ≥ 3 (OR 3.878, p < 0.001), and non-polypropylene mesh (OR 1.818, p = 0.003) as independent predictors for SSI. Hernia surgery was independently associated with a lower risk for SSI (OR 0.165, p < 0.001).

CONCLUSION

This study revealed emergency hospitalization, previous laparotomy, duration of operation, laparotomy, as well as bariatric, colorectal, and emergency surgery, abdominal contamination or infection, and usage of non-polypropylene mesh as independent predictors for SSI. In contrast, hernia surgery was associated with a lower risk for SSI. The knowledge of these predictors will help to balance benefits of IPOM implantation against the risk for SSI.

Comparison of short-term outcomes and survival between minimally invasive colectomy and open colectomy in patients 80 years of age and older

We investigated the short- and long-term outcomes of patients 80 years of age and older with colon cancer who underwent robotic colectomy versus laparoscopic colectomy. Data for patients treated at a comprehensive cancer center between January 2006 and November 2018 were collected retrospectively. Outcomes from minimally invasive laparoscopic or robotic colectomy were compared. Survival was analyzed by the Kaplan-Meier method with significance evaluated by the log-rank test. The laparoscopic (n = 104) and the robotic (n = 75) colectomy groups did not differ across baseline characteristics. Patients who underwent a robotic colectomy had a shorter median length of hospital stay (5 versus 6 days; p < 0.001) and underwent fewer conversions to open surgery (3% versus 17%; p = 0.002) compared to the laparoscopic cohort. The groups did not differ in postoperative complication rates, overall survival or disease-free survival. Elderly patients undergoing robotic colectomy for colon cancer have a shorter hospital stay and lower rates of conversion without compromise to oncologic outcomes.

Laparoscopic Pancreatoduodenectomy in Elderly Patients: A Systematic Review and Meta-Analysis

Background and Aims: Recent single-center retrospective studies have focused on laparoscopic pancreatoduodenectomy (LPD) in elderly patients, and compared the outcomes between the laparoscopic and open approaches. Our study aimed to determine the outcomes of LPD in the elderly patients, by performing a systematic review and a meta-analysis of relevant studies. Methods: A comprehensive literature review was conducted utilizing the Embase, Medline, PubMed, Scopus and Cochrane databases to identify all studies that compared laparoscopic vs. open approach for pancreatoduodenectomy (PD). Results: Five retrospective studies were included in the final analysis. Overall, 90-day mortality rates were significantly decreased after LPD in elderly patients compared with open approaches (RR = 0.56; 95%CI: 0.32−0.96; p = 0.037, I2 = 0%). The laparoscopic approach had similar mortality rate at 30-day, readmission rate in hospital, Clavien−Dindo complications, pancreatic fistula grade B/C, complete resection rate, reoperation for complications and blood loss as the open approach. Additionally, comparing with younger patients (<70 years old), no significant differences were seen in elderly cohort patients regarding mortality rate at 90 days, readmission rate to hospital, and complication rate. Conclusions: Based on our meta-analysis, we identify that LPD in elderly is a safe procedure, with significantly lower 90-day mortality rates when compared with the open approach. Our results should be considered with caution, considering the retrospective analyses of the included studies; larger prospective studies are required.

Laparoscopic versus open surgery for elderly patients with colorectal cancer: a systematic review and meta-analysis of matched studies

BACKGROUND

To compare clinical and survival outcomes between laparoscopic versus open surgery in elderly colorectal cancer patients.

METHODS

PubMed, Embase and Scopus databases were systematically searched. The review included studies that were either randomized controlled trials (RCTs) or observational in design. STATA was used for statistical analysis.

RESULTS

The meta-analysis was conducted with 24 studies. Compared with elderly subjects with open surgery, those undergoing laparoscopic surgery had a lower risk of mortality (within 3 months postoperatively) (RR 0.70, 95% CI: 0.53, 0.94). The long-term overall survival (HR 0.96, 95% CI: 0.89, 1.04), disease-free survival (HR 1.02, 95% CI: 0.93, 1.13), risk of recurrence (RR 1.44, 95% CI: 0.90, 2.30) and readmission (RR 1.11, 95% CI: 0.88, 1.40) rates were statistically similar in both the groups. The operative time (in minutes) was higher (WMD 30.37, 95% CI: 17.75, 43.0) and the blood loss (in ml) was lower (WMD -78.85, 95% CI: -101.96, -55.75) in those undergoing laparoscopic surgery. The length of hospital stay (in days) (WMD -2.53, 95% CI: -3.11, -1.95) and the time of return of bowel movements (in days) (WMD -1.06, 95% CI: -1.20, -0.93) was lower in those with laparoscopic surgery. The pooled risk of complications was lower in those with laparoscopic surgery (RR 0.66, 95% CI: 0.60, 0.74), compared with open surgery.

CONCLUSIONS

Findings suggest that in elderly subjects with colorectal cancer, laparoscopic surgery appears to be more beneficial than open surgery and should be prioritized, subject to the availability of required technical skills and facilities.

Colorectal cancer surgery in elderly patients 80 years and older: a comparison with younger age groups

BACKGROUND

A reduction in complications and mortality can be observed over the last few decades among elderly patients in the early postoperative period for colorectal cancer (CRC) surgery, but long-term outcomes are largely unknown. This study aimed to investigate the long-term outcomes of elderly patients 80 years and older after CRC surgery in comparison with younger age groups. The influence of clinical, oncological, and physical parameters on outcome were retrospectively analyzed.

METHODS

A total of 346 patients underwent CRC surgery with curative intent between January 2013 and December 2017. Patients were divided into three age groups: younger than 60 (n=47), between 60 and 79 (n=218), and 80 and older (n=81). Clinicopathological variables including comorbidity, modified frailty index, prognostic nutrition index (PNI), operative/postoperative data, and outcome including cause of death were compared among age groups. To identify factors associated with death from CRC and other causes, univariate and multivariate analyses using the Cox proportional hazards model were performed.

RESULTS

Immediate postoperative morbidity of patients with Clavien-Dindo grades of III or greater (16.0%) and the 30-day mortality rate (2.5%) of patients 80 years and older were not statistically different from those of younger age groups. Long-term disease-free survival was also similar among age groups, suggesting CRC surgery provides oncological benefit to patients irrespective of age. Multivariate analysis revealed that R1 resection, advanced tumor stage, carcinoembryonic antigen (CEA) level of >5 ng/mL, undifferentiated tumor, and longer postoperative hospital stay were risk factors for CRC death. Long-term overall survival was significantly reduced in comparison to younger age groups. Seventy percent of deaths in elderly patients during follow-up were primarily from respiratory failure and cardiovascular disease. Multivariate analysis demonstrated that advanced age, frailty, low PNI, and open procedure were risk factors for other causes of mortality.

CONCLUSIONS

Elderly patients undergoing CRC surgery appeared to enjoy similar oncological benefits as younger age groups. Since both modified frailty index and PNI were correlated with mortality unrelated to CRC, preoperative assessment of these factors can be important for predicting outcome and selecting patients for prehabilitation.

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.

The Trends in Adoption, Outcomes, and Costs of Laparoscopic Surgery for Colorectal Cancer in the Elderly Population

BACKGROUND

The elderly constitute the majority of both colorectal cancer and surgical volume. Despite established safety and feasibility, laparoscopy may remain underutilized for colorectal cancer resections in the elderly. With proven benefits, increasing laparoscopy in elderly colorectal cancer patients could substantially improve outcomes. Our goal was to evaluate utilization and outcomes for laparoscopic colorectal cancer surgery in the elderly.

METHODS

A national inpatient database was reviewed for elective inpatient resections for colorectal cancer from 2010 to 2015. Patients were stratified into elderly (≥ 65 years) and non-elderly cohorts (< 65 years), then grouped into open or laparoscopic procedures. The main outcomes were trends in utilization by approach and total costs, length of stay (LOS), readmission, and complications by approach in the elderly. Multivariable regression models were used to control for differences across platforms, adjusting for patient demographics, comorbidities, and hospital characteristics.

RESULTS

Laparoscopic adoption for colorectal cancer in the elderly increased gradually until 2013, then declined, with simultaneously increasing rates of open surgery. Laparoscopy significantly improved all primary outcomes compared to open surgery (all p < 0.01). From the adjusted analysis, laparoscopy reduced complications by 30%, length of stay by 1.99 days, and total costs by $3276/admission. Laparoscopic patients were 34% less likely to be readmitted; when readmitted, the episodes were less expensive when index procedure was laparoscopic.

CONCLUSION

The adoption of laparoscopy for colorectal cancer surgery in the elderly is slow and even declining recently. In addition to the clinical benefits, there are reduced overall costs, creating a tremendous value proposition if use can be expanded.

PRECIS

This national contemporary study shows the slow uptake and recent decline in adaption of laparoscopic surgery for colorectal cancer in the elderly, despite the benefits in clinical outcomes and costs found. This data can be used to target education, regionalization, and quality improvement efforts in this expanding population.

Age and comorbidities do not affect short-term outcomes after laparoscopic rectal cancer resection in elderly patients. A multi-institutional cohort study in 287 patients

Postoperative complications and mortality rates after rectal cancer surgery are higher in elderly than in non-elderly patients. The aim of this study is to evaluate whether, like in open surgery, age and comorbidities affect postoperative outcomes limiting the benefits of a laparoscopic approach. Between April 2011 and July 2020, data of 287 patients with rectal cancer submitted to laparoscopic rectal resection from different institutions were collected in an electronic database and were categorized into two groups: < 75 years and ≥ 75 years of age. Perioperative data and short-term outcomes were compared between these groups. Risk factors for postoperative complications were determined on multivariate analysis, including age groups and previous comorbidities as variables. Seventy-seven elderly patients had both higher ASA scores (p < 0.001) and cardiovascular disease rates (p = 0.02) compared with 210 non-elderly patients. There were no significative differences between groups in terms of overall postoperative complications (p = 0.3), number of patients with complications (p = 0.2), length of stay (p = 0.2) and death during hospitalization (p = 0.9). The only independent variables correlated with postoperative morbidity were male gender (OR 2.56; 95% CI 1.53-3.68, p < 0.01) and low-medium localization of the tumor (OR 2.12; 75% CI 1.43-4.21, p < 0.01). Although older people are more frail patients, short-term postoperative outcomes in patients ≥ 75 years of age were similar to those of younger patients after laparoscopic surgery for rectal cancer. Elderly patients benefit from laparoscopic rectal resection as well as non-elderly patient, despite advanced age and comorbidities.

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.

Advantage of laparoscopy surgery for elderly colorectal cancer patients without compromising oncologic outcome

Background

Laparoscopic surgery has achieved significant results in elderly patients with colorectal cancer (CRC). In this study, we compared the short-term and long-term outcomes of open surgery and laparoscopic surgery in patients with CRC aged above 75 years at a single tertiary medical center.

Methods

We analyzed 967 patients who underwent curative resection for primary colorectal adenocarcinoma without distant metastasis between January 2009 and December 2015, in a single institution. Of the enrolled patients, 305 underwent laparoscopic surgery, and 662 received open laparotomy surgery.

Results

Compared to the patients who underwent open surgery, those who received laparoscopic surgery had significantly shorter postoperative stay (10.3 vs. 13.5 days p < 0.001) and similar postoperative morbidity (p = 0.354) and mortality (p = 0.082). In the laparoscopy cohort, six of 305 patients were converted to open surgery and one died. The long-term overall survival, cancer-specific survival, and recurrence rate were similar between both cohorts in each stage.

Conclusions

Laparoscopic surgery is suitable for elderly patients owing to shorter postoperative stay, similar long-term outcomes with open surgery, and acceptable low conversion rates. For long-term overall and oncological outcomes, the results of laparoscopic surgery were similar to that of open surgery in each TNM stage.

Preventive intraperitoneal hyperthermic perfusion chemotherapy for patients with T4 stage colon adenocarcinoma

BACKGROUND

Hyperthermic intraperitoneal chemotherapy (HIPEC) has been shown to be an effective treatment for peritoneal tumors; whether preventive HIPEC after radical resection for T4 stage colon adenocarcinoma could decrease peritoneal recurrence remains unknown. The aim of the present study was to compare peritoneal recurrence and short-term survival in patients with T4 stage colon adenocarcinoma undergoing HIPEC plus adjuvant chemotherapy or adjuvant chemotherapy alone following surgery.

METHODS

We retrospectively reviewed T4 stage colon adenocarcinoma patients who had radical tumor resection at our institution between January 2014 and January 2019. Clinical data were extracted from the database at our institution, and patient survival and long-term complications were assessed through repeated outpatient examinations and telephone interviews.

RESULTS

A total of 352 patients were included in this study; 157 patients received postoperative HIPEC plus adjuvant chemotherapy (HIPEC group), 195 patients received adjuvant chemotherapy alone (conventional chemotherapy group). Forty-one (26.1%) patients in the HIPEC group had a peritoneal recurrence and the peritoneum was the first site of tumor recurrence in 6 (14.6%) of them. However, 73 (37.4%) patients experienced peritoneal recurrence in the conventional group, and the peritoneum was the first site of tumor recurrence in 25 (34.2%) (p = 0.019). Disease-free survival in the HIPEC group at 1 and 3 years was 93.3% and 61.1%, respectively, versus 89.3% and 51.7% in the conventional chemotherapy group (p = 0.038). Overall survival in the HIPEC group at 1 and 3 years was 100.0% and 82.7%, respectively, versus 100.0% and 76.9% in the conventional chemotherapy group (p = 0.420). The two groups did not differ with respect to severe complications.

CONCLUSIONS

Preventive HIPEC after radical surgery may decrease peritoneal recurrence and promote disease-free survival for T4 stage colon adenocarcinoma. Large-scale randomized controlled studies are needed to confirm the results of our study.

Feasibility of a tailored ERAS programme in octogenarian patients undergoing minimally invasive surgery for colorectal cancer

BACKGROUND

The enhanced recovery after surgery (ERAS) is nowadays a widely accepted multimodal programme of care in colorectal surgery, but still there is some reluctance in its application to very elderly patients.

AIM

The aim of this study is to investigate short-term outcomes of laparoscopic resection for colorectal cancer in octogenarian patients within the ERAS programme.

METHODS

Data on 162 consecutive patients aged ≥ 80 years receiving elective minimally invasive colorectal resections within ERAS programme were collected in a multicentre, retrospective database in the period 2008-2017 in Italy. Univariate and multivariate analyses were performed to assess possible risk factors for poor clinical outcomes.

RESULTS

The postoperative minor morbidity rate (Clavien-Dindo 1 and 2) was 25.9%. The incidence of postoperative major morbidity rate (severe medical and surgical complications defined as Clavien-Dindo 3 and 4) accounted 6.1% and only 1.8% had an anastomotic leakage. Reoperation rate was 5.5%, perioperative 30-day mortality was 1.8%, and 30-day readmission rate was 6.8%. On average, patients were released after 6 days. A univariate analysis showed that possible risk factors for severe medical complications were: low preoperative albumin level, high Charlson Age Comorbidity Index Score and number of days in the intensive care unit (ICU); risk factors for severe surgical complications were: low preoperative albumin level; risk factors for late hospital discharge were: multivisceral resections, number of days in ICU and body mass index (BMI) > 25 kg/m². The multivariate analysis confirmed a low level of preoperative albumin and a longer ICU stay as independent risk factors for both postoperative severe surgical complications and late hospital discharge.

DISCUSSION

The minimal invasive nature of the laparoscopic approach together with a multimodal analgesia therapy, the early resumption to oral diet and mobilisation could minimize the surgical stress and play an essential role in order to reduce medical morbidity in high-risk patients.

CONCLUSION

Colorectal surgery within ERAS programme in octogenarians is a safe and flexible treatment in high-volume centres.

Effect of Age on Laparoscopic Surgery and Postoperative Chemotherapy in Elderly Patients With Colorectal Cancer

PURPOSE

We aimed to evaluate the postoperative complications of laparoscopic colorectal cancer (CRC) surgery and the adverse events of postoperative chemotherapy in elderly patients compared to younger patients and to identify the factors influencing the termination of postoperative chemotherapy.

METHODS

Between June 2015 and May 2018, 188 patients with CRC underwent laparoscopic surgery with curative intent. Patients aged ≥ 70 were defined as elderly. Postoperative complications and adverse events of chemotherapy were assessed by using the Clavien-Dindo classification and the Common Terminology Criteria for Adverse Events, respectively. The clinicopathological factors were analyzed retrospectively.

RESULTS

Seventy-eight patients were considered elderly with a mean age of 77.5 ± 5.5 years. Overall postoperative complications occurred in 68 patients (36.2%). Age and primary tumor location were independent predictors of overall postoperative complications. Smoking history was the only independent predictor of major postoperative complications. Of 113 patients who were recommended postoperative chemotherapy, 90 patients (79.6%) received postoperative chemotherapy. Overall adverse events occurred in 40 patients (44.4%). The American Society of Anesthesiologists physical status classification and chemotherapy regimen were significantly associated with overall adverse events. The chemotherapy regimen was the only factor significantly associated with severe adverse events. Of 90 patients, postoperative chemotherapy could not be completed in 11 (12.2%). Age was the only factor significantly associated with stopping postoperative chemotherapy (P = 0.003).

CONCLUSION

This study shows that laparoscopic CRC surgery and postoperative chemotherapy were feasible in elderly patients. Further efforts are needed to ensure that elderly patients have the opportunity to make informed decisions regarding postoperative chemotherapy.

Outcomes of colorectal cancer surgery in the nonagenarians: 20-year result from a tertiary center

Background

There is a foreseeable trend that life expectancy is on the rise in many parts of the world. More and more patients will present with colorectal cancer at extreme old age and advanced age is a well-known risk factor for adverse outcomes after surgery. The aim of this study is to evaluate the outcomes of colorectal cancer surgery in patients aged 90 or above.

Method

A retrospective analysis of consecutive patients aged 90 or above who underwent operations for colorectal cancer between January 1996 and December 2015 was performed. The primary outcomes were the complications rate, 30-day and 180-day mortality rates.

Results

A total of 57 patients were included in the analysis. The majority of them were women (64.9%). The median age was 92 years. Most of the surgery was of curative intent (77.2%), performed under elective setting (57.9%) and with open approach (78.9%). 36.8% of patients had postoperative complications, with pneumonia being the commonest. The 30-day and 180-day mortality rate was 7 and 31.6% respectively. History of ischemic heart disease and surgery under emergency setting were predictors of postoperative complications. Pneumonia, preoperative leukocytosis and Charlson comorbidity score ≥ 9 were predictors of 180-day mortality. The one and two-year survival rate for elective surgery was 69.7 and 54.5% respectively.

Conclusion

The outcomes of colorectal cancer surgery for nonagenarians could be favorable in a selected group of patients. Future study on better risk profiling and ways to improve outcomes is warranted.

Safe surgery in the elderly: A review of outcomes following robotic proctectomy from the Nationwide Inpatient Sample in a cross-sectional study

Background

As our nation's population ages, operating on older and sicker patients occurs more frequently. Robotic operations have been thought to bridge the gap between a laparoscopic and an open approach, especially in more complex cases like proctectomy.

Methods

Our objective was to evaluate the use and outcomes of robotic proctectomy compared to open and laparoscopic approaches for rectal cancer in the elderly. A retrospective cross-sectional cohort study utilizing the Nationwide Inpatient Sample (NIS; 2006-2013) was performed. All cases were restricted to age 70 years old or greater.

Results

We identified 6740 admissions for rectal cancer including: 5879 open, 666 laparoscopic, and 195 robotic procedures. The median age was 77 years old. The incidence of a robotic proctectomy increased by 39%, while the open approach declined by 6% over the time period studied. Median (interquartile range) length of stay was shorter for robotic procedures at 4.3 (3-7) days, compared to laparoscopic 5.8 (4-8) and open at 6.7 (5-10) days (p < 0.01), while median total hospital charges were greater in the robotic group compared to laparoscopic and open cases ($64,743 vs. $55,813 vs. $50,355, respectively, p < 0.01). There was no significant difference in the risk of total complications between the different approaches following multivariate analysis.

Conclusion

Robotic proctectomy was associated with a shorter LOS, and this may act as a surrogate marker for an overall improvement in adverse events. These results demonstrate that a robotic approach is a safe and feasible option, and should not be discounted solely based on age or comorbidities.

Feasibility and Safety of Laparoscopic Right Colectomy in Oldest-Old Patients with Colon Cancer: Results of the CLIMHET Study Group

BACKGROUND

Laparoscopy for colorectal cancer treatment is widely accepted. However, there is no consensus as to whether or not laparoscopy can be considered the preferred treatment strategy in octogenarian and nonagenarian patients with colon cancer. The aim of this study was to compare operative and postoperative outcomes of laparoscopic right colectomy between oldest-old (≥80 years) and younger (<80 years) patients with colon cancer.

METHODS

The study population was sampled from the CLIMHET Study Group cohort. Between January 2005 and December 2015, data were retrieved for all patients who had undergone elective laparoscopic right colectomy for colon cancer in five University Hospital centers in France (CHU of Clermont-Ferrand, Hôpital Civil of Strasbourg-IRCAD, Hôpital Henri-Mondor of Créteil, Hôpital Européen Georges Pompidou of Paris, and CHRU of Tours).

RESULTS

Overall, 473 cancer patients were selected and analyzed. There were 156 oldest-old patients (median age: 84.1 years, range: 80-96) and 317 younger patients (median age: 67 years, range: 25-79). After adjusting based on propensity score on gender, obesity, American Society of Anesthesiologists score, smoking, arteriopathy, coronaropathy, comorbidity, and American Joint Committee on Cancer staging, no significant difference was found in operative and postoperative outcomes, except for time to resume a regular diet (3.6 days versus 3.0 days, P = .008) and length of hospital stay (12.1 days versus 9.1 days, P = .03), which were longer for oldest-old patients. Overall and disease-free survival rates were also equivalent between groups.

CONCLUSION

These findings support that laparoscopic right colectomy can be safely performed in cancer patients aged 80 and older, and its outcomes are similar in oldest-old and younger patients.

Identification of factors predictive of postoperative morbidity and short-term mortality in older patients after colorectal carcinoma resection: A single-center retrospective study

OBJECTIVES

The aim of this study is to investigate the effect of age on patient outcome after colorectal carcinoma (CRC) resection in patients over 65 years of age.

METHODS

This study included patients aged 65 years and older who underwent CRC resection between 2003 and 2013 at a single-center institution. Patients were divided into two groups: Group A (65-74 years old) and Group B (≥75 years old).

RESULTS

Multivariable logistic analysis of 415 patients revealed serum albumin levels on the third postoperative day (POD) (Odds Ratio (OR), 0.44; 95% CI, 0.21-0.94; P = 0.03) and C-reactive protein (CRP) levels (OR, 1.05; 95% CI, 1.00-1.01; P = 0.04) in patients with colon cancer as predictive factors for morbidity. In addition, the multivariable logistic analysis revealed serum albumin levels (OR, 0.27; 95% CI, 0.08-0.87; P = 0.03) in patients with rectal cancer as predictive factors for morbidity. The multivariate Cox Proportional Hazards Model identified re-intervention for colon cancer (Hazard Ratio (HR), 4.57; 95% CI, 1.36-15.4 P = 0.01) and for rectal cancer (HR, 11.8; 95% CI, 1.08-129 P = 0.04) as a predictive factor for 30-day mortality. Serum albumin level on the third POD was predictive of 30-day mortality (HR, 0.30; 95% CI, 0.13-0.71; P = 0.01) and of 1-year mortality (HR, 0.34; 95% CI, 0.17-0.66; P < 0.01) in patients with colon cancer.

CONCLUSION

Age is not predictive of postoperative morbidity and mortality in patients with CRC. Serum albumin levels on the third POD can predict morbidity and mortality for colon and rectal carcinoma in older patients undergoing colorectal resections.

[Minimally invasive surgery for colorectal cancer in advanced age patients]

AIM

To evaluate the role of laparoscopic surgery for colorectal cancer in advanced age patients.

MATERIAL AND METHODS

290 patients with colorectal cancer were enrolled including 121 patients with rectal cancer and 169 patients with colon cancer. Main group consisted of 171 patients over 60 years old, control group - 119 patients younger 60 years old.

RESULTS

Radical advanced procedures on different parts of colon including laparoscopic approach were performed in the majority of advanced age patients. Outcomes were considered as good, we did not notice serious complications (5.4% after rectal surgery, 3.9% after colon surgery). Differences were not significant compared with younger patients including laparoscopic interventions for emergency indications. Nevertheless, surgical treatment of advanced age patients with colorectal cancer makes special demands for equipping of the clinic and physicians' qualification.

CONCLUSION

Advanced age is not a serious limitation in choice of laparoscopic access in both elective and emergency surgery in patients with colorectal cancer.

Respiratory complications after colonic procedures in chronic obstructive pulmonary disease: does laparoscopy offer a benefit?

BACKGROUND

Patients with severe chronic obstructive pulmonary disease (COPD) are at a higher risk for postoperative respiratory complications. Despite the benefits of a minimally invasive approach, laparoscopic pneumoperitoneum can substantially reduce functional residual capacity and raise alveolar dead space, potentially increasing the risk of respiratory failure which may be poorly tolerated by COPD patients. This raises controversy as to whether open techniques should be preferentially employed in this population.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2011 to 2014 was used to examine the clinical data from patients with COPD who electively underwent laparoscopic and open colectomy. Patients defined as having COPD demonstrated either functional disability, chronic use of bronchodilators, prior COPD-related hospitalization, or reduced forced expiratory reserve volumes on lung testing (FEV1 <75%). Demographic data and preoperative characteristics were compared. Linear and logistic regressions were utilized to perform multivariate analysis and determine risk-adjusted outcomes.

RESULTS

Of the 4397 patients with COPD, 53.8% underwent laparoscopic colectomy (LC) while 46.2% underwent open colectomy (OC). The LC and OC groups were similar with respect to demographic data and preoperative comorbidities. Equivalent frequencies of exertional dyspnea (LC 35.4 vs OC 37.7%, P = 0.11) were noted. After multivariate risk adjustment, OC demonstrated an increased rate of overall respiratory complications including pneumonia, reintubation, and prolonged ventilator dependency when compared to LC (OR 1.60, 95% CI 1.30-1.98, P < 0.01). OC was associated with longer length of stay (10 ± 8 vs. 6.7 ± 7 days, P < 0.01) and higher readmission (OR 1.36, 95% CI 1.09-1.68, P < 0.01) compared to LC.

CONCLUSION

Despite the potential risks of laparoscopic pneumoperitoneum in the susceptible COPD population, a minimally invasive approach was associated with lower risk of postoperative respiratory complications, shorter length of stay, and decrease in postoperative morbidity.

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.

Laparoscopy Can Safely be Performed in Frail Patients Undergoing Colon Resection for Cancer

The present study aims to evaluate the role of laparoscopy in frail patients undergoing colorectal surgery for colorectal cancer. A review of the 2011 to 2014 American College of Surgeons National Surgical Quality Improvement Program database was performed to identify frail patients (using a frailty index), who underwent resection for colorectal cancer. Univariable and multivariable analyses were performed to evaluate 30-day mortality and Clavien–Dindo grade IV (CD-IV) complications. A total of 52,087 patients with colorectal cancer were identified, of which frailty accounted for 2.63 per cent (index score ≥5). Patients above the age 85 were considered frail 6.8 per cent of the time and accounted for 24.5 per cent of patients with frailty. Laparoscopic surgery was performed in 32.9 and 53.1 per cent of patients with and without frailty (P < 0.001). Patients with frailty were less likely to die within 30 days of surgery if younger (P = 0.004), performed electively (P < 0.001), or laparoscopically (P < 0.001). On multivariate analysis, laparoscopy and elective surgery were associated with better perioperative survival; whereas, older age, male sex, and tobacco use were associated with 30-day mortality. Laparoscopy and lower body mass index were associated with fewer Clavien–Dindo grade IV complications. Although laparoscopy is performed less commonly in the frail, this study indicated better perioperative outcomes for patients undergoing elective surgery who were <85 years old.

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.

There is no difference in outcome between laparoscopic and open surgery for rectal cancer: a systematic review and meta-analysis on short- and long-term oncologic outcomes

Background

Until recently there has been little data available about long-term outcomes of laparoscopic rectal cancer surgery. But new randomized controlled trials regarding laparoscopic colorectal surgery have been published. The aim of this study was to compare the short- and long-term oncologic outcomes of laparoscopy and open surgery for rectal cancer through a systematic review of the literature and a meta-analysis of relevant RCTs.

Methods

A systematic review of Medline, Embase and the Cochrane library from January 1966 to October 2016 with a subsequent meta-analysis was performed. Only randomized controlled trials with data on circumferential resection margins were included. The primary outcome was the status of circumferential resection margins. Secondary outcomes included lymph node yield, distal resection margins, disease-free and overall survival rates for 3 and 5 years and local recurrence rates.

Results

Eleven studies were evaluated, involving a total of 2018 patients in the laparoscopic group and 1526 patients in the open group. The presence of involved circumferential margins was reported in all studies. There were no statistically significant differences in the number of positive circumferential margins between the laparoscopic group and open group, RR 1.16, 95% CI 0.89–1.50 and no significant differences in involvement of distal margins (RR 1.13 95% CI 0.35–3.66), completeness of mesorectal excision (RR 1.22, 95% CI 0.82–1.82) or number of harvested lymph nodes (mean difference = −0.01, 95% CI −0.89 to 0.87). Disease-free survival rates at 3 and 5 years were not different (p = 0.26 and p = 0.71 respectively), and neither were overall survival rates (p = 0.19 and p = 0.64 respectively), nor local recurrence rates (RR 0.88, 95% CI 0.63–1.23).

Conclusions

Laparoscopic surgery for rectal cancer is associated with similar short-term and long-term oncologic outcomes compared to open surgery. The oncologic quality of extracted specimens seems comparable regardless of the approach used.

Electronic supplementary material

The online version of this article (doi:10.1007/s10151-017-1662-4) contains supplementary material, which is available to authorized users.

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.

Laparoscopic resection of rectal cancer in the elderly

Recent published trials have failed to demonstrate that laparoscopic resection is not inferior to open resection of rectal cancer in terms of pathologic outcomes. However, there have been numerous studies showing the benefit of laparoscopic resection in terms of short-term complications and quality of life. Fewer complications and shorter hospital stays improve the chance of maintaining functional status, which is very important for the elderly population. Thus, laparoscopic resection of rectal cancer remains a viable option for the elderly.

Impact of frailty on approach to colonic resection: Laparoscopy vs open surgery

AIM

To understand the influence of frailty on postoperative outcomes for laparoscopic and open colectomy.

METHODS

Data were obtained from the National Surgical Quality Improvement Program (2005-2012) for patients undergoing colon resection [open colectomy (OC) and laparoscopic colectomy (LC)]. Patients were classified as non-frail (0 points), low frailty (1 point), moderate frailty (2 points), and severe frailty (≥ 3) using the Modified Frailty Index. 30-d mortality and complications were used as the primary end point and analyzed for the overall population. Complications were grouped into major and minor. Subset analysis was performed for patients undergoing colectomy (total colectomy, partial colectomy and sigmoid colectomy) and separately for patients undergoing rectal surgery (abdominoperineal resection, low anterior resection, and proctocolectomy). We analyzed the data using SAS Platform JMP Pro version 10.0.0 (SAS Institute Inc., Cary, NC, United States).

RESULTS

A total of 94811 patients were identified; the majority underwent OC (58.7%), were white (76.9%), and non-frail (44.8%). The median age was 61.3 years. Prolonged length of stay (LOS) occurred in 4.7%, and 30-d mortality was 2.28%. Patients undergoing OC were older (61.89 ± 15.31 vs 60.55 ± 14.93) and had a higher ASA score (48.3% ASA3 vs 57.7% ASA2 in the LC group) (P < 0.0001). Most patients were non-frail (42.5% OC vs 48% LC, P < 0.0001). Complications, prolonged LOS, and mortality were significantly more common in patients undergoing OC (P < 0.0001). OC had a higher risk of death and complications compared to LC for all frailty scores (non-frail: OR = 4.7, and OR = 4.67; mildly frail: OR = 2.51, and OR = 2.47; moderately frail: OR = 2.94, and OR = 2.02, severely frail: OR = 2.37, and OR = 2.34, P < 0.05) and an increase in absolute mortality with increasing frailty (non-frail 0.68% OC, mildly frail 1.39%, moderately frail 3.44%, and severely frail 5.83%, P < 0.0001).

CONCLUSION

LC is associated with improved outcomes. Although the odds of mortality are higher in non-frail, there is a progressive increase in mortality with increasing frailty.