Laparoscopic versus open surgery for colorectal cancer in the older person: A systematic review

The impact of time to surgery on oncological outcomes in stage I-III dMMR colon cancer - A nationwide cohort study

INTRODUCTION

One of the considerations when investigating neoadjuvant interventions is the prolonging of time from diagnosis to curative surgery (i.e. the treatment interval [TI]). The aim of this study was to investigate the association between the length of TI and overall survival and disease-free survival in patients with deficient mismatch repair (dMMR) colon cancer.

MATERIALS AND METHODS

This retrospective propensity score-adjusted study included all patients of ≥18 years of age undergoing elective curative surgery for stage I-III, dMMR colon cancer. Data were extracted from four Danish patient databases. Outcomes were investigated in groups with TIs of ≤14 days versus >14 days. Propensity scores were computed using all demographics, diagnoses and measurements. Matching was done in a 1:1 ratio.

RESULTS

A total of 4130 patients were included in the study with a mean age of 73.8 years and a median follow-up time of 43.9 months. After matching, 2794 patients were included in the analysis of overall survival. No significant difference in overall survival was seen between patients with TIs of ≤14 days versus >14 days (hazard ratio [HR], 0.97; 95% confidence interval [CI], 0.81-1.17; p = 0.78). In the analysis of disease-free survival, 1798 patients were included after matching. This showed no significant difference between patients with TIs of ≤14 days versus >14 days (HR, 0.85; 95% CI, 0.69-1.06; p = 0.14).

CONCLUSION

No associations were found between TI and overall survival and disease-free survival in patients with stage I-III, dMMR colon cancer undergoing elective curative surgery.

Robotic-assisted Gynecological Surgery in Older Patients - a Comparative Cohort Study of Perioperative Outcomes

Study design Because of current demographic developments, a hypothesis was proposed whereby older female patients aged > 65 years can be safely operated using minimally invasive, robotic-assisted surgery, despite having more preoperative comorbidities. A comparative cohort study was designed to compare the age group ≥ 65 years (older age group, OAG) with the age group < 65 years (younger age group, YAG) after robotic-assisted gynecological surgery (RAS) in two German centers. Patients and methods Consecutive RAS procedures performed between 2016 and 2021 at the Women's University Hospital of Jena and the Robotic Center Eisenach to treat benign or oncological indications were included in the study. The age groups were compared according to their preoperative comorbidities (ASA, Charlson comorbidity index [CCI], cumulative illness rating scale - geriatric version [CIRS-G]) and perioperative parameters such as Clavien-Dindo (CD) classification of surgical complications. Analysis was performed using Welch's t -test, chi ² test, and Fisher's exact test. Results A total of 242 datasets were identified, of which 63 (73 ± 5 years) were OAG and 179 were YAG (48 ± 10 years). Patient characteristics and the percentage of benign or oncological indications did not differ between the two age groups. Comorbidity scores and the percentage of obese patients were higher in the OAG group: CCI (2.7 ± 2.0 vs. 1.5 ± 1.3; p < 0.001), CIRS-G (9.7 ± 3.9 vs. 5.4 ± 2.9; p < 0.001), ASA class II/III (91.8% vs. 74.1%; p = 0.004), obesity (54.1% vs. 38.2%; p = 0.030). There was no difference between age groups, even grouped for benign or oncological indications, with regard to perioperative parameters such as duration of surgery (p = 0.088; p = 0.368), length of hospital stay (p = 0.786; p = 0.814), decrease in Hb levels (p = 0.811; p = 0.058), conversion rate (p = 1.000; p = 1.000) and CD complications (p = 0.433; p = 0.745). Conclusion Although preoperative comorbidity was higher in the group of older female patients, no differences were found between age groups with regard to perioperative outcomes following robotic-assisted gynecological surgery. Patient age is not a contraindication for robotic gynecological surgery.

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.

Evaluation of clinical prognostic variables on short-term outcome for colorectal cancer surgery: An overview and minimum dataset

INTRODUCTION

Surgery for colorectal cancer is associated with post-operative morbidity and mortality. Multiple systematic reviews have reported on individual factors affecting short-term outcome following surgical resection. This umbrella review aims to synthesize the available evidence on host and other factors associated with short-term post-operative complications.

METHODS

A comprehensive search identified systematic reviews reporting on short-term outcomes following colorectal cancer surgery using PubMed, Cochrane Database of Systematic Reviews and Web of Science from inception to 8th September 2020. All reported clinicopathological variables were extracted from published systematic reviews.

RESULTS

The present overview identified multiple validated factors affecting short-term outcomes in patients undergoing colorectal cancer resection. In particular, factors consistently associated with post-operative outcome differed with the type of complication; infective, non-infective or mortality. A minimum dataset was identified for future studies and included pre-operative age, sex, diabetes status, body mass index, body composition (sarcopenia, visceral obesity) and functional status (ASA, frailty). A recommended dataset included antibiotic prophylaxis, iron therapy, blood transfusion, erythropoietin, steroid use, enhance recovery programme and finally potential dataset included measures of the systemic inflammatory response CONCLUSION: A minimum dataset of mandatory, recommended, and potential baseline variables to be included in studies of patients undergoing colorectal cancer resection is proposed. This will maximise the benefit of such study datasets.

Challenges in Geriatric Oncology-A Surgeon's Perspective

As our global population ages, we will see more cancer diagnoses in older adults. Surgery is an important treatment modality for solid tumours, forming the majority of all cancers. However, the management of older adults with cancer can be more complex compared to their younger counterparts. This narrative review will outline the current challenges facing older adults with cancer and potential solutions. The challenges facing older adults with cancer are complex and include lack of high-level clinical trials targeting older adults and selection of the right patient for surgery. This may be standard surgical treatment, minimally invasive surgery or alternative therapies (no surgery) which can be local or systemic. The next challenge is to identify the individual patient's vulnerabilities to allow them to be maximally optimised for treatment. Prehabilitation has been shown to be of benefit in some cancer settings but uniform guidance across all surgical specialties is required. Greater awareness of geriatric conditions amongst surgical oncologists and integration of geriatric assessment into a surgical clinic are potential solutions. Enhanced recovery programmes tailored to older adults could reduce postoperative functional decline. Ultimately, the greatest challenge an older adult with cancer may face is the mindset of their treating clinicians-a shared care approach between surgical oncologists and geriatricians is required.

The Association Between Treatment Interval and Survival in Patients With Colon or Rectal Cancer: A Systematic Review

BACKGROUND

Surgery for colon or rectal cancer is associated with a high incidence of complications, especially in patients with a low aerobic fitness. Those patients might benefit from a comprehensive preoperative workup including prehabilitation. However, time between diagnosis and treatment is often limited due to current treatment guidelines. To date, it is unclear whether the treatment interval can be extended without compromising survival.

METHODS

A systematic review concerning the association between treatment intervals and survival in patients who underwent elective curative surgery for colon or rectal cancer was performed. A search up to December 2020 was conducted in PubMed, Cinahl and Embase. Original research articles were eligible. Quality assessment was performed using the Downs and Black checklist.

RESULTS

Eleven observational studies were included (897 947 patients). In colon cancer, treatment intervals that were statistically significant associated with reduced overall survival or cancer-specific survival ranged between > 30 and > 84 days. In rectal cancer, only one out of four studies showed that treatment intervals > 49 days was associated with reduced cancer-specific survival.

CONCLUSIONS

This systematic review identified that studies investigating the association between treatment intervals and survival are heterogeneous with regard to treatment interval definitions, treatment interval time intervals and used outcome measures. These aspects need standardization before a reliable estimate of an optimal treatment interval can be made. In addition, further research should focus on establishing optimal treatment intervals in patients at high risk for postoperative complications, as particularly these patients might benefit from extended diagnosis to treatment intervals permitting comprehensive preoperative preparation.

Do older patients (> 80 years) also benefit from ERAS after colorectal resection? A safety and feasibility study

BACKGROUND AND AIMS

The aim of this study was to evaluate the safety and feasibility of a standard Enhanced Recovery After Surgery (ERAS) program following colorectal resection in a geriatric population, aged 80 years and older.

METHODS

In this single-center before-after cohort study all patients aged 80 years and older were included after colorectal resection. Patients were divided in a pre-ERAS and an ERAS group, according to the type of perioperative care. Data were prospectively collected and analysed retrospectively. The primary outcome was short-term complication rate. Secondary outcome parameters were length of stay (LOS), 30-day mortality and readmission rate.

RESULTS

Over 4 years, 219 patients were included. Of those, 151 underwent colonic and 68 rectal resection, following the ERAS protocol perioperatively in 45 and 21 cases. There were no differences in complication rate, 30-day mortality or readmission rate in the pre-ERAS versus ERAS groups. LOS after colonic resection was reduced by 2.5 days in the ERAS group (p = 0.020). Laparoscopy was found to be an independent variable of LOS (p < 0.001, p = 0.009) and complication rate (p = 0.011, p < 0.001) for colonic and rectal surgery respectively.

DISCUSSION

A standard ERAS protocol is safe and feasible in older patients undergoing colorectal resection. Colon resection was related with shorter LOS without increasing morbidity, readmission rate nor 30-day mortality. No adverse outcome after rectal resection was found either. Laparoscopy was associated with lower complication rate and shorter LOS.

CONCLUSION

A laparoscopic approach within an ERAS protocol should be considered for colorectal resection in every patient regardless of age.

Benefits of minimally-invasive surgery for sigmoid and rectal cancer in older adults compared with younger adults: Do older adults have the most to gain?

INTRODUCTION

Randomized trials demonstrated oncologic safety and short-term benefits of laparoscopy. We investigated if the benefit of laparoscopy on short-term outcomes is greater for older adults compared with younger adults.

METHODS

We identified all older (≥70 years old) and younger (<70) adults with primary sigmoid and rectal cancer treated with resection between 2002 and 2018 from an institutional database. We compared 30-day postoperative outcomes using multivariable logistic regression with an interaction term between age group and surgical approach. Primary outcomes were death, major (Clavien-Dindo III-IV) and minor (Clavien-Dindo I-II) complications, and wound complications.

RESULTS

We included 792 patients, 293 (37%) older and 499 (63%) younger. Use of laparoscopy was similar between age groups: 120/293 (41%) older, 204/499 (41%) younger (p = .98). All patients had 30-day follow-up. Compared with open resection, minimally-invasive resection was associated with a greater reduction in deaths in older adults than in younger adults (absolute difference in older adults 7.0% less versus 2.1% less in younger adults; adjusted odds ratio [aOR] older 3.01, 95% confidence interval [CI] 1.31-7.33; aOR younger 0.31, 95% CI 0.05-1.24; interaction p = .01). Similarly, minimally-invasive resection was associated with a greater reduction in major complications in older adults than in younger adults (absolute difference in older adults 6.4% less versus 2.4% less in younger adults; aOR older 1.91, 95% CI 1.07-3.41; aOR younger 0.70, 95% CI 0.34-1.38; interaction p = .03).

CONCLUSIONS

Minimally-invasive compared with open surgery demonstrated a differential benefit on postoperative death and major complications between younger and older adults.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Stent experiences in emergency conditions in acute mechanical intestinal obstruction caused by colorectal cancer

INTRODUCTION

Stent treatment can be applied to avoid surgery in surgically risky patients or to turn a high-risk emergency operation into a lower-risk elective operation and save time.

AIM

In this study, the techniques, clinical efficacy, safety and complications of endoscopic stents applied in emergency conditions were evaluated in patients with acute mechanical intestinal obstruction (AMIO) due to colorectal cancer.

MATERIAL AND METHODS

Between 2013 and 2015, 23 patients with an average age of 69.5 ±13.5 years who presented with AMIO and anastomosis stenosis secondarily to cancer to the emergency department were subjected to stent treatment under emergency conditions.

RESULTS

Thirteen (56.5%) patients were diagnosed with colon cancer, 5 (21.7%) with rectal cancer, and 5 (21.7%) with stenosis in the previous anastomosis line. Fourteen (60.9%) patients were diagnosed with stage 4 cancer, 7 (30.4%) with stage 3 cancer and 2 (8.7%) with stage 2 cancer. The stents were applied to the sigmoid colon in 10 (43.5%) patients, to the recto-sigmoid area in 9 (39.1%) patients and to the rectum area in 4 (17.4%) patients. While 14 (60.9%) patients had local or locally advanced disease, 9 (39.1%) patients had metastases in different parts of their bodies, particularly in their livers.

CONCLUSIONS

The study demonstrates that stents offer a favorable therapeutic alternative to emergency surgery and are associated with promising short-term outcomes as well as an acceptable safety profile for AMIO.

Prognostic Nutritional Index predicts morbidity after curative surgery for colorectal cancer

INTRODUCTION

Colorectal cancer (CRC) is a major health concern and it is associated with significant morbidity and mortality. Over the last decades, the relationship between cancer and nutritional and inflammatory status in oncologic patients was studied thoroughly and multiple immunonutritional scores were developed. These scores have been mainly related to the prognosis of several cancers. An interaction between the tumour and the host is generated, triggering a systemic inflammatory reaction leading to several neuroendocrine changes. This situation favours a tendency towards anorexia and catabolism. Our hypothesis is that nutritional and inflammatory status of oncologic patients is correlated to postoperative morbidity.

METHODS

This is a prospective observational cohort study with those patients undergoing curative surgery for CRC at our institution between September 2015 and March 2017. Nutritional and inflammatory status was established using Onodera's Prognostic Nutritional Index (PNI). Complications (overall, severe, infectious and anastomotic leakage) were carefully collected during the first 30 days of the postoperative period.

RESULTS

After carrying out the multivariate analysis, PNI turned out to be a great predictive and protective factor for overall complications (RR: 0.279; 95% CI: 0.141-0.552), severe complications (RR: 0.355; 95% CI: 0.130-0.965), infectious complications (RR: 0.220; 95% CI: 0.099-0.489) and anastomotic leakage (RR: 0.151; 95% CI: 0.036-0.640).

CONCLUSION

Our work reports that PNI is an independent predictive factor for the development of postoperative complications following curative surgery for CRC.

The ALCCaS Trial: A Randomized Controlled Trial Comparing Quality of Life Following Laparoscopic Versus Open Colectomy for Colon Cancer

BACKGROUND

This study reports the quality-of-life assessment of the ALCCaS trial. The ALCCaS trial compared laparoscopic and open resection for colon cancer. It reported equivalence of survival at 5 years. Quality of life was measured as a secondary outcome.

OBJECTIVE

This study aimed to report on the quality of life data of the ALCCaS Trial.

DESIGN

This study reports a randomized controlled trial comparing laparoscopic with open colonic resection.

SETTINGS

The study was conducted in Australasia.

PATIENTS

Patients with a single adenocarcinoma of the right, left, or sigmoid colon, presenting for elective treatment, were eligible for randomization.

INTERVENTIONS

Open and laparoscopic colonic resections were performed.

MAIN OUTCOME MEASURES

Patient symptoms and quality of life were measured using the Symptoms Distress Scale, the Quality of Life Index, and the Global Quality of Life Score preoperatively, and at 2 days, 2 weeks, and 2 months postoperatively.

RESULTS

Of the 592 patients enrolled in ALCCaS, 425 completed at least 1 quality-of-life measure at 4 time points (71.8% of cohort). Those who received the laparoscopic intervention had better quality of life postoperatively in terms of the Symptoms Distress Scale (p < 0.01), Quality of Life Index (p < 0.01), and Global Quality of Life (p < 0.01). In intention-to-treat analyses, those assigned to laparoscopic surgery had a better quality of life postoperatively in terms of the Symptoms Distress Scale (p < 0.01) and Quality of Life Index (p < 0.01), whereas Global Quality of Life was not significant (p = 0.056). The subscales better for laparoscopic resection at all 3 postoperative time points were appetite, insomnia, pain, fatigue, bowel, daily living, and health (p < 0.05).

LIMITATIONS

The primary limitation was the different response rates for the 3 quality-of-life measures.

CONCLUSIONS

There was a short-term gain in quality of life maintained at 2 months postsurgery for those who received laparoscopic relative to open colonic resection. See Video Abstract at http://links.lww.com/DCR/A691.

Comparison Between Laparoscopic and Open Resection Following Neoadjuvant Chemoradiotherapy for Mid-Low Rectal Cancer Patients: A Meta-Analysis

INTRODUCTION

The optimal approach of resection for mid-low rectal cancer after neoadjuvant chemoradiotherapy (nCRT) is still controversial. The aim of this meta-analysis was to clarify the safety and feasibility of laparoscopic surgery compared with open resection.

MATERIALS AND METHODS

We performed a literature search for studies on PubMed, Embase and Cochrane Library up to March 1, 2018. Review Manager software was applied for data analysis. We used weighted mean difference (WMD) for continuous parameters and odds ratio (OR) for dichotomous variables. Confidence interval (CI) was set at 95% and a P value <.05 was considered statistically significant.

RESULTS

A total of seven studies met the inclusion criteria for the meta-analysis: 466 patients in laparoscopic group and 491 in open group. The pooled result revealed that laparoscopic resection had a favorable blood loss (WMD = -116.88 mL; 95% CI: -189.78 to -43.99; P = .002), analogous lymph nodes harvest (WMD = -0.30; 95% CI: -1.29 to 0.70; P = .56), less postoperative complications (OR = 0.63; 95% CI: 0.46-0.88; P = .006), shorter time to pass first flatus (WMD = -0.76 day; 95% CI: -1.00 to -0.51; P < .00001), and stay in hospital (WMD = -2.71 days; 95% CI: -4.54 to -0.88; P = .004), despite similar operating time (WMD = 11.17 minutes; 95% CI: -14.37 to 36.70; P = .39).

CONCLUSIONS

Laparoscopic resection might be a technically safe and feasible approach for mid-low rectal cancer patients after nCRT compared with open resection.

Frailty as a predictor of mortality in the elderly emergency general surgery patient

BACKGROUND

The number of surgical procedures performed in elderly and frail patients has greatly increased in the last decades. However, there is little research in the elderly emergency general surgery patient. The aim of this study was to assess the prevalence of frailty in the emergency general surgery population in Belgium. Secondly, we examined the length of hospital stay, readmission rate and mortality at 30 and 90 days.

METHODS

We conducted a prospective observational study at Ghent University Hospital. All patients older than 65 admitted to a general surgery ward from the emergency department were eligible for inclusion. Primary endpoint was mortality at 30 days. Secondary outcomes were mortality at 90 days, readmissions and length of stay. Cross-sectional observations were performed using the Fisher exact test, Mann-Whitney U-test, or one-way ANOVA. We performed a COX multivariable analysis to identify independent variables associated with mortality at 30 and 90 days as well as the readmission risk.

RESULTS

Data were collected from 98 patients in a four-month period. 23.5% of patients were deemed frail. 79% of all patients underwent abdominal surgery. Univariate analyses showed that polypharmacy, multimorbidity, a history of falls, hearing impairment and urinary incontinence were statistically significantly different between the non-frail and the group. Frail patients showed a higher incidence for mortality within 30 days (9% versus 1.3% (p = .053)). There were no differences between the two groups for mortality at 90 days, readmission, length of stay and operation. Frailty was a predictor for mortality at 90 days (p= .025) (hazard ratio (HR) 10.83 (95%CI 1.34-87.4)). Operation (p= .084) (HR 0.16 (95%CI 0.16-1.29)) and the presence of chronic cardiac failure (p= .049) (HR 0.38 (95%CI 0.14-0.99)) were protective for mortality at 90 days.

CONCLUSION

Frailty is a significant predictor for mortality for elderly patients undergoing emergency abdominal/general surgery.

LEVEL OF EVIDENCE

Level II therapeutic study.

Frailty and cognitive impairment: Unique challenges in the older emergency surgical patient

INTRODUCTION

Older patients (>65 years of age) admitted as general surgical emergencies increasingly require improved recognition of their specific needs relative to younger patients. Two such needs are frailty and cognitive impairment. These are evolving research areas that the emergency surgeon increasingly requires knowledge of to improve short- and long-term patient outcomes.

METHODS

This paper reviews the evidence for frailty and cognitive impairment in the acute surgical setting by defining frailty and cognitive impairment, introducing methods of diagnosis, discussing the influence on prognosis and proposing strategies to improve older patient outcomes.

RESULTS

Frailty is present in 25% of the older surgical population. Using frailty-scoring tools, frailty was associated with a significantly longer hospital stay and higher mortality at 30 and 90 days after admission to an acute surgical unit. Cognitive impairment is present in a high number of older acute surgical patients (approximately 70%), whilst acute onset cognitive impairment, termed delirium, is documented in 18%. However, patients with delirium had significantly longer hospital stays and higher in-hospital mortality than those with cognitive impairment.

CONCLUSIONS

Improved knowledge of frailty and delirium by the emergency surgeon allows the specialised needs of older surgical patients to be taken into account. Early recognition, and consideration of minimally invasive surgery or radiological intervention alongside potentially transferable successful elective interventions such as comprehensive geriatric assessment, may help to improve short- and long-term patient outcomes in this vulnerable population.

Laparoscopic single site (LESS) and classic video-laparoscopic cholecystectomy in the elderly: A single centre experience

Laparoscopic cholecystectomy (LC) is the gold-standard surgical method used to treat gallbladder diseases. Recently Laparoendoscopic single site surgery (LESS) has gained greater interest and diffusion for the surgical treatment of several pathologies. In elderly patients, just few randomized controlled trials are present in the literature that confirm the clinical advantages of LESS compared with the classic laparoscopic procedures. We present in this paper the preliminary results of this randomized prospective study regarding the feasibility and safety of LESS cholecystectomy versus classic laparoscopic technique. We demonstrated that LESS technique compared with traditional technique show some advantages like: acceptable operative times, lower post-operative discomfort and sometimes reduction added complications. In addition we also demonstrate that fewer incisions and less scarring which mean less pain, and fewer parietal complications are related to this surgical procedure. In conclusion in the elderly LESS cholecystectomy technique is to be considered a suitable alternative to traditional three-port cholecystectomy.

Do elderly patients have the most to gain from laparoscopic surgery?

Populations are aging worldwide, people are living longer, and the surgical needs of elderly patients are rising. Laparoscopic techniques have become more common with improved training, surgeon skill and evidence of improved outcomes. Benefits of laparoscopy include decreased blood loss, postoperative pain, and hospital length of stay; improved mobilization, quicker return to normal activity; and fewer pulmonary, thrombotic, and abdominal wall complications. Indeed, for many common pathologies laparoscopy has become the gold standard, unless contraindicated. It has been questioned as to whether elderly patients can reap the same benefits from laparoscopic surgery. The concern in elderly patients is that physiologic demands may outweigh the benefit seen in younger patients. This question stems from concerns related to longer operative times, increased technical challenge, as well as the impact of physiologic demands of pneumoperitoneum and patient positioning. However, with anesthesia and adequate perioperative cardiac care, there is no evidence that these factors lead to worse clinical outcomes in elderly patients. In contrast, perhaps elderly patients - with increased prevalence of multi-morbidity, geriatric syndromes and diminished physiologic reserve - have the most to gain from a laparoscopic approach.