Robotic Versus Laparoscopic Colorectal Cancer Surgery in Elderly Patients: A Propensity Score Match Analysis

Robotic versus laparoscopic surgery for colorectal cancer in older patients: a systematic review and meta-analysis

OBJECTIVE

Robotic surgery is being increasingly used for colorectal cancer surgery. However, its utility versus laparoscopic surgery in older patients is unclear. We systematically examined evidence to assess the differences in short-term outcomes of robotic versus laparoscopic surgery for colorectal cancer in older patients.

MATERIAL AND METHODS

Comparative studies published on PubMed, Web of Science, Embase, and CENTRAL databases were searched up to August 30th, 2023.

RESULTS

Seven studies totaling 14,043 patients were included. Meta-analysis showed no difference in the operation time between the robotic and laparoscopic groups. Meta-analysis of ClavienDindo complications showed no difference between the robotic and laparoscopic groups for grades I and II or grades III and IV complications. Similarly, conversion to open surgery, reoperation rates and length of hospital stay were not significantly different between the two groups. Readmission rates and mortality rates were significantly lower with robotic surgery.

CONCLUSION

This first meta-analysis comparing outcomes of robotic and laparoscopic surgery in older colorectal cancer patients shows that both approaches result in no difference in operating time, complication rates, conversion to open surgery, reoperation rates, and LOS. Scarce data shows that mortality and readmission rates may be lower with robotic surgery.

Feasibility of robotic surgery in elderly patients with rectal cancer: a meta-analysis

Rectal cancer's prevalence increases with an aging population, disproportionately affecting the elderly. The suitability of surgical interventions for this demographic is contentious due to underrepresentation during surgery. This study examines the practicality of utilizing Da Vinci surgery for rectal cancer patients who are 70 years and older. Information was gathered from PubMed, Embase, Scopus and the Cochrane Library, with a focus on English-language publications. Statistical analysis was performed using RevMan 5.4, presenting outcomes for categorical variables in risk ratios. Out of 890 patients across 5 studies, 240 were categorized as elderly, while 650 fell into the younger age group. Notable distinctions were noted in harvested lymph nodes, BMI, and postoperative outcomes, whereas factors like the length of hospital stay, Clavien-Dindo classification, and radial resection margin did not display significance. Although age increases postoperative risk, evidence emphasizes frailty, not age alone, as the primary determining factor.

Open, laparoscopic liver resection and percutaneous thermal ablation in elderly patients with hepatocellular carcinoma: outcomes and therapeutic strategy

BACKGROUND

Liver resection and percutaneous thermal ablation (PTA) are considered curative option for hepatocellular carcinoma (HCC). This study aims to compare short- and long-term outcomes between open liver resection (OLR), laparoscopic liver resection (LLR), and PTA in elderly patients with single HCC and to define a liver map for therapeutic strategy according to HCC location and size.

METHODS

A multicenter retrospective study was conducted in 10 European Hospital Center, including 239 consecutive liver resection (OLR and LLR) and PTA in elderly patients ≥ 70 years old with single HCC ≤ 30 mm. Perioperative data and long-term oncological outcomes were collected and compared between groups before and after propensity score matching.

RESULTS

A total of 239 patients were enrolled, distributed as follows: 61 in the ORL group, 88 in the LLR group, and 90 in the PTA group. The hospital stay was longer in OLR and LLR groups compared to the PTA group (6, 5 and 3 days, respectively, p < 0.05). Morbidity was lower in the PTA group compared to the OLR group (11 vs. 26%, respectively, p < 0.05). Overall survival (OS) at 5 years was significantly higher in the OLR and LLR groups compared to the PTA group (82, 81, and 34%, respectively, p < 0.001). Disease-free survival (DFS) at 5 years was also significantly higher in the ORL and LLR groups compared to the PTA group (66, 50 and 20%, respectively, p < 0.001). These results were also confirmed after a propensity score matching analysis between surgery group (OLR and LLR) and the PTA group. PTA was the most used treatment for subcapsular and deep HCC not in contact with vascular structures compared to OLR and LLR.

CONCLUSION

PTA in elderly patients ensures a shorter hospital stay and lower morbidity but worst survival compared to liver resection.

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.

Robot-assisted vs. laparoscopic right hemicolectomy in octogenarians and nonagenarians: an analysis of the US nationwide inpatient sample 2005-2018

BACKGROUND

Colorectal cancer (CRC) is a significant health concern, particularly among older adults. Outcomes between laparoscopic and robot-assisted surgeries for right-sided colon cancers in the oldest old population have yet to be evaluated despite increased use of these surgeries.

AIM

This study aimed to compare clinical outcomes after robot-assisted right hemicolectomy (RARH) versus laparoscopic right hemicolectomy (LRH) in octogenarian and nonagenarian patients.

METHODS

This population-based, retrospective and observational study analyzed the data of adults ≥ 80 years old diagnosed with right-side colon cancer who received RARH or LRH. All data were extracted from the US National Inpatient Sample (NIS) database 2005-2018. Associations between type of surgery and in-hospital outcomes were determined using univariate and multivariable logistic regression and linear regression analysis.

RESULTS

Data of 7,550 patients (representing 37,126 hospitalized patients in the U.S.) were analyzed. Mean age of the study population was 84.8 years, 61.4% were females, and 79.1% were non-smokers. After adjusting for relevant confounders, regression analysis showed that patients undergoing RARH had a significantly shorter LOS (adjusted Beta (aBeta), -0.24, 95% CI: -0.32, -0.15) but greater total hospital costs (aBeta, 26.54, 95% CI: 24.64, 28.44) than patients undergoing LRH. No significant differences in mortality, perioperative complications, and risk of unfavorable discharge were observed between the two procedures (p > 0.05). Stratified analyses by frailty status revealed consistent results.

CONCLUSIONS

RARH is associated with a significantly shorter LOS but higher total hospital costs than LRH among octogenarians and nonagenarians. Other short-term outcomes for this population are similar between the two procedures, including in-hospital mortality, perioperative complications, and unfavorable discharge. These findings also apply to frail patients.

Outcomes of Robot-Assisted Versus Laparoscopic Surgery for Colorectal Cancer in Adults Aged 75 Years and Older: A Propensity Score-Matched Analysis of the US Nationwide Inpatient Sample

BACKGROUND

Robot-assisted surgery has been increasingly adopted in colorectal cancer resection.

OBJECTIVE

The study aimed to compare the inpatient outcomes of robot-assisted versus conventional laparoscopic colorectal cancer resection in patients aged 75 years and older.

DESIGN

A retrospective, population-based study.

SETTINGS

This study analyzed data from the United States Nationwide Inpatient Sample from 2005 to 2018.

PATIENTS

Patients with colorectal cancer aged 75 years and older and who underwent robot-assisted or conventional laparoscopic resection.

MAIN OUTCOME MEASURES

Postoperative complications, prolonged length of stay, and total hospital costs were assessed.

RESULTS

Data from 14,108 patients were analyzed. After adjustment, any postoperative complications (adjusted OR = 0.87; 95% CI, 0.77-0.99; p = 0.030) and prolonged length of stay (adjusted OR = 0.78; 95% CI, 0.67-0.91; p = 0.001) were significantly less in the robotic than the laparoscopic group. In addition, robotic surgery was associated with significantly higher total hospital costs (26.06 USD greater cost; 95% CI, 21.35-30.77 USD; p < 0.001).

LIMITATIONS

The analysis was limited by its retrospective and observational nature, potential coding errors, and the lack of intraoperative factors, such as operative time, laboratory measures, and information on surgeons' experience.

CONCLUSIONS

In the United States, in patients with colorectal cancer aged 75 years and older who were undergoing tumor resections, compared to conventional laparoscopic surgery, robotic surgery is associated with better inpatient outcomes in terms of complication rate and risk of prolonged length of stay. This finding is especially true among patients with colon cancer. However, robotic surgery is associated with higher total hospital costs. See Video Abstract .

RESULTADOS DE LA CIRUGA ASISTIDA POR ROBOT FRENTE A LA CIRUGA LAPAROSCPICA PARA EL CNCER COLORRECTAL EN ADULTOS AOS DE EDAD UN ANLISIS EMPAREJADO POR PUNTUACIN DE PROPENSIN DE LA MUESTRA NACIONAL DE PACIENTES HOSPITALIZADOS DE ESTADOS UNIDOS

ANTECEDENTES:La cirugía asistida por robot se ha adoptado cada vez más en la resección del cáncer colorrectal.OBJETIVO:El estudio tuvo como objetivo comparar los resultados hospitalarios de la resección del cáncer colorrectal asistida por robot versus la laparoscópica convencional en pacientes ≥ 75 años.DISEÑO:Estudio retrospectivo de base poblacional.AJUSTES:Este estudio analizó datos de la Muestra Nacional de Pacientes Hospitalizados de Estados Unidos de 2005 a 2018.PACIENTES:Pacientes con cáncer colorrectal ≥ 75 años y sometidos a resección laparoscópica convencional o asistida por robot.PRINCIPALES MEDIDAS DE RESULTADO:Se evaluaron las complicaciones posoperatorias, la duración prolongada de la estancia hospitalaria y los costos hospitalarios totales.RESULTADOS:Se analizaron datos de 14.108 pacientes. Después del ajuste, cualquier complicación posoperatoria (aOR = 0,87; IC del 95 %: 0,77-0,99, p = 0,030) y duración prolongada de la estancia hospitalaria (aOR = 0,78; IC del 95 %: 0,67-0,91, p = 0,001) fueron significativamente menores en el grupo robótico que el grupo laparoscópico. Además, la cirugía robótica se asoció con costos hospitalarios totales significativamente mayores ($26,06 USD mayor costo; IC 95%: 21,35-30,77 USD, p < 0,001).LIMITACIONES:El análisis estuvo limitado por su naturaleza retrospectiva y observacional, posibles errores de codificación y la falta de factores intraoperatorios como el tiempo operatorio, medidas de laboratorio e información sobre la experiencia de los cirujanos.CONCLUSIONES:En Estados Unidos, los pacientes con cáncer colorrectal ≥ 75 años que se sometieron a resecciones tumorales, en comparación con la cirugía laparoscópica convencional, la cirugía robótica se asocia con mejores resultados hospitalarios en términos de tasa de complicaciones y riesgo de estadía prolongada, especialmente entre pacientes con cáncer de colon. Sin embargo, la cirugía robótica se asocia a costes hospitalarios totales más elevados. (Traducción-Yesenia Rojas-Khalil ).

Emergency robotic surgery: the experience of a single center and review of the literature

BACKGROUNDS

Laparoscopic surgery is widely used in abdominal emergency surgery (AES), and the possibility of extending this approach to the more recent robotic surgery (RS) arouses great interest. The slow diffusion of robotic technology mainly due to high costs and the longer RS operative time when compared to laparoscopy may represent disincentives, especially in AES. This study aims to report our experience in the use of RS in AES assessing its safety and feasibility, with particular focus on intra- and post-operative complications, conversion rate, and surgical learning curve. Our data were also compared to other experiences though an extensive literature review.

METHODS

We retrospectively analysed a single surgeon series of the last 10 years. From January 2014 to December 2023, 36 patients underwent urgent or emergency RS. The robotic devices used were Da Vinci Si (15 cases) and Xi (21 cases).

RESULTS

36 (4.3%) out of 834 robotic procedures were included in our analysis: 20 (56.56%) females. The mean age was 63 years and 30% of patients were ≥ 70 years. 2 (5.55%) procedures were performed at night. No conversions to open were reported in this series. According to the Clavien-Dindo classification, 2 (5.5%) major complications were collected. Intraoperative and 30-day mortality were 0%.

CONCLUSIONS

Our study demonstrates that RS may be a useful and reliable approach also to AES and intraoperative laparoscopic complications when performed in selected hemodynamically stable patients in very well-trained robotic centers. The technology may increase the minimally invasive use and conversion rate in emergent settings in a completely robotic or hybrid approach.

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.

Robotic Rectal Resection for Rectal Cancer in Elderly Patients: A Systematic Review and Meta-Analysis

Rectal cancer is estimated to increase due to an expanding aging population, thus affecting elderly patients more frequently. The optimal surgical treatment for this type of patient remains controversial because they are often excluded from or underrepresented in trials. This meta-analysis aimed to evaluate the feasibility and the safety of robotic surgery in elderly patients (>70 years old) undergoing curative treatment for rectal cancer. Studies comparing elderly (E) and young (Y) patients submitted to robotic rectal resection were searched on PubMed, Embase, and the Cochrane Library. Data regarding surgical oncologic quality, post-operative, and survival outcomes were extracted. Overall, 322 patients underwent robotic resection (81 in the E group and 241 in the Y group) for rectal cancer. No differences between the two groups were found regarding distal margins and the number of nodes yielded (12.70 in the E group vs. 14.02 in the Y group, p = 0.16). No differences were found in conversion rate, postoperative morbidity, mortality, and length of stay. Survival outcomes were only reported in one study. The results of this study suggest that elderly patients can be submitted to robotic resection for rectal cancer with the same oncologic surgical quality offered to young patients, without increasing postoperative mortality and morbidity.

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.

Robot-assisted general surgery is safe during the learning curve: a 5-year Australian experience

Robot-assisted general surgery has become increasingly common in the Australian public sector since 2003. It provides significant technical advantages compared to laparoscopic surgery. Currently, it is estimated that the learning curve for surgeons starting off with robotic surgery is complete after 15 cases. This is a retrospective case series, following the progress of four surgeons with minimal robotic experience over 5 years. Patients undergoing colorectal procedures and hernia repairs were included. 303 robotic cases were included in this study, 193 colorectal surgeries and 110 hernia repairs. 20.2% of colorectal patients experienced an adverse event and 10.0% of hernia patients had a complication. The learning curve was correlated to the average docking time, and it was found that this was complete after 2 years, or after a minimum of 12 to 15 cases. Patient length of stay decreases as surgeon experience increases. Robotic surgery is a safe approach to colorectal surgery and hernia repairs with some potential benefits in terms of patient outcomes as surgeon experience increases.

Robotic surgery in elderly patients with colorectal cancer: Review of the current literature

With an ageing global population, we will see an increasing number of elderly patients with colorectal cancer (CRC) requiring surgery. However, it should be recognized that the elderly are a heterogenous group, with varying physiological and functional status. While traditionally viewed to be associated with frailty, comorbidities, and a higher risk of post operative morbidity, the advancements in minimally invasive surgery (MIS) and improvements in perioperative care have allowed CRC surgery to be safe and feasible in the elderly - chronological age alone should therefore not strictly be an exclusion criterion for curative surgery. However, as a form of MIS, laparoscopic assisted colorectal surgery (LACS) has the inherent disadvantages of: (1) Dependence on a trained assistant for retraction and laparoscope control; (2) The loss of wristed movement with reduced dexterity and suboptimal ergonomics; (3) A lack of intuitive movement due to the levering effect of trocars; and (4) An amplification of physiological tremors. Representing a technical evolution of LACS, robotic assisted colorectal surgery was introduced to overcome these limitations. In this minireview, we examine the evidence for robotic surgery in the elderly with CRC.

Comparison of Non-Oncological Postoperative Outcomes Following Robotic and Laparoscopic Colorectal Resection for Colorectal Malignancy: A Systematic Review and Meta-Analysis

The objective of this systematic review and meta-analysis is to compare the postoperative outcomes of robotic and laparoscopic colorectal resection for colorectal malignancy. We performed a systematic review using a comprehensive search strategy on several electronic databases (PubMed, PubMed Central, Medline, and Google Scholar) in April 2022. Postoperative outcomes of robotic versus laparoscopic surgery for colorectal cancer were compared using 12 end points. Observational studies, randomized controlled trials, and nonrandomized clinical trials comparing robotic and laparoscopic resection for colorectal cancer were included. The statistical analysis was performed using the risk ratio (RR) for categorical variables and the standardized mean differences (SMD) for continuous variables. Sixteen studies involving 2,318 patients were included. The difference in length of hospital stay was significantly shorter with robotic access (SMD = -0.10, 95% CI = -0.19, -0.01, P = 0.04, I2 = 0%). Regarding intra-abdominal abscesses, the analysis showed an advantage in favor of the robotic group, but the result was not statically significant (RR = 0.54, 95% CI = 0.28, 1.05, P = 0.07, I2 = 0%). Mechanical obstruction was found to be higher in robotic group, favoring laparoscopic access, but was not significant (RR = 1.91, 95% CI = 0.95, 3.83, P = 0.07, I2 = 0%). There was no difference in time to pass flatus and consume a soft diet. The rates of anastomotic leakage, ileus, wound infection, readmission, mortality, and incisional hernias were similar with both approaches. Robotic surgery for colorectal cancer is associated with a shorter hospital stay, with no differences in mortality and postoperative morbidity.

Robotic and laparoscopic surgical procedures for colorectal cancer

The study aims to investigate perioperative indices and immediate outcomes of laparoscopic and robotic surgical interventions in colorectal cancer patients. The study included 163 patients [90 (55.2%) females and 73 (44.8%) males, aged 67.46 ± 6.72 years, on average] who had surgery for morphologically checked colorectal cancer. Of those, 101 patients had laparoscopic surgery (Group 1), and 62 patients had robot-assisted surgery (Group 2). The study found that the safety profile of both robot and laparoscopic procedures for colorectal cancer is comparable. The total complication rate in the laparoscopic group was 6.9% (in 7 patients), in the robot-assisted group-11.3% (in 7 patients) (χ² = 0.93, p = 0.34). Robotic surgery for colorectal cancer is a promising direction for improving patients' level and quality of care with this oncological pathology.

Robot-Assisted vs Laparoscopic Right Hemicolectomy in Octogenarians

OBJECTIVE

With increasing age, there is greater need for right-sided colonic resections than its left-sided counterparts. Older age is associated with limited physical and functional status, which carries greater operative risk. Improvements in robotic surgery questions its role, especially in older adults, compared with laparoscopy. The objective is to investigate whether robotic right hemicolectomy (RRH) is as safe and effective as laparoscopic right hemicolectomy (LHR) in octogenarians (age >80 years).

DESIGN

Retrospective cross-sectional analysis.

SETTINGS AND PARTICIPANTS

Octogenarians who underwent elective RRH and LRH by the Tweed Colorectal Group over 5 years.

METHODS

Complications within 30 days, age, gender, smoking status, immunocompromised status, presence of diabetes, American Society of Anesthesiologists (ASA) physical status score, preoperative Eastern Cooperative Oncology Group (ECOG) performance status, mFI-5 (modified frailty index), operative time, method of anastomosis, postoperative length of stay (LOS), need for rehabilitation, and short-term oncologic data using the TNM criteria were compared using univariate and multivariate analysis.

RESULTS

Seventy-eight elective patients were included. LRH and RRH groups had similar median ages, gender distribution, and comorbidities. Across the entire cohort, 61.5% had no 30-day complications. RRH had nonsignificantly shorter operative time but significantly shorter LOS (5 vs 8 days) and fewer minor complications (24.5% vs 34.5%). Major complications and overall complications were not significantly different between the groups. Lower ASA and ECOG status were associated with lower complication rates across both groups. Oncologic resection outcomes were similar for both approaches.

CONCLUSIONS AND IMPLICATIONS

RRH does not confer an increased risk of complications compared to LRH in the octogenarians and may be a viable alternative in the field of minimally invasive surgery for older patients. Future research should focus on intracorporeal anastomoses, as it is a potential confounder leading to the shorter inpatient LOS shown in our robotic group.

Laparoscopic Radical Resection of Colorectal Cancer in the Treatment of Elderly Colorectal Cancer and Its Effect on Gastrointestinal Function

Objective

To explore the efficacy and safety of laparoscopic radical resection of colorectal cancer in the elderly patients and its impact on gastrointestinal function.

Methods

A total of 122 elderly patients with colorectal cancer admitted to our hospital from March 2020 to June 2021 were selected as the research subjects, and they were divided into the control group (n = 61) and the observation group (n = 61). The control group was treated with traditional laparotomy, and the observation group was treated with laparoscopic radical resection of colorectal cancer. The clinical data of operation time, incision length, intraoperative bleeding volume, and hospitalization time in the two groups were recorded. Serum motilin (MTL) and gastrin (GAS) levels were measured pre- and post-operatively. The duration of abdominal distension, the time for the abdominal sound to return to normal, the time for the anal exhaust to normal, and the time for normal food intake were recorded after operation. The patients were followed up for 6 months post-operatively, and the complications during follow-up were recorded.

Results

The total response rate of the observation group (95.08%) was higher than that of the control group (81.97%) (P < 0.05). The operation time, incision length, intraoperative bleeding volume, and hospitalization time of the observation group were lower than those of the control group (P < 0.05). The duration of abdominal distension, the time for bowel sounds to return to normal, the time for the anus to exhaust gas to normal, and the normal eating time in the observation group were all lower than those in the control group (P < 0.05). After surgery, the levels of MTL and GAS in the two groups were lower than those before surgery, and those in the observation group were lower than those in the control group (P < 0.05). The total incidence of complications in the observation group (3.28%) was lower than that in the control group (13.12%) (P < 0.05).

Conclusion

Laparoscopic radical resection of colorectal cancer in the elderly patients has good effect, short operation time, less trauma, less blood loss during operation, short hospital stay, good recovery of gastrointestinal function, fewer complications, and high safety.

Operative and Survival Outcomes of Robotic-Assisted Surgery for Colorectal Cancer in Elderly and Very Elderly Patients: A Study in a Tertiary Hospital in South Korea

Materials and Methods

Data of all patients ≥75 years who underwent a robotic-assisted curative resection in Korea University Anam Hospital, Seoul, South Korea, between January 2007 and January 2021 were extracted from a prospectively maintained colorectal cancer database. Patients were subdivided into the three groups according to the age: youngest-old (YO: 75–80 years), middle-old (MO: 81–85), and oldest-old (OO: ≥86 years). Intraoperative findings, postoperative, and oncological outcomes were compared between the groups.

Results

Seventy-six consecutive patients (female 52.6%) were included; mean age was 80 years (SD 0.33); mean body mass index (BMI), 23.8 20.9 kg/m² (SD 3.58); mean total operative time, 279 min (SD 80.93); mean blood loss, 186 ml (SD 204.03); mean postoperative length of stay, 14 days (SD 12.03). Major complications were seen in 2.1% of patients. The 30-day mortality rate was 0%. Average number of lymph node harvested was 20.9 (SD 12.33). Postoperative complications were not statistically different between the groups. Mean follow-up time for cancer-specific survival (CSS) was 99.28 months for the YO, 72.11 months for MO, and 31.25 months for OO groups (p = 0.045). The CSS rates at 5 years were 27.0%, 21.0%, and 0%, respectively. Recurrence risk was 10.50 times higher in the OO group than the others (adjusted HR, 95% CI 1.868–59.047, p = 0.008). In the multivariable analysis, TNM stage was not a risk factor for CSS in all groups. The number of the harvested nodes was a protective factor for recurrence (HR of 0.932, 95% CI 0.875–0.992, p = 0.027) and CSS (HR of 0.928, 95% CI 0.861–0.999, p = 0.047) in elderly patients.

Conclusion

Robotic surgery is highly feasible in elderly and very elderly colorectal cancer patients, providing a favorable operative safety profile and an acceptable cancer-specific survival outcome.

Postoperative complications after robotic resection of colorectal cancer: An analysis based on 5-year experience at a large-scale center

BACKGROUND

As a common gastrointestinal malignancy, colorectal cancer (CRC) poses a serious health threat globally. Robotic surgery is one of the future trends in surgical treatment of CRC. Robotic surgery has several technical advantages over laparoscopic surgery, including 3D visualization, elimination of the fulcrum effect, and better ergonomic positioning, which together lead to better surgical outcomes and faster recovery. However, analysis of independent factors of postoperative complications after robotic surgery is still insufficient.

AIM

To analyze the incidence and risk factors for postoperative complications after robotic surgery in patients with CRC.

METHODS

In total, 1040 patients who had undergone robotic surgical resection for CRC between May 2015 and May 2020 were analyzed retrospectively. Postoperative complications were categorized according to the Clavien-Dindo (C-D) classification, and possible risk factors were evaluated.

RESULTS

Among 1040 patients who had undergone robotic surgery for CRC, the overall, severe, local, and systemic complication rates were 12.2%, 2.4%, 8.8%, and 3.5%, respectively. Multivariate analysis revealed that multiple organ resection (P < 0.001) and level III American Society of Anesthesiologists (ASA) score (P = 0.006) were independent risk factors for overall complications. Multivariate analysis identified multiple organ resection (P < 0.001) and comorbidities (P = 0.029) as independent risk factors for severe complications (C-D grade III or higher). Regarding local complications, multiple organ resection (P = 0.002) and multiple bowel resection (P = 0.027) were independent risk factors. Multiple organ resection (P < 0.001) and level III ASA score (P = 0.007) were independent risk factors for systemic complications. Additionally, sigmoid colectomy had a lower incidence of overall complications (6.4%; P = 0.006) and local complications (4.7%; P = 0.028) than other types of colorectal surgery.

CONCLUSION

Multiple organ resection, level III ASA score, comorbidities, and multiple bowel resection were risk factors for postoperative complications, with multiple organ resection being the most likely.

Robotic versus laparoscopic colorectal surgery in elderly patients in terms of recovery time: a monocentric experience

Colorectal cancer has a great socio-sanitary relevance. It represents the third cancer by incidence and mortality. Ageing plays a major role in the development of colorectal cancer and this tumour, in patients aged 65 and older, has gradually increased over the past decade. The robotic technique is considered the evolution of conventional laparoscopy. Few studies evaluate the effects of robotic surgery in elderly patient, and even fewer are those that compare it with laparoscopic surgery in this population. The aim of this study was to evaluate the perioperative outcomes of robotic colorectal surgery compared to laparoscopic colorectal surgery in patients older than 65 years. We conducted a retrospective study enrolling 83 elderly patients (age > 65) undergoing robotic and laparoscopic colectomy (32 and 51, respectively) between January 2019 and January 2021. For statistical analysis, p values were calculated using t test and chi-square test. p < 0.05 is the criterion for statistical significance. Statistical analyses were performed with the Number Cruncher Statistical System (NCSS) 2020 data analysis version 20.0.1 (Utah, USA). The operation time was higher in robotic left (p = 0.003, mean time 249.6 vs 211.7 min) and right (p = 0.004, mean time 238.5 vs 183.5 min) hemicolectomy and similar for procedures on rectosigmoid and rectum when compared to laparoscopic technique. In terms of length of hospital stay and recovery of bowel function, these values were significantly lower for robotic group in left hemicolectomy (p = 0.004), rectum (p = 0.003) and rectosigmoid (p = 0.003), while right hemicolectomy was similar in two groups (p = 0.26). There was no statistically significant difference between the groups regarding conversion rate, postoperative complications, length of specimen, number of lymph nodes encountered and oncological results. Colorectal robotic surgery in elderly patients appears as a feasible and safe surgical approach when compared to the laparoscopic one, showing a shorter recovery and a reduction of length of stay with similar oncological outcomes even if with an increase of operating times.

Comparison Between Laparoscopic and Robotic Surgery in Elderly Patients With Endometrial Cancer: A Retrospective Multicentric Study

Introduction

Elderly endometrial cancer (EEC) patients represent a challenging clinical situation because of the increasing number of clinical morbidities. In this setting of patients, minimally invasive surgery (MIS) has been shown to improve surgical and clinical outcomes. The aim of this study was to evaluate the peri-operative and oncological outcomes of EEC patients who had undergone laparoscopic (LS) or robotic surgery (RS).

Materials and Methods

This is a retrospective multi-institutional study in which endometrial cancer patients of 70 years or older who had undergone MIS for EC from April 2002 to October 2018 were considered. Owing to the non-randomized nature of the study design and the possible allocation biases arising from the retrospective comparison between LS and RS groups, we also performed a propensity score-matched analysis (PSMA).

Results

A total of 537 patients with EC were included in the study: 346 who underwent LS and 191 who underwent RS. No significant statistical differences were found between the two groups in terms of surgical and survival outcomes. 188 were analyzed after PSMA (94 patients in the LS group were matched with 94 patients in the RS group). The median estimated blood loss was higher in the LS group (p=0.001) and the median operative time was higher in the RS group (p=0.0003). No differences emerged between LS and RS in terms of disease free survival (DFS) (p=0.890) and overall survival (OS) (p=0.683).

Conclusions

Our study showed that when compared LS and RS, RS showed lower blood losses and higher operative times. However, none of the two approaches demonstrated to be superior in terms of survival outcomes. For this reason, each patient should be evaluated individually to determine the best surgical approach.

Perioperative and oncologic outcomes in young and octogenarian patients with colorectal cancer: a comparison at the extremes

INTRODUCTION

In colorectal cancer (CRC), surgical outcomes in the young (< 50) and octogenarian populations are believed to be poor due to an aggressive phenotype in the former, and increased frailty in the latter. Given that age-related effects are inversely related between groups, we compared short- and long-term outcomes of young and octogenarian patients with CRC to determine the dominance of one age-related factor over another.

METHODS

A prospectively collected database from 2015 to 2020 of all CRC was analyzed. Cases were divided into metastatic and non-metastatic groups.

RESULTS

Among non-metastatic cases, there were 34 young and 113 octogenarian patients. Mean CEA was higher among octogenarians (11.2 vs 32.8 units/ml; p = 0.041). Octogenarians suffered from more comorbidities than younger counterparts, with increased rates of postoperative UTI (3.3% vs 10.3%; p = 0.246) and pneumonia (3.1% vs 8.8%; p = 0.331). There was no increased rate of reintervention or Clavien-Dindo scores. We noticed a statistically significant higher proportion of extramural vascular invasion (EMVI) (8.8% vs 32.3%; p = 0.003) among the young. When excluding octogenarians who had declined surgery, Kaplan-Meier analysis showed no difference in disease-free (p = 0.290) or overall survival (p = 0.111). Among metastatic cases, there were 21 young and 19 octogenarian patients. Young patients were treated more aggressively with chemotherapy (55.6% vs 12.5%; p = 0.040). There was however no difference in overall survival between groups (p = 0.610).

CONCLUSIONS

Octogenarians may have more comorbidities, but can achieve similar surgical outcomes with younger patients. There is no reason to suspect a more aggressive phenotype in younger patients.

Multidisciplinary management of elderly patients with rectal cancer: recommendations from the SICG (Italian Society of Geriatric Surgery), SIFIPAC (Italian Society of Surgical Pathophysiology), SICE (Italian Society of Endoscopic Surgery and new technologies), and the WSES (World Society of Emergency Surgery) International Consensus Project

BACKGROUND AND AIMS

Although rectal cancer is predominantly a disease of older patients, current guidelines do not incorporate optimal treatment recommendations for the elderly and address only partially the associated specific challenges encountered in this population. This results in a wide variation and disparity in delivering a standard of care to this subset of patients. As the burden of rectal cancer in the elderly population continues to increase, it is crucial to assess whether current recommendations on treatment strategies for the general population can be adopted for the older adults, with the same beneficial oncological and functional outcomes. This multidisciplinary experts' consensus aims to refine current rectal cancer-specific guidelines for the elderly population in order to help to maximize rectal cancer therapeutic strategies while minimizing adverse impacts on functional outcomes and quality of life for these patients.

METHODS

The discussion among the steering group of clinical experts and methodologists from the societies' expert panel involved clinicians practicing in general surgery, colorectal surgery, surgical oncology, geriatric oncology, geriatrics, gastroenterologists, radiologists, oncologists, radiation oncologists, and endoscopists. Research topics and questions were formulated, revised, and unanimously approved by all experts in two subsequent modified Delphi rounds in December 2020-January 2021. The steering committee was divided into nine teams following the main research field of members. Each conducted their literature search and drafted statements and recommendations on their research question. Literature search has been updated up to 2020 and statements and recommendations have been developed according to the GRADE methodology. A modified Delphi methodology was implemented to reach agreement among the experts on all statements and recommendations.

CONCLUSIONS

The 2021 SICG-SIFIPAC-SICE-WSES consensus for the multidisciplinary management of elderly patients with rectal cancer aims to provide updated evidence-based statements and recommendations on each of the following topics: epidemiology, pre-intervention strategies, diagnosis and staging, neoadjuvant chemoradiation, surgery, watch and wait strategy, adjuvant chemotherapy, synchronous liver metastases, and emergency presentation of rectal cancer.

Robotic Versus Laparoscopic Partial Mesorectal Excision for Cancer of the High Rectum: A Single-Center Study with Propensity Score Matching Analysis

BACKGROUND

The role of robotic surgery for partial mesorectal excision (PME) in patients with high rectal cancer (RC) remains unexplored. This study aimed to compare the operative and postoperative outcomes of robotic (R-PME) versus laparoscopic (L-PME) PME for high RC.

METHODS

This was a single-center propensity score cohort study of consecutive patients diagnosed with RC in the high rectum (>10 to 15 cm from the anal verge) who underwent surgery between September 2012 and May 2019.

RESULTS

Of 131 selected patients (50 R-PME and 81 L-PME), 88 were matched using propensity score (44 per group). Operative and postoperative variables were similar between R-PME and L-PME patients, except for operative time (220 min and 190 min, respectively; p < 0.0001). No conversion was needed. Overall morbidity was 15.9%; 4 patients (4.5%) developed anastomotic leakage. The mean hospital stay was 7.25 days for R-PME vs. 7.64 days for L-PME (p = 0.597). R0 resection was achieved in 100% of R-PME and 90.9% of L-PME (p = 0.116). Only 3 patients (1 R-PME, 2 L-PME) received a permanent stoma (p = 1). No group differences were observed for overall or disease-free survival rates at 5 years. The costs of R-PME were significantly higher than those of L-PME.

CONCLUSION

Minimally invasive surgery can be performed safely for PME in high RC. No difference can be detected between R-PME and L-PME for both short- and long-term outcomes, leaving the choice of the surgical approach to the surgeon's experience. Specific health economic studies are needed to evaluate the cost-effectiveness of robotic surgery for RC.

The impact of surgical approach on short- and long-term outcomes after rectal cancer resection in elderly patients: a national cancer database propensity score matched comparison of robotic, laparoscopic, and open approaches

BACKGROUND

Elderly patients are underrepresented in studies demonstrating the advantages of laparoscopy for the management of colorectal diseases. Moreover, few studies have examined the robotic approach in this population. In this retrospective analysis, we compare outcomes for open, laparoscopic, and robotic approaches in elderly patients with nonmetastatic rectal cancer.

METHODS

The U.S. National Cancer Database was queried for patients aged ≥ 65 with nonmetastatic adenocarcinoma of the rectum who underwent surgical resection from 2010 to 2016. Groups were separated based on approach (open, laparoscopic, robotic). One-to-one nearest neighbor propensity score matching (PSM) ± 1% caliper was performed across surgical approach cohorts to balance potential confounding covariates. Kaplan-Meier estimation and Cox-proportional hazards regression were used to analyze the primary outcome of survival. Secondary outcomes were analyzed by way of logistic regression.

RESULTS

Inclusion criteria and PSM identified 1891 patients per approach (n = 5673). PSM provided adequate discrimination between cohorts (0.6 < AUC < 0.8), and potential confounding covariates did not significantly differ (respective P > 0.05). After PSM, robotic and laparoscopic approaches were associated with decreased odds of 90 day mortality compared to the open approach (P < 0.05). Compared to laparoscopy, a robotic approach was associated with increased odds of ≥ 12 regional lymph nodes examined and negative circumferential resection margin (P < 0.05). No differences were seen in 30 day or 90 day mortality between robotic and laparoscopic approaches. Cox proportional hazards regression showed that both robotic and laparoscopic approaches were significantly associated with decreased mortality hazards relative to open.

CONCLUSION

Our study demonstrates that in elderly patients, minimally invasive surgery for rectal adenocarcinoma was associated with equivalent or improved short- and long-term mortality over open surgery. Compared to laparoscopy, the robotic approach showed no survival disadvantage and greater odds of an appropriate oncological resection. Our study adds evidence to the conclusion that robotic rectal surgery can be safely performed in patients regardless of age.

Conversions related to adhesions in abdominal surgery. Robotic versus laparoscopic approach: A multicentre experience

BACKGROUND

An advantage of robotic surgery over laparoscopy is the lower rate of unplanned conversion. One of the implicated reasons for conversion is adhesions from previous abdominal surgeries (PASs).

METHODS

A comparative analysis of 98 patients with history of open PAS treated by laparoscopic or robotic surgery was performed. Primary endpoint was the rate of conversion to open surgery related to adhesiolysis. Secondary endpoints were short-term outcomes and complications.

RESULTS

Conversion rate specifically related to adhesiolysis was significantly lower in robotic group (13 for laparoscopic group vs. 2 for robotic group; p = 0.046). Conversions occurred during adhesiolysis were significantly related to severity of adhesions expressed by peritoneal adhesion index (PAI) score (p < 0.001), number of abdominal areas involved by adhesions (p < 0.001) and severity of PAI into the target area of surgical intervention (p = 0.021).

CONCLUSIONS

Benefits of robotic surgery are more noticeable in performing procedures with increasing technical difficulties.

Cutoff of 25% for Ki67 expression is a good classification tool for prognosis in colorectal cancer in the AJCC‑8 stratification

Ki‑67 expression has been widely used in clinical practice as an index to evaluate the proliferative activity of tumor cells. The cutoff for Ki67 expression in order to increase the prognostic value of Ki67 expression in colorectal cancer varies. The present study assessed the relationship between the 25% cutoff for Ki67 expression and prognosis in colorectal cancer in the AJCC‑8 (American Joint Committee on Cancer 8 edition) stratification. The current trial included 1,090 colorectal cancer patients enrolled from 2006 to 2012 at Huzhou Central Hospital. Ki67 expression was classified according to 25% intervals, dividing the patients into four groups. Measurement data were analyzed by ANOVA, and count data by Crosstabs. Bivariate correlation analysis was performed to assess clinicopathological indicators based on Ki67 expression. Disease‑free survival (DFS) and overall survival (OS) based on Ki67 levels were analyzed by the Kaplan‑Meier method. A total of 1,090 patients of the 2,080 enrolled CRC cases were evaluated (52.4%). Invasive depth, tumor differentiation, tumor size, AJCC‑8, positive number of lymph nodes and chemotherapy status showed significant differences in the various Ki67 expression groups (all P<0.05), with significant correlations (Spearman rho: 0.170, 0.456, 0.22, 0.195, 0.514 and ‑0.201, respectively, all P<0.001). DFS and OS for the different Ki67 level groups based on AJCC‑8 stratification were analyzed, and no significance was found in stage IV (P=0.334). DFS and OS survival rates were assessed at different Ki67 expression levels, and no significant differences were found (all P>0.05). Cox regression analysis showed that invasive depth, lymph node metastasis, tumor differentiation, AJCC‑8 and Ki67 were independent factors affecting colorectal cancer (P=0.030, all others P<0.001). In conclusion, a cutoff of 25% for Ki67 expression is a good classification tool. High Ki67 has a close association with poor prognosis in colorectal cancer and independently predicts prognosis in the AJCC‑8 stratification.

Minimizing the impact of colorectal surgery in the older patient: The role of minimally invasive surgery in the geriatric population

With an aging population comes a greater incidence of colorectal cancer and a corresponding need for surgical resection in the geriatric population. This heterogeneous group of patients may benefit from multidisciplinary pre-operative evaluation and optimization, prehabilitation, enhanced recovery protocols, and a minimally invasive approach to resection. Concerns regarding the ability of the older patient to tolerate the physiologic demands of pneumoperitoneum have not been validated. Conversely, these vulnerable patients may experience a greater reduction in morbidity than their younger counterparts through the use of minimally invasive techniques.

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.