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Keller DS, Curtis N, Burt HA, Ammirati CA, Collings AT, Polk HC, Carrano FM, Antoniou SA, Hanna N, Piotet LM, Hill S, Cuijpers ACM, Tejedor P, Milone M, Andriopoulou E, Kontovounisios C, Leeds IL, Awad ZT, Barber MW, Al-Mansour M, Nassif G, West MA, Pryor AD, Carli F, Demartines N, Bouvy ND, Passera R, Arezzo A, Francis N. EAES/SAGES evidence-based recommendations and expert consensus on optimization of perioperative care in older adults. Surg Endosc 2024; 38:4104-4126. [PMID: 38942944 PMCID: PMC11289045 DOI: 10.1007/s00464-024-10977-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Accepted: 05/30/2024] [Indexed: 06/30/2024]
Abstract
BACKGROUND As the population ages, more older adults are presenting for surgery. Age-related declines in physiological reserve and functional capacity can result in frailty and poor outcomes after surgery. Hence, optimizing perioperative care in older patients is imperative. Enhanced Recovery After Surgery (ERAS) pathways and Minimally Invasive Surgery (MIS) may influence surgical outcomes, but current use and impact on older adults patients is unknown. The aim of this study was to provide evidence-based recommendations on perioperative care of older adults undergoing major abdominal surgery. METHODS Expert consensus determined working definitions for key terms and metrics related to perioperative care. A systematic literature review and meta-analysis was performed using the PubMed, Embase, Cochrane Library, and Clinicaltrials.gov databases for 24 pre-defined key questions in the topic areas of prehabilitation, MIS, and ERAS in major abdominal surgery (colorectal, upper gastrointestinal (UGI), Hernia, and hepatopancreatic biliary (HPB)) to generate evidence-based recommendations following the GRADE methodology. RESULT Older adults were defined as 65 years and older. Over 20,000 articles were initially retrieved from search parameters. Evidence synthesis was performed across the three topic areas from 172 studies, with meta-analyses conducted for MIS and ERAS topics. The use of MIS and ERAS was recommended for older adult patients particularly when undergoing colorectal surgery. Expert opinion recommended prehabilitation, cessation of smoking and alcohol, and correction of anemia in all colorectal, UGI, Hernia, and HPB procedures in older adults. All recommendations were conditional, with low to very low certainty of evidence, with the exception of ERAS program in colorectal surgery. CONCLUSIONS MIS and ERAS are recommended in older adults undergoing major abdominal surgery, with evidence supporting use in colorectal surgery. Though expert opinion supported prehabilitation, there is insufficient evidence supporting use. This work has identified evidence gaps for further studies to optimize older adults undergoing major abdominal surgery.
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Affiliation(s)
- Deborah S Keller
- Department of Digestive Surgery, University of Strasbourg, Strasbourg, FR, USA
| | - Nathan Curtis
- Surgical Unit, Dorset County Hospital, Dorchester, Dorset, UK
| | | | | | - Amelia T Collings
- Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Hiram C Polk
- Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Francesco Maria Carrano
- Department of General and Minimally Invasive Surgery, Busto Arsizio Circolo Hospital, ASST-Valle Olona, Varese, Italy
| | - Stavros A Antoniou
- Department of General Surgery, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Nader Hanna
- Department of Surgery, Queen's University, Kingston, ON, Canada
| | | | - Sarah Hill
- Department of Surgery, The University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Anne C M Cuijpers
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Patricia Tejedor
- Department of Colorectal Surgery, University Hospital Gregorio Marañón, Madrid, Spain
| | - Marco Milone
- Department of Clinical and Surgical Gastrointestinal Diseases, University of Naples "Federico II", Via Pansini 5, Naples, Italy
| | - Eleni Andriopoulou
- Department of Surgery, Hellenic Red Cross Korgialeneio Benakeio NHS, Athens, Greece
| | - Christos Kontovounisios
- Department of Surgery and Cancer, Imperial College London, Chelsea and Westminster Campus and the Royal Marsden Hospital, London, UK
| | - Ira L Leeds
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Ziad T Awad
- Department of Surgery, University of Florida, Jacksonville, FL, USA
| | - Meghan Wandtke Barber
- Department of Surgery, The University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Mazen Al-Mansour
- Department of Surgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - George Nassif
- Department of Colorectal Surgery, AdventHealth, Orlando, FL, USA
| | - Malcolm A West
- Cancer Sciences Unit, Faculty of Medicine, University of Southampton, Southampton, UK
- Complex Cancer and Exenterative Service, University Hospitals Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, Perioperative and Critical Care Theme, University of Southampton, Southampton, UK
| | - Aurora D Pryor
- Long Island Jewish Medical Center and System Chief for Bariatric Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Great Neck, NY, USA
| | - Franco Carli
- Department of Anesthesia, Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada
| | | | - Nicole D Bouvy
- Innovative Surgical Techniques, Endoscopic and Endocrine Surgery, Department of Surgery, Maastricht University Medical Center, Amsterdam, Netherlands
| | - Roberto Passera
- Division of Nuclear Medicine, University of Torino, Turin, Italy
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Turin, Italy
| | - Nader Francis
- Department of Surgery, Yeovil District Hospital, Higher Kingston, Yeovil, UK.
- The Griffin Institute, Northwick Park and St Mark's Hospital, Y Block, Watford Rd, Harrow, HA1 3UJ, UK.
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Ammirati CA, Passera R, Beltrami E, Peluso C, Francis N, Arezzo A. Laparoscopic and robotic surgery for colorectal cancer in older patients: a systematic review and meta-analysis. MINIM INVASIV THER 2024:1-17. [PMID: 38946054 DOI: 10.1080/13645706.2024.2360094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 04/21/2024] [Indexed: 07/02/2024]
Abstract
INTRODUCTION As life expectancy has been increasing, older patients are becoming more central to the healthcare system, leading to more intensive care use and longer hospital stays. Nevertheless, advancements in minimally invasive surgical techniques offer safe and effective options for older patients with colorectal diseases. This study aims to provide comprehensive evidence on the role of minimally invasive surgery in treating colorectal diseases in older patients. MATERIAL AND METHODS All articles directly compared the minimally invasive approach with open surgery in patients aged ≥65 years. The present metanalysis took 30-day complications as primary outcomes. Length of hospital stay, readmission, and 30-day mortality were also assessed, as secondary outcomes. Further subgroup analyses were carried out based on surgery setting, lesion features, and location. RESULTS After searching the main databases, 84 articles were included. Evaluation of 30-day complications rate, length of hospital stay, and 30-day mortality significantly favored minimally invasive approaches. The outcome readmission did not show any significant difference. CONCLUSIONS The current metanalysis demonstrates clear advantages of minimally invasive techniques over open surgery in colorectal procedures for older patients, particularly in reducing complications, mortality, and hospitalization. This suggests that prioritizing these techniques, based on available expertise and facilities, could improve outcomes and quality of care for older patients undergoing colorectal surgery.
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Affiliation(s)
| | - Roberto Passera
- Nuclear Medicine Division, Department of Medical Sciences, AOU Città della Salute e della Scienza di Torino, University of Turin, Torino, Italy
| | - Elsa Beltrami
- Department of Surgical Sciences, University of Turin, Torino, Italy
| | - Chiara Peluso
- Department of Surgical Sciences, University of Turin, Torino, Italy
| | - Nader Francis
- Department of Colorectal Surgery, Yeovil District Hospital Foundation Trust, Yeovil, UK
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Turin, Torino, Italy
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Wang J, Yang Y, Li W, Yang B, Tian Z, Wang G. Application value of laparoscopic surgery in elderly patients (≥ 75 years) with colorectal cancer and prognostic factors influencing 5-year overall survival. Am J Transl Res 2024; 16:2633-2644. [PMID: 39006255 PMCID: PMC11236657 DOI: 10.62347/rdmb8197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 05/28/2024] [Indexed: 07/16/2024]
Abstract
OBJECTIVE To investigate the application value of laparoscopic surgery in elderly patients (≥ 75 years) with colorectal cancer, and to identify the prognostic factors influencing the long-term survival in this demographic, and to establish a predictive nomogram model. METHODS A retrospective analysis was conducted on 146 elderly (≥ 75 years old) colorectal cancer patients who underwent radical surgery in Baoji People's Hospital from August 2016 to February 2018, including 55 patients who underwent laparotomy and 91 patients who underwent laparoscopic surgery. Survival curves were plotted using the Kaplan-Meier method, and differences in prognosis were assessed using the Log-rank test. Prognostic impacts of various factors on 5-year survival were analyzed using a Cox proportional hazards model. Significant predictors identified in the Cox model were used to construct a nomogram for predicting survival, which was then validated for accuracy and clinical utility. RESULTS Laparoscopic surgery was associated with shorter hospital stays (P = 0.022), although at a higher cost (P = 0.011). The laparoscopic group also had less intraoperative bleeding (P < 0.001), incision length (P < 0.001), time to first postoperative expectoration (P < 0.001), time to first postoperative feeding (P = 0.002), and time to postoperative peritoneal drainage (P = 0.003) compared to the open surgery group. Additionally, the rate of postoperative wound complications was also lower in the laparoscopic group (P = 0.014). There was no significant difference in the 5-year post-treatment survival between the two groups (P = 0.150). Multifactorial Cox regression analysis revealed that a history of diabetes mellitus (P = 0.037), vascular infiltration (P = 0.026), nerve bundle invasion (P = 0.001), and TNM stage (P = 0.001) were independent prognostic factors affecting the 5-year survival of patients with advanced colorectal cancer. The constructed nomogram showed high predictive accuracy for 1-, 3-, and 5-year survival, with AUC values of 0.91, 0.87, and 0.79, respectively. Calibration curves and decision curve analysis confirmed the model's clinical utility. Risk formula: History of diabetes mellitus * -0.696194503 + Vascular infiltration * -0.769736513 + Nerve bundle invasion * -1.1709777 + TNM staging * 1.201933691. CONCLUSION Laparoscopic surgery can reduce intraoperative trauma and accelerate postoperative recovery in elderly colorectal cancer patients (≥ 75 years) compared to open surgery. The developed nomogram model based on independent prognostic factors such as diabetes history, vascular infiltration, nerve bundle invasion, and TNM staging, facilitates tailored prognostic assessment, enhancing individual patient management.
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Affiliation(s)
- Jia Wang
- Department of General Surgery, Baoji People's Hospital Baoji 721000, Shaanxi, China
| | - Yang Yang
- Department of General Surgery, Baoji People's Hospital Baoji 721000, Shaanxi, China
| | - Wenqing Li
- Department of General Surgery, Baoji People's Hospital Baoji 721000, Shaanxi, China
| | - Bowei Yang
- Department of General Surgery, Baoji People's Hospital Baoji 721000, Shaanxi, China
| | - Zhiqiang Tian
- Department of General Surgery, Baoji People's Hospital Baoji 721000, Shaanxi, China
| | - Gaobo Wang
- Department of General Surgery, Baoji People's Hospital Baoji 721000, Shaanxi, China
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Application Effect of Robot-Assisted Laparoscopy in Hepatectomy for Colorectal Cancer Patients with Liver Metastases. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:5492943. [PMID: 35756424 PMCID: PMC9225905 DOI: 10.1155/2022/5492943] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 03/28/2022] [Accepted: 04/07/2022] [Indexed: 11/17/2022]
Abstract
Objective Application effect of Leonardo's robot-assisted laparoscopy in hepatectomy for colorectal cancer patients with liver metastases. Methods A total of 122 patients with sCRLM treated in our hospital from May 2015 to June 2018 were selected and divided into observation group (n = 61) and control group (n = 61) according to random number table method. The observation group was treated with robot-assisted laparoscopic hepatectomy, while the control group was treated with conventional laparoscopic hepatectomy. The perioperative time, intraoperative blood transfusion, intraoperative blood loss, average intraoperative blood transfusion, and hepatic portal occlusion time of the two groups were observed. Serum cortisol (Cor), norepinephrine (NE), and glucose (Glu) levels were detected before and after surgery in the two groups. The oxygen consumption and carbon dioxide output of patients were measured 1 day before surgery and 1~3 days after surgery, and the resting energy expenditure (REE) value was calculated. The levels of CD3+, CD4+, and CD8+ were determined by flow cytometry. The incidence of complications was compared between the two groups. Patients were followed up for 3 years after discharge, and Kaplan-Meier method was used to analyze the survival of the two groups. Results The operation time, intraoperative blood transfusion, intraoperative blood loss, and average intraoperative blood transfusion in the observation group were all less than those in the control group, and the differences were statistically significant (P < 0.05). Three days after operation, the levels of serum Cor, NE, and Glu were increased in both groups, and the observation group was lower than the control group; the difference was statistically significant (P < 0.05). The REE level of observation group was lower than that of control group after 1 day, 2 days, and 3 days after surgery, and the difference was statistically significant (P < 0.05). Three days after operation, the levels of serum CD3+ and CD4+ were decreased in both groups, and the observation group was higher than the control group; the difference was statistically significant (P < 0.05). The incidence of complications in the observation group (3.28%) was lower than that in the control group (13.11%); the difference was statistically significant (P < 0.05).There was no significant difference in survival rate between the two groups after 1, 2, and 3 years of follow-up (P > 0.05). Conclusion The application of robot-assisted laparoscopy in patients with sCRLM can effectively improve the perioperative situation of patients, reduce stress, energy metabolism, and immune damage, and reduce the incidence of complications.
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Flynn DE, Mao D, Yerkovich S, Franz R, Iswariah H, Hughes A, Shaw I, Tam D, Chandrasegaram M. Should we resect colorectal cancer in patients over the age of 85? World J Gastrointest Oncol 2021; 13:185-196. [PMID: 33738046 PMCID: PMC7953345 DOI: 10.4251/wjgo.v13.i3.185] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 12/31/2020] [Accepted: 01/28/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The prevalence of colorectal cancer in the elderly is rising, with increasing numbers of older patients undergoing surgery. However, there is a paucity of information on the surgical outcomes and operative techniques used in this population.
AIM To evaluate the post-operative outcomes for patients ≥ 85 years old following colorectal cancer resection as well as evaluating the outcomes of laparoscopic resection of colorectal cancer in patients over 85.
METHODS Patients who underwent colorectal cancer resection at our institution between January 2010 and December 2018 were included. The study was divided into two parts. For part one, patients were divided into two groups based on age: Those age ≥ 85 years old (n = 48) and those aged 75-84 years old (n = 136). Short term surgical outcomes and clinicopathological features were compared using appropriate parametric and non-parametric testing. For part two, patient’s over 85 years old were divided into two groups based upon operative technique: Laparoscopic (n = 37) vs open (n = 11) colorectal resection. Short-term post-operative outcomes of each approach were assessed.
RESULTS The median length of stay between patients over 85 and those aged 75-85 was eight days, with no statistically significant difference between the groups (P = 0.29). No significant difference was identified between the older and younger groups with regards to severity of complications (P = 0.93), American Society of Anaesthesiologists grading (P = 0.43) or 30-d mortality (2% vs 2%, P = 0.96). Patients over 85 who underwent laparoscopic colorectal resection were compared to those who underwent an open resection. The median length of stay between the groups was similar (8 vs 9 d respectively) with no significant difference in length of stay (P = 0.18). There was no significant difference in 30-d mortality rates (0% vs 9%, P = 0.063) or severity of complication grades (P = 0.46) between the laparoscopic and open surgical groups.
CONCLUSION No significant short term surgical differences were identified in patients ≥ 85 years old when compared to those 75-85 years old. There is no difference in short term surgical outcomes between laparoscopic or open colorectal resections in patients over 85.
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Affiliation(s)
- David E Flynn
- Department of General Surgery, The Prince Charles Hospital, Chermside 4032, Queensland, Australia
| | - Derek Mao
- Department of General Surgery, The Prince Charles Hospital, Brisbane 4032, Queensland, Australia
| | - Stephanie Yerkovich
- The Common Good Foundation, The Prince Charles Hospital, Brisbane 4032, Queensland, Australia
| | - Robert Franz
- Department of General Surgery, The Prince Charles Hospital, Brisbane 4032, Queensland, Australia
| | - Harish Iswariah
- Department of General Surgery, The Prince Charles Hospital, Brisbane 4032, Queensland, Australia
| | - Andrew Hughes
- Department of General Surgery, The Prince Charles Hospital, Brisbane 4032, Queensland, Australia
| | - Ian Shaw
- Department of General Surgery, The Prince Charles Hospital, Brisbane 4032, Queensland, Australia
| | - Diana Tam
- Department of General Surgery, The Prince Charles Hospital, Brisbane 4032, Queensland, Australia
| | - Manju Chandrasegaram
- Department of General Surgery, The Prince Charles Hospital, Brisbane 4032, Queensland, Australia
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