Postoperative complications in elderly patients with colorectal cancer: comparison of open and laparoscopic surgical procedures. Surg Laparosc Endosc Percutan Tech. 2009;19:488-492. [PMID: 20027093 DOI: 10.1097/sle.0b013e3181bd9562]

Clinical and oncologic outcomes of laparoscopic versus open surgery in elderly patients with colorectal cancer: a retrospective multicenter study

BACKGROUND

Laparoscopic surgery is commonly used in elderly patients over 80 years old. The purpose of this study was to compare the perioperative and oncologic outcomes between laparoscopic surgery and open surgery in elderly patients with colorectal cancer.

METHODS

We retrospectively analyzed the medical records of patients aged ≥ 80 years who underwent curative resection of colorectal cancer at six Hallym University-affiliated hospitals. The perioperative outcomes and oncologic outcomes were compared between laparoscopic and open surgery RESULTS: Of 294 elderly patients, 104 (35.3%) underwent open surgery and 190 (64.7%) underwent laparoscopic surgery. The postoperative hospital stay (P = 0.019) and time to soft diet (P = 0.009) were shorter in the laparoscopic group than in the open group. Postoperative complications were less frequent in the laparoscopic group than in the open group (P < 0.001), including wound infection (P = 0.005), ileus (P = 0.005), and pneumonia (P = 0.001). The 3-year overall survival (OS) (P = 0.982) and recurrence-free survival rates (RFS) (P = 0.532) were similar in both groups. In multivariable analyses, positive lymph node status was the only independent factor associated with OS (P = 0.019) and RFS (P = 0.012). Laparoscopic surgery was not associated with OS (P = 0.874) and RFS (P = 0.772).

CONCLUSION

Laparoscopic surgery offers several perioperative advantages over open surgery and similar long-term oncological outcomes for elderly patients with colorectal cancer. Therefore, we suggest that laparoscopic surgery can be safely performed for the treatment of elderly patients (≥ 80 years old) with colorectal cancer.

Prognostic Nutritional Index as a Predictor of Postoperative Outcome in Patients Aged 85 Years or Older After Colorectal Cancer Surgery

The preoperative prognostic nutritional index (PNI) calculated based on the serum albumin concentration and peripheral blood lymphocyte count has been reported to correlate with the prognosis in patients undergoing cancer surgery. However, in case of very old patients over 85 years old, the value of preoperative PNI in colorectal cancer has not been studied in any detail. The aim of this study was to assess the PNI as a predictor of postoperative outcome in elderly patients over 85 years old with colorectal cancer. We performed a retrospective review in forty-five patients over 85 years old who underwent colorectal tumor resection at our hospital from April 2013 to March 2018. The correlations between preoperative PNI and postoperative complications were examined. The incidence rate of postoperative complications was 31.1% (14/45). All of cases with postoperative complications were improved conservatively. The median preoperative PNI was 43.20 (range 24.05–57.05) in the validation study. According to the receiver operating characteristic (ROC) curve, cutoff value of PNI was set at 45.0 in the validation study. An univariate analysis demonstrated that PNI (p = 0.0006), operation style (elective/emergency) (p = 0.03), operation approach (open/laparoscopy) (p = 0.03), and T factor (p = 0.04). A multivariate analysis showed that PNI was independent predictive factor of postoperative complications. Moreover 3-year overall survival rates of patients in the PNI ≧ 45 and PNI < 45 were 100% and 63.8%, respectively (p = 0.009). This study suggested that PNI is a pivotal independent predictor of the postoperative outcome among elderly patients over 85 years old after colorectal cancer surgery.

Hospital malnutrition in northeast and southeast Asia: A systematic literature review

BACKGROUND & AIMS

Hospital malnutrition is a prevalent yet frequently under-recognised condition that is associated with adverse clinical and economic consequences. Systematic reviews from various regions of the world have provided regional estimates of the prevalence of malnutrition and the magnitude of the associated health and economic burden; however, a systematic assessment of the prevalence and consequences of hospital malnutrition in northeast and southeast Asia has not been conducted.

METHODS

We performed a systematic literature search for articles on hospital malnutrition in 11 Asian countries published in English between January 1, 1997 and January 15, 2018. Studies reporting data on the prevalence, clinical consequences, or economic impact of hospital malnutrition in an adult inpatient population with a sample size ≥30 were eligible for inclusion.

RESULTS

The literature search identified 3207 citations; of these, 92 studies (N = 62,280) met the criteria for inclusion. There was substantial variability in study populations and assessment methods; however, a majority of studies reported a malnutrition prevalence of >40%. Malnutrition was associated with an increase in clinical complications, mortality, length of hospitalisation, hospital readmissions, and healthcare costs.

CONCLUSIONS

Hospital malnutrition is a highly prevalent condition among hospitalised patients in northeast and southeast Asia. Additionally, poor nutritional status is associated with increased morbidity and mortality and increased healthcare costs. Further research aimed at improving the identification and proactive management of hospitalised patients at risk for malnutrition is necessary to improve patient outcomes and alleviate the burden on local healthcare budgets.

Systematic review of laparoscopic vs open surgery for colorectal cancer in elderly patients

AIM: To verify the safety and validity of laparoscopic surgery for the treatment of colorectal cancer in elderly patients.

METHODS: A meta-analysis was performed of a systematic search of studies on an electronic database. Studies that compared laparoscopic colectomy (LAC) in elderly colorectal cancer patients with open colectomy (OC) were retrieved, and their short and long-term outcomes compared. Elderly people were defined as 65 years old or more. Inclusion criteria were set at: Resection of colorectal cancer, comparison between laparoscopic and OC and no significant difference in backgrounds between groups.

RESULTS: Fifteen studies were identified for analysis. LAC was performed on 1436 patients, and OC performed on 1810 patients. In analyses of short-term outcomes, operation time for LAC was longer than for OC (mean difference = 34.4162, 95%CI: 17.8473-50.9851, P < 0.0001). The following clinical parameters were lower in LAC than in OC: Amount of estimated blood loss (mean difference = -93.3738, 95%CI: -132.3437 to -54.4039, P < 0.0001), overall morbidity (OR = 0.5427, 95%CI: 0.4425-0.6655, P < 0.0001), incisional surgical site infection (OR = 0.6262, 95%CI: 0.4310-0.9097, P = 0.0140), bowel obstruction and ileus (OR = 0.6248, 95%CI: 0.4519-0.8638, P = 0.0044) and cardiovascular complications (OR = 0.4767, 95%CI: 0.2805-0.8101, P = 0.0062). In analyses of long-term outcomes (median follow-up period: 36.4 mo in LAC, 34.3 mo in OC), there was no significant difference in overall survival (mean difference = 0.8321, 95%CI: 0.5331-1.2990, P = 0.4187) and disease specific survival (mean difference = 1.0254, 95%CI: 0.6707-1.5675, P = 0.9209). There was also no significant difference in the number of dissected lymph nodes (mean difference = -0.1360, 95%CI: -4.0553-3.7833, P = 0.9458).

CONCLUSION: LAC in elderly colorectal cancer patients had benefits in short-term outcomes compared with OC except operation time. The long-term outcomes and oncological clearance of LAC were similar to that of OC. These results support the assertion that LAC is an effective procedure for elderly patients with colorectal cancer.

Laparoscopic Splenectomy for the Elderly Liver Cirrhotic Patients With Hypersplenism: A Retrospective Comparable Study

A growing body of evidence has supported the benefits of laparoscopic splenectomy (LS) for hypersplenism due to liver cirrhosis. With the increased proportion of elderly persons worldwide, it is necessary to investigate the risks and benefits of LS in elderly liver cirrhotic patients.From September 2003 to March 2012, LS and open splenectomy (OS) were performed for 21 (Group 1) and 19 (Group 3) patients, respectively, all of whom were 65 years of age and older; in addition, 39 patients who were <65 years old were treated with LS and referred to as Group 2. Data (i.e., demographic characteristics and preoperative, intraoperative, and postoperative information) were retrospectively collected. Between-group comparisons were performed for the above-mentioned data.Compared with the patients in Group 3, the patients in Group 1 required longer operative times, fewer transfusions, less intensive care, a shorter postoperative course, and a shorter time to the first oral intake, and they had less blood loss and fewer postoperative short-term complications. During the follow-up period, compared with the preoperative status, significant changes in hemoglobin, leukocyte, platelet, and albumin levels were observed in all groups, whereas changes in the total BILirubin (BIL), aspartate aminotransferase (AST), and alanine aminotransferase (ALT) levels were inconspicuous.Patients >65 years of age with hypersplenism caused by liver cirrhosis can safely undergo LS.

Meta-analysis of the risk of small bowel obstruction following open or laparoscopic colorectal surgery

Background

One of the potential advantages of laparoscopic compared with open colorectal surgery is a reduction in postoperative bowel obstruction events. Early reports support this proposal, but accumulated evidence is lacking.

Methods

A systematic review and meta-analysis was performed of randomized clinical trials and observational studies by searching the PubMed and Cochrane Library databases from 1990 to August 2015. The primary outcomes were early and late postoperative bowel obstruction following laparoscopic and open colorectal surgery. Both ileus and bowel obstruction were defined as a postoperative bowel obstruction. Subgroup and sensitivity analyses were performed, and a random-effects model was used to account for the heterogeneity among the studies.

Results

Twenty-four randomized clinical trials and 88 observational studies were included in the meta-analysis; 106 studies reported early outcome and 12 late outcome. Collectively, these studies reported on the outcomes of 148 392 patients, of whom 58 133 had laparoscopic surgery and 90 259 open surgery. Compared with open surgery, laparoscopic surgery was associated with reduced rates of early (odds ratio 0·62, 95 per cent c.i. 0·54 to 0·72; P &lt; 0·001) and late (odds ratio 0·61, 0·41 to 0·92; P = 0·019) postoperative bowel obstruction. Weighted mean values for early postoperative bowel obstruction were 8 (95 per cent c.i. 6 to 10) and 5 (3 to 7) per cent for open and laparoscopic surgery respectively, and for late bowel obstruction were 4 (2 to 6) and 3 (1 to 5) per cent respectively.

Conclusion

The reduction in postoperative bowel obstruction demonstrates an advantage of laparoscopic surgery in patients with colorectal disease.

Short-term results of a randomized study between laparoscopic and open surgery in elderly colorectal cancer patients

BACKGROUND

In surgical treatment of elderly patients, securing the safety of surgery and radical cure must be balanced. Our purpose was to verify the safety and validity of laparoscopic surgery for the treatment of colorectal cancer in elderly patients.

METHODS

Patients with cTis–T4a colorectal cancer who were 75 years or older were randomized to receive open or laparoscopic surgery. Exclusion criteria were patients who had a bulky tumor, rectal cancer that required pelvic side wall lymphadenectomy, and history of colon resection. Patients were divided according to tumor location (right colon, left colon, and rectum). The short-term outcomes were compared between the two groups.

RESULTS

One hundred patients (right 43, left 28, and rectum 29) were registered in each group from August 2008 to August 2012. There were no differences in patient characteristics between the two groups. Three patients were converted from laparoscopic to open, because of bleeding, excision of peritoneum metastasis, and patient’s desire, respectively. In the short-term results (open:laparoscopic), there were significant differences in the rates of complications (36:23 %) and ileus (12:4 %), amount of blood loss (157:63 mL), and duration of surgery (150:172 min). There were no significant differences in the pathological margins, and the number of dissected lymph nodes. In the subgroup analysis according to the tumor location, there were significant differences in the rate of complications (39.4:22.5 %), amount of blood loss (135:42 mL), duration of surgery (139:160 min), and length of postoperative stay (13.0:10.0 days) in the colon cancer. There were no significant differences in short-term results in the rectal cancer.

CONCLUSIONS

Laparoscopic surgery in elderly colorectal cancer patients did not result in a difference in radical cure compared with open surgery, and the short-term results except the duration of surgery were excellent. It is an effective procedure for elderly patients with colorectal cancer, especially colon cancer.

Is laparoscopic colorectal surgery beneficial for elderly patients? A systematic review and meta-analysis

BACKGROUND

Elderly patients who undergo major abdominal surgery are potentially at a higher risk of perioperative mortality and postoperative complications. Although laparoscopic surgery has been widely accepted as a less invasive surgical procedure for colorectal diseases, the benefits for elderly patients have not been validated.

AIM

To compare postoperative outcomes and long-term survival between laparoscopic and open colorectal surgery in the elderly population.

METHODS

A literature search was electronically performed to identify all studies comparing postoperative outcomes between laparoscopic and open colorectal resections in the elderly population. Primary outcomes were postoperative mortality and complications, and the secondary outcome was long-term survival.

RESULTS

Overall, 30 studies (70,946 patients) met our inclusion criteria. Laparoscopic surgery was significantly associated with a decreased risk of perioperative mortality [odds ratio (OR), 0.55; 95% confidence interval (CI), 0.45-0.68; P < 0.01] and postoperative complications (OR, 0.55; 95% CI, 0.48-0.63; P < 0.01) compared with open surgery. There was no significant difference in long-term survival between the two procedures (OR, 0.89; 95% CI, 0.72-1.07; P = 0.31).

CONCLUSIONS

Laparoscopic colorectal surgery in the elderly population has significant advantages in terms of short-term outcomes. Aggressive application of laparoscopic colorectal surgery should be considered for the elderly population.

Colorectal surgical mortality and morbidity in elderly patients: comparison of POSSUM, P-POSSUM, CR-POSSUM, and CR-BHOM

PURPOSE

This study aims to compare the predictive value of POSSUM, P-POSSUM, CR-POSSUM and CR-BHOM in colorectal surgical mortality and morbidity in patients over 80 years old.

METHODS

This is a retrospective observational longitudinal study. A total of 991 patients who underwent major colorectal surgery between 2008 and 2012 in a secondary hospital in Portugal were screened, and 204 who were over 80 years old were included. Subgroup analysis was performed for malignant/benign disease and emergent/elective surgery. The main outcome measure was 30-day postoperative mortality and morbidity with Clavien-Dindo classification ≥ 2.

RESULTS

Of the 204 patients included in this study, 155 had malignant disease, and 65 underwent emergent procedures. Overall average age was 84.3 ± 3.9 years (range 80-100). Overall surgical mortality and morbidity were 18.6% (n = 38) and 52.4% (n = 87), respectively. Expected mortality followed the order P-POSSUM<CR-POSSUM<CR-BHOM (p < 0.001), and expected morbidity followed the order POSSUM<CR-BHOM (p < 0.001) in all groups. All scores were higher in the emergent surgery group compared with elective surgery (p < 0.05). All scores had sensitivity below 60%. Physiology scores were higher among patients with surgical mortality (p < 0.05), with no differences in operative scores.

CONCLUSIONS

In our population, CR-POSSUM was the best predictor of surgical mortality. POSSUM and P-POSSUM underestimated surgical mortality and morbidity, and CR-BHOM overestimated surgical mortality, being however the best predictor of morbidity. Nevertheless, none of the scores showed sufficient discriminatory power to have clinical application value. Moreover, our results suggest that, in elderly patients, it is the patient's health status and not the type of surgery that is mainly responsible for the surgical outcome.

Laparoscopic colorectal surgery confers lower mortality in the elderly: a systematic review and meta-analysis of 66,483 patients

BACKGROUND

Increasing life expectancy requires specific attention on geriatric patients. Data support a potential reduction of surgical morbidity for patients undergoing laparoscopic surgery as compared to conventional surgery. The aim of this study was to investigate the comparative effect of laparoscopic and open colorectal surgery on geriatric patients.

METHODS

A systematic review of electronic information sources was undertaken. Studies that provided outcome data on patients aged 65 years or older, subjected to laparoscopic or open colorectal surgery, were considered. Mortality, morbidity, cardiac and pulmonary complications were the outcome measures of treatment effect. The methodological quality of selected studies was independently appraised by two reviewers. Random effects model was applied to synthesize outcome data.

RESULTS

Twenty-seven articles providing data for 66,592 patients were included in the analysis. Patients undergoing laparoscopic surgery had a decreased risk for mortality (2.2 vs. 5.4 %; OR 0.55, 95 % CI 0.44-0.67), overall morbidity (19.3 vs. 26.7 %; OR 0.54, 95 % CI 0.46-0.63), cardiac (4.7 vs. 7.7 %; OR 0.60, 95 % CI 0.39-0.92) and respiratory complications (3.9 vs. 6.3 %; OR 0.67, 95 % CI 0.47-0.95). Sensitivity analysis including reports with similar age, American Society of Anesthesiologists score and/or similar prevalence of cardiopulmonary morbidity between the laparoscopic and the open treatment arm validated the outcome estimates of the primary analysis.

CONCLUSIONS

This analysis supports a substantial benefit for elderly patients undergoing laparoscopic in comparison with open colorectal surgery. The comparative effect of either approach on geriatric patients with pulmonary and cardiac comorbidities is a subject of further investigation.

Risk factor evaluation for postoperative complications in laparoscopic colorectal surgery by a classic severity grading system

Using the uniform complication grading system to evaluate postoperative complications after laparoscopic colorectal surgery is the purpose of the present study. Surgical complications were defined as grades I, II, III, IV, and V recommended by Dindo et al. Patients were categorized into three pairs: complication group (CG) and non-complication group (NCG), minor complication group (MiCG, grades I-II) and non-minor complication group (NMiCG), and major complication group (MaCG, grades III-V) and non-major complication group (NMaCG); of the 570 patients, 431 patients were discharged with no complications, and 174 complications occurred in 119 patients. The percent of grades I, II, III, IV, and V complications were 4.7, 20, 4.7, 0.7, and 0.4 %, respectively. Complications were significantly associated with male gender, larger tumor volume, and more estimated blood loss (EBL). The multivariate analysis revealed that male and EBL ≥150 ml were found to be independent predictors of postoperative complications. In subgroup analysis, patients with larger tumor volume were at significantly higher risk of postoperative major complications, and male gender and EBL ≥150 ml remained independent predictors of developing minor postoperative complications. Patients with postoperative complications would significantly experience longer hospital stay, later fluid intake, and delayed urinary catheter removal. Male, larger tumor volume, and more EBL were significant risk factors for laparoscopic colorectomy.

Grading of complications and risk factor evaluation in laparoscopic colorectal surgery

BACKGROUND

A grading system for postoperative complications is important for quality control and comparison among investigations. The objective of the current study was to evaluate complications associated with laparoscopic colorectal surgery according to a standardized grading system, and to examine risk factors associated with different complication grades.

METHODS

Data of all patients who underwent elective laparoscopic colorectal surgery at two medical centers between September 2003 and January 2011 were collected prospectively. Complications were graded retrospectively into five categories based on a previously proposed grading system for colorectal operations. Age, gender, BMI, Charlson comorbidity score, indication for surgery, pathology site, conversion rate, learning curve, operative times, previous abdominal surgery, concurrent surgical procedures performed, and length of hospital stay were evaluated as risk factors and outcome measures for complications.

RESULTS

A total of 501 patients were included in the study. Of them, 30.5 % suffered at least one complication and 6.5 % more than one. Complications that were mainly medical or surgical site infections requiring minor intervention (grades 1 and 2) occurred in 22.9 % of patients. Surgical complications requiring invasive interference (grades 3 and 4) occurred in 7.4 % of patients and mortality (grade 5) occurred in 0.2 % (1 patient). Length of hospital stay was directly related to complication grade. Average hospital stay was 6.8 ± 3.5, 10.5 ± 5.1, and 20.2 ± 12.3 days for patients with no complications, grade 1-2 complications, and grade 3-4 complications, respectively (p < 0.01). Minor complications (grades 1-2) were associated with conversion (p < 0.01), high Charlson score (p = 0.004), and additional surgical procedures (p = 0.04). Major complications (grades 3-4) were associated solely with conversion (p < 0.01) and rectal pathology (p < 0.01).

CONCLUSION

This study demonstrates the use of a uniform grading system for complications in laparoscopic colorectal surgery. Conversion was found to be associated with all grades of complications.

Is 30-day mortality an appropriate measure of risk in elderly patients undergoing elective colorectal resection?

AIM

The study aimed to define mortality in the elderly following elective colorectal resection and to identify the most meaningful postoperative period to report mortality rates in this group of patients.

METHOD

A systematic review was undertaken to identify studies that reported on mortality in the elderly following elective colorectal resection. Searches of MEDLINE, Embase and PubMed databases were carried out by two independent reviewers and the results were collated. Two reviewers conducted literature searches independently and the third reviewer acted as an arbiter in case of discordance.

RESULTS

Two-hundred and thirty-six studies published in 2000 or later were identified in the search. Studies were excluded if they included emergency surgery, included patients receiving surgery before 1995, or did not comment on mortality in an elderly age group. Seventeen studies were finally included in the review. Thirty-day or postoperative mortality rates varied from 0 to 13.3%. Short-term mortality was low in elderly patients selected for minimal access surgery. National population and registry observational audits reported higher short-term mortality rates than most small case series or cohort studies. One national audit demonstrated that a significant mortality risk persists for up to 1 year after surgery.

CONCLUSION

Historical case series suggest that 30-day mortality following colorectal resection in the elderly is low. The reliability of 30-day mortality measures to reflect surgical success in this cohort is, however, questionable as a significant proportion of patients die in the months following surgery.

Laparoscopic versus open colorectal resection in the elderly population

BACKGROUND

Elderly patients are often regarded as high-risk patients for major abdominal surgery because of a lack of functional reserve and associated medical comorbidities. The aim of this systematic review and pooled analysis was to review the current data published regarding the differences in operative outcomes of laparoscopic and open surgery in the elderly population.

METHODS

A systematic literature search of Medline, Embase, Web of Science, and Cochrane databases was performed. Studies that compared outcome following laparoscopic and open colorectal resections in the elderly (≥70) population were included. Primary outcomes were operative death, anastomotic leak, pneumonia, length of hospital stay, and return to bowel function. Secondary outcomes were operative time, intraoperative blood loss, postoperative cardiac morbidity, ileus, and postoperative wound infection.

RESULTS

The results of this systematic review and pooled analysis demonstrate the safety and potential benefits of laparoscopic colorectal resection in the elderly population. The latter include reduction in length of hospital stay, intraoperative blood loss, incidence of postoperative pneumonia, time to return of normal bowel function, incidence of postoperative cardiac complications, and wound infections.

CONCLUSION

The results of this pooled analysis demonstrate the potential short-term advantages of laparoscopic colorectal resection in the elderly population. Further studies are required to examine the long-term survival following laparoscopic and open colorectal resections in the elderly population.

Evaluation of laparoscopic versus open colorectal surgery in elderly patients more than 70 years old: an evaluation of 727 patients

BACKGROUND

With longer life expectancy, surgeons can expect to operate on older patients. Laparoscopic colorectal (LC) surgery has been demonstrated to be superior to open surgery. Controversy persists, however, regarding benefits of LC in the elderly due to increase in operative time. The aim of our study was to compare short-term outcomes of LC versus open colorectal (OC) surgery in elderly patients.

MATERIALS AND METHODS

Patients ≥70 years old that underwent elective LC between 2005 and 2008 were compared with controls who underwent OC. Data was extracted from a prospectively collected database.

RESULTS

Seven hundred and twenty-seven patients underwent colorectal resection in this study period (LC n = 225, OC n = 502). The laparoscopic arm was characterised by shorter incisions (LC 6.0 cm vs. OC 12.0 cm, p < 0.001) but longer operating times (LC 125 min vs. OC 85 min, p < 0.001). Median use of narcotics and length of stay were significantly shorter in the laparoscopic group (LC 2 days vs. OC 3 days, p < 0.001 and LC 6 days vs. OC 7 days, p < 0.001, respectively). There was no significant difference in median recovery of bowel function (LC 4 days vs. OC 4 days, p = 0.14) and post-operative morbidity (p = 0.725). Thirty-day mortality was significantly lower in the laparoscopic arm (LC 1.3% vs. OC 4.6%, p = 0.03)

CONCLUSION

This is the largest series from a single institution comparing LC and OC in elderly patients. In our series, LC in elderly patients was safe and not associated with a higher morbidity. LC was also associated with less narcotic use and shorter length of stay.