Laparoscopic surgery for extremely elderly patients (≥85)-experience from a single center

doi:10.21203/rs.3.rs-2602466/v1

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Laparoscopic surgery for extremely elderly patients (≥85)-experience from a single center

https://doi.org/10.21203/rs.3.rs-2602466/v1

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Background: More and more extremely elderly patients (≥85) with colorectal cancer are being encountered in routine clinical practice. For these patients, the laparoscopic approach has been considered as a less invasive alternative. Whereas, it is not so easy for us to accomplish controlled clinical trials among extremely elderly patients. The present study was performed to evaluate the feasibility and safety of laparoscopic surgery for extremely elderly patients.

Materials and Methods: Medical records of extremely elderly patients with colorectal cancer who had underwent curative laparoscopic or open surgery were retrospectively reviewed. The clinicopathological characteristics and surgery-related outcomes of these patients were recorded and analyzed.

Results: A total of 110 extremely elderly patients had undergone curative surgery at our center, including 47 open surgeries and 63 laparoscopic surgeries. The mean operation times for open surgery and laparoscopic surgery were 199.94 (±64.17) and 195.71 (±77.85) minutes, respectively. Intraoperative blood transfusion during laparoscopic surgery (258.73±549.38 ml) was not significantly different from that for open surgery (160.64±273.05 ml) (P=0.264). In the open group, 2 patients experienced major complications. In the laparoscopic group, 4 patients experienced major complications. The laparoscopic group was not significantly different from the open group in terms of overall survival (P=0.763) and recurrence-free survival (P=0.323). Of these 110 patients, the oldest was a woman aged 100 years and 10 months who had undergone curative laparoscopic sigmoidectomy.

Conclusion: For extremely elderly patients with colorectal cancer, laparoscopic surgery is feasible and safe. We report the success of laparoscopic surgery for a patient aged 100 years with sigmoid colon cancer.

Colorectal cancer

Extremely elderly

Laparoscopic surgery

Postoperative outcomes

Colorectal cancer (CRC) is the third most common cancer around the world and it causes the second most cancer-related deaths[1]. Currently, in China, the proportion of elderly patients is increasing and more and more extremely elderly patients are being encountered in routine clinical practice[2]. For patients with colorectal cancer, laparoscopic surgery could result in faster recovery and shorter hospital stay[3, 4]. Moreover, laparoscopic surgery has been considered a less invasive alternative for elderly patients[5, 6] However, it has been proven not so easy for us to conduct controlled clinical trials. Thus, this study was performed to assess feasibility and safety of laparoscopic surgery for extremely elderly patients with colorectal cancer. A female patient aged 100 years had undergone curative laparoscopic surgery at our center. We believe that this study could provide some useful suggestions for treating extremely elderly patients with colorectal cancer despite the fact that this study is a retrospective one.

Study population

The present study was approved by The Ethics Committee, Guangdong Provincial Hospital of Traditional Chinese Medicine. All the patients were 85 years old or older. All these patients had undergone curative laparoscopic or open resection of colorectal cancer between January 2009 and December 2015 at The Department of Gastrointestianl Surgery, Guangdong Provincial Hospital of Traditional Chinese Medicine. Colonoscopy and computed tomography (CT) were performed routinely preoperatively. For rectal cancer, magnetic resonance imaging (MRI) was routinely performed to assess the depth of invasion (T stage) and whether levator ani was invaded. Patients would undergone a bowel preparation using magnesium sulfate except emergent cases. For patients undergoing elective surgery, enhanced recovery after surgery would be introduced. The clinicopathological characteristics of each patient including age, gender, tumor size, tumor location, gross morphology, differentiation, histological component, vessel invasion, depth of invasion (T stage), lymph node metastasis (N stage), Union Internationale Against cancer and the American joint Committee on cancer (UICC/AJCC), carcino-embryonic antigen (CEA) and carbohydrate antigen 199(CA-199). Additionally, intraoperative results and postoperative short-term outcomes were recorded.

Surgical Procedures And Follow-ups

For extremely elderly patients without distant metastasis identified by preoperative imaging, curative open or laparoscopic surgery would be performed. However, laparoscopic surgery was preferred over open surgery since the superiority of laparoscopic surgery over open surgery had been demonstrated. Both open and laparoscopic surgeries for extremely elderly patients were accomplished by skilled surgeons and assistants under general anesthesia. Surgeries were performed according to previous studies[7, 8]. After surgery, all the patients were instructed to attend a follow-up lasting five years with a 3-month interval. The follow-up scheme included physical examination (every 3 months), blood examination (mainly tumor markers) (every 3 months), contrast-enhanced CT (every six months) and colonoscopy (every year).

Statistical Analyses

All the statistical analyses were accomplished by SPSS 22.0 software package. Quantitative variables were compared using t test while categorical ones were compared by Pearson’s χ2 or Fisher exact test. The duration between curative surgery and death (no matter the cause) was defined as overall survival (OS) and the time length between curative surgery and cancer recurrence was recorded as recurrence-free survival (RFS). Comparisons whose P values less than 0.05 were considered as statistically significant. The laparoscopic group was compared with the open group in terms of short-term and long-term outcomes. OS and RFS of the laparoscopic group were compared with those of the open group by plotting Kaplan-Meier curves and the statistical significances of these comparisons were evaluated by log-rank test.

Cases of surgeries for super-elderly patients

A total of 110 extremely elderly patients with colorectal cancer underwent curative surgery at The Department of Gastrointestinal Surgery, Guangdong Provincial Hospital of Traditional Chinese Medicine, including 47 open surgeries and 63 laparoscopic surgeries (Table 1). There were 90 patients aged between 85 and 89 years, 13 ones between 90 and 95 years, 7 ones between 96 and 100 years and 0 aged 100 or more. There were 60 male patients and 50 female ones. 37 ones had right-sided tumors, 42 left-sided colon tumors and 37 ones had rectal cancer. 22 ones were stage I cancer while 49 patients had stage II and 39 ones with stage III cancer.

Baseline Characteristics

Open surgery was compared with the laparoscopic approach in terms of baseline characteristics, revealing that open surgery was not significantly different from laparoscopic surgery in terms of most variables (Table 1).

Intraoperative Results And Postoperative Outcomes

Then open surgery was compared with the laparoscopic surgery in terms of intraoperative results and postoperative outcomes, demonstrating that two approaches were not significantly different in terms of most variables except longer hospitalization (P = 0.009), higher incidence of urinary infection (P = 0.042) and intestinal obstruction (P = 0.042) after open surgery (Table 2).

Kaplan-meier Analysis

Then open surgery was compared with the laparoscopic approach in terms of OS and RFS, demonstrating that open surgery was not significantly different from the laparoscopic approach regarding OS (P = 0.763, Fig. 1A) and RFS (P = 0.323, Fig. 1B).

Case Presentation Of A Patient Aged 100 Years

An extremely elderly female patient aged 100 years and 10 months consulted Professor Liaonan Zou due to sudden onset of melena. Then colonoscopy was performed and an advanced cancer with obvious bleeding located at the sigmoid colon was detected (Fig. 2A), which was histologically confirmed as a moderately differentiated adenocarcinoma (Fig. 2B). Then a CT scan was performed to assess the involvement of lymph nodes and distant metastasis, demonstrating neither lymph node involvement nor distant metastasis (Fig. 2C). Preoperatively, mild anemia was observed (102g/L). Carbohydrate antigen 19 − 9 and carcinoembryonic antigen were 16.12 U/mL and 7.27 ng/mL, respectively. This patient concurrently suffered from hypertension, diabetes mellitus and atrial fibrillation. The ejection fraction of the left ventricular was 61%. Her American Society of Anesthesiologists (ASA) score was 3. The patient^,s body mass index was 22.65kg/m².

Surgical Procedures

The surgery was performed under CO₂ insufflation at a pressure of 12 mmHg. Slight adhesion was encountered. Laparoscopic sigmoidectomy with lymph node dissection was performed as previously described[9]. The double stapling technique was adopted to accomplish anastomosis. The operation time was 145 minutes and no intraoperative blood transfusion was recorded. The pathological stage of this patient was IIA (T3N0M0).

Course Of Postoperative Recovery

2 days after surgery, she began to drink some glucose and sodium chloride fluid. On the fourth day after surgery, she began to have some liquid diet. Additionally, she was able to get out of bed and walk around. 9 days after surgery, she was discharged from the hospital. No major postoperative morbidities were observed. She did not experience cancer recurrence or death 1 year after surgery and her quality of life was barely affected by this surgery.

Currently, minimally invasive surgeries have become the preferred approach for colorectal cancer. Since it is not so easy for us to conduct randomized controlled trials among extremely elderly patients, studies comparing open surgeries and laparoscopic surgeries are scarce[10]. According to some retrospective studies and meta-analyses, laparoscopic surgeries were associated with shorter operation time, less blood loss, lower incidence of complications and shorter hospital stay[11–14]. Furthermore, laparoscopic surgery has been demonstrated to lead to favorable long-term outcomes [15, 16].

Surgeries for benign diseases not requiring a large abdominal incision were defined as minor surgeries. These minor surgeries were usually accomplished laparoscopically since significantly less adhesion was expected after laparoscopic surgery. Whereas, surgeries for cancers where widespread dissection and a large incision would be performed were defined as major surgeries. Thus, significant intra-abdominal adhesions would be commonly encountered and the laparoscopic approach would be waived. We have consecutively performed curative surgeries for 110 extremely elderly patients. 6 patients (5.45%) experienced major postoperative complications. Fortunately, none of the 110 patients did not experience 30-day mortality, which was better than those from some previous studies[12, 17]

In theory, extremely elderly patients are at rather high risk of postoperative complications and mortality. Therefore, it is necessary for us to perform thorough examinations to fully assess their tolerability to laparoscopic or open surgery. Usually at our center, the following examinations would be performed to evaluate their tolerability: liver function test, kidney function test, coagulation test, echocardiography, and pulmonary function test. Additionally, a senior anesthesiologist would be heroutinely consulted to evaluate their tolerability.

In the case presentation, the patient aged 100 years and 10 months suffered from several co-morbidities that were considered as risk factors. However, she had excellent general conditions and was aware of his disease, which, were the main reasons why we decided to perform laparoscopic surgery for him. This laparoscopic surgery was accomplished with a short operation time and no significant bleeding. For elderly patients, physical rehabilitation is a crucial aspect in preventing postoperative complications. For this patient, she was encouraged to get off bed early and after surgery, no major complications were recorded. As far as we know, this case was one of the not so many extremely elderly patients (aged 100 or older) undergoing curative laparoscopic surgery for colorectal cancer. Therefore, our study could provide some useful suggestions for managing super-elderly patients.

However, there were some shortcomings to be specified. Firstly, this study was a retrospective one, suggesting that selection bias was not absolutely avoidable. Therefore, prospective randomized studies are needed to fully assess the feasibility and safety of laparoscopic surgery for super-elderly patients. Secondly, there were a relatively small number of patients included in this study, warranting studies including a large number of patients. Thirdly, this study only included patients from China. Thus, findings of this study should not be directly applied among patients from western countries and further studies should be accomplished before the wide application of laparoscopic surgery among super-elderly patients in these countries. However, as mentioned above, it was not so easy for us to accomplish randomized controlled studies and our study still could provide some useful guidance for us managing extremely elderly patients.

In conclusion, laparoscopic surgery for super-elderly patients with colorectal cancer was feasible and could be safely performed. However, thorough preoperative examinations should be performed to fully evaluate eligibility and potential risks.

CRC: colorectal cancer; CT: computed tomography; MRI: magnetic resonance imaging;

UICC/AJCC: Union Internationale Against cancer and the American joint Committee on cancer;

CEA: carcino-embryonic antigen; CA-199: carbohydrate antigen 199; OS: overall survival; RFS: recurrence-free survival; ASA: American Society of Anesthesiologists

Ethics approval and consent to participate

This study was approved by The Ethics Committee, The First Affiliated Hospital, Guangzhou University of Chinese Medicine and all the patients included in this study had given his or her informed consent in written form. During the whole process, relevant guidelines and regulations were adhered to.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

The present study did not receive any financial supports.

Authors' contributions

W. W, J. L. J and T. L. A designed this study. J. L. J and T. L. A supervised this study. L. N. Z, L. N. D, and L. L. F collected the data. Y. W. W and Y. W accomplished statistical analyses in this study. Y. W. W and Y. W prepared the manuscript. T. L. A and M. L. W revised the manuscript. All the authors read and approved the final version of this study.

Acknowledgements

The authors would express their appreciation to Xue Tang from Shenzhen People^,s Hospital for her assistance with statistical analyses.

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Table 1 Comparisons between laparoscopic surgery and open surgery among extremely elderly patients regarding baseline characteristics

Characteristics	No.	Laparoscopic Surgery	Open Surgery	χ²/t	P
		(N=63)	(N=47)	Value	Value
Age		82.95±2.91	82.77±3.37	0.311	0.757
＜85y	90(81.8)	51(81.0)	39(83.0)	0.074	0.785
≥85y	20(18.2)	12(19.0)	8(17.0)
Gender				0.279	0.598
Male	60(54.5)	33(52.4)	27(57.4)
Female	50(45.5)	30(47.6)	20(42.6)
Abdominal mass				2.301	0.129
No	107(97.3)	60(95.2)	47(100)
Yes	3(2.7)	3(4.8)	0(0)
Weight loss				0.001	0.980
No	61(55.5)	35(55.6)	26(55.3)
Yes	49(44.5)	28(44.4)	21(44.7)
Intestinal obstruction				1.393	0.238
No	79(71.8)	48(76.2)	31(66.0)
Yes	31(28.2)	15(23.8)	16(34.0)
Tumor size				0.171	0.679
＜5cm	54(49.1)	32(50.8)	22(46.8)
≥5cm	56(50.9)	31(49.2)	25(53.2)
Location				0.906	0.636
Right-sided	37(33.6)	19(30.2)	18(38.3)
Left-sided	42(38.2)	26(41.3)	16(34.0)
Rectum	31(28.2)	18(28.6)	13(27.7)
Gross morphology				7.944	0.019
Massive	39(35.5)	16(25.4)	23(48.9)
Ulcerative	51(46.4)	36(57.1)	15(31.9)
Infiltrative	20(18.1)	11(17.5)	9(19.1)
Differentiation				0.337	0.845
Poor	20(18.2)	12(19.0)	8(17.0)
Medium	84(76.4)	47(74.6)	37(78.7)
Well	6(5.4)	4(6.3)	2(4.3)
Component				1.406	0.495
Adenocarcinoma	98(89.1)	57(90.5)	41(87.2)
Mucinous	11(10.0)	5(7.9)	6(12.8)
Siglet-ring carcinoma	1(0.9)	1(1.6)	0(0)
Vessel invasion				1.761	0.184
No	104(94.5)	58(92.1)	46(97.9)
Yes	6(5.5)	5(7.9)	1(2.1)
T				4.452	0.217
T1	5(4.5)	4(6.3)	1(2.1)
T2	18(16.4)	7(11.1)	11(23.4)
T3	40(36.4)	22(34.9)	18(38.3)
T4	47(42.7)	30(47.6)	17(36.2)
N				0.601	0.740
N0	74(67.3)	41(65.1)	33(70.2)
N1	25(22.7)	16(25.4)	9(19.1)
N2	11(10.0)	6(9.5)	5(10.7)
AJCC				1.619	0.445
Ⅰ	22(20.0)	10(15.9)	12(25.5)
Ⅱ	49(44.5)	29(46.0)	20(42.6)
Ⅲ	39(35.5)	24(38.1)	15(31.9)
CEA level(µg/L)				2.821	0.093
＜5	57(51.8)	37(58.7)	20(42.6)
≥5	53(48.2)	26(41.3)	27(57.4)
CA199				0.598	0.439
＜37	85(77.3)	47(74.6)	38(80.9)
≥37	25(22.7)	16(25.4)	9(19.1)

Table 2 Comparisons between laparoscopic surgery and open surgery among extremely elderly patients regarding postoperative complications

Characteristics	No.	Laparoscopic Surgery	Open Surgery	χ²/t	P
		(N=63)	(N=47)	Value	Value
Operation time		195.71±77.85	199.94±64.17	-0.303	0.763
Hospitalization after surgery		10.62±3.64	15.40±11.72	-2.703	0.009
Intraoperative blood transfusion		258.73±549.38	160.64±273.05	1.124	0.264
No	73(66.4)	40(63.5)	33(70.2)	0.545	0.461
Yes	37(33.6)	23(36.5)	14(29.8)
Abdominal infection				3.097	0.078
No	106(96.4)	59(93.7)	47(100)
Yes	4(3.6)	4(6.3)	0(0)
Pulmonary infection				0.037	0.847
No	99(90.0)	57(90.5)	42(89.4)
Yes	11(10.0)	6(9.5)	5(10.6)
Urinary infection				4.134	0.042
No	107(97.3)	63(100)	44(93.6)
Yes	3(2.7)	0(0)	3(6.4)
Urinary retention				0.533	0.465
No	106(96.4)	60(95.2)	46(97.9)
Yes	4(3.6)	3(4.8)	1(2.1)
Ureter injury				1.353	0.245
No	109(99.1)	63(100)	46(97.9)
Yes	1(0.9)	0(0)	1(2.1)
Incision infection				1.520	0.218
No	108(98.2)	61(96.8)	47(100)
Yes	2(1.8)	2(3.2)	0(0)
Postoperative intestinal obstruction				4.134	0.042
No	107(97.3)	63(100)	44(93.6)
Yes	3(2.7)	0(0)	3(6.4)
Anastomotic fistula				1.106	0.293
No	105(95.5)	59(93.7)	46(97.9)
Yes	5(4.5)	4(6.3)	1(2.1)

No competing interests reported.

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Version 1

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Laparoscopic surgery for extremely elderly patients (≥85)-experience from a single center

Status:

Version 1

Abstract

Figures

Background

Materials And Methods

Study population

Surgical Procedures And Follow-ups

Statistical Analyses

Results

Cases of surgeries for super-elderly patients

Baseline Characteristics

Intraoperative Results And Postoperative Outcomes

Kaplan-meier Analysis

Case Presentation Of A Patient Aged 100 Years

Surgical Procedures

Course Of Postoperative Recovery

Discussion

Conclusions

Abbreviations

Declarations

Ethics approval and consent to participate

Consent for publication

Authors' contributions

References

Tables

Additional Declarations

Status:

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