This is a retrospective study analyzing laparoscopic radical surgery for elderly CRC patients with the largest sample size from a single academic medical center. The results presented the real-world experience in a single institute to strengthen the laparoscopic procedure for elderly patients with CRC. In our study, although elderly patients with CRC who underwent laparoscopy were prone to develop early T stage cancer, obesity, and high serum albumin level, their length of postoperative stay was significantly shorter, their postoperative morbidity and mortality were similar to that of those underwent open surgery, and the rate of conversion was acceptably low (six out of 305 patients, and one died). In each TNM stage, the long-term outcomes including OS rate, CSS rate, and CRR between the open surgery group and the laparoscopic group were also similar.
For elderly patients with non-metastatic CRC who underwent surgery, we revealed that the overall postoperative morbidity and mortality rates were similar in both the groups. The postoperative morbidity rate was 15.4% and the mortality rate was 0.3% in the laparoscopic group. The operative mortality and morbidity of laparoscopy were similar and even lower compared to some reports [16-21], and the results represented the real-world condition about short-term outcome in Taiwan. The role of laparoscopic surgery in CRC treatment is accepted worldwide [8, 22]. However, considering the surgical risks in elderly patients (high risks of anesthesia, operative morbidity and mortality, malnutrition, immunity decline, poor performance status, and having comorbidities) [23] and long operation time, surgeons may refrain from performing laparoscopic surgery on elderly patients. Seshadri et al. reported that 62 octogenarians who received laparoscopic colorectal procedure (including benign disease) in the 1990s resulted in favorable postoperative outcome [24]. Law et al. compared the groups of open and laparoscopic colorectal resections of malignant or benign colorectal disease in Asians aged above 70 years in the early 2000, and the two groups shared similar postoperative morbidity rates [25]. Fujii et al. had reported that the postoperative complication rate in the laparoscopic group was lower than that in the open group (23% vs. 36%) for elderly patients, and the postoperative ileus rate in the laparoscopic group was significantly lower [20].
The conversion rate was 2% in our study and it was similar to or even lower than previous studies (6.1%-21%) [13, 16, 26-29]. Of these converted patients, only three developed postoperative morbidity and none had tumor recurrence during follow-up. The short-term or long-term outcomes may not be influenced by the conversion if adequate surgical safety is achieved. The retrieved lymph nodes in the two groups were sufficient as suggested by the guidelines. We agreed that laparoscopic surgery could meet the similar oncological quality as open surgery for CRC treatment through this study. The length of postoperative stay was shorter in the laparoscopic group, and several studies had confirmed the result [16, 18, 25, 28, 30-32]. The most evident benefit for elderly patients to receive laparoscopy surgery is the reduced hospital stay.
To our knowledge, there were few studies focusing on the long-term oncological outcomes in elderly patients receiving open and laparoscopic surgery. This study is the largest cohort from a single medical center to analyze laparoscopic surgery for the elderly patients with CRC. The long-term oncological outcomes including OS, CSS, and CRR did not differ between the two groups. In our study, patients in the open group had much advanced TNM stage and abnormal CEA level compared to the laparoscopy group. This finding may be owing to the surgeons’ preference for patient selection. However, we divided the patients into three groups by TNM stage, and the long-term oncological outcomes showed no difference in each group. Several studies had reported that OS and disease-free survival did not differ between patients undergoing open surgery and laparoscopy [14, 31-33].
This study reports cancer-specific survival and cumulative recurrence rate, which were observed lesser in similar studies. We analyzed CSS as the elderly patients with CRC passed away not only owing to malignancy but also multiple causes related to aging, and resulting in significant reduction in OS. In this study, the CSS rate for each TNM group was about 15%-30% higher than the OS rate. Hinoi and his colleague reported that the 3-year CSS rates for both colon and rectal cancer patients aged above 80 years were approximately 86.5%-93.4%, similar to our result (88%) [32]. For elderly patients, once the recurrence occurred, they may not be able to tolerate recurrence treatment compared to younger patients. Cumulative recurrence was analyzed in this study for evaluating the efficacy and oncological quality of open and laparoscopic surgery. The cumulative recurrence rate was similar in each TNM stage group as mentioned in a few previous studies. According to our results, laparoscopic surgery for CRC treatment in elderly patients, could be used as a standard method for radical resection of malignancies.
The present study has some potential limitations. First, this is a retrospective study conducted at a single institute while collecting data prospectively and is subject to various biases. Second, the selection bias is an essential issue because the choice of laparoscopy or laparotomy surgery is subjective to surgeons’ preference, although the long-term outcome was compared at each stage.