Purpose: To assess the feasibility and safety of laparoscopic colorectal re-section among octogenarians. Method: All patients who underwent laparoscopic colorectal resection were identified from an IRB approved, prospectively maintained laparoscopy database of a single surgeon, between the years 2004-2010. The patients were classified into two subgroups, below and above the age of 80 years (octogenarians and non octogenarians). Also, an additional group of patients, age above >80 years, who underwent open colon or rectal resection, was identified from the departmental database, while matching for age, gender, ASA score, type and indication (benign or malignant) for surgery. The subgroups were compared for postoperative morbidity and recovery parameters. Results: Seventy four patients under-went laparoscopic colorectal resection procedures by a single surgeon (20 octogenarian and 54 non-octogenarian patients). Mean age was 85.2 vs 62.1, respectively. Colon cancer was the most common indication for surgery in both groups of octogenarians. The Conversion rate was comparable between non and octogenarians. Postoperative morbidity rate and length of hospital stay were significantly higher after open procedures as compared to laparoscopic ones, in octogenarian and non octogenarian patients, 50% vs 15% vs 13%, p = 0.0001, and 12.4 vs 8.9 vs 7.6 days, p = 0.01, respectively. Conclusions: Laparoscopic colorectal resection is feasible and safe in octogenarians.
Life expectancy has significantly increased over the last decades, and major operations are now frequently required in elderly patients. Advanced age is a risk factor which may drive surgeons to omit operative treatment in this particular group. In addition, age related comorbidities are a serious obstacle that may not allow general anesthesia in the advanced age groups, and may be associated with high postoperative morbidity rate [
Laparoscopic approach has been widely employed in abdominal operations. Laparoscopy and pneumoperitoneum are usually associated with physiologic changes that affect the pulmonary and cardiovascular systems [
Laparoscopic technique is frequently used for colorectal procedures [
Since most common indications for colon or rectal resection in the elders, i.e. pelvic floor disorders, colorectal malignancy and diverticulosis [
Most studies that have discussed the laparoscopic colorectal surgery in elderly patients have evaluated patients above 65 years old. It is still not well defined whether octogenarians (age >80) may gain benefits from laparoscopic colectomy as in younger patients [
This study aims to assess the feasibility and safety of laparoscopic colorectal resection among octogenarians, and to define benefits in terms of early outcomes as compared to younger patients and to same age counterparts undergoing open colorectal surgery. Since it is a single surgeon series, a reliable outcome as compared to previous published papers are expected.
All patients who underwent laparoscopic colon or rectal resection were identified from an institutional review board (IRB) approved, prospectively maintained laparoscopy database of a single surgeon at Rambam health care campus, between the years 2004-2010. The surgeon has completed a two years training in laparoscopic surgery after general surgery residency, and practicing surgery for a total of 14 years. Generally, all patients who require bowel surgery at this service will be operated on using the laparoscopic technique, except for patients who cannot tolerate pneumoperitoneum, due to heart and/or respiratory failure, or patients with multiple previous laparotomies.
The patients were classified into two subgroups, above and below the age of 80 years (octogenarians and non octogenarians). Also, an additional group of patients, age above 80 years, who underwent open colorectal resection, was identified from the departmental database, while matching for age, gender, ASA score, type and indication (benign or malignant) for surgery. Open procedures were performed by several experienced staff surgeons. Patients with a history of multiple previous abdominal operations were excluded from the control group.
Patients’ demographics, disease characteristics, intraoperative details, and early postoperative outcomes (within 30 days after surgery) were collected, from the database and charts review.
Intraoperative details included operative time, conversion rate and intraoperative complications i.e. bowel injury, hemorrhage or cardiovascular complications. Postoperative outcomes pertained to length of hospital stay (LOS), postoperative complications i.e. cardiovascular complications, leak or abscess, wound infection, other infectious complications and postoperative ileus (defined as lack of bowel movement within 5 days post surgery or reinsertion of nasogastric tube due to vomiting). Also were collected the reoperation and readmission rates, and mortality events.
The subgroups were compared for early morbidity and mortality, and recovery parameters, aiming at assessing the differences in outcomes among octogenarians undergoing open and laparoscopic colorectal procedures, and also to evaluate outcomes of laparoscopic colorectal procedures in octogenarian as compared to younger patients.
Descriptive data were presented as mean ± standard deviation (SD), and median (range), number of patients and percentages. The student’s t-test was used to compare normally distributed variables; otherwise the Mann-Whitney nonparametric test was applied. Comparison between groups for discrete variables was performed by the chi-square test or Fisher’s exact test when appropriate. A P value ≤0.05 was considered statistically significant.
A total of eighty three patients underwent colon or rectal resection by the same surgeon during the study period. Laparoscopic technique was used in 74 patients. Twenty patients were 80 years or older and 54 were <80 year old. Mean age was 85.2 and 62.1 years respectively. The control group consists of 20 octogenarian patients who underwent open colorectal procedures with mean age of 85.3 years. Patients’ demographics are listed in
Of the laparoscopic subgroups, more patients in the octogenarian subgroup were operated for malignant disease. Types of the surgical procedures distributed equally between the subgroups,
Early postoperative morbidity and LOS were significantly greater in the open group as compared to the laparoscopic octogenarian and non octogenarian subgroups, 50% vs. 15% vs. 13%, p = 0.0001, and 12.4 ± 7 vs. 8.9 ± 5.1 vs. 7.6 ± 7 days, p = 0.01 , respectively. Postoperative morbidity and LOS were significantly greater in the open octogenarian group as compared to their laparoscopic counterparts,
Laparoscopy Age >80 (N = 20) | Laparoscopy Age <80 (N = 54) | Open Age >80 (N = 20) | p-value* | p-value** | |
---|---|---|---|---|---|
Age, years (mean ± SD) | 85.2 ± 4.4 | 62.1 ± 15.3 | 85.3 ± 3.3 | 0.0001 | 0.93 |
Gender (female/male) | 13/7 | 15/39 | 13/7 | 0.54 | 1 |
ASA score (mean ± SD) | 2.6 (±1) | 2.2 (±1.1) | 2.8 (±1.1) | 0.103 | 0.55 |
Indication for surgery | 0.29 | 0.69 | |||
Colon/rectal cancer | 14 | 27 | 15 | ||
Adenoma | 2 | 5 | 3 | ||
Diverticular disease | 1 | 17 | 1 | ||
Volvulus | 2 | 3 | |||
Bowel obstruction | 1 | 2 | 1 | ||
Inflammatory bowel disease | 1 | ||||
Type of operation | 0.42 | 0.99 | |||
Right Hemicolectomy | 12 (60%) | 20 (38%) | 12 (60%) | ||
Left Hemicolectomy | 1 (5%) | 7 (12.4%) | 1 (5%) | ||
Sigmoidectomy | 3 (15%) | 12 (22%) | 3 (15%) | ||
Subtotal Colectomy | 1 (5%) | 1 (1.9%) | 1 (5%) | ||
Anterior Resection/Abdominoperineal Resection | 3 (15%) | 12 (22.7%) | 3 (15%) |
SD―standard deviation. *Laparoscopic groups age >80 vs age <80. **Octogenarians laparoscopic vs open groups.
Laparoscopy Age >80 (N = 20) | Laparoscopy Age <80 (N = 54) | Open Age >80 (N = 20) | p-value | |
---|---|---|---|---|
Operative time; min (median (range)) | 100 (60 - 200) | 110 (45 - 270) | 109 (50 - 240) | 0.14 |
Intraoperative complications | 0 | 0 | 0 | |
Conversion rate | 1 (5%) | 4 (7.4%) | N/A | 0.71* |
N/A―Not applicable. *P value for laparoscopic groups.
Laparoscopy Age >80 (N = 20) | Laparoscopy Age <80 (N = 54) | Open Age >80 (N = 20) | p-value* | p-value** | |
---|---|---|---|---|---|
Length of stay (days ± SD) | 5.1 ± 8.9 | 7.6 ± 7 | 12.4 ± 7 | 0.45 | 0.045 |
Postoperative morbidity | 3 (15%) | 7 (12.9%) | 10 (50%) | 1 | 0.04 |
Infectious | 1 (5%) | 3 (5.5%) | 4 (20%) | 1 | 0.34 |
Hemorrhage | 0 | 1 (1.85%) | 1 (5%) | 0.99 | 0.99 |
Paralytic Ileus | 1 (5%) | 0 | 2 (10%) | 0.27 | 1 |
Cardiovascular | 0 | 1 (1.85%) | 1 (5%) | 0.99 | 0.99 |
Neurological | 0 | 0 | 1 (5%) | 1 | 0.99 |
Pulmonary | 0 | 1 (1.85%) | 1 (5%) | 0.99 | 0.99 |
Urinary | 0 | 1 (1.85%) | 0 | 0.99 | 1 |
Other | 1 (5%) | 0 | 0 | 0.27 | 0.99 |
Reoperations | 1 (5%) | 1 (1.85%) | 1(5%) | 0.47 | 1 |
Readmissions | 1 (5%) | 3 (5.6%) | 4 (20%) | 1 | 0.34 |
Mortality | 0 | 0 | 1 (5%) | 1 | 0.99 |
SD―standard deviation. *laparoscopic groups age >80 vs age <80. **octogenarians laparoscopic vs open groups.
Recovery parameters, i.e. time to first flatus and time elapsed to resume diet, were significantly greater in the open colorectal surgery group,
Minimally invasive colorectal surgery has been reported with decreased morbidity as compared to open procedures [
Laparoscopy Age >80 (N = 20) | Laparoscopy Age <80 (N = 54) | Open Age >80 (N = 20) | p-value | |
---|---|---|---|---|
First flatus (days); Median (range) | 3.5 (2 - 8) | 3 (1 - 8) | 5.5 (2 - 9) | 0.037 |
First bowel movement (days); Median (range) | 4 (0 - 8) | 4 (0 - 9) | 5 (2 - 10) | 0.094 |
Diet (days); Median (range) | 3 (1 - 9) | 4 (1 - 8) | 6 (2 - 11) | 0.017 |
SD―standard deviation.
In the present study, based on a single surgeon series, we compared the early postoperative outcomes of laparoscopic colon and rectal resection in octogenarian and younger patients. We assumed that early recovery and low postoperative morbidity related to laparoscopy [
We believe that our study presents a reliable data since it is a single surgeon series. This may, in turn, contribute to the comparable results in the different laparoscopic age groups. In particular, laparoscopic colorectal surgery in skilled hands is associated with better outcomes [
Herein we also compared the laparoscopic octogenarian group with same age counterparts who underwent open colorectal surgery, aiming at highlighting the differences of laparoscopic and open approaches in this age group. Favorable outcomes were documented in the laparoscopic group, which is well with previously published data [
The correlation between age, operative technique, open or laparoscopy, and operative time is controversial [
Several limitations should be addressed. First, the small sample size of the octogenarian group. Second, the open procedures were performed by several surgeons with variable experience, therefore the postoperative outcomes are expected to be high.
Our results demonstrate that the minimally invasive colorectal surgery is equally safe and effective in octogenerian and non-octogenarian patients. The increased morbidity associated with open procedures in octogenarians is further supports the superiority of the laparoscopic approach in this age group. Therefore, Laparoscopy should be encouraged in elderly patients, in particular, in patients without major comorbidities and with no definite contraindications.
Drs. Wisam Khoury, Razan Khoury, Yoram Kluger, Ahmad Assalia, and Ahmad Mahajna have no conflict of interests or financial ties to disclose.
Khoury, W., Khoury, R., Kluger, Y., Assalia, A. and Mahajna, A. (2018) Laporoscopic Colorectal Resection in Octogenerians Is as Good as in Younger Patients. Open Journal of Gastroenterology, 8, 86-93. https://doi.org/10.4236/ojgas.2018.83009