Abstract
Background/Aim: The study was performed to examine the suitability of laparoscopic surgery for elderly patients with colorectal cancer. Patients and Methods: The subjects were 242 patients aged ≥80 years who underwent primary tumor resection of colorectal cancer using laparoscopic assisted colectomy (LAC, n=145) or open colectomy (OC, n=97). Propensity score matching used to balance the characteristics of the groups resulted in 76 patients being assigned to each group. Results: Before matching, Glasgow Prognostic Score (GPS), American Society of Anesthesiologists physical status (ASA-PS), and previous abdominal surgery differed significantly between the groups (p<0.05), but after matching, all covariates were balanced (p≥0.05). Short-term outcomes were better after LAC (p<0.05), including fewer postoperative complications and less delirium. Regarding long-term outcomes, 5-year overall survival did not differ significantly between the groups (p=0.91). Conclusion: In elderly patients with colorectal cancer, short-term results are better after LAC than OC and long-term results are similar. These findings indicate that LAC is acceptable in this patient population.
The number of elderly people is increasing in Japan and worldwide. Cancer incidence has been increasing continuously, and colorectal cancer is now one of the most common cancers in both men and women. As a result, the number of elderly patients with colorectal cancer is increasing (1, 2). Since elderly patients generally have weaker cardiopulmonary function than younger patients, surgery for elderly patients has been considered risky and these patients may have been discouraged from undergoing an operation. However, the more recent view is that surgery on elderly patients can be safe, and it has been shown that laparoscopic surgery, which is becoming common for colorectal cancer (3, 4), can be performed safely in both young and elderly patients (5). Thus, we have been performing laparoscopic surgery for elderly patients with colorectal cancer for several years. In this study, we examined the suitability and safety of this surgery for these patients by investigating complications and prognosis after laparoscopic assisted colectomy (LAC) and open colectomy (OC).
Patients and Methods
The subjects were patients aged ≥80 years with colorectal cancer who underwent primary tumor resection at Juntendo University Hospital, Department of Coloproctological Surgery between 2003 and 2017, including those with stage 4 cancer. Cases with duplicate cancers and multiple organ resection, and conversion cases from laparoscopy to open colectomy were excluded. Consequently, 242 patients were initially enrolled in the study. The decision to perform laparoscopic or open surgery was made by the primary surgeon after discussion in preoperative conferences. In the early period of introduction of laparoscopy, elderly patients and patients with a history of laparotomy, advanced cancer, transverse colon cancer, or relatively poor cardiopulmonary function were mostly treated with laparotomy, rather than laparoscopy. With the acquisition of greater experience with the laparoscopic technique, the selection criteria have gradually been moderated, and laparoscopy is now often chosen for elderly and frail patients, regardless of the location of the cancer and even if they have had previous laparotomy or have advanced cancer.
Patient factors investigated included age, sex, body mass index (BMI), Union for International Cancer Control 7th edition TNM stage (6), Glasgow Prognostic Score (GPS) (7, 8), tumor location, previous abdominal surgery, and American Society of Anesthesiologists physical status (ASA-PS) (9). Short-term outcomes included the duration of the operation (min), blood loss (ml), days to solid diet, postoperative length of stay (LOS), and postoperative complications (POCs), which were defined as those occurring within 30 days of surgery and were Grade II or higher according to the Clavien-Dindo Classification (10). Long-term outcomes were evaluated based on overall survival (OS).
For propensity score matching, the patient factors listed above and the surgical procedure (LAC/OC) were designated as confounders. Based on the propensity scores, one-to-one nearest neighbor matching without replacement was performed within a caliper width of 0.20 logit of the standard deviation. This resulted in matching of 76 patients in each group, and all variables were balanced. Medians are used for continuous variables. In statistical analysis, the Mann-Whitney U-test was used for continuous data, and χ2 and Fisher exact tests were used for categorical data. All analyses were performed using JMP® v.11 (SAS Institute, Cary, NC, USA).
Results
The 242 patients enrolled in the study were aged 80 to 103 years, with a median age of 83 years, a male: female ratio of 118:124, and a LAC:OC ratio of 145:97 (Table I). Before propensity matching (Table II), Glasgow Prognostic Score (GPS), American Society of Anesthesiologists physical status (ASA-PS), and previous abdominal surgery differed significantly between the LAC and OC groups (all p<0.05), but there were no differences in age, sex, BMI, tumor location, and stage (all p≥0.05). After matching (Table III), the 76 patients in each group had all variables balanced and there were no longer any significant differences between the two groups (all p≥0.05).
Characteristics of patients over 80 years old who were subjected to colorectal cancer surgery (N=242).
Comparison of the LAC and OC groups before matching using univariate analysis of clinicopathological items.
Univariate analysis of patient characteristics in the LAC and OC groups after propensity score matching.
A comparison of short-term outcomes between the propensity-matched LAC and OC groups is shown in Table IV. The duration of the operation was significantly longer in the LAC group (p=0.001), but blood loss, days to solid diet, postoperative LOS and POCs were all better after LAC (all p<0.05). The detailed results for POCs are shown in Table V. The most common complication was delirium, but this occurred at a significantly lower rate in the LAC group (p<0.001). No other POCs differed significantly between the groups, and there was no mortality or reoperation within 30 days after surgery in either group.
Univariate analysis of short-term outcomes in the LAC and OC groups after propensity score matching.
Univariate analysis of postoperative complicationsa in the LAC and OC groups after propensity score matching.
OS curves reflecting long-term outcomes are shown in Figure 1. These curves indicated a hazard ratio of 0.97, and the 5-year OS rate did not differ significantly between LAC and OC (60.3% vs. 66.3%, log-rank test: p=0.91). A subanalysis of the data was performed to identify factors with a strong influence on OS. Multivariate analysis for OS using a Cox proportional hazards with age, sex, BMI, stage, GPS, tumor location, ASA-PS, operative time, blood loss, POCs, and operative procedure (LAC/OC) as variables (Table VI) identified sex, ASA-PS, tumor location, and stage as significant independent factors (all p<0.05) that affected OS.
Overall survival curves after laparoscopic assisted colectomy (LAC) and open colectomy (OC) procedures. There was no difference between the two groups (hazard ratio=0.97; 95%CI=0.52-1.79, 5-year survival, 60.3% vs. 66.3%, log-rank test: p=0.911).
Multivariate analysis (Cox proportional hazards) of overall survival.
Discussion
Life expectancy is increasing for both men and women due to changes in lifestyle and medical advances. According to the Ministry of Health, Labour and Welfare, the average life expectancy of Japanese people in 2019 was 81.4 years for males and 87.5 years for females, and these ages have increased every year for the past few years to a record high (11, 12). As a result, the current era is referred to as the “aging society”. Not only the number of elderly people, but also their proportion in the total population is getting higher; that is, the proportion of younger people to take care of elderly people is decreasing. This has become a major social concern and will soon become a reality (13). The number of elderly patients with colorectal cancer is also increasing and the approach to treatment of these patients is also an important issue.
Surgery for elderly patients with colorectal cancer used to be avoided due to limited surgical skills, anesthesia techniques, and perioperative management and care (14). However, in recent years, improvements in these areas have made surgical treatment for such patients more common. In addition, the development of laparoscopic techniques has shifted treatment for elderly patients with colorectal cancer to laparoscopic surgery (3-5). Since this surgery has now been in widespread use in Japan for several years, we decided to examine its suitability for elderly patients with colorectal cancer in this study.
Our results showed that short-term outcomes differed significantly between LAC and OC. As previously reported, the duration of the operation was longer for LAC, but blood loss, time to a solid diet, postoperative LOS, and POCs were all less after LAC compared to OC (15). Delirium was by far the most common POC. Jelle et al. reported that occurrence of delirium was related to an increase in adverse events, length of hospital stay and mortality (16). Therefore, it is important to control delirium, and our results showed that delirium was significantly less common after LAC than after OC. This may be because patients are calmer after LAC because the procedure is less invasive to the abdominal wall, compared to OC. Mitsuyoshi et al. found that fewer ports resulted in less delirium in cases limited to laparoscopic colorectal resection (17). This feature may be a major advantage of LAC, particularly because POCs can be fatal in elderly patients because of their reduced physical strength. In addition, the significantly shorter postoperative LOS may be valuable in maintaining the mental, physical, and economic well-being of elderly patients.
With regard to long-term outcomes, the Japanese Society for Cancer of the Colon and Rectum (JSCCR) states that the 5-year survival rate for colorectal cancer, including all ages, stages, and sites, is 72.1% (18). In the current study, the 5-year OS rate for colorectal cancer in our patients aged ≥80 years old was 65.7% (data not shown), which appears to be relatively favorable. Furthermore, there was no significant difference between the survival curves after LAC and OC, indicating the acceptability of LAC. However, as shown in multivariate analysis, the prognosis was significantly worse when four factors (male, low ASA-PS, right-side colorectal cancer, and advanced stage) were present. Thus, laparoscopy is a good option for surgery, but it is important to judge the indications for surgery carefully.
The study has the following limitations. Since the data collection period was relatively long (15 years), the selection criteria for LAC versus OC differed during the study period. Thus, indications for previous abdominal surgery, GPS, ASA-PS, and stage have been moderated as we have acquired more experience with LAC. In addition, the number of cases was limited by the single-center design and propensity score matching. Therefore, further comparison of LAC and OC for elderly patients with colorectal cancer should be performed in a prospective study, since many centers and surgeons in Japan have become accustomed to the use of laparoscopic surgery.
Based on the results of the study, we draw the following conclusions. For elderly patients (over 80 years of age) with colorectal cancer, short-term outcomes were better after LAC than after OC, and long-term outcomes were similar. Therefore, LAC seems to be a feasible procedure for these patients. Given that life expectancy is increasing yearly and is now close to 90 years of age, it seems to be reasonable to choose laparoscopy for colorectal cancer surgery. However, because of the high probability of a poor prognosis for males and patients with poor ASA-PS, right-side colorectal cancer, and an advanced stage, surgeons need to consider the indications for surgery carefully.
Footnotes
Authors’ Contributions
All Authors except SN performed the operations and perioperative management in this study. MK, Kiichi S, YK, and YT performed the data collection. SN, AO, and TI contributed to the statistical consideration. MK, Kazuhiro S and Kiichi S drafted and revised the manuscript. Kazuhiro S is a chairperson of our department and supervised the writing of the manuscript. All Authors read and approved the final manuscript.
Conflicts of Interest
The Authors declare that there are no conflicts of interest regarding this study.
- Received March 14, 2021.
- Revision received March 30, 2021.
- Accepted March 31, 2021.
- Copyright © 2021 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.
