Laparoscopic colorectal surgery: Is it beneficial in the over 80s?

Introduction

Our population is an ageing one, increasing the incidence of patients over the age of 80 requiring colorectal surgery. Currently, 2.4% of the UK population are over 85 years of age, an increase from 1.6% in 1992. ¹ This will pose great challenges to the surgeon who finds himself faced with the difficult task of performing major laparoscopic colorectal surgery in a population of this age group. The effectiveness of surgery in the elderly is dependent on the probability that patients will return to a productive post-operative lifestyle that is improved by the surgical intervention, or at the very least, not diminished by it. The National Institute for Clinical Excellence advises that laparoscopic resection is recommended as an alternative to open resection for individuals in whom both open and laparoscopic surgery are considered suitable. ² Nonetheless, an element of hesitancy persists when considering the elderly patient for any complex laparoscopic procedure.

Advancing age is associated with a higher risk of co-morbidity, later presentation of disease and an increased likelihood of undergoing emergency surgery.^3,4 In addition, there is evidence that increasing age results in a decreased frequency of potentially curative surgery, even if co-morbidities have been adjusted for, suggesting that bias still exists when choosing to operate on the elderly patient. ⁵ A recent meta-analysis proposed that the correlation between age and prognosis may be confounded by differences in stage presentation, tumour site, pre-existing co morbidities and type of treatment received. ⁴ Our target population is clearly a heterogeneous group and one should be careful to draw conclusions without carefully evaluating all facets of the patient.

The benefits of laparoscopic surgery are widely recognised; with earlier recovery of bowel function, less analgesia post-operatively and shorter hospital stays being important advantages over open colorectal surgery.^6,7 Percentage of laparoscopic surgery is on the rise, with 25% of colonic resections being performed laparoscopically by March 2009 nationally. ² Previous studies have suggested that laparoscopic surgery should be considered in the elderly as there is no significant difference in complication rates. ⁸ Indeed, one study declared that benefits of laparoscopic surgery are more pronounced in the elderly patient. ⁹

One issue remains: what defines the term ‘elderly’. Amelioration of the health of the general public has led to a need for studies to evaluate the difference in adverse outcomes in patients much older than those looked at in the past. Our study aims to focus on patients over the age of 80; the octogenarian generation, and to compare the difference in preoperative co-morbidities, cancer stage and surgical outcome measures with patients below the age of 80 undergoing elective laparoscopic colorectal resection.

Methods

Data were retrieved from a prospectively maintained laparoscopic colorectal surgery database from February 2010 to June 2011. All patients undergoing laparoscopic colorectal surgery for cancer at Northampton General Hospital during that time were included. Patients in whom laparoscopic surgery was initiated but then converted to open surgery were also included on an intention to treat basis. Patients who underwent planned open colorectal surgery were excluded.

Patients were subdivided into two groups: over 80 years of age and those under 80 years of age. Outcome measures compared between the groups were the American Society of Anaesthesiologists (ASA) grade, Dukes’ stage at presentation, conversion to open surgery, number of days spent on the intensive care unit and high dependency unit post-operatively, total hospital stay, complications and re-admission rates.

All the patients underwent the enhanced recovery programme following surgery. They were allowed free fluids and high calorie containing drinks for up to 4 h before operation. Patients undergoing right hemicolectomy did not receive bowel preparation, while those having left-sided surgery received a phosphate enema on the morning of surgery. They all received antibiotic and DVT prophylaxis and no nasogastric tubes were used.

Post-operative analgesic regime was based around either PCA morphine or epidural analgesia for 48 h. Patients were also given regular paracetamol with NSAIDs and tramadol used for breakthrough pain. Oral fluids were immediately commenced post-operatively and normal diet encouraged from day 1. Chest physiotherapy and active mobilisation were commenced on day 1. Patients had to be fully mobile, apyrexial, passing flatus or faeces, using oral analgesics only for pain before being considered for discharge.

Statistical analysis was carried out using the Mann–Whitney U test or Fisher’s exact test where appropriate with measurements of continuous outcomes analysed by repeated measures linear regression analysis.

Results

Sixty-seven patients who met the inclusion criteria were identified. Table 1 shows the baseline characteristics for both groups of patients. Fifty-seven (85%) patients were under the age of 80, while 10 (15%) were over the age of 80 at the time of their surgery. Comparisons of their ASA grade revealed, as expected, a better ASA grade in the under 80 s group reflecting overall co-morbidities of the different age groups; 23% of patients in the under 80 group had an ASA of 3 while 60% of those in the over 80 group had an ASA of 3 (p = 0.01). On the contrary, the prognosis between the two groups was similar. Good prognosis was classified as having a Dukes’ grade A or B cancer, while poor prognosis was grade C or D cancer. There were no patients with Dukes’ D cancer as these were mostly palliative care or in cases where surgery was required for symptomatic relief, the decision was to proceed to open surgery.

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Table 1.

Baseline characteristics.

Characteristics	Under 80 s	Over 80 s
Number of patients	57	10
ASA
1	6	1
2	38	3
3	13	6
4	–	–
Duke stage
A	10	1
B	25	7
C	22	2
D	–	–
Sex
Male	34	7
Female	23	3

Table 2 shows the outcomes in both groups. Conversion to open surgery was similar in both age groups; 20% in the over 80 group were converted, while 26% in the under 80 group were converted (p = 0.67). None of the patients in both groups required intensive care stay. Two patients in the over 80 age group required high dependency care post-operatively for 24 h due to cardio-respiratory problems. Total length of stay was similar for both groups (5 days vs. 5 days; p = 0.33). There were no statistically significant differences in complication rates between the groups (20% vs. 17%; p = 0.81). There were also no differences in re-admission rates (10% vs. 5.2%); p = 0.56).

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Table 2.

Outcomes following surgery.

Outcomes	Under 80 s	Over 80 s	p
Conversions	15 (26)	2 (20)	0.67
ITU stay	0 day	0 day	0.94
HDU stay	0 day	1 day	0.84
Total hospital stay	5 days	5 days	0.33
Complications	9 (17)	2 (20)	0.81
Re-admissions	3 (5.2)	1 (10)	0.56

Table 3 shows the different complications between the groups. Three of the patients in the under 80 group had anastomotic leak requiring re-operation. Other complications were minor ranging from wound infection to urinary retention.

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Table 3.

Complications.

Complications	Under 80 s	Over 80 s
Anastomotic leak	3	–
Wound infection	2	1
Chest infection	2	–
Urinary retention	1	1
Pulmonary oedema	1	–
Total	9	2

Discussion

The reality of modern day surgical practice is that a higher proportion of patients requiring surgery are of an older age. Yet, common misconceptions continue to surround old age as an independent factor in predicting morbidity and mortality in surgical procedures. It is imperative that this outdated theory is banished from contemporary practise in order to ensure as surgeons we are providing equality in our care to patients of all ages.

Laparoscopic surgery presents unique challenges in particular with the elderly, as the pneumoperitoneum required for visualisation of the abdomen can lead to an increase in systemic vascular resistance and central filling pressure, with a subsequent decrease in cardiac index. This could be unfavourable in the elderly patient with co-existing cardiac co-morbidities and decreased cardiac reserve. ¹

Theoretically, it follows that cardiac complications should be increased in patients undergoing laparoscopic procedures, a presumption which could deter most surgeons from choosing this method of surgery in the elderly. Several studies have shown this to be untrue; summarised in the systematic review by Grailey et al. ¹⁰ with there being a reduction in the incidence of cardiac complications in laparoscopic colectomy patients compared to open (pooled odds ratio = 0.58; 95%, p = 0.04).

In addition, laparoscopic operative time is on average longer than its open counterpart.^11,12 This has been attributed to the technical challenges involved in the procedures and the relative less experience in laparoscopic surgery overall. However, as more surgeons are becoming trained in laparoscopic procedures this may be less of an issue in the near future. The effect of prolonged anaesthesia has been suggested to decrease cognitive function in the elderly;^13,14 however, another study investigating genereal anaesthesia effects in elderly patients concluded that patients who were not independent prior to surgery had a worse outcome overall compared to those who were dependent. ¹⁵

Despite these seemingly negative impacts of laparoscopic surgery and its consequences in the elderly population, the evidence to suggest that this cohort benefit from these procedures is overwhelming and it is suggested that improving anaesthetic technique, laparoscopic operative time with adequate training and enhanced recovery with pre-operative optimisation could decrease the risk of anaesthesia. ¹⁶

We only had 10 patients over the age of 80 in this study compared to 57 patients under the age of 80. The relatively small numbers of the over 80 s could be viewed as a weakness of the study. This may be explained by the fact that this cohort usually present with more advanced disease and the decision at the multidisciplinary meeting would have been to proceed to open surgery. All patients having open surgery were excluded from the study.

From our experience, laparoscopic colorectal surgery was deemed to be as effective in the elderly as those under the age of 80. We should aim to steer away from the ideology that surgery in this cohort is unfavourable and attempt to provide all patients who are suitable for laparoscopic surgery with this option.