Discussion
The results of our study demonstrate that there is no significant difference between the short-term surgical outcomes between patients over 85 and those 75-85 years old who undergo colorectal cancer resection in terms of median length of stay, grading of complications and 30-day mortality. The results also indicate that the short-term outcomes from laparoscopic resection in those over 85 are similar to those of open surgery. This study is one of the first studies to utilise the Clavien-Dindo grading of complications for the assessment of short-term outcomes in this demographic.
Kunio et al.12 examined a similar cohort of patients (75-85 year old’s vs over 85 year old’s) and compared the same three short-term outcomes following colorectal cancer surgery. The results stipulated that patients over 85 years old have a significantly higher mortality when compared to those in the 75-84 year old group (24% vs 9%, p=0.048). However, there was no significant difference in length of stay or post-operative complications. The paper investigated the prevalence of specific complications (such as ‘pulmonary complications’ or ‘anastomotic leak’). They demonstrated a higher incidence of pulmonary complications in the 85+ population but no other remarkable differences in complications. This study concluded that the mortality rate was higher for the 85+ population but interestingly our data demonstrates similar post-operative mortality rates between the groups.
The decision to perform a colorectal surgical resection in those over 85 is based on numerous factors including patient preference, disease stage, patient comorbid status and frailty. Although our patients over 85 have a similar comorbid burden to those aged 75-85, this may not reflect a patient’s frailty which can play a large part in determining therapy for a patient. Certain surgical scales of frailty such as the Modified Frailty Index have been shown to predict mortality in general surgical procedures13,14 for patients over 60. Unfortunately frailty scales are rarely utilised by colorectal surgical teams but can play a large role as a factor in determining whether to offer surgery.
From our research we can conclude that the short-term outcomes from surgery in the over 85 year old’s group are comparable to those who are 75-85 year old. This should serve to support surgical intervention in appropriate patients over 85.
Despite the increasing use of laparoscopic surgery for colorectal cancer resections, there is a paucity of information on its use in patients at the extremes of age. As demonstrated in Table 5, there were no significant differences in the length of stay, 30-day mortality or grading of complications between open and laparoscopic procedures in those aged over 85.
There was a significantly higher proportion of open procedures for emergency operations (55% vs 8%, p=0.002). This is understandable as the open approach affords ease of access, manoeuvrability and manipulation of distended or friable bowel in the setting of a bowel obstruction or perforation. Decisions on surgical approach are based upon multiple factors including urgency, anatomical considerations, surgeon expertise and personal preference. In general, there is a higher proportion of laparoscopic procedures performed on those aged over 85 at our institution.
These results demonstrate that there is no difference in short term outcomes between a laparoscopic or open approach in those over 85. This conclusion is supported by research from Francesc et al.15 who demonstrated that laparoscopic approaches in those over 85 are not associated with an increase in morbidity or length of stay.
It should be noted that patients who underwent surgery in this study and those included within this cohort are those that were deemed appropriate candidates for surgery. There may have been patients who were too comorbid or frail for surgery who did not proceed with a surgical resection.
Colorectal cancer resection should be offered to appropriate patients, regardless of age. The short-term outcomes of those over 85 years old are not different to those aged 75-85 and demonstrate that age alone should not be a determining factor.
Our research also shows that laparoscopic resection of colorectal cancer has equitable short term post-operative outcomes to open resections.