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.