The demographics and clinical characteristics of the patients enrolled in the study. There were 40 patients in the LPS group and 40 patients in the open group. Mean (SD) age was 81.3 (2.3) years in the OP group and 68.0 (3.1) years in the YP group. The two groups were well matched for demographics and nutritional variables. Among patients with cancer of the rectum, the mean (SD) distance of the tumour from the anal verge was 7 (3.1) cm in the OP group and 6 (3.4) cm in the YP group (Table ).
Demographics and clinical characteristics of the two groups
No difference was found with respect to TNM cancer stage and type of operation performed. The mean number of lymph nodes intraoperatively collected was 18.2 (8.8) in the OP group and 18.7 (7.8) in the YP group (P = 0.74).
In 1 patient (2.5%) in the OP group and 1 patient in the YP, conversion to open surgery was necessary in the first case for adhesion in the second for narrow pelvis. There was no conversion for laparoscopic complications.
Operative variables are listed in Table The mean operative time was nearly the same. Mean operative blood loss was the same. (Table )
Intraoperative variables in the two groups
The overall mortality rate was 0%. The reoperation rate was 5% (2/40 patients) in the OP group and 2.5% (1/40 patients) in the YP group. There was nearly no difference with respect to the type of postoperative complications in the two groups except for a greater incidence of pulmonary and cardiac complications in OP group.
Patients in both groups have experienced an earlier mean canalization, a faster recovery of bowel function 4.8 (2.1) days and mean length of hospital stay 9.8 (5.3) days compared with the outcomes of conventional open surgery.
The mean time of follow-up was 24.7 (median, 22; range, 12–55) months. Analysis of complications that occurred later than 30 days after surgery was censored at one year after operation. At the time of complications analysis, there were 35 patients alive in the OP group and 39 in the YP group. Complications occurred in three patients OP (two intestinal obstruction, one incisional hernia on previous trocar site) and in two patients YP (one intestinal obstruction, one incisional hernia on previous trocar site. Hospital readmission was necessary for two OP patients (intestinal obstruction) and for one patients in the YP group (intestinal obstruction). (Table ).
Number of patients with postoperative complications in the two groups
Studies reporting the early outcome after laparoscopic colorectal resection in elderly patients have been published in the literature [11
], but some studies were lacking proper controls and only a few papers considered cancer patients only [12
]. Moreover, in our study patients were matched for the site of primary disease and the operations performed were homogeneous in the two groups, avoiding the bias of unbalanced operations.
Our findings support the hypothesis that laparoscopic surgery in the elderly is safe and stress the fact that age per se in the absence of significant disease should not be considered a prognostic factor in gastrointestinal surgery. In our study there was a low conversion rate and no conversion was a result of intraoperative complications. The low conversion rate and the absence of intraoperative complications caused by the minimally invasive technique reported here may reflect adequate training of the surgical team and a strict selection policy, which mandates the exclusion of patients with locally advanced disease.
In the OP group the overall morbidity rate was 30%, which is comparable with other studies of laparoscopic colectomy in elderly patients and is consistent with the results of studies in general population. In particular, we found a different incidence ( more in the OP) of both cardiac and pulmonary complications but if we compare OP with old people treated with traditional approach (open surgery) there is no difference. These findings are consistent with the pooled rate reported by Abraham et al
. in a systematic review of randomized trials comparing the short-term outcome after laparoscopic resection with open resection for colorectal cancer. These findings are noteworthy and suggest that the laparoscopic technique could be safely used in elderly patients who seem to tolerate well the hemodynamic and ventilatory changes observed in laparoscopic surgery, the longer operation time, and the frequent steep head-down tilt (Trendelenburg position) which are usually required during a laparoscopic operation. All the aforementioned variables have been previously reported to influence intraoperative and postoperative morbidity rate in high risk patients [19
In this study the overall morbidity rate was not statistically different in the two groups.
The analysis of operative variables confirmed that the laparoscopic operation in OP was no longer and there is no difference in blood loss compared with the same operation in younger people
There was no difference in hospital stay, it was 9.8 days. As reported by others for elderly patients [14
] length of hospital stay for laparoscopy patients was the same compared with the Younger patients, Similar findings were reported by Senagore and colleagues who found no difference between patients 70 years old or older who underwent laparoscopic colectomy compared with patients younger than 60 years [23
]. The shorter length of hospital stay observed in the LPS group could be ascribed to the earlier recovery of bowel function and to the better recovery to full independence. Other factors that could influence the duration of hospital stay are less postoperative pain and analgesic consumption, a lower postoperative complication rate, and an earlier recovery of full ambulation activity [21
]. Using a multimodal rehabilitation protocol, Badram and colleagues reported a median postoperative stay of 2.5 days for patients with a median age of 81 years who had undergone laparoscopic colonic resection. However, they reported a high readmission and reoperation rate, which could affect the independence rate in these critically ill patients [21
The significantly lower need for post hospital nursing observed in the LPS group deserves major consideration, in particular for high-risk patients, such as octogenarians, because of quality of life and financial implications.