Nicolas Lopez-Acevedo, MD, Matthew N Johnson, BA, Austin D Williams, MD, Jessica R Pochedly, MD, Joseph L Frenkel, MD, John H Marks, MD. Lankenau Medical Center
Introduction
As the population ages, the need for surgery in patients older than 80 continues to increase. Fears regarding high operative mortality rates often hamper optimal surgical treatment of these patients. Minimally invasive surgery may offer a better option for these patients. Mindful that the one-year mortality for the general population of 84-year-olds in the U.S. is 8.4%, we evaluated short and long term mortality following laparoscopic colorectal resection in patients 80 or older.
Methods
From a prospective database containing 1768 laparoscopic colorectal surgeries performed between August 1996 and August 2014, we identified 189 patients 80 years and older. Patients not having a major resection were excluded, leaving 179 patients. This group was analyzed for perioperative morbidity and mortality rates at 30, 60, 90 days, 6, and 12 months. Causes of death were categorized as surgery-related, cancer-related, and unrelated to surgery. Patients’ disposition to home, nursing care or rehabilitation facility was recorded. A subset analysis for mortality was performed to compare outcomes of octogenarians and nonagenarians, diagnosis, procedure type, operative time, blood loss and by discharge status.
Results
Of 179 patients, 106 were women. Mean age was 83.9 years (80-95); 18 were > 90. Mean BMI was 25.2 (15.7-42.1). 52% had previous abdominal surgery. Diagnoses were 65.4% cancer, 14.5% polyp, 10.1% diverticulitis, 5.0% rectal prolapse, and 5.0% other. Procedures were pelvic TME (n=55), left colectomy (n=42), right colectomy (n=79), and other (n=3). Conversion to open was 2.8%. Morbidity rate was 29%; major morbidity rate was 12.8%. Anastomotic leak rate was 1.1%. Median discharge was POD #5 (1-46 days). 72% were discharged home, 18% to skilled nursing, 6% to rehabilitation facility, and 4% unknown. Overall 30-day and 1-year mortality was 0.6% and 9.8%, respectively. Cumulative mortality rates are shown in Table 1.
Table 1. Cumulative Mortality Rates.
| 30 Days | 60 Days | 90 Days | 6 Months | 12 Months | |
| Overall Mortality Rate | 0.6% | 1.7% | 3.4% | 5.9% | 9.8% |
| 80-89 Year Old Mortality Rate | 0.6% | 1.3% | 3.2% | 5.9% | 11.2% |
| ≥ 90 Year Old Mortality Rate | 0.0% | 5.6% | 5.6% | 5.6% | 6.2% |
Mortality was surgery-related in 38%, cancer-related in 31%, and unrelated to surgery in 31%. Lower mortality rate was found in patients with OR time < 4 hrs vs. > 4hrs (P= 0.007), EBL of ≤ 200 mL vs. > 200 mL (P=0.009), and for right colectomy vs. TME/Left (P= 0.02). ASA classification, diagnosis and discharge disposition did not show statistically significant differences.
Conclusions
Major colorectal resections can be performed in 80+ year old patients with a low mortality laparoscopically. The 30 day mortality was <1%, mortality at 1 year was 9.8%, compared to an 8.4% annual mortality for the general population at 84. Median LOS was 5 days and 72% were discharged home. Minimally invasive colorectal surgery offers excellent outcomes in the elderly patient population and should be encouraged, not withheld, in the 80+ year old group.