Advertisement

Feasibility of a tailored ERAS programme in octogenarian patients undergoing minimally invasive surgery for colorectal cancer

  • N. DepalmaEmail author
  • D. Cassini
  • M. Grieco
  • V. Barbieri
  • A. Altamura
  • F. Manoochehri
  • M. Viola
  • G. Baldazzi
Original Article
  • 47 Downloads

Abstract

Background

The enhanced recovery after surgery (ERAS) is nowadays a widely accepted multimodal programme of care in colorectal surgery, but still there is some reluctance in its application to very elderly patients.

Aim

The aim of this study is to investigate short-term outcomes of laparoscopic resection for colorectal cancer in octogenarian patients within the ERAS programme.

Methods

Data on 162 consecutive patients aged ≥ 80 years receiving elective minimally invasive colorectal resections within ERAS programme were collected in a multicentre, retrospective database in the period 2008–2017 in Italy. Univariate and multivariate analyses were performed to assess possible risk factors for poor clinical outcomes.

Results

The postoperative minor morbidity rate (Clavien–Dindo 1 and 2) was 25.9%. The incidence of postoperative major morbidity rate (severe medical and surgical complications defined as Clavien–Dindo 3 and 4) accounted 6.1% and only 1.8% had an anastomotic leakage. Reoperation rate was 5.5%, perioperative 30-day mortality was 1.8%, and 30-day readmission rate was 6.8%. On average, patients were released after 6 days. A univariate analysis showed that possible risk factors for severe medical complications were: low preoperative albumin level, high Charlson Age Comorbidity Index Score and number of days in the intensive care unit (ICU); risk factors for severe surgical complications were: low preoperative albumin level; risk factors for late hospital discharge were: multivisceral resections, number of days in ICU and body mass index (BMI) > 25 kg/m2. The multivariate analysis confirmed a low level of preoperative albumin and a longer ICU stay as independent risk factors for both postoperative severe surgical complications and late hospital discharge.

Discussion

The minimal invasive nature of the laparoscopic approach together with a multimodal analgesia therapy, the early resumption to oral diet and mobilisation could minimize the surgical stress and play an essential role in order to reduce medical morbidity in high-risk patients.

Conclusion

Colorectal surgery within ERAS programme in octogenarians is a safe and flexible treatment in high-volume centres.

Keywords

Laparoscopic colorectal resection Octogenarian patients ERAS program in colorectal surgery Colorectal cancer 

Notes

Acknowledgements

The research presented here was the product of a team-work. Doctor CD and doctor DN contributed to the design and supervised all the research’s process. Doctor GM was in charge of the statistical analysis and also provided a general support to the manuscript. Thanks go to doctor FM, AA and BV for their assistance with data collection. We gratefully acknowledge the support and professionalism of doctor BG and VM who performed all the surgical procedures.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Compliance with ethical standards

Conflict of interest

The present paper is not based on any previous communication to a society or meeting. The authors declare they have no conflict of interest.

Ethical approval

This study was approved by the institutional Ethics Committee and conducted according to the declaration of Helsinki.

Informed consent

Informed consent was obtained from all patients. All authors gave their consentment for paper publication.

References

  1. 1.
    Kehlet H, Wilmore DW (2002) Multimodal strategies to improve surgical outcome. Am J Surg 183:630–641CrossRefGoogle Scholar
  2. 2.
    Greco M, Capretti G, Beretta L et al (2014) Enhanced recovery program in colorectal surgery: a metaanalysis of randomized controlled trials. World J Surg 38:1531–1541CrossRefGoogle Scholar
  3. 3.
    Varadhan KK, Neal KR, Dejong CH et al (2010) The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr 29:434–440CrossRefGoogle Scholar
  4. 4.
    Roulin D, Donadini A, Gander S et al (2013) Cost-effectiveness of the implementation of an enhanced recovery protocol for colorectal surgery. Br J Surg 100:1108–1114CrossRefGoogle Scholar
  5. 5.
    Fearon KC, Ljungqvist O, Von Meyenfeldt M et al (2005) Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 24:466–477CrossRefGoogle Scholar
  6. 6.
    Eurostat (2018) Causes of death—standardised death rate by residence. http://ec.europa.eu/eurostat/statisticsexplained/index.php/Causes_of_death_statistics/it. Accessed 23 November 2018
  7. 7.
    Owens WD, Felts JA, Spitznagel EL Jr (1978) ASA physical status classifications: a study of consistency of ratings. Anesthesiology 49:239–243CrossRefGoogle Scholar
  8. 8.
    Sobin LH, Compton CC (2010) TNM seventh edition: what’s new, what’s changed communication from the International Union Against Cancer and the American Joint Committee on Cancer. Cancer 116:5336–5339CrossRefGoogle Scholar
  9. 9.
    Charlson M, Szatrowski TP, Peterson J et al (1994) Validation of a combined comorbidity index. J Clin Epidemiol 47:1245–1251CrossRefGoogle Scholar
  10. 10.
    Clavien PA, de Oliveira ML, Vauthey JN et al (2009) Clavien–Dindo classification of surgical complications: five-year experience. Ann Surg 250:187–196CrossRefGoogle Scholar
  11. 11.
    National Comprehensive Cancer Network. (2018) Clinical practice Guidelines in Oncology. https://www.nccn.org/professionals/physician_gls/default.aspx. Accessed 19 October, 2018
  12. 12.
    AIOM (2016) I numeri del cancro in Italia 2016. Il Pensiero Scientifico Editore, Roma, pp 28–29, ISBN 978-88-490-0568-4Google Scholar
  13. 13.
    Hermans E, van Schaik PM, Prins HA et al (2010) Outcome of colonic surgery in elderly patients with colon cancer. J Oncol.  https://doi.org/10.1155/2010/865908 Google Scholar
  14. 14.
    De Marco MF, Janssen-Heijnen ML, van der Heijden LH et al (2000) Comorbidity and colorectal cancer according to subsite and stage: a population-based study. Eur J Cancer 36:95–99CrossRefGoogle Scholar
  15. 15.
    Zhu Q, Mao Z, Jin J et al (2010) The safety of CO2 pneumoperitoneum for elderly patients during laparoscopic colorectal surgery. Surg Laparosc Endosc Percutan Tech 20:54–57CrossRefGoogle Scholar
  16. 16.
    Xie M, Qin H, Luo Q et al (2015) Laparoscopic colorectal resection in octogenarian patients is it safe? A Systematic review and meta-analysis. Medicine 94(42):e1765CrossRefGoogle Scholar
  17. 17.
    Li Y, Wang S, Gao S et al (2016) Laparoscopic colorectal resection versus open colorectal resection in octogenarians: a systematic review and meta-analysis of safety and efficacy. Tech Coloproctol 20:153–162CrossRefGoogle Scholar
  18. 18.
    Devoto L, Celentano V, Cohen R et al (2017) Colorectal cancer surgery in the very elderly patient: a systematic review of laparoscopic versus open colorectal resection. Int J Colorectal Dis 32:1237–1242CrossRefGoogle Scholar
  19. 19.
    Bagnall NM, Malietzis G, Kennedy RH et al (2014) A systematic review of enhanced recovery care after colorectal surgery in elderly patients. Colorectal Dis 16:947–956CrossRefGoogle Scholar
  20. 20.
    Wang Q, Suo J, Jiang J et al (2012) Effectiveness of fast-track rehabilitation vs conventional care in laparoscopic colorectal resection for elderly patients: a randomized trial. Colorectal Dis 14:1009–1013CrossRefGoogle Scholar
  21. 21.
    Jia Y, Jin G, Guo S et al (2013) Fast-track surgery decreases the incidence of postoperative delirium and other complications in elderly patients with colorectal carcinoma. Langenbecks Arch Surg 399:77–84CrossRefGoogle Scholar
  22. 22.
    Jung WB, Shin JY, Suh B (2017) The short-term outcome and safety of laparoscopic colorectal cancer resection in very elderly patients. Korean J Gastroenterol 69:291–297CrossRefGoogle Scholar
  23. 23.
    Forsmo HM, Erichsen C, Rasdal A et al (2017) Enhanced recovery after colorectal surgery (ERAS) in elderly patients is feasible and achieves similar results as in younger patients. Gerontol Geriatr Med 3:2333721417706299Google Scholar
  24. 24.
    Gonzalez Ayora S, Pastor C, Guadalajara H et al (2016) Enhanced recovery care after colorectal surgery in elderly patients: compliance and outcomes of a multicenter study from the Spanish working group on ERAS. Int J Colorectal Dis 31:1625–1631CrossRefGoogle Scholar
  25. 25.
    Baek SJ, Kim SH, Kim SY et al (2013) The safety of a “fast-track” program after laparoscopic colorectal surgery is comparable in older patients as in younger patients. Surg Endosc 27:122–123Google Scholar
  26. 26.
    Stocchi L, Nelson H, Young-Fadok TM et al (2000) Safety and advantages of laparoscopic vs. open colectomy in the elderly: matched-control study. Dis Colon Rectum 43:326–332CrossRefGoogle Scholar
  27. 27.
    Franklin ME Jr, Rosenthal D, Abrego-Medina D et al (1996) Prospective comparison of open vs. laparoscopic colon surgery for carcinoma. 5-year results. Dis Colon Rectum 39:S35–S46CrossRefGoogle Scholar
  28. 28.
    Rumstadt B, Guenther N, Wendling P et al (2009) Multimodal perioperative rehabilitation for colonic surgery in the elderly. World J Surg 33:1757–1763CrossRefGoogle Scholar
  29. 29.
    Pędziwiatr M, Pisarska M, Wierdak M et al (2015) The use of the enhanced recovery after surgery (ERAS) protocol in patients undergoing laparoscopic surgery for colorectal cancer: a comparative analysis of patients aged above 80 and below 55. Pol Przegl Chir. 87:565–572Google Scholar
  30. 30.
    Kehlet H (2018) ERAS Implementation-Time To Move Forward. Ann Surg 267:998–999CrossRefGoogle Scholar
  31. 31.
    Fish DR, Mancuso CA, Garcia-Aquilar JE et al (2017) Readmission after ileostomy creation retrospective review of a common and significant event. Ann Surg 265:379–387CrossRefGoogle Scholar
  32. 32.
    Messaris E, Sehgal R, Deiling S et al (2012) Dehydration is the most common indication for readmission after diverting ileostomy creation. Dis Colon Rectum 55:175–180CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Emergency Surgery Department“Sapienza” Medical SchoolRomeItaly
  2. 2.Department of General and Mini-invasive SurgeryAbano TermeItaly
  3. 3.General Surgery DepartmentFondazione Policlinico Universitario Agostino Gemelli–Catholic UniversityRomeItaly
  4. 4.Department of General SurgeryCardinale Panico di Tricase HospitalLecceItaly
  5. 5.Department of General SurgerySesto San Giovanni HospitalMilanItaly

Personalised recommendations