Keywords

1 Epidemiology of Colorectal Cancer

Cancer of the colon and rectum (CRC) is the third most common cancer in men and the second most common in women with 1,340,000 new diagnoses worldwide [1] and is therefore considered one of the most life-threatening and common neoplastic diseases all over the world [2].

Asia contributes with the highest rate (1,009,400/52.3% of incident cases and 506,499/54.2% of deaths in 2020). In the United States, in the same year, there were about 104,610 new cases of colon cancer and 43,340 patients affected by rectal cancer [3]. According to the AIOM (Italian Association of Medical Oncology) registry, there were approximately 43,700 new diagnoses in Italy in 2020 (men 23,400; women 20,300) [4]. In terms of mortality, 21,700 deaths were expected in Italy in 2021 (men 11,500; women 10,200). Disease-free survival at 5 years from diagnosis is 65% and 66% in men and in women, respectively [4]. The relative cumulative survival rate following a diagnosis of CRC is 64% at 5 years and 58% at 10 years. Stage at diagnosis remains the most important predictor of CRC survival. The 5-year survival rate is 90% for the 39% of patients diagnosed with localized-stage disease, but declines to 71% and 14% for those diagnosed with regional and distant stages, respectively [4, 5]. Black ethnicity, age > 60 years, and low socioeconomic status are also well-known factors associated with a diagnosis of advanced-stage CRC.

2 Who’s “Elderly”?

Many publications evaluate clinical and prognostic data in populations of different ages, varying from 65 to 80 years; consequently, the lack of a clear definition of an elderly patient is one of the most difficult problems in evaluating the outcomes of colorectal surgery in the older population.

“Elderly” is a very variable definition that arises from the environmental culture of the patient; a chronological age of ≥65 years has been defined and, more recently, it has been divided into “early elderly” for those aged 65 to 74 years and “late elderly” for those aged over 75 years. Frailty can be defined as an increased susceptibility to develop multiple chronic diseases; it relates to senescence and represents a major risk factor for multimorbidity and mortality [6]. Difficulties in enrolling in clinical trials elderly patients from a specific population are related to the presence of comorbidities, disability and organ-specific physiological changes that impair the application of current guidelines, as these are established for younger patients. Hence the importance of a multidisciplinary onco-geriatric approach that can take into account the patient in his complexity and make use of objective tools for evaluating multiple pathologies.

Vulnerability assessment, Multidimensional Geriatric Assessment (MGA) or Comprehensive Geriatric Assessment (CGA) are evaluation tools developed by geriatric medicine with the aim of planning medical and socio-health care for the patient [7, 8]. MGA has been defined as a methodology “with which the multiple problems of the elderly individual are identified and explained, their limitations and resources are assessed, their care needs are defined and an overall care program is developed to interventions to meet these needs”. After an accurate MGA or CGA of the limited physiologic reserves and comorbidity, and application of a pre-habilitation program, all the patients with CRC able to undergo surgery should receive the same treatment as the younger population, according to the International Society of Geriatric Oncology (SIOG). Also surgery alone, however, can achieve favorable long-term outcomes and age is not independently associated with complications after open surgery for CRC.

3 Epidemiology of Colorectal Cancer in the Elderly

It should be considered that 30–40% of CRC cases occur in patients above 75 years, confirming a higher incidence in older patients [1,2,3,4,5]. Literature reports indicate that 75% of CRC diagnoses are in patients over 65 years, with a peak risk around the age of 70 years, while it is infrequently diagnosed before the age of 40 years. Subjects over 80 years account for 20% of the total number of cancer diagnoses, which can be quantified in about 2 cases per 100 women and in 3–4 cases per 100 men every year [4].

4 Robotic Colorectal Surgery

Since the Food and Drug Administration approval of Intuitive Surgical’s da Vinci robotic system in 2000, more than 20 years of robotic-assisted surgery has been performed all over the world.

The progressive discovery of the potential benefits of robotic-assisted surgery versus open or laparoscopic surgery resulted in increasing numbers of robotic procedures being performed across different surgical specialties. The introduction of robotic 3D imaging, independent camera control, wristed instruments, motion scaling and tremor filtration has helped to overcome some laparoscopic challenges in an ergonomically favorable environment.

The use of the robotic procedure for colorectal surgery was first introduced by Weber et al. in 2002 [9]. In the early years, patients older than 70 years were excluded and only young people with low ASA scores, low BMI and good performance status were selected. Prolonged and steep Trendelenburg position and the longer operative time in cases of colorectal surgery scared the pioneers of this surgery. On the contrary, improved skill and stability, particularly within confined spaces such as the pelvis, enhance the ability of the surgeon to perform a procedure via a minimally invasive approach. Moreover, lower conversion rates, less blood loss, and shorter length of stay are often reported in the literature; in colorectal surgery, the conversion rate from laparoscopic to open approach is still in the order of 15%. All these advantages are gained only after a slow learning curve and longer operating time [10]. Several studies have assessed the number of cases required to achieve expertise in robotic surgery. As reported by Müller et al., approximately 40 cases is a reasonable number also for an expert surgeon [11]. However, one of the most critical factors influencing the perioperative outcome after colorectal robotic surgery is patient selection, and these authors confirm that case complexity and not only case load should be considered crucial for the safe implementation of robotic surgery in clinical practice.

Better short-term outcomes and reduced rates of conversion to open surgery compared to laparoscopic surgery, especially when applied in selected patients, are reported in some studies on laparoscopic-assisted colorectal surgery (LACS) and robotic-assisted colorectal surgery (RACS) [12,13,14,15,16].

In the systematic review and meta-analysis of Sheng et al. [17], including 40 studies comprehensively compared, the efficacy of RACS, LACS, and open surgery for CRC was evaluated with the potential scale reduction factor (PSRF): the values of operation time, estimated blood loss, length of hospital stay, complication, mortality, and anastomotic leakage ranged from 1.00 to 1.01, whereas those of wound infection, bleeding, and ileus ranged from 1.00 to 1.02. LACS and RACS had the longest operation time and the shortest hospital stay compared with open procedures. In the LACS group, blood loss, complications, mortality, bleeding, and ileus occurred less frequently. Better, but without significant difference, were the rates of anastomotic leakage and wound infection in LACS if compared with RACS and open surgery. RACS might be a better treatment for patients with CRC. Recent comparisons of new platforms, able to reduce expensive robotic procedures and simplify the preoperative set-up, suggest RACS may be the best method for the treatment of CRC (Fig. 22.1).

Fig. 22.1
A photograph. Three surgeons look at a screen. Surgical instruments wrapped in the plastic observed. A medical professional sits in front of the screen of a machine.

The CMR Versius robotic platform

Full size image

5 Robotic Colorectal Surgery in the Elderly

Evaluating the use of robotic surgery also in the elderly population is important if we consider that this population is increasing. The literature is still minimal, but some studies have demonstrated the feasibility of RACS in elderly patients with cancer [18,19,20].

In the review by Ceccarelli et al. [21], 363 patients (402 robotic procedures) were divided into three groups by age (group 1: <65 years; group 2: 65–79 years; group 3: ≥80 years) and subjected to minimally invasive robot-assisted surgery for different diseases (81% for oncologic reasons); 56% of them were male, with a mean age of 65.6 years (range 18–89). CRC surgery represented the most frequent procedure (43%) in the entire patient cohort. Examining only the right colectomy group, despite a higher conversion rate in the two older groups and the small sample of ≥80-year-old patients, the authors report a similar mean operative time and hospital stay. Overall, the study concludes that robot-assisted surgery is a safe and effective technique for the aging patient population, especially for major abdominal cancer surgery in terms of risk of death or morbidity. Moreover, prolonged operative time and steep positions (Trendelenburg) did not represent an issue for the majority of patients. In clinical practice, considering the high direct costs, the decision for robotic surgical treatment in elderly patients should be made with a tailored approach.

Another prospective study was conducted by Hugo Cuellar-Gomez et al. [22] on a CRC database of 76 consecutive patients (≥75 years) who underwent a robotic-assisted CRC curative resection at Korea University Anam Hospital with the da Vinci S, Si or Xi Surgical Systems (Intuitive Surgical Inc., Sunnyvale, CA, USA). After dividing the sample into three groups, i.e., young-old (YO: 75–80 years), medium-old (MO: 81–85), and oldest-old (OO: ≥86 years), the intraoperative and postoperative findings and the oncological outcomes were compared. Postoperative complications were not statistically different between the groups. Mean follow-up time for cancer-specific survival (CSS) and recurrence risk were statistically different (p = 0.045 and p = 0.008, respectively). The CSS rates at 5 years were 27.0%, 21.0%, and 0%, respectively. At multivariate analysis, TNM stage was not a risk factor for CSS in any of the groups and the number of harvested nodes was an independent protective factor for recurrence (p = 0.027) and CSS (p = 0.047) in elderly patients. Robotic surgery is consequently considered highly feasible in elderly and very elderly CRC patients, providing a favorable operative safety profile and an acceptable CSS outcome.

Oldani et al. [23], although in a two-year limited experience with 50 colorectal surgeries in 28 young and 22 old patients, showed a significantly higher mean ASA score in the elderly but no statistically significant differences in terms of postoperative morbidity, hospital stay, first diet intake, first flatus canalization and oncological outcome in comparison with the younger group.

In a retrospective review, Asako Fukuoka et al. [24] evaluated the surgical outcomes, postoperative short-term outcomes and prognosis of 1240 patients (1131/91.2%, <85 years old) in order to better select elderly patients for robotic surgery. ASA scores were significantly poorer in the elderly group; on the contrary, the rate of reduction of lymph node dissection range, overall morbidity and respective frequencies of pneumonia and thromboembolism were significantly higher in the elderly. The CSS was not statistically different between the groups. Postoperative hospital stay was significantly longer in the elderly group (p < 0.05); overall survival was significantly lower in the elderly (p < 0.05) but relapse-free survival was not significant. The authors conclude that, after proper assessment and careful management of perioperative surgical risks, robotic CRC surgery can be indicated in elderly patients.

Westrich et al. [25] performed an evaluation of short-term outcomes in 58 consecutive patients undergoing robotic curative CRC resection, divided into two groups: old (OG: 80–85 years) and very old (VOG: ≥86 years). No statistical differences were found in terms of short-term results; major complications were globally seen in 12% of patients, and the 90-day mortality rate was 1.7%. Overall and disease-free survival were 81% and 87.3%, respectively, with a significant difference in overall survival in favor of the OG (p = 0.024). Also these authors consider robotic CRC surgery feasible in octogenarians, with good clinical outcomes and survival.

The literature examined, though mostly based on retrospective clinical records or with limited numbers of patients, confirms that the robotic CRC surgical approach is safe and feasible and offers many systemic benefits in elderly patients. Age alone should not be considered an exclusion criterion for robotic procedures.

6 Conclusions

The majority of older patients are affected by gastrointestinal and oncologic diseases and CRC surgery is increasingly performed today. Unfortunately, the use of multidimensional evaluations or better, an onco-geriatric selection is rare. Cooperation between surgeons, anesthesiologists and geriatricians is infrequent, although the literature confirms that, for this category of patients, preoperative selection and assessment are crucial.

After the good results of ERAS (Enhanced Recovery After Surgery) protocols in aged people, we have to take into account the pre-habilitation phase, in order to obtain better outcomes.

It is widely demonstrated that patients with CRC can tolerate a minimally invasive (laparoscopic or robotic) approach and that age alone is not a recognized absolute contraindication. The elderly population, even if selected for open or laparoscopic surgery, should not be excluded from the now well-known benefits of robotic procedures.

According to reports from high-volume robotic centers, RACS is safe, feasible, and well tolerated for elderly and very elderly patients. Aged populations show postoperative clinical outcomes comparable to those of younger patients. Further and larger observational and randomized prospective studies are necessary to validate the application of robotic colorectal surgery in the elderly population, to achieve better short- and long-term postoperative results. Finally, considering the high direct costs of the procedure, minimally invasive robot-assisted surgery should be performed on a case-by-case basis and tailored to each patient so as to better evaluate also the final effect on their quality of life.