Retrospective Cohort Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Oct 27, 2019; 11(10): 395-406
Published online Oct 27, 2019. doi: 10.4240/wjgs.v11.i10.395
Impact of age on feasibility and short-term outcomes of ERAS after laparoscopic colorectal resection
Corrado Pedrazzani, Cristian Conti, Giulia Turri, Enrico Lazzarini, Marzia Tripepi, Giovanni Scotton, Matteo Rivelli, Alfredo Guglielmi
Corrado Pedrazzani, Cristian Conti, Giulia Turri, Enrico Lazzarini, Marzia Tripepi, Giovanni Scotton, Matteo Rivelli, Alfredo Guglielmi, Division of General and Hepatobiliary Surgery, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona Hospital Trust, Verona 37134, Italy
Author contributions: Pedrazzani C, Conti C and Guglielmi A designed the research; Rivelli M, Lazzarini E and Scotton G performed the research; Pedrazzani C and Turri G analysed the data; Conti C wrote the paper; Pedrazzani C, Tripepi M and Guglielmi A critically revised the manuscript for important intellectual content.
Institutional review board statement: The study was reviewed and approved by the Ethics Committee of University of Verona, Verona, Italy, with ID number: 53538.
Informed consent statement: Patients were not required to give informed consent to the study because the analysis used anonymous data that were obtained after each patient agreed to treatment by written consent.
Conflict-of-interest statement: The authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest.
Data sharing statement: Deidentified participant data from prospectively collected database are available upon reasonable request to the corresponding author.
STROBE statement: The authors have read the STROBE Statement - checklist of items, and the manuscript was prepared and revised according to the STROBE Statement - checklist of items.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Corrado Pedrazzani, MD, Associate Professor, Surgeon, Division of General and Hepatobiliary Surgery, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona Hospital Trust, Piazzale “L. Scuro” 10, Verona 37134, Italy.
Telephone: +39-45-8126719 Fax: +39-45-8027426
Received: April 19, 2019
Peer-review started: April 19, 2019
First decision: August 2, 2019
Revised: October 14, 2019
Accepted: October 18, 2019
Article in press: October 18, 2019
Published online: October 27, 2019
Research background

Life expectancy is increasing worldwide, and a growing number of colorectal resections are expected to be operated in older patients in the next future. Age has been traditionally considered a risk factor for poor surgical outcomes and delayed recovery after surgery. After the advent of laparoscopy, more recently, enhanced recovery protocols (ERP) aimed at further improvement in surgical results for elderly patients.

Research motivation

Fast-track protocols have proved their efficacy in improving length of stay, morbidity and recovery after colorectal surgery. Nevertheless, most studies have excluded elderly patients assuming greater frailty and lower compliance to ERP. Moreover, few papers have evaluated the most challenging recovery goals for this population.

Research objectives

The main objectives of this study were to evaluate the feasibility and safety of ERP in elderly patients undergoing colorectal resection with minimally invasive approach. Global compliance to fast-track items was evaluated together with its impact on discharge delay.

Research methods

Our prospectively maintained departmental database of patients undergoing colorectal resection between March 2014 and July 2018 was examined to identify patients enrolled in fast-track protocol. According to the World Health Organization’s definition of elderly and old elderly, patients were divided in 3 groups (Group A, ≤ 65 years old, Group B, 66-75 years old and Group C, > 76 years old). Clinic and pathologic characteristics of the three groups were compared. Further analysis included short-term outcomes and recovery results considering fast-track protocol compliance as the amount of ERP’s items successfully achieved.

Research results

Of 317 patients who underwent laparoscopic colorectal resection during the study period, 225 met the inclusion criteria and were divided in Group A (n = 112), Group B (n = 57) and Group C (n = 56). Although a higher rate of patients with more than two comorbidities was observed in Group B and C (P < 0.001), major complication, reoperation and readmission rates were comparably low among the three groups. Whilst the median time to fulfil the proposed discharge criteria was significantly shorter in Group A and B (P = 0.040), median length of hospital stay (LOS) was comparable within groups. The most difficult ERP goals to be achieved in the elderly were carbohydrate rich drink consumption (P = 0.022) and walking resumption on the first post-operative day (P = 0.032). Furthermore, Group C resulted less efficient in early urinary catheter removal (P = 0.013).

Research conclusions

This study found no age-related differences in the main short-term outcomes after laparoscopic colorectal resection performed within a fast-track protocol. Morbidity, reoperation and surgical complication rates were similar in the three groups. Even tough elderly patients required more time to fulfil discharge criteria no differences in LOS were observed. Global compliance within Group B and C was satisfying although room for specific items’ improvement was highlighted.

Research perspectives

Our results suggest that elderly patients can be safely enrolled within ERP. Reasons for fast-track goals failure should be registered in prospectively collected databases and considered for further research. The evidence of characteristic age-related difficulties in achieving ERP objectives could then lead to the definition of specific targets for prehabilitation programs.