Published online Oct 27, 2019. doi: 10.4240/wjgs.v11.i10.395
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
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.
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.
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.
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.
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).
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.
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.