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Laparoscopic GI surgery safe for octogenarians.

NATIONAL HARBOR, MD. -- Advanced age need not be an impediment to laparoscopic surgery for colon resection or paraesophageal hernia.

Two retrospective studies found that octogenarians not only tolerated laparoscopic surgery, but came through both colorectal surgery and paraesophageal hernia repair with excellent outcomes.

A shortened hospital stay is one of the biggest benefits the elderly can reap from a laparoscopic procedure, said Dr. Steven Wexner, chair of the colorectal surgery department at the Cleveland Clinic, Weston, Fla.

"Leaving the hospital sooner is beneficial to older patients because it lessens their chances of a hospital-acquired infection, fall, or psychological changes," said Dr. Wexner, lead author on one of the studies. "Unless there is a specific contraindication, these older patients [who need colorectal surgery] should be offered a laparoscopic procedure."

Dr. Wexner and his colleague, Dr. Rodrigo Pinto, examined outcomes in 83 laparoscopic and 116 open colorectal resections among a group of 199 octogenarians. The patients' mean age was 84 years, and their mean American Society of Anesthesiologists class was 2.7. Cancer was the most common diagnosis, occurring in 86% of the open surgery group and 89% of the laparoscopic surgery group. Diverticular disease was present in 9% of the open group and 8% of the laparoscopic group. The remainder of the patients had other disorders.

The patients underwent a variety of surgical procedures including right, sigmoid, and transverse colectomy; sigmoid colectomy; low anterior resection; abdomino-perineal resection; left hemicolectomy; and proctacolectomy. Stomas were constructed in 47% of the open group and 10% of the laparoscopic group.

The mean operative time was not significantly different between the groups. However, the laparoscopic group lost significantly less blood than the open group (mean 100 vs. 200 mL), required significantly fewer intraoperative transfusions (3 vs. 19), and had a significantly shorter incision length (mean 9 vs. 23 cm).

The overall rate of major surgical complications was 5% in each group. Three patients in each group required reoperation. The rate of medical complications was lower--but not significantly lower--in the laparoscopic group, compared with the open group (25% vs. 39%). There was no significant difference in mortality.

The overall morbidity rate was 49% for open surgery and 30% for laparoscopic surgery, a significant difference. Patients who underwent laparoscopic surgery left the hospital a mean of 2 days earlier than did open surgery patients (6 vs. 8 days).

The open conversion rate was 25% (21 cases). The converted cases had a longer mean operative time than those completed laparoscopically (197 vs. 156 minutes), greater mean blood loss (220 vs. 129 mL), more surgical complications (96% vs. 5%), and more postsurgical medical complications (79% vs. 21%). All the differences were significant. Overall, however, "laparoscopic colorectal resection was very safe and effective for these patients," Dr. Wexner said.

Dr. Heidi Fitzgerald of Dartmouth-Hitchcock Medical Center, Lebanon, N.H., reported on a series of 59 elderly patients (aged 80 or older) who underwent paraesophageal hernia repair. Based on her findings of a low mortality rate (two patients) and an 86% rate of symptom resolution, she and her colleagues recommended elective laparoscopic repair for octogenarians rather than watchful waiting.

The decision to repair electively or not is a controversial one, Dr. Fitzgerald said. "The major concern with paraesophageal hernias is their 10%-30% risk of complications, including hemorrhage, volvulus, strangulation, and perforation," she said. Mortality rates in untreated patients undergoing emergent surgery have ranged from 5.4% to 26% in various studies. The only study to examine the issue in the very elderly found a 16% mortality rate associated with emergent repair, compared with a 2.5% rate in elective repair in patients 80 years and older.

The mean age of Dr. Fitzgerald's patients was 86 years, and 76% were women. All repairs were completed laparoscopically.

The mean operating time was 193 minutes. Five intraoperative complications occurred. They included three pneumothoraces, which were treated in the recovery unit with needle decompression, an esophageal perforation that was recognized and repaired intraoperatively, and an esophageal perforation that was noted on postoperative day 2 and required a reoperation.

Major complications occurred in 21 patients (36%) over the 30-day postoperative period. They included two cardiac arrhythmias; four cases of dysphagia, three of which required dilation; one empyema and one aspiration pneumonia that required admission to the intensive care unit; and four cases of anemia that required transfusion.

Two patients died in the hospital after surgery. One patient had an esophageal leak that was repaired, but resulted in a fatal sepsis. One patient needed a reoperation for bleeding and subsequently developed renal and cardiac failure; the family elected to withdraw life support.

Dr. Fitzgerald had complete 1-month follow-up data on 86% of the patients (51). Thirty-nine percent of the patients (23) reported complete symptom resolution, and 47% (28) reported partial resolution.

"This was a small sample size, but despite this, we feel that laparoscopic paraesophageal hernia repair can be performed safely with minimal perioperative morbidity in octogenarians. We now advocate this approach as opposed to watchful waiting in this subset of symptomatic patients."


Major Finding: Octogenarians who underwent elective laparoscopic colorectal surgery had significantly lower overall morbidity than did those who underwent open surgery (30% vs. 49%) and left the hospital earlier (6 vs. 8 days). Octogenarians who had laparoscopic repair of paraesophageal hernia had an 86% rate of symptom resolution and a 36% rate of major complications over the 30-day postoperative period.

Data Source: Two retrospective series comprising 258 patients.

Disclosures: Dr. Pinto and Dr. Fitzgerald had no disclosures. Dr. Wexner disclosed relationships with numerous medical equipment companies, including some that manufacture laparoscopic surgical instruments.

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Title Annotation:GERIATRICS
Author:Sullivan, Michele
Publication:Internal Medicine News
Article Type:Report
Geographic Code:1USA
Date:Jun 15, 2010
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