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Laparoscopic Colorectal Surgery After 80

John Marks MD

MDSection of Colon and Rectal SurgeryLankenau Hospital, Wynnewood PA

John Marks MD Chief: Section of Colorectal Surgery Main Line Health System

Professor: Lankenau Institute of Medical Research

Director: Fellowship in Minimally Invasive Colorectal Surgery and Rectal Cancer Management

Speakers Disclosures

Covideon- educational grant support, consultant, speakers bureau

Wolfe- consultant, speakers bureau , pStryker- consultant, speakers bureauGlaxo Smith Kline- consultantZassi- consultant, honorariaSurgiquest- Scientific Advisory BoardAdolor- speakers bureau

Can we?

Laparoscopic Colorectal Surgery After 80

Can we?Should we?

What’s the issue?

What is the next Challenges of Laparoscopic Colorectal Surgery

It’s hard.

Need to learn it or the surgeon will take a wrong turn

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Commonly claimed “Problems” laparoscopic colorectal surgery in

the elderly:

1. “Can’t do it”2 “Takes too long”2. Takes too long3. “Dangerous in the elderly”4. “Want to get my hands on

things”5. “Tissue too fragile”

“Convictions are more dangerous enemies of truth than lies.”

Friedrich Wilhelm Nietzche

USA150,000 new colorectal cancers/ year

100,000 colon50 000 rectal

2007

50,000 rectal

Benign diseases

5-15% of colon resectionsdone laparoscopically

% Colorectal Cancer Treated Laparoscopically ????

S. Korea>50%?

Always < 20%

>50%?

A Comparative Evaluation A Comparative Evaluation of Laparoscopicof Laparoscopic--Assisted Assisted

VersusVersusOpen Colectomy for Colon CancerOpen Colectomy for Colon Cancer

COST Study Group TrialCOST Study Group Trial

John Marks, MDJohn Marks, MDWynnewood, PennsylvaniaWynnewood, Pennsylvania

N Engl J Med. 2004 May 13;N Engl J Med. 2004 May 13;350(20):2050350(20):2050--5959

COST Study Group COST Study Group Surgical ParticipantsSurgical Participants

H. AsbunH. Asbun D. FowlerD. Fowler D. Litwin D. Litwin R. Schlinkert R. Schlinkert R. BellR. Bell E. Froines E. Froines J. Lukaszczyk A. Senagore J. Lukaszczyk A. Senagore D. BirchD. Birch J. Greif J. Greif P. Marcello P. Marcello C. Simmang C. Simmang E. BirnbaumE. Birnbaum R. Gould R. Gould J. MarksJ. Marks J. Stauffer J. Stauffer R. Boorse R. Boorse R. Hartmann R. Hartmann S. Oommen S. Oommen E. Suddleson E. Suddleson T. Brown T. Brown G. Hoffman G. Hoffman A. Ortega A. Ortega J. Sutton, Jr. J. Sutton, Jr. B Ch i t G H bb d IIB Ch i t G H bb d II A P kA P k L S tL S tB. Christensen G. Hubbard II B. Christensen G. Hubbard II A. Park A. Park L. Swanstrom L. Swanstrom W. Chapman III J. Hyder W. Chapman III J. Hyder D. Rattner D. Rattner R.C. Thomas, Jr R.C. Thomas, Jr R. Cleary R. Cleary R. Josloff R. Josloff W. T. Reilly W. T. Reilly C. Thibault C. Thibault C. Delaney C. Delaney L. B. Katz L. B. Katz W. K. Ruffin W. K. Ruffin A. Tootla A. Tootla A. Ferrara A. Ferrara H. C. Kim H. C. Kim B. Salky B. Salky S. Wexner S. Wexner A. Fine A. Fine S. Larach S. Larach L. Sand L. Sand R. Whelan R. Whelan R. A. Forse R. A. Forse D. Lauter D. Lauter B. Schirmer B. Schirmer S. WohlgemuthS. Wohlgemuth

T. YoungT. Young--FadokFadokOthers: G. Schroeder, M. O’Connell, J. Weeks, L. Healy, E. Green, Others: G. Schroeder, M. O’Connell, J. Weeks, L. Healy, E. Green,

L. FlodenL. Floden

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LAPAROSCOPIC COLECTOMY TRIALLAPAROSCOPIC COLECTOMY TRIALSchemaSchema

OpenOpencolectomycolectomy

OpenOpencolectomycolectomy

Observation*Observation*Observation*Observation*Pt with 1Pt with 1°°Pt with 1Pt with 1°°

CP1044924-17

ObservationObservation(event(event

monitoring)monitoring)

ObservationObservation(event(event

monitoring)monitoring)

LaparoscopicLaparoscopic--assistedassisted

colectomycolectomy

LaparoscopicLaparoscopic--assistedassisted

colectomycolectomy

Pt with 1Pt with 1colon ACAcolon ACAPt with 1Pt with 1colon ACAcolon ACA StratifyStratifyStratifyStratify RandomizeRandomize

LAPAROSCOPIC COLECTOMYLAPAROSCOPIC COLECTOMYCOST Trial COST Trial -- Recovery Benefits*Recovery Benefits*

Open*Open* LACLACn=428 n=435n=428 n=435

Length of stayLength of stay 6 (56 (5--7)7) 5 (45 (4--6)6)

Open*Open* LACLACn=428 n=435n=428 n=435

Length of stayLength of stay 6 (56 (5--7)7) 5 (45 (4--6)6)20% Longer Hospitalization

CP1044924-28

g yg y (( )) (( ))NarcoticsNarcotics 4 (34 (3--5)5) 3 (23 (2--4)4)Oral analgesicOral analgesic 2 (12 (1--3)3) 1(11(1--2)2)

g yg y (( )) (( ))NarcoticsNarcotics 4 (34 (3--5)5) 3 (23 (2--4)4)Oral analgesicOral analgesic 2 (12 (1--3)3) 1(11(1--2)2)

*in days; median values;(interquartile range)*in days; median values;(interquartile range)

g p

33% More IV Narcotics100% More analgesic requirements

Improved Quality of Life While Recovering from Surgery

0.4

0.6

0.8

1.0

Cumulativeincidence ofrecurrence

Cumulativeincidence ofrecurrence

All stagesOpen colectomyLaparoscopic colectomy

All stagesOpen colectomyLaparoscopic colectomy

Local Recurrence Rate

0.0

0.2

0 1 2 3 4 5YearsYears

Number at riskOpen 395 345 289 240 177 109Laparoscopic 414 368 311 242 185 118

Number at riskOpen 395 345 289 240 177 109Laparoscopic 414 368 311 242 185 118

P=0.32P=0.32

CP1139914-2

40

60

80

100

Alive(%)

Alive(%)

Survival

0

20

0 1 2 3 4 5YearsYears

P=0.51P=0.51

All stagesOpen colectomyLaparoscopic colectomy

All stagesOpen colectomyLaparoscopic colectomy

Number at riskOpen 392 369 320 267 201 130Laparoscopic 414 389 348 271 206 138

Number at riskOpen 392 369 320 267 201 130Laparoscopic 414 389 348 271 206 138

CP1139914-6

There are no compelling There are no compelling reasons not to offer reasons not to offer

LAPAROSCOPIC COLECTOMYLAPAROSCOPIC COLECTOMYConclusionsConclusions

There are There are nono reasons to reasons to withhold laparoscopic withhold laparoscopic

colectomy to appropriatelycolectomy to appropriatelylaparoscopic colectomy to laparoscopic colectomy to appropriately selected appropriately selected patients with colon cancer.patients with colon cancer.

CaveatCaveat::Should always be discussed as an optionShould always be discussed as an option

colectomy to appropriately colectomy to appropriately selected patients with colon selected patients with colon

cancer.cancer.

LAPAROSCOPIC COLECTOMY LAPAROSCOPIC COLECTOMY Barcelona TrialBarcelona Trial

1993 1993 -- 19981998219 Patients (111 LAC)219 Patients (111 LAC)1993 1993 -- 19981998219 Patients (111 LAC)219 Patients (111 LAC)

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219 Patients (111 LAC)219 Patients (111 LAC)Randomized ComparisonRandomized ComparisonIntention to Treat AnalysisIntention to Treat AnalysisLancet 2002; 359: 2227Lancet 2002; 359: 2227

219 Patients (111 LAC)219 Patients (111 LAC)Randomized ComparisonRandomized ComparisonIntention to Treat AnalysisIntention to Treat AnalysisLancet 2002; 359: 2227Lancet 2002; 359: 2227

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Cancer Specific Survival p=0.02

93%

76%

CP1044924-2

LAPAROSCOPIC COLECTOMY LAPAROSCOPIC COLECTOMY Barcelona Trial Barcelona Trial -- InterpretationInterpretation

Antonio Lacy, et al:Antonio Lacy, et al:

“LAC is more effective than OC “LAC is more effective than OC Antonio Lacy, et al:Antonio Lacy, et al:

“LAC is more effective than OC “LAC is more effective than OC

CP1044924-18

for treatment of colon cancer in for treatment of colon cancer in terms of morbidity, hospital terms of morbidity, hospital stay, tumor recurrence, and stay, tumor recurrence, and cancercancer--related survival.”related survival.”

for treatment of colon cancer in for treatment of colon cancer in terms of morbidity, hospital terms of morbidity, hospital stay, tumor recurrence, and stay, tumor recurrence, and cancercancer--related survival.”related survival.”

Lancet 2002; 359: 2224-29

Effector PhaseEffector Phase

-- After Laparoscopy, effector cell After Laparoscopy, effector cell functions are better preserved:functions are better preserved:-- Monocyte and macrophageMonocyte and macrophageMonocyte and macrophage Monocyte and macrophage

functionsfunctions-- Neutrophil functionsNeutrophil functions-- Natural Killer cell functionsNatural Killer cell functions-- Cytotoxic T cell functions Cytotoxic T cell functions

Animal Tumor StudiesAnimal Tumor Studies

-- Tumors grow larger and are Tumors grow larger and are more easily established after more easily established after l t th l il t th l ilaparotomy than laparoscopy in laparotomy than laparoscopy in mice*mice*

* * Allendorf JD et al. Surg Endosc 1998;12(8)1035Allendorf JD et al. Surg Endosc 1998;12(8)1035--8.8.

Identification of Lung Identification of Lung MetastasesMetastases

Anesthesia Laparoscopy Laparotomy

Obstacles to Lap Colon Surgery in the ElderlyObstacles to Lap Colon Surgery in the Elderly

Cynic’s View

Least experienced surgeon + Most difficult operation= Poor outcome/Little enthusiasm

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LAPAROSCOPIC COLECTOMYLAPAROSCOPIC COLECTOMYContraindicationsContraindications

•• Rectal CancerRectal Cancer•• Transverse colon cancerTransverse colon cancer•• Acutely obstructed/perforated cancerAcutely obstructed/perforated cancer•• Advanced local disease (T4)Advanced local disease (T4)Advanced local disease (T4)Advanced local disease (T4)•• Stage IV diseaseStage IV disease•• ASA classification IV or VASA classification IV or V•• Any concurrent or previous malignant tumorAny concurrent or previous malignant tumor•• Associated GI diseasesAssociated GI diseases•• Pregnant womenPregnant women

No Specific Data regarding the elderly

We Can, but should We???We Can, but should We???

Challenges for laparsocopic Challenges for laparsocopic surgery in the elderlysurgery in the elderly

1.1.Calcific vesselsCalcific vessels22 HypercapniaHypercapnia2.2.HypercapniaHypercapnia

Organize operation accordinglyOrganize operation accordingly

High Risk=High Risk=

Redefining contraindications to Redefining contraindications to laparoscopic colorectal resection for highlaparoscopic colorectal resection for high--

risk patients.risk patients.

Surg Endo 2008, 22:1899Surg Endo 2008, 22:1899--19041904Marks J, Kawun U, Hamdan W and Marks GMarks J, Kawun U, Hamdan W and Marks G

N=362High Risk= High Risk= 1.1. Morbidly ObeseMorbidly Obese2.2. Age Age >> 80 yo80 yo3.3. Radiation TreatmentRadiation Treatment4.4. ASA ASA >> IIIIII

N 36

Laparoscopic ExperienceLaparoscopic ExperienceN=903N=903

# Patients # Patients >>80 yrs = 94 80 yrs = 94 >> 90 yrs = 2290 yrs = 22>> 90 yrs = 2290 yrs = 22

Represents 10.5% of our Represents 10.5% of our laparoscopic experiencelaparoscopic experience

ElderlyElderlyPatients over 80 years oldPatients over 80 years old

•• 57 Women, 37 Men57 Women, 37 Men•• Mean Age = 84Mean Age = 84 (80(80--92)92)

Methods

Mean Age = 84Mean Age = 84 (80(80--92)92)

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Relative ContraindicationsRelative Contraindications

•• N = 66 Patients*N = 66 Patients* (70.2%)(70.2%)•• Previous Radiation Therapy:Previous Radiation Therapy: 2121

Methods N= 100%

•• Emergent Operation:Emergent Operation: 11•• Previous Abdominal Operation: Previous Abdominal Operation: 5050•• Multiple Organ Resection:Multiple Organ Resection: 77

Primary DiagnosisPrimary Diagnosis

•• Cancer:Cancer: 5959•• Large Polyp:Large Polyp: 1919

Methods

•• Diverticulitis:Diverticulitis: 88•• Rectal Prolapse:Rectal Prolapse: 55•• OtherOther 22

ProceduresProcedures

•• Low Anterior Resection:Low Anterior Resection: 1717•• Abdominoperineal Resection:Abdominoperineal Resection: 66•• Left Colectomy:Left Colectomy: 1212•• Right Colectomy:Right Colectomy: 4141

Methods

•• Right Colectomy:Right Colectomy: 4141•• TATATATA 66•• Diverting Stoma:Diverting Stoma: 77•• Hartmann:Hartmann: 33•• Extended Right Colectomy:Extended Right Colectomy: 22

•• Rectopexy:Rectopexy: 11

Number of Trochars

21%

8% 1%

70%

3 4 5 6

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Ports & IncisionsPorts & Incisions

•• PortsPorts•• Mean Number = 3.4Mean Number = 3.4 (3(3--6)6)•• 3: (N = 64)3: (N = 64)

Results

•• 4: (N = 19)4: (N = 19)•• 5: (N=7)5: (N=7)•• 6: (N=1)6: (N=1)

•• Largest IncisionLargest Incision•• Mean Size = 4.58 cm (0.8Mean Size = 4.58 cm (0.8--9.0)9.0)

ConversionConversion

•• In 2 cases the tumors were too In 2 cases the tumors were too ll

Results N = 3 N = 3 (3.2%)(3.2%)

largelarge•• 1 patient had hypercapnia1 patient had hypercapnia

( lap assist( lap assist-- splenic flexure splenic flexure down)down)

Peri-Operative Course

• No MortalityM bidit 22 6% (N 21)

Results

• Morbidity = 22.6% (N = 21)• Pneumonia N=1• MI N=2• Arrhythmia n=3• Anastomotic leak n=1 (1.4%)

Peri-Operative Course

• 75% tolerated clears by POD #2• 66% tolerated house diet by POD #3

Results

• Average length of stay = 7.5 days (2-46)– Average length of stay* = 5.7 days (2-16)

Conclusions

Laparoscopic colorectal surgery can be performed safely in the elderly

Age by itself should not alter minimally invasive colo-rectal management decisions

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Conclusions

This increasing patient population has the p pgreatest to gain by minimally invasive surgery