Introduction

In all Western industrialized countries, the constantly changing age pyramid with a growing proportion of elderly and old persons is giving rise to much discussion about medical services. The elderly/old patient also keeps cropping up in discussions about basic therapeutic/surgical measures.

We now have more than 10 years of experience in the field of laparoscopic colorectal surgery, and the feasibility of numerous different procedures has been demonstrated.

Against the above-mentioned background of the universal and extensive use of laparoscopic colorectal surgery, the question arises as to whether, in a large population of patients, differences are to be found between younger and older patients with regard both to the indication spectrum and intra- and postoperative complications.

Materials and methods

Since 1 September 1995, hospitals in Germany, Austria, Switzerland and Italy (currently 105 in all) have been recording the data of all those consecutive patients in whom a laparoscopic colorectal intervention was performed or initiated (intention-to-treat principle). The data are collected by the respective hospital using appropriate forms and are then sent to the study centre, where they are examined for plausibility and completeness and entered into an SPSS data bank by the staff of the Institute for Quality Control in Operative Medicine (An-Institute) at the Otto-von-Guericke University of Magdeburg. The specific analysis of the data is then effected using the statistical applications of the SPSS programme.

Statistical examination for significance of the individual parameters for the different age groups is then done with the chi-square test and the two-sided Fisher’s exact test. A p value of <0.05 was taken to be significant.

Following the practice of numerous authors, the cut-off point between younger and older patients was, for this analysis, selected to be 75 years [4, 9, 10, 13, 15].

Results

During the observation period, the data of a total of 4823 patients from 69 of the participating hospitals were checked for completeness and plausibility, entered into the data bank and analysed. Breakdown by age revealed 909 patients (18.8%) older than 75 years and 3914 patients (81.2%) younger than 75 years.

The analysis of the spectrum of procedures in both age groups revealed highly significant differences for two indication groups. Although the older patients had a clearly disproportionately higher number of malignant diseases (statistically significant for both colon and rectal carcinomas, but also for prolapse), the younger patients had a statistically significant preponderance of inflammatory bowel diseases (diverticulitis, Crohn’s disease, ulcerative colitis). Equal distributions were observed only for adenomas and the less common indications for surgery (Table 1).

Table 1 Indications for surgery, all patients
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With regard to the course of the operation, no age-specific differences were to be found. The rates of conversion to an open procedure [58 (6.4%) for patients >75 years vs 226 (5.8%) for patients <75 years; n.s.], as also that of intraoperative complications were distributed equally in both groups (Table 2). Nor did an analysis of the individual complications reveal significant differences for any of the various complications, irrespective of the procedure involved, between older and younger patients. An analysis of the postoperative complications of the overall population revealed a highly significant statistical difference between the two age groups for virtually all of the individual complications (Table 3). This significant difference between older and younger patients, favouring the latter, was also observed for postoperative mortality [37 (4.1%) for patients >75 years vs 27 (0.7%) for patients <75 years; p<0.001]. This led logically to the question as to whether a selective consideration of individual typically commonly performed procedures would also reveal this obvious difference in postoperative morbidity and mortality.

Table 2 Intraoperative complications, all patients
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Table 3 Postoperative morbidity, all patients
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A subgroup analysis of postoperative complications and mortality was then performed for the most common diseases (sigmoid diverticulitis, curatively operated sigmoid carcinoma, curatively operated rectal carcinoma) in both groups.

For all three comparisons the results were identical, the older patients always had a statistically significantly higher rate of general complications (pneumonia, cardiopulmonary diseases, urinary tract infection). An analysis of postoperative mortality also showed a higher rate for the older patients (Table 4). No significant difference was found for complications directly associated with the procedure and necessitating re-operation (bleeding, anastomotic leak, postoperative ileus). This also applied to the surgical complications that were treatable by conservative means (Tables 5, 6, and 7). The sole deviation from this situation was a significant increase in the number of older patients with postoperative ileus requiring re-operation after surgery for diverticulitis.

Table 4 Postoperative mortality
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Table 5 Postoperative morbidity, curatively operated sigmoid carcinoma
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Table 6 Postoperative morbidity, curatively operated rectal carcinoma
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Table 7 Postoperative morbidity, diverticulitis
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Discussion

The changing age structure of the population in the industrialized countries resulting in an ever larger proportion of elderly and old persons has focused more attention on this age group. This development, in combination with ever improving diagnostic procedures and demands for comprehensive care, has led to the fact that hospitalized patients are becoming ever older. This applies in equal measure to the indication for colorectal interventions.

Despite the reported appreciably more common multimorbidity in patients older than 75 or 80 years, and the higher rate of postoperative complications [1–3, 5], there is a general consensus that advanced age is in itself not a contraindication for colorectal surgery [5, 6, 8–10, 12]. It is however obvious that the establishment of the indication for a particular procedure must be more strictly applied [7, 21]. As a logical result of this, there has been a shift in the indication spectrum towards life-saving procedures, that is, in which there is an absolute necessity for taking action. This compulsion to act applies in the case of cancer and, to a relatively lesser degree, to diseases with a major impact on the patient’s quality of life, such as rectal prolapse. This shift in the indication spectrum was also to be observed in our own patient population in which there was a significantly higher percentage of cancer cases, and also patients with prolapse in the older patient group. Elective operations such as those for recurrent diverticulitis, in contrast, decreased significantly. This phenomenon was also reported by Schwandner et al. [19]. This picture is certainly not due to selection; rather, the differences in the incidence of the various indications can be explained by a variation in the prevalence of the individual diseases in the different age groups. The sole exception here is cancer, in which the higher rate of surgery in the older patients is possibly due to the fact that the age-related general reservations against curative colorectal surgery in the old patient with an associated limited life expectancy recede somewhat into the background.

An analysis of the complications consistently shows that intraoperative complications are no more frequent in the older patient than in the younger patient. This observation was confirmed not only by us, but also by Schwandner et al., Payne et al., Poon et al. and the Colorectal Cancer Collaborative Group [5, 15, 16, 19]. A plausible explanation for this observation is the fact that the intervention is not tailored to the individual age of the patient, but that a standardized procedure, for example, for the treatment of colorectal carcinoma, can be performed, with no compromising of quality, in the elderly patient, too.

In addition, with regard to the postoperative surgical complications, the consensus of opinion is that the specific problems directly associated with the surgical procedure are not increased by advanced age. This applies equally to all specific complications (ileus, transit disorders, wound healing disturbances, afterbleeds) as also to anastomotic leaks [5, 14–16, 21]. The reports in the literature thus clearly support the results of our own study. The sole, and thus highly relevant, difference between the younger and older age groups is in preoperative comorbidity. Older patients have a clearly increased rate of accompanying diseases of every kind [1, 2, 11, 14, 21]. Of these, cardiopulmonary and respiratory diseases occupy a central position [1, 2, 5, 11, 14, 15, 19]. In the opinion of the above-mentioned authors, these accompanying diseases are the underlying basis for the general postoperative morbidity. It therefore follows that patients with a higher rate of accompanying diseases must also have a higher rate of general complications. This has proved to be the case in the patients investigated in the Study Group Laparoscopic Colorectal Surgery, as also, in identical manner, in other patient groups investigated [2, 5, 7, 14, 21].

There is also a general consensus of opinion that laparoscopic colorectal procedures can be carried out with good intraoperative and postoperative complication rates in older patients too [17, 21]. In particular, in comparison with the open approach, laparoscopic procedures appear to have clear postoperative advantages due to the modified access in colorectal disease. Thus, Peters, reporting on 108 patients older than 65 years, observed a clear advantage for the laparoscopic approach, particularly with regard to hospitalization [17]. In 72 patients older than 60 years, Reissman, too, reported a definitive advantage of the laparoscopic approach with regard to postoperative ileus and hospital stay [18]. This advantage of laparoscopy is almost certainly a contributory reason why, in his patient population, Schwandner, like us in the Study Group Laparoscopic Colorectal Surgery, observed a clear shift in the indications [19]. As a result of this shift, the younger patients more frequently presented with inflammatory bowel diseases (Crohn’s disease, ulcerative colitis, recurrent sigmoid diverticulitis), whereas the older patients more frequently had pelvic problems and colorectal cancer. This observation, however, also appears to confirm that in cancer patients, the generally observed reservations against curative colorectal surgery on account of the advanced age of the patients and their associated limited life expectancy appear to fade into the background, and that these patients, in particular—presumably also on account of its advantages in terms of postoperative course—preferentially receive a laparoscopic procedure [7, 20, 21].