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Quyn AJ et al . Right hemicolectomy in the elderly406 Right Hemicolectomies374 Elective 32 Emergency206 > 70 years125 Open 81 Laparoscopicing with colorectal cancer requiring surgical management.Since the successful introduction of laparoscopiccolectomy by Verdeja et al [1] , laparoscopic surgery for thetreatment of colorectal cancer has been widely adapted.Laparoscopic colorectal surgery has been shown in manystudies to be associated with superior perioperative outcomeswhen compared to open colorectal surgery withreported advantages including less analgesic requirements,earlier return of bowel function, as well as shorterhospital stay [2,3] .Laparoscopic colectomy in the elderly has also beenshown to be safe [4-12] , however it is unknown whetherelderly patients gain the same benefits from laparoscopiccolectomy that younger patients have been shown to receive.Concern regarding laparoscopic colectomy in theelderly population relates to the age-associated increasein co-morbidities, the significantly longer operative times,and the physiologic effects that prolonged time underanaesthesia and CO2 pneumoperitoneum have upon themultiple co-morbid conditions of these patients are unknown[13] .In addition, right hemi-colectomy is a very differentoperation to other colectomies. The operation does notinvolve the mobilisation of a difficult flexure and canoften be completed through a small transverse incision.Studies have suggested that laparotomy via transverse skincrease incision can provide benefits in terms of ease ofoperation, reduced postoperative pain, earlier return ofbowel function and more rapid discharge from hospital [14] .The aim of this study was to compare the short-termsurgical outcomes of laparoscopically-assisted right hemicolectomy(LRH) and open right hemicolectomy (ORH).MATERIALS AND METHODS168 < 70 yearsFigure 1 Patients presenting to NHS Tayside for elective right hemicolectomy.All patients undergoing a right hemicolectomy in NHSTayside (Ninewells Hospital and Perth Royal Infirmary)between January 2006 and May 2011 were included inour analysis. Patients were identified from a dedicatedprospective database. Data was collected by way of proforma,this included: (1) patient characteristics (admissiondate, age, gender, presentation); (2) intervention details(type of surgical intervention, details of surgery, lengthof procedure, grade of surgeon, total length of hospitalstay, date of discharge, discharge destination and whetherthis was different from admission); and (3) complications,outcome and mortality (including peri-operative and inhospital mortality).Additional information was reported form detailedcase-note review as required. The primary endpoints foranalysis were morbidity and mortality. Our secondaryendpoints were operative duration, length of hospitalstay and discharge destination. Data was reported on anintention-to-treat basis.Operative procedureDetails of the operative procedure have been previouslydescribed but are summarised here [15] . All patients wereadministered prophylactic antibiotics at induction. WithLRH a standard four port medial to lateral dissection wasperformed with high ligation of the ileocolic pedicle. Thespecimens were either extracted through a right iliac fossamuscle splitting incision or through an extended umbilicalincision and an extracorporeal anastomosis performed.An Alexis wound protector (Applied Medical, UnitedStates) was used in all cases. An ORH was performedthrough a transverse muscle cutting incision when possible.A midline incision would be considered if previouslaparotomy though a midline incision. A lateral to medialapproach with high ligation of the ileocolic pedicle wasperformed routinely. With both techniques either a sideto-sideileocolic anastomosis or an interrupted end-toendseromuscular sutured anastomosis was performed atthe operating surgeon’s discretion.There has been no consistent definition of the agecut-off for elderly in the literature. However, severalstudies evaluating the risks of mortality after colorectalsurgery have shown an increased mortality rate after surgeryin patients aged more than 70 compared to patientsaged less than 70 [16,17] . We have thus used the age of70 years as our cut-off, to evaluate the short-term outcomesof laparoscopic colorectal surgery versus opencolorectal surgery in our institution.Statistical analysisData were processed using the Statistical Package for SocialSciences, version 18.0 (SPSS, Inc., Chicago, IL, UnitedStates, 2010). Qualitative variables were summarised byfrequency and percentage, while non-normally distributedquantitative variables were described by the median andrange. Student’s t-test and Fischer’s exact test as appropriate.Statistical significance was determined (P < 0.05).Data was analysed on an intention to treat basis.RESULTSThree hundred and seventy-four patients underwent electiveright hemicolectomy during the study period with206 patients aged 70 years or older (Figure 1). Of these,106 patients were male. One hundred and twenty-fivepatients underwent an ORH and 81 patients had a LRH.WJGS|www.wjgnet.com188 June 27, 2013|Volume 5|Issue 6|
Quyn AJ et al . Right hemicolectomy in the elderlyTable 1 Demographics and clinical characteristics of patient groupsTable 2 Operative details and post operative morbidityThe clinical and demographic data are summarised inTable 1. There were no significant differences betweenthe two groups. The indication for resection was cancerin the majority of cases. Both groups had a similar distributionof early (stages 1 and 2) and advanced tumours(stages 3 and 4; Table 1).Seven patients required conversion to open surgery.Reasons for conversion include dense adhesions fromprevious surgery and tumour related factors such as localinvasion of surrounding structures or anatomic uncertainty.There was a significant difference in mean operatingtime with 139 ± 36 min in the open group vs 197 ±53 min in laparoscopic (P = 0.001). The incidence ofpost-operative morbidities was 27% of open proceduresand 38% of laparoscopic procedures (Table 2). Superficialwound infection requiring antibiotics occurred in10% of ORH and 13% of LRH. The primary site ofinfection in the laparoscopic group was the extractionsite. All incidences resolved with antibiotics. One patienthad a deep wound dehiscence in the open group. Theincidence of pneumonia and ileus were similar in bothgroups. Two patients required reoperation in the opengroup for anastomotic leak related collections. Five patientsin the laparoscopic group required re-operationinvolving laparotomy. One patient required a laparotomyfor ischaemic small bowel and four required a laparotomyfor anastomotic leak. Overall in-hospital mortality was1.6% in open procedures vs 1.2% in laparoscopic.The mean length of hospital stay was 11.2 ± 7.8 d inopen and 9.6 ± 10.7 d in laparoscopic (P = 0.28). Fivepercent of patients in the open group required transferto further inpatient facility for further rehabilitationcompared to 2% although this failed to reach statisticalsignificance. Long term oncological outcome was notevaluated in this study.DISCUSSIONOpen (n = 125) Lap (n = 81)Age, yr (range) 79 (70-93) 78 (70-91)Sex (M/F) 62/63 44/37Cancer stage1 21 82 45 293 35 204 3 1Polyp 18 10Crohn’s disease 1 0The number of elderly patients presenting with colorectalcancer has paralleled the increased life expectancy inthe last decades. This has led to a large, and constantlyrising, number of elderly patients with colorectal cancerreferred for surgical treatment. Studies have shown thatcolorectal surgery in elderly patients is generally well toleratedalthough pre-morbid cardiopulmonary conditionsOpen Laparoscopic P value(n = 125) (n = 81)Operative time (min) 139 ± 36 197 ± 53 0.001Length of stay (d) 11.2 9.6 NSMorbidity 27% 38% NSWound infection 13 11 NSPneumonia 8 9 NSIleus 5 6 NSUrinary infection 3 3 NSCardiac event 4 3 NSAnastomotic leak 2 4 NSReoperation 2 5 NSMortality 1.60% 1.20% NSNS: Not significant.do predispose to higher morbidity and mortality rates ascompared to younger patients [5] .Laparoscopic colorectal resection is fast becomingthe gold standard of treatment for both malignant andbenign colorectal lesions, with improved short-term andcomparable long-term outcomes when compared to theopen method [2,3,18] . The benefits of laparoscopy have beenattributed to less post-operative pain, better pulmonaryfunction and reduced stress response [19-21] . These outcomesare particularly important in elderly patients whoare at higher risk of post-operative morbidity and mortality.However, there are concerns regarding the safety oflaparoscopic colorectal surgery in elderly patients, mainlyrelated to longer operative time as well as physiologicalstresses associated with carbon dioxide pneumoperitoneumand steep Trendelenburg required for the main durationof surgery. Hypercapnia, reduce venous return andincrease peak airway pressure and decrease pulmonarycompliance may all potentially increase the risk of cardiorespiratorycomplications [22] .Several studies have described laparoscopic colectomyas safe and feasible in the elderly population with reducedmorbidity and reduced length of hospital stay whencompared to open surgery [5-11] . This is the first study tospecifically assess right hemicolectomy in the elderly population.In our series, there was no significant differencein length of hospital stay or morbidity. This conclusionis not drawn from a laparoscopic series which is inferiorto other studies as our results are comparable with thepublished literature [8-11,23] . In addition we have previouslypublished on the benefits of laparoscopic colectomy forcancer in a standard population [15] .The incidence of laparotomy for complications washigher in the laparoscopic group, 6% vs 1% in the opengroup, however this did not achieve statistical significancepossibly relating to the small numbers in this study. Webelieve that elderly patients undergoing right hemicolectomydo not obtain the same benefits of laparoscopicsurgery and that this relates to the very different accessrequired and technical aspects of a right hemicolectomycompared to a left sided resection.WJGS|www.wjgnet.com189 June 27, 2013|Volume 5|Issue 6|
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