Condition
Examples
Unstable coronary syndromes
Unstable or severe angina (CCS class III or IV)a
Recent MIb
Decompensated heart failure (NYHA functional class IV, worsening or new-onset HF)
Significant arrhythmias
High-grade AV block
Mobitz II AV block
Third-degree AV block
Symptomatic ventricular arrhythmias
Supraventricular arrhythmias (including atrial fibrillation) with uncontrolled ventricular rate (HR > 100 bpm at rest)
Symptomatic bradycardia
Newly recognized ventricular tachycardia
Severe valvular disease
Severe aortic stenosis (mean pressure gradient greater than 40 mmHg, aortic valve area <1.0 cm2, or symptomatic)
Symptomatic mitral stenosis (progressive dyspnea on exertion, exertional presyncope, or HF)
In the absence of serious comorbidities, a rough assessment of exercise tolerance may be all that is needed to determine if further testing is needed (Table 28.2). Age as a sole criterion defines only the need for EKG and chest X-ray for patients over 50 years. Advanced age alone is not an indication for further cardiac testing. In patients with good exercise tolerance (>4 METS) [2], further testing for any elective procedure is usually unnecessary. Of note, elective abdominal operations are considered intermediate-risk operations.
Table 28.2
Estimated energy requirements for various activities
Metabolic equivalent (MET) | Activity |
|---|---|
1 MET | Eat, dress, use the toilet |
Walk indoors around the house | |
Walk a block or 2 on level ground at 2–3 mph? | |
4 MET | Do light housework (dusting, washing dishes) |
Climb a flight of stairs or walk up a hill? | |
Walk on level ground at 4 mph? | |
Run a short distance | |
Do heavy housework (scrubbing floors, lifting/moving furniture) | |
Participate in moderate recreational activities (golf, bowling, dancing, double tennis, baseball or football catch) | |
>10 METS | Participate in strenuous sports (swimming, single tennis, football, basketball, skiing) |
Other significant clinical risk factors include a history of ischemic heart disease, compensated or prior CHF, diabetes mellitus, renal insufficiency, and cerebrovascular disease, which all represent comorbidities that may require preoperative evaluation.
Exercise tolerance is an excellent overall assessment of fitness, and in the setting of good exercise tolerance, even with multiple clinical risk factors described above, often intermediate-risk surgery can be undertaken with acceptable risk. Perioperative heart rate control with beta-blockade should be considered mandatory in anyone with any of the above risk factors since this has been shown to reduce cardiac morbidity and mortality [3].
When a patient has any of these other significant comorbidities, a specific workup may be indicated as per the AHA guidelines [2]:
Pulmonary Disease. The presence of restrictive or obstructive pulmonary disease significantly increases the risk of perioperative pulmonary complications. In these cases, preoperative pulmonary testing to determine volume and diffusion capacity, response to bronchodilators, and a baseline blood gas will help guide postoperative therapy.
Diabetes Mellitus. This is the most common metabolic disease associated with advanced age and is often associated with coronary disease. The presence of insulin-dependent DM increases the risk of perioperative myocardial ischemia and heart failure. Careful attention to glucose management with insulin infusions and tight glycemic control has been found to significantly reduce postoperative wound infection in CABG pts, and this paradigm can be applied to major abdominal surgery.
Renal Failure. Renal failure is associated with an increased risk of perioperative cardiac morbidity. In addition, preoperative levels of creatinine >2 mg/dl are associated with an increased risk of postoperative renal failure, cardiac complications, and increased mortality.
Hematologic Disorders. Preoperative anemia can impose cardiac stress, worsen ischemia, and exacerbate preexisting CHF. In one study looking at patients undergoing prostate and major vascular surgery, a hematocrit <28 % was associated with an increased risk of perioperative ischemia and postoperative complications.
Laparoscopy in the Elderly: What Are the Outcomes?
As improvements in health care and advances in medicine have led to an aging population, colorectal surgeons are now required to evaluate and operate on increasingly older patients. The use of a laparoscopic approach would seem to be an attractive alternative to traditional open approaches in this patient population in whom minimizing postoperative complications and enhancing postoperative recovery are likely to have significant benefit. A population-based study of laparoscopic colorectal cancer surgery in the United Kingdom from 2006 to 2008 showed that the use of laparoscopy for colorectal procedures increased from 10.0 % in 2006 to 28.4 % in 2008. Of 58,135 resections, 54.6 % were inpatients greater than 70 years of age. Age did not have an effect on whether laparoscopy was attempted; 18.5 % of resections in patients older than 70 years were performed laparoscopically, which was similar to the overall rate of 18.8 % in all patients [4].
Early Studies
Early in the experience with laparoscopic colorectal surgery, initial reports sought to establish safety, in terms of equivalency or improved morbidity and mortality, compared with open procedures. In 1995, Peters and Fleshman published the results of a prospective study describing the outcomes of minimally invasive colectomy attempted in 103 patients greater than 65 years old, 78.6 % of which were able to be completed laparoscopically. Complication rates were no different in patients who underwent successful laparoscopic resection compared with those who required conversion to laparotomy. The length of stay was significantly lower in patients who underwent successful minimally invasive colectomy (5.3 vs. 8.1 days, p < 0.001) [5].
In 1996, Reissman and Wexner published the results of a study looking at outcome in “older” patients, which they defined as age greater than 60 years. Thirty-six “older” patients (mean age 73) undergoing laparoscopic or laparoscopic-assisted colorectal procedures were compared with 36 younger patients (mean age 44). No differences were seen in rates of complications (11 % vs. 14 %), conversion (8 % vs. 11 %), length of ileus (2.8 vs. 4.2 days), or hospital stay (5.2 vs. 6.5 days) [6].
More recently, a review of data from the Nationwide Inpatient Sample (NIS) database for 2009 showed that 35.4 % of colorectal resections were performed laparoscopically [7]. Controlling for a number of factors, including age, multivariate analysis showed improved short-term outcomes in the laparoscopy group, as well as decreased length of stay and lower cost.
Comparisons of Laparoscopic Outcomes in the Young vs. Elderly
A number of reports have shown equivalent short-term outcomes in older patients when compared with younger patients undergoing laparoscopic colorectal surgery. Unfortunately, most of these are small case series or case-control studies (Table 28.3).
Table 28.3
Comparison of outcomes for laparoscopic colectomy in younger vs. older patients
Author | Year | Age | N | Conversion rate (%) | Hospital stay (days) | Morbidity (%) | Mortality (%) |
|---|---|---|---|---|---|---|---|
Reissman [6] | 1996 | <60 | 36 | 8 | 5.2 | 11 | 0 |
>60 | 36 | 11 | 6.5 | 14 | 0 | ||
Delgado [39] | 2000 | <70 | 70 | 11.4 | 5 ± 2 | 15.6 | 0 |
>70 | 59 | 16.9 | 6 ± 2 | 21.4 | 1.6 | ||
Senagore [22] | 2003 | <60 | 181 | 3.9 ± 5.9 | 10.5 | 0 | |
>70 | 50 | 4.2 ± 3.0 | 16 | 0 | |||
Sklow [8] | 2003 | <75 | 38 | 16 | 6.1 ± 0.4 | 29 | 0 |
>75 | 39 | 8 | 6.1 ± 0.3 | 31 | 2.6 | ||
Chautard [9] | 2008 | <70 | 103 | 16 | 10 ± 9 | 27 | 0 |
>70 | 75 | 21 | 11 ± 8 | 32 | 0 | ||
Akiyoshi [11] | 2009 | <75 | 228 | 0.4 % | 15 | 13.6 | 0 |
>75 | 44 | 0 | 19 | 11.8 | 0 | ||
Fiscon [20] | 2010 | <75 | 50 | 4 | 9 | 8 | 0 |
>75 | 50 | 6 | 10 | 24* | 0 | ||
Roscio [10] | 2011 | <70 | 101 | 2 | 8.1 ± 2.8 | 3.8 | 0 |
>70 | 58 | 1.7 | 10.8 ± 6.6* | 3.4 | 1.7 |
Sklow et al. published a retrospective review of patients greater than and less than 75 years of age undergoing laparoscopic colectomy who were case-matched with controls undergoing open colectomy. Complication rates were similar between the laparoscopy and open groups, and laparoscopy was associated with a faster return of bowel function and less narcotic usage postoperatively. Interestingly, faster postoperative recovery was seen with laparoscopic left colectomies in the older group compared to the open group, while faster recovery was seen with laparoscopic right colectomies in the younger group compared with the open group [8]. In 2008, Chautard et al. described a matched case-control study comparing 75 patients greater than 70 years old with 103 patients less than 70 years old undergoing laparoscopic colorectal surgery. While the older group had more frequent cardiopulmonary preoperative comorbidities (80 % vs. 33 %, p < 0.001), the groups had similar operative time (244 ± 89 vs. 242 ± 80 min), complication rates (32 % vs. 26 %), and hospital stay (11 ± 8 vs. 10 ± 9 days) [9].
Roscio et al. reported a series of 159 consecutive patients undergoing laparoscopic resection for colorectal cancer grouped by age less than or greater than 70 years and found no differences in terms of time to return of bowel function or postoperative complications. Older patients in this study had more comorbid conditions and had a significantly longer length of stay [10].
Looking specifically at rectal cancer, Akiyoshi et al. compared 44 elderly patients greater than 75 years of age undergoing laparoscopic rectal resection (group A) with 228 patients less than 75 years old undergoing laparoscopic proctectomy (group B) and 43 patients greater than 75 years old undergoing open rectal resection (Group C). While group A had a higher ASA classification than group B, the rate of postoperative complications did not differ between the two (13.6 % vs. 11.8 %). Complications were seen less frequently in group A than in C (13.6 % vs. 25.6 %), though this did not reach statistical significance. Group A also demonstrated faster return to flatus (1.3 vs. 3.7 days, p < 0.001), shorter time to liquid diet (2.2 vs. 7.0 days, p < 0.001), and a shorter hospital stay (19 vs. 22 days, p = 0.002) [11].
Comparisons of Laparoscopic vs. Open Outcomes in the Elderly
Similar to comparisons of laparoscopy in the young vs. the elderly, most of the published data comparing laparoscopic to open procedures in the elderly is limited to case-control series (Table 28.4). In 2000, Stocchi et al. described a series of 42 patients greater than 75 years old undergoing laparoscopic-assisted colectomies that were matched to 42 similar patients undergoing open colectomy. Despite longer operative times (190 vs. 142 min, p < 0.001), the laparoscopic-assisted group had fewer complications (14.3 % vs. 33.3 %, p = 0.04), less narcotic usage (2.7 vs. 4.8 days, p < 0.001), faster return to bowel movements (3.9 vs. 5.9 days, p < 0.001), and shorter hospital stay (6.5 vs. 10.2 days, p < 0.001). Additionally, independent-living status was more frequently maintained postoperatively in the laparoscopic-assisted group compared with the open group (35/37 vs. 29/38, p = 0.025)—a key factor in looking at outcome with elderly patients that many studies do not address [12].
Table 28.4
Comparison of outcomes for laparoscopic vs. open colectomy in the elderly (*p < 0.05)
Author | Year | Open vs. lap | N | Conversion rate (%) | Hospital stay (days) | Morbidity (%) | Mortality (%) |
|---|---|---|---|---|---|---|---|
Stewart [13] | 1999 | Lap | 42 | 11.9 | 9 | 16.6 | 7.1 |
Open | 35 | 17 | 42.8* | 11.4 | |||
Delgado [39] | 2000 | Lap | 59 | 16.9 | 6 ± 2 | 10.2 | 1.6 |
Open | 67 | 7 ± 3* | 31.3 %* | 0 | |||
Stocchi [12] | 2000 | Lap | 42 | 14.3 | 6.5 ± 4.0 | 14.3 | 0 |
Open | 42 | 10.2 ± 4.4* | 33.3* | 0 | |||
Law [14] | 2002 | Lap | 65 | 12.3 | 7 | 27.7 | 1.5 |
Open | 89 | 9* | 37 | 5.6 | |||
Senagore [22] | 2003 | Lap | 50
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