Surgical oncology in patients aged 80 years and older is associated with increased postoperative morbidity and mortality: A systematic review and meta-analysis of literature over 25 years

Journal Pre-proof Surgical oncology in patients aged 80 years and older is associated with increased postoperative morbidity and mortality: A systematic review and meta-analysis of literature over 25 years V. Lopez-Lopez, A.J. Gómez-Ruiz, D. Eshmuminov, P.A. Cascales-Campos, F. Alconchel, J. Arevalo-Perez, R. Robles Campos, P. Parrilla Paricio PII:

S0960-7404(19)30420-7

DOI:

https://doi.org/10.1016/j.suronc.2019.12.007

Reference:

SO 1314

To appear in:

Surgical Oncology

Received Date: 23 August 2019 Revised Date:

19 November 2019

Accepted Date: 18 December 2019

Please cite this article as: Lopez-Lopez V, Gómez-Ruiz AJ, Eshmuminov D, Cascales-Campos PA, Alconchel F, Arevalo-Perez J, Robles Campos R, Parrilla Paricio P, Surgical oncology in patients aged 80 years and older is associated with increased postoperative morbidity and mortality: A systematic review and meta-analysis of literature over 25 years, Surgical Oncology (2020), doi: https:// doi.org/10.1016/j.suronc.2019.12.007. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Ltd.

Surgical oncology in patients aged 80 years and older is associated with increased postoperative morbidity and mortality: A systematic review and metaanalysis of literature over 25 years. Lopez-Lopez V, MD, PhD1; Gómez-Ruiz AJ, MD1; D. Eshmuminov MD2; CascalesCampos PA, MD, PhD1; Alconchel F, MD1; Arevalo-Perez J, MD, PhD3; Robles Campos R, MD, PhD1 and Parrilla Paricio P, MD, PhD1. 1

Virgen de la Arrixaca Clinic and University Hospital. IMIB. Murcia. Spain.

2

Department of Surgery, Swiss HPB and Transplantation Centre, University Hospital

Zurich, Zurich, Switzerland. 3

Memorial Sloan Kettering Cancer Center. Radiology departament. New York. USA.

Corresponding Author: Gómez-Ruiz AJ. Virgen de la Arrixaca Clinic and University Hospital. General and Digestive Surgery. El Palmar, Murcia (Spain). Mail: [email protected]. Phone: 0034968369677. Fax: 0034968395537.

The content of this paper has not been previously communicated in any society or meeting. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

ABSTRACT Background: The study aim is to analyze the evolution over the last 25 years of the results reported after abdominal oncological surgery in patients aged 80 years of age and older. The primary endpoint was morbidity and mortality in this group of patients; the secondary endpoint was overall survival. Methods: A systematic search strategy was used to browse through Medline/PubMed, EMBASE, Scopus, ClinicalTrials.gov, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials using a combination of standardized index terms. Studies published between 1997 and 2017 were selected. Only those studies that showed morbidity and mortality after digestive and hepatobiliary tract oncological surgery in individuals aged 80 years and older were included. The PROSPERO registration number is CRD42018087921. PRISMA and MOOSE guidelines were applied. Results: A total of 79 studies were included, categorized by origin of malignancy: esophageal (7), stomach (26), liver (4), pancreas (19), and colorectal (23). Compared with the nonelderly group, the elderly group had similar esophageal morbidity with higher mortality (RR 2.51, 1.50 to 4.21; P = 0.0005); higher gastric morbidity (RR 1.25, 1.09 to 1.43; P =0.001), and mortality (RR 2.51, 1.81 to 3.49; P = 0.0001); similar liver morbidity and mortality; higher pancreatic morbidity (RR 1.17, 1.03 to 1.33; P = 0.02) and mortality (RR 2.37, 1.86 to 3.03; P < 0.00001); and similar colorectal morbidity with higher mortality (RR 4.44, 1.91 to 10.32; P = 0.005). Conclusion: Oncological surgery of most abdominal visceral tumors is associated with increased morbidity and mortality in patients older than 80 years.

Keywords: Elderly; aged 80; surgery

Highlights: The increase in age is directly associated with the increase in cancer rate. There is a growing interest in the establishment of selection criteria in the elderly for the realization of oncological surgery. Oncological surgery of most abdominal visceral tumors is associated with increased morbidity and mortality in patients older than 80 years.

1. INTRODUCTION While the increase in the average human life expectancy is an achievement, it also presents several challenges, the most notable being comprehensive attention to health needs and cancer management. The elderly population needs greater health resources, and this translates to increased costs to health systems. After cardiovascular disease, cancer is the next most important cause of morbidity and mortality in this age group. Increased age is directly associated with an increased rate of cancer, which reaches an 11-fold higher incidence in elderly patients[1,2]. Standardization of oncological treatments in this age group is difficult because the elderly population is a very heterogeneous group that is often underrepresented in the medical literature. Decision-making based exclusively on age in the elderly patient has become obsolete, and the individualization of treatments is paramount in this scenario. Establishing general guidelines in cancer surgery is especially delicate, and parameters such as potential years of life lost are not applicable to certain age segments or comparable to morbidity and mortality. Currently, experience in geriatric oncological surgery has increased exponentially due to better preoperative patient management,

advances

specialization

of

in

anesthesia

the professionals

who

and treat

resuscitation, this

group

improvement

and

of

new

patients,

chemotherapies, and greater experience in the various options and surgical techniques[3,4]. Chronological age alone was classically the reason for discrimination in the evaluation of a cancer patient who is a candidate for a surgical procedure. However, aging consists of a series of physiological and cognitive changes that are each accompanied by an increase in comorbidity, all of which makes geriatric evaluation a more complex process[5]. This lack of consensus is evident when reviewing the surgical approach in this cohort of patients, where both 65 and 85 years of age are used as cut-off points, thus making it difficult to compare results in many cases.

Within this variability, most articles analyze data on patients over 70 years of age with good results; however, the aging trend makes us question whether these results are also applicable to individuals aged 80 years and older. This population has increased progressively in number, and in patients older than 85 years, cancer is the leading cause of death, with no gender predilection. The aim of this study was to analyze the evolution over the last 25 years of the results reported after hepatobiliary and digestive tract oncological surgery in patients aged 80 years and older in order to determine, based on scientific evidence, the objective criteria that allow better estimation in this group of patients. The primary endpoint was morbidity and mortality. Secondary endpoints were survival outcomes.

2. MATERIALS AND METHODS 2.1.

Search strategy and study selection criteria

A comprehensive systematic search based on recommendations of the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) statement[6], the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement [7], and the Assessment of Multiple Systematic Reviews (AMSTAR) tool[8] was performed. A medical librarian-developed systematic search strategy was utilized to browse through Medline/PubMed, EMBASE, Scopus, ClinicalTrials.gov, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials using a combination of standardized index terms and plain language to cover the following terms: (elderly OR individuals aged 80 and older) AND ("Esophageal Neoplasms"[Mesh]) AND ("Esophagus/surgery"[Mesh]) AND ("Stomach Neoplasms"[Mesh]) AND ("Stomach/surgery"[Mesh]) AND ("Liver Neoplasms"[Mesh]) AND

("Liver/surgery"[Mesh])

("Pancreas/surgery"[Mesh])

AND

AND

("Pancreatic

("Colonic

Neoplasms"[Mesh])

Neoplasms"[Mesh]

OR

AND "Rectal

Neoplasms"[Mesh]) AND ("Colon/surgery"[Mesh] OR "Rectum/surgery"[Mesh]). A manual search of references from relevant articles was also performed. Both comparative and non-comparative studies of non-elderly patients and those aged 80 and older, including esophagus, stomach, liver, pancreas, and colorectal surgery, were identified. Only those studies that showed morbidity and mortality data were included. Searches were limited to studies published in English, using standard limitations provided by the respective databases. The final search was performed in December 2017. This systematic review was registered in the international PROSPERO database (CRD42018087921; http://www.crd.york.ac.uk/PROSPERO/). 2.2.

Data Extraction and Assessment of Methodological Quality

Two independent researchers (V.L. and A.G.) screened the bibliographies of relevant review articles and publications in the field. The titles and abstracts of these publications were screened by the same two researchers together. In the event of any disagreement, two more reviewers (F.A. and P.C) were involved as reported previously. The level of evidence of included studies was assessed based on the definitions of the Oxford Centre for Evidence-Based Medicine[9]. The risk of bias in individual studies was assessed by means of the Newcastle–Ottawa quality assessment scale[10]. 2.3.

Data collection and measures

Descriptive data were collected, including the study population (dates of recruitment, number of patients, age), indications for hepatobiliary and digestive tract surgical oncology in individuals aged 80 years and older, and surgical procedures performed. The total number of patients with complications was determined. In comparative studies between non-elderly patients and those aged 80 and older, morbidity was analyzed, including complications that occurred during the same hospital stay, and information on each patient was summarized for the whole admission period. Where

complications had been reported separately, their highest rate was used for analysis. The severity of complications was also assessed for each strategy using the Clavien– Dindo classification [11]. Mortality was reported as in-hospital and 90-day mortality. In studies where long-term oncological outcomes were also included, we analyzed overall survival and other survival parameters such as disease free-survival, recurrence-free survival, or cause-specific survival. 2.4.

Data synthesis

Missing mean and standard deviation data were calculated from reported median and range values [12], unless the corresponding authors provided the actual data. For quantitative synthesis of comparative studies, a fixed-effect or random-effects metaanalysis was used, as appropriate, with standardized mean differences reported for continuous outcomes and risk ratios (RRs) for binary outcomes, along with 95% confidence intervals (CI) and two-sided P values for each outcome. These analyses were carried out in Review Manager (RevMan) version 5.3 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark). Summaries of the intervention effects for single-group, non-comparative studies were similarly reported using Comprehensive Meta-Analysis software (Biostat, Englewood, New Jersey, USA) with random-effects meta-analysis, as reported previously. Heterogeneity between studies in effect measures was assessed using both the χ2 test and the I2 statistic.

3. RESULTS 3.1.

Study Selection and Characteristics

The initial database search resulted in 8069 hits. Screening of the bibliographies of relevant review articles and publications in the field yielded 21 additional articles not found in the automatic database search. After removal of duplicates, 8064 records remained. After screening by title and abstract, 351 articles were identified and

underwent review of the full text. Most were excluded due to a lack of specific outcome data on elderly patients over the age of 80 (n = 191). Others were excluded because they were in a language other than English (n = 70), letters or editorials (n = 9), or redundant publications from the same institution (n = 2). Refer to Figure 1 for a detailed flow schema according to PRISMA guidelines. Characteristics of comparative and noncomparative studies are shown in Table 1 and Table 2. Forest plots comparing morbidity and mortality between old vs young patients in different surgical strategies are shown in figures 2-4. According to the year of publication of each article, we observed an increase in the number of articles on cancer surgery in elderly patients in the last 10 years, especially in colorectal and pancreatic surgery (Figure 5). Of all the studies included, most of them were from Asian authors (53.6%), mainly from Japanese institutions (Figure 6). Oncological surgery for stomach cancer in the elderly was the type of surgery most frequently reported by Oriental authors (92% of the articles), and there was a difference regarding colon and rectal surgery, reported by occidental authors in most cases. Regarding the surgical approach, only 14 of the 79 studies analyzed the laparoscopic approach (3 in the stomach and 11 in the colorectal group). In colorectal surgery, 10 of the 11 studies compared open versus laparoscopic surgery, and in all the studies, morbidity and mortality were lower in the laparoscopic group or equal in the two groups. 3.2.

Esophageal surgery

A total of 177 patients from seven studies[9-15] were included in the meta-analysis. Morbidity and mortality rates in older patients were 41.8% (95% CI 2.72 to 5.81) and 10.2% (95% CI 0.6 to 1.62) and in young patients, 42.7% (95% CI 3.36 to 5.23) and 3% (95% CI 0.2 to 0.4), respectively. Comparison of morbidity between young and old patients demonstrated similar risk levels in older patients (RR 1.01, 0.68 to 1.49; P = 0.98). Heterogeneity among included studies was I2 = 82%; P < 0.01. The risk of

mortality after esophageal surgery was higher in older patients (RR 2.51, 1.50 to 4.21; P = 0.0005). Heterogeneity among included studies was I2 = 0%; P = 0.59. Overall survival was 9%–49.2% at 5 years. Of the five studies that compared overall survival in individuals aged 80 years and older with non-aged individuals, four had statistically significantly worse survival (Table 3). 3.3.

Gastric surgery

A total of 2,030 patients from 26 studies[16-42], were included in the meta-analysis. Morbidity and mortality rates in older patients were 29% (95% CI 2.33 to 3.54) and 3.8% (95% CI 0.28 to 0.53) and in young patients, 21.8% (95% CI 1.77 to 2.65) and 1.4% (95% CI 0.1 to 0.2), respectively. Comparison of morbidity between young and old patients demonstrated a higher risk in older patients (RR 1.25, 1.09 to 1.43; P = 0.001). Heterogeneity among included studies was I2 = 46%; P = 0.02. The risk of mortality after gastric surgery was higher in older patients (RR 2.51, 1.81 to 3.49; P = 0.0001). Heterogeneity among included studies was I2 = 0%, P = 0.63. Overall survival was 73.3%–86.4%, 54.1%–83.8%, and 25.8%–83.8% at 1, 3, and 5 years, respectively. Of the studies that compared overall survival between individuals aged 80 years and older and non-aged individuals, 10 found statistically significantly worse survival (Table 4). 3.4.

Liver surgery

A total of 64 patients from four studies were included in the meta-analysis[43-46]. Morbidity and mortality rates in older patients were 31.3% (95% CI 1.85 to 4.78) and 3% (95% CI 0.08 to 1.14) and in young patients, 30.9% (95% CI 1.91 to 4.59) and 1% (95% CI 0.04 to 0.3), respectively. Comparison of morbidity between young and old patients demonstrated similar risk levels between the two groups (RR 1.03, 0.71 to 1.48; P = 0.89). Heterogeneity among included studies was I2 = 0%; P = 0.96. The risk of mortality after liver surgery was similar in older patients (RR 1.74, 0.32 to 9.48; P = 0.52. Heterogeneity among included studies was I2 = 0%; P = 0.61.

Overall survival was 26%–78% at 5 years, and there were no statistically significant differences between studies comparing the overall survival of individuals aged 80 years and older with that of non-aged individuals (Table 5). 3.5.

Pancreatic surgery

A total of 1,640 patients were included in the meta-analysis[47-66]. Morbidity and mortality rates in older patients were 48.9% (95% CI 4.36 to 5.42) and 5.3% (95% CI 0.41 to 0.67) and in young patients, 41.3% (95% CI 3.72 to 4.56) and 2% (95% CI 0.18 to 0.30), respectively. Comparison of morbidity between young and old patients demonstrated higher risk in older patients (RR 1.17, 1.03 to 1.33; P = 0.02). Heterogeneity among included studies was; I2 = 76%; P = 0.0001. Similarly, the risk of mortality after pancreatic surgery was higher in older patients (RR 2.37, 1.86 to 3.03; P < 0.00001). Heterogeneity among included studies was I2 = 1%; P = 0.44. Overall survival was 38.7%–73%, 0%–33%, and 0%–46% at 1, 3, and 5 years, respectively. Of the 15 studies that compared the overall survival of individuals aged 80 years and older with that of non-aged individuals, 3 showed statistically significantly worse survival (Table 6). 3.6.

Colorectal surgery

A total of 114,672 patients were included in the meta-analysis[67-74]. Morbidity and mortality rates in older patients were 31.9% (95% CI 2.53 to 3.94) and 5.4% (95% CI 0.42 to 0.69) and in young patients, 17.4% (95% CI 0.94 to 2.99) and 1.8% (95% CI 0.1 to 0.32), respectively. Comparison of morbidity between young and old patients demonstrated similar risk levels between the two groups (RR 1.58, 0.89 to 2.80; P = 0.12). Heterogeneity among included studies was I2 = 96%; P < 0.00001. The risk of mortality after colorectal surgery was higher in older patients (RR 4.44, 1.91 to 10.32; P = 0.005). Heterogeneity among included studies was I2 = 82%; P < 0.00001. Only three studies analyzed overall survival. They found an overall survival of 94.95% up to 22.7 months, 70.2%–85.5% at 3 years, and 56% at 5 years (Table 7).

4. DISCUSSION Since the beginning of the 1950s, there have been studies related to oncological surgery in patients aged 80 years and older, but the topic has been studied more intensively in the last 25 years in this subpopulation of patients. The decision of whether or not to operate on an elderly patient can be very difficult, and chronological age by itself is not an absolute contraindication. Most studies that have compared the results between elderly and younger patients after esophageal resection have obtained comparable morbidity outcomes. However, some authors, such as Tapias et al.[18], describe worse results with a significant increase in postoperative complications in patients ≥80 years of age: 62.5% compared to 47.6% in patients aged 70–79 years and 37.2% in patients aged <70 years. In addition, the lethality of surgical complications after esophagectomy is strongly related to age (up to eight times greater in the case of anastomotic leak). These results coincide with the present analysis, which found comparable morbidity and significantly higher mortality in the elderly group. Gastric cancer, like esophageal cancer, is considered a disease of the elderly with a peak incidence in the seventh decade of life. Oncological surgery experience with stomach cancer in the elderly was reported most frequently by Asian authors. The results of the present study confirmed that the short-term outcomes of this type of surgery are the worst in elderly patients. Nonetheless, some authors (Kubota et al.[23], Katai et al.[26], Coniglio et al.[27]) reported similar postoperative morbidity and mortality rates after gastric curative resection in individuals aged 80 years and older and in patients under 80 years of age, especially without comorbidities. Thus, in this cohort of patients, the selection criteria are the keys to improving the results.

The largest number of diagnoses of colon and rectal cancer occur between 80 and 89 years of age. In agreement with the trend of this study, a systematic review of patients with colon cancer compared the results of individuals aged 80 years and older and nonagenarian patients, with the latter having worse results in terms of morbidity, mortality,

and

readmission

rates.

Regarding

rectal

cancer,

two

multicenter

studies[87,90] confirmed the increase in postoperative morbidity and mortality (from 0.5% in patients under 50 years of age to 13% in patients over 80 years of age). In addition, similarly to results for esophageal cancer, anastomotic leakage is associated with a significant increase in mortality in individuals aged 80 years and older (sepsis, abscesses, cardiac and pulmonary complications) compared with younger patients. A recent study[92] designed and internally validated a simple score for predicting perioperative mortality, and they concluded that patients aged 80 years or older, with chronic obstructive pulmonary disease, who underwent palliative surgery would have a 23.5% risk of death within 30 days of the intervention. Age has been identified as a risk factor in the short-term outcomes of pancreatic surgery. Although advocates of surgical resection in the elderly population have found rates of immediate postoperative complications similar to those of younger patients, most studies report higher morbidity and mortality rates in the older age group compared with young people. Nevertheless, it should be noted that in the present review, more than 90% of the procedures were distal pancreatectomies. On the other hand, the John Hopkins series[52], which includes resected patients older than 90 years, describes a mortality rate of 4.1% in patients over 80 years of age and 1.7% in those under 80 years of age, concluding that age is not an independent factor for mortality. That shows that possibly in superspecialized centers with a large volume of patients

similar

results

can

be

achieved

in

elderly

patients

even

in

duodenopancreatectomies. Nevertheless, it should be noted that in the present review, more than 90% of the procedures were distal pancreatectomies.

In individuals aged 80 years and older, experience in liver surgery is scarce; there are multiple studies on hepatectomies in elderly patients (under 80 years), but the results are controversial, both in hepatocarcinoma and liver metastases of colorectal cancer. A recent meta-analysis[93] reported that elderly patients undergoing major hepatectomy did not show statistically significant differences in morbidity and mortality compared with young patients. The resection of hepatic metastases from colorectal cancer in elderly patients has been shown to be safe, with morbidity and mortality similar to that in the non-elderly population; however, it has been described that the rate of surgical resection of liver metastases from colorectal cancer is only 8%–20% in older patients. In this group of patients it seems that the results are similar and the morbidity of the patients seems to be more related to their comorbidities than to the surgical procedure itself. Therefore, although no statistically significant differences have been found in the present study, we must be very cautious in the interpretation of the results and more studies are needed in this subpopulation of patients. Among the studies comparing the different types of surgery in non-octogenarians, morbidity was higher in gastric and pancreatic surgery in those aged 80 years and older, but these results should be interpreted with care due to the heterogeneity of the studies. Regarding mortality, excluding liver surgery (with only 4 studies included) in all the other etiologies, it was higher in patients aged 80 years and older, and only in the colorectal surgery group was there no heterogeneity between studies. Regarding the laparoscopic approach in this cohort of patients, with the exception of respiratory complications, a decrease in postoperative morbidity was described, probably related to lower intraoperative blood loss, lower requirements for analgesia, earlier ambulation, and shorter hospital stays. All these aspects are crucial to a better recovery in elderly patients. Only in the gastric and colorectal groups, the laparoscopic approach was analyzed in the literature and, in elderly patients, the laparoscopic group showed, in all studies, lower or equal morbidity and mortality relative to the open group.

A recently published meta-analysis about laparoscopic liver surgery in elderly patients between 65 and 75 years of age indicated that laparoscopy is a feasible and safe alternative to open surgery, providing a lower rate of morbidity and favorable postoperative recovery and outcomes[94]. Thus, minimally invasive surgery is a way to improve the results and reduce the percentage of complications in this population of patients due to that the intrinsic characteristics of the laparoscopic approach can help to obtain better results in these patients since they would be subjected to less surgical aggression.

The analysis of long-term oncological results in this group of patients is complicated by frequent death from causes unrelated to cancer. Few studies have analyzed these long-term oncological results, and most of them examined overall survival and not cancer-specific survival. It is difficult to compare both patient populations because survival in the group of elderly patients is possibly due to causes other than cancer. To make a correct comparison between the two groups, we value the inclusion of specific cancer-related survival, but unfortunately, the vast majority of the articles included in the study did not collect this data. Nevertheless, regarding overall survival, outcomes of esophageal and stomach cancer are worse in older than in younger individuals; outcomes of pancreatic and liver cancer are similar in both groups of patients; and the experience in colorectal cancer in the articles included in this meta-analysis is minimal. 4.1.

Limitations

Despite the frequency with which cancer is described in the elderly population, this subpopulation of patients continues to be underrepresented in cancer research and in the literature. One of the main drawbacks of any study on the elderly population is the difficulty of starting a prospective study and the relatively small sample size of the series. Some of the limitations mentioned above are reflected in the present meta-

analysis. Although we present the largest meta-analysis on hepatopancreatobiliary and digestive tract oncological surgery in patients aged 80 years and older, the biases of the study may have led to a lack of statistical significance in the differences observed in morbidity and survival rates. It is important to emphasize that elderly patients represent a very select subpopulation, and even when a considerable number of elderly patients are included, the results cannot be extrapolated to the entire elderly population. Normally, the inclusion criteria are too strict and make it difficult to generalize the study results; however, criteria that are too broad may endanger patient safety and generate an excessively heterogeneous study population. With respect to the risk of biases arising from the selection of patients and the realization of the meta-analysis, we have minimized these by carrying out our study in the same way as previous ones [95-97]. Finally, we did not analyze elderly persons with and without comorbidities, and of course elderly people tend to have more comorbidities and respectively more mortality. Conclusions After oncological surgery, older patients have a higher morbidity and mortality than young patients. Patients aged 80 years and older showed an increase in morbidity after gastric and pancreatic surgery and an increase in mortality in all etiologies, excluding liver surgery. 4.2.

Future perspectives

The main challenge in the medical-surgical treatment of cancer in the elderly lies fundamentally in treating the disease with a curative intent without putting the patient’s life at risk, allowing them to return to their daily lives and thus improve their life expectancy, or at least not decrease it with the surgical procedure. Selection criteria are the key to improving postoperative outcomes. In order to do so, the Comprehensive Geriatric Assessment (CGA)[98] provides better information on the problems of nutrition, cognition, coping with daily tasks, other health problems, and quality of life.

The importance of the CGA for predicting the results of surgery has been widely described[99-102]. Preoperative deterioration, cognitive status, low albumin levels, a history of previous falls, a low hematocrit level, any functional dependence, or a high burden of comorbidities are closely related to increased mortality in the first 6 months after discharge in patients undergoing abdominal cancer surgery. In summary, oncological surgery for tumors of the hepatobiliary and digestive tracts in individuals aged 80 years and older can be carried out carefully as long as it is tailored to those patients who present a favorable geriatric integral assessment, choosing the correct surgical indication, a precise surgical technique, an adequate preoperative treatment, and postoperative management that meets the patient’s needs. It seems that the management of these patients in centralized centers and the use of minimally invasive approaches it is may be the way to improve postoperative results.

5. CONFLICT OF INTEREST AND FINANCIAL DISCLOSURES Authors declare no conflict of interest, funding or financial disclosures.

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Figure legends Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Flow Diagram of the Systematic Literature Search and Review Protocol.

Figure 2. Forest plots comparing morbidity and mortality between old vs young patients in different surgical strategies: A: Morbidity after esophagus surgery. B: mortality after esophagus surgery. C: Morbidity after stomach surgery. D: mortality after stomach surgery. Risk ratios are shown with 95 per cent confidence intervals.

Figure 3. Forest plots comparing morbidity and mortality between old vs young patients in different surgical strategies: A: Morbidity after liver surgery. B: mortality after liver surgery. C: Morbidity after pancreas surgery. D: mortality after pancreas surgery. E: Morbidity after colon/rectum surgery. F: mortality after colon/rectum surgery. Risk ratios are shown with 95 per cent confidence intervals.

Figure 4. Forest plots comparing morbidity and mortality between old vs young patients in colorectal suergery: A: Morbidity after colon/rectum surgery. B: mortality after colon/rectum surgery. Risk ratios are shown with 95 per cent confidence intervals.

Figure 5: Published articles according to the year of publication and the type of surgery.

Figure 6: Published articles according to according to the place of publication (oriental vs occidental) and the type of surgery.

Table 1. Characteristics of comparative studies with evidence level and bias evaluation (n = 53).

Author

Year

Country

Alexiou et al.13 Moskovitz et al. 14 Morita et al.16 Zehetner et al.17 Tapias et al.18 Miyata et al.19 Tsujitani et al.20 Hanazaki et al.21 Katai et al.22 Kubota et al.23 Eguchi et al.25 Coniglio et al.27 Hsu et al.30 Mita et al.32 Takeshita et al.34 Fujiwara et al.36 Miyasaka et

1998 UK

Esophagus

Old/youn gn 36/134

Evidenc e level 3b

Quality score 7

2006 USA

Esophagus

31/309

3b

8

2008 Japan 2010 USA

Esophagus Esophagus

16/652 47/513

3b 3b

7 9

2013 USA 2015 Japan 1996 Japan

Esophagus Esophagus Stomach

16/458 23/300 43/1399

3b 3b 3b

8 8 8

1998 Japan

Stomach

50/239

3b

9

1998 2000 2003 2004

Stomach Stomach Stomach Stomach

112/2664 33/568 80/2095 53/228

3b 3b 3b 3b

8 7 8 8

2012 Taiwan 2013 Japan 2013 Japan

Stomach Stomach Stomach

164/2258 60/336 104/1089

3b 3b 3b

9 8 9

2014 Japan

Stomach

81/251

3b

8

2015 Japan

Stomach

9/253

3b

8

Japan Japan Japan Italy

Surgery

al.37 Mikami et al.39 Sakurai et al.40 Takeuchi et al.42 Zhou43 Yang et al.44 Casella et al.45 Wu CC et al.46 Nanashima et al.47 Yamada et al.48 Nozawa et al.49 Sohn et al.50 Chen et al.51 Makary et al.52 Tani et al.53 Lee et al.55 Khan et al.56 Hatzaras et al.57 De la Fuente et al.58 Nanashima et al.59

2015 Japan 2015 Japan

Stomach Stomach

47/394 95/336

3b 3b

9 7

2015 Japan

Stomach

186/807

3b

8

2015 Japan 2017 Korea 2017 Italy

Stomach Stomach Stomach

39/690 68/756 26/34

3b 3b 3b

7 7 8

1999 Taiwan 2011 Japan

Liver Liver

21/239 12/176

3b 3b

8 8

2012 Japan

Liver

11/267

3b

8

2014 Japan

Liver

20/411

3b

7

1998 2003 2006 2009 2010 2010 2011

Pancreas Pancreas Pancreas Pancreas Pancreas Pancreas Pancreas

46/681 16/82 207/2491 25/310 74/703 53/564 27/490

3b 3b 3b 3b 3b 3b 3b

8 7 8 8 8 9 9

2011 USA

Pancreas

593/5700

3b

7

2012 Japan

Pancreas

6/141

3b

8

USA Taiwan USA Japan USA USA USA

Melis et al.60 Turrini et al.61

2012 USA 2013 France

Pancreas Pancreas

25/175 64/868

3b 3b

9 8

Belyaev et al.62 Oguro et al.63 Beltrame et al.65 Tamirisa et al.66 Sho et al.67 Sugiura et al.68 Isbister et al.69 Smith et al.71 Maeda et al.76 Al-Refaie et al.77 Pawa et al.80 Bircan et al.84 Vallribera et al.85 Tabbakh et al.86 Pirrera et al.89

2013 Germany

Pancreas

76/1629

3b

9

2013 Japan 2015 Italy

Pancreas Pancreas

22/539 23/362

3b 3b

8 9

2016 USA

Pancreas

198/2496

1b

9

2016 Japan 2017 Japan

Pancreas Pancreas

99/1302 28/199

3b 3b

8 8

1997 New Zealand 2002 UK 2011 Japan 2011 USA

Colon/rectum

88/1923

3b

9

Colon/rectum Colon/rectum Colon/rectum

1b 3b 1b

8 8 9

2012 UK 2014 Turkey 2014 USA

Colon/rectum Colon/rectum Colon/rectum

65/235 59/283 4162/1521 3 130/558 56/109 90/455

1b 3b 3b

8 8 8

2015 UK

Colon/rectum

10/57

4

8

2016 Italy

Colon/rectum

291/1106

3b

8

Table 2. Characteristics of non-comparative studies with evidence level and bias evaluation (n = 26).

Author

Yea r

Countr y

Surgery

Old/youn gn

Eviden ce level

Takeno et al.15 Otani et al.24

200 8 200 0 200 4 201 0 201 2 201 2 201 3 201 3 201 5 201 5 200 9 201 5

Japan

8

3b

Japan

Esophagu s Stomach

Qualit y score 6

18

3b

6

Japan

Stomach

141

4

6

Japan

Stomach

18

4

7

Japan

Stomach

83

3b

6

Japan

Stomach

212

4

6

Japan

Stomach

24

4

6

Japan

Stomach

24

4

6

Korea

Stomach

99

3b

5

Japan

Stomach

161

3b

6

USA

Pancreas

32

4

6

Japan

Pancreas

26

3b

5

Katai et al.26 Yamada et al.28 Hayashi et al.29 Isobe et al.31 Oya et al.33 Yamada et al.35 Kwon et al.38 Takama et al.41 Hardacre et al.54 Kinoshita et al.64

Stewart et al.70 Vignali et al.72 Tan et al.73 Kurian et al.74 Lian et al.75 Issa et al.78 Pinto et al.79 Savlovschi et al.81 Hatakeyama et al.82 Jafari et al.83 Hinoi et al.87 Gomes et al.88 Niitsu et al.90 Roscio et al.91

199 9 200 5 200 9 201 0 201 0 201 1 201 1 201 3 201 3 201 4 201 5 201 5 201 6 201 6

Australi a Italy Japan USA USA Israel USA Romani a Japan USA Japan Portuga l Japan Italy

Colon/rect um Colon/rect um Colon/rect um Colon/rect um Colon/rect um Colon/rect um Colon/rect um Colon/rect um Colon/rect um Colon/rect um Colon/rect um Colon/rect um Colon/rect um Colon/rect um

77

4

6

122

3b

5

121

4

6

245

4

6

194

3b

7

93

3b

6

199

3b

7

36

4

7

82

3b

7

106921

2b

7

918

3b

8

139

3b

7

398

3b

6

129

3b

5

Table 3. Esophagus. Author

Year

Numb

Age

er

Median

Morbility

age

(%)

e.s.

Mortality

e.s.

OS

s.s.

DFS

(%)

s.

Surgical

s.

procedures

Alexiou et 13 al.

1998

36

≥ 80

81.5±1.7

36.1

ns

5.6

ns

Median: 20 m 19.8% at 5 y

ns

-

-

LT (99), L+RT (45), TH (5)

Moskovitz et 14 al.

2006

31

≥ 80

-

16.1*

ns

19.4

p<0 .01

Median: 16.8 m

p=0 .01

-

-

-

Takeno et 15 al.

2008

8

≥80

-

37.5

-

12.5

-

37.5% at 5 y

-

-

-

-

Morita et al.

2008

16

≥ 80

-

25

p<0 .05

6

p<0 .01

36% and 9% at 3 and 5 y

p<0 .01

-

-

GP (14), CP (2)

Zehetner et 17 al.

2010

47

≥ 80

82 (8186)

53 (26)

ns

9

ns

Median: 19.7 m

p= 0.0 002 p=0 .00 06 -

-

-

16

TH (37), TT (4), Thoracoscopic (3) 18 Tapias et al. 2013 16 ≥ 80 82.2±1.6 87.5 (62.5) p<0 6.3 p= 49.2% at 5 y L+RT (7), LT .01 0.0 (4), TH (4), 1 08 L+RT+C (1) 19 Miyata et al. 2015 23 ≥85 47.8 ns 0 ns 41.5% at 5 y L+RT (16), L+RT+C (4), TH (1) *Major complications. L: laparoscopic approach. O: Open aprpoach. Ro: robot. s.s. statistically significant difference between young and elderly; ns: non significant. m: months. y: years. TT: A thoracotomy was performed (unespecified). TH: transhiatal. L: Laparotomy. RT: Right thoracotomy. C: Cervicotomy. LT: Left thoracotomy / thoracoabdominal approach. GP: Gastroplasty. CP: Coloplasty. YP: Yeyunoplasty.

Table 4. Stomach. Author

Year

Numb

Age

er

Median

Morbility

age

(%)

e.s.

Mortality

e.s.

OS

s.s.

DFS

(%)

s.

Surgical

s.

procedures

Tsujitani et 20 al.

1996

43

≥80

-

34.8

ns

5

ns

28 and 4.4 at 5 and 10 y

p˂0 .05

-

-

18% TG

Hanazaki et 21 al.

1998

50

≥80

81.8 (8095)

10

ns

2

ns

73.3, 57.7 and 46.1 at 1, 3 and 5y

p˂0 .01

n s

18% TG

Katai et al.

1998

112

≥80

82.7

32.1

ns

10.7

p˂0 .01

32.6 at 5 y

p˂0 .05

OS curative resection: 91.1, 82.2 and 65 at 1, 3 and 5 y OS curative resection: 44.4 at 5 y

28.5% TG

Kubota et 23 al.

2000

33

≥80

-

39.4

ns

3.5

ns

53.2 and 53.2 at 5 and 10 y

-

-

Otani et al.

2000

18

≥85

61.1

-

11.1

-

-

-

-

22.2% TG

Eguchi et 25 al.

2003

80

≥80

87.3 (8591) -

p=0 .00 04 -

p ˂ 0. 0 5 -

18.8

ns

3.8

ns

-

P< 0.0 001

Diseasespecific survival

-

Katai et al.

2004

141

≥80

83 (8094)

27

-

0

-

59 and 48.8 at 3 and 5 y

-

Coniglio et 27 al.

2004

53

≥80

83.1± 2.7

16

ns

8

ns

25.8% at 5 y

p< 0.0 01

OS curative resection: 70 and 56.5 at 3 and 5 y Diseasespecific survival

p < 0. 0 1) -

22

24

26

n s

31.2% TG

36% TG

Yamada et 28 al. Hayashi et 29 al. 30 Hsu et al.

2010

18(L)

≥80

82±1.5

38.8*

-

0

-

-

-

-

-

11.1% TG

2012

83

≥80

-

18 (8.4*)

-

3.6

-

-

-

-

-

22% TG

2012

164

≥80

83 (80– 93)

18.3

p˂0 .03

3

ns

-

23.8% TG

2012

31.1 16.1 23.3 16.8

-

ns -

1.9 1.8 0 0

-

2013 2013

ns -

-

-

-

24.8% TG 8.9% TG 23.3% TG 16.7% TG

Takeshita et 34 al.

2013

104

≥80

81.8±1.4 86.5±1.8 84.5±3.9 83.75 ±3.13 -

-

32

80-84 ≥85 ≥80 ≥80

-

Mita et al. 33 Oya et al.

161 51 60 24

p< 0.0 01 -

-

Isobe et al.

54.1, 44.9 and 35.5 at 3,5 and 10 y 68.5 at 5 y 70.1 ay 5 y -

32.7

ns

1.9

ns

-

-

n s

24% TG

Yamada et 35 al. Fujiwara et 36 al.

2013

24

≥ 85

86±1

58.3

-

8.3

-

-

p=0 .00 01 -

-

-

37.5% TG

2014

81

≥80

83.5

13.6

ns

4.9

p=0 .04

86.4, 61.9 and 47,1 at 1, 3 and 5y

p˂0 .00 1

p = 0. 0 3

24.6% TG

Miyasaka et 37 al. 38 Kwon et al.

2015

9 (L)

≥85

86.7±2.3

11

ns

0

ns

-

-

Cause specific survival: 90.2, 66.5 and 58.9 at 1, 3 and 5 y -

-

-

2015

30 (L) 69 (O)

≥80

82.3 ± 2.4 82.8 ± 2.3

30 (13.3) 34.8 (15.9)

-

0 2.9

-

70% at 5 y (L) 52% at 5 y (O)

-

Mikami et 39 al.

2015

47

≥80

82 (80– 89)

36.2

0

ns

-

Sakurai et 40 al. Takama et 41 al.

2015

95

≥80

82.9±2.3

23.2 (7.4)

p=0 .04 9 ns

1.1

ns

2015

161

≥85

-

41.4(10.3)

-

3.4

-

31

-

13.3% TG (L) 33.3% TG (O)

-

DFS: 81.8 at 5 y (L) 65.1 at 5 years (O) -

-

31.9% TG

-

-

-

-

29.5% TG

83.8, 83.8 and 83.8 at 1, 3 and

-

-

-

24.1% TG

Takeuchi et 42 al.

2015

186

≥80

83.9±3.1

68.8 (12.4)

43

2015

39

≥80

82 (8083)

47.8 (12.7*)

Yang et al.

2017

68

≥80

82.4 ± 2.4

14.7

Casella et 45 al.

2017

26

≥80

-

23.1

Zhou

44

p˂0 .00 1 p˂0 .00 1 P= 0.0 43 ns

1.6

ns

5y -

2.6

ns

-

-

-

-

46.2% TG

4.4

P= 0.0 05 ns

-

-

-

-

20.6% TG

-

p= 0.0 2

-

n s

19.2% TG

15.3

-

-

-

22.6% TG

*Major complications. L: laparoscopic approach. O: Open aprpoach. s.s. statistically significant difference between young and elderly; ns: non significant. m: months. y: years. TG: total gastrectomy.

Table 5. Liver. Author

Year

Number

Age

Medi

Morbility

e.

Mortality

an

(%)

s.

(%)

e.s.

OS

s.s.

DFS

s.s.

Surgical procedures

age Wu CC et

1999

46

al.

21 (81%

≥80

C)

82.7

14.3

ns

0

ns

50.6 at 5 y

ns

-

-

14.3

50

ns

0

ns

78% at 5 y

ns

36% and 0%

ns

25

-

±3.1 (8089

Nanashim a et al.

2011

47

Yamada et

12 (33%

˃80

C) 2012

11

at 3 and 5 y ˃80

48

al.

Nozawa et 49

al.

-

80.8

36 (9*)

ns

30

ns

0

ns

26% at 5 y

ns

-

-

ns

66,9% at 5y

ns

33,7% at 3 y

-

±1 2014

20

≥80

81.5 ±1.5

0

5

*Major complications. L: laparoscopic approach. O: Open aprpoach. Ro: robot. s.s. statistically significant difference between young and elderly; ns: non significant. m: months. y: years. C: Cirrhotics. MH: Major hepatectomy.

Table 6. Pancreas. Author

Year

Number

Age

Medi

Morbility

e.

Mortality

an

(%)

s.

(%)

e.s.

OS

s.s.

DFS

s.s.

Surgical procedures

age Sohn

et

1998

46

≥80

50

al.

Chen

et

2003

16

≥80

51

al.

82

57

p

4.3

ns

Median:

38

(80-

=

m

90)

0.

73%,

0

and 20% (at

5

1, 2 and 5 y)

81.5(

51

ns

13

ns

80-

ns

-

-

PD

(45),

TP

(1) 65%

Median: 17,6

ns

-

-

p<0.

-

-

m

89) Makary et 52

al.

2006

197

80-89

82

52.8

p

4.1

p=0

Median:

19

10

≥90

(80-

50

<

0

.02

m

001

(187), TP (10),

-

59.1%,

p<0.

vascular

002

resections (5)

90)

0.

90

0

45,8%

(90-

5

24,4% at 1, 2

103)

ns

and 5 y

and

≥90: Median:

15

m 60%,

25%

and 0% at 1, 2 and 5 y

80-89:

PD

≥90: PD (10)

Tani

et

2009

25

≥80

53

al.

Hardacre

2009

32

≥80

54

et al.

82.3(

44

ns

0

ns

-

-

-

-

PD

(25),

80-

vascular

87)

resection (1).

82

66

-

0

-

Median: 14,4

(80-

months

89)

57%,

ns

-

PD (26), DP (5),

TP

(1),

vascular

49%,

and 24% at

resections (4).

1, 2 and 5 y 55

Lee et al.

2010

74

≥80

82.6

47.3

(81.4

(18.9)

ns

5.4 at 1 m

ns

-

-

-

-

PD

(74),

vascular

-

resections (11)

84.4) Khan

et

2010

53

≥80

-

51

-

2

ns

56

al.

Median:

13,

ns

5m

Hatzaras

2011

27

≥80

57

et al.

83.4

52

ns

3.7

ns

m

91)

56.6%

ns

11,8 m

Median: 33.3

(80-

Median DFS:

ns

-

PD (78), DP (10), TP (4).

-

PD (20), DP (5)

and

33.1% at 2 and 5 y De

la

Fuente et 58

al.

2011

593

≥80

82.9

45.2

p

±2.6

(32.2)

< 0. 0

6.35

p<0 .05

-

-

-

-

PD (593)

5 Nanashim a et al. Melis

2012

6

≥80

-

50

ns

0

ns

-

-

-

-

PD (3), DP (3)

2012

25

≥80

83.1

68

p

4% at 1 m

ns

Median: 17,3

ns

-

-

PD (25)

ns

-

-

PD (56), DP

59

et

60

al.

±2.4

Turrini et

2013

64

≥80

61

al.

83(8

56

=

m

0.

68.2%

0

4.5%

3

and 5 y

ns

4.7

ns

0-87)

and at

1

Median:

30

m

(8),

38.7%,

resections (7).

33.2%

and

0%

1,3

at

vascular

and 5 y Belyaev et

2013

76

≥80

62

al.

82.3

72.4

p

9.2

(80-

(21.1)

=

19.7 at 1

61.4%,

0.

and 3 m

44.6%

92)

and

ns

Median: 18

ns

-

-

PD (27), DP (3), TP (8)

and

0

18.8% at 1, 2

0

and 5 y

0 1 Oguro 63

al.

et

2013

22

≥80

81.5

(27.3)

p

4.5 at 1 m

ns

Median:

43

ns

Median DFS:

(80-

=

m

13 m

90)

0.

46% at 5 y

0% at 5 y

ns

PD (22)

0 0 8 Kinoshita

2015

26

≥80

64

et al.

82

50 (8)

-

0 at 1 m

ns

Median: 12,4

ns

-

-

PD (16), DP

(80-

m

(9),

TP

87)

50% at 1 y

vascular

(1),

resections (10) Beltrame

2015

23

≥80

65

et al.

82.6

43

N

0 at 1 m

-

(80-

Median:

19

ns

m

Median:

13

ns

PD (21), TP (2), one patient underwent multivisceral resection.

-

PD (142), TP

m

86)

Tamirisa

2016

198

≥80

66

et al.

82.9

39.4

± 2.8

(29.3)

N

3%

p=0

-

-

-

.02

(3), DP (50), enucleation (1),

vascular

resections (35) Sho

et

2016

99

≥80

-

23

N

2

N

67

al.

Median 16.6

P=0.

m

006

55%, and

-

P=0-

-

013

11% 3%

at

1,3 and 5 y Sugiura et 68

al.

2017

28

≥80

82

7.7

N

0

N

Median:

14

(80–

m

88)

61%, 4% and

P<0.

Median: 7 m

P=0.

PD

001

39%, 4% and

016

vascular

4% at 1, 3

(28),

resections.

10

4% at 1, 3

and 5 y

and 5 y *Major complications. L: laparoscopic approach. O: Open aprpoach. s.s. statistically significant difference between young and elderly; ns: non significant. m: months. y: years. TP: Total pancreatectomy. PD: Pancreaticoduodenectomy. DP: Distal pancreatectomy. CP: Central pancreatectomy. Vascular resection refers venous resection.

Table 7. Colon and rectum.

Author

Year

Number

Age

Medi

Morbility

e.

Mortality

an

(%)

s.

(%)

e.s.

OS

s.s.

DFS

s.s.

Surgical procedures

age Isbister et 69 al.

1997

88

≥80

Stewart et 70 al.

1999

42 (L) 35 (O)

≥80

Smith et 71 al.

2002

65

Vignali et 72 al.

2005

Tan et 73 al.

Kurian et 74 al.

43*

ns

11.9

p<0 .02

-

-

-

-

>80: 14 RH, 3 LH, 11 SC, 1 TC, 6 AR, 5 APR, 6 HO, 17 others. Total: 14 RH, 4 LH, 30 SC, 10 AR, 17 APR, 2 others. >80: 49,3% RH, 15,4% SC, 5,8% APR.

84 (80– 94)

16.6 57.1

-

7.1 11.4

-

-

-

-

-

≥80

83 (8093)

46.4

10.1

ns

59% at 5 y

ns

-

-

61 (L) 61 (O)

≥80

21.5 31.1

2,4

-

-

-

-

Total: 36 RH, 30 LH, 22 SC, 31 AR+APR.

2009

121

≥80

82.3 (2.3) 83.1 (3.1) 83.5 (8099)

p < 0. 0 0 1 H 2

30.6 (26.4*)

-

1.6

-

94.9% at 22.7 m

ns

-

-

2010

150 (L) 95 (O)

≥80

84.3 (80– 95) 84.9 (80–

23 42

-

2 9.5

-

-

-

-

-

Total: 55 SR, 2 RH, 31 SC, 21 AR, 8 APR, 2 HO, 2 Others Total: RH: 128, LH: 103.

94) 82.8 (3.3) 82.8 (3.2) 83,5 +-3.7

Lian et 75 al.

2010

97 (L) 97 (O)

≥80

Maeda et 76 al.

2011

59

>80

Al-Refaie 77 et al.

2011

4162

>80

-

2.55*

Issa et 78 al.

2011

47 (L) 46 (O)

≥80

30.4 35.6

Pinto et 79 al.

2011

83 (L) 116 (O)

≥80

83.6 (3.6) 82.9 (2.9) 84.7 ± 0.4 84.3 ± 0.3

Pawa et 80 al.

2012

130

≥80

Savlovsch 81 i et al.

2013

36

≥80

Hatakeya

2013

48 (L)

>80

37.1 43.3

-

5.2 5.2

-

-

-

-

-

Total: 110 RH, 75 LH, 6 TC, 3 SC

40,7

p = 0. 0 2 4 p < 0. 0 5 -

0

ns

-

-

-

-

-

5.9

p<0 .00 1

-

-

-

-

-

2.1 6.5

-

-

-

-

-

Total: 47 RH, 13 LH, 32 SC, 1 TC.

30.1 49.1

-

2.4 3.4

-

-

-

-

-

Total: 84 RH, 9 LH, 43 SC, 26 AR, 23 APR, 9 TC, 5 SC.

83 (80– 95)

26.2

16.2

p<0 .00 01

-

-

-

-

>80: 49 RH, 2 TC, 5 LH, 25 SC, 33 AR, 9 APR, 7 Other.

83 (8091) 82.7(

27.7

p < 0. 0 0 0 1 -

16.6

-

-

-

-

-

-

37.5

-

0

-

-

-

-

-

-

82

ma et al.

34 (O)

Jafari et 83 al.

2014

106921

≥85

Bircan et 84 al.

2014

56

≥80

Vallribera 85 et al.

2014

45 (L) 45 (O)

Tabbakh 86 et al. Hinoi et 87 al.

2015

2.8) 83.5( 4.1) 88 (8690)

44

44,9

p < 0. 0 5

8

p<0 .05

-

-

-

-

80-84: 28.5%, LC, 58.2% RH, 6.6% SR, 1.6% TC, 5% others. >85: 26% LC, 60.9% RH, 7.4% SR, 1.4% TC. >80: 8 RH, 15 SR, 9 LH, 5 AR, 4 APR. Total: 207 SC, 58 LH, 8 SR, 255 RH. -

21.4

ns

7,1

ns

-

-

-

-

≥85

85.6 3±3. 55 -

35.6 35.6

-

6.7 11.1

-

-

-

-

-

57 (L)

≥80

-

20

-

0

-

-

-

-

-

2015

Colon 402 (L) 402 (O)

≥80

24.9 36.3

-

0 0.7

-

85,5% (L) at 3y 81,2% (O) at 3y

ns

74,4%(L) at 3 y 75,6%(O) at 3y

ns

31 RH, 97 SR, 173 LH, 170 SC, 18 HO.

Hinoi et 87 al.

2015

Rectum 57 (L) 57 (O)

≥80

40.4 47.4

-

0 0

-

78,6% (L) at 3y 70,2% (O) at 3y

ns

74,6% (L) at 3y 63,4% (O) at 3y

ns

-

Gomes et 88 al. Pirrera et 89 al.

2015

139

≥80

47.9

-

16.5

-

-

-

-

-

-

2016

291

>80

83(8 1– 85) 83 (81– 85) 83(8 1– 85) 83 (81– 85) 84.4 ±3.9 84,1 (80-

38,8

p =

8,2; 13,1 at 1 and 3

p=0 .00

-

-

-

-

-

97)

Niitsu et 90 al.

2016

103 (L) 295 (O)

0. 0 0 1 -

m

1

84 25.2 0 >80: 126 RH, 40.3 1 46 SR, 78 LH, (81– 86) 18 SC, 37 HO, 18 APR, 68 83 AR. (81– 86) Roscio et ≥80 84 2016 96 46.8 ns 1 ns >80: 44 RH, 91 al. (81(Colon) 63 0 38 LH, 30 AR, 33 86) 14 Other. (Rectum 84 ) (8286) *Major complications. L: laparoscopic approach. O: Open approach. Ro: robot. s.s. statistically significant difference between young and elderly; ns: non significant. m: months. y: years. RH: right hemicolectomy. LH: left hemicolectomy. SC: sigmoid colectomy. TC: total colectomy. AR: anterior resection. APR: abdomino-perineal resection. HO: Hartmann’s operation. SR: segmental resection. ≥80