Minimally invasive rectal cancer surgery after neoadjuvant therapy in selected elderly and frail patients: A single-center real-world experience

doi:10.4240/wjgs.123538

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World Journal of Gastrointestinal Surgery

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1948-9366

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

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Copyright: ©Author(s) 2026. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution-NonCommercial (CC BY-NC 4.0) license. No commercial re-use. See permissions. Published by Baishideng Publishing Group Inc.

World J Gastrointest Surg. Oct 27, 2026; 18(10): 123538
Published online Oct 27, 2026. doi: 10.4240/wjgs.123538

Minimally invasive rectal cancer surgery after neoadjuvant therapy in selected elderly and frail patients: A single-center real-world experience

Valentina Zucchini, Leonardo Solaini, Andrea Avanzolini, Giorgio Ercolani

Valentina Zucchini, Andrea Avanzolini, Department of General and Oncologic Surgery, Morgagni-Pierantoni Hospital, Forli 47121, Emilia-Romagna, Italy

Leonardo Solaini, Giorgio Ercolani, Department of Medical and Surgical Sciences, University of Bologna, Bologna 40126, Emilia-Romagna, Italy

Author contributions: Zucchini V contributed to data curation, formal analysis, and writing of the original draft; Solaini L, Avanzolini A, and Ercolani G contributed to conceptualization; Solaini L and Ercolani G contributed to supervision; Avanzolini A contributed to data collection. All authors contributed to manuscript revision and approved the final version of the manuscript.

AI contribution statement: AI tools (ChatGPT) were used solely for linguistic refinement and formatting assistance. No AI tool was involved in the generation of research data, interpretation of results, or formulation of conclusions. All AI-generated outputs were critically reviewed and revised by the authors.

Institutional review board statement: The study was reviewed and approved by the Comitato Etico di Area Vasta Emilia Centro, IRST-IRCCS, Meldola, Italy (approval No. 5956/2020, I.5/262).

Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.

Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.

STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.

Data sharing statement: The technical appendix, statistical code, and de-identified dataset are available from the corresponding author at leonardo.solaini2@unibo.it upon reasonable request, subject to approval by the local Ethics Committee and applicable data-protection regulations. Written informed consent for the collection and use of clinical data for research purposes was obtained from all patients.

Corresponding author: Leonardo Solaini, MD, Professor, Department of Medical and Surgical Sciences, University of Bologna, via Carlo Forlanini 34, Bologna 40126, Emilia-Romagna, Italy. leonardo.solaini2@unibo.it

Received: May 21, 2026
Revised: June 22, 2026
Accepted: July 9, 2026
Published online: October 27, 2026
Processing time: 143 Days and 17.7 Hours

Abstract

BACKGROUND

Management of elderly and frail patients with rectal cancer remains challenging after neoadjuvant therapy, as concerns about postoperative morbidity may influence treatment allocation. Evidence on the safety and oncologic adequacy of minimally invasive surgery in this setting remains limited. We hypothesized that, among highly selected elderly and frail patients completing neoadjuvant treatment, curative-intent minimally invasive surgery would provide acceptable postoperative and oncologic outcomes.

AIM

To evaluate postoperative and oncologic outcomes in selected elderly and frail patients undergoing minimally invasive rectal cancer surgery after neoadjuvant therapy.

METHODS

This retrospective single-center study analyzed a prospectively maintained database of patients with histologically confirmed rectal adenocarcinoma undergoing curative-intent minimally invasive surgery after neoadjuvant therapy from 2014 to 2025. Elderly patients were aged 80 years or older; frailty was defined as a 5-item modified frailty index score of at least 2. Postoperative outcomes, 90-day mortality, overall survival, cancer-specific survival, and disease-free survival were compared according to age and frailty status using appropriate comparative and survival analyses.

RESULTS

Among 142 patients, 23 (16.2%) were aged 80 years or older and 16 (11.3%) were frail. Elderly patients had more major postoperative complications than younger patients (30.4% vs 5.9%, P = 0.002) and more medical complications (60.9% vs 34.5%, P = 0.017). Surgical complications, anastomotic leak, reintervention, conversion to open surgery, and R0 resection rates were comparable between age groups. Overall survival was lower in elderly patients, whereas cancer-specific and disease-free survival were comparable. Frailty was not consistently associated with postoperative or survival outcomes.

CONCLUSION

In highly selected elderly and frail patients, minimally invasive rectal surgery after neoadjuvant therapy yields acceptable surgical and oncologic outcomes, supporting individualized multidisciplinary rather than age-based treatment decisions.

Keywords: Rectal neoplasms; Frailty; Octogenarians; Minimally invasive surgical procedures; Postoperative complications; Neoadjuvant therapy

Core Tip: In this single-center real-world cohort, elderly and frail patients with rectal cancer who completed neoadjuvant therapy and were selected for curative-intent minimally invasive surgery achieved acceptable technical and oncologic outcomes. Patients aged 80 years or older had more medical and major postoperative complications and poorer overall survival, whereas surgical complications, cancer-specific survival, and disease-free survival were broadly comparable with those of younger patients. These findings support individualized multidisciplinary assessment rather than age-based exclusion in appropriately selected candidates.