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

Table 1 Baseline characteristics stratified by age group, n (%)/mean ± SD

Variable	Age ≥ 80 years (n = 23)	Age < 80 years (n = 119)	P value
Body mass index	26.3 ± 4.0	25.4 ± 4.2	-
ACCI	11.2 ± 1.9	6.7 ± 2.9	< 0.001
ASA score	3.0 ± 0.2	2.4 ± 0.6	< 0.001
Male sex	14 (60.9)	72 (60.5)	0.98
Comorbidities ≥ 1	18 (78.3)	54 (45.4)	< 0.01
Previous surgery	5 (21.7)	30 (25.2)	0.72
Smoking	3 (13.0)	36 (31.1)	0.10
Frail (mFI-5 ≥ 2)	5 (21.7)	11 (9.2)	0.09
Neoadjuvant treatment
CH-RT	21 (91.3)	79 (66.4)	0.02
TNT	2 (8.7)	40 (33.6)	0.02
Chemotherapy backbone
Fluoropyrimidine-based	16 (88.9)	67 (63.8)	-
Oxaliplatin-based	1 (5.6)	33 (31.4)	-
Irinotecan-based	1 (5.6)	5 (4.8)	-
Biologic therapy	2 (11.1)	14 (13.3)	-

ACCI: Age-Adjusted Charlson Comorbidity Index; ASA: American Society of Anesthesiologists; mFI: 5-item modified frailty index; CH-RT: Chemoradiotherapy; TNT: Total neoadjuvant therapy.

Table 2 Intraoperative characteristics stratified by age group, n (%)/mean ± SD

Variable	Age ≥ 80 years (n = 23)	Age < 80 years (n = 119)	P value
Tumor distance (cm)	7.6 ± 3.0	8.7 ± 3.6	0.30
Tumor location
Low	7 (30.4)	24 (20.2)	0.40
Middle	13 (56.5)	65 (54.6)	0.95
High	3 (13.0)	30 (25.2)	0.20
Lymph nodes harvested, median (range)	23 (11-38)	17 (3-40)	0.01
R0 resection	21/22 (95.5)	115/119 (96.6)	0.85
Type of surgery
Low anterior resection	16 (69.6)	109 (91.6)	0.02
Abdominoperineal resection	6 (26.1)	9 (7.6)	0.02
Hartmann	1 (4.3)	1 (0.8)	-
Surgical approach
Robotic	19 (82.6)	104 (87.4)	0.60
Laparoscopic	4 (17.4)	15 (12.6)	0.60
Stoma
Ileostomy	3 (13.0)	88 (73.9)	< 0.001
Colostomy	20 (87.0)	20 (16.8)	< 0.001
Operative time (minutes)	366 ± 109	408 ± 127	0.15
Blood transfusion	3 (13.0)	1 (0.8)	0.10
Conversion	1 (4.3)	8 (6.7)	0.45
Pelvic drain	22 (95.7)	118 (99.2)	0.80
Mesorectal excision
TME	22 (95.7)	111 (93.3)	0.70
PME	1 (4.3)	8 (6.7)	0.70

TME: Total mesorectal excision; PME: Partial mesorectal excision.

Table 3 Postoperative outcomes stratified by age and frailty, n (%)

Variable	Age ≥ 80 years (n = 23)	Age < 80 years (n = 119)	P value (age)	Frail (n = 16)	Non-frail (n = 126)	P value (frail)
ICU admission	12 (52.2)	53 (44.9)	-
ICU stay (days), median	1.5	1	-
Medical complications	14 (60.9)	41 (34.5)	0.017	6 (37.5)	49 (38.9)	0.914
Surgical complications	6 (26.1)	17 (14.3)	0.165	4 (25.0)	19 (15.1)	0.165
Clavien-Dindo ≥ 3	7 (30.4)	7 (5.9)	0.002	3 (21.4)	13 (10.2)	0.205
Anastomotic leak	6 (26.1)	20 (16.8)	0.292	4 (25.0)	22 (17.5)	0.292
Reintervention	2 (8.7)	7 (5.9)	0.612	2 (12.5)	7 (5.6)	0.612
Length of stay (days), median (IQR)	10 (8.5)	8 (5.0)	0.044
Length of stay (days), range	6-27	5-33
90-day mortality	1 (4.3)	0 (0)	0.162	0 (0)	1 (0.7)	-
Stoma reversal	2 (8.7)	64 (54.7)	< 0.001	7 (43.8)	59 (47.6)	0.704

ICU: Included intensive care unit; IQR: Interquartile range.

Table 4 Survival outcomes: Overall survival, cancer-specific survival, and disease-free survival stratified by age and frailty

Outcome	Variable	Median (months)	IQR/CI	Log-rank P value	HR univariable (95%CI)	P value	HR multivariable (95%CI)	P value
Overall survival	Age ≥ 80 years	47	29-NR	0.021	Ref		Ref
	Age < 80 years	NR			0.41 (0.19-0.89)	0.025	0.44 (0.20-0.98)	0.044
	Frail	32	22-NR	0.058	Ref		Ref
	Non-frail	NR			0.43 (0.17-1.06)	0.066	0.48 (0.19-1.22)	0.124
	Age ≥ 80 + frail	20	9
	Age ≥ 80 + non-frail	26.5	34.5
	Age < 80 + frail	32	13
	Age < 80 + non-frail	33.5	34.0
Cancer-specific survival	Age ≥ 80	26	18-47	0.14	Ref		Ref
	Age < 80	32	26-38		0.42 (0.18-0.96)	0.040	0.43 (0.19-1.00)	0.051
	Frail	NR		0.38	Ref		Ref
	Non-frail	NR			0.62 (0.21-1.82)	0.384	0.71 (0.24-2.12)	0.541
Disease-free survival	Age ≥ 80	NR	≥ 31	0.53	Ref
	Age < 80	NR	≥ 69		1.40 (0.49-4.00)	0.527
	Frail	NR	≥ 13	0.10	Ref
	Non-frail	NR	≥ 69		0.48 (0.20-1.18)	0.110

IQR: Interquartile range; HR: Hazard ratio; CI: Confidence interval; NR: Not reached; Ref: References.