Efficacy of laparoscopic radical resection of colorectal cancer in older patients and its effects on inflammatory factors

Abstract

BACKGROUND

Currently, open surgery for colorectal cancer (CRC) exhibits certain therapeutic efficacy; however, it may also hinder postoperative recovery in patients. Therefore, more advanced surgical methods are required to ensure smoother postoperative recovery.

AIM

To analyze the efficacy of laparoscopic radical resection of CRC (LRRCC) in treating older patients with CRC and the effect of this procedure on inflammatory factors.

METHODS

The study included 104 older patients with CRC admitted from August 2022 to August 2024. Participants undergoing open radical resection of CRC were categorized as the control group (50 patients), whereas those receiving LRRCC were classified as the research group (54 patients). Subsequently, comparative analyses involved data on efficacy, postoperative complications (ileus, incision infection, anastomotic fistula, and pulmonary infection), surgery-related parameters (operation duration and intraoperative bleeding volume), postoperative recovery-related indicators (time to first postoperative passage of flatus and defecation and length of hospital stay), and inflammatory factors (tumor necrosis factor-α, high-sensitivity C-reactive protein, and interleukin-6).

RESULTS

Data revealed markedly superior therapeutic efficacy and a lower overall postoperative complication rate in the research group compared to the control group. The research group demonstrated substantially less intraoperative bleeding, less time to first postoperative passage of flatus and defecation, and a shorter length of hospital stay despite a notably longer operation duration compared to the control group. Further, tumor necrosis factor-α, high-sensitivity C-reactive protein, and interleukin-6 levels in the research group were significantly reduced 3 days postoperatively compared to both the preoperative and control group values.

CONCLUSION

LRRCC for older patients with CRC exhibited superior therapeutic efficacy compared to open radical resection and significantly suppressed postoperative stress-related inflammatory responses, which merits clinical application and promotion.

Key Words: Laparoscopy; Radical resection of colorectal cancer; Colorectal cancer in the elderly; Therapeutic effect; Inflammatory factor

Core Tip: This study aimed to determine the clinical advantages of laparoscopic radical resection of colorectal cancer (LRRCC) in elderly patients across multiple dimensions, including therapeutic efficacy, postoperative complications, surgical outcomes, recovery, and inflammatory factors. A retrospective analysis was conducted on 104 elderly patients with colorectal cancer. The results revealed that LRRCC in elderly patients provides both higher efficacy and safety. Although LRRCC prolonged the operation time, it significantly reduced intraoperative blood loss, accelerated postoperative recovery, and effectively suppressed serum inflammatory factors in patients. These results indicate LRRCC as a safe and reliable surgical approach for elderly patients with colorectal cancer while providing valuable information for clinical surgical practice.

INTRODUCTION

Colorectal cancer (CRC) is the second leading cause of cancer-related fatalities and the third most prevalent cancer globally[1]. Factors such as aging, smoking, obesity, physical inactivity, and poor dietary patterns augment the risk of developing CRC[2]. The incidence risk of CRC has decreased in high-income economies; however, its incidence in emerging economies continues to increase. Moreover, the risk of developing CRC increases with age, thereby posing a particularly significant threat to the elderly population[3,4]. Surgery, radiotherapy, and chemotherapy constitute the principal therapeutic options for CRC. Among these, surgery is the sole curative approach and can be applied to patients in the early disease stage as well as to some selected patients with recurrent and metastatic disease, not only facilitating complete tumor resection and prolonging patient survival but also helping to reduce the risk of recurrence[5-7]. However, older patients with CRC present with specific characteristics, including a compromised physiological state, lower surgical tolerance, multiple concurrent chronic comorbidities, and a relatively increased risk of postoperative complications, requiring more stringent surgical treatment[8]. The current open surgical procedures for CRC treatment have exhibited certain efficacy and demonstrated advantages such as large incisions, clear intraoperative visualization, and distinct anatomical delineation. However, these procedures have several drawbacks, including risks of massive hemorrhage and intestinal inflammation that cause internal environmental imbalances and pronounced stress responses in the patient’s body, thereby impeding postoperative recovery[9-11]. Laparoscopic radical resection of CRC (LRRCC), as a minimally invasive surgical technique, has achieved short-term outcomes comparable to those of open surgery[12,13]. Zhang et al[14] revealed that LRRCC for patients with CRC complicated by ileus is effective in ameliorating serum pain-associated factors and inflammatory factors (IFs), with fewer complications and superior efficacy compared to open surgery. This study aimed to analyze the clinical outcomes of LRRCC in older patients with CRC from multiple perspectives, including therapeutic efficacy, postoperative complications, surgical outcomes, postoperative recovery, and IFs, representing the innovation and strength of this research.

MATERIALS AND METHODS

General data

The study participants were 104 older patients with CRC admitted to Wujin Hospital Affiliated to Jiangsu University, from August 2022 to August 2024. Participants who underwent open radical resection of CRC were categorized as the control group (50 patients), whereas those who received LRRCC were classified as the research group (54 patients).

Patient selection criteria

The inclusion criteria were as follows: (1) CRC diagnosis confirmed by pathological biopsy or computed tomography examination; (2) Possession of relevant surgical indications for radical resection of CRC; (3) First-time treatment; tumor-node-metastasis stage ranging from stages I to III; (4) Tolerance to surgery and anesthetics; and (5) Availability of complete medical records. The exclusion criteria were: (1) Presence of complete ileus; (2) Gastrointestinal bleeding; (3) History of gastrointestinal surgery; (4) Coexistence of other malignant tumors; (5) Presence of coagulation disorders or autoimmune system deficiencies; (6) Mental disorders or cognitive dysfunction; and (7) Excessive tumor diameter posing challenges in laparoscopic surgery.

Treatment methods

Both patient groups received routine treatments such as nutritional supplementation and anti-infection. A liquid diet was administered 24 hours preoperatively. Fasting was initiated 12 hours preoperatively, and water intake was prohibited 8 hours preoperatively. Patients were given an oral electrolyte powder (two bags) each time to clean their intestines. The control group underwent open radical resection of CRC. The patient was placed in the supine position and received general anesthesia via tracheal intubation. After identifying the tumor location based on imaging results, the surgical area was routinely disinfected and the abdominal cavity was incised. The diseased area was then resected, and the corresponding lymph nodes were dissected. Subsequently, the intestinal tract was anastomosed with a stapler. Thereafter, the abdominal incision was closed layer by layer, and a drainage tube was placed. The research group underwent LRRCC. The patient was placed supine and anesthetized with endotracheal intubation. An artificial pneumoperitoneum (pressure, 15 mmHg) was established after routine disinfection, and a laparoscope was inserted. The tumor was resected, and the surrounding lymph nodes were dissected under the laparoscopic vision. The intestinal tract was then anastomosed with a stapler, and the incision was finally closed.

Detection indicators

Therapeutic efficacy: Criteria for assessing therapeutic efficacy were as follows. The treatment was considered markedly effective when all of the following characteristics were met: Radical resection of the tumor with both proximal and distal resection margins of ≥ 5 cm from the tumor and postoperative pathological examination revealing ≥ 12 lymph nodes being cleared, with no evidence of cancer metastasis. Effective treatment was defined as the satisfaction of all the following criteria: radical resection of the tumor with both proximal and distal resection margins of ≥ 5 cm from the tumor and postoperative pathological examination showing < 12 lymph nodes being cleared. Relatively effective treatment was defined as the satisfaction of either of the following criteria: relative radical resection of the tumor with either the proximal or distal resection margin of < 5 cm from the tumor and postoperative pathological examination revealing the presence of lymph node metastasis. The treatment was considered ineffective when either of the following characteristics were met: palliative resection owing to peritoneal metastasis of the tumor and treatment with procedures, such as colostomy or digestive tract bypass surgery, to relieve obstruction or alleviate symptoms. The overall treatment effective rate was calculated as the percentage of the sum of markedly effective, effective, and relatively effective cases to the total number of cases.

Postoperative complications: We primarily observed and recorded adverse event cases, such as ileus, incision infection, anastomotic fistula, and pulmonary infection, and computed the incidence rates.

Surgery-related parameters: The surgical duration and intraoperative bleeding volume of both groups of patients were monitored and recorded.

Postoperative recovery-related indexes: The time to first postoperative passage of flatus and defecation and the length of hospital stay were statistically analyzed.

IFs: Fasting venous blood of 5 mL was drawn from patients in the early morning pre- and postoperatively, and the serum was collected after centrifugation to measure tumor necrosis factor-α (TNF-α), high-sensitivity C-reactive protein (hs-CRP), and interleukin-6 (IL-6) levels by enzyme-linked immunosorbent assay.

Statistical analysis

In this study, both quantitative and categorical data were imported into the Statistical Package for the Social Sciences version 20.0 software package for statistical analysis. Categorical data were presented as the number of cases/percentage (n, %). Quantitative data, all following normal distribution and homogeneity of variance, were expressed as mean ± SE. The χ² test was used for comparing categorical data. The independent-sample t-test was utilized for comparing quantitative data between groups, whereas the paired t-test was employed for comparing quantitative data pre- and postoperatively. A P value of < 0.05 indicated statistical significance.

RESULTS

General data of the two groups

The control and research groups demonstrated no statistical differences in general data, including sex, age, disease duration, tumor type, and tumor-node-metastasis staging (P > 0.05, Table 1).

Table 1 General information of the two groups.

Indicators	Control group (n = 50)	Research group (n = 54)	χ2/t	P value
Gender (male/female)	27/23	30/24	0.025	0.874
Age (years)	69.16 ± 5.48	68.54 ± 5.19	0.636	0.526
Disease course (years)	2.52 ± 0.61	2.46 ± 0.97	0.406	0.686
Tumor type (rectal/colon cancer)	28/22	32/22	0.113	0.737
TNM staging (I/II/III)	9/26/15	8/23/23	1.775	0.412

TNM: Tumor-node-metastasis.

Therapeutic efficacy of the two groups

Markedly effective, effective, relatively effective, and ineffective cases accounted for 10, 13, 12, and 15 patients in the control group and 18, 15, 14, and 7 patients in the research group, respectively. The comparison of the overall treatment effective rate between the two groups was statistically significant in the research group (87.04% vs 70.00%, P = 0.034, Table 2).

Table 2 Therapeutic efficacy in the two groups, n (%).

Indicators	Control group (n = 50)	Research group (n = 54)	χ2	P value
Markedly effective	10 (20.00)	18 (33.33)
Effective	13 (26.00)	15 (27.78)
Relatively effective	12 (24.00)	14 (25.93)
Ineffective	15 (30.00)	7 (12.96)
Overall effective	35 (70.00)	47 (87.04)	4.518	0.034

Postoperative complications in the two groups

Statistical analysis of the number of postoperative complications, including ileus, incision infection, anastomotic fistula, and pulmonary infection, revealed that 16 and 5 patients in the control and research groups, respectively, experienced postoperative complications. The overall postoperative complication rate was statistically lower in the research group than in the control group (P = 0.004, Table 3).

Table 3 Postoperative complications in the two groups, n (%).

Indicators	Control group (n = 50)	Research group (n = 54)	χ2	P value
Ileus	4 (8.00)	2 (3.70)
Incision infection	6 (12.00)	1 (1.85)
Anastomotic fistula	4 (8.00)	0 (0.00)
Pulmonary infection	2 (4.00)	2 (3.70)
Total	16 (32.00)	5 (9.26)	8.331	0.004

Surgery-related parameters of the two groups

Statistical analysis of surgery-related parameters, such as operation duration and intraoperative bleeding volume, indicated that the operation duration in the research group was 175.93 ± 44.01 minutes, which was significantly longer than the duration of 124.70 ± 26.71 minutes in the control group (P < 0.001). The intraoperative blood loss in the research group was 56.80 ± 7.53 mL, which was lower than that in the control group at 85.34 ± 10.01 mL (P < 0.001, Table 4).

Table 4 Surgery-related parameters of the two groups.

Indicators	Control group (n = 50)	Research group (n = 54)	t	P value
Operation duration (minutes)	124.70 ± 26.71	175.93 ± 44.01	7.107	< 0.001
Intraoperative bleeding volume (mL)	85.34 ± 10.01	56.80 ± 7.53	16.508	< 0.001

Postoperative recovery-related indicators in the two groups

Statistical analyses of postoperative recovery-related indicators revealed that the time to first postoperative passage of flatus was 2.22 ± 0.77 days and 3.74 ± 1.34 days, the time to first postoperative defecation was 3.87 ± 1.35 days and 5.22 ± 1.67 days, the length of hospital stay was 9.81 ± 2.49 days and 12.76 ± 3.46 days in the research and control groups, respectively. Comparative analysis revealed that all of the above postoperative recovery-related indicators were significantly lower in the research group than in the control group (P < 0.001, Table 5).

Table 5 Postoperative recovery-related indicators in the two groups.

Indicators	Control group (n = 50)	Research group (n = 54)	t	P value
Time to first postoperative passage of flatus (days)	3.74 ± 1.34	2.22 ± 0.77	7.158	< 0.001
Time to first postoperative defecation (days)	5.22 ± 1.67	3.87 ± 1.35	4.549	< 0.001
Length of hospital stay (days)	12.76 ± 3.46	9.81 ± 2.49	5.018	< 0.001

IFs in the two groups

The detection of IFs, including TNF-α, hs-CRP, and IL-6, revealed no statistical inter-group differences preoperatively (P > 0.05). Postoperatively, all the indicators in both groups significantly decreased (P < 0.05), with even lower levels in the research group than in the control group (P < 0.05, Table 6).

Table 6 Inflammatory factors in the two groups.

Indicators	Control group (n = 50)	Research group (n = 54)	t	P value
TNF-α (ng/L)
Before surgery	494.90 ± 90.86	501.65 ± 87.21	0.387	0.700
After surgery	446.36 ± 55.33	355.94 ± 69.70	7.289	< 0.001
hs-CRP (mg/L)
Before surgery	7.80 ± 2.27	7.27 ± 2.28	1.187	0.238
After surgery	6.27 ± 1.99	5.22 ± 1.41	3.123	0.002
IL-6 (μg/L)
Before surgery	351.98 ± 44.19	359.65 ± 59.62	0.741	0.461
After surgery	309.06 ± 44.88	220.09 ± 38.14	10.920	< 0.001

TNF-α: Tumor necrosis factor-α; hs-CRP: High-sensitivity C-reactive protein; IL-6: Interleukin-6.

DISCUSSION

Several studies have analyzed the surgical treatment of older patients with CRC in detail. Xue et al[15] revealed that robotic surgery can be effectively used for older patients with CRC with anemia and/or hematological diseases, which leads to less blood loss and operation time, conversion rate, postoperative complications, recovery, and long-term outcomes comparable with those of laparoscopic surgery. Further, Qian et al[16] reported that the use of thermal insulation nursing in the operating room during LRRCC is conducive to preventing intraoperative hypothermia, reducing the risk of postoperative complications, improving sleep quality, and speeding up rehabilitation. Furthermore, Luo et al[17] identified multiple risk factors for CRC recurrence after LRRCC, such as the neutrophil-to-lymphocyte ratio, cytokeratin 19 fragment antigen 21-1 expression level, and vascular endothelial growth factor, thereby providing effective clinical monitoring guidance for reducing the risk of postoperative recurrence in patients. All the aforementioned studies have provided valuable clinical references for optimizing the treatment regimens and related management strategies of older patients with CRC. In this study, the research group demonstrated a significantly higher overall treatment effective rate than the control group (87.04% vs 70.00%), indicating that LRRCC exhibited a superior effect on the radical excision of the tumor in patients with CRC. This may be attributed to the minimal interference with the patient’s body during LRRCC, with no significant traction on the abdominal organs. Meanwhile, multidimensional analysis of deep-seated lesions can be conducted under the premise of fully protecting the organs from damage, enabling surgeons to more accurately determine the solid tumor and non-target lesions, thereby achieving effective lesion resection[18-20]. In terms of safety, the total incidence rate of complications, including ileus, incision infection, anastomotic fistula, and pulmonary infection, was notably lower in the research group than in the control group. This indicates that LRRCC can, to a certain extent, help reduce the risk of occurrence of these complications in older patients with CRC. This is associated with the characteristic of LRRCC to completely resect the mesorectum and prevent long-term exposure of the organs, which helps to reduce the risk of infection and postoperative intestinal adhesion[21]. Yoshimatsu et al[22] revealed that LRRCC for elderly patients aged over 80 years significantly lowered the risk of incisional surgical site infection, indicating that this surgical approach exhibits a certain safety level in such patients. This procedure exhibited a relatively longer operation time for older patients with CRC compared to open surgery; however, it caused a markedly lower intraoperative bleeding volume. This may be associated with the relatively minor damage to the gastrointestinal tract of older patients with CRC during LRRCC. Liu et al[23] demonstrated that LRRCC for older adults with CRC has been associated with a shorter operation duration, less intraoperative bleeding, lower complication rate, and superior effect on promoting gastrointestinal function recovery, which supports our research results. Furthermore, this study revealed that elderly patients undergoing LRRCC experienced less time to first postoperative passage of flatus and defecation as well as a shorter length of hospital stay, indicating the benefits of this surgical approach in promoting postoperative recovery. Presumably, this is because LRRCC is effective and safe in treating older patients with CRC, with a relatively low amount of bleeding during operation, which prevents the effect of massive bleeding on the body. Minciuna et al[24] revealed that LRRCC for elderly patients is associated with a significantly shorter hospital stay compared to open surgery, which coincides with our results. Huang et al[25] demonstrated that laparoscopic radical resection for patients with rectal cancer can expedite postoperative intestinal function recovery and reduce analgesic use and average hospital stay, with a long-term survival rate comparable to that of open radical resection. IF assessment indicated markedly reduced postoperative TNF-α, hs-CRP, and IL-6 levels in the research group relative to the preoperative levels and those in the control group, indicating that LRRCC is more helpful for suppressing serum inflammatory response in older patients with CRC. Similarly, He et al[26] indicated that LRRCC significantly reduces IL-6, IL-8, and CRP levels while significantly increasing IL-10 levels.

Our study has several limitations. First, samples were sourced from a single center, with a small size and concentrated origin, which may cause information-collection bias. To improve the accuracy of the research results, future investigations should incorporate multicenter studies with large sample sizes. Second, a long-term follow-up was not conducted in this study. Assessing long-term clinical outcomes through additional follow-up would be instrumental in further determining the potential clinical advantages of LRRCC treatment. Finally, factors affecting efficacy or complications in patients with CRC have not been thoroughly investigated. Conducting supplementary analyses could help optimize the clinical management of LRRCC. Future studies will attempt to overcome these limitations.

CONCLUSION

Taken together, LRRCC is highly effective and safe for older patients with CRC, as it reduces the amount of intraoperative bleeding, speeds up the postoperative rehabilitation of patients, and effectively suppresses serum IF levels. Our results indicate that LRRCC is an effective and safe surgical alternative for older patients with CRC. They also provide valuable clinical references and novel information for the clinical management of this condition.