Impact of laparoscopic and open surgery on stoma formation and postoperative outcomes in elderly patients with obstructive colorectal cancer following self-expandable metallic stent placement: a systematic review and meta-analysis

Abstract

Colorectal cancer (CRC) is a leading cause of cancer-related mortality, particularly in elderly patients. Obstructive CRC, often treated with self-expandable metallic stents (SEMS) as a bridge to surgery, requires careful consideration of the surgical approach. This systematic review and meta-analysis compares laparoscopic surgery (LS) and open surgery (OpS) for managing obstructive CRC in patients aged 65 and older following SEMS placement. This age group is often underexamined in clinical studies, and the existing research frequently includes a heterogeneous mix of age groups, limiting its applicability to elderly populations. A comprehensive literature search was conducted through PubMed, Scopus, and Cochrane Library up to November 2024. Studies comparing LS and OpS outcomes in patients aged 65 and older who had SEMS placement were included. Outcomes, such as anastomotic leakage, ileus, mortality, postoperative complications, anastomosis rates, stoma construction, and wound infections were analyzed. The data from observational studies were synthesized using random-effects models. The meta-analysis of seven studies involving 326 patients (166 in laparoscopic and 160 in OpS) showed no significant differences between the two approaches in most postoperative outcomes. Specifically, for anastomotic leakage (OR = 0.65, 95% CI 0.18-2.28, P = 0.50, I² = 0%), ileus (OR = 0.69, 95% CI 0.13-3.55, P = 0.65, I² = 29%), mortality (OR = 0.97, 95% CI 0.33-2.82, P = 0.95, I² = 0%), overall postoperative complication rates (OR = 0.58, 95% CI 0.29-1.13, P = 0.11, I² = 23%), and anastomosis rates (OR = 0.65, 95% CI 0.18-2.28, P = 0.50, I² = 0%), no significant differences were observed. However, laparoscopic surgery was associated with a significantly lower rate of stoma construction (OR = 0.08, 95% CI 0.01-0.64, P = 0.02, I² = 0%). Wound infection rates showed no significant difference between the two approaches (OR = 0.60, 95% CI 0.21-1.72, P = 0.35, I² = 0%). Sensitivity analysis using a fixed-effects model confirmed that none of the outcomes changed significantly, reinforcing the robustness of the findings. These results suggest that while laparoscopic surgery and open surgery yield comparable clinical outcomes, laparoscopic surgery may offer the added benefit of reducing stoma formation. Both laparoscopic surgery and open surgery demonstrated comparable effectiveness for managing obstructive colorectal cancer, with LS showing a significant advantage in reducing stoma construction rates. Although these findings suggest LS may be preferable for older patients, individual factors, such as comorbidities and tumor stage must guide the choice of approach. Further research is necessary to assess long-term outcomes and patient-reported outcomes, which will provide more robust evidence to inform clinical decisions and policy. PROSPERO registration: CRD42024609401.

Keywords: Colectomy; Elderly patients; Laparoscopic; Minimally invasive surgery; Obstructive colorectal cancer; Open surgery; Self-expandable metallic stent.