Here we report the guidelines for surgical intervention on vulnerable elderly patients with colorectal cancer. Appropriate preoperative and intraoperative evaluations are important when performing surgery to treat elderly patients with colorectal cancer. Preoperative risk factors including deterioration of physical and cognitive function, malnutrition, comorbidities, polypharmacy, and decreases in skeletal muscle mass are associated with increased rates of postoperative complications and death. Limiting intraoperative fluid administration, fluid management based on goal-directed therapy (GDT), and anesthesia-depth management using EEG monitoring to prevent hypothermia, cutaneous injury, muscular damage, neuropathy, and circulatory disturbance lead to reduced postoperative complications. However, there are insufficient data to establish a clinically significant association between risk factors and postoperative complications. Moreover, there are no data to determine if surgical intervention results in acceptable outcomes for vulnerable patients who undergo invasive surgery and who are poor candidates for standard treatment. In order to solve these problems, it is necessary to accumulate and analyze data based on comprehensive geriatric assessment (CGA).

This paper explains the following clinical questions about the surgical treatment of prefrail elderly patients with colorectal cancer and presents answers. This is from the Surgical Treatment Working Group of the scientific research project, “A study on infrastructure improvements necessary to develop cancer treatment policies for elderly patients” by the Ministry of Health, Labour and Welfare. CQ1: In the case of elderly patients with dementia with colorectal cancer, whose approval is necessary for treatment? CQ2: Is treatment necessary for early-stage colorectal cancer in elderly patients? CQ3: Is a standard surgery possible for elderly patients with advanced colorectal cancer? CQ4: What is the indication for surgery on stage IV colorectal cancer in elderly patients? CQ5: Is laparoscopic surgery effective on elderly patients with colorectal cancer? CQ6: Should an artificial anus be proactively installed during radical resection of a rectal cancer? CQ7: Can serious postoperative complications in elderly patients with colorectal cancer be predicted? CQ8: Are the amount of bleeding and operating time adequate to make an intraoperative assessment of elderly patients with colorectal cancer? CQ9: What is the appropriate method of anesthesia for elderly patients with colorectal cancer? These clinical questions should be considered when deciding actual treatment policies.

The number of elderly cancer patients has been increasing for the past several decades in Japan. The selection of appropriate treatment for elderly patients with cancer is sometimes difficult because of their diverse characteristics and individual differences. In particular, for prefrail cancer patients, who are between fit and frail, the experience of medical staff affects the selection of treatment. Therefore, 10 clinical questions (CQs) have been suggested as provisional clinical opinions for radiotherapy in prefrail elderly colorectal cancer patients by the Radiation Therapy Working Group, comprising seven radiation oncologists, one gastroenterologist, and one gastroenterological surgeon. The present report examines CQ 1－5 as follows. CQ1: “What are the difficulties of radiotherapy for prefrail elderly patients with colorectal cancer?”; CQ2: “What is the branching point between standard treatment and reduced-intensity treatment with radiotherapy in prefrail elderly patients with colorectal cancer?”; CQ3: “What is the appropriate comprehensive geriatric assessment for elderly cancer patients to be treated with radiotherapy?”; CQ4: “What should be noted about the adverse events caused by radiotherapy in prefrail elderly patients with colorectal cancer?” and CQ5: “What should be noted about the adverse events caused by preoperative chemoradiation therapy in prefrail elderly patients with locally advanced rectal cancer?”

The number of elderly cancer patients has been increasing for the past several decades in Japan. The selection of appropriate treatment for elderly patients with cancer is sometimes difficult because of their diverse characteristics and individual differences. In particular, for prefrail cancer patients, who are between fit and frail, the experience of medical staff affects the selection of treatment. Therefore, 10 clinical questions (CQs) have been suggested as provisional clinical opinions for radiotherapy in prefrail elderly colorectal cancer patients by the Radiation Therapy Working Group, comprising seven radiation oncologists, one gastroenterologist, and one gastroenterological surgeon. The present report examines CQ 6－10 as follows, along with the appendix. CQ6: “Is it necessary to perform preoperative chemoradiotherapy in prefrail elderly patients with resectable locally advanced rectal cancer?”; CQ7: “Is it recommended to perform chemoradiotherapy for prefrail elderly rectal cancer patients with non-resectable pelvic recurrence after surgery?”; CQ8: “What is the indication for palliative radiotherapy in prefrail elderly colorectal cancer patients with pelvic recurrence after surgery?”; CQ9: “What is the indication for radiotherapy in prefrail elderly colorectal cancer patients with liver metastasis?” and CQ10: “What is the indication for radiotherapy in prefrail elderly colorectal cancer patients with lung metastasis?”

Low anterior resection syndrome (LARS) is inevitable following low anterior resection due to rectal resection. The actual clinical status of LARS in Tokyo and the surrounding districts was revealed by conducting a written questionnaire containing 16 categories. As a whole, the surgeons were cautious regarding LARS, with preoperative informed consent. However, there were some discrepancies in terms of degree of understanding of LARS between surgeons and patients. Patients seemed to expect retrieving their “normal” bowel function; their disappointments resulted in them changing doctors or being referred to another facility, even including the psychological department. LARS should be treated to reduce the discrepancy of understanding by informing patients the inability retrieving normal bowel function.

Gangrenous ischemic colitis has the risk of residual intestinal necrosis (on-going ischemia: OGI) and the operation strategy is often difficult. Case 1 was an 86-year-old female who underwent left hemi-colectomy and colostomy, but OGI occurred postoperatively, necessitating residual colectomy, necrotic intestine resection and ileostomy. She died due to short bowel syndrome. Case 2 was a 99-year-old female who underwent total colectomy and ileostomy, but she also had postoperative OGI and died due to DIC. Case 3 was a 67-year-old female who underwent total colectomy, exclusion mucus fistula and ileostomy. Mucus fistula and ileostomy closure were performed after her general condition had improved. Necrotic intestine resection and divided stoma construction (DSC) may be considered as a surgical strategy in cases of gangrenous ischemic colitis.