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Ulcerative colitis (UC) and regional ileitis were rst described by Hale-White and Crohn, respectively, mainly in patients under 60 years of age [1]. Regional ileitis was subsequently dened as Crohn’s disease (CD). For a long time, UC and CD— which are the two main inammatory bowel diseases (IBD)—have been considered conditions typical of young people, but in the last 30years, an increasing number of patients have been diagnosed with IBD after 60years of age. Although there is no general agreement about the threshold of age for dening the “elderly” IBD patient, currently about 10–15% of the patients affected by UC and CD are over 65years. This change in the epidemiology of IBD has several implications in the clinical course and evolution of UC and CD.The main differences between young and elderly patients are being related to the drugs used for medical therapy and the indi­cations to surgery. Elderly patients have clinical characteristics, related to their pro­le of frailty that may affect medical and surgical treatment. Therefore, the surgical management of elderly patients with IBD needs to be carefully considered and must rely on adequate knowledge.

Family history and genetic alterations occur less frequently in the elderly than in young patients [13, 14]. Gender distribution varies in the different populations, but female prevalence is typical of CD, and male prevalence is typical of UC [7, 15, 16]. Elderly patients with IBD have intestinal bleeding, anaemia and malnutrition more frequently than young patients [9]. Furthermore, they have higher Charlson’s index and more comorbidities [17], including diabetes, chronic pulmonary diseases and cardiac and cerebrovascular disease.

involved. Contradictory results have been reported concerning the rate of perianal CD involvement in the elderly [4, 12, 16, 19, 20].

Elderly patients show similar responses to rescue therapy [10], suggesting that this should be attempted. However, the threshold for surgery should be lower in the elderly, because postoperative complications (i.e. toxic megacolon, intra-abdominal septic complications and mortality) are more common when surgery is delayed. Prompt surgery achieves a dramatic reduction in mortality in elderly patients [43]. When patients received biologics, it is safer to defer pouch formation to a later stage irrespective of disease activity at surgery, in order to reduce the risks of postopera­tive pelvic sepsis [40]. The rectal stump should be either secured to the abdominal wall or used to create a stula in frail patients [44]. This measure avoids pelvic col­lections in the event of rectal stump suture leak and eases subsequent surgery. Importantly, patients must accept undergoing scheduled follow-ups and adhere to the surveillance pathway including endoscopy. The risk of pouch-related adenocar­cinoma is lower than colorectal cancer risk in the general population [45]. Endoscopic follow-up is not recommended after IPAA in patients without high-risk features for cancer according to the Guidelines of the European Crohn’s and Colitis Organisation (ECCO) [46]. Long-standing disease and cancer/dysplasia on the specimen increases the risk of pouch-related cancer by eight times irrespective of mucosectomy [45, 47]. In addition, some patients may be diagnosed with CD later in life or develop other-than-adenocarcinoma pouch cancers without systemic symptoms [48, 49], suggesting that scheduled follow-up with exible pouchoscopy is a safe choice in elderly patients.

patients, even if a higher proportion of elderly patients tend to take antidiarrheal medications [51, 52, 55].

Stryker etal. suggested that elderly patients are more likely to have difculty with the daily management of their stoma, although their overall quality of life is equal to or superior to that of younger patients with terminal ileostomy [57].

As the cumulative lifetime risk of mortality related to IBD seems to be negligible, we are facing two different types of elderly patients with CD, those patients with a diagnosis at a young age and having aged with CD and those developing it in the old age [12]. These two different clinical characteristics are not marginal, since the disease location, behaviour and the need for surgery seem to be different between the two groups. The need for surgery should be lower in elderly onset, with less common recurrence rate but shorter time to recurrence. Older patients have less frequently penetrating CD but are less likely to be operated on with laparoscopy; they have more systemic and local complications (including anastomotic leakage) and longer hospital stay [12, 26, 62].

When surgery is necessary for CD complications, peri- and intraoperative strate­gies are no different for younger patients. Laparoscopy is the preferred surgical approach whenever technically possible. However, both in CD and UC, many elderly patients have already received abdominal surgery, related or not to IBD, making laparoscopy extremely difcult if not contraindicated [38, 63–72].

When intestinal resection is necessary, a minimal bowel resection is indicated, with no need of microscopically disease-free margins and extended mesentery dis­section [100]. Strong evidence shows that stapled, wide-lumen, functional end-to­end anastomosis is the best technique for reconstruction [101, 102].

111–114].