With the change of living environment, living habits and dietary structure, the incidence and mortality rate of intestinal tumors, especially colorectal cancer, have been increasing year by year in China, and now rank the third and fifth in malignant tumors, respectively. With the arrival of aging society, the proportion of colorectal cancer patients among the elderly is increasing. It has been reported that the incidence of colorectal cancer is increasing at an annual rate of 2%, and 23% of the new cases are elderly patients.1 Elderly people have declining function of important organs and weakened tissue regeneration and repair ability, and they often have comorbidities such as cardiovascular disease, chronic lung disease, diabetes mellitus, renal insufficiency, etc. The tolerance of surgery is greatly reduced, and the risk of postoperative complications of important organs such as heart, lung, brain and kidney, and anastomotic leakage is significantly increased.2 Therefore, the risk of surgery is significantly increased. Therefore, the concept of minimally invasive surgery and minimally invasive treatment are particularly important for elderly patients with intestinal tumors. With the continuous improvement of endoscopic and lumpectomy techniques, minimally invasive treatment has become the mainstream method of intestinal tumor treatment.3-7 For elderly patients with intestinal tumor, the selection of minimally invasive treatment methods, the grasp of surgical indications, and the perioperative evaluation and management are all crucial. With the maturation and promotion of laparoscopic technology, laparoscopic colorectal cancer surgery has become the standard procedure for colorectal cancer treatment and has been widely carried out in many large hospitals in China; its recent efficacy such as less trauma, faster recovery and shorter hospitalization time, and long-term efficacy such as tumor recurrence and metastasis have also been proved by evidence-based medicine, however, the application of laparoscopic colorectal cancer surgery in elderly patients has been limited. However, the application of laparoscopic colorectal cancer surgery in elderly patients has been limited. Traditionally, it is believed that elderly people have reduced function of important organs and many comorbidities, and the tolerance of surgery is greatly reduced. However, with the accumulation of experience and the improvement of laparoscopic techniques, the safety of laparoscopic colorectal surgery applied in elderly and even elderly patients has been confirmed, and elderly patients are no longer a contraindication to laparoscopic surgery. Several controlled studies at home and abroad have confirmed that laparoscopic radical colorectal cancer surgery is safe and effective for the elderly, and its recent results are better than those of conventional surgery, even reducing the incidence of perioperative complications.2,8-11 Combined with our own experience, we believe that laparoscopic surgery can be tolerated as long as the patient can tolerate general anesthesia for conventional surgery. Of course, as with conventional surgery, the prerequisites for successful laparoscopic surgery in the elderly are accurate and comprehensive preoperative evaluation, adequate preoperative preparation, meticulous perioperative management, and close cooperation with the relevant departments. We performed a total of 160 laparoscopic colorectal cancer surgeries in 2014, including 37 cases in elderly people >70 years old and 9 cases in elderly patients >80 years old, all of which were successfully completed, and 4 cases were transferred to the ICU ward for transitional treatment after surgery, all of which were successfully recovered without perioperative death or serious complications. At present, laparoscopic surgery has become the preferred treatment for elderly colorectal cancer patients in our colorectal surgery department. 1.1 Evaluation of the safety and effectiveness of laparoscopic bowel surgery Several foreign studies have confirmed that for elderly colorectal cancer patients, laparoscopic surgery has the advantages of less bleeding, faster recovery of bowel movement after surgery, early feeding, more lymphatic clearance, shorter hospital stay, and even lower complication rate compared with traditional surgery, despite the slightly longer operation time, with significant recent postoperative results, completely overturning the traditional concept8-10. In addition, a number of domestic controlled studies have also reached similar conclusions, and it has been postulated that the reason for this may be that laparoscopic surgery is less invasive, which can avoid postoperative coughing and sputum excretion due to wound pain, thus reducing respiratory and circulatory complications, and can promote early bedtime activity and facilitate the recovery of bowel movement, resulting in rapid postoperative recovery.2,11 The above results have also been confirmed by basic studies. Lü Yu-chen et al.12 compared the changes of stress levels and visceral protein indexes between laparoscopic and conventional radical colorectal cancer surgery in elderly patients in a controlled study, and found that laparoscopic surgery is less traumatic than open surgery and has lower stress levels, which is conducive to the recovery of visceral protein in the body, providing a theoretical basis for the minimally invasive nature of laparoscopic surgery and fast postoperative recovery. In addition, the long-term curative effect of laparoscopic radical rectal cancer surgery in elderly patients has been confirmed13, while the long-term curative effect of laparoscopic radical colon cancer surgery in elderly patients remains to be further observed. 1.2 Surgical selection of laparoscopic intestinal surgery Laparoscopic surgery for the elderly should be performed to ensure surgical quality while minimizing the operative time; therefore, for beginners, the operative time is often longer due to unskilled surgical operation and surgical group cooperation, and the operative risk is greatly increased for the elderly, especially the elderly patients with many comorbidities, so it is recommended to choose the elderly to perform laparoscopic surgery after passing the learning curve and Therefore, it is recommended that laparoscopic surgery be performed on elderly patients after the learning curve has been passed and that the indications for surgery be gradually relaxed. During surgery, the surgical team must work closely together to minimize the operative time; if there is hemodynamic instability, or if the operating space is small, or if the operation is difficult, and if the estimated operative time is long, the operation should be promptly and decisively transferred to open abdomen. And the choice of surgical methods should also be based on prudence, such as Hartmann surgery for rectal cancer, low or ultra-low anterior resection followed by prophylactic fistula, etc., to reduce the risk of perioperative complications. 1.3 Perioperative management of laparoscopic bowel surgery Elderly patients with colorectal cancer may have heart, lung, brain, liver, kidney, and other important organ comorbidities, and the perioperative management of both conventional and laparoscopic surgery requires great attention and close multidisciplinary collaboration.14 Lin Guole et al.1 developed a detailed procedure for elderly patients undergoing laparoscopic colorectal cancer surgery, which mainly includes a set of procedures worthy of clinical promotion The main components include (1) comprehensive preoperative examination and adequate preoperative evaluation; (2) individualized treatment plan and minimally invasive surgery as much as possible; (3) specialist consultation with relevant departments for timely intervention and treatment of co-morbidities; for patients with severe coronary artery disease, coronary stent implantation or coronary artery bypass grafting can be performed first before colorectal cancer surgery according to their condition. (4) Pre-operative multidisciplinary consultation is routinely organized to fully communicate with patients and their families and to formulate surgical risk management plans. (5) High-risk patients should be transferred to the intensive care unit for transition after surgery. (6) Postoperative multidisciplinary collaboration, active treatment of primary diseases and effective control of coexisting diseases; giving rise to the concept of rapid recovery, minimizing patient trauma and reducing the occurrence of surgical complications, etc. In addition, colorectal cancer surgery, especially sigmoid colon cancer and rectal cancer surgery, is generally performed in the lithotomy position, and the blood flow back to the lower limbs is impaired, so deep vein thrombosis of the lower limbs is more likely to occur after surgery, which should be paid more attention to in elderly patients. Measures such as getting out of bed early after surgery, applying anticoagulant drugs and using inflatable pumps when available can effectively prevent the formation of venous thrombosis.15 2. Endoscopic treatment Endoscopic technology, initially used as a diagnostic tool, is increasingly used for the treatment of gastrointestinal diseases. Endoscopic resection of early colorectal cancer is a minimally invasive treatment method emerging in recent years, among which Endoscopic Mucosal Resection (EMR) and Endoscopic Submucosal Dissection (ESD) are most frequently used, enabling many patients to avoid open or laparoscopic surgery. The EMR is suitable for flat lesions of 5 mm or more than 20 mm in diameter, but for flat lesions >20 mm in diameter, the EMR can only be performed by resection in blocks, and this method can easily lead to ESD is performed by submucosal peeling of the mucosa, which enables complete resection of larger lesions in one go and is suitable for flat lesions >20 mm in diameter; however, due to the larger peeling area, the operation is more difficult and the incidence of complications such as bleeding and perforation increases. Enhancement technique, magnification technique or endoscopic ultrasound must be used to accurately determine the depth of tumor infiltration and clarify whether it is intramucosal or submucosal cancer; and to accurately measure the tumor size, clarify the type of tumor differentiation, and the status of lymph node metastasis. For postoperative pathological histological examination suggesting submucosal lymphovascular or vascular infiltration of the lesion or incompletely resected hypofractionated adenocarcinoma, remedial surgical treatment is recommended5. The most common and dangerous complications after EMR and ESD are bleeding and perforation. Intraoperative or postoperative bleeding can be stopped by hot biopsy forceps, hemostatic clips, pharmacological hemostasis, sclerotherapy treatment, and if necessary, a combination of multiple means.16 Postoperative EMR and ESD wounds should be closed with hemostatic clips as much as possible to prevent perforation; once they occur, they should be repaired with endoscopic metal clips or metal clips combined with nylon cord sutures as much as possible and closely observed postoperatively; if endoscopic unmanageable perforation is encountered, the option of Laparoscopic perforation repair should be performed.16 After endoscopic treatment of early colorectal cancer, close follow-up should be performed, and those with residual or recurrence should continue to undergo endoscopic treatment or additional surgical resection, depending on the situation. Several studies at home and abroad have confirmed that ESD is a minimally invasive, safe, effective and feasible treatment for benign colorectal tumors and early colorectal cancer, which is especially suitable for elderly patients16-18. 3. Combined laparoscopic-endoscopic treatment As mentioned above, minimally invasive surgery represented by both laparoscopic and endoscopic techniques plays an important role in the treatment of elderly patients with colorectal tumors; in some cases, (1) endoscopic tumor localization during laparoscopic colorectal surgery; after the completion of laparoscopic colorectal surgery anastomosis, it is feasible to inspect the anastomosis for bleeding; if there is active bleeding, the bleeding can be stopped by electrocautery or clamping under the enteroscope. (2) Laparoscopic assistance during ESD, such as colorectal refractory polyps at special sites (e.g., hepatic flexure, splenic flexure, etc.), and polyps with large volume or broad-based non-tip stalk, ESD is prone to perforation, which can be repaired in time under laparoscopy if necessary.4 The combined application of laparoscopy and endoscopy not only expands the indications for endoscopic treatment, but also facilitates the process of laparoscopic surgery, reduces perioperative complications, and is beneficial to Postoperative rehabilitation of patients. In addition, the combined application of dual scopes also includes endoscopic tumor marking before laparoscopic colorectal cancer surgery, which facilitates intraoperative tumor localization and intraoperative lymph node dissection, avoids intraoperative colonoscopy and can shorten the operation time, which is also beneficial for elderly patients. For patients with acute intestinal obstruction of colorectal cancer, colonoscopy can be performed first, while taking biopsy to clarify the pathological nature, self-expanding metal stent (SEM)19 can be placed to release the obstruction, and then laparoscopic surgery can be performed 1 week later, which is beneficial to reduce the risk of surgery, complete resection and anastomosis in one phase, reduce the patient’s pain, improve the patient’s quality of life and avoid secondary surgery, which is especially valuable for elderly patients, which also belongs to the category of bimicroscopic combination. At present, the application of metal stent is greatly restricted because of the cost, which can be replaced by intestinal obstruction catheter; in addition, there is a risk of tumor rupture and perforation after stent placement, which should be explained to the family and prepared for emergency surgery. In recent years, we have treated many patients with colorectal cancer combined with intestinal obstruction using intestinal obstruction catheters and metal stents, and found that metal stents have more advantages in reducing patients’ pain, relieving obstruction and preparing the intestine, which is worthy of clinical promotion. 4.Transanal endoscopic microsurgery (TEM) TEM (transanal endoscopic microsurgery) technology is a transanal surgical operating system invented by Buss of Germany, the whole operation process is similar to single-hole laparoscopy, in line with the natural ofifice transluminal endoscopic surgery (NOTES). The TEM technique is suitable for local excision of benign tumors and early rectal cancer in the upper and middle rectum and lower sigmoid colon (5-500px). Compared with ESD, TEM surgery can obtain more satisfactory resected specimens, more complete resection, and can also perform microscopic suturing, which is more secure for the treatment of trauma, less risk of bleeding and perforation, and less expensive and more acceptable to patients.TEM surgery has the characteristics of less trauma, good exposure, precise resection, and less complications, which is especially suitable for elderly patients with early colorectal cancer. We started to carry out TEM surgery in 2014 and have completed 4 cases of local resection of rectal tumors, including 1 case of elderly patients; the surgical procedure and postoperative recovery were smooth, with no complications such as bleeding and perforation, and no tumor recurrence on review. We appreciate that TEM surgery is difficult in terms of body position selection, equipment connection and surgical operation, which requires special training and learning. 5.Expansion of minimally invasive concept Minimally invasive technology not only refers to anatomical minimally invasive represented by laparoscopic endoscopic technology, but also includes functional minimally invasive represented by rapid recovery theory to reduce systemic stress, psychological trauma and so on. The theory of fast track surgery (FTS) was first proposed by Kehlet in Denmark in 1999 and was soon applied to the field of colorectal surgery.6,20 It refers to the use of a series of evidence-based optimization measures in the perioperative period to achieve the least stressful blow, the smallest surgical incision, the best internal environmental stability, the lightest inflammatory response, the lowest psychological trauma, and the fastest operative outcome. Minimally invasive results such as the lowest psychological trauma and the fastest postoperative recovery.7 Specifically in colorectal surgery, the components include: adequate preoperative psychological preparation and functional exercise, avoiding mechanical bowel preparation as much as possible, shortening fasting time and not placing a gastric tube; using minimally invasive surgery, prophylactic analgesia, and paying attention to warmth; limiting intraoperative and postoperative rehydration; early postoperative removal of tubes, early bed mobility, and early postoperative initiation of food intake. Evidence-based medicine has proved that accelerated rehabilitation treatment for colorectal cancer can reduce the incidence of postoperative complications and shorten the length of hospital stay.6 We have introduced the concept of FTS in colorectal surgery since 2008, and through our application experience, we believe that FTS is not only suitable for young patients with few coexisting diseases and good health, but also for elderly patients with many comorbidities; however, FTS is not just blindly seeking for speed, but also integrating the concept of minimally invasive surgery into the whole perioperative process. However, FTS does not focus on speed, but individualizes the treatment by integrating the concept of minimally invasive into the whole perioperative process. For elderly colorectal cancer patients, our FTS measures mainly include: (1) shortening preoperative fasting time, short mechanical bowel preparation, and paying attention to maintaining electrolyte balance; (2) no preoperative gastric tube; (3) routine laparoscopic surgery; (4) restrictive rehydration during the perioperative period; (5) early postoperative feeding and water intake, early bedtime activities, and early removal of tubes, etc. In conclusion, with the promotion and popularization of minimally invasive technology and minimally invasive concept, and under the guidance of more evidence-based medical evidence, the treatment of elderly patients with intestinal tumors will also break the tradition and enter the minimally invasive era, thus benefiting more elderly patients.