Mortality Increases for Octogenarians Undergoing Esophagogastrectomy for Esophageal Cancer

Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, United States
The Annals of thoracic surgery (Impact Factor: 3.85). 01/2007; 82(6):2031-6; discussion 2036. DOI: 10.1016/j.athoracsur.2006.06.053
Source: PubMed


As the general population ages, it becomes increasingly important to understand the potential contribution of chronologic age to mortality after esophagectomy. Because this risk is poorly defined, we sought to determine whether extreme age (>80 years) is an independent risk factor after esophagectomy.
We analyzed a prospectively maintained, single-institution database of 858 consecutive patients who underwent esophagectomy between January 1996 and May 2005. Data evaluated included patient demographics, medical comorbidity, types of resections performed, length of stay, postoperative adverse events, and overall survival. We used univariate, multivariate, and Kaplan-Meier analysis to determine the influence of age on postoperative morbidity, in-hospital survival, and overall survival.
Of 858 patients, 31 (10 female, 21 male) were older than 80 years of age. Preliminary analysis indicated that patients younger than 50 years (n = 107) had significantly fewer comorbidities; these were excluded from the analysis. In the remaining 751 patients, the age older than 80 cohort was compared with patients aged 50 to 79. Patients aged 50 to 79 were grouped because of similar characteristics (length of stay, hospital death). There were no significant differences in comorbidities, types of resections, or postoperative complication type or severity between the two groups. Postoperative death, length of stay, and survival, however, were significantly worse in patients older than 80. In a logistic regression model controlling for comorbidity, age older than 80 was significantly associated with increased perioperative mortality (hazard-ratio, 3.9; p < 0.01).
Patients older than 80 years have increased mortality risk after esophagectomy, independent of comorbidity. Octogenarian status should be a consideration in the management of these patients.

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    • "The actual age limit is the only factor that remains controversial. Esophagectomy for patients above 70 has been extensively reported, and recently, certain authors have reported identical results with patients above 75 years of age [12] [26] [27] and even older than 80 years of age [15]. It would seem that preoperative patient evaluation for risks of postoperative complications would be more pertinent using scores that integrate patient age and comorbidities (such as the Steyeberg, the P-POSSUM, or the O-POSSUM score) rather than relying simply on age criteria [27]. "
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    ABSTRACT: The standard treatment of locally-advanced esophageal adenocarcinoma consists of neoadjuvant radiochemotherapy followed by surgical resection. Very little data are available concerning the feasibility of this strategy in patients older than 70 years of age. Between 1996 and 2008, 118 patients underwent transthoracic esophagectomy with lymphadenectomy for adenocarcinoma of the esophagus and gastric cardia (Siewert I and II). These were divided into three groups for comparison: Group I (age less than 70 years, neoadjuvant treatment followed by surgery; n=66); Group II (age greater or equal to 70 years, surgery alone; n=32); Group III (age greater or equal to 70 years, neoadjuvant treatment followed by surgery; n=20). Data concerning comorbidities, type of intervention, morbidity, mortality, survival and quality of life were analyzed. There was no difference among the three groups with regard to comorbidity and preoperative evaluation. The patients in Groups I and III had more locally-advanced tumors (P<0.001). There was some disparity between the types of surgery proposed. The Lewis-Santy esophagectomy was most commonly used (90%, 50%, and 65% respectively). The 90-day mortality was 8%, 15%, and 15% respectively. There was no statistically significant difference in the incidence of postoperative pulmonary, cardiac, or digestive complications among the three groups. No difference was found in 5-year survival and quality of life. Neoadjuvant radiochemotherapy for elderly patients (age above 70 years) with esophageal adenocarcinoma did not seem to increase postoperative morbidity or mortality, nor was there any difference in quality of life, nor any effect on survival, no matter what the age of the patient.
    Full-text · Article · May 2012 · Journal of Visceral Surgery
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    • "More recent studies showed acceptable results regarding mortality and survival because of better surgical techniques, centralization, and more intensive perioperative care.8,10–12,16–19,21,27 Therefore, some studies focus on even older patients (>75 or >80 years).9,12,16 "
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    ABSTRACT: Elderly patients who undergo esophagectomy for cancer often have a high prevalence of coexisting diseases, which may adversely affect their postoperative course. We determined the relationship of advanced age (i.e., > or =70 years) with outcome and evaluated age as a selection criterion for surgery. Between January 1991 and January 2007, we performed a curative-intent extended transthoracic esophagectomy in 234 patients with cancer of the esophagus. Patients were divided into two age groups: <70 years (group I; 170 patients) and > or =70 years (group II; 64 patients). Both groups were comparable regarding comorbidity (American Society of Anesthesiologists classification), and tumor and surgical characteristics. The overall in-hospital mortality rate was 6.2% (group I, 5%, vs. group II, 11%, P = 0.09). Advanced age was not a prognostic factor for developing postoperative complications (odds ratio, 1.578; 95% confidence interval, 0.857-2.904; P = 0.143). The overall number of complications was equal with 58% in group I vs. 69% in group II (P = 0.142). Moreover, the occurrence of complications in elderly patients did not influence survival (P = 0.174). Recurrences developed more in patients <70 years (58% vs. 42%, P = 0.028). The overall 5-year survival was 35%, and, when included, postoperative mortality was 33% in both groups (P = 0.676).The presence of comorbidity was an independent prognostic factor for survival (P = 0.002). Advanced age (> or =70 years) has minor influence on postoperative course, recurrent disease, and survival in patients who underwent an extended esophagectomy. Age alone is not a prognostic indicator for survival. We propose that a radical resection should not be withheld in elderly patients with limited frailty and comorbidity.
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    ABSTRACT: Neoplasms of the esophagus and gastroesophageal junction are aggressive tumors that often present at an advanced stage, and that historically have been associated with poor survival despite therapy. 16,470 Americans are diagnosed with and 14,280 die of esophageal cancer annually, and the incidence is increasing. In fact, the incidence of esophageal adenocarcinoma (EAC) has increased in the last 25 years, greater than the incidence of any other major malignancy in the United States. Esophageal cancer is primarily a disease of the elderly. The median age at diagnosis is 69 years, with 61.5% of those diagnosed being age 65 or older. While surgery remains the best single modality of therapy in terms of survival and durable control of dysphagia, careful patient selection and medical optimization of existing comorbidities is of paramount importance in maintaining acceptable surgical outcomes, especially in the elderly. Whether postsurgical outcome in the elderly is worse than for younger patients remains controversial. It seems likely that the best possible surgical outcomes are obtained in elderly patients who are meticulously screened, medically optimized with regards to existing comorbidities, and undergo surgery in a high-volume tertiary referral center. Recent data suggest that elderly patients with early EAC have improved survival following surgery rather than chemoradiation. Palliative esophagectomy for advanced stage malignancy is associated with mortality rates in excess of 20% and morbidity rates as high as 50% and should therefore be avoided. Very effective palliation can be obtained with chemotherapy, radiation therapy, and endoscopic interventions such as stenting.
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