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Ann Thorac Surg 2001;71:414-418
© 2001 The Society of Thoracic Surgeons

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Original article: general thoracic

Esophageal resection in elderly esophageal carcinoma patients: improvement in postoperative complications

^a Second Department of Surgery, Shimane Medical University, Shimane, Japan

Accepted for publication August 21, 2000.

Address reprint requests to Dr Kinugasa, Second Department of Surgery, Shimane Medical University, Enya-cho 89-1, Izumo 693-8501, Shimane, Japan
e-mail: kinugasa{at}shimane-med.ac.jp

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. Advanced age is considered to be a relative contraindication for radical esophagectomy with a three-field lymph node dissection.

Methods. Preoperative risks, postoperative morbidity and mortality, and long-term survival in 55 elderly patients (70 years) who had undergone extensive esophagectomy for esophageal carcinoma were compared with those of 149 younger patients (<70 years).

Results. Elderly patients had worse preoperative cardiopulmonary function and had more frequent postoperative cardiopulmonary complications compared with younger patients (p < 0.05). The postoperative death rate was not statistically different between the elderly (10.9%) and younger groups (5.4%). When the study period was divided into an early and a late phase, the postoperative death rate dropped significantly (p < 0.05) in recent years (1.4%) when compared with the previous era (10.0%). The overall survival rates were not different between elderly and younger patients.

Conclusions. Preoperative cardiopulmonary risk factors and postoperative complications after esophagectomy were more frequently noticed in elderly patients than in younger patients. A dramatic improvement in postoperative death was noticed in recent years. The long-term survival of elderly patients after extended esophagectomy was almost similar to that in younger patients.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Perioperative management of elderly patients after a major surgical procedure is an important issue as the elderly population is increasing in recent years. Esophageal carcinoma is one of the most malignant tumors with a dismal prognosis; half of the patients die within 2 years, and the overall 5-year survival rate is only 20% after resection of the tumor [1, 2]. The poor prognosis of esophageal carcinoma patients even after a curative resection raises a suspicion regarding this extensive procedure because of a high mortality and morbidity after esophagectomy [3–6]. Several studies comparing the results of esophagectomy between elderly and younger patients showed that elderly patients generally had a high mortality [7] and poor long-term survival [8–11]. On the contrary, because of recent advances in the perioperative intensive care management, some authors proposed that esophagectomy in the elderly could be performed with an acceptable mortality rate in selected patients [12–15].

Since the early 1980s, esophagectomy along with a three-field extensive lymph node dissection has become the standard surgical procedure to achieve an accurate pathologic staging and a better prognosis in Japan [16–18] Favorable results from Japanese series encouraged early introduction of such extended esophagectomy in the Western countries [19, 20]. Although mortality and morbidity rates after radical esophagectomy with a three-field lymphadenectomy in the younger patients are acceptable [17, 18], the result of such an extensive procedure in the elderly patients is not known.

The purpose of this work was to analyze the short and long-term outcomes after extended esophagectomy along with a three-field lymph node dissection in the elderly patients.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Between January 1981 and May 1999, 246 patients with primary squamous cell carcinoma of the thoracic esophagus were admitted to the Second Department of Surgery, Shimane Medical University. Seventy-two were elderly patients (>70 years) and 174 were younger (<70 years). Among those, 204 patients (82.9%) underwent surgical resection; 55 (76.4%) were in the elderly group and 149 (85.6%) were in the younger group. Forty-five patients (81.8%) in the elderly and 110 patients (73.8%) in the younger group underwent R0 (curative) resection.

One hundred ninety-three of 204 patients (94.6%) underwent a right transthoracic subtotal esophagectomy with a three-field dissection of the regional lymph nodes including the cervical (bilateral supraclavicular regions), mediastinal (periesophagus and around the trachea including recurrent laryngeal nerve nodes), and abdominal (perigastric region and around the celiac axis) lymph nodes. Eight patients with lower-third esophageal cancers underwent left transthoracic lower esophagectomy with dissection of lower mediastinal and perigastric lymph nodes, and in another 3 patients a blunt esophagectomy was performed without any lymph node dissection. Reconstruction was performed by gastric tube in 173 patients, jejunum in 7 patients, and colon in 22 patients. Two patients had two-stage operations for reconstruction. In most instances, the retrosternal route was used for the reconstruction. Esophagogastrostomy, esophagoileostomy, or esophagocolostomy was performed in the neck through a cervical incision.

All patients had detailed preoperative risk assessments based on history of chronic lung, heart, liver, and renal diseases, chest roentgenogram, electrocardiogram, arterial blood gas analysis, spirometry, and hematological tests. The preoperative risk factors analyzed included weight loss, anemia, hypertension, pulmonary dysfunction, cardiac dysfunction, liver dysfunction, renal dysfunction, and diabetes mellitus.

Definitions of risk assessments were as follows: (1) weight loss more than 10%; (2) anemia, defined as hemoglobin less than 12 g/dL; (3) pulmonary dysfunction, defined as forced expiratory volume at 1 second less than 70% of predicated normal value, vital capacity less than 80% of predicted normal value, or hypoxia (arterial oxygen tension < 70 mm Hg) or hypercarbia (arterial carbon dioxide tension > 45 mm Hg); (4) cardiac dysfunction, defined as history of ischemic heart disease, heart failure, or abnormal electrocardiogram; (5) liver dysfunction, defined as history of cirrhosis or chronic hepatitis, increase of serum aminotransferases more than 50 IU/L, or indocyanine green clearance test more than 10%; (6) renal dysfunction, defined as history of chronic renal disease, increase of serum creatinine more than 1.5 mg/dL, or 24-hour creatinine clearance less than 80 mL/min; and (7) hypertension, defined as prescribed history of hypertension, systolic blood pressure more than 160 mm Hg, or diastolic pressure more than 90 mm Hg. Definitions of postoperative complications were as follows: (1) anastomotic leakage, defined as anastomotic insufficiency requiring surgical drainage or reanastomosis; (2) pulmonary complication; defined as pneumonia (positive bacterial culture of the sputum), pulmonary edema, atelectasis, or hypoxia requiring reintubation; (3) cardiac complication, defined as heart failure or arrhythmia requiring medication; and (4) intraabdominal abscess, defined as intraabdominal sepsis requiring drainage or laparotomy.

Clinicopathologic characteristics based on the TNM classification of the malignant tumors [21], therapeutic methods, and the postoperative morbidity and mortality between elderly and younger patients were retrospectively investigated. Patients received a regular follow-up at the outpatient department, and all information was compiled within a database. An update inquiry about the present status of all surviving patients was conducted by telephone or letter contact in May 1999.

The standard ² test or Fisher’s exact test was used for comparative analyses. The survival rates were estimated by the Kaplan-Meier method [22], and the statistical analysis was performed by the log-rank test to test for equality of the survival curves. The level of significance was p less than 0.05.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
Among 246 patients, 72 were elderly and 174 were younger patients. In 72 elderly patients, 55 underwent surgical resection, making an operability rate of 76.4%, and of these, 45 patients (81.8%) were considered to be curatively resected (R0). The causes of inoperability in elderly patients were poor general condition in 2, advanced diseases in 11, coexistent multiple hepatocellular carcinomas in 1, and refusal in 3. In 174 younger patients, 149 patients (operability rate, 85.6%) received surgical resection, and of these, 110 patients (73.8%) underwent an R0 resection. The causes of inoperability were advanced diseases in 23 and poor general condition in 2. In the elderly group, 33 patients were between 70 and 74 years old, 18 patients were between 75 and 79 years old, and 4 patients were octogenarians. The highest age was 83 years old. The following analyses were performed between the elderly group (n = 55) and the younger group (n = 149) who underwent surgical resection.

Clinicopathologic characteristics and preoperative risks
The clinicopathologic characteristics between the elderly and younger groups are shown in Table 1. There were no significant differences in sex, tumor location, and pTNM stage. A significant number of patients in the younger group had well-differentiated tumors in contrast to a predominance of moderate to poorly differentiated tumors in the elderly group (p < 0.01). Many patients in the elderly group had significantly poorer pulmonary (p < 0.01), cardiac (p < 0.05), and renal (p < 0.01) function than those in the younger group, whereas liver function and diabetes mellitus status were not different between the two groups (Table 2).

View larger version (15K): [in this window] [in a new window]   Fig 1. Overall survival rates in elderly and younger patients who underwent esophageal resection. The 1-, 3-, and 5-year overall survival rates in the elderly group were 56.2%, 40.7%, and 32.9%, respectively, whereas those in the younger group were 71.5%, 43.2%, and 35.3%, respectively (p = 0.27). The number of patients at risk at each year after operation is shown below the figure.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

Fifty-five of 72 elderly patients (76%) underwent esophagectomy, and only 2 were preoperatively judged as inoperable because of poor general conditions in this study. This indicates that surgical resection could be performed in a high percentage of elderly patients and thus advanced age alone should not be considered as a contraindication for esophagectomy. Preoperative risk assessment is an important aspect of patient selection for esophagectomy, as a significant number of these patients had cardiopulmonary or renal dysfunction in the preoperative period. Similarly, a significant number of patients in this group suffered from cardiopulmonary complications in the postoperative period. Pulmonary complication was one of the most common causes of surgical complication–related deaths in both groups. These results strongly suggest that greater preoperative precautions must be taken to manage cardiopulmonary complications in the elderly patients.

Although a significant number of patients had miscellaneous postoperative complications, only a few of them succumbed to death because of those complications. Also, the postoperative death rate after extended esophagectomy was not statistically different between the two groups. The rate of operative mortality in elderly esophageal carcinoma patients has been reported to be 6% to 27% [8, 11, 23, 24], which is comparable to our rate of 10.9%. Furthermore, the results of Table 5 indicate that morbidity and postoperative mortality dropped dramatically in recent years. This improvement in surgical outcome with time might be attributed in part to the significant improvement in surgical technique and improvement in perioperative patient care in our institution. Indeed, shorter operative time, reduced blood loss, and fewer perioperative blood transfusions were noticed in recent years compared with the previous era. For example, recently cervical and abdominal lymph node dissections are performed simultaneously by two separate surgical teams to reduce the total operative time. Also, use of stapling devices for construction of the gastric tube has contributed to reduced operative time in recent years. The pulmonary complication rate decreased to only 25.7% in recent years in contrast to 34.6% in the previous era. Recently, preoperative incentive spirometry is routinely performed by a respiratory therapist, and during the postoperative period cricothyroidotomy [25] and repeated bronchoscopy are performed to keep the airway clear of sputum. Moreover, reduced incidence of recurrent laryngeal nerve paralysis in recent years may have an impact on the reduced incidence of pulmonary complication during this period. Finally, efficient postoperative pain control by epidural anesthesia block might have improved postoperative activity of the patients and, therefore, might have contributed to reduced incidence of pulmonary complication in the recent era.

The 5-year overall survival rate of 32.9% in the elderly group was similar to that of 35.3% in the younger group (p = 0.27). However, the long-term survival data in the present study seemed to be better than those previously reported from other institutions (13% to 30% of 5-year overall or disease-specific survival rate) where two-field lymph node dissection are routinely performed [8, 12, 15, 23, 24]. Considering an almost similar prevalence of postoperative deaths and long-term survival both in the elderly and younger groups, it could be concluded that a radical esophagectomy with an extensive lymph node dissection is feasible in elderly patients. However, a careful patient selection procedure must be used to exclude the high-risk elderly patients from the operative list and thus will help to reduce the postoperative morbidity and mortality rate in this group of patients.

In conclusion, our results indicate that (1) preoperative cardiopulmonary risk factors and postoperative cardiopulmonary complications after esophagectomy are common in the elderly patients; (2) extended esophagectomy produced a comparatively higher postoperative death rate in elderly patients but it was not statistically significant when compared with the younger patients; and (3) improved perioperative patient care has helped to dramatically reduce the postoperative death rate in recent years.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kinugasa, S. Articles by Nagasue, N. Search for Related Content PubMed PubMed Citation Articles by Kinugasa, S. Articles by Nagasue, N. Related Collections Esophagus - cancer