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Ann Thorac Surg 1997;63:1423-1427
© 1997 The Society of Thoracic Surgeons

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Original Article: General Thoracic

Esophagectomy for Cancer in the Patient Aged 70 Years and Older

Service de Chirurgie Thoracique, Hôpital du Haut-Lêque, Pessac, France

Accepted for publication November 14, 1996.

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Patient Selection Patients Aged 70 Years... Results Patients Aged Less Than... Comparison of the Two... Comment References

 
Background. Advanced age increases the risk of any major surgical intervention, particularly esophageal resection. High morbidity and increased mortality have been reported in operations for esophageal cancer in the elderly.

Methods. To determine outcome, risk factors, and the advisability of esophageal resection in the elderly, a single-institution retrospective review was performed of esophagectomy for cancer over a 14-year period. From January 1, 1980, to December 31, 1993, 540 patients underwent esophageal resection for esophageal cancer. These patients were divided into two groups: group 1, n = 89, patients 70 years of age or older; and group 2, n = 451, patients younger than 70 years of age. The two groups were compared according to preoperative risk factors, morbidity rate, mortality rate, mean stay in the hospital after operation, and long-term survival.

Results. Adenocarcinoma of the esophagogastric junction was the most common tumor in group 1 and was usually managed with a single incisional approach. There were no significant differences between the groups concerning morbidity (24.7% in group 1), mortality (7.8% in group 1), mean stay in the hospital (23.3 days in group 1), or long-term survival (59%, 23%, and 13% at 1, 3, and 5 years, respectively, in group 1).

Conclusions. These results suggest that esophagectomy can be performed in selected elderly patients without increasing morbidity or mortality and with long-term survival.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Patient Selection Patients Aged 70 Years... Results Patients Aged Less Than... Comparison of the Two... Comment References

 
See also page 1427.

The diagnosis of esophageal cancer in a patient aged 70 years or older always raises the question of whether a major operation is indicated, given the known increased morbidity associated with operating on these frail patients [1]. However, the average life expectancy in France is now 72 years for men and 81 years for women. This cancer is found more and more frequently in patients over 70 years of age because of our aging population. Operative treatment still offers the longest and most comfortable survival for patients suffering from esophageal cancer [2]. Although some authors [3, 4] have reported a higher mortality rate in patients more than 70 years old, our practice seemed to show that results could be satisfactory without extra morbidity in selected patients. Thus, to study the results and to determine our selection factors for operative treatment of esophageal cancer in these patients, we performed a retrospective analysis of a single institution's cohort of 89 patients aged 70 years or older, operated on between January 1980 and December 1993. The results were then compared with those obtained in a series of 451 patients aged 70 years or less, operated on within the same period and according to the same principles.

For editorial comment, see page 1225.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Patient Selection Patients Aged 70 Years... Results Patients Aged Less Than... Comparison of the Two... Comment References

 
Five hundred forty patients were operated on consecutively from January 1980 through December 1993 at the thoracic surgical unit Hospital Xavier Arnozan (Prof. Louis Couraud). We split these patients into two groups: group 1, 89 patients aged 70 years and older; and group 2, 451 patients aged 70 years or less. Thus, this study constitutes a large single-institution series of patients aged 70 years and older. The patient records were retrieved, and clinical data, preoperative investigations, operative details, and histologic results were recorded for all patients. We also obtained follow-up information during our annual office visit or from the referring physician or general practitioner.

All data were stored on Medlog (Logi-Soft, Fontainbleau, France) software. Statistical analysis was performed using ² tests or analysis of variance on the same software. Survival curves were constructed using the method of Kaplan and Meier, then compared by a log rank method. A p value less than 0.05 was considered significant.

	Patient Selection

Top Footnotes Abstract Introduction Patients and Methods Patient Selection Patients Aged 70 Years... Results Patients Aged Less Than... Comparison of the Two... Comment References

 
In all patients, preoperative workup and staging were performed, and their functional status was evaluated. The staging included an esophagoscopy, bronchoscopy performed in our department, abdominal ultrasound scan, barium swallow, bone scan, and chest and abdominal computed tomographic scan (after 1984). Transesophageal ultrasound was not commonly performed. For each patient, we estimated percentage loss of weight (relative to their normal weight) as an index of nutritional status. Patients with severe dysphagia with poor nutritional status underwent preoperative feeding for a week or less using a fine-bore nasogastric tube passed through the stenosis during the endoscopy, or by intravenous nutrition. The preoperative assessment evaluated cardiorespiratory status and nutritional status. Pulmonary function tests and arterial blood gas analysis were always performed to assess the respiratory status. An electrocardiogram was always performed. Echocardiography and an exercise stress test were routinely performed in patients over 70 years old. The preoperative selection and management were performed by the same surgical and anesthetic team. Tumor resectability was assessed by computed tomographic scan, esophagoscopy, and rigid bronchoscopy. Rigid bronchoscopy was performed to assess the mobility of the membranous trachea and bronchi to exclude tracheobronchial invasion. For the patient to be considered for operation, the preoperative assessment had to show first that the tumor could be resected completely and second that the patient had adequate cardiopulmonary reserve to tolerate a thoracotomy. Thus, patients over 70 years of age were considered for operation only if the forced expiratory volume in 1 second was more than 50% of that predicted, vital capacity was greater than 60% predicted, residual volume was not greater than 120% predicted, and resting oxygen saturation was more than 65 mm Hg.

Patients suffering from unstable coronary artery disease were treated and stabilized before operation, but patients aged 70 years or older who had an indication for coronary artery bypass grafting were excluded from an esophageal operation. The esophagectomy was performed on the same admission in all patients if the preoperative assessment was satisfactory. However, in group 2, 47 patients underwent preoperative chemotherapy and radiation therapy between January 1991 and October 1993. This preoperative treatment was given up after October 1993 because of disappointing preliminary results. None of the patients in group 1 (patients aged 70 years and older) received this treatment.

The philosophy of operative management was not modified during the study period, and it was the same for all surgeons. All surgical procedures were performed by experienced surgeons (L.C., J.F.V., J.B.J., J.D.). The operative approach was chosen according to the site of tumor, history of former thoracic diseases or interventions, and general status, and keeping in mind oncologic surgical principles, including adequate margins of resection (more than 5 cm from the tumor edge proximally). In patients over 70 years of age, our preferred approach for lower-third tumor was a left thoracolaparotomy. An isoperistaltic tube gastroplasty was performed using the technique we have described previously [5, 6]. A crushing of the pylorus was routinely performed. Anastomoses were performed with a two-layer, hand-sewn interrupted suture technique using an absorbable monofilament suture material (3-0), such as polydioxanone (PDS; Ethicon, Neuilly sur Seine, France). A nasogastric suction tube was passed through the anastomosis and left in place until the water-soluble contrast swallow. Patients were extubated postoperatively as soon as their central temperature and respiratory function permitted. Postoperatively, patients received parenteral feeding, and since 1985 most of them have also received enteral nutrition through a jejunostomy feeding tube. Low-dose jejunostomy feeding was initiated on postoperative day 2. A water-soluble contrast swallow was performed on day 7 before allowing oral feeding.

	Patients Aged 70 Years and Older

Top Footnotes Abstract Introduction Patients and Methods Patient Selection Patients Aged 70 Years... Results Patients Aged Less Than... Comparison of the Two... Comment References

 
There were 78 men (87.6%) and 11 women (12.4%) aged 70 or older (group 1), with a mean age of 75 years (range, 70 to 84 years). Thirty-five patients were more than 75 years old (Fig 1). Recruitment was continuous throughout the 14 years. Forty-seven patients were referred in the first 7 years and 48 in the last 7 years. Most patients suffered from dysphagia (78 patients, 87.6%). Twenty patients (22.5%) had weight loss reaching 10% or more of their usual weight. In many cases the diagnosis was delayed; for the whole group, the mean interval between the first symptom and the operation was 86.7 days. Twenty-one patients (23.5%) had a history of gastric or esophageal disease. Two patients (2.2%) had a history of cancer; one rectal cancer and one bronchial cancer were both considered cured.

View larger version (23K): [in this window] [in a new window]   Fig 1. . Distribution of patients older than 70 years.

	Results

Top Footnotes Abstract Introduction Patients and Methods Patient Selection Patients Aged 70 Years... Results Patients Aged Less Than... Comparison of the Two... Comment References

Histologic analysis found 33 squamous carcinomas (37.1%), 53 adenocarcinomas (59.6%), and 3 undifferentiated carcinomas (3%). These results and the histologic staging according to the Union Internationale Contre le Cancer 1987 are shown in Table 4.

Follow-up included all patients but 2, who were lost. The average follow-up of our series was 22 months. Sixty-eight patients (78.2%) have died, 1 patient is alive with tumor recurrence, and 16 (18.4%) are alive and healthy. The actuarial survival at 1, 3, and 5 years was 59.1%, 23.3%, and 13.3%, respectively.

	Patients Aged Less Than 70 Years

Top Footnotes Abstract Introduction Patients and Methods Patient Selection Patients Aged 70 Years... Results Patients Aged Less Than... Comparison of the Two... Comment References

 
Group 2 included 451 patients (414 men and 37 women) aged between 18 and 69 years (mean, 58 years). These patients were operated on during the same period as those in group 1. In this group, the morbidity and mortality rates were 26.8% and 5.5%, respectively. The mean length of hospital stay was 23.2 days. Histologic findings and staging are summarized in Table 4. The actuarial survival at 1, 3, and 5 years was 64.0%, 25.9%, and 20.7%, respectively.

	Comparison of the Two Groups

Top Footnotes Abstract Introduction Patients and Methods Patient Selection Patients Aged 70 Years... Results Patients Aged Less Than... Comparison of the Two... Comment References

 
We compared the results obtained in each group. Presenting symptoms were similar in both groups. The delay between the appearance of the first symptoms and the diagnosis should be emphasized; the mean delay in the two groups was 86 days. The weight loss was similar in both groups: 112 patients (24.8%) in group 1 had a weight loss reaching 10% of more of their usual weight, compared with 22.5% in group 2. Analysis of operative morbidity factors found a statistically significant increased risk in patients aged 70 and older (see Table 2). The tumor was situated at the cardia more frequently in the first group (see Table 1) and was treated primarily with a one-stage thoracic approach in this group (see Table 3). Adenocarcinoma was more frequent in group 1. Tumor histology and staging were similar between the groups. The results of operative treatment in each group are compared in Table 5; there were no significant differences between the groups concerning morbidity (² = 0.10; p = 0.78) or mortality (² = 0.82; p = 0.53). The mean postoperative hospital stay was the same. Comparison of the survival curve between the groups showed no significant difference (p = 0.13).

	Comment

Top Footnotes Abstract Introduction Patients and Methods Patient Selection Patients Aged 70 Years... Results Patients Aged Less Than... Comparison of the Two... Comment References

The long-term survival in our series is similar to that found in other series [1, 7]. None of our patients aged 70 years or older had preoperative adjuvant treatment. In fact, we did not believe that such treatment was indicated for these already frail patients, given the lack of evidence for its efficacy so far [8]. We considered resection only in those patients suffering from a resectable tumor. The complexity of such an operation certainly increases morbidity, mainly because of the duration of the operation. We prefer to use a single-stage approach by left thoracolaparotomy in patients aged 70 years or older, provided that adequate tumor resection can be achieved. Our previous results reported in a series of 210 patients undergoing such an approach confirmed our choice of this method (5-year survival, 17% [9]). Thus, left thoracolaparotomy was the approach in 67.4% of the patients aged 70 years and older, whereas it was performed in 34.6% of the patients aged less than 70 years (see Table 3). We have always tried to extubate the patient as soon as possible after operation once he or she was stable and had rewarmed. The low incidence of respiratory complications (6 patients, 6.7%) supports our policy. Caldwell and associates [10] reported a significant decrease of cardiovascular complications when the duration of postoperative mechanical ventilation was decreased after esophagectomy. Such a major operation justifies a cardiovascular and respiratory assessment to select patients. The pulmonary function tests were always satisfactory (forced expiratory volume in 1 second: range, 2,208 to 2,330 mL/s). The cardiovascular assessment often included echocardiography and an effort test. More than 20% of patients had lost more than 10% of their normal body weight when the disease was diagnosed. The delay before diagnosis was similar in both groups. This may be explained by the fact that many of our patients came from rural areas, where medical attention is sought less frequently than in urban areas. We always kept in mind the same oncologic principles of complete resectability of the tumor with mediastinal resection of lymph nodes by thoracotomy, whatever the patient's age. It has been shown that esophagectomy without thoracotomy does not reduce overall morbidity or respiratory complications [11, 12]. This was also reported by Naunheim and associates [4]: In patients aged 70 years and older, the transhiatal approach was responsible for the same morbidity as the transthoracic approach (morbidity = 18% and 19%, respectively). The long-term survival reported in that series was inferior to ours.

In conclusion, although patients more than 70 years old referred for operation have already been selected to a degree, it is important for the surgeon to assess the physiologic reserves and identify preoperative risk factors in these patients so that selection is optimal. After careful selection, we have been able to achieve equivalent results in 89 patients over 70 years of age and in 451 younger patients. These results confirm that these patients will benefit from operation if the surgeon adheres to the same oncologic surgical principles while trying to diminish the aggressivity of the procedure.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Patient Selection Patients Aged 70 Years... Results Patients Aged Less Than... Comparison of the Two... Comment References

 
Address reprint requests to Dr Jougon, Service de Chirurgie Thoracique, Hôpital du Haut-Lévêque, 33604 Pessac, France.

	References

Top Footnotes Abstract Introduction Patients and Methods Patient Selection Patients Aged 70 Years... Results Patients Aged Less Than... Comparison of the Two... Comment References

 

1. Richelme H, Benchimol D, Bourgeon A, et al. La chirurgie d'exérèse de l'oesophage après 70 ans. Chirurgie 1988;114:150–9.[Medline]
2. Richelme H, Baulieux J. Le traitement des cancers de l'oesophage. Monographie de l'association française de chirurgie. Paris: Masson Éditeur, 1986.
3. Griffin S, Desai J, Charlton M, Townsend E, Fountain SW. Factors influencing mortality and morbidity following oesophageal resection. Eur J Cardiothorac Surg 1989;3:419–24.[Abstract]
4. Naunheim KS, Hanosh J, Zwischenberger J, et al. Esophagectomy in the septuagenarian. Ann Thorac Surg 1993;56:880–4.[Abstract]
5. Couraud L, Mériot S. Le traitement des cancers du tiers inférieur et du tiers moyen de l'oesophage par résection et gastroplastie tubulée isopéristaltique. Résultats à court et à long terme dans une série de 256 cas. Chirurgie 1982;108:703–7.[Medline]
6. Couraud L, Hafez-Alqudah A, Clerc P, Mériot S. The current role of partial esophagectomy in the surgical treatment of middle and lower third esophageal carcinoma. In: Delarue NC, Wilkins EW, Wong J, eds. Esophageal cancer. St. Louis: C.V. Mosby, 1988:181–5.
7. Adam DJ, Craig SR, Sang CTM, Cameron EWJ, Walker WS. Esophagectomy for carcinoma in the octagenarian. Ann Thorac Surg 1996;61:190–4.
8. Sharpe DAC, Moghissi K. Resectional surgery in carcinoma of the oesophagus and cardia: what influences long-term survival? Eur J Cardiothorac Surg 1996;10:359–64.[Abstract]
9. Jougon J, Velly JF, Clerc F, Martigne C, Couraud L. La thoracophrénotomie gauche dans l'exérèse des cancers du cardia et du tiers inférieur de l'oesophage: a propos d'une série de 210 cas. Chirurgie 1993–1994;120:211–5.
10. Caldwell MTP, Murphy PG, Page R, Walsh TN, Hennessy TPJ. Timing of extubation after oesophagectomy. Br J Surg 1993;80:1537–9.[Medline]
11. Goldminc M, Maddern G, LePrise E, Meunier B, Campion JP, Launois B. Oesophagectomy by transhiatal approach or thoracotomy: a prospective randomised trial. Br J Surg 1993;80:367–70.[Medline]
12. Shahian DM, Neptune WB, Ellis FH, Watkins E. Transthoracic versus extrathoracic esophagectomy: mortality, morbidity, and long-term survival. Ann Thorac Surg 1986;41:237–46.[Abstract]

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This Article Abstract 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 Author home page(s): Jacques B. Jougon John Duffy Jean Dubrez Jean-François Velly Louis Couraud Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Jougon, J. B. Articles by Couraud, L. Search for Related Content PubMed PubMed Citation Articles by Jougon, J. B. Articles by Couraud, L. Related Collections Related Article