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      Is Surgery in the Elderly for Oesophageal Cancer Justifiable? Results from a Single Centre

      research-article
      1 , 1 , 1 , 2 , *
      ISRN Surgery
      Hindawi Publishing Corporation

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          Abstract

          Aims. Advanced age is an identified risk factor for patients undergoing oncological surgical resection. The surgery for oesophageal cancer is associated with significant morbidity and mortality. Our aim was to study the operative management of elderly patients (≥70 years) at a single institute. Methods. The data was collected from 206 patients who have undergone operative resection of oesophageal cancer. The demographic, operative, histological, and postoperative follow-up of all patients were analysed. Results. A total of 46 patients of ≥70 years who had surgical resection for oesophageal cancer were identified. Patients ≥70 years had poor overall survival ( P = 0.00). Also elderly patients with nodal involvement had poor survival ( P = 0.04). Age at the time of surgery had no impact on the incidence of postoperative complication and inpatient mortality. Both the univariate and multivariate analyses showed age, nodal stage, and positive resection margins as independent prognostic factors for patients undergoing surgery for oesophageal cancer. Conclusions. Advanced age is associated with poor outcome following oesophageal resection. However, the optimisation of both preoperative and postoperative care can significantly improve outcomes. The decision of operative management should be individualised. Age should be considered as one of the factors in surgical resection of oesophageal cancer in the elderly patients.

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          Most cited references28

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          Predictive factors for postoperative pulmonary complications and mortality after esophagectomy for cancer.

          This study aimed at: (1) documenting the evolution of surgical results of esophagectomy in a high-volume center, (2) identifying predictive factors of pulmonary complications and mortality, and (3) examining whether preoperative chemoradiation therapy would complicate postoperative recovery. Pulmonary complications and mortality rate after esophagectomy remain substantial, and factors responsible have not been adequately studied. Neoadjuvant chemoradiation is widely used; it is hypothesized that this may lead to adverse postoperative outcome. Prospectively collected data were used to analyze outcome in 421 patients with intrathoracic squamous cell esophageal cancer who underwent resection. Logistic regression analyses determined independent predictors of pulmonary complications and death. Two time periods were compared: period I (January 1990 to June 1995) and period II (July 1995 to December 2001). In the later period, neoadjuvant chemoradiation therapy was introduced. Transthoracic resections were carried out in 83% of patients. Neoadjuvant chemoradiation was given to 42% of patients in period II. Major pulmonary complications occurred in 15.9%, and were primarily responsible for 55% of hospital deaths. Thirty-day and hospital mortality rates were 1.4% and 4.8%, respectively. Logistic regression analysis identified age, operation duration, and proximal tumor location as risk factors for pulmonary complications, whereas advanced age and higher blood loss were predictive of mortality. Chemoradiation did not lead to worse outcome. When period I and II were compared, hospital mortality rate reduced from 7.8% to 1.1%, P = 0.001, with correspondingly less blood loss (median blood loss was 700 ml (range: 200-2700 (period I) and 450 ml (range: 100-7000) (period II), P < 0.01). A 1.1% mortality rate was achieved in the last 6 years of the study period. Preoperative chemoradiation did not result in worse outcome. Reduction in mortality rate correlated with decreased blood loss.
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            Results of esophagectomy for esophageal cancer in elderly patients: age has little influence on outcome and survival.

            The aging of the population and a longer life expectancy have led to an increased number of elderly patients with esophageal cancer being referred for surgical treatment. The aim of this study was to assess the effects of age on the outcome of surgery for esophageal cancer at a single institution. Perioperative outcome and long-term survival of patients at least 70 years old undergoing esophagectomy between 1992 and 2005 for cancer of the esophagus or esophagogastric junction were compared with findings in younger patients. Patients who underwent an abdominal procedure only were excluded from the analysis. The analysis considered 580 patients younger than 70 years and 159 at least 70 years old. Clinical presentation in the two groups was similar, as were postoperative morbidity and mortality, despite significant differences in perioperative risk factors. Irrespective of age, overall survival was 34% at 5 years for all patients and 37% for patients with R0 resection. Increased experience and refinements in perioperative care explain the better results of esophagectomy in elderly patients in recent years. Short- and long-term outcomes after esophagectomy for carcinoma in patients older than 70 years are comparable with those of their younger counterparts. Advanced age per se thus should not be considered a contraindication to esophageal resection.
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              Perioperative medical management of patients with COPD

              Chronic obstructive pulmonary disease (COPD) and heart diseases are considered independent risk factors for mortality and major cardiopulmonary complications after surgery. Coronary artery disease, heart failure and COPD share common risk factors and are often encountered, - isolated or combined -, in many surgical candidates. Perioperative optimization of these high-risk patients deserves a thorough understanding of the patient cardiopulmonary diseases as well as the respiratory consequences of surgery and anesthesia. In contrast with cardiac risk stratification where the extent of heart disease largely influences postoperative cardiac outcome, surgical-related factors (ie, upper abdominal and intra-thoracic procedures, duration of anesthesia, presence of a nasogastric tube) largely dominate patient’s comorbidities as risk factors for postoperative pulmonary complications. Although most COPD patients tolerate tracheal intubation under “smooth” anesthetic induction without serious adverse effects, regional anesthetic blockade and application of laryngeal masks or non-invasive positive pressure ventilation should be considered whenever possible, in order to provide optimal pain control and to prevent upper airway injuries as well as lung baro-volotrauma. Minimally-invasive procedures and modern multimodal analgesic regimen are helpful to minimize the surgical stress response, to speed up the physiological recovery process and to shorten the hospital stay. Reflex-induced bronchoconstriction and hyperdynamic inflation during mechanical ventilation could be prevented by using bronchodilating volatile anesthetics and adjusting the ventilatory settings with long expiration times. Intraoperatively, the depth of anesthesia, the circulatory volume and neuromuscular blockade should be assessed with modern physiological monitoring tools to titrate the administration of anesthetic agents, fluids and myorelaxant drugs. The recovery of postoperative lung volume can be facilitated by patient’s education and empowerment, lung recruitment maneuvers, non-invasive pressure support ventilation and early ambulation.
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                Author and article information

                Journal
                ISRN Surg
                ISRN Surg
                ISRN.SURGERY
                ISRN Surgery
                Hindawi Publishing Corporation
                2090-5785
                2090-5793
                2013
                24 September 2013
                : 2013
                : 609252
                Affiliations
                1Departments of Gastrointestinal Surgery and Histopathology, The University Hospital of South Manchester, SouthMoor Road, Wythenshawe, Manchester M23 9LT, UK
                2Department of General Surgery, University Hospital South Manchester, Southmoor Road, Manchester M23 9LT, UK
                Author notes

                Academic Editors: C. F. Bianchi, D. Laub, and A. Polydorou

                Article
                10.1155/2013/609252
                3800610
                e0bef240-eb77-44ce-ac57-b0e23f8487cb
                Copyright © 2013 A. Mirza et al.

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 8 July 2013
                : 14 August 2013
                Categories
                Research Article

                Surgery
                Surgery

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