Esophageal cancer resection in the elderly

Eur J Cardio-thorac Surg (1996) 10:941-946 © Springer-Verlag 1996 P. Thomas C. Doddoli P. Neville J. Pons P. Lienne R. Giudicelli M. Giovannini J. F. Seitz P. Fuentes Received: 12 September 1995 Accepted: 6 February 1995 Presented at the Ninth Annual Meeting of The European Association for Cardiothoracic Surgery, Paris, France, 24-27 September, 1995 R Thomas (~) • C. Doddoli. R Neville • J. Pons • R Lienne • R. Giudicelli • R Fuentes Department of Thoracic Surgery, Sainte Marguerite University Hospital, 270 Bd Sainte Marguerite, F-13274 Marseille Cedex 9, France M. Giovannini • J. E Seitz Department of Digestive Oncology, Paoli-Calmettes Institute, Marseille, France Esophageal cancer resection in the elderly Abstract Objective. Esophageal cancer is a disease whose prognosis is dismal and its surgery involves considerable risks, consequently the opportunity of esophageal resection in elderly patients with esophageal cancer is questionnable. The aim of this study was to analyze, with respect to their age, the outcome of 386 consecutive patients who underwent esophagectomy and simultaneous replacement for cancer. Methods. A chart review of all patients with esophageal carcinoma admitted to our institution was undertaken for the period January 1979-December 1994. Results. The portion of patients of 70 years of age and older (14.5%) has slightly increased during the period. Location to the lower third of the esophagus and adenocarcinoma type were prevalent in the 56 elderly patients (group I), but their postsurgical TNM staging was identical to that of the 330 younger patients (group II). Other clinical features, i.e. preoperative weight loss and the presence of co-morbid diseases, Introduction As a result of the aging of the population and, simultaneously, the increased life expectancy in Western countries, patients of 70 years who are potentially candidates for major surgery are becoming a frequent problem for surgeons to deal with. However, there is a reluctance to refer pa- Downloaded from https://academic.oup.com/ejcts/article-abstract/10/11/941/441769 by guest on 27 July 2018 however, were comparable in the two groups. Pulmonary function, as assessed by spirometry, was significantly worse among the older patients, but blood gas determinations were not different. Operative mortality was comparable, between the two groups (10.7% vs 11.2%). Major morbidity included anastomotic leak (10.7% vs 13.6%) and pulmonary complications (17.9% vs 20.6%) in both groups. Excellent palliation of dysphagia was achieved in 92% of the 50 group I patients who survived the operation. Long-term survival was not different in elderly patients (5-year rate: 17%) when compared with that of younger patients (18.9%). Conclusion. These data suggest that esophagectomy can be performed safely in selected septuagenarian patients, thus allowing a substantial survival with excellent functional status in a portion of these patients. [Eur J Cardio-thorac Surg (1996) 10:941-946] Key words Esophageal carcinoma • Elderly • Surgery tients for operative therapy once they have reached advanced age [ 17], particularly in those with esophageal cancer because they usually present with deteriorated nutritional status and are often weakened by associated diseases resulting from alcohol and tobacco abuse. Finally, the poor prognosis of cancer of the esophagus combined with the shorter expected survival of elderly patients tends to favor palliative therapies. On the other hand, advances made in 942 p o s t o p e r a t i v e i n t e n s i v e care m a n a g e m e n t h a v e c o n s i d e r a b l y m o d i f i e d the e n v i r o n m e n t o f e s o p h a g e a l surgery. O u r attitude, as in the t r e a t m e n t o f other i n t r a t h o r a c i c c a n c e r s [20], has a l w a y s b e e n to p r o p o s e c u r a t i v e r e s e c t i o n w h e n e v e r p o s s i b l e . T h e p u r p o s e o f this w o r k was r e t r o s p e c t i v e l y to a n a l y z e the early a n d l o n g - t e r m o u t c o m e o f a s i n g l e i n s t i t u t i o n ' s s u r g i c a l c o h o r t a c c o r d i n g to p a t i e n t s ' ages. Material and methods Population The data of all patients with carcinoma of the esophagus admitted to the Department of Thoracic Surgery at S ainte Marguerite University Hospital were reviewed for the period January 1979-December 1994. Among 539 consecutive patients, 50 had undergone sequential esophageal resection and replacement, 37 a palliative bypass, and 386 simultaneous resection and replacement. This last patient group constitutes the clinical material of this study. The portion of patients aged 70 years or more has slightly increased during the period of the study: 11.6% in 1979-1982, 14.5% in 1983-1986, 12.3% in 1987-1990 and 18.3% in 1991-1994. Two groups were designed for comparison. Group I included 56 patients aged over 70 years (73.5 years _+3.5, range 70-84), and group II consisted of the 330 remaining younger patients (57.2 years _+7.7, range 31-69). The comparison of clinical features between the two groups (Table 1) did not show any difference with regard to health status or the presence of co-morbid diseases. Preoperative work-up Physiologic evaluation included physical examination and blood analysis to assess liver and renal functions as well as hemostasis. Cardiac function was also evaluated with chest X-ray and electrocardiogram. From 1990, the preoperative work-up was completed in elderly patients with routine echocardiography to quantify the left ejection fraction and detect potential myocardial akinetic areas. Exercise stress testing was electively performed in symptomatic patients. Pulmonary function, as assessed by spirometry, was significantly worse among the group I patients, but blood gas determinations were not different (Table 1). All patients had esophageal endoscopic evaluation with biopsies, barium swallow and abdominal ultrasonography. Routine bronchoscopy was performed, except in patients with a tumor located in the distal esophagus and gastroesophageal junction. Patients with squamous cell carcinoma underwent complete endoscopic examination of the esophageal and the pharyngolarnygeal epithelium with vital staining to identify potential multiple tumoral foci [14]. From 1985, this work-up was completed with computed tomography from the thoracic inlet to umbilicus, and from 1991 by endoscopic ultrasonography. Pathology The patients were staged according to the postsurgical TNM classification from the UICC [22]. Tumor site was anatomically defined as follows: proximal - cricopharynx to aortic arch, middle - aortic arch to inferior pulmonary vein, distal - caudad to inferior pulmonary vein. Gastroesophageal junction tumors were included if more than 50% of the tumor mass was located in the esophagus. Table 2 shows that prevalent histologic type and tumor location in group I were adenocarcinoma and distal esophagus or gastroesophageal junction, respectively. Downloaded from https://academic.oup.com/ejcts/article-abstract/10/11/941/441769 by guest on 27 July 2018 Table 1 Clinical features. Univariate analysis with the chi-square test. (Numbers in parenthesis are percentages, 1 weight loss up to 10% of the premorbid weight, 2 history of ENT cancer, 3 documented peripheral or coronary arteriosclerosis, 4 steatosis or cirrhosis diagnosed on liver biopsies, 5 mean value and standard deviation. FEV1 forced expiratory volume in 1 s, FVC forced vital capacity, N.S. non-significant,PaCO 2 partial pressure of carbon dioxide, Pa02 partial pressure of oxygen.) Variables Group I (n=56) (_>70 years) Group II (n=330) (<70 years) P value Sex ratio M/F 46/10 297/33 0.05<P_<0.10 Weight loss > 10% 1 13(23.2) 110(33.3) N.S. 3 (5.4) 39 (11.8) N.S. ENT cancer 2 Arteriopathy 3 6 (10.8) 33 (10) N.S. Liver disfunction 4 4 (7.1) 42 (12.7) N.S. Pulmonary function 5 FVC (1) FEV 1 (l/s) PaO 2 (mmHg) PaCO 2 (mmHg) 3.6+0.7 2.4+0.6 80+7.1 38+2.8 4.1+0.8 2.9_+0.7 82_+7.2 37.8+2.7 P = 0.0002 P=0.0001 N.S. N.S. Table 2 Pathological features. Univariate analysis with the chisquare test. (Numbers in parenthesis are percentages, N.S. non-significant, * absence of residual tumor after induction therapy) Variables Group I (n=56) (>70 years) Group II (n=330) (<70 years) Location Proximal Middle Distal 4 (7.2) 12 (21.4) 40 (71.4) 65 (19.7) 105 (31.8) 160 (48.5) Histology Adenocarcinoma Squamous cell 31 (55.4) 25 (44.6) 101 (30.6) 229 (69.4) Barrett's esophagus 12 (38.7) 39 (38.6) 0 3 (5.4) 7 (12.5) 18 (32.1) 23 (41.1) 5 (8.9) 17 (5.2) 14 (4.2) 45 (13.6) 98 (29.7) 118 (35.8) 38 (11.5) P value (Chi-2 test) P<0.02 P<0.001 N.S. T TO* Tis Yl T2 T3 T4 N.S. N NO N1 Stage 0 I IIA IIB III IV 30 (53.6) 26 (46.4) 3 (5.4) 5 (8.9) 20 (35.7) 10 (17.9) 18 (32.1) 0 181 (54.8) 149 (45.2) 28 35 102 49 106 10 (8.5) (10.6) (30.9) (14.8) (32.1) (3.1) N.S. N.S. 943 Table 3 Treatment procedures. Univariate analysis with the chisquare test. (Numbers in parenthesis are percentages, * preoperative chemo plus radiotherapy, C cervicotomy, L laparotomy, L T left thoracotomy, N.S. non-significant, R T right thoracotomy.) Variables Induction therapy* Surgical approaches RT-L-C L-RT L-C LT Group I (n=56) (>70 years) Group II P value (n=330) (<70 years) 3 (5.4) 48 (14.5) 12 (21.5) 19 (33.9) 11 (19.6) 14 (25) 141 (42.7) 63 (19.1) 114 (34.5) 12 (3.7) Pharyngo-laryngectomy 2 (3.6) 32 (9.7) N.S. O.05<P<O.lO were younger. The difference between respective resectability rates (93.3% vs 84.2%) was close to being significant ( 0 . 0 5 < P < 0 . 1 ) . From 1989 to 1994 we could identify a total of 229 patients with esophageal cancer who have been admitted to our institution. A m o n g them, 50 (21.8%) were not operated on for various reasons, including poor health and tumoral extension. During this period, the overall operability rate was 62.5% in elderly patients, while it was 81.5% in y o u n g e r patients. This difference was significant (P<0.01). P_<O.O01 Operative mortality Total gastrectomy 1 (1.8) 27 (8.2) N.S. Extended resection to spleen/pancreas Esophageal substitute Stomach Colon 3 (5.4) 22 (6.7) N.S. 52 (92.8) 4 (7.2) 254 (77) 76 (23) P<_0.01 Proximal anastomosis Hand-fashionned Stapler 43 (76.8) 13 (23.2) 276 (83.6) 54 (16.4) N.S. The overall operative mortality was comparable in the two groups: 10.7% in elderly patients and 11.2% in y o u n g e r patients. The 30-day mortality was 8.9% in group I and 7.9% in group II, and the difference was not significant. Causes o f death in group I patients were: pneumonitis (n = 3), digestive hemorrhage (n = 1), myocardial infarction (n= 1), and small bowel obstruction related to peritoneal metastasis after palliative resection (n = 1). Operative mortality decreased gradually in both groups during the course of the study to reach 5.3% and 3.5%, respectively, between 1991 and 1994. Therapeutic methods From 1989, patients with locality advanced tumor received a preoperative chemotherapy (5-fluorouracil and cisplatin) combined with a concomittant fractioned radiotherapy, whatever the histologic type of the tumor [18]. This treatment has been more often performed in group II patients (Table 3). Other patients were operated on without induction therapy. As a consequence of the prevalent tumoral location in elderly patients, partial esophagectomy via left thoracotomy or combined laparotomy and right thoracotomy were more frequent in these patients, as well as a gastric substitute for esophageal replacement. Statistical analysis Disease variables were collected and stored using a computerized database. Operative mortality included the 30-day mortality as well as any later death occurring during the initial postoperative hospital stay. Follow-up information was obtained until March 1995 on all survivors during office visits or by correspondence with the patient, his family or physician. Percentages were compared by the chisquare test and means by Student' s t-test. Probability of survival was estimated using the method of Kaplan-Meier from the date of the operation and included the operative mortality as well as all cancer-related and -unrelated deaths. Means are presented as + the standard deviation. Survival rates are given with their intervals of confidence. Differences between survival curves have been assessed by the logrank test. The statistically significant threshold was 5%. Postoperative complications Postoperative course was uneventful in 169 patients: 28 of group I and 141 of group II (50% vs 42.7%, non-significant). Mean postoperative hospital stay of the above patients did not differ: 19.8 days.+4.1 and 21.5 days.+6.5, respectively. Two hundred seventeen patients (56.1%) experienced one or more postoperative complications. For the patients who survived the complication, mean postoperative hospital stay was 34 days_+ 14.2 in group I patients and 37.4 days_+22.8 in group II patients (non-significant). Table 4 details the main fatal and non-fatal complications that occurred in the two groups. There were no significant differences. In group I patients, no significant difference could be identified with regard to the surgical approach (with or without thoracotomy: 51.1% vs 45.5%). In both groups, the most frequent complication was pulmonary disturbances. The mortality resulting from pulmonary complications was 30% in group I patients and 26.5% in group II patients (non-significant). Survival Results Operability and resectability Between 1979 and 1994, 66 further patients underwent an exploratory operation: 4 were older than 70 years and 62 Downloaded from https://academic.oup.com/ejcts/article-abstract/10/11/941/441769 by guest on 27 July 2018 Long-term survival a m o n g elderly patients did not differ significantly when compared to that o f younger patients (Fig. 1). The median survival was 21 months in group I patients and 15 months in group II patients. The probabilities of survival were 65.6% [ 5 3 . 1 - 7 8 . 2 ] and 57% [ 5 1 . 5 - 6 2 . 5 ] 944 Table 4 Postoperative complications. (Numbers in parenthesis are percentages, * parenchymatous pulmonary disturbances occurring in the absence of concomitant anastomotic leakage or necrosis of the viscus transposed, including pneumonia, and need for prolonged or recurrent mechanical respiratory support. Diagnosis of pneumonia was retained when 2 of the 3 following criteria were present: parenchymatous abnormalities on chest X-ray, fever, blood gas disturbances.) Complications Group I Group II Significance Anastomotic leaks Clinical evidence of leakage Diagnosed only at X-ray examination Necrosis of the viscus transposed Hemothorax/hemoperitoneum Miscellaneous surgical complications Reoperations Pulmonary complications * Cardiovascular complications Miscellaneous medical complications 6 (10.7) 3 (5.4) 3 2 (3.6) 5 (8.9) 5 (8.9) 10 (17.9) 2 (3.6) 3 (5.4) 45 (13.6) 36 (10.9) 9 4 (1.2) 19 (5.8) 46 (13.9) 50 (15.2) 68 (20.6) 6 (1.8) 28 (8.5) N.S. 1- 0,9- = 0,8,,~ 0,70,60,5- 0,40., 0,30,2- < 70 YEARS 0,1o 2'4 a; 4'8 6; Survival (months) Fig. 1 Survival curves (Kaplan-Meier) at 1 year, 36.4% [22.9-49.8] and 27% [21.9-32.2] at 3 years and 17% [5.3-28.7] and 18.9% [6.7-26.8] at 5 years, respectively. At the end of the study, among the 343 patients who survived the operation, 233 were dead and 110 were alive. The portion of cancer-related deaths was similar in the two groups (65.7% vs 75.2%, non-significant). Oral feeding was restored with substantial digestive comfort in the majority of the cases. Dysphagia recurred in 11 group I patients: benign anastomotic narrowing treated successfully in all cases by endoscopic dilatations in seven cases, and recurrent malignant disease in four cases. Discussion This work reports the long-term experience of a single team involved in the treatment of esophageal carcinoma. In the course of a period of 16 years, we observed a moderate but indisputable increase in the number of patients aged 70 Downloaded from https://academic.oup.com/ejcts/article-abstract/10/11/941/441769 by guest on 27 July 2018 N.S. N.S. N.S. N.S. N.S. N.S. N.S. years and more. When compared to younger patients, a significantly larger proportion of women was noted. This is probably due to the greater life expectancy of females than males, and has already been reported [13, 16]. Adenocarcinoma and location to the distal esophagus have also been previously reported as prevalent in elderly patients [11, 13, 16]. In our experience, this prevalence is mainly due to the fact that elderly patients with a tumor located in the proximal esophagus have been refused for surgery, given the higher risk of unresectability in this location by reason of tumoral extension to the tracheo-bronchial tree on the one hand, and our reluctance to perform an esophageal resection extending to the pharyngolarynx in patients over 70 on the other. Complex epidemiologic trends are also probably involved, as witnessed by the dramatic increase of the incidence of esophageal adenocarcinoma both in Europe and USA [1, 7]. Nutritional status, associated diseases linked with tobacco (history of ENT cancer, atherosclerosis) and alcohol consumption (liver dysfunction) as well as the local tumoral extension, as judged by the postsurgical TNM staging, were similar in the two groups, testifying to the homogeneity of the operability and resectability criteria that were followed by the team whatever the age of patients, thus allowing for the clinical comparison between the two groups. The operative mortality of this series represents a reasonable estimation of the currently acceptable risk from esophagectomy in patients of advanced age that ranges from 6% to 26.6% in the literature of the past decade [5 - 7 , 10-13, 15]. As shown by our results, this mortality rate has dramatically decreased in recent years. Obviously, this improvement is linked to the technologic advances made in this area, and the anesthetic and postoperative care in relation to this operation, but is also the consequence of the selection undertaken by the surgical team among this population of high-risk patients [19]. In our experience, more than on-third of the patients aged over 70 years, but less than 20% of the younger patients, who were referred to our institution for the treatment of an esophageal cancer were not operated on. Besides, the resectability rate 945 was higher in elderly patients, underlining the rigor of indications regarding both the functional Status and the tumoral extension in this group of patients. Length of postoperative stay was selected as a variable in this study, as we thought it reflected the resilience of patients and the occurrence of complications. In our study, advanced age was not recognized as a predictor of increased length of hospitalization. In both groups overall morbidity was high and mainly related to anastomotic leak and pulmonary complications. In contrast with the findings of Griffin et al. [5], these postoperative complications were neither more frequent nor more severe in patients aged over 70 years. As previously reported in numerous retrospective [6, 10, 13, 16, 20] and prospective studies [12] or multivariate analyses [21], the incidence of anastomotic leaks was not influenced by patient age. Whether age predisposes [4, 16] or not [3] to pulmonary complications is all the more a matter of controversy as there are no uniform inclusion criteria for this complication in most of the trials published. For example, the multivariate analysis conducted by Tsutsui et al. [21] showed that advanced age was an independant predictor of postoperative hypoxemia and prolonged respiratory support, whereas it was not correlated to the occurrence of postopertive pneumonia. We have observed neither an increased frequency nor particular gravity of pulmonary complications in elderly patients, despite significantly worse spirometric figures when compared to those of younger patients. This is in keeping with the above mentioned study, where there was not relationship between the preoperative spirometric variables and postoperative pulmonary complications, contrary to preoperative arterial oxygen tension. As a matter of fact, these was no difference in blood gas values between our two groups of patients. Long-term survival was not influenced by patient age. This is keeping with all reports in the literature [10, 16, 23] except one [6], and seems to be the logical consequence of the similar patients distribution regarding the tumor staging in both groups, which is known to represent the main predictor of survival [2, 8]. Furthermore, the cause of death was linked mainly to cancer in the two groups, despite a difference of 16 years in mean ages that would normally have resulted in a greater incidence of death from cardiovascular causes. This fact clearly illustrates the poor prognosis of esophageal cancer, whose influence cancels that of advanced age. However, benefits from oncologic surgery in elderly patients should not be considered exclusively in terms of long-term outcome. Indeed, in such a section of the population, submitted to high risks of various cancers and cardiovascular diseases, even the efficient control of one of the potential causes of death does not significantly affect the overall survival [9]. Thus, the role of surgery in providing satisfactory alimentary comfort in the long run is of paramount importance. In that respect the finding in the present study, that excellent and durable palliation of dysphagia was achieved in 90% of the patients, supports the contention that even elderly patients should be considered for surgical intervention. In summary, our results show that it is possible, with a judicious selection, to limit the mortality and morbidity from esophagectomy in elderly patients within acceptable rates. An excellent and durable palliation of dysphagia could be achieved in the majority of our group, of whom one-third are still alive 3 years after the intervention. These results are sufficient grounds not to deny surgery as a therapeutic option in the septuagenarian with esophageal carcinoma. References 1. Blot WJ, Devesa SS, Fraumeni JF (1993) Continuing climb in rates of esophageal adenocarcinoma: an update. JAMA 270:1320 2. Elias D, Lasser P, Hatchouel JM, Escndier B, Spielmann M, Girinsky T, Kac J (I 993) Etude multifactorielle prospective des facteurs pronostiques de 200 cancers 6pidermo~'desde l'oesophage opdr6s. DEfinition des malades tirant bdn~fice de l'ex6rbse chirurgicale. Gastroenterol Clin Biol 17:17-25 3. Elman A, Giuli R, Sancho-Garnier H (1988) Risk factors of pulmonary complications following esophagectomy in carcinoma of the esophagus: results of the prospective study conducted by the OESO group. In: Siewert JR, H61scher AH (eds) Diseases of the esophagus. Springer, Berlin Heidelberg New York, pp 224-228 4. Fan ST, Lau WY, Yip WC (1987) Prediction of postoperative pulmonary complications in esophagogastric cancer surgery. Br J Surg 74:408-410 5. Griffin S, Desai J, Charlton M, Towsend E, Fountain SW (1989) Factors influencing mortality and morbidity following esophageal resection. Eur J Cardiothorac Surg 3:419-424 6. Kitamura M, Nishihira T, Hirayama K, Kasai M (1988) Surgical treatment for patients 70 years of age or older with carcinoma of the esophagus. In: Siewert JR, H61scher AH (eds) Disease of the esophagus. Springer, Berlin Heidelberg New York, pp 261-263 7. Lund O, Hasenkam JM, Aagaard MT, Kimose HH (1989) Time-related changes in characteristics of prognostic significance of carcinomas of the esophagus and cardia. Br J Surg 76:1301-1307 Downloaded from https://academic.oup.com/ejcts/article-abstract/10/11/941/441769 by guest on 27 July 2018 8. Lund O, Kimose HH, Aagaard MT, Hasenkam JM, Erlandsen M (199~) Risk stratification and long-term results after surgical treatment of carcinomas of the thoracic esophagus and cardia. A 25-year retrospective study. J Thorac Cardiovasc Surg 99:200-209 9. Maloney JV (1981) The limits of medicine. Ann Surg 194:247-249 10. Mori M, Shinji O, Tsutsui S, Matsuura H, Kuwano H, Sugimachi K (1990) Esophageal carcinoma in young patients. Ann Thorac Surg 49:284-286 11. Naunheim KS, Hanosh J, Zwischenberger J, Turrentine MW, Kesler KA, Reeder LB, Ferguson MK, Baue AE (1993) Esophagectomy in the septuagenarian. Ann Thorac Surg 56:880-884 946 12. Peracchia A, Bardini R, Ruol A, Asolati M, Scibetta D (1988) Esophagovisceral anastomotic leak. A prospective statistical study of predisposing factors. J Thorac Cardiovasc Surg 95:685-691 13. Peracchia A, Bardini R, Ruol A, Castoro C, Segalin A, Cavazzini F, Asolat M (1988) Carcinoma of the esophagus in the elderly (70 years of age or older). Indications and results of surgery. Dis Esoph 3:147-152 14. Reboud E, Pradoura JP, Giudicelli R, Fuentes P (1983) Multicentricit6 du cancer de l'oesophage. Chirurgie 109:41-46 15. Richelme H, Baulieux J (1986) Le traitement des cancers de l'oesophage. Masson, Paris, pp 83-132 16. Richelme H, Benchimol D, Bourgeon A, Limouse B, Mouroux J, Berre A, Pulcini A (1988) La chirurgie d'ex6r~se de l'oesophage apr~s 70 ans. Chirurgie 114:150-159 17. Samet J, Hunt WC, Kay C, Humble CG, Goodwin JS (1986) Choice of cancer therapy varies with age of patient. JAMA 255:3385-3390 18. Sielezneff I, Thomas R Giovannini M, Giudicelli R, Seitz JF, Fuentes P (1993) Esophageal carcinoma with doubtful extirpability: value of preoperative chemo plus radiotherapy. Eur J Cardiothoracic Surg 7:606-611 19. Sikes ED Jr, Detmer DE (1979) Aging and surgical risk in older citizens of Wisconsin. Wis Med J 78:27-31 20. Thomas P, Sielezneff I, Ragni J, Giudicelli R, Fuentes P (1993) Is lung cancer resection justified in patients aged over 70 years? Eur J Cardiothorac Surg 7: 2 4 6 - 251 21. Tsutsui S, Moriguchi S, Morita M, Kuwano H, Matsuda H, Mori M, Matsuura H, Sugimachi K (1992) Multivariate analysis of postoperative complications after esophageal resection. Ann Thorac Surg 53:1052-1056 22. Union Internationale Contre le Cancer (1988) Classification TNM des tumeurs malignes, 4th edn. Springer, Berlin Heidelberg New York, pp 4 2 - 4 8 23. Yamanaka H, Hiramatsu Y, Kawaguchi Y, Kohima Y, Hioki K, Yamamoto M (1991) Surgical treatment for poor-risk patients with carcinoma of the esophagus. Jpn J Surg 21:178-183 or through right thoracotomy plus laparotomy/left cervicotomy (Akiyama) in elderly patients. I agree with you that this is probably part of the reason for the low morbidity experienced by our elderly patients. The equal survival in the two groups, in our opinion, clearly illustrates the poor prognosis of esophageal cancer, the influence of which cancels that of advanced age. transhiatal approach, and we performed, without a real selection, a lot of these operations, because we were convinced that it was associated with low morbidity, and since we have re-evaluated our experience and have noticed that this operation was associated with the same risk as the transthoracic approach, we now reserve the transhiatal approach to tumors located in the upper part of the esophagus. But in most cases we have the same policy now with elderly patients, if they are operable. During the course of this study, among the patients who were referred to our institution, only 62% of patients were operated on when they were aged over 70 years, whereas more than 80% of the younger patients were operated on. And, conversely, the resectability rate was higher in the elderly patients, and that reflects the fact that we are more rigorous in this section of population in terms of both functional operability and the tumor extension. Discussion Mr. Moghissi (Hull, England):This is a very good presentation and I congratulate you, not having a difference in mortality or, in fact, long survival between the people over the age of 70 and under the age of 70. I find it a bit unusual, since in my own series there was a difference, but probably the difference is - and that is the question that I am going to ask you - whether in fact the type of operation between the two groups was different? In other words, did you have more the left thoracotomy and the lower esophagectomy, partial esophagectomy, esophagogastrectomy, in the older category of patients rather than the younger ones: in whom you probably had more cases of the two-stage laparotomy and right thoracotomy or total gastrectomy? Is that what you found or, in fact, was there no difference? Dr. Thomas: Obviously, the type of operation was different in the two groups. Younger patients underwent more radical operations regarding both the extent of esophagectomy and associated procedures, i.e., laryngectomy or total gastrectomy. Regarding the surgical approach, partial esophagectomy via left thoracotomy or combined laparotomy and right thoracotomy (Ivor Lewis) were more frequent than total esophagectomy without thoracotomy Mr. J. Thorpe (Sheffield, England): It is very difficult to compare different operations and different anastomoses. I tend to reserve the transhiatal esophagectomy for the elderly and those with respiratory compromise. The question is, how do you decide when to do a transhiatal esophagectomy or a transthoracic approach with stomach to neck, how do you make that choice? I have just reviewed an article actually saying that there is a high risk of morbidity and mortality in the younger age groups, but in fact from what I have seen from the literature, there really doesn't seem to be any age influence at all on the subsequent survival of these patients. Dr. Thomas: Concerning your first question, we have to point out that this is a single institutional experience, and in the early 1980s, there was a sort of fashion for the Downloaded from https://academic.oup.com/ejcts/article-abstract/10/11/941/441769 by guest on 27 July 2018 Dr. Lerut: I really don't think that is matters very much which approach. I mean, we always choose the transthoracic approach regardless of the age. The only thing that we really regard as important is the extent of the lymphadenectomy, and I think that is what really influences morbidity and mortality.