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Systematic review and pooled analysis assessing the association between elderly age and outcome following surgical resection of esophageal malignancy

Authors


  • Funding: None.

  • Conflict of Interest: None.

Dr Donald E. Low, FACS, FRCS (C), Department of Thoracic Surgery, Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, WA 98111, USA. Email: donald.low@vmmc.org

SUMMARY

The incidence of esophageal malignancy continues to increase worldwide. At the same time, average life expectancy levels continue to climb, ensuring that more patients will present in their 70s, 80s, and 90s. The aim of this pooled analysis is to compare short- and long-term outcomes for elderly and younger patients undergoing esophagectomy for malignancy. Studies comparing the outcomes of esophagectomy for malignancy in elderly and young cohorts of patients were included. The minimum threshold age used to define the elderly cohort was 70 years. Primary outcomes were in-hospital mortality, overall and cancer-related 5-year survival. Secondary outcomes were the length of hospital stay, the incidence of anastomotic leak, conduit ischemia, cardiac and pulmonary complications, and the use of neoadjuvant therapy. Twenty-five publications comprising 9531 and 2573 operations on younger and elderly cohorts of patients respectively were analyzed. Elderly patients were less likely to receive neoadjuvant therapy (14.6% vs. 29.47%; pooled odds ratio [POR]= 0.48; 95% confidence interval [C.I.]= 0.35–0.65; P < 0.05). Esophagectomy in elderly patients was associated with increased in-hospital mortality (7.83% vs. 4.21%; POR = 1.87; 95% C.I. = 1.54–2.26; P < 0.05), as well as increased pulmonary (21.77% vs. 19.49%) and cardiac (18.7% vs. 13.17%) complications. Subset analysis of studies using an age threshold of 80 years showed an even more significant association between in-hospital mortality and elderly age (pooled odds ratio = 3.19; 95% C.I. = 1.6–6.35; P < 0.05). There were no significant differences between the groups in length of hospital stay, incidence of anastomotic leak, or conduit ischemia. The elderly group showed reduced overall 5-year survival (21.23% vs. 29.01%; pooled odds ratio = 0.73; 95% C.I. = 0.62–0.87; P < 0.05) and reduced cancer-free 5-year survival (34.4% vs. 41.8%; POR = 0.75; 95% C.I. = 0.64–0.89; P < 0.05). Elderly patients are at increased risk of pulmonary and cardiac complications, and perioperative mortality following esophagectomy, and show reduced cancer-related 5-year survival compared with younger patients. These patients represent a high-risk cohort, who requires thorough assessment of medical comorbidity, targeted counseling, and optimized treatment pathways.

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