Esophagectomy for carcinoma: impact of age on clinical results and survival

Advances in perioperative management have allowed more and more elderly patients to undergo major surgery with postoperative morbidity and mortality rates similar to those of younger individuals. The aim of this study was to evaluate the impact of age on the clinical outcome and long-term survival of patients with oesophageal cancer undergoing oesophagectomy. Eight hundred and seventy-five patients with oesophageal carcinoma were divided into two groups: A (n = 393) aged > or = 65 years, and B (n = 482) aged < 65 years. One hundred and forty-nine (38%) patients in group A underwent surgery compared to 263 (55%) in group B (P < 0.01). Postoperative mortality and the prevalence of anastomotic leak and respiratory complications were similar in both groups. There was, however, a higher prevalence of cardiovascular complications in group A (13% versus 3%, P < 0.01). Five-year survival was about 35% in both groups. In conclusion, advanced age should not be considered a contra-indication to oesophagectomy for carcinoma, since the long-term survival of elderly patients undergoing resection is similar to that of younger ones.     

Oesophagectomy for carcinoma of the oesophagus and oesophagogastric junction.

OBJECTIVE: Oesophageal carcinoma has a poor prognosis; surgical resection remains the only chance of cure but is still associated with a significant morbidity and mortality. The aim of this study was to review the results of one surgeon for oesophageal resection for carcinoma of the oesophagus and oesophagogastric junction over a 23 year period. METHODS: Between January 1974 and December 1996, 591 patients (408 males; 183 females; mean age 66 years) underwent an oesophageal resection for carcinoma of the oesophagus or oesophagogastric junction. RESULTS: In hospital mortality was 8.8% (52/591). This has decreased to less than 5% for resections between 1985 and 1996. Non-fatal complications occurred in 21% of patients (123/591). Survival, including in hospital mortality (+/-SEM), was 53.98% (+/-2), 31.77% (+/-2) and 15.3% (+/-2) at 1, 2 and 5 years respectively. CONCLUSION: Early mortality following oesophageal resection has fallen in recent years. Despite considerable experience, long term survival remains disappointingly low.     

Surgical resection for gastric cancer in elderly patients: is there a difference in outcome?

BACKGROUND: Early and long-term outcome of gastrectomy for gastric cancer in elderly adults has been a subject of controversy and debate. MATERIALS AND METHODS: Clinical information was reviewed for patients undergoing gastrectomy for gastric cancer during an 11-year period (1990-2000) at the University of Tennessee Medical Center at Knoxville. Patient demographics, tumor characteristics, operative mortality and morbidity, survival, and length of hospitalization were reviewed. RESULTS: Of 48 patients who underwent gastric resection for gastric adenocarcinoma, 24 were older than 70 and 24 younger than 70. There were no differences between the two groups regarding tumor characteristics, including location, tumor size, grade, gross pathology, lymph node involvement, lymphovascular invasion, and stage. In the elderly group, 75% underwent subtotal gastrectomy and 25% had total gastrectomy with or without resection of adjacent organs. In the younger patients, these numbers were 66.6% and 33.3%, respectively, which was statistically insignificant (P = 0.5). Five-year survival was 16.6% among elderly patients compared to 20.8% in the younger patients (P = 0.45). Half of the elderly patients and 39% of young patients had other comorbidities (P = 0.45). Postoperative mortality and morbidity was 8.33% and 33.3% in elderly patients, compared to 4.2% and 33.3%, respectively, in the younger group. These results were statistically insignificant (P = 0.4). The median postoperative length of stay was 15 days (95 percent confidence interval, 11-19 days) in younger patients compared to 18 days (95 percent confidence interval, 13-22 days) in the elderly group (P = 0.3). CONCLUSION: This study suggests that gastrectomy can be carried out safely in elderly patients. The early and long-term outcomes in elderly patients (over age 70) are comparable to younger patients (under age 70). Age alone should not preclude gastric resection in elderly patients.     

Validity of hepatic resection for cancer in the elderly

This retrospective review assessed the safety and validity of elective hepatic resection for cancer in patients > or = 65 years of age. Fifty-two patients (31M; 21F; mean age: 70 +/- 5 years; range: 65-82) > or = 65 years of age underwent hepatic resection for cancer between January 1992 and May 1999). The overall preoperative mortality rate was 8%. The mean hospital stay was 23 +/- 10 days (range: 6-45 days), and admission to the intensive care unit was required for only 1 patient. By univariate analysis, preoperative jaundice (p = 0.03), length of surgery (> or = 240 min.) (p = 0.006), preoperative blood transfusions (> or = 500 cc) (p = 0.001), and extent of hepatic resection (p = 0.01), were predictors of postoperative complications. In a multivariate analysis only preoperative blood transfusions predicted complications (p = 0.01). When outcome was compared with that in 65 patients younger than 65 years of age who had hepatic resection for cancer during the same period, there were no difference in terms of morbidity, mortality, and mean hospital stay The 1-, 3-, and 5-year survival rate for patients > or = 65 years of age and for patients < 65 years of age were 89%, 61%, and 45%, and 87%, 46% and 39% respectively. Hepatic resections can be performed for the elderly with acceptable morbidity and mortality rates and possible long-term survival. Chronological age alone is not a contraindication to liver surgery for malignancies.     

老年非小细胞肺癌病人疗效分析

目的 探讨70岁以上老年非小细胞肺癌病人手术、辅助化疗的效果及预后的特点.方法 将70岁以上手术治疗的老年非小细胞肺癌病人按照性别、分期、病理类型、手术方式、是否接受辅助性化疗5个因素与年轻病例进行1:1匹配.用Kaplan-Meier法统计生存率,Log-rank进行差异性检验,用Pearson χ2检验分析手术死亡率及术后短期死亡率在两组人群中的分布差异.结果 共有1304例符合条件并完成匹配,≥70岁者652例,＜70岁者652例.两组总的5年生存率差异无统计学意义(P=0.056),两组之间手术死亡率差异无统计学意义(P=0.265),术后短期死亡率差异有统计学意义(P=0.003),经辅助化疗后两组人群5年生存率大致相等(49.40%对43.89%,P=0.096),两组人群均受益(P=0.049;P=0.000).结论 有手术指征的老年非小细胞肺癌病人应积极手术治疗,术后应行辅助化疗,老年病人经恰当的综合治疗后效果不比年轻者差.     

The role of video assisted thoracoscopic pleurectomy/decortication in the therapeutic management of malignant pleural mesothelioma.

OBJECTIVE: Extrapleural pneumonectomy (EPP) has high mortality and morbidity; radical pleurectomy decortication (P/D) carries less mortality but still significant morbidity. This surgery is not suitable for many patients with malignant pleural mesothelioma (MPM) for whom video assisted thoracic surgery (VATS) offers a minimally invasive alternative. We aimed to assess the role of VATS decortication for MPM. METHODS: Over a 9-year period 208 patients underwent therapeutic surgery for MPM in our unit. One hundred and twelve of the patients underwent EPP, 29 had a P/D and 67 had VATS decortication. Sixty-three of the 208 patients (EPP n=13, P/D n=8 and VATS decortication n=42) were 65 years of age or older at the time of the operation (57 males and 6 females, age 70 (65-80) years). In this group we analyzed perioperative morbidity and mortality and long-term survival data using the Kaplan-Meier method. RESULTS: Postoperative stay and 30-day mortality was significantly lower for VATS P/D than for EPP (14.3 days vs 36.6 days, p<0.05 and mortality 7.1% vs 23%, respectively). There was no significant difference in the overall mean survival between the two groups (11.5 months for EPP and 14 months for VATS P/D, p=0.6). CONCLUSION: VATS decortication should be considered in the therapeutic strategy for MPM.     

Is gastrectomy safe in the elderly? A single institution review

The population of the United States is aging. Studies within the last several years have demonstrated that major abdominal operations in elderly patients can be done safely, but with increased rates of complications. We set out to determine the rates of morbidity and mortality in elderly patients undergoing gastric resection at a tertiary care university hospital. A retrospective analysis was performed of 157 consecutive gastric resections between January 1998 and July 2007. Group A (n = 99) consisted of patients < 75-years-old at surgery, whereas group B (n = 58) included patients who were ≥ 75 years of age at time of surgery. These two groups had their clinical and demographic data analyzed. Postoperative length of hospital stay, perioperative major morbidity, and in-hospital mortality were analyzed using analysis of variance, χ(2), and multivariate analyses. The average age of patients in group A was 57 years, compared with 81 years in group B. We found no significant difference in the percentage of gastric resections for malignancy (group A, 49% vs group B, 62%) or emergency surgery (group A, 10% vs group B, 10%) between age groups. There was a significant increase in length of stay in the older patients (11.7 days vs 17.6 days; P = 0.032), as well as major complications (11.1% in group A vs 27.6% in group B; P = 0.008). The in-hospital mortality rates approached significance (group A, 4% vs group B, 12%; P = 0.057). Gastric resection in elderly patients carries with it longer hospital stays, higher risk of complications, and in-hospital mortality rates despite similarity in patient disease. This information is imperative to convey to the elderly patients in the preoperative period before gastric resection.     

Impact of preoperative radiochemotherapy on postoperative course and survival in patients with locally advanced squamous cell oesophageal carcinoma

BACKGROUND: The aim of this study was to determine the effect of neoadjuvant radiochemotherapy (RCT) on postoperative complications and survival after surgery for locally advanced oesophageal squamous cell carcinoma. METHODS: Postoperative course and survival were compared in 144 patients who had neoadjuvant RCT and 80 control patients who had surgery alone for locally advanced oesophageal squamous cell carcinoma (radiological stage T3, N0 or N1, M0). RESULTS: The two groups were comparable in terms of American Society of Anesthesiologists grade, age, sex, weight loss, tumour location, presence of lymph node metastasis and surgical approach. Postoperative mortality rates were 6.3 and 9 per cent (P=0.481), with morbidity rates of 40.3 and 41 percent (P=0.887) in the RCT and control group respectively. Complete resection (R0) rates were 74.3 and 48 percent respectively (P<0.001). Significant downstaging was observed in the RCT group (P<0.001), with 16.0 percent of patients having a complete pathological response. Median survival was 29 versus 15 months, and the 5-year survival rate 37 versus 17 percent (P=0.002) in RCT and control groups respectively. CONCLUSION: Neoadjuvant RCT significantly enhanced R0 resection and survival rates in patients with stage T3 oesophageal squamous cell carcinoma, with no increase in postoperative mortality and morbidity rates.     

Outcomes after major hepatectomy in elderly patients

BACKGROUND: We aimed to study the early and longterm outcomes of patients 70 years and older undergoing major liver resections, and compare the results with patients below the age of 70 years. STUDY DESIGN: All patients undergoing major liver resection (defined as three segments or more) from January 1993 to June 2004 were included. Patients were studied in two groups: 70 years of age and older (group E, elderly) and less than 70 years old (group Y, young). Early outcomes and longterm survival were analyzed. RESULTS: A total of 517 patients underwent major liver resection: group E, n=127; group Y, n=390 patients. There was no difference in operative mortality (group E, 7.9%; group Y, 5.4%; p=0.32) or postoperative morbidity (p=0.22) between the groups. Overall and disease-free survivals were not notably different for all patients (59% versus 57%, p=0.89; 60% versus 55%, p=0.28, respectively) or for a subgroup of patients with colorectal liver metastases (61% versus 55%, p=0.76; 60% versus 47%, p=0.07) in groups E versus Y, respectively. In multivariable analysis, American Society of Anesthesiologists grade 3 (p=0.024, hazard ratio [HR]=1.59, versus grade 1, 95% CI=1.06 to 2.39) and intraoperative transfusion>3 U (p<0.0005, HR=2.56, 95% CI=1.84 to 3.56) were predictors for overall survival. More than three tumors (p=0.025, HR=1.41, 95% CI=1.04 to 1.90) and redo resection (p=0.001, HR=2.80, 95% CI=1.51 to 5.19) were predictors of disease-free survival. CONCLUSIONS: Major liver resections can be safely performed in patients 70 years of age or older, with early results and survival similar to those in the younger than 70 age group. American Society of Anesthesiologists grade 3 and intraoperative transfusions>3 U were predictors for overall survival, and more than three tumors and redo resection were predictors for disease-free survival.     

Quality of life in patients over 70 years of age after heart valve replacement.

BACKGROUND: Previous studies on valve replacement in patients over 70 years of age have been concerned with early and long-term outcome. Little is known, however, of the quality of life (QOL) of survivors following surgery. METHODS: Thirty-one consecutive patients, mean age 74.0+/-3.1 years, who underwent heart valve replacement were reviewed and questioned as to their physical and social activities before and after surgery and compared with 75 patients aged less than 70 years old who underwent similar procedures during the same time interval. QOL was measured by using the Rosser distress and disability scores. RESULTS: Hospital mortality in the elderly group was the same as in the younger group (9.7% vs 2.7%, p = 0.121). Median 5-year survival was 79% in the elderly group and 92% in the younger group (p = 0.068). Overall morbidity due to valve-related complications was 3.55%/patient-year in the elderly group and 2. 35%/patient-year in the younger group, and freedom from all valve-related complications at 5 years was 76%, and 83%, respectively (p = 0.202). There were significant improvements in the distress and disability scores postoperatively (mean interval: 32. 4+/-20.4 months). The QOL value rose from 0.960 to 0.981 in the elderly group (p = 0.0004), and from 0.975 to 0.984 in the younger group (p = 0.07), suggesting that the magnitude of improvement in the elderly group was superior to that in the younger group. CONCLUSIONS: Heart valve replacement in patients over the age of 70 years was associated with reasonable early and mid-term morbidity. We believe that significant improvements in the symptoms, functional status, and QOL of the patients can be expected.     

The influence of age on the outcome of primary coronary artery bypass grafting.

BACKGROUND: With the steady increase in the number of elderly patients requiring coronary artery bypass grafting (CABG), scepticism still exists as to whether this operation is justified in older patients or not, and whether there is an upper age limit. The aim of this study was to examine the effects of increasing age on the outcome of CABG. METHODS: A retrospective review was performed on 2127 consecutive patients undergoing primary CABG from January 1990 through June 1996. The patients were arbitrarily divided into age groups: 69 years or less (n=1607), 70-75 years (n=371), 76-80 years (n=129) and older than 80 years (n=20). Mortality, morbidity and long-term survival for each group was compared. RESULTS: The groups containing the elderly patients showed an over-representation of women, as well as a higher frequency of arterial hypertension, hyperlipidemia, previous infarction and diabetes. More patients, amongst the elderly, had unstable angina and diffuse coronary disease requiring urgent surgery and coronary thrombendarterectomy compared to those <70 years. Hospital mortality did not differ between the groups, 1.8, 3.0, 2.3 and 5.0%. There was an increased incidence of low postoperative cardiac output and a higher incidence of gastro-intestinal complications amongst the elderly. The 5-year survival was 92.2% (<70 years), 87.0% (70-75 years) and 86.3% (76-80 years) and the cardiac event-free survival was 87.5% (<70 years), 78.4% (70-75 years) and 80.8% (76-80 years) at 5 years. CONCLUSIONS: An acceptable early mortality and medium-term survival (5 years) together with excellent functional medium-term results support the justification of primary CABG in older patients irrespective of age.     

Interest in intestinal resection for treatment of advanced ovarian cancer

AIM OF THE STUDY: Digestive surgery is often necessary for surgical management of advanced ovarian carcinoma. PATIENTS AND METHODS: In a series of 62 patients with stage III ovarian carcinoma, postoperative morbidity and mortality, overall survival after 5 years and disease-free survival after 2 years were studied and corelated with several patients criteria (age, stage of the disease, residual disease, type of surgery, CA125 normalisation delay, postoperative complications and hospital stay). Patients were divided into two groups according to the surgical treatment. The first group (n = 17) included patients treated by gynecologic and digestive surgery, the second group (n = 45) included patients treated by gynecologic surgery only. All patients were proposed for chemotherapy included platyn salt. Mean age was 60 years (range: 20-83). The stage of the cancer was stage IIIa in 7 cases, stage IIIb in ten and stage IIIc in 45. RESULTS: Postoperative mortality was 3.5% (2/62). Postoperative morbidity was 26% (13/62). No statistical differences were noted for hospital stay, general morbidity, surgical morbidity when a gastric resection or a colon resections or a splenectomy were performed. Overall survival at 5 years was 56%. Residual disease less than 2 cm3 is the only prognostic factor for overall survival (56% vs 23% [P = 0.03]) and disease-free survival (86% vs 46% [P = 0.02]). CONCLUSION: This study including 62 patients confirmed the prognostic significance of extensive cytoreductive surgery for treatment in advanced ovarian epithelial cancer without increasing the postoperative morbidy and mortality.     

Surgical treatment of advanced colorectal cancer in the elderly

The aim of the study was to compare the short and long-term outcomes of older and younger colorectal cancer patients with advanced disease resected with a curative intent. Six hundred and ninety-two patients were analysed. Four hundred and seventy-nine patients were younger than 70 years (Group 1), and 213 were 70 years of age or above (Group 2). The overall perioperative mortality rate in the younger group was 0.8% (n = 7), as against 1.4% (n = 3) in the elderly group (p = NS). The morbidity rates were 35% and 42%, respectively (p = NS). At univariate analysis, the elderly patients had a worse overall survival compared to the younger group, when only patients undergoing postoperative chemo-radiotherapy were considered (54% vs 67% overall survival at 5 years; p = 0.03). Using logistic regression analysis, tumour stage (p < 0.0001) and radicality of surgery (p < 0.0001) correlated significantly with overall survival rates in the elderly. Colorectal surgery for malignancy can be performed safely in the elderly with acceptable morbidity and mortality rates and long-term survival.     

Hepatectomy as Treatment of Choice for Hepatocellular Carcinoma in Elderly Cirrhotic Patients

In recent decades liver resection has become a safe procedure; however, the outcome of hepatectomies in aged cirrhotic patients is often uncertain. To elucidate early and long-term outcomes of hepatectomy for HCC in the elderly, we studied 241 cirrhotic patients who underwent liver resection for HCC between 1985 and 2003. According to their age at the time of surgery, patients were divided into two groups: aged > 70 years (64 patients) and aged ≤ 70 years (177 patients). Operative mortality was 3.1% in the elderly and 9.6% in the younger group (p = 0.113). Postoperative morbidity and liver failure rates were higher in the younger group (42.4% versus 23.4%, p = 0.0073; 12.9% versus l.6%, p = 0.0065). Five-year survival rates are 48.6% in the elderly group and 32.3% in the younger group (p = 0.081). Considering only radical resections in Child-Pugh A patients, survival remains similar in the two groups (p = 0.072). Disease-free survival is not different in the two groups. A survival analysis performed according to the tumor diameter shows a better survival for elderly Child-Pugh A patients with HCC larger than 5 cm radically resected (50.8% versus 16.1% 5-year survival, p = 0.034). In univariate analysis, tumor size is not a prognostic factor in the elderly, whereas younger patients with large tumors have a worse outcome. Age by itself is not a contraindication for surgery, and selected cirrhotic patients with HCC who are 70 years of age or older could benefit from resection, even in the presence of large tumors. Long-term results of liver resections for HCC in the elderly may be even better than in younger patients.     

Liver and Pancreatic Resection in the Elderly

Background: Liver resection, or pancreaticoduodenectomy, has traditionally been thought to have a high morbidity and. mortality rate among the elderly. Recent improvements in surgical and anesthetic techniques, an increasing number of elderly patients, and an increasing need to justify use of limited health care resources prompted an assessment of recent surgical outcomes.Methods: Five hundred seventy-seven liver resections (July 1985–July 1994) performed for metastatic colorectal cancer and 488 pancreatic resections (October 1983–July 1994) performed for pancreatic malignancies were identified in departmental data bases. Outcomes of patients younger than age 70 years were compared with those of patients age 70 years or older.Results: Liver resection for 128 patients age 70 years or older resulted in a 4% perioperative. mortality rate and a 42% complication rate. Median hospital stay was 13 days, and 8% of the patients required admission to the intensive care unit (ICU). Median survival was 40 months, and the 5-year survival rate was 35%. No difference were found between results for the elderly and those for younger patients who had undergone liver resection, except for a minimally shorter hospital stay fortheyoungerpatients (median, 12 days vs. 13 days p=0.003). Pancreatic resection for 138 elderly patients resulted in a mortality rate of 6% and a complication rate of 45%. Median stay was 20 days, and 19% of the patients required ICU admission, results identical to those for the younger cohort. Long-term survival was poorer for the elderly patients, with a 5-year survival rate of 21% compared with 29% for the younger cohort (p=0.03).Conclusions: Major liver or pancreatic resections can be performed for the elderly with acceptable morbidity and mortality rates and possible long-term survival. Chronologic age alone is not a contraindication to liver or pancreatic resection for malignancy.     

Hepatic resection for hepatocellular carcinoma in the elderly

BACKGROUND: Although the number of elderly people undergoing surgery for hepatocellular carcinoma (HCC) has increased because of the prolonged life expectancy rate, potential benefits of hepatectomy for elderly patients with HCC have not been fully delineated. STUDY DESIGN: Using medical records, surgical outcomes of HCC in 103 patients 70 years of age or older undergoing hepatic resection (older group) were clarified and compared with those of 283 patients younger than 70 years of age (younger group) in this retrospective study. Postresection prognostic factors were evaluated by multivariate analysis using Cox's proportional hazards model. RESULTS: There were no significant differences in postoperative complication, operative mortality, and overall hospital death rates between the two groups. Overall 3- and 5-year survival rates for the older group and the younger group were 51.0% versus 55.2%, and 42.2% versus 40.0%, respectively (p = 0.95). Disease-free 3- and 5-year survival rates for the older group and the younger group were 35.2% versus 37.6%, and 16.6% versus 24.2%, respectively (p = 0.66). Multivariate analysis revealed that the presence of liver cirrhosis and vascular invasion were independently significant factors of poor overall survival. CONCLUSIONS: Selected elderly patients with HCC benefited from resection as much as young patients, and age by itself may not be a contraindication to surgery. Postresection longterm prognosis in the elderly was determined by the presence of liver cirrhosis and vascular invasion.     

Aortic valve replacement (AVR): influence of age on operative morbidity and mortality.

Retrospective analysis of 306 patients following aortic valve replacement (AVR) was carried out between 1985-89. Patients were divided into two groups: group 1 patients were less than 70 years of age and group 2 were greater than 70 years of age. The multivariant analysis of risk factors showed the only increased risk for surgery was the NYHA class IV in either group. There was no overall difference in morbidity and mortality. The actuarial survival rate for group 2 patients was 95% at 1 year and 75% at 5 years. This was not different when compared for death in age- and sex-matched controls from the general population. AVR in the elderly is safe, the long-term result is good and it remains the treatment of choice unless there is an absolute contraindication.     

Craniofacial resections in the elderly: an outcome study

OBJECT: The elderly population is increasing in number and is healthier now than in the past. The purpose of this study was to examine complications and outcomes following craniofacial resection (CFR) in elderly patients and to compare findings with those of a matched younger cohort. METHODS: All patients 70 years of age or older undergoing CFR at the M.D. Anderson Cancer Center (elderly group) between December 1992 and July 2003 were identified by examining the Department of Neurosurgery database. A random cohort of 28 patients younger than 70 years of age (control group) was selected from the overall population of patients who underwent CFR. There were 28 patients ranging in age from 70 to 84 years (median 74 years). Major local complications occurred in seven elderly patients (25%) and in six control patients (21%) (p = 0.75), and major systemic complications occurred in nine elderly patients (32%) and in three control patients (11%) (p = 0.05). There was one perioperative death in both groups of patients. The median duration of disease-specific survival for the elderly patients was not reached (mean 6.8 years); however, it was 8.3 years for control patients (p = 0.24). Predictors of poorer overall survival from a multivariate analysis of the elderly group included presence of cardiac disease (p = 0.005), a major systemic perioperative complication (p = 0.03), and a preoperative Karnofsky Performance Scale score less than 100 (p = 0.04). CONCLUSIONS: In this study of elderly patients who underwent CFR, there was no difference in disease-specific survival when compared with a matched cohort of younger patients. There was, however, an increased incidence of perioperative major systemic complications in the elderly group.     

Pancreatic or liver resection for malignancy is safe and effective for the elderly.

BACKGROUND: Liver resection, or pancreaticoduodenectomy, has traditionally been thought to have a high morbidity and mortality rate among the elderly. Recent improvements in surgical and anesthetic techniques, an increasing number of elderly patients, and an increasing need to justify use of limited health care resources prompted an assessment of recent surgical outcomes. METHODS: Five hundred seventy-seven liver resections (July 1985-July 1994) performed for metastatic colorectal cancer and 488 pancreatic resections (October 1983-July 1994) performed for pancreatic malignancies were identified in departmental data bases. Outcomes of patients younger than age 70 years were compared with those of patients age 70 years or older. RESULTS: Liver resection for 128 patients age 70 years or older resulted in a 4% perioperative mortality rate and a 42% complication rate. Median hospital stay was 13 days, and 8% of the patients required admission to the intensive care unit (ICU). Median survival was 40 months, and the 5-year survival rate was 35%. No differences were found between results for the elderly and those for younger patients who had undergone liver resection, except for a minimally shorter hospital stay for the younger patients (median, 12 days vs. 13 days; p = 0.003). Pancreatic resection for 138 elderly patients resulted in a mortality rate of 6% and a complication rate of 45%. Median stay was 20 days, and 19% of the patients required ICU admission, results identical to those for the younger cohort. Long-term survival was poorer for the elderly patients, with a 5-year survival rate of 21% compared with 29% for the younger cohort (p = 0.03). CONCLUSIONS: Major liver or pancreatic resections can be performed for the elderly with acceptable morbidity and mortality rates and possible long-term survival. Chronological age alone is not a contraindication to liver or pancreatic resection for malignancy.     

Hospital volume does not influence long-term survival of patients undergoing surgery for oesophageal or gastric cancer

BACKGROUND: Guidelines suggest that surgery for oesophageal and gastric cancer should be conducted in large cancer centres. This national study examined the relationship between hospital volume and outcome in Scotland. METHODS: This was a prospective, population-based study of 3293 consecutive patients with oesophageal or gastric cancer diagnosed between 1997 and 1999. Some 1302 patients underwent surgery and were followed for 5 years after operation. RESULTS: The 5-year adjusted overall survival rate for the 3293 patients was 18.7 (95 per cent confidence interval (c.i.) 17.2 to 20.2) per cent and that after surgical resection was 39.6 (95 per cent c.i. 36.3 to 43.0) per cent. Death within 1 year after surgical resection was associated with a postoperative complication (odds ratio (OR) 2.5 (95 per cent c.i. 1.6 to 3.8); P < 0.001) or resection margin involvement by tumour (OR 7.2 (95 per cent c.i. 1.1 to 47.5); P = 0.042) after adjustment for age, sex and tumour location. There was no relationship between hospital volume and postoperative morbidity or mortality, nor between survival and volume of patients either for hospital of diagnosis or hospital of surgery. CONCLUSION: This population-based study of oesophageal and gastric cancer suggests that the link between hospital volume and long-term survival for patients undergoing surgery requires re-evaluation.