Outcomes of Esophagectomy in the Elderly- Is It Worth the Effort?

Abstract Background Esophageal cancer is the sixth most common cancer in India and most patients are diagnosed at locally or loco-regionally advanced stages. Multimodal management offers the best chance of cure, with surgery being the cornerstone. With improved life expectancy, elderly patients with esophageal cancer are being referred for surgery more frequently. Although recent studies have shown encouraging outcomes, increased post-operative complications are common. The aim of our study was to evaluate morbidity and survival in patients above 70 years undergoing curative surgery for esophageal cancer from 2011 to 2021 at our centre. Methods Of 2291 patients undergoing esophagectomy, 122 were above 70 years, ten were inoperable. Mean age was 73.3 years (70-84 years), with 78% males and 83% squamous cell carcinoma, most common location being lower-third (63.6%). Of the 110 patients, 80 (72.7%) received neoadjuvant treatment, 68(61.8%) were ASA grade II or more. McKneown’s approach was common, utilized in 55%, of which minimally invasive in 53%, with Ivor- Lewis, left thoraco-abdominal and transhiatal approaches in the rest. Mean blood loss was 350 ml, with mean operative time of 270 minutes and circumferential positivity rate of 12.7%. Results The mean ICU stay was 1 day, with the mean hospital stay being 13 days. Almost half (49%) had Clavien-Dindo grade III or higher morbidity, with pulmonary complications seen in 27%. Anastomotic leakage was seen in 20/110 (18%), with only 2 patients needing an intervention. 30-day mortality was 8.2%. Recurrences were seen in 21 patients, anastomotic and regional recurrences in 6, distant in 6, regional with distant in 9. The median recurrence free survival was 26 months with 3-year RFS of 43.7%. With a median follow-up of 25 months, median overall survival was 30 months and 3-year OS was 45.3%. Conclusion Despite higher post-operative morbidity and mortality, elderly patients have reasonable recurrence free and overall survival outcomes with curative surgery. With continuing refinements in prehabilitation, operative techniques, wider adoption of minimally invasive surgery, intra-operative management and post-operative care, early post-operative outcomes are likely to improve further. Elderly patients with resectable esophageal cancer should not be denied surgery.