Patient selection for oesophagectomy

Introduction: Surgical resection of oesophageal cancer is a major procedure with potential for significant morbidity and mortality. Patient selection can be challenging, as operative benefit must be balanced against risk and impact on quality of life. This study defines modern trends in patient selection, and evaluates the impact of age, stage, and comorbidities on complications and survival following oesophagectomy, in a tertiary Australian experience. Methods: Data were compiled across two 15-year operative eras ('Era 1': 1981-1995; and 'Era 2': 1996-2010), with patients followed minimum 3 years. A total of 180 unselected records were analysed (powered for a relative hazard ratio of 0.5). Analyses defined patient selection trends, and for Era 2, the impact of age, comorbidities (Charlson score), and disease (T/N stage) on complications (Clavien-Dindo grade) and survival (Kaplan-Meier). A further sub-analysis was conducted with data divided into three 10-year periods. Results: The age of operated patients increased from Era 1 to 2 (mean + 5 years; P < 0.001), but survival and complication rates were unchanged, including in patients ≥ 75 years (P > 0.5). In Era 2, reflecting recent practice, survival duration matched T/N stage (P < 0.001) but was independent of age at surgery (P = 0.56) and comorbidity score (P = 0.78). However, grade of worst post-operative complication, including death (rate: 3.8 %), was correlated with both age (P < 0.01) and comorbidity score (P < 0.01). Discussion: Older patients are now undergoing oesophagectomy. However, if they are selected appropriately, then older patients and those with comorbidities can expect similar stage-matched survival outcomes to younger fitter patients, despite their higher operative risk. Poor outcomes persist in patients with locally advanced disease, and selection in this group should prioritise quality of life.