The incidence of esophageal cancer and pancreatic cancer in the senior age has increased relatively in recent years, which is the result of the quiet arrival of an aging society with the development of society and the improvement of people’s living standard and the increase of life expectancy of the population. Generally, 60-70 years old is called old age, 70 to 80 years old is called senior age, and over 80 years old is called super senior age. The elderly patient population has its own physiological, psychological and social characteristics, and the related treatment issues also need to be discussed in a special way.
As we all know, surgery has the outstanding advantages of being radical and non-biologically resistant, and it is still the first choice for the treatment of most solid tumors today. With recent advances in anesthesia techniques, surgical instruments and equipment, materials and drugs, and perioperative monitoring, the surgical indications for high-grade esophageal and cardia cancers have expanded much more than before.
The success of surgery and good postoperative results have brought uplift and encouragement. However, the expansion of surgical indications has led to a corresponding increase in postoperative complications. Most surgical deaths within 30 days after surgery are in this age group. The increase of surgical complications and surgical death is related to the high blow and heavy trauma of major open-heart surgery on the one hand, and to the poor physical condition of elderly patients with esophageal and cardia cancer on the other hand, with more complicated past medical history and often combined with multiple organ diseases at the same time.
The more common comorbidities include malnutrition, anemia and diabetes; cardiovascular, cerebrovascular and respiratory system diseases; old thoracic and abdominal diseases and surgical experience, potential subclinical hypofunctional state of multiple organs, long-term smoking and alcohol consumption, and certain psychological and social family uncertainties may also have serious effects on the postoperative period. Even some seemingly common complications can become insurmountable obstacles in the lives of highly aged patients.
Common postoperative complications include pneumonia including infectious and aspiration pneumonia, atelectasis, pulmonary edema, respiratory failure, etc.; cardiovascular complications include various atrial or ventricular arrhythmias, hypertension, heart failure, myocardial infarction, pulmonary embolism due to deep vein embolism, etc.; other complications include hypoproteinemia, diabetes-related complications resulting in anastomosis, poor wound edema, severe infections including mycobacterial and multiple organ failure.
Therefore, the treatment of elderly patients should be strictly differentiated and treated carefully. On the basis of thorough preoperative examination and full understanding of the patient’s cardiopulmonary and other organ functions, the patient’s condition and physical status, especially the ability to resist surgical blows, should be comprehensively evaluated during the preoperative consultation and discussion. It is also important to understand the affordability of patients and their families for treatment costs. Develop appropriate and different individualized treatment plans.
For patients with better general physical condition and greater possibility and certainty of surgical resection, especially those who can be radically resected, they should actively explain and explain their condition and fully prepare for surgery; including treatment and alleviation of cardiopulmonary and other organ diseases, improvement of nutritional status, correction of anemia and hypoproteinemia, and respiratory function training in order to strive for surgical treatment. Minimize surgical blows, minimize bleeding, operate gently and shorten the operation time. To cooperate well with anesthesiologists and strengthen respiratory management, especially thorough aspiration before extubation.
After surgery, close monitoring, adequate nebulization for effective sputum excretion, frequent back patting and leg rubbing, and encouragement of bedside activities. For patients with a tendency to blood hypercoagulation, postoperative administration of salvia etc. can be used to prevent deep vein thrombosis. Due to insufficient cardiopulmonary reserve function in elderly patients, cardiopulmonary complications are likely to occur after surgery and must be managed promptly, including tracheoscopic aspiration, tracheotomy and mechanical ventilation assisted breathing when necessary.
In some patients, the nutritional status is very poor due to the longer period of esophageal obstruction and difficulty in eating before admission. After admission, nasal feeding of high-calorie nutrition such as soy milk and broth was given to rapidly improve the physical condition and enhance the ability to tolerate the surgical shock. The next day after surgery, the intestinal function was initiated by nasal nutrition, and the quality and quantity gradually increased. Food intake is usually started 5 days after surgery, and fine rotten noodles are started at 9 days.
This avoids post-operative transfusions of blood, plasma and protein, reduces complications associated with prolonged and extensive post-operative parenteral nutrition, and also reduces the cost of treatment. For the surgery of middle and lower thoracic esophageal cancer in the elderly, we adopt a mechanical anastomosis of the stomach with the esophagus from behind and above the aortic arch by lifting the stomach over the esophageal bed. This procedure is particularly suitable for patients with low cardiopulmonary function and ultra-advanced age.
For some high-grade lesions, including cervical segment and high-grade upper thoracic esophageal cancer, on the basis of the principle of radical tumor surgical treatment, the left cervical epigastric median two-incision esophageal extraction is used to avoid open-heart operation and improve safety; or the right thoracic postero-lateral incision is used to free the stomach through the esophageal fissure, and the right thoracic super-thoracic apex esophagogastric anastomosis is used to avoid the more invasive conventional left cervical, right thoracic postero-lateral and epigastric median three incisions. This avoids the more invasive conventional left cervical, right postero-lateral thoracic and median epigastric incisions. The posterior transthoracic gastric anastomosis is much less cardiopulmonary in nature than the cervical anastomosis via the esophageal bed. For residual gastroesophageal cancer with previous major gastrectomy, the residual stomach, spleen and tail of the pancreas can be pulled into the thoracic cavity and anastomosed under the esophagogastric arch. For some medullary or ulcerated esophageal cancers with high and long lesions, which may invade the tracheal membrane or large blood vessels and have a large niche that will be perforated, half amount of radiotherapy (4000 rad) can be given preoperatively, which will improve the surgical resection rate and increase the safety of surgery.
In cardia cancer surgery, the authors used a combined small transthoracic-abdominal incision (10-12 cm long) with a lightly invasive surgical approach, preserving the esophageal fissure and diaphragm, which made the operation easier and simpler and the lymph node dissection next to the left abdominal gastric vessel more complete, improving the radicality of the operation. It significantly shortens the operation time compared with the conventional simple open-chest approach, with less postoperative wound pain, easier coughing and sputum excretion, and fewer pulmonary complications. Once the need for total gastrectomy is found intraoperatively, the operation can be completed conveniently by slightly enlarging the incision.
For total gastric surgery for pancreatic cancer, we use R-Y total mechanical anastomosis closure, which reduces the operation time and postoperative complications with excellent results. Some patients with very poor pulmonary function who cannot tolerate open-chest strikes, and patients whose left thoracic adhesion atresia will be extremely difficult or cause severe trauma by transthoracic approach, can be operated by trans-epigastric pathway, but it should be noted that the upper incision margin should be large enough, i.e. for the lower thoracic segment of the esophagus the resection should be long enough to ensure a clean upper margin.
Postoperative radiotherapy and chemotherapy for elderly esophageal and cardia cancers should be treated with caution, and the necessity and effect of postoperative chemotherapy should not be overstated. Short courses of chemotherapy should be used flexibly and appropriately according to the patient’s physical and immune recovery, while adequate antiemetic, whitening, nutritional and other bailout drugs and supportive therapies should be given. According to the latest literature from the 2002 ASCO meeting, the Tysodi (or paclitaxel) + 5-FU + tetrahydrofolate regimen is recommended. For patients with post-surgical pathological findings of lymph node metastases or palliative surgery, appropriate radiotherapy may be indicated.
According to the “bio-psycho-social” medical model, patients should make the necessary psychological adjustments with the help of medical staff and family members after completing hospital treatment, and encourage patients to return to normal life, start a new life, and establish confidence and courage to overcome the disease. confidence and courage to overcome the disease. We should pay attention to the quality of life after surgery, and we should have small and frequent meals. A patient’s rosy complexion and weight gain after being discharged from the hospital for a period of time indicates a better nutritional status and good physical recovery. Regular postoperative review should not be neglected either.
The WHO has proposed three goals for the treatment of advanced tumors: “to reduce pain, improve quality of life and prolong life as much as possible”. On the basis of symptomatic treatment, we adopt the first placement of esophageal or cardia memory metal stent to solve the problem of eating, and then give radiotherapy or other comprehensive treatment, which can achieve the above three goals and save the treatment cost and reduce unnecessary pain, which is welcomed by patients and families.