Complications including dysphagia following transoral non-robotic surgery for pharyngeal and laryngeal squamous cell carcinoma: A retrospective multicenter study.

OBJECTIVE: Transoral surgery is a minimally invasive treatment but may cause severe dysphagia at a lower rate than chemoradiotherapy. METHODS: We compared clinical information, surgical complications, and swallowing function in patients who underwent transoral nonrobotic surgery for laryngo-pharyngeal squamous cell carcinoma between 2015 and 2021 in a multicenter retrospective study. RESULTS: Six hundred and forty patients were included. Postoperative bleeding was observed in 20 cases (3.1%), and the risk factor was advanced T category. Postoperative laryngeal edema was observed in 13 cases (2.0%), and the risk factors were prior radiotherapy, advanced T stage, and concurrent neck dissection in patients with resected HPC. Dysphagia requiring nutritional support was observed in 29 cases (4.5%) at 1 month postoperatively and in 19 cases (3.0%) at 1 year postoperatively, respectively. The risk factors for long-term dysphagia were prior radiotherapy and advanced T category. Short-term risk factors for dysphagia were prior radiotherapy, advanced T category, and concurrent neck dissection, while long-term risk factors for dysphagia were only prior radiotherapy and advanced T category. CONCLUSION: Prior radiotherapy, advanced T stage, and concurrent neck dissection increased the incidence of postoperative laryngeal edema and short-term dysphagia, but concurrent neck dissection did not affect long-term dysphagia. Such features should be considered when considering the indication for transoral surgery and postoperative management.

Impact of cervical lymph node metastasis on transoral surgery for hypopharyngeal squamous cell carcinoma: A retrospective multicenter study.

BACKGROUND: Hypopharyngeal carcinoma is likely to spread to the lymph nodes, but there is no established strategy for management in transoral surgery. METHODS: We compared oncologic and functional outcomes in a retrospective multicenter study of patients who underwent transoral surgery for hypopharyngeal carcinoma between 2015 and 2021. RESULTS: Two-hundred and thirty-two patients were included. Comparing patients with and without adjuvant radiotherapy, 3-year regional recurrence-free survival (RRFS) was not significantly different in pN2b and pN2c, but was significantly worse in pN3b without adjuvant radiotherapy. In patients without neck dissection, the 3-year RRFS was 85.6%, 76.8%, and 70.0% for T1, T2, and T3 primary lesions, respectively, and was significantly worse for T2 or higher (p = 0.035). CONCLUSIONS: In the absence of extracapsular invasion, regional control did not deteriorate without adjuvant therapy. If prophylactic neck dissection is not performed, careful follow-up is necessary if the primary lesion is T2 or greater.

Local recurrence and metachronous multiple cancers after transoral nonrobotic surgery for pharyngeal and laryngeal squamous cell carcinoma: A retrospective multicenter study.

BACKGROUND: Late laryngopharyngeal cancers after transoral surgery include not only local recurrences but also metachronous multiple cancers. METHODS: We compared clinical information, surgical outcomes, and late laryngopharyngeal cancers in patients who underwent transoral nonrobotic surgery for laryngopharyngeal squamous cell carcinoma without lymph node metastases between 2015 and 2021 in a multicenter retrospective study. RESULTS: Four hundred and fifty-seven patients were included. Positive surgical margins were found in 121 patients (26.5%). Twenty-two patients (4.8%) received additional treatment. Positive horizontal margins of invasive carcinoma (p = 0.003) and positive horizontal margins of carcinoma in situ only (p = 0.032) were independent risk factors for local recurrence, and prior radiotherapy (p = 0.001) for metachronous multiple cancers. Local control was significantly worse without additional treatment (p = 0.049), but there was no significant difference in survival. CONCLUSIONS: Patients with positive margins had an increased frequency of local recurrence, but salvage therapy was effective.

Parathyroid carcinoma: impact of preoperative diagnosis on the choice of surgical procedure.

The operative procedure in the surgical treatment of parathyroid carcinoma differs from that of benign hyperparathyroidism. However, preoperative differentiation is often difficult. This study elucidated how clinicians diagnose parathyroid carcinoma and the relationship between preoperative diagnosis and the operative course. Using a retrospective chart review, twenty cases of parathyroid carcinoma from nine participating centers were examined. In 11 cases with preoperative suspicion of malignancy, at least one of these three features was found: elevated serum calcium level (>14 mg/dL), palpable mass, and irregular margin on ultrasonography. Although an intact parathyroid hormone (iPTH) threshold to suspect malignancy has not been established, six cases showed marked iPTH elevation exceeding 8.0 times the upper limit of normal. One case was excluded from analysis due to hemodialysis. Compared with the four cases that showed calcium elevation, the iPTH threshold might represent better sensitivity. Among 9 cases of benign preoperative diagnosis, six cases were performed with pericapsular resection. In three cases where malignancy was suspected in the middle of the operation, the recommended en bloc resection with ipsilateral thyroid lobectomy was not performed but a parathyroidectomy with surrounding soft tissue. In contrast, 10 preoperatively suspected cases underwent en bloc resection, and one case underwent pericapsular resection followed by supplementary ipsilateral hemithyroidectomy due to the uncertain pre- and intraoperative findings to determine the diagnosis. In conclusion, the surgical procedure for parathyroid carcinoma strongly depends on the preoperative diagnosis. The presence of excessive iPTH levels might contribute to improved preoperative diagnostic sensitivity for parathyroid carcinoma.

Neck Dissections Based on Sentinel Lymph Node Navigation Versus Elective Neck Dissections in Early Oral Cancers: A Randomized, Multicenter, and Noninferiority Trial.

PURPOSE: This study aimed to compare patients with early oral cavity squamous cell carcinoma (OCSCC) (tumor category [T] 1-2, node-negative, and no distant metastasis) treated with traditional elective neck dissection (ND) with those managed by sentinel lymph node biopsy (SLNB) using survival and neck function and complications as end points. METHODS: Sixteen institutions in Japan participated in the study (trial registration number: UMIN000006510). Patients of age ≥ 18 years with histologically confirmed, previously untreated OCSCC (Union for International Cancer Control TNM Classification of Malignant Tumors 7th edition T1-2, node-negative no distant metastasis), with ≥ 4 mm (T1) depth of invasion, were randomly assigned to undergo standard selective ND (ND group; n = 137) or SLNB-navigated ND (SLNB group; n = 134). The primary end point was the 3-year overall survival rate, with a 12% noninferiority margin; secondary end points included postoperative neck functionality and complications and 3-year disease-free survival. Sentinel lymph nodes underwent intraoperative multislice frozen section analyses for the diagnosis. Patients with positive sentinel lymph nodes underwent either one-stage or second-look ND. RESULTS: Pathologic metastasis-positive nodes were observed in 24.8% (34 of 137) and 33.6% (46 of 134) of patients in the ND and SLNB groups, respectively (P = .190). The 3-year overall survival in the SLNB group (87.9%; lower limit of one-sided 95% CI, 82.4) was noninferior to that in the ND group (86.6%; lower limit 95% CI, 80.9; P for noninferiority < .001). The 3-year disease-free survival rate was 78.7% (lower limit 95% CI, 72.1) and 81.3% (75.0) in the SLNB and ND groups, respectively (P for noninferiority < .001). The scores of neck functionality in the SLNB group were significantly better than those in the ND group. CONCLUSION: SLNB-navigated ND may replace elective ND without a survival disadvantage and reduce postoperative neck disability in patients with early-stage OCSCC.

Sensory preservation in neck dissection: outcomes of a sub-sternocleidomastoid approach.

OBJECTIVE: Cutaneous anesthesia in early postoperative period is common after neck dissection even if the cervical nerve (CN) rootlets are preserved. The aim of this study was to evaluate if the preservation of the terminal branches of CNs using sub-sternocleidomastoid (SCM) approach combined with medially placed skin incision can prevent early postoperative anesthesia. MATERIAL AND METHODS: A retrospective chart review was performed on 129 neck dissections in 87 head and neck cancer patients. RESULTS: The early postoperative sensory preservation rates for the ear tab, submandibular, lateral neck, and sub-clavicular areas of CN rootlet-preserved necks (n = 86) were 75.6%, 20.9%, 74.4%, and 86.0%, respectively, compared with 37.2%, 2.3%, 2.3%, and 4.7%, respectively, in CN rootlet-resected necks (n = 43). In CN rootlet-preserved necks, the sub-SCM approach (n = 54) showed 81.5%, 27.8%, 92.6%, and 94.4% preservation rates, respectively, compared with 65.6%, 9.4%, 43.8%, and 71.9%, respectively, using the conventional subplatysmal approach (n = 32). The rates were significantly better in the submandibular, lateral neck, and sub-clavicular areas after sub-SCM approach. CONCLUSIONS: Preservation of CN rootlets is a required element for sensory preservation in neck dissection. The sub-SCM approach can effectively prevent early postoperative cutaneous anesthesia following CN-preserving neck dissection.

Oncologic safety of cervical nerve preservation in neck dissection for head and neck cancer.

BACKGROUND: Although the functional merits of preserving cervical nerves in neck dissection for head and neck cancer have been reported, the oncologic safety has not yet been determined. Therefore, the purpose of this study was to evaluate the safety of cervical nerve preservation. METHODS: A retrospective chart review was performed on patients with head and neck cancer who had been treated by neck dissection between 2009 and 2014 at Kyoto Medical Center. Management of cervical nerves and clinical results were analyzed. RESULTS: A total of 335 sides of neck dissection had been performed in 222 patients. Cervical nerves were preserved in 175 neck sides and resected in 160 sides. The 5-year overall survival (OS) rate calculated by the Kaplan-Meier method was 71%. The 5-year neck control rate was 95% in cervical nerve preserved sides and 89% in cervical nerve resected sides. CONCLUSION: Preserving cervical nerves in neck dissection is oncologically safe in selected cases.

Cystadenocarcinoma of the salivary glands with potential lymph node metastasis.

Cystadenocarcinoma derived from the salivary gland in the head and neck region is an extremely rare malignancy. Therefore, the clinicopathological characteristics is not well understood. The purpose of this study was to clarify the clinicopathological characteristics, and present a total of four patients who were treated at the National Cancer Center Hospital East during the period between 1995 and 2012. The patients were all male, with ages ranging from 47 to 74 years old. The primary sites were the parotid glands, submandibular gland and minor salivary gland of the tongue. Within the follow-up period from 19 to 54 months, lymph node metastases were observed in three of the four patients. However, all the patients were salvaged by additional resection, including neck dissection, and remain alive to date without distant metastases. Cystadenocarcinoma is classified as a low-grade histological subtype of salivary gland tumors. Although the tumor has the potential to produce lymph node metastases, as shown in our patients, it is generally an indolent tumor with a good prognosis as compared with high-grade subtypes. This study suggests that a long-term follow up paying close attention to lymph node metastases is necessary for cystadenocarcinoma.

Feasibility of salvage endoscopic resection for patients with locoregional failure after definitive radiotherapy for pharyngeal cancer.

BACKGROUND AND STUDY AIMS: Local failure after radiation therapy for pharyngeal squamous cell carcinoma (PSCC) is problematic. The safety of endoscopic resection for lesions within the radiation therapy (RT) field has not been assessed. We evaluated salvage endoscopic resection in patients with locoregional failure after definitive radiotherapy for PSCC. PATIENTS AND METHODS: We retrospectively evaluated the clinical outcomes and long-term survival of 16 patients initially treated with more than 60 Gy of radiation for PSCC. These patients later presented with 19 superficial metachronous or recurrent PSCC lesions within the radiation field and were treated with salvage endoscopic resection. RESULTS: Local recurrence developed at the primary site in 3 patients after a complete response to RT. The other 13 had multiple metachronous squamous cell carcinomas within the original RT field. Major complications associated with salvage endoscopic resection included aspiration pneumonia in 1 patient and a requirement for temporary tracheostomy in 3 patients. During a median follow-up period of 37 months (range, 2 - 72 months), 13 patients had no recurrence, 2 patients developed local recurrence, and 1 patient developed lymph node metastases. At present, 5 of the 16 patients have died: 2 of PSCC progression, 1 of esophageal squamous cell carcinoma, and the remaining 2 of unknown causes. The 3-year survival rate was 68.6 %. CONCLUSIONS: Endoscopic resection is a potentially curative salvage treatment option for patients with superficial locoregional failure after definitive radiotherapy for PSCC.

Nine cases of carcinoma with neuroendocrine features in the head and neck: clinicopathological characteristics and clinical outcomes.

OBJECTIVE: As neuroendocrine carcinomas in the head and neck region are extremely rare, their clinicopathological characteristics remain largely unknown. Moreover, the 2005 World Health Organization classification criteria for head and neck carcinomas with neuroendocrine features have numerous limitations. Therefore, the clinicopathological features and patient outcomes of these tumors must be clarified. METHODS: Between 2007 and 2012, we encountered nine cases of head and neck cancer involving a neuroendocrine carcinoma component. We investigated these tumors according to the 2010 World Health Organization classification criteria for neuroendocrine tumors, and their clinicopathological characteristics and clinical outcomes were examined. RESULTS: Carcinomas with neuroendocrine features were found to have an aggressive clinical course, which corresponded with the Ki-67 index and mitotic count. CONCLUSIONS: Owing to the difficulty in appropriately diagnosing head and neck carcinomas with neuroendocrine features using the current classification system, a new classification system should be developed for use in these cases.

Gastrostomy dependence in head and neck carcinoma patient receiving post-operative therapy.

OBJECTIVE: Post-operative concurrent chemoradiotherapy significantly improves the rates of locoregional control and disease-free survival in high-risk patients but has significant adverse effects. Percutaneous endoscopic gastrostomy and opioid-based pain control increase treatment completion rates but can result in dysphagia. METHODS: The rate and duration of use of prophylactically placed percutaneous endoscopic gastrostomies were evaluated in 43 patients who underwent post-operative radiotherapy or chemoradiotherapy from April 2007 through March 2010. All patients completed treatment and received 60 Gy or more of radiotherapy. RESULTS: Thirty four of 43 patients (79.1%) used percutaneous endoscopic gastrostomies, which could later be removed in 25 of 34 patients. The median period of use was 108 days. Only one disease-free patient was permanently dependent on percutaneous endoscopic gastrostomy feeding. The frequency of percutaneous endoscopic gastrostomy use among patients with oral, oropharyngeal and hypopharyngeal cancer was 91.7, 100 and 54.5%, respectively. CONCLUSIONS: Prolonged percutaneous endoscopic gastrostomy use is not required in patients receiving post-operative chemoradiotherapy and will not lead to dysphagia.

Super-radical surgery for anaplastic thyroid carcinoma: a large cohort study using the Anaplastic Thyroid Carcinoma Research Consortium of Japan database.

BACKGROUND: The consequences of super-radical resection in patients with anaplastic thyroid carcinoma (ATC) have not been fully investigated. METHODS: This retrospective study used the multicenter ATC Research Consortium of Japan database. Among 233 stage IVB patients, 23 underwent super-radical resection (group S). Outcomes for group S were compared to those for patients with restricted curative surgery (group R; n = 49), palliative surgery (group P; n = 72) or no surgery (group N; n = 80). RESULTS: One-year cause-specific survival rate for group S was 33%. It was identical to group R (p = .94) and significantly better than groups N and P (p = .0065). Permanent tracheostomy was significantly more frequent in group S than in other groups, but only 5 patients died directly from local disease. CONCLUSIONS: Radical resection offers significantly better outcomes than limited surgery. Super-radical procedures may be indicated in select patients to avoid mortality due to locally uncontrolled disease at the expense of tracheostomy.

[Frequency and distributions of cervical lymph node metastases in oropharyngeal squamous cell carcinoma].

OBJECTIVES: To examine the frequency and distribution of cervical lymph node metastases in oropharyngeal squamous cell carcinoma (SCC) and the necessities of prophylactic treatment of the neck. METHODOLOGY: We conducted a retrospective study of 242 patients with SCC of the oropharynx treated by surgery as the initial therapy at the National Cancer Center East Hospital from 1994 to 2008, excluding 53 patients who had local recurrences and 9 patients who had previously undergone neck dissection for metastasis from an unknown primary. We defined "potential lymph node metastases" as cases pathologically positive for lymph node metastases and/or secondary lymph node metastases and analyzed the necessity of prophylactic neck dissection for cases clinically negative for cervical metastases. RESULTS: One hundred and eighty patients (148 males, 32 females) were included. The median age was 62 years (35 to 78). The clinical stages were Stage I in 20 patients, Stage II in 36 patients, Stage III in 39 patients, and Stage IV in 85 patients. In the ipsilateral neck of 70 patients at clinical stage N0, 15 patients (21.4%) were positive for potential lymph node metastases. There was no significant difference in the frequency of metastases by subsite. In terms of T classification, the positivity rates were 5.0% in patients at T1, 19.4% at T2, 44.4% at T3, and 60.0% at T4. In the contralateral neck of 70 patients at clinical stage N0, only 2 patients (2.9%) were positive for potential lymph node metastases. In the contralateral neck of 93 patients at clinical stage N1, N2a, or N2b (i.e., unilateral lymph node swelling), 16 patients (17.2%) were positive for potential lymph node metastases. The positivity rates by subsite were higher in patients with anterior, superior and posterior wall cancer than those with lateral wall cancer. CONCLUSIONS: In the ipsilateral neck of patients at clinical stage N0, prophylactic neck dissection is not necessary for patients at T1 but necessary for those at T3 or T4. In the contralateral neck of such patients, prophylactic neck dissection is not recommended. In the contralateral neck of patients with unilateral lymph node swelling, prophylactic neck dissection is recommended for patients with anterior, superior or posterior wall cancer.

The effectiveness of chemoradiation therapy and salvage surgery for hypopharyngeal squamous cell carcinoma.

OBJECTIVE: The objective of this study was to evaluate the results of salvage surgery after definitive chemoradiation for hypopharyngeal squamous cell carcinoma. METHODS: This was a retrospective cohort study. Of the 79 patients with previously untreated hypopharyngeal squamous cell carcinoma who received definitive chemoradiation from January 2004 to January 2009, 24 who had recurrence and underwent salvage surgery at the National Cancer Center Hospital East, Chiba, Japan, were enrolled in this study. RESULTS: Of the 24 patients who underwent salvage surgery with curative intent, 13 had an isolated local failure, eight had an isolated neck failure and three had combined local and regional failure. Postoperative surgical complications were observed in eight (33.3%) patients. Of the 24 patients undergoing salvage surgery, 12 (50%) had recurrence. In 11 of these patients, death ensued from salvage failure, defined as the presence of any recurrence after salvage treatment. The causes of cancer-specific death ensuing from salvage failure were regional recurrence of the tumor (n = 6) (one of whom had concurrent distant metastases) and distant metastases alone (n = 5). No local recurrence after salvage surgery was observed in our group of patients. The disease-free and overall 24-month survival rates were 49.0 and 50.0%, respectively. Those patients who initially presented with unresectable disease had lower overall survival compared with those who initially presented with resectable disease (P = 0.0003). CONCLUSIONS: The oncologic outcomes were acceptable in those patients in whom salvage surgery was carried out. Those who initially presented with unresectable disease had a poor prognosis.

Observation as an option for epithelial positive margin after partial glossectomy in stage I and II squamous cell carcinoma: analysis of 365 cases.

OBJECTIVE: This study was conducted to assess local recurrence and clinical prognosis in patients diagnosed as having a positive margin in the epithelial layer after a partial glossectomy treated by close observation. METHODS: A total of 365 cases of squamous cell carcinoma of the tongue diagnosed as clinical Stage I or II, treated by partial glossectomy in the National Cancer Center Hospital East between 1992 and 2006, were studied retrospectively. RESULTS: Pathological findings showed that 13 cases had positive margins in the epithelial layer, 4 (30.8%) of whom showed up with local recurrence in 4.4 years (3.0-5.0) on average. Lymph node recurrence was not observed and the 5-year overall survival rate was 76.2% in those 13 cases. The treatment for the recurrent cases was an additional partial glossectomy without neck dissection, which resulted in no recurrence and a survival rate of 100% after an average follow-up of 6.7 years. CONCLUSIONS: We suggest careful observation as one option for cases diagnosed with epithelial positive margin.

Mucosal defect repair with a polyglycolic acid sheet.

OBJECTIVE: Early-stage oral or oropharyngeal carcinomas are often treated with surgical resection. Resulting wounds that are too large for primary closure can be covered with skin grafts or patches made from various biomaterials. Recently, polyglycolic acid sheets have been used for this purpose. METHODS: We treated six patients with large wounds resulting from the resection of oral or oropharyngeal squamous cell carcinoma by grafting polyglycolic acid sheet patches. All patients were initially treated at the National Cancer Center East Hospital from March 2010 through July 2012. After mucosal resection, the wounds were covered with polyglycolic acid sheet patches attached with fibrin glue. Oral intake was started 4 days after surgery. RESULTS: Mucosal resection was the initial treatment in seven patients (five with oral squamous cell carcinoma and two with oropharyngeal squamous cell carcinoma). The polyglycolic acid sheet patches became detached in two patients (on the day of surgery and on postoperative day 6), who then required large doses of analgesics. A patient who underwent tooth extraction also required large doses of analgesics. The other four patients required only small doses of analgesics. One patient had bleeding at the surgical site. No adverse effects were caused by the polyglycolic acid sheet patch or by fibrin glue. CONCLUSIONS: Our study has shown that grafting of a polyglycolic acid sheet patch is effective and provides good pain control for patients with large, open wounds after mucosal resection of oral or oropharyngeal squamous cell carcinoma. We plan to evaluate tissue contraction and oral intake after polyglycolic acid patch grafting.

Narrow band imaging endoscopy for unknown primary tumor sites of the neck.

BACKGROUND: Examinations used to search for unknown primary tumors of squamous cell carcinomas of the neck include CT, MRI, laryngoscopy, gastrointestinal endoscopy, and positron-emission tomography (PET). Narrow band imaging (NBI) endoscopy in which an optical color-separation filter is used to narrow the bandwidth of spectral transmittance is also used. METHODS: Twenty-eight patients in whom primary squamous cell carcinomas could not be detected with conventional white light laryngoscopy underwent NBI endoscopy and PET. RESULTS: Primary lesions were detected with NBI endoscopy in 3 patients, but no primary lesions were detected with PET. However, PET was used to detect a lower gingival cancer and a palatine tonsillar cancer. CONCLUSION: Both PET and NBI endoscopy is effective for detecting unknown primary tumors of squamous cell carcinomas of the neck.

Prospective trial of chemotherapy-enhanced accelerated radiotherapy for larynx preservation in patients with intermediate-volume hypopharyngeal cancer.

BACKGROUND: Altered fractionation radiotherapy (RT) improves locoregional control in head and neck cancer without aggravation of late adverse events. To improve successful larynx-preservation rates in patients with resectable, intermediate-volume hypopharyngeal cancer, a prospective trial of chemotherapy-enhanced accelerated RT was conducted. METHODS: Patients with T2 to T4 hypopharyngeal cancer received 40 Gray (Gy)/4 weeks to the entire neck followed by boost RT administering 30 Gy/2 weeks (1.5 Gy twice-daily fractionation). Cisplatin and 5-fluorouracil were administered concomitantly only during boost RT. RESULTS: Thirty-five patients were enrolled in this study. All patients completed this protocol as planned. After a median follow-up period for surviving patients of 59 months (24-90 months), overall survival and local control rates at 3 years were 91% (95% confidence interval, 81% to 100%), and 88% (79% to 99%), respectively. All surviving patients maintained normalcy of diets. CONCLUSION: This regimen was feasible with encouraging oncological and functional outcomes.

Analysis of operative mortality and post-operative lethal complications after head and neck reconstruction with free tissue transfer.

OBJECTIVE: Operative mortality is the most important index for assessing operative results, which has rarely been examined in reconstructive surgery. The aims of this study were to establish a representative index of operative mortality after head and neck reconstruction and to consider measures to improve operative results. METHODS: We reviewed cases of head and neck reconstruction by means of free tissue transfer performed from July 1992 through December 2005 at the National Cancer Center Hospital East, Chiba, Japan. The subjects were 1249 patients with a mean age of 62 years. Operative mortality was evaluated on the basis of the 30-day post-operative mortality rate and the in-hospital mortality rate. Statistical analysis was performed with the Cochran-Armitage test. RESULTS: The 30-day post-operative mortality rate was 0.88% (11 of 1249 patients), and the in-hospital mortality rate was 1.84% (23 of 1249 patients). The 30-day post-operative mortality was significantly correlated with age (P = 0.002), but the in-hospital mortality was not (P = 0.148). Among patients older than 80 years, the 30-day post-operative mortality rate was 8.57%. The most common cause of 30-day post-operative death was cerebral infarction. Of the 23 in-hospital deaths, 13 were due to cancer recurrence. CONCLUSIONS: These results indicate that head and neck reconstruction with free flaps is reliable. However, the high 30-day post-operative mortality rate among patients 80 years or older should be considered when deciding whether to operate. To decrease the operative mortality rate, careful perioperative management is needed to prevent complications and shorten the hospital stay.