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Endoscopic resection (ER) including endoscopic submucosal dissection has been widely accepted for treatment of early gastric cancer (EGC) in Japan. Additional surgery is recommended when ER is non-curative histologically. Many elderly patients, however, do not undergo radical surgery due to comorbid disease or limited life expectancy. The aim of this study is to assess the survival outcomes of radical surgery compared with observation only in elderly patients after non-curative ER.We reviewed existing data of all elderly patients (older than 75 years) who had undergone ER for EGC at the National Cancer Center Hospital between January 1999 and December 2005. We compared the overall and disease-free survival rates between three patients groups: curative ER, non-curative ER with additional surgery, and non-curative ER without additional surgery.In total, 428 patients underwent ER; 308 (72%) curative ER and 120 (28%) non-curative ER. Of the 120 non-curative ER patients, 38 patients (31.7%) underwent additional surgery and 82 patients (68.3%) were followed without surgery. There was no significant difference in American Society of Anesthesiologist score between three groups. Patients who did not undergo surgery tended to be older. Overall 5-year survival rates in the curative ER, non-curative ER with surgery, and non-curative ER without surgery were 85, 92, and 63%, respectively. There was no significant difference in overall and disease-free survival between patients in the curative ER and non-curative ER with surgery groups. On the contrary, a significant difference in overall and disease-free survival was evident between the curative ER and non-curative ER without surgery groups (hazard ratio (95% confidence interval): 1.89 (1.08–3.28), 2.30 (1.35–3.94)).In our elderly patient cohort, additional surgery following non-curative ER improved overall and disease-free survival compared with non-surgical observation only. Thus, surgery should be considered following non-curative ER in EGC patients >75 years of age.