Should we deny surgery for malignant hepato-pancreatico-biliary tumors to elderly patients?

Early outcome following hepatic resection in patients older than 80 years of age

BACKGROUND

We aimed to study the early outcome of patients 80 years of age and older undergoing liver resection and to compare the results with the outcomes of patients younger than 80 years of age.

METHODS

All 350 consecutive patients undergoing hepatic resections from 2004 April to 2008 October were included. Patients were divided into two groups: 80 years of age and older (group I; n = 43) and less than 80 years of age (group II; n = 307). Preoperative clinicopathological features, intraoperative factors, in-hospital mortality, postoperative complications, length of hospital stay, operative mortality, morbidity, and prognosis after discharge were analyzed and compared between groups I and II.

RESULTS

There was no significant difference between the two groups regarding the indication for hepatic resection. Hepatitis viral status was significantly different between groups: patients without hepatitis B or C viral infection were more common in group I than in group II. Regarding preoperative liver function, serum levels of albumin were significantly lower in group I than in group II. Although the operative time was significantly shorter in group I than in group II, no difference was found between groups regarding such operative factors as type of hepatectomy, blood loss, and rate of blood transfusion. After elimination of 16 patients with extrahepatic bile duct resection and reconstruction, no difference existed between the two groups in operative time. There was no postoperative mortality nor in-hospital mortality in group I; in group II one postoperative death (0.3%) and two in-hospital deaths (0.6%) were recorded. There was no difference between groups in the incidence of morbidity and early prognosis after discharge.

CONCLUSIONS

The results indicate that hepatic resection for elderly patients over 80 can be safely performed given careful patient selection.

Surgical aspects in management of hepato-pancreatico-biliary tumours in the elderly

Hepato-pancreatico-biliary (HPB) surgery encompasses major hepatic resection and pancreatic surgery, both procedures of high complexity with a potentially high complication rate. The establishment of centres of excellence with a high patient volume has lowered the complication and increased the resection rate. Besides this, increased life expectancy and improved general health status have increased the number of elderly patients eligible for major surgery. Because elderly patients have more co-morbidities and decreased life expectancy, the benefit of these procedures must be critically evaluated in such patients. Analysis of the literature on this subject demonstrated that pancreatico-duodenectomy can be performed safely in selected elderly patients (80 years of age or older), with morbidity and mortality rates approaching those observed in younger patients. This aspect was also confirmed by cost analysis studies that reported similar data in both groups. Similar findings are also reported for major hepatic resection in elderly patients with either hepatocellular carcinoma (HCC), Klatskin tumour or gallbladder carcinoma. Nevertheless, those elderly patients who will benefit from surgery must be critically selected.

Surgical palliation of unresectable pancreatic head cancer in elderly patients

AIM: To determine if surgical biliary bypass would provide improved quality of residual life and safe palliation in elderly patients with unresectable pancreatic head cancer.

METHODS: Nineteen patients, 65 years of age or older, were managed with surgical biliary bypass (Group A). These patients were compared with 19 patients under 65 years of age who were managed with surgical biliary bypass (Group B). In addition, the results for group A were compared with those obtained from 17 patients, 65 years of age or older (Group C), who received percutaneous transhepatic biliary drainage to evaluate the quality of residual life.

RESULTS: Five patients (26.0%) in Group A had complications, including one intraabdominal abscess, one pulmonary atelectasis, and three wound infections. One death (5.3%) occurred on postoperative day 3. With respect to morbidity, mortality, and postoperative hospitalization, no statistically significant difference was noted between Groups A and B. The number of readmissions and the rate of recurrent jaundice were lower in Group A than in Group C, to a statistically significant degree (P = 0.019, P = 0.029, respectively). The median hospital-free survival period and the median overall survival were also significantly longer in Group A (P = 0.001 and P < 0.001, respectively).

CONCLUSION: Surgical palliation does not increase the morbidity or mortality rates, but it does increase the survival rate and improve the quality of life in elderly patients with unresectable pancreatic head cancer.

Liver dysfunction and sepsis determine operative mortality after liver resection

BACKGROUND

Liver failure is the principal cause of death after hepatectomy. Its progression towards death and its relationship with sepsis are unclear. This study analysed predictors of mortality in patients with liver dysfunction and the role of sepsis in the death of these patients.

METHODS

The study focused on patients with liver dysfunction, excluding those with vascular thrombosis, after liver resection at one of two centres between 1998 and 2006.

RESULTS

Liver dysfunction occurred after 57 (4.5 per cent) of 1271 hepatectomies. Fifty-three patients without vascular thrombosis were included in the analysis, with a mortality rate of 23 per cent. Independent predictors of death were age (odds ratio (OR) 1.18 per year increase; P = 0.017), cirrhosis (OR 54.09; P = 0.004) and postoperative sepsis (OR 37.58; P = 0.005). Sepsis occurred in 15 patients (28 per cent), seven of whom died. Intestinal pathogens were isolated in 12 patients with sepsis. The risk of sepsis was significantly increased in those with surgical complications (11 of 16 versus four of 37; P < 0.001).

CONCLUSION

Sepsis plays a key role in the death of patients with liver dysfunction after hepatectomy. Early recognition and aggressive treatment of sepsis may reduce mortality.

The survival paradox of elderly patients after major liver resections

OBJECTIVE

The objective of this study is to assess the outcome of liver resections in the elderly in a matched control analysis.

PATIENTS AND METHODS

From a prospective single center database of 628 patients, 132 patients were aged 60 years or over and underwent a primary major liver resection. Of these patients, 93 could be matched one-to-one with a control patient, aged less than 60 years, with the same diagnosis and the same type of liver resection. The mean age difference was 16.7 years.

RESULTS

Patients over 60 years of age had a significantly higher American Society of Anaesthesiologists (ASA) grade. All other demographics and operative characteristics were not different. In-hospital mortality and morbidity were higher in the patients over 60 years of age (11% versus 2%, p = 0.017 and 47% versus 31%, p = 0.024). One-, 3-, and 5-year survival rates in the patients over 60 years of age were 81%, 58%, and 42%, respectively, compared to 90%, 59%, and 42% in the control patients (p = 0.558). Unified model Cox regression analysis showed that resection margin status (hazard ratio 2.51) and ASA grade (hazard ratio 2.26), and not age, were determining factors for survival.

CONCLUSION

This finding underlines the important fact that in patient selection for major liver resections, ASA grade is more important than patient age.

Liver resection for colorectal liver metastases in older patients

INTRODUCTION

Seventy-six percentages of patients with a newly diagnosed colorectal carcinoma are between 65 and 85 years old. A substantial proportion will develop liver metastases, for which resection is the only potential curative treatment. This study was conducted to investigate both the feasibility, and short- and long-term outcomes of liver resection for colorectal liver metastases in elderly patients.

METHODS

Between August 1990 and April 2007 data were prospectively collected on patients over 70 years of age who underwent a liver resection for colorectal liver metastases in a single centre.

RESULTS

One hundred and eighty-one liver resections were performed in 178 consecutive patients (median age 74 years). Thirty-four patients (18.8%) received neoadjuvant chemotherapy (all FOLFOX) prior to liver surgery and the majority (57.5%) of liver resections involved more than two Couinaud's segments. Median hospital stay was 13 days, 70 (38.5%) patients had postoperative complications, and overall in hospital mortality was 4.9% (9 patients). Overall- and disease-free survival rates at 1, 3 and 5 years were 86.1%, 43.2% and 31.5% and 65.8%, 26% and 16%, respectively. In multivariate analysis: T3 primary staging; major liver resections; more than three liver lesions; and the occurrence of postoperative complications were associated with inferior overall survival.

CONCLUSIONS

Liver resection for colorectal liver metastases in elderly patients is safe and may offer long-time survival to a substantial percentage of patients. We strongly recommend considering senior patients for surgical treatment whenever possible.

Potential utility of xenobiotic mitogens in the context of liver regeneration in the elderly and living-related transplantation

Although liver regeneration occurring after partial hepatectomy (PH) is greatly reduced in aged mice, liver hyperplasia induced by xenobiotic mitogens was found to be age independent. Here, we investigated the potential utility of mitogens in stimulating liver regeneration in old mice subjected to two-third PH. Although virtually no hepatocytes entered S phase 48 h after PH, pretreatment (2 h prior to surgery) with 1,4-bis(2-(3,5-dichloropyridyloxy)benzene (TCPOBOP), a ligand of constitutive androstane receptor, induced an increase of bromodeoxyuridine incorporation and enhanced the expression of cyclin D1, cyclin A and proliferating cell nuclear antigen . Next, we investigated the potential utility of mitogens in the context of donor conditioning prior to living-related transplantation. Three days after TCPOBOP administration to intact young mice, an almost doubling of the liver mass and DNA content occurred; the regenerative response to two-third resection of the TCPOBOP-induced hyperplastic liver was similar to that of mice subjected to PH alone, suggesting that an increased liver mass at the time of surgery does not inhibit the regenerative capacity. The present results suggest that mitogen-induced hyperplasia is a promising tool in conditions characterized by reduced regenerative capacity, such as in the elderly, or when a rapid increase of liver mass is required, such as in living-related transplantation.

Increased ischemic injury in old mouse liver: an ATP-dependent mechanism

Although livers exhibit only minimal morphologic changes with age, how older livers tolerate pathologic conditions such as normothermic ischemia is unknown. Young 6-week-old mice and old 60-week-old mice underwent 60 minutes of hepatic ischemia and various periods of reperfusion. Markers of hepatocyte injury, hepatic energy content, and mitochondrial function were determined. Ischemic preconditioning and glucose injection were evaluated as protective strategies against reperfusion injury in old mice. Reperfusion injury was far worse in old mice compared with mice in the young control group. Ischemic preconditioning was highly protective against reperfusion injury in young but not in old mice. Older livers had dramatically reduced adenosine triphosphate (ATP) levels and glycogen contents. The low intrahepatic energy level in old mice was associated with a reduced mitochondrial ATP production. Preoperative injection of glucose restored the intrahepatic ATP content and protected against reperfusion injury. Furthermore, glucose injection restored the protective effect of ischemic preconditioning, resulting in additive protection when both strategies were combined. Aging of the liver is associated with mitochondrial dysfunction and decreased intrahepatic energy content, resulting in poorer tolerance against ischemic injury. Improving intrahepatic ATP levels in old livers by glucose injection protects the old liver against ischemic injury and restores the protective effects of ischemic preconditioning.

Assessment of complications after pancreatic surgery: A novel grading system applied to 633 patients undergoing pancreaticoduodenectomy

OBJECTIVE

To define a simple and reproducible classification of complications following pancreaticoduodenectomy (PD) based on a therapy-oriented severity grading system.

BACKGROUND

While mortality is rare after PD, morbidity rates remain high. The lack of standardization in evaluating morbidity after PD has severely hampered meaningful comparisons over time and among centers. We adapted a novel classification of complication to stratify morbidity by severity after PD, to test whether the incidence of pancreatic fistula has changed over time, and to identify risk factors in a single North American center.

METHODS

The classification was applied to a consecutive series of 633 patients undergoing PD between February 2003 and August 2005. Another series of 141 patients treated between 1987 and 1990 was also analyzed to identify changes in the incidence and severity of fistula. Univariate and multivariate analyses were performed to link respective complications with preoperative and intraoperative parameters, length of hospital stay, and long-term survival.

RESULTS

A total of 263 (41.5%) patients did not develop any complication, while 370 (58.5%) had at least one complication; 62 (10.0%) patients had only grade I complications (no need for specific intervention), 192 patients (30.0%) had grade II (need for drug therapy such as antibiotics), 85 patients (13.5%) had grade III (need for invasive therapy), and 19 patients (3.0%) had grade IV complications (organ dysfunction with ICU stay). Grade V (death) occurred in 12 patients (2.0%). A total of 57 patients (9.0%) developed pancreatic fistula, of which 33 (58.0%) were classified as grade II, 17 (30.0%) as grade III, 5 (9.0%) as grade IV, and 2 (3.5%) as grade V. Delayed gastric emptying was documented in 80 patients (12.7%); half of them were scored as grade II and the other half as grade III. A significant decrease in the incidence of fistula was observed between the 2 periods analyzed (14.0% vs. 9.0%, P < 0.001), mostly due to a decrease in grade II fistula. Cardiovascular disease was a risk factor for overall morbidity and complication severity, while texture of the gland and cardiovascular disease were risk factors for pancreatic fistula.

CONCLUSION

This study demonstrates the applicability and utility of a new classification in grading complications following pancreatic surgery. This novel approach may provide a standardized, objective, and reproducible assessment of pancreas surgery enabling meaningful comparison among centers and over time.

Outcomes after Major Hepatectomy in Elderly Patients

BACKGROUND

We aimed to study the early and longterm outcomes of patients 70 years and older undergoing major liver resections, and compare the results with patients below the age of 70 years.

STUDY DESIGN

All patients undergoing major liver resection (defined as three segments or more) from January 1993 to June 2004 were included. Patients were studied in two groups: 70 years of age and older (group E, elderly) and less than 70 years old (group Y, young). Early outcomes and longterm survival were analyzed.

RESULTS

A total of 517 patients underwent major liver resection: group E, n=127; group Y, n=390 patients. There was no difference in operative mortality (group E, 7.9%; group Y, 5.4%; p=0.32) or postoperative morbidity (p=0.22) between the groups. Overall and disease-free survivals were not notably different for all patients (59% versus 57%, p=0.89; 60% versus 55%, p=0.28, respectively) or for a subgroup of patients with colorectal liver metastases (61% versus 55%, p=0.76; 60% versus 47%, p=0.07) in groups E versus Y, respectively. In multivariable analysis, American Society of Anesthesiologists grade 3 (p=0.024, hazard ratio [HR]=1.59, versus grade 1, 95% CI=1.06 to 2.39) and intraoperative transfusion>3 U (p<0.0005, HR=2.56, 95% CI=1.84 to 3.56) were predictors for overall survival. More than three tumors (p=0.025, HR=1.41, 95% CI=1.04 to 1.90) and redo resection (p=0.001, HR=2.80, 95% CI=1.51 to 5.19) were predictors of disease-free survival.

CONCLUSIONS

Major liver resections can be safely performed in patients 70 years of age or older, with early results and survival similar to those in the younger than 70 age group. American Society of Anesthesiologists grade 3 and intraoperative transfusions>3 U were predictors for overall survival, and more than three tumors and redo resection were predictors for disease-free survival.