Liver resections in over-75-year-old patients: surgical hazard or current practice?

Robot-assisted minimally invasive liver surgery in elderly patients: A single-centre, propensity score- matched study

BACKGROUND

The aim was to evaluate the short-term results of robot-assisted minimally invasive liver surgery(Robot-assisted liver surgery (RLS)) in elderly patients.

METHODS

Between November 2019 and July 2022, RLS was performed on 100 consecutive patients. Patients were divided into a middle-aged group (Group1:＜75years) and an elderly group(Group2:≧75years). A propensity score matching(PSM) analysis with a ratio of 1:1 was performed.

RESULTS

After PSM, there were 28 patients in each group. There were no significant differences in clinicopathologic characteristics, type of resection and intraoperative variables. Postoperative complications and length of hospital stay were comparable in Groups 1 and 2. In a comparison between minor and major hepatectomy in Group 2, there were no significant differences in any of the factors.

CONCLUSIONS

The study showed that RLS for patients over 75years had similar short-term outcomes as for younger patients down to middle-aged, especially the risk of perioperative complications was comparable.

Systematic review and meta-analysis of 90-day and 30-day mortality after liver resection in the elderly

BACKGROUND

With the aging population worldwide, the number of elderly patients presenting for liver resection because of liver malignancies is increasing. Data on the perioperative mortality in this population are limited and contradictory. We performed a systematic review and meta-analysis to determine the mortality of elderly patients after hepatectomy.

METHODS

Using the Preferred Reporting Items for Systematic reviews and Meta-Analyses 2020 guidelines, we searched 3 databases to identify studies that investigated 30-day and 90-day mortality after hepatectomy for patients ≥65 years of age. We categorized the patients by age into 4 groups (≥65, ≥70, ≥75, and ≥80 years), which were analyzed separately for mortality. All analyses were conducted with IBM SPSS Statistics for Windows version 28.

RESULTS

Using PubMed, Embase, and Scopus, we identified 441 articles. After study selection and quality assessment, we included 66 studies consisting of 29,998 patients in the final meta-analysis. The pooled estimates for 30-day and 90-day mortality in the ≥65, ≥70, ≥75, and ≥80 age groups years were 1.3% (95% confidence interval 0.59%-2.06%), 2.8% (95% confidence interval 1.80%-3.69%), 3.0% (95% confidence interval 1.68%-4.30%), and 1.7% (95% confidence interval 1.22%-2.20%) and 2.7% (95% confidence interval 1.45%-3.87%), 2.8% (95% confidence interval 1.49%-4.02%), 5.1% (95% confidence interval 2.76%-7.42%), and 2.4% (95% confidence interval 0.60%-4.16%), respectively.

CONCLUSION

This meta-analysis summarizes the 30-day and 90-day mortality rates after liver resection in the elderly patients. Liver resection in this population selected for surgery appears to be relatively safe. Advanced age alone may not be a sufficient exclusion criterion for surgery. These age-specific mortality data can be used to educate patients at the time of preoperative counseling.

Systematic Review and Meta-Analysis of Liver Resection for Colorectal Metastases in Elderly Patients

BACKGROUND

This systematic review and meta-analysis evaluated the short- and long-term outcomes of liver resection for colorectal liver metastases (CRLM) in elderly patients.

METHODS

A PubMed, EMBASE, and Cochrane Library search was performed from January 1995 to April 2017, for studies comparing both short- and long-term outcomes in younger and elderly patients undergoing liver resection for CRLM.

RESULTS

Eleven studies comparing patients aged <70 years with patients aged >70 years and 4 studies comparing patients aged <75 years with patients aged >75 years were included. Postoperative morbidity was similar in patients aged >70 years (27 vs. 30%; p = 0.35) but higher in patients aged >75 years (21 vs. 32%; p = 0.001). Postoperative mortality was higher in both patients aged >70 years (2 vs. 4%; p = 0.01) and in patients aged >75 years (1 vs. 6%; p = 0.02). Mean 5-year overall survival was lower in patients aged >70 years (40 vs. 32%; p < 0.001) but equal in patients aged >75 years (42 vs. 32%; p = 0.06).

CONCLUSION

Although postoperative morbidity and mortality were increased with higher age, liver resection for CRLM seems justified in selected elderly patients.

Operative morbidity and survival following hepatectomy for colorectal liver metastasis in octogenarians: a contemporary case matched series

BACKGROUND

Clinical outcomes of octogenarians undergoing hepatectomy for colorectal liver metastases (CRLM) are poorly characterized. The current study evaluated operative morbidity, mortality and survival outcomes among a contemporary cohort of octogenarians.

METHODS

Patients undergoing their first hepatectomy for CRLM were identified from institutional databases and those ≥80 years old (y) were matched 1:1 to a group of patients <80 y. Data pertaining to surgical morbidity/mortality and survival were compared using standard statistical methods.

RESULTS

From 2002 to 2012, 1391 hepatectomies were performed for CRLM, 55 (4%) in patients ≥80 y. Major complications occurred twice as frequently among patients ≥80 y [10 (19%) ≥80 y versus 5 (9%) <80 y, (p = 0.270)]. No matched patient <80 y. died within 90 d of operation, whereas, 4 (7%) patients ≥80 y did, p = 0.125. Median follow-up was significantly longer for the <80 y group [44 (1-146) versus. 23 (0-102) mths, p = 0.006]. Probability of disease recurrence was not different between groups (p = 0.123) nor was the cumulative incidence of death from disease (p = 0.371). However, patients ≥80 y had significantly higher incidence of non-cancer related death (p = 0.012).

CONCLUSIONS

Hepatectomy for CRLM among well-selected octogenarians is reasonable with cancer related survival outcomes similar to those observed in younger patients. However, it is associated with clinically significant morbidity/mortality and continued efforts directed at optimizing perioperative care are necessary to improve early outcomes among octogenarians.

Short- and long-term outcomes of elderly patients undergoing liver resection for colorectal liver metastasis

BACKGROUND

Metastatic colorectal cancer is a disease of advancing age. Increased life expectancy has dramatically increased the number of older patients being assessed for hepatectomy. The objective of the study is to assess the safety and survival of hepatic resection in older patients, with colorectal liver metastases (CLM) and compare that with younger patients.

METHODS

All patients undergoing hepatic resection of CLM were included. Patients were divided in groups, less than 75 and 75 and over. Prospectively collected data on patient demographics and post-operative complications were retrospectively analysed. Overall survival was calculated in both groups.

RESULTS

Twenty-nine patients over the age of 75 underwent hepatic resection for CLM. A total of 158 patients under the age of 75 underwent resection. Overall, 66% of patients received neoadjuvant chemotherapy and 64% underwent major resection. Ninety-day mortality was 1 out of 29 and 1 out of 158, respectively (P = 0.15). Overall complication rate was low, 4 out of 29 and 26 out of 158 (P = 0.45). Median length of stay was similar in the older population, 8.5 versus 8 days (P = 0.65). Overall 5-year survival was 58% in the over 75 group and 56% in the under 75 group (P = 0.31).

CONCLUSION

Hepatic resection for CLM can be achieved safely in patients over the age of 75 and with equivalent short- and long-term outcomes.

The Influence of Aging on Hepatic Regeneration and Early Outcome after Portal Vein Occlusion: A Case-Control Study

BACKGROUND

Portal vein occlusion (PVO) is used to increase inadequate future liver remnant volume (FLRV). Impaired liver regeneration has been reported in aged animals. This study was designed to evaluate the impact of patient age on hepatic regeneration.

METHODS

Sixty patients aged ≥70 years were matched 1:1 with 60 patients aged <70 years. Matching criteria were sex, diabetes, cirrhosis, pre-PVO chemotherapy and bevacizumab administration, and jaundice.

RESULTS

The median ages in the older and younger groups were 76 (range 70-83) years and 59 (range 20-69) years, respectively (p < 0.001). Median FLRV following PVO (33.1 ± 6.8 vs. 31.9 ± 6.0 %) and volumetric increase (0.52 ± 0.35 vs. 0.49 ± 0.34) were similar in the two groups. Of the older and younger patients, 10 % and 1.7 %, respectively, did not undergo liver surgery after PVO (p = 0.051). Mortality (5.5 vs. 6.7 %) and major morbidity (25.9.8 vs. 22 %) rates were similar. Liver failure rate was higher in older patients (35.1 vs. 16.9 %, p < 0.026), mainly due to Grade A liver failure (20.3 vs. 8.4 %, p < 0.001). Multivariate analysis showed that age ≥ 70 years [odds ratio (OR) 3.03; 95 % confidence interval (CI) 1.18-7.78; p = 0.020] and biliary cancer diagnosis (OR 4.69; 95 % CI 1.81-12.09; p = 0.001) were independent risk factors for postoperative liver failure.

CONCLUSIONS

Liver regeneration after PVO is not impaired by age. Nevertheless, liver resection in elderly patients is performed less often after PVO and carries a higher risk of liver failure.

Safety of hepatectomy for elderly patients with hepatocellular carcinoma

The number of elderly patients with hepatocellular carcinoma (HCC) has been increasing. Characteristics of elderly HCC patients are a higher proportion of females, a lower rate of positive hepatitis B surface antigen, and a higher rate of positive hepatitis C antibodies. Careful patient selection is vital for performing hepatectomy safely in elderly HCC patients. Treatment strategy should be decided by not only considering tumor stage and hepatic functional reserve, but also physiological status, including comorbid disease. Various assessment tools have been applied to predict the risk of hepatectomy. The reported mortality and morbidity rates after hepatectomy in elderly HCC patients ranged from 0% to 42.9% and from 9% to 51%, respectively. Overall survival rate after hepatectomy in elderly HCC patients at 5 years ranged from 26% to 75.9%. Both short-term and long-term results after hepatectomy for strictly selected elderly HCC patients are almost the same as those for younger patients. However, considering physiological characteristics and the high prevalence of comorbid disease in elderly patients, it is important to assess patients more meticulously and to select them strictly if scheduled to undergo major hepatectomy.

Outcome following major hepatic resection in the elderly patients

Recent advances in operative techniques, anaesthesiologic management and intensive care have greatly reduced morbidity and mortality of major hepatectomy allowing a progressive broadening of its indications by including patients with chronic liver disorders as well as elderly subjects. It is apparent that with the aging population, more elderly patients are being referred for surgery. Selecting appropriate candidates for surgical resection is therefore crucial to maximize the benefit derived from surgery. Nevertheless, it is not clear whether advanced age itself increases surgical risk or additional age-independent variables are associated with higher operative morbidity. Regardless of the indications for surgery and the extent of planned liver resections, this population is more likely to suffer from relevant disorders. Previous studies on the safety of major liver resections in the elderly patients cite morbidity and mortality rates of approximately 30-40% and 4-5% respectively. In addition, hepatic resections for hepatocellular carcinoma or colorectal liver metastases have been reported as safe in the elderly as in the younger population. Nevertheless, a small number of investigations studied the outcome of major hepatectomy in the population over 70 years of age. The aim of our study was to evaluate overall experience with liver resections in the elderly population by comparing the early as well as the long-term outcome of the procedure in 70 years and older versus the less than 70 age group and to identify whether the age of patients alone is associated with increased rate and severity of postoperative complications.

Hepatic resection for hepatocellular carcinoma in super-elderly patients aged 80 years and older in the first decade of the 21st century

PURPOSE

We evaluated the preoperative and postoperative characteristics and prognosis of super-elderly patients with hepatocellular carcinoma (HCC).

METHODS

Four hundred and thirty-one patients who underwent hepatic resection for HCC were classified into three groups according to their age at the time of surgery: super-elderly (≥80 years; n = 20), elderly (70-80 years; n = 172) and younger (<70 years; n = 239). We compared the clinical characteristics, preoperative and postoperative factors and prognosis among the groups to evaluate whether liver resection is appropriate for super-elderly patients.

RESULTS

The liver function was not significantly different among the groups. The proportion of patients with preoperative cardiovascular and respiratory disease and hypertension was higher in the super-elderly group compared to the other groups. The super-elderly group had shorter operations and reduced hemorrhage rates compared to the other groups. Postoperative cardiovascular complications and delirium were more frequently observed in the super-elderly group. The overall and tumor-free survival rates were not significantly different among the groups. Super-elderly patients had a lower rate of liver or HCC-related death and a higher rate of death due to other causes than the other groups.

CONCLUSIONS

Super-elderly HCC patients who are appropriately evaluated and selected might have a favorable prognosis after undergoing hepatic resection.

Prediction of postoperative complications in elderly patients with hepatocellular carcinoma

BACKGROUND

The aim of the present study was to investigate whether advanced age was associated with a higher rate of postoperative complications and identify the predictive factors for postoperative complications in elderly patients with hepatocellular carcinoma (HCC).

METHODS

Between January 2000 and December 2010, 256 patients who underwent hepatectomy for HCC were investigated. Elderly patients were defined as those aged ≥75 y. The clinicopathologic data and outcomes after hepatectomy for 64 elderly and 192 younger patients were retrospectively collected and compared.

RESULTS

There were no significant differences in the incidence of postoperative complications (P = 0.936) or the long-term survival after hepatectomy (P = 0.641) between the elderly and younger patients. In multivariate analysis, the estimation of physiological ability and surgical stress-preoperative risk score (PRS) was an independent risk factor for postoperative morbidity in the elderly patients (P < 0.01). Moreover, the patients were analyzed according to the PRS for the assessment of their general preoperative condition and liver damage grade based on the hepatic reserve. The rate of postoperative complications in the patients with a PRS ≥0.5 and liver damage B was significantly higher in the elderly patients (P < 0.01), whereas a PRS and liver damage grade did not affect the incidence of postoperative morbidity in the younger patients (P = 0.516).

CONCLUSIONS

Hepatectomy for elderly patients with HCC is feasible as well as safe, and the preoperative assessment using the estimation of physiological ability and surgical stress scoring system, combined with the liver damage grade, can help to improve the safety of this procedure for elderly HCC patients.

Resection of colorectal liver metastases in the elderly: does age matter?

AIM

Despite the incidence of colorectal cancer increasing with age the proportion of patients undergoing surgery for colorectal liver metastases decreases dramatically in the elderly. Is this referral or selection bias justified?

METHOD

A prospective database of resection for colorectal liver metastases at a single centre was retrospectively analysed to compare the outcome in patients aged ≥75 years (group E) with those aged <75 years (group Y). Data were analysed using the Kaplan-Meier method with Cox regression modelling.

RESULTS

Of 1443 resections, 151 (10.5%) in group E were compared with 1292 (89.5%) in group Y. The two groups were matched apart from higher American Society of Anesthesiology scores (P=0.001) and less use of chemotherapy (P=0.01) in the elderly. Perioperative morbidity and 90-day mortality were higher in the elderly compared with the younger group (32.5%vs 21.2%, P=0.02, and 7.3%vs 1.3%, P=0.001). In the last 5 years, mortality in the elderly improved and was no longer significantly different from that of the younger patients [n=2/76 (2.6%) vs n=9/559 (1.6%); P=0.063]. The 5-year survival was similar in groups E and Y for cancer-specific (41.4%vs 41.6%, P=0.917), overall (37.0%vs 38.2%) and median (44.1 months vs 43.6 months, P=0.697) survival respectively.

CONCLUSION

In the elderly liver resection for metastatic disease can be performed with acceptable mortality and morbidity with as good a prospect of survival as for younger patients.

A comparative analysis of hepatocellular carcinoma after hepatic resection in young versus elderly patients

PURPOSE

The aim of this study was to investigate the clinical outcomes after surgical treatment of hepatocellular carcinoma (HCC) in the elderly patients compared with younger patients.

METHODS

Clinicopathological data and treatment outcomes in 61 elderly (≥70 years old) and 90 younger (≤40 years old) patients with HCC who underwent curative liver resection between 2000 and 2010 were retrospectively collected and compared using various parameters.

RESULTS

The older HCC group was more likely to have hepatitis C virus and non-B non-C hepatitis virus infection, higher values of indocyanine green retention at 15 min (ICGR)(15), more preoperative comorbidities, and more postoperative complications. There were no significant differences in intraoperative parameters and pathologic features. The recurrence rate, overall survival and disease-free survival rates were similar amongst the two groups. The only independent prognostic factor of overall survival was postoperative complications.

CONCLUSION

Our findings suggest that age by itself does not have an adverse effect on operative outcomes, including long-term prognosis. For young and elderly HCC patients, hepatic resection is a safe and effective treatment.

Hepatocellular Carcinomas and Primary Liver Tumors as Predictive Factors for Postoperative Mortality after Liver Resection: A Meta-Analysis of More than 35,000 Hepatic Resections

Liver resection is considered the therapeutic gold standard for primary and metastatic liver neoplasms. The reduction of postoperative complications and mortality has resulted in a more aggressive approach to hepatic malignancies. For the most part, results of liver surgery have been published by highly experienced institutions, but the observations of highly specialized units results may not reflect the current status of hepatic surgery, underestimating mortality and complications. The objective of this study is to evaluate morbidity and mortality as a result of liver resection for primary and metastatic lesions, analyzing a large number of studies with a meta-analytic process taking into account the overdispersion of data. An extensive literature search has been conducted, and 148 papers published between January 2000 and April 2008, including a total of 36,629 patients from both high-volume and low volume institutions, were included in the meta-analysis. A beta binomial model was used to provide a robust estimate of the summary event rate by pooling overdispersion binomial data from different studies. Overall morbidity and mortality after liver surgery were 29.32 per cent and 3.15 per cent, respectively. Significantly higher postoperative mortality was observed after liver resection for hepatocellular carcinomas and primary hepatic tumors. The application of a beta binomial model to correct for overdispersion of liver surgery data showed significantly higher postoperative mortality rates in patients with hepatocellular carcinomas or primary hepatic tumors after liver resection.

Outcomes of elderly patients undergoing cytoreductive surgery and perioperative intraperitoneal chemotherapy for colorectal cancer peritoneal carcinomatosis

BACKGROUND

The combined treatment of cytoreductive surgery (CRS) and perioperative chemotherapy (PIC) for colorectal peritoneal carcinomatosis (PC) is a rigorous surgical treatment most suited for fit and young patients. With technical maturity and improved perioperative care, we examined the outcomes of elderly patients undergoing CRS and PIC for colorectal PC.

METHODS

All consecutive patients treated in two tertiary centers for PC of colorectal cancer who were 70 years of age or older at the time of surgery were included. Data on patient characteristics, concomitant diseases, operation details, perioperative course, and follow-up were retrieved from medical charts. Primary outcomes were perioperative morbidity and mortality. Secondary outcomes were disease-free and overall survival.

RESULTS

Twenty-four patients (11 male) were included in this study (mean age 73.5 years). In eight patients major complications occurred. In six patients the postoperative course was complicated by minor adverse events. There was no perioperative mortality. Median overall survival was 35 months with a 6, 12, and 18 months survival rate of 94%, 83%, and 68%, respectively.

CONCLUSIONS

CRS and PIC for colorectal PC may be safely performed with acceptable morbidity in selected elderly patients. When considering patients for surgery, performance status, and the disease extent should be used as eligibility criteria rather than age.

Prognosis of patients with hepatocellular carcinoma after hepatic resection: are elderly patients suitable for surgery?

AIM

The indication for hepatectomy is still controversial in elderly patients with hepatocellular carcinoma (HCC). We examined the clinicopathological features and survival of 188 HCC patients who underwent hepatectomy.

PATIENTS/METHODS

Patients were divided into four age groups: Age(<50) group (young patients <50 years of age, n = 9), Age(50-69) group (between 50-69 years, n = 110), Age(70-79) group (70-79 years, n = 57), and Age(≥80) group (≥80 years, n = 12). Physiologic ability and surgical stress (E-PASS) score, including preoperative risk score (PRS), surgical stress score (SSS), and comprehensive risk score (CRS) were assessed.

RESULTS

Proportion of patients of Age(70-79) and Age(≥80) groups increased significantly in the last 5 years (P < 0.01). Co-morbidity, performance status, and American Society of Anesthesiologists score significantly increased with age (P < 0.05). Proportions of patients with irregular findings and necro-inflammatory activity were significantly lower in Age(70-79) and Age(≥80) groups than in other groups (P < 0.05). Systemic postoperative complications were high in Age(70-79) and Age(≥80) groups. PRS increased significantly with age (P < 0.05). Multivariate analysis identified PRS ≥0.32 and age ≥70 years as significant determinants of systemic complications (P < 0.05). There were no significant differences in postoperative survivals among the groups.

CONCLUSIONS

Careful follow-up and proper decision on hepatectomy upon assessment of PRS are important in elderly HCC patients.

p66(Shc) has a pivotal function in impaired liver regeneration in aged mice by a redox-dependent mechanism

Liver regeneration involves complicated processes and is affected by various patho-physiological conditions. This study was designed to examine the molecular mechanisms underlying the aging-associated impairment of liver regeneration. Male C57BL/6J mice were used as young and aged mice (<10 weeks and >20 months old, respectively). These mice were subjected to 70% partial hepatectomy (PH). Liver regeneration and liver injury/stresses were evaluated chronologically after PH. Post-hepatectomy liver regeneration was markedly impaired in aged mice. Though the extent of hepatocyte proliferation in the regenerating liver was similar in aged and young mice, cell growth was absent in aged mice. Oxidative stress (OS) was observed immediately after hepatectomy, followed by marked apoptosis in aged mice. Signaling molecules regarding cell proliferation (mitogen-activated protein kinase, STAT3, p46/52(Shc)) and anti-oxidation (catalase, superoxide dismutase, Ref-1, glutathione peroxidase) were expressed/activated after hepatectomy in livers of both aged and young mice. Akt was not activated in aged-mouse liver, but its expression was similar to that in young mice. p66(Shc), known as an age-/oxidant-associated protein, was strongly phosphorylated. By knocking down p66(Shc), the impairment of liver regeneration was normalized. OS immediately after hepatectomy induced subsequent liver injury (apoptosis), and deletion of p66(Shc) suppressed both OS and hepatocyte apoptosis in the regenerating liver of aged mice. Though we need additional data in other animal models to fully understand the mechanism, p66(Shc) may have a pivotal function in the impairment of liver regeneration in aged mice by triggering OS and subsequent apoptosis. This data may provide a clue to understanding the mechanism underlying the association between aging and the impairment of liver regeneration.

Long-term outcomes and prognostic factors of elderly patients with hepatocellular carcinoma undergoing hepatectomy

OBJECTIVE

The present study aimed to evaluate the long-term outcomes and prognostic factors of elderly patients with hepatocellular carcinoma (HCC) undergoing hepatectomy.

MATERIAL AND METHODS

From January 1983 to December 2006, 2,283 patients with HCC received hepatectomy in Sun Yat-sen University Cancer Center. The clinicopathological data and treatment outcomes of 67 elderly HCC patients (elderly group, > or =70 years of age) and 268 patients (control group, <70 years of age) who were selected randomly from the 2216 younger patients were compared retrospectively.

RESULTS

The elderly HCC patients had lower hepatitis B surface antigen-positive rate (P < 0.001), lower rate of marked alpha-fetoprotein elevation (P = 0.004), higher infection rate of hepatitis C virus (P = 0.010), more preoperative comorbidities (P < 0.001), higher rate of tumor encapsulation (P = 0.040), and better overall survival rate (P = 0.017); whereas there were no significant differences between these two groups in other factors, including gender ratio, liver function, accompanying cirrhosis, pathological tumor-node-metastasis (pTNM) staging, satellite nodules, vascular invasion, tumor rupture, resection margin, intraoperative blood loss, incidence of postoperative complications, hospital mortality, and disease-free survival rate. Multivariate analysis showed that pTNM staging was an independent prognostic factor of long-term survival in elderly patients with HCC.

CONCLUSION

HCC in the elderly was less HBV-associated, less advanced, and less aggressive. Hepatectomy for selected elderly patients with HCC possibly have a better curative effect compared with younger patients. For the elderly patients without preoperative comorbidities or with controlled comorbidities, hepatectomy is a safe and effective treatment. pTNM staging is the only independent predictor of postoperative overall survival in elderly HCC patients.

Selective use of older adults in right lobe living donor liver transplantation

Many centers are reluctant to use older donors (>44 years) for adult right-lobe living donor liver transplantation (RLDLT) due to concerns about possible increased morbidity in donors and poorer outcomes in recipients. Since 2000, 130 adult RLDLTs have been performed at our institution. Recipients were divided into those who received a right lobe graft from a donor </=age 44 (n = 89, 68%; median age 30) and those who received a liver graft from a donor age >44 (n = 41, 32%; mean age 52). The two donor and recipient populations had similar demographic and operative profiles. With a median follow-up of 29 months, the severity and number of complications in older donors were similar to those in younger donors. No living donor died. Older donor allografts had initial allograft dysfunction compared to younger donors. Complication rates were similar among recipients in both groups but there was a higher bile duct stricture rate with older donor grafts (27% vs. 12%; p = 0.04). One-year recipient graft survival was 86% for older donors and 85% for younger donors (p = 0.95). Early experience with the use of selected older adults (>44 years) for RLDLT is encouraging, but may be associated with a higher rate of biliary complications in the recipient.