Major liver resections in the elderly-is an aggressive approach justified?

Surgical treatment of liver hydatid cyst in elderly patients: A propensity score-matching retrospective cohort study

BACKGROUND

Cystic echinococcosis is a clinically complex chronic parasitic disease and a major socioeconomic problem in endemic areas. The safety of liver resection in elderly patients is often debated among medical professionals. We analyzed the postoperative morbidity and mortality rates of elderly patients who underwent surgery at our unit.

METHODS

We retrospectively evaluated patients with liver hydatid cysts which were surgically removed at our unit. Patients were divided into two groups: Group 1 (patients < 70 years), and Group 2 (patients ≥ 70 years). Propensity score matching (PSM) and comparative analyses between groups were performed.

RESULTS

The unmatched cohort consisted of 279 patients (Group 1: 244; Group 2: 35). After PSM, we compared the outcomes for 56 patients from Group 1 to 31 patients from Group 2. A higher rate of severe complications was observed in Group 2 (25.8% vs 5.36%, p = 0.014). No difference was found in the rates of infectious, cardiorespiratory, or hemorrhagic complications between both groups, and in the mortality rate either (0.00% vs 6.45%, p = 0.124).

CONCLUSIONS

Liver surgery in selected elderly patients is safe and practicable. The low postoperative morbidity rate in these patients is acceptable, albeit higher, due to their comorbidities.

Liver resection for colorectal liver-limited metastases in elderly patients: a propensity score matching analysis

Background

Few studies have focused on the role of hepatectomy for colorectal liver-limited metastases in elderly patients compared to matched younger patients.

Methods

From January 2000 to December 2018, 724 patients underwent hepatectomy for colorectal liver-limited metastases. Based on a 1:2 propensity score matching (PSM) model, 64 elderly patients (≥ 70 years of age) were matched to 128 younger patients (< 70 years of age) to obtain two balanced groups with regard to demographic, therapeutic, and prognostic factors.

Results

There were 73 elderly and 651 younger patients in the unmatched cohort. Compared with the younger group (YG), the elderly group (EG) had significantly higher proportion of American Society of Anesthesiologists score III and comorbidities and lower proportion of more than 3 liver metastases and postoperative chemotherapy (p < 0.05). After PSM for these factors, rat sarcoma virus proto-oncogene/B-Raf proto-oncogene (RAS/BRAF) mutation status and primary tumor sidedness, the EG had significantly less median intraoperative blood loss than the YG (175 ml vs. 200 ml, p = 0.046), a shorter median postoperative hospital stay (8 days vs. 11 days, p = 0.020), and a higher readmission rate (4.7% vs.0%, p = 0.036). The EG also had longer disease-free survival (DFS), overall survival (OS), and cancer-specific survival (CSS) compared to the YG, but these findings were not statistically significant (p > 0.05). Old age was not an independent factor for DFS, OS, and CSS by Cox multivariate regression analysis (p > 0.05).

Conclusions

Hepatectomy is safe for colorectal liver-limited metastases in elderly patients, and these patients may subsequently benefit from prolonged DFS, OS, and CSS.

The impact of age on post-operative liver function following right hepatectomy: a retrospective, single centre experience

BACKGROUND

An increasing number of patients undergoing liver resection are of advancing age. The impact of ageing on liver regeneration and post-operative outcomes following a major resection are uncertain. We aimed to investigate risk factors for patients who developed Post Hepatectomy Liver Failure (PHLF) following right hepatectomy with age as the primary risk-factor.

METHOD

Patients undergoing right hepatectomy between July 2004-July 2018 were included. ROC analysis was performed to identify at which age PHLF development-risk increased. Secondary endpoints were length of stay (LOS), complications, and cost.

RESULTS

332-patients were included. ROC demonstrated a cut-off age of 75-years in which PHLF risk increased. >75 there was an increased risk of PHLF (35% >75yrs vs. 7% <75yrs (p = <0.001), OR = 8.8 (95% CI = 3.6-21)) There was no difference between the age groups for any other PHLF risk factor. Patients >75yrs had longer LOS (11-days vs. 7-days (p = 0.04). Patients who developed PHLF had increased hospital costs: £10,987.50 (£6175-£46,050) vs. £2575 (£900-£46,050 p = 0.01).

CONCLUSIONS

Patients >75yrs have increased risk of developing PHLF after right hepatectomy, contributing to increased mortality and economic burden. Pre-operatively identifying patients at-risk of PHLF is important to consider liver volume optimization strategies and improve outcomes.

Age Does Not Affect Metoprolol's Effect on Perioperative Outcomes (From the POISE Database)

BACKGROUND:

Perioperative β-blockade reduces the incidence of myocardial infarction but increases that of death, stroke, and hypotension. The elderly may experience few benefits but more harms associated with β-blockade due to a normal effect of aging, that of a reduced resting heart rate. The tested hypothesis was that the effect of perioperative β-blockade is more significant with increasing age.

METHODS:

To determine whether the effect of perioperative β-blockade on the primary composite event, clinically significant hypotension, myocardial infarction, stroke, and death varies with age, we interrogated data from the perioperative ischemia evaluation (POISE) study. The POISE study randomly assigned 8351 patients, aged ≥45 years, in 23 countries, undergoing major noncardiac surgery to either 200 mg metoprolol CR daily or placebo for 30 days. Odds ratios or hazard ratios for time to events, when available, for each of the adverse effects were measured according to decile of age, and interaction term between age and treatment was calculated. No adjustment was made for multiple outcomes.

RESULTS:

Age was associated with higher incidences of the major outcomes of clinically significant hypotension, myocardial infarction, and death. Age was associated with a minimal reduction in resting heart rate from 84.2 (standard error, 0.63; ages 45–54 years) to 80.9 (standard error, 0.70; ages >85 years; P < .0001). We found no evidence of any interaction between age and study group regarding any of the major outcomes, although the limited sample size does not exclude any but large interactions.

CONCLUSIONS:

The effect of perioperative β-blockade on the major outcomes studied did not vary with age. Resting heart rate decreases slightly with age. Our data do not support a recommendation for the use of perioperative β-blockade in any age subgroup to achieve benefits but avoid harms. Therefore, current recommendations against the use of β-blockers in high-risk patients undergoing noncardiac surgery apply across all age groups.

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.

Population-based study on resection rates and survival in patients with colorectal liver metastasis in Norway

Background

Detailed knowledge about the proportion of patients with colorectal liver metastases (CLM) undergoing resection is sparse. The aim of this study was to analyse cumulative resection rates and survival in patients with CLM.

Methods

For this population-based study of patients developing CLM during 2011–2013, data were extracted from the Norwegian Patient Registry and the Cancer Registry of Norway.

Results

A total of 2960 patients had CLM; their median overall survival was 10·9 months. Liver resection was performed in 538 patients. The cumulative resection rate was 20·0 per cent. The cumulative resection rate was 23·3 per cent in patients aged less than 40 years, 31·1 per cent in patients aged 40–59 years, 24·7 per cent in those aged 60–74 years, 17·9 per cent in those aged 75–79 years and 4·7 per cent in patients aged 80 years or more (P &lt; 0·001). In multivariable analysis, resection rate was associated with age, extrahepatic metastases, disease-free interval and geographical region. Overall survival after diagnosis of CLM was affected by liver resection (hazard ratio (HR) 0·54, 95 per cent c.i. 0·34 to 0·86), rectal cancer (HR 0·82, 0·74 to 0·90), metachronous disease (HR 0·66, 0·60 to 0·74), increasing age (HR 1·32, 1·28 to 1·37), region, and extrahepatic metastases (HR 1·90, 1·74 to 2·07). Three- and 4-year overall survival rates after hepatectomy were 73·2 and 54·8 per cent respectively.

Conclusion

The cumulative resection rate in patients with CLM in Norway between 2011 and 2013 was 20 per cent. Resection rates varied across geographical regions, and with patient and disease characteristics.

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.

Optimal management of colorectal liver metastases in older patients: a decision analysis

BACKGROUND

Comparative trials evaluating management strategies for colorectal cancer liver metastases (CLM) are lacking, especially for older patients. This study developed a decision-analytic model to quantify outcomes associated with treatment strategies for CLM in older patients.

METHODS

A Markov-decision model was built to examine the effect on life expectancy (LE) and quality-adjusted life expectancy (QALE) for best supportive care (BSC), systemic chemotherapy (SC), radiofrequency ablation (RFA) and hepatic resection (HR). The baseline patient cohort assumptions included healthy 70-year-old CLM patients after a primary cancer resection. Event and transition probabilities and utilities were derived from a literature review. Deterministic and probabilistic sensitivity analyses were performed on all study parameters.

RESULTS

In base case analysis, BSC, SC, RFA and HR yielded LEs of 11.9, 23.1, 34.8 and 37.0 months, and QALEs of 7.8, 13.2, 22.0 and 25.0 months, respectively. Model results were sensitive to age, comorbidity, length of model simulation and utility after HR. Probabilistic sensitivity analysis showed increasing preference for RFA over HR with increasing patient age.

CONCLUSIONS

HR may be optimal for healthy 70-year-old patients with CLM. In older patients with comorbidities, RFA may provide better LE and QALE. Treatment decisions in older cancer patients should account for patient age, comorbidities, local expertise and individual values.

Hepatectomia em pacientes idosos

INTRODUÇÃO: A expectativa de vida da população tem aumentado nos últimos anos, como também houve progressão da incidência de neoplasias primárias e secundárias do fígado. A medicina vem acompanhando esse processo, mas ainda há receios quanto ao uso de tratamentos cirúrgicos agressivos em pacientes idosos, especialmente no que tange à cirurgia do fígado. OBJETIVO: Analisar a influência da idade na morbimortalidade de pacientes submetidos à ressecção hepática. MÉTODOS: Revisão bilbliográfica através dos sites do PubMed, Scielo e Bireme, com os descritores "elderly", "hepatectomy", "hepatic resection", "postoperative complications", "morbidity", "mortality". Foram selecionados os trabalhos que compararam os resultados de hepatectomia entre grupos de pacientes jovens e idosos. CONCLUSÃO: A idade não é fator predisponente à piora dos resultados na ressecção hepática.

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.

Adjuvant oxaliplatin- or irinotecan-containing chemotherapy improves overall survival following resection of metachronous colorectal liver metastases

PURPOSE

Adjuvant systemic 5-fluorouracil (5-FU)-based chemotherapy improves survival after resection of synchronous colorectal liver metastases (CLMs), but not metachronous. We retrospectively examined if adjuvant chemotherapy with new regimen containing oxaliplatin or irinotecan improved survivals after resection of metachronous CLMs.

METHODS

Between 2000 and 2007, 52 patients having undertaken resection of metachronous CLMs with curative intent were identified from Taipei Veterans General Hospital hospitalization registry. One patient with perioperative mortality and another being lost to follow-up within 3 months after metastasectomy were excluded. Thirty-one patients experienced six to 12 cycles of FOLFOX or FOLFIRI chemotherapy while 19 patients with 5-FU/leucovorin (LV)-based chemotherapy following CLM resection. The primary end point was disease-free survival (DFS) and secondary end point, overall survival (OS).

RESULTS

By the univariate analysis, median DFS was 34.3 months in the FOLFOX/FOLFIRI group vs 14.2 months in the 5-FU/LV group (P = 0.022). The median OS and 5-year survival rates were longer than 57.7 months (not reached, with median follow-up of 35.5 months) and 54.0%, respectively, in the FOLFOX/FOLFIRI group compared to 49 months and 34.6% in the 5-FU/LV group (P = 0.027). FOLFOX/FOLFIRI chemotherapy was shown by multivariate analyses to be an independent factor predicting a better DFS (hazard ratio [HR] = 0.37; 95% CI: 0.15-0.94; P = 0.036) and a better OS (HR = 0.27; 95% CI: 0.083-0.86, P = 0.026) than 5-FU/LV-based.

CONCLUSIONS

Adjuvant FOLFOX/FOLFIRI chemotherapy following resection of metachronous CLMs is demonstrated to have better DFS and OS than 5-FU/LV chemotherapy.

EORTC Elderly Task Force experts' opinion for the treatment of colon cancer in older patients

As a result of an increasing life expectancy, the incidence of colon cancer in the older population is rising. As a consequence oncologists and their older patients commonly face the dilemma of whether or not to give/receive treatment for colon cancer. However, the paucity of large, well conducted prospective trials makes it difficult to provide evidence-based clinical recommendations for these patients. The current evidence supports the safety and efficacy of treatment for colon cancer in fit older patients and demonstrates that treatment outcome can be similar to that of their younger counterparts. However, it should be noted that these data are derived from retrospective studies which are likely to suffer from selection bias. Despite a growing body of data, further work is still needed to establish optimal strategies to care for this special population and prospective specific trials for older colon cancer patients are clearly needed.