Liver resection for octogenarians in a French center: prolonged hepatic pedicle occlusion and male sex increase major complications

Characteristics, Therapeutic Approaches and Outcomes of Patients Older than 80 Years Old with Metastatic Colorectal Cancer Compared with Younger Patients

Background: While advances in therapies have improved metastatic cancer survival rates, elderly patients with colorectal cancer often experience delayed diagnoses, receive less frequent systemic therapies, and show inferior survival outcomes compared to younger groups. Patients over the age of 80 years old face greater treatment risks due to frailty and comorbidities. In this article, we examine characteristics, treatment and outcomes in older adults with metastatic colorectal cancer. Methods: The medical records of all patients aged 80 years and above and comparable patients aged 65-75 years old, who were diagnosed with stage 4 colorectal cancer at a cancer center over a six-year period, were retrospectively reviewed. Results: Patients in the 80 years old and older group more frequently had right-sided primary colon cancer (71.5%), compared to younger patients aged 65-75 years old (34.1%, p = 0.006). Patients in the younger cohort more commonly presented with stage 4 disease at initial diagnosis (59.5%) compared to older patients (22.2%). Elevated carcinoembryonic antigen (CEA) levels were more commonly identified in younger metastatic patients (76.3% vs. 46.4%, p = 0.013). Patients in the younger age group were more likely to have received previous neoadjuvant and adjuvant chemotherapy prior to metastatic progression (p = 0.02, and p = 0.01); however, a significant difference in palliative chemotherapy was not identified between the age groups of metastatic patients. The adverse effects of chemotherapy treatment were similar between the age groups. Conclusions: The active treatment of metastatic colorectal cancer in patients aged 80 and above is feasible when tailored according to the patients' performance status, comorbidities, and life expectancy. Understanding metastatic disease presentations in elderly patients can improve treatment outcomes in this challenging-to-treat group.

Short-term outcomes after liver resection with vascular reconstruction: Results from a study with the National Clinical Database of Japan

BACKGROUND

Although curative resection with vascular reconstruction improves the prognosis of blood-invading locally advanced hepatobiliary tumors, the mortality and morbidity of the procedure remains unclear. This study aimed to clarify the risk factors associated with mortality and morbidity in patients undergoing liver resection with vascular reconstruction.

METHODS

This retrospective observational study included 1215 patients undergoing hepatectomy of more than one section with vascular reconstruction, except for left lateral sectionectomy registered in the National Clinical Database (NCD) between 2015 and 2019. The rates of surgical mortality and relevant clinical factors were evaluated.

RESULTS

Among the four types of vascular reconstruction, portal venous reconstruction was frequently performed in 724 patients (59.6% of the enrolled patients). Surgical mortality was 8.1%. Patients with hepatic artery reconstruction had the highest surgical mortality rate of 15.8%. In other types of reconstruction, surgical mortality was 9.1% in the portal vein, 5.2% in inferior vena cava, and 4.9% in hepatic vein. Factors significantly associated with surgical mortality include age, sex (male), preoperative comorbidity (American Society of Anesthesiologists grade >3, respiratory distress, diabetes, preoperative pneumonia, weight loss, and obstructive jaundice), poorer liver functional reserve (indocyanine green retention rate at 15 min and prothrombin time/international normalized ratio >1.1) and accompanying biliary reconstruction.

CONCLUSIONS

The NCD revealed the detailed status of liver resection combined with vascular reconstruction in Japan. Based on the results of this analysis, understanding the factors that influence the outcome and postoperative course of each procedure will provide patients with accurate information and opportunities to improve future outcomes.

A new risk calculation model for complications of hepatectomy in adults over 75

BACKGROUND

Owing to poor organ function reserve, older adults have a high risk of postoperative complications. However, there is no well-established system for assessing the risk of complications after hepatectomy in older adults.

METHODS

This study aimed to design a risk assessment tool to predict the risk of complications after hepatectomy in adults older than 75 years. A total of 326 patients were identified. A logistic regression equation was used to create the Risk Assessment System of Hepatectomy in Adults (RASHA) for the prediction of complications (Clavien‒Dindo classification ≥ II).

RESULTS

Multivariate correlation analysis revealed that comorbidity (≥ 5 kinds of disease or < 5 kinds of disease, odds ratio [OR] = 5.552, P < 0.001), fatigue (yes or no, OR = 4.630, P = 0.009), Child‒Pugh (B or A, OR = 4.211, P = 0.004), number of liver segments to be removed (≥ 3 or ≤ 2, OR = 4.101, P = 0.001), and adjacent organ resection (yes or no, OR = 1.523, P = 0.010) were independent risk factors for postoperative complications after hepatectomy in older persons (aged ≥ 75 years). A binomial logistic regression model was established to evaluate the RASHA score (including the RASHA scale and RASHA formula). The area under the curve (AUC) for the RASHA scale was 0.916, and the cut-off value was 12.5. The AUC for the RASHA formula was 0.801, and the cut-off value was 0.2106.

CONCLUSION

RASHA can be used to effectively predict the postoperative complications of hepatectomy through perioperative variables in adults older than 75 years.

TRIAL REGISTRATION

The Research Registry: researchregistry8531. https://www.researchregistry.com/browse-the-registry#home/registrationdetails/63901824ae49230021a5a0cf/ .

Presentation, Molecular Characteristics, Treatment, and Outcomes of Colorectal Cancer in Patients Older than 80 Years Old

Background: An increasing proportion of the population of patients with cancer presents at an advanced age, increasing the challenges of successful and well-tolerated treatments. In the older spectrum of the geriatric cancer patients, those older than 80 years old, challenges are even higher because of increasing comorbidities and decreasing organ function reserves. Methods: Studies regarding colorectal cancer presentation, treatment, and prognosis in patients older than 80 years old available in the literature were evaluated and were compiled within a narrative review. Molecular attributes of colorectal cancer in the subset of patients older than 80 years old in published genomic cohorts were also reviewed and were compared with similar attributes in younger patients. Results: Characteristics of colorectal cancer in octogenarians are in many aspects similar to younger patients, but patients older than 80 years old present more often with right colon cancers. Surgical treatment of colorectal cancer in selected patients over 80 years old is feasible and should be pursued. Adjuvant chemotherapy is under-utilized in this population. Although combination chemotherapy is in most cases not advisable, monotherapy with fluoropyrimidine derivatives is feasible and efficacious. Conclusions: Outcomes of colorectal cancer patients over the age of 80 years old may be optimized with a combination of standard treatments adjusted to the individual patient's functional status and organ reserves. Increased support for the older age group during their colorectal cancer treatment modalities would improve oncologic outcomes with decreasing adverse outcomes of therapies.

Tumor burden score-AFP-albumin-bilirubin grade score predicts the survival of patients with hepatocellular carcinoma after liver resection

PURPOSE

There is little information regarding the overall survival (OS) predictive ability of the combination of tumor burden score (TBS), α-fetoprotein (AFP), and albumin-bilirubin (ALBI) grade for patients with hepatocellular carcinoma (HCC). Here, we aimed to develop a model including TBS, AFP, and ALBI grade to predict HCC patient OS following liver resection.

METHODS

Patients (N = 1556) from six centers were randomly divided 1:1 into training and validation sets. The X-Tile software was used to determine the optimal cutoff values. The time-dependent area under the receiver operating characteristic curve (AUROC) was calculated to assess the prognostic ability of the different models.

RESULTS

In the training set, tumor differentiation, TBS, AFP, ALBI grade, and Barcelona Clinic Liver Cancer (BCLC) stage were independently related to OS. According to the coefficient values of TBS, AFP, and ALBI grade, we developed the TBS-AFP-ALBI (TAA) score using a simplified point system (0, 2 for low/high TBS, 0, 1 for low/high AFP and 0,1 for ALBI grade 1/2). Patients were further divided into low TAA (TAA ≤ 1), medium TAA (TAA = 2-3), and high TAA (TAA= 4) groups. TAA scores (low: referent; medium, HR = 1.994, 95% CI = 1.492-2.666; high, HR = 2.413, 95% CI = 1.630-3.573) were independently associated with patient survival in the validation set. The TAA scores showed higher AUROCs than BCLC stage for the prediction of 1-, 3-, and 5-year OS in both the training and validation sets.

CONCLUSION

TAA is a simple score that has better OS prediction performance than the BCLC stage in predicting OS for HCC patients after liver resection.

Textbook Outcomes in Liver Surgery: a Systematic Review

BACKGROUND

Assessment of the quality of care among patients undergoing hepatectomy may be inadequate using traditional "siloed" postoperative surgical outcome metrics. In turn, the combination of several quality metrics into a single composite Textbook Outcome in Liver Surgery (TOLS) may be more representative of "ideal" surgical care.

METHODS

Adhering to PRISMA guidelines, a search for primary articles on post-operative TOLS evaluation after hepatectomy was performed. Studies that did not present hepatectomy outcomes, pediatric or transplantation populations, duplicated series, and editorials were excluded. Studies were evaluated in aggregate for methodological variation, TOLS rates, factors associated with TOLS, hospital variation, and overall findings.

RESULTS

Among 207 identified publications, 32 observational cohort studies were selected for inclusion in the review. There was a total of 90,077 hepatic resections performed from 1993 to 2020 in the analytic cohort. While TOLS definitions varied widely, all studies used an "all-or-none" composite structure combining a median of 5 (range: 4-7) discrete parameters. Observed TOLS rates varied in the different reported populations from 11.2 to 77.0%. TOLS was associated with patient, hospital, and operative factors.

CONCLUSIONS

This systematic review summarizes the contemporary international experience with TOLS to assess surgical performance following hepatobiliary surgery. TOLS is a single composite metric that may be more patient-centered, as well as better suited to quantify "optimal" care and compare performance among centers performing liver surgery.

Textbook outcome in hepato-pancreato-biliary surgery: systematic review

BACKGROUND

Textbook outcome (TO) is a multidimensional measure reflecting the ideal outcome after surgery. As a benchmarking tool, it provides an objective overview of quality of care. Uniform definitions of TO in hepato-pancreato-biliary (HPB) surgery are missing. This study aimed to provide a definition of TO in HPB surgery and identify obstacles and predictors for achieving it.

METHODS

A systematic literature search was conducted using PubMed, Embase, and Cochrane Database according to PRISMA guidelines. Studies published between 1993 and 2021 were retrieved. After selection, two independent reviewers extracted descriptive statistics and derived summary estimates of the occurrence of TO criteria and obstacles for achieving TO using co-occurrence maps.

RESULTS

Overall, 30 studies were included. TO rates ranged between 16-69 per cent. Commonly chosen co-occurring criteria to define TO included 'no prolonged length of stay (LOS)', 'no complications', 'no readmission', and 'no deaths'. Major obstacles for achieving TO in HPB surgery were prolonged LOS, complications, and readmission. On multivariable analysis, TO predicted better overall and disease-free survival in patients with cancer. Achievement of TO was more likely in dedicated centres and associated with procedural and structural indicators, including high case-mix index and surgical volume.

CONCLUSION

TO is a useful quality measure to benchmark surgical outcome. Future definitions of TO in HPB surgery should include 'no prolonged LOS', 'no complications', 'no readmission', and 'no deaths'.