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Pérez Reyes M, Sánchez Pérez B, León Díaz FJ, Pérez Daga JA, Mirón Fernández I, Santoyo Santoyo J. Implementation of an ERAS protocol on elderly patients in liver resection. Cir Esp 2023; 101:274-282. [PMID: 35918049 DOI: 10.1016/j.cireng.2022.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 12/08/2021] [Indexed: 04/21/2023]
Abstract
BACKGROUND The increase of quality of life, the improvement in the perioperative care programs, the use of the frailty index, and the surgical innovation has allowed to access of complex abdominal surgery for elderly patients like liver resection. Despite of this, in patients aged 70 or older there is a limitation for the implementation ERAS protocolos. The aim of this study is to evaluate the implementation ERAS protocol on elderly patients (≥70 years) undergoing liver resection. METHODS A prospective cohort study of patients who underwent liver resection from December 2017 to December 2019 with an ERAS program. We compare the outcomes in patients ≥70 years (G ≥ 70) versus <70 years (G < 70). The frailty was measured with the Physical Frailty Phenotype score. RESULTS A total of 101 patients were included. 32 of these (31.6%) were patients ≥70 years. 90% of the both groups had performed >70% of the ERAS. Oral diet tolerance and mobilization on the first postoperative day were quicker in <70 years group. The hospital stay was similar in both groups (3.07days/2.7days). Morbidity and mortality were similar; Clavien I-II(G ≥ 70:41% vs G < 70:30,5%) and Clavien ≥ III (G ≥ 70:6% vs G < 70:8.5%), like hospital readmissions. Mortality was <1%. ERAS protocol compliance was associated with a decrease in complications (ERAS < 70%:80% vs ERAS > 90%:20%; p = 0.02) and decrease in severity of complications in both study groups. Frailty was found in 6% of the elderly group; the only patient who died had a frailty index of 4. CONCLUSION Implementation of ERAS protocol for elderly patients is possible, with major improvements in perioperative outcomes, without an increase in morbidity, mortality neither readmissions.
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Affiliation(s)
- María Pérez Reyes
- Hospital Regional Universitario de Málaga, Universidad de Málaga, Málaga, Spain.
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Arfa S, Turco C, Lakkis Z, Bourgeois S, Fouet I, Evrard P, Sennegon E, Roucoux A, Paquette B, Devaux B, Rietsch-Koenig A, Heyd B, Doussot A. Delayed return of gastrointestinal function after hepatectomy in an ERAS program: incidence and risk factors. HPB (Oxford) 2022; 24:1560-1568. [PMID: 35484074 DOI: 10.1016/j.hpb.2022.03.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/17/2022] [Accepted: 03/29/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Delayed return of gastrointestinal function (DGIF) after hepatectomy can involve increased morbidity and prolonged hospital stay. Yet, data on incidence and risks factors are lacking. METHODS All consecutive patients who underwent hepatectomy between June 2018 and December 2020 were included. All patients were included in an enhanced recovery after surgery (ERAS) program. DGIF was defined by the need for nasogastric tube (NGT) insertion after surgery. DGIF risk factors were identified. RESULTS Overall, 206 patients underwent hepatectomy. DGIF occurred in 41 patients (19.9%) after a median time of 2 days (range, 1-14). Among them, 6 patients (14.6%) developed aspiration pneumonia, of which one required ICU for mechanical ventilation. DGIF developed along with an intraabdominal complication in 7 patients (biliary fistula, n = 5; anastomotic fistula, n = 1; adhesive small bowel obstruction, n = 1). DGIF was associated with significantly increased severe morbidity rate (p = 0.001), prolonged time to normal food intake (p < 0.001) and hospital stay (p < 0.001) and significantly decreased overall compliance rate (p = 0.001). Independent risk factors of DGIF were age (p < 0.001), vascular reconstruction (p = 0.007), anaesthetic induction using volatiles (p = 0.003) and epidural analgesia (p = 0.004). Using these 4 variables, a simple DGIF risk score has been developed allowing patient stratification in low-, intermediate- and high-risk groups. CONCLUSION DGIF after hepatectomy was frequently observed and significantly impacted postoperative outcomes. Identifying risk factors remains critical for preventing its occurrence.
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Affiliation(s)
- Sara Arfa
- Department of Digestive Surgical Oncology -Liver Transplantation Unit, CHU Besançon, France
| | - Célia Turco
- Department of Digestive Surgical Oncology -Liver Transplantation Unit, CHU Besançon, France
| | - Zaher Lakkis
- Department of Digestive Surgical Oncology -Liver Transplantation Unit, CHU Besançon, France
| | - Sandrine Bourgeois
- Department of Digestive Surgical Oncology -Liver Transplantation Unit, CHU Besançon, France
| | - Isabelle Fouet
- Department of Anesthesiology and Intensive Care Medicine. CHU Besançon, France
| | - Philippe Evrard
- Department of Digestive Surgical Oncology -Liver Transplantation Unit, CHU Besançon, France
| | - Elise Sennegon
- Department of Digestive Surgical Oncology -Liver Transplantation Unit, CHU Besançon, France
| | - Alexandra Roucoux
- Department of Digestive Surgical Oncology -Liver Transplantation Unit, CHU Besançon, France
| | - Brice Paquette
- Department of Digestive Surgical Oncology -Liver Transplantation Unit, CHU Besançon, France
| | - Bénédicte Devaux
- Department of Anesthesiology and Intensive Care Medicine. CHU Besançon, France
| | - Anne Rietsch-Koenig
- Department of Anesthesiology and Intensive Care Medicine. CHU Besançon, France
| | - Bruno Heyd
- Department of Digestive Surgical Oncology -Liver Transplantation Unit, CHU Besançon, France
| | - Alexandre Doussot
- Department of Digestive Surgical Oncology -Liver Transplantation Unit, CHU Besançon, France.
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Ghanie A, Formica MK, Dhir M. Systematic review and meta-analysis of 90-day and 30-day mortality after liver resection in the elderly. Surgery 2022; 172:1164-1173. [PMID: 35973874 DOI: 10.1016/j.surg.2022.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 05/22/2022] [Accepted: 05/30/2022] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Amanda Ghanie
- College of Medicine, SUNY Upstate Medical University, Syracuse, NY. http://www.twitter.com/GhanieAmanda
| | - Margaret K Formica
- Department of Public Health and Preventive Medicine, SUNY Upstate Medical University, Syracuse, NY
| | - Mashaal Dhir
- Department of Surgery, Division of Surgical Oncology, SUNY Upstate Medical University, Syracuse, NY.
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Chen Q, Zhang Y, Deng Y, Huang Z, Zhao H, Cai J. Outcomes of simultaneous resection for elderly patients with colorectal liver metastasis: A propensity score matching analysis. Cancer Med 2022; 11:4913-4926. [PMID: 35608250 PMCID: PMC9761077 DOI: 10.1002/cam4.4826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/24/2022] [Accepted: 05/04/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Evidence on simultaneous resection for elderly patients (age ≥ 70 years) with colorectal liver metastasis (CRLM) is lacking. METHODS Four hundred and eighty-two CRLM patients treated by simultaneous resection were categorised into young group (age < 70 years) and elderly group (age ≥ 70 years). Propensity score matching (PSM1) was performed to adjust for differences in baseline characteristics and compare short-term outcomes. An additional propensity score matching (PSM2) including short-term outcomes was performed to analyse survival. Subgroup analysis was performed in patients stratified by the Clinical Risk Score (CRS). RESULTS After PSM1, 87 young group patients were matched to 50 elderly group patients. Patients in the elderly group had a significantly higher rate of overall post-operative complications (68.0% vs. 46.0%, p = 0.013). After PSM2, 89 young group patients were matched to 47 elderly group patients. Progression-free survival (PFS) was comparable between the two groups (median 11.0 months vs. 9.8 months, p = 0.346). Age ≥ 70 independently predicted worse overall survival (OS) (Hazard ratio, HR = 2.57, 95% confidence interval, CI 1.37-4.82) in multivariate analysis. In the subgroup multivariate analysis of patients with CRS score 3-5, age ≥ 70 was independently associated with worse PFS (HR = 1.62, 95% CI 1.01-2.62) and OS (HR = 2.34, 95% CI 1.26-4.35). CONCLUSIONS Simultaneous resection for elderly CRLM patients is acceptable. Further studies are required to determine the optimal treatment for elderly CRLM patients with high CRS scores.
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Affiliation(s)
- Qichen Chen
- Department of Hepatobiliary Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Yizhou Zhang
- Department of Hepatobiliary Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Yiqiao Deng
- Department of Hepatobiliary Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Zhen Huang
- Department of Hepatobiliary Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Hong Zhao
- Department of Hepatobiliary Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Jianqiang Cai
- Department of Hepatobiliary Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
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Pérez Reyes M, Sánchez Pérez B, León Díaz FJ, Pérez Daga JA, Mirón Fernández I, Santoyo Santoyo J. Implementación del protocolo ERAS en ancianos sometidos a resección hepática. Cir Esp 2022. [DOI: 10.1016/j.ciresp.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Di Martino M, Dorcaratto D, Primavesi F, Syn N, Blanco-Terés L, Dupré A, Piardi T, Rhaiem R, Fernández GB, De Armas Conde N, Rodríguez Sanjuán JC, Santiago RF, Fernández-Moreno MC, Ferret G, Ben SL, Suárez Muñoz MÁ, Perez-Alonso AJ, Koh YX, Jones R, Vennarecci G, Martín-Pérez E. Liver resection in elderly patients with extensive CRLM: Are we offering an adequate treatment? A propensity score matched analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2021; 48:1331-1338. [PMID: 35000821 DOI: 10.1016/j.ejso.2021.12.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 11/24/2021] [Accepted: 12/21/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Data on the management of elderly patients with extensive colorectal liver metastases (CRLM) are scarce and conflicting. This study assesses differences in management and long-term oncological outcomes between older and younger patients with CRLM and a high Tumour Burden Score (TBS). METHODS International multicentre retrospective study on patients with CRLM and a category 3 TBS, submitted to liver resection. Patients were divided into two groups according to their age (younger and older than 75) and were compared using propensity score matching (PSM) analysis and multivariable regression models. Differences in management and oncological outcomes including recurrence-free survival (RFS) and overall survival (OS) were assessed. RESULTS The study included 386 patients, median follow-up was 48 months. The unmatched comparison revealed a higher ASA score (p = 0.035), less synchronous CRLM (47% vs 68%, p = 0.003), a lower median number of lesions (1 vs 3, p = 0.004) and less perioperative chemotherapy (CTx) (66% vs 88%, p < 0.001) in the elderly group. Despite the absence of CTx being an independent predictor of decreased RFS and OS (HR 0.760, p = 0.044 and HR 0.719, p = 0.049, respectively), the elderly group still received less CTx (OR 0.317, p = 0.001) than the younger group. After PSM (n = 100 patients), the two groups were comparable, however, CTx administration was still significantly lower in the elderly group. CONCLUSION Liver resection should be considered in patients aged 75 and older, even if they present with extensive liver disease. Despite CTx being associated with improved oncological outcomes, a large percentage of elderly patients with CRLM are undertreated.
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Affiliation(s)
- Marcello Di Martino
- HPB Unit, Department of General and Digestive Surgery, Hospital Universitario La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain; Department Hepatobiliar Surgery and Liver Transplant. A.O.R.N. Cardarelli, Napoli, Italy
| | - Dimitri Dorcaratto
- Department of Surgery, Liver, Biliary, and Pancreatic Unit, Biomedical Research Institute INCLIVA, Hospital Clínico University of Valencia, Valencia, Spain.
| | - Florian Primavesi
- Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom; Salzkammergutklinikum Vöcklabruck, Vöcklabruck, Austria.
| | - Nicholas Syn
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore.
| | - Lara Blanco-Terés
- HPB Unit, Department of General and Digestive Surgery, Hospital Universitario La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain.
| | - Aurélien Dupré
- Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom; Department of Surgical Oncology, Centre Léon Bérard, Lyon, France.
| | - Tullio Piardi
- Department of HBP and Digestive Oncological Surgery, Robert Debré University Hospital, Reims, France; Department of Surgery, HPB Unit, Simone Veil Hospital, Troyes, France.
| | - Rami Rhaiem
- Department of HBP and Digestive Oncological Surgery, Robert Debré University Hospital, Reims, France.
| | - Gerardo Blanco Fernández
- Department of HBP and Liver Transplantation Surgery. University Hospital of Badajoz. INUBE (Instituto Universitario de Investigación Biosanitaria de Extremadura). University of Extremadura, Badajoz, Spain.
| | - Noelia De Armas Conde
- Department of HBP and Liver Transplantation Surgery. University Hospital of Badajoz. INUBE (Instituto Universitario de Investigación Biosanitaria de Extremadura). University of Extremadura, Badajoz, Spain.
| | | | | | | | - Georgina Ferret
- Hospital Universitari de Girona Dr Josep Trueta, Girona, Spain.
| | | | | | - Alejandro J Perez-Alonso
- Unidad de Cirugia HBP y Trasplante Hepático, Hospital Universitario Virgen de las Nieves, Granada, Spain.
| | - Ye-Xin Koh
- Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom.
| | - Robert Jones
- Department of Surgery, Liver, Biliary, and Pancreatic Unit, Biomedical Research Institute INCLIVA, Hospital Clínico University of Valencia, Valencia, Spain.
| | - Giovanni Vennarecci
- Department Hepatobiliar Surgery and Liver Transplant. A.O.R.N. Cardarelli, Napoli, Italy.
| | - Elena Martín-Pérez
- HPB Unit, Department of General and Digestive Surgery, Hospital Universitario La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain.
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Yoshino K, Hamzaoui Y, Yoh T, Ftériche FS, Aussilhou B, Beaufrère A, Belghiti J, Soubrane O, Cauchy F, Dokmak S. Liver resection for octogenarians in a French center: prolonged hepatic pedicle occlusion and male sex increase major complications. Langenbecks Arch Surg 2021; 406:1543-1552. [PMID: 34057599 DOI: 10.1007/s00423-021-02210-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 05/17/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE The prolonged life expectancy and increase in aging of the population have led surgeons to propose hepatectomy in the elderly population. In this study, we evaluate the surgical outcome of octogenarians in a single French center. METHODS Between 2000 and 2020, 78 patients over 80 years old were retrospectively analyzed. The risk factors of major complications (Clavien-Dindo ≥ grade IIIa) and patient performance after surgery by using textbook outcome (TO) (no surgical complications, no prolonged hospital stay (≤ 15 days), no readmission ≤90 days after discharge, and no mortality ≤90 days after surgery) were studied. RESULTS The main surgical indication was for malignancy (96%), including mainly colorectal liver metastases (n = 41; 53%) and hepatocellular carcinoma (n = 22; 28%), and major hepatectomy was performed in 28 patients (36%). There were 6 (8%) postoperative mortalities. The most frequent complications were pulmonary (n = 22; 32%), followed by renal insufficiency (n = 22; 28%) and delirium (n = 16; 21%). Major complications occurred in 19 (24%) patients. On multivariate analysis, the main risk factors for major complications were the median vascular clamping time (0 vs 35; P = 0.04) and male sex (P = 0.046). TO was ultimately achieved in 30 patients (38%), and there was no prognostic factor for achievement of TO. CONCLUSIONS Hepatectomy in octogenarians is associated with acceptable morbidity and mortality. Meanwhile, prolonged hepatic pedicle clamping should be avoided especially if hepatectomy is planned in a male patient.
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Affiliation(s)
- Kenji Yoshino
- Department of HPB Surgery and Liver Transplantation, DMU DIGEST, University of Paris, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, 92100, Clichy, France
| | - Yanis Hamzaoui
- Department of HPB Surgery and Liver Transplantation, DMU DIGEST, University of Paris, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, 92100, Clichy, France
| | - Tomoaki Yoh
- Department of HPB Surgery and Liver Transplantation, DMU DIGEST, University of Paris, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, 92100, Clichy, France
| | - Fadhel Samir Ftériche
- Department of HPB Surgery and Liver Transplantation, DMU DIGEST, University of Paris, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, 92100, Clichy, France
| | - Béatrice Aussilhou
- Department of HPB Surgery and Liver Transplantation, DMU DIGEST, University of Paris, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, 92100, Clichy, France
| | - Aurélie Beaufrère
- Department of Pathology, University of Paris, Hôpital Beaujon, AP-HP, Clichy, France
| | - Jacques Belghiti
- Department of HPB Surgery and Liver Transplantation, DMU DIGEST, University of Paris, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, 92100, Clichy, France
| | - Olivier Soubrane
- Department of HPB Surgery and Liver Transplantation, DMU DIGEST, University of Paris, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, 92100, Clichy, France
| | - François Cauchy
- Department of HPB Surgery and Liver Transplantation, DMU DIGEST, University of Paris, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, 92100, Clichy, France
| | - Safi Dokmak
- Department of HPB Surgery and Liver Transplantation, DMU DIGEST, University of Paris, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, 92100, Clichy, France.
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Alabraba E, Gomez D. Systematic Review of Treatments for Colorectal Metastases in Elderly Patients to Guide Surveillance Cessation Following Hepatic Resection for Colorectal Liver Metastases. Am J Clin Oncol 2021; 44:210-223. [PMID: 33710135 DOI: 10.1097/coc.0000000000000803] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although included in surveillance programmes for colorectal cancer (CRC) metastases, elderly patients are susceptible to declines in health and quality of life that may render them unsuitable for further surveillance. Deciding when to cease surveillance is challenging. METHODS There are no publications focused on surveillance of elderly patients for CRC metastases. A systematic review of studies reporting treatment outcomes for CRC metastases in elderly patients was performed to assess the risk-benefit balance of the key objectives of surveillance; detecting and treating CRC metastases. RESULTS Sixty-eight eligible studies reported outcomes for surgery and chemotherapy in the elderly. Liver resections and use of chemotherapy, including biologics, are more conservative and have poorer outcomes in the elderly compared with younger patients. Selected studies demonstrated poorer quality-of-life (QoL) following surgery and chemotherapy. Studies of ablation in elderly patients are limited. DISCUSSION The survival benefit of treating CRC metastases with surgery or chemotherapy decreases with advancing age and QoL may decline in the elderly. The relatively lower efficacy and detrimental QoL impact of multimodal therapy options for detected CRC metastases in the elderly questions the benefit of surveillance in some elderly patients. Care of elderly patients should thus be customized based on their preference, formal geriatric assessment, natural life-expectancy, and the perceived risk-benefit balance of treating recurrent CRC metastases. Clinicians may consider surveillance cessation in patients aged 75 years and above if geriatric assessment is unsatisfactory, patients decline surveillance, or patient fitness deteriorates catastrophically.
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Affiliation(s)
- Edward Alabraba
- Department of Hepatobiliary Surgery and Pancreatic Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust
| | - Dhanny Gomez
- Department of Hepatobiliary Surgery and Pancreatic Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust
- NIHR Nottingham Digestive Disease Biomedical Research Unit, University of Nottingham, Nottingham, UK
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9
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Liver resections for colorectal liver metastases in elderly patients. Eur Surg 2020. [DOI: 10.1007/s10353-020-00685-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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10
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Zhao H, Zhu Y, Zhang J, Wu Y, Xiang X, Zhang Z, Li T, Liu L. The Beneficial Effect of HES on Vascular Permeability and Its Relationship With Endothelial Glycocalyx and Intercellular Junction After Hemorrhagic Shock. Front Pharmacol 2020; 11:597. [PMID: 32457611 PMCID: PMC7227604 DOI: 10.3389/fphar.2020.00597] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 04/17/2020] [Indexed: 12/11/2022] Open
Abstract
Background Vascular leakage is a common complication of hemorrhagic shock. Endothelial glycocalyx plays a crucial role in the protection of vascular endothelial barrier function. Hydroxyethyl starch (HES) is a commonly used resuscitation fluid for hemorrhagic shock. However, whether the protective effect of HES on vascular permeability after hemorrhagic shock is associated with the endothelial glycocalyx is unclear. Methods Using hemorrhagic shock rat model and hypoxia treated vascular endothelial cells (VECs), effects of HES (130/0.4) on pulmonary vascular permeability and the relationship to endothelial glycocalyx were observed. Results Pulmonary vascular permeability was significantly increased after hemorrhagic shock, as evidenced by the increased permeability of pulmonary vessels to albumin-fluorescein isothiocyanate conjugate (FITC-BSA) and Evans blue, the decreased transendothelial electrical resistance of VECs and the increased transmittance of FITC-BSA. The structure of the endothelial glycocalyx was destroyed, showing a decrease in thickness. The expression of heparan sulfate, hyaluronic acid, and chondroitin sulfate, the components of the endothelial glycocalyx, was significantly decreased. HES (130/0.4) significantly improved the vascular barrier function, recovered the thickness and the expression of components of the endothelial glycocalyx by down-regulating the expression of heparinase, hyaluronidase, and neuraminidase, and meanwhile increased the expression of intercellular junction proteins ZO-1, occludin, and VE-cadherin. Degradation of endothelial glycocalyx with degrading enzyme (heparinase, hyaluronidase, and neuraminidase) abolished the beneficial effect of HES on vascular permeability, but had no significant effect on the recovery of the expression of endothelial intercellular junction proteins induced by HES (130/0.4). HES (130/0.4) decreased the expression of cleaved-caspase-3 induced by hemorrhagic shock. Conclusions HES (130/0.4) has protective effect on vascular barrier function after hemorrgic shock.The mechanism is mainly related to the protective effect of HES on endothelial glycocalyx and intercellular junction proteins. The protective effect of HES on endothelial glycocalyx was associated with the down-regulated expression of heparinase, hyaluronidase, and neuraminidase. HES (130/0.4) had an anti-apoptotic effect in hemorrhagic shock.
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Affiliation(s)
- Hongliang Zhao
- State Key Laboratory of Trauma, Burns and Combined Injury, Shock and Transfusion Department, Research Institute of Surgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Yu Zhu
- State Key Laboratory of Trauma, Burns and Combined Injury, Shock and Transfusion Department, Research Institute of Surgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Jie Zhang
- State Key Laboratory of Trauma, Burns and Combined Injury, Shock and Transfusion Department, Research Institute of Surgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Yue Wu
- State Key Laboratory of Trauma, Burns and Combined Injury, Shock and Transfusion Department, Research Institute of Surgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Xinming Xiang
- State Key Laboratory of Trauma, Burns and Combined Injury, Shock and Transfusion Department, Research Institute of Surgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Zisen Zhang
- State Key Laboratory of Trauma, Burns and Combined Injury, Shock and Transfusion Department, Research Institute of Surgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Tao Li
- State Key Laboratory of Trauma, Burns and Combined Injury, Shock and Transfusion Department, Research Institute of Surgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Liangming Liu
- State Key Laboratory of Trauma, Burns and Combined Injury, Shock and Transfusion Department, Research Institute of Surgery, Daping Hospital, Army Medical University, Chongqing, China
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Stevens CL, Reid JL, Babidge WJ, Maddern GJ. Peer review of mortality after hepatectomy in Australia. HPB (Oxford) 2020; 22:611-621. [PMID: 31558369 DOI: 10.1016/j.hpb.2019.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 08/27/2019] [Accepted: 09/02/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The data within the Australian and New Zealand Audit of Surgical Mortality (ANZASM) provides a unique opportunity to consider the contributing factors to perioperative deaths as determined by peer review. Consideration of the factors contributing to mortality after hepatectomy can provide greater insight into how deaths can be prevented. The objective of this study was to determine the reasons for patient deaths post-hepatectomy in Australia. METHODS ANZASM data from 1 January 2010 to 30 Jun 2017 was reviewed and all deaths following hepatectomy were selected for analysis. Assessors determinations of whether management could have been improved were reviewed, and then classified into groups of significant clinical events using thematic analysis with a data driven approach. RESULTS The study included 88 deaths reported to ANZASM after hepatectomy. The assessors questioned the decision to operate in 23/88 (25%) patients with a further nine (10%) patients insufficiently investigated prior to resection. ANZASM assessors determined that there was a delay in recognising a significant complication in 16/88 (18%) patients. CONCLUSION Multi-disciplinary decision making is strongly recommended when deciding which patients to treat with hepatic resection. Optimal care post-hepatectomy includes early recognition of complications and enactment of an adequate rescue plan.
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Affiliation(s)
- Claire L Stevens
- Discipline of Surgery, University of Adelaide, The Queen Elizabeth Hospital, Australia.
| | - Jessica L Reid
- Discipline of Surgery, University of Adelaide, The Queen Elizabeth Hospital, Australia
| | - Wendy J Babidge
- Discipline of Surgery, University of Adelaide, Australian and New Zealand Audit of Surgical Mortality, Royal Australasian College of Surgeons, Australia
| | - Guy J Maddern
- Discipline of Surgery, University of Adelaide, The Queen Elizabeth Hospital, Australia
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12
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Progressive Oncological Surgery Is Associated with Increased Curative Resection Rates and Improved Survival in Metastatic Colorectal Cancer. Cancers (Basel) 2019; 11:cancers11020218. [PMID: 30769860 PMCID: PMC6406820 DOI: 10.3390/cancers11020218] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 02/07/2019] [Accepted: 02/12/2019] [Indexed: 02/07/2023] Open
Abstract
Background: Secondary resection rates in first-line chemotherapy trials for metastatic colorectal cancer (mCRC) remain below 15%, representing a clear contrast to reports by specialised surgical centres, where progressive liver, peritoneal-surface, and pulmonary surgery increased access to curative-intent treatment. We present a long-term evaluation of oncosurgical management in a single-centre, analysing the aggregate effect of gradual implementation of surgical subspecialties and systemic treatments on mCRC patients’ resection rates and prognosis. Methods: Patients with newly diagnosed mCRC from 2003 to 2014 were retrospectively categorised into palliative treatment (PAT) and curative intent surgery (CIS) and three time periods were analysed for treatment changes and factors associated with survival. Results: Four hundred-twenty patients were treated (PAT:250/CIS:170). Over time periods, the number of presenting patients remained consistent, whereas curative resection rates increased from 29% to 55%, facilitated by an increment of patients undergoing hepatectomy (21 to 35%), pulmonary surgery (6 to 17%), and peritonectomy/intraoperative chemotherapy (0 to 8%). Also, recently, significantly more multi-line systemic treatments were applied. The median survival markedly improved from 21.9 months (2003–2006; 95% confidence interval (CI) 17.3–26.5) to 36.5 months (2011–2014; 95% CI 26.6–46.4; p = 0.018). PAT was a significant factor of poor survival and diagnosis of mCRC in the latest time period was independently associated with a distinctly lower risk for palliative treatment (odds ratio 0.15). Conclusions: In modern eras of medical oncology, achieving appropriate resection rates through utilization of state-of-the-art oncological surgery by dedicated experts represents a cornerstone for long-term survival in mCRC.
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13
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Vallance AE, Young AL, Kuryba A, Braun M, Hill J, Jayne DG, van der Meulen J, Lodge JP, Walker K. The impact of advancing age on incidence of hepatectomy and post-operative outcomes in patients with colorectal cancer liver metastases: a population-based cohort study. HPB (Oxford) 2019; 21:167-174. [PMID: 30076012 DOI: 10.1016/j.hpb.2018.06.1808] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 06/11/2018] [Accepted: 06/24/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Clinical outcomes for elderly patients undergoing liver resection for colorectal cancer (CRC) liver metastases are poorly characterised. This study aimed to investigate the impact of advancing age on the incidence of liver resection and post-operative outcomes. METHODS Patients in the National Bowel Cancer Audit undergoing major CRC resection from 2010 to 2016 in England were included. Liver resection was identified from linked Hospital Episode Statistics data. A Cox-proportional hazards model was used to compare 3-year mortality. RESULTS Of 117,005 patients, 6081 underwent liver resection. For patients <65 years there was 1 liver resection per 12 cases, 65-74, 1 per 17, and ≥75, 1 per 40. 90-day mortality after liver resection increased with advancing age (<65 0.9% (26/2829), 65-74 2.8% (57/2070), ≥75 4.0% (47/1182); P < 0.001). Age was an independent risk factor for 3-year mortality. Patients 65-74 did not have adjusted mortality higher than those <65, yet age ≥75 was associated with increased overall mortality (Hazard ratio (HR) 1.47 (95% CI 1.30-1.68)) and cancer-specific mortality (HR 1.30 (95% CI 1.13-1.49)). CONCLUSION Although advancing age was associated with higher rates of 90-day mortality following liver resection, 3-year mortality for patients 65-74 years was comparable to younger patients. These results will aid clinicians and patients in pre-operative decision-making.
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Affiliation(s)
- Abigail E Vallance
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, WC2A 3PE, UK.
| | - Alastair L Young
- Department of Hepatobiliary Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, LS9 7TF, UK
| | - Angela Kuryba
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, WC2A 3PE, UK
| | - Michael Braun
- Medical Oncology, The Christie NHS Foundation Trust, Manchester, M20 4BX, UK
| | - James Hill
- Department of Colorectal Surgery, Manchester Royal Infirmary, Manchester, M13 9WL, UK
| | - David G Jayne
- Faculty of Medicine and Health, University of Leeds, Leeds, LS2 9JT, UK
| | - Jan van der Meulen
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, WC2A 3PE, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, WC1H 9SH, UK
| | - Jeremy P Lodge
- Department of Hepatobiliary Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, LS9 7TF, UK
| | - Kate Walker
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, WC2A 3PE, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, WC1H 9SH, UK
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14
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Xu F, Tang B, Jin TQ, Dai CL. Current status of surgical treatment of colorectal liver metastases. World J Clin Cases 2018; 6:716-734. [PMID: 30510936 PMCID: PMC6264988 DOI: 10.12998/wjcc.v6.i14.716] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 09/14/2018] [Accepted: 10/22/2018] [Indexed: 02/05/2023] Open
Abstract
Liver metastasis (LM) is one of the major causes of death in patients with colorectal cancer (CRC). Approximately 60% of CRC patients develop LM during the course of their illness. About 85% of these patients have unresectable disease at the time of presentation. Surgical resection is currently the only curative treatment for patients with colorectal LM (CRLM). In recent years, with the help of modern multimodality therapy including systemic chemotherapy, radiation therapy, and surgery, the outcomes of CRLM treatment have significantly improved. This article summarizes the current status of surgical treatment of CRLM including evaluation of resectability, treatment for resectable LM, conversion therapy and liver transplantation for unresectable cases, liver resection for recurrent CRLM and elderly patients, and surgery for concomitant hepatic and extra-hepatic metastatic disease (EHMD). We believe that with the help of modern multimodality therapy, an aggressive oncosurgical approach should be implemented as it has the possibility of achieving a cure, even when EHMD is present in patients with CRLM.
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Affiliation(s)
- Feng Xu
- Department of Hepatobiliary and Splenic Surgery, Shengjing Hospital, China Medical University, Shenyang 110004, Liaoning Province, China
| | - Bin Tang
- Department of Hepatobiliary and Splenic Surgery, Shengjing Hospital, China Medical University, Shenyang 110004, Liaoning Province, China
| | - Tian-Qiang Jin
- Department of Hepatobiliary and Splenic Surgery, Shengjing Hospital, China Medical University, Shenyang 110004, Liaoning Province, China
| | - Chao-Liu Dai
- Department of Hepatobiliary and Splenic Surgery, Shengjing Hospital, China Medical University, Shenyang 110004, Liaoning Province, China
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15
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Shahrokni A, Alexander K. The Age of Talking About Age Alone is Over. Ann Surg Oncol 2018; 26:12-14. [DOI: 10.1245/s10434-018-6983-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Indexed: 12/18/2022]
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16
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Brudvik KW, Røsok B, Naresh U, Yaqub S, Fretland ÅA, Labori KJ, Edwin B, Bjørnbeth BA. Survival after resection of colorectal liver metastases in octogenarians and sexagenarians compared to their respective age-matched national population. Hepatobiliary Surg Nutr 2018; 7:234-241. [PMID: 30221151 DOI: 10.21037/hbsn.2017.09.03] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background The aim of the current study was to investigate survival after resection of colorectal liver metastases (CLM) in octogenarians. The survival of octogenarian patients was compared to the survival of the national population of octogenarians and the survival of sexagenarians, the latter representing the average-age patient undergoing resection of CLM. Methods Octogenarian and sexagenarian were defined as person 80-89 and 60-69 years of age, respectively. Survival analyses of patients who underwent resection of CLM between 2002 and 2014 were performed. Data from Statistics Norway were used to estimate the survival of the age-matched national population of octogenarians (ageM-Octo) and the age-matched national population of sexagenarians (ageM-Sexa). Results During the study period, 59 octogenarians underwent resection of CLM. The majority of patients underwent a minor liver resection (n=50). In octogenarians, the 5-year survival was 32.5% and 66.3% [difference, 33.8 percentage points (pp)] in patients and ageM-Octo, respectively. The 10-year survival was 14.1% and 31.2% (difference, 17.1 pp) in patients and ageM-Octo, respectively. In sexagenarians, the 5-year survival was 50.9% and 96.2% (difference, 45.3 pp) in patients and ageM-Sexa, respectively. The 10-year survival was 35.7% and 90.3% (difference, 54.6 pp) in patients and ageM-Sexa, respectively. The 5-year cancer-specific survival and 5-year recurrence-free survival (RFS) after resection of CLM in octogenarians were 43.1% and 32.9%, respectively. Conclusions After resection of CLM, the survival was poorer in octogenarians than in sexagenarians. However, the difference between the survival curves of patients and their age-matched population was smaller in octogenarians. In practice, this finding may indicate a greater benefit of resection in the elderly than the survival rates alone would suggest.
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Affiliation(s)
| | - Bård Røsok
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| | - Usha Naresh
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| | - Sheraz Yaqub
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| | - Åsmund Avdem Fretland
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway.,The Intervention Centre, Oslo University Hospital, Oslo, Norway.,Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Knut Jørgen Labori
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| | - Bjørn Edwin
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway.,The Intervention Centre, Oslo University Hospital, Oslo, Norway.,Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Bjørn Atle Bjørnbeth
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
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17
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Wei F. Does an extreme age (≥80 years) affect outcomes in patients after liver cancer surgery? A meta-analysis. ANZ J Surg 2018; 89:25-31. [PMID: 29885205 DOI: 10.1111/ans.14676] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 04/09/2018] [Accepted: 04/11/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Increasing global life expectancy has resulted in a greater demand for cancer surgery in aged patients. However, whether extreme age causes poorer clinical outcomes remains unclear. This meta-analysis aimed to evaluate the impact of extreme age (≥80 years) on outcomes in patients after liver cancer surgery. METHODS A systematic search was performed to enrol relevant studies. Data were analysed using fixed-effects or random-effects models. Eight retrospective studies involving 253 participants older than 80 years were included. RESULTS Compared with younger patients, patients of extreme age (≥80 years) who had undergone curative liver cancer surgery experienced less operating time and blood loss (both P < 0.0001); a larger size (weighted mean difference = 0.48 cm, 95% confidence interval (CI) 0.08-0.87 cm; P = 0.02) and more advanced stage of hepatocellular carcinoma (risk ratio (RR) = 1.20, 95% CI 1.04-1.39; P = 0.01); a higher overall morbidity (RR = 1.24, 95% CI 1.05-1.47; P = 0.01); and more post-operative ileus (POI) (RR = 3.45, 95% CI 1.03-11.56; P = 0.04), delirium (RR = 3.04, 95% CI 1.36-6.78; P = 0.007) and cardiovascular events (RR = 6.17, 95% CI 2.79-13.60; P < 0.00001). No significant difference was noted in overall (hazard ratio (HR) = 1.15, 95% CI 0.87-1.53; P = 0.32) or disease-free (HR = 0.96, 95% CI 0.75-1.24; P = 0.77) survival. CONCLUSION Although an extreme age may not be a contraindication for undertaking liver cancer surgery, it may cause more morbidity. Perioperative intervention should be considered for prevention and early treatment of POI, delirium and cardiovascular events.
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Affiliation(s)
- Fangqiang Wei
- School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.,Department of Developmental Biology, Pittsburgh Liver Research Center, McGowan Institute for Regenerative Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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18
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Stevens CL, Babidge WJ, Maddern GJ. Variability of perioperative mortality of hepatic resection in Australia. ANZ J Surg 2018; 88:1022-1027. [DOI: 10.1111/ans.14408] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 12/22/2017] [Accepted: 01/03/2018] [Indexed: 12/22/2022]
Affiliation(s)
- Claire L. Stevens
- Discipline of Surgery; The University of Adelaide, The Queen Elizabeth Hospital; Adelaide South Australia Australia
| | - Wendy J. Babidge
- Australia and New Zealand Audit of Surgical Mortality; Royal Australasian College of Surgeons; Adelaide South Australia Australia
| | - Guy J. Maddern
- Australia and New Zealand Audit of Surgical Mortality; Royal Australasian College of Surgeons; Adelaide South Australia Australia
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19
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van Dijk DPJ, van Woerden V, Cakir H, den Dulk M, Olde Damink SWM, Dejong CHC. ERAS: Improving outcome in the cachectic HPB patient. J Surg Oncol 2017; 116:617-622. [PMID: 28767125 PMCID: PMC5697643 DOI: 10.1002/jso.24767] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 06/28/2017] [Indexed: 12/14/2022]
Abstract
The enhanced recovery after surgery (ERAS) program has reduced postoperative morbidity and duration of hospital stay but not mortality in patients undergoing hepatopancreatobiliary (HPB) surgery. Many HPB patients suffer from cancer cachexia, a syndrome of severe weight and muscle loss. This may affect outcomes of HPB surgery even within an ERAS program. A tailored ERAS approach may be essential in further improving outcome in this vulnerable patient category.
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Affiliation(s)
- David P J van Dijk
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Victor van Woerden
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Hamit Cakir
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Marcel den Dulk
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of General, Visceral and Transplantation Surgery, RWTH University Hospital Aachen, Aachen, Germany
| | - Steven W M Olde Damink
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands.,Department of General, Visceral and Transplantation Surgery, RWTH University Hospital Aachen, Aachen, Germany
| | - Cornelis H C Dejong
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands.,Department of General, Visceral and Transplantation Surgery, RWTH University Hospital Aachen, Aachen, Germany.,GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
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