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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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2
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Chang HL, Jones AL. Current Status of Biologics in Perioperative Treatment for Resectable or Borderline Resectable Liver Metastases. CURRENT COLORECTAL CANCER REPORTS 2021. [DOI: 10.1007/s11888-021-00464-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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3
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Jin KM, Wang K, Bao Q, Wang HW, Xing BC. Liver resection for colorectal liver-limited metastases in elderly patients: a propensity score matching analysis. World J Surg Oncol 2020; 18:275. [PMID: 33099304 PMCID: PMC7585677 DOI: 10.1186/s12957-020-02055-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 10/15/2020] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
- Ke-Min Jin
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Hepatobiliary and Pancreatic Surgery Unit I, Peking University Cancer Hospital & Institute, No. 52, Fu Cheng Road, Beijing, 100142, People's Republic of China
| | - Kun Wang
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Hepatobiliary and Pancreatic Surgery Unit I, Peking University Cancer Hospital & Institute, No. 52, Fu Cheng Road, Beijing, 100142, People's Republic of China
| | - Quan Bao
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Hepatobiliary and Pancreatic Surgery Unit I, Peking University Cancer Hospital & Institute, No. 52, Fu Cheng Road, Beijing, 100142, People's Republic of China
| | - Hong-Wei Wang
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Hepatobiliary and Pancreatic Surgery Unit I, Peking University Cancer Hospital & Institute, No. 52, Fu Cheng Road, Beijing, 100142, People's Republic of China
| | - Bao-Cai Xing
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Hepatobiliary and Pancreatic Surgery Unit I, Peking University Cancer Hospital & Institute, No. 52, Fu Cheng Road, Beijing, 100142, People's Republic of China.
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4
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Hata T, Mise Y, Ono Y, Sato T, Inoue Y, Ito H, Takahashi Y, Yanaga K, Saiura A. Multidisciplinary treatment for colorectal liver metastases in elderly patients. World J Surg Oncol 2020; 18:173. [PMID: 32680531 PMCID: PMC7368701 DOI: 10.1186/s12957-020-01950-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 07/07/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Limited data describe the therapeutic practice and outcomes of colorectal liver metastases (CRLMs) in elderly patients. We aimed to evaluate the impact of age on multidisciplinary treatment for CRLMs. METHODS We reviewed treatment and outcomes for patients in different age groups who underwent initial hepatectomy for CRLMs from 2004 through 2012. RESULTS We studied 462 patients who were divided into three groups by age: ≤ 64 years (n = 265), 65-74 years (n = 151), and ≥ 75 years (n = 46). The rate of major hepatectomy and incidence of postoperative complications did not differ between groups. Adjuvant chemotherapy was used less in the ≥ 75-year group (19.6%) than that in the ≤ 64 (54.3%) or 65-74 age group (43.5%). Repeat hepatectomy for liver recurrence was performed less in the ≥ 75-year group (35%) than in the ≤ 64 (57%) or 65-74 (66%) age group. The 5-year disease-specific survival (DSS) rate of 44.2% in the ≥ 75-year group was lower than in the ≤ 64 (59.0%) or 65-74 (64.7%) age group. Multivariate analysis revealed age ≥ 75 years was an independent predictor of poor DSS. CONCLUSIONS Liver resection for CRLMs can be performed safely in elderly patients. However, repeat resection for recurrence are performed less frequently in the elderly, which may lead to the poorer disease-specific prognosis.
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Affiliation(s)
- Taigo Hata
- Department of Hepatobiliary Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.,Department of Surgery, Jikei University School of Medicine, 3-19-18 Nishi-shinbashi, Minato-ku, Tokyo, 105-8471, Japan
| | - Yoshihiro Mise
- Department of Hepatobiliary Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.,Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, 113-8431, Japan
| | - Yoshihiro Ono
- Department of Hepatobiliary Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Takafumi Sato
- Department of Hepatobiliary Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yosuke Inoue
- Department of Hepatobiliary Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Hiromichi Ito
- Department of Hepatobiliary Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yu Takahashi
- Department of Hepatobiliary Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Katsuhiko Yanaga
- Department of Surgery, Jikei University School of Medicine, 3-19-18 Nishi-shinbashi, Minato-ku, Tokyo, 105-8471, Japan
| | - Akio Saiura
- Department of Hepatobiliary Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan. .,Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, 113-8431, Japan.
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5
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de’Angelis N, Baldini C, Brustia R, Pessaux P, Sommacale D, Laurent A, Le Roy B, Tacher V, Kobeiter H, Luciani A, Paillaud E, Aparicio T, Canuï-Poitrine F, Liuu E. Surgical and regional treatments for colorectal cancer metastases in older patients: A systematic review and meta-analysis. PLoS One 2020; 15:e0230914. [PMID: 32320417 PMCID: PMC7176093 DOI: 10.1371/journal.pone.0230914] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 03/11/2020] [Indexed: 12/13/2022] Open
Abstract
Objective The present study explored the existing literature to describe the outcomes of surgical and regional treatments for colorectal cancer metastases (mCRC) in older patients. Methods A literature search was conducted in PubMed, EMBASE, Cochrane and ClinicalTrials.gov for studies published since 2000 that investigated the short- and long-term outcomes of regional treatments (surgical or non-surgical) for mCRC in patients aged ≥65 years. Pooled data analyses were conducted by calculating the risk ratio (RR), mean differences (MD) and hazard ratio (HR) between older and younger patients or between two different approaches in older patients. Results After screening 266 articles, 29 were included in this review. These studies reported the outcomes of surgery (n = 19) and non-surgical local ablation treatments (n = 3) for CRC metastases in older vs. younger patients or compared the outcomes of different interventions in older patients (n = 7). When comparing older vs. younger patients undergoing liver surgery for mCRC, pooled data analysis showed higher postoperative mortality [RR = 2.53 (95%CI: 2.00–3.21)] and shorter overall survival [HR = 1.17 (95%CI: 1.07–1.18)] in older patients, whereas no differences in operative outcomes, postoperative complications and disease-free survival were found. When comparing laparoscopy vs. open surgery for liver resection in older mCRC patients, laparoscopy was associated with fewer postoperative complications [RR = 0.27 (95%CI: 0.10–0.73)]. Conclusion Liver resection for mCRC should not be disregarded a priori in older patients, who show similar operative and postoperative outcomes as younger patients. However, clinicians should consider that they are at increased risk of postoperative mortality and have a worse overall survival, which may reflect comorbidities and frailty.
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Affiliation(s)
- Nicola de’Angelis
- Unit of Digestive, Hepato-Pancreato-Biliary Surgery, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
- * E-mail:
| | - Capucine Baldini
- Drug Development Department, Gustave Roussy Cancer Campus, University Paris-Saclay, Villejuif, France
| | - Raffaele Brustia
- Department of Hepato-biliary and Liver Transplantation Surgery, Pitié-Salpêtrière University Hospital, APHP, Paris, France
| | - Patrick Pessaux
- Digestive, and Endocrine Surgery, Nouvel Hôpital Civil, Université de Strasbourg, and U1110 Inserm, Institute of Viral and Liver Disease, Strasbourg, France
| | - Daniele Sommacale
- Department of General and Digestive Surgery, Hôpital Robert Debré, Centre Hospitalier Universitaire de Reims, Université de Reims Champagne-Ardenne, Reims, France
| | - Alexis Laurent
- Unit of Digestive, Hepato-Pancreato-Biliary Surgery, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| | - Bertrand Le Roy
- Department of Digestive Surgery, University Hospital of Saint-Etienne, Saint-Priest-en-Jarez, France
| | - Vania Tacher
- Departement of Radiology, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| | - Hicham Kobeiter
- Departement of Radiology, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| | - Alain Luciani
- Departement of Radiology, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| | - Elena Paillaud
- Hopital Europeen Georges Pompidou, Department of Geriatrics, Paris, France
| | - Thomas Aparicio
- Gastroenterology and Digestive Oncology Department, Saint Louis Hospital, AP-HP, and University of Paris, Paris, France
| | - Florence Canuï-Poitrine
- Department of Epidemiology and Biostatistics, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| | - Evelyne Liuu
- Department of Geriatrics, CHU La Milétrie, Poitiers University Hospital, Grand Poitiers, France
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6
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Chu KKW, Chok KSH. Is the treatment outcome of hepatocellular carcinoma inferior in elderly patients? World J Gastroenterol 2019; 25:3563-3571. [PMID: 31367157 PMCID: PMC6658391 DOI: 10.3748/wjg.v25.i27.3563] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/15/2019] [Accepted: 06/23/2019] [Indexed: 02/06/2023] Open
Abstract
In view of the increasing life expectancy in different parts of the world, a larger proportion of elderly patients with hepatocellular carcinoma (HCC) requiring oncological treatment is expected. The clinicopathological characteristics of HCC in elderly patients and in younger patients are different. Elderly patients, in general, also have more comorbidities. Evaluation of the efficacy of different HCC treatment options in elderly patients is necessary to optimize treatment outcomes for them. Treatment modalities for HCC include hepatectomy, liver transplantation, radiofrequency ablation, transarterial chemoembolization, and molecular-targeted therapy with sorafenib. In this review, current evidence on the risks and outcomes of the different HCC treatments for elderly patients are discussed. According to data in the literature, elderly patients and younger patients benefited similarly from HCC treatments. More clinical data are needed for the determination of selecting criteria on elderly HCC patients to maximize their chance of getting the most appropriate and effective treatments. As such, further studies evaluating the outcomes of different HCC treatment modalities in elderly patients are warranted.
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Affiliation(s)
| | - Kenneth Siu Ho Chok
- Department of Surgery and State Key Laboratory for Liver Research, The University of Hong Kong, Hong Kong, China
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7
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Surgical approach and geriatric evaluation for elderly patients with colorectal cancer. Updates Surg 2019; 71:411-417. [PMID: 30953329 DOI: 10.1007/s13304-019-00650-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 03/25/2019] [Indexed: 12/14/2022]
Abstract
This review aims to define the most appropriate surgical approach and geriatric evaluation for elderly patients with colorectal cancer (CRC). Surgery represents the main treatment for CRC, but elderly cancer patients still represent a challenge for the surgeon due to frequent comorbidities such as cardiovascular and pulmonary diseases, which increase operative risk as well as the risk of postoperative morbidity and mortality. Cancer patients with comorbidities show lower survival rates and quality of life, together with higher healthcare costs. There is also evidence that patients with comorbidities sometimes receive modified treatment, compromising optimal care. To optimize treatment, the approach to elderly cancer patients needs a multidisciplinary team to assess preoperative conditions, prevent post-surgical complications and improve outcome, especially for frail patients. Laparoscopic surgery for CRC shows a number of advantages compared to conventional surgery such as less postoperative pain, rapid return to prior activities and a decrease in costs. Recent studies confirm that laparoscopic procedures could be performed safely on both older and younger patients with no difference compared with open surgery as regards morbidity or length of hospital stay.
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8
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Impact of Advanced Age on Survival in Patients Undergoing Resection of Hepatocellular Carcinoma. Ann Surg 2019; 269:692-699. [DOI: 10.1097/sla.0000000000002526] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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9
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Montroni I, Ugolini G, Saur NM, Spinelli A, Rostoft S, Millan M, Wolthuis A, Daniels IR, Hompes R, Penna M, Fürst A, Papamichael D, Desai AM, Cascinu S, Gèrard JP, Myint AS, Lemmens VE, Berho M, Lawler M, De Liguori Carino N, Potenti F, Nanni O, Altini M, Beets G, Rutten H, Winchester D, Wexner SD, Audisio RA. Personalized management of elderly patients with rectal cancer: Expert recommendations of the European Society of Surgical Oncology, European Society of Coloproctology, International Society of Geriatric Oncology, and American College of Surgeons Commission on Cancer. Eur J Surg Oncol 2018; 44:1685-1702. [DOI: 10.1016/j.ejso.2018.08.003] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 07/22/2018] [Accepted: 08/03/2018] [Indexed: 12/23/2022] Open
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10
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Yue M, Li S, Yan G, Li C, Kang Z. Short- and long-term outcomes of laparoscopic hepatectomy for colorectal liver metastases in elderly patients. Cancer Manag Res 2018; 10:2581-2587. [PMID: 30127644 PMCID: PMC6089117 DOI: 10.2147/cmar.s156379] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Purpose This study aimed to evaluate the short- and long-term outcomes of laparoscopic hepatectomy (LH) for colorectal liver metastases (CRLM) in elderly patients. Patients and methods Between January 2009 and January 2016, LH was performed for 241 consecutive patients who were ≥60 years old and had CRLM. Based on their age at the LH, the patients were divided into an elderly group (≥70 years old, 78 patients) and a middle-aged group (60–69 years old, 163 patients). The short- and long-term outcomes were compared between the two groups. Results Compared to the middle-aged group, the elderly group had higher values for Charlson comorbidity index, proportion of preoperative chemotherapy, and American Society of Anesthesiologists score. No other significant differences were observed in the preoperative characteristics. The elderly group had a higher conversion rate, compared to the middle-aged group, although no significant differences were observed in the surgical procedures, surgical times, intraoperative blood losses, numbers and severities of postoperative 90-day complications, postoperative 90-day mortality rates, pathology results, and other short-term outcomes. Long-term follow-up revealed similar rates of recurrence, disease-free survival, and overall survival in the two groups. Multivariable analysis revealed that age did not independently predict overall survival or disease-free survival. Conclusion Similar short- and long-term outcomes were observed after LH for CRLM in elderly and middle-aged patients. Thus, advanced age is not a contraindication for LH treatment in this setting.
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Affiliation(s)
- Meng Yue
- Department of Surgery, First Hospital, JiLin University, Changchun, Jilin, People's Republic of China,
| | - Shiquan Li
- Department of Surgery, First Hospital, JiLin University, Changchun, Jilin, People's Republic of China,
| | - Guoqiang Yan
- Department of Surgery, First Hospital, JiLin University, Changchun, Jilin, People's Republic of China,
| | - Chenyao Li
- Department of Surgery, First Hospital, JiLin University, Changchun, Jilin, People's Republic of China,
| | - Zhenhua Kang
- Department of Surgery, First Hospital, JiLin University, Changchun, Jilin, People's Republic of China,
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van Tuil T, Dhaif AA, Te Riele WW, van Ramshorst B, van Santvoort HC. Systematic Review and Meta-Analysis of Liver Resection for Colorectal Metastases in Elderly Patients. Dig Surg 2018; 36:111-123. [PMID: 29502126 DOI: 10.1159/000487274] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 01/28/2018] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Tim van Tuil
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Ali A Dhaif
- Department of Surgery, Salmaniya Medical Complex, Ministry of Health, Manama, Bahrain
| | - Wouter W Te Riele
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Bert van Ramshorst
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
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12
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Sucandy I, Cheek S, Tsung A, Marsh JW, Geller DA. Minimally invasive liver resection for primary and metastatic liver tumors: influence of age on perioperative complications and mortality. Surg Endosc 2017; 32:1885-1891. [PMID: 29046959 DOI: 10.1007/s00464-017-5880-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 09/11/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND As minimally invasive technique becomes more popular, an increasing number of elderly patients were considered for minimally invasive liver resection (MILR). Limited physiologic reserve remains a major concern, which frequently leads surgeons to recommend nonresectional alternatives. We sought to evaluate complications and outcomes of elderly patients undergoing MILR. METHODS Eight hundred and thirty-one patients who underwent MILR were classified into groups A, B, and C based on age [(< 70, n = 629), (70-79, n = 148), (≥ 80, n = 54) years old, respectively]. RESULTS Gender distribution, BMI, and cirrhotic status were comparable among all groups. Groups B and C had higher MELD (p = 0.047) and ASA (p = 0.001) scores. Operative time (170, 157, 152 min; p = 0.64) and estimated blood loss (145, 130, 145 ml; p = 0.95) were statistically equal. Overall postoperative complications were greater in groups B and C (12.9 and 9.3 vs. 6.5%, respectively). Complications in group C were all minor. Clavien-Dindo grade III-IV complications were higher in group B when compared to group A (6.8 vs. 2.7%, p = 0.43). There was no significant difference in cardiopulmonary complications, thromboembolic events, ICU admissions, and transfusion rates seen in groups B and C when compared to group A. Duration of hospital stay was statistically longer in groups B and C (3.6, 3.5 vs. 2.5 days, p = 0.0012). 30- and 90-day mortality rates were comparable among the groups, irrespective of age. CONCLUSIONS In spite of greater preoperative comorbidities and ASA score, there was no significant increase in postoperative morbidity after minimally invasive liver resection in patients ≥ 70 years of age.
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Affiliation(s)
- Iswanto Sucandy
- University of Pittsburgh Medical Center/UPMC Liver Cancer Center, 3459 Fifth Avenue, UPMC Montefiore, 7-South, Pittsburgh, PA, 15213-2582, USA. .,University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Susannah Cheek
- University of Pittsburgh Medical Center/UPMC Liver Cancer Center, 3459 Fifth Avenue, UPMC Montefiore, 7-South, Pittsburgh, PA, 15213-2582, USA.,University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Allan Tsung
- University of Pittsburgh Medical Center/UPMC Liver Cancer Center, 3459 Fifth Avenue, UPMC Montefiore, 7-South, Pittsburgh, PA, 15213-2582, USA.,University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - J Wallis Marsh
- University of Pittsburgh Medical Center/UPMC Liver Cancer Center, 3459 Fifth Avenue, UPMC Montefiore, 7-South, Pittsburgh, PA, 15213-2582, USA.,University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - David A Geller
- University of Pittsburgh Medical Center/UPMC Liver Cancer Center, 3459 Fifth Avenue, UPMC Montefiore, 7-South, Pittsburgh, PA, 15213-2582, USA.,University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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13
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Synchronous colorectal liver metastases: focus on the elderly. Langenbecks Arch Surg 2017; 402:1223-1232. [DOI: 10.1007/s00423-017-1611-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 07/20/2017] [Indexed: 12/14/2022]
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14
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Kim JH, Min SK, Lee H, Hong G, Lee HK. The safety and risk factors of major hepatobiliary pancreatic surgery in patients older than 80 years. Ann Surg Treat Res 2016; 91:288-294. [PMID: 27904850 PMCID: PMC5128374 DOI: 10.4174/astr.2016.91.6.288] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 07/19/2016] [Accepted: 08/03/2016] [Indexed: 12/30/2022] Open
Abstract
Purpose Recently, the number of elderly patients has increased due to a longer life expectancy. Among these elderly patients, more octogenarians will be diagnosed with major hepatobiliary pancreatic (HBP) diseases. Therefore, we need to evaluate the safety and risk factors of major HBP surgery in patients older than 80 years. Methods From January 2000 to April 2015, patients who underwent major HBP surgery were identified. The patients were divided into 2 groups according to their age at the time of surgery: Group O (≥80 years) and group Y (<80 years). The patient characteristics and intra- and postoperative outcomes were retrospectively investigated in the 2 groups. Results The median age was 84 years (range, 80–95 years) in group O and 61 years (range, 27–79 years) in group Y. group O had worse American Society of Anesthesiologists (ASA) physical status (ASA ≥ III: 23% vs. 7%, P = 0.002) and was associated with a higher rate of hypertension and heart problems as comorbidities. There were significant differences in albumin and BUN, favoring group Y. The length of intensive care unit stay was longer in group O, whereas the overall complication and mortality rates did not show statistical difference. But, there was a significant difference in systemic complication of both Clavien-Dindo classification grade ≥II and ≥III as complications were divided into surgical site complication and systemic complication. Conclusion Major HBP surgery can be performed safely in patients older than 80 years if postoperative management is appropriately provided.
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Affiliation(s)
- Jong Hun Kim
- Department of Surgery, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea
| | - Seog Ki Min
- Department of Surgery, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea
| | - Huisong Lee
- Department of Surgery, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea
| | - Geun Hong
- Department of Surgery, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea
| | - Hyeon Kook Lee
- Department of Surgery, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea
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15
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Kim BJ, Tzeng CWD, Cooper AB, Vauthey JN, Aloia TA. Borderline operability in hepatectomy patients is associated with higher rates of failure to rescue after severe complications. J Surg Oncol 2016; 115:337-343. [PMID: 27807846 DOI: 10.1002/jso.24506] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 10/21/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND/OBJECTIVE To understand the influence of age and comorbidities, this study analyzed the incidence and risk factors for post-hepatectomy morbidity/mortality in patients with "borderline" (BL) operability, defined by the preoperative factors: age ≥75 years, dependent function, lung disease, ascites/varices, myocardial infarction, stroke, steroids, weight loss >10%, and/or sepsis. METHODS All elective hepatectomies were identified in the 2005-2013 ACS-NSQIP database. Predictors of 30-day morbidity/mortality in BL patients were analyzed. RESULTS A 3,574/15,920 (22.4%) patients met BL criteria. Despite non-BL and BL patients undergoing similar magnitude hepatectomies (P > 0.4), BL patients had higher severe complication (SC, 23.3% vs. 15.3%) and mortality rates (3.7% vs. 1.2%, P < 0.001). BL patients with any SC experienced a 14.1% mortality rate (vs. 7.3%, non-BL, P < 0.001). Independent risk factors for SC in BL patients included American Society of Anesthesiologists (ASA) score >3 (odds ratio, OR - 1.29), smoking (OR - 1.41), albumin <3.5 g/dl (OR - 1.36), bilirubin >1 (OR - 2.21), operative time >240 min (OR - 1.58), additional colorectal procedure (OR - 1.78), and concurrent procedure (OR - 1.73, all P < 0.05). Independent predictors of mortality included disseminated cancer (OR - 0.44), albumin <3.5 g/dl (OR - 1.94), thrombocytopenia (OR - 1.95), and extended/right hepatectomy (OR - 2.81, all P < 0.01). CONCLUSIONS Hepatectomy patients meeting BL criteria have an overall post-hepatectomy mortality rate that is triple that of non-BL patients. With less clinical reserve, BL patients who suffer SC are at greater risk of post-hepatectomy death. J. Surg. Oncol. 2017;115:337-343. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Bradford J Kim
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Amanda B Cooper
- Department of Surgery, Penn State College of Medicine, Hershey, Pennsylvania
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Thomas A Aloia
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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16
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Orcutt ST, Massarweh NN, Li LT, Artinyan A, Richardson PA, Albo D, Anaya DA. Patterns of Care for Colorectal Liver Metastasis Within an Integrated Health System: Secular Trends and Outcomes. Ann Surg Oncol 2016; 24:23-30. [PMID: 27342829 DOI: 10.1245/s10434-016-5351-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Utilization of evidence-based treatments for patients with colorectal liver metastasis (CRC-LM) outside high-volume centers is not well-characterized. We sought to describe trends in treatment and outcomes, and identify predictors of therapy within a nationwide integrated health system. METHODS Observational cohort study of patients with CRC-LM treated within the Veterans Affairs (VA) health system (1998-2012). Secular trends and outcomes were compared on the basis of treatment type. Multivariate regression was used to identify predictors of no treatment (chemotherapy or surgery). RESULTS Among 3270 patients, 57.3 % received treatment (chemotherapy and/or surgery) during the study period. The proportion receiving treatment doubled (38 % in 1998 vs. 68 % in 2012; trend test, p < 0.001), primarily driven by increased use of chemotherapy (26 vs. 57 %; trend test, p < 0.001). Among patients having surgery (16 %), the proportion having ablation (10 vs. 61.9 %; trend test, p < 0.001) and multimodality therapy (15 vs. 67 %; trend test, p < 0.001) increased significantly over time. Older patients [65-75 years: odds ratio (OR) 1.65, 95 % confidence interval (CI) 1.39-1.97; >75 years: OR 3.84, 95 % CI 3.13-4.69] and those with high comorbidity index (Charlson ≥3: OR 1.47, 95 % CI 1.16-1.85) were more likely to be untreated. Overall survival was significantly different based on treatment strategy (log-rank p < 0.001). CONCLUSIONS The proportion of CRC-LM patients receiving treatment within the largest integrated health system in the US (VA health system) has increased substantially over time; however, one in three patients still does not receive any treatment. Future initiatives should focus on increasing treatment among older patients as well as on evaluating reasons leading to the no-treatment approach and increased use of ablation procedures.
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Affiliation(s)
- Sonia T Orcutt
- Section of Hepatobiliary Tumors, Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Nader N Massarweh
- Veterans Affairs Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Houston, TX, USA.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Linda T Li
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Avo Artinyan
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Peter A Richardson
- Veterans Affairs Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Houston, TX, USA.,Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Daniel Albo
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Daniel A Anaya
- Section of Hepatobiliary Tumors, Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA. .,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.
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17
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Nardo B, Serafini S, Ruggiero M, Grande R, Fugetto F, Zullo A, Novello M, Rizzuto A, Bonaiuto E, Vaccarisi S, Cavallari G, Serra R, Cannistrà M, Sacco R. Liver resection for metastases from colorectal cancer in very elderly patients: New surgical horizons. Int J Surg 2016; 33 Suppl 1:S135-41. [PMID: 27353843 DOI: 10.1016/j.ijsu.2016.06.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION AND AIM Patients with colorectal cancer (CRC) may develop liver metastases. Surgical resection remains the best treatment of choice for colorectal liver metastases (CRLM) according to resectability criteria, with a long-term survival of 25% up to 41% after 5 years. Advanced age is associated with a higher incidence and co-morbidity, particularly cardiovascular disease, as well as deteriorating physiological reserves. The aim of this study was to analyse the overall and disease-free survival for patients with CRLM according to their chronological age. METHODS Patients with CRLM were enrolled in the study. Data on gender, age, co-morbidity, metastasis characteristics (number, size and total metastatic volume (TMV)), use of perioperative chemotherapy and operative and post-operative complications were collected. Then, according to recent World Health Organization (WHO) guidelines, the patients were grouped by age. Statistical analysis was performed using the software R (ver. 2.14.1). RESULTS Hepatic resection was performed in 149 patients (21 patients in the very elderly group, 79 in the elderly group and 49 in the younger group). The three groups were comparable in terms of operative duration, transfusion rate, length of high-dependency unit (HDU) stay and post-operative hospital stay. The very elderly group showed a non-significant increase in post-operative morbidity. The 30-day and 60-day/inpatient mortality rates increased with age without any significant statistically difference between the three groups (very elderly group 4.8% and 4.8%; elderly group: 2.5% and 3.8%; and younger group 0% and 2%). At 5 years, the overall survival was 28.6% for very elderly patients (≥75 years), 33.3% for elderly patients (≥65 to <75 years) and 43.5% for younger patients (≤65 years). The 1-, 3- and 5-year disease-free survival was similar across the groups. CONCLUSIONS Liver resection for CRLM in carefully selected patients above the age of 75 can be performed with acceptable morbidity and mortality rates, similar to those in younger patients. Moreover, the severity of CRLM in elderly patients is proven to be lesser than in younger patients. Thus, we can conclude that advanced chronological age cannot be considered a contraindication to hepatic resection for CRLM.
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Affiliation(s)
- Bruno Nardo
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Italy; Department of Surgery, Annunziata Hospital of Cosenza, Cosenza, Italy.
| | - Simone Serafini
- Department of Surgery, Annunziata Hospital of Cosenza, Cosenza, Italy.
| | - Michele Ruggiero
- Department of Surgery, Annunziata Hospital of Cosenza, Cosenza, Italy.
| | - Raffaele Grande
- Department of Medical and Surgical Sciences, University of Catanzaro, Italy.
| | - Francesco Fugetto
- Department of Medical and Surgical Science, University of Modena, Italy.
| | - Alessandra Zullo
- Department of Medical and Surgical Sciences, University of Catanzaro, Italy.
| | - Matteo Novello
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Italy.
| | - Antonia Rizzuto
- Department of Medical and Surgical Sciences, University of Catanzaro, Italy.
| | | | | | - Giuseppe Cavallari
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), S. Orsola-Malpighi Hospital, University of Bologna, Italy.
| | - Raffaele Serra
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), S. Orsola-Malpighi Hospital, University of Bologna, Italy.
| | - Marco Cannistrà
- Department of Surgery, Annunziata Hospital of Cosenza, Cosenza, Italy.
| | - Rosario Sacco
- Department of Medical and Surgical Sciences, University of Catanzaro, Italy.
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Xie M, Zhu J, He X, Yang Z, Chen X, Lan P, Lian L. Liver Metastasis from Colorectal Cancer in the Elderly: Is Surgery Justified? Dig Dis Sci 2015; 60:3525-35. [PMID: 26173502 DOI: 10.1007/s10620-015-3789-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 06/29/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND The elderly population with liver metastasis from colorectal cancer has been increasing. As the potentially curative treatment, the role of liver resection in the elderly remains undetermined. AIMS This study provides a meta-analysis on the outcome of liver resection of colorectal liver metastasis in patients aged over 70. METHODS PubMed, Embase, Ovid, Web of Science, and Cochrane databases from the years 2000 to 2015 were searched for eligible studies. Data on perioperative mortality, postoperative complications, and survival were collected. RESULTS Twelve retrospective studies with a total of 11,285 patients (2498 elderly patients and 8787 younger patients) were identified. The elderly (>70 years old) were associated with a similar overall complication rate (30.5 vs. 28.0%; OR 1.08; 95% CI 0.91-1.28; p = 0.39) and a higher 30-day mortality (OR 1.92; 95% CI 1.12-3.31; p = 0.02) after liver resection of colorectal liver metastasis (CRLM). The overall survival showed a significant difference in favor of the younger patients (HR 0.76; 95% CI 0.65-0.89; p = 0.0007). However, with regard to disease-free survival, there was no significant difference between elderly and younger patients (HR 0.93; 95% CI 0.82-1.06; p = 0.30). CONCLUSION Liver resection of CRLM is relatively safe in carefully selected elderly patients. Liver resection should be offered to selected elderly patients with CRLM.
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Affiliation(s)
- Minghao Xie
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Erheng Rd, Guangzhou, 510655, Guangdong, People's Republic of China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Jinling Zhu
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Erheng Rd, Guangzhou, 510655, Guangdong, People's Republic of China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Xiaosheng He
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Erheng Rd, Guangzhou, 510655, Guangdong, People's Republic of China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Zihuan Yang
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
- Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Xinlin Chen
- Department of Preventive Medicine and Biostatistics, Basic Medical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, People's Republic of China
| | - Ping Lan
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Erheng Rd, Guangzhou, 510655, Guangdong, People's Republic of China.
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China.
| | - Lei Lian
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Erheng Rd, Guangzhou, 510655, Guangdong, People's Republic of China.
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China.
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Wang XT, Wang HG, Duan WD, Wu CY, Chen MY, Li H, Huang X, Zhang FB, Dong JH. Pure Laparoscopic Versus Open Liver Resection for Primary Liver Carcinoma in Elderly Patients: A Single-Center, Case-Matched Study. Medicine (Baltimore) 2015; 94:e1854. [PMID: 26512595 PMCID: PMC4985409 DOI: 10.1097/md.0000000000001854] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 08/05/2015] [Accepted: 09/26/2015] [Indexed: 12/13/2022] Open
Abstract
Pure laparoscopic liver resection (PLLR) has been reported to be as safe and effective as open liver resection (OLR) for liver lesions, and it is associated with less intraoperative blood loss, shorter hospital stay, and lower complication rate. However, studies comparing PLLR with OLR in elderly patients were limited. The aim of this study was to analyze the short-term outcome of PLLR versus OLR for primary liver carcinoma (PLC) in elderly patients.Between January 2008 and October 2014, 30 consecutive elderly patients (≥70 years) who underwent PLLR for PLC were included into analysis. Sixty patients who received OLR for PLC during the same study period were also included as a case-matched control group. Patients were well matched in terms of age, sex, comorbid illness, Child Pugh class, American Society of Anesthesiologists grade, tumor size, tumor location, and extent of hepatectomy.No significant differences were observed with regard to patient preoperative baseline status, median tumor size (Group PLLR 4.0 cm vs Group OLR 5.0 cm, P = 0.125), tumor location, extent of hepatectomy, and operation time (Group PLLR 133 minutes vs Group OLR 170 minutes, P = 0.073). Compared with OLR, the PLLR group displayed a significantly less frequent Pringle maneuver application (10.0% vs 70.0%, P < 0.001), less blood loss (100 vs 300 mL; P < 0.001), shorter hospital stay (5 vs 10 days; P < 0.001), and lower total hospitalization cost ($9147.50 vs $10,867.10, P = 0.008). The postoperative complication rates were similar between groups (Group PLLR 10.0% vs Group OLR 16.7%; P = 0.532). There was no hospital mortality in both groups.PLLR for PLC is as safe and feasible as OLR, but with less blood loss, shorter hospital stay, and lower hospitalization cost for selected elderly patients.
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Affiliation(s)
- Xi-Tao Wang
- From the Department of Hepatobiliary Surgery (X-TW, H-GW, W-DD, M-YC, HL, XH, F-B, J-HD), Chinese PLA General Hospital, Beijing; School of Medicine (X-TW, XH, F-B, J-HD), Nankai University, Tianjin; and Institute of Systems Biomedicine (C-YW), Peking University, Beijing, China
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20
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Major Hepatectomy for Colorectal Metastases in the Elderly: A Tertiary Center Experience. Int Surg 2015. [DOI: 10.9738/intsurg-d-14-00155.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The purpose of this retrospective study was to investigate whether patients over 70 years old are at significantly higher risk for worse outcomes following major liver resection. Hepatic resection is the only treatment offering long-term survival for patients with colorectal liver metastases. As the population considered for metastasectomy is aging, there are still controversial published results regarding the safety of major hepatectomy in elderly patients. Between December 2002 and April 2010, 327 patients underwent major liver resection for colorectal liver metastasis. Patients were stratified into 2 groups: group A, <70 years old; and group B, ≥70 years old. Recorded, analyzed, and compared data across groups included the following: (1) patient characteristics including age, sex, American Society of Anesthesiologists performance status, primary tumor site and stage, adjuvant chemotherapy, number and size of metastatic lesions; (2) perioperative data including extent of resection, in-hospital mortality, postoperative morbidity, length of hospital stay, length of intensive treatment unit stay and blood loss; and (3) overall survival. The patients' characteristics were similar as were the characteristics of their tumors. There was no difference in overall morbidity (25% versus 22%) or postoperative mortality (2.6% versus 2.9%) (P = 0.44 and 0.57, respectively). The overall survival was 67% versus 62% in group A and B, respectively (P = 0.09). Elderly patients can safely undergo major liver resection for colorectal liver metastases with short- and long-term outcomes comparable with younger patients.
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21
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Phan K, An VVG, Ha H, Phan S, Lam V, Pleass H. Hepatic resection for malignant liver tumours in the elderly: a systematic review and meta-analysis. ANZ J Surg 2015; 85:815-22. [DOI: 10.1111/ans.13211] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2015] [Indexed: 12/13/2022]
Affiliation(s)
- Kevin Phan
- Sydney Medical School; The University of Sydney; Sydney New South Wales Australia
- Department of Surgery; Westmead Hospital; Sydney New South Wales Australia
- St Vincent's Clinical School; The University of New South Wales; Sydney New South Wales Australia
| | - Vincent Vinh Gia An
- Sydney Medical School; The University of Sydney; Sydney New South Wales Australia
- Department of Surgery; Westmead Hospital; Sydney New South Wales Australia
| | - Hakeem Ha
- St Vincent's Clinical School; The University of New South Wales; Sydney New South Wales Australia
| | - Steven Phan
- Sydney Medical School; The University of Sydney; Sydney New South Wales Australia
| | - Vincent Lam
- Sydney Medical School; The University of Sydney; Sydney New South Wales Australia
- Department of Surgery; Westmead Hospital; Sydney New South Wales Australia
| | - Henry Pleass
- Sydney Medical School; The University of Sydney; Sydney New South Wales Australia
- Department of Surgery; Westmead Hospital; Sydney New South Wales Australia
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Abstract
BACKGROUND With the increase in average life expectancy in recent decades, the proportion of elderly patients requiring liver surgery is rising. The aim of the meta-analysis reported here was to evaluate the safety and efficacy of hepatectomy in elderly patients. METHODS An extensive electronic search was performed for relevant articles that compare the outcomes of hepatectomy in patients ≥70 years of age with those in younger patients prior to October 2012. Analysis of pooled data was performed with RevMan 5.0. RESULTS Twenty-eight observational studies involving 15,480 patients were included in the analysis. Compared with the younger patients, elderly patients experienced more complications (31.8 vs 28.7 %; P = 0.002), mainly as a result of increased cardiac complications (7.5 vs 1.9 %; P < 0.001) and delirium (11.7 vs 4.5 %; P < 0.001). Postoperative major surgical complications (12.6 vs 11.3 %; P = 0.55) and mortality (3.6 vs 3.3 %; P = 0.68) were comparable between elderly and younger patients. For patients with malignancies, both the 5-year disease-free survival (26.5 vs 26.3 %; P = 0.60) and overall survival (39.5 vs 40.7 %; P = 0.29) did not differ significantly between the two groups. CONCLUSIONS Postoperative major surgical complications, mortality, and long-term results in elderly patients seem to be comparable with those in younger patients, suggesting that age alone should not be considered a contraindication for hepatectomy.
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Narita M, Oussoultzoglou E, Bachellier P, Jaeck D, Uemoto S. Post-hepatectomy liver failure in patients with colorectal liver metastases. Surg Today 2015; 45:1218-26. [DOI: 10.1007/s00595-015-1113-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 11/04/2014] [Indexed: 12/17/2022]
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Yang S, Alibhai SMH, Kennedy ED, El-Sedfy A, Dixon M, Coburn N, Kiss A, Law CHL. Optimal management of colorectal liver metastases in older patients: a decision analysis. HPB (Oxford) 2014; 16:1031-42. [PMID: 24961482 PMCID: PMC4487755 DOI: 10.1111/hpb.12292] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 04/22/2014] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Simon Yang
- Division of General Surgery, University of TorontoToronto, ON
| | - Shabbir MH Alibhai
- Department of Medicine, University Health NetworkToronto, ON,Department of Health Policy Management & Evaluation, University of TorontoToronto, ON
| | - Erin D Kennedy
- Division of General Surgery, University of TorontoToronto, ON,Department of Health Policy Management & Evaluation, University of TorontoToronto, ON,Division of General Surgery, Mount Sinai HospitalToronto, ON
| | - Abraham El-Sedfy
- Department of Surgery, Saint Barnabas Medical CenterLivingston, NJ
| | - Matthew Dixon
- Department of Surgery, Maimonides Medical CenterBrooklyn, NY
| | - Natalie Coburn
- Division of General Surgery, University of TorontoToronto, ON,Department of Health Policy Management & Evaluation, University of TorontoToronto, ON,Division of General Surgery, Sunnybrook Health Sciences CentreToronto, ON
| | - Alex Kiss
- Department of Health Policy Management & Evaluation, University of TorontoToronto, ON,Institute for Clinical Evaluative SciencesToronto, ON
| | - Calvin HL Law
- Division of General Surgery, University of TorontoToronto, ON,Department of Health Policy Management & Evaluation, University of TorontoToronto, ON,Division of General Surgery, Sunnybrook Health Sciences CentreToronto, ON,Correspondence, Calvin H.L. Law, Division of General Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Suite T2-025, Toronto, Ontario, Canada M4N 3M5. Tel: +1 416 480 4825. Fax: +1 416 480 5804. E-mail:
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25
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Vargas GM, Parmar AD, Sheffield KM, Tamirisa NP, Brown KM, Riall TS. Impact of liver-directed therapy in colorectal cancer liver metastases. J Surg Res 2014; 191:42-50. [PMID: 24990539 PMCID: PMC4134714 DOI: 10.1016/j.jss.2014.05.070] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 05/20/2014] [Accepted: 05/23/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND There is a paucity of data on the current management and outcomes of liver-directed therapy (LDT) in older patients presenting with stage IV colorectal cancer (CRC). The aim of the study was to evaluate treatment patterns and outcomes in use of LDT in the setting of improved chemotherapy. METHODS We used Cancer Registry and linked Medicare claims to identify patients aged ≥66 y undergoing surgical resection of the primary tumor and chemotherapy after presenting with stage IV CRC (2001-2007). LDT was defined as liver resection and/or ablation-embolization. RESULTS We identified 5500 patients. LDT was used in 34.9% of patients; liver resection was performed in 1686 patients (30.7%), and ablation-embolization in 554 patients (10.1%), with 322 patients having both resection and ablation-embolization. Use of LDT was negatively associated with increasing year of diagnosis (odds ratio [OR] = 0.96, 95% confidence interval [CI] 0.93-0.99), age >85 y (OR = 0.61, 95% CI 0.45-0.82), and poor tumor differentiation (OR = 0.73, 95% CI 0.64-0.83). LDT was associated with improved survival (median 28.4 versus 21.1 mo, P < 0.0001); however, survival improved for all patients over time. We found a significant interaction between LDT and period of diagnosis and noted a greater survival improvement with LDT for those diagnosed in the late (2005-2007) period. CONCLUSIONS Older patients with stage IV CRC are experiencing improved survival over time, independent of age, comorbidity, and use of LDT. However, many older patients deemed to be appropriate candidates for resection of the primary tumor and receipt of systemic chemotherapy did not receive LDT. Our data suggest that improved patient selection may be positively impacting outcomes. Early referral and optimal selection of patients for LDT has the potential to further improve survival in older patients presenting with advanced colorectal cancer.
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Affiliation(s)
- Gabriela M Vargas
- Department of Surgery, The University of Texas Medical Branch, Galveston, Texas.
| | - Abhishek D Parmar
- Department of Surgery, The University of Texas Medical Branch, Galveston, Texas; Department of Surgery, The University of California, Oakland, California
| | - Kristin M Sheffield
- Department of Surgery, The University of Texas Medical Branch, Galveston, Texas
| | - Nina P Tamirisa
- Department of Surgery, The University of Texas Medical Branch, Galveston, Texas; Department of Surgery, The University of California, Oakland, California
| | - Kimberly M Brown
- Department of Surgery, The University of Texas Medical Branch, Galveston, Texas
| | - Taylor S Riall
- Department of Surgery, The University of Texas Medical Branch, Galveston, Texas
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Laparoscopic major hepatectomy for colorectal liver metastases in elderly patients: a single-center, case-matched study. Surg Endosc 2014; 29:1368-75. [PMID: 25149638 DOI: 10.1007/s00464-014-3806-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 08/06/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND The incidence of colorectal cancer liver metastases (CRLM) among elderly patients has increased; therefore, older patients are increasingly being considered for hepatic resection. However, data regarding the outcome of laparoscopic major hepatectomy (LMH) in elderly patients are limited. The aim of this study was to evaluate the safety and feasibility of LMH in elderly patients with CRLM. METHODS From January 1998 to September 2013, a total of 31 patients aged ≥ 70 years (elderly group) were matched with 62 patients < 70 years (young group) by demographics, tumor characteristics, and details of surgical procedures. RESULTS The elderly group was characterized by a higher incidence of hypertension (41.9 vs. 17.7 %, P = 0.022), ≥ 2 comorbidities (32.3 vs. 11.3 %, P = 0.021), and lower prevalence of metastatic rectal cancer (12.9 vs. 38.7 %, P = 0.015). Intraoperative variables, such as surgical duration (300 vs. 240 min, P = 0.920), blood loss (400 vs. 300 mL, P = 0.361), and transfusion rate (9.7 vs. 12.9 %, P = 0.726), were not notably different between the groups. Postoperative mortality (0 vs. 0 %), complications (54.8 vs. 41.9 %, P = 0.276), and major complications (27.4 vs. 16.1 %, P = 0.303, respectively) were comparable between the groups. The 3-year overall survival rates were 61.7 % in the young group (median 40 months) and 57.9 % in the elderly group (median 39 months), respectively (P = 0.842). CONCLUSIONS Our results clearly demonstrated that LMH for CRLM could be safely performed in elderly patients; thus, advanced age itself should not be regarded as a contraindication for LMH.
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Tzeng CWD, Cooper AB, Vauthey JN, Curley SA, Aloia TA. Predictors of morbidity and mortality after hepatectomy in elderly patients: analysis of 7621 NSQIP patients. HPB (Oxford) 2014; 16:459-68. [PMID: 24033514 PMCID: PMC4008164 DOI: 10.1111/hpb.12155] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Accepted: 06/03/2013] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Increasingly, surgeons are performing hepatectomies in older patients. This study was designed to analyse the incidences of and risk factors for post-hepatectomy morbidity and mortality in elderly patients. METHODS All elective hepatectomies for the period 2005-2010 recorded in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database were evaluated. Factors associated with 30-day rates of morbidity and mortality were compared between patients aged ≥75 years and those aged <75 years. RESULTS Elderly patients accounted for 894 of 7621 (11.7%) hepatectomies. These patients more frequently had comorbidities (diabetes, cardiovascular or lung disease, lower albumin, elevated creatinine, anaesthesia risk; all P < 0.05) and were more likely to undergo partial or left rather than right or extended hepatectomies (P = 0.013). Despite the lesser surgical magnitude of these procedures, elderly patients experienced higher rates of severe complications (23.9% versus 18.4%; P < 0.001) and overall postoperative mortality (4.8% versus 2.0%; P < 0.001). The occurrence of any severe complication was associated with a mortality rate of 20.1% in elderly patients and 10.8% in non-elderly patients (P < 0.001). This disparity in mortality was more pronounced in patients with two or more (31.7% versus 20.2%; P < 0.001) and three or more (46.3% versus 31.1%; P < 0.001) severe complications. Independent risk factors for severe complications and/or mortality included an albumin level of < 4 g/dl, lung disease, intraoperative transfusion, a concurrent intra-abdominal operation, and an operative time of >240 min (all P < 0.05). CONCLUSIONS Given their lower physiologic reserve, elderly patients are at much greater risk for mortality after severe complications. To improve outcomes, surgeons should balance age and preoperative comorbidities with magnitude of hepatectomy.
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Affiliation(s)
| | | | | | | | - Thomas A Aloia
- Correspondence Thomas A. Aloia, Department of Surgical Oncology, Unit 1484, University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX 77030, USA. Tel: + 1 713 563 0189. Fax: + 1 713 745 1921. E-mail:
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Ugolini G, Ghignone F, Zattoni D, Veronese G, Montroni I. Personalized surgical management of colorectal cancer in elderly population. World J Gastroenterol 2014; 20:3762-3777. [PMID: 24833841 PMCID: PMC3983435 DOI: 10.3748/wjg.v20.i14.3762] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Revised: 12/09/2013] [Accepted: 01/05/2014] [Indexed: 02/06/2023] Open
Abstract
Colorectal cancer (CRC) in the elderly is extremely common but only a few clinicians are familiar with the complexity of issues which present in the geriatric population. In this phase of the life cycle, treatment is frequently suboptimal. Despite the fact that, nowadays, older people tend to be healthier than in previous generations, surgical undertreatment is frequently encountered. On the other hand, surgical overtreatment in the vulnerable or frail patient can lead to unacceptable postoperative outcomes with high mortality or persistent disability. Unfortunately, due to the geriatric patient being traditionally excluded from randomized controlled trials for a variety of factors (heterogeneity, frailty, etc.), there is a dearth of evidence-based clinical guidelines for the management of these patients. The objective of this review was to summarize the most relevant clinical studies available in order to assist clinicians in the management of CRC in the elderly. More than in any other patient group, both surgical and non-surgical management strategies should be carefully individualized in the elderly population affected by CRC. Although cure and sphincter preservation are the primary goals, many other variables need to be taken into account, such as maintenance of cognitive status, independence, life expectancy and quality of life.
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Adham M, Bredt LC, Robert M, Perinel J, Lombard-Bohas C, Ponchon T, Valette PJ. Pancreatic resection in elderly patients: should it be denied? Langenbecks Arch Surg 2014. [DOI: https:/doi.org/10.1007/s00423-014-1183-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Pancreatic resection in elderly patients: should it be denied? Langenbecks Arch Surg 2014; 399:449-59. [PMID: 24671518 DOI: 10.1007/s00423-014-1183-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 03/11/2014] [Indexed: 02/08/2023]
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Mizuguchi T, Kawamoto M, Meguro M, Okita K, Ota S, Ishii M, Ueki T, Nishidate T, Kimura Y, Furuhata T, Hirata K. Impact of aging on morbidity and mortality after liver resection: a systematic review and meta-analysis. Surg Today 2014; 45:259-70. [PMID: 24526292 DOI: 10.1007/s00595-014-0863-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 12/26/2013] [Indexed: 02/06/2023]
Abstract
Surgery involving elderly patients is becoming increasingly common due to the rapid aging of societies all over the world. The objective of this study was to elucidate the prognostic differences between elderly and young patients who undergo liver resection. A systematic review based on the PRISMA flow diagram was conducted. Ovid Medline and PubMed were used to search for relevant literature published between January 2000 and March 2013, and the modified MINORS score was used to assess the methodological quality. In cases of hepatocellular carcinoma and miscellaneous liver tumors, the morbidity and mortality rate did not differ significantly between the elderly and young patients. For patients with colorectal metastatic liver cancer, the mortality of the young patients was 2.7 times lower than that of elderly patients. Our review of high-quality retrospective studies was able to elucidate the clinical risks of age on the outcomes after liver surgery in specific patient populations.
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Affiliation(s)
- Toru Mizuguchi
- Department of Surgery I, Sapporo Medical University School of Medicine, Sapporo Medical University Hospital, Sapporo Medical University, S-1, W-16, Chuo-Ku, Sapporo, Hokkaido, 060-8543, Japan,
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Parikh AA, Ni S, Koyama T, Pawlik TM, Penson D. Trends in the multimodality treatment of resectable colorectal liver metastases: an underutilized strategy. J Gastrointest Surg 2013; 17:1938-46. [PMID: 24018590 DOI: 10.1007/s11605-013-2325-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 08/17/2013] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Advances in multimodality therapy have led to increased survival for patients with metastatic colorectal cancer, but the impact on patients undergoing resection for colorectal liver metastases is unclear. The purpose of this study was to evaluate patterns of treatment for resectable colorectal liver metastases in the USA over the last two decades. METHODS Using the Surveillance, Epidemiology, and End Results-Medicare database, 1,926 patients who underwent hepatic resection for colorectal liver metastasis between 1991 and 2007 were included and divided into two cohorts: period 1 (1991-2000) and period 2 (2001-2007). Demographic data, treatment patterns, and outcomes of the two periods were compared by univariate methods. Multivariable regression models were constructed to predict the use of perioperative chemotherapy, postoperative complications, and 90-day mortality following liver resection. RESULTS The overall use of perioperative chemotherapy was 33 % and did not differ between periods, but shifted from postoperative to preoperative over time. By multivariable analysis, older age, black race, stage III primary cancer, and metachronous disease were predictive of lesser likelihood of chemotherapy use. The use of preoperative chemotherapy was not associated with any increase in perioperative morbidity or mortality. CONCLUSIONS Despite increased survival and widespread recommendations for the use of multimodality therapy, the overall resection rate and use of perioperative chemotherapy for resectable colorectal liver metastases remain underutilized and have not increased over time. Efforts to investigate barriers to the widespread use of multimodality therapy for these patients are warranted.
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Affiliation(s)
- Alexander A Parikh
- Department of Surgery, Vanderbilt University School of Medicine, Nashville, TN, USA,
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Orcutt ST, Artinyan A, Li LT, Silberfein EJ, Berger DH, Albo D, Anaya DA. Postoperative mortality and need for transitional care following liver resection for metastatic disease in elderly patients: a population-level analysis of 4026 patients. HPB (Oxford) 2012; 14:863-70. [PMID: 23134189 PMCID: PMC3521916 DOI: 10.1111/j.1477-2574.2012.00577.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2012] [Accepted: 08/23/2012] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The goal of this study was to characterize the association of age with postoperative mortality and need for transitional care following hepatectomy for liver metastases. METHODS A retrospective cohort study using the Nationwide Inpatient Sample (2005-2008) was performed. Patients undergoing hepatectomy for liver metastases were categorized by age as: Young (aged <65 years); Old (aged 65-74 years), and Oldest (aged ≥75 years). Multivariate logistic regression analyses were performed to identify predictors of in-hospital mortality and need for transitional care (non-home discharge). RESULTS A total of 4026 patients were identified; 36.6% (n = 1475) were elderly (aged ≥65 years). Rates of in-hospital mortality and non-home discharge increased with advancing age group [1.3% vs. 2.2% vs. 3.3% (P = 0.005) and 2.1% vs. 6.1% vs. 18.3% (P < 0.001), respectively]. Independent predictors of in-hospital mortality were age within the Oldest category [odds ratio (OR) 2.21, 95% confidence interval (CI) 1.19-4.12] and a Deyo Comorbidity Index score of ≥3 (OR 6.95, 95% CI 3.55-13.60). Independent predictors for need for transitional care were age within the Old group (OR 2.44, 95% CI 1.66-3.58), age within the Oldest group (OR 8.48, 95% CI 5.87-12.24), a Deyo score of 1 (OR 2.00, 95% CI 1.40-2.85), a Deyo score of 2 (OR 4.70, 95% CI 2.93-7.56), a Deyo score of ≥3 (OR 6.41, 95% CI 3.67-11.20), and female gender (OR 1.56, 95% CI 1.15-2.11). CONCLUSIONS Although increasing age was associated with higher risk for in-hospital mortality, the absolute risk was low and within accepted ranges, and comorbidity was the primary driver of mortality. Conversely, need for transitional care was significantly more common in elderly patients. Therefore, liver resection for metastases is safe in well-selected elderly patients, although consideration should be made for potential transitional care needs.
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Affiliation(s)
- Sonia T Orcutt
- Department of Surgery, Division of Surgical Oncology, Baylor College of MedicineHouston, TX, USA
| | - Avo Artinyan
- Department of Surgery, Division of Surgical Oncology, Baylor College of MedicineHouston, TX, USA,Operative Care Line, Michael E. DeBakey Veterans Affairs Medical CenterHouston, TX, USA
| | - Linda T Li
- Department of Surgery, Division of Surgical Oncology, Baylor College of MedicineHouston, TX, USA,Houston Veterans Affairs Health Services Research and Development Center of ExcellenceHouston, TX, USA
| | - Eric J Silberfein
- Department of Surgery, Division of Surgical Oncology, Baylor College of MedicineHouston, TX, USA,General Surgery, Ben Taub General HospitalHouston, TX, USA
| | - David H Berger
- Department of Surgery, Division of Surgical Oncology, Baylor College of MedicineHouston, TX, USA,Houston Veterans Affairs Health Services Research and Development Center of ExcellenceHouston, TX, USA
| | - Daniel Albo
- Department of Surgery, Division of Surgical Oncology, Baylor College of MedicineHouston, TX, USA
| | - Daniel A Anaya
- Department of Surgery, Division of Surgical Oncology, Baylor College of MedicineHouston, TX, USA,Houston Veterans Affairs Health Services Research and Development Center of ExcellenceHouston, TX, USA
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Ramacciato G, D'Angelo F, Baldini R, Petrucciani N, Antolino L, Aurello P, Nigri G, Bellagamba R, Pezzoli F, Balesh A, Cucchetti A, Cescon M, Gaudio MD, Ravaioli M, Pinna AD. 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. Am Surg 2012. [DOI: 10.1177/000313481207800438] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Giovanni Ramacciato
- Faculty of Medicine and Psychology St. Andrea Hospital, Hepato-biliary and Pancreatic Surgery
| | - Francesco D'Angelo
- Faculty of Medicine and Psychology St. Andrea Hospital, Hepato-biliary and Pancreatic Surgery
| | - Rossella Baldini
- Department of Statistical Sciences, Sapienza University of Rome, Rome, Italy
| | - NiccolÒ Petrucciani
- Faculty of Medicine and Psychology St. Andrea Hospital, Hepato-biliary and Pancreatic Surgery
| | - Laura Antolino
- Faculty of Medicine and Psychology St. Andrea Hospital, Hepato-biliary and Pancreatic Surgery
| | - Paolo Aurello
- Faculty of Medicine and Psychology St. Andrea Hospital, Hepato-biliary and Pancreatic Surgery
| | - Giuseppe Nigri
- Faculty of Medicine and Psychology St. Andrea Hospital, Hepato-biliary and Pancreatic Surgery
| | - Riccardo Bellagamba
- Faculty of Medicine and Psychology St. Andrea Hospital, Hepato-biliary and Pancreatic Surgery
| | - Francesca Pezzoli
- Faculty of Medicine and Psychology St. Andrea Hospital, Hepato-biliary and Pancreatic Surgery
| | - Albert Balesh
- Faculty of Medicine and Psychology St. Andrea Hospital, Hepato-biliary and Pancreatic Surgery
| | - Alessandro Cucchetti
- University of Bologna, Sant'Orsola-Malpighi Hospital, Liver and Multi-Organ Transplantation Unit, Bologna, Italy
| | - Matteo Cescon
- University of Bologna, Sant'Orsola-Malpighi Hospital, Liver and Multi-Organ Transplantation Unit, Bologna, Italy
| | - Massimo Del Gaudio
- University of Bologna, Sant'Orsola-Malpighi Hospital, Liver and Multi-Organ Transplantation Unit, Bologna, Italy
| | - Matteo Ravaioli
- University of Bologna, Sant'Orsola-Malpighi Hospital, Liver and Multi-Organ Transplantation Unit, Bologna, Italy
| | - Antonio Daniele Pinna
- University of Bologna, Sant'Orsola-Malpighi Hospital, Liver and Multi-Organ Transplantation Unit, Bologna, Italy
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Di Benedetto F, Berretta M, D'Amico G, Montalti R, De Ruvo N, Cautero N, Guerrini GP, Ballarin R, Spaggiari M, Tarantino G, Di Sandro S, Pecchi A, Luppi G, Gerunda GE. Liver resection for colorectal metastases in older adults: a paired matched analysis. J Am Geriatr Soc 2012; 59:2282-90. [PMID: 22188075 DOI: 10.1111/j.1532-5415.2011.03734.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To assess the safety and long-term results of hepatic resection of colorectal liver metastases (CLM) in older adults. DESIGN Case-control. SETTING Single liver and multivisceral transplant center. PARTICIPANTS Individuals with CLM: 32 aged 70 and older (older group) and 32 younger than 70 (younger group) matched in a 1:1 ratio according to sex, primary tumor site, liver metastases at diagnosis, number of metastases, maximum tumor size, infiltration of cut margin, type of hepatic resection, and hepatic resection timing. MEASUREMENTS Postoperative complications and survival rates. RESULTS There was no significant difference in preoperative clinical findings between the two study groups. The incidence of cumulative postoperative complications was similar in the older (28.1%) and younger (34.4%) groups (P = .10). One-, 3-, and 5-year disease-free survival rates were 57.6%, 32.9%, and 16.4%, respectively, in the younger group and 67.9%, 29.2%, and 19.5%, respectively, in the older group (P = .72). One-, 3-, and 5-year participant survival rates were 84.1%, 51.9%, and 33.3%, respectively, in the older group and 93.6%, 63%, and 28%, respectively, in the younger group (P = .50). CONCLUSIONS Resection of colorectal liver metastases in older adults can be performed with low mortality and morbidity and offers a long-time survival advantage to many of these individuals. Based on the results of this case-control study, older adults should be considered for surgical treatment whenever possible.
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Affiliation(s)
- Fabrizio Di Benedetto
- Liver and Multivisceral Transplant Center, Hepatopancreatic and Biliary Surgery, University of Modena and Reggio Emilia, Modena, Italy.
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Mayo SC, Heckman JE, Shore AD, Nathan H, Parikh AA, Bridges JFP, Anders RA, Anaya DA, Becker NS, Pawlik TM. Shifting trends in liver-directed management of patients with colorectal liver metastasis: a population-based analysis. Surgery 2011; 150:204-16. [PMID: 21801959 PMCID: PMC3568532 DOI: 10.1016/j.surg.2011.06.013] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Accepted: 06/14/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND We sought to evaluate population-based temporal trends in perioperative management, as well as short- and long-term outcomes associated with the operative management of colorectal liver metastasis (CRLM). METHODS Using Surveillance, Epidemiology and End Results-Medicare linked data, we identified 2,121 patients with operatively managed CRLM between 1991 and 2006. Clinicopathologic data, trends in operative management, and survival were examined. RESULTS Preoperative evaluation included computed tomography (CT; 66%), magnetic resonance imaging (MRI; 5%), and positron emission tomography (PET; 2%) with a temporal increase in the use of all 3 modalities over time (all P < .05). Patients undergoing hepatectomy only (n = 1,267; 60%) decreased over time, whereas the use of ablation alone (n = 668; 32%) and combined resection plus ablation (n = 186; 9%) increased (all P < .05). The use of both preoperative (10% to 16%) and adjuvant chemotherapy (35% to 47%) increased over time (P < .05). There was a marked temporal increase in patient comorbidities (>3 comorbidities: 1991-1995, 3%; 2003-2006, 12%; P < .001); however, perioperative complications (63%) and 30-day mortality (3%) did not change over time (both P > .05); 90-day mortality decreased from 9% to 7% over the study period (P = .007). Overall the 1-, 3-, and 5-year survivals were 74%, 42%, and 28% with no improvement over time (P = .19). On multivariate analysis, synchronous disease (hazard ratio [HR], 1.7) and use of ablation alone (HR, 1.2) were associated independently with a worse survival (both P < .05). CONCLUSION Most patients were evaluated with CT; PET was employed rarely. Although there was a temporal increase in chemotherapy utilization, only one half of patients received perioperative chemotherapy. Mortality associated with hepatic operations was low, but morbidity remained high with no temporal change despite an increased number of patient medical comorbidities.
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Affiliation(s)
- Skye C. Mayo
- Department of Surgery, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Jennifer E. Heckman
- Department of Surgery, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Andrew D. Shore
- Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Hari Nathan
- Department of Surgery, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Alexander A. Parikh
- Department of Surgery, Vanderbilt University School Of Medicine, Nashville, TN
| | - John F. P. Bridges
- Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Robert A. Anders
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniel A. Anaya
- Department of Surgery, Baylor College Of Medicine, Houston, TX
| | | | - Timothy M. Pawlik
- Department of Surgery, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Cannon RM, Martin RCG, Callender GG, McMasters KM, Scoggins CR. Safety and efficacy of hepatectomy for colorectal metastases in the elderly. J Surg Oncol 2011; 104:804-8. [PMID: 21792943 DOI: 10.1002/jso.22042] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2011] [Accepted: 07/05/2011] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES The aim of this study was to determine the safety and efficacy of hepatic metastasectomy in elderly patients with colorectal liver metastases (CLM). METHODS A retrospective review of a hepatobiliary database was performed on consecutive patients treated with metastasectomy for CLM. Patients were stratified by age (<70 years old vs. ≥70). Patient and tumor characteristics as well as operative factors were compared, as were morbidity, mortality, and length of stay. Logistic regression and Cox proportional hazards were used to evaluate the association of age and postoperative outcomes. RESULTS There were 59 elderly (median age 75) and 220 non-elderly (median age 58) patients analyzed over a 13 year period. The Charlson comorbidity index was higher in the elderly group (mean 4.7 vs. 4.4 P = 0.005). Postoperative morbidity and mortality were 52.5 and 0% vs. 48.2 and 4.1% in the elderly and non-elderly groups, respectively (P = 0.56 and P = 0.21). There were no differences in median DFS (21.8 months vs. 28.9 months; P = 0.157) or OS (36 months vs. 47.7 months; P = 0.070) between the elderly and non-elderly groups, respectively. CONCLUSIONS Age itself does not appear to be a significant contraindication to liver resection, including major hepatectomy, when patients are appropriately selected.
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Affiliation(s)
- Robert M Cannon
- Division of Surgical Oncology, Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
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Rahbari NN, Garden OJ, Padbury R, Brooke-Smith M, Crawford M, Adam R, Koch M, Makuuchi M, Dematteo RP, Christophi C, Banting S, Usatoff V, Nagino M, Maddern G, Hugh TJ, Vauthey JN, Greig P, Rees M, Yokoyama Y, Fan ST, Nimura Y, Figueras J, Capussotti L, Büchler MW, Weitz J. Posthepatectomy liver failure: A definition and grading by the International Study Group of Liver Surgery (ISGLS). Surgery 2011; 149:713-24. [PMID: 21236455 DOI: 10.1016/j.surg.2010.10.001] [Citation(s) in RCA: 1533] [Impact Index Per Article: 117.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2010] [Accepted: 10/18/2010] [Indexed: 12/13/2022]
Affiliation(s)
- Nuh N Rahbari
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
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Cho SW, Steel J, Tsung A, Marsh JW, Geller DA, Gamblin TC. Safety of liver resection in the elderly: how important is age? Ann Surg Oncol 2010; 18:1088-95. [PMID: 21046265 DOI: 10.1245/s10434-010-1404-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2010] [Indexed: 12/15/2022]
Abstract
BACKGROUND With the aging population, more elderly patients are being considered for hepatic resection. We investigated whether advanced age was associated with higher rate and severity of postoperative complications. METHODS A total of 75 patients aged ≥70 years (group E) were matched with 75 patients aged <70 years (group Y) by the extent of liver resection and by operative indications. Primary outcome measures were rates and severity of complications. Secondary outcome measures were length of hospital stay and discharge destination. Univariate analysis was also performed to identify variables associated with higher surgical risk. RESULTS Male-to-female ratio was 43:32 in both groups. Overall complication rates were 44 and 33.3% in group E and Y, respectively (P = 0.241; odds ratio = 1.57; 95% confidence interval [95% CI], 0.81-3.05). There was no mortality in both groups. The only postoperative age-related morbidity was confusion in the elderly. There was no difference in the rates of severe complications (grade ≥3) between group E and group Y (16 vs. 14.7%; P = 0.744; odds ratio = 1.11; 95% CI, 0.46-2.70). Median length of hospital stay were 7 and 6 days, respectively (P = 0.01). Nineteen percent and 1% of patients in group E and group Y were discharge to rehabilitation facilities, respectively (P = 0.001). Univariate analysis showed that preoperative systemic chemotherapy and longer operative time were associated with higher morbidity in the elderly. CONCLUSIONS Liver resection can be performed in patients aged ≥70 years as safely as in younger patients. Duration and timing of systemic chemotherapy before liver resection should be optimized to minimize postoperative morbidity.
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Affiliation(s)
- S W Cho
- UPMC Liver Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Reddy SK, Clary BM. A New Era in Defining Indications for Resectability of Colorectal Cancer Liver Metastases. CURRENT COLORECTAL CANCER REPORTS 2010. [DOI: 10.1007/s11888-010-0049-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
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Tamandl D, Gruenberger B, Herberger B, Kaczirek K, Gruenberger T. Surgery after neoadjuvant chemotherapy for colorectal liver metastases is safe and feasible in elderly patients. J Surg Oncol 2009; 100:364-71. [PMID: 19235181 DOI: 10.1002/jso.21259] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Surgery for colorectal liver metastases is part of the endeavor to cure metastatic colorectal cancer (mCRC). Neoadjuvant chemotherapy increases progression free survival in resectable patients. The safety and feasibility of this concept has not been investigated in elderly patients. METHODS We performed a comparative analysis of data from 244 patients who were resected for colorectal liver metastases between 1999 and 2004 at our institution. Seventy patients were aged 70 or older; they form the basis of this analysis. RESULTS Twenty-nine patients received neoadjuvant chemotherapy (oxaliplatin-based chemotherapy (XELOX), 19; 5-fluorouracil (5-FU), 10) prior to surgery. XELOX was associated with higher response rates to chemotherapy (CR + PR: XELOX 68% vs. 5-FU 0%, P = 0.001), and responding patients had a better overall (OS, P < 0.001) and recurrence free survival (RFS, P < 0.001) compared to others. Response to neoadjuvant chemotherapy was the only factor on multivariate analysis predicting longer OS and RFS (P = 0.01 and P = 0.001). CONCLUSION Neoadjuvant chemotherapy can be administered safely in patients older than 70 years and appears to be effective in prolonging long-term outcome. Patients responding to neoadjuvant treatment have a significantly better prognosis after liver resection.
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Affiliation(s)
- Dietmar Tamandl
- Department of Surgery, Hepatobiliary Service, Medical University Vienna, Vienna, Austria
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Chiappa A, Makuuchi M, Lygidakis NJ, Zbar AP, Chong G, Bertani E, Sitzler PJ, Biffi R, Pace U, Bianchi PP, Contino G, Misitano P, Orsi F, Travaini L, Trifirò G, Zampino MG, Fazio N, Goldhirsch A, Andreoni B. The management of colorectal liver metastases: Expanding the role of hepatic resection in the age of multimodal therapy. Crit Rev Oncol Hematol 2009; 72:65-75. [PMID: 19147371 DOI: 10.1016/j.critrevonc.2008.11.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2008] [Accepted: 11/12/2008] [Indexed: 02/06/2023] Open
Abstract
Colorectal cancer (CRC) caused nearly 204,000 deaths in Europe in 2004. Despite recent advances in the treatment of advanced disease, which include the incorporation of two new cytotoxic agents irinotecan and oxaliplatin into first-line regimens, the concept of planned sequential therapy involving three active agents during the course of a patient's treatment and the integrated use of targeted monoclonal antibodies, the 5-year survival rates for patients with advanced CRC remain unacceptably low. For patients with colorectal liver metastases, liver resection offers the only potential for cure. This review, based on the outcomes of a meeting of European experts (surgeons and medical oncologists), considers the current treatment strategies available to patients with CRC liver metastases, the criteria for the selection of those patients most likely to benefit and suggests where future progress may occur.
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Affiliation(s)
- A Chiappa
- Department of General Surgery-Laparoscopic Surgery, University of Milano, European Institute of Oncology, Milano, Italy.
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Abstract
BACKGROUND AND AIMS As the mean life expectancy rises, the incidence of patients 75 years of age and older who present with colorectal liver metastases continues to increase. The purpose of our study was to evaluate the outcome of major hepatic resections in the elderly population. PATIENT AND METHODS From April 1998 to December 2006, 572 consecutive patients with colorectal liver metastases were treated at our Institution. Of these, 59 were 75 years or older. There was an intent to proceed with major liver resections in all cases. Data were analyzed according to diagnosis, comorbidities, extent of liver resection, postoperative complications, overall survival, and disease-free survival. RESULTS Surgical treatment included right hepatectomies (n = 8), left hepatectomies (n = 4), and sectionectomies (more than three segments; n = 33). Fourteen (n = 14) patients received an explorative laparotomy alone. Morbidity and hospital mortality were 10% and 3%, respectively. Overall survival of 1, 3, and 5 years was 90%, 64%, and 33%, respectively. The corresponding disease-free survival was 74%, 42%, and 32%. Resection margin (R class) was the only predictor of survival by both uni- and multivariate analyses. CONCLUSION Hepatic resections can be performed safely in selected patients 75 years of age or older.
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Ijtsma AJC, Boevé LMS, van der Hilst CS, de Boer MT, de Jong KP, Peeters PMJG, Gouw ASH, Porte RJ, Slooff MJH. The survival paradox of elderly patients after major liver resections. J Gastrointest Surg 2008; 12:2196-203. [PMID: 18651195 DOI: 10.1007/s11605-008-0563-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2008] [Accepted: 06/04/2008] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The objective of this study is to assess the outcome of liver resections in the elderly in a matched control analysis. PATIENTS AND METHODS From a prospective single center database of 628 patients, 132 patients were aged 60 years or over and underwent a primary major liver resection. Of these patients, 93 could be matched one-to-one with a control patient, aged less than 60 years, with the same diagnosis and the same type of liver resection. The mean age difference was 16.7 years. RESULTS Patients over 60 years of age had a significantly higher American Society of Anaesthesiologists (ASA) grade. All other demographics and operative characteristics were not different. In-hospital mortality and morbidity were higher in the patients over 60 years of age (11% versus 2%, p = 0.017 and 47% versus 31%, p = 0.024). One-, 3-, and 5-year survival rates in the patients over 60 years of age were 81%, 58%, and 42%, respectively, compared to 90%, 59%, and 42% in the control patients (p = 0.558). Unified model Cox regression analysis showed that resection margin status (hazard ratio 2.51) and ASA grade (hazard ratio 2.26), and not age, were determining factors for survival. CONCLUSION This finding underlines the important fact that in patient selection for major liver resections, ASA grade is more important than patient age.
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Affiliation(s)
- Alexander J C Ijtsma
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, P.O. Box 30.001, The Netherlands.
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Schiesser M, Chen JWC, Maddern GJ, Padbury RTA. Perioperative morbidity affects long-term survival in patients following liver resection for colorectal metastases. J Gastrointest Surg 2008; 12:1054-60. [PMID: 18085344 DOI: 10.1007/s11605-007-0438-y] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2007] [Accepted: 11/14/2007] [Indexed: 01/31/2023]
Abstract
BACKGROUND Hepatic resection is the treatment of choice in patients with colorectal liver metastases. Perioperative morbidity is associated with decreased long-term survival in several cancers. The aim of this study was to assess the impact of perioperative morbidity and other prognostic factors on the outcome of patients undergoing liver resection for colorectal metastases. METHODS One hundred ninety seven patients undergoing liver resection with curative intent were investigated. The influence of prognostic factors, such as complications, tumor stage, margins, age, sex, number of lesions, transfusion, portal inflow obstruction, and era and type of resection, was assessed using univariate and multivariate analysis. Complications were graded using an objective surgical complication classification. RESULTS The 5-year survival rate was 38%, with a median follow up of 4.5 years. The disease-free survival rate at 5 years was 23%. The perioperative morbidity and mortality rates were 30 and 2.5%, respectively. The median survival of patients with perioperative complications was 3.2 years, compared to 4.4 years in those patients without complications (p < 0.01). For patients with positive resection margins, the median survival was 2.1 years, compared 4.4 years in patients with a margin (p = 0.019). CONCLUSION Perioperative morbidity and a positive resection margin had a negative impact on long-term survival in patients following liver resection for colorectal metastases.
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Affiliation(s)
- M Schiesser
- Department of Visceral and Transplantation Surgery, University Hospital of Zurich, Zurich, Switzerland
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Mann CD, Neal CP, Pattenden CJ, Metcalfe MS, Garcea G, Dennison AR, Berry DP. Major resection of hepatic colorectal liver metastases in elderly patients – An aggressive approach is justified. Eur J Surg Oncol 2008; 34:428-32. [PMID: 17466484 DOI: 10.1016/j.ejso.2007.03.013] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2007] [Accepted: 03/15/2007] [Indexed: 12/12/2022] Open
Abstract
AIMS With a progressively ageing population, increasing numbers of elderly patients will present with colorectal metastases and be referred for surgical resection. The aim of this study was to assess the safety of hepatic resection in patients over 70 years of age by comparing outcomes with those of a younger cohort of patients. METHODS Forty-nine patients over 70 years of age who underwent hepatic resection of colorectal liver metastases were compared to 142 patients less than 70 years of age in terms of pre-, peri- and post-operative results, as well as long-term survival. RESULTS Major resections were performed in 61% of the elderly group and 68% of the younger group. The two groups were comparable in terms of operative duration, transfusion rate, length of HDU stay and post-operative hospital stay. The elderly group had a non-significant increase in post-operative morbidity. The 30-day and 60-day/inpatient mortality rates were similar between the two groups (elderly 0% and 4%; younger 2% and 3%). Long-term disease-free survival was similar between elderly and younger patients. CONCLUSION This study confirms that an aggressive surgical policy towards colorectal metastases in elderly patients is associated with low peri-operative morbidity and mortality, as well as good long-term outcomes.
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Affiliation(s)
- C D Mann
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, University Hospitals of Leicester, Gwendolen Road, Leicester, LE5 4PW, UK.
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Bruce C, Köhne CH, Audisio RA. Treatment of advanced colorectal cancer in the elderly. Eur J Surg Oncol 2007; 33 Suppl 2:S84-7. [PMID: 18006266 DOI: 10.1016/j.ejso.2007.09.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2007] [Accepted: 09/26/2007] [Indexed: 11/18/2022] Open
Abstract
The recent improved survival in advanced colorectal cancer, owing in a large part to advances in adjuvant treatment, has mainly been reported in studies of younger patient groups. Less is known about outcome in elderly patients, the fastest growing cohort of cancer patients. The antimetabolite capecitabine used sequentially or concomitantly with the topoisomerase 1 inhibitor irinotecan or the DNA cross linking agent oxaliplatin are now considered to be the standard first line chemotherapy regime. The role of surgery in advanced colorectal cancer in the elderly is restricted to the relief of bowel obstruction and where appropriate resection of hepatic metastasis. Advanced chronological age has not been shown to be a contraindication to the consideration of these interventions. Indeed, chronological age alone does not provide sufficient guidance when considering the appropriateness of any palliative treatment regime in the elderly.
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Affiliation(s)
- C Bruce
- Mersey Deanery, Liverpool, UK
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Cummings LC, Payes JD, Cooper GS. Survival after hepatic resection in metastatic colorectal cancer: a population-based study. Cancer 2007; 109:718-26. [PMID: 17238180 DOI: 10.1002/cncr.22448] [Citation(s) in RCA: 228] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Hepatectomy is the standard of care for patients with colorectal cancer who have isolated hepatic metastases; however, the long-term survival benefits of hepatectomy in this population have not been characterized well outside of case series. For the current study, a population-based database was used to compare the survival of patients with liver metastases from colorectal cancer who did and did not undergo hepatectomy. METHODS Patients aged >or=65 years with incident colorectal cancer who were diagnosed from 1991 to 2001 were identified from the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Liver metastasis diagnoses, colorectal resections, and hepatectomies were identified from hospital, outpatient, and physician-supplier claims. Patients who did not undergo colorectal resection were excluded. Five-year survival from the time of cancer diagnosis was determined by the Kaplan-Meier method. Cox proportional hazards models were used to evaluate survival. RESULTS Among 13,599 patients who were identified with incident colorectal cancer and liver metastases, 7673 patients (56.4%) presented with stage IV disease, and the remaining patients presented with earlier stage disease and developed subsequent metastases. Only 833 patients (6.1%) in the cohort underwent hepatic resection, and their 30-day mortality rate was 4.3%. The 5-year survival was 32.8% among patients who underwent hepatic resection, compared with 10.5% among patients who did not undergo hepatic resection (P < .0001), and better survival was observed in the subset of patients who presented initially with disease in stages I through III. In a Cox model, which was controlled for age, sex, race, comorbidities, and stage at presentation, lack of hepatic resection was associated with a 2.78-fold increased risk of death. CONCLUSIONS Although hepatectomy rates among patients with colorectal cancer were low, hepatic resection was associated with improved survival.
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Affiliation(s)
- Linda C Cummings
- Division of Gastroenterology, Department of Medicine, University Hospitals Case Medical Center, Cleveland, Ohio 44106, USA.
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Tamandl D, Gruenberger B, Herberger B, Schoppmann S, Bodingbauer M, Schindl M, Puhalla H, Fleischmann E, Schima W, Jakesz R, Laengle F, Gruenberger T. Selective resection of colorectal liver metastases. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2006; 33:174-82. [PMID: 17046194 DOI: 10.1016/j.ejso.2006.09.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2006] [Accepted: 09/06/2006] [Indexed: 11/26/2022]
Abstract
AIMS Safety of liver surgery for colorectal cancer liver metastases after neoadjuvant chemotherapy has to be re-evaluated. PATIENTS AND METHODS Two hundred Patients were prospectively analyzed after surgery for colorectal cancer liver metastases between 2001 and 2004 at our institution. Special emphasis was given to perioperative morbidity and mortality under modern perioperative care. RESULTS There was no in-hospital mortality and the perioperative morbidity was 10% (20/200). Four patients had to be reoperated due to bile leak or intraabdominal abscess. The remainder either had infectious complications or pleural effusion and/or ascites requiring tapping. Variables strongly associated with decreased survival were T, N, G and UICC (International Union against cancer) classification of the primary, hepatic lesions>5 cm and elevated tumour markers. Short disease free interval and neoadjuvant chemotherapy without response predicted impaired recurrence free survival (RFS). Multivariate analysis revealed lymph node status and differentiation of the primary, presence of extrahepatic tumour and gender as factors associated with decreased survival. Administration of neoadjuvant chemotherapy was not associated with higher postoperative morbidity or prolonged hospital stay. CONCLUSIONS Modern dissection techniques and improved perioperative care contributed to a very low rate of surgery-related morbidity (10%) and a zero percent mortality which was also observed in patients pretreated with neoadjuvant chemotherapy prior to resection. Liver resection in experienced hands has become a safe part in the potentially curative attempt of treating patients with metastatic colorectal cancer.
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Affiliation(s)
- D Tamandl
- Department of Surgery, Hepatobiliary Service, Vienna Medical University, Währinger Gürtel 18-20, 1090 Vienna, Austria.
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Gallego R, Sanchez N, Maurel J. Chemotherapy for elderly patients with advanced colorectal carcinoma. Expert Rev Anticancer Ther 2006; 6:795-800. [PMID: 16759169 DOI: 10.1586/14737140.6.5.795] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
There is an increasing need to redefine treatment strategies in elderly patients with advanced colorectal carcinoma since they constitute more than 50% of newly diagnosed patients. Taking into account that the vast majority of clinical trials in advanced colorectal carcinoma include patients up to 75 years old, it seems reasonable to consider those patients over 75 years as elderly. In general, 20% of patients have favorable factors (fewer than four liver nodules less than 5 cm in size) and are suitable for local treatments (surgery or local-ablative therapies). Additionally, 40% of patients have poor performance status or are severely disabled owing to geriatric syndromes and/or comorbid diseases (advanced stage) that preclude any treatment strategies. The remainder of patients (fit elderly patients not suitable for radical treatments) constitute the focus of this review.
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Affiliation(s)
- Rosa Gallego
- Medical Oncology Service, Villarroel 170, 08036, Barcelona, Catalonia, Spain
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