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

Survival analysis and identification of prognostic factors in colorectal liver metastasis after liver resection

INTRODUCTION

Liver resection is the only curative treatment for colorectal liver metastasis. The identification of predictive factors leads to personalize patient management to enhance their long-term outcomes. This population-based study aimed to characterize factors associated with, and survival impact of patients who received hepatectomy for colorectal liver metastasis.

METHODS

A retrospective cohort study of all the hepatectomies for colorectal liver metastasis performed at third-level hospital of Spain (2010-2018) was conducted. The Kaplan-Meier method was used for survival analyses. Multivariable Cox and regression models were used to determine prognostic factors associated with overall survival.

RESULTS

The 5-year overall survival and disease-free survival were 42 and 33%, respectively. Survival analysis showed that metastasis features (number, largest size, distribution, and extrahepatic disease) and postsurgical factors (transfusion, major complications, and positive margin resection), as well as non-mutated KRAS, showed a significant association with survival. Otherwise, on multivariate analysis, only 5 independent risk factors were identified: major size metastasis >4 cm, RAS mutation, positive margin resection, intraoperative transfusion, and major complications.

CONCLUSIONS

According to our findings, major size metastasis >4 cm, intraoperative transfusion, and major postoperative complications continue to be traditional prognostic factors. Meanwhile, the KRAS biomarker has a powerful impact as a survival prognostic factor.

Repeated hepatic resection for colorectal liver metastases: is this concept safe and feasible?

Background

The beneficial outcomes of hepatectomy in patients with colorectal metastases have encouraged the attempts of repeated hepatectomy in patients with recurrent disease. Although studies have provided encouraging results regarding perioperative outcomes and survival rates following repeated hepatectomy, it remains unclear whether the reported outcomes reflect the therapeutic results of redo hepatectomy or rather reflect the effect of selection bias. The aim of this study was to investigate differences among patients who underwent single and repeated hepatectomy and to hereby identify prognostic factors that contribute to the premises of repeated resection.

Methods

Patients who underwent hepatectomy due to colorectal metastases were listed in a retrospective database. Study participants were divided into a single partial hepatectomy group, a multiple partial hepatectomies group, and into subgroups of two or more than two hepatectomies.

Results

A total of 338 patients with 439 partial liver resections were included in the analysis. The overall survival rate after 1, 3, and 5 years was 89%, 56%, and 36%, respectively. The survival benefit in patients who underwent multiple partial liver resections versus those with a single partial resection was 10%, 16%, and 4% after 1, 3, and 5 years, respectively. Repeated hepatectomy was not associated with increased rates of surgical and non-surgical complications.

Conclusion

Beneficial outcomes have been found in terms of median overall survival and perioperative morbidity in patients with recurrence of colorectal hepatic metastases after partial and tissue-sparing repeated liver resections.

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

PURPOSE

The prolonged life expectancy and increase in aging of the population have led surgeons to propose hepatectomy in the elderly population. In this study, we evaluate the surgical outcome of octogenarians in a single French center.

METHODS

Between 2000 and 2020, 78 patients over 80 years old were retrospectively analyzed. The risk factors of major complications (Clavien-Dindo ≥ grade IIIa) and patient performance after surgery by using textbook outcome (TO) (no surgical complications, no prolonged hospital stay (≤ 15 days), no readmission ≤90 days after discharge, and no mortality ≤90 days after surgery) were studied.

RESULTS

The main surgical indication was for malignancy (96%), including mainly colorectal liver metastases (n = 41; 53%) and hepatocellular carcinoma (n = 22; 28%), and major hepatectomy was performed in 28 patients (36%). There were 6 (8%) postoperative mortalities. The most frequent complications were pulmonary (n = 22; 32%), followed by renal insufficiency (n = 22; 28%) and delirium (n = 16; 21%). Major complications occurred in 19 (24%) patients. On multivariate analysis, the main risk factors for major complications were the median vascular clamping time (0 vs 35; P = 0.04) and male sex (P = 0.046). TO was ultimately achieved in 30 patients (38%), and there was no prognostic factor for achievement of TO.

CONCLUSIONS

Hepatectomy in octogenarians is associated with acceptable morbidity and mortality. Meanwhile, prolonged hepatic pedicle clamping should be avoided especially if hepatectomy is planned in a male patient.

Systematic Review of Treatments for Colorectal Metastases in Elderly Patients to Guide Surveillance Cessation Following Hepatic Resection for Colorectal Liver Metastases

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.

Surgical and regional treatments for colorectal cancer metastases in older patients: A systematic review and meta-analysis

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.

Short-term autonomy and survival after hepatectomy in the elderly

AIM

To study morbi-mortality, survival after hepatectomy in elderly patients, and influence on their short-term autonomy.

PATIENTS AND METHODS

This is a retrospective study conducted between 2002 and 2017 comparing patients less than 65 years old (controls) to those more than 65 years old (cases) from a prospective database, with retrospective collection of geriatric data. Cases were divided into three sub-groups (65-70 years, 70-80 years and>80 years).

RESULTS

Four hundred and eighty-two patients were included. There was no age difference in number of major hepatectomies (P=0.5506), length of stay (P=0.3215), mortality at 90 days (P=0.3915), and surgical complications (P=0.1467). There were more Grade 1 Clavien medical complications among the patients aged over 65 years (P=0.1737). There was no difference in overall survival (P=0.460) or disease-free survival (P=0.108) according to age after adjustment for type of disease and hepatectomy. One-third of patients had geriatric complications. The "home discharge" rate decreased significantly with age from 92% to 68% (P=0.0001). Early loss of autonomy after hospitalization increased with age, 16% between 65 and 70 years, 23% between 70 and 80 years and 36% after 80 years (P=0.10). We identified four independent predictors of loss of autonomy: age>70 years, cholangiocarcinoma, length of stay>10 days, and metachronous colorectal cancer.

CONCLUSIONS

Elderly patients had the same management as young patients, with no difference in surgery or survival, but with an increase in early loss of autonomy.

Does an extreme age (≥80 years) affect outcomes in patients after liver cancer surgery? A meta-analysis

BACKGROUND

Increasing global life expectancy has resulted in a greater demand for cancer surgery in aged patients. However, whether extreme age causes poorer clinical outcomes remains unclear. This meta-analysis aimed to evaluate the impact of extreme age (≥80 years) on outcomes in patients after liver cancer surgery.

METHODS

A systematic search was performed to enrol relevant studies. Data were analysed using fixed-effects or random-effects models. Eight retrospective studies involving 253 participants older than 80 years were included.

RESULTS

Compared with younger patients, patients of extreme age (≥80 years) who had undergone curative liver cancer surgery experienced less operating time and blood loss (both P < 0.0001); a larger size (weighted mean difference = 0.48 cm, 95% confidence interval (CI) 0.08-0.87 cm; P = 0.02) and more advanced stage of hepatocellular carcinoma (risk ratio (RR) = 1.20, 95% CI 1.04-1.39; P = 0.01); a higher overall morbidity (RR = 1.24, 95% CI 1.05-1.47; P = 0.01); and more post-operative ileus (POI) (RR = 3.45, 95% CI 1.03-11.56; P = 0.04), delirium (RR = 3.04, 95% CI 1.36-6.78; P = 0.007) and cardiovascular events (RR = 6.17, 95% CI 2.79-13.60; P < 0.00001). No significant difference was noted in overall (hazard ratio (HR) = 1.15, 95% CI 0.87-1.53; P = 0.32) or disease-free (HR = 0.96, 95% CI 0.75-1.24; P = 0.77) survival.

CONCLUSION

Although an extreme age may not be a contraindication for undertaking liver cancer surgery, it may cause more morbidity. Perioperative intervention should be considered for prevention and early treatment of POI, delirium and cardiovascular events.