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Yu M, Lu L, Wu R. Perihilar cholangiocarcinoma resection: Is it beneficial for survival in elderly patients? GASTROENTEROLOGIA Y HEPATOLOGIA 2024; 47:691-701. [PMID: 37806347 DOI: 10.1016/j.gastrohep.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/25/2023] [Accepted: 10/03/2023] [Indexed: 10/10/2023]
Abstract
INTRODUCTION As the population ages, surgeons are growing frequently faced with hard choices among a vast array of treatment options for the elderly. This study was to investigate safety and efficacy of resection in elderly patients with perihilar cholangiocarcinoma (PHCC). PATIENTS AND METHODS Literature reading and meta-analysis unveiled that elderly PHCC patients held a higher risk of death within 90 days after hepatectomy relative to younger patients, but their 5-year overall survival and disease-free survival were comparable. Among PHCC patients who underwent hepatectomy, the proportion of elderly patients with tumor classification Bismuth I-II and tumor stage pStage 1-3 was significantly higher than that of younger patients. RESULTS Curative resection R0 was more common in elderly patients than younger patients, but the difference was not statistically significant. Because of more comorbidities and less physiological reserve of elderly patients, they seemed to suffer more postoperative complications. CONCLUSION Considering improved life expectancy, it is crucial to treat elderly PHCC patients appropriately and attempts should be made to radical surgery based on comorbidities and functional status.
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Affiliation(s)
- Min Yu
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, China.
| | - Lina Lu
- Digestive Department, Jinhua Wenrong Hospital, Jinhua, China
| | - Rongjin Wu
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, China
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Gajdos C, Ryan C, Savulionyte G, Schwaitzberg S, Nader N. Liver resection versus ablation in geriatric populations - Does one method impart improved in-hospital mortality? Turk J Surg 2024; 40:47-53. [PMID: 39035997 PMCID: PMC11257722 DOI: 10.47717/turkjsurg.2024.6358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 03/11/2024] [Indexed: 07/23/2024]
Abstract
Objectives This study aimed to compare surgical resection versus ablation for managing liver malignancies in patients 65 and older. Material and Methods Cases with liver tumors were extracted from the NSQIP database for patients aged ≥65 years. Following propensity score matching, multivariate Cox regression was used for 30-day morbidity and mortality for liver resection and ablation. Results Following a propensity score matching, 1048 patients were 1:1 matched for comorbid conditions. Patients stayed in the hospital three days longer after resection (p<0.001). Mortality was lower after ablation (p= 0.013). This difference was more prominent in patients with primary liver tumors (p= 0.008). Group A had a 10-fold lower risk of developing an abdominal abscess, a fourfold decrease in hospital-associated pneumonia (p= 0.001) and reintubation, a 10-fold reduction in bleeding requiring transfusion (p<0.001), and a three-fold decrease in risk of developing sepsis (p<0.001). Conclusion Despite being a generally sicker patient population with worse underlying liver function, ablative techniques were associated with a lower risk of adverse outcomes when compared to more aggressive resection of primary malignant tumors of the liver.
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Affiliation(s)
- Csaba Gajdos
- Department of Surgery, Buffalo University Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
| | - Carrie Ryan
- Department of Surgery, Buffalo University Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
| | - Goda Savulionyte
- Department of Surgery, Buffalo University Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
| | - Steven Schwaitzberg
- Department of Surgery, Buffalo University Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
| | - Nader Nader
- Department of Anesthesiology, Buffalo University Jacobs Faculty of Medicine and Biomedical Scinces, Buffalo, USA
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Merath K, Tiwari A, Court C, Parikh A, Dillhoff M, Cloyd J, Ejaz A, Pawlik TM. Postoperative Liver Failure: Definitions, Risk factors, Prediction Models and Prevention Strategies. J Gastrointest Surg 2023; 27:2640-2649. [PMID: 37783906 DOI: 10.1007/s11605-023-05834-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 09/07/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND Liver resection is the treatment for a variety of benign and malignant conditions. Despite advances in preoperative selection, surgical technique, and perioperative management, post hepatectomy liver failure (PHLF) is still a leading cause of morbidity and mortality following liver resection. METHODS A review of the literature was performed utilizing MEDLINE/PubMed and Web of Science databases in May of 2023. The MESH terms "liver failure," "liver insufficiency," and "hepatic failure" in combination with "liver surgery," "liver resection," and "hepatectomy" were searched in the title and/or abstract. The references of relevant articles were reviewed to identify additional eligible publications. RESULTS PHLF can have devastating physiological consequences. In general, risk factors can be categorized as patient-related, primary liver function-related, or perioperative factors. Currently, no effective treatment options are available and the management of PHLF is largely supportive. Therefore, identifying risk factors and preventative strategies for PHLF is paramount. Ensuring an adequate future liver remnant is important to mitigate risk of PHLF. Dynamic liver function tests provide more objective assessment of liver function based on the metabolic capacity of the liver and have the advantage of easy administration, low cost, and easy reproducibility. CONCLUSION Given the absence of randomized data specifically related to the management of PHLF, current strategies are based on the principles of management of acute liver failure from any cause. In addition, goal-directed therapy for organ dysfunction, as well as identification and treatment of reversible factors in the postoperative period are critical.
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Affiliation(s)
- Katiuscha Merath
- Division of Surgical Oncology, University of Texas Health Science Center San Antonio MD Anderson Cancer Center, San Antonio, TX, USA
| | - Ankur Tiwari
- Division of Surgical Oncology, University of Texas Health Science Center San Antonio MD Anderson Cancer Center, San Antonio, TX, USA
| | - Colin Court
- Division of Surgical Oncology, University of Texas Health Science Center San Antonio MD Anderson Cancer Center, San Antonio, TX, USA
| | - Alexander Parikh
- Division of Surgical Oncology, University of Texas Health Science Center San Antonio MD Anderson Cancer Center, San Antonio, TX, USA
| | - Mary Dillhoff
- Department of Surgery, Division of Surgical Oncology, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12Th Ave., Suite 670, Columbus, OH, USA
| | - Jordan Cloyd
- Department of Surgery, Division of Surgical Oncology, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12Th Ave., Suite 670, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, Division of Surgical Oncology, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12Th Ave., Suite 670, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12Th Ave., Suite 670, Columbus, OH, USA.
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Ahmed FA, Khan SA, Hafeez MS, Jehan FS, Aziz H. Outcomes in elderly patients undergoing hepatic resection compared to ablative therapy for hepatocellular carcinoma. J Surg Oncol 2023; 128:803-811. [PMID: 37288805 DOI: 10.1002/jso.27369] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 05/21/2023] [Accepted: 05/27/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND AND OBJECTIVES Hepatic resection is an excellent option in the care of patients with hepatocellular carcinoma (HCC). Elderly patients often forego hepatic resection in favor of liver-directed ablative therapies due to the increased likelihood of adverse postoperative outcomes due to age. We sought to determine long-term outcomes in patients who underwent hepatic resection compared to liver-directed ablative therapy in this patient population. METHODS We queried the National Cancer Database for elderly patients (≥70 years) diagnosed with HCC between 2004 and 2018. The primary outcome was overall survival (OS) computed using the Kaplan-Meier method and Cox proportional hazard regression. RESULTS A total of 10 032 patients were included in this analysis. On unadjusted analysis (p < 0.001) as well as multivariable analysis (hazard ratio: 0.65, 95% confidence interval: 0.57-0.73), hepatic resection was associated with improved OS. The protective association between hepatic resection and OS persisted after 1:1 propensity score matching. CONCLUSIONS Hepatic resection is associated with improved survival for well-selected elderly patients with HCC. While age is often thought of as influencing the decision to offer surgery, our study, in combination with others, demonstrates that it should not. Instead, other objective indicators of performance and functional status may be considered.
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Affiliation(s)
- Fasih A Ahmed
- Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Sameer A Khan
- Department of Surgery, University of Pennsylvania Hospitals System, Philadelphia, Pennsylvania, USA
| | - Muhammad S Hafeez
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Faisal S Jehan
- Department of Surgery, Westchester Medical Center-New York Medical College, Valhalla, New York, USA
| | - Hassan Aziz
- Division of Transplant and Hepatobiliary Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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Patkar S, Agarwal J, Kunte A, Pandrowala S, Goel M. Oncologic Liver Resections in a Geriatric Population: Peri-operative, Long-Term and Quality-of-Life Outcomes-Experience from a High-Volume Centre in India. World J Surg 2023; 47:1049-1057. [PMID: 36627459 DOI: 10.1007/s00268-023-06895-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/25/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Elderly patients can often be overlooked as candidates for a major hepatic resection, by virtue of their age. To enable better patient selection for hepatic resections in this age group, we analysed the outcomes of liver resections in elderly patients to identify any potential prognostic factors. METHODS We conducted a retrospective review of a prospectively maintained database of hepatic resections from 1 January 2010 to 31 October 2021 and analysed the post-operative outcomes in patients aged 65 years or older. Short-term outcomes were analysed in terms of length of hospital stay, 90-day major morbidity, and 90-day mortality. Long-term outcome was defined by the disease-free survival, overall survival and quality of life. RESULTS Over a period of 11 years, 170 elderly patients underwent oncologic liver resections, of which 68 (40%) underwent a major hepatectomy. The overall morbidity and mortality rates were 32.8% and 5.3%, respectively. Extent of hepatic resection, increasing age, concomitant resection of other organs and a biliary-enteric anastomosis were independent predictors for poor immediate post-operative outcomes. Median disease-free survival and overall survival were 30 months and 78 months, respectively. The global health status was excellent in majority of patients with a mean score of 88.62. CONCLUSION Major oncologic liver resections can be performed in well-selected geriatric population with acceptable peri-operative, long-term and quality-of-life outcomes.
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Affiliation(s)
- Shraddha Patkar
- Department of Surgical Oncology - GI and HPB Services, Tata Memorial Hospital, Homi Bhabha National Institute, Ernest Borges Marg, Parel, Mumbai, 400012, India
| | - Jasmine Agarwal
- Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Ernest Borges Marg, Parel, Mumbai, 400012, India
| | - Aditya Kunte
- Department of Surgical Oncology - GI and HPB Services, Tata Memorial Hospital, Homi Bhabha National Institute, Ernest Borges Marg, Parel, Mumbai, 400012, India
| | - Saneya Pandrowala
- Department of Surgical Oncology - GI and HPB Services, Tata Memorial Hospital, Homi Bhabha National Institute, Ernest Borges Marg, Parel, Mumbai, 400012, India
| | - Mahesh Goel
- Department of Surgical Oncology - GI and HPB Services, Tata Memorial Hospital, Homi Bhabha National Institute, Ernest Borges Marg, Parel, Mumbai, 400012, India.
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Tanaka S, Kubo S, Ishizawa T. Positioning of Minimally Invasive Liver Surgery for Hepatocellular Carcinoma: From Laparoscopic to Robot-Assisted Liver Resection. Cancers (Basel) 2023; 15:cancers15020488. [PMID: 36672437 PMCID: PMC9856586 DOI: 10.3390/cancers15020488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 01/09/2023] [Accepted: 01/11/2023] [Indexed: 01/15/2023] Open
Abstract
Laparoscopic liver resection (LLR) is widely accepted in the surgical treatment of hepatocellular carcinoma (HCC) through international consensus conferences and the development of difficulty classifications. LLR has been reported to result in earlier postoperative recovery and fewer postoperative complications than open liver resection (OLR) for HCC. However, the prevalence of liver cirrhosis, obesity, the elderly, HCC recurrence (repeat liver resection), and major resection must be considered for LLR for HCC. Some systematic reviews, meta-analysis studies, and large cohort studies indicated that LLR is technically feasible for selected patients with HCC with these factors that led to less intraoperative blood loss, fewer transfusions and postoperative complication incidences, and shorter hospital stays than OLR. Furthermore, some reported LLR prevents postoperative loss of independence. No difference was reported in long-term outcomes among patients with HCC who underwent LLR and OLR; however, some recent reports indicated better long-term outcomes with LLR. In recent years, robot-assisted liver resection (RALR) has gradually become popular, and its short- and long-term results for HCC are not different from those of LLR. Additionally, RALR is expected to become the mainstay of minimally invasive surgery in the future.
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Affiliation(s)
- Shogo Tanaka
- Correspondence: ; Tel.: +81-6-6645-3841; Fax: +81-6-6646-6057
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Jaén-Torrejimeno I, López-Guerra D, Rojas-Holguín A, De-Armas-Conde N, Blanco-Fernández G. Surgical treatment of liver hydatid cyst in elderly patients: A propensity score-matching retrospective cohort study. Acta Trop 2022; 232:106466. [PMID: 35460646 DOI: 10.1016/j.actatropica.2022.106466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/16/2022] [Accepted: 04/11/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Cystic echinococcosis is a clinically complex chronic parasitic disease and a major socioeconomic problem in endemic areas. The safety of liver resection in elderly patients is often debated among medical professionals. We analyzed the postoperative morbidity and mortality rates of elderly patients who underwent surgery at our unit. METHODS We retrospectively evaluated patients with liver hydatid cysts which were surgically removed at our unit. Patients were divided into two groups: Group 1 (patients < 70 years), and Group 2 (patients ≥ 70 years). Propensity score matching (PSM) and comparative analyses between groups were performed. RESULTS The unmatched cohort consisted of 279 patients (Group 1: 244; Group 2: 35). After PSM, we compared the outcomes for 56 patients from Group 1 to 31 patients from Group 2. A higher rate of severe complications was observed in Group 2 (25.8% vs 5.36%, p = 0.014). No difference was found in the rates of infectious, cardiorespiratory, or hemorrhagic complications between both groups, and in the mortality rate either (0.00% vs 6.45%, p = 0.124). CONCLUSIONS Liver surgery in selected elderly patients is safe and practicable. The low postoperative morbidity rate in these patients is acceptable, albeit higher, due to their comorbidities.
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Affiliation(s)
- Isabel Jaén-Torrejimeno
- Hospital Universitario de Badajoz. Servicio de Cirugía Hepatobiliopancreática y Trasplante Hepático. Avda. Elvas sn. 06080 Badajoz. España
| | - Diego López-Guerra
- Universidad de Extremadura. Facultad de Medicina y Ciencias de la Salud. Avda. de Elvas sn. 06006. Badajoz. España; Hospital Universitario de Badajoz. Servicio de Cirugía Hepatobiliopancreática y Trasplante Hepático. Avda. Elvas sn. 06080 Badajoz. España
| | - Adela Rojas-Holguín
- Universidad de Extremadura. Facultad de Medicina y Ciencias de la Salud. Avda. de Elvas sn. 06006. Badajoz. España; Hospital Universitario de Badajoz. Servicio de Cirugía Hepatobiliopancreática y Trasplante Hepático. Avda. Elvas sn. 06080 Badajoz. España
| | - Noelia De-Armas-Conde
- Hospital Universitario de Badajoz. Servicio de Cirugía Hepatobiliopancreática y Trasplante Hepático. Avda. Elvas sn. 06080 Badajoz. España
| | - Gerardo Blanco-Fernández
- Universidad de Extremadura. Facultad de Medicina y Ciencias de la Salud. Avda. de Elvas sn. 06006. Badajoz. España; Hospital Universitario de Badajoz. Servicio de Cirugía Hepatobiliopancreática y Trasplante Hepático. Avda. Elvas sn. 06080 Badajoz. España.
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8
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Macias RI, Monte MJ, Serrano MA, González-Santiago JM, Martín-Arribas I, Simão AL, Castro RE, González-Gallego J, Mauriz JL, Marin JJ. Impact of aging on primary liver cancer: epidemiology, pathogenesis and therapeutics. Aging (Albany NY) 2021; 13:23416-23434. [PMID: 34633987 PMCID: PMC8544321 DOI: 10.18632/aging.203620] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 09/28/2021] [Indexed: 01/18/2023]
Abstract
Aging involves progressive physiological and metabolic reprogramming to adapt to gradual deterioration of organs and functions. This includes mechanisms of defense against pre-malignant transformations. Thus, certain tumors are more prone to appear in elderly patients. This is the case of the two most frequent types of primary liver cancer, i.e., hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (iCCA). Accordingly, aging hallmarks, such as genomic instability, telomere attrition, epigenetic alterations, altered proteostasis, mitochondrial dysfunction, cellular senescence, exhaustion of stem cell niches, impaired intracellular communication, and deregulated nutrient sensing can play an important role in liver carcinogenesis in the elders. In addition, increased liver fragility determines a worse response to risk factors, which more frequently affect the aged population. This, together with the difficulty to carry out an early detection of HCC and iCCA, accounts for the late diagnosis of these tumors, which usually occurs in patients with approximately 60 and 70 years, respectively. Furthermore, there has been a considerable controversy on what treatment should be used in the management of HCC and iCCA in elderly patients. The consensus reached by numerous studies that have investigated the feasibility and safety of different curative and palliative therapeutic approaches in elders with liver tumors is that advanced age itself is not a contraindication for specific treatments, although the frequent presence of comorbidities in these individuals should be taken into consideration for their management.
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Affiliation(s)
- Rocio I.R. Macias
- Experimental Hepatology and Drug Targeting (HEVEPHARM) Group, University of Salamanca, IBSAL, Salamanca, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Carlos III National Institute of Health, Madrid, Spain
| | - Maria J. Monte
- Experimental Hepatology and Drug Targeting (HEVEPHARM) Group, University of Salamanca, IBSAL, Salamanca, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Carlos III National Institute of Health, Madrid, Spain
| | - Maria A. Serrano
- Experimental Hepatology and Drug Targeting (HEVEPHARM) Group, University of Salamanca, IBSAL, Salamanca, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Carlos III National Institute of Health, Madrid, Spain
| | - Jesús M. González-Santiago
- Department of Gastroenterology and Hepatology, University Hospital of Salamanca, IBSAL, Salamanca, Spain
| | - Isabel Martín-Arribas
- Department of Gastroenterology and Hepatology, University Hospital of Salamanca, IBSAL, Salamanca, Spain
| | - André L. Simão
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal
| | - Rui E. Castro
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal
| | - Javier González-Gallego
- Institute of Biomedicine (IBIOMED), University of León, León, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Carlos III National Institute of Health, Madrid, Spain
| | - José L. Mauriz
- Institute of Biomedicine (IBIOMED), University of León, León, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Carlos III National Institute of Health, Madrid, Spain
| | - Jose J.G. Marin
- Experimental Hepatology and Drug Targeting (HEVEPHARM) Group, University of Salamanca, IBSAL, Salamanca, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Carlos III National Institute of Health, Madrid, Spain
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Evaluation and Management of Colorectal Cancer Hepatic Metastases. Dis Colon Rectum 2021; 64:777-780. [PMID: 33872286 DOI: 10.1097/dcr.0000000000002103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
A 65-year-old man presents with new liver lesions on surveillance imaging 2 years after a right hemicolectomy for cecal adenocarcinoma. The primary tumor was pT3N1, microsatellite stable, and KRAS wild type. He completed adjuvant FOLFOX. His CEA level is 22 ng/mL. There are two 1.5-cm lesions in the right lobe near the dome of the liver and a 4-cm lesion in segment II. No luminal recurrence is detected endoscopically, and there is no evidence of peritoneal or pulmonary disease.
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Federico P, Giunta EF, Pappalardo A, Tufo A, Marte G, Attademo L, Fabbrocini A, Petrillo A, Daniele B. How to Treat Hepatocellular Carcinoma in Elderly Patients. Pharmaceuticals (Basel) 2021; 14:233. [PMID: 33800217 PMCID: PMC8001824 DOI: 10.3390/ph14030233] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/27/2021] [Accepted: 03/01/2021] [Indexed: 02/08/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is the primary tumour of the liver with the greatest incidence, particularly in the elderly. Additionally, improvements in the treatments for chronic liver diseases have increased the number of elderly patients who might be affected by HCC. Little evidence exists regarding HCC in old patients, and the elderly are still underrepresented and undertreated in clinical trials. In fact, this population represents a complex subgroup of patients who are hard to manage, especially due to the presence of multiple comorbidities. Therefore, the choice of treatment is mainly decided by the physician in the clinical practice, who often tend not to treat elderly patients in order to avoid the possibility of adverse events, which may alter their unstable equilibrium. In this context, the clarification of the optimal treatment strategy for elderly patients affected by HCC has become an urgent necessity. The aim of this review is to provide an overview of the available data regarding the treatment of HCC in elderly patients, starting from the definition of "elderly" and the geriatric assessment and scales. We explain the possible treatment choices according to the Barcelona Clinic Liver Cancer (BCLC) scale and their feasibility in the elderly population.
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Affiliation(s)
- Piera Federico
- Medical Oncology Unit, Ospedale del Mare, 80147 Napoli, Italy; (E.F.G.); (A.P.); (L.A.); (A.F.); (A.P.); (B.D.)
| | - Emilio Francesco Giunta
- Medical Oncology Unit, Ospedale del Mare, 80147 Napoli, Italy; (E.F.G.); (A.P.); (L.A.); (A.F.); (A.P.); (B.D.)
- Department of Precision Medicine, School of Medicine, University of Study of Campania “L. Vanvitelli”, 80131 Napoli, Italy
| | - Annalisa Pappalardo
- Medical Oncology Unit, Ospedale del Mare, 80147 Napoli, Italy; (E.F.G.); (A.P.); (L.A.); (A.F.); (A.P.); (B.D.)
- Department of Precision Medicine, School of Medicine, University of Study of Campania “L. Vanvitelli”, 80131 Napoli, Italy
| | - Andrea Tufo
- Surgical Unit, Ospedale del Mare, 80147 Napoli, Italy; (A.T.); (G.M.)
| | - Gianpaolo Marte
- Surgical Unit, Ospedale del Mare, 80147 Napoli, Italy; (A.T.); (G.M.)
| | - Laura Attademo
- Medical Oncology Unit, Ospedale del Mare, 80147 Napoli, Italy; (E.F.G.); (A.P.); (L.A.); (A.F.); (A.P.); (B.D.)
| | - Antonietta Fabbrocini
- Medical Oncology Unit, Ospedale del Mare, 80147 Napoli, Italy; (E.F.G.); (A.P.); (L.A.); (A.F.); (A.P.); (B.D.)
| | - Angelica Petrillo
- Medical Oncology Unit, Ospedale del Mare, 80147 Napoli, Italy; (E.F.G.); (A.P.); (L.A.); (A.F.); (A.P.); (B.D.)
- Department of Precision Medicine, School of Medicine, University of Study of Campania “L. Vanvitelli”, 80131 Napoli, Italy
| | - Bruno Daniele
- Medical Oncology Unit, Ospedale del Mare, 80147 Napoli, Italy; (E.F.G.); (A.P.); (L.A.); (A.F.); (A.P.); (B.D.)
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Paolini C, Bencini L, Gabellini L, Urciuoli I, Pacciani S, Tribuzi A, Moraldi L, Calistri M, Coratti A. Robotic versus open pancreaticoduodenectomy: Is there any difference for frail patients? Surg Oncol 2021; 37:101515. [PMID: 33429323 DOI: 10.1016/j.suronc.2020.12.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 12/09/2020] [Accepted: 12/22/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Old age and frailty are predictors of early postoperative results after pancreatic surgery. We analysed the results of robotic and open pancreatoduodenectomy in elderly and frail patients. METHODS Data from the local robotic pancreatoduodenectomy database were reviewed and matched with those from open operations during the same period (2014-2020). Both old age and frailty were used to determine any correlation with postoperative outcomes. Elderly patients were defined as patients aged 70 years or more, while frailty was classified according to the validated modified Frailty Index. RESULTS A total of 118 pancreatoduodenectomies were included in the analysis: 65 (55.1%) robotic and 53 (44.9%) open. More than 50% of patients were frail. Overall, 7.6% of patients experienced grade IV Clavien-Dindo complications, and 3.4% died within 90 days after surgery. Frail patients experienced a similar rate of severe complications after robotic vs. open operations (5.3 vs. 11.6; p = 0.439) but earlier refeeding (3 days vs. 4 days; p = 0.006) and earlier drain removal (6 days vs. 7 days; p = 0.046) when operated on by a robotic approach. The oncological outcomes, including limphnodes retrieval, residual disease, recurrences, and survival, were not influenced by the surgical approach. Non-elderly patients also showed more benefits with the robotic approach (lower complication index, earlier refeeding, and drain removal). CONCLUSIONS Robotic pancreatoduodenectomy is associated with risks of major complications that are comparable to those of open operation in frail patients. Some perioperative parameters (refeeding, drain removal) seem to favour robotics in frail patients and younger patients, although at the price of longer operating times.
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Affiliation(s)
- Claudia Paolini
- Surgical Oncology and Robotics, Careggi University Hospital, Florence, Italy
| | - Lapo Bencini
- Surgical Oncology and Robotics, Careggi University Hospital, Florence, Italy.
| | - Linda Gabellini
- Surgical Oncology and Robotics, Careggi University Hospital, Florence, Italy
| | - Irene Urciuoli
- Surgical Oncology and Robotics, Careggi University Hospital, Florence, Italy
| | - Sabrina Pacciani
- Surgical Oncology and Robotics, Careggi University Hospital, Florence, Italy
| | - Angela Tribuzi
- Surgical Oncology and Robotics, Careggi University Hospital, Florence, Italy
| | - Luca Moraldi
- Surgical Oncology and Robotics, Careggi University Hospital, Florence, Italy
| | - Massimo Calistri
- Surgical Oncology and Robotics, Careggi University Hospital, Florence, Italy
| | - Andrea Coratti
- Surgical Oncology and Robotics, Careggi University Hospital, Florence, Italy
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12
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Sahara K, Paredes AZ, Merath K, Tsilimigras DI, Bagante F, Ratti F, Marques HP, Soubrane O, Beal EW, Lam V, Poultsides GA, Popescu I, Alexandrescu S, Martel G, Aklile W, Guglielmi A, Hugh T, Aldrighetti L, Endo I, Pawlik TM. Evaluation of the ACS NSQIP Surgical Risk Calculator in Elderly Patients Undergoing Hepatectomy for Hepatocellular Carcinoma. J Gastrointest Surg 2020; 24:551-559. [PMID: 30937717 DOI: 10.1007/s11605-019-04174-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 02/20/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) surgical risk calculator (SRC) aims to help predict patient-specific risk for morbidity and mortality. The performance of the SRC among an elderly population undergoing curative-intent hepatectomy for hepatocellular carcinoma (HCC) remains unknown. METHODS Patients > 70 years of age who underwent hepatectomy for HCC between 1998 and 2017 were identified using a multi-institutional international database. To estimate the performance of SRC, 12 observed postoperative outcomes were compared with median SRC-predicted risk, and C-statistics and Brier scores were calculated. RESULTS Among 500 patients, median age was 75 years (IQR 72-78). Most patients (n = 324, 64.8%) underwent a minor hepatectomy, while 35.2% underwent a major hepatectomy. The observed incidence of venous thromboembolism (VTE) (3.2%) and renal failure (RF) (4.4%) exceeded the median predicted risk (VTE, 1.8%; IQR 1.5-3.1 and RF, 1.0%; IQR 0.5-2.0). In contrast, the observed incidence of 30-day readmission (7.0%) and non-home discharge (2.5%) was lower than median-predicted risk (30-day readmission, 9.4%; IQR 7.4-12.8 and non-home discharge, 5.7%; IQR 3.3-11.7). Only 57.8% and 71.2% of patients who experienced readmission (C-statistic, 0.578; 95%CI 0.468-0.688) or mortality (C-statistic, 0.712; 95%CI 0.508-0.917) were correctly identified by the model. CONCLUSION Among elderly patients undergoing hepatectomy for HCC, the SRC underestimated the risk of complications such as VTE and RF, while being no better than chance in estimating the risk of readmission. The ACS SRC has limited clinical applicability in estimating perioperative risk among elderly patients being considered for hepatic resection of HCC.
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Affiliation(s)
- Kota Sahara
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.,Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Anghela Z Paredes
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Katiuscha Merath
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Fabio Bagante
- Department of Surgery, University of Verona, Verona, Italy
| | | | - Hugo P Marques
- Department of Surgery, Curry Cabral Hospital, Lisbon, Portugal
| | - Olivier Soubrane
- Department of Hepatobiliopancreatic Surgery, APHP, Beaujon Hospital, Clichy, France
| | - Eliza W Beal
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Vincent Lam
- Department of Surgery, Westmead Hospital, Sydney, Australia
| | | | - Irinel Popescu
- Department of Surgery, Fundeni Clinical Institute, Bucharest, Romania
| | | | | | - Workneh Aklile
- Department of Surgery, University of Ottawa, Ottawa, Canada
| | | | - Tom Hugh
- Department of Surgery, The University of Sydney, School of Medicine, Sydney, Australia
| | | | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Timothy M Pawlik
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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13
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Papis D, Vagliasindi A, Maida P. Hepatobiliary and pancreatic surgery in the elderly: Current status. Ann Hepatobiliary Pancreat Surg 2020; 24:1-5. [PMID: 32181422 PMCID: PMC7061045 DOI: 10.14701/ahbps.2020.24.1.1] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 09/14/2019] [Accepted: 09/16/2019] [Indexed: 12/15/2022] Open
Abstract
Hepato-pancreatico-biliary (HPB) surgery includes major hepatic resection and pancreatic surgery, both procedures are complex and have a potentially high complication rate. The presence of centers of excellence with a high patients volume has lowered the complication and increased the resection rate. Increased life expectancy and improved general health status have increased the number of elderly patients eligible for major surgery. Since old patients have more co-morbidities and decreased life expectancy, the benefit of these procedures need to be critically evaluated in this group. Analysis of the literature related to this argument demonstrated that pancreatoduodenectomy can be performed safely in selected elderly patients (70 years of age or older), with morbidity and mortality rates comparable those observed in younger patients. This aspect was also confirmed by cost analysis studies that reported similar data in both groups. Similar findings are also reported for major hepatic resection in elderly patients with either hepatocellular carcinoma (HCC), Klatskin tumor or gallbladder carcinoma. More studies are needed regarding the subgroup of very elderly patients (80 years or older). Nevertheless, those elderly patients who will benefit from surgery must be adequatelly selected.
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Affiliation(s)
- Davide Papis
- General Surgery Unit, Del Mare Hospital, Naples, Italy
| | | | - Pietro Maida
- General Surgery Unit, Del Mare Hospital, Naples, Italy
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14
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Lee TC, Morris MC, Patel SH, Shah SA. Expanding the Surgical Pool for Hepatic Resection to Treat Biliary and Primary Liver Tumors. Surg Oncol Clin N Am 2019; 28:763-782. [PMID: 31472918 DOI: 10.1016/j.soc.2019.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Surgical management of primary liver and biliary tract tumors has evolved over the past several decades, resulting in improved outcomes in these malignancies with historically poor prognoses. Expansion of patient selection criteria, progress in neoadjuvant and adjuvant therapies, development of techniques to increase future liver remnant, and the select utilization of liver transplantation have all contributed to increasing the patient pool for surgical intervention. Ongoing and future studies need to focus on improving multimodality treatment regimens and further refining the selection criteria for transplantation in order to optimize utilization of limited organ resources.
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Affiliation(s)
- Tiffany C Lee
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0558, Cincinnati, OH 45267-0558, USA
| | - Mackenzie C Morris
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0558, Cincinnati, OH 45267-0558, USA
| | - Sameer H Patel
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0558, Cincinnati, OH 45267-0558, USA
| | - Shimul A Shah
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0558, Cincinnati, OH 45267-0558, USA.
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15
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Preoperative Risk Assessment for Loss of Independence Following Hepatic Resection in Elderly Patients: A Prospective Multicenter Study. Ann Surg 2019; 274:e253-e261. [PMID: 31460876 DOI: 10.1097/sla.0000000000003585] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To establish a preoperative risk assessment method for loss of independence after hepatic resection. SUMMARY BACKGROUND DATA Hepatic resection often results in loss of independence in preoperatively self-sufficient elderly people. Elderly patients should therefore be carefully selected for surgery. METHODS In this prospective, multicenter study, 347 independently-living patients aged ≥65 years, scheduled for hepatic resection, were divided into study (n = 232) and validation (n = 115) cohorts. We investigated the risk factors for postoperative loss of independence in the study cohort and verified our findings with the validation cohort. Loss of independence was defined as transfer to a rehabilitation facility, discharge to residence with home-based healthcare, 30-day readmission for poor functionality, and 90-day mortality (except for cancer-related deaths). RESULTS In the study cohort, univariate and multivariate analyses indicated that frailty, age ≥ 76 years, and open surgery were independent risk factors for postoperative loss of independence. Proportions of patients with postoperative loss of independence in the study and validation cohorts were respectively 3.0% and 0% among those with no applicable risk factors, 8.1% and 12.5% among those with 1 applicable risk factor, 25.5% and 25.0% among those with 2 applicable risk factors, and 56.3% and 50.0% among those with all 3 factors applicable (P < 0.001 for both cohorts). Areas under the receiver operating characteristic curves for the study and validation groups were 0.777 and 0.783, respectively. CONCLUSIONS Preoperative risk assessments using these 3 factors may be effective in predicting and planning for postoperative loss of independence after hepatic resection in elderly patients.
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16
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Nomi T, Hirokawa F, Kaibori M, Ueno M, Tanaka S, Hokuto D, Noda T, Nakai T, Ikoma H, Iida H, Komeda K, Ishizaki M, Hayami S, Eguchi H, Matsumoto M, Morimura R, Maehira H, Sho M, Kubo S. Laparoscopic versus open liver resection for hepatocellular carcinoma in elderly patients: a multi-centre propensity score-based analysis. Surg Endosc 2019; 34:658-666. [PMID: 31093748 DOI: 10.1007/s00464-019-06812-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 04/29/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND The frequency of liver resection in elderly patients has been increasing. However, data are limited regarding the safety of laparoscopic liver resection (LLR) compared with that of open liver resection (OLR) for hepatocellular carcinoma (HCC) in elderly patients. The present study aimed to compare short-term outcomes between LLR and OLR in elderly patients with HCC using propensity score matching. METHODS The study included 630 patients (age, ≥ 75 years) who underwent liver resection for HCC at nine liver centres between April 2010 and December 2017. Patients were divided into LLR and OLR groups, and perioperative outcomes were compared between the groups. In addition, subgroup analysis was performed according to age (75-79 and ≥ 80 years). RESULTS Of the 630 patients, 221 and 409 were included in the LLR and OLR groups, respectively. After propensity score matching, 155 patients were included in each group. Intraoperative blood loss and the transfusion, post-operative overall complication and major complication rates were lower in the matched LLR than the matched OLR group (P < 0.001, P = 0.004, P < 0.001 and P < 0.001, respectively). Moreover, post-operative pulmonary and cardiovascular complications were less frequent in the matched LLR group (P = 0.008 and P = 0.014, respectively). In subgroup analysis, among octogenarians, the post-operative major complication rate was lower and hospital stay was shorter in the matched LLR than the matched OLR group (P < 0.001 and P < 0.001, respectively). CONCLUSION LLR for HCC is associated with good short-term outcomes in patients aged ≥ 75 years compared with OLR. LLR is safe and feasible in selected octogenarians with HCC.
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Affiliation(s)
- Takeo Nomi
- Department of Surgery, Nara Medical University, 840, Shijocho, Kashihara, Nara, 634-8522, Japan.
| | - Fumitoshi Hirokawa
- Department of General and Gastroenterological Surgery, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Masaki Kaibori
- Department of Surgery, Hirakata Hospital, Kansai Medical University, Hirakata, Osaka, Japan
| | - Masaki Ueno
- Second Department of Surgery, Wakayama Medical University, Wakayama, Japan
| | - Shogo Tanaka
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Daisuke Hokuto
- Department of Surgery, Nara Medical University, 840, Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Takehiro Noda
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Takuya Nakai
- Department of Surgery, Faculty of Medicine, Kindai University, Osakasayama, Osaka, Japan
| | - Hisashi Ikoma
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hiroya Iida
- Division of Gastrointestinal, Breast, and General Surgery, Department of Surgery, Shiga University of Medical Science, Otsu, Shiga Prefecture, Japan
| | - Koji Komeda
- Department of General and Gastroenterological Surgery, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Morihiko Ishizaki
- Department of Surgery, Hirakata Hospital, Kansai Medical University, Hirakata, Osaka, Japan
| | - Shinya Hayami
- Second Department of Surgery, Wakayama Medical University, Wakayama, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Masataka Matsumoto
- Department of Surgery, Faculty of Medicine, Kindai University, Osakasayama, Osaka, Japan
| | - Ryo Morimura
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hiromitsu Maehira
- Division of Gastrointestinal, Breast, and General Surgery, Department of Surgery, Shiga University of Medical Science, Otsu, Shiga Prefecture, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, 840, Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Shoji Kubo
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
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17
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Vallance AE, Young AL, Kuryba A, Braun M, Hill J, Jayne DG, van der Meulen J, Lodge JP, Walker K. The impact of advancing age on incidence of hepatectomy and post-operative outcomes in patients with colorectal cancer liver metastases: a population-based cohort study. HPB (Oxford) 2019; 21:167-174. [PMID: 30076012 DOI: 10.1016/j.hpb.2018.06.1808] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 06/11/2018] [Accepted: 06/24/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Clinical outcomes for elderly patients undergoing liver resection for colorectal cancer (CRC) liver metastases are poorly characterised. This study aimed to investigate the impact of advancing age on the incidence of liver resection and post-operative outcomes. METHODS Patients in the National Bowel Cancer Audit undergoing major CRC resection from 2010 to 2016 in England were included. Liver resection was identified from linked Hospital Episode Statistics data. A Cox-proportional hazards model was used to compare 3-year mortality. RESULTS Of 117,005 patients, 6081 underwent liver resection. For patients <65 years there was 1 liver resection per 12 cases, 65-74, 1 per 17, and ≥75, 1 per 40. 90-day mortality after liver resection increased with advancing age (<65 0.9% (26/2829), 65-74 2.8% (57/2070), ≥75 4.0% (47/1182); P < 0.001). Age was an independent risk factor for 3-year mortality. Patients 65-74 did not have adjusted mortality higher than those <65, yet age ≥75 was associated with increased overall mortality (Hazard ratio (HR) 1.47 (95% CI 1.30-1.68)) and cancer-specific mortality (HR 1.30 (95% CI 1.13-1.49)). CONCLUSION Although advancing age was associated with higher rates of 90-day mortality following liver resection, 3-year mortality for patients 65-74 years was comparable to younger patients. These results will aid clinicians and patients in pre-operative decision-making.
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Affiliation(s)
- Abigail E Vallance
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, WC2A 3PE, UK.
| | - Alastair L Young
- Department of Hepatobiliary Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, LS9 7TF, UK
| | - Angela Kuryba
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, WC2A 3PE, UK
| | - Michael Braun
- Medical Oncology, The Christie NHS Foundation Trust, Manchester, M20 4BX, UK
| | - James Hill
- Department of Colorectal Surgery, Manchester Royal Infirmary, Manchester, M13 9WL, UK
| | - David G Jayne
- Faculty of Medicine and Health, University of Leeds, Leeds, LS2 9JT, UK
| | - Jan van der Meulen
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, WC2A 3PE, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, WC1H 9SH, UK
| | - Jeremy P Lodge
- Department of Hepatobiliary Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, LS9 7TF, UK
| | - Kate Walker
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, WC2A 3PE, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, WC1H 9SH, UK
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18
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van der Windt DJ, Bou-Samra P, Dadashzadeh ER, Chen X, Varley PR, Tsung A. Preoperative risk analysis index for frailty predicts short-term outcomes after hepatopancreatobiliary surgery. HPB (Oxford) 2018; 20:1181-1188. [PMID: 30005992 DOI: 10.1016/j.hpb.2018.05.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 05/10/2018] [Accepted: 05/19/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND The Risk Analysis Index (RAI) for frailty is a rapid survey for comorbidities and performance status, which predicts mortality after general surgery. We aimed to validate the RAI in predicting outcomes after hepatopancreatobiliary surgery. METHODS Associations of RAI, determined in 162 patients prior to undergoing hepatopancreatobiliary surgery, with prospectively collected 30-day post-operative outcomes were analyzed with multivariate logistic and linear regression. RESULTS Patients (age 62 ± 14, 51% female) had a median RAI of 7, range 0-25. With every unit increase in RAI, length of stay increased by 5% (95% CI: 2-7%), odds of ICU admission increased by 10% (0-20%), ICU length of stay increased by 21% (9-34%), and odds of discharge to a nursing facility increased by 8% (0-17%) (all P < 0.05). Particularly in patients who suffered a first post-operative complication, RAI was associated with additional complications (1.6 unit increase in Comprehensive Complication Index per unit increase in RAI, P = 0.002). In a direct comparison in a subset of 74 patients, RAI and the ACS-NSQIP Risk Calculator performed comparably in predicting outcomes. CONCLUSION While RAI and ACS-NSQIP Risk Calculator comparatively predicted short-term outcomes after HPB surgery, RAI has been specifically designed to identify frail patients who can potentially benefit from preoperative prehabilitation interventions.
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Affiliation(s)
- Dirk J van der Windt
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Patrick Bou-Samra
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Xilin Chen
- Pittsburgh Surgical Outcomes Research Center (PittSORCe), University of Pittsburgh, Pittsburgh, PA, USA
| | - Patrick R Varley
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Allan Tsung
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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19
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Yasuda S, Nomi T, Hokuto D, Yoshikawa T, Matsuo Y, Sho M. Liver Regeneration After Major Liver Resection for Hepatocellular Carcinoma in the Elderly. J INVEST SURG 2018; 33:332-338. [PMID: 30388925 DOI: 10.1080/08941939.2018.1517839] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: With an aging population, more elderly patients are being considered for hepatic resection for hepatocellular carcinoma (HCC). This study aimed to evaluate postoperative outcomes including liver regeneration after major hepatectomy for HCC in the elderly.Methods: We assessed 41 patients who underwent major hepatectomy (≥3 segments) at our institute between 2000 and 2013. Patients were divided into two age groups, elderly group (age ≥70 years, n = 23) and younger group (age <70 years, n = 18). Clinicopathological data and outcomes were retrospectively compared. To evaluate the effect of aging on liver regeneration, we measured liver volumes preoperatively and at 1 and 6 months after liver resection using a 3D simulation imaging system.Results: Overall and major complications after hepatectomy were not different between elderly and younger groups, and no case of mortality was recorded. Moreover, recurrence-free and overall survivals were similar in both groups. With regard to liver regeneration, no differences were observed between elderly and younger groups at 1 and 6 months after liver resection. Baseline liver functions were comparable between the groups. Furthermore, the only factor associated with liver regeneration was resected liver volume (R2 = 0.631, p < 0.001). Age was not correlated with liver regeneration rate (R2 = 0.00537, p = 0.695).Conclusions: Liver regeneration after major hepatectomy for HCC was not affected by age and that resected liver volume is an important factor for liver regeneration. Short- and long-term outcomes after major hepatectomy were similar in elderly and younger patients.
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Affiliation(s)
- Satoshi Yasuda
- Department of Surgery, Nara Medical University, 840 Shijo-cho Kashihara-shi, Nara 634-8522, Japan
| | - Takeo Nomi
- Department of Surgery, Nara Medical University, 840 Shijo-cho Kashihara-shi, Nara 634-8522, Japan
| | - Daisuke Hokuto
- Department of Surgery, Nara Medical University, 840 Shijo-cho Kashihara-shi, Nara 634-8522, Japan
| | - Takahiro Yoshikawa
- Department of Surgery, Nara Medical University, 840 Shijo-cho Kashihara-shi, Nara 634-8522, Japan
| | - Yasuko Matsuo
- Department of Surgery, Nara Medical University, 840 Shijo-cho Kashihara-shi, Nara 634-8522, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, 840 Shijo-cho Kashihara-shi, Nara 634-8522, Japan
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20
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Brudvik KW, Røsok B, Naresh U, Yaqub S, Fretland ÅA, Labori KJ, Edwin B, Bjørnbeth BA. Survival after resection of colorectal liver metastases in octogenarians and sexagenarians compared to their respective age-matched national population. Hepatobiliary Surg Nutr 2018; 7:234-241. [PMID: 30221151 DOI: 10.21037/hbsn.2017.09.03] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background The aim of the current study was to investigate survival after resection of colorectal liver metastases (CLM) in octogenarians. The survival of octogenarian patients was compared to the survival of the national population of octogenarians and the survival of sexagenarians, the latter representing the average-age patient undergoing resection of CLM. Methods Octogenarian and sexagenarian were defined as person 80-89 and 60-69 years of age, respectively. Survival analyses of patients who underwent resection of CLM between 2002 and 2014 were performed. Data from Statistics Norway were used to estimate the survival of the age-matched national population of octogenarians (ageM-Octo) and the age-matched national population of sexagenarians (ageM-Sexa). Results During the study period, 59 octogenarians underwent resection of CLM. The majority of patients underwent a minor liver resection (n=50). In octogenarians, the 5-year survival was 32.5% and 66.3% [difference, 33.8 percentage points (pp)] in patients and ageM-Octo, respectively. The 10-year survival was 14.1% and 31.2% (difference, 17.1 pp) in patients and ageM-Octo, respectively. In sexagenarians, the 5-year survival was 50.9% and 96.2% (difference, 45.3 pp) in patients and ageM-Sexa, respectively. The 10-year survival was 35.7% and 90.3% (difference, 54.6 pp) in patients and ageM-Sexa, respectively. The 5-year cancer-specific survival and 5-year recurrence-free survival (RFS) after resection of CLM in octogenarians were 43.1% and 32.9%, respectively. Conclusions After resection of CLM, the survival was poorer in octogenarians than in sexagenarians. However, the difference between the survival curves of patients and their age-matched population was smaller in octogenarians. In practice, this finding may indicate a greater benefit of resection in the elderly than the survival rates alone would suggest.
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Affiliation(s)
| | - Bård Røsok
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| | - Usha Naresh
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| | - Sheraz Yaqub
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| | - Åsmund Avdem Fretland
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway.,The Intervention Centre, Oslo University Hospital, Oslo, Norway.,Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Knut Jørgen Labori
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| | - Bjørn Edwin
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway.,The Intervention Centre, Oslo University Hospital, Oslo, Norway.,Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Bjørn Atle Bjørnbeth
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
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21
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Tanaka S, Ueno M, Iida H, Kaibori M, Nomi T, Hirokawa F, Ikoma H, Nakai T, Eguchi H, Kubo S. Preoperative assessment of frailty predicts age-related events after hepatic resection: a prospective multicenter study. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2018; 25:377-387. [DOI: 10.1002/jhbp.568] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Shogo Tanaka
- Department of Hepato-Biliary-Pancreatic Surgery; Osaka City University Graduate School of Medicine; Osaka Japan
| | - Masaki Ueno
- Second Department of Surgery; Wakayama Medical University; Wakayama Japan
| | - Hiroya Iida
- Division of Gastrointestinal, Breast and General Surgery; Department of Surgery; Shiga University of Medical Science; Otsu Shiga Japan
| | - Masaki Kaibori
- Department of Surgery; Hirakata Hospital; Kansai Medical University; Hirakata Osaka Japan
| | - Takeo Nomi
- Department of Surgery; Nara Medical University; Kashihara Nara Japan
| | - Fumitoshi Hirokawa
- Department of General and Gastroenterological Surgery; Osaka Medical College; Takatsuki Osaka Japan
| | - Hisashi Ikoma
- Division of Digestive Surgery; Department of Surgery; Kyoto Prefectural University of Medicine; Kyoto Japan
| | - Takuya Nakai
- Department of Surgery; Faculty of Medicine; Kindai University; Osaka-Sayama Osaka Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery; Graduate School of Medicine; Osaka University; Suita Osaka Japan
| | - Shoji Kubo
- Department of Hepato-Biliary-Pancreatic Surgery; Osaka City University Graduate School of Medicine; Osaka Japan
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22
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De Blasi V, Memeo R, Adam R, Goéré D, Cherqui D, Regimbeau JM, Rivoire M, Perotto LO, Navarro F, Sa Cunha A, Pessaux P. Major Hepatectomy for Colorectal Liver Metastases in Patients Aged Over 80: A Propensity Score Matching Analysis. Dig Surg 2018; 35:333-341. [PMID: 29669343 DOI: 10.1159/000486522] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 12/28/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the results of major hepatectomies for metastasis in elderly colorectal cancer patients, for whom limited data exist in the literature. METHODS From January 2006 to January 2013, 3,034 patients underwent hepatectomy for colorectal liver metastasis in 32 French surgical centers. Repeat hepatectomies were excluded from the study. Based on a 1: 4 propensity score matching model, 42 patients aged ≥80 (OG) were matched with 168 patients <80 years (YG) in order to obtain 2 well-balanced and homogeneous groups with regards to therapy and prognostic factors. RESULTS The unmatched cohort consisted of 744 patients (OG: n = 42; YG: n = 702). After PS matching, there was no difference in terms of general morbidity, rates of Dindo-Clavien score ≥III (OG: 16% vs. YG: 21%, p = 0.663), surgical morbidity (OG: 16% vs. YG: 21%, p = 0.663), reoperation (OG:10% vs. YG: 5%, p = 0.263), 90-day mortality (OG: 0% vs. YG:2%, p = 1), and total median hospital stay (OG: 12 vs. YG: 12, p = 0.972). Both groups experienced similar 3- and 5-year overall survival (82 and 82% OG vs.78 and 67% YG) and disease-free survival (40 and 35% OG vs. 45 and 35% YG at 3 and 5 years). CONCLUSIONS No difference in perioperative and postoperative outcomes and disease-free and overall survival was found. Major hepatectomy in selected octogenarian patients is safe and feasible.
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Affiliation(s)
- Vito De Blasi
- Institut Hospitalo-Universitaire (IHU), Institute for Minimally Invasive Hybrid Image-Guided Surgery, Université de Strasbourg, Strasbourg, France.,Institut de Recherche Contre les Cancers de l'Appareil Digestif (IRCAD), Strasbourg, France.,General, Digestive, and Endocrine Surgery, Nouvel Hôpital Civil, Strasbourg, France
| | - Riccardo Memeo
- Institut Hospitalo-Universitaire (IHU), Institute for Minimally Invasive Hybrid Image-Guided Surgery, Université de Strasbourg, Strasbourg, France.,Institut de Recherche Contre les Cancers de l'Appareil Digestif (IRCAD), Strasbourg, France.,General, Digestive, and Endocrine Surgery, Nouvel Hôpital Civil, Strasbourg, France
| | - René Adam
- Department of Surgery, Hôpital Paul Brousse, Villejuif, France
| | - Diane Goéré
- Department of Surgery, Institut Gustave Roussy, Villejuif, France
| | - Daniel Cherqui
- Department of Surgery, Hôpital Paul Brousse, Villejuif, France
| | | | | | - Laura Ornella Perotto
- Institut Hospitalo-Universitaire (IHU), Institute for Minimally Invasive Hybrid Image-Guided Surgery, Université de Strasbourg, Strasbourg, France.,Institut de Recherche Contre les Cancers de l'Appareil Digestif (IRCAD), Strasbourg, France.,General, Digestive, and Endocrine Surgery, Nouvel Hôpital Civil, Strasbourg, France
| | - Francis Navarro
- Department of Digestive Surgery, Université de Montpellier, Hôpital Saint-Eloi, Montpellier, France
| | | | - Patrick Pessaux
- Institut Hospitalo-Universitaire (IHU), Institute for Minimally Invasive Hybrid Image-Guided Surgery, Université de Strasbourg, Strasbourg, France.,Institut de Recherche Contre les Cancers de l'Appareil Digestif (IRCAD), Strasbourg, France.,General, Digestive, and Endocrine Surgery, Nouvel Hôpital Civil, Strasbourg, France
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23
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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: 28] [Impact Index Per Article: 4.7] [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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24
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Tufo A, Dunne DFJ, Manu N, Joshi H, Lacasia C, Jones L, Malik HZ, Poston GJ, Fenwick SW. Hepatectomy for octogenarians with colorectal liver metastasis in the era of enhanced recovery. Eur J Surg Oncol 2018; 44:1040-1047. [PMID: 29456045 DOI: 10.1016/j.ejso.2018.01.089] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 12/20/2017] [Accepted: 01/16/2018] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Concern exists regarding the use of hepatectomy to treat colorectal liver metastasis (CRLM) in octogenarians due to prior studies suggesting elevated morbidity and mortality. Cardiopulmonary exercise testing (CPET) within pre-operative assessment and enhanced recovery after surgery (ERAS) have both been shown to be associated with low morbidity and mortality in patients undergoing hepatectomy. This study sought to compare the outcomes of octogenarians with patients aged 70-79 undergoing hepatectomy for CRLM, within a center utilizing both CPET and ERAS. METHODS Consecutive patients age 70 or older who underwent hepatectomy for CRLM at Aintree University Hospital (Liverpool,UK), between May 2008 and May 2015 were identified from a prospectively maintained cancer database. Data were extracted and comparisons drawn. RESULTS 127 patients aged 70-79 years and 34 octogenarians underwent respectively 137 and 35 hepatectomy for CRLM. There was no difference in hospital stay (6 days), morbidity and mortality between the groups. OS at 1, 3 and 5 years were 86.7%, 55% and 35.8% for those aged 70-79 compared to 79.4%, 37.3% and 20.4% for the octogenarians (p=0.127). DFS at 1,3 and 5 years was 52.5%, 31.7% and 31.7% for 70-79 group compared to 46.2%, 31.5% and 16.8% for the octogenarians (p=0.838). On multivariate analysis major hepatectomy was associated with an increased risk of post-operative complications, inferior OS and DFS. Chronological age was not a predictor of postoperative complications, poorer OS or DFS. CONCLUSIONS Appropriately selected octogenarians can have similar postoperative outcomes to patients aged 70-79 when undergoing hepatectomy for CRLM using ERAS combined with CPET. This study advocates using CPET and ERAS in the selection and management of octogenarian patients with CRLM undergoing hepatectomy.
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Affiliation(s)
- Andrea Tufo
- Liverpool Hepatobiliary Centre, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK.
| | - Declan F J Dunne
- Liverpool Hepatobiliary Centre, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK
| | - Nichola Manu
- Liverpool Hepatobiliary Centre, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK
| | - Heman Joshi
- Liverpool Hepatobiliary Centre, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK
| | - Carmen Lacasia
- Liverpool Hepatobiliary Centre, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK
| | - Louise Jones
- Liverpool Hepatobiliary Centre, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK
| | - Hassan Z Malik
- Liverpool Hepatobiliary Centre, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK
| | - Graeme J Poston
- Liverpool Hepatobiliary Centre, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK
| | - Stephen W Fenwick
- Liverpool Hepatobiliary Centre, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK
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25
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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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26
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Post-hepatectomy hyperbilirubinemia: The point of no return. Am J Surg 2017; 214:93-99. [DOI: 10.1016/j.amjsurg.2016.11.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 11/11/2016] [Accepted: 11/21/2016] [Indexed: 12/12/2022]
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27
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Leal JN, Sadot E, Gonen M, Lichtman S, Kingham TP, Allen PJ, DeMatteo RP, Jarnagin WR, D’Angelica MI. Operative morbidity and survival following hepatectomy for colorectal liver metastasis in octogenarians: a contemporary case matched series. HPB (Oxford) 2017; 19:162-169. [PMID: 27914765 PMCID: PMC5608029 DOI: 10.1016/j.hpb.2016.09.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 09/11/2016] [Accepted: 09/15/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Clinical outcomes of octogenarians undergoing hepatectomy for colorectal liver metastases (CRLM) are poorly characterized. The current study evaluated operative morbidity, mortality and survival outcomes among a contemporary cohort of octogenarians. METHODS Patients undergoing their first hepatectomy for CRLM were identified from institutional databases and those ≥80 years old (y) were matched 1:1 to a group of patients <80 y. Data pertaining to surgical morbidity/mortality and survival were compared using standard statistical methods. RESULTS From 2002 to 2012, 1391 hepatectomies were performed for CRLM, 55 (4%) in patients ≥80 y. Major complications occurred twice as frequently among patients ≥80 y [10 (19%) ≥80 y versus 5 (9%) <80 y, (p = 0.270)]. No matched patient <80 y. died within 90 d of operation, whereas, 4 (7%) patients ≥80 y did, p = 0.125. Median follow-up was significantly longer for the <80 y group [44 (1-146) versus. 23 (0-102) mths, p = 0.006]. Probability of disease recurrence was not different between groups (p = 0.123) nor was the cumulative incidence of death from disease (p = 0.371). However, patients ≥80 y had significantly higher incidence of non-cancer related death (p = 0.012). CONCLUSIONS Hepatectomy for CRLM among well-selected octogenarians is reasonable with cancer related survival outcomes similar to those observed in younger patients. However, it is associated with clinically significant morbidity/mortality and continued efforts directed at optimizing perioperative care are necessary to improve early outcomes among octogenarians.
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Affiliation(s)
- Julie N. Leal
- Department of Surgery, Memorial Sloan Kettering Cancer Center
| | - Eran Sadot
- Department of Surgery, Memorial Sloan Kettering Cancer Center
| | - Mithat Gonen
- Department of Epidemiology/Biostatistics, Memorial Sloan Kettering Cancer Center
| | - Stuart Lichtman
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center
| | | | - Peter J. Allen
- Department of Surgery, Memorial Sloan Kettering Cancer Center
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28
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Gandy RC, Stavrakis T, Haghighi KS. Short- and long-term outcomes of elderly patients undergoing liver resection for colorectal liver metastasis. ANZ J Surg 2016; 88:E103-E107. [PMID: 27796073 DOI: 10.1111/ans.13690] [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: 02/17/2016] [Revised: 06/08/2016] [Accepted: 06/11/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Metastatic colorectal cancer is a disease of advancing age. Increased life expectancy has dramatically increased the number of older patients being assessed for hepatectomy. The objective of the study is to assess the safety and survival of hepatic resection in older patients, with colorectal liver metastases (CLM) and compare that with younger patients. METHODS All patients undergoing hepatic resection of CLM were included. Patients were divided in groups, less than 75 and 75 and over. Prospectively collected data on patient demographics and post-operative complications were retrospectively analysed. Overall survival was calculated in both groups. RESULTS Twenty-nine patients over the age of 75 underwent hepatic resection for CLM. A total of 158 patients under the age of 75 underwent resection. Overall, 66% of patients received neoadjuvant chemotherapy and 64% underwent major resection. Ninety-day mortality was 1 out of 29 and 1 out of 158, respectively (P = 0.15). Overall complication rate was low, 4 out of 29 and 26 out of 158 (P = 0.45). Median length of stay was similar in the older population, 8.5 versus 8 days (P = 0.65). Overall 5-year survival was 58% in the over 75 group and 56% in the under 75 group (P = 0.31). CONCLUSION Hepatic resection for CLM can be achieved safely in patients over the age of 75 and with equivalent short- and long-term outcomes.
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Affiliation(s)
- Robert C Gandy
- Department of Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia.,Prince of Wales Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Timothy Stavrakis
- Department of Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia.,Department of Anaesthesia, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Koroush S Haghighi
- Department of Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia.,Prince of Wales Clinical School, The University of New South Wales, Sydney, New South Wales, Australia.,Department of Surgery, St Vincent's Hospital, Sydney, New South Wales, Australia
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29
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Yazici P, Akyuz M, Yigitbas H, Dural C, Okoh A, Aydin N, Berber E. A comparison of perioperative outcomes in elderly patients with malignant liver tumors undergoing laparoscopic liver resection versus radiofrequency ablation. Surg Endosc 2016; 31:1269-1274. [PMID: 27444839 DOI: 10.1007/s00464-016-5105-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 07/09/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Liver resection is the treatment option with the best chance for cure in patients with malignant liver tumors. However, there are concerns regarding postoperative recovery in elderly patients, which may lead to a preference of non-resectional therapies over hepatectomy in this patient population. Although laparoscopic liver resection (LLR) is associated with a faster recovery compared to open hepatectomy, there are scant data on how elderly patients tolerate LLR. The aim of this study was to analyze the perioperative outcomes of LLR in elderly patients with hepatic malignancies, with a comparison to laparoscopic RFA (LRFA). METHODS A retrospective analysis of a prospective database for liver tumors identified a total of 82 patients older than 65 years who underwent laparoscopic treatment of their liver tumors in a single tertiary care center between 2000 and 2014. These patients were equally distributed into LLR and LRFA treatment arms. RESULTS Mean age, American Society of Anesthesiologists (ASA) score and tumor type (predominantly metastatic colorectal cancer) were similar in both groups. Patients in the LRFA group had more tumors (2.1 ± 1.8 vs. 1.2 ± 0.6, p < 0.01), whereas tumors were larger in the LLR group (3.8 ± 1.6 vs. 2.8 ± 1.1 cm, p < 0.01). Although the operative time (116 vs. 214 min, p < 0.01) and hospital stay (2.1 vs. 3.4 days, p = 0.010) were shorter for the LRFA versus LLR group, respectively, morbidity (4.8 vs. 7.3 %) and mortality (0 vs. 0 %) were similar. Local recurrence was significantly higher in the LRFA versus LLR group (29 vs. 2.4 %, respectively, p = 0.002). However, there was no statistical difference in disease-free and overall survival between two groups (28 vs. 30 and 51 vs. 54 months, p = 0.443 and 0.768, respectively). CONCLUSIONS This study showed that LLR was tolerated as well as LRFA in elderly patients with similar comorbidities. We suggest LLR to be considered as an option in selected elderly patients who are deemed poor candidates for open hepatectomy.
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Affiliation(s)
- Pinar Yazici
- Department of General Surgery, Cleveland Clinic, 9500 Euclid Avenue/F20, Cleveland, OH, 44195, USA
| | - Muhammet Akyuz
- Department of General Surgery, Cleveland Clinic, 9500 Euclid Avenue/F20, Cleveland, OH, 44195, USA
| | - Hakan Yigitbas
- Department of General Surgery, Cleveland Clinic, 9500 Euclid Avenue/F20, Cleveland, OH, 44195, USA
| | - Cem Dural
- Department of General Surgery, Cleveland Clinic, 9500 Euclid Avenue/F20, Cleveland, OH, 44195, USA
| | - Alexis Okoh
- Department of General Surgery, Cleveland Clinic, 9500 Euclid Avenue/F20, Cleveland, OH, 44195, USA
| | - Nail Aydin
- Department of General Surgery, Cleveland Clinic, 9500 Euclid Avenue/F20, Cleveland, OH, 44195, USA
| | - Eren Berber
- Department of General Surgery, Cleveland Clinic, 9500 Euclid Avenue/F20, Cleveland, OH, 44195, USA.
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30
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Robotic liver surgery for minor hepatic resections: a comparison with laparoscopic and open standard procedures. Langenbecks Arch Surg 2016; 401:707-14. [DOI: 10.1007/s00423-016-1440-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 04/19/2016] [Indexed: 02/06/2023]
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31
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Nachmany I, Pencovich N, Zohar N, Goykhman Y, Lubezky N, Nakache R, Klausner JM. Resection of colorectal liver metastases in the elderly-Is it justified? J Surg Oncol 2016; 113:485-8. [DOI: 10.1002/jso.24188] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 01/17/2016] [Indexed: 12/26/2022]
Affiliation(s)
- Ido Nachmany
- Division of General Surgery; Department of General Surgery B; Tel-Aviv Sourasky Medical Center; The Nikolas & Elizabeth Shlezak Fund for Experimental Surgery; Sackler Faculty of Medicine; Tel-Aviv University; Tel-Aviv Israel
| | - Niv Pencovich
- Division of General Surgery; Department of General Surgery B; Tel-Aviv Sourasky Medical Center; The Nikolas & Elizabeth Shlezak Fund for Experimental Surgery; Sackler Faculty of Medicine; Tel-Aviv University; Tel-Aviv Israel
| | - Nitzan Zohar
- Division of General Surgery; Department of General Surgery B; Tel-Aviv Sourasky Medical Center; The Nikolas & Elizabeth Shlezak Fund for Experimental Surgery; Sackler Faculty of Medicine; Tel-Aviv University; Tel-Aviv Israel
| | - Yaacov Goykhman
- Division of General Surgery; Department of General Surgery B; Tel-Aviv Sourasky Medical Center; The Nikolas & Elizabeth Shlezak Fund for Experimental Surgery; Sackler Faculty of Medicine; Tel-Aviv University; Tel-Aviv Israel
| | - Nir Lubezky
- Division of General Surgery; Department of General Surgery B; Tel-Aviv Sourasky Medical Center; The Nikolas & Elizabeth Shlezak Fund for Experimental Surgery; Sackler Faculty of Medicine; Tel-Aviv University; Tel-Aviv Israel
| | - Richard Nakache
- Division of General Surgery; Department of General Surgery B; Tel-Aviv Sourasky Medical Center; The Nikolas & Elizabeth Shlezak Fund for Experimental Surgery; Sackler Faculty of Medicine; Tel-Aviv University; Tel-Aviv Israel
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32
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Higashi T, Hayashi H, Taki K, Sakamoto K, Kuroki H, Nitta H, Hashimoto D, Chikamoto A, Beppu T, Baba H. Sarcopenia, but not visceral fat amount, is a risk factor of postoperative complications after major hepatectomy. Int J Clin Oncol 2015; 21:310-319. [DOI: 10.1007/s10147-015-0898-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 08/17/2015] [Indexed: 12/15/2022]
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33
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Higashi T, Hayashi H, Kaida T, Arima K, Takeyama H, Taki K, Izumi D, Tokunaga R, Kosumi K, Nakagawa S, Okabe H, Imai K, Nitta H, Hashimoto D, Chikamoto A, Beppu T, Baba H. Prognostic Impact of Visceral Fat Amount and Branched-Chain Amino Acids (BCAA) in Hepatocellular Carcinoma. Ann Surg Oncol 2015; 22 Suppl 3:S1041-7. [PMID: 26305023 DOI: 10.1245/s10434-015-4796-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Indexed: 01/06/2023]
Abstract
BACKGROUND Dysregulation of lipid and amino acid metabolism in patients with liver diseases results in obesity-related carcinogenesis and decreased levels of branched-chain amino acids (BCAA), respectively. This study assessed the clinical and prognostic impact of visceral fat amount (VFA) and its association with amino acid metabolism in patients with hepatocellular carcinoma (HCC). METHODS In this study, 215 patients who underwent hepatic resection for HCC were divided into two groups based on VFA criteria for metabolic abnormalities in Japan. Computed tomography was used to measure VFA at the third lumbar vertebra in the inferior direction. RESULTS Of the 215 patients, 132 had high and 83 had low VFA. High VFA was significantly associated with older age and higher body mass index (BMI), subcutaneous fat amount, and BCAA, but not with liver function, nutrient status, or tumoral factors. VFA was positively correlated with BMI (P < 0.0001; r = 0.63) and BCAA levels (P < 0.0001; r = 0.29). Overall survival was significantly greater in the high than in the low VFA group (P = 0.002). Multivariate analyses showed that high VFA [hazard ratio (HR) 7.06; P = 0.024] and neutrophil/lymphocyte ratio (HR 3.47; P = 0.049) were significantly prognostic of overall survival, whereas subcutaneous fat amount, BMI, BCAA, serum albumin, and prognostic nutritional index were not. CONCLUSIONS High VFA was associated with a high BCAA level, with high VFA prognostic of improved overall survival in Japanese patients with HCC.
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Affiliation(s)
- Takaaki Higashi
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Hiromitsu Hayashi
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Takayoshi Kaida
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Kota Arima
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Hideaki Takeyama
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Katsunobu Taki
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Daisuke Izumi
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Ryuma Tokunaga
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Keisuke Kosumi
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Shigeki Nakagawa
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Hirohisa Okabe
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Katsunobu Imai
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Hidetoshi Nitta
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Daisuke Hashimoto
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Akira Chikamoto
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Toru Beppu
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan.
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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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Sulpice L, Rayar M, Campillo B, Pery C, Guillaud A, Meunier B, Boudjema K. Advanced age remains an achilles heel for liver resections. World J Surg 2014; 38:918-26. [PMID: 24337318 DOI: 10.1007/s00268-013-2367-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND As the general population is aging, surgery in elderly patients has become a major public health issue. This basic question is especially true for liver resection (LR). The aim of this study was to evaluate the operative risks of LR in the elderly. METHODS Retrospective analysis of a large recent and monocentric database of LR was performed between January 1, 2005 and May 31, 2011. Patients were categorized into three groups (<60, 60-74, and ≥75 years old) to analyze postoperative outcomes and 1-year mortality. Clinicopathologic factors likely to influence outcomes were assessed by univariate and multivariate analysis. RESULTS Altogether, 1,001 consecutive LRs were performed in 912 patients (mean age 62 ± 13 years). The distribution of the LR by age was 372 (37.2 %), 477 (47.6 %), and 152 (15.2 %) in patients <60, 60-74, and ≥75 years, respectively. The overall morbidity and mortality rates were 33.3 and 2.5 %, respectively. Age ≥75 years was independently associated with postoperative mortality [odds ratio (OR) 4.75, 95 % confidence interval (CI) 1.5-15.1; p = 0.008] and 1-year mortality (OR 2.8, 95 % CI 1.2-6.6; p = 0.015). The postoperative complication rate (p = 0.216) was not increased, even for major complications (p = 0.09). The other independent risk factors for mortality were a cirrhotic liver (p = 0.017), preoperative arterial chemoembolization (p = 0.001), caval vein clamping (p = 0.001), and intraoperative blood transfusion (p = 0.044). CONCLUSIONS Age beyond 75 years represent a risk factor of death after LR and should be avoided after chemoembolization or in cirrhotic patients. A specific assessment using geriatric indexes might be the key to success in this population.
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Affiliation(s)
- Laurent Sulpice
- Service de Chirurgie Hépatobiliaire et Digestive, Hôpital Pontchaillou, Centre Hospitalier Universitaire de Rennes, Université de Rennes 1, Rennes, France,
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Mastoraki A, Tsakali A, Papanikolaou IS, Danias N, Smyrniotis V, Arkadopoulos N. Outcome following major hepatic resection in the elderly patients. Clin Res Hepatol Gastroenterol 2014; 38:462-6. [PMID: 24582424 DOI: 10.1016/j.clinre.2014.01.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Revised: 12/27/2013] [Accepted: 01/17/2014] [Indexed: 02/04/2023]
Abstract
Recent advances in operative techniques, anaesthesiologic management and intensive care have greatly reduced morbidity and mortality of major hepatectomy allowing a progressive broadening of its indications by including patients with chronic liver disorders as well as elderly subjects. It is apparent that with the aging population, more elderly patients are being referred for surgery. Selecting appropriate candidates for surgical resection is therefore crucial to maximize the benefit derived from surgery. Nevertheless, it is not clear whether advanced age itself increases surgical risk or additional age-independent variables are associated with higher operative morbidity. Regardless of the indications for surgery and the extent of planned liver resections, this population is more likely to suffer from relevant disorders. Previous studies on the safety of major liver resections in the elderly patients cite morbidity and mortality rates of approximately 30-40% and 4-5% respectively. In addition, hepatic resections for hepatocellular carcinoma or colorectal liver metastases have been reported as safe in the elderly as in the younger population. Nevertheless, a small number of investigations studied the outcome of major hepatectomy in the population over 70 years of age. The aim of our study was to evaluate overall experience with liver resections in the elderly population by comparing the early as well as the long-term outcome of the procedure in 70 years and older versus the less than 70 age group and to identify whether the age of patients alone is associated with increased rate and severity of postoperative complications.
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Affiliation(s)
- Aikaterini Mastoraki
- 4th Department of Surgery, Athens University, Medical School, ATTIKON University Hospital, 1, Rimini Street, 12462 Chaidari, Athens, Greece.
| | - Athina Tsakali
- 4th Department of Surgery, Athens University, Medical School, ATTIKON University Hospital, 1, Rimini Street, 12462 Chaidari, Athens, Greece
| | - Ioannis S Papanikolaou
- Hepatogastroenterology Unit, 2nd Department of Internal Medicine, ATTIKON University Hospital, 1, Rimini Street, 12462 Chaidari, Athens, Greece
| | - Nikolaos Danias
- 4th Department of Surgery, Athens University, Medical School, ATTIKON University Hospital, 1, Rimini Street, 12462 Chaidari, Athens, Greece
| | - Vasilios Smyrniotis
- 4th Department of Surgery, Athens University, Medical School, ATTIKON University Hospital, 1, Rimini Street, 12462 Chaidari, Athens, Greece
| | - Nikolaos Arkadopoulos
- 4th Department of Surgery, Athens University, Medical School, ATTIKON University Hospital, 1, Rimini Street, 12462 Chaidari, Athens, Greece
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Wang HQ, Yang J, Yan LN, Zhang XW, Yang JY. Liver resection in hepatitis B related-hepatocellular carcinoma: Clinical outcomes and safety in elderly patients. World J Gastroenterol 2014; 20:6620-6625. [PMID: 24914386 PMCID: PMC4047350 DOI: 10.3748/wjg.v20.i21.6620] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2013] [Revised: 01/05/2014] [Accepted: 03/19/2014] [Indexed: 02/07/2023] Open
Abstract
AIM: To compare the morbidity and mortality in young and elderly hepatocellular carcinoma (HCC) patients undergoing liver resection.
METHODS: We retrospectively enrolled 1543 consecutive hepatitis B (HBV)-related HCC patients undergoing elective hepatic resection in our cohort, including 207 elderly patients (≥ 65 years) and 1336 younger patients (< 65 years). Patient characteristics and clinical outcomes after liver resection were compared between the two groups.
RESULTS: Elderly patients had more preoperative comorbidities and lower alanine aminotransferase and aspartate aminotransferase levels. Positive rates for hepatitis B surface antigen (P < 0.001), hepatitis B e antigen (P < 0.001) and HBV DNA (P = 0.017) were more common in younger patients. Overall complications and their severity classified using the Clavien system were similar in the two groups (33.3% vs 29.6%, P = 0.271). Elderly patients had a higher rate of postoperative cardiovascular complications (3.9% vs 0.6%, P = 0.001), neurological complications (2.9% vs 0.4%, P < 0.001) and mortality (3.4% vs 1.2%, P = 0.035), and had more hospital stay requirement (13 d vs 12 d , P < 0.001) and more intensive care unit stay (36.7% vs 27.8%, P = 0.008) compared with younger patients. However, postoperative hepatic insufficiency was more common in the younger group (7.7% vs 3.4%, P = 0.024).
CONCLUSION: Hepatectomy can be safely performed in elderly patients. Age should not be regarded as a contraindication to liver resection with expected higher complication and mortality rates.
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Vibert E, Pittau G, Gelli M, Cunha AS, Jamot L, Faivre J, Castro Benitez C, Castaing D, Adam R. Actual incidence and long-term consequences of posthepatectomy liver failure after hepatectomy for colorectal liver metastases. Surgery 2013; 155:94-105. [PMID: 24694360 DOI: 10.1016/j.surg.2013.05.039] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Accepted: 05/31/2013] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Posthepatectomy liver failure (PHLF) is a severe complication after hepatectomy for colorectal liver metastases. This study evaluated its actual incidence and its effects on short- and long-term overall survival (OS) in a specialized center. MATERIALS AND METHODS Between 2006 and 2008, 193 patients who underwent 232 hepatectomies (147 minor and 85 major) for colorectal liver metastasis were studied prospectively. Hepatectomy was performed if the remnant liver volume was >0.5% of body weight. Uni- and multivariate analyses on OS after all hepatectomies (n = 232) or major resection only (n = 85) were then performed on pre-, intra-, and postoperative (including pathological) data to determine the consequences of PHLF by comparison with those of other intra- and postoperative events. RESULTS The 3-month postoperative mortality rate was 0.8%. PHLF was observed in six patients (7%) after major hepatectomy and in one (0.6%) after minor hepatectomy. With a 25-month follow-up, the 2-year OS rate was 84%. Preoperatively, pulmonary metastasis was the only determinant of OS. Intra- and postoperatively, four factors were determinant of OS: PHLF (risk ratio [RR] = 3.84, P = .04), mental confusion (RR = 3.11, P = .006), fluid collection (RR = 2.9, P = .01) and transfusion (RR = 2.27, P = .009). After major hepatectomy, only PHLF (RR = 4.14, P = .01) and confusion (RR = 3.6, P = .02) were identified. CONCLUSION With improvements in postoperative management, PHLF was found to be less responsible for 3-month mortality but remains an event that exerts a major impact on 2-year survival.
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Affiliation(s)
- Eric Vibert
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France; Inserm, Unité 785, Villejuif, France; Université Paris-Sud, Villejuif, France.
| | - Gabriella Pittau
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France; Université Paris-Sud, Villejuif, France
| | | | - Antonio Sa Cunha
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France; Inserm, Unité 785, Villejuif, France; Université Paris-Sud, Villejuif, France
| | | | - Jamila Faivre
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France; Inserm, Unité 785, Villejuif, France; Université Paris-Sud, Villejuif, France
| | | | - Denis Castaing
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France; Inserm, Unité 785, Villejuif, France; Université Paris-Sud, Villejuif, France
| | - René Adam
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France; Université Paris-Sud, Villejuif, France
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Ueno M, Hayami S, Tani M, Kawai M, Hirono S, Yamaue H. Recent trends in hepatectomy for elderly patients with hepatocellular carcinoma. Surg Today 2013; 44:1651-9. [DOI: 10.1007/s00595-013-0739-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 08/07/2013] [Indexed: 12/15/2022]
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Ide T, Miyoshi A, Kitahara K, Noshiro H. Prediction of postoperative complications in elderly patients with hepatocellular carcinoma. J Surg Res 2013; 185:614-9. [PMID: 23932657 DOI: 10.1016/j.jss.2013.07.016] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Revised: 06/24/2013] [Accepted: 07/08/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND The aim of the present study was to investigate whether advanced age was associated with a higher rate of postoperative complications and identify the predictive factors for postoperative complications in elderly patients with hepatocellular carcinoma (HCC). METHODS Between January 2000 and December 2010, 256 patients who underwent hepatectomy for HCC were investigated. Elderly patients were defined as those aged ≥75 y. The clinicopathologic data and outcomes after hepatectomy for 64 elderly and 192 younger patients were retrospectively collected and compared. RESULTS There were no significant differences in the incidence of postoperative complications (P = 0.936) or the long-term survival after hepatectomy (P = 0.641) between the elderly and younger patients. In multivariate analysis, the estimation of physiological ability and surgical stress-preoperative risk score (PRS) was an independent risk factor for postoperative morbidity in the elderly patients (P < 0.01). Moreover, the patients were analyzed according to the PRS for the assessment of their general preoperative condition and liver damage grade based on the hepatic reserve. The rate of postoperative complications in the patients with a PRS ≥0.5 and liver damage B was significantly higher in the elderly patients (P < 0.01), whereas a PRS and liver damage grade did not affect the incidence of postoperative morbidity in the younger patients (P = 0.516). CONCLUSIONS Hepatectomy for elderly patients with HCC is feasible as well as safe, and the preoperative assessment using the estimation of physiological ability and surgical stress scoring system, combined with the liver damage grade, can help to improve the safety of this procedure for elderly HCC patients.
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Affiliation(s)
- Takao Ide
- Department of Surgery, Saga University Faculty of Medicine, Saga, Japan.
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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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Fornaro L, Masi G, Caparello C, Vivaldi C, Falcone A. Resectable liver metastases from colorectal cancer: where we are now and where do we go from here? COLORECTAL CANCER 2012. [DOI: 10.2217/crc.12.47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
SUMMARY Liver metastases from colorectal cancer represent a peculiar clinical scenario in everyday practice, since treatment should achieve long-term survival or even a cure in selected patients. Presentation may vary between single cases, ranging from easily resectable lesions to more advanced metastatic spreading for which surgery can only be considered after major tumor shrinkage. For resectable liver metastases, surgery remains the essential step in the curative approach to the disease, even though different ablative procedures may be considered as valuable alternatives in certain subsets. Postoperative or perioperative chemotherapy may further improve long-term outcome, even though treatment benefits and harms related to liver toxicity should be carefully balanced in each patient. A comprehensive multidisciplinary assessment of patient- and tumor-related features remains the key to complement the clinical aspects with the biological characterization in the framework of a personalized therapeutic approach.
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Affiliation(s)
- Lorenzo Fornaro
- Istituto di Scienze della Vita, Scuola Superiore di Studi Universitari e di Perfezionamento Sant’Anna, Piazza Martiri della Libertà 33, 56127 Pisa, Italy
| | - Gianluca Masi
- UO Oncologia Medica 2 Universitaria, Azienda Ospedaliero-Universitaria Pisana, Via Roma 67, 56126 Pisa, Italy
| | - Chiara Caparello
- UO Oncologia Medica 2 Universitaria, Azienda Ospedaliero-Universitaria Pisana, Via Roma 67, 56126 Pisa, Italy
| | - Caterina Vivaldi
- UO Oncologia Medica 2 Universitaria, Azienda Ospedaliero-Universitaria Pisana, Via Roma 67, 56126 Pisa, Italy
| | - Alfredo Falcone
- UO Oncologia Medica 2 Universitaria, Azienda Ospedaliero-Universitaria Pisana, Via Roma 67, 56126 Pisa, Italy
- Dipartimento di Oncologia, dei Trapianti e delle Nuove Tecnologie in Medicina, Università di Pisa, Via Roma 55, 56126 Pisa, Italy
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Cook EJ, Welsh FKS, Chandrakumaran K, John TG, Rees M. Resection of colorectal liver metastases in the elderly: does age matter? Colorectal Dis 2012; 14:1210-6. [PMID: 22251850 DOI: 10.1111/j.1463-1318.2012.02946.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AIM Despite the incidence of colorectal cancer increasing with age the proportion of patients undergoing surgery for colorectal liver metastases decreases dramatically in the elderly. Is this referral or selection bias justified? METHOD A prospective database of resection for colorectal liver metastases at a single centre was retrospectively analysed to compare the outcome in patients aged ≥75 years (group E) with those aged <75 years (group Y). Data were analysed using the Kaplan-Meier method with Cox regression modelling. RESULTS Of 1443 resections, 151 (10.5%) in group E were compared with 1292 (89.5%) in group Y. The two groups were matched apart from higher American Society of Anesthesiology scores (P=0.001) and less use of chemotherapy (P=0.01) in the elderly. Perioperative morbidity and 90-day mortality were higher in the elderly compared with the younger group (32.5%vs 21.2%, P=0.02, and 7.3%vs 1.3%, P=0.001). In the last 5 years, mortality in the elderly improved and was no longer significantly different from that of the younger patients [n=2/76 (2.6%) vs n=9/559 (1.6%); P=0.063]. The 5-year survival was similar in groups E and Y for cancer-specific (41.4%vs 41.6%, P=0.917), overall (37.0%vs 38.2%) and median (44.1 months vs 43.6 months, P=0.697) survival respectively. CONCLUSION In the elderly liver resection for metastatic disease can be performed with acceptable mortality and morbidity with as good a prospect of survival as for younger patients.
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Affiliation(s)
- E J Cook
- Department of Hepatobiliary Surgery, Basingstoke and North Hampshire Foundation Trust, Basingstoke, Hampshire, UK
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Surgical treatment of perihilar cholangiocarcinoma in octogenarians: a single center experience. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2012; 20:324-31. [DOI: 10.1007/s00534-012-0529-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Mayo SC, Shore AD, Nathan H, Edil BH, Hirose K, Anders RA, Wolfgang CL, Schulick RD, Choti MA, Pawlik TM. Refining the definition of perioperative mortality following hepatectomy using death within 90 days as the standard criterion. HPB (Oxford) 2011; 13:473-82. [PMID: 21689231 PMCID: PMC3133714 DOI: 10.1111/j.1477-2574.2011.00326.x] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Accepted: 04/08/2011] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Defining perioperative mortality as death that occurs within 30 days of surgery may underestimate 'true' mortality among patients undergoing hepatic resection. To better define perioperative mortality, trends in the risk for death during the first 90 days after hepatectomy were assessed. METHODS Surveillance, Epidemiology and End Results (SEER) Medicare data were used to identify 2597 patients who underwent hepatic resection during 1991-2006. Data on their clinicopathological characteristics, surgical management and perioperative mortality were collected and survival was assessed at 30, 60 and 90 days post-surgery. RESULTS Overall, 5.7% of patients died within the first 30 days. Postoperative mortality at 60 and 90 days were 8.3% and 10.1%. In-hospital mortality after hepatic resection was greater among patients with hepatocellular carcinoma (HCC) than among those with colorectal liver metastases (CRLM) (8.9% and 3.8%, respectively; P < 0.001). In CRLM patients, mortality increased from 4.3% at 30 days to 8.4% at 90 days, whereas mortality in HCC patients increased from 9.7% at 30 days to 15.0% at 90 days (both P < 0.05). Patients with HCC were twice as likely as CRLM patients to die within 30 days [odds ratio (OR) 2.03], 60 days (OR = 1.74) and 90 days (OR = 1.71) (all P < 0.001). Differences in 30- and 90-day mortality were greatest among HCC patients undergoing major hepatic resection (P < 0.05). CONCLUSIONS Reporting deaths that occur within a maximum of 30 days of surgery underestimates the mortality associated with hepatic resection. Traditional 30-day definitions of mortality are misleading and surgeons should report all perioperative outcomes that occur within 90 days of hepatic resection.
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Affiliation(s)
- Skye C Mayo
- Department of Surgery, School of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Russolillo N, Ferrero A, Viganò L, Langella S, Amisano M, Capussotti L. Liver trisectionectomies for primary and secondary liver cancer in the modern era: results of a single tertiary center. Updates Surg 2010; 62:161-9. [PMID: 21161705 DOI: 10.1007/s13304-010-0038-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2010] [Accepted: 11/30/2010] [Indexed: 11/29/2022]
Abstract
Recent advances in patient selection and surgical technique have resulted in low mortality and morbidity rates after liver resections. The aim of this study was to evaluate the operative risks of liver trisectionectomies in comparison with major resections. The data prospectively collected of patients who underwent trisectionectomies (TR Group, n = 54) and major hepatectomies (MH Group, n = 175) without biliary reconstruction were compared. Besides, the early results of patients who underwent right trisectionectomies (RTR Group, n = 36) and left trisectionectomies (LTR Group, n = 18) were compared. There was no significant difference in patient characteristics of MH and TR groups excluded for a high portal vein embolization (PVE) in TR group. Mortality (1% in MH group and 3.7% in TR group, p = 0.206) and overall morbidity rates (39% in MH group and 48% in TR group, p = 0.225) were similar between two groups. A higher proportion of patients in TR group developed liver failure (p = 0.024) and required blood transfusion (30 vs. 11%, p < 0.001). The median hospital stay after trisectionectomies was higher in TR group than MH group (p = 0.053). There was no significant difference in patient characteristics of LTR and RTR groups excluded for lymphadenectomy which was higher in LTR group (p = 0.008) and PVE rate higher in RTR group (p = 0.01). The overall morbidity (44 vs. 55%) and mortality (2.7 vs. 5.5%) were comparable between two groups. A higher proportion of patients in RTR group required blood transfusion (39 vs. 11%, p = 0.032). At multivariate analysis, age was the only positive predictor for morbidity after trisectionectomies (p = 0.010). Trisectionectomies can be performed safely. Left trisectionectomies are as safe as right trisectionectomies. The accurate preoperative selection is necessary to reduce operative risks.
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Affiliation(s)
- Nadia Russolillo
- Department HPB and Digestive Surgery, Ospedale Mauriziano "Umberto I", Largo Turati, 620-10128, Turin, Italy,
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