Liver resection in the elderly: A retrospective cohort study of 460 patients – Feasible and safe

Safety and feasibility of liver resection including major hepatectomy for geriatric patients with hepatocellular carcinoma: a retrospective observational study

BACKGROUND

It is unclear whether hepatectomy, which ranges in invasiveness from partial to major hepatectomy, is safe and feasible for older adult patients. Therefore, we compared its postoperative complications and long-term outcomes between younger and older adult patients.

METHODS

Patients who underwent hepatectomies for hepatocellular carcinoma (N = 883) were evaluated. Patients were divided into two groups: aged < 75 years (N = 593) and ≥ 75 years (N = 290). Short-term outcomes and prognoses were compared between the groups in the entire cohort. The same analyses were performed for the major hepatectomy cohort.

RESULTS

In the entire cohort, no significant differences were found in complications between patients aged < 75 and ≥ 75 years, and the multivariate analysis did not reveal age as a prognostic factor for postoperative complications. However, overall survival was significantly worse in older patients, although no significant differences were noted in time to recurrence or cancer-specific survival. In the multivariate analyses of time to recurrence, overall survival, and cancer-specific survival, although older age was an independent poor prognostic factor for overall survival, it was not a prognostic factor for time to recurrence and cancer-specific survival. In the major hepatectomy subgroup, short- and long-term outcomes, including time to recurrence, overall survival, and cancer-specific survival, did not differ significantly between the age groups. In the multivariate analysis, age was not a significant prognostic factor for complications, time to recurrence, overall survival, or cancer-specific survival.

CONCLUSION

Hepatectomy, including minor and major hepatectomy, may be safe and oncologically feasible options for selected older adult patients with hepatocellular carcinoma.

Resection of intrahepatic cholangiocarcinoma in octogenarians: a single-center analysis

The rapidly aging population in industrialized countries comes with an increased incidence of intrahepatic cholangiocarcinoma (iCC) which presents new challenges for oncological treatments especially in elderly patients. Thus, the question arises to what extent the benefit of surgical resections, as the only curative treatment option, outweighs possible perioperative risks in patients ≥ 80 years of age (octogenarians). We therefore retrospectively analyzed 311 patients who underwent resection for iCC at Hannover Medical School between January 1996 and December 2022. In total, there were 11 patients older than 80 years in our collective. Despite similar tumor size, octogenarians underwent comparatively less extensive surgery (54.5% major resections in octogenarians vs. 82.7% in all other patients; p = 0.033) with comparable rates of lymphadenectomy and tumor-free resection margins. Furthermore, we did not observe increased major postoperative morbidity (Clavien-Dindo ≥ IIIa complications: 27.3% vs. 34.3% in all other patients; p = 0.754) or mortality (estimated 1-year OS of 70.7% vs. 72.5% in all other patients, p = 0.099). The length of intensive care unit (ICU) or intermediate care unit (IMC) stay was significantly longer in octogenarians, however, with a comparable length in total hospital stay. The estimated overall survival (OS) did also not differ significantly, although a trend towards reduced long-term survival was observed (14.5 months vs. 28.03 months in all other patients; p = 0.099). In conclusion, primary resection is a justifiable and safe therapeutic option even in octogenarians but requires an even more thorough preoperative patient selection.

Oncologic Liver Resections in a Geriatric Population: Peri-operative, Long-Term and Quality-of-Life Outcomes-Experience from a High-Volume Centre in India

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.

Preservation of Mitochondrial Health in Liver Ischemia/Reperfusion Injury

Liver ischemia-reperfusion injury (LIRI) is a major cause of the development of complications in different clinical settings such as liver resection and liver transplantation. Damage arising from LIRI is a major risk factor for early graft rejection and is associated with higher morbidity and mortality after surgery. Although the mechanisms leading to the injury of parenchymal and non-parenchymal liver cells are not yet fully understood, mitochondrial dysfunction is recognized as a hallmark of LIRI that exacerbates cellular injury. Mitochondria play a major role in glucose metabolism, energy production, reactive oxygen species (ROS) signaling, calcium homeostasis and cell death. The diverse roles of mitochondria make it essential to preserve mitochondrial health in order to maintain cellular activity and liver integrity during liver ischemia/reperfusion (I/R). A growing body of studies suggest that protecting mitochondria by regulating mitochondrial biogenesis, fission/fusion and mitophagy during liver I/R ameliorates LIRI. Targeting mitochondria in conditions that exacerbate mitochondrial dysfunction, such as steatosis and aging, has been successful in decreasing their susceptibility to LIRI. Studying mitochondrial dysfunction will help understand the underlying mechanisms of cellular damage during LIRI which is important for the development of new therapeutic strategies aimed at improving patient outcomes. In this review, we highlight the progress made in recent years regarding the role of mitochondria in liver I/R and discuss the impact of liver conditions on LIRI.

Mitochondrial Autophagy in Ischemic Aged Livers

Mitochondrial autophagy (mitophagy) is a central catabolic event for mitochondrial quality control. Defective or insufficient mitophagy, thus, can result in mitochondrial dysfunction, and ultimately cell death. There is a strong causal relationship between ischemia/reperfusion (I/R) injury and mitochondrial dysfunction following liver resection and transplantation. Compared to young patients, elderly patients poorly tolerate I/R injury. Accumulation of abnormal mitochondria after I/R is more prominent in aged livers than in young counterparts. This review highlights how altered autophagy is mechanistically involved in age-dependent hypersensitivity to reperfusion injury.

Surgical treatment of liver hydatid cyst in elderly patients: A propensity score-matching retrospective cohort study

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.

Short-term outcomes of laparoscopic versus open hepatectomy in the elderly patient: systematic review and meta-analysis

BACKGROUND AND AIM

Favorable outcomes of laparoscopic hepatectomy (LH) over open hepatectomy (OH) have been demonstrated. LH offers less postoperative morbidity, less blood loss, and shorter hospital stay, while maintaining oncological safety. Only limited evidence about outcomes of LH in elderly is currently available. Therefore, this study aimed to compare short term outcomes of LH to OH for patients >65 years.

METHODS

A systematic review and meta-analysis were performed according to Cochrane guidelines. Embase, PubMed, Cochrane Library, and Google Scholar were searched to identify eligible studies. Studies were included if they compared LH to OH, and focused on an elderly population, or had a majority of patients >65 years. Perioperative and postoperative outcomes were analyzed.

RESULTS

Thirteen studies with 1174 patients (LH:532, OH:642) were included for analysis. When compared to OH, elderly undergoing LH had significantly less postoperative complications (risk ratio [RR]0.52; 95% confidence interval (CI):0.43-0.63), less blood loss (mean difference [MD]-198.58; 95% CI:-299.88 to -97.28), and shorter length of stay (MD-4.83; 95%CI:-7.91 to -1.84), while oncological safety was non-inferior (RR1.04; 95%CI:1.00-1.08).

CONCLUSIONS

Within the elderly population LH seems to be superior to OH, concerning short-term outcomes. However, for broader applicability more trials are needed including more difficult and major resections.

Predicting morbidity in liver resection surgery: external validation of the revised frailty index and development of a novel predictive model

BACKGROUND

Perioperative complications of liver resection surgery are common but individual patient-level prediction is difficult. Most risk models are unvalidated and may not be clinically useful. We aimed to validate a risk prediction model for complications of liver resection, the Revised Frailty Index (rFI), at a high volume centre. We also aimed to derive a predictive model for complications in our cohort.

METHODS

Records were reviewed for 300 patients undergoing liver resection. The rFI's discrimination of 90-day major complications was assessed by receiver operating curve analysis. Logistic regression analysis was then used to fit rFI covariates to our dataset. A further analysis produced a model with optimal discrimination of 90-day major complications.

RESULTS

The rFI was a poor discriminator of 90-day major complications (AUROC 0.562) among patients at our centre. The rFI optimised fit model demonstrated improved discrimination of 90-day major complications (AUROC 0.685). We developed a novel model with improved fit and similar discrimination (AUROC 0.710).

CONCLUSION

We were unable to validate the rFI as a predictor of complications. We developed a novel model with discrimination at least equal to other published risk models. However, there is an unmet need for well-validated, clinically useful risk tools in this area.

Short- and Long-Term Outcomes After Hepatectomy in Elderly Patients with Hepatocellular Carcinoma: An Analysis of 229 Cases from a Developing Country

Background

The number of elderly patients with HCC who undergo liver resection is increasing. Because of the advanced age of the patients, increased postoperative morbidity and reduced overall survival are expected in this population. The study aim was to compare clinicopathologic and operative features, short- and long-term outcomes among hepatocellular carcinoma (HCC) patients from three age groups undergoing potentially curative liver resection in a developing country.

Methods

Prospectively collected data relating to 229 patients who underwent curative-intent liver resection from January 2009 until December 2018 were analyzed. The patients were divided into two age groups: G1 was below 70 years old (n=151) and G2 was 70 years old and older (n=78). Demographic, clinical, operative data, short- and long-term outcomes were compared between the two groups. Univariate and multivariate analyses of prognostic factors were performed.

Results

The mean overall morbidity rate of the patients was 31.1% (G1), and 46.2% (G2) by age group. Postoperative morbidity was significantly higher in the G2 group (p=0.03). There was no difference in major morbidity between the two groups (p=0.214). No significant difference in mortality rate and overall survival was found between the study groups (p=0.280, p=0.383). Both age ≥70 years (ie, G2 group) and liver cirrhosis were identified as prognostic factors for postoperative morbidity, and a Child-Pugh score B as a negative prognostic factor for overall survival. In subgroup analysis of patients with cirrhosis, age ≥70, diabetes mellitus and perioperative transfusion were identified as prognostic factors for postoperative morbidity.

Conclusion

The study confirmed the safety and feasibility of liver resection in elderly patients with HCC. However, appropriate patient selection among the elderly is mandatory in order to improve short- and long-term outcomes.

Intra-operative anaesthetic management of older patients undergoing liver surgery

Older patients represent a growing proportion of the general surgical caseload. This includes those undergoing liver resection, with figures rising faster than the rate of population ageing. The physiology of ageing leads to changes in all body systems which may render the provision of safe anaesthesia more challenging than in younger patients. Anaesthesia for liver surgery has specific principles, largely aimed at reducing venous bleeding from the liver, and those related to complex major surgery. This review explores the principles of anaesthesia for liver resection and describes how they may require modification in the older patient. The traditional approach of low central venous pressure anaesthesia in order to reduce bleeding may need to be altered in the presence of a cardiovascular system less able to tolerate hypotension and hypoperfusion. These changes in physiology should also lower the threshold for invasive monitoring. The provision of effective analgesia perioperatively should be tailored to minimise the surgical stress response and opiate use. Careful consideration of general principles of intra-operative care for older patients, such as positioning, drug dosing, avoidance of excessively deep anaesthesia, and maintenance of normothermia are also important given the prolonged, complex nature of liver surgery. This individualised approach, with careful attention to changes in physiology allows liver resections to be undertaken in older patients without increases in mortality.

New frontiers in liver resection for hepatocellular carcinoma

Liver resection is one of the main curative options for early hepatocellular carcinoma (HCC) in patients with cirrhosis and is the treatment of choice in non-cirrhotic patients. However, careful patient selection is required to balance the risk of postoperative liver failure and the potential benefit on long-term outcomes. In the last decades, improved surgical techniques and perioperative management, as well as better patient selection, have enabled the indications for liver resection to be expanded. In this review, we aim to describe the main indications for liver resection in the management of HCC, its role compared to percutaneous ablation and liver transplantation in the therapeutic algorithm, as well as the recent advances in liver surgery that could be used to improve the prognosis of patients with HCC.

Low thoracic muscle radiation attenuation is associated with postoperative pneumonia following partial hepatectomy for colorectal metastasis

BACKGROUND

Low skeletal muscle radiation attenuation (SM-RA) is indicative of myosteatosis and diminished muscle function. It is predictive of poor outcome following oncological surgery in several cancer types. Postoperative pneumonia is a known risk factor for increased postoperative mortality. We hypothesized that low SM-RA of the respiratory muscles at the 4th thoracic-vertebra (T4) is associated with postoperative pneumonia following liver surgery.

METHODS

Postoperative pneumonia was identified using prospective infection control data. Computed tomography body composition analysis was performed at the L3-and T4 level to determine SM-RA. Body composition variables were corrected for confounders and related to postoperative pneumonia and admission time by multivariable logistic regression.

RESULTS

Body composition analysis of 180 patients was performed. Twenty-one patients developed postoperative pneumonia (11.6%). Multivariable analysis showed that low T4 SM-RA as well as low L3 SM-RA were significantly associated with postoperative pneumonia (OR 3.65, 95% CI 1.41-9.49, p < 0.01) and (OR 3.22, 95% CI 1.20-8.61, p = 0.02, respectively).

CONCLUSION

Low SM-RA at either the L3-or T4-level is associated with a higher risk of postoperative pneumonia following CLRM resection.

Resection of intrahepatic cholangiocarcinoma in elderly patients - is it reasonable?

Background

Intrahepatic cholangiocarinoma (ICC) has a rising incidence in western countries. Often major or extended resections are necessary for complete tumor removal. Due to demographical trends the number of elderly patients diagnosed with ICC is rising accordingly. Aim of this study is to show whether resection of ICC in elderly patients is reasonable or not.

Methods

Between January 2008 and June 2018 all consecutive patients with ICC were collected. Analyses were focussed on the performed resection, its extent, postoperative morbidity and mortality as well as survival. Statistics were performed with Chi² test for categorical data and for survival analyses the Kaplan Meier model with log rank test was used.

Results

In total 210 patients underwent surgical exploration with 150 resections (71.4%). Patients were divided in 70-years cut-off groups (> 70 vs < 70 years of age) as well as a young (age 30–50, n = 23), middle-age (50–70, n = 76) and old (> 70, n = 51) group, whose results are presented here. Resectability (p = 0.709), extent of surgery (p = 0.765), morbidity (p = 0.420) and mortality (p = 0.965) was comparable between the different age groups. Neither visceral (p = 0.991) nor vascular (p = 0.614) extension differed significantly, likewise tumor recurrence (p = 0.300) or the localisation of recurrence (p = 0.722). In comparison of patients > or < 70 years of age, recurrence-free survival (RFS) was significantly better for the younger group (p = 0.047). For overall survival (OS) a benefit could be shown, but without reaching significance (p = 0.072). In subgroup analysis the middle-age group had significant better OS (p = 0.020) and RFS (p = 0.038) compared to the old group. Additionally, a better OS (p = 0.076) and RFS (p = 0.179) was shown in comparison with the young group as well, but without reaching significance. The young compared to the old group had analogous OS (p = 0.931) and RFS (p = 0.845).

Conclusion

Resection of ICC in elderly patients is not associated with an increased perioperative risk. Even extended resections can be performed in elderly patients without obvious disadvantages. Middle-age patients have a clear benefit for OS and RFS, while young and old patients have a comparable and worse long-term outcome.

Expanding the Surgical Pool for Hepatic Resection to Treat Biliary and Primary Liver Tumors

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.

The efficacy and safety of totally laparoscopic hepatectomy for non-cirrhotic hepatocellular carcinoma in the elderly

Background

Laparoscopic hepatectomy (LH) has been identified to be effective and safe for elderly patients (≥70 years). This study aims to assess the short-and long-term outcome of totally laparoscopic liver resection for elderly patients with Hepatocellular carcinoma (HCC).

Methods

We retrospectively reviewed 93 patients with HCC who underwent LH from August, 2003 to July, 2013 in a single center. Short-term operative and postoperative outcomes together with long-term outcomes, including disease free survival (DFS) and overall survival (OS) were analyzed.

Results

A total of 81 patients was finally reviewed, of which 23 patients (28.40%) were grouped to elderly (≥70 years) and 58 patients (71.60%) were divided into younger group (< 70 years). The mean ages of patients in the elderly and younger cohorts were 74.9 ± 3.4 and 50.9 ± 12.7 years old, respectively. The median follow-up durations in elderly cohort and young cohort were 30 months and 24 months. The mean postoperative hospital stay was nearly 4 days longer in the elderly cohort than that in younger group (13.4 vs 9.5; p = 0.003). The elderly cohort has a higher rate of non-surgical complications than that in the younger cohort (P = 0.045), while the risks of surgical complications were comparable between the two groups. For the postoperative complications, elderly patients were more easily to develop grade III or more of Clavien-Dindo classification than that in the younger patients (P = 0.008). The median OS in the elderly group and younger group was 44.09 months and 42.49 months, respectively, with p = 0.089. The median DFS in the elderly group and the younger group was 39.87 months and 37.86 months, respectively, with p = 0.0616.

Conclusions

Elderly patients could obtain comparable operative and survival benefits from LH for HCC as younger counterparts. Age may not be a contraindication to laparoscopic liver resection for elderly patients.

Liver Transplantation and Liver Resection for Cirrhotic Patients with Hepatocellular Carcinoma: Comparison of Long-Term Survivals

BACKGROUND

Both liver transplantation (LT) and liver resection (LR) represent curative treatment options for hepatocellular carcinoma (HCC) in patients with liver cirrhosis. In this study, we have compared outcomes between historical and more recent patient cohorts scheduled either for LT or LR, respectively.

METHODS

Clinicopathological data of all patients with HCC and cirrhosis who underwent LT or LR between 1989 and 2011 were evaluated. Overall survival of patients with HCC within the Milan criteria (MC) was analyzed focusing on changes between different time periods.

RESULTS

In total, 364 and 141 patients underwent LT and LR for HCC in cirrhosis, respectively. Among patients with HCC within MC, 214 and 59 underwent LT and LR, respectively. Postoperative morbidity (37 vs. 11%, P < .0001), but not mortality (3 vs. 1%, P = .165), was higher after LR than after LT for HCC within MC. In the period 1989-2004, overall survival (OS) was significantly higher in patients who underwent LT compared to LR for HCC within MC (5-year OS: 77 vs. 36%, P < .0001). Interestingly, in the more recent period 2005-2011, OS was comparable between LT and LR for HCC within MC (5-year OS: 73 vs. 61%, P = .07).

CONCLUSION

We have noted an improvement of outcomes among patients selected for partial hepatectomy in recent years that were comparable to stable results after LT in cirrhotic patients with HCC. Whether those improvements are due to advances in liver surgery, optimized perioperative managament for patients with liver cirrhosis, and the development of modern multimodal treatment strategies for the recurrent lesions appears plausible.

Major Hepatectomy for Colorectal Liver Metastases in Patients Aged Over 80: A Propensity Score Matching Analysis

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.

Effect of Age (over 75 Years) on Postoperative Complications and Survival in Patients Undergoing Hepatic Resection for Hepatocellular Carcinoma

BACKGROUND

Thanks to technical advancement in surgery for hepatocellular carcinoma (HCC), hepatic resection (HR) for elderly HCC patients has become safer. However, elderly patients may have shorter long-term survival after surgery if compared with younger patients because of their expected life span. The aim of the present study was to evaluate clinical outcomes and safety after HR in HCC patients aged >75 years (older) compared with HCC patients aged <75 years (younger).

METHOD

One hundred sixty-eight patients who underwent HR for HCC from 1998 to 2015 in our Center were analyzed using a prospective database. Complications, disease-free survival rates, and cumulative survival rates were compared between the two groups.

RESULTS

During the immediate postoperative period, no differences were found about liver-related complications, hospital stay and 90-day mortality. However, older patients had more complications in class II or higher (Clavien classification) (p = 0.017). Although disease-free survival in both groups was similar (p = 0.099), overall survival was worse in the elderly group (p = 0.024). On multivariate analysis, only age ≥75 years was significantly related to overall survival.

CONCLUSION

If elderly patients with liver cirrhosis and HCC are appropriately selected and evaluated, they might have favorable prognoses after HR.