Perioperative outcome of elderly versus younger patients undergoing major hepatic or pancreatic surgery

Qiang Lu, Jian-Wen Lu, Zheng Wu, Xue-Min Liu, Jian-Hui Li, Jian Dong, Guo-Zhi Yin, Yi Lv, Xu-Feng Zhang, Qiang Lu, Jian-Wen Lu, Zheng Wu, Xue-Min Liu, Jian-Hui Li, Jian Dong, Guo-Zhi Yin, Yi Lv, Xu-Feng Zhang

Abstract

Objective: The aim of this study was to determine the safety of elderly cancer patients (≥70 years) undergoing hepatic resection (HR) or pancreaticoduodenectomy (PD) in comparison with younger adults (<70 years).

Methods: A total of 1,012 consecutive patients undergoing HR or PD were included. The incidence and severity of morbidity were documented within 30 days postoperatively and compared between elderly and younger groups. Risk factors associated with postoperative morbidity were investigated by multivariate logistic regression analysis.

Results: Elderly patients (n=111, 11.0%) had more comorbidities and worse preoperative general condition and liver function versus younger patients (n=901, 89.0%), and thus were more likely to develop infectious (eg, systemic sepsis and urinary tract infection, both p<0.01) and technical-associated complications (intraperitoneal bleeding and biliary/pancreatic fistula, p=0.029 and p=0.074, respectively). However, the incidence and severity of complications were comparable between elderly and younger patients in the whole cohort, and also in HR and PD surgery groups separately. Preoperative hemoglobin (odds ratio [OR] 1.4, p=0.007) and intraoperative blood transfusion (OR 1.9, p=0.002), rather than age, were independently associated with postoperative morbidity. Hepatitis (OR 2.9, p=0.001), preoperative hemoglobin (OR 1.6, p=0.036), and pancreatic versus hepatic surgery (OR 2.3, p=0.005) were independently associated with postoperative infectious. For elderly patients only, American Society of Anesthesiologists (ASA) score III (OR 2.1, p=0.033) and intraoperative blood transfusion (OR 3.2, p=0.030) were independently associated with postoperative morbidity.

Conclusion: HR and PD can be safely performed in selected elderly patients versus younger patients. Elderly patients with ASA score III or above should be cautiously selected for major surgeries.

Keywords: elderly; hepatectomy; morbidity; pancreaticoduodenectomy.

Conflict of interest statement

Disclosure The authors report no conflicts of interest in this work.

Figures

Figure 1
Figure 1
(A) Overall incidence of postoperative complications following HR or PD in elderly and younger patients. (B) Clavien–Dindo classification of postoperative morbidity in elderly and younger patients who underwent HR or PD. Abbreviations: HR, hepatic resection; PD, pancreaticoduodenectomy.

References

    1. Dall TM, Gallo PD, Chakrabarti R, West T, Semilla AP, Storm MV. An aging population and growing disease burden will require a large and specialized health care workforce by 2025. Health Aff. 2013;32(11):2013–2020.
    1. Beliveau MM, Multach M. Perioperative care for the elderly patient. Med Clin North Am. 2003;87(1):273–289.
    1. Piccirillo JF, Tierney RM, Costas I, Grove L, Spitznagel EL. Prognostic importance of comorbidity in a hospital-based cancer registry. JAMA. 2004;291(20):2441–2447.
    1. Lemmens VEPP, Janssen-Heijnen MLG, Verheij CDGW, Houterman S, Repelaer van Driel OJ, Coebergh JWW. Co-morbidity leads to altered treatment and worse survival of elderly patients with colorectal cancer. Br J Surg. 2005;92(5):615–623.
    1. Shahir MA, Lemmens VEPP, van de Poll-Franse LV, Voogd AC, Martijn H, Janssen-Heijnen MLG. Elderly patients with rectal cancer have a higher risk of treatment-related complications and a poorer prognosis than younger patients: a population-based study. Eur J Cancer. 2006;42(17):3015–3021.
    1. Kim IH, Kisseleva T, Brenner DA. Aging and liver disease. Curr Opin Gastroenterol. 2015;31(3):184–191.
    1. Chantarojanasiri T, Hirooka Y, Ratanachu-ek T, Kawashima H, Ohno E, Goto H. Evolution of pancreas in aging: degenerative variation or early changes of disease? J Med Ultrason. 2014;42(2):177–183.
    1. Saisho Y, Butler AE, Meier JJ, et al. Pancreas volumes in humans from birth to age one hundred taking into account sex, obesity, and presence of type-2 diabetes. Clin Anat. 2007;20(8):933–942.
    1. Wang H-Q. Liver resection in hepatitis B-related hepatocellular carcinoma: clinical outcomes and safety in elderly patients. World J Gastroenterol. 2014;20(21):6620–6625.
    1. Higuera O. Management of pancreatic cancer in the elderly. World J Gastroenterol. 2016;22(2):764–775.
    1. van der Geest LGM, Besselink MGH, van Gestel YRBM, et al. Pancreatic cancer surgery in elderly patients: balancing between short-term harm and long-term benefit. A population-based study in the Netherlands. Acta Oncol. 2015;55(3):278–285.
    1. Partridge JSL, Harari D, Dhesi JK. Frailty in the older surgical patient: a review. Age Ageing. 2012;41(2):142–147.
    1. Su C-W, Lei HJ, Chau GY, et al. The effect of age on the long-term prognosis of patients with hepatocellular carcinoma after resection surgery. Arch Surg. 2012;147(2):137–144.
    1. Kow AW, Kwon CH, Song S, Kim JM, Joh JW. Clinicopathological factors and long-term outcome comparing between lung and peritoneal metastasectomy after hepatectomy for hepatocellular carcinoma in a tertiary institution. Surgery. 2015;157(4):645–653.
    1. Nozawa A, Kubo S, Takemura S, et al. Hepatic resection for hepatocellular carcinoma in super-elderly patients aged 80 years and older in the first decade of the 21st century. Surg Today. 2014;45(7):851–857.
    1. Lee SH, Choi HC, Jeong S-H, et al. Hepatocellular carcinoma in older adults: clinical features, treatments, and survival. J Am Geriatr Soc. 2011;59(2):241–250.
    1. Borzio M, Dionigi E, Vitale A, et al. Management and prognosis of hepatocellular carcinoma in the elderly: results of an in-field multicenter cohort study. Liver Int. 2017;37(8):1184–1192.
    1. Frakes JM, Strom T, Springett GM, et al. Resected pancreatic cancer outcomes in the elderly. J Geriatr Oncol. 2015;6(2):127–132.
    1. Marsoner K, Kornprat P, Sodeck G, et al. Pancreas cancer surgery in octogenarians – should we or should we not? Anticancer Res. 2016;36(4):1979–1984.
    1. Kauffmann R, Fong Y. Post-hepatectomy liver failure. Hepatobiliary Surg Nutr. 2014;3(5):238–246.
    1. Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P. Acute renal failure – definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care. 2004;8(4):R204–R212.
    1. Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus definitions for sepsis and septic shock (sepsis-3) JAMA. 2016;315(8):801–810.
    1. Welsch T, Borm M, Degrate L, Hinz U, Büchler MW, Wente MN. Evaluation of the International Study Group of Pancreatic Surgery definition of delayed gastric emptying after pancreatoduodenectomy in a high-volume centre. Br J Surg. 2010;97(7):1043–1050.
    1. Balducci L, Extermann M. Management of cancer in the older person: a practical approach. Oncologist. 2000;5(3):224–237.
    1. Repetto L, Fratino L, Audisio RA, et al. Comprehensive geriatric assessment adds information to Eastern Cooperative Oncology Group performance status in elderly cancer patients: an Italian Group for Geriatric Oncology Study. J Clin Oncol. 2002;20(2):494–502.
    1. Robinson TN, Wallace JI, Wu DS, et al. Accumulated frailty characteristics predict postoperative discharge institutionalization in the geriatric patient. J Am Coll Surg. 2011;213(1):37–42.
    1. Pofahl WE, Pories AJ. Current status and future directions of geriatric general surgery. J Am Geriatr Soc. 2003;51(7 Suppl):S351–S354.
    1. Kanda M, Fujii T, Suenaga M, et al. Pancreatoduodenectomy with portal vein resection is feasible and potentially beneficial for elderly patients with pancreatic cancer. Pancreas. 2014;43(6):951–958.
    1. Hakim FT, Flomerfelt FA, Boyiadzis M, Gress RE. Aging, immunity and cancer. Curr Opin Immunol. 2004;16(2):151–156.
    1. Montecino-Rodriguez E, Berent-Maoz B, Dorshkind K. Causes, consequences, and reversal of immune system aging. J Clin Invest. 2013;123(3):958–965.
    1. Pfister G, Savino W. Can the immune system still be efficient in the elderly? An immunological and immunoendocrine therapeutic perspective. Neuroimmunomodulation. 2008;15(4–6):351–364.
    1. Rowe TA, Juthani-Mehta M. Diagnosis and management of urinary tract infection in older adults. Infect Dis Clin North Am. 2014;28(1):75–89.
    1. Matthews SJ, Lancaster JW. Urinary tract infections in the elderly population. Am J Geriatr Pharmacother. 2011;9(5):286–309.
    1. Tenke P, Köves B, Johansen TEB. An update on prevention and treatment of catheter-associated urinary tract infections. Curr Opin Infect Dis. 2014;27(1):102–107.
    1. Tambyah PA, Oon J. Catheter-associated urinary tract infection. Curr Opin Infect Dis. 2012;25(4):365–370.
    1. Kim IH, Kisseleva T, Brenner DA. Aging and liver disease. Curr Opin Gastroenterol. 2015;31(3):184–191.
    1. Tee MC, Shubert CR, Ubl DS, Habermann EB, Nagorney DM, Que FG. Preoperative anemia is associated with increased use of hospital resources in patients undergoing elective hepatectomy. Surgery. 2015;158(4):1027–1038.
    1. Tohme S, Varley PR, Landsittel DP, Chidi AP, Tsung A. Preoperative anemia and postoperative outcomes after hepatectomy. HPB. 2016;18(3):255–261.
    1. Liu L, Wang Z, Jiang S, et al. Perioperative allogenenic blood transfusion is associated with worse clinical outcomes for hepatocellular carcinoma: a meta-analysis. PLoS One. 2013;8(5):1–10.
    1. Kaplan J, Sarnaik S, Gitlin J, Lusher J. Diminished helper/suppressor lymphocyte ratios and natural killer activity in recipients of repeated blood transfusions. Blood. 1984;64(1):308–310.
    1. Ross A, Mohammed S, VanBuren G, et al. An assessment of the necessity of transfusion during pancreatoduodenectomy. Surgery. 2013;154(3):504–511.
    1. Kooby DA, Stockman J, Ben-Porat L, et al. Influence of transfusions on perioperative and long-term outcome in patients following hepatic resection for colorectal metastases. Ann Surg. 2003;237(6):860–870.
    1. Kimura N, Toyoki Y, Ishido K, et al. Perioperative blood transfusion as a poor prognostic factor after aggressive surgical resection for hilar cholangiocarcinoma. J Gastrointest Surg. 2015;19(5):866–879.
    1. Sima CS, Jarnagin WR, Fong Y, et al. Predicting the risk of perioperative transfusion for patients undergoing elective hepatectomy. Ann Surg. 2009;250(6):914–921.
    1. Kim JM, Cho BI, Kwon CH, et al. Hepatectomy is a reasonable option for older patients with hepatocellular carcinoma. Am J Surg. 2015;209(2):391–397.
    1. Miceli A, Romeo F, Glauber M, de Siena PM, Caputo M, Angelini GD. Preoperative anemia increases mortality and postoperative morbidity after cardiac surgery. J Cardiothorac Surg. 2014;9:137.
    1. Okano K, Hirao T, Unno M, et al. Postoperative infectious complications after pancreatic resection. Br J Surg. 2015;102(12):1551–1560.
    1. Hirokawa F, Hayashi M, Miyamoto Y, et al. Evaluation of postoperative antibiotic prophylaxis after liver resection: a randomized controlled trial. Am J Surg. 2013;206(1):8–15.
    1. Garwood RA, Sawyer RG, Thompson L, Adams RB. Infectious complications after hepatic resection. Am Surg. 2004;70(9):787–792.
    1. Moreno Elola-Olaso A, Davenport DL, Hundley JC, Daily MF, Gedaly R. Predictors of surgical site infection after liver resection: a multicentre analysis using National Surgical Quality Improvement Program data. HPB. 2012;14(2):136–141.
    1. Kueht M, Bebko S, Helmick R, Awad S. Hepatitis C status and infectious complications in the surgical intensive care unit: a retrospective analysis of 1,941 consecutive patients. Am J Surg. 2016;211(6):1064–1070.
    1. Cerullo M, Gani F, Chen SY, et al. Physiologic correlates of intraoperative blood transfusion among patients undergoing major gastrointestinal operations. Surgery. 2017;162(2):211–222.

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