Impact of Liver Cirrhosis on Perioperative Outcomes Among Elderly Patients Undergoing Hepatectomy: the Effect of Minimally Invasive Surgery

Abstract

Background

The impact of cirrhosis on perioperative outcomes for elderly patients undergoing hepatectomy remains not well defined. We sought to determine the influence of underlying cirrhosis and minimally invasive surgery (MIS) on postoperative outcomes among elderly patients who underwent a hepatectomy.

Methods

Patients who underwent hepatectomy between 2013 and 2015 were identified using the Center for Medicare Services (CMS) 100% Limited Data Set (LDS) Standard Analytic Files (SAFs). Short-term outcomes after hepatectomy, stratified by the presence of cirrhosis and MIS, were examined.

Results

Among 7452 patients who underwent a hepatectomy, a minority had cirrhosis (n = 481, 6.5%) whereas the vast majority did not (n = 6971, 93.5%). Overall, median patient age was 72 years (IQR 68–76) and preoperative Charlson comorbidity score was 6 (IQR 2–8). Patients with cirrhosis were more likely to be younger (median age 71 [67–76] vs 72 [IQR 68–76] years), male (64.4% vs 50%), African American (8.1% vs 6.4%) and have a malignant diagnosis (87.1% vs 78.7%) compared to non-cirrhotic patients (all p < 0.001). There was no difference among patients with and without cirrhosis regarding type of hepatectomy or surgical approach (open vs MIS) (both p > 0.05). Patients with versus without cirrhosis had similar complication rates (24.1% vs 22.3%, p = 0.36), as well as 30-day (6.2% vs 5%, p = 0.25) and 90-day (10.4% vs 8.5%, p = 0.15) mortality. MIS reduced the length-of-stay in non-cirrhotic patients (OR 0.79, 95% CI 0.62–0.99, p < 0.05), yet was not associated with morbidity or mortality (both p > 0.05).

Conclusion

The presence of cirrhosis did not generally impact outcomes in elderly patients undergoing hepatectomy for benign and malignant diseases. MIS hepatectomy in the elderly Medicare beneficiary population reduced LOS among patients without cirrhosis, yet was not associated with differences in morbidity or mortality.

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References

  1. 1.

    Ali N, O’Rourke C, El-Hayek K, Chalikonda S, Jeyarajah DR, Walsh RM. Estimating the need for hepato-pancreatico-biliary surgeons in the USA. HPB : the official journal of the International Hepato Pancreato Biliary Association. 2015;17(4):352–6. doi:https://doi.org/10.1111/hpb.12370.

    Article  Google Scholar 

  2. 2.

    Setiawan VW, Stram DO, Porcel J, Lu SC, Le Marchand L, Noureddin M. Prevalence of chronic liver disease and cirrhosis by underlying cause in understudied ethnic groups: The multiethnic cohort. Hepatology. 2016;64(6):1969–77. doi:https://doi.org/10.1002/hep.28677.

    Article  PubMed  PubMed Central  Google Scholar 

  3. 3.

    Zerillo J, Agarwal P, Poeran J, Zubizarreta N, Poultsides G, Schwartz M et al. Perioperative Management in Hepatic Resections: Comparative Effectiveness of Neuraxial Anesthesia and Disparity of Care Patterns. Anesthesia and analgesia. 2018;127(4):855–63. doi:https://doi.org/10.1213/ane.0000000000003579.

    Article  PubMed  Google Scholar 

  4. 4.

    Bell BP, Manos MM, Zaman A, Terrault N, Thomas A, Navarro VJ et al. The epidemiology of newly diagnosed chronic liver disease in gastroenterology practices in the United States: results from population-based surveillance. The American journal of gastroenterology. 2008;103(11):2727–36; quiz 37. doi:https://doi.org/10.1111/j.1572-0241.2008.02071.x.

    Article  PubMed  Google Scholar 

  5. 5.

    Fan ST, Lai EC, Lo CM, Ng IO, Wong J. Hospital mortality of major hepatectomy for hepatocellular carcinoma associated with cirrhosis. Archives of surgery (Chicago, Ill : 1960). 1995;130(2):198–203.

    CAS  Article  Google Scholar 

  6. 6.

    Gozzetti G, Mazziotti A, Cavallari A, Bellusci R, Bolondi L, Grigioni W et al. Clinical experience with hepatic resections for hepatocellular carcinoma in patients with cirrhosis. Surgery, gynecology & obstetrics. 1988;166(6):503–10.

    CAS  Google Scholar 

  7. 7.

    Nagasue N, Kohno H, Chang YC, Taniura H, Yamanoi A, Uchida M et al. Liver resection for hepatocellular carcinoma. Results of 229 consecutive patients during 11 years. Annals of surgery. 1993;217(4):375–84.

    CAS  Article  Google Scholar 

  8. 8.

    Xu HW, Liu F, Li HY, Wei YG, Li B. Outcomes following laparoscopic versus open major hepatectomy for hepatocellular carcinoma in patients with cirrhosis: a propensity score-matched analysis. Surgical endoscopy. 2018;32(2):712–9. doi:https://doi.org/10.1007/s00464-017-5727-2.

    Article  PubMed  Google Scholar 

  9. 9.

    Cauchy F, Fuks D, Nomi T, Dokmak S, Scatton O, Schwarz L et al. Benefits of Laparoscopy in Elderly Patients Requiring Major Liver Resection. Journal of the American College of Surgeons. 2016;222(2):174–84.e10. doi:https://doi.org/10.1016/j.jamcollsurg.2015.11.006.

    Article  PubMed  Google Scholar 

  10. 10.

    Schmucker DL. Age-related changes in liver structure and function: Implications for disease ? Exp Gerontol. 2005;40(8-9):650-9. doi:https://doi.org/10.1016/j.exger.2005.06.009.

    CAS  Article  PubMed  Google Scholar 

  11. 11.

    Poon RT, Fan ST, Lo CM, Liu CL, Lam CM, Yuen WK et al. Extended hepatic resection for hepatocellular carcinoma in patients with cirrhosis: is it justified? Annals of surgery. 2002;236(5):602-11. doi:https://doi.org/10.1097/01.sla.0000033038.38956.5e.

    Article  PubMed  PubMed Central  Google Scholar 

  12. 12.

    Wu CC, Cheng SB, Ho WM, Chen JT, Liu TJ, P’Eng F K. Liver resection for hepatocellular carcinoma in patients with cirrhosis. The British journal of surgery. 2005;92(3):348–55. doi:https://doi.org/10.1002/bjs.4838.

    Article  PubMed  Google Scholar 

  13. 13.

    Menon KV, Al-Mukhtar A, Aldouri A, Prasad RK, Lodge PA, Toogood GJ. Outcomes after major hepatectomy in elderly patients. Journal of the American College of Surgeons. 2006;203(5):677–83. doi:https://doi.org/10.1016/j.jamcollsurg.2006.07.025.

    Article  PubMed  Google Scholar 

  14. 14.

    Paredes AZ, Beal EW, Bagante F, Dillhoff ME, Cloyd JM, Pawlik TM. Patterns of readmission among the elderly after hepatopancreatobiliary surgery. American journal of surgery. 2018. doi:https://doi.org/10.1016/j.amjsurg.2018.09.011.

    Article  Google Scholar 

  15. 15.

    Gani F, Cerullo M, Amini N, Buettner S, Margonis GA, Sasaki K et al. Frailty as a Risk Predictor of Morbidity and Mortality Following Liver Surgery. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract. 2017;21(5):822–30. doi:https://doi.org/10.1007/s11605-017-3373-6.

    Article  Google Scholar 

  16. 16.

    Li J, Shen Y, Tan L, Feng M, Wang H, Xi Y et al. Is minimally invasive esophagectomy beneficial to elderly patients with esophageal cancer? Surgical endoscopy. 2015;29(4):925–30. doi:https://doi.org/10.1007/s00464-014-3753-x.

    Article  PubMed  Google Scholar 

  17. 17.

    Fan CJ, Chien HL, Weiss MJ, He J, Wolfgang CL, Cameron JL et al. Minimally invasive versus open surgery in the Medicare population: a comparison of post-operative and economic outcomes. Surgical endoscopy. 2018;32(9):3874–80. doi:https://doi.org/10.1007/s00464-018-6126-z.

    Article  PubMed  Google Scholar 

  18. 18.

    Clark JR, Wills VL, Hunt DR. Cirrhosis and laparoscopic cholecystectomy. Surg Laparosc Endosc Percutan Tech. 2001;11(3):165–9.

    CAS  Article  Google Scholar 

  19. 19.

    Yoon YI, Kim KH, Kang SH, Kim WJ, Shin MH, Lee SK et al. Pure Laparoscopic Versus Open Right Hepatectomy for Hepatocellular Carcinoma in Patients With Cirrhosis: A Propensity Score Matched Analysis. Annals of surgery. 2017;265(5):856–63. doi:https://doi.org/10.1097/sla.0000000000002072.

    Article  PubMed  Google Scholar 

  20. 20.

    Chen J, Bai T, Zhang Y, Xie ZB, Wang XB, Wu FX et al. The safety and efficacy of laparoscopic and open hepatectomy in hepatocellular carcinoma patients with liver cirrhosis: a systematic review. International journal of clinical and experimental medicine. 2015;8(11):20679–89.

    CAS  PubMed  PubMed Central  Google Scholar 

  21. 21.

    Tsilimigras DI, Moris D, Vagios S, Merath K, Pawlik TM. Safety and oncologic outcomes of robotic liver resections: A systematic review. J Surg Oncol. 2018;117(7):1517–30. doi:https://doi.org/10.1002/jso.25018.

    Article  PubMed  Google Scholar 

  22. 22.

    Ciria R, Cherqui D, Geller DA, Briceno J, Wakabayashi G. Comparative Short-term Benefits of Laparoscopic Liver Resection: 9000 Cases and Climbing. Annals of surgery. 2016;263(4):761–77. doi:https://doi.org/10.1097/sla.0000000000001413.

    Article  PubMed  Google Scholar 

  23. 23.

    Cheung TT, Dai WC, Tsang SH, Chan AC, Chok KS, Chan SC et al. Pure Laparoscopic Hepatectomy Versus Open Hepatectomy for Hepatocellular Carcinoma in 110 Patients With Liver Cirrhosis: A Propensity Analysis at a Single Center. Annals of surgery. 2016;264(4):612–20. doi:https://doi.org/10.1097/sla.0000000000001848.

    Article  PubMed  Google Scholar 

  24. 24.

    Wang WL, Zhu Y, Cheng JW, Li MX, Xia JM, Hao J et al. Major hepatectomy is safe for hepatocellular carcinoma in elderly patients with cirrhosis. European journal of gastroenterology & hepatology. 2014;26(4):444–51. doi:https://doi.org/10.1097/meg.0000000000000046.

    Article  Google Scholar 

  25. 25.

    Quan H, Sundararajan V, Halfon P, Fong A, Burnand B, Luthi JC et al. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Medical care. 2005;43(11):1130–9.

    Article  Google Scholar 

  26. 26.

    Iezzoni LI, Daley J, Heeren T, Foley SM, Fisher ES, Duncan C et al. Identifying complications of care using administrative data. Medical care. 1994;32(7):700–15.

    CAS  Article  Google Scholar 

  27. 27.

    Osborne NH, Nicholas LH, Ryan AM, Thumma JR, Dimick JB. Association of hospital participation in a quality reporting program with surgical outcomes and expenditures for Medicare beneficiaries. Jama. 2015;313(5):496–504. doi:https://doi.org/10.1001/jama.2015.25.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  28. 28.

    Iezzoni LI, Daley J, Heeren T, Foley SM, Hughes JS, Fisher ES et al. Using administrative data to screen hospitals for high complication rates. Inquiry : a journal of medical care organization, provision and financing. 1994;31(1):40–55.

    CAS  PubMed  Google Scholar 

  29. 29.

    Mokdad AA, Lopez AD, Shahraz S, Lozano R, Mokdad AH, Stanaway J et al. Liver cirrhosis mortality in 187 countries between 1980 and 2010: a systematic analysis. BMC Med. 2014;12:145. doi:https://doi.org/10.1186/s12916-014-0145-y.

    Article  PubMed  PubMed Central  Google Scholar 

  30. 30.

    Petrowsky H, Clavien PA. Should we deny surgery for malignant hepato-pancreatico-biliary tumors to elderly patients? World journal of surgery. 2005;29(9):1093–100. doi:https://doi.org/10.1007/s00268-005-1130-6.

    Article  PubMed  Google Scholar 

  31. 31.

    Poon RT, Fan ST, Lo CM, Liu CL, Lam CM, Yuen WK et al. Improving perioperative outcome expands the role of hepatectomy in management of benign and malignant hepatobiliary diseases: analysis of 1222 consecutive patients from a prospective database. Annals of surgery. 2004;240(4):698–708; discussion -10.

    PubMed  PubMed Central  Google Scholar 

  32. 32.

    Müller-Höcker J, Aust D, Rohrbach H, Napiwotzky J, Reith A, Link TA et al. Defects of the respiratory chain in the normal human liver and in cirrhosis during aging. Hepatology. 1997;26(3):709–19. doi:https://doi.org/10.1002/hep.510260324.

    Article  PubMed  Google Scholar 

  33. 33.

    Brouwer A, Barelds RJ, Knook DL. Age-related changes in the endocytic capacity of rat liver Kupffer and endothelial cells. Hepatology. 1985;5(3):362–6.

    CAS  Article  Google Scholar 

  34. 34.

    Sastre J, Pallardó FV, Plá R, Pellín A, Juan G, O’Connor JE et al. Aging of the liver: age-associated mitochondrial damage in intact hepatocytes. Hepatology. 1996;24(5):1199–205. doi:https://doi.org/10.1002/hep.510240536.

    CAS  Article  PubMed  Google Scholar 

  35. 35.

    Vitale A, Spolverato G, Bagante F, Gani F, Popescu I, Marques HP et al. A multi-institutional analysis of elderly patients undergoing a liver resection for intrahepatic cholangiocarcinoma. J Surg Oncol. 2016;113(4):420–6. doi:https://doi.org/10.1002/jso.24148.

    Article  PubMed  Google Scholar 

  36. 36.

    Zhang X-F, Bagante F, Chakedis J, Moris D, Beal EW, Weiss M et al. Perioperative and Long-Term Outcome for Intrahepatic Cholangiocarcinoma: Impact of Major Versus Minor Hepatectomy. Journal of Gastrointestinal Surgery. 2017;21(11):1841–50. doi:https://doi.org/10.1007/s11605-017-3499-6.

    Article  PubMed  Google Scholar 

  37. 37.

    Cheung TT, Poon RT, Yuen WK, Chok KS, Jenkins CR, Chan SC et al. Long-term survival analysis of pure laparoscopic versus open hepatectomy for hepatocellular carcinoma in patients with cirrhosis: a single-center experience. Annals of surgery. 2013;257(3):506-11. doi:https://doi.org/10.1097/SLA.0b013e31827b947a.

    Article  PubMed  Google Scholar 

  38. 38.

    Belli G, Fantini C, D’Agostino A, Cioffi L, Langella S, Russolillo N et al. Laparoscopic versus open liver resection for hepatocellular carcinoma in patients with histologically proven cirrhosis: short- and middle-term results. Surgical endoscopy. 2007;21(11):2004–11. doi:https://doi.org/10.1007/s00464-007-9503-6.

    CAS  Article  PubMed  Google Scholar 

  39. 39.

    Belli G, Limongelli P, Fantini C, D’Agostino A, Cioffi L, Belli A et al. Laparoscopic and open treatment of hepatocellular carcinoma in patients with cirrhosis. The British journal of surgery. 2009;96(9):1041–8. doi:https://doi.org/10.1002/bjs.6680.

    CAS  Article  PubMed  Google Scholar 

  40. 40.

    Kaneko H, Tsuchiya M, Otsuka Y, Yajima S, Minagawa T, Watanabe M et al. Laparoscopic hepatectomy for hepatocellular carcinoma in cirrhotic patients. Journal of hepato-biliary-pancreatic surgery. 2009;16(4):433–8. doi:https://doi.org/10.1007/s00534-009-0123-5.

    Article  PubMed  Google Scholar 

  41. 41.

    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. Surgical endoscopy. 2018;32(4):1885–91. doi:https://doi.org/10.1007/s00464-017-5880-7.

    Article  PubMed  Google Scholar 

  42. 42.

    Nomi T, Fuks D, Kawaguchi Y, Mal F, Nakajima Y, Gayet B. Laparoscopic major hepatectomy for colorectal liver metastases in elderly patients: a single-center, case-matched study. Surgical endoscopy. 2015;29(6):1368–75. doi:https://doi.org/10.1007/s00464-014-3806-1.

    Article  PubMed  Google Scholar 

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Correspondence to Timothy M. Pawlik.

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Sahara, K., Paredes, A.Z., Tsilimigras, D.I. et al. Impact of Liver Cirrhosis on Perioperative Outcomes Among Elderly Patients Undergoing Hepatectomy: the Effect of Minimally Invasive Surgery. J Gastrointest Surg 23, 2346–2353 (2019). https://doi.org/10.1007/s11605-019-04117-z

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Keywords

  • Cirrhosis
  • Elderly
  • Hepatectomy
  • Outcomes