Skip to main content
SpringerLink
Log in

Liver Resection in the Elderly: Significance of Comorbidities and Blood Loss

  • Original Article
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Objective

Liver resection is increasingly performed in elderly patients who are suspected of increased postoperative morbidity (PM) and reduced overall survival (OS). Patient selection based on the identification of age-adjusted risk factors may help to decrease PM and OS.

Design and Participants

Prospectively collected data of 879 patients undergoing elective hepatic resection were analyzed. This population was stratified into three age cohorts: >70 years (n = 228; 26 %), 60–69 years (n = 309; 35 %), and <60 years (n = 342; 39 %). Multivariate survival analysis was performed.

Results

The incidence of severe (p < 0.01) and non-surgical (p < 0.001) postoperative complications was higher in older compared to younger patients. Major estimated blood loss (EBL; p = 0.039) and comorbidities (p = 0.002) independently increased PM. EBL was comparable between all age cohorts. However, preexisting comorbidities, major EBL, and postoperative complications markedly decreased OS in contrast to younger patients. Adjusted for age, independent predictors of OS were comorbidities (HR = 1.51; p = 0.001), major hepatectomy (HR = 1.33; p = 0.025), increased EBL (HR = 1.32; p = 0.031), and postoperative complications (HR = 1.64; p < 0.001).

Conclusion

Although increased age should not be a contraindication for liver resection, this study accents the avoidance of major blood loss in elderly patients and a stringent patient selection based on preexisting comorbidities.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Reddy SK, Barbas AS, Turley RS, Gamblin TC, Geller DA, Marsh JW, Tsung A, Clary BM, Lagoo-Deenadayalan S. Major liver resection in elderly patients: a multi-institutional analysis. J Am Coll Surg 2011;212:787–795.

    Article  PubMed  Google Scholar 

  2. Melloul E, Halkic N, Raptis DA, Tempia A, Demartines N. Right hepatectomy in patients over 70 years of age: an analysis of liver function and outcome. World J Surg 2012.

  3. Fong Y, Brennan MF, Cohen AM, Heffernan N, Freiman A, Blumgart LH. Liver resection in the elderly. Br J Surg 1997;84:1386–1390.

    Article  CAS  PubMed  Google Scholar 

  4. Smith BD, Smith GL, Hurria A, Hortobagyi GN, Buchholz TA. Future of cancer incidence in the United States: burdens upon an aging, changing nation. J Clin Oncol 2009;27:2758–2765.

    Article  PubMed  Google Scholar 

  5. Hanazaki K, Kajikawa S, Shimozawa N, Shimada K, Hiraguri M, Koide N, Adachi W, Amano J. Hepatic resection for hepatocellular carcinoma in the elderly. J Am Coll Surg 2001;192:38–46.

    Article  CAS  PubMed  Google Scholar 

  6. Pasetto LM, Lise M, Monfardini S. Preoperative assessment of elderly cancer patients. Crit Rev Oncol Hematol 2007;64:10–18.

    Article  PubMed  Google Scholar 

  7. Aldrighetti L, Arru M, Caterini R, Finazzi R, Comotti L, Torri G, Ferla G. Impact of advanced age on the outcome of liver resection. World J Surg 2003;27:1149–1154.

    Article  PubMed  Google Scholar 

  8. Cescon M, Grazi GL, Del GM, Ercolani G, Ravaioli M, Nardo B, Cavallari A. Outcome of right hepatectomies in patients older than 70 years. Arch Surg 2003;138:547–552.

    Article  PubMed  Google Scholar 

  9. Ettorre GM, Sommacale D, Farges O, Sauvanet A, Guevara O, Belghiti J. Postoperative liver function after elective right hepatectomy in elderly patients. Br J Surg 2001;88:73–76.

    Article  CAS  PubMed  Google Scholar 

  10. Menon KV, Al-Mukhtar A, Aldouri A, Prasad RK, Lodge PA, Toogood GJ. Outcomes after major hepatectomy in elderly patients. J Am Coll Surg 2006;203:677–683.

    Article  PubMed  Google Scholar 

  11. Shirabe K, Kajiyama K, Harimoto N, Gion T, Tsujita E, Abe T, Wakiyama S, Nagaie T, Maehara Y. Early outcome following hepatic resection in patients older than 80 years of age. World J Surg 2009;33:1927–1932.

    Article  PubMed  Google Scholar 

  12. Lee CR, Lim JH, Kim SH, Ahn SH, Park YN, Choi GH, Choi JS, Kim KS. A comparative analysis of hepatocellular carcinoma after hepatic resection in young versus elderly patients. J Gastrointest Surg 2012;16:1736–1743.

    Article  PubMed  Google Scholar 

  13. Ezaki T, Yukaya H, Ogawa Y. Evaluation of hepatic resection for hepatocellular carcinoma in the elderly. Br J Surg 1987;74:471–473.

    Article  CAS  PubMed  Google Scholar 

  14. Koperna T, Kisser M, Schulz F. Hepatic resection in the elderly. World J Surg 1998;22:406–412.

    Article  CAS  PubMed  Google Scholar 

  15. Mentha G, Huber O, Robert J, Klopfenstein C, Egeli R, Rohner A. Elective hepatic resection in the elderly. Br J Surg 1992;79:557–559.

    Article  CAS  PubMed  Google Scholar 

  16. Nagasue N, Chang YC, Takemoto Y, Taniura H, Kohno H, Nakamura T. Liver resection in the aged (seventy years or older) with hepatocellular carcinoma. Surgery 1993;113:148–154.

    CAS  PubMed  Google Scholar 

  17. Tsujita E, Utsunomiya T, Ohta M, Tagawa T, Matsuyama A, Okazaki J, Yamamoto M, Tsutsui S, Ishida T. Outcome of repeat hepatectomy in patients with hepatocellular carcinoma aged 75 years and older. Surgery 2010;147:696–703.

    Article  PubMed  Google Scholar 

  18. Wu CC, Chen JT, Ho WL, Yeh DC, Tang JS, Liu TJ, P'eng FK. Liver resection for hepatocellular carcinoma in octogenarians. Surgery 1999;125:332–338.

    Article  CAS  PubMed  Google Scholar 

  19. Takenaka K, Shimada M, Higashi H, Adachi E, Nishizaki T, Yanaga K, Matsumata T, Ikeda T, Sugimachi K. Liver resection for hepatocellular carcinoma in the elderly. Arch Surg 1994;129:846–850.

    Article  CAS  PubMed  Google Scholar 

  20. Von EE, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet 2007;370:1453–1457

    Article  Google Scholar 

  21. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373–383.

    Article  CAS  PubMed  Google Scholar 

  22. Strasberg SM. Nomenclature of hepatic anatomy and resections: a review of the Brisbane 2000 system. J Hepatobiliary Pancreat Surg 2005;12:351–355.

    Article  PubMed  Google Scholar 

  23. Hardy JF. Current status of transfusion triggers for red blood cell concentrates. Transfus Apher Sci 2004;31:55–66.

    Article  PubMed  Google Scholar 

  24. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205–213.

    Article  PubMed Central  PubMed  Google Scholar 

  25. Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, de Santibañes E, Pekolj J, Slankamenac K, Bassi C, Graf R, Vonlanthen R, Padbury R, Cameron JL, Makuuchi M. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 2009;250:187–196.

    Google Scholar 

  26. Adam R, Frilling A, Elias D, Laurent C, Ramos E, Capussotti L, Poston GJ, Wicherts DA, de Haas RJ. Liver resection of colorectal metastases in elderly patients. Br J Surg 2010;97:366–376.

    Article  CAS  PubMed  Google Scholar 

  27. Zacharias T, Jaeck D, Oussoultzoglou E, Bachellier P, Weber JC. First and repeat resection of colorectal liver metastases in elderly patients. Ann Surg 2004;240:858–865.

    Article  PubMed Central  PubMed  Google Scholar 

  28. Turrini O, Guiramand J, Moutardier V, Viret F, Bories E, Giovannini M, Mokart D, Blache JL, Delpero JR. [Major hepatectomy for metastasis of colorectal cancer improves survival in the elderly]. Ann Chir 2005;130:562–565.

    Article  CAS  PubMed  Google Scholar 

  29. Ferrero A, Vigano L, Polastri R, Ribero D, Lo TR, Muratore A, Capussotti L. Hepatectomy as treatment of choice for hepatocellular carcinoma in elderly cirrhotic patients. World J Surg 2005;29:1101–1105.

    Article  PubMed  Google Scholar 

  30. Yeh CN, Lee WC, Jeng LB, Chen MF. Hepatic resection for hepatocellular carcinoma in elderly patients. Hepatogastroenterology 2004;51:219–223.

    PubMed  Google Scholar 

  31. Neugut AI, Fleischauer AT, Sundararajan V, Mitra N, Heitjan DF, Jacobson JS, Grann VR. Use of adjuvant chemotherapy and radiation therapy for rectal cancer among the elderly: a population-based study. J Clin Oncol 2002;20:2643–2650.

    Article  PubMed  Google Scholar 

  32. Yee KW, Pater JL, Pho L, Zee B, Siu LL. Enrollment of older patients in cancer treatment trials in Canada: why is age a barrier?. J Clin Oncol 2003;21:1618–1623.

    Article  PubMed  Google Scholar 

  33. Jessup JM, Stewart A, Greene FL, Minsky BD. Adjuvant chemotherapy for stage III colon cancer: implications of race/ethnicity, age, and differentiation. JAMA 2005;294:2703–2711.

    Article  CAS  PubMed  Google Scholar 

  34. Hutchins LF, Unger JM, Crowley JJ, Coltman CA, Jr., Albain KS. Underrepresentation of patients 65 years of age or older in cancer-treatment trials. N Engl J Med 1999;341:2061–2067.

    Article  CAS  PubMed  Google Scholar 

  35. Unger JM, Coltman CA, Jr., Crowley JJ, Hutchins LF, Martino S, Livingston RB, Macdonald JS, Blanke CD, Gandara DR, Crawford ED, Albain KS. Impact of the year 2000 Medicare policy change on older patient enrollment to cancer clinical trials. J Clin Oncol 2006;24:141–144.

    Article  PubMed  Google Scholar 

  36. Kahn KL, Adams JL, Weeks JC, Chrischilles EA, Schrag D, Ayanian JZ, Kiefe CI, Ganz PA, Bhoopalam N, Potosky AL, Harrington DP, Fletcher RH. Adjuvant chemotherapy use and adverse events among older patients with stage III colon cancer. JAMA 2010;303:1037–1045.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  37. Manfredi S, Lepage C, Hatem C, Coatmeur O, Faivre J, Bouvier AM. Epidemiology and management of liver metastases from colorectal cancer. Ann Surg 2006;244:254–259.

    Article  PubMed Central  PubMed  Google Scholar 

  38. Leporrier J, Maurel J, Chiche L, Bara S, Segol P, Launoy G. A population-based study of the incidence, management and prognosis of hepatic metastases from colorectal cancer. Br J Surg 2006;93:465–474.

    Article  CAS  PubMed  Google Scholar 

  39. Mirici-Cappa F, Gramenzi A, Santi V, Zambruni A, Di MA, Frigerio M, Maraldi F, Di Nolfo MA, Del PP, Benvegnu L, Rapaccini G, Farinati F, Zoli M, Borzio F, Giannini EG, Caturelli E, Bernardi M, Trevisani F. Treatments for hepatocellular carcinoma in elderly patients are as effective as in younger patients: a 20-year multicentre experience. Gut 2010;59:387–396.

    Article  PubMed  Google Scholar 

  40. Al-Refaie WB, Parsons HM, Henderson WG, Jensen EH, Tuttle TM, Vickers SM, Rothenberger DA, Virnig BA. Major cancer surgery in the elderly: results from the American College of Surgeons National Surgical Quality Improvement Program. Ann Surg 2010;251:311–318.

    Article  PubMed  Google Scholar 

  41. Torzilli G, Makuuchi M, Inoue K, Takayama T, Sakamoto Y, Sugawara Y, Kubota K, Zucchi A. No-mortality liver resection for hepatocellular carcinoma in cirrhotic and noncirrhotic patients: is there a way? A prospective analysis of our approach. Arch Surg 1999;134:984–992.

    Article  CAS  PubMed  Google Scholar 

  42. Yamamoto K, Takenaka K, Matsumata T, Shimada M, Itasaka H, Shirabe K, Sugimachi K. Right hepatic lobectomy in elderly patients with hepatocellular carcinoma. Hepatogastroenterology 1997;44:514–518.

    CAS  PubMed  Google Scholar 

  43. Yanaga K, Kanematsu T, Takenaka K, Matsumata T, Yoshida Y, Sugimachi K. Hepatic resection for hepatocellular carcinoma in elderly patients. Am J Surg 1988;155:238–241.

    Article  CAS  PubMed  Google Scholar 

  44. Fortner JG, Lincer RM. Hepatic resection in the elderly. Ann Surg 1990;211:141–145.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  45. Melendez J, Ferri E, Zwillman M, Fischer M, DeMatteo R, Leung D, Jarnagin W, Fong Y, Blumgart LH. Extended hepatic resection: a 6-year retrospective study of risk factors for perioperative mortality. J Am Coll Surg 2001;192:47–53.

    Article  CAS  PubMed  Google Scholar 

  46. Bui LL, Smith AJ, Bercovici M, Szalai JP, Hanna SS. Minimising blood loss and transfusion requirements in hepatic resection. HPB (Oxford) 2002;4:5–10.

    Article  Google Scholar 

  47. Duron JJ, Duron E, Dugue T, Pujol J, Muscari F, Collet D, Pessaux P, Hay JM. Risk factors for mortality in major digestive surgery in the elderly: a multicenter prospective study. Ann Surg 2011;254:375–382.

    Article  PubMed  Google Scholar 

  48. Mavros MN, de JM, Dogeas E, Hyder O, Pawlik TM. Impact of complications on long-term survival after resection of colorectal liver metastases. Br J Surg 2013;100:711–718.

  49. Preston SD, Southall AR, Nel M, Das SK. Geriatric surgery is about disease, not age. J R Soc Med 2008;101:409–415.

    Article  PubMed Central  PubMed  Google Scholar 

Download references

Acknowledgments

The authors thank Professor Horst Domdey for critically revising the manuscript and Dr. Hans-Martin Hornung for his dedicated work with the IT administration of the liver database.

Conflicts of Interests

There was no funding received for the present study. There are no financial or personal conflicts of any of the authors.

Author information

Authors and Affiliations

  1. Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, University of Munich, Campus Grosshadern, Marchioninistr. 15, 81377, Munich, Germany

    Tobias S. Schiergens, Carsta Stielow, Stefanie Schreiber, Karl-Walter Jauch, Markus Rentsch & Wolfgang E. Thasler

  2. Department of Anesthesiology, University of Munich, Munich, Germany

    Cyrill Hornuss

Authors
  1. Tobias S. Schiergens
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Carsta Stielow
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Stefanie Schreiber
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Cyrill Hornuss
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Karl-Walter Jauch
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Markus Rentsch
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Wolfgang E. Thasler
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Wolfgang E. Thasler.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Schiergens, T.S., Stielow, C., Schreiber, S. et al. Liver Resection in the Elderly: Significance of Comorbidities and Blood Loss. J Gastrointest Surg 18, 1161–1170 (2014). https://doi.org/10.1007/s11605-014-2516-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11605-014-2516-2

Keywords

Search

Navigation