Advertisement

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

  • Kota Sahara
  • Anghela Z. Paredes
  • Diamantis I. Tsilimigras
  • J. Madison Hyer
  • Katiuscha Merath
  • Lu Wu
  • Rittal Mehta
  • Eliza W. Beal
  • Susan White
  • Itaru Endo
  • Timothy M. PawlikEmail author
Original Article

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.

Keywords

Cirrhosis Elderly Hepatectomy Outcomes 

Notes

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Supplementary material

11605_2019_4117_MOESM1_ESM.docx (17 kb)
ESM 1 (DOCX 16 kb)

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.CrossRefGoogle 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.CrossRefGoogle 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.CrossRefGoogle 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.CrossRefGoogle 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.CrossRefGoogle 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.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.CrossRefGoogle 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.CrossRefGoogle 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.CrossRefGoogle 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.CrossRefGoogle 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.CrossRefGoogle 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.CrossRefGoogle 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.CrossRefGoogle 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.
  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.CrossRefGoogle 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.CrossRefGoogle 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.CrossRefGoogle Scholar
  18. 18.
    Clark JR, Wills VL, Hunt DR. Cirrhosis and laparoscopic cholecystectomy. Surg Laparosc Endosc Percutan Tech. 2001;11(3):165–9.CrossRefGoogle 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.CrossRefGoogle 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.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.CrossRefGoogle 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.CrossRefGoogle 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.CrossRefGoogle 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.CrossRefGoogle 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.CrossRefGoogle 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.CrossRefGoogle 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.CrossRefGoogle 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.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.CrossRefGoogle 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.CrossRefGoogle 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.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.CrossRefGoogle 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.CrossRefGoogle 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.CrossRefGoogle 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.CrossRefGoogle 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.CrossRefGoogle 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.CrossRefGoogle 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.CrossRefGoogle 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.CrossRefGoogle 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.CrossRefGoogle 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.CrossRefGoogle 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.CrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2019

Authors and Affiliations

  • Kota Sahara
    • 1
    • 2
  • Anghela Z. Paredes
    • 1
  • Diamantis I. Tsilimigras
    • 1
  • J. Madison Hyer
    • 1
  • Katiuscha Merath
    • 1
  • Lu Wu
    • 1
  • Rittal Mehta
    • 1
  • Eliza W. Beal
    • 1
  • Susan White
    • 3
  • Itaru Endo
    • 2
  • Timothy M. Pawlik
    • 1
    • 4
    Email author
  1. 1.Division of Surgical OncologyThe Ohio State University Wexner Medical Center and James Comprehensive Cancer CenterColumbusUSA
  2. 2.Gastroenterological Surgery DivisionYokohama City University School of MedicineYokohamaJapan
  3. 3.Division of Health Information Management and Systems, The Ohio State Wexner Medical CenterThe Ohio State UniversityColumbusUSA
  4. 4.Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer ResearchThe Ohio State University, Wexner Medical CenterColumbusUSA

Personalised recommendations