Predictors of morbidity and mortality after hepatectomy in elderly patients: analysis of 7621 NSQIP patients

Abstract

Objectives: Increasingly, surgeons are performing hepatectomies in older patients. This study was designed to analyse the incidences of and risk factors for post-hepatectomy morbidity and mortality in elderly patients.

Methods: All elective hepatectomies for the period 2005-2010 recorded in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database were evaluated. Factors associated with 30-day rates of morbidity and mortality were compared between patients aged ≥75 years and those aged <75 years.

Results: Elderly patients accounted for 894 of 7621 (11.7%) hepatectomies. These patients more frequently had comorbidities (diabetes, cardiovascular or lung disease, lower albumin, elevated creatinine, anaesthesia risk; all P < 0.05) and were more likely to undergo partial or left rather than right or extended hepatectomies (P = 0.013). Despite the lesser surgical magnitude of these procedures, elderly patients experienced higher rates of severe complications (23.9% versus 18.4%; P < 0.001) and overall postoperative mortality (4.8% versus 2.0%; P < 0.001). The occurrence of any severe complication was associated with a mortality rate of 20.1% in elderly patients and 10.8% in non-elderly patients (P < 0.001). This disparity in mortality was more pronounced in patients with two or more (31.7% versus 20.2%; P < 0.001) and three or more (46.3% versus 31.1%; P < 0.001) severe complications. Independent risk factors for severe complications and/or mortality included an albumin level of < 4 g/dl, lung disease, intraoperative transfusion, a concurrent intra-abdominal operation, and an operative time of >240 min (all P < 0.05).

Conclusions: Given their lower physiologic reserve, elderly patients are at much greater risk for mortality after severe complications. To improve outcomes, surgeons should balance age and preoperative comorbidities with magnitude of hepatectomy.

Figure 1

Proportions of patients aged < 75 years and ≥75 years in whom operative time was >240 min and undergoing right or extended hepatectomy, showing that operative time and magnitude of hepatectomy are lower in elderly patients

Figure 2

Proportions of patients affected by severe complications across all extents of hepatectomy, showing that greater age increases the risk for severe complications

Figure 3

Mortality rates in patients aged < 75 years and ≥75 years showing that mortality increases with extent of hepatectomy and older patient age, with the greatest disparity observed after right and extended hepatectomies. Statistical comparison is between right/extended and partial/left hepatectomies

Figure 4

Mortality within 30 days in patients aged < 75 years and ≥75 years according to the number of severe complications (SCs) recorded. Failure to rescue worsens as the burden of severe complications increases. Mortality rates following severe complications increase with the number of concomitant severe complications and older patient age

Figure 5

Schematic of the anatomy of a complication. On a given day, a surgeon cannot change the factors in the bottom two circles. However, the two circles at the top represent risk factors for complications which are potentially modifiable. The upper left circle reflects patient selection and medical optimization of operability. The upper right circle reflects the surgeon's judgement in choosing an appropriate magnitude of hepatectomy