Postoperative mortality and need for transitional care following liver resection for metastatic disease in elderly patients: A population-level analysis of 4026 patients

Department of Surgery, Division of Surgical Oncology, Baylor College of Medicine, Houston, TX, USA.
HPB (Impact Factor: 2.68). 12/2012; 14(12):863-70. DOI: 10.1111/j.1477-2574.2012.00577.x
Source: PubMed


The goal of this study was to characterize the association of age with postoperative mortality and need for transitional care following hepatectomy for liver metastases.
A retrospective cohort study using the Nationwide Inpatient Sample (2005-2008) was performed. Patients undergoing hepatectomy for liver metastases were categorized by age as: Young (aged <65 years); Old (aged 65-74 years), and Oldest (aged ≥75 years). Multivariate logistic regression analyses were performed to identify predictors of in-hospital mortality and need for transitional care (non-home discharge).
A total of 4026 patients were identified; 36.6% (n = 1475) were elderly (aged ≥65 years). Rates of in-hospital mortality and non-home discharge increased with advancing age group [1.3% vs. 2.2% vs. 3.3% (P = 0.005) and 2.1% vs. 6.1% vs. 18.3% (P < 0.001), respectively]. Independent predictors of in-hospital mortality were age within the Oldest category [odds ratio (OR) 2.21, 95% confidence interval (CI) 1.19-4.12] and a Deyo Comorbidity Index score of ≥3 (OR 6.95, 95% CI 3.55-13.60). Independent predictors for need for transitional care were age within the Old group (OR 2.44, 95% CI 1.66-3.58), age within the Oldest group (OR 8.48, 95% CI 5.87-12.24), a Deyo score of 1 (OR 2.00, 95% CI 1.40-2.85), a Deyo score of 2 (OR 4.70, 95% CI 2.93-7.56), a Deyo score of ≥3 (OR 6.41, 95% CI 3.67-11.20), and female gender (OR 1.56, 95% CI 1.15-2.11).
Although increasing age was associated with higher risk for in-hospital mortality, the absolute risk was low and within accepted ranges, and comorbidity was the primary driver of mortality. Conversely, need for transitional care was significantly more common in elderly patients. Therefore, liver resection for metastases is safe in well-selected elderly patients, although consideration should be made for potential transitional care needs.

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    ABSTRACT: Background: Although controversial, recent data suggest a benefit associated with primary tumor resection (PTR) in metastatic colon cancer (mCC) patients. However, utilization of the various management strategies over time relative to surgery, in particular multimodality treatment (MMT), as well as the impact of age on treatment remains unclear. Study design: Historical cohort study of mCC patients in the National Cancer Data Base (1998-2009). Temporal trends in treatment utilization (chemotherapy, PTR alone, MMT) were evaluated. Using a landmark approach, the association between treatment, age, and risk of death was evaluated with multivariable Cox regression, including interaction. Results: Among 103,100 mCC patients, PTR decreased 50.1 % during the study period, whereas MMT and chemotherapy increased 27.4 and 104.8 %, respectively (trend test, p < 0.001). Patients aged ≥75 years were the only group for whom PTR alone was the most common intervention over time and performed more commonly (33.8 %) than MMT (23.8 %) in the most recent study year. Relative to MMT, risk of death was higher for all other management strategies. The sequence of PTR and chemotherapy (reference-surgery first) did not affect risk of death (chemotherapy first-1.05 [0.95-1.15]), as long resection was a part of MMT (PTR alone-1.16 [1.08-1.23]). Patient age did not impact the relative benefit associated with competing management strategies. Conclusions: Although the benefit associated with PTR in mCC patients is a function of MMT, PTR alone remains a common management strategy among older patients. Given the aging U.S. population, exploring provider biases and patient preferences may be necessary to optimize management of mCC patients.
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