Is laparoscopic liver surgery really safe in elderly patients?

We have read the article of Sucandy et al. entitled “Minimally invasive liver resection for primary and metastatic liver tumors: influence of age on perioperative complications and mortality” published in Surgical Endoscopy (2018) (1). We want to congratulate the authors for this interesting analysis about outcomes of elderly patients undergoing surgery as this represents a challenge we face in the everyday reality giving indications for a surgical intervention in a progressive aging population. We would also like to make some contributions focusing on some critical points. In the paper, the authors stated that minimally invasive liver resection (MILR) can be performed in patients >70 or 80 years old without increased of morbidity and mortality rate. In fact, in spite of greater preoperative American Society of Anesthesiologists (ASA) score and comorbidities, advanced age by itself has been demonstrated to be not a limiting factor for curative liver resection with minimally invasive approach. However, some issues remain unaddressed. First, it is well known that the experience of surgeons in MILS can influence the results (2). To overcome the difficulties associated with minimally invasive hepatic resections the training of surgeons and an appropriate learning curve is essential (3). Unfortunately, in the paper the baseline characteristics of the 3 analyzed groups did not include the evaluation of the surgeons learning curve. A consideration could be made in this regard between the intraoperative variables not related to demographic or clinicopathologic patients’ characteristic, to test if the surgeon experience can be confounding factor for the perioperative outcome. Second, as suggested by the authors themselves, a robust conclusion could be obtained only by using a propensity score matched analysis as reported by others authors (4,5). In all studies published in literature, comparing young and older patients, the older group includes a super-selected population of patients. It is actually, paradoxically, that in the paper the group of age >80 (group C) developed only minor complications (Clavien-Dindo grade 1 and 2) compared to patients of age >70 (group A) and patients 70 through 79 years of age (group B). This appears to be curious but reflects the progressive better selection in increasing age of patients undergoing surgery. For this reason, it is questionable the statement that patients >80 years have the same or lower complication rate comparted with other groups of patients. It should be interesting to analyze the results comparing the “best selected” patients in each of the 3 groups. In fact, in a real clinical scenario, the surgeon has no doubt to give indication for surgery to a young patient with a liver tumor, whereas has to choose only fit elderly patients for to recommend surgical liver resection rather than an alternative treatment or a conservative approach. Third and last point, in the paper surgical procedures were not classified according to the Brisbane 2000 nomenclature (6). This represent an important limit in the comparison of anatomical resection procedures as reported in literature. In fact, the most frequent “major hepatectomy” reported in the group of >80 years age old patients were a left lateral sectionectomy, corresponding in Brisbane nomenclature to a bi-segmentectomy or “minor hepatectomy”. As clear, this selection bias could explain the lower morbidity and mortality rate in the group of >80 years patients. In addition, the authors do not consider in the analysis the anatomical location of the tumor. It is well known (7), that in case of tumor located in posterosuperior segments (I, VII, VIII and superior part of VI segment) the laparoscopic approach is not as feasible as for antero-inferior (V, VI) of peripheral left segments (II, III). In conclusion, despite the interesting data reported by Sucandy et al. (1), the feasibility and safety of MILS in elderly patients, remains still debated. The well-known advantages related to the laparoscopic approach could be limited by the frailty of elderly patients, especially when requiring major hepatectomy.

Acknowledgments

We would thank the Prof. Nardo for the opportunity in write this Editorial.

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Laparoscopic Surgery. The article did not undergo external peer review.

Conflicts of Interest: The authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/ls.2018.09.03). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Sucandy I, Cheek S, Tsung A, et al. Minimally invasive liver resection for primary and metastatic liver tumors: influence of age on perioperative complications and mortality. Surg Endosc 2018;32:1885-91. [Crossref] [PubMed]
2. Buell JF, Cherqui D, Geller DA, et al. The international position on laparoscopic liver surgery: The Louisville Statement, 2008. Ann Surg 2009;250:825-30. [Crossref] [PubMed]
3. Coelho FF, Kruger JA, Fonseca GM, et al. Laparoscopic liver resection: Experience based guidelines. World J Gastrointest Surg 2016;8:5-26. [Crossref] [PubMed]
4. Takahara T, Wakabayashi G, Beppu T, et al. Long-term and perioperative outcomes of laparoscopic versus open liver resection for hepatocellular carcinoma with propensity score matching: a multi-institutional Japanese study. J Hepatobiliary Pancreat Sci 2015;22:721-7. [Crossref] [PubMed]
5. Ahn KS, Kang KJ, Kim YH, et al. A propensity score-matched case-control comparative study of laparoscopic and open liver resection for hepatocellular carcinoma. J Laparoendosc Adv Surg Tech A 2014;24:872-7. [Crossref] [PubMed]
6. Strasberg SM. Nomenclature of hepatic anatomy and resections: a review of the Brisbane 2000 system. J Hepatobiliary Pancreat Surg 2005;12:351-5. [Crossref] [PubMed]
7. Nguyen KT, Gamblin TC, Geller DA. World review of laparoscopic liver resection-2,804 patients. Ann Surg 2009;250:831-41. [Crossref] [PubMed]