Minimally invasive hepatectomy reduces major morbidity and hospital resource utilization in the elderly

Background: Elderly patients undergoing liver resection are at increased risk for surgical morbidity and mortality. Previous studies suggest minimally invasive hepatectomy (MIH) is associated with some improved peri-operative outcomes compared to open hepatectomy (OH), such as decreased length of stay (LOS) and blood loss. We aimed to determine whether MIH (laparoscopic, robotic, both, or assisted) compared to OH may mitigate increased peri-operative risks in elderly patients undergoing liver resection for all indications. Methods: 13,775 patients undergoing elective liver resections (sub-segmentectomy excluded) from 2014-2016 were identified in the participant use file from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) with hepatectomy targeted procedure variables. Elderly (Age ≥ 75 years) were compared to non-elderly patients with respect to risk-adjusted surgical mortality, major morbidity, and hospital resource utilization. Major morbidity was defined as any reoperation, invasive intervention, or end organ failure. Major hepatectomy was defined as any trisectionectomy or hemihepatectomy compared to partial hepatectomy. Multivariable logistic regression models were constructed to evaluate outcomes between MIH and OH in the elderly subgroup, controlling for variables identified on baseline demographic analysis to be significant confounders of the intervention-outcome association. Effect modification by extent of hepatectomy was also evaluated. Results: On multivariable analysis, elderly patients had increased risk of 30-day mortality (OR = 2.8, P < 0.001), major morbidity (OR = 1.2, P = 0.021), post-hepatectomy liver failure (OR = 1.5, P = 0.015), prolonged LOS (OR = 1.5, P < 0.001), and discharge to destination other than home (OR = 4.2, P < 0.001). When examining the effect of MIH on outcomes in the elderly subgroup on multivariable analysis, MIH compared to OH was associated with decreased risk of major morbidity (OR = 0.66, P = 0.038), postoperative invasive interventions (OR = 0.47, P = 0.018), bleeding requiring transfusion (OR = 0.37, P < 0.001), and prolonged LOS (OR = 0.49, P < 0.001), but no effect on mortality and other relevant outcomes was seen [Table]. These results were not modified by the extent of hepatectomy performed. Conclusion: In a prospective, multi-center, and nationally representative sample, MIH compared to OH improves perioperative major morbidity, need for invasive interventions, bleeding requiring transfusion, and prolonged LOS in the elderly. There were no significant differences between MIH and OH in the elderly with respect to mortality, reoperation, post hepatectomy liver failure, bile leak, discharge disposition other than home, and readmission. Elderly patients may benefit from MIH for both major and minor hepatectomy.