Author’s Reply: Impact of Aging on Hepatic Malignancy Resection: is Age Really a Risk Factor for Mortality?

Abstract

Dear Editor, We are thankful for Dr Yeow’s interest in our article [1], and we are appreciative of his constructive comments. We agree that frailty, sarcopenia, and malnutrition are important factors affecting surgical outcomes [2]. Our database was prospectively collected from 2001 before the recent reports that highlighted these factors, and as such, these data were not available for evaluation. Moving forward, we will be collecting such datapoints crucial in evaluating hepatectomy outcomes. It would have been beneficial for readers if we had clarified our distribution of primary and secondary hepatic malignancy. We agree that primary and secondary hepatic malignancy has potential differences in long-term outcomes owing to differences in pathophysiology. Recent studies seem to demonstrate that older patients with colorectal liver metastasis tend to experience higher rates of mortality as compared to hepatocellular carcinoma due to tumor progression rather than the hepatectomy itself [3]. In our study, there is no significant difference between the distribution of primary or secondary hepatic malignancy between each age group (Table 1). Age was included as a continuous predictor to increase the power of the model to detect a significant difference. Bivariate binary logistic regression models were used to find which predictors had a statistically significant association with mortality, while adjusting for age at operation. We agree it does appear that inclusion of two multivariable binary logistic regression models (for outcomes: 30-day mortality and 90-day mortality) would have been more reflective of real-life experience, compared with only bivariate models. As the sample size of the dataset is n = 357, these models would allow inclusion of all the 15 a priori predictors in the same model without facing problems of sparse data. To further expand on the patient selection described under the discussion section, in addition to the multidisciplinary team (MDT) management of such patients, weekly MDT meetings allow patients with hepatic malignancy to be evaluated by all of the consultants in the department. Patients with significant of multiple comorbidities are referred to high-risk anesthetic and physician clinics run by internal medicine physicians. During the high physician high-risk clinics, potentially modifiable comorbidities are identified and optimized (e.g., diabetes, hypertension) and perioperative complication prevention plans are instituted (e.g., delirium prevention plan) [4]. We accept the limitations of our data and should continue to improve on our prospectively collected database. This clarification should assist the readers in evaluating the impact of aging on hepatic malignancy resection.