Major Hepatectomy for Perihilar Cholangiocarcinoma in the Elderly: Oncologically Advantageous, but Proceed with Caution

Objective: As the U.S. population ages, an increasing number of elderly patients are being evaluated for surgical resection of gastrointestinal malignancy. This study aims to evaluate short- and long-term outcomes after major hepatectomy for perihilar cholangiocarcinoma in the geriatric population. Methods: Patients who underwent major hepatectomy for perihilar cholangiocarcinoma were retrospectively identified using the U.S. Extrahepatic Biliary Malignancy Consortium database. Patients were stratified into two groups based on age at the time of surgery (age >75 and age <75). Patient factors, tumor characteristics, operative outcomes, and survival were evaluated. Results: Of 210 patients who underwent resection of perihilar cholangiocarcinoma from 2000–2014, 41 (20%) patients age were >75 years old. Margins, T-stage, N-stage, presence of lymphovascular invasion (LVI) and tumor grade were similar in the two groups. Postoperative morbidity (77.5% vs. 68%, p=0.34) and 90-day mortality (22% vs. 10%, p=0.09) were higher in older patients, but did not reach statistical significance. Overall survival was significantly worse in those older than 75 years (5-year, 14.5% vs 22%, P=0.003), but disease-specific survival rates were comparable between the two groups (5-year, 47.9 vs. 38.5%, P=0.74, Figure). On multivariate analysis, only advanced stage, but not age or presence of LVI, was an independent predictor of poor survival. Conclusion: Failure-to-rescue from complications is substantial for patients older than 75 years undergoing major hepatectomy for perihilar cholangiocarcinoma. However, if the operation can be performed safely, the long-term cancer-specific outcome appears similar to that of younger patients.