Introduction Hepatectomy offers the only possibility of cure to patients with colorectal liver metastases (CRLM) and although 50% of CRLM patients are >70, only 25% of those undergoing hepatectomy are >70.1 This is likely to be due to the higher perioperative mortality. Cardiopulmonary exercise testing (CPET) can identify patients at higher operative risk.2 We introduced CPET on 1 October 2009. This study assesses its effect on patient selection and outcome.
Methods After 1 October 2009 all patients undergoing resection of CRLM meeting one of the following criteria underwent CPET. Criteria
Planned extended right/or extended left resection
Data were collected prospectively. Group (A) 1 October 2009–21 February 2011 was compared to a published historical series 1 August 1990 to 1 April 2007 (Group B). We also compared our results to a recently published series from LiverMetSuvey (LMS).1
Results Group A 155 patients, Group B 654 patients. In Group A 64 (41%) patients were 70+, Group B 181 (28%) patients (p<0.0001). Within the over 70's groups here was no difference in male:female ratio or postoperative complications, but there was an increased use of neoadjuvant chemotherapy in Group A 26 patients (40%) vs 34 patients (19%) Group B (p=0.001). In hospital mortality was 1.6% (1 patient) Group A vs 4.9% (9 patients) group B (p=0.46). Comparing Group A to LMS data1 from 1/1986 to 6/2007 (7764 resections). Group A 41% aged 70+ vs 21% LMS (p<0.01). No significant difference in neoadjuvant chemotherapy use (Group A 41% vs LMS 34%) (p=0.22), or 60 day mortality (Group A—1 patient (1.6%) vs 62 (3.8%) LMS) (p=0.51).
Conclusion CPET enabled accurate preoperative fitness assessment and led to a significant increase in the number of patients over the age of 70 proceeding to surgery. There is a trend towards lower mortality possibly due to better preoperative assessment. We believe that the number of hepatectomies undertaken for CRLM in patients aged over 70 would rise if CPET were introduced as a standard preoperative assessment tool.
Competing interests None declared.
References 1. Adam R, Frilling A, Elias D, et al; LiverMetSurvey Centres. Liver resection of colorectal metastasis in elderly patients. Br J Surg 2010;97:366–76.
2. Smith TB, Stonell C, Purkayastha S, et al. Cardiopulmonary exercise testing as a risk assessment method in non cardio-pulmonary surgery: a systematic review. Anaesthesia 2009;64:883–93.