Perihilar cholangiocarcinoma resection: Is it beneficial for survival in elderly patients? | Gastroenterología y Hepatología (English Edition)

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"documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Gastroenterol Hepatol. 2024;47:683-90" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "Original article" "titulo" => "Spontaneously ruptured hepatocellular carcinoma on non-cirrhotic liver: A prospective case series" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "683" "paginaFinal" => "690" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Rotura espontánea de carcinoma hepatocelular en hígado no cirrótico: serie prospectiva de casos" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1127 "Ancho" => 1258 "Tamanyo" => 62447 ] ] "descripcion" => array:1 [ "en" => "Survival in patients treated by surgery: 4 non-cirrhotic patients with ruptured HCC versus 86 non-cirrhotic patients with non-ruptured HCC. 1- and 3-year survival rates were 100% and 75%, respectively, in rHCC and 95.3% and 76.9% in nrHCC (p=0.46). rHCC: ruptured hepatocellular carcinoma; nrHCC: non-ruptured hepatocellular carcinoma." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Marta Romero-Gutiérrez, Sonia Pascual, Laura Márquez, Mariano Gómez-Rubio, Mireia Miquel, Cristina Alarcón, Teresa Ferrer, Carles Aracil, Diana Horta, Raquel Latorre, Jesús González Santiago, Vanesa Bernal, Cristina Fernández, Belén Piqueras, María Luisa Gutiérrez, Ana Martín, Julia Morillas, Dalia Morales, Sonia Blanco, Paloma Rendón, Inmaculada Chico, Milagros Testillano, Carolina Delgado, Ana Matilla, Rafael Gómez Rodríguez" "autores" => array:25 [ 0 => array:2 [ "nombre" => "Marta" "apellidos" => "Romero-Gutiérrez" ] 1 => array:2 [ "nombre" => "Sonia" "apellidos" => "Pascual" ] 2 => array:2 [ "nombre" => "Laura" "apellidos" => "Márquez" ] 3 => array:2 [ "nombre" => "Mariano" "apellidos" => "Gómez-Rubio" ] 4 => array:2 [ "nombre" => "Mireia" "apellidos" => "Miquel" ] 5 => array:2 [ "nombre" => "Cristina" "apellidos" => "Alarcón" ] 6 => array:2 [ "nombre" => "Teresa" "apellidos" => "Ferrer" ] 7 => array:2 [ "nombre" => "Carles" "apellidos" => "Aracil" ] 8 => array:2 [ "nombre" => "Diana" "apellidos" => "Horta" ] 9 => array:2 [ "nombre" => "Raquel" "apellidos" => "Latorre" ] 10 => array:2 [ "nombre" => "Jesús" "apellidos" => "González Santiago" ] 11 => array:2 [ "nombre" => "Vanesa" "apellidos" => "Bernal" ] 12 => array:2 [ "nombre" => "Cristina" "apellidos" => "Fernández" ] 13 => array:2 [ "nombre" => "Belén" "apellidos" => "Piqueras" ] 14 => array:2 [ "nombre" => "María Luisa" "apellidos" => "Gutiérrez" ] 15 => array:2 [ "nombre" => "Ana" "apellidos" => "Martín" ] 16 => array:2 [ "nombre" => "Julia" "apellidos" => "Morillas" ] 17 => array:2 [ "nombre" => "Dalia" "apellidos" => "Morales" ] 18 => array:2 [ "nombre" => "Sonia" "apellidos" => "Blanco" ] 19 => array:2 [ "nombre" => "Paloma" "apellidos" => "Rendón" ] 20 => array:2 [ "nombre" => "Inmaculada" "apellidos" => "Chico" ] 21 => array:2 [ "nombre" => "Milagros" "apellidos" => "Testillano" ] 22 => array:2 [ "nombre" => "Carolina" "apellidos" => "Delgado" ] 23 => array:2 [ "nombre" => "Ana" "apellidos" => "Matilla" ] 24 => array:2 [ "nombre" => "Rafael" "apellidos" => "Gómez Rodríguez" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2444382424000993?idApp=UINPBA00004N" "url" => "/24443824/0000004700000007/v2_202409230509/S2444382424000993/v2_202409230509/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "Original article" "titulo" => "Perihilar cholangiocarcinoma resection: Is it beneficial for survival in elderly patients?" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "691" "paginaFinal" => "701" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Min Yu, Lina Lu, Rongjin Wu" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Min" "apellidos" => "Yu" "email" => array:1 [ 0 => "yumin88657@163.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Lina" "apellidos" => "Lu" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Rongjin" "apellidos" => "Wu" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Hepatobiliary and Pancreatic Surgery, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, China" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Digestive Department, Jinhua Wenrong Hospital, Jinhua, China" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Extirpación del colangiocarcinoma perihiliar: ¿es beneficioso para la supervivencia de los pacientes mayores?" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 4352 "Ancho" => 4150 "Tamanyo" => 827681 ] ] "descripcion" => array:1 [ "en" => "Comparison of long-term outcomes between elderly and young PHCC patients. (A) Random-effects meta-analysis model of 5-year OS in elderly PHCC patients versus young PHCC patients; (B) Fixed-effects meta-analysis model of 5-year DFS in elderly PHCC patients versus young PHCC patients." ] ] ] "textoCompleto" => "IntroductionCholangiocarcinoma (CCA) is a malignancy originating from biliary system and the second most common one of primary liver cancer. It is divided into perihilar cholangiocarcinoma (PHCC), intrahepatic cholangiocarcinoma (IHCC) and distal cholangiocarcinoma (DCC) based on anatomical location.<a class="elsevierStyleCrossRef" href="#bib0290">1</a> PHCC is the most prevalent type and takes up for 50–60% of CCA cases,<a class="elsevierStyleCrossRef" href="#bib0295">2</a> and its morbidity and mortality have been on the rise for the past two or three decades.<a class="elsevierStyleCrossRef" href="#bib0300">3</a> Since PHCC is asymptomatic in its early stages, most patients are not diagnosed until in the advanced stage.<a class="elsevierStyleCrossRef" href="#bib0305">4</a> Advanced PHCC is often poorly treated with currently available chemotherapy and radiotherapy, whereas surgical resection is the only option.<a class="elsevierStyleCrossRefs" href="#bib0310">5,6</a>The incidence of PHCC rises with age and peaks between ages of 60 and 80.<a class="elsevierStyleCrossRef" href="#bib0320">7</a> Human life expectancy continues to increase with improved living conditions and advances in medical technology, while the number of elderly PHCC patients also increases sharply. Nevertheless, elderly patients often have age-related problems, comprising medical comorbidities, poor physical status, and functional or structural changes in the liver that may lead to less tolerance to resection and make them at higher risk of poor outcome.<a class="elsevierStyleCrossRef" href="#bib0325">8</a> In addition, most malignancies are diagnosed in patients aged over 70.<a class="elsevierStyleCrossRef" href="#bib0330">9</a> Besides, given complexity and invasiveness of PHCC resection and the high postoperative morbidity and mortality, surgeons may hesitate to perform curative resection in elderly PHCC patients, and advanced age is classified as a contraindication for major surgery.<a class="elsevierStyleCrossRefs" href="#bib0330">9,10</a>In recent years, better understanding of liver anatomy, advances in surgical techniques and equipment, improved perioperative management, and advancements in adjuvant therapy techniques have improved the safety of hepatectomy and expanded surgical indications.<a class="elsevierStyleCrossRef" href="#bib0340">11</a> Studies on liver tumors proved feasibility and safety of hepatectomy in elderly patients. These studies revealed that elderly patients who received hepatectomy had a low acceptable complication rate and a favorable prognosis.<a class="elsevierStyleCrossRefs" href="#bib0345">12–14</a> Other investigations illustrated the survival outcome of PHCC resection in the elderly, but the results are controversial.<a class="elsevierStyleCrossRefs" href="#bib0360">15–17</a>Considering the increase in life expectancy and number of elderly PHCC patients, it is crucial to assess survival benefit of PHCC resection for elderly patients to decide the treatment. To our knowledge, no studies have systematically assessed survival outcomes of the elderly undergoing PHCC liver surgery, and this is the first review article of survival benefits of PHCC resection in the elderly.Materials and methodsLiterature search strategyPubMed, Embase, and Web of Science databases were systematically searched to collect relevant articles published in English from the time of database initiation to September 2022. The literature search was conducted using a combination of medical subject headings (Mesh) and free words, mainly including (perihilar cholangiocarcinoma) OR (cholangiocarcinoma) OR (hilar cholangiocarcinoma) OR (bile duct tumor) AND (hepatectomy) OR (surgery) AND (elderly patients). In addition, the reference lists of included articles were manually screened for relevant studies that potentially met the inclusion requirements.Selection of literatureInclusion criteria(1) Subjects: elderly patients diagnosed with PHCC; (2) Study type: randomized controlled trial and cohort study; (3) Intervention: PHCC resection; (4) Outcome indicators: 5-year Overall survival (OS), 5-year disease-free survival (DFS), postoperative mortality, histological results (Bismuth classification, tumor stage, resection margin).Exclusion criteria(1) No comparison with the younger group; (2) No OS or DFS was reported; (3) Non-English literature, repeatedly published literature, or guidelines, reviews, case analysis, expert experience, meeting records, technical reports, editorials, etc.; (4) Inconsistent or unextractable literature data.Statistical methodsMeta-analysis was performed applying Review Manager 5.4 software, and odds ratio (OR) functions as the effect indicator for enumeration data (count data). Point estimates and 95% confidence intervals (CI) were given for each effect size. Heterogeneity among the results was determined by Chi-square test, and the heterogeneity was quantitatively determined by I2. I2≤50% and p≥0.1 indicated no statistical heterogeneity among studies, with adoption of a fixed-effect model; On the contrary, there was statistical heterogeneity, with application of random-effects model for meta-analysis.ResultsBaseline characteristics of elderly PHCC patients who underwent hepatectomyA preliminary search was conducted on 459 literatures, of which 8 were excluded due to duplication. 267 literatures with inconsistent theme were ruled out by browsing titles, and 146 literatures were abandoned by browsing abstract. After the evaluation of the remaining 38 literatures, 33 of which were excluded because meta-analysis could not be performed were excluded (only abstract, non-comparison research, review articles, and unextractable data). Eventually, 5 literatures were included,<a class="elsevierStyleCrossRefs" href="#bib0360">15,18–21</a> which were retrospective cohort studies. <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> displays the literature screening process.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Several investigations have retrospectively analyzed effectiveness and safety of hepatectomy in elderly patients with PHCC. Analysis of baseline characteristics revealed that these studies included elderly patients using 70, 75, and 80 years as cutoffs. The proportion of males is higher than females in both younger and elderly patients. Most studies showed a higher proportion of patients receiving preoperative biliary drainage and portal vein embolization, and two of these studies showed a substantially lower proportion of elderly patients receiving portal vein embolization than younger patients.<a class="elsevierStyleCrossRefs" href="#bib0375">18,20</a> With regard to comorbidities, in two Japanese studies with 80 years as the cutoff,<a class="elsevierStyleCrossRefs" href="#bib0360">15,18</a> proportion of elderly PHCC patients with combined hypertension is higher than younger patients, and the proportion of both younger and elderly patients with combined diabetes mellitus is relatively low. But in an Italian study with a cutoff of 70 years,<a class="elsevierStyleCrossRef" href="#bib0380">19</a> the proportion of elderly patients with combined hypertension is substantially lower than that of younger patients, and the proportion of both younger and elderly patients with combined diabetes mellitus is relatively high (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Prognosis of hepatectomy in elderly patients with PHCCCurrently, 3 publications compared hepatectomy-related mortality in elderly and younger PHCC patients,<a class="elsevierStyleCrossRefs" href="#bib0360">15,18,19</a> with surgery-related mortality ranging from 0% to 21.7% in elderly patients and 1.3–11.1% in younger patients. The fixed-effects meta-analysis model illustrated that patients had no significant difference in postoperative mortality at α=0.05 (OR=1.86, 95% CI=0.67–5.10, p=0.23, <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2A</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>For short-term outcomes of hepatectomy in elderly PHCC patients, this study found by fixed-effects meta-analysis model that mortality at 90 days postoperatively in elderly patients was significantly higher than in younger patients (OR=2.35, 95% CI=1.53–3.60, p<0.0001, <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2B</a>). Similarly, Jonathan et al.<a class="elsevierStyleCrossRef" href="#bib0390">21</a> revealed a substantial association of patients over 80 years who underwent hepatectomy with a markedly increased risk of death at 30 and 90 days. However, despite risk of early death, the best way to achieve long-term survival in elderly patients with non-metastatic PHCC is resection. Moreover, survival beyond 3 years without radical resection is extremely rare. Besides, most studies reported no difference in terms of short-term prognosis between elderly patients and younger patients. None of the patients over 80 who received resection die within 90 days after surgery as reported in the study by Yasukawa et al.<a class="elsevierStyleCrossRef" href="#bib0375">18</a> Ripamonti et al.<a class="elsevierStyleCrossRef" href="#bib0380">19</a> illustrated that mortality rates for elderly and younger patients are 21.7% and 11.3% within 90 days after surgery, respectively, with a non-significant difference.Earlier studies regarding long-term outcome of hepatectomy in elderly PHCC patients presented that 5-year OS rate of elderly patients with PHCC undergoing hepatectomy ranged from 10.2% to 40.9%, while 5-year OS rate of younger patients ranged from 26.3% to 38.9%.<a class="elsevierStyleCrossRefs" href="#bib0360">15,18–21</a> In this study, random-effects and fixed-effects meta-analysis models revealed no significant differences at α=0.05 in the 5-year OS (OR=0.67, 95% CI=0.37–1.20, p=0.18, <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3A</a>) and 5-year DFS (OR=0.57, 95% CI=0.24–1.38, p=0.22, <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3B</a>) between elderly patients and younger patients. Most studies concluded that long-term prognosis of radical resection in elderly PHCC patients is comparable to that of younger PHCC patients.<a class="elsevierStyleCrossRefs" href="#bib0360">15,18–20</a> Because elderly patients with substantial comorbidities, poor or declining physical status, and expected higher surgical risk were considered unsuitable for surgery by preoperative evaluation, they were not included in these studies.<a class="elsevierStyleCrossRefs" href="#bib0360">15,18,20</a> The rates of portal vein embolization and combined portal vein resection were notably lower in elderly patients in these studies, indicating a potential selection bias in their tendency to avoid highly invasive procedures.<a class="elsevierStyleCrossRefs" href="#bib0375">18,20</a><elsevierMultimedia ident="fig0015"></elsevierMultimedia>Histopathological findings in elderly patients with PHCCProposed in 1975, Bismuth–Corlette classification of hilar cholangiocarcinoma has been the most widely used classification.<a class="elsevierStyleCrossRefs" href="#bib0395">22,23</a> Hilar cholangiocarcinoma was classified as involvement of hepatic duct below bifurcation (type I), bifurcation (type II), right hepatic duct (type IIIa), left hepatic duct (type IIIb), left and right hepatic ducts or multifocal involvement (type IV).<a class="elsevierStyleCrossRef" href="#bib0405">24</a> Extrahepatic choledochotomy is feasible for Bismuth–Corlette types I and II, whereas Bismuth–Corlette types III and IV require hepatic resection due to possible invasion of the proximal bile duct with a poorer surgical outcome.<a class="elsevierStyleCrossRef" href="#bib0410">25</a> Fixed-effects meta-analysis model showed that Bismuth type I or II tumors (OR=1.77, 95% CI=1.07–2.93, p=0.03, <a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4A</a>) and early-stage tumors (pStage 1–3) (OR=2.48, 95% CI=1.40–4.37, p=0.002, <a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4B</a>) in elderly patients were more prevalent than in younger patients. These data evinced that PHCC progression in elderly patients was lower than in younger patients. The lower degree of PHCC progression made elderly patients less likely to undergo extensive hepatectomy, such as combined pancreaticoduodenectomy and combined portal vein or hepatic arterectomy. This may also be one of the reasons why long-term prognoses of older PHCC patients received radical resection are comparable to younger patients.<elsevierMultimedia ident="fig0020"></elsevierMultimedia>Hepatectomy resection margins in elderly patients with PHCCCCAs in different anatomical locations require different surgeries. Clinicians usually adopt hepatectomy for IHCC and pancreaticoduodenectomy for DCC, but PHCC is the “gray area” in the spectrum of CCA. Achieving negative margins is hard and requires extensive pancreatic resection or, more commonly, hepatic resection with revascularization.<a class="elsevierStyleCrossRefs" href="#bib0415">26,27</a> Four publications have reported on the resection margins of hepatectomy in elderly patients with PHCC. The results of a random-effects meta-analysis model revealed no statistical significance of differences in curative resection R0 between elderly patients and younger patients (OR=1.43, 95% CI=0.66–3.08, p=0.36, <a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). The influence of resection margins on prognosis is well established, and generally concluded that positive resection margin is a critical cause of dismal prognosis.<a class="elsevierStyleCrossRefs" href="#bib0425">28,29</a> When planning the extent of surgical resection, surgeons must strike a balance between safety and radicality. Surgeons may prefer to perform less extensive surgery on elderly patients because they are more fragile and have less physiological reserve than younger patients.<a class="elsevierStyleCrossRef" href="#bib0360">15</a> The milder degree of pathologic progression in elderly patients undergoing hepatectomy may explain slightly higher rate of implementation of curative resection R0.<elsevierMultimedia ident="fig0025"></elsevierMultimedia>DiscussionDefinition of the elderlyThe definition of elderly patients is changing over time, complicating analysis of outcomes that published at varying periods. As the population ages, increasing studies have recently used 75 or even 80 years as a cutoff age for the elderly,<a class="elsevierStyleCrossRefs" href="#bib0435">30–32</a> whereas prior to 2010, most reports defined elderly patients with CCA as ≥70 years.<a class="elsevierStyleCrossRefs" href="#bib0380">19,33</a> Despite these differences, most investigations suggested that old age alone is not a deciding factor to dismiss any oncologic treatment in the first place.<a class="elsevierStyleCrossRefs" href="#bib0380">19,34</a> Nevertheless, oncologists still need to consider age-related comorbidities before determining treatment strategies for the elderly.Characteristics of elderly patients with liver cancerSenescence is featured by cellular senescence led by telomere shortening in successive cell divisions, which causes cessation of somatic cell proliferation. DNA damage, oxidative stress, epigenetic alterations, mitochondrial dysfunction, and altered metabolic pathways may lead to cellular and tissue senescence.<a class="elsevierStyleCrossRef" href="#bib0460">35</a> Aging alters the biological functions of the liver, which usually decreases in protein synthesis (especially albumin) and metabolic functions with age.<a class="elsevierStyleCrossRef" href="#bib0465">36</a> Additionally, the liver is capable of regenerating itself after surgical resection.<a class="elsevierStyleCrossRef" href="#bib0470">37</a> The most significant impact of aging on liver is the delayed and/or decreased proliferation following tissue loss due to surgery or chemical injury.<a class="elsevierStyleCrossRef" href="#bib0475">38</a> Molecular mechanism-related studies revealed that the possible cause is the accumulation of multi-protein C/EBPalpha-Brm-HDAC1 complex in the aging liver, which occupies and silences the E2F-dependent promoter, thereby hampering liver regenerative ability of elderly mice.<a class="elsevierStyleCrossRef" href="#bib0480">39</a> Aging can lead to symptoms of frailty, sarcopenia, and malnutrition in the human body.<a class="elsevierStyleCrossRef" href="#bib0485">40</a> Lurje et al.<a class="elsevierStyleCrossRef" href="#bib0490">41</a> conducted a comprehensive analysis of sarcopenia in patients with biliary tract cancer, including PHCC. They found that patients with sarcopenia had a threefold higher risk of postoperative complications compared to those without sarcopenia. Tatsumi et al.<a class="elsevierStyleCrossRef" href="#bib0495">42</a> reported a case of postoperative sarcopenia in a PHCC patient who experienced prolonged bed rest due to malnutrition and frailty. The patient's condition improved following treatment. Moreover, these three symptoms are common comorbidities in patients with liver cirrhosis.<a class="elsevierStyleCrossRef" href="#bib0500">43</a>A survey reported that above 80% of cancer patients over 65 have leastwise one comorbidity that requires treatment.<a class="elsevierStyleCrossRef" href="#bib0505">44</a> A study of comorbidities in liver cancer patients of different ages and genders revealed that proportion of comorbidities in elderly patients is significantly higher than in younger patients, and age is proportional to the ratio of comorbid chronic diseases like hypertension, coronary heart disease, diabetes, and cerebral infarction.<a class="elsevierStyleCrossRef" href="#bib0510">45</a> Patients with comorbidities were more likely to have more complex treatment, higher health care costs, lower quality of life, and lower survival rates than those without comorbidities.<a class="elsevierStyleCrossRef" href="#bib0505">44</a>Risks of hepatectomy in elderly patientsThe main treatment for PHCC patients is radical resection, and the criteria for radical resection include negative surgical margins (R0), complete resection of extrahepatic bile ducts, hepatic resection, and complete lymph node dissection.<a class="elsevierStyleCrossRef" href="#bib0515">46</a> For some patients who preclude radical resection, palliative resection or bile-intestinal drainage can be considered, and liver transplantation for individual patients without lymph node metastasis has been widely accepted. Besides, laparoscopy and da Vinci robot have been used for the surgical treatment of hilar cholangiocarcinoma.<a class="elsevierStyleCrossRef" href="#bib0520">47</a> During the surgical procedure, several challenges may arise, including the need for preoperative biliary drainage and portal vein embolization.<a class="elsevierStyleCrossRef" href="#bib0525">48</a> Residual liver function and the curability of the tumor are determinants of postoperative and long-term tumor prognosis,<a class="elsevierStyleCrossRef" href="#bib0530">49</a> which may have certain impact on the analysis of patient age in this study.Currently, radical resection is the most effective way to achieve long-term survival for PHCC patients, and survival rates for patients undergoing R1 or R2 resection are substantially better than those for patients with unresectable tumors.<a class="elsevierStyleCrossRefs" href="#bib0535">50,51</a> However, due to the special site of PHCC, which is highly prone to invade portal vein and hepatic artery, and to cause metastasis to surrounding lymph nodes and nerve invasion, this surgical approach is more difficult and invasive than other abdominal surgical approaches. Therefore, the risks and benefits must be considered when determining the indication for surgery, especially in elderly patients. The poorer physical status and reduced functional reserve of elderly patients may put them at risk for poorer postoperative outcomes.<a class="elsevierStyleCrossRef" href="#bib0325">8</a> As reported, preoperative assessment of patients is critical, and several assessment systems, such as PACE, POSSUM, and E-Pass, are available to predict postoperative morbidity and mortality in patients with gastrectomy and colectomy.<a class="elsevierStyleCrossRef" href="#bib0545">52</a> Nonetheless, no evidence can prove the possibility of these systems available for PHCC.<a class="elsevierStyleCrossRef" href="#bib0545">52</a> Whether elderly PHCC patients require surgery may depend largely on the experience of the surgeon. If surgery is not performed, shifting toward systemic treatment, such as neoadjuvant therapy, may contribute to improving local and distant control, achieving R0 resection, and preventing distant metastasis.<a class="elsevierStyleCrossRef" href="#bib0550">53</a>Several studies assessed the feasibility of hepatectomy for other liver cancers in elderly patients (such as colorectal cancer liver metastases (CRLM) and hepatocellular carcinoma (HCC), but the results were inconsistent. Ezaki et al.<a class="elsevierStyleCrossRef" href="#bib0555">54</a> and Mazzoni et al.<a class="elsevierStyleCrossRef" href="#bib0560">55</a> have not uncovered the influence of old age on postoperative outcomes in HCC and CRLM patients, whereas Nachmany et al.<a class="elsevierStyleCrossRef" href="#bib0565">56</a> discovered higher incidence of postoperative complications in elderly CRLM patients than that in young patients. Vitale et al.<a class="elsevierStyleCrossRef" href="#bib0570">57</a> carried out a multi-center retrospective study of 584 IHCC patients, indicating that long-term overall survival (OS) and disease-free survival (DFS) are comparable in elderly and young patients undergoing IHCC resection (OS, 13.3% vs. 24.4%; DFS, 7.3% vs. 12.0%; p>0.05), but the risk of perioperative complications is raised in elderly patients (24.0% vs. 14.9%, p=0.01).Complications of hepatectomy in elderly patients with PHCCThe aging society underscores the fact that surgery in the elderly is inevitable, even in PHCC. A study has investigated the survival outcomes of surgical interventions in elderly patients with PHCC. Yasukawa et al.<a class="elsevierStyleCrossRef" href="#bib0375">18</a> conducted a retrospective analysis and found that elderly PHCC patients who underwent surgery had a significantly higher one-year overall survival compared to those who did not receive surgical treatment (95.0% vs. 17.6%; p<0.001). Although surgical interventions in the elderly population come with inherent risks and challenges, they may provide better survival outcomes compared to the natural course of the disease. Considering that patients may be bedridden or suffer from surgical complications, indications for surgery in elderly patients are debated, especially in PHCC, where a high rate of postoperative complications is predicted. In the study by Yu Takahashi et al.,<a class="elsevierStyleCrossRef" href="#bib0370">17</a> a significant difference was seen in incidence of serious complications after extensive hepatectomy in elderly and non-elderly PHCC patients. In the study by Akashi et al.,<a class="elsevierStyleCrossRef" href="#bib0360">15</a> postoperative pneumonia is more common in adults over 80 years (8% vs 1.0%), and increased respiratory complications is more affected by age-associated decrease in respiratory function, implying that special attention should be given to elderly patients with respiratory complications. Several studies differed the opinion and reported comparable complication rates between elderly patients and younger patients.<a class="elsevierStyleCrossRefs" href="#bib0375">18,19</a> Yasukawa et al.<a class="elsevierStyleCrossRef" href="#bib0375">18</a> also suggested that right hemicolectomy in elderly patients over 80, although acceptable, has a high rate of complications, such as post-hepatectomy bile leak, post-hepatectomy liver failure (grade B), and Clavien–Dindo grade III complications. These results enlighten us to determine the indications for surgery for elderly PHCC patients prudently.ConclusionIn conclusion, long-term prognostic outcomes after hepatectomy are comparable in elderly and younger PHCC patients, but elderly patients hold a higher risk of postoperative early death than younger patients. The elderly who requires aggressive surgery should not deny surgery only considering age. However, considering the complexity of PHCC resection and relative vulnerability of elderly patients, the treatment team should carefully select the elderly patients who can be operated on and strengthen the surgical and perioperative management. Here are our recommendations: 1. For elderly patients without serious complications and with good functional status, a thorough evaluation should be conducted to assess their suitability for curative surgery, aiming to achieve long-term survival benefits. 2. For elderly patients with significant organ dysfunction complications such as cardiovascular or pulmonary conditions, a careful assessment of the surgical risk versus survival benefits is necessary. Surgical treatment should be cautiously selected in such cases. 3. Additionally, the patient's postoperative recovery capacity can also serve as a reference indicator for surgical selection. Besides, studies are supposed to devote to the development of assessment systems for determining surgical indications in elderly PHCC patients.Authors’ contributionsMY contributed to conceptualization and data curation. LNL contributed to methodology and formal analysis. RJW contributed to writing. All authors have reviewed and approved the final manuscript.Ethics approval and consent to participateNot applicable.Data availability statementThe data used to support the findings of this study are available from the corresponding author upon request.FundingNot applicable.Conflict of interestsThe authors declare that they have no competing interests." "textoCompletoSecciones" => array:1 [ "secciones" => array:16 [ 0 => array:3 [ "identificador" => "xres2247307" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1880091" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2247308" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1880090" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Materials and methods" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Literature search strategy" ] 1 => array:3 [ "identificador" => "sec0020" "titulo" => "Selection of literature" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Inclusion criteria" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Exclusion criteria" ] ] ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Statistical methods" ] ] ] 6 => array:3 [ "identificador" => "sec0040" "titulo" => "Results" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Baseline characteristics of elderly PHCC patients who underwent hepatectomy" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Prognosis of hepatectomy in elderly patients with PHCC" ] 2 => array:2 [ "identificador" => "sec0055" "titulo" => "Histopathological findings in elderly patients with PHCC" ] 3 => array:2 [ "identificador" => "sec0060" "titulo" => "Hepatectomy resection margins in elderly patients with PHCC" ] ] ] 7 => array:3 [ "identificador" => "sec0065" "titulo" => "Discussion" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0070" "titulo" => "Definition of the elderly" ] 1 => array:2 [ "identificador" => "sec0075" "titulo" => "Characteristics of elderly patients with liver cancer" ] 2 => array:2 [ "identificador" => "sec0080" "titulo" => "Risks of hepatectomy in elderly patients" ] 3 => array:2 [ "identificador" => "sec0085" "titulo" => "Complications of hepatectomy in elderly patients with PHCC" ] ] ] 8 => array:2 [ "identificador" => "sec0090" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0095" "titulo" => "Authors’ contributions" ] 10 => array:2 [ "identificador" => "sec0100" "titulo" => "Ethics approval and consent to participate" ] 11 => array:2 [ "identificador" => "sec0105" "titulo" => "Data availability statement" ] 12 => array:2 [ "identificador" => "sec0110" "titulo" => "Funding" ] 13 => array:2 [ "identificador" => "sec0115" "titulo" => "Conflict of interests" ] 14 => array:2 [ "identificador" => "xack775402" "titulo" => "Acknowledgement" ] 15 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-07-31" "fechaAceptado" => "2023-10-03" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1880091" "palabras" => array:3 [ 0 => "Perihilar cholangiocarcinoma" 1 => "Hepatectomy" 2 => "The elderly" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1880090" "palabras" => array:3 [ 0 => "Colangiocarcinoma perihiliar hepático" 1 => "Hepatectomía" 2 => "Ancianos" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionAs the population ages, surgeons are growing frequently faced with hard choices among a vast array of treatment options for the elderly. This study was to investigate safety and efficacy of resection in elderly patients with perihilar cholangiocarcinoma (PHCC). Patients and methodsLiterature reading and meta-analysis unveiled that elderly PHCC patients held a higher risk of death within 90 days after hepatectomy relative to younger patients, but their 5-year overall survival and disease-free survival were comparable. Among PHCC patients who underwent hepatectomy, the proportion of elderly patients with tumor classification Bismuth I–II and tumor stage pStage 1–3 was significantly higher than that of younger patients. ResultsCurative resection R0 was more common in elderly patients than younger patients, but the difference was not statistically significant. Because of more comorbidities and less physiological reserve of elderly patients, they seemed to suffer more postoperative complications. ConclusionConsidering improved life expectancy, it is crucial to treat elderly PHCC patients appropriately and attempts should be made to radical surgery based on comorbidities and functional status." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónA medida que la población envejece, los cirujanos a menudo se enfrentan a opciones difíciles entre los muchos programas de tratamiento que ofrecen a los ancianos. El objetivo de este estudio es explorar la seguridad y la eficacia de la extirpación del colangiocarcinoma perihiliar (PHCC, por sus siglas en inglés) en los pacientes ancianos. Pacientes y métodosLa lectura de la literatura y el metaanálisis muestran que los pacientes ancianos con PHCC tienen un mayor riesgo de muerte a los 90 días posteriores a la hepatectomía que los pacientes jóvenes, pero su supervivencia total a 5 años y su supervivencia libre de enfermedad son comparables. Entre los pacientes con PHCC que se sometieron a una hepatectomía, el porcentaje de pacientes mayores con clasificación tumoral de bismuto I-II y con estadificación tumoral de pStage 1-3 fue significativamente mayor que el de pacientes jóvenes. ResultadosLa extirpación terapéutica R0 es más común en los pacientes mayores que en los pacientes jóvenes, pero la diferencia no es estadísticamente significativa. Debido a que los pacientes ancianos tienen más comorbilidades, menos reservas fisiológicas y más complicaciones postoperatorias. ConclusiónTeniendo en cuenta el aumento de la esperanza de vida, el tratamiento adecuado de los pacientes ancianos con PHCC es crucial, y la cirugía radical debe intentarse de acuerdo con las comorbilidades y el estado funcional." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2120 "Ancho" => 2167 "Tamanyo" => 289266 ] ] "descripcion" => array:1 [ "en" => "Flow chart for literature screening." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 3819 "Ancho" => 4150 "Tamanyo" => 734648 ] ] "descripcion" => array:1 [ "en" => "Short-term postoperative outcomes in elderly patients versus younger patients. (A) Fixed-effects meta-analysis model of surgery-related deaths after hepatectomy in elderly and younger PHCC patients; (B) Fixed-effects meta-analysis model of 90-day mortality in elderly PHCC patients versus younger PHCC patients." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 4352 "Ancho" => 4150 "Tamanyo" => 827681 ] ] "descripcion" => array:1 [ "en" => "Comparison of long-term outcomes between elderly and young PHCC patients. (A) Random-effects meta-analysis model of 5-year OS in elderly PHCC patients versus young PHCC patients; (B) Fixed-effects meta-analysis model of 5-year DFS in elderly PHCC patients versus young PHCC patients." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 3998 "Ancho" => 4161 "Tamanyo" => 747180 ] ] "descripcion" => array:1 [ "en" => "Histopathological comparison of elderly patients with young patients. (A) Comparison of the proportion of elderly patients with younger patients with Bismuth type I or II PHCC; (B) Comparison of the proportion of elderly patients with younger patients with pStage 1–3 PHCC." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 2516 "Ancho" => 4155 "Tamanyo" => 454628 ] ] "descripcion" => array:1 [ "en" => "Comparison of the percentage of curative resection R0 in elderly patients versus younger patients." ] ] 5 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "References:" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Reference \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Year \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Country \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Age \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Sample size \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Sex (male/female) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Biliary drainage \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Portal vein embolization \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Hypertension \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Diabetes mellitus \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Akashi et al.<a class="elsevierStyleCrossRef" href="#tblfn0005">1</a></td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2018 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Japan \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21/19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34 (85.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19 (47.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 (55.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 (17.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">603 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">381/222 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">538 (89.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">303 (50.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">195 (32.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">75 (12.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="10" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yasukawa et al.<a class="elsevierStyleCrossRef" href="#tblfn0010">2</a></td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2021 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Japan \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13/7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 (60.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (10.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 (50.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (10.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">227 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">169/58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">172 (75.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">97 (42.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">90 (39.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30 (13.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="10" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ripamonti et al.<a class="elsevierStyleCrossRef" href="#tblfn0015">3</a></td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2021 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Italy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 (47.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 (95.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (26.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 (87.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25 (46.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">51 (94.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42 (77.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50 (92.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="10" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Koki Maeda et al.<a class="elsevierStyleCrossRef" href="#tblfn0020">4</a></td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2022 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Japan \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14/7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (4.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (19.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">81 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">49/32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24 (29.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 (12.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="10" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Jonathan et al.<a class="elsevierStyleCrossRef" href="#tblfn0025">5</a></td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2020 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">United States \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">149 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1430 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3662758.png" ] ] ] "notaPie" => array:5 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "1" "nota" => "Akashi K, et al. 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Perihilar cholangiocarcinoma resection: Is it beneficial for survival in elderly patients?

Extirpación del colangiocarcinoma perihiliar: ¿es beneficioso para la supervivencia de los pacientes mayores?

Min Yua,

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yumin88657@163.com

Corresponding author.

, Lina Lub, Rongjin Wua

a Department of Hepatobiliary and Pancreatic Surgery, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, China

b Digestive Department, Jinhua Wenrong Hospital, Jinhua, China

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    "titulo" => "Perihilar cholangiocarcinoma resection&#58; Is it beneficial for survival in elderly patients&#63;"
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            "entidad" => "Department of Hepatobiliary and Pancreatic Surgery&#44; Affiliated Jinhua Hospital&#44; Zhejiang University School of Medicine&#44; Jinhua&#44; China"
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        "titulo" => "Extirpaci&#243;n del colangiocarcinoma perihiliar&#58; &#191;es beneficioso para la supervivencia de los pacientes mayores&#63;"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Comparison of long-term outcomes between elderly and young PHCC patients&#46; &#40;A&#41; Random-effects meta-analysis model of 5-year OS in elderly PHCC patients versus young PHCC patients&#59; &#40;B&#41; Fixed-effects meta-analysis model of 5-year DFS in elderly PHCC patients versus young PHCC patients&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Cholangiocarcinoma &#40;CCA&#41; is a malignancy originating from biliary system and the second most common one of primary liver cancer&#46; It is divided into perihilar cholangiocarcinoma &#40;PHCC&#41;&#44; intrahepatic cholangiocarcinoma &#40;IHCC&#41; and distal cholangiocarcinoma &#40;DCC&#41; based on anatomical location&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">1</span></a> PHCC is the most prevalent type and takes up for 50&#8211;60&#37; of CCA cases&#44;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">2</span></a> and its morbidity and mortality have been on the rise for the past two or three decades&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">3</span></a> Since PHCC is asymptomatic in its early stages&#44; most patients are not diagnosed until in the advanced stage&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">4</span></a> Advanced PHCC is often poorly treated with currently available chemotherapy and radiotherapy&#44; whereas surgical resection is the only option&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The incidence of PHCC rises with age and peaks between ages of 60 and 80&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">7</span></a> Human life expectancy continues to increase with improved living conditions and advances in medical technology&#44; while the number of elderly PHCC patients also increases sharply&#46; Nevertheless&#44; elderly patients often have age-related problems&#44; comprising medical comorbidities&#44; poor physical status&#44; and functional or structural changes in the liver that may lead to less tolerance to resection and make them at higher risk of poor outcome&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">8</span></a> In addition&#44; most malignancies are diagnosed in patients aged over 70&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">9</span></a> Besides&#44; given complexity and invasiveness of PHCC resection and the high postoperative morbidity and mortality&#44; surgeons may hesitate to perform curative resection in elderly PHCC patients&#44; and advanced age is classified as a contraindication for major surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In recent years&#44; better understanding of liver anatomy&#44; advances in surgical techniques and equipment&#44; improved perioperative management&#44; and advancements in adjuvant therapy techniques have improved the safety of hepatectomy and expanded surgical indications&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">11</span></a> Studies on liver tumors proved feasibility and safety of hepatectomy in elderly patients&#46; These studies revealed that elderly patients who received hepatectomy had a low acceptable complication rate and a favorable prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">12&#8211;14</span></a> Other investigations illustrated the survival outcome of PHCC resection in the elderly&#44; but the results are controversial&#46;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">15&#8211;17</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Considering the increase in life expectancy and number of elderly PHCC patients&#44; it is crucial to assess survival benefit of PHCC resection for elderly patients to decide the treatment&#46; To our knowledge&#44; no studies have systematically assessed survival outcomes of the elderly undergoing PHCC liver surgery&#44; and this is the first review article of survival benefits of PHCC resection in the elderly&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Literature search strategy</span><p id="par0025" class="elsevierStylePara elsevierViewall">PubMed&#44; Embase&#44; and Web of Science databases were systematically searched to collect relevant articles published in English from the time of database initiation to September 2022&#46; The literature search was conducted using a combination of medical subject headings &#40;Mesh&#41; and free words&#44; mainly including &#40;perihilar cholangiocarcinoma&#41; OR &#40;cholangiocarcinoma&#41; OR &#40;hilar cholangiocarcinoma&#41; OR &#40;bile duct tumor&#41; AND &#40;hepatectomy&#41; OR &#40;surgery&#41; AND &#40;elderly patients&#41;&#46; In addition&#44; the reference lists of included articles were manually screened for relevant studies that potentially met the inclusion requirements&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Selection of literature</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Inclusion criteria</span><p id="par0030" class="elsevierStylePara elsevierViewall">&#40;1&#41; Subjects&#58; elderly patients diagnosed with PHCC&#59; &#40;2&#41; Study type&#58; randomized controlled trial and cohort study&#59; &#40;3&#41; Intervention&#58; PHCC resection&#59; &#40;4&#41; Outcome indicators&#58; 5-year Overall survival &#40;OS&#41;&#44; 5-year disease-free survival &#40;DFS&#41;&#44; postoperative mortality&#44; histological results &#40;Bismuth classification&#44; tumor stage&#44; resection margin&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Exclusion criteria</span><p id="par0035" class="elsevierStylePara elsevierViewall">&#40;1&#41; No comparison with the younger group&#59; &#40;2&#41; No OS or DFS was reported&#59; &#40;3&#41; Non-English literature&#44; repeatedly published literature&#44; or guidelines&#44; reviews&#44; case analysis&#44; expert experience&#44; meeting records&#44; technical reports&#44; editorials&#44; etc&#46;&#59; &#40;4&#41; Inconsistent or unextractable literature data&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Statistical methods</span><p id="par0040" class="elsevierStylePara elsevierViewall">Meta-analysis was performed applying Review Manager 5&#46;4 software&#44; and odds ratio &#40;OR&#41; functions as the effect indicator for enumeration data &#40;count data&#41;&#46; Point estimates and 95&#37; confidence intervals &#40;CI&#41; were given for each effect size&#46; Heterogeneity among the results was determined by Chi-square test&#44; and the heterogeneity was quantitatively determined by <span class="elsevierStyleItalic">I</span><span class="elsevierStyleSup">2</span>&#46; <span class="elsevierStyleItalic">I</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>50&#37; and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>0&#46;1 indicated no statistical heterogeneity among studies&#44; with adoption of a fixed-effect model&#59; On the contrary&#44; there was statistical heterogeneity&#44; with application of random-effects model for meta-analysis&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Baseline characteristics of elderly PHCC patients who underwent hepatectomy</span><p id="par0045" class="elsevierStylePara elsevierViewall">A preliminary search was conducted on 459 literatures&#44; of which 8 were excluded due to duplication&#46; 267 literatures with inconsistent theme were ruled out by browsing titles&#44; and 146 literatures were abandoned by browsing abstract&#46; After the evaluation of the remaining 38 literatures&#44; 33 of which were excluded because meta-analysis could not be performed were excluded &#40;only abstract&#44; non-comparison research&#44; review articles&#44; and unextractable data&#41;&#46; Eventually&#44; 5 literatures were included&#44;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">15&#44;18&#8211;21</span></a> which were retrospective cohort studies&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> displays the literature screening process&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Several investigations have retrospectively analyzed effectiveness and safety of hepatectomy in elderly patients with PHCC&#46; Analysis of baseline characteristics revealed that these studies included elderly patients using 70&#44; 75&#44; and 80 years as cutoffs&#46; The proportion of males is higher than females in both younger and elderly patients&#46; Most studies showed a higher proportion of patients receiving preoperative biliary drainage and portal vein embolization&#44; and two of these studies showed a substantially lower proportion of elderly patients receiving portal vein embolization than younger patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">18&#44;20</span></a> With regard to comorbidities&#44; in two Japanese studies with 80 years as the cutoff&#44;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">15&#44;18</span></a> proportion of elderly PHCC patients with combined hypertension is higher than younger patients&#44; and the proportion of both younger and elderly patients with combined diabetes mellitus is relatively low&#46; But in an Italian study with a cutoff of 70 years&#44;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">19</span></a> the proportion of elderly patients with combined hypertension is substantially lower than that of younger patients&#44; and the proportion of both younger and elderly patients with combined diabetes mellitus is relatively high &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Prognosis of hepatectomy in elderly patients with PHCC</span><p id="par0055" class="elsevierStylePara elsevierViewall">Currently&#44; 3 publications compared hepatectomy-related mortality in elderly and younger PHCC patients&#44;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">15&#44;18&#44;19</span></a> with surgery-related mortality ranging from 0&#37; to 21&#46;7&#37; in elderly patients and 1&#46;3&#8211;11&#46;1&#37; in younger patients&#46; The fixed-effects meta-analysis model illustrated that patients had no significant difference in postoperative mortality at <span class="elsevierStyleItalic">&#945;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;05 &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;86&#44; 95&#37; CI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;67&#8211;5&#46;10&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;23&#44; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2A</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">For short-term outcomes of hepatectomy in elderly PHCC patients&#44; this study found by fixed-effects meta-analysis model that mortality at 90 days postoperatively in elderly patients was significantly higher than in younger patients &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;35&#44; 95&#37; CI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;53&#8211;3&#46;60&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#44; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2B</a>&#41;&#46; Similarly&#44; Jonathan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">21</span></a> revealed a substantial association of patients over 80 years who underwent hepatectomy with a markedly increased risk of death at 30 and 90 days&#46; However&#44; despite risk of early death&#44; the best way to achieve long-term survival in elderly patients with non-metastatic PHCC is resection&#46; Moreover&#44; survival beyond 3 years without radical resection is extremely rare&#46; Besides&#44; most studies reported no difference in terms of short-term prognosis between elderly patients and younger patients&#46; None of the patients over 80 who received resection die within 90 days after surgery as reported in the study by Yasukawa et al&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">18</span></a> Ripamonti et al&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">19</span></a> illustrated that mortality rates for elderly and younger patients are 21&#46;7&#37; and 11&#46;3&#37; within 90 days after surgery&#44; respectively&#44; with a non-significant difference&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Earlier studies regarding long-term outcome of hepatectomy in elderly PHCC patients presented that 5-year OS rate of elderly patients with PHCC undergoing hepatectomy ranged from 10&#46;2&#37; to 40&#46;9&#37;&#44; while 5-year OS rate of younger patients ranged from 26&#46;3&#37; to 38&#46;9&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">15&#44;18&#8211;21</span></a> In this study&#44; random-effects and fixed-effects meta-analysis models revealed no significant differences at <span class="elsevierStyleItalic">&#945;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;05 in the 5-year OS &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;67&#44; 95&#37; CI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;37&#8211;1&#46;20&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;18&#44; <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3A</a>&#41; and 5-year DFS &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;57&#44; 95&#37; CI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;24&#8211;1&#46;38&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;22&#44; <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3B</a>&#41; between elderly patients and younger patients&#46; Most studies concluded that long-term prognosis of radical resection in elderly PHCC patients is comparable to that of younger PHCC patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">15&#44;18&#8211;20</span></a> Because elderly patients with substantial comorbidities&#44; poor or declining physical status&#44; and expected higher surgical risk were considered unsuitable for surgery by preoperative evaluation&#44; they were not included in these studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">15&#44;18&#44;20</span></a> The rates of portal vein embolization and combined portal vein resection were notably lower in elderly patients in these studies&#44; indicating a potential selection bias in their tendency to avoid highly invasive procedures&#46;<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">18&#44;20</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Histopathological findings in elderly patients with PHCC</span><p id="par0070" class="elsevierStylePara elsevierViewall">Proposed in 1975&#44; Bismuth&#8211;Corlette classification of hilar cholangiocarcinoma has been the most widely used classification&#46;<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">22&#44;23</span></a> Hilar cholangiocarcinoma was classified as involvement of hepatic duct below bifurcation &#40;type I&#41;&#44; bifurcation &#40;type II&#41;&#44; right hepatic duct &#40;type IIIa&#41;&#44; left hepatic duct &#40;type IIIb&#41;&#44; left and right hepatic ducts or multifocal involvement &#40;type IV&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">24</span></a> Extrahepatic choledochotomy is feasible for Bismuth&#8211;Corlette types I and II&#44; whereas Bismuth&#8211;Corlette types III and IV require hepatic resection due to possible invasion of the proximal bile duct with a poorer surgical outcome&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">25</span></a> Fixed-effects meta-analysis model showed that Bismuth type I or II tumors &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;77&#44; 95&#37; CI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;07&#8211;2&#46;93&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;03&#44; <a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4A</a>&#41; and early-stage tumors &#40;pStage 1&#8211;3&#41; &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;48&#44; 95&#37; CI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;40&#8211;4&#46;37&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;002&#44; <a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4B</a>&#41; in elderly patients were more prevalent than in younger patients&#46; These data evinced that PHCC progression in elderly patients was lower than in younger patients&#46; The lower degree of PHCC progression made elderly patients less likely to undergo extensive hepatectomy&#44; such as combined pancreaticoduodenectomy and combined portal vein or hepatic arterectomy&#46; This may also be one of the reasons why long-term prognoses of older PHCC patients received radical resection are comparable to younger patients&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Hepatectomy resection margins in elderly patients with PHCC</span><p id="par0075" class="elsevierStylePara elsevierViewall">CCAs in different anatomical locations require different surgeries&#46; Clinicians usually adopt hepatectomy for IHCC and pancreaticoduodenectomy for DCC&#44; but PHCC is the &#8220;gray area&#8221; in the spectrum of CCA&#46; Achieving negative margins is hard and requires extensive pancreatic resection or&#44; more commonly&#44; hepatic resection with revascularization&#46;<a class="elsevierStyleCrossRefs" href="#bib0415"><span class="elsevierStyleSup">26&#44;27</span></a> Four publications have reported on the resection margins of hepatectomy in elderly patients with PHCC&#46; The results of a random-effects meta-analysis model revealed no statistical significance of differences in curative resection R0 between elderly patients and younger patients &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;43&#44; 95&#37; CI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;66&#8211;3&#46;08&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;36&#44; <a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; The influence of resection margins on prognosis is well established&#44; and generally concluded that positive resection margin is a critical cause of dismal prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0425"><span class="elsevierStyleSup">28&#44;29</span></a> When planning the extent of surgical resection&#44; surgeons must strike a balance between safety and radicality&#46; Surgeons may prefer to perform less extensive surgery on elderly patients because they are more fragile and have less physiological reserve than younger patients&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">15</span></a> The milder degree of pathologic progression in elderly patients undergoing hepatectomy may explain slightly higher rate of implementation of curative resection R0&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Discussion</span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Definition of the elderly</span><p id="par0080" class="elsevierStylePara elsevierViewall">The definition of elderly patients is changing over time&#44; complicating analysis of outcomes that published at varying periods&#46; As the population ages&#44; increasing studies have recently used 75 or even 80 years as a cutoff age for the elderly&#44;<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">30&#8211;32</span></a> whereas prior to 2010&#44; most reports defined elderly patients with CCA as &#8805;<span class="elsevierStyleHsp" style=""></span>70 years&#46;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">19&#44;33</span></a> Despite these differences&#44; most investigations suggested that old age alone is not a deciding factor to dismiss any oncologic treatment in the first place&#46;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">19&#44;34</span></a> Nevertheless&#44; oncologists still need to consider age-related comorbidities before determining treatment strategies for the elderly&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Characteristics of elderly patients with liver cancer</span><p id="par0085" class="elsevierStylePara elsevierViewall">Senescence is featured by cellular senescence led by telomere shortening in successive cell divisions&#44; which causes cessation of somatic cell proliferation&#46; DNA damage&#44; oxidative stress&#44; epigenetic alterations&#44; mitochondrial dysfunction&#44; and altered metabolic pathways may lead to cellular and tissue senescence&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">35</span></a> Aging alters the biological functions of the liver&#44; which usually decreases in protein synthesis &#40;especially albumin&#41; and metabolic functions with age&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">36</span></a> Additionally&#44; the liver is capable of regenerating itself after surgical resection&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">37</span></a> The most significant impact of aging on liver is the delayed and&#47;or decreased proliferation following tissue loss due to surgery or chemical injury&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">38</span></a> Molecular mechanism-related studies revealed that the possible cause is the accumulation of multi-protein C&#47;EBPalpha-Brm-HDAC1 complex in the aging liver&#44; which occupies and silences the E2F-dependent promoter&#44; thereby hampering liver regenerative ability of elderly mice&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">39</span></a> Aging can lead to symptoms of frailty&#44; sarcopenia&#44; and malnutrition in the human body&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">40</span></a> Lurje et al&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">41</span></a> conducted a comprehensive analysis of sarcopenia in patients with biliary tract cancer&#44; including PHCC&#46; They found that patients with sarcopenia had a threefold higher risk of postoperative complications compared to those without sarcopenia&#46; Tatsumi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">42</span></a> reported a case of postoperative sarcopenia in a PHCC patient who experienced prolonged bed rest due to malnutrition and frailty&#46; The patient&#39;s condition improved following treatment&#46; Moreover&#44; these three symptoms are common comorbidities in patients with liver cirrhosis&#46;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">43</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">A survey reported that above 80&#37; of cancer patients over 65 have leastwise one comorbidity that requires treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">44</span></a> A study of comorbidities in liver cancer patients of different ages and genders revealed that proportion of comorbidities in elderly patients is significantly higher than in younger patients&#44; and age is proportional to the ratio of comorbid chronic diseases like hypertension&#44; coronary heart disease&#44; diabetes&#44; and cerebral infarction&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">45</span></a> Patients with comorbidities were more likely to have more complex treatment&#44; higher health care costs&#44; lower quality of life&#44; and lower survival rates than those without comorbidities&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">44</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Risks of hepatectomy in elderly patients</span><p id="par0095" class="elsevierStylePara elsevierViewall">The main treatment for PHCC patients is radical resection&#44; and the criteria for radical resection include negative surgical margins &#40;R0&#41;&#44; complete resection of extrahepatic bile ducts&#44; hepatic resection&#44; and complete lymph node dissection&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">46</span></a> For some patients who preclude radical resection&#44; palliative resection or bile-intestinal drainage can be considered&#44; and liver transplantation for individual patients without lymph node metastasis has been widely accepted&#46; Besides&#44; laparoscopy and da Vinci robot have been used for the surgical treatment of hilar cholangiocarcinoma&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">47</span></a> During the surgical procedure&#44; several challenges may arise&#44; including the need for preoperative biliary drainage and portal vein embolization&#46;<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">48</span></a> Residual liver function and the curability of the tumor are determinants of postoperative and long-term tumor prognosis&#44;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">49</span></a> which may have certain impact on the analysis of patient age in this study&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Currently&#44; radical resection is the most effective way to achieve long-term survival for PHCC patients&#44; and survival rates for patients undergoing R1 or R2 resection are substantially better than those for patients with unresectable tumors&#46;<a class="elsevierStyleCrossRefs" href="#bib0535"><span class="elsevierStyleSup">50&#44;51</span></a> However&#44; due to the special site of PHCC&#44; which is highly prone to invade portal vein and hepatic artery&#44; and to cause metastasis to surrounding lymph nodes and nerve invasion&#44; this surgical approach is more difficult and invasive than other abdominal surgical approaches&#46; Therefore&#44; the risks and benefits must be considered when determining the indication for surgery&#44; especially in elderly patients&#46; The poorer physical status and reduced functional reserve of elderly patients may put them at risk for poorer postoperative outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">8</span></a> As reported&#44; preoperative assessment of patients is critical&#44; and several assessment systems&#44; such as PACE&#44; POSSUM&#44; and E-Pass&#44; are available to predict postoperative morbidity and mortality in patients with gastrectomy and colectomy&#46;<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">52</span></a> Nonetheless&#44; no evidence can prove the possibility of these systems available for PHCC&#46;<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">52</span></a> Whether elderly PHCC patients require surgery may depend largely on the experience of the surgeon&#46; If surgery is not performed&#44; shifting toward systemic treatment&#44; such as neoadjuvant therapy&#44; may contribute to improving local and distant control&#44; achieving R0 resection&#44; and preventing distant metastasis&#46;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">53</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Several studies assessed the feasibility of hepatectomy for other liver cancers in elderly patients &#40;such as colorectal cancer liver metastases &#40;CRLM&#41; and hepatocellular carcinoma &#40;HCC&#41;&#44; but the results were inconsistent&#46; Ezaki et al&#46;<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">54</span></a> and Mazzoni et al&#46;<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">55</span></a> have not uncovered the influence of old age on postoperative outcomes in HCC and CRLM patients&#44; whereas Nachmany et al&#46;<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">56</span></a> discovered higher incidence of postoperative complications in elderly CRLM patients than that in young patients&#46; Vitale et al&#46;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">57</span></a> carried out a multi-center retrospective study of 584 IHCC patients&#44; indicating that long-term overall survival &#40;OS&#41; and disease-free survival &#40;DFS&#41; are comparable in elderly and young patients undergoing IHCC resection &#40;OS&#44; 13&#46;3&#37; vs&#46; 24&#46;4&#37;&#59; DFS&#44; 7&#46;3&#37; vs&#46; 12&#46;0&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#44; but the risk of perioperative complications is raised in elderly patients &#40;24&#46;0&#37; vs&#46; 14&#46;9&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Complications of hepatectomy in elderly patients with PHCC</span><p id="par0110" class="elsevierStylePara elsevierViewall">The aging society underscores the fact that surgery in the elderly is inevitable&#44; even in PHCC&#46; A study has investigated the survival outcomes of surgical interventions in elderly patients with PHCC&#46; Yasukawa et al&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">18</span></a> conducted a retrospective analysis and found that elderly PHCC patients who underwent surgery had a significantly higher one-year overall survival compared to those who did not receive surgical treatment &#40;95&#46;0&#37; vs&#46; 17&#46;6&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Although surgical interventions in the elderly population come with inherent risks and challenges&#44; they may provide better survival outcomes compared to the natural course of the disease&#46; Considering that patients may be bedridden or suffer from surgical complications&#44; indications for surgery in elderly patients are debated&#44; especially in PHCC&#44; where a high rate of postoperative complications is predicted&#46; In the study by Yu Takahashi et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">17</span></a> a significant difference was seen in incidence of serious complications after extensive hepatectomy in elderly and non-elderly PHCC patients&#46; In the study by Akashi et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">15</span></a> postoperative pneumonia is more common in adults over 80 years &#40;8&#37; vs 1&#46;0&#37;&#41;&#44; and increased respiratory complications is more affected by age-associated decrease in respiratory function&#44; implying that special attention should be given to elderly patients with respiratory complications&#46; Several studies differed the opinion and reported comparable complication rates between elderly patients and younger patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">18&#44;19</span></a> Yasukawa et al&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">18</span></a> also suggested that right hemicolectomy in elderly patients over 80&#44; although acceptable&#44; has a high rate of complications&#44; such as post-hepatectomy bile leak&#44; post-hepatectomy liver failure &#40;grade B&#41;&#44; and Clavien&#8211;Dindo grade III complications&#46; These results enlighten us to determine the indications for surgery for elderly PHCC patients prudently&#46;</p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conclusion</span><p id="par0115" class="elsevierStylePara elsevierViewall">In conclusion&#44; long-term prognostic outcomes after hepatectomy are comparable in elderly and younger PHCC patients&#44; but elderly patients hold a higher risk of postoperative early death than younger patients&#46; The elderly who requires aggressive surgery should not deny surgery only considering age&#46; However&#44; considering the complexity of PHCC resection and relative vulnerability of elderly patients&#44; the treatment team should carefully select the elderly patients who can be operated on and strengthen the surgical and perioperative management&#46; Here are our recommendations&#58; 1&#46; For elderly patients without serious complications and with good functional status&#44; a thorough evaluation should be conducted to assess their suitability for curative surgery&#44; aiming to achieve long-term survival benefits&#46; 2&#46; For elderly patients with significant organ dysfunction complications such as cardiovascular or pulmonary conditions&#44; a careful assessment of the surgical risk versus survival benefits is necessary&#46; Surgical treatment should be cautiously selected in such cases&#46; 3&#46; Additionally&#44; the patient&#39;s postoperative recovery capacity can also serve as a reference indicator for surgical selection&#46; Besides&#44; studies are supposed to devote to the development of assessment systems for determining surgical indications in elderly PHCC patients&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Authors&#8217; contributions</span><p id="par0120" class="elsevierStylePara elsevierViewall">MY contributed to conceptualization and data curation&#46; LNL contributed to methodology and formal analysis&#46; RJW contributed to writing&#46; All authors have reviewed and approved the final manuscript&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Ethics approval and consent to participate</span><p id="par0125" class="elsevierStylePara elsevierViewall">Not applicable&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Data availability statement</span><p id="par0130" class="elsevierStylePara elsevierViewall">The data used to support the findings of this study are available from the corresponding author upon request&#46;</p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Funding</span><p id="par0135" class="elsevierStylePara elsevierViewall">Not applicable&#46;</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Conflict of interests</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors declare that they have no competing interests&#46;</p></span></span>"
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    "fechaRecibido" => "2023-07-31"
    "fechaAceptado" => "2023-10-03"
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            0 => "Perihilar cholangiocarcinoma"
            1 => "Hepatectomy"
            2 => "The elderly"
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          "palabras" => array:3 [
            0 => "Colangiocarcinoma perihiliar hep&#225;tico"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">As the population ages&#44; surgeons are growing frequently faced with hard choices among a vast array of treatment options for the elderly&#46; This study was to investigate safety and efficacy of resection in elderly patients with perihilar cholangiocarcinoma &#40;PHCC&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Literature reading and meta-analysis unveiled that elderly PHCC patients held a higher risk of death within 90 days after hepatectomy relative to younger patients&#44; but their 5-year overall survival and disease-free survival were comparable&#46; Among PHCC patients who underwent hepatectomy&#44; the proportion of elderly patients with tumor classification Bismuth I&#8211;II and tumor stage pStage 1&#8211;3 was significantly higher than that of younger patients&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Curative resection R0 was more common in elderly patients than younger patients&#44; but the difference was not statistically significant&#46; Because of more comorbidities and less physiological reserve of elderly patients&#44; they seemed to suffer more postoperative complications&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Considering improved life expectancy&#44; it is crucial to treat elderly PHCC patients appropriately and attempts should be made to radical surgery based on comorbidities and functional status&#46;</p></span>"
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Sample size&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Sex &#40;male&#47;female&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Biliary drainage&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Portal vein embolization&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Hypertension&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Diabetes mellitus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " rowspan="2" align="left" valign="\n
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                  \t\t\t\t">Akashi et al&#46;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">1</span></a></td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2018&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Japan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#8805;<span class="elsevierStyleHsp" style=""></span>80&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">40&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">21&#47;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">34 &#40;85&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">19 &#40;47&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">22 &#40;55&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">7 &#40;17&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">603&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">381&#47;222&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">538 &#40;89&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">303 &#40;50&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">195 &#40;32&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">75 &#40;12&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="10" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " rowspan="2" align="left" valign="\n
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                  \t\t\t\t">Yasukawa et al&#46;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">2</span></a></td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2021&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Japan&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8805;<span class="elsevierStyleHsp" style=""></span>80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">13&#47;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">12 &#40;60&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2 &#40;10&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">10 &#40;50&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;10&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>80&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">227&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">169&#47;58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">172 &#40;75&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">97 &#40;42&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">90 &#40;39&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30 &#40;13&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="10" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ripamonti et al&#46;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">3</span></a></td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2021&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Italy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8805;<span class="elsevierStyleHsp" style=""></span>70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;47&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22 &#40;95&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;26&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20 &#40;87&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25 &#40;46&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">51 &#40;94&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42 &#40;77&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50 &#40;92&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="10" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Koki Maeda et al&#46;<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">4</span></a></td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2022&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Japan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8805;<span class="elsevierStyleHsp" style=""></span>75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#47;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;4&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;19&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">81&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">49&#47;32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24 &#40;29&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;12&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="10" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Jonathan et al&#46;<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">5</span></a></td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2020&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">United States&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8805;<span class="elsevierStyleHsp" style=""></span>80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">149&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1430&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab3662758.png"
              ]
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          ]
          "notaPie" => array:5 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "1"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Akashi K&#44; et al&#46; Surgery for perihilar cholangiocarcinoma from a viewpoint of age&#58; Is it beneficial to octogenarians in an aging society&#63; <span class="elsevierStyleItalic">Surgery</span> 2018&#59; 164&#58; 1023&#8211;1029&#44; <span class="elsevierStyleInterRef" id="intr0005" href="doi:10.1016/j.surg.2018.05.051">doi&#58;10&#46;1016&#47;j&#46;surg&#46;2018&#46;05&#46;051</span>&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "2"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Yasukawa K&#44; et al&#46; The survival benefit of surgery for perihilar cholangiocarcinoma in octogenarians&#58; Shinshu University experience&#46; <span class="elsevierStyleItalic">J Surg Oncol</span> 2021&#59; 124&#58; 67&#8211;78&#44; <span class="elsevierStyleInterRef" id="intr0010" href="doi:10.1002/jso.26488">doi&#58;10&#46;1002&#47;jso&#46;26488</span>&#46;</p>"
            ]
            2 => array:3 [
              "identificador" => "tblfn0015"
              "etiqueta" => "3"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Ripamonti L&#44; et al&#46; Major hepatectomy for perihilar cholangiocarcinoma in elderly patients&#58; is it reasonable&#63; <span class="elsevierStyleItalic">Updates Surg</span> 2022&#59; 74&#58; 203&#8211;211&#44; <span class="elsevierStyleInterRef" id="intr0015" href="doi:10.1007/s13304-021-01111-6">doi&#58;10&#46;1007&#47;s13304-021-01111-6</span>&#46;</p>"
            ]
            3 => array:3 [
              "identificador" => "tblfn0020"
              "etiqueta" => "4"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Maeda K&#44; et al&#46; Safety and benefits of major hepatectomy with extrahepatic bile duct resection in older perihilar cholangiocarcinoma patients&#46; <span class="elsevierStyleItalic">Langenbecks Arch Surg</span> 2022&#59; 407&#58; 2861&#8211;2872&#44; <span class="elsevierStyleInterRef" id="intr0020" href="doi:10.1007/s00423-022-02654-x">doi&#58;10&#46;1007&#47;s00423-022-02654-x</span>&#46;</p>"
            ]
            4 => array:3 [
              "identificador" => "tblfn0025"
              "etiqueta" => "5"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Hue JJ&#44; et al&#46; Reassessing the role of surgery in the elderly or chronically sick with proximal extrahepatic cholangiocarcinoma&#46; <span class="elsevierStyleItalic">Surgery</span> 2021&#59; 169&#58; 233&#8211;239&#44; <span class="elsevierStyleInterRef" id="intr0025" href="doi:10.1016/j.surg.2020.09.011">doi&#58;10&#46;1016&#47;j&#46;surg&#46;2020&#46;09&#46;011</span>&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Baseline characteristics of elderly patients with PHCC who underwent hepatectomy&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:57 [
            0 => array:3 [
              "identificador" => "bib0290"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
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Article information

ISSN: 24443824
Original language: English

DOI:10.1016/j.gastre.2024.04.034

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