Should we deny surgery for malignant hepato-pancreatico-biliary tumors to elderly patients?

Malignant hepato-pancreatico-biliary (HPB) tumors have their highest incidence within the sixth to eighth decades of life. The aging of the world population has resulted in a dramatic increase in the number of elderly patients considered for resection of malignant HPB tumors. Because elderly patients are more likely to have more co-morbidities, cognitive impairment, and decreased life expectancy, the benefit and appropriateness of these procedures must be scrutinized for geriatric patients. Therefore, many surgeons have compared the perioperative and long-term outcome of hepatic and pancreatic resections for elderly and younger patients. In most series the elderly population was defined by an age of 70 years or older. The results demonstrate that hepatic resection for hepatocellular carcinoma and colorectal liver metastases can be safely performed in well-selected elderly patients with long-term outcome comparable to younger patients. Similar findings are also reported for pancreatic resection in elderly patients with either ampullary or pancreatic cancer. Although the survival benefit of pancreatico-duodenectomy is limited in all age groups, the absence of competitive therapy justifies this procedure as the sole curative option in younger as well as older patients. Data on resection of gallbladder cancer and hilar bile duct cancer in the elderly are sparse, but there is evidence from large series on resection of these types of tumors that advanced age per se is not a risk factor for reduced outcome. Therefore, surgical options should not be denied to elderly patients with a malignant HPB tumor, and the evaluation should include surgeons expert in HPB surgery.