ICC, arising above the second-order bile ducts, is a relatively infrequent type of primary hepatic malignancy, which accounts for only 5–10% of liver cancers[3]. The patient prognosis of ICC is comparatively poor, with 3- and 5-year overall survival rates of 30% and 18%, respectively[4]. Surgery is currently the first choice in patients with ICC, which is the only curative form of treatment that offers a chance for long-term survival. In this study, we reported a 110-year-old woman who received a partial hepatectomy and lymph node dissection to treat ICC. To our best knowledge, this should be the first case in the world to had a partial hepatectomy in centenarians, furthermore, she seems to be one of the oldest patients who underwent surgery.
With the development of medicine, the number of centenarians is increasing steadily in recent years, which is undoubtedly an extraordinary achievement of the healthcare system. However, elderly people also pose an unparalleled challenge to the medical system in turn. Undoubtedly, this patient is very lucky. The abdominal contrast-enhanced CT showed a visible lump with unclear boundaries in the left lateral lobe of liver, about 6*7cm in size, future liver volume(FLR) more than 60%, with no evidence of lymph node or distant metastasis. This is necessary for the operation. Preoperative examination showed that the cardiopulmonary function was acceptable. The surgery in this age group not forbidden rather not encouraged due high risk of mortality. Nevertheless, more and more studies has shown that the centenarians, as had long been forbiddened, can exceptionally healthy as well as younger counterparts after procedures various operations - most of them are vascular and orthopedic surgery - such as spine surgery, vascular procedures, two step surgery of colorectal cancer, aortic valve repair, laparoscopic cholecystectomy and primary and even revision joint arthroplasty[5–12]. There is some controversy over the necessity of surgical resection of liver malignant tumors among the oldest age group owing to short-term postoperative life expectancy estimates in clinical, still. We knows that the main challenge faced by centenarians is the vulnerable bodies are lack of physiological reserve but not the surgery itself. They could tolerate operations but not complications. We had done a lot for everything to go well.
First, we conducted a comprehensive examination to identify and treat correctable comorbidities immediately so that surgery could be arranged in time. Based on these preoperative assessments, the enhanced recovery after surgery multidisciplinary team (ERAS-MDT) has taken a series of measures to improve the patient's physical state: (I) We used selective COX-2 inhibitors for patients to alleviate pain; (II) We provided a quieter room for the patient and asked her have a desultory conversation with family members during daytime to intervene sleep and relieve tension; (III) Nutritionist prepared sufficient enteral nutrition for her; (IV) We require patients to performed breathing exercises such as balloon blowing and physical training as far as possible to improve cardiopulmonary function.
Second, we have prepared a series of measures to deal with various of possible unexpected situations during the operation: (I) The anesthesiology expert team implemented the anesthesia method of intraspinal combined with combined intravenous and inhalation anesthesia(CIIA) to minimize the influence of narcotic drugs on the circulation of the centenarian. (II) In order to intuitively catch the changes of vital signs and maximize the safety of the patients' lives, we also adopted central venous catheterization, radial artery catheterization and monitor the depth of anaesthesia on the basis of routine monitoring. (III) In order to avoid the occurrence of liver failure as much as possible, most importantly, surgeons, the prestigious in the Dujiangyan Medical Center, complete the operation in the shortest time without block the hepatic portal. (IV) At the same time, many experts, such as Cardiovascular, Respiratory, and Critical Care Medicine, were standby outside the operation room.
We chose to perform an open procedure. The patient is 110 years old and may not be able to withstand abdominal inflation. In addition, open surgery can fully expose the visual field, shorten the operation time, and reduce the occurrence of complications. Due to the extremely beneficial anesthesia control - CIIA, the endotracheal intubation was pulled out successfully in 10 minutes after the operation, and supplemented by perfect analgesia, which effectively reduced the patient's stress reaction. Similarly, we applied a series of measures to promote postoperative rehabilitation.
Third, postoperative rehabilitation is also crucial. (I) The ERAS-MDT is mean to patients: selective COX-2 inhibitor for pain relief, extubation of gastric tube and urinary tube early to reduce stress, early enteral nutrition(EEN) and out of bed activities on postoperative day 1; (II) Low-molecular-weight heparin (4,000 IU), administered subcutaneously, qd, 1 day postoperatively for thromboprophylaxis until discharge; Enteral nutrition combined with parenteral nutrition was given after surgery; (III) Fluid administration for maintaining water and electrolyting balance. Facts have been proved that the measures of ERAS-MDT were extremely correct. The patients recover gastrointestinal function early, had no mental, thrombosis, etc.
In addition, the adjuvant treatment of cancer in centenarians needs further research. We should pay attention to the treatment of centenarians.