Of 154 elective hepatectomies performed during the 13 year period from 1973 to 1985 for hepatocellular carcinoma, 27 (17.5 percent) were performed on patients 65 years of age or older. Among these elderly patients, 40.7 percent died in the hospital compared with 21.3 percent of the younger patients (p less than 0.05). Sepsis accounted for 72.7 percent of the hospital deaths among the elderly patients, in contrast to 25.9 percent among the younger patients. The overall incidence of hospital death due to sepsis was significantly higher in the elderly patients (p less than 0.001). Hepatic lobectomy or segmentectomy in the elderly patients with cirrhosis was followed by hospital death in 88.9 percent compared with 25 percent of the elderly patients without cirrhosis (p less than 0.01). A higher incidence of hospital death occurred among the elderly in Okuda's stage I (p less than 0.05), Child's class A (p less than 0.02), and in those with concomitant systemic disorders (p less than 0.05). We conclude that in patients 65 years of age or older with hepatocellular carcinoma, concomitant systemic disorders play a role in determining the outcome of hepatectomy. Elderly patients with cirrhosis are high-risk candidates for major hepatectomy for whom limited hepatic resection should be considered.