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Phillipos J, Lim KZ, Pham H, Johari Y, Pilgrim CHC, Smith M. Outcomes following pancreaticoduodenectomy for octogenarians: a systematic review and meta-analysis. HPB (Oxford) 2024; 26:1435-1447. [PMID: 39266363 DOI: 10.1016/j.hpb.2024.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 07/24/2024] [Accepted: 08/13/2024] [Indexed: 09/14/2024]
Abstract
BACKGROUND An increasing number of elderly patients are being diagnosed with pancreatic cancer, with increasing need to consider pancreatic surgery. This study aims to provide an updated systematic review and meta-analysis to evaluate the outcomes following pancreaticoduodenectomy in octogenarians. METHODS A systematic review and meta-analysis was performed via a search of Medline, PubMed and Cochrane databases. Studies comparing outcomes of patients >80 years to younger patients undergoing PD were included. RESULTS 26 studies were included. This included 22481 patients, with 20134 (89.6%) aged <80 years old, and 2347 (10.4%) octogenarians. Octogenarians were associated with higher rates of mortality (OR 2.37 (95%CI 1.91-2.94, p < 0.00001)), all-cause morbidity (OR 1.60 (95%CI 1.30-1.96), p<0.00001) and re-operation (OR 1.41 (95%CI 1.13-1.75), p = 0.002). Octogenarians had a two-fold risk of cardiac complications and respiratory complications (OR 2.13 (95%CI 1.67-2.73), p < 0.00001), (OR 2.38 (95%CI 1.72-3.27), p < 0.0001). There was no difference in postoperative pancreatic fistula, post-pancreatectomy hemorrhage or delayed gastric emptying. Younger patients were more likely to return to adjuvant therapy (OR 0.20 (95%CI 0.12-0.34), p < 0.00001). CONCLUSIONS Octogenerians are associated with higher mortality rate, postoperative complications, and reduced likelihood to undergo adjuvant therapy. Careful preoperative assessment and selection of elderly patients for consideration of pancreatic surgery is essential.
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Affiliation(s)
- Joseph Phillipos
- Department of General Surgery, Alfred Health, Victoria, Melbourne, Australia.
| | - Kai-Zheong Lim
- Department of General Surgery, Alfred Health, Victoria, Melbourne, Australia; Department of Surgery, Monash University, Victoria, Melbourne, Australia
| | - Helen Pham
- Department of General Surgery, Alfred Health, Victoria, Melbourne, Australia
| | - Yazmin Johari
- Department of General Surgery, Alfred Health, Victoria, Melbourne, Australia
| | - Charles H C Pilgrim
- Department of HPB Surgery, The Alfred Hospital, Victoria, Melbourne, Australia; Central Clinical School, Monash University, Victoria, Melbourne, Australia
| | - Marty Smith
- Department of HPB Surgery, The Alfred Hospital, Victoria, Melbourne, Australia; Central Clinical School, Monash University, Victoria, Melbourne, Australia
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Martin WT, Bonds M, Fischer L, Morris KT, Sarwar Z, Stewart K, Garwe T, Paniccia A, Schulick RD, Jain A, Edil BH. Learning Curve of a Laparoscopic Pancreaticoduodenectomy Program at a Second Institution. Am Surg 2024:31348241246163. [PMID: 38587270 DOI: 10.1177/00031348241246163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
BACKGROUND Historically, pancreaticoduodenectomy (PD) has been performed via a laparotomy, but increasingly, laparoscopic and robotic platforms are being employed for PD. Laparoscopic PD has a steep surgeon specific learning curve and programmatic elements that must be optimized. These factors may limit a surgeon who is proficient at laparoscopic PD to develop a program at another institution. We hypothesize that the learning curve for a surgeon transferring a program to a second institution is shorter than the initial laparoscopic PD learning curve for the same surgeon. METHODS A retrospective review of patients who underwent laparoscopic PD for any indication at the first institution (FI) from 2012 to 2017 and the second institution (SI) from 2018 to 2021 was conducted. Standard statistical analysis was performed. The learning curve was identified using one-sided CUSUM analysis of operative times. RESULT We identified 110 participants, 90 from the FI and 20 from the SI. More patients at the FI were diagnosed with periampullary adenocarcinoma on final pathology compared to the SI (65.6% vs 40.0%, P = .0132). FI operative times stabilized after the 25th laparoscopic PD and SI operative times stabilized after the 5th operation. No statistically significant difference was identified in postoperative complications. CONCLUSIONS The learning curve and average operative time of an SI laparoscopic PD program was shorter than the initial learning curve for a single surgeon with comparable outcomes. This suggests that complex minimally invasive surgical programs can be safely transferred to another high-volume institution without significant loss of progress.
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Affiliation(s)
- W Taylor Martin
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Morgan Bonds
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Laura Fischer
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Katherine T Morris
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Zoona Sarwar
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma, OK, USA
| | - Kenneth Stewart
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma, OK, USA
| | - Tabitha Garwe
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma, OK, USA
| | - Alessandro Paniccia
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Richard D Schulick
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ajay Jain
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Barish H Edil
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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Suto H, Fuke T, Matsukawa H, Ando Y, Oshima M, Nagao M, Takahashi S, Shibata T, Yamana H, Kamada H, Kobara H, Okuyama H, Kumamoto K, Okano K. Short- and Long-Term Outcomes of Neoadjuvant Chemoradiotherapy Followed by Pancreatoduodenectomy in Elderly Patients with Resectable and Borderline Resectable Pancreatic Cancer: A Retrospective Study. J Clin Med 2024; 13:1216. [PMID: 38592055 PMCID: PMC10931964 DOI: 10.3390/jcm13051216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 02/16/2024] [Accepted: 02/19/2024] [Indexed: 04/10/2024] Open
Abstract
Background: The efficacy of neoadjuvant chemoradiotherapy (NACRT) followed by pancreatoduodenectomy (PD) in elderly patients with pancreatic ductal adenocarcinoma (PDAC) remains unclear. Methods: This retrospective analysis of prospectively collected data examined the effect of NACRT followed by PD in elderly patients with PDAC. A total of 112 patients with resectable (R-) and borderline resectable (BR-) PDAC, who were planned for PD and received NACRT between 2009 and 2022, were assessed. Changes induced by NACRT, surgical outcomes, nutritional status, renal and endocrine functions, and prognosis were compared between elderly (≥75 years, n = 43) and non-elderly (<75 years, n = 69) patients over two years following PD. Results: Completion and adverse event rates during NACRT, nutritional status, renal function, endocrine function over two years postoperatively, and prognosis did not significantly differ between the two groups. Low prognostic index after NACRT and the absence of postoperative adjuvant chemotherapy may be adverse prognostic indicators for elderly patients undergoing NACRT for R- and BR-PDAC. Conclusions: Despite a higher incidence of postoperative complications, NACRT followed by PD can be safely performed in elderly patients, resulting in a prognosis similar to that in non-elderly patients.
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Affiliation(s)
- Hironobu Suto
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Miki 761-0793, Kagawa, Japan; (T.F.); (H.M.); (Y.A.); (M.O.); (M.N.); (K.K.); (K.O.)
| | - Takuro Fuke
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Miki 761-0793, Kagawa, Japan; (T.F.); (H.M.); (Y.A.); (M.O.); (M.N.); (K.K.); (K.O.)
| | - Hiroyuki Matsukawa
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Miki 761-0793, Kagawa, Japan; (T.F.); (H.M.); (Y.A.); (M.O.); (M.N.); (K.K.); (K.O.)
| | - Yasuhisa Ando
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Miki 761-0793, Kagawa, Japan; (T.F.); (H.M.); (Y.A.); (M.O.); (M.N.); (K.K.); (K.O.)
| | - Minoru Oshima
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Miki 761-0793, Kagawa, Japan; (T.F.); (H.M.); (Y.A.); (M.O.); (M.N.); (K.K.); (K.O.)
| | - Mina Nagao
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Miki 761-0793, Kagawa, Japan; (T.F.); (H.M.); (Y.A.); (M.O.); (M.N.); (K.K.); (K.O.)
- Department of Molecular Oncologic Pathology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Miki 761-0793, Kagawa, Japan
| | - Shigeo Takahashi
- Department of Radiation Oncology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Miki 761-0793, Kagawa, Japan; (S.T.); (T.S.)
| | - Toru Shibata
- Department of Radiation Oncology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Miki 761-0793, Kagawa, Japan; (S.T.); (T.S.)
| | - Hiroki Yamana
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Miki 761-0793, Kagawa, Japan; (H.Y.); (H.K.); (H.K.)
| | - Hideki Kamada
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Miki 761-0793, Kagawa, Japan; (H.Y.); (H.K.); (H.K.)
| | - Hideki Kobara
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Miki 761-0793, Kagawa, Japan; (H.Y.); (H.K.); (H.K.)
| | - Hiroyuki Okuyama
- Department of Clinical Oncology, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Miki 761-0793, Kagawa, Japan;
| | - Kensuke Kumamoto
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Miki 761-0793, Kagawa, Japan; (T.F.); (H.M.); (Y.A.); (M.O.); (M.N.); (K.K.); (K.O.)
| | - Keiichi Okano
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Miki 761-0793, Kagawa, Japan; (T.F.); (H.M.); (Y.A.); (M.O.); (M.N.); (K.K.); (K.O.)
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Kwak HV, Dzubnar JM, Hsu DS, Chang AL, Spitzer AL, Kazantsev GB, Peng PD, Chang CK. Survival of Elderly Patients Undergoing Pancreatoduodenectomy in an Integrated Health System. J Surg Res 2023; 288:315-320. [PMID: 37058988 DOI: 10.1016/j.jss.2023.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 02/28/2023] [Accepted: 03/16/2023] [Indexed: 04/16/2023]
Abstract
INTRODUCTION The purpose of this study is to examine pancreatoduodenectomy (PD) perioperative outcomes and consider how age may be related to overall survival in an integrated health system. MATERIALS AND METHODS A retrospective review was performed of 309 patients who underwent PD between December 2008 and December 2019. Patients were divided into two groups: aged 75 y or less and more than 75 y, defined as senior surgical patients. Univariate and multivariable analyses of predictive clinicopathologic factors associated with overall survival at 5 y were performed. RESULTS In both groups, the majority underwent PD for malignant disease. The proportion of senior surgical patients alive at 5 y was 33.3% compared to 53.6% of younger patients (P = 0.003). There were also statistically significant differences between the two groups with respect to body mass index, cancer antigen 19-9, Eastern Cooperative Oncology Group performance status, and Charlson comorbidity index. On multivariable analysis, disease type, cancer antigen 19-9, hemoglobin A1c, length of surgery, length of stay, Charlson comorbidity index, and Eastern Cooperative Oncology Group performance status were found to be statistically significant factors for overall survival. Age was not significantly related to overall survival on multivariable logistic regression and when the analysis was limited to pancreatic cancer patients. CONCLUSIONS Although the difference in overall survival between patients aged less than and more than 75 years was significant, age was not an independent risk factor for overall survival on multivariable analysis. Rather than a patient's chronological age, his/her physiologic age including medical comorbidities and functional status may be more correlated to overall survival.
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Affiliation(s)
- Hyunjee V Kwak
- Department of Surgery, University of California San Francisco-East Bay, Oakland, California.
| | - Jessica M Dzubnar
- Department of Surgery, University of California San Francisco-East Bay, Oakland, California
| | - Diana S Hsu
- Department of Surgery, University of California San Francisco-East Bay, Oakland, California
| | | | - Austin L Spitzer
- Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, California
| | - George B Kazantsev
- Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, California
| | - Peter D Peng
- Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, California
| | - Ching-Kuo Chang
- Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, California
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Zhao Z, Zhou S, Tang Y, Zhou L, Ji H, Tang Z, Dai R. Impact of age on short-term outcomes after pancreaticoduodenectomy: A retrospective case-control study of 260 patients. Front Surg 2023; 10:1031409. [PMID: 37066018 PMCID: PMC10097935 DOI: 10.3389/fsurg.2023.1031409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 03/13/2023] [Indexed: 03/31/2023] Open
Abstract
BACKGROUND Although the increase of perioperative complications in the elderly undergoing pancreaticoduodenectomy (PD) surgery has been recognized, the definition of the "old patient" of PD in the studies is different and there is no accepted cut-off value at present. METHODS 279 consecutive patients who have undergone PD in our center between January 2012 and May 2020 were analyzed. Demographic features, clinical-pathological data and short-term outcomes were collected. The patients were divided into two groups, and the cut-off value (62.5 years) is picked based on the highest Youden Index. Primary endpoints were perioperative morbidity and mortality, and complications were classified according to the Clavien-Dindo Score. RESULTS A total of 260 patients with PD were included in this study. Postoperative pathology confirmed pancreatic tumors in 62 patients, bile duct tumor in 105, duodenal tumor in 90, and others in 3. Age (OR = 1.09, P < 0.01), and albumin (OR = 0.34, P < 0.05) were significantly correlated with postoperative Clavien-Dindo Score ≥3b. There were 173 (66.5%) patients in the younger group (<62.5 years) and 87 (33.5%) in the elderly group (≥62.5 years). Significant difference between two groups was demonstrated for Clavien-Dindo Score ≥3b (P < 0.01), postoperative pancreatic fistula (P < 0.05), and perioperative deceases (P < 0.05). CONCLUSIONS Age and albumin were significantly correlated with postoperative Clavien-Dindo Score ≥3b, and there was no significant difference in predicting the grade of Clavien-Dindo Score. The cut-off value of elderly patients with PD was 62.5 years old and there were useful in predicting Clavien-Dindo Score ≥3b, pancreatic fistula, and perioperative death.
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Affiliation(s)
- Zhirong Zhao
- Hospital of Southwest Jiaotong University, The General Hospital of Western Theater Command, Chengdu, China
- General Surgery Center, General Hospital of Western Theater Command, Chengdu, China
| | - Shibo Zhou
- General Surgery Center, General Hospital of Western Theater Command, Chengdu, China
- College of Clinical MedicineSouthwest Medical University, Luzhou, China
| | - Yaping Tang
- Hospital of Southwest Jiaotong University, The General Hospital of Western Theater Command, Chengdu, China
- General Surgery Center, General Hospital of Western Theater Command, Chengdu, China
| | - Lichen Zhou
- General Surgery Center, General Hospital of Western Theater Command, Chengdu, China
- College of Clinical MedicineSouthwest Medical University, Luzhou, China
| | - Hua Ji
- General Surgery Center, General Hospital of Western Theater Command, Chengdu, China
- College of Clinical MedicineSouthwest Medical University, Luzhou, China
| | - Zheng Tang
- General Surgery Center, General Hospital of Western Theater Command, Chengdu, China
- College of Clinical MedicineSouthwest Medical University, Luzhou, China
| | - Ruiwu Dai
- Hospital of Southwest Jiaotong University, The General Hospital of Western Theater Command, Chengdu, China
- General Surgery Center, General Hospital of Western Theater Command, Chengdu, China
- College of Clinical MedicineSouthwest Medical University, Luzhou, China
- Pancreatic Injury and Repair Key Laboratory of Sichuan Province, General Hospital of Western Theater Command, Chengdu, China
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Efficacy of neoadjuvant chemoradiotherapy followed by pancreatic resection for older patients with resectable and borderline resectable pancreatic ductal adenocarcinoma. HPB (Oxford) 2023; 25:136-145. [PMID: 36307256 DOI: 10.1016/j.hpb.2022.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 06/27/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND The benefit of preoperative treatment followed by pancreatic resection in older patients with pancreatic ductal adenocarcinoma (PDAC) remains unclear. In this retrospective analysis of prospectively collected data, we evaluated the significance and safety of preoperative treatment followed by curative resection for older PDAC patients. METHODS We evaluated 122 patients with resectable and borderline resectable PDAC who received neoadjuvant chemoradiotherapy (NACRT) followed by curative resection between 2009 and 2019. Changes in the prognostic nutritional indices during NACRT, surgical outcomes, and prognosis were compared between older (≥75 years, n = 44) and younger patients (<75 years, n = 78). RESULTS The completion rate, adverse event rate, changes in prognostic nutritional indices during NACRT, and prognosis were similar between the groups. In multivariate analysis, an elevated C-reactive protein/albumin ratio (CRP/Alb) ≥ 33.1% during NACRT (p = 0.035) and no postoperative adjuvant chemotherapy (p = 0.041) were identified as significant predictors of overall survival. CONCLUSIONS NACRT followed by pancreatic resection could be safely performed in older patients, with a similar prognosis as that of younger patients, despite an increased frequency of postoperative complications. Elevated CRP/Alb during NACRT and no postoperative adjuvant chemotherapy were poor prognostic factors for older patients.
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Norimatsu Y, Ito K, Takemura N, Inagaki F, Mihara F, Kokudo N. Estimation of Physiologic Ability and Surgical Stress (E-PASS) Predicts Postoperative Major Complications After Hepato-Pancreato Biliary Surgery in the Elderly. World J Surg 2022; 46:2788-2796. [PMID: 36066664 DOI: 10.1007/s00268-022-06716-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND As society ages, an increasing number of elderly patients require hepato-pancreato-biliary (HPB) surgery. We investigated the risk factors for complications in elderly patients undergoing HPB surgery using surgical risk scoring models. METHODS We retrospectively investigated 184 elderly patients (≥ 65 years old) who underwent HPB surgery, including the liver, pancreas, bile duct, and/or gallbladder resection, with exemption to simple cholecystectomy between January 2017 and December 2019. The surgical risk scoring models used included the Estimation of Physiological Ability and Surgical Stress (E-PASS), Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM), and Geriatric 8 (G8). We evaluated the correlations between the scores and severe complications. Complications were classified as severe (Clavien-Dindo classification [C-D] ≥ III) or non-severe (C-D ≤ II). RESULTS Complications occurred in 78 patients (24 C-D ≥ III, 54 C-D ≤ II). Preoperative risk score (PRS), surgical stress score (SSS), and comprehensive risk score (CRS) were significantly higher in patients with C-D ≥ IIIa than in those with C-D ≤ II. Multiple logistic regression analysis revealed that PRS (P = 0.01) and SSS (P = 0.04) were independent predictive factors for severe complications. However, the POSSUM and G8 models showed no significant correlations to severe complications. CONCLUSION E-PASS is a useful model for predicting complications in elderly patients undergoing HPB surgery.
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Affiliation(s)
- Yu Norimatsu
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Kyoji Ito
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Nobuyuki Takemura
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan.
| | - Fuyuki Inagaki
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Fuminori Mihara
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
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Raza SS, Nutu OA, Powell-Brett S, Carvalheiro Boteon A, Hodson J, Abradelo M, Dasari B, Isaac J, Chatzizacharias N, Marudanayagam R, Mirza DF, Roberts JK, Sutcliffe RP. Impact of an enhanced recovery after surgery protocol on short-term outcomes in elderly patients undergoing pancreaticoduodenectomy. HPB (Oxford) 2022; 24:1720-1728. [PMID: 35643908 DOI: 10.1016/j.hpb.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/30/2022] [Accepted: 05/06/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND To determine whether the short-term benefits associated with an enhanced recovery after surgery programme (ERAS) following pancreaticoduodenectomy (PD) vary with age. METHODS 830 consecutive patients who underwent PD between January 2009 and March 2019 were divided according to age: elderly (≥75 years) vs. non-elderly patients (<75 years). Within each age group, cohort characteristics and outcomes were compared between patients treated pre- and post-ERAS (ERAS was systematically introduced in December 2012). Univariable and multivariable analysis were then performed, to assess whether ERAS was independently associated with length of hospital stay (LOS). RESULTS Of the entire cohort, 577 of 830 patients (69.5%) were managed according to an ERAS protocol, and 170 patients (20.5%) were aged ≥75 years old. Patients treated post-ERAS were significantly more comorbid than those pre-ERAS, with a mean Charlson Comorbidity Index of 4.6 vs. 4.1 (p < 0.001) and 6.0 vs. 5.7 (p = 0.039) for the non-elderly and elderly subgroups, respectively. There were significantly fewer medical complications in non-elderly patients treated post-ERAS compared to pre-ERAS (12.4% vs. 22.4%; p = 0.002), but not in elderly patients (23.6% vs. 14.0%; p = 0.203). On multivariable analysis, ERAS was independently associated with reduced LOS in both elderly (14.8% reduction, 95% CI: 0.7-27.0%, p = 0.041) and non-elderly patients (15.6% reduction, 95% CI: 9.2-21.6%, p < 0.001), with the effect size being similar in each group. CONCLUSION ERAS protocols can be safely applied to patients undergoing pancreaticoduodenectomy irrespective of age. Implementation of an ERAS protocol was associated with a significant reduction in postoperative LOS in both elderly and non-elderly patients, despite higher comorbidity in the post-ERAS period.
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Affiliation(s)
- Syed S Raza
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Oana A Nutu
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | | | | | - James Hodson
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | | | - Bobby Dasari
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - John Isaac
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
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9
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Hackner D, Hobbs M, Merkel S, Siepmann T, Krautz C, Weber GF, Grützmann R, Brunner M. Impact of Patient Age on Postoperative Short-Term and Long-Term Outcome after Pancreatic Resection of Pancreatic Ductal Adenocarcinoma. Cancers (Basel) 2022; 14:cancers14163929. [PMID: 36010922 PMCID: PMC9406071 DOI: 10.3390/cancers14163929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/04/2022] [Accepted: 08/09/2022] [Indexed: 12/02/2022] Open
Abstract
(1) Purpose: to evaluate the impact of age on postoperative short-term and long-term outcomes in patients undergoing curative pancreatic resection for PDAC. (2) Methods: This retrospective single-center study comprised 213 patients who had undergone primary resection of PDAC from January 2000 to December 2018 at the University Hospital of Erlangen, Germany. Patients were stratified according the age into two groups: younger (≤70 years) and older (>70 years) patients. Postoperative outcome and long-term survival were compared between the groups. (3) Results: There were no significant differences regarding inhospital morbidity (58% vs. 67%, p = 0.255) or inhospital mortality (2% vs. 7%, p = 0.073) between the two groups. The median overall survival (OS) and disease-free survival (DFS) were significantly shorter in elderly patients (OS: 29.2 vs. 17.1 months, p < 0.001, respectively; DFS: 14.9 vs. 10.4 months, p = 0.034). Multivariate analysis revealed that age was a significant independent prognostic predictor for OS and DFS (HR 2.23, 95% CI 1.58−3.15; p < 0.001 for OS and HR 1.62, 95% CI 1.17−2.24; p = 0.004 for DFS). (4) Conclusion: patient age significantly influenced overall and disease-free survival in patients with PDAC undergoing primary resection in curative intent.
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Affiliation(s)
- Danilo Hackner
- Department of General and Visceral Surgery, Friedrich-Alexander-University (FAU) Erlangen-Nuremberg, 91054 Erlangen, Germany
- Division of Health Care Sciences, Dresden International University, 01067 Dresden, Germany
| | - Mirianna Hobbs
- Department of General and Visceral Surgery, Friedrich-Alexander-University (FAU) Erlangen-Nuremberg, 91054 Erlangen, Germany
| | - Susanne Merkel
- Department of General and Visceral Surgery, Friedrich-Alexander-University (FAU) Erlangen-Nuremberg, 91054 Erlangen, Germany
| | - Timo Siepmann
- Division of Health Care Sciences, Dresden International University, 01067 Dresden, Germany
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01069 Dresden, Germany
| | - Christian Krautz
- Department of General and Visceral Surgery, Friedrich-Alexander-University (FAU) Erlangen-Nuremberg, 91054 Erlangen, Germany
| | - Georg F. Weber
- Department of General and Visceral Surgery, Friedrich-Alexander-University (FAU) Erlangen-Nuremberg, 91054 Erlangen, Germany
| | - Robert Grützmann
- Department of General and Visceral Surgery, Friedrich-Alexander-University (FAU) Erlangen-Nuremberg, 91054 Erlangen, Germany
| | - Maximilian Brunner
- Department of General and Visceral Surgery, Friedrich-Alexander-University (FAU) Erlangen-Nuremberg, 91054 Erlangen, Germany
- Correspondence: ; Tel.: +49-09131-85-33296
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10
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Xu Y, Zhang Y, Han S, Jin D, Xu X, Kuang T, Wu W, Wang D, Lou W. Prognostic Effect of Age in Resected Pancreatic Cancer Patients: A Propensity Score Matching Analysis. Front Oncol 2022; 12:789351. [PMID: 35433408 PMCID: PMC9008824 DOI: 10.3389/fonc.2022.789351] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 03/04/2022] [Indexed: 01/11/2023] Open
Abstract
Background While the elderly population account for an indispensable proportion in pancreatic ductal adenocarcinoma (PDAC), these patients are underrepresented in clinical trials. Whether surgery offered the same benefit for elderly patients as that for younger cohort and which factors affected long-term outcome of elderly population remained unclear. Aims This study aims to evaluate long-term prognosis of elderly PDAC patients (≥70 years old) after surgery and to investigate potential prognostic factors. Methods This retrospective study included PDAC patients receiving radical resection from January 2012 to July 2019 in Zhongshan Hospital Fudan University. Patients were divided into young (<70) and old groups (≥70). Propensity score matching (PSM) was conducted to eliminate the confounding factors. We investigated potential prognostic factors via Cox proportional hazards model and Kaplan–Meier estimator. Nomogram model and forest plot were constructed to illustrate the prognostic value of age. Results A total of 552 PDAC patients who received radical resection were included in this research. Elderly patients showed poorer nutritional status and were less likely to received adjuvant treatment. After matching, although age [hazard ratio (HR)=1.025, 95%CI 0.997–1.054; p=0.083] was not statistically significant in the multivariate cox regression analysis, further survival analysis showed that patients in the old group had poorer overall survival (OS) when compared with young group (p=0.039). Furthermore, reception of adjuvant chemotherapy (HR=0.411, 95%CI 0.201-0.837; p=0.014) was the only independent prognostic factor among elderly patients and could significantly improve OS. Subgroup analysis indicated that age had better prognostic value in PDAC patients with good preoperative nutritional status and relative low tumor burden. Finally, a prognostic prediction model contained age, reception of adjuvant chemotherapy, American Joint Committee on Cancer (AJCC) 8th T and N stage was constructed and presented in nomogram, whose Harrell’s concordance index was 0.7478 (95%CI, 0.6960–0.7996). The calibration curves at 1 and 3 years indicated an optimal conformity between actual and nomogram-predicted survival probability in the PDAC patient who received surgery. Conclusion The elderly PDAC patients were associated with worse OS survival after radical resection, and the noticeable negative effect of age was observed among PDAC patients with better preoperative nutritional status and less aggressive tumor biology. Adjuvant chemotherapy was essential to improve survival outcome of elderly PDAC patients following radical resection.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Wenhui Lou
- *Correspondence: Dansong Wang, ; Wenhui Lou,
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11
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Quero G, Pecorelli N, Paiella S, Fiorillo C, Petrone MC, Capretti G, Laterza V, De Sio D, Menghi R, Kauffmann E, Nobile S, Butturini G, Ferrari G, Rosa F, Coratti A, Casadei R, Mazzaferro V, Boggi U, Zerbi A, Salvia R, Falconi M, Alfieri S. Pancreaticoduodenectomy in octogenarians: The importance of "biological age" on clinical outcomes. Surg Oncol 2022; 40:101688. [PMID: 34844071 DOI: 10.1016/j.suronc.2021.101688] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 11/01/2021] [Accepted: 11/22/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION With the prolongation of life expectancy, an increasing number of elderly patients are evaluated for pancreatic surgery. However, the influence of increasing age on outcomes after pancreaticoduodenectomy (PD) is still unclear, especially in octogenarians. Aim of this study is to evaluate the perioperative characteristics and outcomes of octogenarians undergoing PD. METHODS Data for 812 patients undergoing PD between 2019 and 2020 in 10 referral centers in Italy were reviewed. Patients aged 80 years or older were matched based on nearest neighbor propensity scores in a 1:1 ratio to patients younger than 80 years. Propensity scores were calculated using 7 perioperative variables including gender, ASA score, neoadjuvant treatment (NAT), biliary stent positioning, type of surgical approach (open, laparoscopic, robot-assisted), associated vascular resections, type of lesion. Perioperative characteristics and short-term postoperative outcomes were compared before and after matching. RESULTS Overall, 81 (10%) patients had 80 years or more. Before matching, octogenarians had a higher rate of ASA score≥ 3 (n = 35, 43.2% vs. n = 207, 28.3%; p = 0.005) and less frequently underwent NAT (n = 11, 13.6% vs. n = 213, 29.1%; p = 0.003). Matching was successfully performed for 70 octogenarians. After matching, no differences in preoperative and intraoperative characteristics were found. Postoperatively, ICU admission was more frequent in octogenarians (50% vs 30%; p = 0.01). Although in-hospital mortality was higher in octogenarians before matching (7.4% vs 2.9% in the younger cohort; p = 0.03), no difference was noted between the matched cohorts (p = 0.36). Postoperative morbidity was comparable between groups in the whole and selected populations. At the multivariate analysis, chronological age was not recognized as a prognostic factor for cumulative major complications, while ASA ≥3 was the only confirmed influencing feature (OR 2.98; 95%CI: 1.6-6.8; p = 0.009). CONCLUSIO In high-volume centers, PD in octogenarians shows similar outcomes than younger patients. Age itself should not be considered an exclusion criterion for PD, but a focused preoperative assessment is essential for adequate patient selection.
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Affiliation(s)
- Giuseppe Quero
- Gemelli Pancreatic Center, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy; CRMPG (Advanced Pancreatic Research Center), Largo Agostino Gemelli, 8, 00168, Rome, Italy; Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168, Rome, Italy
| | - Nicolò Pecorelli
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy; Pancreato-Biliary Endoscopy and EUS Division, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Salvatore Paiella
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Claudio Fiorillo
- Gemelli Pancreatic Center, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy; CRMPG (Advanced Pancreatic Research Center), Largo Agostino Gemelli, 8, 00168, Rome, Italy.
| | - Maria Chiara Petrone
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy; Pancreato-Biliary Endoscopy and EUS Division, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Capretti
- Humanitas Clinical and Research Center - IRCCS, Rozzano, MI, Italy; Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, MI, Italy
| | - Vito Laterza
- Gemelli Pancreatic Center, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy; CRMPG (Advanced Pancreatic Research Center), Largo Agostino Gemelli, 8, 00168, Rome, Italy
| | - Davide De Sio
- Gemelli Pancreatic Center, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy; CRMPG (Advanced Pancreatic Research Center), Largo Agostino Gemelli, 8, 00168, Rome, Italy
| | - Roberta Menghi
- Gemelli Pancreatic Center, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy; CRMPG (Advanced Pancreatic Research Center), Largo Agostino Gemelli, 8, 00168, Rome, Italy
| | - Emanuele Kauffmann
- Chirurgia Generale Universitaria dell'Ospedale di Cisanello, Via Paradisa, 2, 56124, Pisa, Italy
| | - Sara Nobile
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Giovanni Butturini
- Casa di Cura Pederzoli, Via Monte Baldo 24, 37019, Peschiera del Garda, Verona, Italy
| | - Giovanni Ferrari
- ASST Grande Ospedale Metropolitano Niguarda, Division of Minimally-invasive Surgical Oncology, Piazza Ospedale Maggiore, 3 20162, Milan, Italy
| | - Fausto Rosa
- Gemelli Pancreatic Center, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy; CRMPG (Advanced Pancreatic Research Center), Largo Agostino Gemelli, 8, 00168, Rome, Italy; Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168, Rome, Italy
| | - Andrea Coratti
- Division of Surgical Oncology and Robotics, Department of Oncology, Careggi University Hospital, Florence, Italy
| | - Riccardo Casadei
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Vincenzo Mazzaferro
- HPB Surgery and Liver Transplantation, Department of Oncology, University of Milan, Milan, Italy; Istituto Nazionale Tumori, Fondazione IRCCS, Milan, Italy
| | - Ugo Boggi
- Chirurgia Generale Universitaria dell'Ospedale di Cisanello, Via Paradisa, 2, 56124, Pisa, Italy
| | - Alessandro Zerbi
- Humanitas Clinical and Research Center - IRCCS, Rozzano, MI, Italy; Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, MI, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy; Pancreato-Biliary Endoscopy and EUS Division, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sergio Alfieri
- Gemelli Pancreatic Center, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy; CRMPG (Advanced Pancreatic Research Center), Largo Agostino Gemelli, 8, 00168, Rome, Italy; Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168, Rome, Italy
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12
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Attard JA, Al-Sarireh B, Bhogal RH, Farrugia A, Fusai G, Harper S, Hidalgo-Salinas C, Jah A, Marangoni G, Mortimer M, Pizanias M, Prachialias A, Roberts KJ, Sew Hee C, Soggiu F, Srinivasan P, Chatzizacharias NA. Short-term outcomes after pancreatoduodenectomy in octogenarians: multicentre case-control study. Br J Surg 2021; 109:89-95. [PMID: 34750618 DOI: 10.1093/bjs/znab374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 09/28/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Pancreatoduodenectomy (PD) is frequently the surgical treatment indicated for a number of pathologies. Elderly patients may be denied surgery because of concerns over poor perioperative outcomes. The aim of this study was to evaluate postoperative clinical outcomes and provide evidence on current UK practice in the elderly population after PD. METHODS This was a multicentre retrospective case-control study of octogenarians undergoing PD between January 2008 and December 2017, matched with younger controls from seven specialist centres in the UK. The primary endpoint was 90-day mortality. Secondary endpoints were index admission mortality, postoperative complications, and 30-day readmission rates. RESULTS In total, 235 octogenarians (median age 81 (range 80-90) years) and 235 controls (age 67 (31-79) years) were included in the study. Eastern Cooperative Oncology Group performance status (median 0 (range 0-3) versus 0 (0-2); P = 0.010) and Charlson Co-morbidity Index score (7 (6-11) versus 5 (2-9); P = 0.001) were higher for octogenarians than controls. Postoperative complication and 30-day readmission rates were comparable. The 90-day mortality rate was higher among octogenarians (9 versus 3 per cent; P = 0.030). Index admission mortality rates were comparable (4 versus 2 per cent; P = 0.160), indicating that the difference in mortality was related to deaths after hospital discharge. Despite the higher 90-day mortality rate in the octogenarian population, multivariable Cox regression analysis did not identify age as an independent predictor of postoperative mortality. CONCLUSION Despite careful patient selection and comparable index admission mortality, 90-day and, particularly, out-of-hospital mortality rates were higher in octogenarians.
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Affiliation(s)
- Joseph A Attard
- Hepatopancreatobiliary and Liver Transplant Unit, Queen Elizabeth Hospital, Birmingham, UK
| | | | | | - Alexia Farrugia
- Department of Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Giuseppe Fusai
- Hepatopancreatobiliary and Liver Transplant Unit, Royal Free Hospital, London, UK
| | - Simon Harper
- Hepatopancreatobiliary Unit, Cambridge University Hospital, Cambridge, UK
| | | | - Asif Jah
- Hepatopancreatobiliary Unit, Cambridge University Hospital, Cambridge, UK
| | - Gabriele Marangoni
- Department of Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Michail Pizanias
- Hepatopancreatobiliary Unit, King's College Hospital, London, UK
| | | | - Keith J Roberts
- Hepatopancreatobiliary and Liver Transplant Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Chloe Sew Hee
- Hepatopancreatobiliary Unit, Cambridge University Hospital, Cambridge, UK
| | - Fiammetta Soggiu
- Hepatopancreatobiliary and Liver Transplant Unit, Royal Free Hospital, London, UK
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13
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Zhang W, Huang Z, Zhang J, Che X. Safety and effectiveness of open pancreaticoduodenectomy in adults aged 70 or older: A meta-analysis. J Geriatr Oncol 2021; 12:1136-1145. [PMID: 33610506 DOI: 10.1016/j.jgo.2021.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 01/19/2021] [Accepted: 02/03/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) is considered the most complicated operation in abdominal surgery. The safety and effectiveness of PD in older patients has been questionable because older adults are often beset by one or more systemic diseases and have poor surgical tolerance. AIM To evaluate the safety and effectiveness of PD in patients aged 70 or older. METHODS We conducted a literature search on PubMed, EMBASE, Cochrane Library and other databases to discover all literature reporting a comparison of the efficacy of PD in patients 70 years old and older versus patients under 70 years old. Our cutoff date is August 2020. Revman5.3 statistical software was used for the analysis. RESULTS Twenty cohort studies were determined to be eligible with a total of 6508 patients; 2274 patients were 70 years old and older and 4234 patients under 70 years old. Meta-analysis results showed that after PD in patients over 70 years of age and older the mortality rate (RR = 2.1, 95%CI:1.59-2.78, p < 0.001), the overall postoperative complications (RR = 1.16,95%CI:1.09-1.23, p < 0.001), intraoperative transfusions (RR = 1.38, 95%CI:1.14-1.23, p = 0.001), severe complications (RR = 1.30,95%CI:1.11-1.52, p = 0.001), the re-operation rate (RR = 1.23,95%CI:1.00-1.51, p = 0.05), the R0 rate (RR = 0.92,95%CI:0.86-0.98, p = 0.01), lymph node dissection (WMD = -4.61,95%CI:-7.24-1.97, p < 0.001) and delayed gastric emptying (RR = 1.24,95%CI:1.04-1.49, p = 0.02) at a rate significantly higher than that of patients under 70 years old. There is no significant difference between patients 70 years old and older and patients under 70 years old in the clinical PF (RR = 1.11,95%CI:0.93-1.34, p = 0.24), bile leakage (RR = 0.68,95%CI:0.41-1.12, p = 0.13), postoperative bleeding (RR = 1,95%CI:0.76-1.30, p = 0.98), wound infection (RR = 1.15,95%CI:0.95-1.39, p = 0.15) and hospital stays (RR = 0.30,95%CI:-1.77-2.37, p = 0.77). CONCLUSION Patients aged 70 years or older have approximately double the risk of postoperative mortality following PD and a higher risk of overall and severe postoperative complications. Furthermore, patients 70 years old and older require more frequent intraoperative transfusions, re-operative interventions and have poorer oncology results (lower R0 rate and fewer lymph node dissections). More multi-center, large sample, and high-quality research is still needed to further verify this conclusion.
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Affiliation(s)
- Wei Zhang
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuan Nanli, Chaoyang District, Beijing 100021, China
| | - Zhangkan Huang
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, 518116, China
| | - Jiangwei Zhang
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuan Nanli, Chaoyang District, Beijing 100021, China
| | - Xu Che
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuan Nanli, Chaoyang District, Beijing 100021, China; Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, 518116, China.
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14
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Utsumi M, Aoki H, Nagahisa S, Une Y, Kimura Y, Watanabe M, Taniguchi F, Arata T, Katsuda K, Tanakaya K. Nutritional assessment and surgical outcomes in very elderly patients undergoing pancreaticoduodenectomy: a retrospective study. Surg Today 2021; 51:941-953. [PMID: 33106898 DOI: 10.1007/s00595-020-02169-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 09/29/2020] [Indexed: 11/09/2022]
Abstract
PURPOSE To evaluate and compare the nutritional factors and clinical outcomes of pancreaticoduodenectomy between elderly and non-elderly patients. METHODS This retrospective study evaluated 122 consecutive patients who underwent pancreaticoduodenectomy from April 2008 to April 2020. Preoperative and postoperative nutritional factors (prognostic nutritional index), complication rates, and survival rates were compared between the elderly (≥ 80 years) and non-elderly (< 80 years) patient groups. Changes in nutrition markers were evaluated before surgery to 1 year after surgery. RESULTS A total of 20 elderly patients (16.4%) and 102 non-elderly patients (83.6%) underwent pancreaticoduodenectomy. Elderly patients had a significantly lower preoperative prognostic nutritional index than did non-elderly patients. At 3 months postoperatively, elderly patients had a lower albumin level and prognostic nutritional index. The median length of hospital stay was significantly longer (39.9 vs. 27 days, P = 0.004), the rate of death due to other diseases was higher, and the overall survival rate was significantly lower (1-/3-/5 year overall survival rates: 78.1%/26.7%/13.3% vs. 87.1%/54.4%/46.7%; log-rank test, P = 0.003) in the elderly group than in the non-elderly group. CONCLUSIONS The results suggest that careful patient selection and optimal perioperative care are necessary to determine whether pancreaticoduodenectomy is indicated for elderly patients.
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Affiliation(s)
- Masashi Utsumi
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, 1-1-1 Atago-machi, Iwakuni-shi, Yamaguchi, 740-8510, Japan.
| | - Hideki Aoki
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, 1-1-1 Atago-machi, Iwakuni-shi, Yamaguchi, 740-8510, Japan
| | - Seiichi Nagahisa
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, 1-1-1 Atago-machi, Iwakuni-shi, Yamaguchi, 740-8510, Japan
| | - Yuta Une
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, 1-1-1 Atago-machi, Iwakuni-shi, Yamaguchi, 740-8510, Japan
| | - Yuji Kimura
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, 1-1-1 Atago-machi, Iwakuni-shi, Yamaguchi, 740-8510, Japan
| | - Megumi Watanabe
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, 1-1-1 Atago-machi, Iwakuni-shi, Yamaguchi, 740-8510, Japan
| | - Fumitaka Taniguchi
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, 1-1-1 Atago-machi, Iwakuni-shi, Yamaguchi, 740-8510, Japan
| | - Takashi Arata
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, 1-1-1 Atago-machi, Iwakuni-shi, Yamaguchi, 740-8510, Japan
| | - Koh Katsuda
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, 1-1-1 Atago-machi, Iwakuni-shi, Yamaguchi, 740-8510, Japan
| | - Kohji Tanakaya
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, 1-1-1 Atago-machi, Iwakuni-shi, Yamaguchi, 740-8510, Japan
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15
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Hayashi D, Natsume S, Shimizu Y, Senda Y, Okuno M, Matsuo K, Ito S, Komori K, Abe T, Hara K. Survival benefit of surgery for very elderly patients with pancreatic cancer: what extent of pancreatectomy is acceptable? NAGOYA JOURNAL OF MEDICAL SCIENCE 2021; 83:239-250. [PMID: 34239172 PMCID: PMC8236693 DOI: 10.18999/nagjms.83.2.239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 10/19/2020] [Indexed: 12/05/2022]
Abstract
The purpose of this study is to clarify the survival benefit and acceptable extent of surgery for very elderly patients with pancreatic cancer. Patients (n=55) ≥80 years with resectable pancreatic cancer were studied. 29 underwent pancreatectomy, 16 underwent chemotherapy, and 10 received best supportive care. Uni and multivariate analysis were performed to explore predictive factors for overall survival (OS) with surgery and chemotherapy (n=45). Postoperative survival of PD (pancreatoduodenectomy) and DP (distal pancreatectomy) and of PD-PVR (PD with portal vein resection) and PD were compared. OS was equivalent with surgery and chemotherapy (median survival time [MST]; 685 vs. 626 days, respectively; p=0.057); 6 patients surivived ≥3 years after surgery. Pancreatectomy was not a prognostic factor. Survival was significantly worse with PD-PVR than with PD, but equivalent with PD and DP. Within 2 years after PD-PVR, 8 patients have died. Surgery was not a positive prognostic factor for very elderly patients with pancreatic cancer, but was the sole chance for survival ≥3 years. Indication for PD-PVR for very elderly patients should be determined more cautiously compared with that for non-elderly patients.
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Affiliation(s)
- Daisuke Hayashi
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Seiji Natsume
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yasuhiro Shimizu
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yoshiki Senda
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Masataka Okuno
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Keitaro Matsuo
- Division of Cancer Epidemiology and Prevention, Aichi Cancer Center Research Institute, Nagoya, Japan
| | - Seiji Ito
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Koji Komori
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Tetsuya Abe
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Kazuo Hara
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
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16
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Hendi M, Mou Y, Lu C, Pan Y, Zhang B, Chen K, Xu X, Zhang R, Zhou Y, Jin W. Laparoscopic pancreaticodoudenectomy: An excellent approach in elderly patients, a multicenter, comparative study. Medicine (Baltimore) 2020; 99:e22175. [PMID: 32957341 PMCID: PMC7505399 DOI: 10.1097/md.0000000000022175] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/05/2020] [Accepted: 08/11/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Management of malignant diseases in elderly patients has become a global clinical issue because of increased life expectancy worldwide. Advancements in surgical techniques and perioperative management have reduced age-related contraindications for LPD. Past articles have reported that elderly patients undergoing laproscopic pancreatoduodenectomy (LPD) are at an increased risk compared to younger patients. The aim of this article is to compare a multicenter center risk of LPD in elderly and nonelderly patients. METHODS Retrospective review (n = 237) of perisurgical outcomes in patients undergoing LPD during the months of September 2012 to December 2017. Outcomes in elderly patients (aged ≥75 years) were compared with those in nonelderly patients. RESULTS Transfer to ICU was more frequent in elderly patients (odds ratio [OR] 6.49, P = .001) and the mean hospital stay was longer (21.4 days compared with 16.6 days), (P = .0033) than for nonelderly patients. There was no statistically significant difference in operation time (P = .494), estimated blood loss (P = .0519), blood transfusion (P = .863), decreased gastric emptying (P = .397), abdominal pain (P = .454), food intake (P = .241), time to self-ambulation (P = 1), reoperation (P = .543), postoperative pancreatic fistula (POPF) grade A (P = .454), POPF grade B (P = .736), POPF grade C (P = .164), hemorrhage (P = .319), bile leakage (P = .428), infection (P = .259), GI bleeding (P = .286), morbidity (P = .272) or mortality (P = .449) between the 2 groups. CONCLUSIONS Elderly patients who underwent LPD in this study had good overall outcomes after LPD that were similar to young patients. The perioperative and long-term outcomes of LPD are not worse. Rates of ICU admission and hospital stays increased in elderly patients undergoing LPD when compared with nonelderly ones. LPD can be performed on elderly patients with similar outcomes as younger patients; therefore, age itself should not be a contraindication for LPD for pancreatic cancer, but it suggests that elderly patients with comorbidities should be more stringently selected for surgery.
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Affiliation(s)
- Maher Hendi
- Zhejiang University, School of Medicine
- Department of Gastrointestinal and Pancreas Surgery, Zhejiang Provincial People's Hospital
| | - Yiping Mou
- Zhejiang University, School of Medicine
- Department of Gastrointestinal and Pancreas Surgery, Zhejiang Provincial People's Hospital
| | - Chao Lu
- Department of Gastrointestinal and Pancreas Surgery, Zhejiang Provincial People's Hospital
| | - Yu Pan
- Zhejiang University, School of Medicine
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Bin Zhang
- Zhejiang University, School of Medicine
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Ke Chen
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiaowu Xu
- Department of Gastrointestinal and Pancreas Surgery, Zhejiang Provincial People's Hospital
| | - Renchao Zhang
- Department of Gastrointestinal and Pancreas Surgery, Zhejiang Provincial People's Hospital
| | - Yucheng Zhou
- Department of Gastrointestinal and Pancreas Surgery, Zhejiang Provincial People's Hospital
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Sakamoto T, Yagyu Y, Uchinaka EI, Hanaki T, Miyatani K, Kihara K, Yamamoto M, Matsunaga T, Tokuyasu N, Honjo S, Fujiwara Y. Surgical Outcomes Following Early Drain Removal After Distal Pancreatectomy in Elderly Patients. In Vivo 2020; 34:2837-2843. [PMID: 32871822 DOI: 10.21873/invivo.12110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 07/10/2020] [Accepted: 07/13/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND/AIM The efficacy and safety of early drain removal following distal pancreatectomy in elderly patients are unclear. We aimed to investigate the short-term surgical outcomes following early drain removal after distal pancreatectomy in elderly patients. PATIENTS AND METHODS Fifty-seven patients aged ≥70 years who underwent distal pancreatectomy at our Hospital were enrolled in the study. Data were retrospectively analyzed to evaluate the short-term surgical outcomes following early drain removal after distal pancreatectomy in elderly patients. RESULTS The incidence of pancreatic fistula following distal pancreatectomy in the early-removal group was significantly lower vs. the conventional group (p=0.022). Multivariate analysis revealed that early drain removal was an independent factor for reducing the risk of pancreatic fistula after distal pancreatectomy in elderly patients (p=0.042). CONCLUSION Early drain removal following distal pancreatectomy is an effective and safe surgical perioperative management procedure to prevent pancreatic fistula in elderly patients.
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Affiliation(s)
- Teruhisa Sakamoto
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, Yonago, Japan
| | - Yakuki Yagyu
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, Yonago, Japan
| | - E I Uchinaka
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, Yonago, Japan
| | - Takehiko Hanaki
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, Yonago, Japan
| | - Kozo Miyatani
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, Yonago, Japan
| | - Kyoichi Kihara
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, Yonago, Japan
| | - Manabu Yamamoto
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, Yonago, Japan
| | - Tomoyuki Matsunaga
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, Yonago, Japan
| | - Naruo Tokuyasu
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, Yonago, Japan
| | - Soichiro Honjo
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, Yonago, Japan
| | - Yoshiyuki Fujiwara
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, Yonago, Japan
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Lopez-Lopez V, Gómez-Ruiz AJ, Eshmuminov D, Cascales-Campos PA, Alconchel F, Arevalo-Perez J, Robles Campos R, Parrilla Paricio P. Surgical oncology in patients aged 80 years and older is associated with increased postoperative morbidity and mortality: A systematic review and meta-analysis of literature over 25 years. Surg Oncol 2020; 33:81-95. [PMID: 32561103 DOI: 10.1016/j.suronc.2019.12.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 11/19/2019] [Accepted: 12/18/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND The study aim is to analyze the evolution over the last 25 years of the results reported after abdominal oncological surgery in patients aged 80 years of age and older. The primary endpoint was morbidity and mortality in this group of patients; the secondary endpoint was overall survival. METHODS A systematic search strategy was used to browse through Medline/PubMed, EMBASE, Scopus, ClinicalTrials.gov, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials using a combination of standardized index terms. Studies published between 1997 and 2017 were selected. Only those studies that showed morbidity and mortality after digestive and hepatobiliary tract oncological surgery in individuals aged 80 years and older were included. The PROSPERO registration number is CRD42018087921. PRISMA and MOOSE guidelines were applied. RESULTS A total of 79 studies were included, categorized by origin of malignancy: esophageal (7), stomach (26), liver (4), pancreas (19), and colorectal (23). Compared with the non-elderly group, the elderly group had similar esophageal morbidity with higher mortality (RR 2.51, 1.50 to 4.21; P = 0.0005); higher gastric morbidity (RR 1.25, 1.09 to 1.43; P = 0.001), and mortality (RR 2.51, 1.81 to 3.49; P = 0.0001); similar liver morbidity and mortality; higher pancreatic morbidity (RR 1.17, 1.03 to 1.33; P = 0.02) and mortality (RR 2.37, 1.86 to 3.03; P < 0.00001); and similar colorectal morbidity with higher mortality (RR 4.44, 1.91 to 10.32; P = 0.005). CONCLUSION Oncological surgery of most abdominal visceral tumors is associated with increased morbidity and mortality in patients older than 80 years.
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Affiliation(s)
- V Lopez-Lopez
- Virgen de La Arrixaca Clinic and University Hospital, IMIB, Murcia, Spain
| | - A J Gómez-Ruiz
- Virgen de La Arrixaca Clinic and University Hospital, IMIB, Murcia, Spain.
| | - D Eshmuminov
- Department of Surgery, Swiss HPB and Transplantation Centre, University Hospital Zurich, Zurich, Switzerland
| | | | - F Alconchel
- Virgen de La Arrixaca Clinic and University Hospital, IMIB, Murcia, Spain
| | - J Arevalo-Perez
- Memorial Sloan Kettering Cancer Center. Radiology Departament, New York, USA
| | - R Robles Campos
- Virgen de La Arrixaca Clinic and University Hospital, IMIB, Murcia, Spain
| | - P Parrilla Paricio
- Virgen de La Arrixaca Clinic and University Hospital, IMIB, Murcia, Spain
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19
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Di Franco G, Palmeri M, Guadagni S, Furbetta N, Gianardi D, Bronzoni J, Palma A, Bianchini M, Musetti S, Bastiani L, Caprili G, Biancofiore G, Mosca F, Di Candio G, Morelli L. Pancreatic resections in elderly patients with high American Society of Anesthesiologists' risk score: a view from a tertiary care center. Aging Clin Exp Res 2020; 32:935-950. [PMID: 31347102 DOI: 10.1007/s40520-019-01276-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 07/12/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND More than 60% of patients affected by pancreatic cancer are ≥ 65 years of age. Surgery represents the only potentially curative treatment for malignant pancreatic neoplasia and a useful treatment for benign diseases. AIM To evaluate outcomes in elderly patients with ASA risk score 4 who underwent pancreatic resection compared to younger patients and elderly patients with lower anesthesiological risk. METHODS A consecutive series of 345 patients underwent pancreatic resection between 2010 and 2017 was reviewed. We compared three groups based on age at the time of surgery: < 65 years (group A), 65-74 years (group B), and ≥ 75 years (group C). Patients in group C were split into two subgroups, ASA 1-3 versus ASA 4, and compared. RESULTS Group A consisted of 117 (34%) patients, group B 128 (37%) patients, and group C 100 (29%) patients. Group C had a significantly higher incidence of comorbidity and ASA 4 status (p < 0.05), and of overall post-operative complications (p < 0.01), because of the higher incidence of post-operative medical complications. No differences in terms of overall surgical complications and post-operative mortality were reported. The mean overall survival was significantly lower for group C (p < 0.01), with no difference in mortality for cancer. Within group C, no differences were reported regarding surgical complications (p = 0.59), mortality (p = 0.34), and mean overall survival (p = 0.53) between ASA 1-3 and ASA 4 patients. CONCLUSIONS Advanced age should not preclude elderly patients with pancreatic diseases from being treated surgically, and ASA 4 in subjects aged ≥ 75 years should not be an absolute contraindication.
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Affiliation(s)
- Gregorio Di Franco
- General Surgery Unit, Department of Surgery, Translational Research and New Technologies in Medicine, University of Pisa, Via Paradisa 2, Pisa, 56125, Italy
| | - Matteo Palmeri
- General Surgery Unit, Department of Surgery, Translational Research and New Technologies in Medicine, University of Pisa, Via Paradisa 2, Pisa, 56125, Italy
| | - Simone Guadagni
- General Surgery Unit, Department of Surgery, Translational Research and New Technologies in Medicine, University of Pisa, Via Paradisa 2, Pisa, 56125, Italy
| | - Niccolò Furbetta
- General Surgery Unit, Department of Surgery, Translational Research and New Technologies in Medicine, University of Pisa, Via Paradisa 2, Pisa, 56125, Italy
| | - Desirée Gianardi
- General Surgery Unit, Department of Surgery, Translational Research and New Technologies in Medicine, University of Pisa, Via Paradisa 2, Pisa, 56125, Italy
| | - Jessica Bronzoni
- General Surgery Unit, Department of Surgery, Translational Research and New Technologies in Medicine, University of Pisa, Via Paradisa 2, Pisa, 56125, Italy
| | - Alessandro Palma
- General Surgery Unit, Department of Surgery, Translational Research and New Technologies in Medicine, University of Pisa, Via Paradisa 2, Pisa, 56125, Italy
| | - Matteo Bianchini
- General Surgery Unit, Department of Surgery, Translational Research and New Technologies in Medicine, University of Pisa, Via Paradisa 2, Pisa, 56125, Italy
| | - Serena Musetti
- General Surgery Unit, Department of Surgery, Translational Research and New Technologies in Medicine, University of Pisa, Via Paradisa 2, Pisa, 56125, Italy
| | - Luca Bastiani
- Institute of Clinical Physiology, National Council of Research, Pisa, Italy
| | - Giovanni Caprili
- General Surgery Unit, Department of Surgery, Translational Research and New Technologies in Medicine, University of Pisa, Via Paradisa 2, Pisa, 56125, Italy
| | | | - Franco Mosca
- EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Pisa, Italy
| | - Giulio Di Candio
- General Surgery Unit, Department of Surgery, Translational Research and New Technologies in Medicine, University of Pisa, Via Paradisa 2, Pisa, 56125, Italy
| | - Luca Morelli
- General Surgery Unit, Department of Surgery, Translational Research and New Technologies in Medicine, University of Pisa, Via Paradisa 2, Pisa, 56125, Italy.
- EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Pisa, Italy.
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20
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Akita M, Ajiki T, Ueno K, Tsugawa D, Tanaka M, Kido M, Toyama H, Fukumoto T. Benefits and limitations of middle bile duct segmental resection for extrahepatic cholangiocarcinoma. Hepatobiliary Pancreat Dis Int 2020; 19:147-152. [PMID: 32037277 DOI: 10.1016/j.hbpd.2020.01.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 01/21/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) is a standardized strategy for patients with middle and distal bile duct cancers. The aim of this study was to compare clinicopathological features of bile duct segmental resection (BDR) with PD in patients with extrahepatic cholangiocarcinoma. METHODS Consecutive cases with extrahepatic cholangiocarcinoma who underwent BDR (n = 21) or PD (n = 84) with achievement of R0 or R1 resection in Kobe University Hospital between January 2000 and December 2016 were enrolled in the present study. RESULTS Patients who underwent PD were significantly younger than those receiving BDR. The frequency of preoperative jaundice, biliary drainage and cholangitis was not significantly different between the two groups. The duration of surgery was longer and there was more intraoperative bleeding in the PD than in the BDR group (553 vs. 421 min, and 770 vs. 402 mL; both P<0.01). More major complications (>Clavien-Dindo IIIa) were observed in the PD group (46% vs. 10%, P<0.01). Postoperative hospital stay was also longer in that group (30 vs. 19 days, P = 0.02). Pathological assessment revealed that tumors were less advanced in the BDR group but the rate of lymph node metastasis was similar in both groups (33% in BDR and 48% in PD, P = 0.24). The rate of R0 resection was significantly higher in the PD group (80% vs. 38%, P<0.01). Adjuvant chemotherapy was more frequently administered to patients in the BDR group (62% vs. 38%, P = 0.04). Although 5-year overall survival rates were similar in both groups (44% for BDR and 51% for PD, P = 0.72), in patients with T1 and T2, the BDR group tended to have poorer prognosis (44% vs. 68% at 5-year, P = 0.09). CONCLUSIONS BDR was comparable in prognosis to PD in middle bile duct cancer. Less invasiveness and lower morbidity of BDR justified this technique for selected patients in a poor general condition.
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Affiliation(s)
- Masayuki Akita
- Department of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, 650-0017, Japan
| | - Tetsuo Ajiki
- Department of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, 650-0017, Japan.
| | - Kimihiko Ueno
- Department of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, 650-0017, Japan
| | - Daisuke Tsugawa
- Department of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, 650-0017, Japan
| | - Motofumi Tanaka
- Department of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, 650-0017, Japan
| | - Masahiro Kido
- Department of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, 650-0017, Japan
| | - Hirochika Toyama
- Department of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, 650-0017, Japan
| | - Takumi Fukumoto
- Department of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, 650-0017, Japan
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21
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Shatveryan GA, Chardarov NK, Nikoda VV, Bagmet NN, Tadzhibova IM, Lishova EA, Ratnikova NP, Karagyozyan GA. [Short-term results of pancreatoduodenectomy in patients over 70 years old]. Khirurgiia (Mosk) 2020:25-32. [PMID: 31994496 DOI: 10.17116/hirurgia202001125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To analyze the immediate results of PDE in patients younger and older 70 years. MATERIAL AND METHODS The study included patients who underwent PDE for various indications from March 2010 to February 2019. All patients are divided into 2 groups: <70 years old and ≥70 years old. Primary endpoints were postoperative mortality and complication rate. RESULTS There were 110 procedures within 9 years. There were 93 patients aged <70 years (group 1) and 17 patients aged ≥70 years (group 2). ASA (American Society of Anesthesiologists) and PMP scores (Preoperative Mortality Predictor) were higher in group 2: 3 (2-3) vs 2 (1-3) (p=0,002) and 12 (6-15) vs 6.5 (5-15) (p<0.001), respectively. Mortality rate was higher in group 2 (11.7% vs. 3.2%) without statistical significance (p=0.16). Overall morbidity (72% vs 76%; p=1.0), incidence of major complications grade ≥IIIa (29% vs 29%), delayed gastric emptying B/C (17.2% vs 17.6%), pancreatic fistula grade B/C (23.6% vs 35.3%, p=0.3), biliary fistula grade B/C (7.5% vs 11.8%; p=0.62), postoperative hospital-stay [22 (8-165) days vs 23 (9-71) days; p=0.92] were comparable in both groups. CONCLUSION Short-term results of PDE in patients aged <70 and ≥70 years are comparable despite higher ASA and PMP scores in the group 2. General status and concomitant diseases should be considered during selection of patients with resectable tumors for PDE. Age per se is not a contraindication for surgery.
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Affiliation(s)
- G A Shatveryan
- Petrovsky National Research Centre of Surgery, Moscow, Russia
| | - N K Chardarov
- Petrovsky National Research Centre of Surgery, Moscow, Russia
| | - V V Nikoda
- Petrovsky National Research Centre of Surgery, Moscow, Russia
| | - N N Bagmet
- Petrovsky National Research Centre of Surgery, Moscow, Russia
| | - I M Tadzhibova
- Petrovsky National Research Centre of Surgery, Moscow, Russia
| | - E A Lishova
- Petrovsky National Research Centre of Surgery, Moscow, Russia
| | - N P Ratnikova
- Petrovsky National Research Centre of Surgery, Moscow, Russia
| | - G A Karagyozyan
- Petrovsky National Research Centre of Surgery, Moscow, Russia
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22
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Meng L, Xia Q, Cai Y, Wang X, Li Y, Cai H, Peng B. Impact of Patient Age on Morbidity and Survival Following Laparoscopic Pancreaticoduodenectomy. Surg Laparosc Endosc Percutan Tech 2019; 29:378-382. [PMID: 31107854 DOI: 10.1097/sle.0000000000000670] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSES To present preliminary perioperative and long-term outcomes in elderly patients compared with younger patients who underwent laparoscopic pancreaticoduodenectomy (LPD). MATERIALS AND METHODS A total of 199 patients who underwent LPD were included in this study. The primary data relating to these patients were collected and analyzed in our center from October 2010 to 2017. RESULTS The intraoperative and postoperative information, including the rate and severity of short-term complications, pathologic outcomes, and other surgical outcomes, showed no significant differences between the 2 groups. Furthermore, the median overall survival for 2 malignant diseases of the young patients was not significantly better than the elderly. CONCLUSIONS Our data suggest that patient age showed little influence on postoperative morbidity, mortality, and long-term survival in pancreatic adenocarcinoma and periampullary adenocarcinoma following LPD, whereas studies with larger sample sizes and longer follow-up are necessary before definitive conclusions can be made.
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Affiliation(s)
- Lingwei Meng
- Departments of General Surgery
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | | | | | - Xin Wang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | | | - He Cai
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Bing Peng
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
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23
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Katz M, Silverstein N, Coll P, Sullivan G, Mortensen EM, Sachs A, Gross JB, Girard E, Liang J, Ristau BT, Stevenson C, Smith PP, Shames BD, Millea R, Ali I, Poulos CM, Ramaraj AB, Otukoya AO, Nolan J, Wahla Z, Hardy C, Al-Naggar I, Bliss LA, McFadden DW. Surgical care of the geriatric patient. Curr Probl Surg 2019; 56:260-329. [DOI: 10.1067/j.cpsurg.2019.03.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 03/13/2019] [Indexed: 12/15/2022]
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24
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Kim JH, Lee H, Choi HH, Min SK, Lee HK. Nutritional risk factors are associated with postoperative complications after pancreaticoduodenectomy. Ann Surg Treat Res 2019; 96:201-207. [PMID: 30941324 PMCID: PMC6444046 DOI: 10.4174/astr.2019.96.4.201] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 11/20/2018] [Accepted: 12/11/2018] [Indexed: 01/04/2023] Open
Abstract
Purpose The purpose of this study was to investigate whether the indicators of nutritional risk screening tool are associated with postoperative complications following pancreaticoduodenectomy (PD). Methods We investigated whether nutritional risk is associated with postoperative complications based on the medical records of 128 patients who underwent PD from 2010. The tool was composed of 6 risk factors: albumin, total lymphocyte count, body mass index, weight loss, dietary intake loss, and nutritional symptoms. The patients were divided into 2 groups: a nutritional risk group and a nonrisk group. The rates of general complications and postoperative pancreatic fistula (POPF) were investigated according to this nutritional status. Results There were 65 patients who did not have any risk factors. However, 63 patients had one risk factor or more. In the nonrisk group, the overall complication rate and serious complication rate were 30.8% and 15.4%, respectively. If there were one or more risk factors, the overall and serious complication rates were 59.5% and 41.3%, respectively (P = 0.001 and P = 0.001, respectively). The rate of clinically relevant POPF (grade B or C) was 9.2% in the nonrisk group. However, this rate was 23.8% in the NRS risk group (P = 0.029). In multivariate analysis, the NRS risk group was a significant factor of clinically relevant POPF (odds ratio, 9.878; 95% confidence interval, 1.527–63.914; P = 0.016). Conclusion There were statistically significant associations between complications and nutritional indicators. A comprehensive analysis of nutritional parameters will help predict postoperative complications.
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Affiliation(s)
- Jong Hun Kim
- Division of HBP surgery, Department of Surgery, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea
| | - Huisong Lee
- Division of HBP surgery, Department of Surgery, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea
| | - Hyun Hwa Choi
- Division of HBP surgery, Department of Surgery, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea
| | - Seog Ki Min
- Division of HBP surgery, Department of Surgery, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea
| | - Hyeon Kook Lee
- Division of HBP surgery, Department of Surgery, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea
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25
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Salami A, Obaid T, Joshi AR. Trends in the clinical presentation, treatment, and survival for pancreatic adenocarcinoma. Am J Surg 2019; 217:103-107. [DOI: 10.1016/j.amjsurg.2018.05.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 04/23/2018] [Accepted: 05/06/2018] [Indexed: 02/05/2023]
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26
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Pancreatoduodenectomy for pancreatic head tumors in the elderly - Systematic review and meta-analysis. Surg Oncol 2018; 27:346-364. [PMID: 30217288 DOI: 10.1016/j.suronc.2018.05.021] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 05/08/2018] [Accepted: 05/13/2018] [Indexed: 02/06/2023]
Abstract
The age at which patients are undergoing pancreatoduodenectomy is increasing worldwide. The data on the outcome of this surgical procedure in the elderly is constantly expanding. This meta-analysis aims to assess the safety of pancreatoduodenectomy in elderly population, primarily focusing on morbidity and mortality. We searched the Medline, Embase and Cochrane databases to identify eligible studies. The most recent search was performed on 10th April 2017. Inclusion criteria were: (1) comparison of the characteristics and perioperative outcomes of older patients versus younger patients undergoing pancreatoduodenectomy; (2) objective evaluation of mortality or overall morbidity; and (3), publication in English. Exclusion criteria were: (1) a lack of comparative data; (2) a lack of primary outcomes or insufficient data to analyze; (3) a focus on procedures other than pancreatoduodenectomy; or (4), the impossibility of extraction of data specifically concerning pancreatoduodenectomy. Primary outcomes were overall morbidity and mortality. Secondary outcomes analyzed postoperative complications, R0 rate and length of hospital stay. 45 eligible studies were chosen, with a combined total of 21,295 patients. Older patients compared to younger patients had a higher risk of death (2.26% vs. 4.54%; RR: 2.23; 95% CI 1.74-2.87) and a higher complication rate (47.23% vs. 39.35%; RR: 1.17; 95% CI 1.12-1.24). There were no differences in pancreatic fistula occurrence (p = 0.27), bile leakage (p = 0.81), postoperative hemorrhage (p = 0.08), or R0 rate (p = 0.92). Our review confirms, that in the case of pancreatoduodenectomy, advanced age is a risk factor for increased non-surgical morbidity and, by extension, higher mortality.
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27
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Kim SY, Fink MA, Perini M, Houli N, Weinberg L, Muralidharan V, Starkey G, Jones RM, Christophi C, Nikfarjam M. Age 80 years and over is not associated with increased morbidity and mortality following pancreaticoduodenectomy. ANZ J Surg 2018; 88:E445-E450. [PMID: 28593708 DOI: 10.1111/ans.14039] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 03/19/2017] [Accepted: 03/20/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) is associated with high morbidity, which is perceived to be increased in the elderly. To our knowledge there have been no Australian series that have compared outcomes of patients over the age of 80 undergoing PD to those who are younger. METHODS Patients who underwent PD between January 2008 and November 2015 were identified from a prospectively maintained database. RESULTS A total of 165 patients underwent PD of whom 17 (10.3%) were aged 80 or over. The pre-operative health status, according to American Society of Anesthesiologists class was similar between the groups (P = 0.420). The 90-day mortality rates (5.9% in the elderly and 2% in the younger group; P = 0.355) and the post-operative complication rates (64.7% in the elderly versus 62.8% in the younger group; P = 0.88) were similar. Overall median length of hospital stay was also similar between the groups, but older patients were far more likely to be discharged to a rehabilitation facility than younger patients (47.1 versus 12.8%; P < 0.0001). Older patients with pancreatic adenocarcinoma (n = 10) had significantly lower median survival than the younger group (n = 69) (16.6 versus 22.5 months; P = 0.048). CONCLUSION No significant differences were seen in the rate of complications following PD in patients aged 80 or over compared to younger patients, although there appears to be a shorter survival in the elderly patients treated for pancreatic cancer. Careful selection of elderly patients and optimal peri-operative care, rather than age should be used to determine whether surgical intervention is indicated in this patient group.
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Affiliation(s)
- Sandy Y Kim
- Department of Surgery, The University of Melbourne, Austin Health, Melbourne, Victoria, Australia
| | - Michael A Fink
- Department of Surgery, The University of Melbourne, Austin Health, Melbourne, Victoria, Australia
| | - Marcos Perini
- Department of Anaesthesia, Austin Health, Melbourne, Victoria, Australia
| | - Nezor Houli
- Department of Surgery, The University of Melbourne, Austin Health, Melbourne, Victoria, Australia
| | - Laurence Weinberg
- Department of Anaesthesia, Austin Health, Melbourne, Victoria, Australia
| | | | - Graham Starkey
- Department of Surgery, The University of Melbourne, Austin Health, Melbourne, Victoria, Australia
| | - Robert M Jones
- Department of Surgery, The University of Melbourne, Austin Health, Melbourne, Victoria, Australia
| | - Christopher Christophi
- Department of Surgery, The University of Melbourne, Austin Health, Melbourne, Victoria, Australia
| | - Mehrdad Nikfarjam
- Department of Surgery, The University of Melbourne, Austin Health, Melbourne, Victoria, Australia
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Guyton RL, Mosquera C, Spaniolas K, Fitzgerald TL. Association of Increasing Frailty with Detrimental Outcomes after Pancreatic Resection. Am Surg 2018. [DOI: 10.1177/000313481808400423] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
An association between detrimental outcomes and frailty has been documented; however, the impact specific to pancreatic surgery is unknown. Using NSQIP data, patients were classified as non-, mildly, moderately, or severely frail. A total of16,028 patients were included inthe study; most of the patients were white (78.5%) and underwent pancreaticoduodenectomy (PD) (67%). Complications occurred in 17.6 per cent cases, and the median length of stay (LOS) was 11.89 days. Prolonged LOS and mortality occurred in 9.1 and 2.3 per cent of the cases. In the PD group, most of the patients were mildly frail (40.6%), followed by nonfrail (39.83%), whereas in the distal pancreatectomy (DP) group, the majority were nonfrail (43.82%), followed by mildly frail (39.37%) ( P < 0.0001). The 30-day complications, mortality, and LOS were significantly higher in patients undergoing PD compared with DP (19.5 vs 14.3%, 2.8 vs 1.2%, and 13.4 vs 8.7 days, respectively; P < 0.0001). PD conferred a significantly higher risk of death in all frailty groups compared with DP [nonfrail: odds ratio (OR) 1.76, mildly frail: OR 1.03, moderately frail: OR 2.03, P < 0.05], with the exception of severely frail patients. Compared with DP, PD conferred a significant risk of complication in all the frailty groups. Increases in frailty are associated with poorer outcomes after pancreatectomy.
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Affiliation(s)
- Rodney Lane Guyton
- Divisions of Surgical Oncology and Minimally Invasive Surgery, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Catalina Mosquera
- Divisions of Surgical Oncology and Minimally Invasive Surgery, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Konstantinos Spaniolas
- Divisions of Bariatric and Minimally Invasive Surgery, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Timothy L. Fitzgerald
- Division of Surgical Oncology, Tufts University School of Medicine-Maine Medical Center, Portland, Maine
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Namur GN, Dantas ACB, Jureidini R, Ribeiro TC, Ribeiro Junior U, Figueira E, Cecconello I, Bacchella T. Advanced age does not increase morbidity in pancreaticoduodenectomy. J Gastrointest Oncol 2018; 9:11-16. [PMID: 29564166 DOI: 10.21037/jgo.2017.10.03] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background Due to rising life expectancy of population, very complex surgical procedures such as pancreaticoduodenectomy (PD), are more commonly being performed in elderly patients. The objective of this study was to evaluate the safety of PD in patients older than 75 years old and the risk factors associated with severe complications. Methods Patients who underwent PD for periampullary tumors were retrospectively reviewed and divided into two groups, A (<75 years) and B (>75 years). The primary endpoint was severe postoperative complications (Clavien 3 or greater). Secondary endpoints were mortality and any complications. Results Ninety consecutive patients underwent PD for periampullary tumors in the studied period, 70 in group A and 20 in group B. Clinical and pathological characteristics of both groups were equivalents except for age. There were no difference regarding the incidence of severe complications (17% vs. 10%, P=0.72) or all complications (50% vs. 50%, P>0.999). Although mortality was greater in group A (8.6% vs. 0%), it was not statistically significant (P=0.333). On multivariate analyses, only male sex, obesity and American Society of Anesthesiology Score of 3 or 4 were associated with severe postoperative complications. Conclusions Poor clinical status, obesity and male gender are associated with severe complications in PD, but not age greater than 75 years, therefore PD can be considered safe in elderly patients and age itself should not be a contraindication for PD.
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Affiliation(s)
| | | | - Ricardo Jureidini
- Department of Gastroenterology, University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Thiago Costa Ribeiro
- Department of Gastroenterology, University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Ulysses Ribeiro Junior
- Department of Gastroenterology, University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Estela Figueira
- Department of Gastroenterology, University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Ivan Cecconello
- Department of Gastroenterology, University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Telesforo Bacchella
- Department of Gastroenterology, University of São Paulo Medical School, São Paulo, SP, Brazil
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Salami A, Alvarez NH, Joshi ART. Geographic disparities in surgical treatment recommendation patterns and survival for pancreatic adenocarcinoma. HPB (Oxford) 2017; 19:1008-1015. [PMID: 28838634 DOI: 10.1016/j.hpb.2017.07.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Accepted: 07/26/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Previous studies have described pessimistic attitudes of physicians toward recommending surgery for early-stage pancreatic adenocarcinoma. However, the impact of geographic region on recommendation patterns of surgical treatment for potentially resectable pancreatic cancer is unknown. METHODS The SEER registry was used to identify patients with early-stage pancreatic adenocarcinoma (AJCC I-II) [2004-2013]. The exposure of interest was geographic region of diagnosis: Midwest, West, Southeast or Northeast. The endpoints of interest were recommendation of no surgery, and overall survival. RESULTS A total of 24,408 patients were identified [Midwest - 10.6%, West - 50.1%, Southeast - 21.7% and Northeast - 17.6%]. Overall, 38% of patients had a recommendation of no surgery by their provider. On univariate analysis, the likelihood of having a recommendation of no surgery was lowest in the NE [OR: Northeast (0.8), West (1.6), Southeast (1.3), and Midwest (Ref); p < 0.05 for all]. This association persisted following risk adjustment. Geographic region was an independent predictor of mortality, irrespective of resection status. CONCLUSION Significant disparities in surgical treatment recommendation patterns and survival for early-stage pancreatic cancer exist based on geographic location. Improved adherence to guideline-driven treatment recommendations, standardization of care processes, and regionalization may help stem the existing variability in care and outcomes.
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Affiliation(s)
- Aitua Salami
- Department of Surgery, Albert Einstein Healthcare Network, Philadelphia, PA, USA.
| | - Nkosi H Alvarez
- Department of Surgery, Albert Einstein Healthcare Network, Philadelphia, PA, USA
| | - Amit R T Joshi
- Department of Surgery, Albert Einstein Healthcare Network, Philadelphia, PA, USA
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Chapman BC, Gajdos C, Hosokawa P, Henderson W, Paniccia A, Overbey DM, Gleisner A, Schulick RD, McCarter MD, Edil BH. Comparison of laparoscopic to open pancreaticoduodenectomy in elderly patients with pancreatic adenocarcinoma. Surg Endosc 2017; 32:2239-2248. [PMID: 29067580 DOI: 10.1007/s00464-017-5915-0] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Accepted: 10/03/2017] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The purpose of the study is to compare perioperative and survival outcomes in elderly patients undergoing laparoscopic pancreaticoduodenectomy (LPD) to those undergoing open pancreaticoduodenectomy (OPD). METHODS Patients aged ≥ 75 years with pancreatic adenocarcinoma undergoing LPD or OPD were identified from the NCDB (2010-2013). Baseline characteristics and perioperative outcomes were compared using a χ 2 and Student's t test. The Kaplan-Meier method was used to generate survival curves, and differences were tested using a log-rank test. A multivariate cox proportional hazard model was applied to estimate the hazard ratio (HR) of LPD on overall survival (OS). RESULTS We identified 1768 patients aged ≥ 75 years who underwent LPD (n = 248, 14.0%) or OPD (n = 1520, 86.0%). The majority of patients in the LPD group had their surgery at facilities performing less than 5 LPDs per year (n = 165, 66.5%). 90-day mortality was significantly lower in the LPD compared to the OPD (7.2 vs. 12.2%, p = 0.049). The laparoscopic conversion rate was 30% (n = 74) and was associated with higher readmission rates (13.5 vs. 8.1%), 30-day mortality (8.0 vs. 3.8%), and 90-day mortality (10.4 vs. 6.0%), but these did not reach statistical significance. Median OS was significantly longer in the LPD group (19.8 vs. 15.6 months, p = 0.022). After adjusting for patient and tumor-related characteristics, there was a trend towards improved survival in the LPD group (HR 0.85, 95% CI 0.69-1.03). CONCLUSION The vast majority of the NCDB participating facilities perform less than 5 LPD cases per year, which was associated with an increased risk of perioperative mortality. Overall 90-day mortality was significantly lower in the LPD group and there was a trend towards improved OS in the LPD group compared to the OPD group after adjusting for patient and tumor-related characteristics. Studies with increased sample size and longer follow-up are needed before definitive conclusions can be made.
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Affiliation(s)
- Brandon C Chapman
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Csaba Gajdos
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Patrick Hosokawa
- Adult and Child Center for Health Outcomes Research and Delivery Science (ACCORDS), Aurora, CO, USA
| | - William Henderson
- Adult and Child Center for Health Outcomes Research and Delivery Science (ACCORDS), Aurora, CO, USA
| | - Alessandro Paniccia
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Douglas M Overbey
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ana Gleisner
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Richard D Schulick
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Martin D McCarter
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Barish H Edil
- Division of Surgical Oncology, University of Colorado School of Medicine, 1665 Aurora Court Room 3337, MS-F-703, Aurora, CO, 80045, USA.
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Sugiura T, Okamura Y, Ito T, Yamamoto Y, Ashida R, Uesaka K. Impact of Patient Age on the Postoperative Survival in Pancreatic Head Cancer. Ann Surg Oncol 2017; 24:3220-3228. [PMID: 28695390 DOI: 10.1245/s10434-017-5994-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Some reports have stated that pancreatoduodenectomy for elderly patients have comparable morbidity and mortality to that of young patients. However, the long-term outcomes of these patients have not been fully evaluated, especially for pancreatic head cancer. METHODS A total of 227 patients who underwent pancreatoduodenectomy for pancreatic head cancer between 2007 and 2014 were included. They were stratified according to age: young (<70 years), elderly (70 to <80 years), and very elderly (≥80 years). The short- and long-term outcomes were evaluated. RESULTS There were no significant differences in terms of morbidity among the three groups. The median disease-free survival times were 15 months in the young, 11 months in the elderly, and 7 months in the very elderly. The disease-free survival of the young patients was significantly better than that in both the elderly and the very elderly (p = 0.012 and p = 0.016). The median overall survival times were 30 months in the young, 20 months in the elderly, and 14 months in the very elderly. The overall survival of the young patients was significantly better than that in both the elderly and the very elderly (p = 0.007 and p < 0.001). The difference was marginal between the elderly and the very elderly (p = 0.053). Multivariate analysis revealed that lymph node metastasis (p < 0.001), age ≥80 years (p = 0.013), lack of adjuvant chemotherapy (p = 0.003), blood transfusion (p = 0.015), and CA 19-9 ≥300 U/ml (p = 0.040) were significant prognostic factors. CONCLUSIONS Patient age influenced the survival after pancreatoduodenectomy for pancreatic cancer.
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Affiliation(s)
- Teiichi Sugiura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan.
| | - Y Okamura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - T Ito
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Y Yamamoto
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - R Ashida
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - K Uesaka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
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Kim SY, Weinberg L, Christophi C, Nikfarjam M. The outcomes of pancreaticoduodenectomy in patients aged 80 or older: a systematic review and meta-analysis. HPB (Oxford) 2017; 19:475-482. [PMID: 28292633 DOI: 10.1016/j.hpb.2017.01.018] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 01/08/2017] [Accepted: 01/11/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND There is an increasing needed to consider pancreaticoduodenectomy (PD) for the treatment of pancreatic and periampullary malignancy in patients aged 80 and over, given the increasing aging population. METHODS A systematic literature search was undertaken to identify selected studies that compared the outcomes of patients aged 80 years or over to those younger undergoing PD. RESULTS In total 18 studies were included for evaluation. Octogenarian or older populations had significantly higher 30-day post-operative mortality rate (OR: 2.22, 95% CI = 1.48-3.31, p < 0.001) and length of hospital stay (OR: 2.23, 95% CI = 1.36-3.10, p < 0.001). The overall post-operative complication rate was higher in the older group compared to the younger population (OR: 1.51, 95% CI = 1.25-1.83, p < 0.001). Elderly patients were more likely to develop pneumonia (OR: 1.72, 95% CI = 1.39-2.13, p < 0.001) and experience delayed gastric emptying (DGE) (OR: 1.77, 95% CI = 1.35-2.31, p < 0.001). The incidence of post-operative pancreatic fistula and bile leak were not significantly different between the groups. Rehabilitation and home nursing care services was also more frequently required by the older patient group at the time of hospital discharge. CONCLUSION Patients aged 80 years and older have approximately double the risk of 30-day post-operative mortality and 50% increased rate of complications following PD. Careful patient selection is required when offering surgery in this age group.
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Affiliation(s)
- Sandy Y Kim
- University of Melbourne, Department of Surgery, Austin Health, Heidelberg, Victoria, Australia
| | - Laurence Weinberg
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Christopher Christophi
- University of Melbourne, Department of Surgery, Austin Health, Heidelberg, Victoria, Australia
| | - Mehrdad Nikfarjam
- University of Melbourne, Department of Surgery, Austin Health, Heidelberg, Victoria, Australia.
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Sperti C, Moletta L, Pozza G. Pancreatic resection in very elderly patients: A critical analysis of existing evidence. World J Gastrointest Oncol 2017; 9:30-36. [PMID: 28144397 PMCID: PMC5241524 DOI: 10.4251/wjgo.v9.i1.30] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 09/19/2016] [Accepted: 11/16/2016] [Indexed: 02/05/2023] Open
Abstract
The aging of the population results in a rise of number of elderly patients (aged 80 years and older) with pancreatic or periampullary cancer, and more pancreatectomies could eventually be performed in such complex patients. However, early and long-term results after pancreatic resection in octogenarians are still controversial, and may trouble the surgeon when approaching this type of population. Evaluation of reported experiences shows that for almost all Authors, pancreatectomy can be performed safely in elderly population, although overall morbidity and mortality rates were 34.9% and 13.2% respectively, with a mean length of hospital stay of 18 d. These features appear higher in older patients compared to the younger counterpart. Less than 50% of patients underwent adjuvant therapy after operation. Long-term survival is reported not significantly different in aged 80 years and older patients, with a median overall survival time of 17.6 mo. The quality of life after pancreatic resection is only sporadically evaluated but, when considered, it highlights the need of health facility service after operation for these "frail" patients. Prospective studies on the quality of life of pancreatectomized octogenarians are welcome. Proper selection of patients, geriatric assessment with multidisciplinary approach, centralization of pancreatic surgery in high-volume centres and rehabilitation programs after surgery appear to be crucial points in order to improve surgical treatments of pancreatic tumors in very elderly patients.
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Hamaoka M, Kobayashi T, Ishiyama K, Ohira M, Tahara H, Kuroda S, Iwako H, Okimoto S, Honmyo N, Ohdan H. Evaluation of the risk factors and prognostic factors of hepatectomy for hepatocellular carcinoma in patients aged 80 years or more. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2017; 24:58-64. [DOI: 10.1002/jhbp.413] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Michinori Hamaoka
- Department of Gastroenterological and Transplant Surgery; Applied Life Sciences; Institute of Biomedical and Health Sciences; Hiroshima University; 1-2-3 Kasumi Minami-ku Hiroshima 734-8551 Japan
| | - Tsuyoshi Kobayashi
- Department of Gastroenterological and Transplant Surgery; Applied Life Sciences; Institute of Biomedical and Health Sciences; Hiroshima University; 1-2-3 Kasumi Minami-ku Hiroshima 734-8551 Japan
| | - Kohei Ishiyama
- Department of Gastroenterological and Transplant Surgery; Applied Life Sciences; Institute of Biomedical and Health Sciences; Hiroshima University; 1-2-3 Kasumi Minami-ku Hiroshima 734-8551 Japan
| | - Masahiro Ohira
- Department of Gastroenterological and Transplant Surgery; Applied Life Sciences; Institute of Biomedical and Health Sciences; Hiroshima University; 1-2-3 Kasumi Minami-ku Hiroshima 734-8551 Japan
| | - Hiroyuki Tahara
- Department of Gastroenterological and Transplant Surgery; Applied Life Sciences; Institute of Biomedical and Health Sciences; Hiroshima University; 1-2-3 Kasumi Minami-ku Hiroshima 734-8551 Japan
| | - Shintaro Kuroda
- Department of Gastroenterological and Transplant Surgery; Applied Life Sciences; Institute of Biomedical and Health Sciences; Hiroshima University; 1-2-3 Kasumi Minami-ku Hiroshima 734-8551 Japan
| | - Hiroshi Iwako
- Department of Gastroenterological and Transplant Surgery; Applied Life Sciences; Institute of Biomedical and Health Sciences; Hiroshima University; 1-2-3 Kasumi Minami-ku Hiroshima 734-8551 Japan
| | - Sho Okimoto
- Department of Gastroenterological and Transplant Surgery; Applied Life Sciences; Institute of Biomedical and Health Sciences; Hiroshima University; 1-2-3 Kasumi Minami-ku Hiroshima 734-8551 Japan
| | - Naruhiko Honmyo
- Department of Gastroenterological and Transplant Surgery; Applied Life Sciences; Institute of Biomedical and Health Sciences; Hiroshima University; 1-2-3 Kasumi Minami-ku Hiroshima 734-8551 Japan
| | - Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery; Applied Life Sciences; Institute of Biomedical and Health Sciences; Hiroshima University; 1-2-3 Kasumi Minami-ku Hiroshima 734-8551 Japan
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Kim JH, Min SK, Lee H, Hong G, Lee HK. The safety and risk factors of major hepatobiliary pancreatic surgery in patients older than 80 years. Ann Surg Treat Res 2016; 91:288-294. [PMID: 27904850 PMCID: PMC5128374 DOI: 10.4174/astr.2016.91.6.288] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 07/19/2016] [Accepted: 08/03/2016] [Indexed: 12/30/2022] Open
Abstract
Purpose Recently, the number of elderly patients has increased due to a longer life expectancy. Among these elderly patients, more octogenarians will be diagnosed with major hepatobiliary pancreatic (HBP) diseases. Therefore, we need to evaluate the safety and risk factors of major HBP surgery in patients older than 80 years. Methods From January 2000 to April 2015, patients who underwent major HBP surgery were identified. The patients were divided into 2 groups according to their age at the time of surgery: Group O (≥80 years) and group Y (<80 years). The patient characteristics and intra- and postoperative outcomes were retrospectively investigated in the 2 groups. Results The median age was 84 years (range, 80–95 years) in group O and 61 years (range, 27–79 years) in group Y. group O had worse American Society of Anesthesiologists (ASA) physical status (ASA ≥ III: 23% vs. 7%, P = 0.002) and was associated with a higher rate of hypertension and heart problems as comorbidities. There were significant differences in albumin and BUN, favoring group Y. The length of intensive care unit stay was longer in group O, whereas the overall complication and mortality rates did not show statistical difference. But, there was a significant difference in systemic complication of both Clavien-Dindo classification grade ≥II and ≥III as complications were divided into surgical site complication and systemic complication. Conclusion Major HBP surgery can be performed safely in patients older than 80 years if postoperative management is appropriately provided.
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Affiliation(s)
- Jong Hun Kim
- Department of Surgery, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea
| | - Seog Ki Min
- Department of Surgery, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea
| | - Huisong Lee
- Department of Surgery, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea
| | - Geun Hong
- Department of Surgery, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea
| | - Hyeon Kook Lee
- Department of Surgery, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea
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Sandini M, Bernasconi DP, Fior D, Molinelli M, Ippolito D, Nespoli L, Caccialanza R, Gianotti L. A high visceral adipose tissue-to-skeletal muscle ratio as a determinant of major complications after pancreatoduodenectomy for cancer. Nutrition 2016; 32:1231-1237. [PMID: 27261062 DOI: 10.1016/j.nut.2016.04.002] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 03/08/2016] [Accepted: 04/11/2016] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Complication rates after pancreatic resections remain high despite improvement in perioperative management. The effects of body composition and the relationship among different body compartments on surgical morbidity are not comprehensively investigated. The aim of this study was to assess whether the evaluation of different body compartments and their relationship was associated with the development of major postoperative complications after pancreatoduodenectomy (PD) for cancer. METHODS We retrospectively analyzed 124 patients who underwent PD and had a staging computed tomography (CT) scan at our center. CT scan was used to measure abdominal skeletal muscle area and volume, as well as visceral fat area (VFA) and volume. The total abdominal muscle area (TAMA) was then normalized for height. The severity of complications was assessed. Univariate and multivariate analyses were performed to investigate correlations between the above variables and postoperative complications. The receiver operating characteristic curve methodology was used to investigate the predictive ability of each parameter. RESULTS Major complications occurred in 42 patients (33.9%). The prevalence of sarcopenia was 24.2%. Regression analyses revealed no correlation between abdominal muscular and adipose tissue areas. Univariate analysis showed that the depletion of muscle area normalized for height was not per se predictive of complications (P = 0.318). Multivariate logistic regression showed that the VFA/TAMA was the only determinant of major complications (odds ratio, 3.20; 95% confidence interval, 1.35-7.60; P = 0.008). The model predictive performance was 0.735 (area under the curve) with a sensitivity of 64.3% and a specificity of 74.4%. CONCLUSION Sarcopenic obesity is a strong predictor of major complications after PD for cancer.
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Affiliation(s)
- Marta Sandini
- School of Medicine and Surgery, Milano-Bicocca University, San Gerardo Hospital, Monza, Italy
| | - Davide P Bernasconi
- School of Medicine and Surgery, Center of Biostatistics for Clinical Epidemiology, Milano-Bicocca University, Monza, Italy
| | - Davide Fior
- Department of Radiology, San Gerardo Hospital, Monza, Italy
| | - Matilde Molinelli
- School of Medicine and Surgery, Milano-Bicocca University, San Gerardo Hospital, Monza, Italy
| | | | - Luca Nespoli
- School of Medicine and Surgery, Milano-Bicocca University, San Gerardo Hospital, Monza, Italy
| | - Riccardo Caccialanza
- Nutrition and Dietetics Service, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Luca Gianotti
- School of Medicine and Surgery, Milano-Bicocca University, San Gerardo Hospital, Monza, Italy.
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El Nakeeb A, Atef E, El Hanafy E, Salem A, Askar W, Ezzat H, Shehta A, Abdel Wahab M. Outcomes of pancreaticoduodenectomy in elderly patients. Hepatobiliary Pancreat Dis Int 2016; 15:419-427. [PMID: 27498583 DOI: 10.1016/s1499-3872(16)60105-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Although the mortality and morbidity of pancreaticoduodenectomy (PD) have improved significantly over the past years, the concerns for elderly patients undergoing PD are still present. Furthermore, the frequency of PD is increasing because of the increasing proportion of elderly patients and the increasing incidence of periampullary tumors. This study aimed to analyze the outcomes of PD in elderly patients. METHODS We studied all patients who had undergone PD in our center between January 1995 and February 2015. The patients were divided into three groups based on age: group I (patients aged <60 years), group II (those aged 60 to 69 years) and group III (those aged ≥70 years). The primary outcome was the rate of total postoperative complications. Secondary endpoint included total operative time, hospital mortality, length of postoperative hospital stay, delayed gastric emptying, re-exploration, and survival rate. RESULTS A total of 828 patients who had undergone PD for resection of periampullary tumor were included in this study. There were 579 (69.9%) patients in group I, 201 (24.3%) in group II, and 48 (5.8%) in group III. The overall incidence of complications was higher in elderly patients (25.9% in group I, 36.8% in group II, and 37.5% in group III; P=0.006). There were more patients complicated with delayed gastric emptying in group II compared with the other two groups. There was no significant difference in the incidence of postoperative pancreatic fistula, biliary leakage, pancreatitis, pulmonary complications and hospital mortality. CONCLUSIONS PD can be performed safely in selected elderly patients. Advanced age alone should not be a contraindication for PD. The outcome of elderly patients who have undergone PD is similar to that of younger patients, and the increased rate of complications is due to the presence of associated comorbidities.
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Affiliation(s)
- Ayman El Nakeeb
- Gastroenterology Surgical Center, Mansoura University, Mansoura 35516, Egypt.
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Relative Contributions of Complications and Failure to Rescue on Mortality in Older Patients Undergoing Pancreatectomy. Ann Surg 2016; 263:385-91. [PMID: 25563871 DOI: 10.1097/sla.0000000000001093] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND For pancreatectomy patients, mortality increases with increasing age. Our study evaluated the relative contribution of overall postoperative complications and failure to rescue rates on the observed increased mortality in older patients undergoing pancreatic resection at specialized centers. METHODS We identified 2694 patients who underwent pancreatic resection from the American College of Surgeons' National Surgical Quality Improvement Pancreatectomy Demonstration Project at 37 high-volume centers. Overall morbidity and in-hospital mortality were determined in patients younger than 80 years (N = 2496) and 80 years or older (N = 198). Failure to rescue was the number of deaths in patients with complications divided by the total number of patients with postoperative complications. RESULTS No significant differences were observed between patients younger than 80 years and those 80 years or older in the rates of overall complications (41.4% vs 39.4%, P = 0.58). In-hospital mortality increased in patients 80 years or older compared to patients younger than 80 years (3.0% vs 1.1%, P = 0.02). Failures to rescue rates were higher in patients 80 years or older (7.7% vs 2.7%, P = 0.01). Across 37 high-volume centers, unadjusted complication rates ranged from 25.0% to 72.2% and failure to rescue rates ranged from 0.0% to 25.0%. Among patients with postoperative complications, comorbidities associated with failure to rescue were ascites, chronic obstructive pulmonary disease, and diabetes. Complications associated with failure to rescue included acute renal failure, septic shock, and postoperative pulmonary complications. CONCLUSIONS In experienced hands, the rates of complications after pancreatectomy in patients 80 years or older compared to patients younger than 80 years were similar. However, when complications occurred, older patients were more likely to die. Interventions to identify and aggressively treat complications are necessary to decrease mortality in vulnerable older patients.
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Prognosis after surgical treatment for pancreatic cancer in patients aged 80 years or older: a multicenter study. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 23:188-97. [DOI: 10.1002/jhbp.320] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 01/12/2016] [Indexed: 12/27/2022]
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Wagner D, DeMarco MM, Amini N, Buttner S, Segev D, Gani F, Pawlik TM. Role of frailty and sarcopenia in predicting outcomes among patients undergoing gastrointestinal surgery. World J Gastrointest Surg 2016; 8:27-40. [PMID: 26843911 PMCID: PMC4724585 DOI: 10.4240/wjgs.v8.i1.27] [Citation(s) in RCA: 148] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 09/19/2015] [Accepted: 10/20/2015] [Indexed: 02/06/2023] Open
Abstract
According to the United States census bureau 20% of Americans will be older than 65 years in 2030 and half of them will need an operation - equating to about 36 million older surgical patients. Older adults are prone to complications during gastrointestinal cancer treatment and therefore may need to undergo special pretreatment assessments that incorporate frailty and sarcopenia assessments. A focused, structured literature review on PubMed and Google Scholar was performed to identify primary research articles, review articles, as well as practice guidelines on frailty and sarcopenia among patients undergoing gastrointestinal surgery. The initial search identified 450 articles; after eliminating duplicates, reports that did not include surgical patients, case series, as well as case reports, 42 publications on the impact of frailty and/or sarcopenia on outcome of patients undergoing gastrointestinal surgery were included. Frailty is defined as a clinically recognizable state of increased vulnerability to physiologic stressors resulting from aging. Frailty is associated with a decline in physiologic reserve and function across multiple physiologic systems. Sarcopenia is a syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength. Unlike cachexia, which is typically associated with weight loss due to chemotherapy or a general malignancy-related cachexia syndrome, sarcopenia relates to muscle mass rather than simply weight. As such, while weight reflects nutritional status, sarcopenia - the loss of muscle mass - is a more accurate and quantitative global marker of frailty. While chronologic age is an important element in assessing a patient's peri-operative risk, physiologic age is a more important determinant of outcomes. Geriatric assessment tools are important components of the pre-operative work-up and can help identify patients who suffer from frailty. Such data are important, as frailty and sarcopenia have repeatedly been demonstrated among the strongest predictors of both short- and long-term outcome following complicated surgical procedures such as esophageal, gastric, colorectal, and hepato-pancreatico-biliary resections.
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Casadei R, Taffurelli G, Silvestri S, Ricci C, Campra D, Minni F. Is age a barrier to pancreaticoduodenectomy? An Italian dual-institution study. Updates Surg 2015; 67:439-47. [PMID: 26614575 DOI: 10.1007/s13304-015-0337-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 11/14/2015] [Indexed: 12/19/2022]
Abstract
The aim of this study is to evaluate the role of age after pancreaticoduodenectomy. This is a retrospective study of 223 patients who underwent pancreaticoduodenectomy for periampullary diseases. Three age groups of patients were compared: ≤70 years of age (group A); between 71 and 79 years of age (group B) and 80 years of age or older (group C). The primary endpoint was the postoperative mortality rate. Secondary endpoints were the overall postoperative morbidity, postoperative pancreatic fistula, postoperative pancreatic haemorrhage, bile leakage, delayed gastric emptying rates, the length of hospital stay, intensive care unit stay, the type of discharge from hospital, reoperation rate and overall survival. Uni-multivariate analyses and Kaplan-Meier curve were carried out. At univariate analysis, only the type of discharge from hospital showed that group B and C patients required a period of rehabilitation more frequently than group A (P = 0.047 and P < 0.001, respectively). Multivariate analysis confirmed that age was not related to postoperative mortality (P = 0.258), morbidity (P = 0.912) and overall survival (P = 0.658), but it was related to type of discharge (P < 0.001). The present study seems to suggest that a pancreaticoduodenectomy is a feasible and safe procedure, even in elderly and very elderly patients even if the latter require a longer period of rehabilitation.
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Affiliation(s)
- Riccardo Casadei
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum, S.Orsola-Malpighi Hospital, University of Bologna, Via Massarenti N.9, 40138, Bologna, Italy.
| | - Giovanni Taffurelli
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum, S.Orsola-Malpighi Hospital, University of Bologna, Via Massarenti N.9, 40138, Bologna, Italy
| | - Stefano Silvestri
- Department of Surgery, San Giovanni Battista, Molinette Hospital, Turin, Italy
| | - Claudio Ricci
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum, S.Orsola-Malpighi Hospital, University of Bologna, Via Massarenti N.9, 40138, Bologna, Italy
| | - Donata Campra
- Department of Surgery, San Giovanni Battista, Molinette Hospital, Turin, Italy
| | - Francesco Minni
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum, S.Orsola-Malpighi Hospital, University of Bologna, Via Massarenti N.9, 40138, Bologna, Italy
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Beltrame V, Gruppo M, Pastorelli D, Pedrazzoli S, Merigliano S, Sperti C. Outcome of pancreaticoduodenectomy in octogenarians: Single institution's experience and review of the literature. J Visc Surg 2015; 152:279-284. [PMID: 26117303 DOI: 10.1016/j.jviscsurg.2015.06.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Pancreatic and perampullary neoplasms in patients aged 80 or older trouble the surgeons because of the risk of surgical treatment. We have reviewed our experience and literature's reports of pancreaticoduodenectomy in octogenarians, evaluating early results and long-term survival in pancreatic cancer group. METHODS Three hundred eighty-five patients who underwent pancreaticoduodenectomy for neoplasms from 1998 to 2011 were included in the study, and were divided in two groups: group 1, patients younger than 80 years of age, and group 2, patients 80 years of age and older. Operative morbidity, mortality, disease-free and long-term survival were analysed. English literature was systematically searched for pancreatic resection's outcome in octogenarians. RESULTS There were 385 pancreaticoduodenectomies: 362 patients were in group 1 and 23 patients in group 2. There was no significant difference regarding gender, and pathologic findings between the two groups. Complications' rate (40 vs. 43%), mortality rate (4% vs. 0%), and overall median survival for pancreatic cancer patients were not statistically different in the two groups (median 21 vs. 19 months). Literature's review showed 14 reports of pancreatic resection in octogenarians. Most of the studies (particularly in centres with high-volume pancreatic surgery) showed that outcome after pancreatectomy was not different in octogenarians or in younger patients. CONCLUSION Pancreaticoduodenectomy is an acceptable option for elderly patients. Age alone should not be considered a contraindication to major pancreatic resection, but a careful preoperative evaluation and an accurate postoperative management are mandatory.
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Affiliation(s)
- V Beltrame
- Department of Surgery, Oncology and Gastroenterology, 3rd Surgical Clinic, University of Padua, via Giustiniani 2, 35128 Padua, Italy
| | - M Gruppo
- Department of Surgery, Oncology and Gastroenterology, 3rd Surgical Clinic, University of Padua, via Giustiniani 2, 35128 Padua, Italy
| | - D Pastorelli
- Department of Oncology, Veneto Institute of Oncology, IOV, via Gattamelata 64, 35128 Padua, Italy
| | - S Pedrazzoli
- Department of Surgery, Oncology and Gastroenterology, 3rd Surgical Clinic, University of Padua, via Giustiniani 2, 35128 Padua, Italy
| | - S Merigliano
- Department of Surgery, Oncology and Gastroenterology, 3rd Surgical Clinic, University of Padua, via Giustiniani 2, 35128 Padua, Italy
| | - C Sperti
- Department of Surgery, Oncology and Gastroenterology, 3rd Surgical Clinic, University of Padua, via Giustiniani 2, 35128 Padua, Italy.
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Kinoshita S, Sho M, Yanagimoto H, Satoi S, Akahori T, Nagai M, Nishiwada S, Yamamoto T, Hirooka S, Yamaki S, Ikeda N, Kwon AH, Nakajima Y. Potential role of surgical resection for pancreatic cancer in the very elderly. Pancreatology 2015; 15:240-6. [PMID: 25888010 DOI: 10.1016/j.pan.2015.03.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 03/19/2015] [Accepted: 03/23/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND There is increasing need to evaluate the surgical indication of pancreatic cancer in very elderly patients. However, the available clinical data are limited, and the optimal treatment is still controversial. The aim of this study was to evaluate the benefit of pancreatic resection in pancreatic cancer patients over the age of 80. METHODS Between 2005 and 2012, 26 octogenarian patients who received pancreatic resection and 20 who received chemotherapy for pancreatic cancer were retrospectively reviewed. Clinicopathological factors, chemotherapy administration status, and survival were compared. Univariate and multivariate analysis of prognostic factors for survival was performed. RESULTS Postoperative major complication rate was 8%, with no mortality. The one-year survival rate and median survival time of the surgery and chemotherapy groups were 50% and 45%, and 12.4 months and 11.7 months, respectively (P = 0.263). Of the 26 resected cases, 6 completed the planned adjuvant chemotherapy treatment course. The median survival time of those 6 completed cases was significantly longer than that of the 20 not completed cases (23.4 versus 10.0 months, P = 0.034). Furthermore, a multivariate analysis of the 26 resected cases showed that distant metastasis (HR 3.206, 95%CI 1.005-10.22, P = 0.049) and completion of the planned adjuvant therapy (HR 4.078, 95%CI 1.162-14.30, P = 0.028) were independent prognostic factors of surgical resection. CONCLUSIONS Surgical resection was safe, but not superior to chemotherapy for pancreatic cancer in octogenarians. In the very elderly, only selected patients may benefit from pancreatic resection.
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Affiliation(s)
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, Japan.
| | | | - Sohei Satoi
- Department of Surgery, Kansai Medical University, Japan
| | | | - Minako Nagai
- Department of Surgery, Nara Medical University, Japan
| | | | | | | | - So Yamaki
- Department of Surgery, Kansai Medical University, Japan
| | - Naoya Ikeda
- Department of Surgery, Nara Prefecture Western Medical Center, Japan
| | - A-Hon Kwon
- Department of Surgery, Kansai Medical University, Japan
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Abstract
OBJECTIVE The aim of this study was to evaluate the safety of pancreatic resections in patients 80 years or older. METHODS A systematic search of the literature was carried out that compared perioperative outcomes after pancreatic resection in patients 80 years or older with patients younger than 80 years. The primary end points were postoperative mortality and morbidity. The secondary end points were incidence of postoperative pancreatic fistula, delayed gastric emptying, bile leak, pneumonia, postoperative infection, cardiologic complications, reoperation, and length of hospital stay. RESULTS Nine studies were found to be suitable for the meta-analysis. The postoperative mortality and morbidity were significantly higher in the group 80 years or older (P < 0.00001 and P = 0.003, respectively) except for patients in whom there were no differences in preoperative comorbidities (P = 0.56 and P = 0.36, respectively). Postoperative cardiac complications were significantly more frequent in patients 80 years or older (P < 0.0001), and the length of hospital stay was significantly longer in octogenarian patients (P = 0.008). CONCLUSIONS Patients 80 years or older have an increased incidence of postoperative mortality, morbidity, and cardiac complications and a longer length of hospital stay than do younger patients. Thus, pancreatic resection can be recommended only in a selected group of patients 80 years or older.
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Implementing an Enhanced Recovery Program After Pancreaticoduodenectomy in Elderly Patients: Is It Feasible? World J Surg 2014; 39:251-8. [PMID: 25212064 DOI: 10.1007/s00268-014-2782-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Sun JW, Zhang PP, Ren H, Hao JH. Pancreaticoduodenectomy and pancreaticoduodenectomy combined with superior mesenteric-portal vein resection for elderly cancer patients. Hepatobiliary Pancreat Dis Int 2014; 13:428-34. [PMID: 25100129 DOI: 10.1016/s1499-3872(14)60046-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND There is an increasing frequency of pancreaticoduodenectomy (PD) and PD with superior mesenteric-portal vein (SMPV) resection in elderly cancer patients. The study aimed to investigate the safety and the survival benefits of PD and PD with SMPV resection in patients under or over 70 years of age. METHODS We divided 296 patients who had undergone PD and PD with SMPV resection into two groups according to their ages: under or over 70 years old. The clinical data were compared between the two groups. RESULTS Preoperative comorbidity rate was higher in elder patients than in younger patients (P=0.001). The elder patients were more likely to have postoperative complications (P=0.003). Specifically, complications above grade III were more likely to occur in the elderly patients (P=0.030). Multivariable analysis showed that age (adjusted OR=2.557, P=0.015) and hypertension (adjusted OR=2.443, P=0.019) were independent predictors of postoperative complications. There was no significant difference in the mortality rates between the two groups (P=0.885). In the PD with SMPV resection series, elderly patients were more likely to have postoperative complications (P=0.063), but this difference was not statistically significant. There was no difference in the survival rate of patients with pancreatic ductal adenocarcinoma between the two groups. Operation type (PD vs PD with SMPV resection) did not affect the survival of patients. CONCLUSIONS Age affects postoperative complication in patients undergoing either PD or PD with SMPV resection. However, extensive experience and advanced perioperative management lower the complication rate to an acceptable limit. Hence it is safe and worthwhile to perform PD for elderly patients. Because of low numbers in the SMPV subset, we could not conclude whether PD with SMPV resection is feasible in elderly patients.
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Affiliation(s)
- Jun-Wei Sun
- Department of Pancreatic Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, China.
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Tani M, Kawai M, Hirono S, Okada KI, Miyazawa M, Shimizu A, Kitahata Y, Yamaue H. Randomized clinical trial of isolated Roux-en-Y versus conventional reconstruction after pancreaticoduodenectomy. Br J Surg 2014; 101:1084-91. [PMID: 24975853 DOI: 10.1002/bjs.9544] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 04/02/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) is associated with a high incidence of postoperative complications including pancreatic fistula. This randomized clinical trial compared the incidence of pancreatic fistula between the isolated Roux-en-Y (IsoRY) and conventional reconstruction (CR) methods. METHODS Patients admitted for PD between June 2009 and September 2012 in a single centre were assigned randomly to CR or IsoRY. The primary endpoint was the incidence of pancreatic fistula (grade A-C) defined according to the International Study Group on Pancreatic Fistula. Secondary endpoints were complication rates, mortality and hospital stay. Multiple logistic regression analysis was performed to identify factors associated with pancreatic fistula. RESULTS Some 153 patients were randomized, 76 to CR and 77 to IsoRY; two patients from the IsoRY group were excluded after randomization. Pancreatic fistula occurred in 26 patients (34 per cent) in the CR group and 25 (33 per cent) in the IsoRY group (P = 0·909). The number of patients with a clinically relevant pancreatic fistula (grade B or C) was similar in the two groups (10 and 11 patients respectively; P = 0·789), as were complication rates (42 versus 40 per cent; P = 0·793) and mortality (none in either group; P = 0·999). Soft pancreas was the only independent risk factor for pancreatic fistula (odds ratio 4·42, 95 per cent confidence interval 1·85 to 10·53; P <0·001). CONCLUSION This study showed that IsoRY reconstruction does not reduce the incidence of pancreatic fistula compared with CR. REGISTRATION NUMBER NCT00915863 (http://www.clinicaltrials.gov/) and UMIN000001967 (http://www.umin.ac.jp/).
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Affiliation(s)
- M Tani
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1 Kimiidera,, Wakayama, 641-8510, Japan
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Adham M, Bredt LC, Robert M, Perinel J, Lombard-Bohas C, Ponchon T, Valette PJ. Pancreatic resection in elderly patients: should it be denied? Langenbecks Arch Surg 2014; 399:449-459. [PMID: 24671518 DOI: 10.1007/s00423-014-1183-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 03/11/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Surgery remains the only potential curative therapy for pancreatic cancer, but compromised physiological reserve and comorbidities may deny pancreatic resection from elderly patients. METHODS The medical records of all patients who underwent pancreatic resection at our institution (2005-2012) were retrospectively reviewed. Postoperative and long-term outcomes were compared between patients with cutoff age of 70 years. RESULTS A total of 228 (66 %) and 116 (34 %) patients were <70 and ≥70 years, respectively. Elderly group had worse ASA scores (P < 0.0001) with higher rates of invasive malignant pathologies (75 vs. 67 %, P = 0.14), mainly pancreatic ductal adenocarcinoma (58.6 vs. 44.7 %, P = 0.01). The most common type of resection was pancreaticoduodenectomy (PD) (59 %), followed by distal pancreatectomy (19.8 %). Mean hospital stay was comparable. Elderly patients had less grade ≥IIIb postoperative complications (12 vs. 20.1 %; P = 0.04) and higher postoperative mortality rates (12.9 vs. 3.9 %; P = 0.04). In multivariable Cox proportional hazards model for postoperative mortality, age ≥ 70 years (HR, 3.5; 95 % CI, 1.3-9.3), pancreaticoduodenectomy (HR, 12.6; 95 % CI, 1.6-96), and intraoperative blood loss were significant (P = 0.012; P = 0.015, and P = 0.005, respectively). The overall 5-year survival rates for all patients, for patients aged <70 and ≥70 years were 56, 55, and 41 %, respectively (P = 0.003). CONCLUSIONS Elderly patients are at higher risk of mortality after pancreatic resection than usually reported case series. Nonetheless, elderly patients can undergo pancreatic resection with acceptable 5-year survival results. Our results contribute for a better, informed decision-making for elderly patients and their family.
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Affiliation(s)
- M Adham
- Department of Hepato-Biliary and Pancreatic Surgery, Lyon Faculty of Medicine-UCBL1, Edouard Herriot Hospital-HCL, Lyon, France,
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Perioperative and long-term outcomes after pancreaticoduodenectomy in elderly patients 80 years of age and older. Langenbecks Arch Surg 2013; 398:531-8. [PMID: 23462741 DOI: 10.1007/s00423-013-1072-7] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Accepted: 02/22/2013] [Indexed: 12/12/2022]
Abstract
PURPOSE Although a pancreaticoduodenectomy (PD) has been recently regarded as a safe surgical procedure at high-volume centers, the efficacy of PD for patients 80 years of age and older is controversial. The aim of this study was to evaluate the perioperative and long-term outcomes following PD in patients 80 years of age and older. METHODS Elderly patients 80 years of age and older who underwent PD between 2001 and 2009 were identified. The perioperative and long-term outcomes were compared with patients younger than 80 years of age. RESULTS Of 561 total patients, 22 patients (3.9 %) were 80 years of age or older. Mortality occurred in one patient (4.5 %). Postoperative major complications (Clavien-Dindo classification ≥ grade III) occurred in six patients (27.3 %) in this group, which was significantly higher than in patients younger than 80 years of age (P = 0.008). The survival of the elderly patients undergoing PD for pancreatic cancer was significantly shorter than that for the same patient group with other diseases (median survival, 13 versus 82 months; P = 0.014). Only one elderly patient with pancreatic cancer survived more than 3 years. CONCLUSIONS PD for pancreatic cancer in patients aged 80 and older should be carefully selected, because it is associated with a higher incidence of severe postoperative complications and a small change of long-term survival.
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