Management of adenocarcinoma of the pancreatic tail in the elderly

INTRODUCTION

Elderly patients with adenocarcinoma of the pancreatic head can achieve reasonable survival with multimodal therapy. An analysis specific to cancers of the pancreatic tail has not been published.

METHODS

We identified patients ≥65 years with localized adenocarcinoma of the pancreatic tail in the National Cancer Database (2011-2017). Patients were grouped by age (65-79 and ≥80 years) and categorized by treatment regimen. Postoperative outcomes and survival were analyzed using propensity score matching and multivariable logistical regression.

RESULTS

2168 patients were included: 73.9% were 65-79 years and 26.1% were ≥80 years. 34.1% of octogenarians did not receive any treatment, relative to 15.9% of younger patients (p < 0.001). Thirty-day mortality rates were similar in operatively managed patients; however, the 90-day mortality rate among octogenarians was greater (3.0% vs. 7.8%, p < 0.001; odds ratio [OR] = 1.85, 95% confidence interval [CI] = 1.07-3.19). Age ≥ 80 was not associated with survival on multivariable hazards regression (hazard ratio [HR] = 1.08, 95% CI = 0.95-1.24). After propensity matching, the addition of chemotherapy was not associated with improved survival relative to distal pancreatectomy alone among octogenarians (HR = 1.09, 95% CI = 0.72-1.65).

CONCLUSIONS

Management of adenocarcinoma of the pancreatic tail varies based on patient age. Resection appears to play a key role in management, but there is substantial upfront risk. Shared decision making should be employed to balance the chance for long-term survival with the risk of early mortality.

Rising Rates of Severe Obesity in Adults Younger Than 50 Correspond to Rise in Hospitalizations for Non-malignant Gastrointestinal Disease

BACKGROUND

Colorectal cancer incidence is rising in adults < 50 years old, possibly due to obesity. Non-malignant colorectal conditions are understudied in this population. We hypothesize that developing severe obesity in young adulthood also corresponds with increased hospitalization rates for non-malignant colorectal conditions.

METHODS

We examined annual percent change (APC) in the prevalence of obesity in adults < 50 using the 2009-2014 National Health and Nutrition Examination Survey. Using the 2010-2014 Nationwide Readmission Database, we then compared yearly hospitalization trends for various gastrointestinal conditions and their outcomes in adults < 50 with severe obesity vs. no obesity.

RESULTS

The prevalence of obesity increased in adults < 50 years in 2009-2014. This increase was most pronounced for severe obesity (APC of + 12.8%). The rate of patients with severe obesity < 50 who were admitted for gastrointestinal diseases has increased by 7.76% per year in 2010-2014 (p < 0.001). This increase was > 10% per year for colorectal conditions such Clostridium difficile infections (APC + 17.3%, p = 0.002), inflammatory bowel disease (APC + 13.1%, p = 0.001), and diverticulitis (APC + 12.7%, p = 0.002). The hospitalization rate for chronic liver diseases and acute pancreatitis also increased by 12.2% and 10.0% per year, respectively (p < 0.01). In contrast, young adults without obesity had lower hospitalization rate for most gastrointestinal diseases. Furthermore, adults with no obesity had lower mortality rates for appendicitis, diverticulitis, pancreatitis and chronic liver diseases than adults with severe obesity.

CONCLUSION

Our data suggest that increased adiposity in young adults is associated with more hospitalization and worse outcomes for infectious/inflammatory gastrointestinal conditions. Future prevention strategies are warranted to ameliorate these trends.

The effect of age on the opportunity to receive cancer treatment

INTRODUCTION

Older adults with cancer may not receive the same opportunities for treatment as younger patients. In this retrospective population-based cohort study, we explored whether age was an independent predictor of receiving specialist consultation and treatment.

METHODS

Patients age 45-99 were identified from the Ontario Cancer Registry having a primary solid tumor diagnosed between 01/Jan/2010 and 31/Dec/2019. We used logistic regression adjusted sociodemographic and clinical characteristics to compare the likelihood of consultation or receipt of treatment using linear splines at critical ages of 65, 80, and 90 years.

RESULTS

A total 168,232 (42%), 165,205 (41%), 57,360 (14%), and 7810 (2%) patients were diagnosed age 45-64, 65-79, 80-89, and 90-99, respectively. The likelihood of surgical consultation decreased as patients reached 65 years [adjusted odds ratio (aOR) 0.86 (0.84-0.89)], which decreased further among octogenarians [aOR 0.63 (0.59-0.67)]. Similar results were observed for consultation with a medical oncologist and radiation oncologist. Receipt of surgery also decreased with age. Three-month post-operative mortality was higher among older patients [aRR 1.38 (1.26-1.50) per 10 years, p < 0.0001], an effect that remained similar as patients reached age 65 + years of age (p = 0.09 for change). For stage I patients, 3-month post-operative survival was high across all age groups, ranging from 99.8% in 45-64 year-olds, 99.4% in 65-79 year-olds, and 98.1% among octogenarians and nonagenarians (lung, colorectal, breast, cervical cancer patients).

CONCLUSION

Older patients were less likely to have specialist consultations. More comprehensive data collection on clinical factors and referral patterns is needed to improve care for elderly cancer patients.

Outcomes After Major Surgical Procedures in Octogenarians: A Nationwide Cohort Study

Introduction

Aging of the worldwide population has been observed, and postoperative outcomes could be worse in elderly patients. This nationwide study assessed trends in number of surgical resections in octogenarians regarding various major surgical procedures and associated postoperative outcomes.

Methods

All patients who underwent surgery between 2014 and 2018 were included from Dutch nationwide quality registries regarding esophageal, stomach, pancreas, colorectal liver metastases, colorectal cancer, lung cancer and abdominal aortic aneurysms (AAA). For each quality registry, the number of patients who were 80 years or older (octogenarians) was calculated per year. Postoperative outcomes were length of stay (LOS), 30 day major morbidity and 30 day mortality between octogenarians and younger patients.

Results

No increase in absolute number and proportion of octogenarians that underwent surgery was observed. Median LOS was higher in octogenarians who underwent surgery for colorectal cancer, colorectal liver metastases, lung cancer, pancreatic disease and esophageal cancer. 30 day major morbidity was higher in octogenarians who underwent surgery for colon cancer, esophageal cancer and elective AAA-repair. 30 day mortality was higher in octogenarians who underwent surgery for colorectal cancer, lung cancer, stomach cancer, pancreatic disease, esophageal cancer and elective AAA-repair. Median LOS decreased between 2014 and 2018 in octogenarians who underwent surgery for stomach cancer and colorectal cancer. 30 day major morbidity decreased between 2014 and 2018 in octogenarians who underwent surgery for colon cancer. No trends were observed in octogenarians regarding 30 day mortality between 2014 and 2018.

Conclusion

No increase over time in absolute number and proportion of octogenarians that underwent major surgery was observed in the Netherlands. Postoperative outcomes were worse in octogenarians.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00268-022-06642-6.

Short-term postoperative outcomes after liver resection in the elderly patient: a nationwide population-based study

BACKGROUND

Liver resection is high-risk surgery in particular in elderly patients. The aim of this study was to explore postoperative outcomes after liver resection in elderly patients.

METHODS

In this nationwide study, all patients who underwent liver resection for primary and secondary liver tumours in the Netherlands between 2014 and 2019 were included. Age groups were composed as younger than 70 (70-), between 70 and 80 (septuagenarians), and 80 years or older (octogenarians). Proportion of liver resections per age group and 30-day major morbidity and 30-day mortality were assessed.

RESULTS

In total, 6587 patients were included of whom 4023 (58.9%) were younger than 70, 2135 (32.4%) were septuagenarians and 429 (6.5%) were octogenarians. The proportion of septuagenarians increased during the study period (aOR:1.06, CI:1.02-1.09, p < 0.001). Thirty-day major morbidity was higher in septuagenarians (11%) and octogenarians (12%) compared to younger patients (9%, p = 0.049). Thirty-day mortality was higher in septuagenarians (4%) and octogenarians (4%) compared to younger patients (2%, p < 0.001). Cardiopulmonary complications occurred more frequently with higher age, liver-specific complications did not. Higher age was associated with higher 30-day morbidity and 30-day mortality in multivariable logistic regression.

CONCLUSION

Thirty-day major morbidity and 30-day mortality are higher after liver resection in elderly patients, attributed mainly to non-surgical cardiopulmonary complications.

U.S. trends in elective and emergent major abdominal surgical procedures from 2002 to 2014 in older adults

BACKGROUND

The U.S. population is aging and projected to undergo an increasing number of general surgical procedures. However, recent trends in the frequency of major abdominal procedures in older adults are currently unknown as improvements in non-operative interventions may obviate the need for major surgery. Thus, we evaluated the trends of major abdominal surgical procedures in older adults in the United States.

METHODS

We performed a retrospective cohort study using the National Inpatient Sample from 2002 to 2014 with trend analysis using National Cancer Institute's Joinpoint Trend Analysis Software. We identified the average annual percent change (AAPC) in the yearly frequency of major abdominal surgical procedures in older adults (≥50 years of age).

RESULTS

Our cohort included a total of 3,951,947 survey-weighted discharges that included a major abdominal surgery in adults ≥50 years of age between 2002 and 2014. Of these discharges, 2,529,507 (64.0%) were for elective abdominal surgeries, 2,062,835 (52.0%) were for female patients, and mean (SD) age was 61.4 (15.9) years. The frequency of major abdominal procedures (elective and emergent) decreased for adults aged 65-74 (AAPC: -1.43, -1.75, -1.11, p < 0.0001), 75-84 (AAPC: -2.75, -3.33, -2.16, p < 0.001), and ≥85 (AAPC: -4.07, -4.67, -3.47, p < 0.0001). The AAPC for elective procedures decreased for older adults aged 75-84 (AAPC = -1.65; -2.44, -0.85: p = 0.0001) and >85 (AAPC = -3.53; -4.57, -2.48: p < 0.0001). All age groups showed decreases in emergent procedures in 50-64 (AAPC = -1.76, -2.00, -1.52, p < 0.0001), 65-74 (AAPC = -3.59, -4.03, -3.14, p < 0.0001), 75-84 (AAPC = -3.90, -4.34, -3.46, p < 0.0001), ≥85 (AAPC = -4.58, -4.98, -4.17, p < 0.0001) age groups.

CONCLUSIONS AND RELEVANCE

In this cohort of older adults, the frequency of emergent and elective major abdominal procedures in adults ≥65 years of age decreased with significant variation among individual procedure types. Future studies are needed to identify the generalizability of our findings to other surgical procedures.

Rising Incidence of Colorectal Cancer in Young Adults Corresponds With Increasing Surgical Resections in Obese Patients

Strong evidence links obesity to esophageal cancer (EC), gastric cancer (GC), colorectal cancer (CRC), and pancreatic cancer (PC). However, national-level studies testing the link between obesity and recent temporal trends in the incidence of these cancers are lacking.

Surgical resection of gastric gastrointestinal stromal tumors (GIST) in octogenarians

BACKGROUND

Localized gastrointestinal stromal tumors (GISTs) are rare tumors typically managed with surgery, but outcomes among octogenarians remain less studied.

METHODS

Octogenarian patients with stage I-III gastric GISTs were identified from the National Cancer Database and classified by resection status. Cox regression and Kaplan-Meier survival analyses analyzed 5-year overall survival (OS). Ninety-day mortality was analyzed following 1:1 propensity score matching.

RESULTS

Identified octogenarians (N = 949) who underwent resection (N = 632) had improved adjusted OS (71% vs 59.6%, HR 0.75, p 0.049) as compared to non-resected patients. Following matching, 90-day mortality was 5.7% and 11% in resected and non-resected patients (p 0.052), respectively. After exclusion of patients with 90-day mortality, resected patients maintained an OS advantage (77.3% vs 71.1%, HR 0.64, p 0.028).

CONCLUSIONS

The majority of octogenarians with localized gastric GIST are treated with surgery portending improved survival but an appreciable mortality, suggesting a necessity for careful selection of older patients for surgery.

Ninety-day mortality after total gastrectomy for gastric cancer

BACKGROUND

Total gastrectomy for gastric cancer is associated with significant 30-day mortality, but this endpoint may underestimate the short-term mortality of the procedure.

METHODS

Retrospective analysis was performed using the National Cancer Database (2004-2015). Patients who underwent total gastrectomy for stage I to III gastric adenocarcinoma were identified and divided into cohorts based on 90-day mortality. Predictors of mortality were analyzed using multivariable logistic regression, and annual trends in mortality rates were calculated by Joinpoint Regression.

RESULTS

Of the 5,484 patients who underwent total gastrectomy, 90-day and 30-day mortality rates were 9.1% and 4.7%, respectively. Factors associated with 90-day mortality included increasing age (odds ratio 1.0, P < .001), income below the median (odds ratio 1.2, P = .039), Charlson-Deyo score ≥2 (odds ratio 1.4, P = .039), treatment at low-volume facilities (odds ratio 1.5, P < .001), N1 (odds ratio 2.0, P < .001), N2 (odds ratio 2.0, P < .001), or N3 (odds ratio 2.7, P < .001) stage disease, having <16 lymph nodes harvested (odds ratio 1.5, P < .001), and lack of treatment with chemotherapy (3.7, P < .001). Lack of health insurance (odds ratio 4.1, P = .080), and positive microscopic margins (odds ratio 1.3, P = .080) were correlated, but not significantly associated, with 90-day mortality. The 90-day mortality rate significantly declined from 14.3% in 2004 to 7.9% in 2015 (P = .006), and the 30-day mortality rate significantly declined from 7.7% in 2004 to 4.8% in 2015 (P = .009).

CONCLUSION

Nearly half of the deaths within 90 days after total gastrectomy for cancer occur beyond 30 days postoperative. Ninety-day mortality has improved over time, but rates remain high, suggesting the need for improved out-of-hospital postoperative care beyond 30 days.

Bariatric Surgery Is Associated with a Recent Temporal Increase in Colorectal Cancer Resections, Most Pronounced in Adults Below 50 Years of Age

BACKGROUND

Colorectal cancer incidence is rising in adults < 50 years old, possibly due to obesity. Having bariatric surgery (BRS) should hypothetically reduce this trend, but data are limited. This study compared trends of colorectal cancer (CRC) versus other obesity-related gastrointestinal cancers (OGCs) between morbidly obese and post-BRS subjects.

MATERIAL AND METHODS

This retrospective cohort study investigated OGC resection trends using the 2006-2013 National Inpatient Sample. Patients with prior BRS and non-BRS controls with body mass index ≥ 40 kg/m² were included (n = 30,279 total). We divided OGCs into CRC and non-CRC OGCs (esophageal, stomach, liver, gallbladder, and pancreas). We calculated OGC resection trends in patients < 50 and ≥ 50 years old using the average annual percent change (AAPC).

RESULTS

BRS patients with OGCs were younger (59.3 vs 62.3 years old), with more female gender (77.4% vs 57.1%) and White race (72.6% vs 67%) compared with controls (p < 0.05). The number of CRC resections increased across all ages in 2006-2013, especially rectal cancer for BRS patients (AAPC + 19.8%, p = 0.04). The steepest rise in early-onset CRC resections was after BRS versus a lesser increase in morbid obesity controls (AAPC + 18.7% and + 13.7%, respectively, p < 0.001). In contrast, non-CRC OGCs increased in our controls but not post-BRS. In a sensitivity analysis, estimated CRC incidence trends also increased post-BRS despite adjusting for increasing BRS prevalence.

CONCLUSION

Our findings suggest that bariatric surgery is associated with a persistent increase in early-onset CRC trends. Studies are warranted to validate our results and test the impact of bariatric surgery on early-onset CRC biological mechanisms.

Thirty-day hospital readmissions after augmentation cystoplasty: A Nationwide readmissions database analysis

INTRODUCTION

Reducing hospital readmissions is a growing priority for hospitals and clinicians in their efforts to improve quality of care and curtail costs. Augmentation cystoplasty is among the most complex and high-morbidity operations in pediatric urology, with up to 25% of patients experiencing a postoperative complication. However, there is a paucity of literature addressing the incidence and characteristics of hospital readmissions after these procedures. This information may be useful in tailoring perioperative interventions to reduce rehospitalization in this population.

OBJECTIVE

This study sought to determine the rate, causes, risk factors, and costs associated with 30-day readmissions for children undergoing augmentation cystoplasty.

STUDY DESIGN

We analyzed the Nationwide Readmissions Database (NRD) for children (≤18 years of age) who underwent augmentation cystoplasty for any indication between 2010 and 2014. Rates, causes, and costs of 30-day readmissions were determined. Multivariate logistic regression was used to identify risk factors for readmission.

RESULTS

Among 1873 identified cases, the 30-day readmission rate was 19.6%, with an average cost per readmission of $11,667. The most common reasons for readmission were gastrointestinal complications (19.6%), urinary tract infections (14.1%), and wound complications (11.2%). The median time to readmission was 13 days (interquartile range 6-19 days). Non-infectious genitourinary complications (e.g. hydronephrosis) ($25,286) and gastrointestinal complications ($12,924) led to the costliest readmissions, while dehydration/vomiting ($3739) and fever ($4803) were the least costly. On multivariate regression, the only significant risk factor for readmission was an indication of neurogenic bladder (OR 3.82, 95% CI 1.03-14.20, p = 0.04).

DISCUSSION

We present the first study to capture readmissions with 30 days of discharge to the same or outside hospitals after augmentation cystoplasty. Limitations include inability to separate planned and unplanned readmissions and 30-day follow-up period, which prevented analysis of readmissions caused by late complications.

CONCLUSION

Approximately one in five children undergoing augmentation cystoplasty are readmitted within 30 days. An indication of neurogenic bladder is an independent risk factor, while gastrointestinal complications and urinary tract infections are the most common reasons for readmission.

Implications of Hospital Volume on Costs Following Esophagectomy in the United States

BACKGROUND

With increasing focus on health care quality and cost containment, volume-based referral strategies have been proposed to improve value in high-cost procedures, such as esophagectomy. While the effect of hospital volume on outcomes has been demonstrated, our goal was to evaluate the economic consequences of volume-based referral practices for esophagectomy.

METHODS

The nationwide inpatient sample (NIS) was queried for the years 2004-2013 for all patients undergoing esophagectomy. Patients were stratified by hospital volume quartile and substratified by preoperative risk and age. Clustered multivariable hierarchical logistic regression analysis was used to assess adjusted costs and mortality.

RESULTS

In total, 9270 patients were clustered based on annual hospital volume quartiles of < 7, 7 to 22, 23 to 87, and > 87 esophagectomies. After stratification by patient variables, high-volume centers performed esophagectomies in high-risk patients at the same cost as low-volume centers without significant difference in resource utilization. Overall, mortality decreased across volume quartiles (lowest 8.9 versus highest 3.6%, p < 0.0001). The greatest volume-mortality differences were observed among patients aged between 70 and 80 years (lowest 12.2 versus highest 6.2%, p = 0.009). Patients with high preoperative risk also derived mortality benefits with increasing hospital volume (lowest 17.5 versus highest 11.8%, p < 0.0001).

CONCLUSIONS

This study demonstrates that the mortality improvements for high-risk patients undergoing esophagectomy at high-volume centers do not come at increased costs. These results suggest that health systems should consider selectively referring high-risk patients to high-volume centers within their region.