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Xu S, Deng X, Wang S, Yu G, Liu J, Gong W. Short‑ and long‑term outcomes after laparoscopic and open pancreatoduodenectomy for elderly patients: a propensity score‑matched study. BMC Geriatr 2024; 24:462. [PMID: 38802742 PMCID: PMC11129404 DOI: 10.1186/s12877-024-05063-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 05/09/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND The feasibility and safety of laparoscopic pancreatoduodenectomy (LPD) in elderly patients is still controversial. This study aimed to compare the clinical outcomes of LPD and open pancreatoduodenectomy (OPD) in elderly patients. METHODS Clinical and follow-up data of elderly patients (≥ 65 years) who underwent LPD or OPD between 2015 and 2022 were retrospectively analyzed. A 1:1 propensity score-matching (PSM) analysis was performed to minimize differences between groups. Univariate and multivariate logistic regression analysis were used to select independent prognostic factors for 90-day mortality. RESULTS Of the 410 elderly patients, 236 underwent LPD and 174 OPD. After PSM, the LPD group had a less estimated blood loss (EBL) (100 vs. 200 mL, P < 0.001), lower rates of intraoperative transfusion (10.4% vs. 19.0%, P = 0.029), more lymph node harvest (11.0 vs. 10.0, P = 0.014) and shorter postoperative length of stay (LOS) (13.0 vs. 16.0 days, P = 0.013). There were no significant differences in serious complications, reoperation, 90-day readmission and mortality rates (all P > 0.05). Multivariate logistic regression analysis showed that post-pancreatectomy hemorrhage (PPH) was an independent risk factor for 90-day mortality. Elderly patients with pancreatic ductal adenocarcinoma (PDAC) who underwent LPD or OPD had similar overall survival (OS) (22.5 vs.20.4 months, P = 0.672) after PSM. CONCLUSIONS It is safe and feasible for elderly patients to undergo LPD with less EBL and a shorter postoperative LOS. There was no statistically significant difference in long-term survival outcomes between elderly PDAC patients who underwent LPD or OPD.
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Affiliation(s)
- Shuai Xu
- Department of Liver Transplantation and Hepatobiliary Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No.324, Jingwu Road, Jinan, Shandong, 250021, China
| | - Xin Deng
- Department of Liver Transplantation and Hepatobiliary Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No.324, Jingwu Road, Jinan, Shandong, 250021, China
| | - Shulin Wang
- Department of Rehabilitation Medicine, The 960th Hospital of the PLA Joint Logistics Support Force, Jinan, Shandong, 250031, China
| | - Guangsheng Yu
- Department of Liver Transplantation and Hepatobiliary Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No.324, Jingwu Road, Jinan, Shandong, 250021, China
| | - Jun Liu
- Department of Liver Transplantation and Hepatobiliary Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No.324, Jingwu Road, Jinan, Shandong, 250021, China.
| | - Wei Gong
- Department of Liver Transplantation and Hepatobiliary Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No.324, Jingwu Road, Jinan, Shandong, 250021, China.
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Mori S, Wakabayashi T, Mishima K, Ozaki T, Fujiyama Y, Wakabayashi G. Benefits of laparoscopic liver resection in elderly patients. Surg Endosc 2023:10.1007/s00464-023-09986-9. [PMID: 36947226 DOI: 10.1007/s00464-023-09986-9] [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: 12/03/2022] [Accepted: 02/25/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND The indications of laparoscopic liver resection (LLR) have expanded to high-risk patients, such as elderly people. However, to date, little evidence has been established of the safety and feasibility of LLR in elderly patients. The short-term outcomes of LLR in elderly patients as compared to non-elderly patients were investigated. METHODS Data of a total of 297 patients who underwent LLR were reviewed. Among these 297 patients, 181 patients were < 75 years age (non-elderly) and 116 patients were ≥ 75 years age (elderly), and the surgical outcomes were compared between the groups. In addition, we evaluated the risk factors for postoperative morbidity (Clavien-Dindo grade ≥ IIIa) utilizing the preoperative, operative, and postoperative variables RESULTS: The preoperative liver/renal function, frequency of anti-thrombotic drug use, number of comorbidities, and American Society of Anesthesiologists-physical status classification were more unfavorable in elderly patients than in non-elderly patients. No significant inter-group differences were observed in the operation time, blood loss, conversion rate, postoperative morbidity, or 30-day mortality. The 3-year overall survival rate was comparable between the two groups. Multivariate analysis identified anti-thrombotic drug use, operation time > 7 h, and peak serum total bilirubin > 2 mg/dl within postoperative day 3 as independent risk factors for Clavien-Dindo ≥ IIIa postoperative morbidity (P = 0.016, P < 0.001, and P = 0.001, respectively). CONCLUSIONS LLR in elderly patients may provide comparable short-term outcomes to those in non-elderly patients.
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Affiliation(s)
- Shozo Mori
- Ageo Central General Hospital, Department of Surgery, Center for Advanced Treatment of HBP Diseases, 1-10-10 Kashiwaza, Ageo, Saitama, 362-8588, Japan.
| | - Taiga Wakabayashi
- Ageo Central General Hospital, Department of Surgery, Center for Advanced Treatment of HBP Diseases, 1-10-10 Kashiwaza, Ageo, Saitama, 362-8588, Japan
| | - Kohei Mishima
- Ageo Central General Hospital, Department of Surgery, Center for Advanced Treatment of HBP Diseases, 1-10-10 Kashiwaza, Ageo, Saitama, 362-8588, Japan
| | - Takahiro Ozaki
- Ageo Central General Hospital, Department of Surgery, Center for Advanced Treatment of HBP Diseases, 1-10-10 Kashiwaza, Ageo, Saitama, 362-8588, Japan
| | - Yoshiki Fujiyama
- Ageo Central General Hospital, Department of Surgery, Center for Advanced Treatment of HBP Diseases, 1-10-10 Kashiwaza, Ageo, Saitama, 362-8588, Japan
| | - Go Wakabayashi
- Ageo Central General Hospital, Department of Surgery, Center for Advanced Treatment of HBP Diseases, 1-10-10 Kashiwaza, Ageo, Saitama, 362-8588, Japan
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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: 0] [Impact Index Per Article: 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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Xu X, Wang J, Duan Q. Effects of surgery on survival of elderly patients with gallbladder cancer: A propensity score matching analysis of the SEER database. Front Oncol 2023; 13:1083618. [PMID: 36937413 PMCID: PMC10016611 DOI: 10.3389/fonc.2023.1083618] [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: 10/29/2022] [Accepted: 02/17/2023] [Indexed: 03/05/2023] Open
Abstract
Background Surgery is the sole curative therapy for gallbladder cancer (GBC) patients. Confronting an aging society, the demand to treat elderly patients with GBC is increasing. But there are few reports on survival benefit in elderly GBC patients treated with surgery. Therefore, we designed this population-based study to assess the survival benefit of surgery in GBC patients aged 70 years or older. Methods GBC patients aged 70 years or older were identified in the surveillance, epidemiology, and end results cancer (SEER) database from 2010 to 2017. A 1:1 propensity score matching (PSM) analysis was conducted to balance the baseline data of patients. Overall survival (OS) and cancer-specific survival (CSS) of patients were evaluated by Kaplan-Meier analysis and compared with log-rank test. Independent risk factors associated with OS and CSS were determined by univariate and multivariate Cox proportional hazard regression analyses and subgroup analysis were performed. Results A total of 2055 GBC patients aged 70 years or older were included in our study, with 1734 patients underwent surgery. Before PSM, the age, AJCC stage, TNM stage, and chemotherapy were significantly different between the surgery and no-surgery group (all P<0.05). Patients with surgery had significantly longer OS and CSS than those without surgery (P<0.0001). After 1:1 PSM, the differences in clinicopathological characteristics were reduced (all P>0.05). Kaplan-Meier analysis also showed patients received surgery had significantly better OS and CSS (P<0.0001). Subgroup analysis further indicated that almost all subgroups received surgery had OS and CSS advantage, especially patients aged 70-84 years old. Finally, univariate and multivariate COX regression analyses showed that age, AJCC stage and T stage were independent prognostic factors for OS and CSS in patients undergoing surgery. Conclusion Our study found that surgery significantly improved OS and CSS in GBC patients aged 70-84 years, but more prospective studies are needed to prove our findings.
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Affiliation(s)
- Xiaoming Xu
- Department of Gastroenterology, Jining First People's Hospital, Jining, China
| | - Jingzhi Wang
- Department of Radiotherapy Oncology, The Affiliated Yancheng First Hospital of Nanjing University Medical School, The First People's Hospital of Yancheng, Yancheng, China
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Kim JS, Chapman WC, Lin Y. Mitochondrial Autophagy in Ischemic Aged Livers. Cells 2022; 11:cells11244083. [PMID: 36552847 PMCID: PMC9816943 DOI: 10.3390/cells11244083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/09/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
Mitochondrial autophagy (mitophagy) is a central catabolic event for mitochondrial quality control. Defective or insufficient mitophagy, thus, can result in mitochondrial dysfunction, and ultimately cell death. There is a strong causal relationship between ischemia/reperfusion (I/R) injury and mitochondrial dysfunction following liver resection and transplantation. Compared to young patients, elderly patients poorly tolerate I/R injury. Accumulation of abnormal mitochondria after I/R is more prominent in aged livers than in young counterparts. This review highlights how altered autophagy is mechanistically involved in age-dependent hypersensitivity to reperfusion injury.
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Affiliation(s)
- Jae-Sung Kim
- Department of Surgery, Washington University in St. Louis, St. Louis, MO 63110, USA; (W.C.C.); (Y.L.)
- Department of Cell Biology & Physiology, Washington University in St. Louis, St. Louis, MO 63110, USA
- Correspondence:
| | - William C. Chapman
- Department of Surgery, Washington University in St. Louis, St. Louis, MO 63110, USA; (W.C.C.); (Y.L.)
| | - Yiing Lin
- Department of Surgery, Washington University in St. Louis, St. Louis, MO 63110, USA; (W.C.C.); (Y.L.)
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Short-term outcomes of robotic versus open pancreaticoduodenectomy in elderly patients: A multicenter retrospective cohort study. Int J Surg 2022; 104:106819. [DOI: 10.1016/j.ijsu.2022.106819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/14/2022] [Accepted: 07/20/2022] [Indexed: 02/07/2023]
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Robotic-assisted pancreatic surgery in the elderly patient: experiences from a high-volume centre. BMC Surg 2021; 21:415. [PMID: 34886818 PMCID: PMC8662827 DOI: 10.1186/s12893-021-01395-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 11/03/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Robotic-assisted pancreatic surgery (RPS) has fundamentally developed over the past few years. For subgroups, e.g. elderly patients, applicability and safety of RPS still needs to be defined. Given prognosticated demographic developments, we aim to assess the role of RPS based on preoperative, operative and postoperative parameters. METHODS We included 129 patients undergoing RPS at our institution between 2017 and 2020. Eleven patients required conversion to open surgery and were excluded from further analysis. We divided patients into two groups; ≥ 70 years old (Group 1; n = 32) and < 70 years old (Group 2; n = 86) at time of resection. RESULTS Most preoperative characteristics were similar in both groups. However, number of patients with previous abdominal surgery was significantly higher in patients ≥ 70 years old (78% vs 37%, p < 0.0001). Operative characteristics did not significantly differ between both groups. Although patients ≥ 70 years old stayed significantly longer at ICU (1.8 vs 0.9 days; p = 0.037), length of hospital stay and postoperative morbidity were equivalent between the groups. CONCLUSION RPS is safe and feasible in elderly patients and shows non-inferiority when compared with younger patients. However, prospectively collected data is needed to define the role of RPS in elderly patients accurately. Trial registration Clinical Trial Register: Deutschen Register Klinischer Studien (DRKS; German Clinical Trials Register). Clinical Registration Number: DRKS00017229 (retrospectively registered, Date of Registration: 2019/07/19, Date of First Enrollment: 2017/10/18).
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Hillebrandt K, Nevermann N, Globke B, Moosburner S, Schmelzle M, Pratschke J. [Impact of the COVID-19 pandemic on hepato-pancreato-biliary surgery and organ transplantation]. Chirurg 2021; 92:918-923. [PMID: 34297148 PMCID: PMC8299733 DOI: 10.1007/s00104-021-01463-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2021] [Indexed: 12/12/2022]
Abstract
Hintergrund und Ziel der Arbeit Im Rahmen der COVID-19(„coronavirus disease 2019“)-Pandemie wurden weitreichende Ressourceneinschränkungen und -umverteilungen innerhalb des Gesundheitssystems notwendig. Diese Übersichtsarbeit beleuchtet die direkten und indirekten Folgen der COVID-19-Pandemie auf die Bereiche der hepatopankreatobiliären (HPB)-Chirurgie und Organtransplantation unter Berücksichtigung aktueller Literatur und veröffentlichter Expertenmeinungen nationaler und internationaler Fachgesellschaften. Entwicklungen der Operationszahlen wurden über die Eurotransplant Statistics Report Library und eine zentrumsinterne Auswertung HPB-chirurgischer Eingriffe analysiert. Ergebnisse In den Bereichen der HPB-Chirurgie und Organtransplantation zeigte sich vor allem in der ersten Pandemiewelle an vielen Zentren ein deutlicher Einbruch der Eingriffszahlen. Interessanterweise konnte meist kein kompensatorischer Zuwachs der Operationen in den Folgemonaten verzeichnet werden. Im Jahrestrend zeigen sich somit leicht rückläufige Zahlen. Ob dieser Trend auf eine erhöhte Sterblichkeit durch verschobene Operationen und geänderte Therapieregimes zurückzuführen ist, lässt sich derzeit zumindest nicht ausschließen. Eine SARS-CoV-2(„severe acute respiratory syndrome coronavirus 2“)-Infektion ist auf jeden Fall mit einem komplikativen Verlauf assoziiert, insbesondere im perioperativen Verlauf und nach Transplantation. Diskussion Aufgrund des erhöhten Risikoprofils der genannten Patientengruppen besteht ein erhöhtes Risiko für einen schweren COVID-19-Verlauf. Dies muss bei der Abwägung von Therapiealternativen, der Schutzempfehlungen und der Priorisierung bei Impfungen in Betracht gezogen werden.
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Affiliation(s)
- K Hillebrandt
- Chirurgische Klinik, Campus Charité Mitte
- Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - N Nevermann
- Chirurgische Klinik, Campus Charité Mitte
- Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - B Globke
- Chirurgische Klinik, Campus Charité Mitte
- Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - S Moosburner
- Chirurgische Klinik, Campus Charité Mitte
- Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - M Schmelzle
- Chirurgische Klinik, Campus Charité Mitte
- Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - Johann Pratschke
- Chirurgische Klinik, Campus Charité Mitte
- Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland.
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Wallace H, Miller T, Angus W, Stott M. Intra-operative anaesthetic management of older patients undergoing liver surgery. Eur J Surg Oncol 2020; 47:545-550. [PMID: 33218699 DOI: 10.1016/j.ejso.2020.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 10/30/2020] [Accepted: 11/06/2020] [Indexed: 02/07/2023] Open
Abstract
Older patients represent a growing proportion of the general surgical caseload. This includes those undergoing liver resection, with figures rising faster than the rate of population ageing. The physiology of ageing leads to changes in all body systems which may render the provision of safe anaesthesia more challenging than in younger patients. Anaesthesia for liver surgery has specific principles, largely aimed at reducing venous bleeding from the liver, and those related to complex major surgery. This review explores the principles of anaesthesia for liver resection and describes how they may require modification in the older patient. The traditional approach of low central venous pressure anaesthesia in order to reduce bleeding may need to be altered in the presence of a cardiovascular system less able to tolerate hypotension and hypoperfusion. These changes in physiology should also lower the threshold for invasive monitoring. The provision of effective analgesia perioperatively should be tailored to minimise the surgical stress response and opiate use. Careful consideration of general principles of intra-operative care for older patients, such as positioning, drug dosing, avoidance of excessively deep anaesthesia, and maintenance of normothermia are also important given the prolonged, complex nature of liver surgery. This individualised approach, with careful attention to changes in physiology allows liver resections to be undertaken in older patients without increases in mortality.
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Affiliation(s)
- Hilary Wallace
- Aintree University Hospital, Lower Lane, Fazakerley, Liverpool, L9 7AL, UK.
| | - Thomas Miller
- Aintree University Hospital, Lower Lane, Fazakerley, Liverpool, L9 7AL, UK
| | - William Angus
- Health Education North West, 3 Piccadilly Place, Manchester, M1 3BN, UK
| | - Matthew Stott
- Aintree University Hospital, Lower Lane, Fazakerley, Liverpool, L9 7AL, UK
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Liu J, Reid J, Trochsler M, Leopardi L, Edwards S, Maddern G. Impact of Ageing on Hepatic Malignancy Resection: Is Age Really a Risk Factor for Mortality? World J Surg 2020; 45:841-848. [PMID: 33146783 DOI: 10.1007/s00268-020-05850-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND With an ageing population, it is paramount for surgeons to comprehend the implications of age on surgical outcomes. This study aims to identify the effects of age on perioperative outcomes post-hepatectomy. METHODS Between 2001 and 2017, 357 hepatectomies were performed in our centre for malignancy. Data recorded include demographic, histopathology and perioperative outcomes. Patients were divided into three age groups (Group 1 < 65 years, Group 2 65-74 years, Group 3 ≥ 75 years). RESULTS With increasing age, there was a trend towards patient having: ASA ≥ 3 (from 32.1% to 60.9%, p < 0.0001), clear margins (from 80.4% to 88.3%, p = 0.2256), days of hospitalisation (from 9.5 ± 6.9 to 12 ± 8.0, p = 0.0003), days of ICU admission (from 2.3 ± 2.8 to 2.8 ± 12.9, p = 0.0790) and morbidity (from 39% to 58.5%, p = 0.0073). Cardiovascular complications and postoperative delirium increase with age. There was no significant difference in mortality across the three groups. Univariate and bivariate binary logistic regressions found no association between mortality and age. When adjusted for age, 30- and 90-day mortality was significantly associated with Clavien-Dindo ≥ 3, length of hospital and cardiac complications. Additionally, 90-day mortality was significantly associated with ASA score ≥3, mass of liver resected, length of ICU stay and hepatobiliary, pulmonary and genitourinary complications. CONCLUSION Increased age is associated with increased post-hepatectomy complications, prolonged hospital stay and ICU admission. However, age itself is not a contraindication for hepatectomy and is not associated with increased mortality. Good histopathology outcomes and low mortality rates are achievable with careful patient selection and appropriate perioperative management.
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Affiliation(s)
- Jianliang Liu
- Faculty of Health and Medical Sciences, The University of Adelaide Medical School, Adelaide, South Australia, Australia
| | - Jessica Reid
- Discipline of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia, Australia
| | - Markus Trochsler
- Discipline of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia, Australia
| | - Lisa Leopardi
- Discipline of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia, Australia
| | - Suzanne Edwards
- Adelaide Health Technology Assessment, School of Public Health, The University of Adelaide, Adelaide, South Australia, Australia
| | - Guy Maddern
- Department of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, 28 Woodville Road, Woodville, South Australia, 5011, Australia.
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Sahara K, Merath K, Hyer JM, Paredes AZ, Tsilimigras DI, Mehta R, Farooq SA, Moro A, Wu L, White S, Endo I, Pawlik TM. Impact of Preoperative Cholangitis on Short-term Outcomes Among Patients Undergoing Liver Resection. J Gastrointest Surg 2020; 24:2508-2516. [PMID: 31745898 DOI: 10.1007/s11605-019-04430-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 10/14/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The impact of preoperative cholangitis (PC) on perioperative outcomes among patients undergoing liver resection remains poorly defined. We sought to characterize the prevalence of PC among patients undergoing hepatectomy and define the impact of PC on postoperative outcomes. METHODS Patients who underwent liver resection between 2013 and 2015 were identified using the Center for Medicare Services (CMS) 100% Limited Data Set (LDS) Standard Analytic Files (SAFs). Short-term outcomes after liver resection, stratified by the presence of PC, were examined. Subgroup analyses were performed to evaluate the relationship between the timing of liver resection relative to PC. RESULTS Among 7392 patients undergoing liver resection, 251 patients (3.4%) experienced PC. Patients with PC were more likely to be male (59.0% vs. 50.6%) and to have a benign diagnosis (34.3% vs. 19.8%) compared with patients without PC (both p<0.05). On multivariable analysis, PC was associated with increased odds of experiencing a complication (OR 1.54, 95%CI 1.17-2.03), extended LOS (OR 2.60, 95%CI 1.99-3.39), 90-day mortality (OR 2.31, 95%CI 1.64-3.26), and higher Medicare expenditures (OR 3.32, 95%CI 2.55-4.32). Among patients with PC, requirement of both endoscopic and percutaneous biliary drainage (OR 5.16, 95%CI 1.36-9.61), as well as liver resection < 2 weeks after PC (OR 2.92, 95%CI 1.13-7.57) were associated with higher odds of 90-day mortality. CONCLUSION Approximately 1 in 30 Medicare beneficiaries undergoing liver resection had a history of PC. PC was associated with an increased risk of adverse short-term outcomes and higher healthcare expenditures among patients undergoing hepatectomy.
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Affiliation(s)
- Kota Sahara
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
- Gastroenterological Surgery Division, Yokohama City University School of Medicine, Yokohama, Japan
| | - Katiuscha Merath
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - J Madison Hyer
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Anghela Z Paredes
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Rittal Mehta
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Syeda A Farooq
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Amika Moro
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Lu Wu
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Susan White
- Division of Health Information Management and Systems, The Ohio State Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Itaru Endo
- Gastroenterological Surgery Division, Yokohama City University School of Medicine, Yokohama, Japan
| | - Timothy M Pawlik
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Wexner Medical Center, The Ohio State University, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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Ke J, Liu Y, Liu F, Ji B. Application of Laparoscopic Pancreatoduodenectomy in Elderly Patients. J Laparoendosc Adv Surg Tech A 2020; 30:797-802. [PMID: 32429782 DOI: 10.1089/lap.2019.0787] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background: Pancreaticoduodenectomy (PD) involves complicated surgical procedures and is associated with high postoperative mortality. PD can be performed using laparoscopy; however, there is a lack of evidence on laparoscopic PD (LPD) outcomes in elderly patients. Therefore, this study aimed to compare LPD outcomes in elderly patients with those in patients aged <65 years and assess elderly outcomes according to the LPD surgical learning curve. Materials and Methods: In this retrospective study, medical records of 75 elderly patients (Group A) and 225 patients aged <65 years (Group B) were reviewed. Preoperative and postoperative data, as well as oncologic outcomes, were collected. To assess the effect of the surgical learning curve on outcomes of elderly patients, patients were equally divided into four phases, based on the number of surgeries performed at the study site. Results: The mean preoperative physical status score was significantly higher in Group A than in Group B (z = 5.222, P < .001), indicating higher disease severity. There were no significant differences in operative time, intraoperative blood loss, vascular reconstruction rate, or intensive care unit (ICU) stay between the groups. The blood transfusion rate (χ2 = 4.301, P = .038) and length of postoperative hospital stay (z = 2.386, P = .017) were significantly higher in Group A than in Group B. The surgical resection margins and the number of lymph nodes harvested did not differ between the two groups; however, a significant difference was observed in pathological results. In assessing the surgical learning curve, the pairwise comparison of means showed that the operation times in phases 3 and 4 were shorter than that in phase 1 (P < .05) and differences in nasogastric tube removal time between the four groups were statistically significant (H = 15.390, P = .002). Conclusions: Advanced age alone should not be a contraindication for LPD, since outcomes for elderly patients who have undergone LPD are similar to those for younger patients.
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Affiliation(s)
- Jianji Ke
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Yahui Liu
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Feiqi Liu
- The Cancer Center, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Bai Ji
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, Changchun, Jilin, China
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13
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Sahara K, Paredes AZ, Tsilimigras DI, Hyer JM, Merath K, Wu L, Mehta R, Beal EW, White S, Endo I, Pawlik TM. Impact of Liver Cirrhosis on Perioperative Outcomes Among Elderly Patients Undergoing Hepatectomy: the Effect of Minimally Invasive Surgery. J Gastrointest Surg 2019; 23:2346-2353. [PMID: 30719676 DOI: 10.1007/s11605-019-04117-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 01/09/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The impact of cirrhosis on perioperative outcomes for elderly patients undergoing hepatectomy remains not well defined. We sought to determine the influence of underlying cirrhosis and minimally invasive surgery (MIS) on postoperative outcomes among elderly patients who underwent a hepatectomy. METHODS Patients who underwent hepatectomy between 2013 and 2015 were identified using the Center for Medicare Services (CMS) 100% Limited Data Set (LDS) Standard Analytic Files (SAFs). Short-term outcomes after hepatectomy, stratified by the presence of cirrhosis and MIS, were examined. RESULTS Among 7452 patients who underwent a hepatectomy, a minority had cirrhosis (n = 481, 6.5%) whereas the vast majority did not (n = 6971, 93.5%). Overall, median patient age was 72 years (IQR 68-76) and preoperative Charlson comorbidity score was 6 (IQR 2-8). Patients with cirrhosis were more likely to be younger (median age 71 [67-76] vs 72 [IQR 68-76] years), male (64.4% vs 50%), African American (8.1% vs 6.4%) and have a malignant diagnosis (87.1% vs 78.7%) compared to non-cirrhotic patients (all p < 0.001). There was no difference among patients with and without cirrhosis regarding type of hepatectomy or surgical approach (open vs MIS) (both p > 0.05). Patients with versus without cirrhosis had similar complication rates (24.1% vs 22.3%, p = 0.36), as well as 30-day (6.2% vs 5%, p = 0.25) and 90-day (10.4% vs 8.5%, p = 0.15) mortality. MIS reduced the length-of-stay in non-cirrhotic patients (OR 0.79, 95% CI 0.62-0.99, p < 0.05), yet was not associated with morbidity or mortality (both p > 0.05). CONCLUSION The presence of cirrhosis did not generally impact outcomes in elderly patients undergoing hepatectomy for benign and malignant diseases. MIS hepatectomy in the elderly Medicare beneficiary population reduced LOS among patients without cirrhosis, yet was not associated with differences in morbidity or mortality.
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Affiliation(s)
- Kota Sahara
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.,Gastroenterological Surgery Division, Yokohama City University School of Medicine, Yokohama, Japan
| | - Anghela Z Paredes
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - J Madison Hyer
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Katiuscha Merath
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Lu Wu
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Rittal Mehta
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Eliza W Beal
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Susan White
- Division of Health Information Management and Systems, The Ohio State Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Itaru Endo
- Gastroenterological Surgery Division, Yokohama City University School of Medicine, Yokohama, Japan
| | - Timothy M Pawlik
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA. .,Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University, Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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14
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Famularo S, Di Sandro S, Giani A, Angrisani M, Lauterio A, Romano F, Gianotti L, De Carlis L. The impact of age and ageing on hepatocarcinoma surgery: Short- and long-term outcomes in a multicentre propensity-matched cohort. Liver Int 2019; 39:894-904. [PMID: 30790410 DOI: 10.1111/liv.14075] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 01/31/2019] [Accepted: 02/04/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Management of malignancy in elderly patients is challenging. We aimed to assess the impact of age and ageing on overall survival (OS), recurrence-free survival (RFS), tumour-specific survival (TSS) and potential years of life lost (PYLL) after surgery for hepatocarcinoma (HCC). METHODS Consecutive patients treated for HCC between 2005 and 2015 were evaluated. Patients were divided according to age-decade. Afterwards, elderly patients (≥75 years) were compared with patients < 75 years. A 1:1 propensity matching was used to reduce the risk of bias. Survival was estimated by Kaplan-Meier method and Cox regression analysis. RESULTS Four hundred and thirty-nine patients were stratified: group 1 (age ≤ 55, n = 72), group 2 (age: 56-65, n = 133), group 3 (age: 66-74, n = 141) and group 4 (age ≥ 75, n = 93). Group 1 had the highest median PYLL (27.6, IQR 24.6-32.5) while group 4 the lowest (2.0, IQR 0-9.6; P < 0.001). Comparing elderly vs younger, there were no significant differences in terms of OS (P = 0.054), TSS (P = 0.321) and RFS (P = 0.240). Ageing was the only variable associated with post-operative complications (OR: 2.51; 95% CI: 1.23-5.13; P = 0.025) and liver-related morbidity was an independent predictor of OS. (HR 2.49, 95% CI: 1.34-4.64, P = 0.004). CONCLUSION Ageing per se is not an absolute contraindication for liver resection, given the acceptable oncologic long-term prognosis, but the worse short-term outcomes in the elderly should induce an accurate patient selection.
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Affiliation(s)
- Simone Famularo
- School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy.,General and Transplant Surgery Unit, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Stefano Di Sandro
- General and Transplant Surgery Unit, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Alessandro Giani
- School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy.,Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Marco Angrisani
- School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy.,Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Andrea Lauterio
- General and Transplant Surgery Unit, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Fabrizio Romano
- School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy.,Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Luca Gianotti
- School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy.,Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Luciano De Carlis
- School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy.,General and Transplant Surgery Unit, Grande Ospedale Metropolitano Niguarda, Milan, Italy
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15
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Sucandy I, Cheek S, Tsung A, Marsh JW, Geller DA. Minimally invasive liver resection for primary and metastatic liver tumors: influence of age on perioperative complications and mortality. Surg Endosc 2017; 32:1885-1891. [PMID: 29046959 DOI: 10.1007/s00464-017-5880-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 09/11/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND As minimally invasive technique becomes more popular, an increasing number of elderly patients were considered for minimally invasive liver resection (MILR). Limited physiologic reserve remains a major concern, which frequently leads surgeons to recommend nonresectional alternatives. We sought to evaluate complications and outcomes of elderly patients undergoing MILR. METHODS Eight hundred and thirty-one patients who underwent MILR were classified into groups A, B, and C based on age [(< 70, n = 629), (70-79, n = 148), (≥ 80, n = 54) years old, respectively]. RESULTS Gender distribution, BMI, and cirrhotic status were comparable among all groups. Groups B and C had higher MELD (p = 0.047) and ASA (p = 0.001) scores. Operative time (170, 157, 152 min; p = 0.64) and estimated blood loss (145, 130, 145 ml; p = 0.95) were statistically equal. Overall postoperative complications were greater in groups B and C (12.9 and 9.3 vs. 6.5%, respectively). Complications in group C were all minor. Clavien-Dindo grade III-IV complications were higher in group B when compared to group A (6.8 vs. 2.7%, p = 0.43). There was no significant difference in cardiopulmonary complications, thromboembolic events, ICU admissions, and transfusion rates seen in groups B and C when compared to group A. Duration of hospital stay was statistically longer in groups B and C (3.6, 3.5 vs. 2.5 days, p = 0.0012). 30- and 90-day mortality rates were comparable among the groups, irrespective of age. CONCLUSIONS In spite of greater preoperative comorbidities and ASA score, there was no significant increase in postoperative morbidity after minimally invasive liver resection in patients ≥ 70 years of age.
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Affiliation(s)
- Iswanto Sucandy
- University of Pittsburgh Medical Center/UPMC Liver Cancer Center, 3459 Fifth Avenue, UPMC Montefiore, 7-South, Pittsburgh, PA, 15213-2582, USA. .,University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Susannah Cheek
- University of Pittsburgh Medical Center/UPMC Liver Cancer Center, 3459 Fifth Avenue, UPMC Montefiore, 7-South, Pittsburgh, PA, 15213-2582, USA.,University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Allan Tsung
- University of Pittsburgh Medical Center/UPMC Liver Cancer Center, 3459 Fifth Avenue, UPMC Montefiore, 7-South, Pittsburgh, PA, 15213-2582, USA.,University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - J Wallis Marsh
- University of Pittsburgh Medical Center/UPMC Liver Cancer Center, 3459 Fifth Avenue, UPMC Montefiore, 7-South, Pittsburgh, PA, 15213-2582, USA.,University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - David A Geller
- University of Pittsburgh Medical Center/UPMC Liver Cancer Center, 3459 Fifth Avenue, UPMC Montefiore, 7-South, Pittsburgh, PA, 15213-2582, USA.,University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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16
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Frailty in major oncologic surgery of upper gastrointestinal tract: How to improve postoperative outcomes. Eur J Surg Oncol 2017; 43:1566-1571. [DOI: 10.1016/j.ejso.2017.06.006] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 04/25/2017] [Accepted: 06/06/2017] [Indexed: 02/07/2023] Open
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17
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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: 2.9] [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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18
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Zouros E, Liakakos T, Machairas A, Patapis P, Tzerbinis H, Manatakis DK, Papadimitriou-Olivgeris M, Dervenis C. Fast-Track Pancreaticoduodenectomy in the Elderly. Am Surg 2017. [DOI: 10.1177/000313481708300318] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
It remains uncertain whether enhanced recovery after surgery (ERAS) protocols can be safely implemented for elderly patients, especially after highly complex surgery such as pancreaticoduodenectomy (PD). The present study was designed to assess the feasibility and safety of an ERAS protocol in elderly patients undergoing PD. Starting January 2010 to February 2015, we prospectively collected data from 85 consecutive patients who underwent PD with a fast-track program. Data of patients older and younger than 70 years were compared. Endpoints were morbidity, mortality, readmissions, length of stay, and compliance with ERAS elements. Forty-five patients were less than 70 years old and 40 patients were 70 years of age or older. Both mortality (4.4% vs 5%; P = 1.000) and overall morbidity (33.3% vs 37.5%; P = 0.821) did not differ significantly between the groups. Rates of intervention and relaparotomy were similar in both groups. Length of stay (10 vs 11.8 days; P = 0.099) did not differ significantly between the groups, nor did the readmission rates (6.7% vs 5.0%; P = 0.272). There were no differences in compliance with ERAS elements between groups. An ERAS program seems feasible and can be safely implemented for elderly patients undergoing PD.
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Affiliation(s)
- Efstratios Zouros
- Department of Surgery, “Konstantopouleio” General Hospital, Athens, Greece
| | | | | | - Paulos Patapis
- Third Department of Surgery, Attiko University Hospital, Athens, Greece
| | - Helen Tzerbinis
- Department of Surgery, “Konstantopouleio” General Hospital, Athens, Greece
| | | | | | - Christos Dervenis
- Department of Surgery, “Konstantopouleio” General Hospital, Athens, Greece
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19
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Bell R, Pandanaboyana S, Nisar S, Upasani V, Toogood G, Lodge JP, Prasad KR. The Impact of Advancing Age on Recurrence and Survival Following Major Hepatectomy for Colorectal Liver Metastases. J Gastrointest Surg 2017; 21:266-274. [PMID: 27770289 DOI: 10.1007/s11605-016-3296-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 10/03/2016] [Indexed: 01/31/2023]
Abstract
INTRODUCTION This study analysed the effect of age on survival in patients undergoing major hepatectomy (MH) for colorectal liver metastases (CRLM). The effect of adjuvant chemotherapy (AC) with age was also assessed. METHOD Patients undergoing MH for CRLM between 1996 and 2011 were reviewed. Patients aged <75 or ≥75 were compared for disease-free (DFS) and overall survival (OS) as well as impact of AC on survival. RESULTS Seven hundred twenty-seven patients underwent MH of which 105 (14 %) were aged ≥75. Morbidity was greater in the ≥75 group (25 versus 34 %, p = 0.048). No difference was noted in mortality. There was no difference in DFS between the two groups at 5 years (16.8 vs 18.9 months (p = 0.570). OS was longer in the <75 group (38.6 vs 32.0 months (p = 0.001). DFS was better in groups receiving AC than those not (<75 24.2 vs 12.2 months (p = <0.001) and ≥75 24 vs 12.1 months (p = 0.007)). OS in the ≥75 group was improved in the group receiving AC compared to the ≥75 group not (41.1 vs 16.6 months, p = 0.005). Age ≥75 was not an independent risk factor for reduced DFS on multivariate analysis. CONCLUSION Well-selected patients aged ≥75 should be considered for MH followed by adjuvant chemotherapy.
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Affiliation(s)
- Richard Bell
- Department of Hepatobiliary and Transplant Surgery, St James University Hospital, ICU Offices, Level 3 Bexley Wing, Leeds, LS9 7TF, UK.
| | - Sanjay Pandanaboyana
- Department of Hepatobiliary Surgery, Auckland City Hospital, Auckland, New Zealand.,Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Saira Nisar
- Department of Hepatobiliary and Transplant Surgery, St James University Hospital, ICU Offices, Level 3 Bexley Wing, Leeds, LS9 7TF, UK
| | - Vivek Upasani
- Department of Hepatobiliary and Transplant Surgery, St James University Hospital, ICU Offices, Level 3 Bexley Wing, Leeds, LS9 7TF, UK
| | - Giles Toogood
- Department of Hepatobiliary and Transplant Surgery, St James University Hospital, ICU Offices, Level 3 Bexley Wing, Leeds, LS9 7TF, UK
| | - J Peter Lodge
- Department of Hepatobiliary and Transplant Surgery, St James University Hospital, ICU Offices, Level 3 Bexley Wing, Leeds, LS9 7TF, UK
| | - K Raj Prasad
- Department of Hepatobiliary and Transplant Surgery, St James University Hospital, ICU Offices, Level 3 Bexley Wing, Leeds, LS9 7TF, UK
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20
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Leal JN, Sadot E, Gonen M, Lichtman S, Kingham TP, Allen PJ, DeMatteo RP, Jarnagin WR, D’Angelica MI. Operative morbidity and survival following hepatectomy for colorectal liver metastasis in octogenarians: a contemporary case matched series. HPB (Oxford) 2017; 19:162-169. [PMID: 27914765 PMCID: PMC5608029 DOI: 10.1016/j.hpb.2016.09.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 09/11/2016] [Accepted: 09/15/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Clinical outcomes of octogenarians undergoing hepatectomy for colorectal liver metastases (CRLM) are poorly characterized. The current study evaluated operative morbidity, mortality and survival outcomes among a contemporary cohort of octogenarians. METHODS Patients undergoing their first hepatectomy for CRLM were identified from institutional databases and those ≥80 years old (y) were matched 1:1 to a group of patients <80 y. Data pertaining to surgical morbidity/mortality and survival were compared using standard statistical methods. RESULTS From 2002 to 2012, 1391 hepatectomies were performed for CRLM, 55 (4%) in patients ≥80 y. Major complications occurred twice as frequently among patients ≥80 y [10 (19%) ≥80 y versus 5 (9%) <80 y, (p = 0.270)]. No matched patient <80 y. died within 90 d of operation, whereas, 4 (7%) patients ≥80 y did, p = 0.125. Median follow-up was significantly longer for the <80 y group [44 (1-146) versus. 23 (0-102) mths, p = 0.006]. Probability of disease recurrence was not different between groups (p = 0.123) nor was the cumulative incidence of death from disease (p = 0.371). However, patients ≥80 y had significantly higher incidence of non-cancer related death (p = 0.012). CONCLUSIONS Hepatectomy for CRLM among well-selected octogenarians is reasonable with cancer related survival outcomes similar to those observed in younger patients. However, it is associated with clinically significant morbidity/mortality and continued efforts directed at optimizing perioperative care are necessary to improve early outcomes among octogenarians.
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Affiliation(s)
- Julie N. Leal
- Department of Surgery, Memorial Sloan Kettering Cancer Center
| | - Eran Sadot
- Department of Surgery, Memorial Sloan Kettering Cancer Center
| | - Mithat Gonen
- Department of Epidemiology/Biostatistics, Memorial Sloan Kettering Cancer Center
| | - Stuart Lichtman
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center
| | | | - Peter J. Allen
- Department of Surgery, Memorial Sloan Kettering Cancer Center
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Andres A, Majno P, Terraz S, Morel P, Roth A, Rubbia-Brandt L, Schiffer E, Ris F, Toso C. Management of patients with colorectal liver metastasis in eleven questions and answers. Expert Rev Anticancer Ther 2016; 16:1277-1290. [PMID: 27744725 DOI: 10.1080/14737140.2016.1249855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Colorectal liver metastasis (CRLM) is the most frequent indication for liver resection in many centers. Recent improvements in oncology, surgery, interventional radiology, pathology and anesthesiology allow curative treatment in a larger proportion of patients with CRLM. Areas covered: We illustrate the various aspects of the management of CRLM through 11 questions that summarize the topic, from the current obtained survival to future perspectives such as transplantation. The limits of a curative treatment are also presented from different angles, such as the benefits of pathology, the surgical options for extreme resections, the available chemotherapies and their efficacy, or the non-surgical ablative treatments. Expert commentary: Given the increasing therapeutic possibilities, we strengthen the importance to analyze the situation of each patient with CRLM in a dedicated multidisciplinary team, in order to offer the best individualized treatment combination.
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Affiliation(s)
- Axel Andres
- a Faculty of Medicine, Hepato-Pancreato-Biliary Centre , Geneva University Hospital , Geneva , Switzerland.,b Faculty of Medicine, Division of Abdominal Surgery , Geneva University Hospital , Geneva , Switzerland
| | - Pietro Majno
- a Faculty of Medicine, Hepato-Pancreato-Biliary Centre , Geneva University Hospital , Geneva , Switzerland.,b Faculty of Medicine, Division of Abdominal Surgery , Geneva University Hospital , Geneva , Switzerland
| | - Sylvain Terraz
- a Faculty of Medicine, Hepato-Pancreato-Biliary Centre , Geneva University Hospital , Geneva , Switzerland.,c Faculty of Medicine, Division of Radiology , Geneva University Hospital , Geneva , Switzerland
| | - Philippe Morel
- a Faculty of Medicine, Hepato-Pancreato-Biliary Centre , Geneva University Hospital , Geneva , Switzerland.,b Faculty of Medicine, Division of Abdominal Surgery , Geneva University Hospital , Geneva , Switzerland
| | - Arnaud Roth
- a Faculty of Medicine, Hepato-Pancreato-Biliary Centre , Geneva University Hospital , Geneva , Switzerland.,d Faculty of Medicine, Division of Oncology , Geneva University Hospital , Geneva , Switzerland
| | - Laura Rubbia-Brandt
- a Faculty of Medicine, Hepato-Pancreato-Biliary Centre , Geneva University Hospital , Geneva , Switzerland.,e Faculty of Medicine, Division of Clinical Pathology , Geneva University Hospital , Geneva , Switzerland
| | - Eduardo Schiffer
- a Faculty of Medicine, Hepato-Pancreato-Biliary Centre , Geneva University Hospital , Geneva , Switzerland.,f Faculty of Medicine, Division of Anesthesiology , Geneva University Hospital , Geneva , Switzerland
| | - Frederic Ris
- b Faculty of Medicine, Division of Abdominal Surgery , Geneva University Hospital , Geneva , Switzerland
| | - Christian Toso
- a Faculty of Medicine, Hepato-Pancreato-Biliary Centre , Geneva University Hospital , Geneva , Switzerland.,b Faculty of Medicine, Division of Abdominal Surgery , Geneva University Hospital , Geneva , Switzerland
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22
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Schiergens TS, Lindenthaler A, Thomas MN, Rentsch M, Mittermeier L, Brand K, Küchenhoff H, Lee S, Guba M, Werner J, Thasler WE. Time-dependent impact of age and comorbidities on long-term overall survival after liver resection. Liver Int 2016; 36:1340-50. [PMID: 26778517 DOI: 10.1111/liv.13068] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 01/07/2016] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Advanced age and comorbidities are known to be associated with increased perioperative risks after liver resection. However, the precise impact of these variables on long-term overall survival (OS) remains unclear. Thus, the aim of this study was to evaluate the confounder-adjusted, time-dependent effect of age and comorbidities on OS following hepatectomy for primary and secondary malignancies. METHODS From a prospective database of 1.143 liver resections, 763 patients treated for primary and secondary malignancies were included. For time-varying OS calculations, a Cox-Aalen model was fitted. The confounder-adjusted hazard was compared with mortality tables of the German population. RESULTS Overall, age (P = 0.003) and comorbidities (P = 0.001) were associated with shortened OS. However, time-dependent analysis indicated that age and comorbidities had no impact on OS within 39 and 55 months after resection respectively. From this time on, a significant decline in OS was shown. Subgroup analysis indicated an earlier increase of the effect of age in patients with hepatocellular carcinoma (17 months) than in those with colorectal metastases (70 months). The confounder-adjusted hazard of 70-year-old patients was increased post-operatively but dropped 66 months after surgery, and the risk of death was comparable to the general population 78 months after resection. At this time, one-third of patients aged 70 years and older were still alive. CONCLUSIONS With regard to long-term outcome, liver resection for both primary and secondary malignancies should not be categorically denied due to age and comorbidities. This information should be considered for the patient selection process and informed consent.
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Affiliation(s)
- Tobias S Schiergens
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, Hospital of the University of Munich, Munich, Germany
| | - Andrea Lindenthaler
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, Hospital of the University of Munich, Munich, Germany
| | - Michael N Thomas
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, Hospital of the University of Munich, Munich, Germany
| | - Markus Rentsch
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, Hospital of the University of Munich, Munich, Germany
| | - Laura Mittermeier
- Statistical Consulting Unit, Department of Statistics, Ludwig-Maximilians-University, Munich, Germany
| | - Katharina Brand
- Statistical Consulting Unit, Department of Statistics, Ludwig-Maximilians-University, Munich, Germany
| | - Helmut Küchenhoff
- Statistical Consulting Unit, Department of Statistics, Ludwig-Maximilians-University, Munich, Germany
| | - Serene Lee
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, Hospital of the University of Munich, Munich, Germany
| | - Markus Guba
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, Hospital of the University of Munich, Munich, Germany
| | - Jens Werner
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, Hospital of the University of Munich, Munich, Germany
| | - Wolfgang E Thasler
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, Hospital of the University of Munich, Munich, Germany
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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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Yazici P, Akyuz M, Yigitbas H, Dural C, Okoh A, Aydin N, Berber E. A comparison of perioperative outcomes in elderly patients with malignant liver tumors undergoing laparoscopic liver resection versus radiofrequency ablation. Surg Endosc 2016; 31:1269-1274. [PMID: 27444839 DOI: 10.1007/s00464-016-5105-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 07/09/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Liver resection is the treatment option with the best chance for cure in patients with malignant liver tumors. However, there are concerns regarding postoperative recovery in elderly patients, which may lead to a preference of non-resectional therapies over hepatectomy in this patient population. Although laparoscopic liver resection (LLR) is associated with a faster recovery compared to open hepatectomy, there are scant data on how elderly patients tolerate LLR. The aim of this study was to analyze the perioperative outcomes of LLR in elderly patients with hepatic malignancies, with a comparison to laparoscopic RFA (LRFA). METHODS A retrospective analysis of a prospective database for liver tumors identified a total of 82 patients older than 65 years who underwent laparoscopic treatment of their liver tumors in a single tertiary care center between 2000 and 2014. These patients were equally distributed into LLR and LRFA treatment arms. RESULTS Mean age, American Society of Anesthesiologists (ASA) score and tumor type (predominantly metastatic colorectal cancer) were similar in both groups. Patients in the LRFA group had more tumors (2.1 ± 1.8 vs. 1.2 ± 0.6, p < 0.01), whereas tumors were larger in the LLR group (3.8 ± 1.6 vs. 2.8 ± 1.1 cm, p < 0.01). Although the operative time (116 vs. 214 min, p < 0.01) and hospital stay (2.1 vs. 3.4 days, p = 0.010) were shorter for the LRFA versus LLR group, respectively, morbidity (4.8 vs. 7.3 %) and mortality (0 vs. 0 %) were similar. Local recurrence was significantly higher in the LRFA versus LLR group (29 vs. 2.4 %, respectively, p = 0.002). However, there was no statistical difference in disease-free and overall survival between two groups (28 vs. 30 and 51 vs. 54 months, p = 0.443 and 0.768, respectively). CONCLUSIONS This study showed that LLR was tolerated as well as LRFA in elderly patients with similar comorbidities. We suggest LLR to be considered as an option in selected elderly patients who are deemed poor candidates for open hepatectomy.
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Affiliation(s)
- Pinar Yazici
- Department of General Surgery, Cleveland Clinic, 9500 Euclid Avenue/F20, Cleveland, OH, 44195, USA
| | - Muhammet Akyuz
- Department of General Surgery, Cleveland Clinic, 9500 Euclid Avenue/F20, Cleveland, OH, 44195, USA
| | - Hakan Yigitbas
- Department of General Surgery, Cleveland Clinic, 9500 Euclid Avenue/F20, Cleveland, OH, 44195, USA
| | - Cem Dural
- Department of General Surgery, Cleveland Clinic, 9500 Euclid Avenue/F20, Cleveland, OH, 44195, USA
| | - Alexis Okoh
- Department of General Surgery, Cleveland Clinic, 9500 Euclid Avenue/F20, Cleveland, OH, 44195, USA
| | - Nail Aydin
- Department of General Surgery, Cleveland Clinic, 9500 Euclid Avenue/F20, Cleveland, OH, 44195, USA
| | - Eren Berber
- Department of General Surgery, Cleveland Clinic, 9500 Euclid Avenue/F20, Cleveland, OH, 44195, USA.
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Park YK, Choi JE, Jung WY, Song SK, Lee JI, Chung CW. Mucosa-associated lymphoid tissue (MALT) lymphoma as an unusual cause of malignant hilar biliary stricture: a case report with literature review. World J Surg Oncol 2016; 14:167. [PMID: 27343073 PMCID: PMC4919877 DOI: 10.1186/s12957-016-0928-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 06/22/2016] [Indexed: 02/07/2023] Open
Abstract
Background Biliary strictures at the hilum of the liver arise from heterogeneous etiologies. The majority is malignant entities, but some may have benign etiologies. It is difficult to distinguish between malignant and benign biliary strictures preoperatively. It has been reported that 5~15 % of preoperative diagnoses of hilar cholangiocarcinoma turn out to be benign lesions or even other types of malignancies. Primary non-Hodgkin’s lymphoma of the extrahepatic bile duct is very rare, with only a few cases reported as mucosa-associated lymphoid tissue (MALT) lymphoma arising from the hepatic duct bifurcation. We herein report a case of a female patient presenting with perihilar bile ducts obstructed by primary MALT lymphoma resembling hilar cholangiocarcinoma, along with a review of the literature. Case presentation An 86-year-old female was referred to our hospital manifesting obstructive jaundice and abdominal pain. The reported imaging studies revealed distended intrahepatic bile duct with the stricture of common hepatic duct including bifurcation, which was suspicious of cholangiocarcinoma of the bile duct. The initial laboratory-confirmed cholestasis with a total bilirubin of 8.6 mg/dL, aspartate amino transferase (AST) 178 U/L, alanine transferase (ALT) 105 U/L, and the tumor marker CA 19-9 was elevated with a value of 167 U/mL. Viral markers for hepatitis B and C viruses were negative. She underwent extrahepatic bile duct resection and hepaticojejunostomy. Histological examination of the resected specimen revealed MALT lymphoma. Postoperative follow-up of 1 year has been completely uneventful, without any symptoms or disease recurrence. Conclusions In exceptional cases, in which radiologic and clinical features point to cholangiocarcinoma, the actual reason for obstructive jaundice and abdominal pain can be a non-Hodgkin’s lymphoma. In the case of a MALT lymphoma, it can be cured with complete resection.
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Affiliation(s)
- Yong Keun Park
- Department of Surgery, Catholic Kwandong University International St. Mary's Hospital, Incheon, South Korea
| | - Jee Eun Choi
- Catholic Kwandong University College of Medicine, Incheon, South Korea
| | - Woon Yong Jung
- Department of Pathology, Catholic Kwandong University International St. Mary's Hospital, Incheon, South Korea
| | - Sung Kyu Song
- Department of Surgery, Catholic Kwandong University International St. Mary's Hospital, Incheon, South Korea
| | - Jong In Lee
- Department of Surgery, Catholic Kwandong University International St. Mary's Hospital, Incheon, South Korea
| | - Chul-Woon Chung
- Department of Surgery, Catholic Kwandong University International St. Mary's Hospital, Incheon, South Korea.
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Agalianos C, Dervenis C. Pancreatic surgery in the elderly: overcoming the prejudices. Ann Gastroenterol 2016; 29:101-2. [PMID: 27065723 PMCID: PMC4805729 DOI: 10.20524/aog.2016.0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
| | - Christos Dervenis
- Department of Surgery, Konstantopouleion General Hospital of Athens (Christos Dervenis), Greece
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Andert A, Lodewick T, Ulmer TF, Schmeding M, Schöning W, Neumann U, Dejong K, Heidenhain C. Liver resection in the elderly: A retrospective cohort study of 460 patients – Feasible and safe. Int J Surg 2016; 28:126-30. [DOI: 10.1016/j.ijsu.2016.02.060] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 02/11/2016] [Indexed: 12/12/2022]
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Cauchy F, Fuks D, Nomi T, Dokmak S, Scatton O, Schwarz L, Barbier L, Belghiti J, Soubrane O, Gayet B. Benefits of Laparoscopy in Elderly Patients Requiring Major Liver Resection. J Am Coll Surg 2016; 222:174-84.e10. [DOI: 10.1016/j.jamcollsurg.2015.11.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 10/30/2015] [Accepted: 11/03/2015] [Indexed: 01/21/2023]
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Wozniak SE, Coleman J, Katlic MR. Optimal Preoperative Evaluation and Perioperative Care of the Geriatric Patient: A Surgeon's Perspective. Anesthesiol Clin 2015; 33:481-489. [PMID: 26315633 DOI: 10.1016/j.anclin.2015.05.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The elderly preoperative patient benefits from an assessment that includes more than a routine physical examination and electrocardiogram. Such an assessment includes domains likely to affect the elderly: cognition, functionality, frailty, polypharmacy, nutrition, and social support. This fosters decisions based on functional age rather than chronologic age and on each patient as an individual. One such assessment is that promulgated by the American College of Surgeons National Surgery Quality Improvement Program/American Geriatrics Society Best Practice Guidelines. We should not miss any opportunity to improve results in this growing population of surgical patients.
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Affiliation(s)
- Susan E Wozniak
- Department of Surgery, Sinai Center for Geriatric Surgery, Sinai Hospital, 2401 West Belvedere Avenue, Baltimore, MD 21215, USA
| | - JoAnn Coleman
- Department of Surgery, Sinai Center for Geriatric Surgery, Sinai Hospital, 2401 West Belvedere Avenue, Baltimore, MD 21215, USA
| | - Mark R Katlic
- Department of Surgery, Sinai Center for Geriatric Surgery, Sinai Hospital, 2401 West Belvedere Avenue, Baltimore, MD 21215, USA.
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DeLuzio MR, Moores C, Dhamija A, Wang Z, Cha C, Boffa DJ, Detterbeck FC, Kim AW. Resection of oligometastatic lung cancer to the pancreas may yield a survival benefit in select patients--a systematic review. Pancreatology 2015; 15:456-462. [PMID: 25900320 DOI: 10.1016/j.pan.2015.03.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 02/12/2015] [Accepted: 03/23/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To conduct a systematic review of the existing literature regarding surgical therapy for oligometastatic lung cancer to the pancreas. METHODS Data was collected on patients with singular pancreatic metastases from lung cancer from papers published between January 1970 and June 2014. This was performed following the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) guidelines. Kaplan-Meier and Cox Regression analyses were then used to determine and compare survival. RESULTS There were 27 papers that fulfilled the search criteria, from which data on 32 patients was collected. Non-small cell lung cancer (NSCLC) was the most prevalent type of primary lung malignancy, and metachronous presentations of metastases were most common. Lesions were most frequently located in the pancreatic head and consequently the most common curative intent metastasectomy was pancreaticoduodenectomy. There was a statistically significant survival benefit for patients whose metastasis were discovered incidentally by surveillance CT as opposed to those whose metastasis were discovered during a work up for new somatic complaints (p = 0.024). The overall median survival for patients undergoing curative intent resection was 29 months, with 2-year and 5-year survivals of 65% and 21% respectively. Palliative surgery or medical only management was associated with a median survival of 8 months and 2-year and 5-year survivals of 25% and 8% respectively. CONCLUSIONS Curative intent resection of isolated pancreatic metastasis from lung cancer may be beneficial in a select group of patients.
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Affiliation(s)
- Matthew R DeLuzio
- Department of Surgery, Yale-New Haven Hospital, New Haven, CT 06520, USA
| | - Craig Moores
- Department of Surgery, Yale-New Haven Hospital, New Haven, CT 06520, USA
| | - Ankit Dhamija
- Department of Surgery, Morristown Medical Center, Morristown, NJ 07960, USA
| | - Zuoheng Wang
- Division of Biostatistics, Yale School of Public Health, New Haven, CT 06520, USA
| | - Charles Cha
- Section of Surgical Oncology, Yale School of Medicine, New Haven, CT 06520, USA
| | - Daniel J Boffa
- Section of Thoracic Surgery, Yale School of Medicine, New Haven, CT 06520, USA
| | - Frank C Detterbeck
- Section of Thoracic Surgery, Yale School of Medicine, New Haven, CT 06520, USA
| | - Anthony W Kim
- Section of Thoracic Surgery, Yale School of Medicine, New Haven, CT 06520, USA.
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Fernandes AI, Tralhão JG, Abrantes A, Hoti E, Alexandrino H, Oliveiros B, Ferreira M, Botelho MF, Sousa FC. Functional hepatocellular regeneration in elderly patients undergoing hepatectomy. Liver Int 2015; 35:1116-23. [PMID: 24325556 DOI: 10.1111/liv.12433] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2013] [Accepted: 12/03/2013] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS More than 50% of liver tumours occur in patients aged 65 years or more. Assessment of functional liver regeneration capacity is crucial to minimize postoperative liver failure. We aimed to study functional hepatocellular regeneration, through scintigraphic quantification of Mebrofenin hepatic extraction fraction (HEF), after partial hepatectomy, comparing elderly patients with younger ones. METHODS One hundred and two patients undergoing partial hepatectomy for primary or secondary hepatic lesions were prospectively included and divided in two groups: Group A - 58 patients aged <65 years (33 men, 53.9 ± 8.7 years), Group B - 44 patients aged ≥65 years (32 men, 71 ± 5 years). Groups were comparable in several aspects except for the presence of cirrhosis (more common in Group B, all patients Child-Pugh score A) and the initial diagnosis (Group B - primary lesions, Group A - metastases). The scintigraphic evaluation of Mebrofenin-HEF was performed before surgery, on the 5th and 30th day post-hepatectomy. RESULTS Mortality and morbidity were 3.4 and 12.1%, respectively, in Group A and 2.3 and 11.4% in Group B (n.s.). HEF values (%), T1/2 (min) and Tmax (min) showed no significant differences between the two groups: Group A (preoperative: HEF = 99.2 ± 1.5%, T1/2 = 36.7 ± 21.3, Tmax = 15 ± 6. Day 5: HEF = 96.3 ± 10.8%, T1/2 = 76.4 ± 75.9; Tmax = 13.3 ± 4.9. Day 30: HEF = 98.4 ± 5.5%, T1/2 = 38.6 ± 7.7, Tmax = 12.8 ± 3.6) and Group B (preoperative: HEF = 95.3 ± 13%, T1/2 = 38.1 ± 24.1; Tmax = 15.9 ± 9.4. Day 5: HEF = 98.4 ± 2.6%, T1/2 = 106.6 ± 131.7; Tmax = 15.1 ± 6.2. Day 30: HEF = 99 ± 2.1%, T1/2 = 40.5 ± 27; Tmax = 15.5 ± 6.7). CONCLUSION Our results suggest that functional hepatocellular regeneration is early, fast and similar between elderly and younger patients. Thus, age alone, does not appear to represent an absolute contraindication to hepatectomy.
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Schmidt T, Strowitzki MJ, Reissfelder C, Rahbari NN, Nienhueser H, Bruckner T, Rahäuser C, Keppler U, Schneider M, Büchler MW, Ulrich A. Influence of age on resection of colorectal liver metastases. J Surg Oncol 2015; 111:729-39. [DOI: 10.1002/jso.23872] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 11/22/2014] [Indexed: 12/19/2022]
Affiliation(s)
- Thomas Schmidt
- Department of General; Visceral and Transplant Surgery; University of Heidelberg; Heidelberg Germany
| | - Moritz J. Strowitzki
- Department of General; Visceral and Transplant Surgery; University of Heidelberg; Heidelberg Germany
| | - Christoph Reissfelder
- Department of Visceral; Thoracic and Vascular Surgery; University Hospital Carl Gustav Carus; Technical University Dresden; Dresden Germany
| | - Nuh N. Rahbari
- Department of Visceral; Thoracic and Vascular Surgery; University Hospital Carl Gustav Carus; Technical University Dresden; Dresden Germany
| | - Henrik Nienhueser
- Department of General; Visceral and Transplant Surgery; University of Heidelberg; Heidelberg Germany
| | - Thomas Bruckner
- Department of Medical Biometry; University of Heidelberg; Heidelberg Germany
| | - Christoph Rahäuser
- Department of General; Visceral and Transplant Surgery; University of Heidelberg; Heidelberg Germany
| | - Ulrich Keppler
- Department of General; Visceral and Transplant Surgery; University of Heidelberg; Heidelberg Germany
| | - Martin Schneider
- Department of General; Visceral and Transplant Surgery; University of Heidelberg; Heidelberg Germany
| | - Markus W. Büchler
- Department of General; Visceral and Transplant Surgery; University of Heidelberg; Heidelberg Germany
| | - Alexis Ulrich
- Department of General; Visceral and Transplant Surgery; University of Heidelberg; Heidelberg Germany
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Shirabe K, Motomura T, Takeishi K, Morita K, Kayashima H, Taketomi A, Ikegami T, Soejima Y, Yoshizumi T, Maehara Y. Human early liver regeneration after hepatectomy in patients with hepatocellular carcinoma: special reference to age. Scand J Surg 2014; 102:101-5. [PMID: 23820685 DOI: 10.1177/1457496913482250] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND AND AIMS This study was conducted to clarify the effects of age on human liver regeneration. PATIENTS AND METHODS Thirty major hepatectomies, equal to or more than two segmentectomies for hepatocellular carcinoma, were performed. Ages ranged from 37 to 85 years and five octogenarians were included. The early regenerative index was defined: (liver volume after 7 days after hepatectomy - estimated remnant liver volume before hepatectomy)/estimated remnant liver volume, using three-dimensional computed tomographic volumetry. Farnesoid X receptor and forkhead box m1 expression in the liver, which has been reported to age-related decrease of liver regeneration in animal model, were examined using real-time polymerase chain reaction. The patients were divided into two groups: low early regenerative index (n = 15), early regenerative index less than 55% and high early regenerative index (n = 15), early regenerative index equal to or more than 55%. RESULTS The mean early regenerative index was 57%. Age (R (2) = 0.274, P = 0.003) and estimated blood loss (R (2) = 0.134, P = 0.0466) were inversely correlated with the early regenerative index, and the expression of farnesoid X receptor and forkhead box m1 was not. The incidence of post-hepatectomy liver failure in the low early regenerative index group was higher than that in the high early regenerative index group (P = 0.0421). CONCLUSIONS Age and intraoperative blood loss are inversely correlated with early liver regeneration in humans. In elderly patients, massive blood loss should be avoided in view of liver regeneration.
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Affiliation(s)
- K Shirabe
- Department of Surgery and Sciences, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Laparoscopic major hepatectomy for colorectal liver metastases in elderly patients: a single-center, case-matched study. Surg Endosc 2014; 29:1368-75. [PMID: 25149638 DOI: 10.1007/s00464-014-3806-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 08/06/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND The incidence of colorectal cancer liver metastases (CRLM) among elderly patients has increased; therefore, older patients are increasingly being considered for hepatic resection. However, data regarding the outcome of laparoscopic major hepatectomy (LMH) in elderly patients are limited. The aim of this study was to evaluate the safety and feasibility of LMH in elderly patients with CRLM. METHODS From January 1998 to September 2013, a total of 31 patients aged ≥ 70 years (elderly group) were matched with 62 patients < 70 years (young group) by demographics, tumor characteristics, and details of surgical procedures. RESULTS The elderly group was characterized by a higher incidence of hypertension (41.9 vs. 17.7 %, P = 0.022), ≥ 2 comorbidities (32.3 vs. 11.3 %, P = 0.021), and lower prevalence of metastatic rectal cancer (12.9 vs. 38.7 %, P = 0.015). Intraoperative variables, such as surgical duration (300 vs. 240 min, P = 0.920), blood loss (400 vs. 300 mL, P = 0.361), and transfusion rate (9.7 vs. 12.9 %, P = 0.726), were not notably different between the groups. Postoperative mortality (0 vs. 0 %), complications (54.8 vs. 41.9 %, P = 0.276), and major complications (27.4 vs. 16.1 %, P = 0.303, respectively) were comparable between the groups. The 3-year overall survival rates were 61.7 % in the young group (median 40 months) and 57.9 % in the elderly group (median 39 months), respectively (P = 0.842). CONCLUSIONS Our results clearly demonstrated that LMH for CRLM could be safely performed in elderly patients; thus, advanced age itself should not be regarded as a contraindication for LMH.
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Faraj W, Alameddine R, Mukherji D, Musallam K, Haydar A, Eloubiedi M, Shamseddine A, Halal A, Abou-Alfa GK, O'Reilly EM, Jamali F, Khalife M. Postoperative outcomes following pancreaticoduodenectomy: how should age affect clinical practice? World J Surg Oncol 2013; 11:131. [PMID: 23742036 PMCID: PMC3693928 DOI: 10.1186/1477-7819-11-131] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Accepted: 05/16/2013] [Indexed: 12/12/2022] Open
Abstract
Background Pancreaticoduodenectomy is an increasingly common procedure performed for both benign and malignant disease. There are conflicting data regarding the safety of pancreatic resection in older patients. Potentially modifiable perioperative risk factors to improve outcomes in older patients have yet to be determined. Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database for 2008 to 2009 was used for this retrospective analysis. Patients undergoing pancreaticoduodenectomy were identified and divided into those above and below the age of 65. Preoperative risk factors and postoperative morbidity and mortality were evaluated. Results Among 2,045 patients included in this analysis, 994 patients were >65 years (48.6%) while 1,051 were (less than or equal to) 65 years (51.4%). Thirty-day mortality was higher in the older age group compared to the younger age group 3.6% vs. 1.9% respectively, P = 0.017, odds ratio 1.94. Older patients had a higher incidence of unplanned intubation, ventilator support >48 h and septic shock compared with younger patients. On multivariate logistic regression, after adjusting for other 30-day postoperative occurrences (significant at the P <0.1 level) only septic shock was independently associated with a higher odds of mortality, unplanned intubation, and ventilator support >48 h in older patients compared with younger patients. Conclusions This report from a population-based database is the first to highlight postoperative sepsis as an independent risk factor for mortality and morbidity in older patients undergoing pancreatic resection. Careful perioperative management addressing this issue is essential for patients over the age of 65.
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Affiliation(s)
- Walid Faraj
- Liver Transplantation and Hepatopancreaticobiliary Surgery, Department of General Surgery, American University of Beirut, Cairo Street, Beirut 1107 2020, Lebanon.
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Laporte GA, Kalil AN. Hepatectomia em pacientes idosos. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2013; 26:136-9. [DOI: 10.1590/s0102-67202013000200014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Accepted: 11/27/2012] [Indexed: 12/15/2022]
Abstract
INTRODUÇÃO: A expectativa de vida da população tem aumentado nos últimos anos, como também houve progressão da incidência de neoplasias primárias e secundárias do fígado. A medicina vem acompanhando esse processo, mas ainda há receios quanto ao uso de tratamentos cirúrgicos agressivos em pacientes idosos, especialmente no que tange à cirurgia do fígado. OBJETIVO: Analisar a influência da idade na morbimortalidade de pacientes submetidos à ressecção hepática. MÉTODOS: Revisão bilbliográfica através dos sites do PubMed, Scielo e Bireme, com os descritores "elderly", "hepatectomy", "hepatic resection", "postoperative complications", "morbidity", "mortality". Foram selecionados os trabalhos que compararam os resultados de hepatectomia entre grupos de pacientes jovens e idosos. CONCLUSÃO: A idade não é fator predisponente à piora dos resultados na ressecção hepática.
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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: 42] [Impact Index Per Article: 3.8] [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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Cook EJ, Welsh FKS, Chandrakumaran K, John TG, Rees M. Resection of colorectal liver metastases in the elderly: does age matter? Colorectal Dis 2012; 14:1210-6. [PMID: 22251850 DOI: 10.1111/j.1463-1318.2012.02946.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AIM Despite the incidence of colorectal cancer increasing with age the proportion of patients undergoing surgery for colorectal liver metastases decreases dramatically in the elderly. Is this referral or selection bias justified? METHOD A prospective database of resection for colorectal liver metastases at a single centre was retrospectively analysed to compare the outcome in patients aged ≥75 years (group E) with those aged <75 years (group Y). Data were analysed using the Kaplan-Meier method with Cox regression modelling. RESULTS Of 1443 resections, 151 (10.5%) in group E were compared with 1292 (89.5%) in group Y. The two groups were matched apart from higher American Society of Anesthesiology scores (P=0.001) and less use of chemotherapy (P=0.01) in the elderly. Perioperative morbidity and 90-day mortality were higher in the elderly compared with the younger group (32.5%vs 21.2%, P=0.02, and 7.3%vs 1.3%, P=0.001). In the last 5 years, mortality in the elderly improved and was no longer significantly different from that of the younger patients [n=2/76 (2.6%) vs n=9/559 (1.6%); P=0.063]. The 5-year survival was similar in groups E and Y for cancer-specific (41.4%vs 41.6%, P=0.917), overall (37.0%vs 38.2%) and median (44.1 months vs 43.6 months, P=0.697) survival respectively. CONCLUSION In the elderly liver resection for metastatic disease can be performed with acceptable mortality and morbidity with as good a prospect of survival as for younger patients.
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Affiliation(s)
- E J Cook
- Department of Hepatobiliary Surgery, Basingstoke and North Hampshire Foundation Trust, Basingstoke, Hampshire, UK
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Weiler N, Waldmann J, Bartsch DK, Rolfes C, Fendrich V. Outcome in patients with long-term treatment in a surgical intensive care unit. Langenbecks Arch Surg 2012; 397:995-9. [PMID: 22699745 DOI: 10.1007/s00423-012-0966-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Accepted: 05/21/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study aimed to evaluate the outcome of patients with abdominal, thoracic or vascular operations and long-term intensive care unit (ICU) treatment. PATIENTS AND METHODS The present retrospective observational cohort study was performed at the authors' surgical ICU at the Marburg University Medical Centre. All patients who stayed at the ICU longer than 48 h and underwent visceral, thoracic or vascular surgery between January 2005 and December 2006 were retrospectively analysed. Patients with an ICU stay of 20 or more days were defined as the long-term study group. Clinical variables were tested for prognostic value. RESULTS In 2 years, 852 patients were treated at the intensive care unit. Follow-up was available in 502 patients, with 219 patients treated for two and more days and a median of 16.4 days. Sixty-seven long-term patients were compared to 152 (69.4 %) patients treated between 2 and 20 days. Overall survival after 12 months was 50.2 % (110/219), while 65.8 % (144/219) were discharged from ICU. Older age, longer treatment at the ICU and increased simplified acute physiology score (SAPS) at admission were associated with decreased 12-month survival, while no statistical differences were observed for the underlying and malignant disease by univariate analysis. The risk of death was 29, 56 and 61 % for patients treated 2-4, 5-19 and ≥20 days at the ICU. Decreased survival of patients treated for 5-19 and ≥20 days were confirmed by logrank test (p = 0.001). CONCLUSIONS Patients with long-term ICU stay showed decreased survival than patients who are treated less than 5 days but similar survival as patients which stayed between 5 and 19 days. Malignant disease is not associated with an unfavourable 12-month survival while older age, higher SAPS index at discharge and longer stay at ICU are. Long-term ICU survivors have no increased risk to succumb after discharge from ICU.
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Affiliation(s)
- Nina Weiler
- Department of Surgery, Philipps University Marburg, Baldingerstraße, Marburg, Germany.
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Kowdley GC, Merchant N, Richardson JP, Somerville J, Gorospe M, Cunningham SC. Cancer surgery in the elderly. ScientificWorldJournal 2012; 2012:303852. [PMID: 22272172 PMCID: PMC3259553 DOI: 10.1100/2012/303852] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2011] [Accepted: 10/18/2011] [Indexed: 12/21/2022] Open
Abstract
The proportions both of elderly patients in the world and of elderly patients with cancer are both increasing. In the evaluation of these patients, physiologic age, and not chronologic age, should be carefully considered in the decision-making process prior to both cancer screening and cancer treatment in an effort to avoid ageism. Many tools exist to help the practitioner determine the physiologic age of the patient, which allows for more appropriate and more individualized risk stratification, both in the pre- and postoperative periods as patients are evaluated for surgical treatments and monitored for surgical complications, respectively. During and after operations in the oncogeriatric populations, physiologic changes occuring that accompany aging include impaired stress response, increased senescence, and decreased immunity, all three of which impact the risk/benefit ratio associated with cancer surgery in the elderly.
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Affiliation(s)
- Gopal C Kowdley
- Department of Surgery, Saint Agnes Hospital Center, 900 Caton Avenue, Baltimore, MD 21229, USA
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Kulik U, Framke T, Grosshennig A, Ceylan A, Bektas H, Klempnauer J, Lehner F. Liver resection of colorectal liver metastases in elderly patients. World J Surg 2011; 35:2063-72. [PMID: 21717239 DOI: 10.1007/s00268-011-1180-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The percentage of elderly patients with colorectal liver metastases (CLM) has increased. Liver resection remains the only curative therapy; data evaluating the outcome in this age group is limited. Aim of the present study was to determine if postoperative morbidity, mortality, and other independent predictors influence survival in patients ≥ 70 years undergoing liver resection for CLM. METHODS Clinical data on primary tumor and metastases of 939 patients after liver resection for CLM between 1994 and 2008 were retrospectively collected and subdivided in three age-groups (≥ 70, 40-69, <40). Independent predictors of survival were evaluated with overall and age-specific univariate and multivariate Cox regression models. RESULTS A total of 939 patients underwent liver resection for CLM, 20.3% aged ≥ 70 years. Overall postoperative mortality and morbidity were 1.08 and 14.82%, revealing no age-related differences. With 5-year survival of 31.8% in the elderly and 37.5% in the mid-age population, age ≥ 70 years was linked with decreased survival (Hazard Ratio [HR] = 1.305; P = 0.0186). Multivariate overall analyses showed size of CLM > 50 mm (HR = 1.376; P = 0.0060), a high amount of transfusion during surgery (HR = 1.676; P = 0.0110), duration of surgery >210 min (HR = 1.241; P = 0.0322), primary UICC (International Union Against Cancer) stage IV (HR = 2.297; P < 0.0001), and performance of repeat resections (HR = 0.652; P = 0.0107) as independent predictors of survival. In the elderly group, effects of UICC IV (HR = 3.260; P = 0.0148) and high numbers of transfusions (HR = 3.647; P = 0.0129) were confirmed; the others did not show statistical significance. CONCLUSIONS Resection of CLM at older age is feasible with morbidity and mortality rates similar to those in younger patients. Although age ≥ 70 was shown to be associated with poorer overall outcome, reasonable 5-year survival was observed.
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Affiliation(s)
- U Kulik
- Department of General-, Visceral- and Transplantation Surgery, Hannover Medical School, Hannover, Germany
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Portolani N, Baiocchi GL, Coniglio A, Tiberio GAM, Prestini K, Gheza F, Benetti A, Maria Giulini S. Limited liver resection: a good indication for the treatment of hepatocellular carcinoma in elderly patients. Jpn J Clin Oncol 2011; 41:1358-65. [PMID: 22039578 DOI: 10.1093/jjco/hyr154] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE Hepatocellular carcinoma is often diagnosed in elderly people. METHODS One hundred and seventy-five patients older than 70 years were operated on for hepatocellular carcinoma (Group 1). The results were compared with 276 resected patients younger than 70 (Group 2) and to 108 aged patients with chronic liver disease without hepatocellular carcinoma (Group 3). RESULTS Hepatocellular carcinoma in the elderly is more frequently associated with hepatitis C virus, less frequently capsulated and less frequently diagnosed by screening programs than in young patients. After resection, no difference was noted in post-operative complications and in mortality rates (3.2%); major hepatic resection in cirrhosis carried a high risk of death (22%). Five years survival was 42%, comparable with the young surgical patients but significantly lower than the medical patients in Group 3. Recurrence of hepatocellular carcinoma was the main reason of death, but it was suitable for a radical treatment in 37.6% of cases, including surgery, with a mean survival of 31 months. CONCLUSIONS Liver resection is a valid option for the treatment of hepatocellular carcinoma in the elderly; major resections in cirrhotic old patients must be reserved for selected cases. Recurrence may be suitable of a radical approach, including surgery.
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Affiliation(s)
- Nazario Portolani
- Department of Medical and Surgical Sciences, Surgical Clinic, Brescia University, Brescia, Italy
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Toyokawa T, Fujita I, Morikawa T, Okamoto A, Miyasaka R, Watanabe K, Horii J, Gobaru M, Terao M, Murakami T, Tomoda J. Clinical outcomes of ESD for early gastric neoplasms in elderly patients. Eur J Clin Invest 2011; 41:474-8. [PMID: 21128933 DOI: 10.1111/j.1365-2362.2010.02428.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) is a standard treatment in Japan for early gastric neoplasms. With an increase in elderly population, the number of elderly patients in whom ESD performed has also steadily increased. AIMS AND METHODS The aim of study was to evaluate the effectiveness of and problems associated with ESD for early gastric neoplasms in elderly patients. Subjects were 514 patients (586 lesions) with early gastric neoplasms performed ESD at two institutions. The patients were classified into an elderly group (age ≥ 75 years) and a nonelderly group (age < 75 years). We compared the characteristics of patients and lesions, treatment results, ESD-related complications and prognosis between the two groups. RESULTS The elderly group included 200 patients (229 lesions), and the nonelderly group included 314 patients (357 lesions). The incidences of underlying disease, such as hypertension and heart disease, and the rate of antiplatelet agents use were significantly higher in the elderly group. En bloc and curative resection rates were high in both groups. The bleeding rate was significantly higher in the elderly group. Residual disease or recurrence rates were very low in both groups. The death rate due to other diseases was significantly higher in the elderly group. CONCLUSIONS This study demonstrates the efficacy of ESD in both elderly and nonelderly patients. However, we must be attentive to ESD-related bleeding, death caused by other diseases, and underlying diseases when we perform ESD in elderly patients.
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Affiliation(s)
- Tatsuya Toyokawa
- Department of Gastroenterology, National Hospital Organization Fukuyama Medical Center, Fukuyama city, Hiroshima, Japan.
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Kow AWC, Sadayan NA, Ernest A, Wang B, Chan CY, Ho CK, Liau KH. Is pancreaticoduodenectomy justified in elderly patients? Surgeon 2011; 10:128-36. [PMID: 22525414 DOI: 10.1016/j.surge.2011.02.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Revised: 01/29/2011] [Accepted: 02/25/2011] [Indexed: 12/18/2022]
Abstract
BACKGROUND Although mortality & morbidity for pancreaticoduodenectomy (PD) have improved significantly over the last two decades, the concern for elderly undergoing PD remains. This study examines the outcome of the elderly patients who had pancreaticoduodenectomy in our institution. METHODS A prospective database comprising 69 patients who underwent pancreaticoduodenectomy between 2001 and May 2008 was analyzed. Using WHO definition, elderly patient is defined as age 65 and above in this study. Two groups of patients were compared [Group 1: Age ≤65 & Group 2: Age >65]. RESULTS The mean age of our patients was 62 ± 11 years. There were 37 (54%) patients in Group 1 and 32 (46%) patients in Group 2. There was no statistical difference between the two groups in terms of gender and race. However, there were more patients in the Group 2 with >2 comorbidities (p = 0.03). The median duration of operation was significantly longer in Group 2 (550 min vs 471 min, p = 0.04). Morbidity rate in Group 2 was higher (56% vs. 44%, p = 0.04). There was higher proportion of post-operative pancreatic fistula (POPF) in the elderly group (37.5% vs. 16.7%, p = 0.05). Majority of them are Grade A POPF according to the ISG definition. The median post-operative length-of-stay (LOS) in hospital was 9 days longer in Group 2 (p = 0.01). Mortality rate between the 2 groups of patients was comparable (0% vs. 3%, p = 0.28). CONCLUSION Elderly patients are at increased risk of morbidity in pancreatocoduodenectomy, in particular POPF. However, morbidity and mortality rates are acceptable. It is therefore justified to offer PD to elderly patients who do not have significant cardiopulmonary comorbidities.
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Affiliation(s)
- A W C Kow
- Department of Surgery, Digestive Disease Centre, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 304833, Singapore
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Reddy SK, Barbas AS, Turley RS, Gamblin TC, Geller DA, Marsh JW, Tsung A, Clary BM, Lagoo-Deenadayalan S. Major liver resection in elderly patients: a multi-institutional analysis. J Am Coll Surg 2011; 212:787-95. [PMID: 21435922 DOI: 10.1016/j.jamcollsurg.2010.12.048] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2010] [Revised: 11/24/2010] [Accepted: 12/29/2010] [Indexed: 12/30/2022]
Abstract
BACKGROUND Because of the aging United States population, increase in overall life expectancy, and rising incidence of hepatobiliary tumors, more elderly patients are considered for hepatic resection. The objective of this study was to assess the influence of age on postoperative outcomes after major hepatectomy among a contemporary cohort from 2 high volume centers. STUDY DESIGN Demographics, diagnoses, surgical treatments, and postoperative outcomes of patients who underwent major hepatic resection were reviewed. RESULTS There were 856 patients who underwent major hepatectomy (resection of 3 or more segments) from 2002 to 2009. Postoperative mortality and morbidity occurred in 53 (6.2%) and 403 (47.1%) patients, respectively. Increasing age was independently associated with postoperative mortality (p = 0.0345). Each 1-year and 10-year increase in age resulted in an odds ratio of mortality after major hepatic resection of 1.036 (95% CI [1.003-1.071]) and 1.426 (95% CI [1.026-1.982]), respectively. This relationship was independent of American Society of Anesthesiology (ASA) score. Increasing age was associated with postoperative sepsis (p = 0.0224, odds ratio for each year 1.025 [range 1.003 to 1.048]) after major hepatic resection, but not overall postoperative morbidity. CONCLUSIONS In the contemporary era, increasing age is independently associated with postoperative mortality after major hepatic resection at high volume academic centers.
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Affiliation(s)
- Srinevas K Reddy
- Department of Surgery, Duke University Medical Center, Durham, NC, USA.
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p66(Shc) has a pivotal function in impaired liver regeneration in aged mice by a redox-dependent mechanism. J Transl Med 2010; 90:1718-26. [PMID: 20567235 DOI: 10.1038/labinvest.2010.119] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Liver regeneration involves complicated processes and is affected by various patho-physiological conditions. This study was designed to examine the molecular mechanisms underlying the aging-associated impairment of liver regeneration. Male C57BL/6J mice were used as young and aged mice (<10 weeks and >20 months old, respectively). These mice were subjected to 70% partial hepatectomy (PH). Liver regeneration and liver injury/stresses were evaluated chronologically after PH. Post-hepatectomy liver regeneration was markedly impaired in aged mice. Though the extent of hepatocyte proliferation in the regenerating liver was similar in aged and young mice, cell growth was absent in aged mice. Oxidative stress (OS) was observed immediately after hepatectomy, followed by marked apoptosis in aged mice. Signaling molecules regarding cell proliferation (mitogen-activated protein kinase, STAT3, p46/52(Shc)) and anti-oxidation (catalase, superoxide dismutase, Ref-1, glutathione peroxidase) were expressed/activated after hepatectomy in livers of both aged and young mice. Akt was not activated in aged-mouse liver, but its expression was similar to that in young mice. p66(Shc), known as an age-/oxidant-associated protein, was strongly phosphorylated. By knocking down p66(Shc), the impairment of liver regeneration was normalized. OS immediately after hepatectomy induced subsequent liver injury (apoptosis), and deletion of p66(Shc) suppressed both OS and hepatocyte apoptosis in the regenerating liver of aged mice. Though we need additional data in other animal models to fully understand the mechanism, p66(Shc) may have a pivotal function in the impairment of liver regeneration in aged mice by triggering OS and subsequent apoptosis. This data may provide a clue to understanding the mechanism underlying the association between aging and the impairment of liver regeneration.
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Cho SW, Steel J, Tsung A, Marsh JW, Geller DA, Gamblin TC. Safety of liver resection in the elderly: how important is age? Ann Surg Oncol 2010; 18:1088-95. [PMID: 21046265 DOI: 10.1245/s10434-010-1404-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2010] [Indexed: 12/15/2022]
Abstract
BACKGROUND With the aging population, more elderly patients are being considered for hepatic resection. We investigated whether advanced age was associated with higher rate and severity of postoperative complications. METHODS A total of 75 patients aged ≥70 years (group E) were matched with 75 patients aged <70 years (group Y) by the extent of liver resection and by operative indications. Primary outcome measures were rates and severity of complications. Secondary outcome measures were length of hospital stay and discharge destination. Univariate analysis was also performed to identify variables associated with higher surgical risk. RESULTS Male-to-female ratio was 43:32 in both groups. Overall complication rates were 44 and 33.3% in group E and Y, respectively (P = 0.241; odds ratio = 1.57; 95% confidence interval [95% CI], 0.81-3.05). There was no mortality in both groups. The only postoperative age-related morbidity was confusion in the elderly. There was no difference in the rates of severe complications (grade ≥3) between group E and group Y (16 vs. 14.7%; P = 0.744; odds ratio = 1.11; 95% CI, 0.46-2.70). Median length of hospital stay were 7 and 6 days, respectively (P = 0.01). Nineteen percent and 1% of patients in group E and group Y were discharge to rehabilitation facilities, respectively (P = 0.001). Univariate analysis showed that preoperative systemic chemotherapy and longer operative time were associated with higher morbidity in the elderly. CONCLUSIONS Liver resection can be performed in patients aged ≥70 years as safely as in younger patients. Duration and timing of systemic chemotherapy before liver resection should be optimized to minimize postoperative morbidity.
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Affiliation(s)
- S W Cho
- UPMC Liver Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Sandroussi C, Brace C, Kennedy ED, Baxter NN, Gallinger S, Wei AC. Sociodemographics and comorbidities influence decisions to undergo pancreatic resection for neoplastic lesions. J Gastrointest Surg 2010; 14:1401-8. [PMID: 20571928 DOI: 10.1007/s11605-010-1255-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2009] [Accepted: 06/07/2010] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Pancreatic resection is being performed with increasing frequency and safety. Technical outcomes and long-term survival for neoplastic lesions are well reported; however, reasons why patients do not undergo surgery for potentially resectable lesions are not well understood. The aim of this study was to determine the factors contributing to the decision not to operate for resectable pancreatic neoplasms. METHODS From 2004 to 2008, all patients with resectable pancreatic neoplasms at a single high-volume hepatopancreaticobiliary center were evaluated. The impact of patient factors, sociodemographics, medical comorbidities (Charlson combined comorbidity index (CCI) and ACCI), disease factors (tumor characteristics), and surgical factors (type of resection required) on the decision to undergo pancreatectomy were analyzed using univariate and multivariate binary logistic regression analysis. RESULTS Three hundred seventy-five patients with resectable pancreatic lesions were identified. The median age was 62 years (21-93); 203 out of 375 (54.1%) were males. Fifty-five (14.7%) did not undergo resection. On univariate analysis, age (odds ratio (OR) 1.116, p < 0.001), non-English speaking background (NESB; OR 4.276, p = 0.001), tumor type (p = 0.001 increased for cystic neoplasms including intraductal papillary mucinous neoplasm), CCI score (OR 1.239, p = 0.001), and ACCI score (OR 1.433, p < 0.001) were associated with an increased risk of not undergoing resection. Gender, age, marital status, and urban residence were not predictive. On multivariate analysis, NESB (p = 0.018) and the ACCI (p = 0.002) remained predictive of not undergoing resection. The majority of patients did not undergo surgery because the patient declined in 25 out of 55 (45.5%), and resection was not offered in 15 out of 55 (27.3%). In the remainder, medical contraindications precluded surgery. Advanced age, tumor type, comorbidities (27.3%), age (21.8%), surgical risk (29.1%), frailty (18.2%), and uncertain diagnosis (5.5%) were cited as reasons for not proceeding with surgery. CONCLUSION Patients with a higher ACCI and those from a NESB are less likely to undergo surgery for resectable neoplastic lesions of the pancreas. These factors must be taken into consideration in the decision-making process when considering surgery for patients with pancreatic neoplasms. Novel strategies should be employed to optimize access to surgery for patients with resectable pancreatic neoplasms.
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Affiliation(s)
- Charbel Sandroussi
- Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
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Clavien PA, Oberkofler CE, Raptis DA, Lehmann K, Rickenbacher A, El-Badry AM. What is critical for liver surgery and partial liver transplantation: size or quality? Hepatology 2010; 52:715-29. [PMID: 20683967 DOI: 10.1002/hep.23713] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Pierre-Alain Clavien
- Swiss Hepato-Pancreatico-Biliary and Transplantation Center, Department of Surgery, University of Zurich, Zurich, Switzerland.
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