Surgical quality data and survival after pancreatic cancer resections: a comparison of results for octogenarians and younger patients

Prognosis of pancreaticoduodenectomy in octogenarians for pancreatic ductal adenocarcinoma with propensity score matched analysis

BACKGROUND

This retrospective study investigates factors affecting surgical and oncological outcome after performing pancreaticoduodenectomy in octogenarian patients diagnosed with pancreatic ductal adenocarcinoma.

METHODS

From January 2009 to December 2018, patients who underwent pancreaticoduodenectomy for pancreatic ductal adenocarcinoma were included. Data were analysed by comparing clinicopathological characteristics, complications, survival, recurrence, adjuvant treatment between octogenarians and the younger group. Propensity score matched analysis was performed due to the small size of the octogenarian group.

RESULTS

A total of 666 patients were included in this study and 24 (3.6%) were included in the octogenarian group. Short term complication rates (P = 0.119) and hospital stay (P = 0.839) did not differ between two groups. Overall survival between the two groups showed significant difference (<80 median 25 months versus ≥80 median 13 months, P = 0.045). However, after propensity score matched analysis, the two groups did not differ in overall survival (<80 median 18 months versus ≥80 median survival 16 months, P = 0.565) or disease-free survival (P = 0.471). Among the octogenarians, six patients survived longer than 24 months even without satisfying all favourable prognostic factors.

CONCLUSION

Considering the general condition of octogenarians diagnosed with pancreatic ductal adenocarcinoma, select patients should be treated more aggressively for the best chance of receiving curative treatment.

Management of adenocarcinoma of the pancreatic tail in the elderly

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Short-term outcomes after pancreatoduodenectomy in octogenarians: multicentre case-control study

BACKGROUND

Pancreatoduodenectomy (PD) is frequently the surgical treatment indicated for a number of pathologies. Elderly patients may be denied surgery because of concerns over poor perioperative outcomes. The aim of this study was to evaluate postoperative clinical outcomes and provide evidence on current UK practice in the elderly population after PD.

METHODS

This was a multicentre retrospective case-control study of octogenarians undergoing PD between January 2008 and December 2017, matched with younger controls from seven specialist centres in the UK. The primary endpoint was 90-day mortality. Secondary endpoints were index admission mortality, postoperative complications, and 30-day readmission rates.

RESULTS

In total, 235 octogenarians (median age 81 (range 80-90) years) and 235 controls (age 67 (31-79) years) were included in the study. Eastern Cooperative Oncology Group performance status (median 0 (range 0-3) versus 0 (0-2); P = 0.010) and Charlson Co-morbidity Index score (7 (6-11) versus 5 (2-9); P = 0.001) were higher for octogenarians than controls. Postoperative complication and 30-day readmission rates were comparable. The 90-day mortality rate was higher among octogenarians (9 versus 3 per cent; P = 0.030). Index admission mortality rates were comparable (4 versus 2 per cent; P = 0.160), indicating that the difference in mortality was related to deaths after hospital discharge. Despite the higher 90-day mortality rate in the octogenarian population, multivariable Cox regression analysis did not identify age as an independent predictor of postoperative mortality.

CONCLUSION

Despite careful patient selection and comparable index admission mortality, 90-day and, particularly, out-of-hospital mortality rates were higher in octogenarians.

There Is No Increase in Perioperative Mortality After Pancreaticoduodenectomy in Octogenarians: Results From the Swedish National Registry for Tumors in the Pancreatic and Periampullary Region

Objective

The aim of this observational study was to compare postoperative mortality and complications between octogenarians and younger patients following pancreaticoduodenectomy (PD).

Summary Background Data

With the growing elderly population and improved operative and postoperative results, PD is performed more frequently in octogenarians. Despite recent studies, it is uncertain whether elderly patients experience worse postoperative outcomes than younger patients.

Methods

All patients registered in the Swedish National Registry for tumors in the pancreatic and periampullary region from 2010 to 2018 who underwent PD were included in the analysis.

Results

Out of 13,936 patients included in the registry, 2793 patients underwent PD and were divided into the following age groups: <70 (n = 1508), 70-79 (n = 1137), and ≥80 (n = 148) years old. There was no significant difference in in-hospital, 30- or 90-day mortality among groups. The 2 older groups had a higher rate of medical and some surgical complications but not a significantly higher rate of complications ≥IIIa according to the Clavien-Dindo classification system. The 2 older groups had lower body mass index, higher American Society of Anesthesiologists and Eastern Cooperative Oncology Group scores, lower smoking rates, and a higher rate of preoperative biliary drainage than the <70-year-old group (all P < 0.001). The operation time was shorter in the oldest group.

Conclusions

Despite the worse preoperative condition of octogenarians than younger patients, short-term mortality and serious complications were not increased. The shorter operation time, however, may indicate that patients in the oldest group were more strictly selected. With careful preoperative consideration, especially regarding cardiovascular morbidity, more octogenarians can potentially be safely offered PD.

Does Major Pancreatic Surgery Have Utility in Nonagenarians with Pancreas Cancer?

OBJECTIVE

This study aims to define the role of surgery and assess different therapies for nonagenarians with localized, nonmetastatic pancreatic adenocarcinoma (PDAC).

METHODS

The National Cancer Database (NCDB) was queried for patients ≥ 90 years of age with nonmetastatic, localized PDAC from 2004-2016. Postoperative mortality was assessed at 30 and 90 days in patients receiving pancreatoduodenectomy or total pancreatectomy. Overall survival (OS) was compared between three treatment groups: surgery alone, chemotherapy alone, and chemoradiation (chemoRT) alone.

RESULTS

Of 380,524 patients with PDAC, 98 patients ≥ 90 years of age underwent curative-intent resection; 55% were female and 75% had a Charlson-Deyo comorbidity score of 0. A total of 17% received postoperative chemotherapy, 51.1% had poorly differentiated tumors with a median tumor size of 3 cm, 55.1% had positive lymph nodes, and 19.4% had positive resection margins. Postoperative median length of stay was 11 days. Postoperative 30- and 90-day mortality was 10.0% and 18.9%, respectively. Median OS for the surgery alone group was 11.6 months compared with 20.4 months in those receiving adjuvant therapy (p = 0.01). Among nonoperative PDAC patients, median OS in patients receiving chemotherapy only (n = 207) was 7.2 months, while chemoRT only (n = 100) was similar to surgery only (11 versus 11.6 months, p = 0.97).

CONCLUSIONS

Even in well-selected nonagenarians, pancreatoduodenectomy or total pancreatectomy carries a high mortality rate. While adjuvant therapy after resection provides the best survival, it is seldom achieved, and chemoRT alone affords identical survival statistics as surgery alone. These data suggest it is reasonable to consider chemoRT as initial therapy, then reassess candidacy for resection if performance status allows.

Postoperative outcomes in elderly patients undergoing pancreatic resection for pancreatic adenocarcinoma: A systematic review and meta-analysis

BACKGROUND

Pancreatic cancer is a disease of the elderly. Surgical resection is usually offered to patients in early stage disease; however, pancreatic resection in the elderly is controversial.

METHODS

MEDLINE, EMBASE and Cochrane Library, were searched for studies comparing short- and long-term outcomes of elderly (above the age of 70) with non-elderly patients (below the age of 70) following pancreatic resection for pancreatic adenocarcinoma over the period from the inception of electronic database to 2017. Twelve articles documenting 4860 patients were included. A meta-analysis of data on patient characteristics, operative techniques, and perioperative outcomes were analysed. Our primary endpoint was postoperative mortality, defined as 30-day mortality or in-hospitalisation mortality.

RESULTS

There were 919 patients in the elderly group and 3941 patients in the non-elderly group. Elderly patients had worse ASA scores (p < 0.001) and more cardiovascular comorbidities (p = 0.002). Tumour size, T-stage, N-stage and tumour grade were similar between the elderly and non-elderly group (p > 0.05). Fewer elderly patients received a concomitant venous resection with their pancreatectomy (RR0.80, p = 0.003, I2 = 0%), achieved a negative margin status (RR0.76, p = 0.02, I2 = 28%) and underwent adjuvant chemotherapy treatment (RR0.69, p < 0.001, I2 = 42%). Overall complication (RR1.15, p < 0.001, I2 = 47%), in particular, respiratory complications (RR2.33, p = 0.004, I2 = 39%), was higher in the elderly group. There was no difference in postoperative pancreatic fistula formation, postoperative haemorrhage, intraabdominal abscess and length of hospital stay between both groups (p > 0.05). Postoperative mortality was similar between both groups (p = 0.17). Subgroup analysis according to the time of enrolment (<2000, ≥2000) showed a significant subgroup effect (Chi2 = 3.44, p = 0.06, I2 = 70.9%) and revealed that postoperative mortality in the elderly group improved over time (Before 2000: n = 1654, subtotal RR2.27, p = 0.02, I2 = 0%; From 2000 onwards: n = 3206, subtotal RR1.00, p = 0.99, I2 = 0%).

CONCLUSION

Fewer elderly patients received chemotherapy and portal vein resection to achieve a clear margin. Pancreatic resection of pancreatic adenocarcinoma can be performed safely on elderly patients with acceptable risks in experienced centres by specialist hepatobiliary surgeons. Age alone should not be the only determinant for the selection of patients for surgical treatment of pancreatic adenocarcinoma.

Association of Increasing Frailty with Detrimental Outcomes after Pancreatic Resection

An association between detrimental outcomes and frailty has been documented; however, the impact specific to pancreatic surgery is unknown. Using NSQIP data, patients were classified as non-, mildly, moderately, or severely frail. A total of16,028 patients were included inthe study; most of the patients were white (78.5%) and underwent pancreaticoduodenectomy (PD) (67%). Complications occurred in 17.6 per cent cases, and the median length of stay (LOS) was 11.89 days. Prolonged LOS and mortality occurred in 9.1 and 2.3 per cent of the cases. In the PD group, most of the patients were mildly frail (40.6%), followed by nonfrail (39.83%), whereas in the distal pancreatectomy (DP) group, the majority were nonfrail (43.82%), followed by mildly frail (39.37%) ( P < 0.0001). The 30-day complications, mortality, and LOS were significantly higher in patients undergoing PD compared with DP (19.5 vs 14.3%, 2.8 vs 1.2%, and 13.4 vs 8.7 days, respectively; P < 0.0001). PD conferred a significantly higher risk of death in all frailty groups compared with DP [nonfrail: odds ratio (OR) 1.76, mildly frail: OR 1.03, moderately frail: OR 2.03, P < 0.05], with the exception of severely frail patients. Compared with DP, PD conferred a significant risk of complication in all the frailty groups. Increases in frailty are associated with poorer outcomes after pancreatectomy.

The outcomes of pancreaticoduodenectomy in patients aged 80 or older: a systematic review and meta-analysis

BACKGROUND

There is an increasing needed to consider pancreaticoduodenectomy (PD) for the treatment of pancreatic and periampullary malignancy in patients aged 80 and over, given the increasing aging population.

METHODS

A systematic literature search was undertaken to identify selected studies that compared the outcomes of patients aged 80 years or over to those younger undergoing PD.

RESULTS

In total 18 studies were included for evaluation. Octogenarian or older populations had significantly higher 30-day post-operative mortality rate (OR: 2.22, 95% CI = 1.48-3.31, p < 0.001) and length of hospital stay (OR: 2.23, 95% CI = 1.36-3.10, p < 0.001). The overall post-operative complication rate was higher in the older group compared to the younger population (OR: 1.51, 95% CI = 1.25-1.83, p < 0.001). Elderly patients were more likely to develop pneumonia (OR: 1.72, 95% CI = 1.39-2.13, p < 0.001) and experience delayed gastric emptying (DGE) (OR: 1.77, 95% CI = 1.35-2.31, p < 0.001). The incidence of post-operative pancreatic fistula and bile leak were not significantly different between the groups. Rehabilitation and home nursing care services was also more frequently required by the older patient group at the time of hospital discharge.

CONCLUSION

Patients aged 80 years and older have approximately double the risk of 30-day post-operative mortality and 50% increased rate of complications following PD. Careful patient selection is required when offering surgery in this age group.