Surgical results of pancreatoduodenectomy in elderly patients

Postoperative Dietary Intake Achievement: A Secondary Analysis of a Randomized Controlled Trial

Sufficient postoperative dietary intake is crucial for ensuring a better surgical outcome. This study aimed to investigate the postoperative dietary intake achievement and predictors of postoperative dietary intake among gynecologic cancer patients. A total of 118 participants were included in this secondary analysis. Postoperative dietary data was pooled and re-classified into early postoperative dietary intake achievement (EDIA) (daily energy intake (DEI) ≥ 75% from the estimated energy requirement (EER)) and delay dietary intake achievement (DDIA) (DEI < 75% EER) There was a significant difference in postoperative changes in weight (p = 0.002), muscle mass (p = 0.018), and handgrip strength (p = 0.010) between the groups. Postoperative daily energy and protein intake in the EDIA was significantly greater than DDIA from operation day to discharged (p = 0.000 and p = 0.036). Four significant independent postoperative dietary intake predictors were found: preoperative whey protein-infused carbohydrate loading (p = 0.000), postoperative nausea vomiting (p = 0.001), age (p = 0.010), and time to tolerate clear fluid (p = 0.016). The multilinear regression model significantly predicted postoperative dietary intake, F (4, 116) = 68.013, p = 0.000, adj. R² = 0.698. With the four predictors’ recognition, the integration of a more specific and comprehensive dietitian-led supportive care with individualized nutrition intervention ought to be considered to promote functional recovery.

Chronological Changes in Appendiceal Pathology Among Patients Who Underwent Appendectomy for Suspected Acute Appendicitis

BACKGROUND

Given recent advances in imaging and the development of diagnostic parameters, the rate of unnecessary appendectomy (i.e., negative appendectomy) has been decreasing. However, the incidence of acute appendicitis (AA) in elderly patients is rising due to the aging of society. We aimed to identify chronological changes in demographics and appendiceal pathology among patients who underwent appendectomy for suspected AA.

METHODS

Data from 881 patients who underwent appendectomy for suspected AA between January 2006 and December 2017 were analyzed. The final diagnosis was based on intraoperative findings, pathological reports, and clinical course. Negative appendectomy was defined as the absence of appendiceal diseases including inflammation, fibrosis, and neoplasm. We compared demographics and appendiceal pathology between early (2006-2011) and late study phases (2012-2017).

RESULTS

The mean age of patients with pathologically proven AA (n = 761) was significantly greater in the late phase than in the early phase (38.6 ± 19.8 years vs. 44.0 ± 20.3 years, p = 0.0002), and the ratio of patients with AA aged ≧ 75 years was also increased (from 5.6 to 8.6%, p = 0.1120). The incidences of complicated appendicitis (defined as perforated or gangrenous appendicitis) and appendiceal diverticulitis (AD) were increased in the late phase compared to those in the early phase (61.3% vs. 77.2% and 3.7% vs. 6.6%, respectively). The negative appendectomy rate was significantly reduced in the late phase compared to that in the early phase (10.0% vs. 2.5%, p < 0.0001).

CONCLUSIONS

During a 12-year period, the mean age of patients with AA and the incidences of complicated appendicitis and AD increased, whereas the negative appendectomy rate decreased.

Grade IV traumatic pancreatic injury with primary duodenum malignant lymphoma following pancreatoduodenectomy: a case report

BACKGROUND

Traumatic pancreatic injury with a main pancreatic duct injury has a high incidence of mortality and requires a prompt and appropriate treatment. However, the best approach, and treatment options, which may be limited, remains controversial especially for the elderly patients. Herein, we present a case of traumatic pancreatic injury in an elderly patient for whom pancreatoduodenectomy was safe and effective.

CASE PRESENTATION

An 87-year-old man was diagnosed with a traumatic pancreatic injury with a main pancreatic duct injury. In addition, the horizontal segment of the duodenum was largely eradicated. There were no comorbidities, and his vital signs were stable. A pancreatoduodenectomy was performed. The postoperative course was uneventful, and he was discharged. Pathological examination revealed a primary follicular lymphoma of the duodenum.

CONCLUSIONS

This case demonstrated that pancreatoduodenectomy could be performed safely for a severe pancreatic injury in an elderly patient. However, special attention should be paid to select the optimal surgical procedure. Further, this was a rare case, as initially a primary follicular lymphoma of the duodenum was suspected as a duodenal injury coexisting with a traumatic pancreatic injury because of the increased duodenal thickness.

Diagnosis of appendiceal diverticulitis by multidetector computed tomography

PURPOSE

Because appendiceal diverticulitis (AD) has a high risk of perforation, precise diagnosis is important for patients with suspected acute appendicitis (AA). In this study, we aimed to reveal the characteristics of computed tomography (CT) images of AD.

METHODS

CT images were comparatively analyzed in patients who underwent appendectomy and had histopathologically proved AD (n = 23) or AA (n = 365) to reveal specific findings of CT image for AD and determine sensitivity and specificity of CT for AD.

RESULTS

Univariate analysis showed that maximal diameter of the appendix in AD was significantly smaller than that in AA. Multivariate analysis showed that saccular structure of the appendix wall, cecum or ascending colon diverticulum and peri-appendiceal or -cecal fluid collection were significant independent indicators of AD. Based on that saccular structure of the appendix wall which was the most important specific finding, the sensitivity and specificity of CT for AD were 48% and 99%, respectively.

CONCLUSION

The saccular structure of the appendix wall, cecum or ascending colon diverticulum and peri-appendiceal or -cecal fluid collection in CT suggest AD in patients with suspected AA. The sensitivity and specificity of CT for diagnosing AD were 48% and 99%, respectively.

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.

Age-related risks of complications after distal pancreatectomy for neuroendocrine and cystic neoplasms

BACKGROUND

Distal pancreatic neuroendocrine tumors (PNET) and pancreatic cystic neoplasms (PCN) are often incidentally found in older adults, requiring careful consideration between operative management and watchful waiting. This study analyzes the short-term complications associated with distal pancreatectomy (DP) for PNET and PCN in older adults to inform clinical decision-making.

METHODS

Patients undergoing DP for PNET and PCN were analyzed using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database and the pancreatectomy procedure-targeted dataset. Associations between decade of age and 30-day outcomes were evaluated.

RESULTS

1626 patients were analyzed from 2014 to 2015. 692 (42.6%) were younger than 60 years, 507 (31.2%) were sexagenarians, 342 (21.0%) were septuagenarians, and 85 (5.2%) were octogenarians. Minimally invasive approaches were used in 62.7%. While septuagenarians and octogenarians constituted 26.3% of the cohort, they were affected by 55.6% of reintubations, 66.7% of failures to wean, 82.4% of myocardial infarctions, and 57.1% of septic shock. Septuagenarians and octogenarians had longer hospital stays, as compared to those younger than 60 years.

CONCLUSION

Septuagenarians and octogenarians are disproportionately affected by perioperative complications after DP for PNET and PCN. Careful patient selection and thorough counseling should be provided when surgery is considered.

Impact of Enhanced Recovery after Surgery protocol on immediate surgical outcome in elderly patients undergoing pancreaticoduodenectomy

The numbers of patients undergoing pancreaticoduodenectomy are increasing and considerable percentage is elderly patients. Pancreaticoduodenectomy is a major and complicated surgery. The morbidity and mortality following pancreaticoduodenectomy have significantly reduced in recent times; it still remains unclear in elderly patients. Applications of Enhanced Recovery after Surgery protocol have contributed for this better outcome. In this retrospective study, patients who underwent pancreaticoduodenectomy with Enhanced Recovery after Surgery protocol were included and divided into two groups (< 60 years vs ≥ 60 years). The "elderly patients" (≥ 60 years) were defined based on the WHO definition for Indian subcontinent. Outcomes were analyzed in terms of postoperative morbidity, mortality and length of hospital stay. Total 103 patients underwent pancreaticoduodenectomy during the study period (January 2012-December 2017). The mean age was 56.6 ± 10.32 years. Fifty-six (54.37%) patients were aged < 60 years (young group) and 47 (45.63%) patients were aged ≥ 60 years (elderly group). There was no difference between the groups in terms of age, gender, co-morbidity, preoperative drainage and diagnosis. There was no significant difference in the morbidity and mortality (p > 0.05). Delayed gastric emptying was the most common complication which was 25.24% (21% vs 23.41%). Pancreatic fistula rate was 13.59% (8.9% vs 12.76%) and hemorrhage was 4.85% (5.4% vs 4.3%). Mortality was 4.85%. Postoperative hospital stay was comparable (14.7 days vs 15.3 days) (p = 0.164). Pancreaticoduodenectomy is a safe surgical procedure in elderly patients in comparison to young patients. Application of Enhanced Recovery after Surgery protocol can improve the outcome further.

Pancreatoduodenectomy for pancreatic head tumors in the elderly - Systematic review and meta-analysis

The age at which patients are undergoing pancreatoduodenectomy is increasing worldwide. The data on the outcome of this surgical procedure in the elderly is constantly expanding. This meta-analysis aims to assess the safety of pancreatoduodenectomy in elderly population, primarily focusing on morbidity and mortality. We searched the Medline, Embase and Cochrane databases to identify eligible studies. The most recent search was performed on 10th April 2017. Inclusion criteria were: (1) comparison of the characteristics and perioperative outcomes of older patients versus younger patients undergoing pancreatoduodenectomy; (2) objective evaluation of mortality or overall morbidity; and (3), publication in English. Exclusion criteria were: (1) a lack of comparative data; (2) a lack of primary outcomes or insufficient data to analyze; (3) a focus on procedures other than pancreatoduodenectomy; or (4), the impossibility of extraction of data specifically concerning pancreatoduodenectomy. Primary outcomes were overall morbidity and mortality. Secondary outcomes analyzed postoperative complications, R0 rate and length of hospital stay. 45 eligible studies were chosen, with a combined total of 21,295 patients. Older patients compared to younger patients had a higher risk of death (2.26% vs. 4.54%; RR: 2.23; 95% CI 1.74-2.87) and a higher complication rate (47.23% vs. 39.35%; RR: 1.17; 95% CI 1.12-1.24). There were no differences in pancreatic fistula occurrence (p = 0.27), bile leakage (p = 0.81), postoperative hemorrhage (p = 0.08), or R0 rate (p = 0.92). Our review confirms, that in the case of pancreatoduodenectomy, advanced age is a risk factor for increased non-surgical morbidity and, by extension, higher mortality.

Outcomes of pancreaticoduodenectomy in elderly patients

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.

Gastric conduit-preserving, radical pancreaticoduodenectomy with microvascular reconstruction for pancreatic head cancer after esophagectomy: report of a case

Pancreaticoduodenectomy is a radical treatment for pancreatic head cancer. However, it is sometimes difficult to perform pancreaticoduodenectomy, particularly in patients who have previously undergone esophagectomy with gastric conduit reconstruction. We herein describe a surgical technique for radical pancreaticoduodenectomy with microvascular reconstruction that preserves the gastric conduit. A 72-year-old male with a previous history of esophagectomy and gastric conduit reconstruction for esophageal cancer was referred to our hospital for surgical treatment of advanced pancreatic head cancer. After considering both the cancer curability and preservation of the gastric conduit, we performed a standard pancreaticoduodenectomy, and added a microvascular anastomosis of the gastroduodenal artery to the right gastroepiploic artery. In addition, we also performed reconstruction of the right gastroepiploic vein. This radical pancreaticoduodenectomy with microvascular reconstruction was safely and successfully performed, and it preserved the gastric conduit. The 6-month follow-up showed recurrence-free survival and a good quality of life.

Combination of the serum carbohydrate antigen 19-9 and carcinoembryonic antigen is a simple and accurate predictor of mortality in pancreatic cancer patients

PURPOSE

The aim of this study was to detect high-performance prognostic biomarkers of pancreatic cancer which would enable the identification of high-risk patients.

METHODS

The subjects were 324 patients who underwent radical surgery for pancreatic ductal adenocarcinoma without neoadjuvant therapy. We evaluated the prognostic impact of four perioperative serum tumor markers, including carbohydrate antigen 19-9 (CA19-9) and carcinoembryonic antigen (CEA). We also evaluated the indices by multiplying the values of two tumor markers (e.g., CA19-9 × CEA).

RESULTS

The preoperative CA19-9 × CEA index had a strong correlation with the prognosis of patients with pancreatic cancer, even when the cut-off was set at the median value. CA19-9 × CEA ≥500 was an independent predictor of mortality (hazard ratio: 1.642, p = 0.021). In the ROC curve analysis of early mortality after surgery, the CA19-9 × CEA index had the highest goodness of fit. The presence of CA19-9 × CEA ≥500 had the largest attributable risk proportion because of its combined high predictive performance and prevalence. The postoperative CA19-9 × CEA index was also a significant predictive marker of mortality.

CONCLUSION

The CA19-9 × CEA index is a strong prognostic biomarker that could help identify pancreatic cancer patients expected to have a poor prognosis so that they can be administered appropriate multidisciplinary treatment.

Pancreatic cancer in the remnant pancreas following primary pancreatic resection

PURPOSE

To clarify the clinical features of cancer in the pancreatic remnant.

METHODS

We retrospectively reviewed the clinical and pathological findings of 10 patients who developed remnant pancreatic cancer in our hospital between 2002 and 2012. The KRAS sequences in both the initial pancreatic tumor and remnant pancreatic cancer were examined in two patients.

RESULTS

Eight patients underwent a second pancreatectomy for remnant pancreatic cancer (resected group), while two patients were not operated on and underwent chemotherapy (unresected group). The remnant pancreatic cancer developed at the cut end of the pancreas (pancreaticogastrostomy site) in four patients. In the resected group, four patients died 17 months after the emergence of the remnant pancreatic cancer and four patients survived during the median 40.5-month observation period. The median survival of the unresected group after the emergence of the remnant pancreatic cancer was 10 months. The findings of the KRAS sequencing and immunohistological staining of the remnant pancreatic cancer for MUC1 and MUC2 in the two patients were consistent with those of the initial pancreatic tumor in one patient, and not consistent in the other.

CONCLUSIONS

Our results suggest that both local recurrence and a new primary cancer can develop in the pancreatic remnant, and repeated pancreatectomy can prolong survival.

Surgical outcomes of pancreaticoduodenectomy for periampullary tumors in elderly patients

BACKGROUNDS

Pancreaticoduodenectomy (PD) is an aggressive surgery with considerable operative risks, but offers the only chance for cure in patients with periampullary tumors. A growing number of elderly patients are being offered PD because of the aging of populations in developed countries. We examined surgical outcomes of PD in patients aged 75 years and older (≥75 years).

METHODS

A retrospective cohort study was performed in 65 consecutive patients who underwent PD for periampullary tumors at a single medical center during the 5 years from 2006 to 2010. We analyzed surgical outcomes such as mortality and morbidity after PD in patients aged ≥75 years (n = 21) compared to those in patients aged <75 years (n = 44).

RESULTS

The positive rate of comorbidities such as hypertension was significantly higher in patients aged ≥75 years than in patients aged <75 years (76 vs. 48 %; p = 0.03). The incidence of wound infection was significantly higher in patients aged ≥75 years than in patients aged <75 years (19 vs. 0 %; p < 0.01). However, there was no significant difference in the mortality rate (0 vs. 2 %; p = 0.49) or the overall morbidity rate (33 vs. 32 %; p = 0.90). There was no significant difference in changes in body weight or serum albumin levels during the 3 months after PD between the two groups, but the recovery of serum prealbumin levels from 1 to 3 months after PD in patients aged ≥75 years was significantly delayed compared to that in patients aged <75 years (p = 0.04). There was no statistically significant difference in long-term survival between the two groups.

CONCLUSIONS

Advanced age alone should not discourage surgeons from offering PD, although nutritional supports after PD for elderly patients aged ≥75 years are needed.

Advanced age is a risk factor for post-operative complications and mortality after a pancreaticoduodenectomy: a meta-analysis and systematic review

BACKGROUND

The aim of this meta-analysis was to analyse the outcomes of major pancreatic surgery among the elderly (≥75 and ≥80 years of age).

METHODS

A systematic literature search was conducted using Embase, MEDLINE, Cochrane and PubMed databases on all studies published between January 1990 and April 2012 reporting peri-operative outcomes after a pancreaticoduodenectomy (PD) among the elderly. Primary end-points measured were peri-operative mortality and the incidence of post-operative complications. Secondary outcomes considered included the incidence of post-operative pancreatic fistula formation (POPF), delayed gastric emptying (DGE), wound infection, pneumonia, post-operative bleeding and length of hospital stay.

RESULTS

Eleven trials were included comprising 5186 patients; 7 studies comparing endpoints in patients aged ≥75 years vs. younger populations and 4 studies comparing endpoints in patients aged ≥80 years vs. younger populations. In both groups, there was a statistically significant increase in the incidence of mortality and post-operative pneumonia in the elderly population. The incidence of post-operative complications was also found to be statistically significant among patients ≥80 years of age vs. their younger cohorts.

CONCLUSIONS

There is an increased incidence of post-operative mortality and pneumonia after a PD among all elderly patients ≥75 years of age, as well as an increased incidence of post-operative complications among patients ≥80 years of age. Additional randomized control trials studying post-PD operative outcomes in elderly vs. younger patients with standardization of comorbidities is therefore necessary to confirm the conclusions presented here.