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Guillot Morales M, Visa L, Brozos Vázquez E, Feliu Batlle J, Khosravi Shahi P, Laquente Sáez B, de San Vicente Hernández BL, Macarulla T, Gironés Sarrió R. Update on the management of older patients with pancreatic adenocarcinoma: a perspective from medical oncology. Clin Transl Oncol 2024; 26:1570-1583. [PMID: 38329611 DOI: 10.1007/s12094-024-03386-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 01/04/2024] [Indexed: 02/09/2024]
Abstract
In the context of pancreatic cancer, surgical intervention is typically recommended for localized tumours, whereas chemotherapy is the preferred approach in the advanced and/or metastatic setting. However, pancreatic cancer is closely linked to ageing, with an average diagnosis at 72 years. Paradoxically, despite its increased occurrence among older individuals, this population is often underrepresented in clinical studies, complicating the decision-making process. Age alone should not determine the therapeutic strategy but, given the high comorbidity and mortality of this disease, a comprehensive geriatric assessment (CGA) is necessary to define the best treatment, prevent toxicity, and optimize older patient care. In this review, a group of experts from the Oncogeriatrics Section of the Spanish Society of Medical Oncology (Sociedad Española de Oncología Médica, SEOM), the Spanish Cooperative Group for the Treatment of Digestive Tumours (Grupo Español de Tratamiento de los Tumores Digestivos, TTD), and the Multidisciplinary Spanish Group of Digestive Cancer (Grupo Español Multidisciplinar en Cáncer Digestivo, GEMCAD) have assessed the available scientific evidence and propose a series of recommendations on the management and treatment of the older population with pancreatic cancer.
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Affiliation(s)
- Mónica Guillot Morales
- Spanish Society of Medical Oncology (SEOM) Oncogeriatrics Section, Department of Medical Oncology, Son Espases University Hospital, Carretera de Valldemossa, 79, Islas Baleares, 07120, Palma de Mallorca, Spain.
| | - Laura Visa
- Spanish Society of Medical Oncology (SEOM) Oncogeriatrics Section, Mar-Parc de Salut Mar Hospital, Barcelona, Spain
| | - Elena Brozos Vázquez
- Spanish Society of Medical Oncology (SEOM) Oncogeriatrics Section, A Coruña University Clinical Hospital, A Coruña, Spain
| | - Jaime Feliu Batlle
- Multidisciplinary Spanish Group of Digestive Cancer (GEMCAD), La Paz University Hospital, IDIPAZ, CIBERONC, Cathedra UAM-AMGEN, Madrid, Spain
| | - Parham Khosravi Shahi
- Spanish Society of Medical Oncology (SEOM) Oncogeriatrics Section, Gregorio Marañón University Hospital, Madrid, Spain
| | - Berta Laquente Sáez
- Spanish Society of Medical Oncology (SEOM) Oncogeriatrics Section, ICO L´Hospitalet-IDIBELL, Barcelona, Spain
| | | | - Teresa Macarulla
- Spanish Cooperative Group for the Treatment of Digestive Tumours (TTD), Hebron University Hospital, Vall d, Barcelona, Spain
| | - Regina Gironés Sarrió
- Spanish Society of Medical Oncology (SEOM), Polytechnic la Fe University Hospital, Valencia, Spain
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Gao WD. One size does not fit all: Perioperative management of patients with heart failure with preserved ejection fraction. J Clin Anesth 2024; 94:111409. [PMID: 38340679 DOI: 10.1016/j.jclinane.2024.111409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 12/18/2023] [Accepted: 02/03/2024] [Indexed: 02/12/2024]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is recognized as an important risk factor for perioperative complications. However, anesthesia management of HFpEF patients remains a considerable challenge without clear guidance. HFpEF is heterogeneous in its pathophysiological processes, diverse clinical presentations, adverse remodeling of cardiovascular and other organs, and clinical outcomes. It is difficult to manage the disease with one fixed approach because of this. This review phenotypes HFpEF patients by combining their clinical features and anesthesia care issues. Five phenotypes of HFpEF patients are identified: A, O, P, C, and Y. The clinical features, anesthesia implications, and anesthesia management for each phenotype are highlighted and discussed. Such an approach to HFpEF patients in the operating room could deliver safe, high-quality perioperative care.
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Carp B, Weinberg L, Fletcher LR, Hinton JV, Cohen A, Slifirski H, Le P, Woodford S, Tosif S, Liu D, Muralidharan V, Perini MV, Nikfarjam M, Lee DK. The effect of an intraoperative patient-specific, surgery-specific haemodynamic algorithm in improving textbook outcomes for hepatobiliary-pancreatic surgery: a multicentre retrospective study. Front Surg 2024; 11:1353143. [PMID: 38859998 PMCID: PMC11163073 DOI: 10.3389/fsurg.2024.1353143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 05/06/2024] [Indexed: 06/12/2024] Open
Abstract
Background The concept of a "textbook outcome" is emerging as a metric for ideal surgical outcomes. We aimed to evaluate the impact of an advanced haemodynamic monitoring (AHDM) algorithm on achieving a textbook outcome in patients undergoing hepatobiliary-pancreatic surgery. Methods This retrospective, multicentre observational study was conducted across private and public teaching sectors in Victoria, Australia. We studied patients managed by a patient-specific, surgery-specific haemodynamic algorithm or via usual care. The primary outcome was the effect of using a patient-specific, surgery-specific AHDM algorithm for achieving a textbook outcome, with adjustment using propensity score matching. The textbook outcome criteria were defined according to the International Expert Delphi Consensus on Defining Textbook Outcome in Liver Surgery and Nationwide Analysis of a Novel Quality Measure in Pancreatic Surgery. Results Of the 780 weighted cases, 477 (61.2%, 95% CI: 57.7%-64.6%) achieved the textbook outcome. Patients in the AHDM group had a higher rate of textbook outcomes [n = 259 (67.8%)] than those in the Usual care group [n = 218 (54.8%); p < 0.001, estimated odds ratio (95% CI) 1.74 (1.30-2.33)]. The AHDM group had a lower rate of surgery-specific complications, severe complications, and a shorter hospital length of stay (LOS) [OR 2.34 (95% CI: 1.30-4.21), 1.79 (95% CI: 1.12-2.85), and 1.83 (95% CI: 1.35-2.46), respectively]. There was no significant difference between the groups for hospital readmission and mortality. Conclusions AHDM use was associated with improved outcomes, supporting its integration in hepatobiliary-pancreatic surgery. Prospective trials are warranted to further evaluate the impact of this AHDM algorithm on achieving a textbook impact on long-term outcomes.
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Affiliation(s)
- Bradly Carp
- Department of Anaesthesia, Austin Health, University of Melbourne, Melbourne, VIC, Australia
| | - Laurence Weinberg
- Department of Anaesthesia, Austin Health, University of Melbourne, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Parkville, VIC, Australia
- Department of Surgery, Austin Health, University of Melbourne, Melbourne, VIC, Australia
| | - Luke R. Fletcher
- Department of Anaesthesia, Austin Health, University of Melbourne, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Parkville, VIC, Australia
- Data Analytical Research Unit, Austin Health, Melbourne, VIC, Australia
| | - Jake V. Hinton
- Department of Anaesthesia, Austin Health, University of Melbourne, Melbourne, VIC, Australia
| | - Adam Cohen
- Department of Anaesthesia, Austin Health, University of Melbourne, Melbourne, VIC, Australia
| | - Hugh Slifirski
- Department of Anaesthesia, Austin Health, University of Melbourne, Melbourne, VIC, Australia
| | - Peter Le
- Department of Anaesthesia, Austin Health, University of Melbourne, Melbourne, VIC, Australia
| | - Stephen Woodford
- Department of Anaesthesia, Austin Health, University of Melbourne, Melbourne, VIC, Australia
| | - Shervin Tosif
- Department of Anaesthesia, Austin Health, University of Melbourne, Melbourne, VIC, Australia
| | - David Liu
- Department of Surgery, Austin Health, University of Melbourne, Melbourne, VIC, Australia
| | | | - Marcos V. Perini
- Department of Surgery, Austin Health, University of Melbourne, Melbourne, VIC, Australia
| | - Mehrdad Nikfarjam
- Department of Surgery, Austin Health, University of Melbourne, Melbourne, VIC, Australia
| | - Dong-Kyu Lee
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
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Duan P, Sun L, Kou K, Li XR, Zhang P. Surgical techniques to prevent delayed gastric emptying after pancreaticoduodenectomy. Hepatobiliary Pancreat Dis Int 2023:S1499-3872(23)00204-7. [PMID: 37980179 DOI: 10.1016/j.hbpd.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 10/31/2023] [Indexed: 11/20/2023]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is one of the most common complications after pancreaticoduodenectomy (PD). DGE represents impaired gastric motility without significant mechanical obstruction and is associated with an increased length of hospital stay, increased healthcare costs, and a high readmission rate. We reviewed published studies on various technical modifications to reduce the incidence of DGE. DATA SOURCES Studies were identified by searching PubMed for relevant articles published up to December 2022. The following search terms were used: "pancreaticoduodenectomy", "pancreaticojejunostomy", "pancreaticogastrostomy", "gastric emptying", "gastroparesis" and "postoperative complications". The search was limited to English publications. Additional articles were identified by a manual search of references from key articles. RESULTS In recent years, various surgical procedures and techniques have been explored to reduce the incidence of DGE. Pyloric resection, Billroth II reconstruction, Braun's enteroenterostomy, and antecolic reconstruction may be associated with a decreased incidence of DGE, but more high-powered studies are needed in the future. Neither laparoscopic nor robotic surgery has demonstrated superiority in preventing DGE, and the use of staplers is controversial regarding whether they can reduce the incidence of DGE. CONCLUSIONS Despite many innovations in surgical techniques, there is no surgical procedure that is superior to others to reduce DGE. Further larger prospective randomized studies are needed.
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Affiliation(s)
- Peng Duan
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, the First Hospital of Jilin University, Changchun 130021, China
| | - Lu Sun
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, the First Hospital of Jilin University, Changchun 130021, China
| | - Kai Kou
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, the First Hospital of Jilin University, Changchun 130021, China
| | - Xin-Rui Li
- Department of Dental Implantology, Hospital of Stomatology, Jilin University, Changchun 130021, China
| | - Ping Zhang
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, the First Hospital of Jilin University, Changchun 130021, China.
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Justo Alonso I, Alonso Murillo L, Marcacuzco Quinto A, Caso Maestro Ó, Rioja Conde P, Fernández C, Jiménez Romero C. Cephalic pancreatoduodenectomy in octogenarian patients with pancreatic tumors. Cir Esp 2023; 101:599-608. [PMID: 37541325 DOI: 10.1016/j.cireng.2022.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 10/30/2022] [Indexed: 08/06/2023]
Abstract
INTRODUCTION Current literature supports the claim that performing a cephalic pancreaticoduodenectomy (CPD) as treatment for pancreatic cancer (PC) is associated with an increase in median survival, both in octogenarian (≥80 years) patients as well as younger patients. METHODS This is a retrospective and comparative trial, comparing results for CPD performed on 30 patients ≥80 years with PC and 159 patients <80 years. RESULTS The patients in the octogenarian group showed a significantly higher rate of preoperative cardiovascular morbidity and a more aggressive tumoral behaviour, including more significant preoperative anemia, jaundice and levels of CA 19-9, higher vascular and neural invasion, and a lower rate of R0 resection despite using the same surgical technique. There were no significant differences in terms of postoperative complications. Postoperative mortality was similar in both groups (3.3% in octogenarians vs 3.1% in patients <80 years). Mortality during follow-up was mainly due to tumour recurrence, cardiovascular complications and COVID-19 in 2 elderly patients. Actuarial survival at 1, 3 and 5 years was significantly larger for patients <80 years old, as compared to octogenarians (85.9%, 61.1% and 39.2% versus 72.7%, 28.9% and 9.6%, respectively; P = 0.001). The presence of a pancreatic fistula and not using external Wirsung stenting were significantly associated with 90-day postoperative mortality after a CPD. CONCLUSIONS Morbidity and mortality post-CPD is similar in octogenarians and patients younger than 80, although long-term survival is shorter due to more aggressive tumours and comorbidities associated with older age.
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Affiliation(s)
- Iago Justo Alonso
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario Doce de Octubre, Departamento de Cirugía, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Hospital Doce de Octubre (imas12) CIBERES, Madrid, Spain
| | - Laura Alonso Murillo
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario Doce de Octubre, Departamento de Cirugía, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Hospital Doce de Octubre (imas12) CIBERES, Madrid, Spain
| | - Alberto Marcacuzco Quinto
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario Doce de Octubre, Departamento de Cirugía, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Hospital Doce de Octubre (imas12) CIBERES, Madrid, Spain
| | - Óscar Caso Maestro
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario Doce de Octubre, Departamento de Cirugía, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Hospital Doce de Octubre (imas12) CIBERES, Madrid, Spain
| | - Paula Rioja Conde
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario Doce de Octubre, Departamento de Cirugía, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Hospital Doce de Octubre (imas12) CIBERES, Madrid, Spain
| | - Clara Fernández
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario Doce de Octubre, Departamento de Cirugía, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Hospital Doce de Octubre (imas12) CIBERES, Madrid, Spain
| | - Carlos Jiménez Romero
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario Doce de Octubre, Departamento de Cirugía, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Hospital Doce de Octubre (imas12) CIBERES, Madrid, Spain.
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Shyr BS, Yu JH, Chen SC, Wang SE, Shyr YM, Shyr BU. Surgical Risks and Survival Outcomes in Robotic Pancreaticoduodenectomy for the Aged Over 80: A Retrospective Cohort Study. Clin Interv Aging 2023; 18:1405-1414. [PMID: 37645471 PMCID: PMC10461739 DOI: 10.2147/cia.s411391] [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: 03/06/2023] [Accepted: 07/20/2023] [Indexed: 08/31/2023] Open
Abstract
Aim Whether to execute pancreaticoduodenectomy or not for older people could pose a dilemma. This study clarifies the safety and justification of robotic pancreaticoduodenectomy (RPD) for older individuals over 80. Methods A total of 500 patients undergoing RPD were divided into group O (≥ 80 y/o) and group Y (< 80 y/o) for comparison. Results There were 62 (12.4%) patients in group O. Surgical mortality was 1.6% for overall patients and higher in group O, 6.5% vs 0.9%; p = 0.001. The surgical complication was comparable between groups O and Y. Delayed gastric emptying and bile leakage were higher in group O, 9.7% vs 2.5%; p = 0.004, and 6.5% vs 0.9%; p = 0.001, respectively. Length of stay was also longer in group O, with a median of 26 vs 19 days; p = 0.001. Survival outcome after RPD was poorer in group O for overall periampullary adenocarcinomas, with a 5-year survival of 48.1% vs 51.2%; p = 0.025 and also for the subgroup of pancreatic head adenocarcinoma, with a 3-year survival of 27.4% vs 42.5%; p = 0.030. Conclusion RPD is safe and justified for the selected octogenarians and even nonagenarians, whoever is fit for a major operation. Nevertheless, pancreatic head cancer and higher mortality risk for the aged over 80 with advanced ASA score ≥ 3 should be informed as part of counselling in offering RPD.
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Affiliation(s)
- Bor-Shiuan Shyr
- General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, Taipei, Taiwan, Republic of China
| | - Jwo-Huey Yu
- General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, Taipei, Taiwan, Republic of China
| | - Shih-Chin Chen
- General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, Taipei, Taiwan, Republic of China
| | - Shin-E Wang
- General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, Taipei, Taiwan, Republic of China
| | - Yi-Ming Shyr
- General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, Taipei, Taiwan, Republic of China
| | - Bor-Uei Shyr
- General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, Taipei, Taiwan, Republic of China
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Kwak HV, Dzubnar JM, Hsu DS, Chang AL, Spitzer AL, Kazantsev GB, Peng PD, Chang CK. Survival of Elderly Patients Undergoing Pancreatoduodenectomy in an Integrated Health System. J Surg Res 2023; 288:315-320. [PMID: 37058988 DOI: 10.1016/j.jss.2023.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 02/28/2023] [Accepted: 03/16/2023] [Indexed: 04/16/2023]
Abstract
INTRODUCTION The purpose of this study is to examine pancreatoduodenectomy (PD) perioperative outcomes and consider how age may be related to overall survival in an integrated health system. MATERIALS AND METHODS A retrospective review was performed of 309 patients who underwent PD between December 2008 and December 2019. Patients were divided into two groups: aged 75 y or less and more than 75 y, defined as senior surgical patients. Univariate and multivariable analyses of predictive clinicopathologic factors associated with overall survival at 5 y were performed. RESULTS In both groups, the majority underwent PD for malignant disease. The proportion of senior surgical patients alive at 5 y was 33.3% compared to 53.6% of younger patients (P = 0.003). There were also statistically significant differences between the two groups with respect to body mass index, cancer antigen 19-9, Eastern Cooperative Oncology Group performance status, and Charlson comorbidity index. On multivariable analysis, disease type, cancer antigen 19-9, hemoglobin A1c, length of surgery, length of stay, Charlson comorbidity index, and Eastern Cooperative Oncology Group performance status were found to be statistically significant factors for overall survival. Age was not significantly related to overall survival on multivariable logistic regression and when the analysis was limited to pancreatic cancer patients. CONCLUSIONS Although the difference in overall survival between patients aged less than and more than 75 years was significant, age was not an independent risk factor for overall survival on multivariable analysis. Rather than a patient's chronological age, his/her physiologic age including medical comorbidities and functional status may be more correlated to overall survival.
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Affiliation(s)
- Hyunjee V Kwak
- Department of Surgery, University of California San Francisco-East Bay, Oakland, California.
| | - Jessica M Dzubnar
- Department of Surgery, University of California San Francisco-East Bay, Oakland, California
| | - Diana S Hsu
- Department of Surgery, University of California San Francisco-East Bay, Oakland, California
| | | | - Austin L Spitzer
- Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, California
| | - George B Kazantsev
- Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, California
| | - Peter D Peng
- Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, California
| | - Ching-Kuo Chang
- Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, California
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Mederos MA, Starr S, Park JY, King JC, Tomlinson JS, Hines OJ, Donahue TR, Girgis MD. Robotic versus open pancreaticoduodenectomy in elderly patients: a propensity score-matched analysis. HPB (Oxford) 2023; 25:301-310. [PMID: 36529625 DOI: 10.1016/j.hpb.2022.11.011] [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: 05/26/2021] [Revised: 09/24/2022] [Accepted: 11/29/2022] [Indexed: 03/05/2023]
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) is complex procedure with high morbidity in the elderly. This retrospective study aimed to compare post-operative outcomes in patients ≥75 years of age who underwent robot-assisted (RA)PD and open PD. METHODS We analyzed 2502 patients ≥75 years of age who underwent PD from 2015 to 2018 in the National Surgical Quality Improvement Program (NSQIP) database. RAPD and open PD patients were propensity score matched 1:5 to assess the 30-day outcomes of interest: postoperative complications, length of stay, discharge destination, and readmissions. RESULTS Of 725 matched patients, 110 underwent RAPD, 615 OPD, and 12 were converted to an open operation. Post-operative outcomes were largely similar between cohorts. RAPD was associated a shorter length of stay (median 8 days, interquartile range [IQR] 6 to 11) than OPD (median 8 days, IQR 7 to 13) (p = 0.003). However, RAPD was associated with more readmissions (28.1% vs. 17.7%; p = 0.02). CONCLUSIONS RAPD in patients ≥75 years of age appears to be safe and has a similar complication profile to open PD. Randomized or well-designed prospective matched studies are needed to confirm these findings.
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Affiliation(s)
- Michael A Mederos
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Department of Surgery, Los Angeles, CA, USA.
| | - Savannah Starr
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Joon Y Park
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Department of Surgery, Los Angeles, CA, USA
| | - Jonathan C King
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Department of Surgery, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Division of Surgical Oncology, Los Angeles, CA, USA
| | - James S Tomlinson
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Department of Surgery, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Division of Surgical Oncology, Los Angeles, CA, USA; VA Greater Los Angeles Healthcare System, Surgical Oncology, Los Angeles, CA, USA
| | - O J Hines
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Department of Surgery, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Division of Surgical Oncology, Los Angeles, CA, USA
| | - Timothy R Donahue
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Department of Surgery, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Division of Surgical Oncology, Los Angeles, CA, USA
| | - Mark D Girgis
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Department of Surgery, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Division of Surgical Oncology, Los Angeles, CA, USA; VA Greater Los Angeles Healthcare System, Surgical Oncology, Los Angeles, CA, USA
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Operative Re-Intervention following Pancreatoduodenectomy: What Has Changed over the Last Decades. J Clin Med 2022; 11:jcm11247512. [PMID: 36556127 PMCID: PMC9782126 DOI: 10.3390/jcm11247512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 12/14/2022] [Accepted: 12/15/2022] [Indexed: 12/23/2022] Open
Abstract
Background: To investigate changes over the last decades in the management of postoperative complications following pancreatoduodenectomy (PD) with special emphasis on reoperations, their indications, and outcomes. Methods: 409 patients who underwent PD between 2008 and 2021 were retrospectively analyzed with respect to their need for reoperations (reoperation, n = 81, 19.8% vs. no reoperation, n = 328, 80.2%). The cohort was then compared to a second cohort comprising patients who underwent PD between 1989 and 2007 (n = 285). Results: 81 patients (19.8%) underwent reoperation. The main cause of reoperation was the dehiscence of pancreatogastrostomy (22.2%). Reoperation was associated with a longer duration of the index operation, more blood loss, and more erythrocyte concentrates being transfused. Patients who underwent reoperation showed more postoperative complications and a higher mortality rate (25% vs. 2%, p < 0.001). Compared to the earlier cohort, the observed increase in reoperations did not lead to increased mortality (5% vs. 6%, p = 353). Conclusions: The main cause for reoperation has changed over the last decades and was the dehiscence of pancreatogastrostomy. Associated with a leakage of pancreatic fluid and clinically relevant PF, it remains the most devastating complication following PD. Strategies for prevention and treatment, e.g., by endoscopic vacuum-assisted-closure therapy are of utmost importance.
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Seufferlein T, Mayerle J, Böck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie zum exokrinen Pankreaskarzinom – Langversion 2.0 – Dezember 2021 – AWMF-Registernummer: 032/010OL. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:e812-e909. [PMID: 36368658 DOI: 10.1055/a-1856-7346] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | | | - Stefan Böck
- Medizinische Klinik und Poliklinik III, Universitätsklinikum München, Germany
| | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie Universitätsklinikum, Heidelberg, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Universitätsklinikum Hamburg-Eppendorf Medizinische Klinik und Poliklinik II Onkologie Hämatologie, Hamburg, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
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Elfrink AKE, Alberga AJ, van Berge Henegouwen MI, Scheurs WH, van der Geest LGM, Verhagen HJM, Dekker JWT, Grünhagen DJ, Wouters MWJM, Klaase JM. Outcomes After Major Surgical Procedures in Octogenarians: A Nationwide Cohort Study. World J Surg 2022; 46:2399-2408. [PMID: 35927369 PMCID: PMC9436861 DOI: 10.1007/s00268-022-06642-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2022] [Indexed: 11/25/2022]
Abstract
Introduction Aging of the worldwide population has been observed, and postoperative outcomes could be worse in elderly patients. This nationwide study assessed trends in number of surgical resections in octogenarians regarding various major surgical procedures and associated postoperative outcomes. Methods All patients who underwent surgery between 2014 and 2018 were included from Dutch nationwide quality registries regarding esophageal, stomach, pancreas, colorectal liver metastases, colorectal cancer, lung cancer and abdominal aortic aneurysms (AAA). For each quality registry, the number of patients who were 80 years or older (octogenarians) was calculated per year. Postoperative outcomes were length of stay (LOS), 30 day major morbidity and 30 day mortality between octogenarians and younger patients. Results No increase in absolute number and proportion of octogenarians that underwent surgery was observed. Median LOS was higher in octogenarians who underwent surgery for colorectal cancer, colorectal liver metastases, lung cancer, pancreatic disease and esophageal cancer. 30 day major morbidity was higher in octogenarians who underwent surgery for colon cancer, esophageal cancer and elective AAA-repair. 30 day mortality was higher in octogenarians who underwent surgery for colorectal cancer, lung cancer, stomach cancer, pancreatic disease, esophageal cancer and elective AAA-repair. Median LOS decreased between 2014 and 2018 in octogenarians who underwent surgery for stomach cancer and colorectal cancer. 30 day major morbidity decreased between 2014 and 2018 in octogenarians who underwent surgery for colon cancer. No trends were observed in octogenarians regarding 30 day mortality between 2014 and 2018. Conclusion No increase over time in absolute number and proportion of octogenarians that underwent major surgery was observed in the Netherlands. Postoperative outcomes were worse in octogenarians. Supplementary Information The online version contains supplementary material available at 10.1007/s00268-022-06642-6.
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Affiliation(s)
- Arthur K E Elfrink
- Scientific Bureau, Dutch Institute for Clinical Auditing, 2333 AA, Leiden, The Netherlands.
- Department of Hepatobiliary Surgery and Liver Transplantation, Universitair Medisch Centrum Groningen, Groningen, The Netherlands.
| | - Anna J Alberga
- Scientific Bureau, Dutch Institute for Clinical Auditing, 2333 AA, Leiden, The Netherlands
- Department of Vascular Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, Locatie AMC, Cancer Center Amsterdam, Universiteit Van Amsterdam, Amsterdam, The Netherlands
| | | | | | | | | | - Dirk J Grünhagen
- Department of Vascular Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Michel W J M Wouters
- Scientific Bureau, Dutch Institute for Clinical Auditing, 2333 AA, Leiden, The Netherlands
- Department of Surgery, Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
| | - Joost M Klaase
- Department of Hepatobiliary Surgery and Liver Transplantation, Universitair Medisch Centrum Groningen, Groningen, The Netherlands
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12
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Seufferlein T, Mayerle J, Böck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie zum exokrinen Pankreaskarzinom – Kurzversion 2.0 – Dezember 2021, AWMF-Registernummer: 032/010OL. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:991-1037. [PMID: 35671996 DOI: 10.1055/a-1771-6811] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
| | | | - Stefan Böck
- Medizinische Klinik und Poliklinik III, Universitätsklinikum München, Germany
| | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie Universitätsklinikum, Heidelberg, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Universitätsklinikum Hamburg-Eppendorf Medizinische Klinik und Poliklinik II Onkologie Hämatologie, Hamburg, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
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13
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Suyama Y, Haruki K, Hamura R, Tsunematsu M, Shirai Y, Taniai T, Yanagaki M, Furukawa K, Onda S, Shiba H, Ikegami T. Strategies and tactics to perform safe pancreaticoduodenectomy for 94-year-old patient: report of a case. Surg Case Rep 2022; 8:39. [PMID: 35244810 PMCID: PMC8897542 DOI: 10.1186/s40792-022-01395-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 03/01/2022] [Indexed: 11/24/2022] Open
Abstract
Background Despite improvement of postoperative management, pancreatoduodenectomy still has a high rate of major complications. Therefore, careful assessment is critically important when we consider high risk surgery for extremely elderly patients. Case presentation A 94-year-old man, who suffered dark urine, epigastric pain, and loss of appetite, was diagnosed as bile duct cancer and underwent endoscopic retrograde biliary drainage. He has past history of hypertension and paroxysmal atrial fibrillation. Computed tomography (CT) showed a nodule in the lower bile duct, which was slowly enhanced by dynamic CT. The patient was evaluated whether he overcomes pancreatoduodenectomy by cardiac ultrasonography, brain magnetic resonance angiography, nutritional evaluation (rapid turnover proteins), and CT-based general assessment, including sarcopenia and osteopenia. The patient was independent in activities of daily living and has enough ejection fraction of 65%, and examinations revealed no impairment of cognitive function, sarcopenia, and osteopenia. With a diagnosis of bile duct cancer with no distant metastasis, the patient underwent subtotal stomach-preserving pancreatoduodenectomy with lymph node dissection. Operation time was 299 min and estimated blood loss was 100 ml. Pathological examination revealed papillary adenocarcinoma of the bile duct (pT3N1M0 Stage IIIB). Enteral nutrition was given through jejunostomy and then the patient started oral intake after an evaluation of swallowing function. Postoperative course was uneventful and all drains including pancreatic duct stent, biliary stent, and jejunostomy were removed by 3 weeks after operation. The levels of rapid turnover proteins dropped at postoperative day 7, but recovered at 1 month after operation via appropriate nutrition and rehabilitation. He remains well with no evidence of tumor recurrence as of 1 year after resection. Conclusions We herein report successfully treated cases of bile duct cancer in 94-year-old patient by pancreatoduodenectomy with careful evaluation of osteopenia, sarcopenia and nutrition.
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Affiliation(s)
- Yu Suyama
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Koichiro Haruki
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Ryoga Hamura
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Masashi Tsunematsu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Yoshihiro Shirai
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Tomohiko Taniai
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Mitsuru Yanagaki
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Kenei Furukawa
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Shinji Onda
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Hiroaki Shiba
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Toru Ikegami
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
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14
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Pineño-Flores C, Ambrona-Zafra D, Rodríguez-Pino JC, Soldevila-Verdeguer C, Palma-Zamora E, Molina-Romero FX, Morón-Canis JM, González-Argente FX, Morales-Soriano R. Cephalic pancreaticoduodenectomy for ductal adenocarcinoma in the elderly. Can we do it safely? Cir Esp 2022; 100:125-132. [PMID: 35221240 DOI: 10.1016/j.cireng.2022.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 01/17/2021] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Surgery and chemotherapy have increased the survival of pancreatic cancer. The decrease in postoperative morbidity and mortality and increase in life expectancy, has expanded the indications por cephalic pancreaticoduodenectomy (PDC), although it remains controversial in the geriatric population. METHODS Retrospective study on a prospective database of patients with ductal adenocarcinoma of pancreas who underwent PDC between 2007-2018. The main objective was to analyse the morbidity-mortality and survival associated with PDC in patients ≥75 years (elderly). RESULTS 79 patients were included, 21 of them older than 75 years (27%); within this group, 23'9% were over 80 years old. The ASA of both groups was similar. Patients ≥75 years required more transfusions. No differences in operating time were observed, although more vascular resection were performed in the elderly (26 vs. 8.7%; P = .037). Morbidity was higher in the elderly (61.9% vs. 46.6%), although without differences. Patients aged ≥75 years had more non-surgical complications (33.3%, P = .050), being pneumonia the most frequent. Postoperative mortality was higher in the ≥75 years (9 vs. 0%; P = .017). The overall survival and disease-free survival did not show significant differences in both groups. CONCLUSIONS Elderly patients had higher postoperative mortality and more non-surgical complications. Survival did not show differences, so with an adequate selection of patients, age should not be considered itself as a contraindication for PDC.
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Affiliation(s)
- Cristina Pineño-Flores
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitari Son Espases, Palma de Mallorca, Balearic Islands, Spain; Instituto de Investigación Sanitaria de Islas Baleares (IdISBa), Hospital Universitari Arnau de Villanova, Palma de Mallorca, Balearic Islands, Spain.
| | - David Ambrona-Zafra
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitari Arnau de Vilanova, Lleida, Catalonia, Spain
| | - Jose Carlos Rodríguez-Pino
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitari Son Espases, Palma de Mallorca, Balearic Islands, Spain
| | - Carla Soldevila-Verdeguer
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitari Son Espases, Palma de Mallorca, Balearic Islands, Spain; Instituto de Investigación Sanitaria de Islas Baleares (IdISBa), Hospital Universitari Arnau de Villanova, Palma de Mallorca, Balearic Islands, Spain
| | - Elias Palma-Zamora
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitari Son Espases, Palma de Mallorca, Balearic Islands, Spain
| | - Francesc Xavier Molina-Romero
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitari Son Espases, Palma de Mallorca, Balearic Islands, Spain; Instituto de Investigación Sanitaria de Islas Baleares (IdISBa), Hospital Universitari Arnau de Villanova, Palma de Mallorca, Balearic Islands, Spain; Facultad de Medicina, Universidad de las Islas Baleares, Palma de Mallorca, Balearic Islands, Spain
| | - Jose Miguel Morón-Canis
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitari Son Espases, Palma de Mallorca, Balearic Islands, Spain
| | - Francesc Xavier González-Argente
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitari Son Espases, Palma de Mallorca, Balearic Islands, Spain; Instituto de Investigación Sanitaria de Islas Baleares (IdISBa), Hospital Universitari Arnau de Villanova, Palma de Mallorca, Balearic Islands, Spain; Facultad de Medicina, Universidad de las Islas Baleares, Palma de Mallorca, Balearic Islands, Spain
| | - Rafael Morales-Soriano
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitari Son Espases, Palma de Mallorca, Balearic Islands, Spain; Instituto de Investigación Sanitaria de Islas Baleares (IdISBa), Hospital Universitari Arnau de Villanova, Palma de Mallorca, Balearic Islands, Spain
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15
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van Dongen JC, van der Geest LGM, de Meijer VE, van Santvoort HC, de Vos-Geelen J, Besselink MG, Groot Koerkamp B, Wilmink JW, van Eijck CHJ. Age and prognosis in patients with pancreatic cancer: a population-based study. Acta Oncol 2022; 61:286-293. [PMID: 34935577 DOI: 10.1080/0284186x.2021.2016949] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The diagnosis of pancreatic ductal adenocarcinoma (PDAC) has an enormous impact on patients, and even more so if they are of younger age. It is unclear how their treatment and outcome compare to older patients. This study compares clinicopathological characteristics and overall survival (OS) of PDAC patients aged <60 years to older PDAC patients. METHOD This is a retrospective, population-based cohort study using Netherlands Cancer Registry data of patients diagnosed with PDAC (1 January 2015-31 December 2018). Kaplan-Meier curves and Cox proportional hazards models were used to assess OS. RESULTS Overall, 10,298 patients were included, of whom 1551 (15%) were <60 years. Patients <60 years were more often male, had better performance status, less comorbidities and less stage I disease, and more often received anticancer treatment (67 vs. 33%, p < 0.001) than older patients. Patients <60 years underwent resection of the tumour more often (22 vs. 14%p < 0.001), more often received chemotherapy, and had a better median OS (6.9 vs. 3.3 months, p < 0.001) compared to older patients. No differences in median OS were demonstrated between both age groups of patients who underwent resection (19.7 vs. 19.4 months, p = 0.123), received chemotherapy alone (7.8 vs. 8.5 months, p = 0.191), or received no anticancer treatment (1.8 vs. 1.9 months, p = 0.600). Patients <60 years with stage-IV disease receiving chemotherapy had a somewhat better OS (7.5 vs. 6.3 months, p = 0.026). CONCLUSION Patients with PDAC <60 years more often underwent resection despite less stage I disease and had superior OS. Stratified for treatment, however, survival was largely similar.
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Affiliation(s)
| | | | - Vincent E. de Meijer
- Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | | | - Judith de Vos-Geelen
- Division of Medical Oncology, Department of Internal Medicine, GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Marc G. Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Johanna W. Wilmink
- Department of Medical Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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16
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Kisch SE, Nussbaum ER, Varsanik MA, O’Hara A, Pozin JJ, Littau MJ, Wang X, Carollo E, Knab LM, Abood G. Octogenarians undergoing pancreaticoduodenectomy: Assessing outcomes, disposition, and timing of chemotherapy. Surg Open Sci 2022; 7:58-61. [PMID: 35036889 PMCID: PMC8749155 DOI: 10.1016/j.sopen.2021.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 11/17/2021] [Accepted: 11/30/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Inclusion of pancreaticoduodenectomy has demonstrated higher rates of curative treatment in pancreatic cancer, yet prior research has suggested increased postoperative complications in octogenarians (patients older than 80 years). This study aimed to understand the impact of age on patients undergoing a pancreaticoduodenectomy, focusing on postoperative outcomes and return to intended oncologic treatment. MATERIALS AND METHODS We conducted a single-institution retrospective cohort study for patients undergoing pancreaticoduodenectomy from 2007 to 2018. Collected data included demographics, preoperative comorbidities, and postoperative data (length of stay, 30-day mortality, 1-year mortality, infection, discharge location). Data were separated into 2 cohorts: octogenarians (≥ 80 years) and nonoctogenarians (< 80). χ2 and independent-sample t tests were used for analysis. RESULTS A total of 649 patients underwent pancreaticoduodenectomy from 2007 to 2018; 63 (9.7%) were octogenarians. No differences were found in infectious complications (P = .607), 30-day mortality (P = .363), or 1-year mortality (P = .895). Octogenarians had a longer length of stay (P = .003) and were more likely to be discharged to skilled nursing facilities (P < .001). There was no significant difference in neoadjuvant chemotherapy administration, although octogenarians were less likely to receive adjuvant chemotherapy (P = .048) and declined adjuvant therapy at a higher rate (P = .003). CONCLUSION Performing a pancreaticoduodenectomy in octogenarians can be safe and effective in a properly selected cohort. Although postoperative morbidity and mortality are similar to younger patients, elderly patients are more likely to be discharged to nursing facilities and less likely to receive adjuvant chemotherapy. This study suggests that age alone should not be a discriminating factor when discussing surgical therapy for pancreatic cancer treatment in octogenarians.
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Affiliation(s)
- Sean E. Kisch
- Loyola University Chicago Stritch School of Medicine, 2160 S 1st Ave, Maywood, IL 60153, USA
| | - Elizabeth R. Nussbaum
- Loyola University Chicago Stritch School of Medicine, 2160 S 1st Ave, Maywood, IL 60153, USA
| | - M. Alyssa Varsanik
- Loyola University Chicago Stritch School of Medicine, 2160 S 1st Ave, Maywood, IL 60153, USA
| | - Alexander O’Hara
- Loyola University Chicago Stritch School of Medicine, 2160 S 1st Ave, Maywood, IL 60153, USA
| | - Jacob J. Pozin
- Loyola University Chicago Stritch School of Medicine, 2160 S 1st Ave, Maywood, IL 60153, USA
| | - Michael J. Littau
- Loyola University Chicago Stritch School of Medicine, 2160 S 1st Ave, Maywood, IL 60153, USA
| | - Xuanji Wang
- Department of Surgery, Division of Surgical Oncology, Loyola University Medical Center, 2160 S 1st Ave, Maywood, IL 60153, USA
| | - Erin Carollo
- Loyola University Chicago Stritch School of Medicine, 2160 S 1st Ave, Maywood, IL 60153, USA
| | - Lawrence M. Knab
- Department of Surgery, Division of Surgical Oncology, Loyola University Medical Center, 2160 S 1st Ave, Maywood, IL 60153, USA
| | - Gerard Abood
- Department of Surgery, Division of Surgical Oncology, Loyola University Medical Center, 2160 S 1st Ave, Maywood, IL 60153, USA
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17
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Attard JA, Al-Sarireh B, Bhogal RH, Farrugia A, Fusai G, Harper S, Hidalgo-Salinas C, Jah A, Marangoni G, Mortimer M, Pizanias M, Prachialias A, Roberts KJ, Sew Hee C, Soggiu F, Srinivasan P, Chatzizacharias NA. Short-term outcomes after pancreatoduodenectomy in octogenarians: multicentre case-control study. Br J Surg 2021; 109:89-95. [PMID: 34750618 DOI: 10.1093/bjs/znab374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 09/28/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Pancreatoduodenectomy (PD) is frequently the surgical treatment indicated for a number of pathologies. Elderly patients may be denied surgery because of concerns over poor perioperative outcomes. The aim of this study was to evaluate postoperative clinical outcomes and provide evidence on current UK practice in the elderly population after PD. METHODS This was a multicentre retrospective case-control study of octogenarians undergoing PD between January 2008 and December 2017, matched with younger controls from seven specialist centres in the UK. The primary endpoint was 90-day mortality. Secondary endpoints were index admission mortality, postoperative complications, and 30-day readmission rates. RESULTS In total, 235 octogenarians (median age 81 (range 80-90) years) and 235 controls (age 67 (31-79) years) were included in the study. Eastern Cooperative Oncology Group performance status (median 0 (range 0-3) versus 0 (0-2); P = 0.010) and Charlson Co-morbidity Index score (7 (6-11) versus 5 (2-9); P = 0.001) were higher for octogenarians than controls. Postoperative complication and 30-day readmission rates were comparable. The 90-day mortality rate was higher among octogenarians (9 versus 3 per cent; P = 0.030). Index admission mortality rates were comparable (4 versus 2 per cent; P = 0.160), indicating that the difference in mortality was related to deaths after hospital discharge. Despite the higher 90-day mortality rate in the octogenarian population, multivariable Cox regression analysis did not identify age as an independent predictor of postoperative mortality. CONCLUSION Despite careful patient selection and comparable index admission mortality, 90-day and, particularly, out-of-hospital mortality rates were higher in octogenarians.
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Affiliation(s)
- Joseph A Attard
- Hepatopancreatobiliary and Liver Transplant Unit, Queen Elizabeth Hospital, Birmingham, UK
| | | | | | - Alexia Farrugia
- Department of Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Giuseppe Fusai
- Hepatopancreatobiliary and Liver Transplant Unit, Royal Free Hospital, London, UK
| | - Simon Harper
- Hepatopancreatobiliary Unit, Cambridge University Hospital, Cambridge, UK
| | | | - Asif Jah
- Hepatopancreatobiliary Unit, Cambridge University Hospital, Cambridge, UK
| | - Gabriele Marangoni
- Department of Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Michail Pizanias
- Hepatopancreatobiliary Unit, King's College Hospital, London, UK
| | | | - Keith J Roberts
- Hepatopancreatobiliary and Liver Transplant Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Chloe Sew Hee
- Hepatopancreatobiliary Unit, Cambridge University Hospital, Cambridge, UK
| | - Fiammetta Soggiu
- Hepatopancreatobiliary and Liver Transplant Unit, Royal Free Hospital, London, UK
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18
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Abstract
ABSTRACT Pancreaticoduodenectomy is considered to be the most complicated operation in abdominal surgery. The purpose of this study was to evaluate the safety and efficacy of laparoscopic pancreaticoduodenectomy (LPD) in elderly patients. We searched PubMed, Embase, and Cochrane Library databases for relevant studies that were published before June 2020. Seven cohort studies were eligible with 3200 patients. The result of meta-analysis showed that, for the elderly, severe complications, clinical pancreas fistula, and delayed gastric emptying in the LPD group were significantly lower than those in the open pancreaticoduodenectomy (OPD) group. There was no significant difference in postoperative bleeding, reoperation, and readmission between the 2 groups. For the LPD, the mortality, delayed gastric emptying, and severe complication in elder patients were significantly higher than those in young patients. There was no significant difference in postoperative bleeding, R0 rate, reoperation rate, and readmission rate between the aged and the young. Therefore, LPD can reduce postoperative complications in elderly patients compared with OPD, which can be used as a potential alternative to OPD in elderly patients. However, laparoscopic approach cannot eliminate the high risk of postoperative death and severe complications caused by age. More high-quality studies need to be done for further verification.
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Affiliation(s)
- Wei Zhang
- From the Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
| | - Zhangkan Huang
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital and Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Jianwei Zhang
- From the Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
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19
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Zhang W, Huang Z, Zhang J, Che X. Safety and effectiveness of open pancreaticoduodenectomy in adults aged 70 or older: A meta-analysis. J Geriatr Oncol 2021; 12:1136-1145. [PMID: 33610506 DOI: 10.1016/j.jgo.2021.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 01/19/2021] [Accepted: 02/03/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) is considered the most complicated operation in abdominal surgery. The safety and effectiveness of PD in older patients has been questionable because older adults are often beset by one or more systemic diseases and have poor surgical tolerance. AIM To evaluate the safety and effectiveness of PD in patients aged 70 or older. METHODS We conducted a literature search on PubMed, EMBASE, Cochrane Library and other databases to discover all literature reporting a comparison of the efficacy of PD in patients 70 years old and older versus patients under 70 years old. Our cutoff date is August 2020. Revman5.3 statistical software was used for the analysis. RESULTS Twenty cohort studies were determined to be eligible with a total of 6508 patients; 2274 patients were 70 years old and older and 4234 patients under 70 years old. Meta-analysis results showed that after PD in patients over 70 years of age and older the mortality rate (RR = 2.1, 95%CI:1.59-2.78, p < 0.001), the overall postoperative complications (RR = 1.16,95%CI:1.09-1.23, p < 0.001), intraoperative transfusions (RR = 1.38, 95%CI:1.14-1.23, p = 0.001), severe complications (RR = 1.30,95%CI:1.11-1.52, p = 0.001), the re-operation rate (RR = 1.23,95%CI:1.00-1.51, p = 0.05), the R0 rate (RR = 0.92,95%CI:0.86-0.98, p = 0.01), lymph node dissection (WMD = -4.61,95%CI:-7.24-1.97, p < 0.001) and delayed gastric emptying (RR = 1.24,95%CI:1.04-1.49, p = 0.02) at a rate significantly higher than that of patients under 70 years old. There is no significant difference between patients 70 years old and older and patients under 70 years old in the clinical PF (RR = 1.11,95%CI:0.93-1.34, p = 0.24), bile leakage (RR = 0.68,95%CI:0.41-1.12, p = 0.13), postoperative bleeding (RR = 1,95%CI:0.76-1.30, p = 0.98), wound infection (RR = 1.15,95%CI:0.95-1.39, p = 0.15) and hospital stays (RR = 0.30,95%CI:-1.77-2.37, p = 0.77). CONCLUSION Patients aged 70 years or older have approximately double the risk of postoperative mortality following PD and a higher risk of overall and severe postoperative complications. Furthermore, patients 70 years old and older require more frequent intraoperative transfusions, re-operative interventions and have poorer oncology results (lower R0 rate and fewer lymph node dissections). More multi-center, large sample, and high-quality research is still needed to further verify this conclusion.
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Affiliation(s)
- Wei Zhang
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuan Nanli, Chaoyang District, Beijing 100021, China
| | - Zhangkan Huang
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, 518116, China
| | - Jiangwei Zhang
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuan Nanli, Chaoyang District, Beijing 100021, China
| | - Xu Che
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuan Nanli, Chaoyang District, Beijing 100021, China; Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, 518116, China.
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20
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Fukushima T, Adachi T, Hanada M, Tanaka T, Oikawa M, Nagura H, Eguchi S, Kozu R. Role of Early Mobilization on the Clinical Course of Patients who Underwent Pancreaticoduodenectomy: A Retrospective Cohort Study. TOHOKU J EXP MED 2021; 254:287-294. [PMID: 34456202 DOI: 10.1620/tjem.254.287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The length of hospital stay is an important outcome measure in patients who have undergone pancreaticoduodenectomy. Although postoperative complications are known to adversely affect the length of hospital stay (LOS), the influence of early mobilization on LOS has not been clarified yet. This study aimed to examine the impact of the initial ambulation day, which is one of the components of early mobilization, on LOS after pancreaticoduodenectomy. We retrospectively enrolled patients who underwent pancreaticoduodenectomy between January 2013 and December 2017. Postoperative complications were evaluated using the Clavien-Dindo classification (CDC) system. Patients were divided into two groups based on the median LOS (early and late-discharge groups) and compared to determine their characteristics. Multivariate logistic regression analysis was performed with LOS as the dependent variable. Patients in the late-discharge group were significantly older, had an initial ambulation delay, and had higher rates of advanced disease stages and a CDC grade ≥ IIIa than those in the early discharge group. In the multivariate logistic regression analysis, CDC grade ≥ IIIa, initial ambulation day, and age were found to be significant independent factors associated with LOS. Our results demonstrated that not only postoperative complications, but also the initial ambulation day, could affect LOS after pancreaticoduodenectomy, emphasizing the importance of early ambulation for patients who undergo this surgery.
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Affiliation(s)
- Takuya Fukushima
- Department of Rehabilitation Medicine, Nagasaki University Hospital.,Department of Musculoskeletal Oncology and Rehabilitation, National Cancer Center
| | - Tomohiko Adachi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences
| | - Masatoshi Hanada
- Department of Rehabilitation Medicine, Nagasaki University Hospital.,Department of Cardiopulmonary Rehabilitation Science, Nagasaki University Graduate School of Biomedical Sciences
| | - Takayuki Tanaka
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences
| | - Masato Oikawa
- Department of Rehabilitation Medicine, Nagasaki University Hospital.,Department of Cardiopulmonary Rehabilitation Science, Nagasaki University Graduate School of Biomedical Sciences
| | - Hiroki Nagura
- Department of Rehabilitation Medicine, Nagasaki University Hospital.,Department of Cardiopulmonary Rehabilitation Science, Nagasaki University Graduate School of Biomedical Sciences
| | - Susumu Eguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences
| | - Ryo Kozu
- Department of Rehabilitation Medicine, Nagasaki University Hospital.,Department of Cardiopulmonary Rehabilitation Science, Nagasaki University Graduate School of Biomedical Sciences
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21
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Association between age and short-term outcomes of gastroenterological surgeries in older patients: an analysis using the National Clinical Database in Japan. Langenbecks Arch Surg 2021; 406:2827-2836. [PMID: 34379197 DOI: 10.1007/s00423-021-02296-5] [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: 11/08/2020] [Accepted: 08/05/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The association between advanced age and postoperative morbidity and mortality after major gastroenterological surgeries remains unclear. This study aimed to assess the association between old age and the short-term postoperative outcomes of gastroenterological surgeries. METHODS We evaluated 327,642 patients who underwent any of the seven major gastroenterological surgeries-esophagectomy, total gastrectomy, distal gastrectomy, right hemicolectomy, low anterior resection, hepatectomy, and pancreatoduodenectomy-and were registered with the Japanese national surgical registry between January 2011 and December 2013. Perioperative characteristics, frequency/nature of postoperative morbidities, and postoperative mortality were compared according to age at the time of surgery. RESULTS Overall, 18% (59,182/327,642) of the entire cohort were aged ≥ 80 years. The overall mortality rates in the entire cohort and in those aged ≥ 80 years were 1.7% and 3.3%, respectively. The postoperative mortality increased with increasing age for all procedures, with the trend persisting even after adjusting for various confounding factors. The incidence of postoperative pneumonia increased with increasing age, and with all procedures, except esophagectomy, subjects aged ≥ 80 years had a markedly higher risk of developing postoperative pneumonia than those aged < 60 years. CONCLUSION Advanced age is associated with significantly worse short-term outcomes in older patients undergoing gastroenterological surgeries. However, we could not identify any distinct cutoff age beyond which major gastroenterological surgery could be considered as being contraindicated. The mortality risk should be carefully considered before recommending major gastroenterological surgeries for older patients.
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22
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Rubin DS, Huisingh-Scheetz M, Ferguson MK, Nagele P, Peden CJ, Lauderdale DS. U.S. trends in elective and emergent major abdominal surgical procedures from 2002 to 2014 in older adults. J Am Geriatr Soc 2021; 69:2220-2230. [PMID: 33969889 PMCID: PMC8373714 DOI: 10.1111/jgs.17189] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 03/15/2021] [Accepted: 04/04/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The U.S. population is aging and projected to undergo an increasing number of general surgical procedures. However, recent trends in the frequency of major abdominal procedures in older adults are currently unknown as improvements in non-operative interventions may obviate the need for major surgery. Thus, we evaluated the trends of major abdominal surgical procedures in older adults in the United States. METHODS We performed a retrospective cohort study using the National Inpatient Sample from 2002 to 2014 with trend analysis using National Cancer Institute's Joinpoint Trend Analysis Software. We identified the average annual percent change (AAPC) in the yearly frequency of major abdominal surgical procedures in older adults (≥50 years of age). RESULTS Our cohort included a total of 3,951,947 survey-weighted discharges that included a major abdominal surgery in adults ≥50 years of age between 2002 and 2014. Of these discharges, 2,529,507 (64.0%) were for elective abdominal surgeries, 2,062,835 (52.0%) were for female patients, and mean (SD) age was 61.4 (15.9) years. The frequency of major abdominal procedures (elective and emergent) decreased for adults aged 65-74 (AAPC: -1.43, -1.75, -1.11, p < 0.0001), 75-84 (AAPC: -2.75, -3.33, -2.16, p < 0.001), and ≥85 (AAPC: -4.07, -4.67, -3.47, p < 0.0001). The AAPC for elective procedures decreased for older adults aged 75-84 (AAPC = -1.65; -2.44, -0.85: p = 0.0001) and >85 (AAPC = -3.53; -4.57, -2.48: p < 0.0001). All age groups showed decreases in emergent procedures in 50-64 (AAPC = -1.76, -2.00, -1.52, p < 0.0001), 65-74 (AAPC = -3.59, -4.03, -3.14, p < 0.0001), 75-84 (AAPC = -3.90, -4.34, -3.46, p < 0.0001), ≥85 (AAPC = -4.58, -4.98, -4.17, p < 0.0001) age groups. CONCLUSIONS AND RELEVANCE In this cohort of older adults, the frequency of emergent and elective major abdominal procedures in adults ≥65 years of age decreased with significant variation among individual procedure types. Future studies are needed to identify the generalizability of our findings to other surgical procedures.
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Affiliation(s)
- Daniel S Rubin
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois, USA
| | - Megan Huisingh-Scheetz
- Section of Geriatrics and Palliative Medicine, University of Chicago, Chicago, Illinois, USA
| | - Mark K Ferguson
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Peter Nagele
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois, USA
| | - Carol J Peden
- Department of Anesthesiology, University of Southern California, Los Angeles, California, USA
- Department of Anesthesiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Diane S Lauderdale
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois, USA
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23
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Flick KF, Schmidt CM, Colgate CL, Yip-Schneider MT, Sublette CM, Maatman TK, Soufi M, Ceppa EP, House MG, Zyromski NJ, Nakeeb A. Preoperative Nomogram Predicts Non-home Discharge in Patients Undergoing Pancreatoduodenectomy. J Gastrointest Surg 2021; 25:1253-1260. [PMID: 32583325 DOI: 10.1007/s11605-020-04689-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 06/04/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND In patients undergoing pancreatoduodenectomy, non-home discharge is common and often results in an unnecessary delay in hospital discharge. This study aimed to develop and validate a preoperative prediction model to identify patients with a high likelihood of non-home discharge following pancreatoduodenectomy. METHODS Patients undergoing pancreatoduodenectomy from 2013 to 2018 were identified using an institutional database. Patients were categorized according to discharge location (home vs. non-home). Preoperative risk factors, including social determinants of health associated with non-home discharge, were identified using Pearson's chi-squared test and then included in a multiple logistic regression model. A training cohort composed of 80% of the sampled patients was used to create the prediction model, and validation carried out using the remaining 20%. Statistical significance was defined as P < 0.05. RESULTS Seven hundred sixty-six pancreatoduodenectomy patients met the study criteria for inclusion in the analysis (non-home, 126; home, 640). Independent predictors of non-home discharge on multivariable analysis were age, marital status, mental health diagnosis, functional health status, dyspnea, and chronic obstructive pulmonary disease. The prediction model was then used to generate a nomogram to predict likelihood of non-home discharge. The training and validation cohorts demonstrated comparable performances with an identical area under the curve (0.81) and an accuracy of 84%. CONCLUSION A prediction model to reliably assess the likelihood of non-home discharge after pancreatoduodenectomy was developed and validated in the present study.
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Affiliation(s)
- Katelyn F Flick
- Department of Surgery, Indiana University Simon Cancer Center, Indianapolis, IN, USA
| | - C Max Schmidt
- Department of Surgery, Indiana University Simon Cancer Center, Indianapolis, IN, USA.
- Department of Biochemistry/Molecular Biology, Indiana University Simon Cancer Center, Indianapolis, IN, USA.
- Walther Oncology Center, Indianapolis, IN, USA.
- Indiana University Simon Comprehensive Cancer Center, Indianapolis, IN, USA.
- Indiana University Health Pancreatic Cyst and Cancer Early Detection Center, Indianapolis, IN, USA.
| | - Cameron L Colgate
- Center for Outcomes Research in Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michele T Yip-Schneider
- Department of Surgery, Indiana University Simon Cancer Center, Indianapolis, IN, USA
- Walther Oncology Center, Indianapolis, IN, USA
- Indiana University Simon Comprehensive Cancer Center, Indianapolis, IN, USA
- Indiana University Health Pancreatic Cyst and Cancer Early Detection Center, Indianapolis, IN, USA
| | | | - Thomas K Maatman
- Department of Surgery, Indiana University Simon Cancer Center, Indianapolis, IN, USA
| | - Mazhar Soufi
- Department of Surgery, Indiana University Simon Cancer Center, Indianapolis, IN, USA
| | - Eugene P Ceppa
- Department of Surgery, Indiana University Simon Cancer Center, Indianapolis, IN, USA
- Indiana University Health Pancreatic Cyst and Cancer Early Detection Center, Indianapolis, IN, USA
| | - Michael G House
- Department of Surgery, Indiana University Simon Cancer Center, Indianapolis, IN, USA
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University Simon Cancer Center, Indianapolis, IN, USA
| | - Attila Nakeeb
- Department of Surgery, Indiana University Simon Cancer Center, Indianapolis, IN, USA
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24
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Enhanced recovery after pancreatoduodenectomy-does age have a bearing? Langenbecks Arch Surg 2021; 406:1093-1101. [PMID: 33774746 DOI: 10.1007/s00423-021-02108-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 01/25/2021] [Indexed: 12/20/2022]
Abstract
INTRODUCTION With the proven benefits of enhanced recovery protocols (ERP) after pancreatoduodenectomy (PD), their implementation has become a well-accepted clinical practice across the major pancreatic surgery centres of the world. The impact of age on the execution of ERP has remained an area of ambiguity. The aim of this study was to assess the impact of age on the feasibility of various postoperative elements of ERP after PD. METHODS A retrospective study was conducted which included 548 patients undergoing PD, managed using ERP, from March 2013 to September 2020. Patients were divided into two groups: < 70 years and ≥ 70 years. Compliance to recovery parameters and postoperative outcomes, including, the incidence of major complications, length of stay (LOS), mortality rates and re-admissions, were compared between the two groups. The impact of age, as a continuous variable, was also studied on the feasibility of each postoperative element. RESULTS One-fifth (113/548) of the cohort comprised of patients aged 70 years and above. The 'elderly' patients had a significantly higher prevalence of diabetes, hypertension, and cardiac disease. They were also more likely to get admitted to the intensive care unit for postoperative monitoring (p < 0.001). The median LOS was 8.0 days in the young and 9.0 days in the elderly (p = 0.253). Rate of major complications (age < 70, n = 37 (8.5%) vs age ≥ 70, n = 7 (6.2%), p = 0.421) and 30-day mortality (age < 70, n = 15 (3.4%) vs age ≥ 70, n = 7 (6.2%), p = 0.185) was not statistically different between the two groups. Compliance of various postoperative elements was similar between the two groups. When studied as a continuous variable, age did not seem to be associated with higher non-compliance of any of the postoperative recovery elements. CONCLUSION Age is not a barrier in the safe implementation of postoperative element of ERPs after PD. Enhanced recovery protocols do not need to be modified for the aged.
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25
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Pineño-Flores C, Ambrona-Zafra D, Rodríguez-Pino JC, Soldevila-Verdeguer C, Palma-Zamora E, Molina-Romero FX, Morón-Canis JM, González-Argente FX, Morales-Soriano R. Cephalic pancreaticoduodenectomy for ductal adenocarcinoma in the elderly. Can we do it safely? Cir Esp 2021; 100:S0009-739X(21)00029-4. [PMID: 33714556 DOI: 10.1016/j.ciresp.2021.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 01/03/2021] [Accepted: 01/17/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Surgery and chemotherapy have increased the survival of pancreatic cancer. The decrease in postoperative morbidity and mortality and increase in life expectancy, has expanded the indications por cephalic pancreaticoduodenectomy (PDC), although it remains controversial in the geriatric population. METHODS Retrospective study on a prospective database of patients with ductal adenocarcinoma of pancreas who underwent PDC between 2007-2018.The main objective was to analyse the morbidity-mortality and survival associated with PDC in patients≥75 years (elderly). RESULTS 79 patients were included, 21 of them older than 75 years (27%); within this group, 23.9% were over 80 years old. The ASA of both groups was similar. Patients≥75 years required more transfusions. No differences in operating time were observed, although more vascular resection were performed in the elderly (26 vs. 8.7%; P=.037). Morbidity was higher in the elderly (61.9 vs. 46.6%), although without differences. Patients aged≥75 years had more non-surgical complications (33.3%, P=.050), being pneumonia the most frequent. Postoperative mortality was higher in the≥75 years (9 vs. 0%; P=.017). The overall survival and disease-free survival did not show significant differences in both groups. CONCLUSIONS Elderly patients had higher postoperative mortality and more non-surgical complications. Survival did not show differences, so with an adequate selection of patients, age should not be considered itself as a contraindication for PDC.
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Affiliation(s)
- Cristina Pineño-Flores
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitari Son Espases, Palma de Mallorca, Baleares, España; Instituto de Investigación Sanitaria de Islas Baleares (IdISBa), Hospital Universitari Arnau de Villanova, Palma de Mallorca, Baleares, España.
| | - David Ambrona-Zafra
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitari Arnau de Vilanova, Lleida, Cataluña, España
| | - Jose Carlos Rodríguez-Pino
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitari Son Espases, Palma de Mallorca, Baleares, España
| | - Carla Soldevila-Verdeguer
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitari Son Espases, Palma de Mallorca, Baleares, España; Instituto de Investigación Sanitaria de Islas Baleares (IdISBa), Hospital Universitari Arnau de Villanova, Palma de Mallorca, Baleares, España
| | - Elias Palma-Zamora
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitari Son Espases, Palma de Mallorca, Baleares, España
| | - Francesc Xavier Molina-Romero
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitari Son Espases, Palma de Mallorca, Baleares, España; Instituto de Investigación Sanitaria de Islas Baleares (IdISBa), Hospital Universitari Arnau de Villanova, Palma de Mallorca, Baleares, España; Facultad de Medicina, Universidad de las Islas Baleares, Palma de Mallorca, Baleares, España
| | - Jose Miguel Morón-Canis
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitari Son Espases, Palma de Mallorca, Baleares, España
| | - Francesc Xavier González-Argente
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitari Son Espases, Palma de Mallorca, Baleares, España; Instituto de Investigación Sanitaria de Islas Baleares (IdISBa), Hospital Universitari Arnau de Villanova, Palma de Mallorca, Baleares, España; Facultad de Medicina, Universidad de las Islas Baleares, Palma de Mallorca, Baleares, España
| | - Rafael Morales-Soriano
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitari Son Espases, Palma de Mallorca, Baleares, España; Instituto de Investigación Sanitaria de Islas Baleares (IdISBa), Hospital Universitari Arnau de Villanova, Palma de Mallorca, Baleares, España
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26
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Farooqui W, Riemenschneider KA, Penninga L, Vyrdal CD, Hansen CP, Storkholm JH. The diagnostic value of C-reactive protein for predicting pancreatic fistula following pancreatoduodenectomy. Scand J Gastroenterol 2021; 56:329-335. [PMID: 33427522 DOI: 10.1080/00365521.2020.1867895] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Pancreaticoduodenectomy is the preferred treatment of neoplasms in the pancreas and duodenum. Postoperative pancreatic fistula is a critical complication. A potential predictive marker is C-reactive protein. This retrospective study examined the predictive value of C-reactive protein as a marker for development of postoperative pancreatic fistulas. METHODS All patients who had a pancreaticoduodenectomy from 1 January 2015 to 31 December 2019, were included. Levels of the biomarker and linear trajectory were determined for postoperative days one to four. Univariate analysis was used to identify predictive variables for a postoperative pancreatic fistula. Receiver operating characteristics curves, specificity, and sensitivity were calculated. RESULTS Five hundred and fifty-two patients underwent pancreaticoduodenectomy. C-reactive protein level greater than 121.5mg/L on the third postoperative day and an increase in C-reactive protein level between the first and fourth postoperative days, greater than 21.7mg/L, seemed to be reliable predictors. For Grade C postoperative pancreatic fistulas, increases in C-reactive protein, greater than 40.6ml/L the first four postoperative days, had a sensitivity of 100%. White blood cell count did not have similar reliability in predicting postoperative pancreatic fistulas. CONCLUSION Our findings indicate that small rises in C-reactive protein during the first postoperative days after pancreaticoduodenectomy are associated with an increased risk of developing postoperative pancreatic fistula.
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Affiliation(s)
- Waqas Farooqui
- Department of Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Luit Penninga
- Department of Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Carsten Palnaes Hansen
- Department of Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jan Henrik Storkholm
- Department of Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Huang Y, Damodaran Prabha R, Chua TC, Arena J, Kotecha K, Mittal A, Gill AJ, Samra JS. Safety and Efficacy of Pancreaticoduodenectomy in Octogenarians. Front Surg 2021; 8:617286. [PMID: 33604352 PMCID: PMC7884922 DOI: 10.3389/fsurg.2021.617286] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 01/08/2021] [Indexed: 11/13/2022] Open
Abstract
Backgrounds: Pancreaticoduodenectomy (PD) remains the only hope of a cure in selected patients with pancreatic adenocarcinoma (PAC). With an aging population, there will be an increasing number of very elderly patients being diagnosed with PAC of whom a selected proportion would be suitable for PD. However, the literature on outcomes of elderly patients after PD remains ambiguous. Therefore, the aim of this study was to examine the safety and efficacy of PD in octogenarians with PAC. Methods: A retrospective analysis of 304 patients with PAC undergoing PD. Patients were divided into two age groups using age of 80 years old as the cut-off. Results: Overall mortality and major morbidity rates were 0.5 and 18.5%, respectively. The octogenarian group had a higher rate of mortality (6.3%, n = 1, p < 0.001), a higher rate of major morbidity (37.5%, n = 6, p = 0.042) and a longer hospital stay (p = 0.035). However, median survival of octogenarians was 15.6 months. Multivariate analysis showed age was not identified as a prognostic factor for major morbidity and overall survival. Conclusion: Age alone should not be an exclusion criterion for consideration of PD. With careful selection, PD can be safely performed in octogenarians. Elderly patients should be referred to a specialized unit for an objective assessment to determine the suitability for this aggressive but potential curative approach.
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Affiliation(s)
- Yeqian Huang
- Department of Gastrointestinal Surgery, Royal North Shore Hospital, St Leonards, NSW, Australia.,Northern Clinical School, University of Sydney, Sydney, NSW, Australia.,South Western Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Ramesh Damodaran Prabha
- Department of Gastrointestinal Surgery, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Terence C Chua
- Department of Surgery, QE II Jubilee Hospital, Metro South Health, Brisbane, QLD, Australia.,School of Medicine, Griffith University, Gold Coast, QLD, Australia.,Discipline of Surgery, The University of Queensland, Brisbane, QLD, Australia
| | - Jennifer Arena
- Department of Gastrointestinal Surgery, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Krishna Kotecha
- Department of Gastrointestinal Surgery, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Anubhav Mittal
- Department of Gastrointestinal Surgery, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Anthony J Gill
- Northern Clinical School, University of Sydney, Sydney, NSW, Australia.,Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, St Leonards, NSW, Australia.,Deparment of Anatomical Pathology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Jaswinder S Samra
- Department of Gastrointestinal Surgery, Royal North Shore Hospital, St Leonards, NSW, Australia.,Macquarie University Hospital, Macquarie University, Sydney, NSW, Australia
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28
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Okabayashi T, Sui K, Murokawa T, Kimura J, Iwata J, Morita S, Iiyama T, Shimada Y. Indications for pancreaticoduodenectomy affected postoperative outcomes in octogenarians. Ann Gastroenterol Surg 2021; 5:102-110. [PMID: 33532686 PMCID: PMC7832957 DOI: 10.1002/ags3.12395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/29/2020] [Accepted: 08/04/2020] [Indexed: 12/07/2022] Open
Abstract
AIMS The safety and efficacy of pancreaticoduodenectomy (PD) in patients over the age of 80 years remain controversial. We aimed to examine post-PD outcomes and to determine the age limit for PD. METHODS Patients were divided into two subgroups: the younger (<80 years) group and octogenarian (≥80 years) group. We retrospectively evaluated the clinical benefit of PD for periampullary diseases in the younger and octogenarian groups, focusing on short- and long-term outcomes. RESULTS From March 2005 to December 2018, 586 consecutive surgically curable patients with diagnosed periampullary diseases were studied, among whom 122 (20.8%) were ≥80 years old. The general preoperative physical condition (G8 screening, instrumental activities of daily living, and Charlson comorbidity index) and nutritional status were significantly worse in the octogenarian group. However, there were no significant differences between the younger and octogenarian groups in postoperative severe complication rates (34% vs 36%) or perioperative mortality rates (1.5% vs 0.0%). We observed significantly poorer 3-, 5-, and 10-year overall survivals in the octogenarian group than in the younger group (P = .007). In the younger group, the main cause of death (89.6%) was cancer recurrence. However, only 60% of patients in the octogenarian group developed and died from cancer recurrence. Increased neutrophilic/lymphocyte ratio and elevated Controlling Nutritional Status score were associated with worse outcomes. CONCLUSIONS It is important to carefully determine the indication for PD in octogenarian patients with periampullary diseases, although patient age over 80 years should not be a contraindication for PD.
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Affiliation(s)
- Takehiro Okabayashi
- Department of Gastroenterological SurgeryKochi Health Sciences CenterKochiJapan
| | - Kenta Sui
- Department of Gastroenterological SurgeryKochi Health Sciences CenterKochiJapan
| | - Takahiro Murokawa
- Department of Gastroenterological SurgeryKochi Health Sciences CenterKochiJapan
| | - Jiro Kimura
- Department of Gastroenterological SurgeryKochi Health Sciences CenterKochiJapan
| | - Jun Iwata
- Department of Diagnostic PathologyKochi Health Sciences CenterKochiJapan
| | - Sojiro Morita
- Department of RadiologyKochi Health Sciences CenterKochiJapan
| | - Tatsuo Iiyama
- Department of BiostatisticsNational Center for Global Health and MedicineShinjuku‐kuJapan
| | - Yasuhiro Shimada
- Department of Clinical OncologyKochi Health Sciences CenterKochiJapan
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Kang CM, Lee JH, Choi JK, Hwang HK, Chung JU, Lee WJ, Kwon KH. Can we recommend surgical treatment to the octogenarian with periampullary cancer?: National database analysis in South Korea. Eur J Cancer 2020; 144:81-90. [PMID: 33341449 DOI: 10.1016/j.ejca.2020.10.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 10/10/2020] [Accepted: 10/20/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND The incidence of periampullary cancer in the elderly is increasing. Safety and oncologic effectiveness of pancreaticoduodenectomy in elderly patients is still controversial. MATERIALS AND METHODS From 2002 to 2016, patients with periampullary cancer were evaluated. Customised health information data provided by the National Health Insurance Corporation (NHIS-2018-1-157) were used for analysis. Chronological changes in the incidence of periampullary cancer and long-term survival outcomes were estimated according to patients' age. RESULT A total of 148,080 patients were found to have periampullary cancer. Chronologically, the incidence of periampullary cancer increased, and the proportion of elderly patients with periampullary cancer prominently increased (about 2.1 times in patients in their 70s and about 4.7 times in those older than 80 years). The number of patients with pylorus-preserving pancreaticoduodenectomy in their 70s (about 5.6 times, p < 0.001) and over 80 years of age (about 8.9 times, p < 0.001) was much higher than the number of patients aged younger than 50 years (about 1.7 times) and in their 60s (about 2.5 times). Long-term survival was different as per diagnosis (p < 0.001). In addition, it was observed that age was a factor attenuating the survival of patients with resected periampullary cancers (p < 0.001). However, in case of patients older than 80 years, those who underwent surgical treatment showed a higher survival rate than those who did not undergo surgical treatment. CONCLUSION We can recommend surgical treatment for elderly patients with resectable periampullary cancer. The survival data in this study can be useful references especially in making treatment plan for octogenarians diagnosed with periampullary cancer.
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Affiliation(s)
- Chang M Kang
- Division of HBP Surgery, Department of Surgery, Yonsei University College of Medicine, South Korea; Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, South Korea
| | - Jin H Lee
- Department of Surgery, National Health Insurance Service Ilsan Hospital, Goyang, South Korea
| | - Jung K Choi
- Department of Policy Research Affairs, National Health Insurance Service Ilsan Hospital, South Korea
| | - Ho K Hwang
- Division of HBP Surgery, Department of Surgery, Yonsei University College of Medicine, South Korea; Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, South Korea
| | - Jae U Chung
- Department of Surgery, National Health Insurance Service Ilsan Hospital, Goyang, South Korea
| | - Woo J Lee
- Division of HBP Surgery, Department of Surgery, Yonsei University College of Medicine, South Korea; Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, South Korea
| | - Kuk H Kwon
- Department of Surgery, National Health Insurance Service Ilsan Hospital, Goyang, South Korea.
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Sato N, Kimura T, Kenjo A, Kofunato Y, Okada R, Ishigame T, Watanabe J, Marubashi S. Early intra-abdominal infection following pancreaticoduodenectomy:associated factors and clinical impact on surgical outcome. Fukushima J Med Sci 2020; 66:124-132. [PMID: 32963204 PMCID: PMC7790468 DOI: 10.5387/fms.2020-11] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Early intra-abdominal infection (IAI) following pancreaticoduodenectomy (PD) is an initial event relating to morbidities caused by postoperative pancreatic fistula (POPF). The aims of this study were to determine factors associated with IAI, and to investigate its impact on postoperative outcome. Consecutive patients, 113 in total, who underwent PD at Fukushima Medical University Hospital between January 2012 and September 2017 were included in this retrospective study. IAI was defined by positive bacterial culture from intra-abdominal drainage fluid any time through postoperative day 3 (POD3). Logistic regression analysis was used to identify the relevant factors associated with IAI. The clinical impact of the POD3 infection indicators related to POPF were assessed by multivariate analysis. The incidence of IAI, POPF, and mortality were 36.1%, 36.1%, and 0%, respectively. Independent factors associated with IAI were preoperative biliary drainage (PBD) (OR = 2.91, CI = 1.16-7.33, p = 0.023) and soft pancreas (OR = 8.67, CI = 2.37-31.77, p = 0.001). Among infection markers on POD3, the significant factors for POPF were CRP (OR = 1.18, CI = 1.08-1.30, p < 0.001), IAI (OR = 7,37, CI = 2.53-21.5, p < 0.001), and drain amylase (OR = 1.00, CI = 1.00-1.01, p = 0.001). In conclusion, PBD, soft pancreas, and higher age were associated with IAI. IAI has a significantly negative impact on postoperative outcome.
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Affiliation(s)
- Naoya Sato
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Fukushima Medical University
| | - Takashi Kimura
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Fukushima Medical University
| | - Akira Kenjo
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Fukushima Medical University
| | - Yasuhide Kofunato
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Fukushima Medical University
| | - Ryo Okada
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Fukushima Medical University
| | - Teruhide Ishigame
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Fukushima Medical University
| | - Junichiro Watanabe
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Fukushima Medical University
| | - Shigeru Marubashi
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Fukushima Medical University
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Johansen KU, Lundgren LM, Gasslander TR, Sandström P, Björnsson B. 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. ANNALS OF SURGERY OPEN 2020; 1:e015. [PMID: 37637454 PMCID: PMC10455282 DOI: 10.1097/as9.0000000000000015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 08/25/2020] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Karin U. Johansen
- From the Department of Surgery, Linköping University, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Linda M. Lundgren
- From the Department of Surgery, Linköping University, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Thomas R. Gasslander
- From the Department of Surgery, Linköping University, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Per Sandström
- From the Department of Surgery, Linköping University, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Bergthor Björnsson
- From the Department of Surgery, Linköping University, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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Meltzer RS, Kooby DA, Switchenko JM, Datta J, Carpizo DR, Maithel SK, Shah MM. Does Major Pancreatic Surgery Have Utility in Nonagenarians with Pancreas Cancer? Ann Surg Oncol 2020; 28:2265-2272. [PMID: 33141373 DOI: 10.1245/s10434-020-09279-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 10/04/2020] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
| | - David A Kooby
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, Georgia
| | - Jeffrey M Switchenko
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Jashodeep Datta
- Division of Surgical Oncology, University of Miami Miller School of Medicine, Miami, USA
| | - Darren R Carpizo
- Division of Surgical Oncology, Wilmot Cancer Institute, University of Rochester, Rochester, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, Georgia
| | - Mihir M Shah
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, Georgia.
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Utsumi M, Aoki H, Nagahisa S, Une Y, Kimura Y, Watanabe M, Taniguchi F, Arata T, Katsuda K, Tanakaya K. Nutritional assessment and surgical outcomes in very elderly patients undergoing pancreaticoduodenectomy: a retrospective study. Surg Today 2020; 51:941-953. [PMID: 33106898 DOI: 10.1007/s00595-020-02169-2] [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: 07/17/2020] [Accepted: 09/29/2020] [Indexed: 11/09/2022]
Abstract
PURPOSE To evaluate and compare the nutritional factors and clinical outcomes of pancreaticoduodenectomy between elderly and non-elderly patients. METHODS This retrospective study evaluated 122 consecutive patients who underwent pancreaticoduodenectomy from April 2008 to April 2020. Preoperative and postoperative nutritional factors (prognostic nutritional index), complication rates, and survival rates were compared between the elderly (≥ 80 years) and non-elderly (< 80 years) patient groups. Changes in nutrition markers were evaluated before surgery to 1 year after surgery. RESULTS A total of 20 elderly patients (16.4%) and 102 non-elderly patients (83.6%) underwent pancreaticoduodenectomy. Elderly patients had a significantly lower preoperative prognostic nutritional index than did non-elderly patients. At 3 months postoperatively, elderly patients had a lower albumin level and prognostic nutritional index. The median length of hospital stay was significantly longer (39.9 vs. 27 days, P = 0.004), the rate of death due to other diseases was higher, and the overall survival rate was significantly lower (1-/3-/5 year overall survival rates: 78.1%/26.7%/13.3% vs. 87.1%/54.4%/46.7%; log-rank test, P = 0.003) in the elderly group than in the non-elderly group. CONCLUSIONS The results suggest that careful patient selection and optimal perioperative care are necessary to determine whether pancreaticoduodenectomy is indicated for elderly patients.
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Affiliation(s)
- Masashi Utsumi
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, 1-1-1 Atago-machi, Iwakuni-shi, Yamaguchi, 740-8510, Japan.
| | - Hideki Aoki
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, 1-1-1 Atago-machi, Iwakuni-shi, Yamaguchi, 740-8510, Japan
| | - Seiichi Nagahisa
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, 1-1-1 Atago-machi, Iwakuni-shi, Yamaguchi, 740-8510, Japan
| | - Yuta Une
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, 1-1-1 Atago-machi, Iwakuni-shi, Yamaguchi, 740-8510, Japan
| | - Yuji Kimura
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, 1-1-1 Atago-machi, Iwakuni-shi, Yamaguchi, 740-8510, Japan
| | - Megumi Watanabe
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, 1-1-1 Atago-machi, Iwakuni-shi, Yamaguchi, 740-8510, Japan
| | - Fumitaka Taniguchi
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, 1-1-1 Atago-machi, Iwakuni-shi, Yamaguchi, 740-8510, Japan
| | - Takashi Arata
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, 1-1-1 Atago-machi, Iwakuni-shi, Yamaguchi, 740-8510, Japan
| | - Koh Katsuda
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, 1-1-1 Atago-machi, Iwakuni-shi, Yamaguchi, 740-8510, Japan
| | - Kohji Tanakaya
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, 1-1-1 Atago-machi, Iwakuni-shi, Yamaguchi, 740-8510, Japan
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Liu Q, Zhao Z, Zhang X, Zhao G, Tan X, Gao Y, Lau WY, Liu R. Robotic pancreaticoduodenectomy in elderly and younger patients: A retrospective cohort study. Int J Surg 2020; 81:61-65. [PMID: 32750491 DOI: 10.1016/j.ijsu.2020.07.049] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/27/2020] [Accepted: 07/19/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Robotic pancreaticoduodenectomy (RPD) has gradually been accepted as it has overcome some of the limitations of laparoscopic surgery. Outcomes following RPD in elderly patients are still uncertain. This study aimed to evaluate the safety and feasibility of RPD in elderly patients. METHODS The demographics and perioperative outcomes of a consecutive series of patients who underwent RPD between January 2018 and September 2019, were retrospectively analyzed. Patients were divided into 2 groups: elderly patients (≥75 years) and younger patients (<75 years). RESULTS Of 431 patients who were included in this study, 77 were elderly patients and 354 were younger patients. Elderly patients had a significantly higher ASA score than younger patients (P < 0.001). There were no significant differences in operative time, estimated blood loss and blood transfusion rate between groups (P > 0.05). Elderly patients had significantly higher morbidity and longer postoperative hospital stay than younger patients (49.3% vs. 31.1%, P = 0.002; 22.8 vs. 13.3 days, P < 0.001, respectively). However, the reoperation, 90-day readmission and mortality rates were comparable in the two groups (P > 0.05). Multivariate analysis demonstrated that a higher ASA score was the only independent factor for postoperative morbidity (OR 2.02, 95% CI 1.06-3.88, P = 0.03), while old age was not (OR 0.81, 95% CI 0.36-1.81, P = 0.80). CONCLUSION This study demonstrated that RDP was safe and feasible in elderly patients. Age should not be a contraindication to RPD. Elderly patients with careful patient selection should be considered for RPD.
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Affiliation(s)
- Qu Liu
- Second Department of Hepatopancreatobiliary Surgery, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Zhiming Zhao
- Second Department of Hepatopancreatobiliary Surgery, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Xiuping Zhang
- Second Department of Hepatopancreatobiliary Surgery, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Guodong Zhao
- Second Department of Hepatopancreatobiliary Surgery, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Xianglong Tan
- Second Department of Hepatopancreatobiliary Surgery, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Yuanxing Gao
- Second Department of Hepatopancreatobiliary Surgery, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Wan Yee Lau
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
| | - Rong Liu
- Second Department of Hepatopancreatobiliary Surgery, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China.
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Carli F, Baldini G. From preoperative assessment to preoperative optimization of frail older patiens. Eur J Surg Oncol 2020; 47:519-523. [PMID: 32753116 DOI: 10.1016/j.ejso.2020.06.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 06/09/2020] [Indexed: 10/24/2022] Open
Abstract
Physiological and mental reserve decreases with age and the ability to mount a response to a stress like surgery can represent a burden to the frail and sarcopenic patient. It is necessary to evaluate the cardiorespiratory capacity and muscle strength before surgery in the older persons and prepare adequately to the same extent the marathon runner prepares before a full marathon. Assessment and stratification of risk are necessary for decision-making, but also for planning interventions aimed at improving the functional and emotional status in anticipation of surgery. Prehabilitation can improve the physiological reserve by optimizing cardiorespiratory capacity, muscle strength, and mental resiliency. Patients with low reserve and chronic medical conditions at high risk can benefit.
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Affiliation(s)
- Francesco Carli
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Room D10.165, 1650 Cedar Ave, Montreal, Quebec, H3G 1A4, Canada.
| | - Gabriele Baldini
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Room D10.165, 1650 Cedar Ave, Montreal, Quebec, H3G 1A4, Canada
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Bongers BC, Dejong CHC, den Dulk M. Enhanced recovery after surgery programmes in older patients undergoing hepatopancreatobiliary surgery: what benefits might prehabilitation have? Eur J Surg Oncol 2020; 47:551-559. [PMID: 32253075 DOI: 10.1016/j.ejso.2020.03.211] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 03/05/2020] [Accepted: 03/21/2020] [Indexed: 12/14/2022] Open
Abstract
Due to an aging population and the related growing number of less physically fit patients with multiple comorbidities, adequate perioperative care is a new and rapidly developing clinical science that is becoming increasingly important. This narrative review focuses on enhanced recovery after surgery (ERAS®) programmes and the growing interest in prehabilitation programmes to improve patient- and treatment-related outcomes in older patients undergoing hepatopancreatobiliary (HPB) surgery. Future steps required in the further development of optimal perioperative care in HPB surgery are also discussed. Multidisciplinary preoperative risk assessment in multiple domains should be performed to identify, discuss, and reduce risks for optimal outcomes, or to consider alternative treatment options. Prehabilitation should focus on high-risk patients based on evidence-based cut-off values and should aim for (partly) supervised multimodal prehabilitation tailored to the individual patient's risk factors. The program should be executed in the living context of these high-risk patients to improve the participation rate and adherence, as well as to involve the patient's informal support system. Developing tailored (multimodal) prehabilitation programmes for the right patients, in the right context, and using the right outcome measures is important to demonstrate its potential to further improve patient- and treatment-related outcomes following HPB surgery.
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Affiliation(s)
- Bart C Bongers
- Department of Nutrition and Movement Sciences, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands; Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands.
| | - Cornelis H C Dejong
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands; Department of Surgery, Uniklinikum RWTH-Aachen, Aachen, Germany.
| | - Marcel den Dulk
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands; Department of Surgery, Uniklinikum RWTH-Aachen, Aachen, Germany.
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Shatveryan GA, Chardarov NK, Nikoda VV, Bagmet NN, Tadzhibova IM, Lishova EA, Ratnikova NP, Karagyozyan GA. [Short-term results of pancreatoduodenectomy in patients over 70 years old]. Khirurgiia (Mosk) 2020:25-32. [PMID: 31994496 DOI: 10.17116/hirurgia202001125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To analyze the immediate results of PDE in patients younger and older 70 years. MATERIAL AND METHODS The study included patients who underwent PDE for various indications from March 2010 to February 2019. All patients are divided into 2 groups: <70 years old and ≥70 years old. Primary endpoints were postoperative mortality and complication rate. RESULTS There were 110 procedures within 9 years. There were 93 patients aged <70 years (group 1) and 17 patients aged ≥70 years (group 2). ASA (American Society of Anesthesiologists) and PMP scores (Preoperative Mortality Predictor) were higher in group 2: 3 (2-3) vs 2 (1-3) (p=0,002) and 12 (6-15) vs 6.5 (5-15) (p<0.001), respectively. Mortality rate was higher in group 2 (11.7% vs. 3.2%) without statistical significance (p=0.16). Overall morbidity (72% vs 76%; p=1.0), incidence of major complications grade ≥IIIa (29% vs 29%), delayed gastric emptying B/C (17.2% vs 17.6%), pancreatic fistula grade B/C (23.6% vs 35.3%, p=0.3), biliary fistula grade B/C (7.5% vs 11.8%; p=0.62), postoperative hospital-stay [22 (8-165) days vs 23 (9-71) days; p=0.92] were comparable in both groups. CONCLUSION Short-term results of PDE in patients aged <70 and ≥70 years are comparable despite higher ASA and PMP scores in the group 2. General status and concomitant diseases should be considered during selection of patients with resectable tumors for PDE. Age per se is not a contraindication for surgery.
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Affiliation(s)
- G A Shatveryan
- Petrovsky National Research Centre of Surgery, Moscow, Russia
| | - N K Chardarov
- Petrovsky National Research Centre of Surgery, Moscow, Russia
| | - V V Nikoda
- Petrovsky National Research Centre of Surgery, Moscow, Russia
| | - N N Bagmet
- Petrovsky National Research Centre of Surgery, Moscow, Russia
| | - I M Tadzhibova
- Petrovsky National Research Centre of Surgery, Moscow, Russia
| | - E A Lishova
- Petrovsky National Research Centre of Surgery, Moscow, Russia
| | - N P Ratnikova
- Petrovsky National Research Centre of Surgery, Moscow, Russia
| | - G A Karagyozyan
- Petrovsky National Research Centre of Surgery, Moscow, Russia
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Tan E, Song J, Lam S, D'Souza M, Crawford M, Sandroussi C. Postoperative outcomes in elderly patients undergoing pancreatic resection for pancreatic adenocarcinoma: A systematic review and meta-analysis. Int J Surg 2019; 72:59-68. [PMID: 31580919 DOI: 10.1016/j.ijsu.2019.09.030] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 09/11/2019] [Accepted: 09/26/2019] [Indexed: 02/09/2023]
Abstract
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.
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Affiliation(s)
- Elinor Tan
- Department of Upper Gastrointestinal Surgery, Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW, 2050, Australia; Surgical Outcomes Research Centre (SOuRCe), The University of Sydney, Darlington, NSW, 2006, Australia; Faculty of Medicine and Health, The University of Sydney, Darlington, NSW, 2006, Australia.
| | - Jialu Song
- Faculty of Medicine and Health, The University of Sydney, Darlington, NSW, 2006, Australia
| | - Susanna Lam
- Department of Upper Gastrointestinal Surgery, Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW, 2050, Australia; Surgical Outcomes Research Centre (SOuRCe), The University of Sydney, Darlington, NSW, 2006, Australia
| | - Mario D'Souza
- Faculty of Medicine and Health, The University of Sydney, Darlington, NSW, 2006, Australia; Sydney Local Health District Clinical Research Centre, Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW, 2050, Australia
| | - Michael Crawford
- Department of Upper Gastrointestinal Surgery, Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW, 2050, Australia
| | - Charbel Sandroussi
- Department of Upper Gastrointestinal Surgery, Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW, 2050, Australia; Surgical Outcomes Research Centre (SOuRCe), The University of Sydney, Darlington, NSW, 2006, Australia; Faculty of Medicine and Health, The University of Sydney, Darlington, NSW, 2006, Australia; RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, 145-147 Missenden Road, Camperdown, NSW, 2050, Australia
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Lim BG, Lee IO. Anesthetic management of geriatric patients. Korean J Anesthesiol 2019; 73:8-29. [PMID: 31636241 PMCID: PMC7000283 DOI: 10.4097/kja.19391] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 10/20/2019] [Indexed: 12/15/2022] Open
Abstract
The number of elderly patients who frequently access health care services is increasing worldwide. While anesthesiologists are developing the expertise to care for these elderly patients, areas of concern remain. We conducted a comprehensive search of major international databases (PubMed, Embase, and Cochrane) and a Korean database (KoreaMed) to review preoperative considerations, intraoperative management, and postoperative problems when anesthetizing elderly patients. Preoperative preparation of elderly patients included functional assessment to identify preexisting cognitive impairment or cardiopulmonary reserve, depression, frailty, nutrition, polypharmacy, and anticoagulation issues. Intraoperative management included anesthetic mode and pharmacology, monitoring, intravenous fluid or transfusion management, lung-protective ventilation, and prevention of hypothermia. Postoperative checklists included perioperative analgesia, postoperative delirium and cognitive dysfunction, and other complications. A higher level of perioperative care was required for older surgical patients, as multiple chronic diseases often makes them prone to developing postoperative complications, including functional decline and loss of independence. Although the guiding evidence remains poor so far, elderly patients have to be provided optimal perioperative care through close interdisciplinary, interprofessional, and cross-sectional collaboration to minimize unwanted postoperative outcomes. Furthermore, along with adequate anesthetic care, well-planned postoperative care should begin immediately after surgery and extend until discharge.
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Affiliation(s)
- Byung-Gun Lim
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Il-Ok Lee
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
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Jang M, Park HW, Huh J, Lee JH, Jeong YK, Nah YW, Park J, Kim KW. Predictive value of sarcopenia and visceral obesity for postoperative pancreatic fistula after pancreaticoduodenectomy analyzed on clinically acquired CT and MRI. Eur Radiol 2019; 29:2417-2425. [PMID: 30406311 DOI: 10.1007/s00330-018-5790-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 09/06/2018] [Accepted: 09/21/2018] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To evaluate predictive values of sarcopenia and visceral obesity measured from preoperative CT/MRIs for postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy in patients with periampullary malignancies. METHODS From the prospectively constructed surgical registry, we included adult patients treated with pancreaticoduodenectomy. Based on CT/MRIs, body morphometric analysis was performed to evaluate the visceral obesity and sarcopenia, based on the areas of visceral fat and skeletal muscle measured at the L3 vertebrae level. We retrieved various perioperative factors from registry. As outcomes of postoperative complications, we evaluated POPF and major complications based on the Clavien-Dindo classification. Multivariate logistic regression analyses were performed. RESULTS From a total of 284 patients (163 males, 121 females) who met the inclusion/exclusion criteria, POPF, major complications, and 60-day mortality occurred in 52 (18.3%), 34 (12.0%), and 6 (2.1%), respectively. Sarcopenia and visceral obesity were noted in 123 (75.5%) and 66 (40.5%) of men and 68 (56.2%) and 53 (43.8%) of women, respectively. Combination of sarcopenia and obesity (sarcopenic obesity) was noted in 31.9% (52/163) of men and in 26.4% (32/121) of women. In multivariate logistic regression analyses, sarcopenic obesity was the only independent predictor for POPF (OR 2.65, 95% CI 1.43-4.93), and the vascular resection during pancreaticoduodenectomy was the only independent predictor for severe complications (OR 3.75, 95% CI 1.61-8.70). CONCLUSION Sarcopenic obesity might be highly predictive for POPF. Body morphometric analysis in preoperative CT/MRI combined with assessment of perioperative clinical features may help to identify high-risk patients and determine perioperative management strategies. KEY POINTS • Sarcopenic obesity might be predictive for postoperative pancreatic fistula after pancreaticoduodenectomy. • The vascular resection during pancreaticoduodenectomy might be predictive of major complications. • Body morphometric analysis might be helpful for identifying high-risk patients.
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Affiliation(s)
- Minji Jang
- Department of Radiology, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, South Korea
| | - Hyung Woo Park
- Department of Surgery, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, South Korea
| | - Jimi Huh
- Department of Radiology, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, South Korea.
- Department of Radiology, Ajou University School of Medicine & Graduate School of Medicine, Ajou University Medical Center, 164 World cup-ro, Yeongtong-gu, Suwon, 16499, South Korea.
| | - Jong Hwa Lee
- Department of Radiology, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, South Korea
| | - Yoong Ki Jeong
- Department of Radiology, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, South Korea
| | - Yang Won Nah
- Department of Surgery, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, South Korea
| | - Jisuk Park
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Kyung Won Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
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Rodriguez-Lopez M, Tejero-Pintor FJ, Perez-Saborido B, Barrera-Rebollo A, Bailon-Cuadrado M, Pacheco-Sanchez D. Severe morbidity after pancreatectomy is accurately predicted by preoperative pancreatic resection score (PREPARE): A prospective validation analysis from a medium-volume center. Hepatobiliary Pancreat Dis Int 2018; 17:559-565. [PMID: 30316626 DOI: 10.1016/j.hbpd.2018.09.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Accepted: 09/18/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Major morbidity in pancreatic surgery remains high. Different scores for predicting complications have been described. Preoperative pancreatic resection (PREPARE) score is based on objective preoperative variables and offers good predictive accuracy for Clavien ≥ III complications. This study aimed to validate this score and analyze other preoperative variables in a prospective study performed in a medium-volume center. METHODS A total of 50 pancreatic resections were included. Preoperative variables were registered and PREPARE was calculated. The main outcome was severe morbidity (Clavien ≥ III) up to 30 days after discharge. The secondary outcomes were length of stay (LOS) and readmission. Statistical validation was performed to compare severe morbidity rate among the scores categories. Association with other preoperative variables (not included in PREPARE) was also tested. RESULTS Of the 50 pancreatic resections, the severe morbidity was 34.0%, with median LOS of 11 days. Readmission rate was 25.5%. Severe morbidity rates according to PREPARE categories were 18.5% in low-risk group, 41.7% in intermediate-risk group, and 63.6% in high-risk group, respectively (P = 0.023). The accuracy was 72% (Hosmer-Lemeshow, P = 0.86). ROC curve was obtained both for PREPARE score expressed as incremental values and categorized as the three risk groups, showing an area under curve (AUC) of 0.736 (95% CI: 0.586-0.887; P = 0.007) and 0.712 (95% CI: 0.555-0.869; P = 0.015), respectively. PREPARE was significant in multivariate analysis. Median LOS was statistically higher as PREPARE category increases (9, 11 and 15 days in low-, intermediate- and high-risk groups, respectively; P = 0.009). Readmission was not associated with any variables. CONCLUSIONS PREPARE behaves as an independent risk factor for severe morbidity after pancreatic surgery. Score validation shows good accuracy prediction. Increasing PREPARE category is also associated with longer LOS.
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Affiliation(s)
- Mario Rodriguez-Lopez
- General and Digestive Surgery Department, Rio-Hortega University Hospital, Valladolid 47012, Spain.
| | | | - Baltasar Perez-Saborido
- General and Digestive Surgery Department, Rio-Hortega University Hospital, Valladolid 47012, Spain
| | - Asterio Barrera-Rebollo
- General and Digestive Surgery Department, Rio-Hortega University Hospital, Valladolid 47012, Spain
| | - Martin Bailon-Cuadrado
- General and Digestive Surgery Department, Rio-Hortega University Hospital, Valladolid 47012, Spain
| | - David Pacheco-Sanchez
- General and Digestive Surgery Department, Rio-Hortega University Hospital, Valladolid 47012, Spain
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Abstract
PURPOSE OF REVIEW Preoperative risk assessment and perioperative factors may help identify patients at increased risk of postoperative complications and allow postoperative management strategies that improve patient outcomes. This review summarizes historical and more recent scoring systems for predicting patients with increased morbidity and mortality in the postoperative period. RECENT FINDINGS Most prediction scores predict postoperative mortality with, at best, moderate accuracy. Scores that incorporate surgery-specific and intraoperative covariates may improve the accuracy of traditional scores. Traditional risk factors including increased ASA physical status score, emergent surgery, intraoperative blood loss and hemodynamic instability are consistently associated with increased mortality using most scoring systems. SUMMARY Preoperative clinical risk indices and risk calculators estimate surgical risk with moderate accuracy. Surgery-specific risk calculators are helpful in identifying patients at increased risk of 30-day mortality. Particular attention should be paid to intraoperative hemodynamic instability, blood loss, extent of surgical excision and volume of resection.
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Tonolini M, Ierardi AM, Carrafiello G. Elucidating early CT after pancreatico-duodenectomy: a primer for radiologists. Insights Imaging 2018; 9:425-436. [PMID: 29654405 PMCID: PMC6108971 DOI: 10.1007/s13244-018-0616-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 02/12/2018] [Accepted: 03/06/2018] [Indexed: 02/07/2023] Open
Abstract
Abstract Pancreatico-duodenectomy (PD) represents the standard surgical treatment for resectable malignancies of the pancreatic head, distal common bile duct, periampullary region and duodenum, and is also performed to manage selected benign tumours and refractory chronic pancreatitis. Despite improved surgical techniques and acceptable mortality, PD remains a technically demanding, high-risk operation burdened with high morbidity (complication rates 40–50% of patients). Multidetector computed tomography (CT) represents the mainstay modality to rapidly investigate the postoperative abdomen, and to provide a consistent basis for an appropriate choice between conservative, interventional or surgical treatment. However, radiologists require familiarity with the surgically altered anatomy, awareness of expected imaging appearances and possible complications to correctly interpret early post-PD CT studies. This paper provides an overview of surgical indications and techniques, discusses risk factors and clinical manifestations of the usual postsurgical complications, and suggests appropriate techniques and indications for early postoperative CT imaging. Afterwards, the usual, normal early post-PD CT findings are presented, including transient fluid, pneumobilia, delayed gastric emptying, identification of pancreatic gland remnant and of surgical anastomoses. Finally, several imaging examples review the most common and some unusual complications such as pancreatic fistula, bile leaks, abscesses, intraluminal and extraluminal haemorrhage, and acute pancreatitis. Teaching Points • Pancreatico-duodenectomy (PD) is a technically demanding surgery burdened with high morbidity (40–50%). • Multidetector CT is the mainstay technique to investigate suspected complications following PD. • Interpreting post-PD CT requires knowledge of surgically altered anatomy and expected findings. • CT showing collection at surgical site supports clinico-biological diagnosis of pancreatic fistula. • Other complications include biliary leaks, haemorrhage, abscesses and venous thrombosis.
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Affiliation(s)
- Massimo Tonolini
- Department of Radiology, "Luigi Sacco" University Hospital, Via G.B. Grassi 74, 20157, Milan, Italy.
| | - Anna Maria Ierardi
- Diagnostic and Interventional Radiology Department, ASST Santi Paolo e Carlo, Via A di Rudinì 8, 20142, Milan, Italy
| | - Gianpaolo Carrafiello
- Diagnostic and Interventional Radiology Department, ASST Santi Paolo e Carlo, Via A di Rudinì 8, 20142, Milan, Italy
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