Impact of Patient Age on Morbidity and Survival Following Laparoscopic Pancreaticoduodenectomy

Short‑ and long‑term outcomes after laparoscopic and open pancreatoduodenectomy for elderly patients: a propensity score‑matched study

BACKGROUND

The feasibility and safety of laparoscopic pancreatoduodenectomy (LPD) in elderly patients is still controversial. This study aimed to compare the clinical outcomes of LPD and open pancreatoduodenectomy (OPD) in elderly patients.

METHODS

Clinical and follow-up data of elderly patients (≥ 65 years) who underwent LPD or OPD between 2015 and 2022 were retrospectively analyzed. A 1:1 propensity score-matching (PSM) analysis was performed to minimize differences between groups. Univariate and multivariate logistic regression analysis were used to select independent prognostic factors for 90-day mortality.

RESULTS

Of the 410 elderly patients, 236 underwent LPD and 174 OPD. After PSM, the LPD group had a less estimated blood loss (EBL) (100 vs. 200 mL, P < 0.001), lower rates of intraoperative transfusion (10.4% vs. 19.0%, P = 0.029), more lymph node harvest (11.0 vs. 10.0, P = 0.014) and shorter postoperative length of stay (LOS) (13.0 vs. 16.0 days, P = 0.013). There were no significant differences in serious complications, reoperation, 90-day readmission and mortality rates (all P > 0.05). Multivariate logistic regression analysis showed that post-pancreatectomy hemorrhage (PPH) was an independent risk factor for 90-day mortality. Elderly patients with pancreatic ductal adenocarcinoma (PDAC) who underwent LPD or OPD had similar overall survival (OS) (22.5 vs.20.4 months, P = 0.672) after PSM.

CONCLUSIONS

It is safe and feasible for elderly patients to undergo LPD with less EBL and a shorter postoperative LOS. There was no statistically significant difference in long-term survival outcomes between elderly PDAC patients who underwent LPD or OPD.

Laparoscopic Pancreaticoduodenectomy in Elderly Patients: Systematic Review and Meta-Analysis

Background

The safety and efficacy of laparoscopic pancreaticoduodenectomy (LPD) in elderly patients who often suffer from pre-existing conditions (e.g., cardiovascular diseases) and poor functional reserve remain unclear. This meta-analysis aimed to evaluate the safety and efficacy of LPD in elderly patients.

Methods

A systematic literature search was conducted using the PubMed, Embase, Web of Science, and Cochrane Library databases. All studies published from their inception to January 2022 reporting perioperative outcomes after LPD in elderly patients were included in the search (Group 1, comparing the perioperative outcomes of LPD and OPD in elderly patients; Group 2, comparing the perioperative outcomes after LPD between elderly and non-elderly patients). The evaluated outcomes included perioperative mortality, postoperative complications, conversion, operative time, estimated blood loss (EBL), postoperative hospital stay (POHS), and readmission.

Results

In total 8 studies were included in the meta-analysis. Pooled analysis of Group 1 showed that EBL, 90-day mortality, major morbidity, bile leak, POH, abdominal infection, reoperation, POP, POCE, and readmission were not significantly different between the LPD and the OPD group. LPD was associated with longer operative time, lower POPF rate, lower DEG rate, and shorter POHS. Pooled analysis of Group 2 showed that mortality, major morbidity, POPF, DEG, bile leak, POH, abdominal infection, reoperation, conversion, operative time, EBL, and readmission were not significantly different between the elderly and the non-elderly group. The POHS of elderly group was significantly longer than non-elderly group.

Conclusion

LPD may be a safe and feasible procedure for elderly patients and is associated with short POHS.

Effect of Laparoscopic Pancreaticoduodenectomy in Elderly People: A Meta-analysis

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.

Laparoscopic pancreaticoduodenectomy with excision of aberrant right hepatic artery after preoperative segmental embolization in mid-bile duct cancer

Laparoscopic pancreaticoduodenectomy has proven to be a safe and effective alternative to open pancreaticoduodenectomy with similar oncologic outcomes. Cases including excision of the hepatic artery with or without reconstruction during pancreaticoduodenectomy have been reported for periampullary cancer. Here we present a case of an 82-year-old patient who underwent laparoscopic pancreaticoduodenectomy following preoperative arterial embolization of an aberrant right hepatic artery arising from the superior mesenteric artery.

Minimally Invasive Pancreaticoduodenectomy in Elderly Patients: Systematic Review and Meta-Analysis

BACKGROUND

Minimally invasive pancreaticoduodenectomy (MIPD) for pancreatic head or periampullary lesions is being utilized with increasing frequency. However, few data are available for the elderly. The objective of this study is to assess the safety and feasibility of MIPD in elderly population, by making a comparison with conventional open pancreaticoduodenectomy (OPD) and with non-elderly population.

METHODS

We conducted a systematic search to identify all eligible studies in Cochrane Library, Ovid, and PubMed from their inception up to April 2020.

RESULTS

Seven retrospective studies involving 2727 patients were included. Of these, 3 compared MIPD and OPD in elderly patients, 2 compared MIPD in elderly and non-elderly patients, and 2 included both outcomes. Compared to those with OPD, elderly patients who underwent MIPD were associated with less 90-day mortality (OR 0.56, 95% CI 0.32-0.97; P = 0.04) and fewer delayed gastric emptying (OR 0.54, 95% CI 0.33-0.88; P = 0.01). On the other hand, no significant difference was observed in terms of 30-day mortality, major morbidity, postoperative pancreatic fistula (grade B/C), postoperative hemorrhage, reoperation, 30-day readmission, and operative time. For patients who have treated with MIPD, elderly did not reveal worse outcomes than non-elderly.

CONCLUSION

MIPD is a safe and feasible procedure for select elderly patients if performed by experienced surgeons from high-volume pancreatic surgery centers. However, further randomized studies are required to confirm this.

The Effect of Age on Short- and Long-Term Outcomes in Patients With Pancreatic Ductal Adenocarcinoma Undergoing Laparoscopic Pancreaticoduodenectomy

OBJECTIVE

The aim of the study was to evaluate the effect of age on outcomes with pancreatic ductal adenocarcinoma (PDAC) undergoing laparoscopic pancreaticoduodenectomy (LPD).

METHODS

We retrospectively collected clinical data of consecutive patients with PDAC undergoing LPD from January 2012 to April 2019. The patients were divided into 2 groups according to age at admission for LPD: younger than 70 and 70 years or older.

RESULTS

A total of 147 patients were included (<70 years, n = 96; ≥70 years, n = 51). The elderly LPD patients had lower serum albumin levels (mean, 37.9 [standard deviation, 4.8] g/L vs 40.7 [standard deviation, 6.8] g/L, P = 0.004) and a larger frequency of comorbidities (62.7% vs 36.5%, P = 0.002) than younger patients. The short-term outcomes showed no significant differences. The median overall survival time of the younger patients was not significantly greater than that of the elderly patients (20.0 [95% confidence interval, 16.1-23.9] months vs 19.0 [95% confidence interval, 13.8-24.2] months, P = 0.902).

CONCLUSIONS

The short- and long-term outcomes of elderly patients with PDAC after LPD were similar to those of younger patients, despite a higher prevalence of multiple chronic illnesses and poorer nutritional conditioning among the elderly patients. These results show that LPD can be applied safely to elderly patients.

The role of older age and obesity in minimally invasive and open pancreatic surgery: A systematic review and meta-analysis

BACKGROUND/OBJECTIVES

The aim of this study was to assess the impact of older age (≥70 years) and obesity (BMI ≥30) on surgical outcomes of minimally invasive pancreatic resections (MIPR). Subsequently, open pancreatic resections or MIPR were compared for elderly and/or obese patients.

METHODS

A systematic review was conducted as part of the 2019 Miami International Evidence-Based Guidelines on MIPR (IG-MIPR). Study quality assessment was according to The Scottish Intercollegiate Guidelines Network (SIGN). A meta-analysis was performed to assess the impact of MIPR or open pancreatic resections in elderly patients.

RESULTS

After screening 682 studies, 13 observational studies with 4629 patients were included. Elderly patients undergoing laparoscopic distal pancreatectomy (LDP) had less blood loss (117 mL, p < 0.001) and a shorter hospital stay (3.5 days p < 0.001) than elderly patients undergoing open distal pancreatectomy (ODP). Postoperative pancreatic fistula (POPF) B/C, major complication and reoperation rate were not significantly different in elderly patients undergoing either laparoscopic or open pancreatoduodenectomy (OPD). One study compared robot PD with OPD in obese patients, indicating that patients with robotic surgery had less blood loss (mean 250 ml vs 500 ml, p = 0.001), shorter operative time (mean 381 min vs 428 min, p = 0.003), and lower rate of POPF B/C (13% vs 28%, p = 0.039).

CONCLUSION

The current available limited evidence does not suggest that MIPR is contraindicated in elderly or obese patients. Additionally, outcomes in MIPR are equal or more beneficial compared to the open approach when applied in these patient groups.

International expert consensus on laparoscopic pancreaticoduodenectomy

IMPORTANCE

While laparoscopic pancreaticoduodenectomy (LPD) is being adopted with increasing enthusiasm worldwide, it is still challenging for both technical and anatomical reasons. Currently, there is no consensus on the technical standards for LPD.

OBJECTIVE

The aim of this consensus statement is to guide the continued safe progression and adoption of LPD.

EVIDENCE REVIEW

An international panel of experts was selected based on their clinical and scientific expertise in laparoscopic and open pancreaticoduodenectomy. Statements were produced upon reviewing the literature and assessed by the members of the expert panel. The literature search and its critical appraisal were limited to articles published in English during the period from 1994 to 2019. The Web of Science, Medline, and Cochrane Library and Clinical Trials databases were searched, The search strategy included, but was not limited to, the terms 'laparoscopic', 'pancreaticoduodenectomy, 'pancreatoduodenectomy', 'Whipple's operation', and 'minimally invasive surgery'. Reference lists from the included articles were manually checked for any additional studies, which were included when appropriate. Delphi method was used to establish expert consensus and the AGREE II-GRS Instrument was applied to assess the methodological quality and externally validate the final statements. The statements were further discussed during a one-day face-to-face meeting at the 1st Summit on Minimally Invasive Pancreatico-Biliary Surgery in Wuhan, China.

FINDINGS

Twenty-eight international experts from 8 countries constructed the expert panel. Sixteen statements were produced by the members of the expert panel. At least 80% of responders agreed with the majority (80%) of statements. Other than three randomized controlled trials published to date, most evidences were based on level 3 or 4 studies according to the AGREE II-GRS Instrument.

CONCLUSIONS AND RELEVANCE

The Wuhan international expert consensus meeting on LPD has produced a set of clinical practice statements for the safe development and progression of LPD. LPD is currently in its development and exploration stages, as defined by the international IDEAL framework for surgical innovation. More robust randomized controlled trial and registry study are essential to proceed with the assessment of LPD.