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Hou TY, Lin YH, Liu YW, Liu YY, Li WF, Kuo MC, Huang SW, Yeh CH, Lin YC, Yin SM. The impact of preoperative nutritional status on postoperative outcomes: an insight from Geriatric Nutritional Risk Index in elderly pancreaticoduodenectomy patients. BMC Surg 2024; 24:100. [PMID: 38580988 PMCID: PMC10996270 DOI: 10.1186/s12893-024-02397-0] [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: 12/28/2023] [Accepted: 03/26/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND Malnutrition is not uncommon among the elderly undergoing pancreatoduodenectomy (PD) and is related to increased complications. Previous studies have shown that the Geriatric Nutritional Risk Index (GNRI) predicts outcomes in various populations. Nevertheless, the research exploring the correlation between GNRI and postoperative outcomes in PD is scarce. This study aimed to investigate the preoperative malnutrition, as measured by GNRI, on outcomes in elderly patients undergoing PD. MATERIALS AND METHODS This retrospective analysis enrolled 144 elderly patients underwent PD for periampullary tumors from November 2016 to December 2021. Patients were stratified based on the GNRI value: high/moderate nutrition risk (GNRI ≤ 92, N = 54), low nutrition risk (92 < GNRI ≤ 98, N = 35), and no nutrition risk (GNRI > 98, N = 55). Perioperative outcomes and postoperative surgical complications were compared between these groups. Univariate and multivariate analyses were performed on major postoperative complications and prolonged postoperative length of stay (PLOS). RESULTS Patients in the high/moderate risk group were significantly older, with lower BMI (P = 0.012), higher mortality rate (11.1%, P = 0.024), longer PLOS (P < 0.001), and higher incidence of over grade IIIB complications (37.0%, P = 0.001), Univariate and multivariate analyses showed the high/moderate risk GNRI group (OR 3.61, P = 0.032), increased age (OR 1.11, P = 0.014) and operative time over 8 h (OR 3.04, P = 0.027) were significantly associated with increased major postoperative complications. The high/moderate risk GNRI group was also a significant predictor for prolonged PLOS (OR 3.91, P = 0.002). CONCLUSIONS Preoperative GNRI has the potential to be a predictive tool for identifying high-risk elderly patients and monitoring nutritional status preoperatively to improve postoperative surgical outcomes following PD.
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Affiliation(s)
- Teng-Yuan Hou
- Division of General Surgery, Department of Surgery, College of Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan
| | - Yu-Hung Lin
- Division of General Surgery, Department of Surgery, College of Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan
| | - Yueh-Wei Liu
- Division of General Surgery, Department of Surgery, College of Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan
| | - Yu-Yin Liu
- Division of General Surgery, Department of Surgery, College of Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan
| | - Wei-Feng Li
- Division of General Surgery, Department of Surgery, College of Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan
| | - Ming-Chun Kuo
- Division of Hematology Oncology, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, Kaohsiung, Taiwan
| | - Szu-Wei Huang
- Department of Obstetrics and Gynecology, College of Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, Kaohsiung, Taiwan
| | - Cheng-Hsi Yeh
- Division of General Surgery, Department of Surgery, College of Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan
| | - Yu-Cheng Lin
- Division of General Surgery, Department of Surgery, College of Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan
| | - Shih-Min Yin
- Division of General Surgery, Department of Surgery, College of Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan.
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Yu ZH, Du MM, Zhang X, Suo JJ, Zeng T, Xie XL, Xiao W, Lu QB, Liu YX, Yao HW. The impact of preoperative biliary drainage on postoperative healthcare-associated infections and clinical outcomes following pancreaticoduodenectomy: a ten-year retrospective analysis. BMC Infect Dis 2024; 24:361. [PMID: 38549089 PMCID: PMC10979617 DOI: 10.1186/s12879-024-09246-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 03/22/2024] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) is a complex procedure and easily accompanied by healthcare-associated infections (HAIs). This study aimed to assess the impact of PBD on postoperative infections and clinical outcomes in PD patients. METHODS The retrospective cohort study were conducted in a tertiary hospital from January 2013 to December 2022. Clinical and epidemiological data were collected from HAIs surveillance system and analyzed. RESULTS Among 2842 patients who underwent PD, 247 (8.7%) were diagnosed with HAIs, with surgical site infection being the most frequent type (n = 177, 71.7%). A total of 369 pathogenic strains were detected, with Klebsiella pneumoniae having the highest proportion, followed by Enterococcu and Escherichia coli. Although no significant association were observed generally between PBD and postoperative HAIs, subgroup analysis revealed that PBD was associated with postoperative HAIs in patients undergoing robotic PD (aRR = 2.174; 95% CI:1.011-4.674; P = 0.047). Prolonging the interval between PBD and PD could reduce postoperative HAIs in patients with cholangiocarcinoma (≥4 week: aRR = 0.292, 95% CI 0.100-0.853; P = 0.024) and robotic PD (≤2 week: aRR = 3.058, 95% CI 1.178-7.940; P = 0.022). PBD was also found to increase transfer of patients to ICU (aRR = 1.351; 95% CI 1.119-1.632; P = 0.002), extended length of stay (P < 0.001) and postoperative length of stay (P = 0.004). CONCLUSION PBD does not exhibit a significant association with postoperative HAIs or other outcomes. However, the implementation of robotic PD, along with a suitable extension of the interval between PBD and PD, appear to confer advantages concerning patients' physiological recuperation. These observations suggest potential strategies that may contribute to enhanced patient outcomes.
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Affiliation(s)
- Zheng-Hao Yu
- Department of Disease Prevention and Control, The First Medical Center, Chinese PLA General Hospital, 28 Fu-Xing Road, Haidian District, Beijing, 100853, P. R. China
- Medical School of Chinese PLA, Beijing, P. R. China
| | - Ming-Mei Du
- Department of Disease Prevention and Control, The First Medical Center, Chinese PLA General Hospital, 28 Fu-Xing Road, Haidian District, Beijing, 100853, P. R. China
| | - Xuan Zhang
- Faculty of Hepato-Pancreato-Biliary Surgery, Chinese PLA General Hospital, Beijing, P. R. China
- Institute of Hepatobiliary Surgery of Chinese PLA, Beijing, P. R. China
| | - Ji-Jiang Suo
- Department of Disease Prevention and Control, The First Medical Center, Chinese PLA General Hospital, 28 Fu-Xing Road, Haidian District, Beijing, 100853, P. R. China
| | - Tao Zeng
- Medical School of Chinese PLA, Beijing, P. R. China
- Faculty of Hepato-Pancreato-Biliary Surgery, Chinese PLA General Hospital, Beijing, P. R. China
| | - Xiao-Lian Xie
- Department of Central Sterile Supply, Ningxia People's Armed Police Corps Hospital, Yinchuan, P. R. China
| | - Wei Xiao
- Department Of Hospital Infection-Control, Lanzhou University Second Hospital, Gansu, P. R. China
| | - Qing-Bin Lu
- Department of Laboratorial Science and Technology, School of Public Health, Peking University, 38 Xue-Yuan Road, Haidian District, Beijing, 100191, P. R. China.
| | - Yun-Xi Liu
- Department of Disease Prevention and Control, The First Medical Center, Chinese PLA General Hospital, 28 Fu-Xing Road, Haidian District, Beijing, 100853, P. R. China.
| | - Hong-Wu Yao
- Department of Disease Prevention and Control, The First Medical Center, Chinese PLA General Hospital, 28 Fu-Xing Road, Haidian District, Beijing, 100853, P. R. China.
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Raza SS, Nutu OA, Powell-Brett S, Carvalheiro Boteon A, Hodson J, Abradelo M, Dasari B, Isaac J, Chatzizacharias N, Marudanayagam R, Mirza DF, Roberts JK, Sutcliffe RP. Impact of an enhanced recovery after surgery protocol on short-term outcomes in elderly patients undergoing pancreaticoduodenectomy. HPB (Oxford) 2022; 24:1720-1728. [PMID: 35643908 DOI: 10.1016/j.hpb.2022.05.002] [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: 02/09/2022] [Revised: 04/30/2022] [Accepted: 05/06/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND To determine whether the short-term benefits associated with an enhanced recovery after surgery programme (ERAS) following pancreaticoduodenectomy (PD) vary with age. METHODS 830 consecutive patients who underwent PD between January 2009 and March 2019 were divided according to age: elderly (≥75 years) vs. non-elderly patients (<75 years). Within each age group, cohort characteristics and outcomes were compared between patients treated pre- and post-ERAS (ERAS was systematically introduced in December 2012). Univariable and multivariable analysis were then performed, to assess whether ERAS was independently associated with length of hospital stay (LOS). RESULTS Of the entire cohort, 577 of 830 patients (69.5%) were managed according to an ERAS protocol, and 170 patients (20.5%) were aged ≥75 years old. Patients treated post-ERAS were significantly more comorbid than those pre-ERAS, with a mean Charlson Comorbidity Index of 4.6 vs. 4.1 (p < 0.001) and 6.0 vs. 5.7 (p = 0.039) for the non-elderly and elderly subgroups, respectively. There were significantly fewer medical complications in non-elderly patients treated post-ERAS compared to pre-ERAS (12.4% vs. 22.4%; p = 0.002), but not in elderly patients (23.6% vs. 14.0%; p = 0.203). On multivariable analysis, ERAS was independently associated with reduced LOS in both elderly (14.8% reduction, 95% CI: 0.7-27.0%, p = 0.041) and non-elderly patients (15.6% reduction, 95% CI: 9.2-21.6%, p < 0.001), with the effect size being similar in each group. CONCLUSION ERAS protocols can be safely applied to patients undergoing pancreaticoduodenectomy irrespective of age. Implementation of an ERAS protocol was associated with a significant reduction in postoperative LOS in both elderly and non-elderly patients, despite higher comorbidity in the post-ERAS period.
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Affiliation(s)
- Syed S Raza
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Oana A Nutu
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | | | | | - James Hodson
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | | | - Bobby Dasari
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - John Isaac
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
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Xu Y, Zhang Y, Han S, Jin D, Xu X, Kuang T, Wu W, Wang D, Lou W. Prognostic Effect of Age in Resected Pancreatic Cancer Patients: A Propensity Score Matching Analysis. Front Oncol 2022; 12:789351. [PMID: 35433408 PMCID: PMC9008824 DOI: 10.3389/fonc.2022.789351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 03/04/2022] [Indexed: 01/11/2023] Open
Abstract
Background While the elderly population account for an indispensable proportion in pancreatic ductal adenocarcinoma (PDAC), these patients are underrepresented in clinical trials. Whether surgery offered the same benefit for elderly patients as that for younger cohort and which factors affected long-term outcome of elderly population remained unclear. Aims This study aims to evaluate long-term prognosis of elderly PDAC patients (≥70 years old) after surgery and to investigate potential prognostic factors. Methods This retrospective study included PDAC patients receiving radical resection from January 2012 to July 2019 in Zhongshan Hospital Fudan University. Patients were divided into young (<70) and old groups (≥70). Propensity score matching (PSM) was conducted to eliminate the confounding factors. We investigated potential prognostic factors via Cox proportional hazards model and Kaplan–Meier estimator. Nomogram model and forest plot were constructed to illustrate the prognostic value of age. Results A total of 552 PDAC patients who received radical resection were included in this research. Elderly patients showed poorer nutritional status and were less likely to received adjuvant treatment. After matching, although age [hazard ratio (HR)=1.025, 95%CI 0.997–1.054; p=0.083] was not statistically significant in the multivariate cox regression analysis, further survival analysis showed that patients in the old group had poorer overall survival (OS) when compared with young group (p=0.039). Furthermore, reception of adjuvant chemotherapy (HR=0.411, 95%CI 0.201-0.837; p=0.014) was the only independent prognostic factor among elderly patients and could significantly improve OS. Subgroup analysis indicated that age had better prognostic value in PDAC patients with good preoperative nutritional status and relative low tumor burden. Finally, a prognostic prediction model contained age, reception of adjuvant chemotherapy, American Joint Committee on Cancer (AJCC) 8th T and N stage was constructed and presented in nomogram, whose Harrell’s concordance index was 0.7478 (95%CI, 0.6960–0.7996). The calibration curves at 1 and 3 years indicated an optimal conformity between actual and nomogram-predicted survival probability in the PDAC patient who received surgery. Conclusion The elderly PDAC patients were associated with worse OS survival after radical resection, and the noticeable negative effect of age was observed among PDAC patients with better preoperative nutritional status and less aggressive tumor biology. Adjuvant chemotherapy was essential to improve survival outcome of elderly PDAC patients following radical resection.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Wenhui Lou
- *Correspondence: Dansong Wang, ; Wenhui Lou,
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Kim JS, Choi M, Kim SH, Choi SH, Kang CM. Safety and feasibility of laparoscopic pancreaticoduodenectomy in octogenarians. Asian J Surg 2021; 45:837-843. [PMID: 34649792 DOI: 10.1016/j.asjsur.2021.09.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 09/27/2021] [Accepted: 09/30/2021] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION With continued technical advances in surgical instruments and growing surgical expertise, many laparoscopic pancreaticoduodenectomies (LPDs) have been safely performed with favorable outcomes, and this approach is being used more frequently. With an increase in the life expectancy, interest in treatments for elderly patients has increased. In this study, we investigated the safety and feasibility of LPD in octogenarians. METHODS From September 2005 to February 2020, resectable/borderline resectable periampullary tumors (PATs) were diagnosed in 71 octogenarians at Sincheon Severance Hospital and CHA Bundang Medical Center. Patients were divided into two groups: those who underwent surgery (PD, N = 38) and those who did not (NPD, N = 33). The group that underwent surgery was further divided into two groups: those who underwent open PD (OPD, N = 19), and those who underwent LPD (LPD, N = 19). Perioperative outcomes, including long-term survival, were retrospectively compared between these groups. RESULTS There was no significant difference in age, sex, comorbidities, diagnosis, and chemo-radiotherapy between the surgery and non-surgery groups. The PD group had a better survival rate than the NPD group (p < 0.05). The baseline characteristics and postoperative outcomes were not significantly different between the OPD and LPD groups. Only three and two patients in the OPD and LPD groups had a biochemical leak (p > 0.999). There was no significant difference in overall survival and disease-free survival between the OPD and LPD groups (p = 0.816, p = 0.446, respectively). CONCLUSIONS LPD is a good alternative for octogenarians with PAT requiring PD.
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Affiliation(s)
- Ji Su Kim
- Department of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, Seoul, South Korea; Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, South Korea
| | - Munseok Choi
- Department of Surgery, Yongin Severance Hospital, Yongin-si, Gyeonggi-do, South Korea
| | - Sung Hyun Kim
- Department of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, Seoul, South Korea; Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, South Korea
| | - Sung Hoon Choi
- Department of Hepatobiliary and Pancreatic Surgery, CHA Bundang Medical Center, CHA University, Seongnam, South Korea.
| | - Chang Moo Kang
- Department of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, Seoul, South Korea; Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, South Korea.
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Tsukagoshi M, Harimoto N, Araki K, Kubo N, Watanabe A, Igarashi T, Ishii N, Yamanaka T, Hagiwara K, Hoshino K, Muranushi R, Yajima T, Shirabe K. Skeletal Muscle Loss and Octogenarian Status Are Associated with S-1 Adjuvant Therapy Discontinuation and Poor Prognosis after Pancreatectomy. Cancers (Basel) 2021; 13:cancers13164105. [PMID: 34439259 PMCID: PMC8391507 DOI: 10.3390/cancers13164105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 08/13/2021] [Indexed: 01/06/2023] Open
Abstract
Simple Summary Significant advances in surgical techniques and perioperative care, together with adjuvant chemotherapy, have contributed to the increasing number of patients with pancreatic cancer undergoing surgery. However, the results of some studies suggest that the postoperative complications and mortality might be higher in elderly patients undergoing pancreatectomy. We aimed to identify the utility of S-1 adjuvant chemotherapy in elderly patients with resected pancreatic cancer. In our cohort of 80 patients, including 16 octogenarians, univariate and multivariate analyses revealed that S-1 adjuvant chemotherapy was associated with improved prognosis in patients with pancreatic cancer. However, we also observed that skeletal muscle loss and age of 80 years or older predicted the failure to complete adjuvant chemotherapy with S-1. We propose that evaluation of skeletal muscle mass should be considered as a useful preoperative assessment approach for determining feasibility of adjuvant chemotherapy in elderly patients. Abstract The efficacy and prognosis of adjuvant chemotherapy for resected pancreatic cancer remain unclear. We investigated the utility and risk factors of S-1 adjuvant chemotherapy in patients with pancreatic cancer undergoing pancreatectomy. This study comprised 80 patients, including 58 patients who received S-1 adjuvant chemotherapy. Skeletal muscle loss was defined using cutoff values of skeletal muscle mass index. In total, 16 (20%) octogenarian patients underwent pancreatectomy. Skeletal muscle loss was present in 56 (70%) patients. The entire course of S-1 adjuvant chemotherapy for 6 months was completed in 33 patients (41%). S-1 adjuvant chemotherapy <6 months was an independent prognostic indicator of poor overall survival. Patients who completed S-1 adjuvant chemotherapy exhibited significantly longer overall and relapse-free survival rates than those did not complete the chemotherapy (p < 0.0001 and p = 0.0003, respectively). Being an octogenarian and skeletal muscle loss were independent variables associated with the discontinuation of S-1 adjuvant chemotherapy. Finally, the S-1 adjuvant chemotherapy rates were 6.3% (1/16) and 28.6% (16/56) in octogenarian patients and those with skeletal muscle loss, respectively. S-1 adjuvant chemotherapy completion was associated with improved prognosis in patients with pancreatic cancer. Skeletal muscle loss and octogenarian status predicted the failure of S-1 adjuvant chemotherapy completion.
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Affiliation(s)
- Mariko Tsukagoshi
- Department of Innovative Cancer Immunotherapy, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi 371-8511, Japan; (M.T.); (T.Y.)
- Division of Hepatobiliary and Pancreatic Surgery, Integrative Center of General Surgery, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi 371-8511, Japan; (K.A.); (N.K.); (A.W.); (T.I.); (N.I.); (T.Y.); (K.H.); (K.H.); (R.M.); (K.S.)
| | - Norifumi Harimoto
- Division of Hepatobiliary and Pancreatic Surgery, Integrative Center of General Surgery, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi 371-8511, Japan; (K.A.); (N.K.); (A.W.); (T.I.); (N.I.); (T.Y.); (K.H.); (K.H.); (R.M.); (K.S.)
- Correspondence: ; Tel.: +81-27-220-8224
| | - Kenichiro Araki
- Division of Hepatobiliary and Pancreatic Surgery, Integrative Center of General Surgery, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi 371-8511, Japan; (K.A.); (N.K.); (A.W.); (T.I.); (N.I.); (T.Y.); (K.H.); (K.H.); (R.M.); (K.S.)
| | - Norio Kubo
- Division of Hepatobiliary and Pancreatic Surgery, Integrative Center of General Surgery, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi 371-8511, Japan; (K.A.); (N.K.); (A.W.); (T.I.); (N.I.); (T.Y.); (K.H.); (K.H.); (R.M.); (K.S.)
| | - Akira Watanabe
- Division of Hepatobiliary and Pancreatic Surgery, Integrative Center of General Surgery, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi 371-8511, Japan; (K.A.); (N.K.); (A.W.); (T.I.); (N.I.); (T.Y.); (K.H.); (K.H.); (R.M.); (K.S.)
| | - Takamichi Igarashi
- Division of Hepatobiliary and Pancreatic Surgery, Integrative Center of General Surgery, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi 371-8511, Japan; (K.A.); (N.K.); (A.W.); (T.I.); (N.I.); (T.Y.); (K.H.); (K.H.); (R.M.); (K.S.)
| | - Norihiro Ishii
- Division of Hepatobiliary and Pancreatic Surgery, Integrative Center of General Surgery, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi 371-8511, Japan; (K.A.); (N.K.); (A.W.); (T.I.); (N.I.); (T.Y.); (K.H.); (K.H.); (R.M.); (K.S.)
| | - Takahiro Yamanaka
- Division of Hepatobiliary and Pancreatic Surgery, Integrative Center of General Surgery, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi 371-8511, Japan; (K.A.); (N.K.); (A.W.); (T.I.); (N.I.); (T.Y.); (K.H.); (K.H.); (R.M.); (K.S.)
| | - Kei Hagiwara
- Division of Hepatobiliary and Pancreatic Surgery, Integrative Center of General Surgery, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi 371-8511, Japan; (K.A.); (N.K.); (A.W.); (T.I.); (N.I.); (T.Y.); (K.H.); (K.H.); (R.M.); (K.S.)
| | - Kouki Hoshino
- Division of Hepatobiliary and Pancreatic Surgery, Integrative Center of General Surgery, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi 371-8511, Japan; (K.A.); (N.K.); (A.W.); (T.I.); (N.I.); (T.Y.); (K.H.); (K.H.); (R.M.); (K.S.)
| | - Ryo Muranushi
- Division of Hepatobiliary and Pancreatic Surgery, Integrative Center of General Surgery, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi 371-8511, Japan; (K.A.); (N.K.); (A.W.); (T.I.); (N.I.); (T.Y.); (K.H.); (K.H.); (R.M.); (K.S.)
| | - Toshiki Yajima
- Department of Innovative Cancer Immunotherapy, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi 371-8511, Japan; (M.T.); (T.Y.)
| | - Ken Shirabe
- Division of Hepatobiliary and Pancreatic Surgery, Integrative Center of General Surgery, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi 371-8511, Japan; (K.A.); (N.K.); (A.W.); (T.I.); (N.I.); (T.Y.); (K.H.); (K.H.); (R.M.); (K.S.)
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Parray A, Bhandare MS, Pandrowala S, Chaudhari VA, Shrikhande SV. Peri-operative, long-term, and quality of life outcomes after pancreaticoduodenectomy in the elderly: greater justification for periampullary cancer compared to pancreatic head cancer. HPB (Oxford) 2021; 23:777-784. [PMID: 33041206 DOI: 10.1016/j.hpb.2020.09.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 09/08/2020] [Accepted: 09/21/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) is more challenging in the elderly. METHODS Data of patients undergoing PD above 70 years of age was analysed to study short and long-term outcomes along with the quality of life parameters (QOL). RESULTS Out of 1271 PDs performed, 94 (7%) patients were 70 years or more. American Society of Anaesthesiology (ASA) scores were higher in comparison to patients below 70 years (ASA 1;20% vs. 54% and ASA 2&3;80% vs. 46%, p < 0.001). The postoperative 90-day mortality rate of 5.3% and morbidity (Clavein Grade III and IV of 27%) was higher but non-significant compared to 3.9% (p = 0.50) and 20% (p = 0.11) in patients less than 70 years. The median survival of 40 months was significantly better for periampullary carcinoma when compared to 15 months in pancreatic ductal adenocarcinoma (PDAC) (p < 0.0001). Patients, less than 70 years had significantly better 3-year survival; 64% vs 43% with periampullary etiology (p < 0.01) and 29% vs 0% with PDAC (p < 0.0001). QLQ-PAN 26 questionnaire responses were suggestive of good long term QOL in these patients. CONCLUSION Although PD is safe and feasible in the elderly population with good long-term QOL, postoperative morbidity and mortality can be slightly higher and long-term survival significantly lower.
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Affiliation(s)
- Amir Parray
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, 400012, Maharashtra, India
| | - Manish S Bhandare
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, 400012, Maharashtra, India.
| | - Saneya Pandrowala
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, 400012, Maharashtra, India
| | - Vikram A Chaudhari
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, 400012, Maharashtra, India
| | - Shailesh V Shrikhande
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, 400012, Maharashtra, India
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Short-term outcomes after minimally invasive versus open pancreaticoduodenectomy in elderly patients: a propensity score-matched analysis. BMC Surg 2021; 21:60. [PMID: 33494734 PMCID: PMC7836577 DOI: 10.1186/s12893-021-01052-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 01/06/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND To date, the evidence on the safety and benefits of minimally invasive pancreatoduodenectomy (MIPD) in elderly patients is still controversy. This study aim to compare the risk and benefit between MIPD and open pancreatoduodenectomy (OPD) in elderly patients. METHODS From 2016 to 2020, we retrospective enrolled 26 patients underwent MIPD and other 119 patients underwent OPD. We firstly compared the baseline characteristics, 90-day mortality and short-term surgical outcomes of MIPD and OPD. Propensity score matching was applied for old age patient (≥ 65-year-old vs. < 65-year-old) for detail safety and feasibility analysis. RESULTS Patients received MIPD is significantly older, had poor performance status, less lymph node harvest, longer operation time, less postoperative hospital stay (POHS) and earlier drain removal. After 1:2 propensity score matching analysis, elderly patients in MIPD group had significantly poor performance status (P = 0.042) compared to OPD group. Patients receiving MIPD had significantly shorter POHS (18 vs. 25 days, P = 0.028), earlier drain removal (16 vs. 21 days, P = 0.012) and smaller delay gastric empty rate (5.9 vs. 32.4% P = 0.036). There was no 90-day mortality (0% vs. 11.8%, P = 0.186) and pulmonary complications (0% vs. 17.6%, P = 0.075) in MIPD group, and the major complication rate is comparable to OPD group (17.6% vs. 29.4%, P = 0.290). CONCLUSION For elderly patients, MIPD is a feasible and safe option even in patients with inferior preoperative performance status. MIPD might also provide potential advantage for elderly patients in minimizing pulmonary complication and overall mortality over OPD.
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van der Heijde N, Balduzzi A, Alseidi A, Dokmak S, Polanco PM, Sandford D, Shrikhande SV, Vollmer C, Wang SE, Besselink MG, Asbun H, Abu Hilal M. The role of older age and obesity in minimally invasive and open pancreatic surgery: A systematic review and meta-analysis. Pancreatology 2020; 20:1234-1242. [PMID: 32782197 DOI: 10.1016/j.pan.2020.06.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 06/14/2020] [Accepted: 06/18/2020] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- N van der Heijde
- Department of Surgery, Southampton University Hospital, Southampton, United Kingdom; Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands.
| | - A Balduzzi
- Department of Surgery, University Hospital, Verona, Italy
| | - A Alseidi
- Department of Surgery, University of California, San Francisco, USA
| | - S Dokmak
- Department of Surgery, Beaujon Hospital, Paris, France
| | - P M Polanco
- Department of Surgery, UT Southwestern Medical Center, Dallas, USA
| | - D Sandford
- Department of Surgery, Washington University, St. Louis, USA
| | - S V Shrikhande
- Department of Surgery, Tata Memorial Hospital, Mumbai, India
| | - C Vollmer
- Department of Surgery, University of Pennsylvania, USA
| | - S E Wang
- Department of Surgery, Taipei Veterans General Hospital and National Yang Ming University, National Yang Ming University, Taipei, Taiwan
| | - M G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - H Asbun
- Miami Cancer Institute, Miami, FL, USA
| | - M Abu Hilal
- Department of Surgery, Southampton University Hospital, Southampton, United Kingdom.
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Tan Y, Tang T, Zhang Y, Zu G, An Y, Chen W, Wu D, Sun D, Chen X. Laparoscopic vs. open pancreaticoduodenectomy: a comparative study in elderly people. Updates Surg 2020; 72:701-707. [PMID: 32152962 DOI: 10.1007/s13304-020-00737-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 02/26/2020] [Indexed: 01/08/2023]
Abstract
The purpose of the study is to evaluate whether laparoscopic pancreatoduodenectomy (LPD) is safe and feasible for elderly patients. From December 2015 to January 2019, 142 LPD surgeries and 93 OPD surgeries were performed by the same surgeon in the third affiliated hospital of Soochow University. After applying the inclusion and exclusion criteria, we retrospectively collected the date of three defined groups: LPD aged < 70 years (group I, 84 patients), LPD aged ≥ 70 years (group II, 56 patients) and OPD aged ≥ 70 years (group III, 28 patients). Baseline characteristics and short-term surgical outcomes of group I and group II, group II and group III were compared. Totally, 168 patients were included in this study; 100 cases were men; 68 cases were women; mean age was 67.9 ± 9.5 years. LPD does not perform as well in elderly as it does in non-elderly patients in terms of intraoperative blood loss (300.0 (200.0-500.0) ml vs. 200.0 (100.0-300.0) ml, p = 0.003), proportion of intraoperative transfusion (17.9% vs. 6.0%, p = 0.026) and time to oral intake (5.0 (4.0-7.0) day vs. 5.0 (3.0-6.0) day, p = 0.036). Operative time, conversion rate, postoperative stay, and proportion of reoperation, Clavien-Dindo classification, 30-day readmission and 90-day mortality were similar in two groups. In elderly patients, when compared with OPD, LPD had the advantage of shorter time to start oral intake (5.0 (4.0-7.0) day vs. 7.0 (5.0-11.3) day, p = 0.005) but the disadvantage of longer operative time (380.0 (306.3-447.5) min vs. 292.5 (255.0-342.5) min, p < 0.001) and higher hospitalization cost (12447.3 (10,189.7-15,340.0) euros vs. 7251.9 (8994.0-11,717.4) euros, p < 0.001). There was no difference between the two groups in terms of postoperative stay, and proportion of reoperation, Clavien-Dindo classification, 30-day readmission and 90-day mortality. LPD is safe and feasible for elderly people, but we need to consider its high cost and long operative time over OPD.
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Affiliation(s)
- Yuwei Tan
- The First People's Hospital of Changzhou, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Tianyu Tang
- The First People's Hospital of Changzhou, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Yue Zhang
- The First People's Hospital of Changzhou, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Guangchen Zu
- The First People's Hospital of Changzhou, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Yong An
- The First People's Hospital of Changzhou, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Weibo Chen
- The First People's Hospital of Changzhou, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Di Wu
- The First People's Hospital of Changzhou, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Donglin Sun
- The First People's Hospital of Changzhou, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Xuemin Chen
- The First People's Hospital of Changzhou, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China.
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Liang Y, Zhao L, Jiang C, Hu P, Wang H, Cai Z, Wang W. Laparoscopic pancreaticoduodenectomy in elderly patients. Surg Endosc 2019; 34:2028-2034. [PMID: 31312964 DOI: 10.1007/s00464-019-06982-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 07/11/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The objective of the study is to evaluate the safety and feasibility of laparoscopic pancreaticoduodenectomy (LPD) in elderly patients by short-term surgical effects. METHODS We retrospectively collected clinical data of 55 non-elderly patients (< 70 years), 27 elderly patients (≥ 70 years) underwent LPD, and 19 elderly patients underwent open pancreaticoduodenectomy (OPD) in biliopancreatic surgery department of Huadong Hospital, affiliated to Fudan University, from Jan 2015 to Jan 2018. Patients were divided into 3 groups: LPD aged < 70 years, LPD aged ≥ 70 years, and OPD aged ≥ 70 years, according to their age at admission and surgical approach in order to compare baseline characteristics and short-term surgical outcomes. RESULTS Totally 101 patients were included in this study; 59 cases were male; 42 cases were female; mean age was 66 years old. Elderly LPD patients seemed to have higher overall morbidity (41% vs. 20%, P = 0.05) compared to non-elderly patients. This difference is even more significant in our multivariable analysis model with an odds ratio of 4.48 (95% CI 1.31-17.87, P = 0.018). The 90-days mortality, operative time, estimated blood loss (EBL), and post-operative hospital stay (POHS) were similar in two groups. Elderly LPD patients had less EBL and shorter POHS than elderly OPD patients. However, the mortality and morbidity rate were comparable in these two groups. CONCLUSIONS Aging patients have higher overall morbidity than younger patients in LPD. However, for aging population who need to undergo pancreaticoduodenectomy, LPD might have some advantages over OPD.
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Affiliation(s)
- Yun Liang
- Department of General Surgery, Huadong Hospital, Fudan University, West 221 Yan-an Road, Shanghai, 200040, China
| | - Liting Zhao
- Department of Biliopancreatic Surgery, Huadong Hospital, Fudan University, West 221 Yan-an Road, Shanghai, 200040, China
| | - Chongyi Jiang
- Department of General Surgery, Huadong Hospital, Fudan University, West 221 Yan-an Road, Shanghai, 200040, China.
| | - Pengfei Hu
- Department of General Surgery, Huadong Hospital, Fudan University, West 221 Yan-an Road, Shanghai, 200040, China
| | - Hongwei Wang
- Department of General Surgery, Huadong Hospital, Fudan University, West 221 Yan-an Road, Shanghai, 200040, China
| | - Zhiwei Cai
- Department of General Surgery, Huadong Hospital, Fudan University, West 221 Yan-an Road, Shanghai, 200040, China
| | - Wei Wang
- Department of Biliopancreatic Surgery, Huadong Hospital, Fudan University, West 221 Yan-an Road, Shanghai, 200040, China.
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Ramanathan R, Al Abbas AI, Mason T, Wolfe LG, Kaplan BJ. Age-related risks of complications after distal pancreatectomy for neuroendocrine and cystic neoplasms. HPB (Oxford) 2019; 21:810-817. [PMID: 30528554 DOI: 10.1016/j.hpb.2018.09.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 08/08/2018] [Accepted: 09/28/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Distal pancreatic neuroendocrine tumors (PNET) and pancreatic cystic neoplasms (PCN) are often incidentally found in older adults, requiring careful consideration between operative management and watchful waiting. This study analyzes the short-term complications associated with distal pancreatectomy (DP) for PNET and PCN in older adults to inform clinical decision-making. METHODS Patients undergoing DP for PNET and PCN were analyzed using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database and the pancreatectomy procedure-targeted dataset. Associations between decade of age and 30-day outcomes were evaluated. RESULTS 1626 patients were analyzed from 2014 to 2015. 692 (42.6%) were younger than 60 years, 507 (31.2%) were sexagenarians, 342 (21.0%) were septuagenarians, and 85 (5.2%) were octogenarians. Minimally invasive approaches were used in 62.7%. While septuagenarians and octogenarians constituted 26.3% of the cohort, they were affected by 55.6% of reintubations, 66.7% of failures to wean, 82.4% of myocardial infarctions, and 57.1% of septic shock. Septuagenarians and octogenarians had longer hospital stays, as compared to those younger than 60 years. CONCLUSION Septuagenarians and octogenarians are disproportionately affected by perioperative complications after DP for PNET and PCN. Careful patient selection and thorough counseling should be provided when surgery is considered.
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Affiliation(s)
- Rajesh Ramanathan
- Department of Surgery, Virginia Commonwealth University Medical Center, Richmond, VA, USA; Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Amr I Al Abbas
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Travis Mason
- Department of Surgery, Virginia Commonwealth University Medical Center, Richmond, VA, USA
| | - Luke G Wolfe
- Department of Surgery, Virginia Commonwealth University Medical Center, Richmond, VA, USA
| | - Brian J Kaplan
- Department of Surgery, Virginia Commonwealth University Medical Center, Richmond, VA, USA.
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Pancreatoduodenectomy for pancreatic head tumors in the elderly - Systematic review and meta-analysis. Surg Oncol 2018; 27:346-364. [PMID: 30217288 DOI: 10.1016/j.suronc.2018.05.021] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 05/08/2018] [Accepted: 05/13/2018] [Indexed: 02/06/2023]
Abstract
The age at which patients are undergoing pancreatoduodenectomy is increasing worldwide. The data on the outcome of this surgical procedure in the elderly is constantly expanding. This meta-analysis aims to assess the safety of pancreatoduodenectomy in elderly population, primarily focusing on morbidity and mortality. We searched the Medline, Embase and Cochrane databases to identify eligible studies. The most recent search was performed on 10th April 2017. Inclusion criteria were: (1) comparison of the characteristics and perioperative outcomes of older patients versus younger patients undergoing pancreatoduodenectomy; (2) objective evaluation of mortality or overall morbidity; and (3), publication in English. Exclusion criteria were: (1) a lack of comparative data; (2) a lack of primary outcomes or insufficient data to analyze; (3) a focus on procedures other than pancreatoduodenectomy; or (4), the impossibility of extraction of data specifically concerning pancreatoduodenectomy. Primary outcomes were overall morbidity and mortality. Secondary outcomes analyzed postoperative complications, R0 rate and length of hospital stay. 45 eligible studies were chosen, with a combined total of 21,295 patients. Older patients compared to younger patients had a higher risk of death (2.26% vs. 4.54%; RR: 2.23; 95% CI 1.74-2.87) and a higher complication rate (47.23% vs. 39.35%; RR: 1.17; 95% CI 1.12-1.24). There were no differences in pancreatic fistula occurrence (p = 0.27), bile leakage (p = 0.81), postoperative hemorrhage (p = 0.08), or R0 rate (p = 0.92). Our review confirms, that in the case of pancreatoduodenectomy, advanced age is a risk factor for increased non-surgical morbidity and, by extension, higher mortality.
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Stereotactic body radiation therapy for palliative management of pancreatic adenocarcinoma in elderly and medically inoperable patients. Oncotarget 2018; 9:16427-16436. [PMID: 29662656 PMCID: PMC5893251 DOI: 10.18632/oncotarget.24713] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 03/02/2018] [Indexed: 01/26/2023] Open
Abstract
Stereotactic body radiation therapy (SBRT) represents a promising treatment option for patients with localized pancreatic ductal adenocarcinoma (PDAC) who cannot tolerate surgical therapy. We retrospectively reviewed the records of patients with localized PDAC treated with SBRT at our institution between 2010 and 2016 to identify patients deemed medically inoperable due to poor performance status, advanced age, and/or comorbid conditions. Overall survival (OS), progression-free survival (PFS), and local progression-free survival (LPFS) were estimated using Kaplan-Meier curves. Twenty-nine patients were included. Median age was 74 (IQR 68-79). Thirteen patients (45%) had an Eastern Cooperative Oncology Group performance status of 2. Six patients (19%) had chronic obstructive pulmonary disease, 9 (31%) had cardiovascular disease, and 17 (58%) had diabetes mellitus. SBRT was delivered over 5 fractions to a median dose of 28 Gy (IQR, 25-33). Twenty-two patients (76%) received induction chemotherapy prior to SBRT, and 9 (31%) received maintenance chemotherapy after SBRT. Median OS was 13 months from diagnosis. Median OS and PFS were 8 and 6 months from SBRT, respectively. Six and 12-month LPFS rates were 91% and 78%, respectively. Patients receiving induction chemotherapy had superior survival from diagnosis than those who did not (14 vs. 7 months, p = 0.01). Three patients (10%) experienced acute grade ≥3 toxicity, and 1 patient (4%) experienced grade ≥3 late toxicity. Symptom relief was achieved at three-month follow-up in 8 of 11 patients (73%) experiencing abdominal pain. These results suggest SBRT may be safe and effective for patients who cannot tolerate surgery.
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Chen YT, Ma FH, Wang CF, Zhao DB, Zhang YW, Tian YT. Elderly patients had more severe postoperative complications after pancreatic resection: A retrospective analysis of 727 patients. World J Gastroenterol 2018; 24:844-851. [PMID: 29467554 PMCID: PMC5807942 DOI: 10.3748/wjg.v24.i7.844] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 01/03/2018] [Accepted: 01/15/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To examine the impact of aging on the short-term outcomes following pancreatic resection (PR) in elderly patients.
METHODS A retrospective cohort study using prospectively collected data was conducted at the China National Cancer Center. Consecutive patients who underwent PR from January 2004 to December 2015 were identified and included. ‘Elderly patient’ was defined as ones age 65 and above. Comorbidities, clinicopathology, perioperative variables, and postoperative morbidity and mortality were compared between the elderly and young patients. Univariate and multivariate analyses were performed using the Cox proportional hazard model for severe postoperative complications (grades IIIb-V).
RESULTS A total of 454 (63.4%) patients were < 65-years-old and 273 (36.6%) patients were ≥ 65-years-old, respectively. Compared to patients < 65-years-old, elderly patients had worse American Society of Anesthesiologists scores (P = 0.007) and more comorbidities (62.6% vs 32.4%, P < 0.001). Elderly patients had more severe postoperative complications (16.8% vs 9.0%, P = 0.002) and higher postoperative mortality rates (5.5% vs 0.9%, P < 0.001). In the multivariate Cox proportional hazards model for severe postoperative complications, age ≥ 65 years [hazard ratio (HR) = 1.63; 95% confidence interval (CI): 1.18-6.30], body mass index ≥ 24 kg/m2 (HR = 1.20, 95%CI: 1.07-5.89), pancreaticoduodenectomy (HR = 4.86, 95%CI: 1.20-8.31) and length of operation ≥ 241 min (HR = 2.97; 95%CI: 1.04-6.14) were significant (P = 0.010, P = 0.041, P = 0.017 and P = 0.012, respectively).
CONCLUSION We found that aging is an independent risk factor for severe postoperative complications after PR. Our results might contribute to more informed decision-making for elderly patients.
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Affiliation(s)
- Ying-Tai Chen
- Department of Pancreatic and Gastric Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Fu-Hai Ma
- Department of Pancreatic and Gastric Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Cheng-Feng Wang
- Department of Pancreatic and Gastric Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Dong-Bing Zhao
- Department of Pancreatic and Gastric Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Ya-Wei Zhang
- Department of Surgery, Yale School of Medicine, New Haven, CT 06520, United States
| | - Yan-Tao Tian
- Department of Pancreatic and Gastric Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
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Corrigan LR, Bracken-Clarke DM, Horgan AM. The challenge of treating older patients with pancreaticobiliary malignancies. Curr Probl Cancer 2018; 42:59-72. [PMID: 29459178 DOI: 10.1016/j.currproblcancer.2018.01.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 01/15/2018] [Accepted: 01/16/2018] [Indexed: 02/06/2023]
Abstract
Pancreatic and biliary tract cancers are aggressive malignancies. They commonly present with metastatic or unresectable disease. Those that do present with resectable cancer have high rates of recurrence. Despite recent advances in surgical technique, chemotherapy, and radiotherapy regimens, they are associated with poor survival outcomes. These cancers represent an exception to the trend of improved overall survival evident in most malignancies in recent decades. Depending on the goal of treatment, active management of pancreatic and biliary cancers involves surgery, chemotherapy, and radiation therapy, either alone or in combination. Both pancreatic and biliary tract cancers have a preponderance in the older population. Older patients are a heterogeneous group; although tolerability of multimodality treatment may be a challenge for some, many fit older patients may be undertreated based on their age alone. The growing field of geriatric oncology has highlighted the importance of a comprehensive assessment of these patients, and not relying on age alone as a discriminating factor for treatment. Management of older patients with pancreaticobiliary cancers is particularly challenging owing to limited prospective data in this population. As such, there is uncertainty with regard to optimal treatment approaches for these patients. In this article, we outline the therapeutic options available to patients with localized or advanced pancreatic and biliary tract cancers, and the evidence for specified treatment options in the elderly. We examine the inclusion and outcomes of elderly patients in relevant clinical trials; the morbidity that may be encountered by elderly patients receiving specified treatments and the tools that may assist the physician in selecting elderly patients for particular treatments.
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Affiliation(s)
- Lynda R Corrigan
- Department of Medical Oncology, University Hospital Waterford, Ardkeen, Co Waterford, Ireland.
| | - Dara M Bracken-Clarke
- Department of Medical Oncology, University Hospital Waterford, Ardkeen, Co Waterford, Ireland
| | - Anne M Horgan
- Department of Medical Oncology, University Hospital Waterford, Ardkeen, Co Waterford, Ireland
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Namm JP, Thakrar KH, Wang CH, Stocker SJ, Sur MD, Berlin J, Dale W, Talamonti MS, Roggin KK. A semi-automated assessment of sarcopenia using psoas area and density predicts outcomes after pancreaticoduodenectomy for pancreatic malignancy. J Gastrointest Oncol 2017; 8:936-944. [PMID: 29299352 PMCID: PMC5750184 DOI: 10.21037/jgo.2017.08.09] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 08/08/2017] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Sarcopenia has been associated with increased adverse outcomes after major abdominal surgery. Sarcopenia defined as decreased muscle volume or increased fatty infiltration may be a proxy for frailty. In conjunction with other preoperative clinical risk factors, radiographic measures of sarcopenia using both muscle size and density may enhance prediction of outcomes after pancreaticoduodenectomy (PD) for malignancy. METHODS Preoperative computed tomography (CT) scans of patients undergoing PD for malignancy were analyzed from a prospective pancreatic surgery database. Sarcopenia was assessed both manually and with a semi-automated technique by measuring the total psoas area index (TPAI) and average Hounsfield units (HU) at the L3 lumbar level to estimate psoas muscle volume and density, respectively. Adjusting for known pre-operative risk factors, preoperative sarcopenia measurements were analyzed relative to perioperative outcomes. RESULTS Sarcopenia assessments of 116 subjects demonstrated good correlation between the semi-automated and the manual techniques (P<0.0001). Lower TPAI (OR 0.34, P=0.009) and HU (OR 0.84, P=0.002) measurements were predictive of discharge to skilled nursing facility (SNF), but not major complications, length of stay, readmissions or recurrence on univariate analysis. Lower TPAI was protective against the risk of organ/space surgical site infection (SSI) including pancreatic fistula (OR 3.12, P=0.019). On multivariate analysis, the semi-automated measurements of TPAI and HU remained as independent predictors of organ/space SSI including pancreatic fistula (OR 4.23, P=0.014) and discharge to SNF (OR 0.79, P=0.019) respectively. CONCLUSIONS When combined with preoperative clinical assessments in patients with pancreatic malignancy, semi-automated sarcopenia metrics are a simple, reproducible method that may enhance prediction of outcomes after PD and help guide clinical management.
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Affiliation(s)
- Jukes P. Namm
- Department of Surgery, Loma Linda University Health, Loma Linda, USA
| | - Kiran H. Thakrar
- Department of Radiology, NorthShore University HealthSystem, Evanston, USA
| | - Chi-Hsiung Wang
- Center for Biomedical Research Informatics, NorthShore University HealthSystem, Evanston, USA
| | - Susan J. Stocker
- Department of Surgery, NorthShore University HealthSystem, Evanston, USA
| | - Malini D. Sur
- Department of Surgery, Mount Sinai Health System, New York, USA
| | - Jonathan Berlin
- Department of Radiology, NorthShore University HealthSystem, Evanston, USA
| | - William Dale
- Department of Supportive Care Medicine, City of Hope, California, USA
| | - Mark S. Talamonti
- Department of Surgery, NorthShore University HealthSystem, Evanston, USA
| | - Kevin K. Roggin
- Department of Surgery, The University of Chicago Medicine, Chicago, USA
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Chapman BC, Gajdos C, Hosokawa P, Henderson W, Paniccia A, Overbey DM, Gleisner A, Schulick RD, McCarter MD, Edil BH. Comparison of laparoscopic to open pancreaticoduodenectomy in elderly patients with pancreatic adenocarcinoma. Surg Endosc 2017; 32:2239-2248. [PMID: 29067580 DOI: 10.1007/s00464-017-5915-0] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Accepted: 10/03/2017] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The purpose of the study is to compare perioperative and survival outcomes in elderly patients undergoing laparoscopic pancreaticoduodenectomy (LPD) to those undergoing open pancreaticoduodenectomy (OPD). METHODS Patients aged ≥ 75 years with pancreatic adenocarcinoma undergoing LPD or OPD were identified from the NCDB (2010-2013). Baseline characteristics and perioperative outcomes were compared using a χ 2 and Student's t test. The Kaplan-Meier method was used to generate survival curves, and differences were tested using a log-rank test. A multivariate cox proportional hazard model was applied to estimate the hazard ratio (HR) of LPD on overall survival (OS). RESULTS We identified 1768 patients aged ≥ 75 years who underwent LPD (n = 248, 14.0%) or OPD (n = 1520, 86.0%). The majority of patients in the LPD group had their surgery at facilities performing less than 5 LPDs per year (n = 165, 66.5%). 90-day mortality was significantly lower in the LPD compared to the OPD (7.2 vs. 12.2%, p = 0.049). The laparoscopic conversion rate was 30% (n = 74) and was associated with higher readmission rates (13.5 vs. 8.1%), 30-day mortality (8.0 vs. 3.8%), and 90-day mortality (10.4 vs. 6.0%), but these did not reach statistical significance. Median OS was significantly longer in the LPD group (19.8 vs. 15.6 months, p = 0.022). After adjusting for patient and tumor-related characteristics, there was a trend towards improved survival in the LPD group (HR 0.85, 95% CI 0.69-1.03). CONCLUSION The vast majority of the NCDB participating facilities perform less than 5 LPD cases per year, which was associated with an increased risk of perioperative mortality. Overall 90-day mortality was significantly lower in the LPD group and there was a trend towards improved OS in the LPD group compared to the OPD group after adjusting for patient and tumor-related characteristics. Studies with increased sample size and longer follow-up are needed before definitive conclusions can be made.
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Affiliation(s)
- Brandon C Chapman
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Csaba Gajdos
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Patrick Hosokawa
- Adult and Child Center for Health Outcomes Research and Delivery Science (ACCORDS), Aurora, CO, USA
| | - William Henderson
- Adult and Child Center for Health Outcomes Research and Delivery Science (ACCORDS), Aurora, CO, USA
| | - Alessandro Paniccia
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Douglas M Overbey
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ana Gleisner
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Richard D Schulick
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Martin D McCarter
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Barish H Edil
- Division of Surgical Oncology, University of Colorado School of Medicine, 1665 Aurora Court Room 3337, MS-F-703, Aurora, CO, 80045, USA.
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El Nakeeb A, El Sorogy M, Salem A, Said R, El Dosoky M, Moneer A, Abdelwahab Ali M, Mahdy Y. Surgical outcomes of pancreaticoduodenectomy in young patients: A case series. Int J Surg 2017; 44:287-294. [DOI: 10.1016/j.ijsu.2017.07.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 06/27/2017] [Accepted: 07/03/2017] [Indexed: 02/08/2023]
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Zouros E, Liakakos T, Machairas A, Patapis P, Tzerbinis H, Manatakis DK, Papadimitriou-Olivgeris M, Dervenis C. Fast-Track Pancreaticoduodenectomy in the Elderly. Am Surg 2017. [DOI: 10.1177/000313481708300318] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
It remains uncertain whether enhanced recovery after surgery (ERAS) protocols can be safely implemented for elderly patients, especially after highly complex surgery such as pancreaticoduodenectomy (PD). The present study was designed to assess the feasibility and safety of an ERAS protocol in elderly patients undergoing PD. Starting January 2010 to February 2015, we prospectively collected data from 85 consecutive patients who underwent PD with a fast-track program. Data of patients older and younger than 70 years were compared. Endpoints were morbidity, mortality, readmissions, length of stay, and compliance with ERAS elements. Forty-five patients were less than 70 years old and 40 patients were 70 years of age or older. Both mortality (4.4% vs 5%; P = 1.000) and overall morbidity (33.3% vs 37.5%; P = 0.821) did not differ significantly between the groups. Rates of intervention and relaparotomy were similar in both groups. Length of stay (10 vs 11.8 days; P = 0.099) did not differ significantly between the groups, nor did the readmission rates (6.7% vs 5.0%; P = 0.272). There were no differences in compliance with ERAS elements between groups. An ERAS program seems feasible and can be safely implemented for elderly patients undergoing PD.
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Affiliation(s)
- Efstratios Zouros
- Department of Surgery, “Konstantopouleio” General Hospital, Athens, Greece
| | | | | | - Paulos Patapis
- Third Department of Surgery, Attiko University Hospital, Athens, Greece
| | - Helen Tzerbinis
- Department of Surgery, “Konstantopouleio” General Hospital, Athens, Greece
| | | | | | - Christos Dervenis
- Department of Surgery, “Konstantopouleio” General Hospital, Athens, Greece
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Liang DH, Shirkey BA, Rosenberg WR, Martinez S. Clinical outcomes of pancreaticoduodenectomy in octogenarians: a surgeon's experience from 2007 to 2015. J Gastrointest Oncol 2016; 7:540-6. [PMID: 27563443 DOI: 10.21037/jgo.2016.03.04] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND As the number of elderly people in our population increases, there will be a greater number of octogenarians who will need pancreaticoduodenectomy as the only curative option for periampullary malignancies. This study evaluated clinical outcomes of pancreaticoduodenectomy in octogenarians, in comparison to younger patients. METHODS A retrospective review was conducted of 216 consecutive patients who underwent pancreaticoduodenectomy from January 2007 to April 2015. A two-sided Fisher's exact statistical analysis was used to compare pre-operative comorbidities, intra-operative factors, surgical pathology, and post-operative complication rates between non-octogenarians and octogenarians. RESULTS One hundred and eighty three non-octogenarians and 33 octogenarians underwent pancreaticoduodenectomy. Of patients with periampullary adenocarcinoma, octogenarians were more likely to present with advanced disease state (P=0.01). The two cohorts had similar ASA scores (P=0.62); however, octogenarians were more likely to have coronary artery disease (P=0.03). The length of operation was shorter in octogenarians (P=0.002). Mortality rates (P=0.49) and overall postoperative complication rates (P=1.0) were similar in two cohorts; however octogenarians had a higher incidence of pulmonary embolism (P=0.02). CONCLUSIONS Our data demonstrates that octogenarians can undergo pancreaticoduodenectomy with outcomes similar to those in younger patients. Thus, patients should not be denied a curative surgical option for periampullary malignancy based on advanced age alone.
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Affiliation(s)
- Diana H Liang
- Department of Surgery, Houston Methodist Hospital, 6550 Fannin St., Smith Tower 1661, Houston, TX, USA
| | - Beverly A Shirkey
- Department of Surgery, Houston Methodist Hospital, 6550 Fannin St., Smith Tower 1661, Houston, TX, USA
| | - Wade R Rosenberg
- Department of Surgery, Houston Methodist Hospital, 6550 Fannin St., Smith Tower 1661, Houston, TX, USA
| | - Sylvia Martinez
- Department of Surgery, Houston Methodist Hospital, 6550 Fannin St., Smith Tower 1661, Houston, TX, USA
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Abstract
BACKGROUND Although the mortality and morbidity of pancreaticoduodenectomy (PD) have improved significantly over the past years, the concerns for elderly patients undergoing PD are still present. Furthermore, the frequency of PD is increasing because of the increasing proportion of elderly patients and the increasing incidence of periampullary tumors. This study aimed to analyze the outcomes of PD in elderly patients. METHODS We studied all patients who had undergone PD in our center between January 1995 and February 2015. The patients were divided into three groups based on age: group I (patients aged <60 years), group II (those aged 60 to 69 years) and group III (those aged ≥70 years). The primary outcome was the rate of total postoperative complications. Secondary endpoint included total operative time, hospital mortality, length of postoperative hospital stay, delayed gastric emptying, re-exploration, and survival rate. RESULTS A total of 828 patients who had undergone PD for resection of periampullary tumor were included in this study. There were 579 (69.9%) patients in group I, 201 (24.3%) in group II, and 48 (5.8%) in group III. The overall incidence of complications was higher in elderly patients (25.9% in group I, 36.8% in group II, and 37.5% in group III; P=0.006). There were more patients complicated with delayed gastric emptying in group II compared with the other two groups. There was no significant difference in the incidence of postoperative pancreatic fistula, biliary leakage, pancreatitis, pulmonary complications and hospital mortality. CONCLUSIONS PD can be performed safely in selected elderly patients. Advanced age alone should not be a contraindication for PD. The outcome of elderly patients who have undergone PD is similar to that of younger patients, and the increased rate of complications is due to the presence of associated comorbidities.
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Higuera O, Ghanem I, Nasimi R, Prieto I, Koren L, Feliu J. Management of pancreatic cancer in the elderly. World J Gastroenterol 2016; 22:764-75. [PMID: 26811623 PMCID: PMC4716075 DOI: 10.3748/wjg.v22.i2.764] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 10/03/2015] [Accepted: 11/09/2015] [Indexed: 02/06/2023] Open
Abstract
Currently, pancreatic adenocarcinoma mainly occurs after 60 years of age, and its prognosis remains poor despite modest improvements in recent decades. The aging of the population will result in a rise in the incidence of pancreatic adenocarcinoma within the next years. Thus, the management of pancreatic cancer in the elderly population is gaining increasing relevance. Older cancer patients represent a heterogeneous group with different biological, functional and psychosocial characteristics that can modify the usual management of this disease, including pharmacokinetic and pharmacodynamic changes, polypharmacy, performance status, comorbidities and organ dysfunction. However, the biological age, not the chronological age, of the patient should be the limiting factor in determining the most appropriate treatment for these patients. Unfortunately, despite the increased incidence of this pathology in older patients, there is an underrepresentation of these patients in clinical trials, and the management of older patients is thus determined by extrapolation from the results of studies performed in younger patients. In this review, the special characteristics of the elderly, the multidisciplinary management of localized and advanced ductal adenocarcinoma of the pancreas and the most recent advances in the management of this condition will be discussed, focusing on surgery, chemotherapy, radiation and palliative care.
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Sur MD, Namm JP, Hemmerich JA, Buschmann MM, Roggin KK, Dale W. Radiographic Sarcopenia and Self-reported Exhaustion Independently Predict NSQIP Serious Complications After Pancreaticoduodenectomy in Older Adults. Ann Surg Oncol 2015; 22:3897-904. [PMID: 26242367 DOI: 10.1245/s10434-015-4763-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Sarcopenia is linked to poor outcomes after abdominal surgery. We hypothesized that radiographic sarcopenia metrics enhance prediction of complications after pancreaticoduodenectomy (PD) when combined with clinical and frailty data. METHODS Preoperative geriatric assessments and CT scans of patients undergoing PD were reviewed. Sarcopenia was assessed at L3 using total psoas area index (TPAI) and weighted average Hounsfield units (HU), i.e., estimates of psoas muscle volume and density. Outcomes included 30-day American College of Surgeons National Surgical Quality Improvement Program (NSQIP) serious complications, Clavien-Dindo complications, unplanned intensive care unit (ICU) admission, hospital length of stay (LOS), non-home facility (NHF) discharge, and readmission rates. RESULTS Low HU score correlated with NSQIP serious complications (r = -0.31, p = 0.0098), Clavien-Dindo complication grade (r = -0.29, p = 0.0183), unplanned ICU admission (r = -0.28, p = 0.0239), and NHF discharge (r = -0.25, p = 0.0426). Controlling for a "base model" of age, body mass index, American Society of Anesthesiologists score, and comorbidity burden, Fried's exhaustion (odds ratio [OR] 4.72 [1.23-17.71], p = 0.021), and HU (OR 0.88 [0.79-0.98], p = 0.024) predicted NSQIP serious complications. Area under the receiver-operator characteristic (AUC) curves demonstrated that the combination of the base model, exhaustion, and HU trended towards improving the prediction of NSQIP serious complications compared with the base model alone (AUC = 0.81 vs. 0.70; p = 0.09). Additionally, when controlling for the base model, TPAI (β-coefficient = 0.55 [0.10-1.01], p = 0.018) and exhaustion (β-coefficient = 2.47 [0.75-4.20], p = 0.005) predicted LOS and exhaustion (OR 4.14 [1.48-11.6], p = 0.007) predicted readmissions. CONCLUSIONS When combined with clinical and frailty assessments, radiographic sarcopenia metrics enhance prediction of post-PD outcomes.
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Affiliation(s)
- Malini D Sur
- Department of Surgery, The University of Chicago, Chicago, IL, USA
| | - Jukes P Namm
- Department of Surgery, The University of Chicago, Chicago, IL, USA
| | - Joshua A Hemmerich
- Section of Geriatrics & Palliative Medicine, Department of Medicine, The University of Chicago, Chicago, IL, USA
| | - Mary M Buschmann
- Section of Geriatrics & Palliative Medicine, Department of Medicine, The University of Chicago, Chicago, IL, USA
| | - Kevin K Roggin
- Department of Surgery, The University of Chicago, Chicago, IL, USA
| | - William Dale
- Section of Geriatrics & Palliative Medicine, Department of Medicine, The University of Chicago, Chicago, IL, USA.
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Schlottmann F, Iovaldi ML, Capitanich P, McCormack L. Outcomes of pancreatic surgery in patients older than 70 years. Cir Esp 2015; 93:638-42. [PMID: 25944478 DOI: 10.1016/j.ciresp.2015.03.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 03/27/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The proportion of elderly patients is growing rapidly. Knowing the results of pancreatic surgery in this group of patients would help surgeons to make therapeutic decisions. The objective is to evaluate the surgical outcomes of pancreatic resections in patients over 70 years. METHODS Retrospective study including patients undergoing pancreatic resection during the period 2009-2014. The sample was divided into 2 groups. G1: Patients under 70 years and G2: Patients older than 70 years. Surgical results between the 2 groups were evaluated. RESULTS Seventy three pancreatic resections were performed, 51 (70%) patients belonged to G1 and 22 (30%) to G2. There were no significant differences between G1 and G2 in terms of operative time and hospitalization days. No significant difference was obtained in the incidence of delayed gastric emptying, pancreatic fistula or biliary fistula. The overall mortality in the series was 4.1% showing difference between both groups, with 2% in G1 and 13.6% in G2 (P=.04). When a sub-analysis in G2 was made, mortality in this group occurred only in patients with significant comorbidities with ASA ≥ 3 (P=.004). Both groups with oncologic disease had similar overall survival and disease-free survival. CONCLUSIONS Age should not be a limiting factor for pancreatic resections. The elderly have similar results as younger patients and their increased perioperative mortality is due to the presence of important associated comorbidities rather than age as an independent risk factor.
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Affiliation(s)
- Francisco Schlottmann
- Servicio de Cirugía General, Departamento de Cirugía, Hospital Alemán, Buenos Aires, Argentina.
| | - Mario L Iovaldi
- Sección de Cirugía Hepatobiliopancreática, Departamento de Cirugía, Hospital Alemán, Buenos Aires, Argentina
| | - Pablo Capitanich
- Sección de Cirugía Hepatobiliopancreática, Departamento de Cirugía, Hospital Alemán, Buenos Aires, Argentina
| | - Lucas McCormack
- Sección de Cirugía Hepatobiliopancreática, Departamento de Cirugía, Hospital Alemán, Buenos Aires, Argentina
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Implementing an Enhanced Recovery Program After Pancreaticoduodenectomy in Elderly Patients: Is It Feasible? World J Surg 2014; 39:251-8. [DOI: 10.1007/s00268-014-2782-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Gerstenhaber F, Grossman J, Lubezky N, Itzkowitz E, Nachmany I, Sever R, Ben-Haim M, Nakache R, Klausner JM, Lahat G. Pancreaticoduodenectomy in elderly adults: is it justified in terms of mortality, long-term morbidity, and quality of life? J Am Geriatr Soc 2013; 61:1351-7. [PMID: 23865843 DOI: 10.1111/jgs.12360] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To evaluate long-term morbidity, mortality, and quality of life (QoL) after pancreaticoduodenectomy (PD) in elderly adults. DESIGN Retrospective cohort study. SETTING Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel. PARTICIPANTS One hundred and sixty-eight individuals aged 70 and older who underwent PD between 1995 and 2010. MEASUREMENTS A prospective pancreatic surgery database was analyzed for postoperative morbidity; mortality; intensive care unit (ICU), hospital, and rehabilitation facility stay; and readmissions after surgery. QoL was assessed using a validated questionnaire completed 3, 6, and 12 months after surgery. RESULTS Seventy-two percent of the participants had an American Society of Anesthesiologists score of 3 or greater. There was no intraoperative death. Thirty- and 60-day postoperative mortality rates were 5.9% and 6.5%, respectively. Median ICU stay was 2 days, and median hospital stay was 22 days. Sixty-four participants (37.5%) were discharged to a rehabilitation facility. The first-year readmission rate was 31%. One- and 2-year overall survival rates were 58% and 36%, respectively. Global QoL scores 3 and 12 months after surgery were 68% and 73%, respectively. Scores were lower yet comparable with those of matched individuals undergoing laparoscopic cholecystectomy. CONCLUSION Most elderly adults with pancreatic cancer survive longer than 1 year after PD; 36% survive longer than 2 years. These individuals are likely to have acceptable long-term morbidity and overall good QoL, corresponding with their age.
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Yamashita YI, Shirabe K, Tsujita E, Takeishi K, Ikeda T, Yoshizumi T, Furukawa Y, Ishida T, Maehara Y. Surgical outcomes of pancreaticoduodenectomy for periampullary tumors in elderly patients. Langenbecks Arch Surg 2013; 398:539-45. [PMID: 23412595 DOI: 10.1007/s00423-013-1061-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Accepted: 02/04/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUNDS Pancreaticoduodenectomy (PD) is an aggressive surgery with considerable operative risks, but offers the only chance for cure in patients with periampullary tumors. A growing number of elderly patients are being offered PD because of the aging of populations in developed countries. We examined surgical outcomes of PD in patients aged 75 years and older (≥75 years). METHODS A retrospective cohort study was performed in 65 consecutive patients who underwent PD for periampullary tumors at a single medical center during the 5 years from 2006 to 2010. We analyzed surgical outcomes such as mortality and morbidity after PD in patients aged ≥75 years (n = 21) compared to those in patients aged <75 years (n = 44). RESULTS The positive rate of comorbidities such as hypertension was significantly higher in patients aged ≥75 years than in patients aged <75 years (76 vs. 48 %; p = 0.03). The incidence of wound infection was significantly higher in patients aged ≥75 years than in patients aged <75 years (19 vs. 0 %; p < 0.01). However, there was no significant difference in the mortality rate (0 vs. 2 %; p = 0.49) or the overall morbidity rate (33 vs. 32 %; p = 0.90). There was no significant difference in changes in body weight or serum albumin levels during the 3 months after PD between the two groups, but the recovery of serum prealbumin levels from 1 to 3 months after PD in patients aged ≥75 years was significantly delayed compared to that in patients aged <75 years (p = 0.04). There was no statistically significant difference in long-term survival between the two groups. CONCLUSIONS Advanced age alone should not discourage surgeons from offering PD, although nutritional supports after PD for elderly patients aged ≥75 years are needed.
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Affiliation(s)
- Yo-Ichi Yamashita
- Department of Surgery, Hiroshima Red Cross Hospital and Atomic Bomb Survivors Hospital, 1-9-6 Senda-machi, Naka-ku, Hiroshima 730-8619, Japan.
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Sukharamwala P, Prashant S, Thoens J, Jonathan T, Szuchmacher M, Mauricio S, Smith J, James S, DeVito P, Peter D. Advanced age is a risk factor for post-operative complications and mortality after a pancreaticoduodenectomy: a meta-analysis and systematic review. HPB (Oxford) 2012; 14:649-57. [PMID: 22954000 PMCID: PMC3461370 DOI: 10.1111/j.1477-2574.2012.00506.x] [Citation(s) in RCA: 115] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Accepted: 05/16/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of this meta-analysis was to analyse the outcomes of major pancreatic surgery among the elderly (≥75 and ≥80 years of age). METHODS A systematic literature search was conducted using Embase, MEDLINE, Cochrane and PubMed databases on all studies published between January 1990 and April 2012 reporting peri-operative outcomes after a pancreaticoduodenectomy (PD) among the elderly. Primary end-points measured were peri-operative mortality and the incidence of post-operative complications. Secondary outcomes considered included the incidence of post-operative pancreatic fistula formation (POPF), delayed gastric emptying (DGE), wound infection, pneumonia, post-operative bleeding and length of hospital stay. RESULTS Eleven trials were included comprising 5186 patients; 7 studies comparing endpoints in patients aged ≥75 years vs. younger populations and 4 studies comparing endpoints in patients aged ≥80 years vs. younger populations. In both groups, there was a statistically significant increase in the incidence of mortality and post-operative pneumonia in the elderly population. The incidence of post-operative complications was also found to be statistically significant among patients ≥80 years of age vs. their younger cohorts. CONCLUSIONS There is an increased incidence of post-operative mortality and pneumonia after a PD among all elderly patients ≥75 years of age, as well as an increased incidence of post-operative complications among patients ≥80 years of age. Additional randomized control trials studying post-PD operative outcomes in elderly vs. younger patients with standardization of comorbidities is therefore necessary to confirm the conclusions presented here.
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Targeting early deaths following pancreaticoduodenectomy to improve survival. J Gastrointest Surg 2012; 16:1869-74. [PMID: 22875597 DOI: 10.1007/s11605-012-1958-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Accepted: 06/28/2012] [Indexed: 01/31/2023]
Abstract
INTRODUCTION There is increasing focus on disease-specific outcomes. This study was undertaken to analyze early mortality after pancreaticoduodenectomy as part of a strategy to improve long-term outcome. METHODS One thousand thirty-one patients who underwent pancreaticoduodenectomy from 1992 to 2010 were studied. Median data are reported. RESULTS Fifty-eight (5.6%) patients died within 90 days after pancreaticoduodenectomy. All patients had at least one significant comorbidity, commonly cardiorespiratory in nature (76%). Sixty percent of patients had depressed serum albumin levels, and 43% were jaundiced. The American Society of Anesthesiologists class was: 17% class II, 72% class III, and 10% class IV. Seventy-four percent had malignant disease. Twenty-two percent of patients underwent a major vascular resection at the time of pancreaticoduodenectomy. Causes of death were vascular/bleeding related (26%), cardiorespiratory causes (17%), multiorgan failure (12%), leak/perforation (10%), cancer progression (9%), infection (7%), or indeterminate (19%). CONCLUSIONS Death within 90 days after pancreaticoduodenectomy is uncommon, occurs in relatively older deconditioned patients, and is generally not causally related to underlying malignancy. Early death is generally associated with vascular or bleeding complications. Strategies to minimize early death should focus on careful patient selection and prompt recognition and management of herald bleeding or vascular thrombosis, as it can often result in perioperative death following pancreaticoduodenectomy.
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