Short- and long-term outcomes of pancreaticoduodenectomy in elderly patients with periampullary cancer

Outcomes following pancreaticoduodenectomy for octogenarians: a systematic review and meta-analysis

BACKGROUND

An increasing number of elderly patients are being diagnosed with pancreatic cancer, with increasing need to consider pancreatic surgery. This study aims to provide an updated systematic review and meta-analysis to evaluate the outcomes following pancreaticoduodenectomy in octogenarians.

METHODS

A systematic review and meta-analysis was performed via a search of Medline, PubMed and Cochrane databases. Studies comparing outcomes of patients >80 years to younger patients undergoing PD were included.

RESULTS

26 studies were included. This included 22481 patients, with 20134 (89.6%) aged <80 years old, and 2347 (10.4%) octogenarians. Octogenarians were associated with higher rates of mortality (OR 2.37 (95%CI 1.91-2.94, p < 0.00001)), all-cause morbidity (OR 1.60 (95%CI 1.30-1.96), p<0.00001) and re-operation (OR 1.41 (95%CI 1.13-1.75), p = 0.002). Octogenarians had a two-fold risk of cardiac complications and respiratory complications (OR 2.13 (95%CI 1.67-2.73), p < 0.00001), (OR 2.38 (95%CI 1.72-3.27), p < 0.0001). There was no difference in postoperative pancreatic fistula, post-pancreatectomy hemorrhage or delayed gastric emptying. Younger patients were more likely to return to adjuvant therapy (OR 0.20 (95%CI 0.12-0.34), p < 0.00001).

CONCLUSIONS

Octogenerians are associated with higher mortality rate, postoperative complications, and reduced likelihood to undergo adjuvant therapy. Careful preoperative assessment and selection of elderly patients for consideration of pancreatic surgery is essential.

Short-term outcomes of pancreatoduodenectomy in older individuals over a 9-year period using real-world data: A multilevel analysis based on a nationwide administrative database in Japan

BACKGROUND

We aimed to evaluate the short-term outcomes of pancreatoduodenectomy (PD) in older individuals.

METHODS

Data from the Japanese Diagnosis Procedure Combination database on 62 275 patients who underwent PD from 1 April 2012 to 31 March 2020 were analyzed. Patients were divided into five age groups: <70, 70-74, 75-79, 80-84, and ≥85 years. The associations between postoperative outcomes and age were investigated using multilevel analysis. The mean differences in length of hospital stay and cost were also compared.

RESULTS

The rate of PD in older individuals increased annually. Compared with the youngest age group (< 70 years), the incidence rate ratios for in-hospital mortality were 1.52 (95% confidence interval [CI]: 1.30-1.76), 2.07 (1.82-2.37), 2.29 (1.94-2.71), and 2.92 (2.20-3.87) in the 70-74, 75-79, 80-84, and ≥ 85-year-old age groups, respectively (all p < .001). Postoperative complications, length of postoperative hospital stay, and cost increased significantly with increasing age.

CONCLUSIONS

These real-world data emphasize the higher levels of morbidity, mortality, and cost in older patients. Careful attention should be paid when considering the indication for PD in older individuals.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Surgical management for elderly patients with pancreatic cancer

Pancreatic cancer, one of the diseases of the elderly, has dismal prognosis, demanding major surgery with high risk and life quality problems, especially in the elderly. Therefore, treatment selection, whether or not to undergo surgery, preoperative risk assessment, and perioperative management of the elderly are becoming critical issues. Although the elderly are expected to have higher morbidity and mortality and lower long-term survival outcomes, surgery is becoming safer over time. Appropriate surgical indication selection, patient-centered decision-making, adequate prehabilitation and postoperative geriatric care are expected to improve surgical outcomes in the elderly. Surgeons must have the concept of geriatric care, and efforts based on institutional systems and academic societies are required. If well selected and prepared, the same surgical principle as non-elderly patients can be applied to elderly patients. In this paper, the surgical treatment of elderly patients with pancreatic cancer is reviewed.

Surgical outcomes and prognostic factors of distal common bile duct adenocarcinoma: chronological analysis in a single high-volume institutional experience

Background

Distal common bile duct (dCBD) cancer is typical indication for pancreaticoduodenectomy (PD). We aimed to retrospectively evaluate surgical outcomes and investigate prognostic factors of dCBD adenocarcinoma for which PD was performed at a single institution.

Methods

We searched consecutive cases of dCBD adenocarcinoma undergone PD at Samsung Medical Center from 1995 to 2018. Cases with distant metastasis or palliative intent were excluded. The year in which the survival rate was dramatically improved was identified and entire years were divided into two periods for comparison. To balance between the two periods, we conducted propensity score matching (PSM) analysis using age, sex, body mass index (BMI), and American Society of Anesthesiologist score.

Results

Total of 804 cases were enrolled in this study. The entire period was divided into early period of 18 years and recent period of 6 years. The early and late period included 466 and 338 patients, respectively. As a result of PSM, balanced 316 patients were selected from each of the two periods. Significant improvements in surgical outcomes were identified, including shorter operation time, fewer blood loss, shorter hospitalization, and favorable overall survival. As results of multivariable analysis of independent risk factors for overall survival, older age and advanced N stage were identified, as expected. It was distinct that aggressive surgery and advanced tumor state in the early period and a lower BMI in the late period negatively affected the survival, respectively.

Conclusions

Surgical outcomes of dCBD cancer underwent PD was improved. There were few modifiable factors to improve survival and continuous further study is needed to detect dCBD cancer in the early stages.

Preoperative measures predicting outcome after pancreatic resection in aged patients

BACKGROUND AND OBJECTIVE

High-risk surgery on aged patients raises challenging ethical and clinical issues. The aim of this study was to analyze the preoperative factors associated with severe complications and returning home after pancreatic resection among patients aged ⩾ 75 years.

PATIENTS AND METHODS

Patients aged ⩾ 75 years undergoing pancreatic resection in 2012-2019 were retrospectively searched from the hospital database. Preoperative indices (Clinical Frailty Scale, Skeletal Muscle Index, Geriatric Nutritional Risk Index, Charlson Comorbidity Index, and National Surgical Quality Improvement Program risk for severe complications) were determined. Postoperative outcome was evaluated by incidence of Clavien-Dindo 3b-5 complications, rate of returning home, and 1-year survival.

RESULTS

A total of 95 patients were included. American Society of Anesthesiologists Class 3-4 covered 50%, Clinical Frailty Scale > 3 22%, Charlson Comorbidity Index > 6 53%, and a sarcopenic Skeletal Muscle Index 51% of these patients. The National Surgical Quality Improvement Program risk for severe complications was higher than average among 21% of patients. Geriatric Nutritional Risk Index showed high risk among 3% of them. In total, 19 patients (20%) experienced a severe (Clavien-Dindo 3b-5) complication. However, 30- and 90-day mortality was 2.1%. Preoperative indices were not associated with severe complications. Most patients (79%) had returned home within 8 weeks of surgery. Not returning home was associated with severe complications (p = 0.010).

CONCLUSIONS

The short-term outcome after pancreatic resection of fit older patients is similar to that of younger, unselected patient groups. In these selected patients, the commonly used preoperative indexes were not associated with severe complications or returning home.

Microscopic transduodenal excision of an ampullary adenoma: A case report and review of the literature

BACKGROUND

Transduodenal local excision is an alternative treatment approach for benign ampullary tumors. However, this procedure has technical difficulties, especially during reconstruction of the pancreaticobiliary ducts. An operating microscope has been widely used by surgeons for delicate surgery due to its major advantages of magnification, illumination, and stereoscopic view. The application of an operating microscope in transduodenal excision of ampullary tumors has not been reported.

CASE SUMMARY

A 55-year-old woman was admitted for investigation of recurrent upper abdominal pain. Physical examination and laboratory tests found no abnormalities. Imaging identified a large mass in the descending part of the duodenum. Esophagogastroduodenoscopy revealed a 3.5-cm-sized villous growth over the major duodenal papilla. Pathology of the endoscopic biopsy indicated a villous adenoma with low-grade dysplasia. Microscopic transduodenal excision of the ampullary tumor was performed. The final pathological diagnosis was villous-tubular adenoma with low-grade dysplasia. The patient was discharged on postoperative day 12 after an uneventful recovery. Endoscopic retrograde cholangiopancreatography was performed 3 mo postoperatively and showed no bile duct or pancreatic duct strictures and no tumor recurrence. The patient is continuing follow-up at our clinic and remains well.

CONCLUSION

Operating microscope-assisted transduodenal local excision is a feasible and effective option for benign ampullary tumors.

Peri-operative, long-term, and quality of life outcomes after pancreaticoduodenectomy in the elderly: greater justification for periampullary cancer compared to pancreatic head cancer

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.

Can we recommend surgical treatment to the octogenarian with periampullary cancer?: National database analysis in South Korea

BACKGROUND

The incidence of periampullary cancer in the elderly is increasing. Safety and oncologic effectiveness of pancreaticoduodenectomy in elderly patients is still controversial.

MATERIALS AND METHODS

From 2002 to 2016, patients with periampullary cancer were evaluated. Customised health information data provided by the National Health Insurance Corporation (NHIS-2018-1-157) were used for analysis. Chronological changes in the incidence of periampullary cancer and long-term survival outcomes were estimated according to patients' age.

RESULT

A total of 148,080 patients were found to have periampullary cancer. Chronologically, the incidence of periampullary cancer increased, and the proportion of elderly patients with periampullary cancer prominently increased (about 2.1 times in patients in their 70s and about 4.7 times in those older than 80 years). The number of patients with pylorus-preserving pancreaticoduodenectomy in their 70s (about 5.6 times, p < 0.001) and over 80 years of age (about 8.9 times, p < 0.001) was much higher than the number of patients aged younger than 50 years (about 1.7 times) and in their 60s (about 2.5 times). Long-term survival was different as per diagnosis (p < 0.001). In addition, it was observed that age was a factor attenuating the survival of patients with resected periampullary cancers (p < 0.001). However, in case of patients older than 80 years, those who underwent surgical treatment showed a higher survival rate than those who did not undergo surgical treatment.

CONCLUSION

We can recommend surgical treatment for elderly patients with resectable periampullary cancer. The survival data in this study can be useful references especially in making treatment plan for octogenarians diagnosed with periampullary cancer.

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

Objective

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

Summary Background Data

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

Methods

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

Results

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

Conclusions

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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