Do not Deny Pancreatic Resection to Elderly Patients

Introduction  Radical resection is the only potential cure for pancreatic malignancies and a useful treatment for other benign diseases, such as pancreatitis. Over the last two decades, medical and surgical improvements have drastically changed the postoperative outcome of elderly patients undergoing pancreatic resection, and appropriate treatment for elderly potential candidates for pancreatic resection has become an important issue. Materials and Methods  Ninety-eight consecutive patients undergoing radical pancreatic resection between 2003 and 2006 at the Surgery Unit of the University of Modena, Italy, were considered and divided into two age groups, i.e., over 75-year-olds (group 1, 23 patients) and under 75-year-olds (group 2, 75 patients). The two groups were compared as regards demographic features, American Society of Anesthesiologists scores, comorbidities, previous major surgery, surgical procedure, postoperative mortality, and morbidity. Results  There were no significant differences between the two groups concerning postoperative mortality, and the duration of hospital stay and days in the postoperative intensive care unit were also similar. Complications such as pancreatic fistulas, wound infections, and pneumonia were more frequent in the older group, but the differences were not statistically significant. The overall median survival was 29.4 months and did not differ significantly between the two groups when calculated using the log-rank test (p = 0.961). Discussion  In the light of these findings and as reported for other series, old age is probably not directly related with any increase in the rate of postoperative complications, but comorbidities (which are naturally related to the patients’ previous life) may have a key role in the postoperative course.     

Prognostic Factors in Periampullary and Pancreatic Tumor Resection in Elderly Patients

Background More than half of all patients with pancreatic adenocarcinoma are over 70 years of age. Life expectancy for the elderly population is increasing and currently major pancreatic resection provides the only meaningful chance of cure for periampullary and pancreatic tumors. Controversy over what constitutes the correct treatment of these tumors in elderly patients continues to this day. The aim of our study was to determine whether age alone or age plus some prognostic factors constitute contraindications to major pancreatic resections. Methods Between 2000 and 2005, data from 88 consecutive patients who had major pancreatic resection for periampullary or pancreatic tumors were entered into a prospective database. Fifty-three patients under 70 years of age (young patients), and 35 patients 70 years of age or older (elderly patients) were compared with respect to several characteristics and the postoperative course. Results Postoperative mortality and morbidity, length of hospital stay, and long-term survival were similar in the two groups. In the elderly group, the mortality rate was significantly higher in patients with chronic obstructive pulmonary disease (COPD), and the morbidity rate was significantly higher in patients with ASA 3 than in patients with ASA 1–2, in whom a pancreaticoduodenectomy or total pancreatectomy had been performed. Conclusions Age alone is not a contraindication for major pancreatic resection. In elderly patients a careful evaluation of the co-morbidities and of the type of surgical procedure is mandatory in order to allow the proper selection of those patients best suited for surgery in specialized centers.     

Liver and Pancreatic Resection in the Elderly

Background: Liver resection, or pancreaticoduodenectomy, has traditionally been thought to have a high morbidity and. mortality rate among the elderly. Recent improvements in surgical and anesthetic techniques, an increasing number of elderly patients, and an increasing need to justify use of limited health care resources prompted an assessment of recent surgical outcomes.Methods: Five hundred seventy-seven liver resections (July 1985–July 1994) performed for metastatic colorectal cancer and 488 pancreatic resections (October 1983–July 1994) performed for pancreatic malignancies were identified in departmental data bases. Outcomes of patients younger than age 70 years were compared with those of patients age 70 years or older.Results: Liver resection for 128 patients age 70 years or older resulted in a 4% perioperative. mortality rate and a 42% complication rate. Median hospital stay was 13 days, and 8% of the patients required admission to the intensive care unit (ICU). Median survival was 40 months, and the 5-year survival rate was 35%. No difference were found between results for the elderly and those for younger patients who had undergone liver resection, except for a minimally shorter hospital stay fortheyoungerpatients (median, 12 days vs. 13 days p=0.003). Pancreatic resection for 138 elderly patients resulted in a mortality rate of 6% and a complication rate of 45%. Median stay was 20 days, and 19% of the patients required ICU admission, results identical to those for the younger cohort. Long-term survival was poorer for the elderly patients, with a 5-year survival rate of 21% compared with 29% for the younger cohort (p=0.03).Conclusions: Major liver or pancreatic resections can be performed for the elderly with acceptable morbidity and mortality rates and possible long-term survival. Chronologic age alone is not a contraindication to liver or pancreatic resection for malignancy.     

腹腔镜结直肠癌切除术在老年病人中的应用

目的探讨老年病人施行腹腔镜结直肠癌切除术的可行性和安全性。方法2003年3月。2006年8月，我院共为142例70岁以上的老年病人施行结直肠癌根治切除术，其中腹腔镜手术75例，开腹手术67例，对两组临床疗效和并发症进行回顾性对比分析。结果腹腔镜组中转开腹手术4例，中转开腹率5．3％。腹腔镜组手术时间长于开腹组[（221．5±36．2）min vs（188．1±55．1）min，t=4．311，P=0．000]。两组均无切缘阳性病例，切除淋巴结数差异无显著性。腹腔镜组术后总的并发症发生率为5．3％（4／75），无围手术期死亡；而开腹组为25．4％（17／67），明显高于腹腔镜组（x^2=11．277，P=0．001），其中7例为较严重的心肺并发症，因肺炎死亡1例。两组术后住院时间和总费用差异无统计学意义（P〉0．05）。结论腹腔镜结直肠癌切除术应用于老年病人安全可行，可以降低并发症发生率。     

Surveillance of Pancreatic Cancer Patients after Surgical Resection

Background  

There are no clear recommendations to guide posttreatment surveillance in patients with pancreatic cancer. Our goal was to describe the posttreatment surveillance patterns in patients undergoing curative-intent resection for pancreatic cancer.     

Fast-Track Management of Patients Undergoing Proximal Pancreatic Resection

INTRODUCTION

To avoid the risk of complications of biliary drainage, a feasibility study was carried out to determine whether it might be possible to fast-track surgical treatment, with resection before biliary drainage, in jaundiced patients with proximal pancreatic/peri-ampullary malignancy.

PATIENTS AND METHODS

Over an 18-month period, based on their presenting bilirubin levels and other logistical factors, all jaundiced patients who might be suitable for fast-track management were identified. Data on complications and hospital stay were compared with those patients in whom a conventional pathway (with biliary drainage) was used during the same time period. Data were also compared with a group of patients from the preceding 6 months.

RESULTS

Nine patients were fast-tracked and 49 patients treated in the conventional pathway. Fast-track patients mean (SD) serum bilirubin level was 265 μmol/l (81.6) at the time of the operation compared to 43 μmol/l (51.3; P ≥ 0.0001) in conventional patients. Mean (SD) of time from referral to operation, 14 days (9) versus 59 days (36.9), was significantly shorter in fast-track patients than conventional patients (P ≤ 0.0001). Length of hospital stay mean (SD) at 17 (6) days versus 22 days (19.6; P = 0.2114), surgical complications and mortality in fast-track patients were similar to conventional patients. Prior to surgery, the 49 conventional patients underwent a total of 73 biliary drainage procedures resulting in seven major complications. Comparison with the group of patients from the previous 6 months indicated that the conventional group were not disadvantaged.

CONCLUSIONS

Fast-track management by resection without biliary drainage of selected patients with distal biliary strictures is safe and has the potential to reduce the waiting time to surgery, overall numbers of biliary drainage procedures and the complications thereof.     

Liver Resection of Colorectal Liver Metastases in Elderly Patients

Background  

The percentage of elderly patients with colorectal liver metastases (CLM) has increased. Liver resection remains the only curative therapy; data evaluating the outcome in this age group is limited. Aim of the present study was to determine if postoperative morbidity, mortality, and other independent predictors influence survival in patients ≥70 years undergoing liver resection for CLM.     

Patterns of Pancreatic Resection Differ Between Patients with Familial and Sporadic Pancreatic Cancer

Background

Although the increased risk of developing pancreatic cancer (PC) in families with a strong history of the disease is well known, characteristics and outcomes of patients with familial PC is not described well.

Aims

This study aims to evaluate outcomes following resection in patients with familial PC.

Methods

We studied 208 patients who underwent resection of PC from 2000 to 2007 and had prospectively completed family history questionnaires for the Biospecimen Resource for Pancreas Research at our institution. We compared clinical characteristics and outcomes of familial and sporadic PC patients.

Results

Familial (N?=?15) and sporadic PC patients (N?=?193) did not have significantly different demographics, pre-operative CA19-9, pre-operative weight loss, R0 status, or T-staging (all p??? 0.05). Familial PC patients had lower pre-operative total serum bilirubin concentrations (p?=?0.03) and lesions outside of the pancreatic head more frequently (p?=?0.02) than sporadic PC patients. There was no difference in survival at 2?years between familial and sporadic PC patients (p?=?0.52).

Conclusions

Familial PC patients appear to develop tumors outside of the pancreatic head more frequently than sporadic PC patients. This difference in tumor distribution may be due to a broader area of cancer susceptibility within the pancreas for familial PC patients.     

高龄进展期直肠癌的外科治疗

目的：探讨高龄进展期直肠癌患者的外科治疗。方法：回顾性分析1996年1月至2003年6月收治的52例70岁以上进展期直肠癌患者的外科治疗资料。结果：52例患者全部经手术治疗．并在围手术期加强对并存病的处理，术后出现粘连性肠梗阻1例，伤口裂开1例，伤口感染4例，2例因并存病导致术后死亡。结论：高龄进展期直肠癌并存病多，手术风险大．但手术仍然是最好的治疗方法，在围手术期加强对并存病的处理，也对提高手术成功率．降低死亡率和并发症的发生率有积极的意义。     

Outcome of Elderly Patients Undergoing Awake-Craniotomy for Tumor Resection

Background

Awake-craniotomy allows maximal tumor resection, which has been associated with extended survival. The feasibility and safety of awake-craniotomy and the effect of extent of resection on survival in the elderly population has not been established. The aim of this study was to compare surgical outcome of elderly patients undergoing awake-craniotomy to that of younger patients.

Methods

Outcomes of consecutive patients younger and older than 65 years who underwent awake-craniotomy at a single institution between 2003 and 2010 were retrospectively reviewed. The groups were compared for clinical variables and surgical outcome parameters, as well as overall survival.

Results

A total of 334 young (45.4 ± 13.2 years, mean ± SD) and 90 elderly (71.7 ± 5.1 years) patients were studied. Distribution of gender, mannitol treatment, hemodynamic stability, and extent of tumor resection were similar. Significantly more younger patients had a better preoperative Karnofsky Performance Scale score (>70) than elderly patients (P = 0.0012). Older patients harbored significantly more high-grade gliomas (HGG) and brain metastases, and fewer low-grade gliomas (P < 0.0001). No significantly higher rate of mortality, or complications were observed in the elderly group. Age was associated with increased length of stay (4.9 ± 6.3 vs. 6.6 ± 7.5 days, P = 0.01). Maximal extent of tumor resection in patients with HGG was associated with prolonged survival in the elderly patients.

Conclusions

Awake-craniotomy is a well-tolerated and safe procedure, even in elderly patients. Gross total tumor resection in elderly patients with HGG was associated with prolonged survival. The data suggest that favorable prognostic factors for patients with malignant brain tumors are also valid in elderly patients.     

Vascular Resection in Pancreatic Cancer

Pancreatic ductal adenocarcinoma (PDAC) is one of the most aggressive malignant tumors and represents the fifth most common cause of cancer-related deaths. It is associated with a poor prognosis, likely due to the tendency of the tumor for early local and distant spread. One of the major obstacles of effectively treating PDAC is the often late diagnosis. Among all options currently available for PDAC, surgical resection offers the only potential cure with 5-year survival rate of approximately 15–20 %. However, in the absence of metastatic disease, which precludes resection, assessment of vascular invasion is an important parameter for determining resectability for pancreatic cancer. The vascular involvement in patients with pancreatic carcinoma ranges between 21 and 64 %. Historically, vascular involvement has been considered a contraindication to resective cure. Meanwhile, the surgical approach of pancreatoduodenectomy (PD) combined with vascular resection and reconstruction has been widely applied in clinical practice to remove the tumor completely. Therefore, vascular invasion is no longer a surgical contraindication and the rate of surgical resection has greatly increased. Moreover, PD combined with vascular resection can account for 20 to 25 % of the total cases of PD surgery in a number of the larger pancreas treatment centers. The aim of this review is to provide an overview of management and outcome of vascular resection in PDAC surgery.     

Long-term Follow-up After Organ-Preserving Pancreatic Head Resection in Patients with Chronic Pancreatitis

In chronic pancreatitis (CP), enlargement of the pancreatic head develops as a result of inflammatory alterations. This report relates to the results attained with an organ-preserving pancreatic head resection (OPPHR) in 135 patients in a 7-year period. The surgical procedure consists of a wide excision of the inflammatory tumor in the region of the pancreatic head, without division and cutting of the pancreas over the portal vein. Reconstruction, with drainage of the secretion from the remaining pancreas into the intestinal tract, takes place through a jejunal Roux-en-Y loop. Only one reoperation was required in consequence to anastomosis bleeding, but no mortality occurred in the postoperative period. The duration of hospitalization ranged between 7 and 12 days. The mean follow-up period was 4.1 years (range, 0.5–7.0). The late mortality rate was 3.7%. The quality of life, measured during the follow-up by using EORTC Quality-of-Life Questionnaire, improved in 89% of the patients. One hundred sixteen patients became complaint-free, while 14 patients had moderate symptoms; the weight increased by a median of 11.3 kg (range, 4–28). The 7-year experience clearly reveals that this OPPHR technique is a safe and effective procedure for definitive control of the complications of CP. Presented at the American Hepato Pancreato Biliary Association Congress, April 19-22, 2007, Las Vegas, Nevada, U.S.A.     

Hepatic Resection is Justified for Elderly Patients with Hepatocellular Carcinoma

BACKGROUND: Hepatic resection is one of the main treatment modalities for patients with hepatocellular carcinoma (HCC); however, surgery is generally stressful and often is avoided for elderly patients. This retrospective study was designed to determine whether the indications for hepatic resection in younger patients with HCC are applicable to elderly patients. METHODS: Subjects were 294 patients in whom 319 hepatic resections were performed for HCC (male/female ratio, 238/81; age range, 18-83 years). The patients were divided into two groups according to age at the time of surgery: 70 years or older (n = 109) and 69 years or younger (n = 210). Surgical strategy and postoperative follow-up methods did not differ between groups. The incidence and severity of postoperative complications classified by the Clavien system were compared between the two groups. Postoperative survival was compared between the two groups and between subgroups based on Japan Integrated Staging (JIS) scores. HCC-related death rates also were compared. RESULTS: No significant between-group difference was found in background liver function or type of hepatic resection. Differences were found in performance status and type of hepatitis virus infection. No difference was observed in the incidence or severity of postoperative complications. Postoperative survival was similar between the two age-based study groups and between the JIS-based subgroups. HCC-related death rates did not differ between groups. CONCLUSIONS: The absence of differences in postoperative outcomes between groups suggests that hepatic resection is justified for HCC in selected patients aged 70 years or older.     

The Relationship Between Age and Chronic Kidney Disease in Patients Undergoing Pancreatic Resection

Background

Severe chronic kidney disease (CKD) predicts adverse outcomes in patients undergoing pancreatectomy, but the impact of milder CKD is unknown. Additionally, some authors have suggested that, due to physiologic changes of aging, CKD is over-diagnosed in patients above age 65.

Methods

Patients undergoing pancreatectomy for malignancy from 2005 to 2014 were identified from the National Surgical Quality Improvement Program. Primary outcomes were all-cause mortality and major complication, defined as myocardial infarction, cardiac arrest, stroke, venous thromboembolism, respiratory failure, deep surgical site infection, pneumonia, acute kidney injury, coma >?24 h, or re-operation occurring within 30 days of surgery.

Results

The mean age of 16,173 participants was 66 (range 18–90). Median preoperative creatinine was 0.80 mg/dL (0.10–11.0), and median preoperative eGFR was 86.36 mL/min/1.73m² (2.98–182.2). Mortality and major complication occurred in 3 and 23% of patients, respectively. In adjusted analyses, CKD stages 2 (adjusted odds ratio (aOR) 1.24, 95% confidence interval (CI) 1.10–1.40), 3a (aOR 1.50, 95% CI 1.24–1.82), 3b (aOR 1.56, 95% CI 1.19–2.06), and 4 (aOR 2.17, 95% CI 1.25–3.76) were associated with increased major complication, and CKD stage 4 was associated with increased mortality (aOR 2.68, 95% CI 1.10–6.56). Age did not influence the relationship between CKD and either outcome.

Conclusion

CKD of any stage was associated with an increased risk of postoperative major complication, and severe CKD was associated with increased mortality among patients undergoing pancreatectomy for malignancy. These associations were not diminished in elderly patients. Our findings could inform preoperative counseling and decision-making.

     

Resolution of New-Onset Diabetes After Radical Pancreatic Resection Predicts Long-term Survival in Patients with Pancreatic Ductal Cell Adenocarcinoma

Purpose

To demonstrate the effect of diabetes mellitus (DM) (stratified by long-term/new-onset presurgical diabetes, resolved/unresolved postsurgical diabetes) on prognosis for pancreatic ductal cell adenocarcinoma (PDAC) after radical resection.

Methods

One hundred ninety-nine patients who underwent radical resection for PDAC between 2007 and 2011 at Ruijin Hospital (Shanghai, China) were retrospectively analyzed. Clinical and pathologic characteristics, surgical and adjuvant chemotherapy related outcomes, disease-free survival (DFS), and postoperative survival were compared among patients with long-term (≥2 years)/new-onset (<2 years) presurgical diabetes and resolved/unresolved postsurgical diabetes. Univariate and multivariable analysis was performed to determine factors associated with DFS and overall survival (OS).

Results

Of 199 patients, 90 (44.7 %) had DM, 64 of which were new onset and 26 of which were long-standing. Resolution of DM after radical pancreatic resection was observed in 65 % (42 of 64) in the new-onset group, but in none of the long-standing group. Resolved new-onset DM patients had larger, well-differentiated tumors compared to patients with unresolved new-onset DM. Patients with long-standing DM had shorter postoperative DFS and OS than nondiabetic/new-onset DM, whereas postoperative resolved new-onset DM is associated with longer DFS and OS than unresolved DM. Morbidity was higher and postoperative hospital stay was longer in patients with new-onset DM compared with patients with long-standing DM and patients without DM. There was no difference in the adjuvant chemotherapy toxicity rate among patients with long-standing or new-onset DM and those without DM.

Conclusions

Different status of DM has different effects on outcome after resection for PDAC. Long-standing DM is related to progression of disease, whereas postsurgical resolved new-onset DM is a favorable prognostic factor.     

Hepatic Resection in the Elderly

p = 0.02) and for primary neoplasia of the liver ( p = 0.002) but not for metastatic disease to the liver. This reflects the high rate of cirrhosis in hepatocellular and cholangiocellular carcinoma (88%) and gallbladder cancer (37.5%). Both pre- and postoperative severe liver dysfunction had a significantly higher risk for postoperative mortality and morbidity, which showed an incremental risk with age. Another organ system able to predict outcome at the beginning of treatment by its moderate severe dysfunction were the lungs. Overall, only right and extended right lobectomies carried a significantly higher risk for postoperative mortality and morbidity. Postoperative complications were recorded in 43% of our patients, with infection the most frequent problem in nearly all of these patients (95%). Pneumonia was the leading complication associated patient survival. All patients who developed pneumonia as a late complication during a complicated postoperative course died postoperatively. The postoperative Goris score of the patients who died was 6.9 ± 2.9 (range 3–11), whereas the surviving patients’ score averaged 2.2 ± 1.9 (range 0–9), which was significantly different ( p = 0.0003). None of the 54 patients with a GORIS score ≤ 2 died postoperatively, whereas 5 of 6 patients with a score ≥ 9 died ( p = 0.0001). Severe liver dysfunction rather than the extent of resection influences clinical mortality. Patients > 80 years of age with a preoperative severe liver dysfunction showed a postoperative mortality of 57%, and all of these patients developed postoperative complications. Therefore resection cannot be recommended for those patients. Cirrhosis led to an unacceptable mortality of 44% after hepatic resection of ≥ 5 liver segments for primary neoplasia of the liver. Major resections cannot be recommended in the aged with gallbladder cancer because 50% of the patients died after such operations. Overall, only resection of ≥ 5 liver segments with segments I to III or less remaining were found to pose a major risk for clinical mortality and morbidity, but the cause of death was preexisting liver dysfunction and cirrhosis in all of these patients. Major resections of large neoplasia of the liver can be recommended even in the aged, but a preoperative preselection of patients with respect to liver function and pulmonary function preoperatively may help lower the postoperative morbidity and mortality, especially in patients who will undergo resection of ≥ 5 liver segments. Major hepatic resection for metastatic disease to the liver in the elderly carries no additional survival risk. Patients > 65 years of age and especially those > 80 years of age are more liable to succumb to postoperative organ failure and complications, especially infections.     

Pancreatic Resection for M1 Pancreatic Ductal Adenocarcinoma

Background Improved safety of pancreatic surgery has led to consideration of more aggressive approaches, such as resection for primary pancreatic ductal adenocarcinoma (PDAC) with metastatic disease (M1). Methods A total of 29 patients who underwent pancreatic resection with resection of associated metastatic disease (interaortocaval lymph node dissection, liver resection, and/or multiorgan resections) were retrospectively identified from a database of 316 R0/R1 pancreatic resections for PDAC. An explorative data analysis of perioperative and clinicopathological parameters, and overall survival was performed by Kaplan-Meier estimation, log rank test, and Fisher’s exact test. Results The overall in-hospital mortality and morbidity of R0/R1 pancreatic resections for M1 disease (n = 29) was 0% and 24.1%, compared with 4.2% and 35.2% of R0/R1 pancreatic resections for M0 disease (n = 287). The median overall survival time was 13.8 months (95% confidence interval [CI], 11.4–20.5), and the estimated 1-year overall survival rate was 58.9% (95% CI, 34.8–76.7) for patients with M1 disease. The median survival in those with metastatic interaortocaval lymph nodes was 27 months (95% CI, 9.6–27.0), whereas it was 11.4 months (95% CI, 7.8–16.5) and 12.9 months (95% CI, 7.2–20.5) for those with liver and peritoneal metastases, respectively. Conclusions Pancreatic resections with M1 disease can be performed with acceptable safety in highly selected patients. The survival after interaortocaval lymph node resection is comparable to that of other lymph nodes that do not constitute M1 disease. Resection of liver and peritoneal metastases, although safe in this series, cannot be generally recommended until further controlled trials can be conducted. S.V.S. and J.K. contributed equally to this article.