Postoperative outcomes in elderly patients undergoing pancreatic resection for pancreatic adenocarcinoma: A systematic review and meta-analysis

Geriatric Assessment and Management, Prehabilitation and Rehabilitation for Older Aldults with Non-Colorectal Digestive Cancers

BACKGROUND

The incidence of cancer in older patients is high, reaching 2.3 million world-wide in 2018 for patients aged over 80. Because the characteristics of this population make therapeutic choices difficult, co-management between geriatricians and other cancer specialists has gradually become essential.

METHODS

This narrative review aims to synthesize current data on the contribution of geriatric assessment in the management of elderly patients with non-colorectal digestive cancers. Oncogeriatric assessment is multi-domain, including the evaluation of co-morbidities, autonomy, nutrition, cognition, mood, and functional assessment.

RESULTS

Oncogeriatric parameters are predictive of mortality and adverse events. In the peri-operative phase of non-colorectal digestive cancer surgical management, geriatric management can assist in the decision-making process, identify frailties, and arrange a specific and personalized trimodal preoperative rehabilitation program, including nutritional management, adapted physical activity, and psychological care. Its aim is to limit the risks of confusion and of decompensation of comorbidities, mainly cardio-respiratory, which is associated with the highest morbidity in biliary-pancreatic surgery for older adults, facilitate recovery of previous autonomy when possible, and shorten hospital stay. For metastatic cancers, or during multimodal management, such as peri-operative chemotherapy for localized gastric cancers or pre-operative radio-chemotherapy for oesophageal or rectal cancers, specific assessment of the tolerance of chemotherapy is necessary. Neuropathic toxicity and chemobrain have a greater impact on elderly patients, with an increased loss of autonomy. Joint geriatric management can reduce the rate of grade 3-5 adverse effects of chemotherapy in particular and improve quality of life.

CONCLUSIONS

Co-management between geriatricians and other specialties should be encouraged wherever possible.

Pancreatic cancer resection in the elderly: state of the art, and future challenges. A systematic review

INTRODUCTION

Pancreatic cancer resection in the elderly population represents a challenging problem. In addition, a chronological age for the "elderly" is lacking. The aim of the present review was to assess the safety and feasibility of major pancreatic tumor resection in elderly patients, considering different age cut-offs (≥70; ≥75 and ≥80 years old).

EVIDENCE ACQUISITION

A search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, on the PubMmed/MEDLINE database. The population analyzed included elderly patients undergoing pancreatic resection for pancreatic cancer as compared with younger patients to evaluate morbidity, mortality, clinically relevant postoperative pancreatic fistula, delayed gastric emptying, post-pancreatectomy hemorrhage, length of stay, overall survival, and disease-free survival.

EVIDENCE SYNTHESIS

The results of each study were reported using Risk Ratio (RR), Odds Ratio (OR) or Mean Difference and their P value. Twenty-four studies were included in the review for a total of 33,896 cases of which 25,937 (76.5%) were young people and 7378 (23.5%) were elderly people. The elderly age cut-off was mainly defined as ≥70 years old. Regarding the age cut-off ≥70 years old, the results comparing elderly patients (≥70 years) and younger patients (<70 years) were similar; for the age cut-offs ≥75 and ≥80 years old. Higher mortality and morbidity rates were found in the studies due to the fact that patients ≥75 and ≥80 years or older more frequently had major comorbidities than the younger patients.

CONCLUSIONS

This review showed that 1) elderly age cut-off has to be considered as ≥ 70 years old, and 2) age alone is not a contraindication for pancreatic cancer resection. However, elderly patients were frailer and more vulnerable than younger patients, and therefore required a careful preoperative assessment.

Neoadjuvant Treatment in Localized Pancreatic Cancer of the Elderly: A Systematic Review of the Current Literature

Background/Objectives: Neoadjuvant therapy (NAT) improves surgical outcomes in pancreatic cancer, but its role in elderly patients remains unclear. Due to comorbidities and lower chemotherapy tolerance, assessing NAT's benefits and risks in this population is essential. This systematic review assesses the impact of NAT on overall survival (OS), surgical resection rates, and treatment-related toxicities(G3-4) in elderly patients with resectable, borderline, or locally advanced pancreatic cancer. Methods: A systematic search was conducted in PubMed, MEDLINE, EMBASE, Scopus, and Cochrane databases according to PRISMA guidelines. Studies reporting that NAT outcomes in elderly patients (≥70 years) were included. The Newcastle-Ottawa scale was used to assess study quality. Subgroup analyses compared NAT versus upfront surgery and outcomes in elderly versus younger patients. Results: Twelve studies (four prospective and eight retrospective) including 11,385 patients met the inclusion criteria. Among 9580 elderly patients, only 24% underwent NAT. NAT significantly improved R0 resection rates compared to upfront surgery (p < 0.001), and elderly patients receiving NAT had a median OS of 26.5 (range 15.7-39.1) months versus 20.3 months (range 11.5-23.8) of upfront surgery and versus 36.2 months (range 23.6-43.0) of NAT in young patients. Elderly patients experienced higher rates of major toxicities (17-57.5%). Personalized regimens, such as gemcitabine/nab-paclitaxel, were better tolerated than FOLFIRINOX. Conclusions: NAT is associated with improved survival and surgical outcomes in elderly pancreatic cancer patients, despite a higher risk of adverse events. Patient selection based on performance status rather than age alone is essential to optimize treatment benefits. Further prospective trials are needed to refine treatment approaches in this population.

Textbook outcome following pancreaticoduodenectomy in elderly patients: age-stratified analysis and predictive factors

Despite advancements in pancreatic surgery, managing elderly patients undergoing pancreaticoduodenectomy (PD) remains challenging. Textbook Outcome (TO) serves as a benchmark for surgical success, but its relevance in elderly patients has not been well explored. This study aims to evaluate TO in elderly patients undergoing PD and identify predictors of TO failure. A retrospective analysis was conducted on elderly patients (≥ 70 years) who underwent PD between January 1, 2017, and December 31, 2023 in two international HPB centers. TO achievement rates were assessed and stratified by age groups (70-74, 75-79, ≥ 80). Uni- and multivariate logistic regression analyses were performed to identify risk factors for TO failure. Of 222 patients, 54.5% achieved TO after PD. TO rates decreased with age, with only 35.0% of octogenarians achieving TO, compared to 57.1% in those aged 70-74. Multivariate analysis revealed that age ≥ 80, an ASA score ≥ 2, and histopathologic types other than pancreatic ductal adenocarcinoma or distal cholangiocarcinoma were significant risk factors for failing to achieve TO. Nearly half of elderly patients achieved TO, with a lower likelihood in older age groups, particularly among octogenarians. Higher ASA scores were also associated with lower TO achievement. These findings underscore the importance of a comprehensive preoperative assessment, considering age, to optimize surgical outcomes in elderly patients undergoing PD.

Pancreaticoduodenectomy in patients < 75 years versus ≥ 75 years old: a comparative study

OBJECTIVE

This study aimed to compare the postoperative outcomes of < 75-year-old patients and ≥ 75-year-old patients who underwent pancreaticoduodenectomy (PD) for pancreatic head and periampullary region tumors.

METHODS

Patients who underwent PD in our hospital between February 2019 and December 2023 were evaluated. Demographics, Eastern Cooperative Oncology Group Performance Status (ECOG-PS) scores, American Society of Anesthesiologists (ASA) scores, comorbidities, hospital stays, complications, and clinicopathological features were analyzed. Patients were divided into < 75 years (Group A) and ≥ 75 years (Group B) groups and compared.

RESULTS

The median age of the entire cohort (n = 155) was 66 years (IQR = 16). There was a significant difference between Group A (n = 128) and Group B (n = 27) regarding the ECOG-PS and ASA scores. There was no significant difference between the groups regarding postoperative complications. The 30-day mortality rate was greater in Group B (p = 0.017). Group B had a cumulative median survival of 10 months, whereas Group A had a median survival of 28 months, with a statistically significant difference (p < 0.001). When age groups were stratified according to ECOG-PS, for ECOG-PS 2-3 Group A, survival was 15 months; for ECOG-PS 2-3 Group B, survival was eight months, and the difference was not statistically significant (p = 0.628).

CONCLUSIONS

With the increasing aging population, patient selection for PD should not be based solely on age. This study demonstrated that PD is safe for patients older than 75 years. In older patients, performance status and the optimization of comorbidities should be considered when deciding on a candidate's suitability for surgery.

Minimally Invasive Pancreaticoduodenectomy in Elderly versus Younger Patients: A Meta-Analysis

(1) Background: With ageing, the number of pancreaticoduodenectomies (PD) for benign or malignant disease is expected to increase in elderly patients. However, whether minimally invasive pancreaticoduodenectomy (MIPD) should be performed in the elderly is not clear yet and it is still debated. (2) Materials and Methods: A systematic review and meta-analysis was conducted including seven published articles comparing the technical and post-operative outcomes of MIPD in elderly versus younger patients up to December 2022. (3) Results: In total, 1378 patients were included in the meta-analysis. In term of overall and Clavien-Dindo I/II complication rates, post-operative pancreatic fistula (POPF) grade > A rates and biliary leakage, abdominal collection, post-operative bleeding and delayed gastric emptying rates, no differences emerged between the two groups. However, this study showed slightly higher intraoperative blood loss [MD 43.41, (95%CI 14.45, 72.38) p = 0.003], Clavien-Dindo ≥ III complication rates [OR 1.87, (95%CI 1.13, 3.11) p = 0.02] and mortality rates [OR 2.61, (95%CI 1.20, 5.68) p = 0.02] in the elderly compared with the younger group. Interestingly, as a minor endpoint, no differences in terms of the mean number of harvested lymphnode and of R0 resection rates were found. (4) Conclusion: MIPD seems to be relatively safe; however, there are slightly higher major morbidity, lung complication and mortality rates in elderly patients, who potentially represent the individuals that may benefit the most from the minimally invasive approach.

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.

Cephalic pancreatoduodenectomy in octogenarian patients with pancreatic tumors

INTRODUCTION

Current literature supports the claim that performing a cephalic pancreaticoduodenectomy (CPD) as treatment for pancreatic cancer (PC) is associated with an increase in median survival, both in octogenarian (≥80 years) patients as well as younger patients.

METHODS

This is a retrospective and comparative trial, comparing results for CPD performed on 30 patients ≥80 years with PC and 159 patients <80 years.

RESULTS

The patients in the octogenarian group showed a significantly higher rate of preoperative cardiovascular morbidity and a more aggressive tumoral behaviour, including more significant preoperative anemia, jaundice and levels of CA 19-9, higher vascular and neural invasion, and a lower rate of R0 resection despite using the same surgical technique. There were no significant differences in terms of postoperative complications. Postoperative mortality was similar in both groups (3.3% in octogenarians vs 3.1% in patients <80 years). Mortality during follow-up was mainly due to tumour recurrence, cardiovascular complications and COVID-19 in 2 elderly patients. Actuarial survival at 1, 3 and 5 years was significantly larger for patients <80 years old, as compared to octogenarians (85.9%, 61.1% and 39.2% versus 72.7%, 28.9% and 9.6%, respectively; P = 0.001). The presence of a pancreatic fistula and not using external Wirsung stenting were significantly associated with 90-day postoperative mortality after a CPD.

CONCLUSIONS

Morbidity and mortality post-CPD is similar in octogenarians and patients younger than 80, although long-term survival is shorter due to more aggressive tumours and comorbidities associated with older age.

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.

Oncological outcomes after pancreatoduodenectomy for pancreatic ductal adenocarcinoma in octogenarians: case-control study

BACKGROUND

By the end of this decade, 70 per cent of all diagnosed pancreatic ductal adenocarcinomas will be in the elderly. Surgical resection is the only curative option. In the elderly perioperative mortality is higher, while controversy still exists as to whether aggressive treatment offers any survival benefit. This study aimed to assess the oncological benefit of pancreatoduodenectomy in octogenarians with pancreatic ductal adenocarcinoma.

METHOD

Retrospective multicentre case-control study of octogenarians and younger controls who underwent pancreatoduodenectomy for pancreatic ductal adenocarcinoma between 2008 and 2017. The primary endpoint was overall survival and the secondary endpoint was disease-free survival.

RESULTS

Overall, 220 patients were included. Although the Charlson co-morbidity index was higher in octogenerians, Eastern Cooperative Oncology Group performance status, ASA and pathological parameters were comparable. Adjuvant therapy was more frequently delivered in the younger group (n = 80, 73 per cent versus n = 58, 53 per cent, P = 0.006). There was no significant difference between octogenarians and controls in overall survival (20 versus 29 months, P = 0.095) or disease-free survival (19 versus 22 months, P = 0.742). On multivariable analysis, age was not an independent predictor of either oncological outcome measured.

CONCLUSION

Octogenarians with pancreatic ductal adenocarcinoma of the head and uncinate process may benefit from comparable oncological outcomes to younger patients with surgical treatment. Due to the age- and disease-related frailty and co-morbidities, careful preoperative assessment and patient selection is of paramount importance.

Are physical performance and frailty assessments useful in targeting and improving access to adjuvant therapy in patients undergoing resection for pancreatic cancer?

BACKGROUND

Many patients fail to receive adjuvant chemotherapy following pancreatic cancer surgery. This study implemented a multimodal, multidisciplinary approach to improving recovery after pancreatoduodenectomy (the 'Fast Recovery' programme) and measured its impact on adjuvant chemotherapy uptake and nutritional decline. The predictive accuracies of a bundle of frailty and physical performance assessments, with respect to the recipient of adjuvant chemotherapy, were also evaluated.

RESULTS

The N = 44 patients treated after the introduction of the 'Fast Recovery' programme were not found to have a significantly higher adjuvant chemotherapy uptake than the N = 409 treated before the pathway change (80.5 vs. 74.3%, p = 0.452), but did have a significantly lower average weight loss at six weeks post-operatively (mean: 4.3 vs. 6.9 kg, p = 0.013). Of the pre-operative frailty and physical performance assessments tested, the 6-min walk test was found to be the strongest predictor of the receipt of adjuvant chemotherapy (area under the ROC curve: 0.91, p = 0.001); all patients achieving distances ≥ 360 m went on to receive adjuvant chemotherapy, compared to 33% of those walking < 360 m.

CONCLUSIONS

The multimodal 'Fast Recovery' programme was not found to significantly improve access to adjuvant chemotherapy, but did appear to have benefits in reducing nutritional decline. Pre-operative assessments were found to be useful in identifying patients at risk of non-receipt of adjuvant therapies, with markers of physical performance appearing to be the best predictors. As such, these markers could be useful in targeting pre- and post-habilitation measures, such as physiotherapy and improved dietetic support.

Short- and Long-Term Outcomes of Pancreatic Cancer Resection in Elderly Patients: A Nationwide Analysis

BACKGROUND

The number of elderly patients with pancreatic cancer is growing, however clinical data on the short-term outcomes, rate of adjuvant chemotherapy, and survival in these patients are limited and we therefore performed a nationwide analysis.

METHODS

Data from the prospective Dutch Pancreatic Cancer Audit were analyzed, including all patients undergoing pancreatic cancer resection between January 2014 and December 2016. Patients were classified into two age groups: <75 and ≥75 years. Major complications (Clavien-Dindo grade 3 or higher), 90-day mortality, rates of adjuvant chemotherapy, and survival were compared between age groups. Factors associated with start of adjuvant chemotherapy and survival were evaluated with logistic regression and multivariable Cox regression analysis.

RESULTS

Of 836 patients, 198 were aged ≥75 years (24%) and 638 were aged <75 years (76%). Median follow-up was 38 months (interquartile range [IQR] 31-47). Major complications (31% vs. 28%; p = 0.43) and 90-day mortality (8% vs. 5%; p = 0.18) did not differ. Adjuvant chemotherapy was started in 37% of patients aged ≥75 years versus 69% of patients aged <75 years (p < 0.001). Median overall survival (OS) was 15 months (95% confidence interval [CI] 14-18) versus 21 months (95% CI 19-24; p < 0.001). Age ≥75 years was not independently associated with OS (hazard ratio 0.96, 95% CI 0.79-1.17; p = 0.71), but was associated with a lower rate of adjuvant chemotherapy (odds ratio 0.27, 95% CI 0.18-0.40; p < 0.001).

CONCLUSIONS

The rate of major complications and 90-day mortality after pancreatic resection did not differ between elderly and younger patients; however, elderly patients were less often treated with adjuvant chemotherapy and their OS was shorter.

Cephalic pancreaticoduodenectomy for ductal adenocarcinoma in the elderly. Can we do it safely?

INTRODUCTION

Surgery and chemotherapy have increased the survival of pancreatic cancer. The decrease in postoperative morbidity and mortality and increase in life expectancy, has expanded the indications por cephalic pancreaticoduodenectomy (PDC), although it remains controversial in the geriatric population.

METHODS

Retrospective study on a prospective database of patients with ductal adenocarcinoma of pancreas who underwent PDC between 2007-2018. The main objective was to analyse the morbidity-mortality and survival associated with PDC in patients ≥75 years (elderly).

RESULTS

79 patients were included, 21 of them older than 75 years (27%); within this group, 23'9% were over 80 years old. The ASA of both groups was similar. Patients ≥75 years required more transfusions. No differences in operating time were observed, although more vascular resection were performed in the elderly (26 vs. 8.7%; P = .037). Morbidity was higher in the elderly (61.9% vs. 46.6%), although without differences. Patients aged ≥75 years had more non-surgical complications (33.3%, P = .050), being pneumonia the most frequent. Postoperative mortality was higher in the ≥75 years (9 vs. 0%; P = .017). The overall survival and disease-free survival did not show significant differences in both groups.

CONCLUSIONS

Elderly patients had higher postoperative mortality and more non-surgical complications. Survival did not show differences, so with an adequate selection of patients, age should not be considered itself as a contraindication for PDC.

Elderly Patients with Nondistant Metastatic Pancreatic Head Adenocarcinoma Cannot Benefit from More Radical Surgery

BACKGROUND

The incidence of pancreatic cancer continues to rise globally, with pancreatic head cancer accounting for nearly 60-70%. Pancreatic head cancer occurs mainly in people over the age of 60, and its morbidity and mortality increase with age. We investigated whether these elderly patients with nondistant metastases would benefit more from expanded pancreaticoduodenectomy (EPD) compared with standard pancreaticoduodenectomy (SPD).

METHODS

3317 elderly patients with pancreatic head cancer from the SEER database were included in the study based on the inclusion and exclusion criteria. These patients were divided into a nonsurgical group and surgical group (including EPD and SPD). Univariate and multivariate Cox proportional hazards models were applied to identify the independent risk factors for cancer-specific survival (CSS). The survival differences between the nonsurgical group and surgical group were compared. Propensity score matching (PSM) methods were applied to balance covariates and reduce the interference of confounding variables. The two groups of patients were matched in a 1 : 1 ratio, and the covariates between the two groups were compared to verify the matching validity. The survival difference in different groups was compared after the matching analysis.

RESULTS

3317 enrolled patients were divided into the surgical group (n = 984) and nonsurgical group (n = 2333). Before PSM, there were significant differences in overall survival (OS) and CSS between the nonsurgical group and surgical group (median OS: 8 months vs. 20 months, P < 0.001; median CSS: 8 months vs. 22 months, P < 0.001). The multivariate CSS Cox regression analysis demonstrated surgery is an independent risk factor. However, no significant differences were founded between the SPD and EPD groups (median OS: 20 months vs. 22 months, P=0.636; median CSS: 22 months vs. 22 months, P=0.270). After PSM, there were also no significant differences in OS and CSS between the SPD and EPD groups (median OS: 23 months vs. 18 months, P=0.415; median CSS: 26 months vs. 18 months, P=0.329).

CONCLUSION

This study uses PSM to evaluate the effects of EPD and SPD for elderly patients with nondistant metastatic pancreatic head adenocarcinoma. It found that surgery is an independent prognostic factor, but expanded surgery has no survival advantage for these patients, whereas SPD provides a better survival advantage than EPD. SPD is a reasonable treatment option for these patients.

LINC00857 regulated by ZNF460 enhances the expression of CLDN12 by sponging miR-150-5p and recruiting SRSF1 for alternative splicing to promote epithelial-mesenchymal transformation of pancreatic adenocarcinoma cells

Recent research unveiled that LINC00857 plays a regulatory role in multiple human cancers, such as lung adenocarcinoma and gastric cancer. Nevertheless, the function of LINC00857 in pancreatic adenocarcinoma (PAAD) remains unclear. This study concentrates on LINC00857 to discuss the relevant molecular mechanism of this gene in PAAD. Quantitative reverse transcription polymerase chain reaction (RT-qPCR) and western blot were implemented for measuring the expressions of RNAs and proteins. Wound healing and Transwell assays were used to assess cell migration and invasion, and fluorescent in situ hybridization (FISH) to locate LINC00857 in PAAD cells. Additionally, mechanism assays were conducted to validate the interaction between genes. Results indicated that LINC00857 was upregulated in PAAD cells and the knockdown of LINC00857 impeded PAAD cell migration, invasion and epithelial-mesenchymal transition (EMT). Further, it was found that LNC00857 regulates CLDN12 expression by targeting miR-150-5p. Moreover, LINC00857 was confirmed to recruit serine/arginine-rich splicing factor 1 (SRSF1) to promote the alternative splicing (AS) targeting CLDN12, affecting the phenotypes of PAAD cells. In addition, the transcription factor ZNF460 was proven to positively regulate LINC00857 expression. To sum up, LINC00857 regulated by ZNF460 upregulates CLDN12 expression by sponging miR-150-5p and recruiting SRSF1 to facilitate the progression of PAAD cells.[Figure: see text].

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.

Achieving 'Marginal Gains' to Optimise Outcomes in Resectable Pancreatic Cancer

Simple Summary

Improving outcomes in pancreatic cancer is achievable through the accumulation of marginal gains. There exists evidence of variation and undertreatment in many areas of the care pathway. By fully realising the existing opportunities, there is the potential for immediate improvements in outcomes and quality of life.

Abstract

Improving outcomes among patients with resectable pancreatic cancer is one of the greatest challenges of modern medicine. Major improvements in survival will result from the development of novel therapies. However, optimising existing pathways, so that patients realise benefits of already proven treatments, presents a clear opportunity to improve outcomes in the short term. This narrative review will focus on treatments and interventions where there is a clear evidence base to improve outcomes in pancreatic cancer, and where there is also evidence of variation and under-treatment. Avoidance of preoperative biliary drainage, treatment of pancreatic exocrine insufficiency, prehabiliation and enhanced recovery after surgery, reducing perioperative complications, optimising opportunities for elderly patients to receive therapy, optimising adjuvant chemotherapy and regular surveillance after surgery are some of the strategies discussed. Each treatment or pathway change represents an opportunity for marginal gain. Accumulation of marginal gains can result in considerable benefit to patients. Given that these interventions already have evidence base, they can be realised quickly and economically.

Significance of frailty in prognosis after surgery in patients with pancreatic ductal adenocarcinoma

Background

Frailty is an important consideration for older patients undergoing surgery. We aimed to investigate whether frailty could be a prognostic factor in patients with pancreatic ductal adenocarcinoma who underwent pancreatic resection.

Methods

One hundred and twenty patients who underwent pancreatic resection for pancreatic ductal adenocarcinoma were enrolled. Frailty was defined as a clinical frailty scale score ≥4. Patients were divided into frailty (n = 29) and non-frailty (n=91) groups, and clinicopathological factors were compared between the two groups.

Results

The frailty group showed an older age, lower serum albumin concentration, lower prognostic nutritional index, larger tumor diameter, and higher rate of lymph node metastasis than the non-frailty group (p < 0.05). Neutrophil–lymphocyte ratio and modified Glasgow prognostic score tended to be higher in the frailty group. Cancer-specific and disease-free survival rates were significantly poor in the frailty group (p < 0.05). With a multivariate analysis, frailty was an independent prognostic factor of cancer-specific survival.

Conclusions

Frailty can predict the prognosis of patients with pancreatic ductal adenocarcinoma who undergo pancreatic resection.

Cephalic pancreaticoduodenectomy for ductal adenocarcinoma in the elderly. Can we do it safely?

INTRODUCTION

Surgery and chemotherapy have increased the survival of pancreatic cancer. The decrease in postoperative morbidity and mortality and increase in life expectancy, has expanded the indications por cephalic pancreaticoduodenectomy (PDC), although it remains controversial in the geriatric population.

METHODS

Retrospective study on a prospective database of patients with ductal adenocarcinoma of pancreas who underwent PDC between 2007-2018.The main objective was to analyse the morbidity-mortality and survival associated with PDC in patients≥75 years (elderly).

RESULTS

79 patients were included, 21 of them older than 75 years (27%); within this group, 23.9% were over 80 years old. The ASA of both groups was similar. Patients≥75 years required more transfusions. No differences in operating time were observed, although more vascular resection were performed in the elderly (26 vs. 8.7%; P=.037). Morbidity was higher in the elderly (61.9 vs. 46.6%), although without differences. Patients aged≥75 years had more non-surgical complications (33.3%, P=.050), being pneumonia the most frequent. Postoperative mortality was higher in the≥75 years (9 vs. 0%; P=.017). The overall survival and disease-free survival did not show significant differences in both groups.

CONCLUSIONS

Elderly patients had higher postoperative mortality and more non-surgical complications. Survival did not show differences, so with an adequate selection of patients, age should not be considered itself as a contraindication for PDC.

Microscopic resection margin status in pancreatic ductal adenocarcinoma - A nationwide analysis

INTRODUCTION

First, this study aimed to assess the prognostic value of different definitions for resection margin status on disease-free survival (DFS) and overall survival (OS) in pancreatic ductal adenocarcinoma (PDAC). Second, preoperative predictors of direct margin involvement were identified.

MATERIALS AND METHODS

This nationwide observational cohort study included all patients who underwent upfront PDAC resection (2014-2016), as registered in the prospective Dutch Pancreatic Cancer Audit. Patients were subdivided into three groups: R0 (≥1 mm margin clearance), R1 (<1 mm margin clearance) or R1 (direct margin involvement). Survival was compared using multivariable Cox regression analysis. Logistic regression with baseline variables was performed to identify preoperative predictors of R1 (direct).

RESULTS

595 patients with a median OS of 18 months (IQR 10-32 months) months were analysed. R0 (≥1 mm) was achieved in 277 patients (47%), R1 (<1 mm) in 146 patients (24%) and R1 (direct) in 172 patients (29%). R1 (direct) was associated with a worse OS, as compared with both R0 (≥1 mm) (hazard ratio (HR) 1.35 [95% and confidence interval (CI) 1.08-1.70); P < 0.01) and R1 (<1 mm) (HR 1.29 [95%CI 1.01-1.67]; P < 0.05). No OS difference was found between R0 (≥1 mm) and R1 (<1 mm) (HR 1.05 [95% CI 0.82-1.34]; P = 0.71). Preoperative predictors associated with an increased risk of R1 (direct) included age, male sex, performance score 2-4, and venous or arterial tumour involvement.

CONCLUSION

Resection margin clearance of <1 mm, but without direct margin involvement, does not affect survival, as compared with a margin clearance of ≥1 mm. Given that any vascular tumour involvement on preoperative imaging was associated with an increased risk of R1 (direct) resection with upfront surgery, neoadjuvant therapy might be considered in these patients.

Treatment and Survival of Elderly Patients with Stage I-II Pancreatic Cancer: A Report of the EURECCA Pancreas Consortium

BACKGROUND

Elderly patients with pancreatic cancer are underrepresented in clinical trials, resulting in a lack of evidence.

OBJECTIVE

The aim of this study was to compare treatment and overall survival (OS) of patients aged ≥ 70 years with stage I-II pancreatic cancer in the EURECCA Pancreas Consortium.

METHODS

This was an observational cohort study of the Belgian (BE), Dutch (NL), and Norwegian (NOR) cancer registries. The primary outcome was OS, while secondary outcomes were resection, 90-day mortality after resection, and (neo)adjuvant and palliative chemotherapy.

RESULTS

In total, 3624 patients were included. Resection (BE: 50.2%; NL: 36.2%; NOR: 41.3%; p < 0.001), use of (neo)adjuvant chemotherapy (BE: 55.9%; NL: 41.9%; NOR: 13.8%; p < 0.001), palliative chemotherapy (BE: 39.5%; NL: 6.0%; NOR: 15.7%; p < 0.001), and 90-day mortality differed (BE: 11.7%; NL: 8.0%; NOR: 5.2%; p < 0.001). Furthermore, median OS in patients with (BE: 17.4; NL: 15.9; NOR: 25.4 months; p < 0.001) and without resection (BE: 7.0; NL: 3.9; NOR: 6.5 months; p < 0.001) also differed.

CONCLUSIONS

Differences were observed in treatment and OS in patients aged ≥ 70 years with stage I-II pancreatic cancer, between the population-based cancer registries. Future studies should focus on selection criteria for (non)surgical treatment in older patients so that clinicians can tailor treatment.

Contemporary management of pancreas cancer in older people

As the population of western countries is aging, the number of patients diagnosed with cancer is growing. Therefore older people, more susceptible to develop pancreatic malignancy, will likely represent the prototype of a pancreatic cancer patient in the near future. Diagnostic modalities utilised for younger patients are also applicable for older individuals. There is accumulative evidence that biological age is not an independent factor predicting poor outcome in elderly patients with resectable disease undergoing surgery, however increased postoperative morbidity and mortality within the elderly group has also been reported. Adjuvant chemotherapy should be offered in all patients with good performance status regardless of their age. Palliative measures for unresectable tumours including relief from biliary and duodenal obstruction as well as chemotherapy should be considered in non-frail patients with reasonable life expectancy. Palliative chemotherapy options are FOLFIRINOX or gemcitabine/nab-paclitaxel for patients with good performance status (0-1) and gemcitabine alone for patients with performance status 2-3. The cornerstone for improving the outcomes of the elderly age group is careful patient selection and perioperative optimization of those who have indication for surgery. Patients and their carers should be involved in the decision making process with emphasis on the expected functional recovery after the proposed treatment modality. The presence of geriatricians in the multidisciplinary team meetings is crucial in order to identify the optimal treatment pathway for elderly patients. Geriatric input regarding peri-habilitation pathways to improve surgical outcomes, to decrease mortality and to expedite patients' functional recovery is highly recommended.

Robotic pancreaticoduodenectomy in elderly and younger patients: A retrospective cohort study

BACKGROUND

Robotic pancreaticoduodenectomy (RPD) has gradually been accepted as it has overcome some of the limitations of laparoscopic surgery. Outcomes following RPD in elderly patients are still uncertain. This study aimed to evaluate the safety and feasibility of RPD in elderly patients.

METHODS

The demographics and perioperative outcomes of a consecutive series of patients who underwent RPD between January 2018 and September 2019, were retrospectively analyzed. Patients were divided into 2 groups: elderly patients (≥75 years) and younger patients (<75 years).

RESULTS

Of 431 patients who were included in this study, 77 were elderly patients and 354 were younger patients. Elderly patients had a significantly higher ASA score than younger patients (P < 0.001). There were no significant differences in operative time, estimated blood loss and blood transfusion rate between groups (P > 0.05). Elderly patients had significantly higher morbidity and longer postoperative hospital stay than younger patients (49.3% vs. 31.1%, P = 0.002; 22.8 vs. 13.3 days, P < 0.001, respectively). However, the reoperation, 90-day readmission and mortality rates were comparable in the two groups (P > 0.05). Multivariate analysis demonstrated that a higher ASA score was the only independent factor for postoperative morbidity (OR 2.02, 95% CI 1.06-3.88, P = 0.03), while old age was not (OR 0.81, 95% CI 0.36-1.81, P = 0.80).

CONCLUSION

This study demonstrated that RDP was safe and feasible in elderly patients. Age should not be a contraindication to RPD. Elderly patients with careful patient selection should be considered for RPD.

Pancreatic Resection in Older Patients: A Retrospective Single-Center Outcome Analysis

Due to increasing life expectancy and improved diagnostic sensitivity, a growing number of older patients are presenting with resectable pancreatic disease entities and are being evaluated for surgery. Intended as an internal quality control for patient selection, we aimed at evaluating septuagenarians and octogenarians compared with patients younger than 70 years of age regarding early postoperative outcome in general, and long-term oncologic outcome in the case of resection for pancreatic adenocarcinoma. A total number of 1231 patients who underwent pancreatic resection for any entity between 2007 and 2019 at our tertiary university medical center in Germany were retrospectively analyzed, accessing a prospectively maintained database. Participants were divided into three groups based on age (<70 years: N = 761; 70–79 years: N = 385; 80–89 years: N = 85) and were evaluated with regard to perioperative variables, postoperative morbidity, mortality and overall survival for the subgroup of patients with pancreatic adenocarcinoma. Pancreatic resection in older individuals was not infrequent. When surgery was performed for carcinoma, patients >70 years of age even constituted almost half of the cases. In spite of increased American Society of Anesthesiologists physical status classification (ASA)-scores and more frequent comorbidities in older patients, similar rates for postoperative morbidity and mortality were observed in all age groups. A significant disparity in the use of (neo-) adjuvant therapy between younger and older pancreatic adenocarcinoma patients was detected. However, median overall survival did not significantly differ between all age groups (<70 years: 28 (95%-CI: 22–34) months; 70–79 years: 21 (17–25) months; 80–89 years: 15 (9–21) months). In conclusion, elderly patients can experience similar perioperative outcomes to those of younger individuals after major pancreatic surgery. The survival benefit from resection of localized pancreatic adenocarcinoma is largely independent of patient age. The results are reassuring with respect to our preoperative practice and clinical judgment regarding careful patient selection. Future randomized trials should decidedly include elderly patients to generate more robust evidence to further optimize treatment recommendation and choice.

Rare postoperative hemorrhage after robotic-assisted pancreatoduodenectomy for pancreatic head cancer: a case report

Post-pancreaticoduodenectomy hemorrhage is a life-threatening complication that occurs in 2-10% of patients. The most common location for post-pancreaticoduodenectomy hemorrhage is the gastroduodenal artery stump. Nonetheless, unusual sources of hemorrhage, which are hard to locate, exist. Here, we report a rare postoperative hemorrhage after robotic-assisted pancreatoduodenectomy for pancreatic head cancer. A 67-year-old man presenting with appetite loss, general fatigue and painless jaundice was admitted to our ward. The patient had an elevated level of carbohydrate antigen 19-9 (50 U/mL). Computed tomography scan revealed a 17-mm wide low-density area in the uncinate process of the pancreas. Magnetic resonance cholangiopancreatography showed the dilation of bile and pancreatic ducts. Robotic-assisted pancreaticoduodenectomy was performed on the patient by using the da Vinci Model S Surgical System. On postoperative days 5 and 6, the patient vomited blood, and bloody fluid was observed in the drainage. Emergent gastroscopic examination was performed and revealed a large amount of hematocele in the stomach. On postoperative day 6, emergency operation was undertaken, and the output jejunal loop was found to have intussuscepted in the stomach. This is the first case report of output jejunal loop intussusception in the stomach that consequently caused hemorrhage after robotic-assisted pancreaticoduodenectomy for pancreatic head cancer.