Pancreatic Disease in the Elderly Patient

Safety of endoscopic ultrasound-guided fine-needle aspiration for pancreatic solid mass in the elderly: A single-center retrospective study

AIM

There are few reports on the safety of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in the elderly. In this study, we investigated the safety of EUS-FNA for pancreatic solid masses in patients aged ≥80 years.

METHODS

This is a single-center retrospective study. A total of 600 patients with pancreatic solid masses who underwent EUS-FNA under midazolam-based sedation at our institution between September 2016 and December 2022 were enrolled in this study. Eligible patients were divided into two groups: an elderly group aged ≥80 (n = 84), as well as a nonelderly group aged ≤79 (n = 516). These two groups were compared.

RESULTS

The elderly group required significantly fewer midazolam doses for sedation (P < 0.001). Adverse events occurred in eight patients (1.3%), including one (1.2%) and seven (1.4%) in the elderly and nonelderly groups, respectively (P = 0.90). There were no cases of early adverse events in the elderly group and six cases (1.2%) in the nonelderly group (P = 0.32). There was one case of late adverse events in both the elderly and nonelderly groups (P = 0.14), and both were needle tract seeding. There was no significant difference between the two groups in the proportion of cases in which percutaneous oxygen saturation decreased to ≤90% during the EUS-FNA.

CONCLUSIONS

Our analysis suggests that EUS-FNA for pancreatic solid masses can be safely performed in patients aged >80 years without increasing the adverse event rate compared to nonelderly patients aged <80 years. Geriatr Gerontol Int 2023; 23: 836-841.

Safety of endoscopic retrograde cholangiopancreatography (ERCP) in patients aged 85 years and older: A single center experience

Objective: To evaluate the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) in elderly patients (≥85 years old).

Material and Methods: Patients who underwent ERCP for any reason within 12 months were evaluated. Patients undergoing ERCP were classified as the elderly group aged 85 years and older or the controls under the age of 85 years.

Results: A total of 1225 patients, 504 males and 721 females, were included in the study. Length of hospital stay, the number of patients in whom pre- cut sphincterotomy was performed in ERCP, and mortality rate showed similar characteristics compared to the control group in patients with advanced age (≥85 years old). Except for pancreatitis, there was no significant difference between the groups in terms of complications related to the procedure. Post ERCP pancreatitis was observed significantly less in the elderly group (p= 0.042). Pre-cut sphincterotomy was required in a total of 191 (15.5%) patients. In patients who underwent pre-cut sphincterotomy and patients with cholangitis, post ERCP complication rates were not significant between the groups.

Conclusion: ERCP is a safe procedure for older patients (≥85 years old) as well as young patients.

Managing Gallstone Disease in the Elderly

Geriatric patients tend to have subtle presentations of biliary disorders and, if untreated, can decompensate acutely. Each biliary disorder warrants formulation of an individualized treatment plan with a multidisciplinary approach. Acute cholecystitis, a common complication of gallstones, is initially managed by conservative measures and subsequently, among patients with optimal surgical risk, through laparoscopic or open cholecystectomy. High-risk patients undergo temporization, percutaneous or endoscopic, followed by definitive intervention. Acute cholecystitis with complications (ie, perforation, gangrene, or small bowel obstruction) warrants emergent cholecystectomy. Gallstone migration into the biliary system can cause choledocholithiasis, often complicated by biliary pancreatitis or cholangitis if not intervened. Therapy for choledocholithiasis is based on biliary clearance through endoscopic and, infrequently, surgical approaches.

Extracorporeal shock wave lithotripsy is safe and effective for geriatric patients with chronic pancreatitis

BACKGROUND AND AIM

Pancreatic extracorporeal shock wave lithotripsy (P-ESWL) is a first-line treatment for chronic pancreatitis (CP) patients with pancreatic stones. However, the performance of P-EWSL in geriatric patients remains unclear. We aimed to evaluate the safety and efficacy of P-ESWL for them.

METHODS

This prospective study was conducted in painful CP patients who underwent P-ESWL. Patients aged over 65 years were included in geriatric group; patients aged under 65 years were assigned to control group. For the long-term follow-up investigation, geriatric patients were matched with patients from the control group in a 1:1 ratio. Primary outcomes were complications of P-ESWL and pain relief. Secondary outcomes included stone clearance, physical and mental health, quality of life score, changes in exocrine and endocrine pancreatic function, and survival.

RESULTS

From March 2011 to March 2016, P-ESWL was performed in 1404 patients (72 in the geriatric group and 1332 in the control group). No significant differences were observed in complications of P-ESWL between the two groups (P = 0.364). Among the 67 (67/72, 93.1%) geriatric patients who underwent follow up for 4.02 years, complete pain relief was achieved in 53 patients, which was not significantly different from that of matched controls (54/70; P = 0.920). The death in the geriatrics was significantly higher (P = 0.007), but none of them were correlated with P-ESWL.

CONCLUSIONS

P-ESWL is safe and effective for geriatric CP patients with pancreatic stones. It can promote significant pain relief and stone clearance and improve quality of life and mental and physical health.

Efficacy and Safety of Therapeutic Endoscopic Retrograde Cholangiopancreatography in the Elderly Over 80 Years

BACKGROUND/AIMS

Concern regarding the safety and efficacy of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in elderly patients is increasing as a result of the aging society. However, there are limited data, especially in the super-aged elderly. This study aimed to evaluate the efficacy and safety of therapeutic ERCP in patients ≥80 years of age.

METHODS

Patients 80 years of age or older (n = 312) and younger than 65 years (n = 312) who underwent therapeutic ERCP from June 2006 to April 2014 were randomly selected and analyzed retrospectively. The main outcome measurements were therapeutic ERCP-related complications and clinical outcomes in the two groups.

RESULTS

Choledocholithiasis combined with gallbladder stone was the most common indication for ERCP in both groups. Comorbid diseases (70.5 and 29.8 %, p < 0.001) and the use of anti-thrombotic drugs (18.6 and 1.6 %, p < 0.001) were more frequent in the super-aged group. The mean procedure time was longer, and the frequency of second ERCP was more common in the super-aged group. However, the technical success rate (94.9 and 97.4 %, p = 0.096) and the procedure-related complication rate (4.8 and 5.8 %, p = 0.592) were not different between the two groups. Post-ERCP pancreatitis occurred in 1.3 % of the super-aged group and in 2.9 % of the control group (p = 0.262). Cardiopulmonary complications occurred in 1.9 % of patients in each group (p = 1.0).

CONCLUSIONS

Therapeutic ERCP is comparable in terms of efficacy and safety between patients ≥80 years and those <65 years of age, although the elderly group had a higher rate of comorbid diseases and used anti-thrombotic drugs more frequently.

ERCP in elderly patients: increased risk of sedation adverse events but low frequency of post-ERCP pancreatitis

BACKGROUND AND AIMS

The continually increasing life expectancy in man comes along with an increasing number of endoscopic interventions performed in patients with advanced or even very advanced age. Data on the feasibility and safety of ERCP in elderly patients are relatively scarce.

METHODS

By a systematic query of the University Hospital Frankfurt clinical database, patients undergoing their first ERCP procedure at our center were retrospectively identified. Patients were grouped according to age at the day of the intervention (>80 years, 61-80 years, 40-60 years, and <40 years). Demographic data, indication, outcome, and risk factors were compared among the indicated groups.

RESULTS

A total of 758 patients who underwent ERCP procedures at our center were identified and included in the study. Main indications for ERCP were intraductal gallstones in 345 patients (45%) and tumor obstruction of the bile ducts (distal common bile duct: n = 126 [16.5%], hilar cholangiocarcinoma: n = 89 [11.7%], tumor of papilla of Vater: n = 16 [2.1%]). Gallstones were the most common cause for ERCP in patients aged >80 years (53.8%), and normal findings indicating exclusion of relevant disease were more frequent in patients <80 years (13.4%) compared with older patients (4.3%) (P < .01). Sedation adverse events were significantly more common in individuals aged >80 years compared with younger patients (3.4% vs 0.5%; P < .01). However, post-ERCP pancreatitis was significantly less frequent in the older patients (>80 years) (0.9% vs 5.3%; P < .05). Other adverse events were equally distributed in all age groups. The ERCP success rate (>80%) was not different among age groups.

CONCLUSIONS

ERCP is safe and efficient in patients aged 80 years or older. However, conscious sedation must be carefully monitored in older patients because risk of sedation adverse events is increased. The incidence of post-ERCP pancreatitis is lower in older patients compared with younger ones.

Preparation of high-risk patients and the choice of guidewire for a successful endoscopic retrograde cholangiopancreatography procedure

Endoscopic retrograde cholangiopancreatography (ERCP) is an essential technique for the diagnosis and treatment of pancreatobiliary diseases. However, ERCP-related complications such as pancreatitis, cholangitis, hemorrhage, and perforation may be problematic. For a successful and safe ERCP, preprocedural evaluations of the patients and intervention-related risk factors are needed. Furthermore, in light of the recent population aging and increase in chronic cardiopulmonary diseases in Korea, precautions including endoscopic sedation and prevention of cardiopulmonary complications should be considered. In this literature review, we describe these risk factors and the use of endoscopic sedation. In addition, we reviewed the commonly available guidewires, including their materials and options, used as a basic accessory for ERCP procedures.

ERCP in the very elderly: outcomes among patients older than eighty

Life expectancy is rising, which is increasing the demand for endoscopic retrograde cholangiopancreatography (ERCP) in the elderly. Little data, particularly on complex procedures, has been reported. In this study, we compare the differences in the success and complications in ERCP between patients older and younger than 80 years old. We used a large endoscopic database reviewing the ERCPs performed and 30-day complications addressing age, degree of difficulty of procedures, and complications. A total of 2,606 patients underwent 3,924 ERCPs. Six hundred and twenty-eight were octogenarians undergoing 728 procedures. Mean age was 83.5 years in the octogenarian group and 59.0 years in the younger group. The endoscopic success rate was lower in octogenarians (96.9 vs. 98.3%, P = 0.004). Overall, complication rates between both groups was significantly less in older compared to younger patients (1.64 vs. 3.50%, P = 0.006). Complication and failure rates were higher as procedure complexity increased in all patients. ERCP in the elderly carries a high degree of success with low complication rates. Elderly patients carry similar risks of bleeding and perforation and a lower risk of pancreatitis.

Pancreatic regenerating protein I in chronic pancreatitis and aging: implications for new therapeutic approaches to diabetes

OBJECTIVES

We investigated the relationship of pancreatic regenerating protein (reg) in models of acinar cell atrophy and aging, and the effect of reg I protein replacement on glucose tolerance.

METHODS

Rats underwent pancreatic duct ligation (PDL) and were followed through 12 months. Aging rats were studied at 12 and 20 months. Intraperitoneal glucose tolerance tests (IPGTTs) were performed, pancreatic reg I, reg I receptor, insulin gene expression, and reg I protein levels were measured. Pancreatic duct ligation and aged animals were treated with exogenous reg I protein and assessed for glucose metabolism.

RESULTS

After PDL, chronic atrophic pancreatitis developed, with a progressive loss of acinar cells and pancreatic reg I. During aging, a similar depression of reg I gene expression was also noted. The reg I levels correlated with pancreatic insulin levels. Twelve months after PDL, IPGTT results were abnormal, which were significantly improved by administration of reg I protein. Aged animals demonstrated depressed IPGTT, which marginally improved after reg I administration. Anti-reg antibody administration to young rats depressed IPGTT to elderly levels.

CONCLUSIONS

Depletion of the acinar product reg I is associated with the pathogenesis of impaired glucose tolerance of pancreatitis-associated diabetes and aging, and replacement therapy could be useful in these patients. Reg I is an acinar cell product, which affects islet function.

The effect of age on short-term outcomes after pancreatic resection: a population-based study

OBJECTIVE

To use a large population-based cohort to determine age-dependent short-term outcomes after pancreatic resection.

METHODS

We identified all pancreatic resections in Texas from 1999 to 2005. Patients were stratified into 4 age groups (<60, 60-69, 70-79, and 80+ years). Bivariate and multivariate analyses were performed to determine the effect of age on mortality, discharge to home versus requiring inpatient nursing care, and length of stay.

RESULTS

Three thousand seven hundred and thirty-six patients underwent pancreatic resection. Unadjusted in-hospital mortality increased with each increasing age group from 2.4% in patients <60 to 11.4% in patients 80 years and older (P < 0.0001). Likewise, postoperative lengths of stay increased with each increasing age group (P = 0.02). Age group independently predicted the need for discharge to an inpatient nursing unit rather than home (P < 0.0001), with the odds ration (OR) increasing with each increasing age group. With each increasing age group, patients were less likely to be resected at high-volume (H-V) hospitals (>10 pancreatic resections/y). Whereas low-volume (L-V) hospitals (< or =10 pancreatic resections/y) had higher mortality rates (3.2% versus 7.3%, P < 0.0001), the difference in mortality between H- and L-V hospitals was more striking in older patients. With increasing age group, mortality increased from 3.0% to 9.5% to 11.4% to 14.7% at L-V hospitals. It increased from 2.0% to 3.5% to 4.5% to 8.7% at H-V hospitals (P < 0.0001). In the multivariate model controlling for gender, race, hospital volume, year of surgery, diagnosis, risk of mortality, severity of illness, admission status, and procedure type, older age group independently predicted increased mortality. The OR for patients 60-69 years was 2.5 (P = 0.0003), the OR for patients 70-79 years was 1.8 (P = 0.02), and the OR for patients 80+ years was 4.4 (P < 0.0001) when compared with patients <60 years.

CONCLUSIONS

In contrast to some previous single-institution studies, we found that increased age is an independent risk factor for mortality after pancreatic resection. For all ages, mortality rates were higher at L-V hospitals, but the difference worsened significantly with increasing age. Older patients had longer lengths of stay, were less likely to be discharged home, and more likely to require care at an inpatient nursing or acute care facility at the time of discharge.

Establishment of risk model for pancreatic cancer in Chinese Han population

AIM: To investigate risk factors for pancreatic cancer and establish a risk model for Han population.

METHODS: This population-based case-control study was carried out from January 2002 to April 2004. One hundred and nineteen pancreatic cancer patients and 238 healthy people completed the questionnaire which was used for risk factor analysis. Logistic regression analysis was used to calculate odds ratio (ORs), 95% confidence intervals (Cls) and β value, which were further used to establish the risk model.

RESULTS: According to the study, people who have smoked more than 17 pack-years had a higher risk to develop pancreatic cancer compared to non-smokers or light smokers (not more than 17 pack-years) (OR 1.98; 95% CI 1.11-3.49, P = 0.017). More importantly, heavy smokers in men had increased risk for developing pancreatic cancer (OR 2.11; 95%CI 1.18-3.78, P = 0.012) than women. Heavy alcohol drinkers (＞20 cup-years) had increased risk for pancreatic cancer (OR 3.68; 95%CI 1.60-8.44). Daily diet with high meat intake was also linked to pancreatic cancer. Moreover, 18.5% of the pancreatic cancer patients had diabetes mellitus compared to the control group of 5.8% (P = 0.0003). Typical symptoms of pancreatic cancer were anorexia, upper abdominal pain, bloating, jaundice and weight loss. Each risk factor was assigned a value to represent its importance associated with pancreatic cancer. Subsequently by adding all the points together, a risk scoring model was established with a value higher than 45 as being at risk to develop pancreatic cancer.

CONCLUSION: Smoking, drinking, high meat diet and diabetes are major risk factors for pancreatic cancer. A risk model for pancreatic cancer in Chinese Han population has been established with an 88.9% sensitivity and a 97.6% specificity.

Pancreatic cancer mortality in China (1991-2000)

AIM: To describe the mortality rate of pancreatic cancer and its distribution in China during the period of 1991-2000.

METHODS: Based on the data of demography and death collected through China’s Disease Surveillance Point System (DSPS) over the period of 1991-2000, the distribution of death rate of pancreatic cancer was described in terms of age group, gender, calendar year, rural/urban residence and administrative district.

RESULTS: A total of 1619 death cases attributed to pancreatic cancer (975 men and 644 women) were reported by DSPS during 1991-2000. The reported, adjusted and age-standardized mortality rates increased from 1.46, 1.75, and 2.18 per 100000 populations in 1991 to 2.38, 3.06, and 3.26 per 100000 populations in 2000. The majority (69.62%) of the deaths of pancreatic cancer were seen in the age group of 60 years and older. The mortality rate was higher in men than in women, but the male to female death rate ratios decreased during the 10 years. Our data also showed that the death rate of pancreatic cancer in urban areas was about 2-4 fold higher than that in rural areas, and in Northeast and East China, the death rates were higher than those in the other 5 administrative districts.

CONCLUSION: The death rate due to pancreatic cancer was rising during the period of 1991-2000 and the peak mortality of pancreatic cancer might arrive in China.

Adenocarcinoma of the Pancreatic Head: A Community Teaching Hospital's Experience from 1982 to 1992

The treatment of adenocarcinoma of the pancreatic head remains variable, with multiple therapeutic options including surgery, biliary stenting, chemotherapy, and radiation therapy. We retrospectively reviewed our experience from 1982 through 1992, which included 160 patients with this diagnosis, evaluating their treatments and outcomes. There were 66 males and 94 females, with a mean age of 70 ± 11 years. Forty patients (25%) had no surgery; of these, 27 had no further treatment, whereas 13 received chemotherapy and/or radiation therapy (CT/RT). Of 120 patients who had surgical exploration, only 19 (16%) were resectable for a potential cure. Eleven of these resected patients had no additional therapy, whereas 8 patients received adjuvant CT/RT. Of the 101 unresectable patients, 62 had no further therapy and 39 received CT/RT. Twenty-two patients (14%) had biliary stents placed, 11 in lieu of surgery, 7 preoperatively, and 4 postoperatively. Perioperative mortality was no different for resectable patients (16%) versus unresectable patients (14%). Overall, 90 patients (56%) had one or more complications related to their disease or treatment, with no differences between groups. Median survivals were as follows: no treatment, 1 month; no surgery with CT/RT, 3.5 months; unresectable with no further treatment, 4 months; unresectable with CT/RT, 8 months; resection with no additonal treatment, 17 months; and resection with CT/RT, 13 months. Patients with resectable disease had a significantly longer survival than patients who had no surgery (P < 0.001) or who were unresectable at exploration (P < 0.001); the addition of CT/RT after resection had no effect on survival (P = 0.8). The addition of CT/RT significantly increased survival for patients who had no surgery (p = .001) and for patients who were explored but were unresectable (p = .002). In conclusion, despite dismal results, surgery remains the mainstay of treatment for adenocarcinoma of the pancreatic head. Although CT/RT did not increase the median survival after resection, it doubled the median survival after noncurative surgery.

Review article: current treatment and optimal patient management in pancreatic cancer

This review analyses the current state of knowledge and understanding concerning the optimum treatment and therapeutic management of patients who suffer from pancreatic cancer. It outlines recent advances in scientific understanding and assesses their potential future value to clinicians in confronting this disease. Despite a significant expansion in scientific knowledge relating to factors underlying the early development of pancreatic carcinoma, the clinician continues to be restricted to a severely limited therapeutic armoury for this disease. Local therapies (surgery and radiation) are inevitably of limited value in the face of a disease that is normally encountered at a stage where metastasis is already highly developed. Despite such limitations, however, surgery performed in specialist units may be of value for 10-20% of patients, with a 5-year survival rate in such units of between 10 and 24%. This may be improved even further by appropriate use of adjuvant treatment. The advanced stage of the disease when normally encountered emphasizes the potential value of systemic treatment in this therapeutic area. Unfortunately systemic treatment (chemotherapy) has been found to be ineffective to date in significantly extending survival, with a low rate and duration of remission being identified in most trials. The challenge for both the health service and the pharmaceutical industry is to harness recent and future developments in scientific knowledge to the practical benefit of clinicians. Where cure is possible it should be vigorously pursued; where it is not, in this field above all others, clinicians have a duty of care. To achieve this it is necessary to abandon the therapeutic nihilism that has characterized the attitudes of clinicians towards this disease in the past. It is time that such nihilism was replaced by a recognition of the challenges and the opportunities available to clinicians in enhancing the quantity and quality of life available to patients. The dictum of 'curing whenever possible but caring always' should be the future therapeutic philosophy used to guide clinicians in this important and rapidly changing therapeutic area.