The impact of old age on surgical outcomes after pancreaticoduodenectomy for distal bile duct cancer

Safety and effectiveness of open pancreaticoduodenectomy in adults aged 70 or older: A meta-analysis

BACKGROUND

Pancreaticoduodenectomy (PD) is considered the most complicated operation in abdominal surgery. The safety and effectiveness of PD in older patients has been questionable because older adults are often beset by one or more systemic diseases and have poor surgical tolerance.

AIM

To evaluate the safety and effectiveness of PD in patients aged 70 or older.

METHODS

We conducted a literature search on PubMed, EMBASE, Cochrane Library and other databases to discover all literature reporting a comparison of the efficacy of PD in patients 70 years old and older versus patients under 70 years old. Our cutoff date is August 2020. Revman5.3 statistical software was used for the analysis.

RESULTS

Twenty cohort studies were determined to be eligible with a total of 6508 patients; 2274 patients were 70 years old and older and 4234 patients under 70 years old. Meta-analysis results showed that after PD in patients over 70 years of age and older the mortality rate (RR = 2.1, 95%CI:1.59-2.78, p < 0.001), the overall postoperative complications (RR = 1.16,95%CI:1.09-1.23, p < 0.001), intraoperative transfusions (RR = 1.38, 95%CI:1.14-1.23, p = 0.001), severe complications (RR = 1.30,95%CI:1.11-1.52, p = 0.001), the re-operation rate (RR = 1.23,95%CI:1.00-1.51, p = 0.05), the R0 rate (RR = 0.92,95%CI:0.86-0.98, p = 0.01), lymph node dissection (WMD = -4.61,95%CI:-7.24-1.97, p < 0.001) and delayed gastric emptying (RR = 1.24,95%CI:1.04-1.49, p = 0.02) at a rate significantly higher than that of patients under 70 years old. There is no significant difference between patients 70 years old and older and patients under 70 years old in the clinical PF (RR = 1.11,95%CI:0.93-1.34, p = 0.24), bile leakage (RR = 0.68,95%CI:0.41-1.12, p = 0.13), postoperative bleeding (RR = 1,95%CI:0.76-1.30, p = 0.98), wound infection (RR = 1.15,95%CI:0.95-1.39, p = 0.15) and hospital stays (RR = 0.30,95%CI:-1.77-2.37, p = 0.77).

CONCLUSION

Patients aged 70 years or older have approximately double the risk of postoperative mortality following PD and a higher risk of overall and severe postoperative complications. Furthermore, patients 70 years old and older require more frequent intraoperative transfusions, re-operative interventions and have poorer oncology results (lower R0 rate and fewer lymph node dissections). More multi-center, large sample, and high-quality research is still needed to further verify this conclusion.

Pancreatoduodenectomy for pancreatic head tumors in the elderly - Systematic review and meta-analysis

The age at which patients are undergoing pancreatoduodenectomy is increasing worldwide. The data on the outcome of this surgical procedure in the elderly is constantly expanding. This meta-analysis aims to assess the safety of pancreatoduodenectomy in elderly population, primarily focusing on morbidity and mortality. We searched the Medline, Embase and Cochrane databases to identify eligible studies. The most recent search was performed on 10th April 2017. Inclusion criteria were: (1) comparison of the characteristics and perioperative outcomes of older patients versus younger patients undergoing pancreatoduodenectomy; (2) objective evaluation of mortality or overall morbidity; and (3), publication in English. Exclusion criteria were: (1) a lack of comparative data; (2) a lack of primary outcomes or insufficient data to analyze; (3) a focus on procedures other than pancreatoduodenectomy; or (4), the impossibility of extraction of data specifically concerning pancreatoduodenectomy. Primary outcomes were overall morbidity and mortality. Secondary outcomes analyzed postoperative complications, R0 rate and length of hospital stay. 45 eligible studies were chosen, with a combined total of 21,295 patients. Older patients compared to younger patients had a higher risk of death (2.26% vs. 4.54%; RR: 2.23; 95% CI 1.74-2.87) and a higher complication rate (47.23% vs. 39.35%; RR: 1.17; 95% CI 1.12-1.24). There were no differences in pancreatic fistula occurrence (p = 0.27), bile leakage (p = 0.81), postoperative hemorrhage (p = 0.08), or R0 rate (p = 0.92). Our review confirms, that in the case of pancreatoduodenectomy, advanced age is a risk factor for increased non-surgical morbidity and, by extension, higher mortality.

The outcomes of pancreaticoduodenectomy in patients aged 80 or older: a systematic review and meta-analysis

BACKGROUND

There is an increasing needed to consider pancreaticoduodenectomy (PD) for the treatment of pancreatic and periampullary malignancy in patients aged 80 and over, given the increasing aging population.

METHODS

A systematic literature search was undertaken to identify selected studies that compared the outcomes of patients aged 80 years or over to those younger undergoing PD.

RESULTS

In total 18 studies were included for evaluation. Octogenarian or older populations had significantly higher 30-day post-operative mortality rate (OR: 2.22, 95% CI = 1.48-3.31, p < 0.001) and length of hospital stay (OR: 2.23, 95% CI = 1.36-3.10, p < 0.001). The overall post-operative complication rate was higher in the older group compared to the younger population (OR: 1.51, 95% CI = 1.25-1.83, p < 0.001). Elderly patients were more likely to develop pneumonia (OR: 1.72, 95% CI = 1.39-2.13, p < 0.001) and experience delayed gastric emptying (DGE) (OR: 1.77, 95% CI = 1.35-2.31, p < 0.001). The incidence of post-operative pancreatic fistula and bile leak were not significantly different between the groups. Rehabilitation and home nursing care services was also more frequently required by the older patient group at the time of hospital discharge.

CONCLUSION

Patients aged 80 years and older have approximately double the risk of 30-day post-operative mortality and 50% increased rate of complications following PD. Careful patient selection is required when offering surgery in this age group.

The safety and risk factors of major hepatobiliary pancreatic surgery in patients older than 80 years

Purpose

Recently, the number of elderly patients has increased due to a longer life expectancy. Among these elderly patients, more octogenarians will be diagnosed with major hepatobiliary pancreatic (HBP) diseases. Therefore, we need to evaluate the safety and risk factors of major HBP surgery in patients older than 80 years.

Methods

From January 2000 to April 2015, patients who underwent major HBP surgery were identified. The patients were divided into 2 groups according to their age at the time of surgery: Group O (≥80 years) and group Y (<80 years). The patient characteristics and intra- and postoperative outcomes were retrospectively investigated in the 2 groups.

Results

The median age was 84 years (range, 80–95 years) in group O and 61 years (range, 27–79 years) in group Y. group O had worse American Society of Anesthesiologists (ASA) physical status (ASA ≥ III: 23% vs. 7%, P = 0.002) and was associated with a higher rate of hypertension and heart problems as comorbidities. There were significant differences in albumin and BUN, favoring group Y. The length of intensive care unit stay was longer in group O, whereas the overall complication and mortality rates did not show statistical difference. But, there was a significant difference in systemic complication of both Clavien-Dindo classification grade ≥II and ≥III as complications were divided into surgical site complication and systemic complication.

Conclusion

Major HBP surgery can be performed safely in patients older than 80 years if postoperative management is appropriately provided.