The Impact of Patient Age ≥80 Years on Postoperative Outcomes and Treatment Costs Following Pancreatic Surgery

Abstract

As life expectancy is increasing, elderly patients are evaluated more frequently for resection of benign or malignant pancreatic lesions. However, the impact of age on postoperative morbidity, mortality, and treatment costs in octogenarian patients (≥80 years) undergoing major pancreatic surgery needs further investigation. The clinicopathological data of patients who underwent pancreatic surgery between January 2015 and March 2019 in a major hepatopancreatobiliary center in Switzerland were assessed. Postoperative outcomes and hospital costs of octogenarians and younger patients were compared in univariate and multivariate regression analysis. During the study period, 346 patients underwent pancreatic resection. Pancreatoduodenectomy, distal pancreatectomy, total pancreatectomy, and other procedures were performed in 54%, 20%, 13%, and 13% of patients, respectively. The major postoperative morbidity rate and postoperative mortality rate were 25% and 3.5%, respectively. A total of 39 patients (11%) were ≥80 years old, and 307 patients were <80 years old. The majority of octogenarians suffered from ductal adenocarcinoma, whereas among younger patients, other indications for a pancreatic resection were predominant (ductal adenocarcinoma 64% vs. 41%, p = 0.006). Age ≥80 was associated with more frequent postoperative medical (pulmonary, cardiovascular) and surgical (high-grade pancreatic fistula, postoperative hemorrhage) complications. Postoperative mortality was significantly higher in octogenarians (15.4% vs. 2%, p < 0.0001). This finding may be explained by the higher rate of type C pancreatic fistula (13% vs. 5%), resulting more frequently in postoperative hemorrhage (18% vs. 5%, p = 0.002) among patients ≥80 years old. In the multivariate logistic regression analysis, patient age ≥80 years predicted postoperative mortality independently of the tumor entity and surgical technique (p = 0.013, OR 6.71, 95% CI [1.5–30.3]). Increased major postoperative morbidity was responsible for lower cost recovery in octogenarians (94% vs. 102%, p = 0.046). In conclusion, patient age ≥80 years is associated with increased postoperative medical and surgical morbidity after major pancreatic surgery leading to lower cost recovery and a lower chance for successful resuscitation in patients requiring revisional surgery for postoperative hemorrhage and/or pancreatic fistula. In octogenarian patients suffering from pancreatic tumors, careful selection, and thorough prehabilitation is crucial to achieve the best postoperative and long-term oncologic outcomes.

Pancreaticoduodenectomy in octogenarians: The importance of “biological age” on clinical outcomes

“…Despite the increased vulnerability of the very elderly population in the entire cohort, no difference was found for postoperative morbidity rate and severity These findings are in line with the pioneeristic study from Johns Hopkins University Hospital [24], that firstly demonstrated the safety and feasibility of PD in octogenarians, as well as with more recent experiences reported in the literature [9,10]. On the counterpart, some reports demonstrated statistically higher morbidity rates in aged groups compared to younger cohorts [11][12][13], and recognized increasing age as a risk factor for post-pancreatectomy onset of complications [39][40][41][42]. These contrasting data may reflect a difference in hospital volume for pancreatic surgery where the different studies were conducted.…”

“…A recent epidemiological study found an age-specific trend towards an increase of PC diagnosis particularly in patients aged 80 years and over [21]. However, only a few studies specifically analyzed the outcomes of PD in the elderly population [10][11][12][13][22][23][24], and even less authors focused on octogenarians [9,11,25]. A few series recognized increasing age as a significant risk factor for a higher incidence of post-operative complications and mortality [26,27], while other authors demonstrated comparable short-term outcomes between octogenarians and younger patients after PD [9,10,25].…”

“…Some authors did not find evidence of association between advanced age and increased postoperative mortality and morbidity after pancreatic surgery [9,10]. On the other hand, several population-based studies have shown unfavorable outcomes in aged patients following pancreatic resection [11][12][13]. Interestingly, only few authors specifically analyzed the clinical outcomes of octogenarians after a demanding surgical procedure such as PD.…”

Neues zur Therapie des Pankreaskarzinoms: Hoffnung am Horizont?

“…Es ist unbestritten, dass ein Team, welches regelmässig onkologische Pankreasresektionen durchführt, besser gewappnet ist, auf anatomische Varianten, lokale Probleme oder auf postoperativ komplizierte Verläufe zu reagieren und Chirurgie-assoziierte Morbidität und Letalität tief zu halten. An der Universitätsklinik für Viszerale Chirurgie und Medizin betrug bei 125 Patienten unter 80 Jahren, die sich 1/2015 bis 3/2019 einer onkologischen Pankreasresektion unterziehen mussten, die Morbidität 20 % und die Letalität 2,4 % [17]. Ein hoher Qualitätsstandard lässt sich aber nicht durch eine einfache Mindestmengenvorgabe erreichen.…”

“…Die GABRINOX-Studie, eine Phase-II-Studie, evaluierte eine Therapie mit Gemcitabin und nab-Paclitaxel im 2-wöchentlichen Wechsel mit FOLFIRINOX. Die Gesamtansprechrate lag bei hohen 63,2 % (95 % KI 49,3-75,5 %) und das mediane Gesamtüberleben bei 17,8 Monaten (95 % KI 11,[7][8][9][10][11][12][13][14][15][16][17][18][19][20][21]3), bei akzeptabler Toxizität [34] -ein weiterer interessanter Therapieansatz, der bis anhin aber noch keine Verwendung im klinischen Alltag findet.…”