Y. Futagawa1, T. Kanehira1, K. Furukawa1, N. Okui1, J. Shimada1, N. Tsutsui1, Y. Fujiwara1, H. Kitamura1, S. Yoshida1, T. Usuba1, T. Nojiri1, S. Fujioka1, T. Misawa1, T. Okamoto1, K. Yanaga1 1The Jikei University School Of Medicine,Surgery,Minato-ku, TOKYO, Japan
Introduction:
~Pancreaticoduodenectomy (PD) is a radical surgical treatment for malignant biliary-pancreatic disorders. To date, indication for PD in elderly patients is determined on a case-to-case basis. However, establishing a certain standardized criteria is important as the aged population (approximately 20% in developed countries) continues to grow. The purpose of this study is to verify the outcomes of PD in the elderly.
Methods:
~We selected 340 patients with pancreatic cancer, bile duct cancer, or papilla of Vater cancer from the 436 patients who underwent PD at our four affiliated hospitals from 2003 to 2010. The subjects were divided into three groups: group A, the non-elderly (aged 64 years or younger; 60 patients with pancreatic cancer, 30 with bile duct cancer, and 25 with papilla of Vater cancer; a total of 115 subjects); group B, the early elderly (65–74 years, 75 with pancreatic cancer, 43 with bile duct cancer, and 26 with papilla of Vater cancer; a total of 144 subjects); and group C, the super-elderly (75 years or older, 43 with pancreatic cancer, 23 with bile duct cancer, and 15 with papilla of Vater cancer; a total of 81 subjects). We compared the long-term outcomes among the three groups. We also examined risk factors for a poor outcome in group C (including 11 subjects aged 81 years or older).
Results:
~The median postoperative hospital stay of groups A, B, and C was 31, 35, and 34 days, respectively (no significant differences). Mortality within 60 days postoperatively in group A was 0.9% (n = 1; liver metastasis); group B, 2.1% (n = 3; pancreatic fistula 1, bone marrow hypoplasia 1, myocardial infarction 1); and group C, 6.3% (n = 5; pseudoaneurysm rupture 1, catheter infection 1, aspiration pneumonia 1, pneumonia 1, liver metastasis 1). (P = 0.04, between groups A and C). The 3- and 5-year overall survival rate (OS) of group A was 44.7% and 38.2%, respectively; 41.6% and 25.7%, respectively for group B; and 19.8% and 9.9%, respectively for group C. (P < 0.05 between groups A and C, and between groups B and C, respectively). In group C, the 50% survival time for pancreatic cancer, bile duct cancer, and papilla of Vater cancer was 410, 820, and 757 days, respectively. In univariate analysis, primary diseases, postoperative complications (delayed gastric emptying), stage of disease, and comorbidities (diabetes mellitus) were detected as the risk factors of poorer survival in group C. In multivariate analysis, pancreatic cancer was a significant adverse prognostic factor (hazard ratio 3.70 in comparison with papilla of Vater cancer, P=0.04).
Conclusion:
~The validity of PD for bile duct cancer and papilla of Vater cancer was confirmed by appropriate preoperative evaluation and postoperative management in the elderly. However, the mortality associated with infectious diseases was high in the elderly. On the other hand, caution should be used for patients with pancreatic cancer, particularly advanced cases.