Abstract
BackgroundThe majority of patients with hepatobiliary and pancreatic (HBP) malignancies are older than 65 years. Due to the heterogeneity of this older population, decisions regarding surgical treatment cannot rely solely on treatment guidelines, but have to take into account patient frailty, geriatric impairments and resilience as well as patient preferences. In the few studies of older patients with HBP malignancies that have included a preoperative geriatric assessment (GA), frailty and elements from the GA such as reduced functional status have emerged as powerful predictors of postoperative morbidity and mortality, length of stay, type of treatment received and survival. A GA is a systematic evaluation of functional status, comorbidities, polypharmacy, cognition, nutritional status, emotional status, and social support. Materials and methodsA Pubmed search identifying clinical studies investigating the association between frailty, GA and outcomes in patients with HBP malignancies. ResultsA total of 20 studies were included in this review. For HBP malignancies, the evidence linking frailty and GA variables to negative outcomes is limited, but generally shows that frailty, functional dependency, comorbidity, and sarcopenia predict postoperative complications and survival. ConclusionAlthough scarcely investigated, frailty and elements from a GA seem to be associated with negative short- and long-term treatment outcomes in older patients with HBP malignancies. Future studies should investigate the impact of geriatric interventions and prehabilitation on outcomes.
Highlights
The majority of patients with hepatobiliary and pancreatic (HBP) malignancies are older than 65 years
In a cohort of 6293 patients who underwent pancreaticoduodenectomy (PD) included in the National Surgical Quality Improvement Program (NSQIP) database for 2005e2009, they looked at 30-day postoperative mortality, major complication rate and overall complication rate and compared younger patients to the 9.4% of patients who were older than 79 years
Age was an independent predictor of all outcomes, but the multivariate analysis showed that decreased functional status had the greatest predictive value for postoperative mortality (odds ratio (OR) 2.80, 95% CI 2.73e4.51) and major complication rate
Summary
The majority of patients with hepatobiliary and pancreatic (HBP) malignancies are older than 65 years. Benefits of surgery seen in non-frail older patients may not be evident in frail patients, and the decision-making needs to incorporate elements of a geriatric assessment (GA) to evaluate frailty. A GA is a structured evaluation of areas where older patients often present with impairments, and includes functional and cognitive status, mobility, sarcopenia, comorbidities, polypharmacy, emotional status, nutritional status, and social network. Based on this assessment the degree of frailty can be estimated, impairments can be targeted (prehabilitation), and shared decision-making can be informed [3]. Future studies should investigate the impact of geriatric interventions and prehabilitation on outcomes
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