Abstract
BackgroundPancreaticoduodenectomy is an increasingly common procedure performed for both benign and malignant disease. There are conflicting data regarding the safety of pancreatic resection in older patients. Potentially modifiable perioperative risk factors to improve outcomes in older patients have yet to be determined.MethodsThe American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database for 2008 to 2009 was used for this retrospective analysis. Patients undergoing pancreaticoduodenectomy were identified and divided into those above and below the age of 65. Preoperative risk factors and postoperative morbidity and mortality were evaluated.ResultsAmong 2,045 patients included in this analysis, 994 patients were >65 years (48.6%) while 1,051 were (less than or equal to) 65 years (51.4%). Thirty-day mortality was higher in the older age group compared to the younger age group 3.6% vs. 1.9% respectively, P = 0.017, odds ratio 1.94. Older patients had a higher incidence of unplanned intubation, ventilator support >48 h and septic shock compared with younger patients. On multivariate logistic regression, after adjusting for other 30-day postoperative occurrences (significant at the P <0.1 level) only septic shock was independently associated with a higher odds of mortality, unplanned intubation, and ventilator support >48 h in older patients compared with younger patients.ConclusionsThis report from a population-based database is the first to highlight postoperative sepsis as an independent risk factor for mortality and morbidity in older patients undergoing pancreatic resection. Careful perioperative management addressing this issue is essential for patients over the age of 65.
Highlights
Pancreaticoduodenectomy is an increasingly common procedure performed for both benign and malignant disease
Older patients had a higher incidence of unplanned intubation, ventilator support >48 h and septic shock compared with younger patients
After adjusting for all risk factors that had a different prevalence between younger and older patients, the odds ratio for septic shock in older compared with younger patients remained essentially unchanged; indicating that none of the evaluated risk factors could explain the observed association between age and septic shock (Table 5). In this large multicenter study, we have found that patients over the age of 65 undergoing pancreaticoduodenectomy have increased postoperative mortality rates compared to younger patients largely due to an increased risk of septic shock
Summary
Pancreaticoduodenectomy is an increasingly common procedure performed for both benign and malignant disease. Modifiable perioperative risk factors to improve outcomes in older patients have yet to be determined. Pancreaticoduodenectomy or the Whipple procedure is a potentially curative treatment for selected pancreatic and periampullary cancers. Over the past three decades, mortality rates following pancreaticoduodenectomy for benign and malignant disease have dropped to less than. Despite advances in adjuvant therapy, the five-year survival rate following pancreaticoduodenectomy for pancreatic cancer remains low at 15 to 25% [4]. In the absence of a uniform cutoff age, identifying older patients at higher risk is cumbersome. Delineating the relative contribution of patient baseline risk factors, operative course and postoperative care to final patient outcomes in older patients is more difficult. While studies from small centers investigating this question lack statistical power, high-volume center studies are flawed by patient selection
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