Outcomes In Octogenarians Research Articles

Case Series of Skull Base Meningioma Resection in the Octogenarian Population.

Introduction The geriatric population is the fastest growing segment of the American population, and octogenarians are increasingly seen by neurosurgeons for relatively common lesions such as meningiomas. Unfortunately, providers do not have clear data to guide decision-making regarding these lesions, particularly if they involve the skull base. Current research in outcomes among the elderly looks at a wide range of ages, often anyone older than 65. Previous studies in octogenarians report a wide-range of mortality rates and do not focus on skull base lesions. This paper strives to clarify the experiences and outcomes of octogenarians. Patients and Methods This retrospective series reviews skull base tumor surgeries performed at a single academic institution over the past 15 years in octogenarian patients. Primary endpoint was 30-day mortality; however, potential risk factors, perioperative morbidity, postdischarge disposition, and longer term follow-up were also captured. Multivariate logistic regression was performed to identify relevant perioperative and medical characteristics that increases the risk of adverse events. Results Fourteen patients underwent craniotomies for skull base procedures with an average age of 84.5, with a 14% 30-day mortality rate. One patient required a tracheostomy on discharge and approximately half were able to either go home or rehabilitation after their procedure. On statistical analysis, there were no noted characteristics that predisposed any of the patients to a poorer outcome. Conclusion Octogenarian patients were able to tolerate surgery for skull base meningiomas resection. This outcome data may be used to inform surgical decision and guide conversation with patients and their families.

Fenestrated-branched endovascular aortic repair is a safe and effective option for octogenarians in treating complex aortic aneurysm compared with nonoctogenarians

ObjectiveOpen repair of complex aortic aneurysms is frequently not an option for octogenarians because of prohibitive surgical risks. This study aimed to analyze the outcomes of fenestrated-branched endovascular aortic repair (F-BEVAR) in octogenarians (≥80 years old) compared with nonoctogenarians (<80 years old). MethodsWe reviewed 893 patients with pararenal or extent I to V thoracoabdominal aneurysms, enrolled in six prospective physician-sponsored investigational device exemption studies from 2012 to 2018. All patients were treated with either company-manufactured off-the-shelf or patient-specific F-BEVAR stent grafts. Data analyzed included demographics, cardiovascular risk factors, history of active cancer, American Society of Anesthesiologists classification, aortic anatomy characteristics, and procedural data. End points included mortality, major adverse events (all-cause mortality, stroke, paralysis, acute kidney injury [RIFLE criteria], dialysis, myocardial infarction, respiratory failure, and bowel ischemia), technical success, hospital length of stay, target artery instability (occlusion/stenosis, endoleak, rupture or death), and secondary interventions. ResultsDuring the study period, 195 octogenarian patients (22%) and 698 (78%) nonoctogenarian patients were treated with F-BEVAR. Octogenarians presented more frequently with a history of cancer (17% vs 11%; P = .01), whereas nonoctogenarians more frequently had hyperlipidemia (76% vs 65%; P = .003), chronic obstructive pulmonary disease (42% vs 33%; P = .04) and American Society of Anesthesiologists class III to V (78% vs 70%; P = .02). Male sex was similar between groups (68% [octogenarians] vs 70% [nonoctogenarians]; P = .62). Octogenarians had a larger mean aneurysm diameter (67 ± 1 mm vs 65 ± 1 mm; P = .002). The thoracoabdominal classification and the use of upper extremity access were similar between groups. Estimated blood loss was also similar (484 ± 454 mL [octogenarian] vs 416 ± 457 mL [nonoctogenarian]; P = .07). Octogenarians had an increased mean number of vessels incorporated into the repair (3.1 ± 1.4 vs 2.7 ± 1.7; P < .001). The technical success rate was 99% for octogenarians and 97% for nonoctogenarians (P = .19). The 30-day mortality rate was 0.5% for octogenarians and 1.3% for the nonoctogenarians (P = .70). Major adverse events (9.2% vs 9.7%), types I/III endoleak (4.6% vs 2.4%) access complication (3.1% vs 3.3%), and length of stay (8.2 ± 27 days vs 5.7 ± 6.3 days) were all similar between the groups. Freedom from target artery instability and freedom from secondary interventions at 3 years were similar between the groups. Octogenarian survival was lower at 3 years compared with nonoctogenarians on univariate analysis (log-rank P < .01) and on multivariable analysis after adjusting for history of active cancer, hyperlipidemia, and chronic obstructive pulmonary disease. ConclusionsDespite small differences in demographics, anatomic factors, and procedural data, F-BEVAR was safe and effective with nearly identical early outcomes in octogenarians in these experienced aortic centers. More extensive clinical experience and longer follow-up are needed to better delineate factors impacting longer term mortality.

Frailty, and not medicines with anticholinergic or sedative effects, predicts adverse outcomes in octogenarians admitted for myocardial infarction: Population-level study.

To determine independent associations between the use of medicines with anticholinergic or sedative effects and frailty with outcomes of length of stay (LOS), coronary artery procedure performed and 30-day deaths in octogenarians admitted for a myocardial infarction (MI). We quantified patient exposure to medicines with anticholinergic or sedative effects using the drug burden index (DBI) and frailty using the hospital frailty risk score (HFRS). We used multivariable regression methods to determine the association between DBI and HFRS with outcomes of LOS, coronary artery procedures performed and 30-day deaths. HFRS and not DBI score was significantly associated with receipt of coronary artery procedures (odds ratio [OR] 0.42; 95% CI 0.28-0.62 for high- versus low-risk groups) and 30-day deaths (OR 1.58; 95% CI 1.12-2.24 for high- versus low-risk groups). Frailty risk is a more important predictor of outcomes than DBI score for octogenarians with an MI.

The Effect of Place of Residence on Treatment Outcomes and Survival in Octogenarian and Nonagenarian Breast Cancer Patients.

IntroductionThe number of octogenarian invasive breast cancer cases is projected to increase, as there is a significant increase in life expectancy. However, no specific treatment guideline has been established so far for this vulnerable group of patients. The aim of the present study was to evaluate the treatment outcomes of octogenarians diagnosed with early and locally advanced invasive breast cancer, to compare those who underwent surgery with conventional treatment and those who did not, and to reveal the potential social factors that may affect their therapy outcomes.Material and methodsA total of 78 patients aged 80 and over were included in the study. There was a significant relationship between a patient’s social milieu and treatment status (p < 0.001). The relationship between receiving endocrine therapy or surgical treatment was also significant (p = 0.029).ResultsThe surgical treatment rate was 90.9% in survivors, which was significantly lower in those who passed away (37.8%, p < 0.001). According to the log-rank test results, life expectancy was significantly longer in operated patients than in non-operated ones (p < 0.001). The median survival length was 62 months (range: 33.8-90.2) in operated patients 80 years of age and above and 19 months (range: 16.3-21.7) in non-operated ones. The surgical treatment frequency was 15.30 times (range: 4.86-48.21) higher in patients living with family than in patients living alone or in a nursing home.ConclusionThus, the social milieu of the patients, especially the place of residence, had a major impact on the treatment of the elderly (octogenarians) patients with breast cancer. Surgery and endocrine therapy as an adjuvant treatment were tolerable and had positive impacts on survival.

Limited Lymph Node Resection Does Not Decrease Postoperative Mortality After Esophagectomy in Octogenarians With Thoracic Esophageal Cancer

BackgroundOctogenarians with esophageal cancer typically have a poor physical condition, reduced physiological reserves, and high postoperative mortality (POM). Extensive lymph node dissection increases surgical trauma and postoperative complications. The purpose of this study was to examine the associations between the number of dissected lymph nodes and short-term and long-term postoperative outcomes in octogenarians with thoracic esophageal cancer. MethodsWe examined the data of patients from the Surveillance, Epidemiology, and End Results database. We divided the patients into two groups in accordance with the number of lymph nodes dissected: patients with <15 examined lymph nodes (eLNs) and patients with ≥15 eLNs. Mortality was quantified at 30, 60, and 90 d after surgery. Univariable and multivariable logistic regression analyses were performed to identify predictors of 90-day mortality. Kaplan–Meier analysis and the log-rank test were used to analyze the overall survival and cause-specific survival of the patients. ResultsA total of 208 octogenarians with thoracic esophageal cancer were included in the analysis. The 30-day POM rates were 10.3% and 6.9%, the 60-day POM rates were 16.9% and 13.9%, and the 90-day POM rates were 21.3% and 19.4% for patients with <15 eLNs and ≥15 eLNs, respectively. However, the differences in POM between the two groups were statistically nonsignificant (all P > 0.05). In accordance with the multivariable logistic regression analysis, age and marital status were significantly associated with 90-day POM. Furthermore, no significant difference was found between the groups in terms of long-term survival. The 5-year overall survival rates were 29% and 26.8% (P = 0.719) and the 5-year cause-specific survival rates were 43.2% and 34.1% (P = 0.446) in patients with <15 eLNs and ≥15 eLNs, respectively. ConclusionsWe have demonstrated that octogenarians undergoing esophagectomy are associated with an unacceptably high POM, and less extensive lymph node resection does not decrease POM. Octogenarians may not benefit from esophagectomy with lymphadenectomy. Additional studies need to be conducted to further guide clinicians performing highly selective esophagectomy.

Impacts of incomplete revascularization following off-pump coronary artery bypass grafting on perioperative outcomes in octogenarians

Objective: To assess the impacts of incomplete revascularization following off-pump coronary artery bypass grafting (OPCABG) on perioperative outcomes in octogenarians. Methods: A retrospective analysis of 242 octogenarian patients with coronary artery disease (CAD) hospitalized in Beijing Anzhen Hospital from June 2008 to July 2016 was performed. These patients were divided into the complete revascularization group (n=181) and the incomplete revascularization group (n=61) depending on whether they underwent complete revascularization. The impacts of incomplete revascularization following OPCABG on perioperative outcomes were summarized and compared between the two groups. Results: Among the 242 patients over 80 years who received OPCABG, there were 198 males (81.8%). Compared to the complete revascularization group, those in the incomplete revascularization group were older [(83.2±1.5) vs (81.5±1.1) years old, P=0.03], with more carotid stenosis (44.3% vs 25.4%, P=0.01), more involved in the diagonal and circumflex branch of coronary artery (49.2% vs 17.1%, P=0.01; 83.6% vs 70.2%, P=0.03), shorter operative time [(4.1±1.7) h vs (4.7±1.2) h, P=0.03), longer preoperative [(7.1±2.3) d vs (5.2±2.0) d, P=0.01] and total hospitalization time [(16.3±6.8) d vs (12.5±4.2) d, P=0.01], however, the differences of the in-hospital mortality and incidence of other perioperative complications were not statistically significant between the two groups (all P>0.05). Conclusion: Compared with complete revascularization, incomplete revascularization following OPCABG in CAD patients over 80 years old does not increase the perioperative mortality and the incidence of other complications, and it reduces the operative time. However, it increases the time of preoperative and total hospital stay.

Impact of endovascular repair on the outcomes of octogenarians with ruptured abdominal aortic aneurysms: a nationwide Japanese study

Abstract Objective This study aimed to clarify the impact of endovascular aneurysm repair (EVAR) on clinical outcomes in Japanese patients of advanced age with ruptured abdominal aortic aneurysm (rAAA). Methods This was a national registry based retrospective comparative study, using data from the Japanese Registry Of All cardiac and vascular Diseases-Diagnostic Procedure Combination (JROAD-DPC), a nationwide claim based database from more than 600 hospitals. Patients admitted with rAAA between April 1, 2012, and March 31, 2015 were included in the study. Patient characteristics, management, and outcomes were compared between the elderly (aged ≥80 y) and the less old. The primary endpoint was in hospital mortality; the secondary endpoint was the functional status at discharge. Results Of 3 969 eligible patients, 49.9% were categorised as elderly. Elderly patients had a higher prevalence of female gender (41.8% vs. 17.0%, p&amp;lt;0.001) and disturbance of consciousness on admission (28.6% vs. 20.7%, p&amp;lt;0.001). They were less likely to undergo open surgical repair (31.6% vs. 56.7%, p&amp;lt;0.001), although EVAR was performed similarly in both groups (13.7% vs. 14.8%, p&amp;lt;0.33). The unadjusted mortality rate (61.8% vs. 37.6%, p&amp;lt;0.001) and mean Barthel index at discharge (73.0 vs. 91.8, p&amp;lt;0.001) were statistically significantly worse in the elderly. Multilevel mixed effect logistic regression analyses showed that old age was detected as an independent predictor of in hospital death (odds ratio 2.75; 95% confidence interval, 2.39–3.17; p&amp;lt;0.001). However, for patients who received EVAR, old age was not statistically significant (odds ratio 1.13; 95% confidence interval, 0.77–1.66; p&amp;lt;0.53). Conclusion Elderly patients with rAAA were less likely to be offered open surgical repair, and the mortality among those who received surgery was high. However, for the small subgroup of elderly patients currently selected for EVAR there was a favourable outcome. The further implementation of EVAR for rAAA in Japan, especially for elderly patients with suitable anatomy, may be justified. Funding Acknowledgement Type of funding source: None

Colorectal EMR outcomes in octogenarians versus younger patients referred for removal of large (≥20 mm) nonpedunculated polyps

Data are limited on safety and outcomes of colorectal EMR in octogenarians (≥80 years old). We sought to review outcome data for patients aged≥80 in a prospectively collected database of patients referred for large polyp removal. We retrospectively evaluated a database of patients referred for large (≥20mm) nonpedunculated polyp removal. From 2000 to 2019, we compared the rates of follow-up, recurrence, adverse events, and synchronous neoplasia detection between younger patients and patients aged≥80. There were 167 patients aged≥80 years and 1686<80 years. Patients in the elderly group returned for surveillance less often (67.1% vs 75.1%, P= .024), had greater first follow-up recurrence rates (27.5% vs 13.8%, P< .001), but had similar adverse event rates (1.8% vs 2.8%, P= .619) compared with younger patients. Rates of synchronous neoplasia were similar and high in both groups. EMR is safe and well tolerated for large polyp removal in patients over 80 years old. Patients aged≥80 years are less likely to present for follow-up after EMR. They had a higher recurrence rate and a similarly high prevalence of synchronous precancerous lesions. Follow-up after EMR should be encouraged in the elderly, and an attempt to clear the colon of synchronous disease at the time of the initial EMR may be warranted.

Outcomes in Octogenarians with Multiple Lower Extremity Fractures

Dimitroulias, Apostolos; Parsikia, Afshin MD; Lewis, Erin MD; McNelis, John MD, FACS, FCCM Author Information

Surviving Sepsis Campaign Implementation In Octogenarians And Nonagenarians With Heart Failure And Septic Shock. Implications, And Clinically Relevant Outcomes

Background With the growing aging population, the incidence and prevalence of heart failure (HF) have increased to epidemic proportions. HF patients, especially the elderly, are more prone to develop severe infections, such as sepsis. However, the clinical characteristics, management, and outcomes of octogenarians and nonagenarians with HF that develop septic shock are unknown. Methods This retrospective cohort study included 356 patients with HF and septic shock admitted to a tertiary cardiovascular center between 01/2015 and 06/2018. Age was dichotomized into ≥80 years [octogenarians (80-89) and nonagenarians (90-99)] and Results Out of the 365 patients with HF and septic shock, 157(44%) were ≥80 years of age (octogenarians and nonagenarians), and the remainder were Outcomes In-hospital mortality was significantly higher for octogenarians and nonagenarians 61% (95/157) vs 45% (89/199) p=0.0053. Furthermore, the implementations of the Surviving Sepsis Campaign bundle (30ml/kg bolus of intravenous crystalloids) was more likely to cause pulmonary edema requiring intravenous diuresis in patients Conclusion Octogenarians and nonagenarians with heart failure and septic shock have significantly higher mortality than other age groups despite the similar implementation of the Surviving Sepsis Campaign. A tailored protocol that addresses the specific characteristics of this population is urgently needed.

Long-term outcomes of laparoscopic surgery in elderly patients with colorectal cancer: A single institutional matched case-control study.

The number of elderly patients with colorectal cancer has gradually increased. Laparoscopic colorectal surgery is widely used to approach colorectal cancer. The aim of this study was to evaluate long-term outcomes in octogenarians who underwent laparoscopic colorectal surgery for colorectal cancer. This study included 158 patients aged 80 or over who underwent surgery for colorectal cancer between 2010 and 2015. We compared long-term outcomes of a laparoscopic colorectal surgery group with those of an open colorectal surgery group by propensity score matching equalizing factors that could affect prognosis such as prognostic nutritional index and Charlson comorbidity index score. Forty-eight pairs were selected after propensity score matching. The cancer-specific 5-year survival rate was 97.1% in the laparoscopic colorectal surgery group and 87.6% in the open colorectal surgery group (P = .17). The overall 5-year survival rate was 77.3% in the laparoscopic colorectal surgery group and 73.9% in the open colorectal surgery group (P = .32). The 5-year recurrence-free survival rate was 95.1% in the laparoscopic colorectal surgery group and 85.4% in the open colorectal surgery group (P = .14). Laparoscopic colorectal surgery for octogenarians with colorectal cancer achieves similar oncological outcomes to open colorectal surgery and should be considered as a treatment option.

Octogenarians and Nonoctogenarians Have Similar Outcomes after Upper Extremity Hemodialysis Access Creation

Routine arteriovenous (AV) access creation in octogenarians is controversial. Our goal was to assess perioperative and long-term outcomes in octogenarians after undergoing upper extremity AV access to determine whether advanced age should influence AV access decision-making. All AV access creations performed at a single institution from 2014-2018 were retrospectively reviewed. Patients were categorized as octogenarians and nonoctogenarians. Perioperative short-term outcomes were compared. Among 620 patients who underwent AV access creation, there were 40 octogenarians and 580 nonoctogenarians. Octogenarians were more likely to have private insurance, coronary artery disease, dementia, previous stroke, impaired ambulation, and less likely to be current smokers. There were no differences in outpatient status or tunneled dialysis catheter presence at creation. Access types were similar radiocephalic (12.5% vs. 14.3%), brachiocephalic (50% vs. 42.6%), brachiobasilic (12.5% vs. 26.2%), and grafts (25% vs. 13.8%). Univariable analysis demonstrated no differences in perioperative return to the operating room, hematoma, and patency loss. There were no differences in 90-day mortality (OR 0.46, 95% CI 0-2.5, P=0.25), readmission (OR 1.36, 95% CI 0.67-2.76, P=0.39), maturation (OR 0.97, 95% CI 0.46-2.01, P=0.93), or reintervention (HR 0.9, 95% CI 0.64-1.25, P=0.53). Octogenarians had lower two-year survival (82.5% vs. 91.9%, P<0.001), but there was no difference in reintervention-free survival (55% vs. 47%, P=0.47) or occlusion-free survival (25% vs. 24%, P=0.62). Octogenarians and nonoctogenarians have similar outcomes after upper extremity dialysis access creation. Advanced age alone should not influence dialysis access creation.

Poor outcome of octogenarians admitted to ICU due to periprosthetic joint infections: a retrospective cohort study

BackgroundEven though surgical techniques and implants have evolved, periprosthetic joint infection (PJI) remains a serious complication leading to poor postoperative outcome and a high mortality. The literature is lacking in studies reporting the mortality of very elderly patients with periprosthetic joint infections, especially in cases when an intensive care unit (ICU) treatment was necessary. We therefore present the first study analyzing patients with an age 80 and higher suffering from a periprosthetic joint infection who had to be admitted to the ICU.MethodsAll patients aged 80 and higher who suffered from a PJI (acute and chronic) after THR or TKR and who have been admitted to the ICU have been included in this retrospective, observational, single-center study.ResultsA total of 57 patients met the inclusion criteria. The cohort consisted of 24 males and 33 females with a mean age of 84.49 (± 4.0) years. The mean SAPS II score was 27.05 (± 15.7), the mean CCI was 3.35 (± 2.28) and the most patient had an ASA score of 3 or higher. The PJI was located at the hip in 71.9% or at the knee in 24.6%. Two patients (3.5%) suffered from a PJI at both locations. Sixteen patients did not survive the ICU stay. Non-survivors showed significantly higher CCI (4.94 vs. 2.73; p = 0.02), higher SAPS II score (34.06 vs. 24.32; p = 0.03), significant more patients who underwent an invasive ventilation (132.7 vs. 28.1; p = 0.006) and significantly more patients who needed RRT (4.9% vs. 50%; p < 0.001). In multivariate analysis, RRT (odds ratio (OR) 15.4, CI 1.69–140.85; p = 0.015), invasive ventilation (OR 9.6, CI 1.28–71.9; p = 0.028) and CCI (OR 1.5, CI 1.004–2.12; p = 0.048) were independent risk factors for mortality.ConclusionVery elderly patients with PJI who needs to be admitted to the ICU are at risk to suffer from a poor outcome. Several risk factors including a chronic infection, high SAPS II Score, high CCI, invasive ventilation and RRT might be associated with a poor outcome.

Impact of Endovascular Repair on the Outcomes of Octogenarians with Ruptured Abdominal Aortic Aneurysms: A Nationwide Japanese Study

This study aimed to clarify the impact of endovascular aneurysm repair (EVAR) on clinical outcomes in Japanese patients of advanced age with ruptured abdominal aortic aneurysm (rAAA). This was a national registry based retrospective comparative study, using data from the Japanese Registry Of All cardiac and vascular Diseases-Diagnostic Procedure Combination (JROAD-DPC), a nationwide claim based database from more than 600 hospitals. Patients admitted with rAAA between April 1, 2012, and March 31, 2015 were included in the study. Patient characteristics, management, and outcomes were compared between the elderly (aged ≥ 80 y) and the less old. The primary endpoint was in hospital mortality; the secondary endpoint was the functional status at discharge. Of 3 969 eligible patients, 49.9% were categorised as elderly. Elderly patients had a higher prevalence of female gender (41.8% vs. 17.0%, p < .001) and disturbance of consciousness on admission (28.6% vs. 20.7%, p < .001). They were less likely to undergo open surgical repair (31.6% vs. 56.7%, p < .001), although EVAR was performed similarly in both groups (13.7% vs. 14.8%, p = .33). The unadjusted mortality rate (61.8% vs. 37.6%, p < .001) and mean Barthel index at discharge (73.0 vs. 91.8, p < .001) were statistically significantly worse in the elderly. Multilevel mixed effect logistic regression analyses showed that old age was detected as an independent predictor of in hospital death (odds ratio 2.75; 95% confidence interval, 2.39–3.17; p < .001). However, for patients who received EVAR, old age was not statistically significant (odds ratio 1.13; 95% confidence interval, 0.77–1.66; p = .53). Elderly patients with rAAA were less likely to be offered open surgical repair, and the mortality among those who received surgery was high. However, for the small subgroup of elderly patients currently selected for EVAR there was a favourable outcome. The further implementation of EVAR for rAAA in Japan, especially for elderly patients with suitable anatomy, may be justified.

Abstract TP17: Outcomes in Octogenarians Undergoing Mechanical Thrombectomy for Acute Ischemic Stroke: A Single Center Experience

Background: Mechanical thrombectomy (MT) for acute ischemic stroke (AIS) in the elderly presents a unique set of challenges and opportunities. Most existing studies include patients up to the age of 90 with stricter criteria of inclusion for patients ≥ 80 years of age. The following study compares the outcomes in octogenarians compared to younger patients in a single center. Methods: We conducted a retrospective chart review of patients who were ≥ 80yo who underwent MT from March 2016 to July 2019. Data on age, recanalization score measured by Thrombolysis in Cerebral Infarction (TICI) score and clinical outcomes were compared to 126 patients &lt; 80 years of age treated during the same time period. Clinical outcomes were classified based on modified Rankin score (mRS) at discharge. Poor outcomes were defined as mRS 4-6. Good recanalization was defined as TICI score 2b or 3. Results: Eighty-three patients with a median age of 86±4.34yo were compared to 126 patients with median age of 63±12.48yo (p&lt;0.0001). Good recanalization was achieved in 74% of patients ≥80yo compared to 84% in patients &lt;80yo (p= 0.06). Poor outcomes were reported in 74.6% of patients ≥80yo compared to 47.0% in patients &lt;80yo (p&lt;0.0001). All-cause mortality was 28.9% in the ≥80yo vs 12.9% in the &lt; 80yo (p=0.006). Conclusion: In our cohort, the clinical outcomes among octogenarians receiving MT were worse than in younger patients despite no difference in recanalization. Various factors may be responsible including overall health status, comorbid conditions and neuroplasticity. Further prospective multicentral studies are needed to better understand the benefit of MT in octogenarians.

Pancreatic resections: 30 and 90-day outcomes in octogenarians

BackgroundPancreatic tumors are frequently found in a geriatric population. Given that the median age of patients with pancreatic cancer is 70 years at diagnosis and the ubiquity of CT and MRI imaging has increased the detection of pancreas masses, pancreatic surgeons often find themselves operating on patients of advanced age. This study sought to evaluate the outcomes of pancreatic resection in an octogenarian population at a single institution with a dedicated surgical oncology team. Study designA retrospective chart review was performed for all patients undergoing pancreatic resection over a 13-year period at an academic community cancer center. Patient characteristics and operative outcomes were compared between patients aged 80 and older, and those younger than 80. Student t-tests, Fisher's exact test, and Kruskal-Wallis tests were used for univariate analyses. ResultsOver the 13-year period, a total of 48 patients of 403 undergoing pancreatic resections were aged 80 or older. Of these 48 patients, 35 underwent pancreaticoduodenectomy (Whipple) and 13 underwent distal pancreatectomy. Patient characteristics including ASA classification were similar among the two age groups. The procedures themselves were equally complicated with similar operative times, transfusion requirements, estimated blood losses, and portal vein resections. The number and severity of complications such as delayed gastric emptying and pancreatic leak were not statistically different between the two groups. Additionally, the 30-day reoperation, readmission, and mortality rates were not statistically different. Outcomes at 90-days revealed an increased rate of readmission amongst octogenarians who underwent Whipple without an increase in rates of major complications. The total number of deaths in the octogenarian group was 3 (6.2%) vs. 6 (1.7%) in the non-octogenarian group (p = 0.080). The median length of stay was similar amongst the two age groups. ConclusionsAt a large-volume academic community cancer center with a dedicated surgical oncology team, highly selected octogenarians can undergo pancreatic resection safely with outcomes that do not differ significantly from their younger counterparts.

Pancreaticoduodenectomy in octogenarians: A UK multicentre case-control study

Presenter: Joseph Attard MD, MSc, MRCSEd | Queen Elizabeth Hospital Background: As a result of the ageing population, pancreaticoduodenectomy is increasingly being offered as curative therapy for periampullary tumours in patients 80 years of age and older. Our aim was to evaluate clinical outcomes and provide evidence on current UK practice in the elderly population after pancreaticoduodenectomy. Methods: A multicentre retrospective case-control analysis of prospectively-maintained databases was performed. This included pancreaticoduodenectomies undertaken between January 2008 and December 2017. Octogenarians who underwent pancreaticoduodenectomy were matched with consecutively-operated younger patients with 1:1 ratio, based on extent of surgery (venous, arterial or additional resection). Pre-operative comorbidities, intra-operative variables, post-operative complications and mortality were compared. Chi-Square, Fisher’s Exact and Mann-Whitney U tests were used as appropriate to compare variables and outcomes between the two groups, with statistical significance set at p<0.05. A survival analysis, using Kaplan-Meier estimators, was also performed to determine overall survival as well as disease-free survival. Results: Six UK specialist HPB centres participated in this study. 181 octogenarians (median age 81 years, range: 80 - 90) who underwent pancreaticoduodenectomy (either classical or pylorus-preserving) were compared to the same number of controls (median age 67 years, range: 31 - 79). Gender and ASA (octogenarians median grade 2 [range: 1 - 4] versus median grade 2 [range: 1 - 3] for controls) were comparable (p=0.75 and p=0.82 respectively). The distribution of performance status scores (octogenarian median score 0 [range: 0 - 3] versus median score 0 [range: 0 - 2] for non-octogenarians) was found to be significantly different (p=0.02). Similarly, Charlson Comorbidity Index scores were significantly higher overall for octogenarians (median 7 [range: 6 - 11] versus 5 [range: 2 -9], p=0.001). Ninety-nine percent of octogenarians and 97% of controls were offered upfront resection. The remainder underwent neoadjuvant treatment prior to surgery. Median length of hospital stay was longer in octogenarians, 17 days (range: 3 – 120 days) compared to 13 days (range: 5 – 81 days) for controls (p=0.001). Negative resection margin (R0) rates were comparable for the two groups, 61% for octogenarians and 58% for controls (p=0.57), as were lymph node ratios, median 0.1 (range: 0 – 0.8) for octogenarians and 0.095 (range: 0 – 1) for controls, p=0.77. Complication rates across the Clavien-Dindo classification categories were not statistically significant (p>0.05 in all categories). Thirty-day mortality was 3 % for octogenarians and 2% for controls (p=0.54). Ninety-day mortality was 7% for octogenarians versus 3% for controls. This difference was not statistically significant (p=0.1). A survival analysis revealed that, while median overall survival was significantly longer for controls, 59 months versus 23 months for octogenarians, (p=0.006); disease-free survival was not statistically different between both groups, with a median of 19 months for octogenarians and 28 months for controls (p=0.22). Median follow-up was 13 months (range: 0 – 100) for octogenarians and 17 months (0 – 111) for controls. Conclusion: Despite the higher ninety-day mortality, pancreaticoduodenectomy outcomes in octogenarians are comparable to their younger counterparts. Pancreaticoduodenectomy should therefore be offered as a curative surgical option in this cohort, in specialised centres after meticulous preoperative assessment.

Impact of Endovascular Repair on the Outcomes of Octogenarians with Ruptured Abdominal Aortic Aneurysms: A Nationwide Japanese Study.

This study aimed to clarify the impact of endovascular aneurysm repair (EVAR) on clinical outcomes in Japanese patients of advanced age with ruptured abdominal aortic aneurysm (rAAA). This was a national registry based retrospective comparative study, using data from the Japanese Registry Of All cardiac and vascular Diseases-Diagnostic Procedure Combination (JROAD-DPC), a nationwide claim based database from more than 600 hospitals. Patients admitted with rAAA between April 1, 2012, and March 31, 2015 were included in the study. Patient characteristics, management, and outcomes were compared between the elderly (aged≥80y) and the less old. The primary endpoint was in hospital mortality; the secondary endpoint was the functional status at discharge. Of 3 969 eligible patients, 49.9% were categorised as elderly. Elderly patients had a higher prevalence of female gender (41.8% vs. 17.0%, p<.001) and disturbance of consciousness on admission (28.6% vs. 20.7%, p<.001). They were less likely to undergo open surgical repair (31.6% vs. 56.7%, p<.001), although EVAR was performed similarly in both groups (13.7% vs. 14.8%, p=.33). The unadjusted mortality rate (61.8% vs. 37.6%, p<.001) and mean Barthel index at discharge (73.0 vs. 91.8, p<.001) were statistically significantly worse in the elderly. Multilevel mixed effect logistic regression analyses showed that old age was detected as an independent predictor of in hospital death (odds ratio 2.75; 95% confidence interval, 2.39-3.17; p<.001). However, for patients who received EVAR, old age was not statistically significant (odds ratio 1.13; 95% confidence interval, 0.77-1.66; p=.53). Elderly patients with rAAA were less likely to be offered open surgical repair, and the mortality among those who received surgery was high. However, for the small subgroup of elderly patients currently selected for EVAR there was a favourable outcome. The further implementation of EVAR for rAAA in Japan, especially for elderly patients with suitable anatomy, may be justified.

Fenestrated-branched Endovascular Aortic Repair (F-BEVAR) is a Safe and Effective Option for Octogenarians in Treating Complex Aortic Aneurysm (CAA) Compared to Non-octogenarians

OBJECTIVE Open repair of complex aortic aneurysms is frequently not an option for octogenarians because of prohibitive surgical risks. This study aimed to analyze the outcomes of fenestrated-branched endovascular aortic repair (F-BEVAR) in octogenarians (≥80 years old) compared with nonoctogenarians (<80 years old). METHODS We reviewed 893 patients with pararenal or extent I to V thoracoabdominal aneurysms, enrolled in six prospective physician-sponsored investigational device exemption studies from 2012 to 2018. All patients were treated with either company-manufactured off-the-shelf or patient-specific F-BEVAR stent grafts. Data analyzed included demographics, cardiovascular risk factors, history of active cancer, American Society of Anesthesiologists classification, aortic anatomy characteristics, and procedural data. End points included mortality, major adverse events (all-cause mortality, stroke, paralysis, acute kidney injury [RIFLE criteria], dialysis, myocardial infarction, respiratory failure, and bowel ischemia), technical success, hospital length of stay, target artery instability (occlusion/stenosis, endoleak, rupture or death), and secondary interventions. RESULTS During the study period, 195 octogenarian patients (22%) and 698 (78%) nonoctogenarian patients were treated with F-BEVAR. Octogenarians presented more frequently with a history of cancer (17% vs 11%; P = .01), whereas nonoctogenarians more frequently had hyperlipidemia (76% vs 65%; P = .003), chronic obstructive pulmonary disease (42% vs 33%; P = .04) and American Society of Anesthesiologists class III to V (78% vs 70%; P = .02). Male sex was similar between groups (68% [octogenarians] vs 70% [nonoctogenarians]; P = .62). Octogenarians had a larger mean aneurysm diameter (67 ± 1 mm vs 65 ± 1 mm; P = .002). The thoracoabdominal classification and the use of upper extremity access were similar between groups. Estimated blood loss was also similar (484 ± 454 mL [octogenarian] vs 416 ± 457 mL [nonoctogenarian]; P = .07). Octogenarians had an increased mean number of vessels incorporated into the repair (3.1 ± 1.4 vs 2.7 ± 1.7; P < .001). The technical success rate was 99% for octogenarians and 97% for nonoctogenarians (P = .19). The 30-day mortality rate was 0.5% for octogenarians and 1.3% for the nonoctogenarians (P = .70). Major adverse events (9.2% vs 9.7%), types I/III endoleak (4.6% vs 2.4%) access complication (3.1% vs 3.3%), and length of stay (8.2 ± 27 days vs 5.7 ± 6.3 days) were all similar between the groups. Freedom from target artery instability and freedom from secondary interventions at 3 years were similar between the groups. Octogenarian survival was lower at 3 years compared with nonoctogenarians on univariate analysis (log-rank P < .01) and on multivariable analysis after adjusting for history of active cancer, hyperlipidemia, and chronic obstructive pulmonary disease. CONCLUSIONS Despite small differences in demographics, anatomic factors, and procedural data, F-BEVAR was safe and effective with nearly identical early outcomes in octogenarians in these experienced aortic centers. More extensive clinical experience and longer follow-up are needed to better delineate factors impacting longer term mortality.

Outcomes of Octogenarians in Lower Extremity Endovascular Revascularization

Introduction - Endovascular surgery has evolved over the last decade to become a viable alternative for peripheral arterial disease (PAD) in high-risk patients due to medical comorbidities including advanced age. Efficacy trials continue to be done but high-risk patients are often preferentially offered endovascular interventions. The aim of this study was to compare outcomes between non-octogenarians and octogenarians following lower extremity endovascular revascularization (LEER). Methods - The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) LEER-targeted surgical cohort (2011-2014) was used to separately examine patients that underwent tibial (TB) or femoropopliteal (FP) angioplasty/stenting interventions. Disease, patient, clinical, and procedural characteristics were extracted (with data from 30 days of postsurgical follow-up), and evaluated using univariate/bivariate analyses (student t, χ2, and Fisher’s exact tests). Independent risk factors and trends were evaluated using multivariate logistic regression. Outcomes included 30-day mortality; readmission; loss of patency (LOP); as well as postoperative wound infection (WI), major amputation, and bleeding requiring intervention/transfusion. Results - The FP endovascular cohort consisted of 4193 patients. 30-day mortality was low (0.91%) and resulted in poor model-fit for both cohorts. Those 80+ years old had a slightly longer length of stay (LOS), higher physiological risk factors (PRF), similar elective vs emergent procedures, and a higher prevalence of CHF. The younger group exhibited more ESRD and HTN. 12.34% of patients were readmitted with age over 80 years, emergent procedures, PRF, ESRD, HTN, WI, and antiplatelet regimen as independent risk factors. Female gender was an independent risk factor for bleeding, as was smoking, emergent procedures, history of CHF, and WI. Major amputation was uncommon (2.55%); however, age, obesity, emergent procedures, bleeding, and WI were significant independent predictors. LOP (1.9%) was only independently predicted by emergent procedure. The TB endovascular cohort included 1105 patients. 30-day mortality was low (0.99%). There was no significant difference in LOS, CHF or hypertension between the older/younger groups. ESRD was more prevalent in the younger group, while the older group exhibited higher PRF. There were 19.5% of patients readmitted within 30 days, and was independently predicted by older age, and ESRD with 5.52% of patients undergoing a major amputation during follow-up. Obesity and bleeding were independent predictors. Bleeding was also examined as an outcome and was predicted by smoking, emergent admission, and ESRD. Conclusion - Following LEER involving the FP system, octogenarians were at a lower risk of major amputation and readmission but there was no difference in post-op WI or LOP. Following procedures involving the TB artery, octogenarians were at a lower risk of WI and readmission but a similar risk of amputation and bleeding. Considering the TB cohort had two-fold higher amputations and more readmissions than the FP cohort and that different risk factors impact the outcomes after each intervention, we must take this into account when discussing procedural options with patients. While sample size and selection bias may affect the results from databases such as ours, these results suggest that octogenarians may do just as well than non-octogenarians following LEER.