Abstract
Aim: To evaluate the efficacy of age on the surgical outcomes in hepatic or pancreatic resection. Patients and Methods: We performed 50 hepatic or pancreatic resections in our community hospital and divided them into 2 groups based on age: patients aged ≥85 years old and patients aged <85 years old. We calculated the Estimation of Physiologic Ability and Surgical Stress (E-PASS) score and the Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM) system and compared the surgical outcome between the two groups. Results: There was no significant difference between the two groups with regard to E-PASS and POSSUM scores. Patients aged ≥85 years had a significantly higher frequency of anti-platelet agents. The incidence of postoperative complications and mortality in patients ≥85 years old were comparable to those in patients aged <85 years old. Conclusion: Hepatic or pancreatic resection for elderly patients aged 85 years or older can be safely performed under a given careful patient selection.
The elderly population has increased in many countries. It was reported that the average life expectancy of the Japanese is the highest in the world (1). As many as a quarter the Japanese population will be at least 65 years old by the year 2025, moreover, it is estimated that people over 65 years old will make up to 40% of the population by the year 2050 (2). Particularly, the aging of society in rural cities has advanced ahead of urban areas. The aging population worldwide has resulted in more elderly patients undergoing major surgery, such as hepatic or pancreatic resections. Hepatic or pancreatic resections, which may cause considerable complications, including intra-abdominal bleeding, intra-abdominal abscess, sepsis and organ failure, require advanced techniques and perioperative management methods (3, 4). Therefore, surgeons must carefully consider the indication for these operations to elderly patients.
There have been several reports about surgical results of hepatic or pancreatic resection in elderly patients (4-6) where advanced age is a contraindication to this type of approach. To our knowledge, no report documents the safety and feasibility of hepatic or pancreatic resection for patients aged 85 years or older.
In the current study, we examined results of two of the most extensive abdominal surgical procedures, liver resection and pancreatic resection. The purpose of the present study was to evaluate the safety of hepatic or pancreatic resection for various indications in patients aged 85 years or older and to show the influence of advanced age on the morbidity and mortality associated with this operation at our hospital.
Patients and Methods
Patients. The Division of Hepato-Pancreatico-biliary (HPB) Surgery, Department of Surgery, Tagawa Municipal Hospital, was established in April 2012. Fifty patients (27 male, 23 female; age range=31-98 years; median age=76.5 years) who underwent hepatic or pancreatic resections for hepatopancreatobiliary (HPB) tumors at our institution between April 2012 and December 2013 were enrolled in this study. Data were retrieved from the prospective database of the patients, which were divided into two age groups: patients age ≥85 years (n=10) and patients aged <85 years (n=40). The first author had conducted all surgical operations in this consecutive series.
Comparison of E-PASS and POSSUM factors.
Preoperative disease severity. We prospectively calculated Estimation of Physiologic Ability and Surgical Stress (E-PASS) score (7) and the Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM) system (8) to evaluate the preoperative disease severity in these patients.
E-PASS predicts the postsurgical risk by quantifying the patient's reserve and surgical stress. It comprises a preoperative risk score (PRS), a surgical stress score (SSS) and a comprehensive risk score (CRS) calculated from the PRS and SSS. The PRS is based on six factors: age, severity of heart disease, severity of pulmonary disease, diabetes mellitus, performance status index and American Society of Anesthesiologists (ASA) physiological status classification. SSS is based on three factors: blood loss/body weight (g/kg), operative time and length of the skin incision.
POSSUM accurately predicts overall mortality and morbidity rates after a wide range of general surgical procedures. It consists of a physiological score (PS) and an operative severity score (OSS). PS is based on twelve factors: age, cardiac signs, respiratory history, systolic blood pressure, pulse rate, Glasgow Coma Scale score, hemoglobin, white blood cell count, serum urea, serum sodium, serum potassium and electrocardiogram. OSS is based on six factors: operation grade, multiple procedures, blood loss, peritoneal soiling, malignancy and mode of surgery.
Surgical procedure. The detail of hepatic resection has been previously reported (9). Parenchymal transection was performed using the Cavitron Ultrasonic Surgical Aspirator (CUSA system; Valleylab Inc., Boulder, CO, USA) and the VIO system containing BiClamp and SOFT COAG (VIO 300D; ERBE Elektromedizin, Tübingen, Germany). Inflow vascular control was performed with intermittent hemi- or total Glisson's sheath occlusion (10). Hepatic resection of 2 or more Couinaud's segments was defined as major hepatic resection.
The details of pancreatic resection have been previously reported (4, 11). Substomach-preserving pancreaticoduodenectomy (SSPPD) with lymph node dissection was performed with the modified Child reconstruction. All pancreaticojejunostomies were performed by duct-to-mucosa and end-to-side anastomosis with internal or external stent drainage for the pancreatic duct. Internal suture rows, duct to mucosa, were performed between the pancreatic duct and jejunal mucosa using 8 interrupted sutures with 5-0 PDS-II (Johnson and Johnson Co., Tokyo, Japan). External suture rows were created as single sutures between the remnant pancreatic parenchyma and jejunal seromuscular tissue using interrupted sutures with 4-0 Prolene (Johnson and Johnson Co.). Distal pancreatectomy with lymph node dissection for tumors in the body or tail of the pancreas was performed using an Echelon 60 linear stapler (green cartridge; Ethicon Endo Surgery Inc., Cincinnati, OH, USA). A fibrin glue (Bolheal; The Chemo-Sero-Therapeutic Research Institute, Kumamoto, Japan) and polyglycolic acid (PGA) felt (Neoveil 50×50 mm; Gunze, Kyoto, Japan) were applied on the pancreas stump in layers of 1ml of liquid fibrinogen and 1ml of liquid thrombin, which are rubbed gently, followed by a PGA felt sheet, 1ml of liquid fibrinogen and 1ml of liquid thrombin.
Comparison of clinical characteristics in the two groups.
Comparison of clinical characteristics in the two groups.
Characteristics and surgical outcomes of patients aged 85 years or older.
Postoperative morbidity was graded according to the Dindo-Clavien classification (12) and we analyzed postoperative complications of Clavien's grade ≥IIIa. Operative mortality was defined as a patient's death within 30 days after surgery.
Statistical analysis. Continuous variables were compared using the Mann-Whitney U-test. Categorical variables were compared using a χ2 test or Fisher's exact test. Differences were considered significant at p<0.05. All statistical analyses were performed using the StatView 5.0 (Abacus Concepts, Berkeley, CA, USA).
Results
Sixteen (34.1%) of fifty patients were 80 years or older of age and 10 (20%) 85 years or older; only 4 (8.0%) were 90 years or older. Thirty-five patients (70%) underwent hepatic resection and 14 of 35 patients major hepatic resection. Fifteen patients (30%) underwent pancreatic resection and 11 of 15 patients SSPPD and others distal pancreatectomy.
Comparison of E-PASS and POSSUM factors is shown in Table I. There was no significant difference between the two groups with regard to preoperative disease severity. As shown in Table II, patients aged ≥85 years had a significantly higher frequency of anti platelet agents. No differences were noted between the two groups in terms of other preoperative factors. The surgical data are shown in Table III. Surgical procedures, duration of operation, operation blood loss, blood transfusion, postoperative complications, postoperative hospital stay and mortality did not differ significantly between the two groups. The characteristics and surgical outcomes of the patients ≥85 years are shown in Table IV. Two patients had postoperative complications after SSPPD, which were intra-abdominal abscess and pancreatic fistula. One patient (No.7) died from heart failure on postoperative day 57.
Discussion
Hepatic or pancreatic resection, evaluating the preoperative disease severity by E-PASS and POSSUM, demonstrated that there was no difference in terms of preoperative status, postoperative complication and mortality between patients aged ≥85 and <85 years. To the best of our knowledge, this is the first report to assess the characteristics between patients aged ≥85 and <85 years who underwent liver or pancreatic resection.
The number of aged people is increasing in Japan and the United States. Based on the WHO report (13), the mean life span of the general population in Japan was 83 years in 2006. In 2005, in the United States, the actual life expectancy of a person at 75 years of age was 12.0 years (14). Furthermore, the number of patients 85 years of age or older is increasing in the United States. In this study, 10 of 50 patients (20%) undergoing hepatic or pancreatic resection were 85 years or older; the oldest patient was 98 years old.
Postoperative risk in patients has been evaluated by risk score, such as the POSSUM score (8). Haga et al. showed that the new scoring system, the E-PASS score, was useful to predict postoperative morbidity and mortality (7). The E-PASS has been applied recently to evaluate patients with liver (15) and pancreatic surgery (16). Therefore, we prospectively evaluated preoperative patients using POSSUM and E-PASS scores. In the present study, there were no significant differences between two groups with regard to PS and PRS, which were calculated by preoperative factors. Moreover, there were no significant differences between the two groups regarding co-morbid disease, the serum level of albumin and renal function. We consider that PS and PRS are useful to select elderly patients for hepatic or pancreatic surgery. If PS and PRS of patients aged ≥85 were similar to those of patients aged <85, they might tolerate hepatic or pancreatic surgery. Next, there were no significant differences between the groups with regard to OSS and SSS, calculated by surgical factors, blood loss, postoperative complication and mortality, although the patients aged ≥85 years had a significantly higher frequency of anti platelet agents than those <85 years. Nanashima et al. (17) reported that 188 HCC patients underwent hepatic resection, with twelve of those (6%) being ≥80 years old. Mean SSS was 0.62 and postoperative complication rate was 50%. In our study, median SSS was 0.45 and postoperative complication rate was 20% in patients aged ≥85 years. Taken together, these results suggest that hepatic or pancreatic resection could be a feasible procedure in our community hospital giving us the freedom to perform these procedures for any aged patient by evaluating POSSUM and E-PASS.
However, there were still several limitations associated with this study by the following: (a) it is a single institutional review; (b) we included a small number of patients; and (c) heterogeneous procedures (hepatic resection and pancreatic resection) are included. These limitations will need to be verified with multi-institutional reviews and possible clinical studies.
In conclusion, there was no difference in terms of preoperative status, postoperative complication and mortality between patients aged ≥85 and <85 years. Evaluation of E-PASS and POSSUM can help stratify elderly patients for indication of hepatic or pancreatic surgery.
Footnotes
Conflicts of Interest
The Authors have no conflicts of interest to declare.
Funding
The Authors have no financial interests linked to this work.
- Received May 22, 2016.
- Revision received July 7, 2016.
- Accepted July 8, 2016.
- Copyright© 2016 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved
