Einfluss des Lebensalters und der Begleiterkrankungen auf die perioperative Mortalität nach 250 Pankreaskopfresektionen

Zusammenfassung

Einleitung: In der gegenwärtigen demografischen Entwicklung bilden ältere Patienten einen zunehmenden Anteil der chirurgischen Patienten. Es ist noch unklar, unter welchen Voraussetzungen bei diesen Patienten auch Pankreasresektionen mit niedriger Mortalität durchgeführt werden können. Patienten und Methodik: Im Zeitraum von 2009 bis 2014 wurden in einem nicht universitären Zentrum 250 konsekutive Pankreaskopfresektionen (PD) durchgeführt. Die perioperativen Daten wurden prospektiv dokumentiert. Ausgehend vom medianen Alter (< 70 Jahre vs. ≥ 70 Jahre) erfolgte eine retrospektive Auswertung des postoperativen Verlaufs sowie Subgruppenanalysen. Ergebnisse: Ältere Patienten hatten signifikant häufiger kardiovaskuläre Komorbiditäten (p = 0,04), einen Diabetes mellitus (p = 0,01), eine eingeschränkte Nierenfunktion (p = 0,01), eine höhere ASA-Einstufung (p < 0,01) und wurden signifikant häufiger wegen Malignomen (p < 0,01) operiert. Die Morbidität war in beiden Gruppen etwa gleich hoch (< 70 Jahre: 57 % vs. ≥ 70 Jahre: 65 %; p = 0,2) Allerdings war die Mortalität (< 70 Jahre: 1,4 % vs. ≥ 70 Jahre: 9,1 %; p < 0,01) bei Patienten über 70 Jahren signifikant erhöht. In der Multivarianzanalyse waren eine Leberzirrhose (p < 0,01) und ein hohes Lebensalter (≥ 70 Jahre; p = 0,04) die einzigen unabhängigen Risikofaktoren für die Krankenhausmortalität. Es zeigte sich aber auch, dass unter bestimmten Voraussetzungen ältere Patienten (in der Subgruppe ≥ 80 Jahre; n = 34) mit niedriger Mortalität (3 %) operiert werden konnten. Schlussfolgerung: Die Indikation zur PD wird bei älteren Patienten häufiger bei Malignomen gestellt. Die perioperative Mortalität ist bei Patienten über 70 Jahren insgesamt signifikant erhöht. Dennoch können die Eingriffe unter bestimmten Voraussetzungen auch bei sogar deutlich älteren Patienten sicher durchgeführt werden.

Abstract

Introduction: In line with the current demographic development, elderly patients make up an increasing proportion of surgical patients. It is still unclear under which conditions pancreatic surgery can be performed with low mortality in these patients. Patients and methods: From 2009 to 2014, 250 consecutive pancreatoduodenectomies (PDs) were performed in a non-university hospital. Perioperative data were documented prospectively. Based on median patient age (< 70 years vs. ≥ 70 years), a retrospective analysis of perioperative morbidity and mortality was performed. In addition, subgroup analyses were conducted. Results: Older patients had a significantly higher frequency of cardiovascular comorbidities (p = 0.04), diabetes mellitus (p = 0.01), impaired renal function (p = 0.01) and a higher ASA classification (p < 0.01). Also, surgical procedures due to malignancy were significantly more common in this group (p < 0.01). Morbidity was equally high in both groups (< 70 years: 57 % vs. ≥ 70 years: 65 %; p = 0.02). Mortality was significantly higher in patients over 70 years of age (< 70 years: 1.4 % vs. ≥ 70 years: 9.1 %; p < 0.01). In a multivariate analysis, only liver cirrhosis (p < 0.01) and age (≥ 70 years; p = 0.04) were independent risk factors for postoperative mortality. However, it was also demonstrated that, under certain conditions, even much older patients (≥ 80 years; n = 34) may be subjected to surgery with a low mortality (3 %). Discussion: In elderly patients, PD is more frequently indicated in cases of malignancy. All in all, perioperative mortality in patients over 70 years of age is significantly elevated. Under certain conditions, however, even much older patients may safely undergo pancreatic surgery.

Schlüsselwörter

Pankreaskopfresektion - Risikofaktor - Alter - Begleiterkrankungen - Leberzirrhose - Niereninsuffizienz

Key words

pancreatic head resection - risk factor - age - liver cirrhosis - renal insufficiency - comorbidity

• Literatur

• 1 Belyaev O, Herzog T, Kaya G et al. Pancreatic surgery in the very old: face to face with a challenge of the near future. World J Surg 2013; 37: 1013-1020
• 2 de la Fuente SG, Bennett KM, Pappas TN et al. Pre- and intraoperative variables affecting early outcomes in elderly patients undergoing pancreaticoduodenectomy. HPB (Oxford) 2011; 13: 887-892
• 3 Melis M, Marcon F, Masi A et al. The safety of a pancreaticoduodenectomy in patients older than 80 years: risk vs. benefits. HPB (Oxford) 2012; 14: 583-588
• 4 Adham M, Bredt LC, Robert M et al. Pancreatic resection in elderly patients: should it be denied?. Langenbecks Arch Surg 2014; 399: 449-459
• 5 Lahat G, Sever R, Lubezky N et al. Pancreatic cancer: surgery is a feasible therapeutic option for elderly patients. World J Surg Oncol 2011; 9: 10-18
• 6 Riediger H, Adam U, Utzolino S et al. Perioperative outcome after pancreatic head resection: a 10-year series of a specialized surgeon in a university hospital and a community hospital. J Gastrointest Surg 2014; 18: 1434-1440
• 7 Sohn TA, Yeo CJ, Cameron JL et al. Should pancreaticoduodenectomy be performed in octogenarians?. J Gastrointest Surg 1998; 2: 207-216
• 8 Gangl O, Fröschl U, Függer R. Surgical quality data and survival after pancreatic cancer resections: a comparison of results for octogenarians and younger patients. Wien Klin Wochenschr 2014; 126: 757-761
• 9 Makary MA, Winter JM, Cameron JL et al. Pancreaticoduodenectomy in the very elderly. J Gastrointest Surg 2006; 10: 347-356
• 10 Oguro S, Shimada K, Kishi Y et al. Perioperative and long-term outcomes after pancreaticoduodenectomy in elderly patients 80 years of age and older. Langenbecks Arch Surg 2013; 398: 531-538
• 11 Riall TS, Reddy DM, Nealon WH et al. The effect of age on short-term outcomes after pancreatic resection: a population-based study. Ann Surg 2008; 248: 459-467
• 12 Tanaka M, Fernandez-Del CC, Adsay V et al. International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas. Pancreatology 2012; 12: 183-197
• 13 Riediger H, Schulz-Malinowski A, Krueger CM et al. [Pancreatojejunostomy in pancreatic head resection using a resorbable monofilament for internal drainage of the anastomosis – clinical experience and perioperative results]. Zentralbl Chir 2012; 137: 575-579
• 14 Strasberg SM, Linehan DC, Hawkins WG. The accordion severity grading system of surgical complications. Ann Surg 2009; 250: 177-186
• 15 Bassi C, Dervenis C, Butturini G et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 2005; 138: 8-13
• 16 Hatzaras I, Schmidt C, Klemanski D et al. Pancreatic resection in the octogenarian: a safe option for pancreatic malignancy. J Am Coll Surg 2011; 212: 373-377
• 17 He J, Edil BH, Cameron JL et al. Young patients undergoing resection of pancreatic cancer fare better than their older counterparts. J Gastrointest Surg 2013; 17: 339-344
• 18 Finlayson E, Fan Z, Birkmeyer JD. Outcomes in octogenarians undergoing high-risk cancer operation: a national study. J Am Coll Surg 2007; 205: 729-734
• 19 Brozzetti S, Mazzoni G, Miccini M et al. Surgical treatment of pancreatic head carcinoma in elderly patients. Arch Surg 2006; 141: 137-142
• 20 Konstantinidis IT, Warshaw AL, Allen JN et al. Pancreatic ductal adenocarcinoma: is there a survival difference for R1 resections versus locally advanced unresectable tumors? What is a “true” R0 resection?. Ann Surg 2013; 257: 731-736
• 21 Riediger H, Keck T, Wellner U et al. The lymph node ratio is the strongest prognostic factor after resection of pancreatic cancer. J Gastrointest Surg 2009; 13: 1337-1344
• 22 Lavu H, Mascaro AA, Grenda DR et al. Margin positive pancreaticoduodenectomy is superior to palliative bypass in locally advanced pancreatic ductal adenocarcinoma. J Gastrointest Surg 2009; 13: 1937-1946
• 23 Sahora K, Ferrone CR, Brugge WR et al. Effects of comorbidities on outcomes of patients with intraductal papillary mucinous neoplasms. Clin Gastroenterol Hepatol 2015; 13: 1816-1823
• 24 Fuks D, Sabbagh C, Yzet T et al. Cirrhosis should not be considered as an absolute contraindication for pancreatoduodenectomy. Hepatogastroenterology 2012; 115: 881-883
• 25 Regimbeau JM, Rebibo L, Dokmak S et al. The short- and long-term outcomes of pancreaticoduodenectomy for cancer in Child A patients are acceptable: a patient-control study from the Surgical French Association report for pancreatic surgery. J Surg Oncol 2015; 111: 776-783
• 26 Neeff H, Mariaskin D, Spangenberg HC et al. Perioperative mortality after non-hepatic general surgery in patients with liver cirrhosis: an analysis of 138 operations in the 2000 s using Child and MELD scores. J Gastrointest Surg 2011; 15: 1-11
• 27 Squires 3rd MH, Lad NL, Fisher SB et al. The effect of preoperative renal insufficiency on postoperative outcomes after major hepatectomy: a multi-institutional analysis of 1,170 patients. J Am Coll Surg 2014; 219: 914-922
• 28 Adam U, Makowiec F, Riediger H et al. Risk factors for complications after pancreatic head resection. Am J Surg 2004; 187: 201-208
• 29 La Torre M, Ziparo V, Nigri G et al. Malnutrition and pancreatic surgery: prevalence and outcomes. J Surg Oncol 2013; 107: 702-708
• 30 Tani M, Kawai M, Hirono S et al. A pancreaticoduodenectomy is acceptable for periampullary tumors in the elderly, even in patients over 80 years of age. J Hepatobiliary Pancreat Surg 2009; 16: 675-680