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Original Article |

Surgical Treatment of Pancreatic Head Carcinoma in Elderly Patients FREE

Stefania Brozzetti, MD; Gianluca Mazzoni, MD, PhD; Michelangelo Miccini, MD; Francesco Puma, MD; Monica De Angelis, MD; Diletta Cassini, MD; Elia Bettelli, MD; Adriano Tocchi, MD; Antonino Cavallaro, MD
[+] Author Affiliations

Author Affiliations: Department of Surgery, University of Rome [[ldquo]]La Sapienza[[rdquo]] Medical School, Rome, Italy (Drs Brozzetti, Mazzoni, Miccini, De Angelis, Cassini, Bettelli, Tocchi, and Cavallaro); Department of General and Thoracic Surgery, University of Perugia Medical School, Perugia, Italy (Dr Puma).


Arch Surg. 2006;141(2):137-142. doi:10.1001/archsurg.141.2.137.
Text Size: A A A
Published online

Hypothesis  The treatment of cancer in elderly patients has become a global clinical issue, considering the increasingly longer life expectancy. Three quarters of patients with pancreatic adenocarcinoma are older than 60 years. Surgical resection is the only chance of cure, and early outcome of pancreaticoduodenectomy in elderly patients is comparable with that obtained in a younger population.

Design  During an 11-year period, 166 patients underwent curative pancreaticoduodenectomy for pancreatic adenocarcinoma. Clinical and demographic factors were evaluated by univariate and multivariate analyses to test their effect on early outcome.

Setting  State university medical school tertiary care center.

Patients  One hundred sixty-six patients underwent curative pancreaticoduodenectomy for pancreatic adenocarcinoma. They were divided into 2 groups according to age (group A for patients older than 70 years, group B for patients younger than 70 years).

Intervention  Pancreaticoduodenectomy was performed using a Whipple procedure. An end-to-end pancreaticojejunostomy was constructed. Lymphadenectomy was carried out along the hepatoduodenal ligament, common hepatic artery, vena cava, superior mesenteric vein, and along the right side of the superior mesenteric artery. Four abdominal drainage sites were routinely used.

Main Outcome Measures  The postoperative hospital stay was calculated and morbidity and mortality were assessed.

Results  Significantly higher operative morbidity and mortality were observed in group A (group A, 49.1% vs group B, 45.8% and 10.5% vs 3.7%, respectively). Underlying comorbid conditions in group B patients influenced postoperative morbidity but not mortality. Rate and nature of surgical complications were indicated as causes of significant higher mortality in group B patients.

Conclusions  An aggressive surgical approach is justified for elderly patients with pancreatic adenocarcinoma. However, surgical complications that lead to reoperation are responsible for a high mortality in elderly patients. In addition to general causes, such as concomitant disorders, reduced functional reserve, poor tolerance to stress, and the texture of the pancreatic remnant, there are specific prognostic factors affecting pancreaticojejunostomy leakage and related mortality.

Pancreatic adenocarcinoma ranks as the third most frequent neoplasm of the gastrointestinal tract and has an extremely rapid, aggressive growth and usually unfavorable prognosis.13 Surgical excision offers the only potential cure for pancreatic malignancy, and pancreaticoduodenectomy is the traditional procedure to treat adenocarcinoma of the head of the pancreas.4,5 Removal of the entire tumor with oncologic R0 is the goal of surgery. While many surgeons are hesitant to attempt radical surgery with an advanced tumor because of the relevant morbidity and mortality, this indication has increasingly been followed.68 Radical pancreatic resection in large volume has been shown to be followed by long-term survival and satisfactory quality of residual life.7,915

Because the size of the elderly population has increased exponentially in the last century, the proportion of older people with resectable pancreatic malignancies has increased.7,16

In the past, dismal early and long-term outcomes restricted pancreaticoduodenectomy to younger patients.10 However, recent studies in patients older than 70 years show that pancreaticoduodenectomy does not rule out an uneventful postoperative course, with a cumulative survival rate not different from that obtained in younger patients.1720 Yet, because of a high incidence of comorbid diseases, elderly patients are still widely considered at high risk for major surgery.18,19,21,22

The aim of the present study was to assess the safety of pancreaticoduodenectomy in patients older than 70 years and to show how advanced age influences morbidity and mortality in such a demanding procedure.

PATIENTS

From January 1990 to December 2000, 193 patients with stage I and stage II adenocarcinoma of the pancreas were considered for curative pancreaticoduodenectomy at the First Department of Surgery of the University of Rome “La Sapienza” Medical School, Rome, Italy, or at the Department of General and Thoracic Surgery of the University of Perugia Medical School, Perugia, Italy. One hundred sixty-six patients with an American Society of Anesthesiologists score less than 4 were submitted to surgery. The study population, which consisted of 102 men and 64 women, with a mean (SD) age of 64.3 (10) years (range, 25-85 years), was divided into 2 groups according to age. Group A patients were 70 years or older, and group B patients were younger than 70 years.

The medical history of each case was reviewed and demographic data, symptoms, and comorbidity (ie, coronary artery disease, hypertension, diabetes mellitus, chronic renal insufficiency, and chronic obstructive pulmonary disease) were considered. All patients underwent contrast-enhanced thoracic and abdominal computed tomography, abdominal ultrasonography, and complete blood tests. Biliary tree examination was performed with endoscopic retrograde cholangiopancreatography or magnetic resonance imaging. No patients underwent preoperative biliary drainage, nor was preoperative or postoperative adjuvant therapy administered.

SURGERY

All procedures were performed under control of 2 experienced pancreatic surgeons. All patients received prophylactic antibiotics preoperatively (cefotaxime sodium plus metronidazole). Octreotide administration was started during the operation and continued for 7 days (0.1 mg subcutaneously 3 times a day) in an uneventful postoperative course. Proton pump inhibitors were administered for 21 days starting the day before surgery. All pancreatic head resections were carried out by experienced senior surgeons. Pancreaticoduodenectomy was performed using a Whipple procedure, and an end-to-end pancreaticojejunostomy (PJA) was constructed with a double-layer anastomosis of interrupted 4-0 nonadsorbable sutures. Lymphadenectomy was carried out along the hepatoduodenal ligament, common hepatic artery, vena cava, superior mesenteric vein, and along the right side of the superior mesenteric artery. No transanastomotic catheters were placed in the pancreatic or biliary ducts. Four abdominal drainage sites were routinely used: 2 soft drains were placed near the pancreaticojejunal anastomoses, 1 drain in the subhepatic space near the hepaticojejunostomy, and 1 in the Douglas pouch. Operative time and intraoperative blood loss were recorded. In the absence of a fistula, the drains were removed after 7 days.

PATHOLOGIC RESULTS

Based on intraoperative dissection, surgeons defined the consistency of the remnant pancreatic parenchyma as “soft and normal” or “hard and atrophic.” Pancreatic duct size was classified as “small” (diameter ≤3 mm) or “dilatated” (diameter >3 mm). All surgical specimens were reviewed by 2 senior pathologists. Clinical and pathologic staging were reassessed according to American Joint Committee on Cancer TNM staging of pancreatic cancer (2002).

EARLY OUTCOME

The postoperative hospital stay was calculated and morbidity and mortality were assessed. Complications were registered and classified as medical or surgical: pancreatic fistula (surgical), stump acute pancreatitis (surgical), biliary fistula (surgical), delayed gastric emptying (surgical), intra-abdominal or gastrointestinal tract bleeding (surgical), cholangitis (surgical), intra-abdominal sepsis (surgical), wound infection (surgical), urinary tract infection (medical), pneumonia or respiratory failure (medical), renal failure (medical), cerebrovascular accident (medical), and myocardial infarction or arrhythmia (medical). Postoperative pancreatic fistula was defined as drainage of greater than 50 mL of amylase-rich fluid (>3 times the upper limit of the reference range for serum amylase level) through the intraoperatively placed drain after day 4 and persisting after day 10. Biliary fistula was defined as biliary staining from drainage fluid. In the presence of pancreatic or biliary fistula therapy, octreotide and antibiotics administration were prolonged and an operative procedure was performed if necessary. Postoperative delayed gastric emptying was defined as a daily output greater than 500 mL from the nasogastric tube after day 5. Mortality was defined as death during hospitalization or within 30 days of hospital discharge after resection.

STUDY END POINTS

Primary end points include postoperative survival, postoperative complications, and length of hospital stay.

STATISTICAL ANALYSIS

The results of parametric and nonparametric data were expressed as mean (SD) and median (SD), respectively. All variables were dichotomized. Confidence intervals were set at 95%. A 2-sided P value of <.05 was considered statistically significant. Univariate comparisons were carried out using Fisher test and χ2 test for discrete variables and t test and Kruskal-Wallis test for continuous variables. Multivariate analysis was performed with a logistic regression test.

PATIENT POPULATION

The mean (SD) age at the time of pancreaticoduodenectomy was 64.3 (10) years (range 25-85 years); 57 patients were 70 years or older (group A). There was a total of 102 men and 64 women. The most frequent symptoms were jaundice and weight loss (78% and 40%, respectively). Bilirubinemia evaluation revealed a mean (SD) value of 8.9 mg/dL (range, 1-21 mg/dL). Eighty-nine patients (53%) had associated medical conditions, 35 (61%) in group A and 54 (49%) in group B (P = .19). Demographic and clinical data are presented in Table 1.

Table Graphic Jump LocationTable 1. Demographic and Clinical Data*
SURGERY

The mean (SD) operative time was 405 (56) minutes (range, 300-610 minutes) (mean, group A, 416 minutes and group B, 399 minutes; P = .07). Intraoperative blood losses were comparable in group A and group B (646 mL vs 676 mL; P = .21), with a mean (SD) value of 666 (148) mL (range, 410-1250 mL), and transfusion requirement did not differ. No resection of the portal-mesenteric axis or adjacent organs was performed, and all patients underwent potentially curative surgery.

PATHOLOGIC RESULTS

The texture of the pancreatic parenchyma was judged by the surgeon to be “soft and normal” in 99 patients (60%) and “hard and atrophic” in 67 patients (40%) (56% in group A and 62% in group B; P = .51). The Wirsung duct size was classified as “small” in 100 cases (60%) (32 in group A and 68 in group B; P = .50). Resected lymph nodes were histologically positive for metastases in 128 specimens (77%) (44 in group A and 84 in group B; P > .99). Table 2 details the pathologic results.

EARLY OUTCOME

The postoperative complications and course are presented in Table 3. There were no intraoperative deaths. Mean postoperative hospital stay was 16 days (range, 10-31 days) (16 days in group A and 16.3 days in group B; P = .62). There was no significant difference in the intensive care unit stay between the 2 groups (3.1 days in group A vs 1.9 days in group B; P = .09). There were 6 postoperative deaths in group A (10.5%) and 4 in group B (3.7%) (P = .09), for an overall mortality rate of 6%. Five patients died following pancreatic fistula and 2, following hemorrhage. Four patients (including the 2 who had hemorrhage) died in the postoperative period from multiple organ failure after sepsis due to PJA leakage. One patient died after myocardial ischemia. The overall complication rate was 42.7% (43.8% in group A and 42.2% in group B; P = .86). The most common complications were pancreatic fistula (9%) and pneumonia (7.2%). The incidence of pancreatic fistula was similar between groups A and B (14% vs 13.8%; P = .99).

In 14 patients, surgical complications were approached conservatively with aggressive medical therapy (ie, octreotide plus antibiotics, total parenteral feeding). In no cases was percutaneous drainage of an infected fluid collection performed. Fourteen patients with instability of clinical course for sepsis or intra-abdominal hemorrhage underwent surgical reintervention with aggressive debridement, extensive drainage, or completion of pancreatectomy when required. Postoperative mortality of reintervention was significantly higher in group A patients (83.3% vs 12.5%; P = .02). All patients were discharged home. Univariate analysis showed no significant difference between the 2 groups of patients, except for reintervention mortality. When length of stay and rates of postoperative morbidity and mortality were considered, univariate analysis showed a worse clinical course in patients with associated diseases, with “soft and normal” parenchyma, and with small Wirsung ducts (Table 4). Multivariate analysis confirmed associated diseases, pancreatic texture consistency, and duct size as the independent factors affecting early outcome after pancreaticoduodenectomy, regardless of the age of patients (Table 5).

Despite poor long-term survival, surgery is the only recognized potentially curative treatment for malignant disease of the pancreatic head.23,24 However, enrollment criteria, the upper limit of surgical aggressiveness, and reconstructive options are still debated.25 In the last few decades, the general goal of enhancing the curative effectiveness of surgical resection has led to extending the excision of the pancreatic head to the regional connective, lymphatic, and neural tissues and to including, in select cases, more or fewer extended segments of portal and mesenteric vessels.6,11,2630 Despite increasing the operative morbidity, this aggressive approach has led to a wider recruitment of patients for potentially curative surgery. However, until recently, elderly patients have been excluded by this trend because of the overall unfavorable long-term outcomes that have caused this approach to be considered unadvisable for patients with short life expectancies.22,3145 Reduced mortality (<5%) and morbidity (<30%) suggest that pancreaticoduodenectomy should be offered to all patients with resectable disease, with no upper age limit.4,6,12,18,20 Furthermore, populations of developed countries are aging, and age is considered an etiological risk factor for pancreatic adenocarcinoma. It is likely that adequate treatment for elderly patients with pancreatic adenocarcinoma will become a topic of discussion in the next few years. Elements affecting pancreatic operative morbidity and mortality have been divided into patient-related, regional-related, and procedure-related factors.35 Patient-related parameters, such as medical comorbidities, have been stressed as the main reasons for higher complication rates in elderly patients.18,20,31,36,37 The significantly higher number of associated medical diseases detected in our group A patients was confirmed by statistical analysis as affecting early outcome. Nevertheless, while an identical aggressive approach was adopted, no difference in surgical complications was evidenced between the 2 groups of patients (30% vs 29%; P = .99). Careful preoperative monitoring, including evaluation of surgical stress compliance, routine postoperative intensive care, use of parenteral support, and octreotide prophylaxis are the main tools adopted successfully in our experience to reduce morbidity and to contain the number of medical complications leading to death. While the rate of surgical complications and that of reintervention did not differ between the 2 groups, a significantly higher operative mortality was observed in group A patients. Such an unfavorable outcome was exclusively attributable to the exceedingly high mortality rate registered in elderly patients undergoing reoperation because of surgical complications, mainly because of PJA-complicated leakage. This leakage remains the most feared complication of pancreatoduodenectomy.15,23,3540 Several studies have shown that rates of PJA leakage are influenced by the texture of the pancreatic remnant.13,21,23,41,42 When this correlation was analyzed in our series, although no correlation was shown to exist between age and texture of the pancreatic remnant, a soft pancreatic stump was an independent factor directly affecting PJA leakage. Experienced surgeons are well aware that hard parenchyma can be anchored tightly to the seromuscular coat of the jejunal loop,21,43,44 while soft and friable parenchyma are easily injured by stitches, making a safe anastomosis difficult to achieve.

Comorbidity, concomitant systemic disorders, reduced “functional reserve,” and poor tolerance to repeat surgical stress are the elements possibly responsible for the high mortality rate in elderly patients.22,45 Whatever the cause, we searched for alternative surgical procedures to lower the reoperation rate and related postoperative mortality, yet obtain standard oncologic clearance. Ligation and chemical occlusion of the pancreatic duct and suture of the pancreatic stump, alternatively used for many years to avoid PJA but never used in the present series, have been recently proposed for the treatment of difficult pancreas.43,46 Should PJA not have been performed in elderly patients with soft pancreatic remnant, accounting in our series for as many as 56% of all elderly patients, it is reasonable that the rate of reoperation and consequent mortality would have been lower. To verify this assumption, in 2001 we began to replace PJA with Wirsung duct closure by ligation in patients older than 70 years with an intraoperative finding of soft gland. The results of this approach, though limited to a few cases, are encouraging. All 6 patients who underwent this procedure developed a clear pancreatic fistula that spontaneously healed within 60 days, with no mortality.

In conclusion, our study confirms pancreaticoduodenectomy as an effective procedure to treat pancreatic adenocarcinoma, safely applicable to patients older than 70 years. Nevertheless, in aged patients with soft pancreatic remnant, the relevant mortality associated with reoperation for PJA disruption should suggest a more cautious surgical strategy.

Correspondence: Adriano Tocchi, MD, Via Bruno Bruni, 94, 00189 Rome, Italy (adriano.tocchi@uniroma1.it).

Accepted for Publication: May 19, 2005.

Wagner  MKulli  CFriess  HSeiler  CABuchler  MW Surgery of pancreatic carcinoma. Swiss Surg 2000;6264- 270
PubMed Link to Article
van Geenen  RCten Kate  FJde Wit  LTvan Gulik  TMObertop  HGouma  DJ Segmental resection and wedge excision of the portal or superior mesenteric vein during pancreatoduodenectomy. Surgery 2001;129158- 163
PubMed Link to Article
Spanknebel  KConlon  KC Advances in the surgical management of pancreatic cancer. Cancer J 2001;7312- 323
PubMed
Yeo  CJCameron  JLLillemoe  KD  et al.  Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma, part 2. Ann Surg 2002;236355- 368
PubMed Link to Article
Conlon  KCKlimstra  DSBrennan  MF Long-term survival after curative resection of pancreatic ductal adenocarcinoma: clinicopathologic analysis of 5-years survivors. Ann Surg 1996;223273- 279
PubMed Link to Article
Stojadinovic  ABrooks  AHoos  AJaques  DPConlon  KCBrennan  MF An evidence-based approach to the surgical management of resectable pancreatic carcinoma. J Am Coll Surg 2003;196954- 964
PubMed Link to Article
Balcom  JH  IVRattner  DWWarshaw  ALChang  YFernandez de Castillo  C Ten-year experience with 733 pancreatic resections. Arch Surg 2001;136391- 398
PubMed Link to Article
Neoptolemos  JPRussell  RCBramhall  STheis  B Low mortality following resection for pancreatic and periampullary tumours in 1026 patients. Br J Surg 1997;841370- 1376
PubMed Link to Article
Huang  JJYeo  CJSohn  TA  et al.  Quality of life and outcomes after pancreaticoduodenectomy. Ann Surg 2000;231890- 898
PubMed Link to Article
Farnell  MBNagorney  DMSarr  MG The Mayo clinic approach to the surgical treatment of adenocarcinoma of the pancreas. Surg Clin North Am 2001;81611- 623
PubMed Link to Article
Yeo  CJCameron  JLSohn  T  et al.  Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s. Ann Surg 1997;226248- 260
PubMed Link to Article
Fernandez-del Castillo  CRattnerr  DWWarshaw  AL Standards for pancreatic resections in the 1990s. Arch Surg 1995;130295- 300
PubMed Link to Article
Bassi  CFalconi  FSalvia  RMascetta  GMolinari  EPederzoli  P Management of complications after pancreaticoduodenectomy in a high volume centre: results on 150 consecutive patients. Dig Surg 2001;18453- 458
PubMed Link to Article
Wade  TPRadford  DMVirgo  KSJohnson  FE Complications and outcome in treatment of pancreatic adenocarcinoma in the United States veteran. J Am Coll Surg 1994;17938- 48
PubMed
Rios  GConrad  ACole  D  et al.  Trends in indications and outcomes in the Whipple procedure over a 40-year period. Am Surg 1999;65889- 893
PubMed
Tsuchiya  RTajima  YMatsuzaki  SOnikuza  SKanematsu  T Early pancreatic cancer. Pancreatology 2001;1597- 603
PubMed Link to Article
DiCarlo  VBalzano  GZerbi  AVilla  E Pancreatic cancer resection in elderly patients. Br J Surg 1998;85607- 610
PubMed Link to Article
Spencer  MPSarr  MGNagorney  DM Radical pancreatectomy for pancreatic cancer in the elderly. Ann Surg 1990;212140- 143
PubMed Link to Article
Bathe  OFLevi  DCaldera  H  et al.  Radical resection of periampullary tumors in the elderly: evaluation of long-term results. World J Surg 2000;24353- 358
PubMed Link to Article
Fong  YBlumgart  LHFortner  JGBrennan  MF Pancreatic or liver resection for malignancy is safe and effective for the elderly. Ann Surg 1995;222426- 437
PubMed Link to Article
Lightner  AMGlasgow  REJordan  TH  et al.  Pancreatic resection in the elderly. J Am Coll Surg 2004;198697- 706
PubMed Link to Article
Aalami  OOFang  TDSong  HMNacamuli  RP Physiological features of aging persons. Arch Surg 2003;1381068- 1076
PubMed Link to Article
Berberat  POFriess  HKleeff  JUhl  WBuchler  MW Prevention and treatment of complications in pancreatic cancer surgery. Dig Surg 1999;16327- 336
PubMed Link to Article
Beger  HGGaunsauge  FLeder  G Pancreatic cancer: who benefits from curative resection? Can J Gastroenterol 2002;16117- 120
PubMed
Hosotani  RDoi  RImamura  M Duct to mucosa pancreaticojejunostomy reduces the risk of pancreatic leakage after pancreatectomy. World J Surg 2002;2699- 104
PubMed Link to Article
Gouma  DJvan Gulik  TMde Wit  LTObertop  H Complications after resection of biliopancreatic cancer. Ann Oncol 1999;10257- 260
PubMed Link to Article
Sasson  ARHoffman  JPRoss  EAKagan  SAPingpank  JFEisenberg  BL En bloc resection for locally advanced cancer of the pancreas: is it worthwhile? J Gastrointest Surg 2002;6147- 157
PubMed Link to Article
Fortner  JGKlimstra  DSSenie  RT  et al.  Tumor size is the primary prognosticator for the pancreatic cancer after regional pancreatectomy. Ann Surg 1996;223147- 153
PubMed Link to Article
Yeo  CJCamerpn  JLSohn  TA  et al.  Pancreaticoduodenectomy with or without extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma: comparison of morbidity and mortality and short-term outcome. Ann Surg 1999;229613- 624
PubMed Link to Article
Traverso  LWKawarada  YIsaji  S  et al.  Extended lymphadenectomy during pancreaticoduodenectomy for cancer of the pancreas. J Gastrointest Surg 2000;4225- 232
Link to Article
Lerut  JPGianello  PROtte  JBKestens  PJ Pancreaticoduodenal resection: surgical experience and evaluation of risk factors in 103 patients. Ann Surg 1984;199432- 437
PubMed Link to Article
Kairaluoma  MIKiviniemi  HStahlberg  M Pancreatic resection for carcinoma for the pancreas and the periampullary region in patients over 70 years of age. Br J Surg 1987;74116- 118
PubMed Link to Article
Richter  ANiedergethmann  MLorenz  DSturm  JWTrede  MPost  S Resection for cancers of the pancreatic head patients aged 70 years or over. Eur J Surg 2002;168339- 344
PubMed Link to Article
Burcharth  FOlsen  SDTrillingsgaard  JFederspiel  BMoesgaard  FStruckmann  JR Pancreaticoduodenectomy for periampullary cancer in patients more than 70 years of age. Hepatogastroenterology 2001;481149- 1152
PubMed
Poon  RTPLo  SHFong  DFan  STWong  J Prevention of pancreatic anastomotic leakage after pancreaticoduodenectomy. Am J Surg 2002;18342- 52
PubMed Link to Article
Adam  UMakowiec  FRiediger  HScharek  WDBenz  SHopt  UT Risk factors for complications after pancreatic head resection. Am J Surg 2004;187201- 208
PubMed Link to Article
Gouma  DJvan Geenen  RCIvan Gulik  TM  et al.  Rates of complications and death after pancreaticoduodenectomy: risk factors and the impact of hospital volume. Ann Surg 2000;232786- 795
PubMed Link to Article
Grobmyer  SRRivadeneira  DEGoodman  CAMackrell  PLieberman  MDDaly  JH Pancreatic anastomotic failure after pancreaticoduodenectomy. Am J Surg 2000;180117- 120
PubMed Link to Article
Buchler  MWFriess  HWagner  MKulli  CWagener  VZ’graggen  K Pancreatic fistula after pancreatic head resection. Br J Surg 2000;87883- 889
PubMed Link to Article
Yeo  CJCameron  JLLillemoe  KD  et al.  Does prophylactic octreotide really decrease the rates of pancreatic fistula and other complications following pancreaticoduodenectomy? results of a prospective randomized placebo-controlled trial. Ann Surg 2000;232419- 429
PubMed Link to Article
Shibuya  TUchiyama  KInai  SShibuya  JShoji  T Improvement of pancreaticojejunostomy in pancreaticoduodenectomy. Int Surg 1995;8057- 60
PubMed
Suzuki  YFujino  YTanioka  Y  et al.  Selection of pancreaticojejunostomy techniques according to pancreatic texture and duct size. Arch Surg 2002;1371044- 1048
PubMed Link to Article
Sikora  SSPosner  MC Management of the pancreatic stumps following pancreaticoduodenectomy. Br J Surg 1995;821590- 1597
PubMed Link to Article
Marcus  SGCohen  HRanson  JH Optimal management of the pancreatic remnant after pancreaticoduodenectomy. Ann Surg 1995;221635- 645
PubMed Link to Article
Monson  KLitvak  DABold  RJ Surgery in the aged population. Arch Surg 2003;1381061- 1067
PubMed Link to Article
Suc  BMsika  SFingerhut  A  et al.  Temporary fibrin glue occlusion of the main pancreatic duct in the prevention of intra-abdominal complications after pancreatic resection: prospective randomized trial. Ann Surg 2003;23757- 65
PubMed Link to Article

Figures

References

Wagner  MKulli  CFriess  HSeiler  CABuchler  MW Surgery of pancreatic carcinoma. Swiss Surg 2000;6264- 270
PubMed Link to Article
van Geenen  RCten Kate  FJde Wit  LTvan Gulik  TMObertop  HGouma  DJ Segmental resection and wedge excision of the portal or superior mesenteric vein during pancreatoduodenectomy. Surgery 2001;129158- 163
PubMed Link to Article
Spanknebel  KConlon  KC Advances in the surgical management of pancreatic cancer. Cancer J 2001;7312- 323
PubMed
Yeo  CJCameron  JLLillemoe  KD  et al.  Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma, part 2. Ann Surg 2002;236355- 368
PubMed Link to Article
Conlon  KCKlimstra  DSBrennan  MF Long-term survival after curative resection of pancreatic ductal adenocarcinoma: clinicopathologic analysis of 5-years survivors. Ann Surg 1996;223273- 279
PubMed Link to Article
Stojadinovic  ABrooks  AHoos  AJaques  DPConlon  KCBrennan  MF An evidence-based approach to the surgical management of resectable pancreatic carcinoma. J Am Coll Surg 2003;196954- 964
PubMed Link to Article
Balcom  JH  IVRattner  DWWarshaw  ALChang  YFernandez de Castillo  C Ten-year experience with 733 pancreatic resections. Arch Surg 2001;136391- 398
PubMed Link to Article
Neoptolemos  JPRussell  RCBramhall  STheis  B Low mortality following resection for pancreatic and periampullary tumours in 1026 patients. Br J Surg 1997;841370- 1376
PubMed Link to Article
Huang  JJYeo  CJSohn  TA  et al.  Quality of life and outcomes after pancreaticoduodenectomy. Ann Surg 2000;231890- 898
PubMed Link to Article
Farnell  MBNagorney  DMSarr  MG The Mayo clinic approach to the surgical treatment of adenocarcinoma of the pancreas. Surg Clin North Am 2001;81611- 623
PubMed Link to Article
Yeo  CJCameron  JLSohn  T  et al.  Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s. Ann Surg 1997;226248- 260
PubMed Link to Article
Fernandez-del Castillo  CRattnerr  DWWarshaw  AL Standards for pancreatic resections in the 1990s. Arch Surg 1995;130295- 300
PubMed Link to Article
Bassi  CFalconi  FSalvia  RMascetta  GMolinari  EPederzoli  P Management of complications after pancreaticoduodenectomy in a high volume centre: results on 150 consecutive patients. Dig Surg 2001;18453- 458
PubMed Link to Article
Wade  TPRadford  DMVirgo  KSJohnson  FE Complications and outcome in treatment of pancreatic adenocarcinoma in the United States veteran. J Am Coll Surg 1994;17938- 48
PubMed
Rios  GConrad  ACole  D  et al.  Trends in indications and outcomes in the Whipple procedure over a 40-year period. Am Surg 1999;65889- 893
PubMed
Tsuchiya  RTajima  YMatsuzaki  SOnikuza  SKanematsu  T Early pancreatic cancer. Pancreatology 2001;1597- 603
PubMed Link to Article
DiCarlo  VBalzano  GZerbi  AVilla  E Pancreatic cancer resection in elderly patients. Br J Surg 1998;85607- 610
PubMed Link to Article
Spencer  MPSarr  MGNagorney  DM Radical pancreatectomy for pancreatic cancer in the elderly. Ann Surg 1990;212140- 143
PubMed Link to Article
Bathe  OFLevi  DCaldera  H  et al.  Radical resection of periampullary tumors in the elderly: evaluation of long-term results. World J Surg 2000;24353- 358
PubMed Link to Article
Fong  YBlumgart  LHFortner  JGBrennan  MF Pancreatic or liver resection for malignancy is safe and effective for the elderly. Ann Surg 1995;222426- 437
PubMed Link to Article
Lightner  AMGlasgow  REJordan  TH  et al.  Pancreatic resection in the elderly. J Am Coll Surg 2004;198697- 706
PubMed Link to Article
Aalami  OOFang  TDSong  HMNacamuli  RP Physiological features of aging persons. Arch Surg 2003;1381068- 1076
PubMed Link to Article
Berberat  POFriess  HKleeff  JUhl  WBuchler  MW Prevention and treatment of complications in pancreatic cancer surgery. Dig Surg 1999;16327- 336
PubMed Link to Article
Beger  HGGaunsauge  FLeder  G Pancreatic cancer: who benefits from curative resection? Can J Gastroenterol 2002;16117- 120
PubMed
Hosotani  RDoi  RImamura  M Duct to mucosa pancreaticojejunostomy reduces the risk of pancreatic leakage after pancreatectomy. World J Surg 2002;2699- 104
PubMed Link to Article
Gouma  DJvan Gulik  TMde Wit  LTObertop  H Complications after resection of biliopancreatic cancer. Ann Oncol 1999;10257- 260
PubMed Link to Article
Sasson  ARHoffman  JPRoss  EAKagan  SAPingpank  JFEisenberg  BL En bloc resection for locally advanced cancer of the pancreas: is it worthwhile? J Gastrointest Surg 2002;6147- 157
PubMed Link to Article
Fortner  JGKlimstra  DSSenie  RT  et al.  Tumor size is the primary prognosticator for the pancreatic cancer after regional pancreatectomy. Ann Surg 1996;223147- 153
PubMed Link to Article
Yeo  CJCamerpn  JLSohn  TA  et al.  Pancreaticoduodenectomy with or without extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma: comparison of morbidity and mortality and short-term outcome. Ann Surg 1999;229613- 624
PubMed Link to Article
Traverso  LWKawarada  YIsaji  S  et al.  Extended lymphadenectomy during pancreaticoduodenectomy for cancer of the pancreas. J Gastrointest Surg 2000;4225- 232
Link to Article
Lerut  JPGianello  PROtte  JBKestens  PJ Pancreaticoduodenal resection: surgical experience and evaluation of risk factors in 103 patients. Ann Surg 1984;199432- 437
PubMed Link to Article
Kairaluoma  MIKiviniemi  HStahlberg  M Pancreatic resection for carcinoma for the pancreas and the periampullary region in patients over 70 years of age. Br J Surg 1987;74116- 118
PubMed Link to Article
Richter  ANiedergethmann  MLorenz  DSturm  JWTrede  MPost  S Resection for cancers of the pancreatic head patients aged 70 years or over. Eur J Surg 2002;168339- 344
PubMed Link to Article
Burcharth  FOlsen  SDTrillingsgaard  JFederspiel  BMoesgaard  FStruckmann  JR Pancreaticoduodenectomy for periampullary cancer in patients more than 70 years of age. Hepatogastroenterology 2001;481149- 1152
PubMed
Poon  RTPLo  SHFong  DFan  STWong  J Prevention of pancreatic anastomotic leakage after pancreaticoduodenectomy. Am J Surg 2002;18342- 52
PubMed Link to Article
Adam  UMakowiec  FRiediger  HScharek  WDBenz  SHopt  UT Risk factors for complications after pancreatic head resection. Am J Surg 2004;187201- 208
PubMed Link to Article
Gouma  DJvan Geenen  RCIvan Gulik  TM  et al.  Rates of complications and death after pancreaticoduodenectomy: risk factors and the impact of hospital volume. Ann Surg 2000;232786- 795
PubMed Link to Article
Grobmyer  SRRivadeneira  DEGoodman  CAMackrell  PLieberman  MDDaly  JH Pancreatic anastomotic failure after pancreaticoduodenectomy. Am J Surg 2000;180117- 120
PubMed Link to Article
Buchler  MWFriess  HWagner  MKulli  CWagener  VZ’graggen  K Pancreatic fistula after pancreatic head resection. Br J Surg 2000;87883- 889
PubMed Link to Article
Yeo  CJCameron  JLLillemoe  KD  et al.  Does prophylactic octreotide really decrease the rates of pancreatic fistula and other complications following pancreaticoduodenectomy? results of a prospective randomized placebo-controlled trial. Ann Surg 2000;232419- 429
PubMed Link to Article
Shibuya  TUchiyama  KInai  SShibuya  JShoji  T Improvement of pancreaticojejunostomy in pancreaticoduodenectomy. Int Surg 1995;8057- 60
PubMed
Suzuki  YFujino  YTanioka  Y  et al.  Selection of pancreaticojejunostomy techniques according to pancreatic texture and duct size. Arch Surg 2002;1371044- 1048
PubMed Link to Article
Sikora  SSPosner  MC Management of the pancreatic stumps following pancreaticoduodenectomy. Br J Surg 1995;821590- 1597
PubMed Link to Article
Marcus  SGCohen  HRanson  JH Optimal management of the pancreatic remnant after pancreaticoduodenectomy. Ann Surg 1995;221635- 645
PubMed Link to Article
Monson  KLitvak  DABold  RJ Surgery in the aged population. Arch Surg 2003;1381061- 1067
PubMed Link to Article
Suc  BMsika  SFingerhut  A  et al.  Temporary fibrin glue occlusion of the main pancreatic duct in the prevention of intra-abdominal complications after pancreatic resection: prospective randomized trial. Ann Surg 2003;23757- 65
PubMed Link to Article

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