Pancreatic Resection in Patients 80 Years or Older A Meta-Analysis and Systematic Review Riccardo Casadei, MD, Claudio Ricci, MD, Enrico Lazzarini, MD, Giovanni Taffurelli, MD, Marielda D’Ambra, MD, Marianna Mastroroberto, MD, Antonio Maria Morselli-Labate, PhD, and Francesco Minni, MD Objective: The aim of this study was to evaluate the safety of pancreatic resections in patients 80 years or older. Methods: A systematic search of the literature was carried out that com- pared perioperative outcomes after pancreatic resection in patients 80 years or older with patients younger than 80 years. The primary end points were postoperative mortality and morbidity. The secondary end points were in- cidence of postoperative pancreatic fistula, delayed gastric emptying, bile leak, pneumonia, postoperative infection, cardiologic complications, reop- eration, and length of hospital stay. Results: Nine studies were found to be suitable for the meta-analysis. The postoperative mortality and morbidity were significantly higher in the group 80 years or older (P < 0.00001 and P = 0.003, respectively) except for patients in whom there were no differences in preoperative comorbidi- ties (P = 0.56 and P = 0.36, respectively). Postoperative cardiac complica- tions were significantly more frequent in patients 80 years or older (P < 0.0001), and the length of hospital stay was significantly longer in oc- togenarian patients (P = 0.008). Conclusions: Patients 80 years or older have an increased incidence of postoperative mortality, morbidity, and cardiac complications and a longer length of hospital stay than do younger patients. Thus, pancreatic resection can be recommended only in a selected group of patients 80 years or older. Key Words: pancreatic resection, elderly, pancreatic cancer, periampullary cancer, octogenarians (Pancreas 2014;43: 1208–1218) T he elderly population has been increasing rapidly in Western countries over time because of improvements in public health, nutrition, prevention, early detection of diseases, and continued medical progress. In 2008, the elderly numbered 38.9 million peo- ple or 12.8% of the US population; they are projected to account for nearly 20% of the population by the year 2030, 1 and by 2050, people older than 85 years are projected to account for 24% of the elderly population and 5% of the overall population. 1,2 In the year 2050, there will be nearly 6-fold as many octogenarians as in the year 2000. 3 Moreover, in 2003, the average life expec- tancy of 75-year-old individuals in the United States was 11.8 years 4 ; in 2004, the probability of survival for an 80-year- old person in Germany was 7.9 years, 5 and the estimations for other Western countries and Japan are comparable. The incidence of pancreatic cancer is strongly related to a mean age of 72 years at diagnosis; approximately 29% of patients with this disease are 75 to 84 years of age, and 13% are 85 years of age at the time of diagnosis. 6,7 Finally, recent improvements in surgical techniques and perioperative care have allowed better results after pancreatic resection in high-volume centers. 8 There- fore, currently, pancreatic surgeons are more frequently observing patients 80 years or older with pancreatic cancer or periampullary neoplasms in whom they have to make a decision as to whether to recommend a pancreatectomy. The decision to recommend a pancreatic resection for pancreatic cancer or other periampullary neoplasms in a very elderly patient is complicated by the frailty of the patient, the strong surgical trauma, and the poor prognosis of the disease. The process of weighing the risks and indications for surgical resection is made even more difficult by the lack of clin- ical data regarding major intra-abdominal surgery in the elderly. In fact, although there are large series of very elderly patients undergoing cardiothoracic 9–11 and vascular 12 procedures, few stud- ies have analyzed the outcomes of very elderly patients following major intra-abdominal surgery. Considering all these factors and the probability that very elderly people will present for surgery more frequently in the future, a mandatory question is: “Can pancreatic resection be rec- ommended in patients 80 years or older?” To answer this question, a meta-analysis and systematic review regarding the postopera- tive outcomes after pancreatic resection in patients 80 years or older and patients younger than 80 years was carried out in order to evaluate whether major pancreatic resection is as efficacious among the elderly population as well as it is in younger patients. MATERIALS AND METHODS Literature Selection A systematic search of the literature was conducted using PubMed, EMBASE, the Cochrane Library, Scopus, and the ISI- Web of Science databases in order to identify all studies published up to 2013 that compared perioperative outcomes in patients 80 years or older with those in patients younger than 80 years. The search terms used MeSH (medical subject headings) and non- controlled vocabulary terms. The following search terms were used in several logical combinations: “pancreaticoduodenectomy, ” “pancreatectomy, ” “duodenal neoplasms/surgery, ” “pancreatic neoplasms/surgery, ”“ampulla of Vater/surgery, ”“80 years of age and over, ”“elderly, and “octogenarian. ” The related articles provided by the various databases were used to broaden the search, and all the abstracts, studies, and citations obtained were reviewed. In addition, the references of all the studies included were screened for any potentially relevant studies. The last search was conducted on April 24, 2013. Data Extraction Each study was independently evaluated by 2 reviewers (E.L. and G.T.) for inclusion or exclusion from the meta- analysis using the data included in the abstract. The following From the Department of Medical and Surgical Sciences, Alma Mater Studiorum– University of Bologna, S. Orsola–Malpighi Hospital, Bologna, Italy. Received for publication December 10, 2013; accepted April 9, 2014. Reprints: Riccardo Casadei, MD, Department of Medical and Surgical Sciences, Alma Mater Studiorum–University of Bologna, S. Orsola–Malpighi Hospital, Via Massarenti n.9, 40138 Bologna, Italy (e‐mail: riccardo.casadei@aosp.bo.it). No funds were obtained for this study. The authors declare no conflict of interest. Copyright © 2014 by Lippincott Williams & Wilkins REVIEW 1208 www.pancreasjournal.com Pancreas • Volume 43, Number 8, November 2014 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.