PANCREATIC RESECTIONS IN THE ELDERLY: A TERTIARY CARE CENTER ANALYSIS WITH PARTICULAR VIEW ON THE HIGH AMERICAN SOCIETY OF ANESTHESIOLOGISTS’ RISK SCORE PATIENTS

Background. Surgery is the only potentially curative treatment for pancreatic cancer. However, the decision to submit elderly patients to pancreatic surgery still remains controversial. Some authors reported that the risk factor is not represented by the advanced age itself, but rather by the comorbidities associated with it, such as cardiovascular and pulmonary diseases and diabetes, common in the elderly population. The aim of this study is to evaluate the outcome of elderly patients with higher American Society of Anesthesiologists’ risk score (ASA 4) who underwent pancreatic resection, compared with younger patients and with elderly patient with lower anaesthesiological risk. Methods. A consecutive series of 345 patients who underwent pancreatic surgery at our tertiary care centre between 2010 and 2017 was reviewed. We compared three groups based on age at the time of surgery: < 65 years (group A), 65-74 years (group B), and  75 years (group C). Moreover, group C patients were divided according to the ASA score in two subgroups: patients with ASA score 1-3 (low-medium risk) vs patients with ASA score 4 (high risk). Prospectively collected data regarding pre-, intra-, post-operative course and follow up of patients belonging to these two subgroups were retrospectively analysed and compared. Results. The group A consisted in 117 (34%) patients, the group B in 128 (37%) patients, and group C in 100 (29%) patients. Group C patients had a significant higher incidence of comorbidities and ASA 4 respect the other two groups (p<0.05). The incidence of the overall post-operative complications was significantly higher in the group C (p<0.01), due to the higher incidence of medical complications. No difference in term of overall surgical complications was reported between the three groups. The reoperation rate was higher in group C (12%) vs group B (2.3%) (p<0.001) but not vs group A (6%) (p=0.15). The mean post-operative length of hospitalization was significant higher in group C (22.4 ± 17.0 days) versus group B (17.9 ± 9.2 days) (p=0.02) and group A (15.9 ± 11.3 days) (p<0.01). No difference was documented for post-operative mortality between the three groups. The mean overall survival was significantly lower for group C (p<0.01), but no difference in mortality for cancer was reported between the three groups. Within Group C, the comparison between patients with ASA score 1-3 and ASA 4 showed no significant differences regarding surgical complications (p=0.59), reoperation rate (p=0.45), mortality (p=0.34) and mean overall survival (p=0.53). Conclusions. Although elderly patients presented a higher rate of postoperative complications and a lower mean overall survival, they did not show a higher perioperative mortality. Furthermore, mortality due to cancer in operated patients was not different between the three groups. For these reasons, the advanced age should not be considered a reason to preclude the surgical option to elderly patients with pancreatic cancer. Furthermore, no differences were found in short-term and long-term survival in elderly patients with different operative risk factors (ASA score), so the higher anesthesiological risk in subjects aged ≥ 75 years should not be considered an absolute contraindication to surgical treatment.