We read with keen interest the recent paper by El Nakeeb et al,^[1] and the subsequent editorial published by Dudeja and Livingstone.^[2] Globally, the authors have correctly and timely portrayed the current role of pancreaticoduodenectomy in the elderly. Actually, most patients are expected to succumb a few years after surgery, being the overall survival slightly enhanced by adjuvant treatments. Moreover, even in the case of benign or borderline malignancy, despite the substantive advances that have been achieved in the perioperative management, surgery is still burdened by some potential life-threatening complications.^{[1, 2]} In this view, we believe that the well-known benefits of minimally invasive surgery can offer aged patients are to be taken into consideration while evaluating quality rather than quantity of life.^[1-4] Indeed, in recent years, minimally invasive surgery has proven to have the potential of providing elderly undergoing major visceral surgery with diminished postoperative complications and shorter hospitalization, with faster return to ambulation and daily activities compared to conventional surgery.^[3]

 

Although the recent years have seen a dramatic penetration of minimally invasive surgery in daily surgical practice, pancreaticoduodenectomy has been historically considered a relative contraindication to the application of laparoscopy.^{[4, 5]} This is essentially due to the deep, retroperitoneal localization of the pancreas, its intrinsic connection with major vasculature and the technical difficulty of the reconstructive phase of the intervention, which requires at least three anastomoses.^[5] Nonetheless, approximately two decades after its first appearance, the application of minimally invasive methods for pancreatic surgery is becoming more widespread, mostly due to increased experience in laparoscopic surgery and the availability of new and sophisticated technologies.^{[4, 5]} Currently, in a progressively growing number of experienced centers, both conventional laparoscopy and robot-assisted surgery can be employed in performing pancreaticoduodenectomy competently, with expected rates of morbidity and mortality while maintaining oncological adequacy.^[4-7]

 

Of note, increasing evidence exists proving not only the surgical efficacy and safety of minimally invasive pancreaticoduodenectomy, but also suggesting significant advantages over conventional surgery on intraoperative blood loss, length of intensive care unit and hospital stay, postoperative wound infection and time to return to daily activities.^[4-7] Several uncertainties on oncological adequacy essentially connected with an appropriate lymphadenectomy and the rates of R0 resection margins have now been allayed.^[5-9] Interestingly, probably due to the enhanced postoperative recovery and lowered rates of postoperative morbidity and wound infection, also a potential role in increasing the percentage of patients being able to receive adjuvant therapies at appropriate timing has been put in connection with minimally invasive surgery.^[5-7]

 

Indeed, in a comprehensive and intriguing review of the literature including twenty-two studies and more than six thousands patients, the comparison between conventional open and minimally invasive pancreaticoduodenectomy did not elicit any statistically significant difference in terms of mortality (0-37.5%), morbidity (26.5%-58.3%), pancreatic fistula or bile leakage.^[6] Contrariwise, minimally invasive surgery was favorably associated with intraoperative blood loss, wound infection rates, duration of hospital stay and oncological outcomes. Despite some selection bias due to surgical difficulty (such as vascular encasement or tumor size), nearly all the comparative studies in the analysis reported on groups of patients that were matched for demographics characteristics. Particularly, in more than half of the studies the mean age was higher in the minimally invasive group.

 

It is noteworthy that in a number of single experiences worldwide several advantages in particular frailty subgroups have been noticed. Of note, the abovementioned advantages of laparoscopy over traditional surgery were also confirmed by Kuroki et al in a specific matched comparison between patients undergoing laparoscopic or traditional pancreaticoduodenectomy, with a mean age of 71.2±8.8 and 73.5±7.3 years, respectively.^[8] Interestingly, geriatric surgical patients were even considered comparatively more appropriate candidates to laparoscopic pancreaticoduodenectomy.^[9] Similarly, it has been suggested that, regardless of chronologic age, patients with severe pulmonary dysfunction are likely to take advantages from a laparoscopic procedure.^[10]

 

Definitive conclusions cannot be drawn on the basis of the current knowledge essentially due to the lack of well-conducted, randomized trials. Nevertheless, the current available evidence from the literature suggests that pancreaticoduodenectomy can be performed in a minimally invasive manner competently, even in aged population.^[4-9]

 

While we congratulate with the authors on their elegant and timely papers, we believe that the decision whether to offer pancreaticoduodenectomy should now be taken according to how much has changed through the last years also with reference to surgical approaches. This is particularly the case of the elderly, who represent the subgroup of patients that may potentially benefit the most from the limited surgical and immunologic trauma and enhanced postoperative recovery connected with minimally invasive surgery.^[2-6]

 

 

Francesco Guerra and Lapo Bencini

Giovanni Battista Levi Sandri

 

 

1 El Nakeeb A, Atef E, El Hanafy E, Salem A, Askar W, Ezzat H, et al. Outcomes of pancreaticoduodenectomy in elderly patients. Hepatobiliary Pancreat Dis Int 2016;15:419-427. PMID: 27498583

2 Dudeja V, Livingstone A. Is age just a number: pancreaticoduodenectomy in elderly patients? Hepatobiliary Pancreat Dis Int 2016;15:346-347. PMID: 27498573

3 Wang JF, Zhang SZ, Zhang NY, Wu ZY, Feng JY, Ying LP, et al. Laparoscopic gastrectomy versus open gastrectomy for elderly patients with gastric cancer: a systematic review and meta-analysis. World J Surg Oncol 2016;14:90. PMID: 27030355

4 Bencini L, Annecchiarico M, Farsi M, Bartolini I, Mirasolo V, Guerra F, et al. Minimally invasive surgical approach to pancreatic malignancies. World J Gastrointest Oncol 2015;7:411- 421. PMID: 26690680

5 Guerra F, Levi Sandri GB, Amore Bonapasta S, Farsi M, Coratti A. The role of robotics in widening the range of application of minimally invasive surgery for pancreaticoduodenectomy. Pancreatology 2016;16:293-294. PMID: 26774496

6 Zhang H, Wu X, Zhu F, Shen M, Tian R, Shi C, et al. Systematic review and meta-analysis of minimally invasive versus open approach for pancreaticoduodenectomy. Surg Endosc 2016; Mar 22. PMID: 27005287

7 Croome KP, Farnell MB, Que FG, Reid-Lombardo KM, Truty MJ, Nagorney DM, et al. Total laparoscopic pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: oncologic advantages over open approaches? Ann Surg 2014;260:633- 640. PMID: 25203880

8 Kuroki T, Adachi T, Okamoto T, Kanematsu T. A non-randomized comparative study of laparoscopy-assisted pancreaticoduodenectomy and open pancreaticoduodenectomy. Hepatogastroenterology 2012;59:570-573. PMID: 21940382

9 Battal M, Yilmaz A, Ozturk G, Karatepe O. The difficulties encountered in conversion from classic pancreaticoduodenectomy to total laparoscopic pancreaticoduodenectomy. J Minim Access Surg 2016;12:338-341. PMID: 27251830

10 Li H, Peng B. Total laparoscopic pancreaticoduodenectomy may benefit patients with severe impaired pulmonary function. Surg Laparosc Endosc Percutan Tech 2015;25:266. PMID: 26039799

 

(doi: 10.1016/S1499-3872(16)60149-2)

Published online November 4, 2016.

 

 

We thank the authors for their commentary on our paper.^[1] Pancreaticoduodenectomy can be performed safely in selected elderly patients. Advanced age alone should not be a contraindication to do pancreaticoduodenectomy. Careful patient selection is the cornerstone to improve the outcome of pancreaticoduodenectomy in elderly. An aggressive approach to pancreatic cancer in the elderly can be justified in high volume centers in order to optimize resectability, and minimize morbidity and mortality. The elderly may potentially benefit from minimally invasive pancreaticoduodenectomy due to limited surgical and immunologic trauma and enhanced postoperative recovery.^{[2, 3]} In this view, we believe that the well-known benefits the minimally invasive surgery offered to elderly patients are to be taken into consideration in decision making.

 

 

Ayman El Nakeeb

 

 

1 El Nakeeb A, Atef E, El Hanafy E, Salem A, Askar W, Ezzat H, et al. Outcomes of pancreaticoduodenectomy in elderly patients. Hepatobiliary Pancreat Dis Int 2016;15:419-427. PMID: 27498583

2 Zhang H, Wu X, Zhu F, Shen M, Tian R, Shi C, et al. Systematic review and meta-analysis of minimally invasive versus open approach for pancreaticoduodenectomy. Surg Endosc 2016; Mar 22. PMID: 27005287

3 Croome KP, Farnell MB, Que FG, Reid-Lombardo KM, Truty MJ, Nagorney DM, et al. Total laparoscopic pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: oncologic advantages over open approaches? Ann Surg 2014;260:633- 640. PMID: 25203880

 

(doi: 10.1016/S1499-3872(16)60150-9)

Published online November 4, 2016.