ABSTRACT
Introduction
Pancreaticoduodenectomy (PD) carries substantial risks in elderly patients, emphasizing the need for optimized perioperative care. Comprehensive geriatric assessments (CGAs) ‐ evaluating medical, functional, and psychosocial domains ‐ may mitigate these risks. This study investigates the impact of a preoperative evaluation by a dedicated geriatric surgery service on outcomes in elderly patients undergoing PD.
Methods and Materials
This was a retrospective cohort study of elderly (age over 75 years) patients that underwent PD (GA + 75, n = 23) following preoperative workup by a specialized geriatric surgery service (GSS). Control groups included elderly patients without geriatric assessment (non‐GA + 75, n = 73) and non‐elderly patients ( < 75 years, n = 275). Short‐ and long‐term outcomes were compared across the groups.
Results
While baseline demographics were similar between GA + 75 and non‐GA + 75 groups, comorbidity profiles differed. Higher rates of chronic obstructive pulmonary disease (21.7% vs. 2.7%, p = 0.002) and asthma (26% vs. 1.4%, p < 0.001) were observed in the GA + 75 group. Despite this, GA + 75 patients had significantly lower rates of postoperative pneumonia (4.3% vs. 18.1%, p < 0.001), readmission (26.1% vs. 41.6%, p < 0.001; also lower than the non‐elderly cohort), and delirium (4.3% vs. 36.1%, p < 0.001). There were no significant differences in overall major complications or 30‐/90‐day survival rates as well as long‐term outcomes between the groups.
Conclusions
Preoperative evaluation by a dedicated GSS was associated with improved postoperative outcomes in elderly patients undergoing PD. These findings support the integration of CGAs into perioperative planning to enhance recovery and reduce complications in older adults.
Keywords: hepatobiliary, nonagenarians, octogenarians, pancreas
1. Introduction
Despite advancements in surgical techniques and perioperative management, PD remains associated with considerable morbidity and mortality. As life expectancy increases, a growing number of elderly patients become candidates for PD, highlighting the need for tailored strategies to optimize perioperative care and improve outcomes in this population [1, 2, 3, 4]. Elderly patients present unique challenges, including a higher burden of comorbidities, diminished physiological reserves, and increased frailty [2]. These factors not only elevate the risk of immediate postoperative complications but also complicate long‐term recovery and functional rehabilitation [3, 4]. Traditional preoperative assessments often fail to capture critical health domains that are particularly relevant to older adults, such as cognitive function, nutritional status, and social support systems [5]. This gap has prompted interest in the use of CGA, which aim to provide a multidimensional evaluation of medical, functional, and psychosocial health [6].
Geriatric assessments are structured, multidisciplinary evaluations designed to identify vulnerabilities and inform individualized interventions [7]. Several studies suggest that such assessments can improve risk stratification, guide surgical decision‐making, and enhance perioperative care planning [6]. However, data on the impact of CGAs on outcomes following high‐risk procedures like PD remain limited.
In recent years, the importance of standardized preoperative evaluation in older adults has gained increasing recognition. Updated risk calculators and clinical guidelines—such as those from the American College of Surgeons and the American Geriatrics Society [8, 9] —have emphasized the value of comprehensive preoperative assessment and management to improve outcomes in elderly surgical patients [4, 10, 11]. In response to this evolving paradigm, we established a dedicated GSS aimed at managing all aspects of perioperative care for elderly surgical candidates. The GSS conducts detailed evaluations and corresponding interventions, participates in multidisciplinary discussions to determine operability, addresses elderly‐specific needs throughout the perioperative period, and facilitates tailored discharge planning.
The objective of this study was to assess the impact of preoperative evaluation by the GSS on surgical outcomes in elderly patients undergoing PD. Outcomes in patients aged 75 and older who were evaluated by the GSS prior to PD were compared to those in similarly aged patients who were not, as well as to a younger PD cohort.
2. Methods
2.1. Establishment of a Dedicated GSS
In January 2022, an independent GSS was established within the Department of Surgery. The service is led by a senior surgeon with extensive experience in surgical oncology and includes a multidisciplinary team comprising a geriatric nurse practitioner (GNP), geriatric physician, surgeons, anesthesiologists, and a physiotherapist. Inclusion criteria for GSS assessment included: age over 80 years; substantial baseline geriatric morbidity; or age over 75 years undergoing major abdominal surgery. Additionally, referrals could be made at the discretion of the attending surgeon.
2.2. Study Design and Patient Population
This retrospective study included patients with that underwent PD at a tertiary referral center between January 2009 and April 2023. All oncological cases were reviewed in weekly multidisciplinary team (MDT) meetings, including pancreatic cancer oncologists, radiation oncologists, radiologists, hepatopancreatobiliary (HPB) surgeons, upper gastrointestinal (GI) surgeons, and gastroenterologists. Non‐oncological cases were discussed within the HPB and upper GI surgical teams prior to surgery. Data were retrieved using MDClone's ADAMS platform, a self‐service query tool that provides comprehensive patient‐level data of wide‐ranging variables in a defined time frame around an index event (mdclone.com). Collected variables included demographics, medical history, comorbidities, tumor characteristics on imaging, perioperative laboratory values, postoperative complications, hospital length of stay, and survival outcomes. All extracted data were manually reviewed and validated. Additional clinical information not routinely coded—such as MDT discussions, specific postoperative complications (e.g., pneumonia, delirium), and discharge disposition (home vs. rehabilitation or nursing facility)—was manually retrieved from patient charts. For patients aged ≥ 75 years, geriatric risk scores were retrospectively calculated using the ACS‐NSQIP Surgical Risk Calculator [8]. Postoperative complications were categorized using the Clavien‐Dindo (CD) classification system, with major complications defined as CD grade > 3a [12]. All study procedures adhered to the Declaration of Helsinki. The institutional review board approved the study (approval number SMC‐9498‐22), and the requirement for informed consent was waived due to the retrospective study design.
2.3. Components of the Geriatric Assessment and Associated Interventions
The preoperative geriatric program extends beyond risk stratification and includes targeted, patient‐centered interventions designed to optimize outcomes in older surgical patients.
2.4. CGA
Patients undergo a structured, clinic‐based geriatric assessment conducted by a trained clinical nurse practitioner with expertise in geriatric surgery. This assessment evaluates the patient's global health status, including medical comorbidities, functional and cognitive status, nutritional state, psychosocial needs, and physiologic reserve, with the goal of identifying vulnerabilities that may affect surgical risk and recovery. Furthermore, as part of the preoperative evaluation, patients are assessed for decision‐making capacity and the presence of advance directives.
2.5. Multidisciplinary Case Discussion
Each case is reviewed in a multidisciplinary forum including geriatricians, surgeons, anesthesiologists, registered dietitian nutritionists, and nursing staff. This discussion determines whether surgery is advisable for the individual patient, weighs the potential benefits and risks, anticipates likely complications, and addresses the need for perioperative and post‐discharge support.
2.6. Patient and Family Education and Prehabilitation Planning
Following completion of the assessment, patients and their families receive tailored education and a structured preoperative preparation plan. This includes:
Respiratory exercises.
General physical conditioning exercises.
A personalized nutritional plan.
Education regarding perioperative pain management.
Delirium prevention strategies, with practical and individualized recommendations: These included early risk identification, minimization of deliriogenic medications, optimization of pain control, sleep hygiene, orientation strategies, early mobilization, and active involvement of family members.
This shared decision‐making process aims to align expectations, improve adherence, and actively engage patients and caregivers in perioperative care.
2.7. Preoperative Optimization When Indicated
In selected cases, when the geriatric nurse practitioner determines that the patient's condition is insufficiently optimized for surgery, elective preoperative hospitalization is recommended. This allows for intensive multidisciplinary optimization and treatment prior to surgery, conducted in full collaboration with the treating surgeon. Including Geriatric‐focused management: Delirium prevention, detection, and treatment, Prevention of cognitive and functional decline, Comprehensive medication review, Pain control, Continence management, and Psychological support.
2.8. Postoperative Support
The care pathway also includes ongoing geriatric team involvement during hospitalization. Patients are followed throughout their inpatient stay, with continued assessment and support aimed at early identification and management of medical, functional, and cognitive issues. This longitudinal involvement allows for reinforcement of preoperative recommendations, proactive delirium prevention, facilitation of early mobilization, and coordination with multidisciplinary teams.
2.9. Discharge Planning and Community Transition
Including early discharge planning, coordination with community services, and support for patient and caregivers post‐discharge.
2.10. Program Workflow and Implementation
When a senior surgeon plans surgery for a patient aged ≥ 80 years, or for a younger patient with significant functional impairment, the patient is referred to the Center for Geriatric Surgery for formal evaluation, the workflow is presented in Figure 1.
Figure 1.
Workflow of the geriatric surgery program. Patients aged ≥ 80 years or younger patients with functional impairment are referred for comprehensive geriatric assessment. The program integrates multidisciplinary decision‐making, targeted prehabilitation, selective preoperative optimization, and geriatric‐focused perioperative management, with continued involvement through discharge planning and transition to community care.
At the center:
The patient undergoes a comprehensive assessment by a geriatric nurse specialist and a physiotherapist.
When indicated, the nurse specialist refers the patient to the center's dietitian for nutritional evaluation and intervention.
Following completion of the assessment:
The case is reviewed by the center director (MG), who determines whether a broader multidisciplinary team discussion is required.
For patients who proceed to surgery:
The geriatric surgery team follows the patient throughout the perioperative hospitalization and actively participates in discharge planning.
The geriatric nurse specialist addresses geriatric‐specific needs, including:
Delirium prevention, early detection, and management.
Prevention of cognitive and functional decline.
Comprehensive medication review.
Pain management.
Continence management.
Psychological support and coping strategies.
Discharge planning and coordination with community services.
In addition, some patients are identified during acute hospitalization rather than preoperatively. In these cases, the geriatric surgery team evaluates and manages the patient during the inpatient stay using the same principles and interventions.
2.11. Statistical Analysis
Descriptive statistics were used to summarize patient characteristics. Continuous variables were reported as means ± standard deviations or medians with interquartile ranges (IQRs), depending on distribution. Categorical variables were expressed as frequencies and percentages. Group comparisons were made using chi‐square tests for categorical variables and either independent t‐tests or Mann–Whitney U tests for continuous variables, as appropriate. Kaplan‐Meier survival curves were constructed to evaluate 90‐day postoperative survival, with log‐rank tests used for between‐group comparisons. Analyses were performed using SAS version 9.4 (UNIX) and RStudio version 3.6.2.
3. Results
Of the 342 patients who underwent PD between January 2009 and April 2023, 95 (27.7%) were aged over 75 years. Among this elderly cohort, 23 patients (24.2%) underwent a preoperative assessment by the GSS (GA + 75), while 72 patients (75.8%) did not (Non‐GA + 75). Demographic and clinical characteristics of elderly patients, stratified by geriatric assessment status, are presented in Table 1. Smoking was absent in the GA + 75 group but present in 16.6% of the Non‐GA + 75 group (p < 0.001). Conversely, the prevalence of chronic obstructive pulmonary disease (COPD) and asthma was significantly higher in the GA + 75 group (21.7% vs. 2.7%, p = 0.002, and 26% vs. 1.4%, p < 0.001, respectively). Preoperative use of mobility aids was more common in the GA + 75 group (56.5% vs. 47.2%, p < 0.001), as was receipt of neoadjuvant therapy (21.7% vs. 1.4%, p < 0.001). Notably, no patients in the GA + 75 group had a documented history of falls, compared to 9.7% in the Non‐GA + 75 group (p < 0.001). Preoperative laboratory markers, including serum albumin, carcinoembryonic antigen (CEA), and CA 19‐9 levels, did not differ significantly between the groups.
Table 1.
Demographics and characteristics of elderly patients with and without perioperative GSS assessment.
| GA + 75 n = 23 | Non GA + 75 n = 75 | Under 75 N = 247 | p | |
|---|---|---|---|---|
| Age (mean) | 81.59 | 79.8 | 63 | 0.551 |
| Gender F (%) | 9 (39.1) | 28 (37) | 101 (40) | 0.947 |
| BMI (median (IQR)) | 25.5 (24.8–26.4) | 25.8 (25.2–26.3) | 25.1 (24.3–26.0) | 0.958 |
| Smoking, n (%) | 0 (0) | 12 (16.6) | 40 (16) | < 0.001 |
| DM, n (%) | 12 (51.17) | 23 (31.9) | 61 (24.6) | 0.073 |
| HTN, n (%) | 14 (60.8) | 45 (62.5) | 150 (60.7) | 0.947 |
| IHD, n (%) | 3 (4.16) | 9 (12.5) | 21 (8.5) | 0.928 |
| CHF, n (%) | 0 | 3 (4.1) | 1 (0.4) | 0.323 |
| COPD, n (%) | 5 (21.7) | 2 (2.7) | 1 (0.4) | 0.002 |
| Asthma, n (%) | 6 (26) | 1 (1.35) | 21 (8.5) | < 0.001 |
| CVA, n (%) | 0 (0) | 2 (2.7) | 0 (0) | 0.422 |
| CRF, n (%) | 3 (4.1) | 7 (9.7) | 2 (0.8) | 0.784 |
| ERCP Before surgery, n (%) | 12 (52.1) | 35 (48.6) | 125 (50.6) | 0.724 |
| Albumin preop (g/dl) | 3.6 ± 0.4 | 3.7 ± 0.2 | 21.1 ± 1.3 | 0.969 |
| CEA preop | 4.86 ± 0.8 | 5.16 ± 0.9 | 4.6 ± 1.1 | 0.347 |
| CA 19‐9 preop | 25.54 ± 3.1 | 51.1 ± 5.6 | 48.2 ± 1.3 | 0.493 |
| Neoadjuvant, n (%) | 5 (21.7) | 1 (3.5) | 70 (28.3) | < 0.001 |
| Mobility aid use, n (%) | 13 (56.2) | 34 (45.3) | 0 | < 0.001 |
| Fall history, n (%) | 0 | 7 (9.7) | 0 | < 0.001 |
Abbreviations: BMI, Body mass index; CA 19‐9, Carbohydrate antigen 19‐9.0 = Data collected/reviewed, result is zero; CEA, Carcinoembryonic antigen; CHF, Congestive Heart Failure; COPD, Chronic Obstructive Pulmonary Disease; CRF, Chronic Renal Failure; CVA, Cerebral vascular accident; DM, Diabetes Mellitus; ERCP, Endoscopic retrograde cholangiopancreatography; HTN, Hypertension; IHD, Ischemic Heart Disease.
A comparison of geriatric assessment parameters between the GA + 75 and Non‐GA + 75 groups, based on preoperative metrics, is presented in Table 2. The predicted hospital length of stay, as calculated by the ACS‐NSQIP Risk Calculator, was slightly longer in the GA + 75 group compared to the Non‐GA + 75 group (9.52 vs. 8.49 days, p = 0.000). The distribution of the American Society of Anesthesiologists (ASA) classifications was similar between groups, with the majority of patients in both cohorts classified as ASA 3 (65.2%). In terms of pre‐admission living arrangements, 65 GA + 75 patients (87%) lived independently at home without personal assistance, compared to 20 patients (91.6%) in the Non‐GA + 75 group (p = 0.33). Documented history of dementia or cognitive impairment was comparable between the groups (5.5% vs. 0%, p = 0.09). Other NSQIP‐predicted functional outcomes—including likelihood of functional decline (51.4% vs. 59.3%, p = 0.83) and new mobility aid use (60.5% vs. 65.6%, p = 0.88) ‐ were also not significantly different between the groups (Table 3).
Table 2.
ACS‐NSQIP comparison of preoperative geriatric assessment.
| GA + 75 n = 23 | Non GA + 75 n = 75 | p | |
|---|---|---|---|
| ASA n (%) | |||
| 1 | 0 | 4 (5.5) | 0.57 |
| 2 | 8 (34.7) | 16 (22.2) | 0.26 |
| 3 | 15 | 47 (65.2) | 0.41 |
| 4 | (65.2) | 4 (5.5) | 0.57 |
| Original Status on Admission n (%) | |||
| Not from home | 0 | 0 | — |
| Supported at home | 3 (13) | 6 (8.3) | 0.43 |
| Alone at home | 20 (87) | 66 (91.6) | 0.33 |
| History of Dementia or Cognitive Impairment n (%) | 0 | 3 (5.5) | 0.44 |
| Post operative delirium %(mean) | 26.63 | 29.848 | 0.71 |
| Functional decline %(mean) | 51.361 | 59.337 | 0.833 |
| New mobility aid use %(mean) | 60.504 | 65.607 | 0.888 |
| New/worsening pressure ulcer %(mean) | 3.178 | 1.497 | 0.477 |
| predicted hospital stay %(median (IQR)) | 9.5 (7.9–11.3) | 8.5 (6.8–10.2) | 0.000 |
| Serious Complication %(mean) | 29.97 | 30.312 | 0.032 |
| any complication %(mean) | 33.543 | 33.473 | 0.477 |
| Pneumonia %(mean) | 6.078 | 5.303 | 0.004 |
| cardiac complication %(mean) | 4.457 | 3.393 | 0.001 |
| surgical site infection %(mean) | 18.443 | 18.94 | 0.048 |
| urinary tract infection %(mean) | 3.026 | 2.693 | 0.009 |
| venous thromboembolism %(mean) | 4.061 | 3.775 | 0.479 |
| renal failure %(mean) | 2.196 | 1.906 | 0.042 |
| Readmission %(mean) | 18.443 | 17.837 | 0.249 |
| Return to OR %(mean) | 5.613 | 5.484 | 0.307 |
| Death %(mean) | 3.826 | 3.011 | 0.042 |
Note: — = Not applicable (measure not relevant or data not collected for this group). Data presented as % of patients that would develop the condition and means according to the ACS‐NSQIP calculator.
Table 3.
Comparison of post‐operative parameters.
| GA + 75 n = 23 | Non‐GA + 75 n = 75 | Under 75 N = 247 | p | |
|---|---|---|---|---|
| Discharge location | ||||
| Home | 23 (100%) | 60 (83.3) | — | 0.253 |
| Facility | 0 | 12 (16.6) | 0.035 | |
| Clavien Dindo | 0.54 | |||
| Minor (≤ 3a) | 16 (66.08) | 51 (41.5) | 102 (41.2) | |
| Major (> 3a) | 3 (13.04) | 16 (11.68) | 38 (15.3) | |
| Pneumonia post‐surgery, n (%) | 1 (4.3) | 13 (18.05) | — | < 0.001 |
| Delirium post‐surgery, n (%) | 1 (4.3) | 26 (36.1) | — | < 0.001 |
| Pancreatic fistula, n (%) | 11 (47.82) | 20 (27.7) | 50 (20.2) | < 0.001 |
| Reoperation, n (%) | 3 (13.04) | 10 (13.8) | 40 (16.1) | 0.523 |
| Readmission, n (%) | 6 (26.08) | 30 (41.6) | 81 (32.2) | < 0.001 |
| Length of stay (days), median (IQR) | 23 (16–32) | 22 (15–30) | 21 (14–29) | 0.641 |
| Surgery Duration(hours), median (IQR) | 7.5 (6.8–8.6) | 6.2 (5.5–7.1) | 5.1 (4.4–5.9) | 0.001 |
Note: — = Not applicable (measure not relevant or data not collected for this group), 0 = Value of zero (data collected and reviewed).
Postoperative outcomes and complications relevant to geriatric patients are summarized in Table 3 and Figure 2. Patients in the GA + 75 group had a significantly longer mean operative time compared to the Non‐GA + 75 group (7.6 vs. 6.2 h, p = 0.001). The incidence of pancreatic fistula was also higher in the GA + 75 group (47.8% vs. 27.7%, p < 0.001); however, the overall rate of major postoperative complications did not differ significantly between the groups. Similarly, reoperation rates were comparable (13.0% vs. 13.8%, p = 0.523). Importantly, GA + 75 patients experienced significantly fewer pulmonary and neurocognitive complications. The incidence of postoperative pneumonia was lower in the GA + 75 group (4.3% vs. 18.1%, p < 0.001), as was the rate of postoperative delirium (4.3% vs. 36.1%, p < 0.001). While the median length of hospital stay was similar between groups (23.3 vs. 22.5 days, p = 0.641), discharge disposition differed significantly. All GA + 75 patients were discharged home, whereas 16.6% of Non‐GA + 75 patients were discharged to a rehabilitation or nursing facility (p = 0.035). Furthermore, the GA + 75 group demonstrated significantly lower 30‐day readmission rates (26.1% vs. 41.6%, p < 0.001).
Figure 2.
Postoperative complications stratified by age and geriatric assessment status. This bar graph compares the incidence of postoperative pneumonia, hospital readmission, and delirium among three patient groups undergoing surgery: elderly patients aged ≥ 75 with a geriatric assessment (GA + 75, blue), elderly patients aged ≥ 75 without a geriatric assessment (non‐GA + 75, green), and non‐elderly patients (non‐Elderly, light green). A significantly lower incidence of pneumonia, readmission, and delirium was observed in the GA + 75 group compared to non‐GA + 75 and non‐elderly patients (all comparisons p < 0.001). Percentages represent the proportion of patients within each group experiencing the specified outcome.
No 90‐day postoperative deaths occurred in the elderly cohort that received a geriatric assessment (Group 1). In contrast, 16 deaths (7.4%) were observed in the non‐elderly cohort (Group 2), and 7 deaths (11.1%) occurred in elderly patients who did not receive a geriatric assessment (Group 3) (Figure 3). While early postoperative mortality appeared lowest in the GA + 75 group, the difference in 90‐day survival between the three cohorts did not reach statistical significance (log‐rank test, p = 0.572).
Figure 3.
Kaplan–Meier analysis of 90‐day postoperative survival by age and geriatric assessment status. Kaplan–Meier survival curves illustrate differences in short‐term postoperative survival among three cohorts of surgical patients: elderly patients aged ≥ 75 who received a geriatric assessment (GA + 75, blue), non‐elderly patients (orange), and elderly patients aged ≥ 75 who did not receive a geriatric assessment (non‐GA + 75, Green). The GA + 75 group maintained 100% survival throughout the 90‐day follow‐up period. In contrast, the non‐GA + 75 group exhibited the lowest survival probability, followed by the non‐elderly group. Differences in early postoperative mortality were most pronounced within the first 30 days; however, these were not statistically significant (log‐rank p = 0.572).
4. Discussion
This study evaluated the implementation of a dedicated GSS for elderly patients undergoing PD and demonstrated that structured preoperative geriatric assessment was associated with a significant reduction in specific postoperative complications—most notably pneumonia and delirium—as well as improved discharge disposition and reduced readmission rates. the incidence of pneumonia and delirium was markedly lower in the GA + 75 group (4.3% vs. 18.1% and 4.3% vs. 36.1%, respectively). These findings are clinically meaningful, as both complications are well‐established contributors to delayed recovery, increased healthcare resource utilization, and diminished long‐term functional outcomes in older surgical patients [13, 14, 15]. Our results are consistent with prior literature demonstrating that geriatric‐specific interventions—such as respiratory optimization, early mobilization, and delirium prevention protocols—can mitigate postoperative risk in this population [16, 17]. Notably, the reduction in complications was observed despite the GA + 75 cohort presenting with a higher burden of baseline vulnerabilities, including increased use of mobility aids and higher rates of chronic pulmonary disease. This suggests that the benefits of the GSS likely derive from its ability to anticipate and proactively manage patient‐specific risks. The fact that all GA + 75 patients were discharged directly home, with no transfers to rehabilitation or skilled nursing facilities, further underscores the potential of comprehensive geriatric assessment to support functional independence and streamline discharge planning following complex surgical procedures [18].
Although overall rates of major complications (Clavien‐Dindo ≥ 3a) and 90‐day survival were similar between groups—mirroring previous findings in this context [19] —the significantly lower readmission rate in the GA + 75 group (26.1% vs. 41.6%) suggests that while geriatric optimization may not eliminate all serious complications, it can meaningfully improve recovery trajectories and post‐discharge care transitions.
An unexpected finding was the higher incidence of postoperative pancreatic fistula in the GA + 75 cohort (47.8% vs. 27.7%), consistent with prior reports suggesting increased susceptibility among elderly patients [20]. The etiology of this difference is unclear and may reflect variations in intraoperative technique, pancreatic gland texture, or other unmeasured confounders, rather than the influence of the GSS itself. Nevertheless, reoperation rates and overall hospital length of stay did not differ significantly between groups, implying that fistula severity or management strategies may have differed in practice. The GA + 75 group also experienced significantly longer operative times (7.6 vs. 4.4 h), a finding previously described in the context of geriatric surgical care [2, 21]. This may reflect greater intraoperative complexity, increased surgical caution, or more deliberate operative strategies influenced by preoperative geriatric input. Whether GSS involvement directly alters intraoperative decision‐making remains an important question for future investigation. As expected, the GSS intervention did not influence DFS or overall survival OS, outcomes that are primarily determined by tumor biology and oncologic factors rather than perioperative management strategies.
This study has several limitations. First, its retrospective design introduces the potential for selection bias. Patients referred to the GSS may have been perceived as higher risk by clinicians, which could confound outcome comparisons. Second, the sample size of the GA + 75 group was relatively small, limiting statistical power and generalizability. Third, while we used validated tools such as the ACS‐NSQIP risk calculator, some variables, such as frailty scores or detailed functional assessments were not systematically captured. Also, as a single‐center study conducted at a high‐volume tertiary referral institution, the findings may not be generalizable to all practice settings. Our patient population represents a complex, high‐risk cohort, many of which were transferred from other centers. This may contribute to the relatively high observed mortality rates in the non‐GA + 75 and < 75‐year groups. Institutions with favorable patient profile and possibly lower baseline morbidity and mortality may observe a smaller absolute benefit from implementation of a dedicated geriatric surgery service. Nonetheless, our findings suggest that geriatric‐focused perioperative interventions may be particularly valuable in high‐risk populations, and underscore the need for multicenter studies to validate these results and assess broader applicability. Finally, the adoption of the GSS occurred later in the study period, introducing the possibility of temporal bias related to institutional changes in surgical technique or postoperative care.
Despite these limitations, our study provides preliminary evidence that structured geriatric assessment, and perioperative management can significantly improve outcomes in elderly patients undergoing high‐risk surgery. These findings support broader integration of geriatric principles into surgical care models and align with national recommendations promoting age‐specific perioperative pathways.
In summary, although pancreaticoduodenectomy has traditionally been associated with high morbidity in elderly patients, our findings demonstrate that targeted geriatric co‐management can substantially improve outcomes. By proactively addressing geriatric‐specific vulnerabilities through comprehensive geriatric assessment and tailored perioperative protocols, we mitigated key drivers of failure‐to‐rescue and reduced the influence of chronological age on postoperative recovery. These results support the integration of dedicated geriatric surgical pathways for high‐risk elderly patients undergoing complex oncologic procedures.
5. Conclusions
Implementation of a dedicated GSS was associated with reduced rates of postoperative pneumonia, delirium, and readmissions in elderly patients undergoing PD. These improvements occurred despite greater baseline comorbidities and longer operative times, suggesting that geriatric assessment may play a critical role in mitigating risk and optimizing recovery. Future prospective studies with larger cohorts are warranted to further evaluate the long‐term impact of geriatric surgical services on functional outcomes and survival.
Funding
The authors received no specific funding for this work.
Conflicts of Interest
The authors declare no conflicts of interest.
Synopsis
This retrospective cohort study evaluated whether preoperative assessment by a dedicated geriatric surgery service improves outcomes in patients over 75 undergoing pancreaticoduodenectomy. Despite a higher burden of pulmonary comorbidities, geriatric‐assessed patients had significantly lower rates of postoperative pneumonia, delirium, and readmission, with similar major complication and survival rates compared to controls. These findings support integrating comprehensive geriatric assessment into perioperative care to improve recovery in elderly surgical patients.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
References
- 1. D'Cruz J. R., Misra S., and Shamsudeen S., “Pancreaticoduodenectomy (Whipple Procedure).” StatPearls (StatPearls Publishing, 2024). [PubMed] [Google Scholar]
- 2. Zhu J., Wang G., Du P., He J., and Li Y., “Minimally Invasive Pancreaticoduodenectomy in Elderly Patients: Systematic Review and Meta‐Analysis,” World Journal of Surgery 45 (2021): 1186–1201, 20210117, 10.1007/s00268-020-05945-w. [DOI] [PubMed] [Google Scholar]
- 3. Yüceler Kaçmaz H., Kahraman H., Akin S., and Sözüer E., “The Effects of Frailty on Quality of Recovery and Complications in Older Adults Undergoing Major Abdominal Surgery: A Prospective Cohort Study,” Journal of Health Sciences and Medicine 6 (2023): 1133–1141. [Google Scholar]
- 4. Sánchez Arteaga A., Tinoco González J., Tallón Aguilar L., et al., “Long‐Term Influence of Frailty in Elderly Patients After Surgical Emergencies,” European Journal of Trauma and Emergency Surgery 48 (2022): 3855–3862. [DOI] [PubMed] [Google Scholar]
- 5. Pang C. L., Gooneratne M., and Partridge J. S. L., “Preoperative Assessment of the Older Patient,” BJA Education 21 (2021): 314–320. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Zietlow K. E., Wong S., Heflin M. T., et al., “Geriatric Preoperative Optimization: A Review,” American Journal of Medicine 135 (2022): 39–48. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. Kuemmerli C., Balzano G., Bouwense S. A., et al., “Are Enhanced Recovery Protocols After Pancreatoduodenectomy Still Efficient When Applied in Elderly Patients? A Systematic Review and Individual Patient Data Meta‐Analysis,” Journal of Hepato‐Biliary‐Pancreatic Sciences 31 (2024): 308–317, 20240129, 10.1002/jhbp.1417. [DOI] [PubMed] [Google Scholar]
- 8. Bilimoria K. Y., Liu Y., Paruch J. L., et al., “Development and Evaluation of the Universal ACS NSQIP Surgical Risk Calculator: A Decision Aid and Informed Consent Tool for Patients and Surgeons,” Journal of the American College of Surgeons 217 (2013): 833–842.e1–3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9. Liu Y., Cohen M. E., Hall B. L., Ko C. Y., and Bilimoria K. Y., “Evaluation and Enhancement of Calibration in the American College of Surgeons NSQIP Surgical Risk Calculator,” Journal of the American College of Surgeons 223 (2016): 231–239. [DOI] [PubMed] [Google Scholar]
- 10. Hung Y. C., Wolf J. H., D'Adamo C. R., Demos J., Katlic M. R., and Svoboda S., “Preoperative Functional Status Is Associated With Discharge to Nonhome in Geriatric Individuals,” Journal of the American Geriatrics Society 69 (2021): 1856–1864. [DOI] [PubMed] [Google Scholar]
- 11. Owodunni O. P., Mostales J. C., Qin C. X., Gabre‐Kidan A., Magnuson T., and Gearhart S. L., “Preoperative Frailty Assessment, Operative Severity Score, and Early Postoperative Loss of Independence in Surgical Patients Age 65 Years or Older,” Journal of the American College of Surgeons 232 (2021): 387–395. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12. Clavien P. A., Barkun J., de Oliveira M. L., et al., “The Clavien‐Dindo Classification of Surgical Complications: Five‐Year Experience,” Annals of Surgery 250 (2009): 187–196, 10.1097/SLA.0b013e3181b13ca2. [DOI] [PubMed] [Google Scholar]
- 13. Fenta E., Teshome D., Kibret S., et al., “Incidence and Risk Factors of Postoperative Delirium in Elderly Surgical Patients 2023,” Scientific Reports 15 (2025): 1400. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14. Yan E., Veitch M., Saripella A., et al., “Association Between Postoperative Delirium and Adverse Outcomes in Older Surgical Patients: A Systematic Review and Meta‐Analysis,” Journal of Clinical Anesthesia 90 (2023): 111221. [DOI] [PubMed] [Google Scholar]
- 15. Bramley P., McArthur K., Blayney A., and McCullagh I., “Risk Factors for Postoperative Delirium: An Umbrella Review of Systematic Reviews,” International Journal of Surgery 93 (2021): 106063. [DOI] [PubMed] [Google Scholar]
- 16. Beaudoin M., Belzile E. L., Gélinas C., et al., “Level of Implementation of Pain Management and Early Mobilization Strategies to Prevent Delirium in Geriatric Trauma Patients: A Mixed‐Methods Study,” International Journal of Orthopaedic and Trauma Nursing 52 (2024): 101050. [DOI] [PubMed] [Google Scholar]
- 17. Deblois S., Bergeron N., Vu T. T. M., Paquin‐Lanthier G., Nauche B., and Pomp A., “The Prevention and Treatment of Postoperative Delirium in the Elderly: A Narrative Systematic Review of Reviews,” Journal of Patient Safety 21 (2025): 174–192. [DOI] [PubMed] [Google Scholar]
- 18. Chumdermpadetsuk R. R., Garland M., Polanco‐Santana J. C., Callery M. P., and Kent T. S., “Predictors of Non‐Home Discharge After Pancreatoduodenectomy in Patients Aged 80 Years and Above,” HPB: The Official Journal of the International Hepato Pancreato Biliary Association 26 (2024): 410–417. [DOI] [PubMed] [Google Scholar]
- 19. Xu S., Deng X., Wang S., Yu G., Liu J., and Gong W., “Short‑And Long‑Term Outcomes After Laparoscopic and Open Pancreatoduodenectomy for Elderly Patients: A Propensity Score‑Matched Study,” BMC Geriatrics 24 (2024): 462. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20. León C. T., Hernández D. S. P., Pardo G. C., et al., “Risk Factors Associated With Postoperative Pancreatic Fistula in the Elderly,” Revista argentina de cirugía 116 (2024): 274–284. [Google Scholar]
- 21. Hendi M., Mou Y., Lu C., et al., “Laparoscopic Pancreaticodoudenectomy: An Excellent Approach in Elderly Patients, a Multicenter, Comparative Study,” Medicine 99 (2020): e22175, 10.1097/md.0000000000022175. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.