Abstract
Background
Recent evidence has shown that enhanced recovery after surgery (ERAS) protocols decrease hospital stay following pancreaticoduodenectomy (PD). The aims of this study were to assess the feasibility and to evaluate the effect of introducing ERAS principles after PD in elderly patients.
Methods
Patients ≥75 years were defined as elderly. Comparison of postoperative outcome was performed between 22 elderly patients who underwent ERAS (elderly ERAS + patients) and a historical cohort of 66 elderly patients who underwent standard protocols (elderly ERAS-patients).
Results
The lowest adherence with ERAS among elderly patients was observed for starting a solid food diet within POD 4 (n = 7) and early drains removal (n = 2). The highest adherence was observed for post-operative glycemic control (n = 21), epidural analgesia (n = 21), mobilization (n = 20) and naso-gastric removal in POD 0 (n = 20). Post-operative outcomes did not differ between elderly ERAS+ and elderly ERAS- patients. In patients with an uneventful postoperative course, the median intention to discharge was earlier in elderly ERAS + patients as compared to the elderly ERAS- patients (4 days versus 8 days, P < 0.001).
Conclusion
An ERAS protocol following PD seems to be feasible and safe among elderly although it is not associated with improved postoperative outcomes.
Introduction
By the end of the 1990s some Authors proposed an optimized management of perioperative care for elective surgical patients.1, 2 This enhanced recovery after surgery (ERAS) program includes a multimodal rehabilitation approach that accelerates recovery decreasing post-operative morbidity and hospital stay after surgical procedures.3, 4, 5 ERAS or fast-track surgery methods include minimally invasive techniques, optimal pain control, and aggressive postoperative rehabilitation, including early enteral (oral) nutrition and ambulation.6 The benefits of introducing ERAS programs have been consistently demonstrated, particularly in colorectal cancer.7, 8, 9 Several studies have demonstrated that ERAS is effective in reducing length of hospital stay and overall complications rate across different surgical specialties.10, 11 Despite mounting evidence for improved outcomes for other surgical procedures, many pancreatic surgeons have remained skeptical that such results can be achieved following pancreaticoduodenectomy (PD). Nevertheless some studies have recently demonstrated that an ERAS protocol is safe and feasible for pancreatic surgery.12 Only one study13 has investigated the feasibility of this approach in elderly patients. Although there are no studies that suggest that age should be a criterion for exclusion from ERAS protocols, older patients' attitudes to ERAS may represent a barrier to the implementation of such a protocol.14 The aims of this study were i) to assess the compliance to an ERAS protocol following PD in elderly patients and ii) to evaluate the effect on postoperative outcomes after introducing ERAS in this population.
Methods
Study population
This was a retrospective, observational study. Given the retrospective nature of the study, ethical committee approval was waived. Since January 2013 an ERAS protocol was introduced at the Department of Surgery of Ancona University. Overall, 102 consecutive patients agreed to participate in the ERAS protocol following PD and signed an informed consent. Of those, 22 (21%) patients were ≥75 years of age and were defined as the elderly group. The remaining 80 patients <75 years represented the control group in the assessment of ERAS compliance.
Perioperative management and assessment of ERAS compliance
The ERAS protocol was inspired by the recommendations proposed by the ERAS society.15 Table 1 shows differences between previously adopted perioperative care protocol and the ERAS pathway. Several items differed from those proposed by the ERAS society.15 In particular, i) preoperative biliary drainage was always carried out in the presence of jaundice with conjugated bilirubin >5 mg/dL, ii) carbohydrate supplementation drinks were avoided, and iii) oral laxatives were not routinely used. A pylorus-preserving PD with standard lymphadenectomy was the preferred operation. The reconstruction phase included an end-to-side duct-to-mucosa pancreatico-jejunostomy. Fluid balance was monitored using the FloTrac® sensor (Edwards Lifesciences LLC, One Edwards Way-Irvine, CA, USA).
Table 1.
Main differences between previously adopted perioperative care protocol and ERAS items following pancreatico-duodenectomy (PD)
| Item | Standard protocol | ERAS pathway |
|---|---|---|
| Preoperative counseling | At surgeon's discretion | Yes |
| Preoperative biliary drainage | Yes | Yes |
| Preoperative nutrition | No | No |
| Bowel preparation | At surgeon's discretion | No |
| Pre-anesthetic medication | No | No |
| Anti-thrombotic prophylaxis | Yes | Yes |
| Antimicrobial prophylaxis | Yes (30–60 min before incision) | Yes (30–60 min before incision) |
| Epidural analgesia | At anesthetist's discretion and/or if not contraindicated | Yes (mid-thoracic) |
| Stop of analgesia | At anesthetist's discretion | Within POD3 |
| Intravenous analgesia | At anesthetist's discretion and/or if epidural analgesia contraindicated | No |
| Incision | Midline laparotomy | Midline laparotomy |
| Avoiding hypothermia | Always | Always |
| Postoperative glycemic control | Subcutaneous or intravenous insulin at anesthetist discretion | Intravenous insulin |
| Nasogastric intubation | At surgeon's discretion | POD0 removal |
| Fluid balance | At anesthetist's discretion | Near-zero balance, balanced crystalloids |
| Perianastomotic drains removal | At surgeon's discretion | Within POD3 if AVD < 2000 U/l in POD1 |
| Somatostatin analogs | At surgeon's discretion | No |
| Urinary drainage | Transurethral catheterization for 2–3 days | Urinary catheter removal within POD3 |
| Postoperative nutrition | At surgeon's discretion | Liquid and soft diet in POD1-2, solid food within POD4 |
| I.V. fluid withdrawal | At surgeon's discretion | Within POD4 |
| Early mobilization | Always in POD1 | Always in POD1 |
POD, Postoperative day; AVD, Amylase value in drains.
Evaluation of ERAS efficacy in elderly patients
A 3:1 case-matched study design was used. Comparisons were performed between 22 elderly patients who underwent ERAS protocol (Elderly ERAS + patients) and a matched group of 66 elderly patients who underwent previously adopted protocol before the implementation of the ERAS program (Elderly ERAS-patients). All these 66 patients were operated by the same surgical team at another institution (Ospedale “Sacro Cuore-Don Calabria”) between 2009 and 2012. Patients were matched 1:3 by age, Body Mass Index (BMI), American Society of Anesthesiology (ASA) score, and Fistula Risk Score (FRS). Complications were defined and classified according to Dindo et al.16 Pancreatic fistula (PF) was defined according to the International Study Group of Pancreatic Fistula (ISGPF) as any measurable volume of fluid on or after postoperative day 3 with amylase content greater than 3 times the serum amylase activity.17 Delayed gastric emptying was defined as need for nasogastric decompression or vomiting occurring after postoperative day 10.18 Fistula risk was determined using the validated, 10-point FRS.19 Individual FRS scores were calculated and then assigned to 4 risk zones according to Callery and colleagues:19 negligible risk, low risk, moderate risk, and high risk. These risk zones were then dichotomized into negligible/low and moderate/high risk groups. The length of stay (LOS) of a patient was counted as the date of discharge minus the date of surgery. Days after readmission were not included in the LOS. Patient was deemed ready for discharge (intention to discharge) under all the following criteria: i) patient had to tolerate at least 2 solid meal without nausea and vomiting, ii) patients had to pass flatus or a bowel movement, iii) patient had to be able to rest or mobilize without significant pain taking oral nonopioid analgesics, iv) patient had to be able to sit up, walk, and performs activities of daily living, v) oral temperature, pulse, blood pressure, respiratory rate, and serum hemoglobin had to be normal or consistent with preoperative levels. Post-operative mortality was defined as 30-day and/or in-hospital mortality.
Statistical analysis
Distribution of continuous variables is reported as median and range. Categorical variables are presented as numbers and percentages. The comparison between subgroups was carried out using Mann–Whitney U test for continuous variables. Qualitative data were compared by the Chi square test or Fischer exact test when necessary. All tests were 2-sided. Statistical analyses were performed in SPSS 16.0 for Windows software (SPSS Inc, Chicago, Illinois, USA). P values were considered significant when less than or equal to 0.05.
Results
Compliance with ERAS items in elderly patients undergoing PD
In the group of patients ≥75 years old there were only 4 octogenarians. Table 2 shows compliance with ERAS items by age after the implementation of ERAS protocol. ERAS items adherence was evaluated also comparing elderly patients with negligible/low FRS (n = 7) and those with moderate/high FRS (n = 15). Patients with negligible/low FRS were more likely to have epidural catheterization (7/7 versus 12/15, P = 0.023).
Table 2.
Compliance with preoperative, intraoperative and postoperative ERAS items
| All patients (n = 102) | <75 years (n = 80) | ≥75 years (n = 22) | P | |
|---|---|---|---|---|
| Intra-operative glycemic control | ||||
| No | 6 (6%) | 5 (6%) | 1 | 0.763 |
| Yes | 96 (96%) | 75 (94%) | 21 | |
| Intra-operative fluid balance (l)a | 0.5 (−1.6 to 2.5) | 0.5 (−1.6 to 2.0) | 0.5 (−0.4 to 2.5) | 0.163 |
| Intra-operative + POD0 fluid balance (l)a | −0.5 (−5.9 to 2.1) | −0.1 (−5.9 to 2.1) | 0.4 (−1.7 to 2.1) | 0.043 |
| Intra-operative + POD0 + POD1 fluid balance (l)a | −1.5 (−10.9 to 2.5) | −1.5 (−10.9 to 2.5) | −1.1(−3.4 to 1.1) | 0.240 |
| Epidural analgesia | ||||
| No | 10 (10%) | 9 (11%) | 1 | 0.349 |
| Yes | 92 (90%) | 71 (89%) | 21 | |
| Stop of analgesia | ||||
| ≤POD3 | 83 (81%) | 67 (84%) | 16 | 0.240 |
| >POD3 | 19 (19%) | 13 (16%) | 6 | |
| Mobilization | ||||
| =POD1 | 98 (96%) | 2 (2%) | 2 | 0.158 |
| >POD1 | 4 (4%) | 78 (98%) | 20 | |
| Naso-gastric tube removal | ||||
| =POD0 | 93 (91%) | 73 (90%) | 20 | 0.960 |
| >POD0 | 9 (9%) | 7 (10%) | 2 | |
| Urinary catheter removal | ||||
| ≤POD3 | 79 (77%) | 63 (79%) | 16 | 0.549 |
| >POD3 | 23 (23%) | 17 (21%) | 6 | |
| Oral liquids | ||||
| =POD1 | 88 (86%) | 71 (89%) | 17 | 0.166 |
| >POD1 | 14 (14%) | 9 (11%) | 5 | |
| Solid food | ||||
| ≤POD4 | 40 (39%) | 33 (41%) | 7 | 0.422 |
| >POD4 | 62 (61%) | 47 (59%) | 15 | |
| I.V. fluid withdrawal | ||||
| ≤POD4 | 78 (76%) | 63 (79%) | 15 | 0.301 |
| >POD4 | 24 (24%) | 17 (21%) | 7 | |
| Drains removal if POD1 AVD ≤ 2000 U/l | ||||
| ≤POD3 | 9 (28%) | 7 (39%) | 2 | 0.876 |
| >POD3 | 24 (72%) | 11 (61%) | 13 | |
POD, Post-operative day; AVD, Amylase value in drains.
Values in bold indicate P < 0.05.
Values are median (range).
Effect on postoperative outcomes of ERAS undergoing PD in elderly patients
Table 3 shows a comparison between elderly matched ERAS- patients and elderly ERAS + patients for demographics and clinical characteristics. A comparison of operative details and post-operative outcomes is depicted in Table 4. When considering only patients who had an uneventful course, the median LOS was similar for both elderly ERAS- (8 days [7–14 days]) and ERAS + groups (8 days [7–8 days]) (P = 1.000). In patients with an uneventful postoperative course, the median intention to discharge was 8 days among elderly patients ERAS- (6–12 days) whereas it was 4 days (4–6 days) for elderly patients ERAS + (P < 0.001). Overall, only 2 of the 20 patients in the elderly ERAS + group who were discharged alive were discharged to a rehabilitation facility. The remaining patients were discharged home.
Table 3.
Comparison of elderly ERAS- patients and elderly ERAS + patients for clinical characteristics
| Variable | Elderly ERAS-(n = 66) | Elderly ERAS + (n = 22) | P |
|---|---|---|---|
| Age (years)a | 77.5 (75–82) | 77 (75–82) | 1 |
| Gender | |||
| Male | 33 (50%) | 14 | 0.267 |
| BMI (Kg/m2) | 25 (18–32) | 25 (21–31) | 0.981 |
| ASA | |||
| I | 5 (34%) | 2 | 0.926 |
| II | 42 (64%) | 13 | |
| III | 1 (2%) | 7 | |
| FRS | |||
| Negligible/low | 20 (30%) | 7 | 0.894 |
| Moderate/High | 46 (70%) | 15 | |
BMI, Body Mass Index; ASA, American Society of Anesthesiology; FRS, Fistula Risk Score according to Callery et al.19
Values are median (range).
Table 4.
Comparison of elderly ERAS- patients and elderly ERAS + patients for operative details and postoperative outcomes
| Variable | Elderly ERAS-(n = 66) | Elderly ERAS + (n = 22) | P |
|---|---|---|---|
| Operative time (minutes)a | 360 (240–600) | 325 (240–420) | 0.251 |
| Complications | |||
| No | 29 | 6 | 0.167 |
| Yes | 37 | 16 | |
| Complications gradeb | |||
| Grade 0 | 23 (35%) | 5 | 0.212 |
| Grade I–II | 26 (39%) | 7 | |
| Grade III–IV | 16 (24%) | 9 | |
| Grade V | 1 (2%) | 1 | |
| Pancreatic fistula | |||
| No | 45 (68%) | 18 | 0.219 |
| Grade A/B/C | 21 (32%) | 4 | |
| Biliary fistula | |||
| No | 57 (86%) | 16 | 0.092 |
| Yes | 9 (14%) | 6 | |
| Chylous leak | |||
| No | 57 (86%) | 22 | 0.158 |
| Yes | 9 (14%) | 0 | |
| DGE syndrome | |||
| No | 55 (83%) | 15 | 0.127 |
| Grade A/B/C | 11 (17%) | 7 | |
| LOSa (days) | 11 (3–67) | 14 (7–53) | 0.253 |
| Intention to discharge (days)a | 10 (7; 67) | 13 (4–45) | 0.287 |
| Readmission | |||
| No | 55 (83%) | 19 | 0.736 |
| Yes | 11 (17%) | 3 | |
| Re-exploration | |||
| No | 63 (95%) | 21 | 1 |
| Yes | 3 (5%) | 1 | |
POD, Post-operative day; LOS, Length of stay; DGE, Delayed gastric emptying.
Values are median (range).
according to Dindo et al.16
Discussion
PD is a challenging operation with a high rate of complications and a measurable mortality risk even in expert hands.20 Age alone is not an absolute contraindication for PD. However an analysis of the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data demonstrated that in patients with loco-regional pancreatic cancer, the likelihood of being evaluated by a surgeon decreased 8% with each increasing year of age.21 Indeed, in the vast majority of the studies the reported morbidity and mortality rates are higher in the group of patients defined as “elderly”.21 However, when considering experiences from single, high-volume, institutions, age is not a predictor of perioperative morbidity and mortality following PD.22, 23 Despite this, a longer length of hospital stay is a typical feature of postoperative recovery after pancreatic resection in older patients and the number of patients requiring ongoing inpatient nursing care at discharge increases significantly with age.13 Increasing age may therefore represent a limitation to the implementation of an enhanced recovery program after PD. There have been no randomized clinical trials of ERAS protocols after pancreatic surgery, however in the studies performed12 it seems safe, feasible and associated with a shorter length of hospital stay.12 The median age reported in these studies was generally under 65 years12 and specific reports on the feasibility and safety of ERAS approach in elderly patients are lacking. Recently, Coolsen and coworkers13 addressed this issue comparing 55 patients ≥70 years old with other 55 patients ≤65 years old. The authors demonstrated that an ERAS program for elderly patients undergoing PD is feasible and safe. In particular, the two groups had similar rates of postoperative complications, mortality, re-laparotomy, and readmission.13 In the present study, more than half of elderly patients fully adhered to all ERAS items. The only items that were associated with a poor compliance were starting a solid diet within POD4 and an early removal of abdominal drains. The main parameter for the management of abdominal drains was a POD1 AVD <2000 U/I but in many patients the characteristic of the drains fluid as well as logistic issues (i.e. unavailability of laboratory for AVD analysis on Sunday) influenced the surgeons decision. Coolsen et al.13 observed a comparable compliance with ERAS items. For better understating the role of age as a possible barrier for the implementation of ERAS protocol, a comparison with younger patients was also made. Of note, no differences were found in terms of ERAS adherence between young and elderly patients. If the implementation of an ERAS protocol following PD seems achievable in elderly patients, the effects on postoperative outcomes are rather dismal. The implementation of an ERAS protocol was not associated with a lower complication rate and the overall LOS was similar to that observed in those patients treated with a standard perioperative protocol. The relatively short postoperative stay in the control group could explain the lack of a clear benefit of the ERAS protocol as regard this aspect. Probably, the real advantage after the implementation of the ERAS protocol is related to a shorter length of stay in those patients who had an uneventful postoperative course. In the present experience, a significant difference was noted in terms of intention to discharge among elderly patients who had a regular postoperative course yet it did not translate to an actual reduction in LOS. Such differences between the intention to discharge and the real LOS are likely multifactorial including the peculiar modality of reimbursement provided by the Italian Health Service, the high number of patients who live far from the hospital, and the fear of patients to leave early the hospital. The authors recognize that the present study has several limitations. The retrospective design is the major limitation of the present study. However, randomized controlled trials are difficult to organize for multimodal recovery programs especially because several protocol elements of an ERAS program already have become standard practice in many hospitals during the last decade. Moreover, the sample size, especially for the elderly population, is too small to exclude a type II error.
In summary, an ERAS protocol for PD seems to be feasible in elderly patients and age alone does not represent a barrier for the compliance with ERAS items. An ERAS protocol following PD seems to be safe among elderly although it is not associated with an improved postoperative course.
Conflict of interest
None declared.
References
- 1.Kehlet H., Wilmore D.W. Multimodal strategies to improve surgical outcome. Am J Surg. 2002;183:630–641. doi: 10.1016/s0002-9610(02)00866-8. [DOI] [PubMed] [Google Scholar]
- 2.Kehlet H., Wilmore D.W. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg. 2008;248:189–198. doi: 10.1097/SLA.0b013e31817f2c1a. [DOI] [PubMed] [Google Scholar]
- 3.Kehlet H., Dahl J.B. Anaesthesia, surgery, and challenges in postoperative recovery. Lancet. 2003;362:1921–1928. doi: 10.1016/S0140-6736(03)14966-5. [DOI] [PubMed] [Google Scholar]
- 4.Fearon K.C., Ljungqvist O., Von Meyenfeldt M., Revhaug A., Dejong C.H., Lassen K. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr. 2005;24:466–477. doi: 10.1016/j.clnu.2005.02.002. [DOI] [PubMed] [Google Scholar]
- 5.Schultz N.A., Larsen P.N., Klarskov B., Plum L.M., Frederiksen H.J., Christensen B.M. Evaluation of a fast-track programme for patients undergoing liver resection. Br J Surg. 2013;100:138–143. doi: 10.1002/bjs.8996. [DOI] [PubMed] [Google Scholar]
- 6.Wilmore D.W., Kehlet H. Management of patients in fast track surgery. BMJ. 2001;322:473–476. doi: 10.1136/bmj.322.7284.473. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Walter C.J., Collin J., Dumville J.C., Drew P.J., Monson J.R. Enhanced recovery in colorectal resections: a systematic review and meta-analysis. Colorectal Dis. 2009;11:344–353. doi: 10.1111/j.1463-1318.2009.01789.x. [DOI] [PubMed] [Google Scholar]
- 8.Wind J., Polle S.W., Fung Kon Jin P.H., Dejong C.H., von Meyenfeldt M.F., Ubbink D.T. Systematic review of enhanced recovery programmes in colonic surgery. Br J Surg. 2006;93:800–809. doi: 10.1002/bjs.5384. [DOI] [PubMed] [Google Scholar]
- 9.Spanjersberg W.R., Reurings J., Keus F., van Laarhoven C.J. Fast track surgery versus conventional recovery strategies for colorectal surgery. Cochrane Database Syst Rev. 2011 Feb 16 doi: 10.1002/14651858.CD007635.pub2. CD007635. [DOI] [PubMed] [Google Scholar]
- 10.Nicholson A., Lowe M.C., Parker J., Lewis S.R., Alderson P., Smith A.F. Systematic review and meta-analysis of enhanced recovery programmes in surgical patients. Br J Surg. 2014;101:172–188. doi: 10.1002/bjs.9394. [DOI] [PubMed] [Google Scholar]
- 11.Fearon K.C., Jenkins J.T., Carli F., Lassen K. Patient optimization for gastrointestinal cancer surgery. Br J Surg. 2013;100:15–27. doi: 10.1002/bjs.8988. [DOI] [PubMed] [Google Scholar]
- 12.Coolsen M.M., van Dam R.M., van der Wilt A.A., Slim K., Lassen K., Dejong C.H. Systematic review and meta-analysis of enhanced recovery after pancreatic surgery with particular emphasis on pancreaticoduodenectomies. World J Surg. 2013;37:1909–1918. doi: 10.1007/s00268-013-2044-3. [DOI] [PubMed] [Google Scholar]
- 13.Coolsen M.M., Bakens M., van dam R.M., Olde Damink S.W.M., Dejong C.H.C. Implementing an enhanced recovery program after pancreaticoduodenectomy in elderly patients: is it feasible? World J Surg. 2015;39:251–258. doi: 10.1007/s00268-014-2782-x. [DOI] [PubMed] [Google Scholar]
- 14.Pearsall E.A., Meghji Z., Pitzul K.B., Aarts M.A., McKenzie M., McLeod R.S. A qualitative study to understand the barriers and enablers in implementing an enhanced recovery after surgery program. Ann Surg. 2014 Jan;261:92–96. doi: 10.1097/SLA.0000000000000604. [DOI] [PubMed] [Google Scholar]
- 15.Lassen K., Coolsen M.M., Slim K., Carli F., de Aguilar-Nascimento J.E., Schafer M. Guidelines for perioperative care for pancreaticoduodenectomy: enhanced recovery after surgery (ERAS(R)) society recommendations. World J Surg. 2013;37:240–258. doi: 10.1007/s00268-012-1771-1. [DOI] [PubMed] [Google Scholar]
- 16.Dindo D., Demartines N., Clavien P.A. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–213. doi: 10.1097/01.sla.0000133083.54934.ae. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Bassi C., Dervenis C., Butturini G., Fingerhut A., Yeo C., Izbicki J. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery. 2005;138:8–13. doi: 10.1016/j.surg.2005.05.001. [DOI] [PubMed] [Google Scholar]
- 18.Wente M.N., Bassi C., Dervenis C., Fingerhut A., Gouma D.J., Izbicki J.R. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the international study group of pancreatic surgery (ISGPS) Surgery. 2007;142:761–768. doi: 10.1016/j.surg.2007.05.005. [DOI] [PubMed] [Google Scholar]
- 19.Callery M.P., Pratt W.B., Kent T.S., Chaikof E.L., Vollmer C.M., Jr. A prospectively validated risk score accurately predicts pancreatic fistula after pancreaticoduodenectomy. J Am Coll Surg. 2013;216:1–14. doi: 10.1016/j.jamcollsurg.2012.09.002. [DOI] [PubMed] [Google Scholar]
- 20.Balzano G., Zerbi A., Capretti G., Rocchetti S., Capitanio V., Di Carlo V. Effect of hospital volume on outcome of pancreaticoduodenectomy in Italy. Br J Surg. 2008;95:357–362. doi: 10.1002/bjs.5982. [DOI] [PubMed] [Google Scholar]
- 21.Riall T.S. What is the effect of age on pancreatic resection? Adv Surg. 2009;43:233–249. doi: 10.1016/j.yasu.2009.02.004. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Makary M.A., Winter J.M., Cameron J.L., Campbell K.A., Chang D., Cunningham S.C. Pancreaticoduodenectomy in the very elderly. J Gastrointest Surg. 2006;10:347–356. doi: 10.1016/j.gassur.2005.12.014. [DOI] [PubMed] [Google Scholar]
- 23.Hodul P., Tansey J., Golts E., Oh D., Pickleman J., Aranha G.V. Age is not a contraindication to pancreaticoduodenectomy. Am Surg. 2001;67:270–275. doi: 10.1016/s0016-5085(00)81967-8. [DOI] [PubMed] [Google Scholar]