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Geriatric Assessment Improves Prediction of Surgical Outcomes in Older Adults Undergoing Pancreaticoduodenectomy: A Prospective Cohort Study

Dale, William MD, PhD*,†; Hemmerich, Joshua PhD*; Kamm, Alaine RN, BSN, MSN, APN-BC; Posner, Mitchell C. MD, FACS; Matthews, Jeffrey B. MD, FACS; Rothman, Randi BA*; Palakodeti, Aparna PhD; Roggin, Kevin K. MD, FACS

doi: 10.1097/SLA.0000000000000226
Original Articles

Objective: To prospectively evaluate the additional value of geriatric assessment (GA) for predicting surgical outcomes in a cohort of older patients undergoing a pancreaticoduodenectomy (PD) for pancreatic tumors.

Background: Older patients are less often referred for possible PD. Standard preoperative assessments may underestimate the likelihood of significant adverse outcomes. The prospective utility of validated GA has not been studied in this group.

Methods: PD-eligible patients were enrolled in a prospective outcome study. Standard preoperative assessments were recorded. Elements of validated GA were also measured, including components of Fried's model of frailty, the Vulnerable Elders Survey (VES-13), and the Short Physical Performance Battery (SPPB). All postoperative adverse events were recorded, systematically reviewed, and graded using the Clavien-Dindo system by a surgeon blinded to the GA results. Multivariate regression analyses were conducted.

Results: Seventy-six older patients underwent a PD. Significant unrecognized vulnerability was identified at the baseline: Fried's “exhaustion” (37.3%), SPPB <10 (28.5%), and VES-13 >3 (15.4%). Within 30 days of PD, 46% experienced a severe complication (Clavien-Dindo grade ≥III). In regression analyses controlling for age, the body mass index, the American Society of Anesthesiologists score, and comorbidity burden, Fried's “exhaustion” predicted major complications [odds ratio (OR) = 4.06; P = 0.01], longer hospital stays (β = 0.27; P = 0.02), and surgical intensive care unit admissions (OR = 4.30; P = 0.01). Both SPPB (OR = 0.61; P = 0.04) and older age predicted discharge to a rehabilitation facility (OR = 1.1; P < 0.05) and age correlated with a lower likelihood of hospital readmission (OR = 0.94; P = 0.02).

Conclusions: Controlling for standard preoperative assessments, worse scores on GA prospectively and independently predicted important adverse outcomes. Geriatric assessment may help identify older patients at high risk for complications from PD.

Older adults with pancreatic cancer are at higher risk for complications from surgical treatment. Undetected vulnerabilities related to frailty may adversely affect surgical outcomes. Preoperative comprehensive geriatric assessments may prospectively identify patients at risk for major complications. If sought for and identified, this risk could be managed expectantly, leading to more accurate preoperative counseling, treatment, and in-hospital care.

*Section of Geriatrics and Palliative Medicine, Department of Medicine

Section of Hematology/Oncology, Department of Medicine

Department of Surgery, the University of Chicago, Chicago, IL.

Reprints: Kevin K. Roggin, MD, FACS, Associate Professor of Surgery and Cancer Research, Program Director, General Surgery Residency Program, the University of Chicago Medicine, 5841 S. Maryland Ave, MC 5094, Chicago, IL 60637. E-mail: kroggin@surgery.bsd.uchicago.edu.

Disclosure: Supported by a grant from the Michael Rolfe Pancreatic Cancer Foundation. The authors declare no conflicts of interest.

The authors of this article have declared all significant potential conflicts of interest (eg, financial activities, relationships, affiliations, and otherwise) to the Editorial Board of the Annals of Surgery. The investigators maintained full independence, without bias, in the conduct of this research.

Data contained in this article have been presented as a poster at the Society of Surgical Oncology Meeting in 2010 (Ann Surg Oncol. 17:S129, P278), short oral presentation at the Chicago Surgical Society Meeting (2011), oral presentation at the Pancreas Club Meeting (2011), quick-shot oral presentation at the DDW/SSAT Annual Meeting (2011), and at the Presidential Poster Session of the American Geriatrics Society Annual Meeting (2012).

Drs Dale and Hemmerich contributed equally to the article.

© 2014 by Lippincott Williams & Wilkins.