Outcome of pancreaticoduodenectomy in octogenarians: Single institution's experience and review of the literature.

INTRODUCTION: Pancreatic and perampullary neoplasms in patients aged 80 or older trouble the surgeons because of the risk of surgical treatment. We have reviewed our experience and literature's reports of pancreaticoduodenectomy in octogenarians, evaluating early results and long-term survival in pancreatic cancer group. METHODS: Three hundred eighty-five patients who underwent pancreaticoduodenectomy for neoplasms from 1998 to 2011 were included in the study, and were divided in two groups: group 1, patients younger than 80 years of age, and group 2, patients 80 years of age and older. Operative morbidity, mortality, disease-free and long-term survival were analysed. English literature was systematically searched for pancreatic resection's outcome in octogenarians. RESULTS: There were 385 pancreaticoduodenectomies: 362 patients were in group 1 and 23 patients in group 2. There was no significant difference regarding gender, and pathologic findings between the two groups. Complications' rate (40 vs. 43%), mortality rate (4% vs. 0%), and overall median survival for pancreatic cancer patients were not statistically different in the two groups (median 21 vs. 19 months). Literature's review showed 14 reports of pancreatic resection in octogenarians. Most of the studies (particularly in centres with high-volume pancreatic surgery) showed that outcome after pancreatectomy was not different in octogenarians or in younger patients. CONCLUSION: Pancreaticoduodenectomy is an acceptable option for elderly patients. Age alone should not be considered a contraindication to major pancreatic resection, but a careful preoperative evaluation and an accurate postoperative management are mandatory.

Plexiform fibromyxoma of the gallbladder.

We report the unusual case of a plexiform fibromyxoma, occasionally assessed in a lithiasic gallbladder. The full thickness assessment of the gallbladder wall revealed an intra-mural, well demarked multi-nodular tumor (1 cm), consisting of a plexiform growth of spindle cells, included within a fibromyxoid stroma with a rich micro-vascular network. The tumor cells featured no nuclear atypia, nor mitotic activity. At the immunohistochemical profiling, the spindle shaped cells unequivocally featured vimentin, SMA, HHF35, collagen IV, and CD34; no cells expressed CD117, PDGFRA, CD10, desmin, GFAP, EMA, and S-100. Faint STAT6 nuclear expression was observed in isolated tumor cells. The molecular profiling did not revealed any CKIT and PDGFRA genes mutations. The uncommon site of the tumor presentation and its aberrant CD34 expression both confer to the reported case a unique place among the myxoid tumors of the gastrointestinal tract.

Elective abdominal aortic aneurysm repair in the very elderly: a systematic review.

Abdominal aortic aneurysm (AAA) is an age related disease, so the aging of the population has meant to more elderly people undergoing AAA repair. The authors conducted a systematic review of the literature to analyze the perioperative mortality and complication rates and long-term survival of elderly people after AAA repair. The literature was searched using the Embase, Cochrane library and Medline databases as at May 2008. All studies reporting on the perioperative and long-term outcomes of patients aged 80 years or more undergoing elective open (OAR) or endovascular AAA repair (EVAR) were considered. The risk of perioperative mortality and morbidity were calculated using the odds ratio (OR), with 95% confidence intervals (CIs), and the chi(2) test. Thirty-five studies on OAR, five on EVAR and four on both were considered. In the OAR group, the mortality rate (38 studies, 1793 patients) was 5.6% (95% CI, 4.5 to 6.7) and the morbidity rate (18 studies, 725 patients) was 26.9% (95% CI, 23.7 to 30.1). Twenty studies reported a median 5-year survival rate of 60% (range, 14% to 86%). In the EVAR group, the mortality rate (9 studies, 1159 patients) was 4.5% (95% CI, 3.3 to 5.7) and the morbidity rate (8 studies, 1078 patients) was 16.5% (95% CI, 14.3 to 18.7). The follow-up data covered less than 5 years in five studies. Although the perioperative death rate was higher after OAR than after EVAR, the difference was not statistically significant (P=0.170; 95% CI, 0.90 to 1.78). The major systemic morbidity rate was significantly higher after OAR (P<0.001; 95% CI, 1.47 to 2.34). Although the perioperative mortality rate was comparable between the two surgical procedures, the marked selection bias cannot be ignored and may well mean that the mortality rates are actually higher for both procedures. Although the mid- and long-term survival rates after OAR and EVAR could seem acceptable, more information is needed on the long-term outcome after EVAR in larger samples in order to assess the durability of this less invasive procedure.