The risk of developing pancreatic cancer dramatically increases with age, with a median age of 72 years at the time of diagnosis[10
]. Thus, the epidemiology of the disease combined with the growth of the elderly population is leading to an increasing number of cases. Even if most patients with pancreatic head cancer are not candidates for radical surgical resection, because of early metastatic spread or extensive local tumor involvement, palliation of obstructive symptoms and pain remains a core component in the management of this disease. Di Carlo et al[11
] reported there was no significant difference in the frequency of locally advanced or metastatic disease in elderly patients (over 70 years) compared with those under 70 years. However, to our knowledge there are few reports on the use of surgical biliary bypass to manage unresectable pancreatic head cancer in old age[12,13
]. Although endoscopic stenting of the bile duct or PTBD can relieve biliary obstruction, surgical bypass is done in many cases because of patient or physician preference, an inability to access the bile duct, or failure of non-surgical palliation[14
]. Surgical bypass can also be performed when a pancreatic head cancer proves to be unresectable during an operation intended to cure the tumor. Significant advances have been made in non-operative palliation for periampullary cancer. Percutaneous or endoscopic palliation of obstructive jaundice can provide biliary decompression with lower early morbidity compared to open biliary bypass surgery[15–18
]. However, these techniques have had disappointing outcomes with regard to recurrent jaundice. Several studies have compared PTBD with endoscopic endoprosthesis in malignant biliary obstruction. The endoscopic approach proved to be safer and more effective compared with PTBD[19,20
]. However, the long-term complications of both these procedures make them less desirable than surgical bypass in those patients who are expected to survive more than a few months[21
It may be a common conception that elderly patients are more susceptible to an increased mortality, morbidity and longer hospitalization than their younger counterparts. Interestingly, reluctance to advise an operation is often unrelated to the presence of co-morbidities or impaired functional status[22
In recent studies, the morbidity of palliative double bypass surgery (biliary-enteric reconstruction, gastrojejunostomy) has ranged between 4.8% and 28%, and mortality has ranged between 1% and 9%[6,7,23,24
]. Nuzzo et al[12
] reported that the morbidity and mortality rates for surgical palliation in elderly patients (> 70 years) with periampullary cancer were comparable to those of younger patients (≤ 70 years), with no statistically significant difference found between the 2 groups. In our study, postoperative morbidity and mortality rates in elderly patients were 26% (5 patients) and 5.3% (one patient), respectively. These figures are comparable to rates reported in other series. Also, there was no significant difference between elderly patients and younger patients in terms of mortality and morbidity rates. Median postoperative hospitalization was 19 d in elderly patients (range, 3-73 d), and there was no statistically significant difference between elderly patients and younger patients in this regard.
To evaluate the efficacy of palliative bypass surgery for the treatment of unresectable pancreatic head cancer in elderly patients, the results were compared against those obtained from patients 65 years of age or older who received PTBD. More frequent recurrent jaundice, readmission, and shorter hospital-free survival were noted in the non-surgical palliation group. Overall, the quality of life, assessed by relief of biliary obstructive symptoms, the number of readmissions, and hospital-free survival, was better after surgical biliary bypass than non-surgical palliation. Survival was improved after surgical bypass. The reasons behind this are not clear, but factors that may contribute include relief of biliary obstruction, low rate of recurrent jaundice, and prevention of gastric obstruction. These may help to improve both the nutritional state of the patients and their general well-being. Therefore, older age alone should not be a contraindication to surgical palliation of unresectable pancreatic head cancer, although elderly patients may require more intensive postoperative care. However, our results must be interpreted with caution because of the selection bias inherent in this study. Actually, surgical palliation was performed in patients who did not have metastatic disease on the preoperative imaging studies. Also stenosis of the biliary duct might be higher in the non-surgical palliation group. Thus, long-term survival and a good quality of survival could be achieved in patients who underwent surgical palliation.
In conclusion, surgical palliation does not increase the morbidity and mortality rates, but it does increase the survival rate and improve the quality of life in elderly patients with unresectable pancreatic head cancer. Further clinical observations and prospective, controlled studies are needed to elucidate the long-term effects of this procedure.