Comparison of the efficacy of laparoscopic and open pancreatoduodenectomy in elderly patients

doi:10.3877/cma.j.issn.1674-6899.2025.04.003

Abstract

Abstract:

Objective

To compare the clinical outcomes of laparoscopic pancreaticoduodenectomy (LPD) and open pancreatoduodenectomy (OPD) in elderly patients.

Methods

Clinical and follow-up data of elderly patients (> 65 years) who underwent LPD or OPD between Jan. 2015 and Dec. 2022 were retrospectively analyzed. A 1∶1 propensity score-matching (PSM) analysis was performed to minimize differences between groups. Univariate and multivariate logistic regression analysis were used to select independent prognostic factors for 90-day mortality.

Results

Of the 410 elderly patients, 236 underwent LPD and 174 OPD. After PSM, the LPD group had a less estimated blood loss (EBL) (100 ml vs. 200 ml, P<0.001), lower rates of intraoperative transfusion (10.4% vs. 19.0%, P=0.029), more lymph node harvest (11.0 vs. 10.0, P=0.014) and shorter postoperative length of stay (LOS) (13.0 days vs. 16.0 days, P=0.013). There were no significant differences in serious complications, reoperation, 90-day readmission and mortality rates (all P>0.05). Multivariate logistic regression analysis showed that post-pancreatectomy hemorrhage (PPH) was an independent risk factor for 90-day mortality. Elderly patients with pancreatic ductal adenocarcinoma (PDAC) who underwent LPD or OPD had similar overall survival (OS) (22.5 months vs. 20.4 months, P=0.672) after PSM.

Conclusions

It is safe and feasible for elderly patients to undergo LPD with less EBL and a shorter postoperative LOS.

Key words: Laparoscopic pancreatoduodenectomy, Open pancreatoduodenectomy, Elderly patients, Pancreatic ductal adenocarcinoma, Propensity score matching

Chunhong Zhao, Yakai Yang, Shuai Xu, Yukun Cao, Jun Liu. Comparison of the efficacy of laparoscopic and open pancreatoduodenectomy in elderly patients[J]. Chinese Journal of Laparoscopic Surgery(Electronic Edition), 2025, 18(04): 203-210.

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Figures/Tables 5

References 40

1	Petrowsky H, Clavien PA. Should we deny surgery for malignant hepato-pancreatico-biliary tumors to elderly patients？[J]. World J Surg, 2005, 29(9)：1093-100.
2	Khan S, Sclabas G, Lombardo KR, et al. Pancreatoduodenectomy for ductal adenocarcinoma in the very elderly; is it safe and justified？[J]. J Gastrointest Surg, 2010, 14(11)：1826-1831.
3	Makary MA, Winter JM, Cameron JL, et al. Pancreaticoduodenectomy in the very elderly[J]. J Gastrointest Surg, 2006, 10(3)：347-356.
4	Chua TC, Saxena A. Extended pancreaticoduodenectomy with vascular resection for pancreatic cancer: a systematic review[J]. J Gastrointest Surg, 2010, 14(9)：1442-1452.
5	Tung S, Davis LE, Hallet J, et al. Population-level symptom assessment following pancreaticoduodenectomy for adenocarcinoma[J]. JAMA Surg, 2019, 154(11)：e193348.
6	Winer J, Can MF, Bartlett DL, et al. The current state of robotic-assisted pancreatic surgery[J]. Nat Rev Gastroenterol Hepatol, 2012, 9(8)：468-476.
7	Subar D, Gobardhan PD, Gayet B. Laparoscopic pancreatic surgery: An overview of the literature and experiences of a single center[J]. Best Pract Res Clin Gastroenterol, 2014, 28(1)：123-132.
8	Song KB, Kim SC, Lee W, et al. Laparoscopic pancreaticoduodenectomy for periampullary tumors: lessons learned from 500 consecutive patients in a single center[J]. Surg Endosc, 2020, 34(3)：1343-1352.
9	Poves I, Burdío F, Morató O, et al. Comparison of perioperative outcomes between laparoscopic and open approach for pancreatoduodenectomy: the PADULAP randomized controlled trial[J]. Ann Surg, 2018, 268(5)：731-739.
10	Palanivelu C, Senthilnathan P, Sabnis SC, et al. Randomized clinical trial of laparoscopic versus open pancreatoduodenectomy for periampullary tumours[J]. Br J Surg, 2017, 104(11)：1443-1450.
11	Croome KP, Farnell MB, Que FG, et al. Total laparoscopic pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: oncologic advantages over open approaches？[J]. Ann Surg, 2014, 260(4)：633-638; discussion 638-640.
12	Klompmaker S, van Hilst J, Wellner UF, et al. Outcomes after minimally-invasive versus open pancreatoduodenectomy: a pan-european propensity score matched study[J]. Ann Surg, 2020, 271(2)：356-363.
13	Nickel F, Haney CM, Kowalewski KF, et al. Laparoscopic versus open pancreaticoduodenectomy: a systematic review and meta-analysis of randomized controlled trials[J]. Ann Surg, 2020, 271(1)：54-66.
14	Wang Q, Chen C, Li H. Laparoscopic pancreaticoduodenectomy in elderly patients: systematic review and meta-analysis[J]. Front Surg, 2022, 9：807940.
15	Liang Y, Zhao L, Jiang C, et al. Laparoscopic pancreaticoduodenectomy in elderly patients[J]. Surg Endosc, 2020, 34(5)：2028-2034.
16	Ke J, Liu Y, Liu F, et al. Application of laparoscopic pancreatoduodenectomy in elderly patients[J]. J Laparoendosc Adv Surg Tech A, 2020, 30(7)：797-802.
17	Wang Q, Li HJ, Dai XM, et al. Laparoscopic versus open liver resection for hepatocellular carcinoma in elderly patients: systematic review and meta-analysis of propensity-score matched studies[J]. Int J Surg, 2022, 105：106821.
18	Zhang XP, Xu S, Hu MG, et al. Short- and long-term outcomes after robotic and open liver resection for elderly patients with hepatocellular carcinoma: a propensity score-matched study[J]. Surg Endosc, 2022, 36(11)：8132-8143.
19	Wang M, Peng B, Liu J, et al. Practice patterns and perioperative outcomes of laparoscopic pancreaticoduodenectomy in China: a retrospective multicenter analysis of 1029 patients[J]. Ann Surg, 2021, 273(1)：145-153.
20	Morató O, Poves I, Burdío F, et al. Evaluation of the learning curve for laparoscopic pancreatoduodenectomy by CUSUM analyses. Cohort study[J]. Int J Surg, 2020, 80：61-67.
21	Wang M, Meng L, Cai Y, et al. Learning curve for laparoscopic pancreaticoduodenectomy: a CUSUM analysis[J]. J Gastrointest Surg, 2016, 20(5)：924-935.
22	Li G, Yuan L, Yu G, et al. A modified suture technique in hepaticojejunostomy[J]. Med Sci Monit, 2020, 26：e921896.
23	Wang M, Li D, Chen R, et al. Laparoscopic versus open pancreatoduodenectomy for pancreatic or periampullary tumours: a multicentre, open-label, randomised controlled trial[J]. Lancet Gastroenterol Hepatol, 2021, 6(6)：438-447.
24	刘军，郑元文. 腹腔镜"一针式降落伞胆肠吻合"缝合方式的应用与探讨[J/OL]. 中华腔镜外科杂志(电子版), 2020, 13(6): 328-331.
25	刘军，许世峰，杨凤辉，等. 腹腔镜胰十二指肠切除术340例报告[J]. 中国实用外科杂志，2020, 40(2): 203-207.
26	曹昱琨，徐帅，李光兵，等. 腹腔镜与开腹胰十二指肠切除术治疗远端胆管癌疗效对比及"教科书式结局"影响因素分析[J]. 肝胆外科杂志，2024, 32(5): 334-341.
27	Shin H, Song KB, Kim YI, et al. Propensity score-matching analysis comparing laparoscopic and open pancreaticoduodenectomy in elderly patients[J]. Sci Rep, 2019, 9(1)：12961.
28	Bilimoria KY, Bentrem DJ, Ko CY, et al. National failure to operate on early stage pancreatic cancer[J]. Ann Surg, 2007, 246(2)：173-180.
29	Wu YL, Yu JX, Xu B. Safe major abdominal operations: hepatectomy, gastrectomy and pancreatoduodenectomy in elder patients[J]. World J Gastroenterol, 2004, 10(13)：1995-1997.
30	Trudeau MT, Casciani F, Maggino L, et al. The influence of intraoperative blood loss on fistula development following pancreatoduodenectomy[J]. Ann Surg, 2022, 276(5)：e527-e535.
31	Seykora TF, Ecker BL, McMillan MT, et al. The beneficial effects of minimizing blood loss in pancreatoduodenectomy[J]. Ann Surg, 2019, 270(1)：147-157.
32	Casciani F, Trudeau MT, Asbun HJ, et al. The effect of high intraoperative blood loss on pancreatic fistula development after pancreatoduodenectomy: an international, multi-institutional propensity score matched analysis[J]. Surgery, 2021, 170(4)：1195-1204.
33	Lyu Y, Cheng Y, Wang B, et al. Minimally invasive versus open pancreaticoduodenectomy: an up-to-date meta-analysis of comparative cohort studies[J]. J Laparoendosc Adv Surg Tech A, 2019, 29(4)：449-457.
34	Farges O, Bendersky N, Truant S, et al. The theory and practice of pancreatic surgery in France[J]. Ann Surg, 2017, 266(5)：797-804.
35	Qin R, Kendrick ML, Wolfgang CL, et al. International expert consensus on laparoscopic pancreaticoduodenectomy[J]. Hepatobiliary Surg Nutr, 2020, 9(4)：464-483.
36	Zhou J, Xin C, Xia T, et al. Laparoscopic pancreaticoduodenectomy in a-92-older Chinese patient for cancer of head of the pancreas: a case report[J]. Medicine (Baltimore), 2017, 96(3)：e5962.
37	Sunagawa H, Mayama Y, Orokawa T, et al. Laparoscopic total remnant pancreatectomy after laparoscopic pancreaticoduodenectomy[J]. Asian J Endosc Surg, 2014, 7(1)：71-74.
38	Meng L, Xia Q, Cai Y, et al. Impact of patient age on morbidity and survival following laparoscopic pancreaticoduodenectomy[J]. Surg Laparosc Endosc Percutan Tech, 2019, 29(5)：378-382.
39	Wente MN, Veit JA, Bassi C, et al. Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition[J]. Surgery, 2007, 142(1)：20-25.
40	Chen JF, Xu SF, Zhao W, et al. Diagnostic and therapeutic strategies to manage post-pancreaticoduodenectomy hemorrhage[J]. World J Surg, 2015, 39(2)：509-515.

变量	PSM前(n＝410)		P值	PSM后(n＝326)		P值
变量	LPD组(n＝236)	OPD组(n＝174)	P值	LPD组(n＝163)	OPD组(n＝163)	P值
年龄(岁)	69.5(67.0~72.8)	69.0(67.0~73.0)	0.372	70.0(67.0~73.0)	69.0(67.0~73.0)	0.951
男性(例)	144.0(61.0)	113.0(64.9)	0.417	107.0(65.6)	105.0(64.4)	0.816
BMI(±s, kg/m²)	23.4±3.1	23.5±3.6	0.740	23.4±3.0	23.5±3.7	0.874
ASA分级[例(%)]
≤Ⅱ	138.0(58.5)	116.0(66.7)	0.091	102.0(62.6)	107.0(65.6)	0.564
Ⅲ	98.0(41.5)	58.0(33.3)		61.0(37.4)	56.0(34.4)
体能状态评分[例(%)]
0	88(37.3)	75(43.1)	0.067	68(41.7)	72(44.2)	0.536
1	86(36.4)	70(40.2)		59(36.2)	63(38.7)
2	62(26.3)	29(16.7)		36(22.1)	28(17.2)
术前合并症[例(%)]
无	107(45.3)	94(54.0)	0.082	81(49.7)	90(55.2)	0.318
有	129(54.7)	80(46.0)		82(50.3)	73(44.8)
CA199(U/ml)	85.3(20.7~253.7)	114.3(38.0~408.8)	0.035	126.0(33.6~297.0)	101.5(34.9~351.5)	0.866
CEA(ng/ml)	2.7(1.8~4.3)	3.4(2.4~5.5)	<0.001	3.0(2.2~4.8)	3.2(2.4~5.2)	0.285
CA125(U/ml)	13.8(9.2~20.2)	17.5(12.3~28.1)	<0.001	15.0(10.2~24.1)	17.1(11.9~26.1)	0.081
病理学诊断[例(%)]
胰腺导管腺癌	55(23.3)	70(40.2)	<0.001	54(33.1)	62(38.0)	0.501
胆管癌	68(28.8)	56(32.2)		54(33.1)	53(32.5)
壶腹及十二指肠癌	67(28.4)	40(23.0)		38(23.3)	40(24.5)
神经内分泌瘤	1(0.4)	1(0.6)		0(0.0)	1(0.6)
胰腺导管内乳头状黏液腺瘤	7(3.0)	2(1.1)		4(2.5)	2(1.2)
胰腺实性假乳头状瘤	3(1.3)	1(0.6)		1(0.6)	1(0.6)
囊性肿瘤	6(2.5)	1(0.6)		4(2.5)	1(0.6)
其他	29(12.3)	3(1.7)		8(4.9)	3(1.8)

变量	PSM前(n＝410)		P值	PSM后(n＝326)		P值
变量	LPD组(n＝236)	OPD组(n＝174)	P值	LPD组(n＝163)	OPD组(n＝163)	P值
年龄(岁)	69.5(67.0~72.8)	69.0(67.0~73.0)	0.372	70.0(67.0~73.0)	69.0(67.0~73.0)	0.951
男性(例)	144.0(61.0)	113.0(64.9)	0.417	107.0(65.6)	105.0(64.4)	0.816
BMI(±s, kg/m²)	23.4±3.1	23.5±3.6	0.740	23.4±3.0	23.5±3.7	0.874
ASA分级[例(%)]
≤Ⅱ	138.0(58.5)	116.0(66.7)	0.091	102.0(62.6)	107.0(65.6)	0.564
Ⅲ	98.0(41.5)	58.0(33.3)		61.0(37.4)	56.0(34.4)
体能状态评分[例(%)]
0	88(37.3)	75(43.1)	0.067	68(41.7)	72(44.2)	0.536
1	86(36.4)	70(40.2)		59(36.2)	63(38.7)
2	62(26.3)	29(16.7)		36(22.1)	28(17.2)
术前合并症[例(%)]
无	107(45.3)	94(54.0)	0.082	81(49.7)	90(55.2)	0.318
有	129(54.7)	80(46.0)		82(50.3)	73(44.8)
CA199(U/ml)	85.3(20.7~253.7)	114.3(38.0~408.8)	0.035	126.0(33.6~297.0)	101.5(34.9~351.5)	0.866
CEA(ng/ml)	2.7(1.8~4.3)	3.4(2.4~5.5)	<0.001	3.0(2.2~4.8)	3.2(2.4~5.2)	0.285
CA125(U/ml)	13.8(9.2~20.2)	17.5(12.3~28.1)	<0.001	15.0(10.2~24.1)	17.1(11.9~26.1)	0.081
病理学诊断[例(%)]
胰腺导管腺癌	55(23.3)	70(40.2)	<0.001	54(33.1)	62(38.0)	0.501
胆管癌	68(28.8)	56(32.2)		54(33.1)	53(32.5)
壶腹及十二指肠癌	67(28.4)	40(23.0)		38(23.3)	40(24.5)
神经内分泌瘤	1(0.4)	1(0.6)		0(0.0)	1(0.6)
胰腺导管内乳头状黏液腺瘤	7(3.0)	2(1.1)		4(2.5)	2(1.2)
胰腺实性假乳头状瘤	3(1.3)	1(0.6)		1(0.6)	1(0.6)
囊性肿瘤	6(2.5)	1(0.6)		4(2.5)	1(0.6)
其他	29(12.3)	3(1.7)		8(4.9)	3(1.8)

变量	PSM前(n＝410)		P值	PSM后(n＝326)		P值
变量	LPD组(n＝236)	OPD组(n＝174)	P值	LPD组(n＝163)	OPD组(n＝163)	P值
手术时间(min)	305.0(288.0~367.5)	295.0(280.0~400.0)	0.303	305.0(289.0~360.0)	295.0(280.0~390.0)	0.074
术中出血量(ml)	100.0(50.0~200.0)	200.0(100.0~300.0)	<0.001	100.0(50.0~200.0)	200.0(100.0~300.0)	<0.001
淋巴结清扫个数(枚)	11.0(8.0~17.0)	10.0(8.0~16.0)	0.123	11.0(8.0~17.0)	10.0(8.0~16.0)	0.014
术中输血[例(%)]	29(12.3)	33(19.0)	0.062	17(10.4)	31(19.0)	0.029
血管重建[例(%)]	10(4.2)	16(9.2)	0.042	9(5.5)	13(8.0)	0.377
中转开腹[例(%)]	12(5.1)	－	－	10(6.1)	－	－
R0切除[例(%)]	224(94.9)	166(95.4)	0.821	152(93.3)	155(95.1)	0.478
胰腺导管腺癌	50(90.9)	65(92.9)		49(90.7)	57(91.9)
胆管癌	64(94.1)	54(96.4)		51(94.4)	52(98.1)
壶腹及十二指肠癌	66(98.5)	39(97.5)		36(94.8)	38(95.0)
其他	44(95.7)	8(100.0)		16(94.1)	8(100.0)
胰瘘[例(%)]
B级	18(7.6)	13(7.5)	0.802	14(8.6)	12(7.4)	0.889
C级	9(3.8)	9(5.2)		6(3.7)	7(4.3)
胃排空延迟[例(%)]
B级	19(8.1)	17(9.8)	0.831	14(8.6)	16(9.8)	0.792
C级	7(3.0)	5(2.9)		7(4.3)	5(3.1)
胆瘘[例(%)]	22(9.3)	16(9.2)	0.965	18(11.0)	15(9.2)	0.582
术后出血[例(%)]	15(6.4)	14(8.0)	0.509	13(8.0)	11(6.7)	0.671
Clavien-Dindo分级≥Ⅲ[例(%)]	34(14.4)	30(17.2)	0.434	29(17.8)	27(16.6)	0.769
术后住院时间(d)	13.0(10.0-18.9)	16.0(12.0-20.5)	0.001	13.0(11.0-20.0)	16.0(12.0-20.6)	0.013
二次手术[例(%)]	10(4.2)	7(4.0)	0.914	9(5.5)	7(4.3)	0.608
90 d再入院率[例(%)]	7(3.0)	7(4.0)	0.560	6(3.7)	7(4.3)	0.777
90 d死亡率[例(%)]	9(3.8)	7(4.0)	0.914	6(3.7)	6(3.7)	1.000

变量	PSM前(n＝410)		P值	PSM后(n＝326)		P值
变量	LPD组(n＝236)	OPD组(n＝174)	P值	LPD组(n＝163)	OPD组(n＝163)	P值
手术时间(min)	305.0(288.0~367.5)	295.0(280.0~400.0)	0.303	305.0(289.0~360.0)	295.0(280.0~390.0)	0.074
术中出血量(ml)	100.0(50.0~200.0)	200.0(100.0~300.0)	<0.001	100.0(50.0~200.0)	200.0(100.0~300.0)	<0.001
淋巴结清扫个数(枚)	11.0(8.0~17.0)	10.0(8.0~16.0)	0.123	11.0(8.0~17.0)	10.0(8.0~16.0)	0.014
术中输血[例(%)]	29(12.3)	33(19.0)	0.062	17(10.4)	31(19.0)	0.029
血管重建[例(%)]	10(4.2)	16(9.2)	0.042	9(5.5)	13(8.0)	0.377
中转开腹[例(%)]	12(5.1)	－	－	10(6.1)	－	－
R0切除[例(%)]	224(94.9)	166(95.4)	0.821	152(93.3)	155(95.1)	0.478
胰腺导管腺癌	50(90.9)	65(92.9)		49(90.7)	57(91.9)
胆管癌	64(94.1)	54(96.4)		51(94.4)	52(98.1)
壶腹及十二指肠癌	66(98.5)	39(97.5)		36(94.8)	38(95.0)
其他	44(95.7)	8(100.0)		16(94.1)	8(100.0)
胰瘘[例(%)]
B级	18(7.6)	13(7.5)	0.802	14(8.6)	12(7.4)	0.889
C级	9(3.8)	9(5.2)		6(3.7)	7(4.3)
胃排空延迟[例(%)]
B级	19(8.1)	17(9.8)	0.831	14(8.6)	16(9.8)	0.792
C级	7(3.0)	5(2.9)		7(4.3)	5(3.1)
胆瘘[例(%)]	22(9.3)	16(9.2)	0.965	18(11.0)	15(9.2)	0.582
术后出血[例(%)]	15(6.4)	14(8.0)	0.509	13(8.0)	11(6.7)	0.671
Clavien-Dindo分级≥Ⅲ[例(%)]	34(14.4)	30(17.2)	0.434	29(17.8)	27(16.6)	0.769
术后住院时间(d)	13.0(10.0-18.9)	16.0(12.0-20.5)	0.001	13.0(11.0-20.0)	16.0(12.0-20.6)	0.013
二次手术[例(%)]	10(4.2)	7(4.0)	0.914	9(5.5)	7(4.3)	0.608
90 d再入院率[例(%)]	7(3.0)	7(4.0)	0.560	6(3.7)	7(4.3)	0.777
90 d死亡率[例(%)]	9(3.8)	7(4.0)	0.914	6(3.7)	6(3.7)	1.000

变量	PSM前(n＝170)		P值	PSM后(n＝118)		P值
变量	LPD组(n＝97)	OPD组(n＝73)	P值	LPD组(n＝59)	OPD组(n＝59)	P值
手术时间(min)	305.0(288.0~380.0)	295.0(279.0~405.0)	0.378	295.0(286.0~340.0)	295.0(278.0~400.0)	0.074
术中出血量(ml)	100.0(50.0~200.0)	200.0(100.0~300.0)	<0.001	100.0(50.0~200.0)	200.0(100.0~300.0)	<0.001
淋巴结清扫个数(枚)	11.0(8.0~16.0)	11.0(8.0~16.0)	0.423	11.0(8.0~17.0)	11.0(8.0~16.0)	0.412
术中输血[例(%)]	16(16.5)	13(17.8)	0.822	7(11.9)	10(16.9)	0.432
血管重建[例(%)]	4(4.1)	6(8.2)	0.261	2(3.4)	4(6.8)	0.675
R0切除[例(%)]	96(99.0)	71(97.3)	0.577	58(98.3)	57(96.6)	1.000
胰瘘[例(%)]
B级	7(7.2)	4(5.5)	0.209	3(5.1)	4(6.8)	0.245
C级	3(3.1)	7(9.6)		1(1.7)	5(8.5)
胃排空延迟[例(%)]
B级	7(7.2)	7(9.6)	0.336	4(6.8)	7(11.9)	0.365
C级	3(3.1)	0(0.0)		2(3.4)	0(0.0)
胆瘘[例(%)]	12(12.4)	8(11.0)	0.777	10(16.9)	6(10.2)	0.282
术后出血[例(%)]	6(6.2)	10(13.7)	0.097	3(5.1)	8(13.6)	0.113
Clavien-Dindo分级≥Ⅲ[例(%)]	14(14.4)	17(23.3)	0.139	8(13.6)	14(23.7)	0.156
术后住院时间(d)	14.5(12.0~21.0)	16.7(12.0~20.0)	0.006	14.0(11.0~19.0)	16.0(12.0~20.0)	0.021
二次手术[例(%)]	3(3.1)	3(4.1)	0.722	2(3.4)	2(3.4)	1.000
90 d再入院率[例(%)]	3(3.1)	5(6.8)	0.436	2(3.4)	3(5.1)	0.648
90 d死亡率[例(%)]	2(2.1)	5(6.8)	0.244	1(1.7)	3(5.1)	0.611

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