Background: Pancreaticoduodenectomy (PD) in the elderly is plausible and safe. To date, current standards of quality for the elderly, and how they compare to those for younger patients, remain unclear. We examined our clinical outcomes and complication rates for elderly patients using a cost-analysis model designed to identify elements for quality improvement. Methods: 166 consecutive patients underwent PD from 10/01 to 11/05. Two patient cohorts defined as elderly (≥75 years) and non-elderly (<75 years) were compared in terms of clinical outcomes. A complication-based cost analysis was developed by merging 4 degrees of clinical impact (none, minor, moderate, and severe) with length of stay (LOS) data, and assigning related costs to reveal the quality impact of complications. Results: Elderly patients comprised one-fourth of all patients. Benchmark standards of quality were achieved in the elderly, and included median EBL 375ml, LOS 9d, mortality 2.6%, and readmission 8%. Despite higher patient acuity (ASA class III/IV 82% vs. 59%), these clinical outcomes were comparable to those of non-elderly patients at a total cost increase of only ,913 per case. However, complication-based cost analysis revealed unique features of PD in the elderly (Table). Minor complications were no more debilitating for elderly patients than for younger patients. Moderate complications required more interventions (blood transfusion, supplemental parenteral nutrition, percutaneous drainage), although costs for the elderly remained comparable to those for younger patients. However, Severe complications were far more threatening to older patients. LOS doubled, ICU duration was >4x longer; and elderly patients more commonly required invasive interventions. These outcomes drove higher costs and increased resource utilization but helped to identify new care-delivery strategies that could improve quality going forward. Conclusion: Quality standards for PD in the elderly can and should equal those for younger patients. Age-related care, including geriatric consultation, supplemental enteral nutrition, and planned early rehab placement, can be designed to mitigate the impact of complications in the elderly, and guarantee quality.
Impact of complications: non-elderly vs. elderly