Medically Managed Hypercholesterolemia and Insulin-Dependent Diabetes Mellitus Preoperatively Predicts Poor Survival After Surgery for Pancreatic Cancer
Ryaz Chagpar*1, Robert C. C. Martin1, Syed a. Ahmad2, Hong Jin Kim4, Sharon Weber3, David Kooby5, Charles a. Staley5, Kelly M. Mcmasters1, Charles R. Scoggins1
1Surgery, University of Louisville, Louisville, KY; 2Surgery, University of Cincinnati, Cincinnati, OH; 3Surgery, University of Wisconsin, Madison, WI; 4Surgery, University of North Carolina, Chapel Hill, NC; 5Surgery, Emory University, Atlanta, GA
Introduction: Although patients with pancreatic cancer (PC) frequently require medications to treat pre-existing conditions, the impact of these treatments on outcomes post resection for is unknown. The purpose of this study was to determine the impact of preoperative medications on overall survival after pancreatic resection. Methods: Multi-institutional data on preoperative medications and outcomes on patients undergoing resection for PC was analyzed. Univariate and multivariate analysis was performed to determine which medications were predictive of early mortality. Results: Of the 518 patients resected for PC, 13.3% were being treated preoperatively with insulin, 14.8% were on an anti-cholesterol medication, 1.7% were on steroids and 7.6% were on thyroxin. On univariate analysis, patients taking preoperative insulin had a higher 90-day mortality rate relative to those not on insulin (13.0% vs. 4.8%, p=0.024), and those on an anti-cholesterol agent had a higher 90-day mortality than those who were not (10.8% vs. 4.6%, p=0.035). Preoperative steroids and thyroxin were not associated with 90-day mortality (p=0.409 and p=0.474, respectively). Medication use was a stronger predictor of 90-day mortality than history of diabetes (p=0.101), cardiac disease (p=0.168), pulmonary disease (p=1.000), or renal dysfunction (p=1.000). Older patients also had a higher risk of early postoperative death (p=0.011). On multivariate analysis, only preoperative insulin usage and anti-cholesterol treatment independently predicted early mortality (OR=2.917, 95%CI: 1.211-7.024, p=0.017, and OR=2.537, 95%CI: 1.055-6.096, p=0.037, respectively). Based on the beta coefficients, a simple scoring system was devised to predict survival after resection based on medication use. Zero points were assigned to patients who were on neither on insulin nor an anti-cholesterol medication, one point to those who were on one or the other, and two points to those who were both on insulin and an anti-cholesterol agent. The score was found to correlate with early postoperative survival (90-day mortality rates of 3.3%, 12.7%, and 13.3% for 0, 1, and 2 points, respectively, p=0.002). Furthermore, increasing score was associated with worse overall survival, with a median survival of 19.6 months, 15.2 months, and 11.2 months, for 0, 1, and 2 points, respectively ( p=0.002). Conclusions: Patients with PC being treated for pre-existing insulin-dependent diabetes or hypercholesterolemia have an increased risk of early postoperative mortality. A simple scoring system based on preoperative medications can be used to predict early and overall survival following resection.
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