Management and Perioperative Morbidity Among Patients With Surgically Managed Pancreatic Adenocarcinoma: a Population-Based Analysis Using SEER-Medicare Data
Skye C. Mayo*1, Marta M. Gilson1, John L. Cameron1, Hari Nathan1, Joseph M. Herman2, Martin a. Makary1, Frederic E. Eckhauser1, Kenzo Hirose1, Barish H. Edil1, Michael a. Choti1, Richard D. Schulick1, Christopher L. Wolfgang1, Timothy M. Pawlik1
1Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD; 2Radiation Oncology, The Johns Hopkins Hospital, Baltimore, MD
Introduction: Surgical resection remains the only potentially curative therapeutic option for patients(pts) with pancreatic adenocarcinoma(PAC). Over the last several decades, advances in surgical technique and perioperative care have reduced perioperative mortality. Changes in perioperative management and morbidity associated with PAC surgery, however, remain poorly characterized. We sought to define the utilization patterns of perioperative and operative procedures for pts with PAC, as well as evaluate population-based temporal trends in morbidity and mortality.Methods: Using Surveillance, Epidemiology and End Results (SEER)-Medicare linked data, we identified 2461 pts with PAC who underwent pancreatic resection from 1991-2005. We collected data to assess morbidity, mortality, and survival while adjusting with the Elixhauser comorbidity index. Trends in preoperative comorbidity indices, perioperative management, type of surgical procedures performed, as well as changes in morbidity and mortality were examined.Results: Preoperative evaluation included ERCP(59%), CT(92%), MRI(14%) and PET(2%) with a temporal increase in the use of all four diagnostic modalities (all P<0.005)(Table). Use of diagnostic laparoscopy increased from 3% to 16%(P<0.001) over time. The proportion of pts who underwent total pancreatectomy(n=28; 1%) or pancreaticoduodenectomy(n=1945; 79%) did not change (both P>0.05) whereas distal pancreatectomy(n=333; 14%) increased over the study period(P=0.04). There was a temporal increase in median pt age(1991-1996: 71yo; 1997-2000: 72yo; 2001-2002: 73yo; 2003-2005: 74yo;P<0.05) and number of pts with multiple preoperative comorbidities (Elixhauser comorbidities ≥3: 1991-1996, 10%; 1997-2000, 17%; 2001-2002, 25%; 2003-2005, 26%;P<0.001). Despite the increase in pt age and comorbidities over time, overall perioperative morbidity(53%) did not change during the study period(P=0.97). The most common postoperative complications were bleeding and need for re-exploration, both of which decreased over time(9% to 4% and 11% to 7%, respectively;both P<0.05). In contrast, there was a temporal increase in the number of percutaneous interventional procedures (8% to 12%;P=0.005). Perioperative mortality decreased by half over the study period(1991-1996: 6% vs. 2003-2005: 3%;P=0.04). The overall 1- and 5-yr survival was 53% and 13%. A modest improvement in median survival(12 to 16 months;P=0.01) was noted over the time periods examined.Conclusions: Mortality associated with pancreatic resection for PAC has decreased by one-half. Despite surgical resection for PAC being offered to older pts with more preoperative comorbidities, the incidence of perioperative complications remained stable. Resection for PAC in an aging population with more medical comorbidities can be performed safely, however further progress is necessary to decrease morbidity.
Trends in Perioperative Staging, Morbidity, and Complications 1991-2005 for Patients with Resected Pancreatic Adenocarcinoma
| 1991-1996 | 1997-2000 | 2001-2002 | 2003-2005 | |
| Number of Patients | 568 | 539 | 500 | 854 |
| *Median Patient Age (years) | 71 | 72 | 73 | 74 |
| *CT | 88% | 89% | 94% | 94% |
| *MRI | 2% | 8% | 19% | 24% |
| *PET | <2% | <2% | <2% | 4% |
| *ERCP | 50% | 61% | 65% | 60% |
| *Diagnostic Laparoscopy | 3% | 8% | 10% | 16% |
| Pancreaticoduodenectomy | 76% | 82% | 81% | 78% |
| *Distal Pancreatectomy | 13% | 10% | 13% | 16% |
| Total Pancreatectomy | 2% | <2% | <2% | <2% |
| *≥3 Elixhauser Comorbidities | 10% | 17% | 25% | 26% |
| Overall Peri-operative Complications | 55% | 50% | 55% | 53% |
| *Peri-operative 30-day Mortality | 6% | 4% | 5% | 3% |
| *Median Survival (months) | 12 | 15 | 12 | 16 |
| *Significant at P<0.05 by test of trend.<2%: Per NCI data usage agreement, no cells with totals less than 11 were reported. | ||||
CT = computed tomography; MRI = magnetic resonance imaging; PET = positron emission tomography; ERCP = endoscopic retrograde cholangiopancreatography.
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