Context The incidence of pancreatic and peri-ampullary cancer is expected to increase significantly among the elderly population. Recently, several authors have published data on peri-operative outcomes of pancreatic resections among the elderly. Objective Primary endpoint was to assess the difference in term of post-operative mortality after pancreatic resections between patients <80 years old and patients ≥80 years old. Secondary end-points were: post-operative morbidity, incidence of postoperative pancreatic fistula, delayed gastric empty, bile leak, infections or sepsis, pulmonary and cardiac complications, reoperation rate and length of hospital stay. Methods Articles were extracted from MEDLINE, Cochrane Library, Scopus and ISI-Web of Science until April 24 th , 2013. Articles were excluded when they were not in English; when the study population was divided in group of ages by using a cut-off different from 80 years; if they were case-reports, review, guidelines, abstracts and letters to editor. The quality of selected studies was assessed with the Newcastle-Ottawa scale. Odds ratios (ORs) were compared with Mantel-Haenzel method by using the statistical software Review Manager Version 5.2 (The Cochrane Collaboration, Software Update, Oxford, London). Results Initial search identified 1,518 reference articles, of these 19 relevant articles were selected and reviewed. Data were extracted from 9 studies (no. of cases 12,930) which met the inclusion criteria. Patients aged ≥80 years had a significantly higher postoperative mortality (OR=2.16, 95% CI: 1.61-2.89; P<0.001), postoperative morbidity (OR=1.66, 95% CI: 1.38-1.99; P<0.001), cardiac complications (OR=2.54, 95% CI: 1.66-3.88; P<0.001) and a longer hospital stay (OR=2.00; 95% CI: 1.86-2.14; P<0.001) than patients <80 years of age. No significant difference were demonstrated between younger and older patients in terms of postoperative pancreatic fistula, delayed gastric empty, bile leak, pulmonary complications, infection or sepsis and reoperation rate. Conclusions According to the results of this meta-analysis, pancreatic resections in patients aged ≥80 should be carefully planned because of an increased risk of morbidity, cardiac complications, longer hospital stay and, most of all, an increased risk of postoperative mortality.
To investigate whether obese subjects with abdominal obesity may be characterized by hyperactivity of the hypothalamic-pituitary-adrenal axis, we examined two groups of obese women with a waist to hip ratio (WHR) lower than 0.80 (n = 13), therefore having peripheral body fat distribution (P-BFD), or a WHR higher than 0.85 (n = 12), thus having abdominal body fat distribution (A-BFD). A group of seven normal weight healthy women served as controls. All subjects underwent the following protocol study that included 1) measurement of daily urinary free cortisol excretion rate; 2) a CRF test (human CRF, 1 microgram/kg BW, as iv bolus), with blood samples taken at regular intervals for ACTH and cortisol determination; and 3) an ACTH test, performed by administering two boli of ACTH (Synacthen, 0.2 microgram/kg BW, iv), at 90-min intervals, with blood samples taken for cortisol determination. Each woman also had a control saline study. Basal levels of both ACTH and cortisol rose significantly after CRF administration in all groups, but this increase was significantly higher in A-BFD than in P-BFD and control women. A significant correlation was found between the incremental area of cortisol and that of ACTH during the CRF test (r = 0.502), but not between these parameters and WHR values. Although the cortisol increase after the ACTH test was higher in A-BFD than in the other groups, these differences were only significant at 60 min during the test and when the analysis for repeated measures was applied. On the contrary, the incremental cortisol area after the ACTH test was not significantly different in the three groups. Moreover, it was not significantly correlated with the incremental cortisol area after CRF test or WHR values. Daily urinary free cortisol excretion rates (per g creatinine), however, were significantly higher in A-BFD than in P-BFD and control women. These results, therefore, suggest that obese women with A-BFD may have hyperactivity of the hypothalamic-pituitary-adrenal axis. This abnormality could be central in origin, due to hypersecretion of CRF or ACTH; alternatively, it could represent an adaptive phenomenon secondary to a state of functional cortisol resistance.
