Precise treatment makes age no longer the absolute threshold of surgery

When faced with the result of “duodenal papilla adenocarcinoma grade II”, Mr. Yang, who was 94-year-old, had to make an important choice of his life: to leave it alone even if he would have only two or three months to live, or to believe the doctors and receive surgery to struggle for a chance to prolong the life?

Mr. Yang lives in a family with longevity genes, his mother lived to be 105 years old, and his wife was 90 years old. Even though, the old couple were still capable of managing their daily life. In May this year, the old gentleman developed symptoms of dark urine, yellow skin, poor appetite, marasmus and fatigue. He then went to a nearby hospital for treatment, but there was no improvement. Seeing their father turn dispirited, Mr. Yang's sons hurried back from around and take him to Renji Hospital.

When Sun Yongwei, director of biliary-pancreatic surgery of Renji Hospital, saw Mr. Yang, the patient had already developed jaundice. The enhanced CT showed that there was an infiltrating mass of a broad bean size at the patient's duodenal papilla and the tumor had already involved part of the pancreas, common bile duct and gallbladder. The common bile duct had been completely blocked. If let it alone, the patient could only have two or three months of life. After consultation with multidisciplinary experts and precise assessment on the patient's condition, Sun Yongwei gave the family two choices: first was the conservative therapy, which meant to give up treatment. Because the obstruction of the bile duct would result in liver dysfunction and recurrent infection, which could not be treated by drug or fluid.On the other hand, the lesion had invaded and blocked the duodenum, which would make the patient unable to eat. The second way was surgery.Although the patients was 90 years old, his physical condition was fortunately better than others in their 80s. He still had the opportunity to be cured and prolong life by early surgery. After open communication, the patient and his family ultimately determined to trust doctors and receive surgery as soon as possible.

In the department of biliary-pancreatic surgery of Renji Hospital, more than 300 patients with biliary and pancreatic cancer are cured every year. Among them, more than 40% are over 65, and more than ten patients over 90 have been successfully treated by surgery in the recent three years. In the traditional concept, elderly age means aging organ, more complications and worse systemic tolerance, which increase difficulties in anesthesia, surgery and infection control. But thanks to accumulation of experience, progress in anesthesia, surgical technique and peri-operative management and development of peri-operative monitoring, the surgeries become more precise and safer. All of these provide opportunities for elderly patients to accept this kind of radical surgery. At present, the biliary-pancreatic surgery team of Renji Hospital is in the domestic advanced level in radical resection rateof biliary and pancreatic cancer and survival rate of choledocho-pancreatico-duodenal junction injury.

Mr. Yang's surgery was started at 9 am August 5th. Under the support of the anesthesia and nursing team, the medical team led by director Sun Yongwei and vice director Hua Rong started the 5-hour fighting of pancreaticoduodenectomy plus jejunum nutrition fistula surgery. The operation resected the invaded head of pancreas and anastomose the common bile duct with the residual pancreasand the stomach with the jejunum respectively. In order to prevent anastomotic leakageat these three sites, a nutrient tube was also placed in the jejunum. According to Sun Yongwei, the good physical condition of the patient allow him to tide over several difficulties smoothly. The first round was anesthesia. The patient’santi-anesthetizing endurance was better than expected and vital signs such as heart rate and blood pressure maintained stable during the anesthesia. The second is operation. Considering the elderly’s tolerance was poorer than the young people, the surgeons tried to control bleeding and shorten the operation time as far as possible.Every step was performed precise and accurate. The whole surgery went smoothly within 5 hours. The third round was the postoperative management. Under the nurses’ operation, the patient tide over the critical post operative period of anti-infection, nutrition support and anesthesia side effects.

Few days after the operation, Mr. Yang was able to eat and speak. The most frequent thing he said was thanks to the doctors! On August 23rd, Mr. Yang was happy to discharge and reunite with the family.The doctors were also sincerely happy about the longevity of this elderly.

According to Wang Jian, chief director of the department of biliary-pancreatic surgery of Renji Hospital, the aging of body organs and tissues is a universal law, but with the improvement of people's living standards, the body metabolism and organ changes of more and more elderly people have not been aging to the extent of the corresponding age, even much better. The United Nations defined the elderly as 75 years old to 89 years old and human’s physiological aging age was delayed by 10 years, which would have a positive impact on people's mental health and anti-aging will. Since that, new concept is needed to evaluate elderly patients’ health condition and their surgery tolerance on the basis of accurate age.

In fact, nowadays, patients over 90 are not rare in biliary-pancreatic surgery, and patients over 70 years are common. Wang Jian said, "This is because that the population of 75-80 years old are at high risk of these diseases, of which some came to us for help in the moment of desperation. The reason why we didn’t give up easily and eventually treat them successfully was that: first, the concept of precise surgery was implemented in each link of patient assessment, planning, operation and management; second, the progress of surgical technique reduced bleeding; the third, we performed strict preoperative and postoperative management; fourth, the application of minimally invasive technique sreduced the surgical damage to the patients. All of these factors improved our success rate of surgery in elderly patients." In addition, he also stressed that risks were inevitable in elderly patients, which requires understanding from patients and their families. Only with trust between doctors and patients, the best results would be achieved.

Correspondent Shan Tan , Translator Yujun Sun