title: Morbidity and mortality after pancreaticoduodenectomy in patients with borderline resectable type C clinical classification.
abstract: BACKGROUND
  We previously described the clinical classification of patients with resectable pancreatic tumor anatomy but marginal performance status (PS) or reversible comorbidities as "borderline resectable type C" (BR-C). This study was designed to analyze the incidence and risk factors for post-pancreaticoduodenectomy (PD) morbidity/mortality in a multi-institutional cohort of BR-C patients.
  
  
  METHODS
  Elective PDs were evaluated from the 2005-10 ACS-NSQIP database. BR-C was defined as age ≥ 80, poor PS, weight loss > 10 %, pulmonary disease, recent myocardial infarction/angina, stroke history, and/or preoperative sepsis. Variables associated with 30-day postoperative major complications (PMC) and mortality were analyzed.
  
  
  RESULTS
  A total of 3,033/8,266 (36.7 %) patients were BR-C. BR-C patients were more likely to suffer PMC (31.3 vs. 26.2 %) and mortality (4.1 vs. 2.3 %). BR-C patients with PMC suffered 50 % higher mortality versus non-BR-C patients with PMC (11.5 vs. 7.7 %) (all p < 0.001). For BR-C patients, multivariate analysis identified the following risk factors for PMC or mortality: albumin < 3.5 g/dL, dyspnea, preoperative sepsis, age ≥ 80, poor PS, anesthesia score ≥ 4, and intraoperative transfusion ≥ 4 units.
  
  
  CONCLUSIONS
  Nationwide, one third of patients undergoing PD are medically borderline. These BR-C patients are at higher risk for and less able to be rescued from PMC. Surgeons should identify and optimize comorbidities and utilize prehabilitation to address functional deficits before elective PD.
authors.affiliation: Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX, 77030, USA.
authors.forename: Ching-Wei D
authors.initials: CW
authors.lastname: Tzeng
authors.forename: Matthew H G
authors.initials: MH
authors.lastname: Katz
authors.forename: Jason B
authors.initials: JB
authors.lastname: Fleming
authors.forename: Jeffrey E
authors.initials: JE
authors.lastname: Lee
authors.forename: Peter W T
authors.initials: PW
authors.lastname: Pisters
authors.forename: Holly M
authors.initials: HM
authors.lastname: Holmes
authors.forename: Gauri R
authors.initials: GR
authors.lastname: Varadhachary
authors.forename: Robert A
authors.initials: RA
authors.lastname: Wolff
authors.forename: James L
authors.initials: JL
authors.lastname: Abbruzzese
authors.forename: Jean-Nicolas
authors.initials: JN
authors.lastname: Vauthey
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Aloia
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001803:Blood Transfusion; D004417:Dyspnea / Q000150:complications; D005260:Female; D006304:Health Status; D006801:Humans; D008297:Male; D008875:Middle Aged; D010190:Pancreatic Neoplasms / Q000145:classification* / Q000150:complications / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000009:adverse effects* / Q000401:mortality*; D012307:Risk Factors; D018805:Sepsis / Q000150:complications; D012709:Serum Albumin / Q000378:metabolism; D055815:Young Adult
chemical_list: D012709:Serum Albumin