Effects of Pancreatic Surgery : Quality of Life, Cost-effectiveness and Postoperative Results

Sammanfattning: BACKGROUND  Pancreatic operations are large procedures with high rates of complications and other potentially impactful consequences such as diabetes and pancreatic exocrine insufficiency. Due to this, and due to the fact that the operations are often occasioned by periampullary tumours with a poor prognosis, it is important to evaluate how the operations affect patients in terms of postoperative results and quality of life. In the constantly developing field of pancreatic surgery, it is also important to evaluate the cost-effectiveness of new methods.  METHODS  The first study was a register study including all patients in the Swedish National Pancreatic and Periampullary Cancer Registry with a diagnosis from 2010-2018 who underwent pancreaticoduodenectomy (PD). Patients were divided into age groups of <70, 70-79 and ≥80 years old and were compared regarding preoperative, perioperative and postoperative data as well as survival.  The second and third studies were based on the randomized controlled trial LAPOP performed in Linköping from 2015-2019 where 60 patients were randomized 1:1 to open or laparoscopic distal pancreatectomy and followed for two years with repeated quality of life questionnaires. For the second study, the EORTC QLQ-C30 and PAN26 questionnaires were collected and compared between groups. For the third study, the EQ-5D questionnaire was used in a cost-effectiveness analysis together with costs collected from patients’ medical records, including all health care-related costs up to 2 years postoperatively. Nonparametric bootstrapping with 10 000 samples was performed to compare quality-adjusted life years  (QALYs) and costs between groups.  The fourth study was a qualitative interview study in which 20 patients undergoing total pancreatectomy (TP) from 2020-2021 in Linköping or Karolinska University Hospitals were interviewed 6-9 months postoperatively about symptoms and life changes after the operation.  RESULTS  In the first study, 2793 patients underwent PD in the study period, of which 1137 patients were 70-79 years of age, and 148 patients were ≥80 years of age. There were no significant differences between groups regarding short-term mortality or the rate of severe complications according to the Clavien-Dindo classification of complications. Patients in the two older groups had a worse preoperative condition and a higher rate of medical and some surgical complications postoperatively.   In the LAPOP trial, 54 patients were included in the quality of life analysis. There was a significant difference in six of the quality of life-domains measured with QLQ-C30 and PAN26 with better results in the laparoscopic group. When comparing values at the two-year measurement, 3 domains had a significant difference and 16 domains a clinically relevant difference of 10 or more, all with better results in the laparoscopic group. In the cost-effectiveness analysis, 56 patients were included in the analysis. Mean health care costs were €3 863 lower in the laparoscopic group (95% CI: -€8 020 to €385), and the QALYs were 0.08 higher (95% CI: -0.09 to 0.25). In the bootstrap analysis, 79% of samples had higher QALYs and lower costs for the laparoscopic group, and 95% were in favour of laparoscopic resection with a cost-per-QALY threshold of €50 000.  Patients undergoing total pancreatectomy voiced symptoms and life changes that revolved around the two main themes: ‘changes in everyday life’ and ‘psychological journey’. In the former, patients described the impact of diabetes, food intake, diarrhoea and the process of recovery, where diabetes in particular appeared to be challenging for some. In the second theme, patients outlined the diagnosis processing, the importance of support from family, friends and the health care system, and a need for more thorough information.   CONCLUSIONS  Despite a worse preoperative condition, elderly patients undergoing PD did not have an increase in short-term mortality or serious complications. With continued careful preoperative examination, in particular regarding cardiovascular comorbidity, octogenarians can likely safely continue to be offered to undergo PD.   After distal pancreatectomy, there was a considerable difference between groups regarding postoperative quality of life in favour of the laparoscopic method, which seemed to remain as long as 2 years postoperatively. The laparoscopic method was also favoured in the cost-effectiveness analysis where it was associated with lower costs and higher QALYs. These results support the ongoing transition from open to minimally invasive distal pancreatectomies.   After TP, patients struggle with a lack of support and education, particularly regarding their diabetes treatment. Efforts should be undertaken to improve and standardize the diabetes care for this group.