When minimally invasive pancreatoduodenectomy becomes risky in elderly patients: BMI and aCCI define the crossover point for surgical safety

Abstract

Aim: To assess whether the surgical approach - open pancreatoduodenectomy (OPD) vs. minimally invasive pancreatoduodenectomy (MIPD) - affects short-term postoperative complications in elderly patients, and to determine whether body mass index (BMI) and age-adjusted Charlson Comorbidity Index (aCCI) modify this effect.

Methods: This retrospective cohort study included 156 elderly patients (≥ 65 years) undergoing pancreatoduodenectomy (PD) between 2020 and 2025. Multivariable logistic regression with interaction terms evaluated effect modification by BMI and aCCI on 30-day postoperative complications. Predicted probability-based scenario analyses were used for risk stratification. Exploratory computed tomography (CT) analyses were performed in a representative subgroup (n = 80).

Results: Overall complication rates were comparable between OPD and MIPD, and surgical approach alone was not an independent predictor of complications. Significant interactions were identified between surgical approach and BMI [odds ratio (OR) = 1.28, P = 0.032] and aCCI (OR = 4.18, P < 0.001). Scenario analyses showed that MIPD was associated with lower predicted complication risk in patients with aCCI ≤ 6 and BMI < 23.43 kg/m², whereas OPD was safer in patients with aCCI > 6. CT analysis demonstrated fewer complications after MIPD in patients with low subcutaneous adipose tissue.

Conclusion: A combined BMI–aCCI–based risk stratification framework supports individualized surgical approach selection in elderly patients undergoing PD.

Keywords

Pancreatoduodenectomy / elderly patients / BMI / aCCI / minimally invasive surgery / open surgery

References

[1] Li GQ,Yang WG.Gut microbiota patterns associated with somatostatin in patients undergoing pancreaticoduodenectomy: a prospective study.Cell Death Discov2020;6:94 PMCID:PMC7522245

[2] Cao Y,Huang ZD.Impact of enhanced recovery after surgery on postoperative recovery for pancreaticoduodenectomy: pooled analysis of observational study.Front Oncol2019;9:687 PMCID:PMC6683725

[3] Li X,Chen C.Development and validation of a patient-specific model to predict postoperative SIRS in older patients: a two-center study.Front Public Health2023;11:1145013 PMCID:PMC10150121

[4] Caban M.Gaps and opportunities in the diagnosis and treatment of pancreatic cancer.Cancers2023;15:5577 PMCID:PMC10705522

[5] Cutolo C,Valeriani M.Is robotic pancreaticoduodenectomy (PD) a valid alternative to open pancreaticoduodenectomy?.Mini-invasive Surg2025;9:40

[6] Shannon A,Ejaz A.A narrative review of the history and recent advances in minimally invasive pancreatic resection.Mini-invasive Surg2023;7:32

[7] Liu Y,Zhang W.Robotic versus laparoscopic total gastrectomy for gastric cancer: a systematic review and meta-analysis of perioperative and oncologic outcomes.Int J Surg2025;111:6397-411 PMCID:PMC12430920

[8] Zhang L,Hu C.Comparison of robotic versus laparoscopic lateral lymph node dissection for advanced lower rectal cancer: a retrospective study at two institutions.Surg Endosc2023;37:4403-13 PMCID:PMC10234855

[9] Abdelmaseeh M,Siddiqa A.Minimally invasive approaches for high-risk and elderly patients with acute cholecystitis: a systematic review of techniques and outcomes.Cureus2025;17:e78271 PMCID:PMC11872040

[10] Ballarin R,Guerrini GP.Minimally invasive pancreaticoduodenectomy in elderly versus younger patients: a meta-analysis.Cancers2024;16:323 PMCID:PMC10813942

[11] Wang J,Huang S,Shi X.Low muscle mass and Charlson comorbidity index are risk factors for short-term postoperative prognosis of elderly patients with gastrointestinal tumor: a cross-sectional study.BMC Geriatr2021;21:730 PMCID:PMC8705191

[12] Bhattacharjee HK,Singh KJ.Age adjusted Charlson comorbidity index (a-CCI) AS a tool to predict 30-day post-operative outcome in general surgery patients.ANZ J Surg2023;93:132-8

[13] Yamashita Y,Sicouri S.Effect of elevated body mass index on outcomes of transcatheter aortic valve replacement for severe aortic stenosis.Anatol J Cardiol2024;28:565-74 PMCID:PMC11633792

[14] Sun Y,Tang Y.Unveiling the impact of body mass index on surgical difficulty and oncological prognosis in low rectal cancer: post-hoc analysis of the LASRE trial.Int J Colorectal Dis2025;40:185 PMCID:PMC12373544

[15] Kowshik V,Sethi P,Subhashri S.Association of handgrip strength and endurance with body composition in head and neck cancer patients.J Family Med Prim Care2021;10:910-6 PMCID:PMC8138385

[16] Wang HB,Zhu F.[Clavien-Dindo classification and influencing factors analysis of complications after laparoscopic pancreaticoduodenectomy].Zhonghua Wai Ke Za Zhi2018;56:828-32

[17] Pulvirenti A,Bassi C.Modifications in the International Study Group for Pancreatic Surgery (ISGPS) definition of postoperative pancreatic fistula.Transl Gastroenterol Hepatol2017;2:107 PMCID:PMC5763010

[18] Hendrix JM.American Society of Anesthesiologists Physical Status Classification System. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2025.

[19] Lee B,Kang CM.Fistula risk score-adjusted comparison of postoperative pancreatic fistula following laparoscopic vs open pancreatoduodenectomy.J Hepatobiliary Pancreat Sci2021;28:1089-97

[20] Salam B,Theis M.Associations between cardiac adipose tissue and abdominal visceral fat and muscle based on computed tomography area and density.Sci Rep2025;15:20192 PMCID:PMC12181233

[21] Sok C,Shah H.Simple preoperative imaging measurements predict postoperative pancreatic fistula after pancreatoduodenectomy.Ann Surg Oncol2024;31:1898-905 PMCID:PMC10922305

[22] Omichi K,Kumamaru H.Association between age and short-term outcomes of gastroenterological surgeries in older patients: an analysis using the National Clinical Database in Japan.Langenbecks Arch Surg2021;406:2827-36

[23] Ikenaga N,Abe T.Risks and benefits of pancreaticoduodenectomy in patients aged 80 years and over.Langenbecks Arch Surg2023;408:108

[24] Cheng H,Chen BPH.Prolonged operative duration is associated with complications: a systematic review and meta-analysis.J Surg Res2018;229:134-44

[25] Cullinane C,Croghan SM,Fleming CA.Effect of obesity on perioperative outcomes following gastrointestinal surgery: meta-analysis.BJS Open2023;7:zrad026 PMCID:PMC10332403

[26] Qi F,Fei F.Impact of pneumoperitoneum pressure on cardiac output in laparoscopic surgery.BMC Anesthesiol2025;25:317 PMCID:PMC12211448

[27] Li G,Lu T.Spatial multi-omics analyses reveal diabetes promotes pancreatic cancer progression by stimulating cholesterol-induced neutrophil extracellular trap formation.Cancer Res2026;

[28] Liu X,Zhang Y.Geriatric nutritional risk index predicts postoperative outcomes in elderly patients with pancreatoduodenectomy: a propensity score-matched analysis.Gland Surg2025;14:807-17 PMCID:PMC12177537

[29] Caleyachetty R,Mohammed NI.Ethnicity-specific BMI cutoffs for obesity based on type 2 diabetes risk in England: a population-based cohort study.Lancet Diabetes Endocrinol2021;9:419-26 PMCID:PMC8208895

[30] Han L, Char DS, Aghaeepour N; Stanford Anesthesia AI Working Group. Artificial intelligence in perioperative care: opportunities and challenges.Anesthesiology2024;141:379-87 PMCID:PMC11239120