quite interesting for me Marcel that you start asking such a question to the community with your very well established expertise! in pts of such age we know that the length or shortness of an operation heavily influences outcome, therefore I would prefer the open approach; no requirement to stop aspirin even in major surgery if indicated as in your pat; all the best to you 

In cases like this one I think that open procedure is indicated  even if  you have expertise  in both procedure since Laparoscopic  procedure is longer ,may reduce venous  return even with low intra peritoneal pressure,reduces portal vein flow  may induce intestinal barrier dysfunction (mainly in elderly )and may damage liver parenchyma 

Dear Dr Machado

I prefer open surgery and saving 4 hours of anesthesia and surgery is vital for your patients and early post op recovery, besides consider the conversion of laparoscopy to open surgery that maybe happen.

Open. In the patient as described, a Whipple should last 3 1/2 hours,

I believe expedite surgery is more mandatory in this xase than minimal invasion.

No doubts. It should be open approach. No room for mistakes or sudden blood loss. The oncology result will not change. I do a lot of open Whipple in geriatric age and they do well as open approach. No pancreatic leak in the last 15 Whipple with my modified pancreatic anastomosis

The duration of 4 hours for an open Whipple and 8 hours for a laparoscopic one is just an example of difference between open and laparoscopic approach. In most techniques laparoscopic approach is longer than their open counterpart. The question here is that the possible benefits from minimally invasive surgery are surpassed for a longer operation in an extremely old patient.

Laparoscopic as the patient is thin built .The conditions are favorable with dilated bile duct and pancreatic duct.

The recovery will be fast.

For friable patients it is important to use the technique which is safest in your hands – this undoubtedly is open PD. Still no one had equal experience in both techniques. 

Open is the prefferable technique.Long time surgery could lay to acidosis catabolic distress compromised anastomoses,intraoperative hemmorhage. I have no leak experience in this kind of anastomosis(invagination technique with self retaining stent): 

p.s:By the way HAPPY 2017 to everybody!

due to the short life expectancy from the risk of Cardiovascular event imposed by the old age

I will go for the safest approach which neither approach and

metallic stent if obstructed

Dear Dr Marcel

Which plan did you choose?

I suppose each patient should be treated on his/her merit , you are dealing with an 87 years old lady , who had a stent placed due to cardiac ischemia , at this age it is appropriate to think about the life expectancy  , and to choose the shortest procedure, you did,t mention about any presence of jaundice , but there is dilated CBD , obviously this could be delte with Billiary   stent very easily , and when the patient start developing signs of gastric outlet obstruction then high  Gastro-Jujinal  anastomosis should be the best choice through laparoscopic approach , that what I will do .

Thank you all for your opinion. The patient decided to spend her Christmas and New Year with the family and that is comprehensible given the gravity of the diagnosis and the poor prognosis of pancreatic cancer. So we put a biliary stent and bilirrubin level returned to normal. Our multidisciplinary decision was to perform an open pancreatoduodenectomy. The decision was based upon the opinion of the cardiologist and anesthesiologist given her cardiac status. If no medical restriction was present we would proceed with lap Whipple despite the age. The lap approach is always longer no matter the experience of the team and this is also true for our team. We already reduced the operative time to around 6-7 hours but still longer than open. In this particular case a dilated biliary and pancreatic duct would facilitate the procedure but the pneumoperitoneum and intraabdominal pressure and decrease of cardiac debit would be hazardous. Thank you again for the valuable and expert opinion. I presented your opinion in our multidisciplinary team meeting and we took it account and decide for open approach. 

Please update the patient status after operation and operation history 

Good Luck

I think is a better option to choose open laparotomy

We have performed pancreaticodoudenectomy in 2 patients >80 years of age. They are both doing well more than 1 year post surgery. Although their tumors were sizeable, they had ampullary origin and thus better prognosis than pancreatic cancer. Open versus lap and curative versus palliative both are intriguing options here.

We finally operated her and we did an open pancreaticoduodenectomy. It was an easy operation car both bile ducts and pancreatic ducts were dilated. Bleeding was minimal and operation took 3 hours and 30 minutes. She spent just one day in ICU and recovery was uneventful. She was discharged on the 7th PO day. She did not develop pancreatic fistula. Final pathology came as IPMN with malignant transformation, non invasive. Lymphnodes were negative.

Thank you all for your valuable opinions.

Marcel

Congratulations  You have  performed the best procedure  for the patient .In patiets like this one we have used a naso enteral tube to start enteral feeding as soon as possible in order to reduce possible intestinal barrier dysfunction as we found in experimental studies  in aging animals  with systemic inflamamation "  Pancreatology 2016,16:52-56"

Open surgery is preferable, in view of the significant difference in duration.

Since you have expertise in both open and laparoscopic surgery, shorter duration of surgery in open surgery is better for the patient.

Good election of the open surgery. Good luck!......