Supplementary table 1: Definitions of complications

Mortality Death of a patient, during or within 90 days after the initial surgical procedure that is related to the surgical procedure.
Readmission Every re-hospitalization due to a complication of the index hospitalization within the first 6 months.
Intra-abdominal abscess Any quantity of purulent fluid leaking via the abdominal drain; walled-off collection of pus in the abdominal cavity at the time of radiological imaging, reoperation or percutaneous drainage; fluid in drain or intra-abdominal collection should be culture positive.
Wound infection Defined according to the Centers for Disease Control and Prevention21 Superficial incisional surgical-site infection and deep incisional surgical site infection which occurs within 30 days after surgery. This includes both the superficial surgical-site infections and the deep incisional surgical site infections. Most of this wound infections were opened at bedside of the patient by the physician or surgeon.
Pancreatic fistula/pancreaticojejunostomy leakage Defined according to the International Study Group of Pancreatic Fistula 22
Delayed gastric emptying Defined according to the International Study Group of Pancreatic Surgery 23
Biliodigestive anastomosis leakage Any quantity of bile leaking via the abdominal wound or drains at least 48 h after surgery, intra-abdominal collection of bile (confirmed radiologically) or cholangiographic evidence of contrast leakage. Laboratory: three times higher bilirubin in the drain or intra-abdominal collection compared with normal serum bilirubin levels.
Sepsis/multi organ failure Definition from the 2001 International Sepsis Definitions Conference24
Post pancreaticoduodenectomy hemorrhage
Definition according to the ISGPS classification of post pancreaticoduodenectomy haemorrhage25
Gastrojejunostomy leakage
Incompetence of the gastrojejunostomy anastomosis documented either by confirmatory upper gastrointestinal contrast x-rays. CT scans, or reoperation26.
CT-drainage Drainage of intra-abdominal fluid collections during CT by inserting a percutaneus drain during the hospitalization or readmission period.
Relaparotomy Any complication after the initial PPPD or Whipple operation leading to a laparotomy as an intervention, during the index hospitalization or the readmission period.

Supplementary table 2: ASA status matched to grade of complication

All patients / ≤ 65 years of age / ≥70 years of age
Dindo-Clavien classification <III / n=35 / n=15 / n=20
ASA I / 12 / 12 / 0
ASA II / 16 / 3 / 13
ASA III / 7 / 0 / 7
ASA IV / 0 / 0 / 0
Dindo-Clavien classification >III / n=34 / n=18 / n=16
ASA I / 10 / 10 / 0
ASA II / 11 / 4 / 7
ASA III / 12 / 3 / 9
ASA IV / 1 / 1 / 0

Supplementary table 3: Patient demographics, pathology and operative data for the 66-69 year group

≤ 65 years of age (n=55) / 66-69 years of age (n=25) / ≥70 years of age (n=55)
Age median (range) / 57 (45-65) / 68 (65-69) / 77 (70-86)
Sex
Male/female / 35/20 / 12/13 / 22/33
ASA class
I / 28 (51%) / 8 (32%) / 1 (2%)
II / 21 (38%) / 13 (52%) / 34 (62%)
III / 5 (9%) / 4 (16%) / 20 (36%)
IV / 1 (2%) / 0 / 0 (0%)
Comorbidity
Cardiovascular / 13 (24%) / 7 (28%) / 25 (45%)
Pulmonary / 2 (4%) / 3 (12%) / 10 (18%)
Diabetes / 6 (11%) / 6 (24%) / 12(21.8%)
Renal disease / 1 (2%) / 2 (8%) / 6 (10.9%)
BMI (range) / 24.9 (18.0-36.1) / 24.6 (18-47) / 24.4 (18.6-36.8)
Pathology
Pancreatic head carcinoma / 34 (62%) / 12 (48%) / 33 (60%)
Duodenal cancer / 2 (4%) / 4 (16%) / 3 (5%)
Ampullary carcinoma / 8 (15%) / 5 (20%) / 12 (22%)
Distal cholangiocarcinoma / 5 (9%) / 3 (12%) / 5 (9%)
Metastasis in pancreas
head / 1 (1,8%) / 1 (4%) / 0 (0%)
Chronic pancreatitis / 2 (4%) / 1 (4%) / 2 (4%)
IPMN / 1 (2%) / 0 / 0 (0%)
Neuro-endocrine tumor / 2 (4%) / 0 / 0 (0%)
Operation type
Whipple / 9 (16%) / 3 (12%) / 8 (15%)
PPPD / 46 (84%) / 22 (88%) / 47 (85%)
Duration of OR time (min) / 345 (180-810) / 310 (190-610) / 340 (217-715)

Abbreviation: ASA: American Society of Anesthesiologists, BMI: Body Mass Index. PPPD= pylorys preserving pancreaticoduodenectomy

Supplementary table 4: Postoperative outcomes for the 66-69 year group

≤ 65 years of age (n=55) / 66-69 years of age (n=25) / ≥70 years of age (n=55)
Dindo-Clavien classification
Minor (I/II) / 15 (27.2%) / 8 (32%) / 20 (36.3%)
Moderate (IIIa/b) / 15 (27.2%) / 4 (16%) / 8 (14.5%)
Severe (Iva en IVb) / 0 (0%) / 1 (4%) / 2 (3.6%)
Mortality < 90days / 3(5,5%) / 1 (4%) / 6 (10.9%)
Readmissions < 6 months / 11 (20%) / 1 (4%) / 7 (12.7%)
Median length of hospital stay (range) / 14 (6-100) / 14 (6-64) / 14 (6-65)
Length of stay uncomplicated (median) / 9 (6-15) / 9 (6-14) / 9 (6-22)
Median LOS Dindo-Clavien grade <III (range) / 10 (6-100) / 14 (6-60) / 14 (7-59)
Median LOS Dindo-Clavien grade >III (range) / 32 (11-83) / 51 (26-64) / 33 (14-65)
Interventions
CT/US-drainage / 10 (18.1%) / 3 (12%) / 8 (14.5%)
Re-operation / 6 (10.9%) / 1 (4%) / 4 (7.2%)

Supplementary table 5: ERAS outcomes for the 66-69 year group

≤ 65 years of age (n=55) / 66-69 years of age (n=25) / ≥70 years of age (n=55)
Resumption of fluid intake POD1 / 53 (96%) / 25 (100%) / 52 (95%)
Resumption of solid intake POD2 / 31 (56%) / 17 (68%) / 35 (63%)
Mobilization from POD 1 / 33 (60%) / 17 (68%) / 35 (63%)
Drain removal on POD 4 / 26 (47%) / 16 (64%) / 28 (51%)
Urinary catheter removal on POD 2 / 38 (69%) / 13 (52%) / 33 (60%)
Removal epidural on POD3 / 44 (80%) / 20 (80%) / 43 (78%)