Biliary Tract Disease in the Aged

Comparison of laparoscopic common bile duct exploration plus cholecystectomy and endoscopic retrograde cholangiopancreatography followed by laparoscopic cholecystectomy for elderly patients with common bile duct stones and gallbladder stones

BACKGROUND

Common bile duct (CBD) stones commonly occur in cholecystectomy cases. The management options include laparoscopic CBD exploration (LCBDE) or endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). Although ERCP is fully developed, it has complications, and LCBDE is a proven alternative. This study aimed to evaluate the safety and efficacy of these treatments in elderly individuals aged ≥70 years.

METHODS

A retrospective study between January 2015 and July 2022 included 160 elderly patients (aged ≥70 years) diagnosed with cholelithiasis and choledocholithiasis. The patients were divided into 1-stage (LCBDE [n = 80]) or 2-stage (ERCP followed by LC [n = 80]) treatment groups. Data collected encompassed comorbidities, symptoms, bile duct clearance, postoperative complications, and long-term outcomes for systematic analysis.

RESULTS

This study analyzed 160 patients treated for CBD stones, comparing 1-stage and 2-stage groups. The 1-stage group had more female patients than the 2-stage group (57.5% vs 37.5%, respectively). The 1-stage group had a mean age of 80.55 ± 7.00 years, which was higher than the mean age in the 2-stage group. American Society of Anesthesiologists classification, Charlson Comorbidity Index, and laboratory findings were similar. Pancreatitis and cholangitis occurred after ERCP in the 2-stage group. Stone clearance rates (92.35% [1-stage group] vs 95.00% [2-stage group]) and biliary leakage incidence (7.5% [1-stage group] vs 3.0% [2-stage group]) were similar, as were postoperative complications and long-term recurrence rates (13.0% [1-stage group] vs 12.5% [2-stage group]).

CONCLUSION

Our research indicates that both the combination of LCBDE and LC and the sequence of ERCP followed by LC are equally efficient and secure when treating CBD stones in elderly patients. Consequently, the 1-stage procedure may be considered the preferred treatment approach for this demographic.

Acute cholecystitis in old adults: the impact of advanced age on the clinical characteristics of the disease and on the surgical outcomes of laparoscopic cholecystectomy

BACKGROUND

Impact of advanced age on disease characteristics of acute cholecystitis (AC), and surgical outcomes after laparoscopic cholecystectomy (LC) has not been established.

METHODS

This single-center retrospective study included patients who underwent LC for AC between April 2010 and December 2020. We analyzed the disease characteristics and surgical outcomes according to age: Group 1 (age < 60 years), Group 2 (60 ≤ age < 80 years), and Group 3 (age ≥ 80 years). Risk factors for complications were assessed using logistic regression analysis.

RESULTS

Of the 1,876 patients (809 [43.1%] women), 723 were in Group 1, 867 in Group 2, and 286 in Group 3. With increasing age, the severity of AC and combined common bile duct stones increased. Group 3 demonstrated significantly worse surgical outcomes when compared to Group 1 and 2 for overall (4.0 vs. 9.1 vs. 18.9%, p < 0.001) and serious complications (1.2 vs. 4.2 vs. 8.0%, p < 0.001), length of hospital stay (2.78 vs. 3.72 vs. 5.87 days, p < 0.001), and open conversion (0.1 vs. 1.0 vs. 2.1%, p = 0.007). Incidental gallbladder cancer was also the most common in Group 3 (0.3 vs. 1.5 vs. 3.1%, p = 0.001). In the multivariate analysis, body mass index < 18.5, moderate/severe AC, and albumin < 2.5 g/dL were significant risk factors for serious complications in Group 3.

CONCLUSION

Advanced age was associated with severe AC, worse surgical outcomes, and a higher rate of incidental gallbladder cancer following LC. Therefore, in patients over 80 years of age with AC, especially those with poor nutritional status and high severity grading, urgent surgery should be avoided, and surgery should be performed after sufficient supportive care to restore nutritional status before LC.

Feasibility of surgeon-performed percutaneous transhepatic gallbladder drainages in patients with acute cholecystitis

Purpose

This study aimed to evaluate the feasibility of surgeon-performed percutaneous transhepatic gallbladder drainage (PTGBD).

Methods

Patients treated with PTGBD for acute cholecystitis (AC), performed by surgeons at Chosun University Hospital for 12 months between March 2017 and February 2018, were enrolled retrospectively, into the S-PTGBD group (n = 134). Patients with PTGBD performed by interventional radiologists for 12 months, 6 months before March 2017, and after February 2018, were included in the X-PTGBD group (n = 107). In addition to the basic characteristics of the patients, severity of AC, comorbidities, intervals from hospital admission to the PTGBDs, procedural times, technical success rates, intention-to-treat rates, and complication rates were evaluated and compared.

Results

Except for the patient’s age (older in S-PTGBD), there were no differences in the patient’s basic profiles, including the severity of the AC and comorbidities. Although the procedural times were significantly shorter in the X-PTGBD group (18.13 minutes vs. 11.39 minutes), effectiveness indicators such as the technical success rates and intention-to-treat rates and safety, such as the major complication rates in the S-PTGBD group, were comparable with those in the X-PTGBD group. The intervals between hospital admissions and PTGBDs were shorter in the S-PTGBD group, although this difference disappeared in the high-risk group. Effectiveness and safety in the high-risk group were also comparable between the groups.

Conclusion

The PTGBDs performed by surgeons are as effective and safe as those performed by interventional radiologists with faster implementation of PTGBD.

Elective Laparoscopic Cholecystectomy Is Better than Conservative Treatment in Elderly Patients with Acute Cholecystitis After Percutaneous Transhepatic Gallbladder Drainage

BACKGROUND

It is unclear whether cholecystectomy is beneficial after percutaneous transhepatic gallbladder drainage (PTGBD) in elderly patients with acute cholecystitis (AC).

METHODS

This single-center, retrospective study included 202 patients aged >80 years with AC without common bile duct (CBD) stones who underwent PTGBD between January 2010 and December 2019.

RESULTS

One hundred and forty-two patients underwent elective laparoscopic cholecystectomy (ELC), and 60 underwent conservative treatment, specifically PTGBD removal (PTGBD-R) in 36 patients and PTGBD maintained (PTGBD-M) in 24 patients. The postoperative major complication (POMC) rate in the ELC group was 8.5%. The cumulative incidence for recurrence of biliary events (BE) in the PTGBD-R group was 22.2%. The cumulative incidence for PTGBD-related complication in the PTGBD-M group was 70.8%. Mortality after initial treatment was not significantly different between the three groups (2.8% vs. 2.8% vs. 8.3%, p=0.381). In multivariate analysis, a Charlson age comorbidity index ≥6 and body mass index ≤19 were significant risk factors for POMC after ELC, and a closed cystic duct was a significant risk factor for recurrent BE after PTGBD-R.

CONCLUSION

ELC is recommended in AC after PTGBD for selected patients aged >80 years without CBD stones due to the high recurrence rate of BE after PTGBD-R and the difficulty associated with PTGBD-M.

Managing Gallstone Disease in the Elderly

Geriatric patients tend to have subtle presentations of biliary disorders and, if untreated, can decompensate acutely. Each biliary disorder warrants formulation of an individualized treatment plan with a multidisciplinary approach. Acute cholecystitis, a common complication of gallstones, is initially managed by conservative measures and subsequently, among patients with optimal surgical risk, through laparoscopic or open cholecystectomy. High-risk patients undergo temporization, percutaneous or endoscopic, followed by definitive intervention. Acute cholecystitis with complications (ie, perforation, gangrene, or small bowel obstruction) warrants emergent cholecystectomy. Gallstone migration into the biliary system can cause choledocholithiasis, often complicated by biliary pancreatitis or cholangitis if not intervened. Therapy for choledocholithiasis is based on biliary clearance through endoscopic and, infrequently, surgical approaches.

Acalculous gangrenous cholecystitis in a young adult: a gastrointestinal manifestation of polyarteritis nodosa

The authors report a rare case of an acalculous gangrenous cholecystitis due to a form of vasculitis, polyarteritis nodosa (PAN). An 18-year-old man was admitted to the hospital with worsening symptoms of nausea, fever, intermittent abdominal pain, and high blood pressure that lasted for 4 days. After a sequential work-up, a diagnostic laparoscopy was performed and revealed a gangrenous cholecystitis with spontaneous perforation. Laparoscopic cholecystectomy was performed successfully. The patient had an uneventful recovery period and was discharged on the second postoperative day. The histopathologic examination showed gangrenous and perforated gallbladder, vasculitis, and clues of PAN. The purpose of this article is to describe a rare condition in a young patient that was diagnosed and treated with minimally invasive surgery.

Cholelithiasis, cholecystitis, and pancreatitis

Cholelithiasis, cholecystitis, and pancreatitis are common conditions in the adult patient population that may be challenging to recognize because of their variable clinical presentations and broad differential diagnoses. This article discusses the pathophysiology of each condition and its common complications. The clinical presentation and evaluation of patients is reviewed with emphasis on current diagnostic tests used to identify severity of illness and the presence of complications. Treatment options are presented for straightforward as well as complicated initial management and disposition.

The effect of aging on oro-cecal transit time in normal subjects and patients with gallstone disease

To ascertain whether aging and/or cholelithiasis can influence oro-cecal transit time (OCTT), we studied a total of 70 subjects, i.e., 10 healthy young adult controls, 22 healthy elderly controls, 18 elderly cholelithiasis patients and 20 elderly subjects with a history of cholecystectomy for gallstones. OCTT was measured by means of the hydrogen breath test after administering a liquid meal of 10 g of lactulose in 200 mL of water, and collecting exhaled breath samples every 10 minutes for 200 minutes. Of all subjects in the group of patients with a history of cholecystectomy, 6/20 were non-hydrogen producers, and therefore were not included in the study. The OCTT was found to be significantly longer in healthy elderly controls, than in healthy young adult controls; the elderly subjects who had undergone cholecystectomy had a longer OCTT than the healthy elderly controls, while no difference was detected when compared to elderly patients with gallstones. In conclusion, OCTT seems to increase in healthy aging. Cholecystectomy also increases OCTT in the elderly, suggesting a link between intestinal motility and the biliary tract which may be of pathophysiological significance.