Considerations concerning laparoscopic cholecystectomy in the extremely elderly

The Safety of Laparoscopic Cholecystectomy in Super-elderly Patients: A Propensity Score Matching Analysis

BACKGROUND

Although reports on the safety of laparoscopic cholecystectomy (LC) exist, few have included patients aged ≥ 85 years. Hence, our study aimed to evaluate surgical outcomes of LC in patients aged ≥ 85 years.

METHODS

After excluding patients who underwent other types of surgeries, 583 patients who underwent LC between 2015 and 2022 were included. Patients were classified into two groups based on age: < 85 years (control group, n = 551) and ≥ 85 years (super-elderly group, n = 32). Propensity score matching (PSM) was performed based on preoperative clinical parameters, and intraoperative and postoperative outcomes were compared.

RESULTS

After PSM, 28 patients were included in each group. Intraoperative blood loss (1 vs. 5 mL, respectively; P = .052) and frequency of serious postoperative complications (Clavien-Dindo class ≥ 2, 2/28 (7.1%) vs. 6/28 (21.4%), P = .252) were similar between the control and elderly groups. There was no significant difference in the length of postoperative stay (control group: 5 (4-24) days vs. super-elderly group: 7 (3-64) days, P = .236). Unfortunately, one case of pneumonia of unknown cause occurred postoperatively, resulting in the death of one patient in the super-elderly group.

CONCLUSIONS

There were no clinically significant differences in the short-term outcomes of LC between super-elderly patients aged ≥ 85 years and patients aged < 85 years. Hence, LC may be relatively safe even in patients aged ≥ 85 years. However, owing to many pre-existing diseases and deterioration of physiological function, careful management during the perioperative period is desirable.

Protective and therapeutic experience of perioperative safety in extremely elderly patients with biliary diseases

To explore the protective and therapeutic measures of improving perioperative safety in extremely elderly patients with biliary diseases, so as to improve the therapeutic efficacy of surgery. A retrospective case–control study of 412 elderly patients with biliary diseases was carried out from July 2013 to July 2019. Seventy eight cases were divided into the high age (HA) group (≥80 years) and 334 into the middle–low age (MLA) group (60–79 years). In the HA compared with MLA group, 1. Preoperative coexisting diseases: the occurrence of coexisting coronary heart disease (CHD), hypertension, chronic bronchitis with emphysema, hypoproteinemia, and anemia were significantly increased; 2. Laboratory examinations: function of liver, kidneys, heart, lungs, and blood coagulation significantly declined; 3. Surgical procedures: open cholecystectomy with transcystic common bile duct (CBD) exploration significantly higher, while laparoscopic cholecystectomy significantly lower; 4. Operative effects: intraoperative blood loss, operation time, postoperative hospital stay, and length of hospitalization significantly increased or prolonged; 5. Postoperative complications: postoperative respiratory failure, pulmonary infection, anemia and electrolyte disorder significantly increased; 6. Therapeutic outcomes: no significant difference in the therapeutic effects. Although the surgical risk was significantly increased, there was no significant difference in the therapeutic efficacy in the HA compared with MLA group, suggesting that surgical treatment in extremely elderly patients with biliary diseases is safe and feasible. The key is to actively treat preoperative coexisting diseases, strictly adhere to surgical indications, reasonably select surgical procedures, precisely perform the operation, closely monitor and control intraoperative emergencies, timely prevent and treat postoperative complications, so as to improve the perioperative safety of extremely elderly patients with biliary diseases.

Perioperative outcomes after laparoscopic cholecystectomy in elderly patients: a systematic review and meta-analysis

BACKGROUND

Laparoscopic cholecystectomy is increasingly performed in an ever ageing population; however, the risks are poorly quantified. The study aims to review the current evidence to quantify further the postoperative risk of cholecystectomy in the elderly population compared to younger patients.

METHOD

A systematic literature search of PubMed, EMBASE and the Cochrane Library databases were conducted including studies reporting laparoscopic cholecystectomy in the elderly population. A meta-analysis was reported in accordance with the recommendations of the Cochrane Library and PRISMA guidelines. Primary outcome was overall complications and secondary outcomes were conversion to open surgery, bile leaks, postoperative mortality and length of stay.

RESULTS

This review identified 99 studies incorporating 326,517 patients. Increasing age was significantly associated with increased rates of overall complications (OR 2.37, CI95% 2.00-2.78), major complication (OR 1.79, CI95% 1.45-2.20), risk of conversion to open cholecystectomy (OR 2.17, CI95% 1.84-2.55), risk of bile leaks (OR 1.50, CI95% 1.07-2.10), risk of postoperative mortality (OR 7.20, CI95% 4.41-11.73) and was significantly associated with increased length of stay (MD 2.21 days, CI95% 1.24-3.18).

CONCLUSION

Postoperative outcomes such as overall and major complications appear to be significantly higher in all age cut-offs in this meta-analysis. This study demonstrated there is a sevenfold increase in perioperative mortality which increases by tenfold in patients > 80 years old. This study appears to confirm preconceived suspicions of higher risks in elderly patients undergoing cholecystectomy and may aid treatment planning and informed consent.

Safety and outcomes of laparoscopic cholecystectomy in the extremely elderly: a systematic review and meta-analysis

Background: Gallstones are a common cause of morbidity in the elderly. Operative treatment is often avoided due to concerns about poor outcomes but the evidence for this is unclear. We aim to consolidate available evidence assessing laparoscopic cholecystectomy outcomes in the extreme elderly (>80s) compared to younger patients. Methods: Studies comparing laparoscopic cholecystectomy in >80s with younger patients were considered. Total complications, mortality, conversion, bile duct injury, and length of stay were compared between the two groups. Results: Twelve studies including 366,522 patients were included. They were of moderate overall quality. The elderly group had more complicated gallbladder disease and also had more co-morbidities and a higher ASA grade. The risk of morbidity was lower in the younger group (RR 0.58 (95% CI 0.58-0.59)) with a slightly lower risk of conversion (RR 0.96 (0.94-0.98)) Length of stay was significantly longer for the elderly patients. Differences in mortality and bile duct injury were non-significant in all but one study. Conclusion: Laparoscopic cholecystectomy is safe and effective in the extreme elderly. Higher complication rates are predominantly related to increased co-morbidities and more complex gallbladder disease. Patients should be carefully selected, and cholecystectomy performed at an earlier stage to minimize these problems.

Conservative management of acute calculous cholecystitis complicated by pancreatitis in an elderly woman: A case report

RATIONALE

Acute calculous cholecystitis is a prevalent disease whose diagnosis and management still face significant debate. Although the overall incidence of gallstone disease is 18.8% in European women aged 30 to 69 years, there is little data and experience in managing acute calculous cholecystitis in populations over 80 years old. The incidence of acute cholecystitis among the elderly is probably increasing. For the reason, we here highlight the advantages and disadvantage of various treatment and management opens based on a 96-year-old patient.

PATIENT CONCERNS

We present a rare case in which a 96-year-old woman suffered from abdominal pain, nausea, and lack of appetite for over a month.

DIAGNOSES

She was diagnosed with acute calculous cholecystitis and pancreatitis.

INTERVENTIONS

She was successfully treated without surgery, regaining her physical health after 5 months.

OUTCOMES

The question of how to manage acute calculous cholecystitis is extremely difficult in many aspects. The patient of very advanced age presented in this paper, not very well diagnosed and with a life-threating condition, survived because of careful treatment and reasonable decision-making.

LESSONS

The take-away from this case is that, in a high-risk senile patient, strict conservative therapy of cholecystitis may be successful, as it can avoid the complications of surgery and leave the patient with a good quality of life.

Laparoscopic Cholecystectomy in the Elderly: An Experience at a Tertiary Care Hospital in Western Nepal

Background

The incidence of gallstone increases with increasing age. No studies have been reported in the elderly population with laparoscopic cholecystectomy from developing nations. The aim of this study was to compare perioperative outcomes of laparoscopic cholecystectomy between the elderly (≥60 years old) and the young (<60 years old).

Methods

From July 2015 to June 2016, a retrospective review of medical records of 78 elderly patients (≥60 years old) and 164 young patients (<60 years old) who underwent laparoscopic cholecystectomy was done. The patients' demographics and perioperative outcomes were analyzed.

Results

Median ages were 65 years (range: 60–80) and 45 years (range: 21–59) for the elderly group and the young group. The majority of patients were female (62.8 and 72%). There were no significant differences in the conversion rate (9 and 7.9%, P = 0.78), postoperative complications (17.9 and 14.6%, P = 0.50), and length of stay in the hospital (4 days for both groups, P = 0.35) between the two groups. There was no mortality in either of the groups.

Conclusion

Our results of laparoscopic cholecystectomy in elderly patients are comparable with those in young patients. Therefore, laparoscopic cholecystectomy is safe even in the elderly population.

Therapeutic experience of 289 elderly patients with biliary diseases

AIM

To present clinical characteristics, diagnosis and treatment strategies in elderly patients with biliary diseases.

METHODS

A total of 289 elderly patients with biliary diseases were enrolled in this study. The clinical data relating to these patients were collected in our hospital from June 2013 to May 2016. Patient age, disease type, coexisting diseases, laboratory examinations, surgical methods, postoperative complications and therapeutic outcomes were analyzed.

RESULTS

The average age of the 289 patients with biliary diseases was 73.9 ± 8.5 years (range, 60-102 years). One hundred and thirty-one patients (45.3%) had one of 10 different biliary diseases, such as gallbladder stones, common bile duct stones, and cholangiocarcinoma. The remaining patients (54.7%) had two types of biliary diseases. One hundred and seventy-nine patients underwent 9 different surgical treatments, including pancreaticoduodenectomy, radical resection of hilar cholangiocarcinoma and laparoscopic cholecystectomy. Ten postoperative complications occurred with an incidence of 39.3% (68/173), and hypopotassemia showed the highest incidence (33.8%, 23/68). One hundred and sixteen patients underwent non-surgical treatments, including anti-infection, symptomatic and supportive treatments. The cure rate was 97.1% (168/173) in the surgical group and 87.1% (101/116) in the non-surgical group. The difference between these two groups was statistically significant (χ² = 17.227, P < 0.05).

CONCLUSION

Active treatment of coexisting diseases, management of indications and surgical opportunities, appropriate selection of surgical procedures, improvements in perioperative therapy, and timely management of postoperative complications are key factors in enhancing therapeutic efficacy in elderly patients with biliary diseases.

Trends in Follow-Up of Patients Presenting to the Emergency Department with Symptomatic Cholelithiasis

BACKGROUND

Fewer than 25% of Medicare beneficiaries presenting with symptomatic cholelithiasis undergo elective cholecystectomy. To better understand underuse of cholecystectomy, we examined physician follow-up patterns after emergency department (ED) visits for symptomatic gallstones.

STUDY DESIGN

We used 100% Texas Medicare claims (2001 to 2010) to identify patients 66 years of age and older who presented to the ED with symptomatic cholelithiasis and were discharged home without cholecystectomy. Timing of outpatient physician visits after ED discharge and rates of emergent cholecystectomy based on physician follow-up patterns were compared.

RESULTS

In total, 11,126 patients presented to the ED with symptomatic cholelithiasis and were discharged without cholecystectomy. After discharge, 5,327 patients (47.9%) had an outpatient surgeon visit, 29.0% saw another physician and never saw a surgeon, and 23.1% never saw a physician; 68.2% of patients who saw a surgeon underwent elective cholecystectomy; and 8.3% of patients who saw a surgeon, 14.6% of patients who saw other physicians and no surgeon, and 77.6% of patients who never saw any physician, required emergent hospitalization (p < 0.0001). For people who did not see a physician, mean time to emergent hospitalization was 7.5 days (median 2 days); 95.9% presented within 2 weeks after their initial presentation.

CONCLUSIONS

Fewer than half of patients were evaluated by a surgeon after an initial ED visit for symptomatic gallstones. Patients who did not have physician follow-up were most likely to require emergent cholecystectomy, suggesting inappropriate ED discharge and highlighting the need for timely follow-up. Early outpatient surgical consultation is critical in determining appropriateness for cholecystectomy and avoiding emergent cholecystectomy in older patients with symptomatic gallstones.

PREOP-Gallstones: A Prognostic Nomogram for the Management of Symptomatic Cholelithiasis in Older Patients

OBJECTIVE AND BACKGROUND

The decision regarding elective cholecystectomy in older patients with symptomatic cholelithiasis is complicated. We developed and validated a prognostic nomogram to guide shared decision making for these patients.

METHODS

We used Medicare claims (1996-2005) to identify the first episode of symptomatic cholelithiasis in patients older than 65 years who did not undergo hospitalization or elective cholecystectomy within 2.5 months of the episode. We described current patterns of care and modeled their risk of emergent gallstone-related hospitalization or cholecystectomy at 2 years. Model discrimination and calibration were assessed using a random split sample of patients.

RESULTS

We identified 92,436 patients who presented to the emergency department (8.3%) or physician's office (91.7%) and who were not immediately admitted. The diagnosis for the initial episode was biliary colic/dyskinesia (65.3%), acute cholecystitis (26.6%), choledocholithiasis (5.7%), or gallstone pancreatitis (2.4%). The 2-year emergent gallstone-related hospitalization rate was 11.1%, with associated in-hospital morbidity and mortality rates of 56.5% and 6.5%. Factors associated with gallstone-related acute hospitalization included male sex, increased age, fewer comorbid conditions, complicated biliary disease on initial presentation, and initial presentation to the emergency department. Our model was well calibrated and identified 51% of patients with a risk less than 10% for 2-year complications and 5.4% with a risk more than 40% (C statistic, 0.69; 95% confidence interval, 0.63-0.75).

CONCLUSIONS

Surgeons can use this prognostic nomogram to accurately provide patients with their 2-year risk of developing gallstone-related complications, allowing patients and physicians to make informed decisions in the context of their symptom severity and its impact on their quality of life.

Clinical outcome for laparoscopic cholecystectomy in extremely elderly patients

PURPOSE

Extremely elderly patients who present with complicated gallstone disease are less likely to undergo definitive treatment. The use of laparoscopic cholecystectomy (LC) in older patients is complicated by comorbid conditions that are concomitant with advanced age and may increase postoperative complications and the frequency of conversion to open surgery. We aimed to evaluate the results of LC in patients (older than 80 years).

METHODS

We retrospectively analyzed 302 patients who underwent LC for acute cholecystitis between January 2011 and December 2013. Total patients were divided into three groups: group 1 patients were younger than 65 years, group 2 patients were between 65 and 79 years, and group 3 patients were older than 80 years. Patient characteristics were compared between the different groups.

RESULTS

The conversion rate was significantly higher in group 3 compared to that in the other groups. Hematoma in gallbladder fossa and intraoperative bleeding were higher in group 3, the difference was not significant. Wound infection was not different between the three groups. Operating time and postoperative hospital stay were significantly higher in group 3 compared to those in the other groups. There was no reported bile leakage and operative mortality. Preoperative percutaneous transhepatic gallbladder drainage and endoscopic retrograde cholangiopancreatography were performed more frequently in group 3 than in the other groups.

CONCLUSION

LC is safe and feasible. It should be the gold-standard approach for extremely elderly patients with acute cholecystitis.

The risk paradox: use of elective cholecystectomy in older patients is independent of their risk of developing complications

BACKGROUND

We recently developed and validated a prognostic model that accurately predicts the 2-year risk of emergent gallstone-related hospitalization in older patients presenting with symptomatic gallstones.

STUDY DESIGN

We used 100% Texas Medicare data (2000 to 2011) to identify patients aged 66 years and older with an initial episode of symptomatic gallstones not requiring emergency hospitalization. At presentation, we calculated each patient's risk of 2-year gallstone-related emergent hospitalization using the previously validated model. Patients were placed into the following risk groups based on model estimates: <30%, 30% to <60%, and ≥ 60%. Within each risk group, we calculated the percent of elective cholecystectomies (≤ 2.5 months from initial episode) performed.

RESULTS

In all, 161,568 patients had an episode of symptomatic gallstones. Mean age was 76.5 ± 7.3 years and 59.9% were female. The 2-year risk of gallstone-related hospitalizations increased from 15.9% to 41.5% to 65.2% across risk groups. For the overall cohort, 22.3% in the low-risk group, 20.9% in the moderate-risk group, and 23.2% in the high-risk group underwent elective cholecystectomy in the 2.5 months after the initial symptomatic episode. In patients with no comorbidities, elective cholecystectomy rates decreased from 34.2% in the low-risk group to 26.7% in the high-risk group. Of patients who did not undergo cholecystectomy, only 9.5% were seen by a surgeon in the 2.5 months after the initial episode.

CONCLUSIONS

The risk of recurrent acute biliary symptoms requiring hospitalization has no influence, or even a paradoxical negative influence, on the decision to perform elective cholecystectomy after an initial symptomatic episode. Translation of the risk prediction model into clinical practice can better align treatment with risk and improve outcomes in older patients with symptomatic gallstones.

Outcomes of laparoscopic cholecystectomy in octogenarians

Laparoscopic cholecystectomy in octogenarians appears to be safe with acceptable morbidity.

Background and Objectives:

Extremely elderly patients usually present with complicated gallstone disease and are less likely to undergo definitive treatment. The purpose of this study was to evaluate the results of laparoscopic cholecystectomy in octogenarians, with an interest in patients presenting initially with complicated gallstone disease and pancreatitis who underwent laparoscopic cholecystectomy during the same hospitalization.

Methods:

Data for 42 patients ≥80 years who underwent an elective laparoscopic cholecystectomy between January 2007 and August 2011 were retrospectively reviewed. Indications for the procedure were stratified into 2 groups: Outpatients, who were admitted electively to undergo cholecystectomy, and Inpatients, who came to our Emergency Room due to complicated biliary diseases. Data analysis included age, sex, ASA score, conversion to open surgery, time spent under general anesthesia, and length of hospital stay.

Results:

Mean age was 83.9 years; 19 (45.2%) were men. Thirteen patients (30.9%) were in the outpatient group, and 13 (30.9%) had a preoperative ASA of 3. Fourteen patients (33.3%) needed ICU. Two patients (4.8%) had their surgery converted. There were 7 (16.7%) postoperative complications, all of them classified as Dindo-Clavien I or II. No differences were noted between groups regarding conversion rates or complications. We had no mortalities in this series. There was no difference in hospital length of stay between the groups.

Conclusion:

Laparoscopic cholecystectomy in the extremely elderly is safe, with acceptable morbidity. Patients with complicated gallstone disease seem not to have worse postoperative outcomes once the initial diagnosis is properly treated and would benefit from definitive therapy during the same hospitalization.

Surgical management of gallbladder disease in the very elderly: are we operating them at the right time?

BACKGROUND

As life expectancy rises worldwide and the prevalence of gallstones increases with age, the number of very elderly patients requiring treatment for gallstone diseases is increasing. The aim of this study was to compare the results of cholecystectomy in patients 80 years or older according to different clinical presentations.

METHODS

This is a retrospective study of 81 patients 80 years or older. Indications for surgery were stratified into three groups: outpatients (symptomatic chronic cholecystitis), inpatients (complicated gallstone diseases), and urgent patients (acute cholecystitis). Data analysis included age, sex, the American Society of Anesthesiologists score, indication for surgery, length of hospital stay, morbidity, and mortality.

RESULTS

The mean age of the patients was 83.9 (range 80-94 years); there were 34 (42%) men. Thirty patients were operated on for acute cholecystitis. Patients in the urgency group significantly required the ICU more often, required a longer hospital stay, and had more complications, with 32% mortality. No differences were found between inpatients and outpatients, with both groups presenting low morbidity, no mortality, and the same postoperative length of stay.

CONCLUSION

More than 80% of the patients were operated on because of complicated gallstone disease. Although the outcomes of patients undergoing semielective cholecystectomy were similar to those of patients treated as outpatients, patients operated with acute cholecystitis presented extremely high morbidity and mortality rates. Thus, we can only recommend that early elective cholecystectomy be performed in elderly patients as soon as they are found to have symptomatic gallstones. Also, further trials are required to elucidate the optimal management of acute cholecystitis in elderly patients.

Cholecystomucoclasis: revaluation of safety and validity in aged populations

Background

We evaluated the safety and validity of cholecystomucoclasis (CM) and compared its intraoperative characteristics with those of standard cholecystectomy (SC).

Methods

We enrolled 174 patients who underwent cholecystectomy and retrospectively evaluated the outcomes of patients in the SC and CM groups.

Results

Significant differences in age (71.1 vs. 61.9 years), American Society of Anesthesiologists physical status (ASA-PS), and serum C-reactive protein levels (CRP) (18.1 vs. 4.7 mg/dL) were observed between the CM and SC groups. Conversely, no significant differences were observed in the operation time (129 vs. 108 min), amount of blood loss (147 vs. 80 mL), intraoperative complications (0% vs. 5.7%), or duration of hospital stay (13.2 vs. 8.9 days) between the 2 groups. A high conversion rate (35.3%), postoperative complications (33%), and frequent drain insertions (94%) were observed in the CM group.

Conclusions

CM is a safe and valid surgical procedure and surgeons should not hesitate to transition to CM for patients who are of advanced age, in poor general condition (high ASA classification), or have high levels of serum CRP.

Colecistectomia videolaparoscópica em 960 pacientes idosos

OBJETIVO: Analisar o tempo operatório, a permanência hospitalar, a taxa de conversão, a morbidade e a mortalidade de pacientes idosos submetidos à colecistectomia videolaparoscópica por doença da vesícula biliar. MÉTODOS: Estudo descritivo, retrospectivo, realizado no prontuário de 960 pacientes, de ambos os sexos, com idade entre 60 e 97 anos no período de janeiro de 1993 a agosto de 2009. RESULTADOS: O tempo operatório variou de nove a 180 minutos. O tempo de internação variou de 24 a 120 horas. A conversão ocorreu em 28 pacientes (2,92%), dos quais 67,9% eram mulheres e 28,6% homens tendo sido em 11 casos (39,3%) realizada minilaparotomia e em 17 (60,7%) a via aberta convencional. As intercorrências no transoperatório foram duas rupturas da vesícula biliar, uma falha no pneumoperitônio e uma na clipagem do ducto cístico. No pós-operatório observaram-se cinco hérnias umbilicais incisionais. As complicações sistêmicas foram: nove arritmias cardíacas, uma icterícia pós-operatória, um infarto agudo do miocárdio e um infarto enteromesentérico. Mortalidade ocorreu em três pacientes (0,3%), um por infarto agudo do miocárdio no transoperatório, uma sepse e um infarto enteromesentérico. CONCLUSÃO: Os pacientes idosos submetidos à colecistectomia videolaparoscópica apresentaram baixo tempo de internação hospitalar e baixa morbimortalidade. O tempo operatório e o de internação hospitalar foram curtos, demonstrando que a colecistectomia videolaparoscópica é procedimento seguro e eficaz nos idosos.

Is laparoscopic cholecystectomy more challenging in male patients?

BACKGROUND

Laparoscopic cholecystectomy (LC) seems to be more challenging in males than in females. The surgery seems to be longer in male patients. There also seems to be an increased rate of conversion to open surgery in male patients. We sought to objectively verify this widespread belief.

METHODS

We performed a retrospective analysis of laparoscopic cholecystectomies performed between January 2004 and November 2009 in our hospital. Within this period 1844 cholecystectomies were performed in our community-based hospital. After a strict inclusion procedure, 1571 cases of LC for symptomatic gallbladder disease were analyzed (501 males, 1071 females). The time for surgery, defined as the interval from placement of the Veress needle to wound closure in minutes, and the rate of conversion to open surgery were the main parameters considered.

RESULTS

The time for surgery in male patients was significantly longer compared to that for females (p<0.0001). The male cohort was significantly older than the female cohort at the time of surgery (p<0.001). The rate of conversion to open surgery was significantly higher in male patients (5.6%) compared to 2.9% for females (p<0.0001).

CONCLUSION

Based on our analysis, LC had a significantly longer duration of surgery in the male cohort. The rate of conversion to open surgery was also significantly higher in male cohort. Thus, LC could be more challenging in male patients.

Prediction and management of a low-lying costal arch which restricts the operative working space during laparoscopic cholecystectomy

BACKGROUND/PURPOSE

Laparoscopic cholecystectomy is difficult to perform in patients with a low-lying costal arch that entirely covers the liver. We conducted this study to clarify the factors related to a low-lying costal arch and establish countermeasures to circumvent this characteristic.

METHODS

The study included 103 consecutive patients who underwent a laparoscopic cholecystectomy. The possible clinical factors associated with a low-lying costal arch restricting the operative working space were analyzed. The position of the liver against the costal arch and the presumed surgical visual angle for laparoscopic cholecystectomy, comprising the hepatic porta, umbilicus, and costal arch, were estimated with abdominal multidetector computed tomography (MDCT).

RESULTS

Seven (7%) patients had a low-lying costal arch presenting an inadequate exposure of Calot's triangle and restricted instrument mobility during laparoscopic cholecystectomy, and three patients required conversion to a laparotomy. A low-lying costal arch was significantly associated with advanced age, shorter stature, lighter body weight, coexisting kyphoscoliosis, gallbladder pathology, laparotomy conversion, and most of all, the liver edge lying above the costal arch and a narrow surgical visual angle upon MDCT. Of the seven patients with a critical low-lying costal arch, four underwent a successful laparoscopic cholecystectomy, this being done by lifting the right costal arch to create a workable surgical field; the rib-lifting procedure was planned as part of the scheduled procedure in the other three patients because the preoperative MDCT examination indicated a poor working space for a laparoscopic cholecystectomy.

CONCLUSIONS

A low-lying costal arch is a substantial risk factor for conversion to a laparotomy when performing a laparoscopic cholecystectomy. However, the operative difficulty related to a low-lying costal arch can be predicted by using preoperative MDCT images and can be managed with proper planning and the appropriate use of the rib-lifting technique.

Laparoscopic cholecystectomy in patients with cirrhosis of the liver and symptomatic cholelithiasis

BACKGROUND

The indications and benefits of laparoscopic cholecystectomy (LC) in patients with liver cirrhosis and symptomatic cholelithiasis have not been satisfactorily documented. The aim of this study was to investigate its efficacy and safety in such patients.

METHODS

Medical records of 38 patients with liver cirrhosis (stages Child-Pugh A and B) who underwent LC were retrospectively reviewed. Demographic characteristics and other parameters including initial presentation, conversion rate, complication rate, mortality, and duration of hospital stay were investigated and compared with noncirrhotic patients' parameters in our database.

RESULTS

Cirrhotic patients who underwent LC were older than noncirrhotic patients (P=0.021). Both the conversion rate (15.78%) and the duration of hospital stay were increased in the cirrhotic group, but without significant differences. Major complications occurred more often in the cirrhotic group (P=0.027), increasing morbidity; however, the mortality was zero.

CONCLUSIONS

LC can be safely performed in Child-Pugh A and B cirrhotic patients with symptomatic gallstone disease, with acceptable complication and conversion rates. The increased risk for a major complication, however, demands more attention than usual.

Outcome of laparoscopic cholecystectomy is not influenced by chronological age in the elderly

AIM: To evaluate the outcome of laparoscopic cholecystectomy (LC) in patients aged 80 years and older.

METHODS: A total of 353 patients aged 65 to 79 years (group 1) and 35 patients aged 80 years and older (group 2) underwent LC. Patients were further classified into two other groups: those with uncomplicated gallbladder disease (group A) or those with complicated gallbladder disease (group B).

RESULTS: There were no significant differences between the age groups (groups 1 and 2) with respect to clinical characteristics such as age, gender, comorbid disease, or disease presentation. Mean operative time, conversion rate, and the incidence of major postoperative complications were similar in groups 1 and 2. However, the percentage of high-risk patients was significantly higher in group 2 than in group 1 (20.0% vs 5.7%, P < 0.01). Group A comprised 322 patients with a mean age of 71.0 ± 5.3 years, and group B comprised 51 patients with a mean age of 69.9 ± 4.8 years. In group B, mean operative time (78.4 ± 49.3 min vs 58.3 ± 35.8 min, P < 0.01), mean postoperative hospital stay (7.9 ± 6.5 d vs 5.0 ± 3.7 d, P < 0.01), and the incidence of major postoperative complications (9.8% vs 3.1%, P < 0.05) were significantly greater than in group A. The conversion rate tended to be higher in group B, but this difference was not significant.

CONCLUSION: Perioperative outcomes in elderly patients who underwent LC seem to be influenced by the severity of gallbladder disease, and not by chronologic age. In octogenarians, LC should be performed at an earlier, uncomplicated stage of the disease whenever possible to improve perioperative outcomes.