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

Which octogenarian patients are at higher risk after cholecystectomy for symptomatic gallstone disease? A single center cohort study

BACKGROUND

Incidence of gallstones in those aged ≥ 80 years is as high as 38%-53%. The decision-making process to select those oldest old patients who could benefit from cholecystectomy is challenging.

AIM

To assess the risk of morbidity of the “oldest-old” patients treated with cholecystectomy in order to provide useful data that could help surgeons in the decision-making process leading to surgery in this population.

METHODS

A retrospective study was conducted between 2010 and 2019. Perioperative variables were collected and compared between patients who had postoperative complications. A model was created and tested to predict severe postoperative morbidity.

RESULTS

The 269 patients were included in the study (193 complicated). The 9.7% of complications were grade 3 or 4 according to the Clavien-Dindo classification. Bilirubin levels were lower in patients who did not have any postoperative complications. American Society of Anesthesiologists scale 4 patients, performing a choledocholithotomy and bilirubin levels were associated with Clavien-Dindo > 2 complications (P < 0.001). The decision curve analysis showed that the proposed model had a higher net benefit than the treating all/none options between threshold probabilities of 11% and 32% of developing a severe complication.

CONCLUSION

Patients with American Society of Anesthesiologists scale 4, higher level of bilirubin and need of choledocholithotomy are at the highest risk of a severely complicated postoperative course. Alternative endoscopic or percutaneous treatments should be considered in this subgroup of octogenarians.

Surgery for acute cholecystitis in severely comorbid patients: a population-based study on acute cholecystitis

Background

International guidelines recommend emergency cholecystectomy for acute cholecystitis in patients who are healthy or have mild systemic disease (ASA1-2). Surgery is also an option for patients with severe systemic disease (ASA3) in clinical practice. The study aimed to investigate the risk of complications in ASA3 patients after surgery for acute cholecystitis.

Method

1 634 patients treated for acute cholecystitis at three Swedish centres between 2017 and 2020 were included in the study. Data was gathered from electronic patient records and the Swedish registry for gallstone surgery, Gallriks. Logistic regression was used to assess the risk of complications adjusted for confounding factors: sex, age, BMI, Charlson comorbidity index, cholecystitis grade, smoking and time to surgery.

Results

725 patients had emergency surgery for acute cholecystitis, 195 were ASA1, 375 ASA2, and 152 ASA3. Complications occurred in 9% of ASA1, 13% of ASA2, and 24% of ASA3 patients. There was no difference in 30-day mortality. ASA3 patients stayed on average 2 days longer after surgery. After adjusting for other factors, the risk of complications was 2.5 times higher in ASA3 patients than in ASA1 patients. The risk of complications after elective surgery was 5% for ASA1, 13% for ASA2 and 14% for ASA3 patients. Regardless of ASA 18% of patients treated non-operatively had a second gallstone complication within 3 months.

Conclusion

Patients with severe systemic disease have an increased risk of complications but not death after emergency surgery. The risk is lower for elective procedures, but a substantial proportion will have new gallstone complications before elective surgery.

Trial registration: Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02453-0.

Cohort cholecystectomies in the Brazilian public system: is access to laparoscopy universal after three decades?

OBJECTIVE

videosurgery in Brazil started in 1990 with the performance of laparoscopic cholecystectomy, being included by the public health system in 2008. We evaluated the current situation of the use of this technology in the Unified Health System (SUS - Sistema Único de Saúde).

METHODS

from 2013 to 2019, 1,406,654 patients registered at the SUS Informatics Department (DATASUS) were analyzed to calculate the rate of laparoscopic cholecystectomies (LC) in relation to open cholecystectomies (OC). Patient characteristics, disease presentation and postoperative mortality were evaluated.

RESULTS

the LC rate reached 41.5% (growth of 68%) with no decrease in the absolute number of OC. In University Hospitals (UH), the LC rate reached 91.96%. The open technique in emergencies was more associated with male patients, aged 60 years or older, with prolonged hospitalization and in the ICU. Those undergoing LC were less predisposed to postoperative death, both electively (OR 0.49; 95% CI 0.42 - 0.56; NNT=20) and urgently (OR 0.23; 95% CI 0.20 - 0.25; NNT ≅1), providing a protective effect.

CONCLUSION

despite the increase in the indication of LC, the open technique during the years studied remained stable and the most used in the public health system in Brazil. The effectiveness of public health policies to shorten the complete implementation of videosurgery in SUS needs to be investigated in future epidemiological studies, as well as its impact on postoperative morbidity and mortality.

The impact of frailty on the postoperative outcomes of patients undergoing cholecystectomy: propensity score matched analysis of 2011-2017 US hospitals

BACKGROUND

Frailty is an aggregate variable that encompasses debilitating geriatric conditions, which potentially affects postoperative outcomes. In this study, we evaluate the relationship between clinical frailty and post-cholecystectomy outcomes using a national registry of hospitalized patients.

METHODS

2011-2017 National Inpatient Sample database was used to identify patients who underwent cholecystectomy. Patients were stratified using the Johns Hopkins ACG frailty definition into binary (frailty and no-frailty) and tripartite frailty (frailty, prefrailty, no-frailty) indicators. The controls were matched to study cohort using 1:1 propensity score-matching and postoperative outcomes were compared.

RESULTS

Post-match, using the binary term, frail patients (n = 40,067) had higher rates of mortality (OR 2.07 95%CI 1.90-2.25), length of stay, costs, and complications. In multivariate, frailty was associated with higher mortality (aOR 2.06 95%CI 1.89-2.24). When using tripartite frailty term, prefrail (n = 35,595) and frail (n = 4472) patients had higher mortality (prefrailty: OR 2.04 95%CI 1.86-2.23; frailty: OR 2.49 95%CI 1.99-3.13), length of stay, costs, and complications. In multivariate, prefrailty and frailty were associated with higher mortality (prefrailty: aOR 2.02 95%CI 1.84-2.21; frailty: aOR 2.54 95%CI 2.02-3.19).

CONCLUSION

This study shows the presence of frailty (and prefrailty) is an independent risk factor of adverse postoperative outcomes in patients undergoing cholecystectomy.

Colecistectomias em coorte no sistema público brasileiro: o acesso à laparoscopia é universal após três décadas?

RESUMO Introdução: a videocirurgia no Brasil iniciou em 1990 com a realização da colecistectomia laparoscópica, sendo incluída pelo sistema público de saúde em 2008. Avaliamos a situação atual do emprego desta tecnologia no Sistema Único de Saúde (SUS). Métodos: de 2013 a 2019, 1.406.654 pacientes registrados no Departamento de Informática do SUS (DATASUS) foram analisados para calcular a taxa de colecistectomias laparoscópicas (CL) em relação a colecistectomias abertas (CA). Avaliaram-se características dos pacientes, apresentação da doença e mortalidade pós-operatória. Resultados: a taxa de CL atingiu 41,5%, com crescimento de 68%, sem ocorrer diminuição do número absoluto de CA. Já em Hospitais Universitários (HUs) a taxa de CL chegou a 91,96%. A técnica aberta em urgências esteve mais associada a pacientes masculinos, com 60 anos ou mais, à internação prolongada e em UTI. Aqueles submetidos à CL estiveram menos predispostos à morte pós-operatória, tanto em caráter eletivo (OR 0,49; IC 95% 0,42 - 0,56; NNT = 20) como na urgência (OR 0,23; IC 95% 0,20 - 0,25; NNT ≅ 1), conferindo efeito protetor. Conclusão: apesar do aumento da indicação da CL, a cirurgia aberta durante os anos estudados se manteve estável e a técnica mais utilizada no sistema público de saúde do Brasil. A efetividade de políticas de saúde pública para abreviar a completa implementação da videocirurgia no SUS necessita ser investigada em estudos epidemiológicos futuros, assim como seu impacto na morbimortalidade pós-operatória.

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.

APACHE IV Score is Useful For Assessment and Stratification of Elderly Patients Over 65 Years With Acute Cholecystitis

PURPOSE

One of the main problems concerning the design of clinical trials in critically ill patients with acute cholecystitis (AC) is the lack of validated, well-established scoring systems to stratify the severity of patient disease states. The aim of this study was to evaluate the performance of the Acute Physiology and Chronic Health Evaluation IV (APACHE IV) scoring system in patients over 65 years with AC.

METHODS

All patients over 65 years of age admitted to our hospital for treatment of AC in the intensive care unit between January 2013 and January 2019 were retrospectively analyzed.

RESULTS

A total of 443 consecutive patients with AC were enrolled in this study. As for the patients over 65 years, the survivors had lower APACHE IV scores and lower risk of death than nonsurvivors (P<0.01). The discrimination of the APACHE IV score prediction was good, with an area under the curve of 0.850 (95% confidence interval, 0.780-0.932). The APACHE IV models were well-calibrated with the Hosmer-Lemeshow goodness-of-fit test (P=0.635). Similar results were obtained for patients over 85 years of age.

CONCLUSION

The APACHE IV model was good at predicting hospital mortality in elderly patients with AC, which would be helpful to make clinical and therapeutic decisions in the future.

Conservative Management of Gallstone Disease in the Elderly Population: Outcomes and Recurrence

BACKGROUND & AIMS

The prevalence of gallstone disease increases with age, being early cholecystectomy the most accepted treatment in the vast majority of patients in order to prevent complications and recurrence. The aim of this study is to determine the recurrence rate and its possible predictors after initial non-operative management.

MATERIALS AND METHODS

We reviewed a consecutive series of patients, older than 65 years, admitted for a gallstone-related disease and treated with a non-operative management between January 2010 and December 2013. We analyzed comorbidities, clinical data, diagnosis, management, recurrence, and its treatment. Median follow-up after the discharge was 2 years. Recurrence was analyzed by a Kaplan-Meier survival curve. Possible recurrence's predictors were analyzed.

RESULTS

The study included 226 patients. Mean age was 80.4 ± 7.2 years, 127 (56%) were female. The main causes of index hospitalization were acute cholecystitis (58%) and biliary pancreatitis (18.1%). After 2 years of follow-up, the recurrence rate was 39.8%; mean time to recurrence was 255.2 ± 42.1 days, 81% of patients recurred within 1 year. Bile duct disease implied a higher recurrence rate than the gallbladder disease group (52% vs 33%, p < 0.001). Subjects with two or more diagnoses during index admission presented higher recurrence rate (32% vs 49%, p < 0.001).

CONCLUSION

More than a third of elderly patients could present a recurrence within 2 years after initial non-operative management. Early cholecystectomy should be considered at index admission in order to prevent recurrence.

Risk factors for elective laparoscopic cholecystectomy morbimortality in elderly

OBJECTIVE

to identify risk factors for the occurrence of postoperative complications in laparoscopic cholecystectomies (LC) in elderly patients.

METHODS

an observational study with analysis of medical records of patients aged 60 years and older, submitted to elective LC at Gaffree e Guinle Universitary Hospital, from 2006 to 2018. Surgeries performed on an emergency basis or converted to the conventional technique were excluded from our study.

RESULTS

a total of 345 patients were included in our study, being 80% females and 62% aged 60-69 years. There were 39 cases of postoperative complications (11.3%), mostly (87%) classified as grades I or II of Clavien-Dindo surgical complication scale. There was only one death. The presence and the number of coexisting diseases and ASA II or III physical status classification of preoperative patients conferred a greater risk for the development of postoperative complications and mortality.

CONCLUSION

our study identified the presence of coexisting diseases, as well as their severity, according to ASA classification, as risk factors for the development of postoperative complications of LC in elderly patients. However, LC proved to be a safe technique when used in these patients with low morbidity and mortality rates.

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.

Determinants of variability in management of acute calculous cholecystitis

BACKGROUND

While evidence supports early compared to delayed cholecystectomy as optimal management of acute calculous cholecystitis (ACC), significant variability in practice remains. The purpose of this study was to identify variables associated with early cholecystectomy, to target opportunities to improve adherence to best practices.

METHODS

Adult patients admitted to surgical units with ACC at two hospitals in a university hospital network between June 2010 and January 2015 were reviewed. Patients with concurrent pancreatitis, cholangitis or severe ACC (with organ system failure) were excluded. Early cholecystectomy was defined as surgery performed during same admission and within 7 days of presentation. Non-operative management was defined as admission for ACC treated conservatively, with or without eventual delayed cholecystectomy. The primary outcome was early cholecystectomy versus initial non-operative management; secondary outcomes included time to cholecystectomy, complications, and total hospital length of stay (LOS).

RESULTS

A total of 374 patients were included. Two hundred and forty six patients (66%) underwent early cholecystectomy, 60 (16%) were treated non-operatively and had delayed cholecystectomy, and 68 (18%) were only treated non-operatively. Median time to OR from initial presentation was 38 h [22-63] for early cholecystectomy patients and 69 days [29-116] for the non-operative patients who had delayed cholecystectomy. When comparing both groups, early cholecystectomy patients were younger and were treated more often at site 1. There were no differences in complications during hospitalization, but early cholecystectomy patients had a lower median total LOS (3 [2-5] vs. 5 [4-9], p < 0.001), and they had fewer gallstone-related events after discharge (1 vs. 18%, p < 0.001). On multiple logistic regression analysis, lower age, hospital site and lower risk of concurrent choledocholithiasis were all significantly associated with early cholecystectomy (p < 0.05).

CONCLUSION

Our data supports early cholecystectomy as best practice in management of ACC with no differences in complications during hospitalization, shorter median LOS and fewer gallstone-related events compared to non-operative management. We identified patient and institutional factors associated with early cholecystectomy. This suggests that multiple strategies will be necessary to promote adherence to best practices in the management of ACC within our institution.

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.

2016 WSES guidelines on acute calculous cholecystitis

Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of “high risk” patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.

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.

Emergency laparoscopy: Role and implementation

Laparoscopic surgery has emerged over the past two decades as the surgical approach of choice in the treatment of many digestive disorders. Laparoscopy has its place in the management of abdominal surgical emergencies since it provides the same benefits: less postoperative pain and shorter length of hospital stay when compared to laparotomy. However, its role in the management of abdominal emergencies has not yet been fully clarified. In this review, we focus on what has been validated concerning the role of emergency laparoscopy in the management of abdominal diseases.

Laparoscopic cholecystectomy: consensus conference-based guidelines

INTRODUCTION

Laparoscopic cholecystectomy (LC) is the gold standard technique for gallbladder diseases in both acute and elective surgery. Nevertheless, reports from national surveys still seem to represent some doubts regarding its diffusion. There is neither a wide consensus on its indications nor on its possible related morbidity. On the other hand, more than 25 years have passed since the introduction of LC, and we have all witnessed the exponential growth of knowledge, skill and technology that has followed it. In 1995, the EAES published its consensus statement on laparoscopic cholecystectomy in which seven main questions were answered, according to the available evidence. During the following 20 years, there have been several additional guidelines on LC, mainly focused on some particular aspect, such as emergency or concomitant biliary tract surgery.

METHODS

In 2012, several Italian surgical societies decided to revisit the clinical recommendations for the role of laparoscopy in the treatment of gallbladder diseases in adults, to update and supplement the existing guidelines with recommendations that reflect what is known and what constitutes good practice concerning LC.

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.

Acute cholecystitis: WSES position statement

Background

The management of acute calculous cholecystitis still offers room for debate in terms of diagnosis, severity scores, treatment options and timing for surgery.

Material and methods

A systematic review about the treatment of acute cholecystitis has been completed. The recommendations of recent guidelines have also been examined taking into account the results of the review.

Results

The evidence available in the literature supports the recommendation about laparoscopic cholecystectomy as treatment of choice for acute cholecystitis. Surgery should be performed as soon as possible after the diagnosis because early treatment reduces total hospital stay and does not increase complication or conversion rates. The antibiotics can play different roles and attention should be posed to the risk of emerging resistance. A surgical or percutaneous drainage of the gallbladder is advocated by some authors in the advanced forms of inflammation or patients with severe co-morbidities; however, the available evidence does not support it, and further studies are necessary to clarify its role.