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

Prevalence and predictors of postcholecystectomy syndrome in Nepalese patients after 1 week of laparoscopic cholecystectomy: a cross-sectional study

Postcholecystectomy syndrome (PCS) is persistent distressing symptoms which develops following a laparoscopic cholecystectomy (LC); in cases when the condition is severe, readmission may be necessary. However, research on the prevalence of PCS and potential factors associated with PCS in Nepalese patients is still limited. An observational point-prevalence, correlational predictive cross-sectional study was conducted to determine the prevalence of PCS and examine what predicting factors including preoperative anxiety, preoperative dyspepsia, smoking, alcohol consumption, and duration of preoperative symptoms are associated with PCS. A total of 127 eligible Nepalese patients who came for follow-up after 1 week of LC at outpatient department of surgery in one single university hospital, Kathmandu, Nepal, were recruited. A set of questionnaires consisting participants' information record form, Hospital Anxiety and Depression Scale (HADS), Leeds Dyspepsia Questionnaires (LDQ), Fagerstrom Test for Nicotine Dependence (FTND), and Alcohol Use Disorder Identification Test (AUDIT) was administered for data collection. The associations between influential factors and PCS were analyzed using Binary logistic regression. 43.3% of participants reported PCS after 1 week of surgery. The findings from logistic regression analysis affirmed that the patients with preoperative anxiety (OR = 6.38, 95%CI = 2.07-19.67, p < 0.01) and moderate to severe dyspepsia (OR = 4.01, 95%CI = 1.34-12.02, p < 0.05) held the likelihood to report PCS 6.38 and 4.01 times, respectively, greater than others. The implications from study results are that screening of anxiety and patients' tailored interventions to reduce anxiety should be implemented preoperatively. An appropriate health education about persistence of PCS and self-management should be provided to those postoperative patients.

Pulmonary function and complication prevention: A randomized controlled trial on lung expansion modalities of older adults undergoing upper abdominal surgery

Postoperative pulmonary complications (PPCs) are a major catastrophic consequence of upper abdominal surgery, resulting in morbidity and mortality. Therefore, the study aims to assess the effect of lung expansion modalities (LEMs) on older adults' pulmonary function and the incidence of pulmonary complications. The study randomly allocated 80 older adults (40 cases and 40 controls). Pulmonary function testing revealed a significant improvement in the study group's forced expiratory volume in one second, sixth second, and oxygen saturation on the fifth postoperative day (POD) compared to the first day [55.23%, 38.41%, and 2.87%; P0.001]. The reported PPCs incidence of the intervention group was less than the control group (15% and 30% on the third POD; 15% and 37.5% on the fifth POD). In conclusion, LEMs provide practical enhancement for the postoperative care of older adults by reducing PPCs by restoring measured pulmonary volumes.

Önemli komorbid durumları olan yaşlı hastalarda epidural anestezi altında kolesistektomi

Purpose: The aim of this study was to evaluate the surgical treatment of gallstone disease with open cholecystectomy under epidural anesthesia in elderly patients with significant comorbid conditions. Materials and Methods: We retrospectively analyzed 80 consecutive elderly patients over 65 years of age with significant comorbid conditions who underwent open cholecytectomy under epidural anesthesia for the surgical treatment of gallstone disease between January 1, 2009 and December 31, 2019, all performed by one surgeon. Results: Mean age was found 77 ± 16 years. Fifty of the patients (62.5%) were females. Forty-seven patients (58.75%) showed an American Society of Anesthesiologist Physical Status (ASA, PS) of 3. The most frequently associated comorbidity involved the cardiovascular system (46 patients, 57.5%). Surgical indications were acute cholecystitis (AC) in 37 patients (46.25%) and chronic cholecystitis in 32 patients (40%). Mean operation time was 55 ± 22 minutes. Hospital stay was mean 12 ± 5 days. Total complication rate was 38.75%, and pulmonary complication was the most frequently encountered (13.75%). 30-day mortality was seen in 5 patients (6.25%). Conclusion: In older, high-risk gallstone patients, an open cholecystectomy with epidural anesthesia may be recommended. For this patient population, the mortality and morbidity rates are acceptable.

Prediction of difficult laparoscopic cholecystectomy: An observational study

Background

Laparoscopic cholecystectomy (LC) is a gold standard treatment of symptomatic gallstone disease. Meanwhile, it is also a challenging procedure demanding excellent expertise for the best outcomes. Many times, difficult laparoscopic cholecystectomy is a nerve-wracking situation for surgeons. It endangers patients by causing potential injury to vital structures. Thus, we aimed to identify predictors for difficult LC.

Methods

A retrospective cross-sectional review of surgical records was done. Patients who underwent laparoscopic cholecystectomy on an elective basis from July 2017 to June 2021 were included in the study. We divided our patients into two groups based on operative findings of difficult LC; difficult LC group and non-difficult LC group. We compared patient's demographics, predictors, and perioperative details and analyzed the data.

Results

A total of 338 patients (82 males) with a median age of 47 years were studied. Total difficult LC was found in 52 patients (15.4%). The overall conversion rate was 8.9%. Logistic multivariable regression analysis revealed that; male gender (odds ratio (OR); 0.171, confidence interval (CI),(0.043-0.675), P; 0.012), past history of acute cholecystitis (OR; 0.038, CI; (0.005-0.309), P; 0.002), gall bladder wall thickness (≥4-5 mm) (OR; 0.074, CI; (0.008-0.666), P; 0.020), fibrotic gallbladder (OR; 166.6, CI; (7.946-3492), P; 0.001), and adhesion at Calot's triangle (OR; 0.021, CI (0.001-0.311), P; 0.005) were independent predictors of difficult LC.

Conclusions

Gender (male), past history of acute cholecystitis, gallbladder wall thickness (≥4-5 mm), fibrotic gallbladder, and adhesion at Calot's triangle are significant predictors for difficult LC. Moreover, an awareness about reliable predictors for difficult LC would be helpful for an appropriate treatment plan and application of the resources to anticipate difficult LC.

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.

Laparoscopic common bile duct exploration in patients with previous abdominal biliary tract operations

Background

A history of abdominal biliary tract surgery has been identified as a relative contraindication for laparoscopic common bile duct exploration (LCBDE), and there are very few reports about laparoscopic procedures in patients with a history of abdominal biliary tract surgery.

Methods

We retrospectively reviewed the clinical outcomes of 227 consecutive patients with previous abdominal biliary tract operations at our institution between December 2013 and June 2019. A total of 110 consecutive patients underwent LCBDE, and 117 consecutive patients underwent open common bile duct exploration (OCBDE). Patient demographics and perioperative variables were compared between the two groups.

Results

The LCBDE group performed significantly better than the OCBDE group with respect to estimated blood loss [30 (5–700) vs. 50 (10–1800) ml; p = 0.041], remnant common bile duct (CBD) stones (17 vs. 28%; p = 0.050), postoperative hospital stay [7 (3–78) vs. 8.5 (4.5–74) days; p = 0.041], and time to oral intake [2.5 (1–7) vs. 3 (2–24) days; p = 0.015]. There were no significant differences in the operation time [170 (60–480) vs. 180 (41–330) minutes; p = 0.067]. A total of 19 patients (17%) in the LCBDE group were converted to open surgery. According to Clavien’s classification of complications, the LCBDE group had significantly fewer postoperative complications than the OCBDE group (40 vs. 57; p = 0.045). There was no mortality in either group. Multiple previous operations (≥ 2 times), a history of open surgery, and previous biliary tract surgery (including bile duct or gallbladder + bile duct other than cholecystectomy alone) were risk factors for postoperative adhesion (p = 0.000, p = 0.000, and p = 0.000, respectively).

Conclusion

LCBDE is ultimately the least invasive, safest, and the most effective treatment option for patients with previous abdominal biliary tract operations and is especially suitable for those with a history of cholecystectomy, few previous operations (< 2 times), or a history of laparoscopic surgery.

Comparative Analysis of Laparoscopic Cholecystectomy Performed in the Elderly and Younger Patients: Should We Abstain from Laparoscopic Cholecystectomy in the Elderly?

BACKGROUND

The elderly population is gradually increasing due to an increase in the quality of life and therefore the frequency of gallbladder stones in the population is also increasing. However, a considerable number of physicians tend to postpone or solve the problem with medical treatment instead of performing surgery in the elderly patients. In this study, we aim to compare the outcomes of laparoscopic cholecystectomy (LC) in the elderly and younger patients.

MATERIAL AND METHODS

The medical records of 665 patients undergoing LC were evaluated retrospectively. The patients were divided into two groups: ≥60 years of age and <60 years of age. Ages, genders, comorbid diseases, indications of surgery, American Society of Anesthesiologists scores, whether it is converted to an open cholecystectomy or not, reasons for conversion if it is converted, total duration of surgery, initiation of oral nutrition, duration of discharge, and postoperative complications of the patients in both groups were recorded.

RESULTS

The American Society of Anesthesiologists scores were statistically significantly higher in ≥60 years age group (p<0.001). The rate of experiencing acute cholecystitis with a stone in the gallbladder was significantly higher in the 60 years group (p=0.025). Comorbidity was statistically significantly higher in the ≥60 years age group (p<0.001). Hospitalization period, the mean hour of initiation of oral nutrition were statistically significantly higher in the ≥60 years age group (p<0.001, p=0.001). Conversion to an open cholecystectomy and postoperative complication rates of the ≥60 years age group were statistically significantly higher (p=0.034, p<0.001).

CONCLUSION

We think that LC can be safely performed in the elderly people as well. However, it should be kept in mind that comorbidity may make the surgery and postoperative follow-up period complicated.