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

The Effect of Increased Intra-Abdominal Pressure on Hemodynamics in Laparoscopic Cholecystectomy-The Experience of a Single Centre

Laparoscopic cholecystectomy is characterized by reduced postoperative pain, shorter hospital stays, rapid return to preoperative physical activity, and less psychological impact on the patient. During laparoscopic cholecystectomy, the intra-abdominal insufflation of carbon dioxide with secondary increase in intra-abdominal pressure can cause important hemodynamic consequences, like decreased cardiac output and blood pressure, as well as compensatory increase in heart rate. The purpose of this study is to evaluate changes in cardiovascular parameters during general anesthesia in patients undergoing laparoscopic cholecystectomy. Retrospective data from 342 patients with cholecystectomy for cholelithiasis performed at Railway Hospital Galati, Romania, were reviewed. All patients received the same intraoperative anesthetics. Female patients were 85.7% (n = 293). More than half of the patients, 53.51% (n = 183), were 40-59 years old, and only 16.37% (n = 56) were under 40 years old. Patients with a normal body mass index (BMI) represented 45.6% (n = 156), 33.3% (n = 114) were underweight, and 12% (n = 42) had grade 1 obesity (BMI 25-29.9 kg/m2). The minimum intraoperative blood pressure correlated with patient gender (p 0.015 < 0.005), with men having a higher blood pressure than women (p 0.006 < 0.05), and for BMI, a higher BMI was associated with elevated blood pressure (p 0.025 < 0.05). Older age correlated with an increased maximum intraoperative blood pressure (p < 0.001 < 0.05) and with maximum intraoperative heart rate (p 0.015 < 0.05). Patients undergoing laparoscopic cholecystectomy experienced significant hemodynamic changes with pneumoperitoneum, but this type of surgical intervention was safe for patients regardless of their age.

Interhospital variation in the nonoperative management of acute cholecystitis

BACKGROUND

Cholecystectomy remains the standard management for acute cholecystitis. Given that rates of nonoperative management have increased, we hypothesize the existence of significant hospital-level variability in operative rates. Thus, we characterized patients who were managed nonoperatively at normal and lower operative hospitals (>90th percentile).

METHODS

All adult admissions for acute cholecystitis were queried using the 2016-2019 Nationwide Readmissions Database. Centers were ranked by nonoperative rate using multi-level, mixed effects modeling. Hospitals in the top decile of nonoperative rate (>9.4%) were classified as Low Operative Hospitals (LOH; others:nLOH). Separate regression models were created to determine factors associated with nonoperative management at LOH and nLOH.

RESULTS

Of an estimated 418,545 patients, 9.9% were managed at 880 LOH. Multilevel modeling demonstrated that 20.6% of the variability was due to hospital factors alone. After adjustment, older age (Adjusted Odds Ratio [AOR] 1.02/year, 95% Confidence Interval [CI] 1.01-1.02) and public insurance (Medicare AOR 1.31, CI 1.21-1.43 and Medicaid AOR 1.43, CI 1.31-1.57; reference: Private Insurance) were associated with nonoperative management at LOH. These were similar at nLOH. At LOH, SNH status (AOR 1.17, CI 1.07-1.28) and small institution size (AOR 1.20, CI 1.09-1.34) were associated with increased odds of nonoperative management.

CONCLUSION

We noted a significant variability in the interhospital variation of the nonoperative management of acute cholecystitis. Nevertheless, comparable clinical and socioeconomic factors contribute to nonoperative management at both LOH and non-LOH. Directed strategies to address persistent non-clinical disparities are necessary to minimize deviation from standard protocol and ensure equitable care.

Percutaneous cholecystostomy in elderly patients with acute cholecystitis: a systematic review and meta-analysis

Percutaneous cholecystostomy (PC) is often preferred over early cholecystectomy (EC) for elderly patients presenting with acute cholecystitis (AC). However, there is a lack of solid data on this issue. Following the PRISMA guidelines, we searched the Medline and Web of Science databases for reports published before December 2022. Studies that assessed elderly patients (aged 65 years and older) with AC treated using PC, in comparison with those treated with EC, were included. Outcomes analyzed were perioperative outcomes and readmissions. The literature search yielded 3279 records, from which 7 papers (1208 patients) met the inclusion criteria. No clinical trials were identified. Patients undergoing PC comprised a higher percentage of cases with ASA III or IV status (OR 3.49, 95%CI 1.59-7.69, p = 0.009) and individuals with moderate to severe AC (OR 1.78, 95%CI 1.00-3.16, p = 0.05). No significant differences were observed in terms of mortality and morbidity. However, patients in the PC groups exhibited a higher rate of readmissions (OR 3.77, 95%CI 2.35-6.05, p < 0.001) and a greater incidence of persistent or recurrent gallstone disease (OR 12.60, 95%CI 3.09-51.38, p < 0.001). Elderly patients selected for PC, displayed greater frailty and more severe AC, but did not exhibit increased post-interventional morbidity and mortality compared to those undergoing EC. Despite their inferior life expectancy, they still presented a greater likelihood of persistent or recurrent disease compared to the control group.

Outcomes after laparoscopic cholecystectomy in patients older than 80 years: two-years follow-up

BACKGROUND

The laparoscopic cholecystectomy is the treatment of choice for patients with benign biliary disease. It is necessary to evaluate survival after laparoscopic cholecystectomy in patients over 80 years old to determine whether the long-term mortality rate is higher than the reported recurrence rate. If so, this age group could benefit from a more conservative approach, such as antibiotic treatment or cholecystostomy. Therefore, the aim of this study was to evaluate the factors associated with 2 years survival after laparoscopic cholecystectomy in patients over 80 years old.

METHODS

We conducted a retrospective observational cohort study. We included all patients over 80 years old who underwent laparoscopic cholecystectomy. Survival analysis was conducted using the Kaplan‒Meier method. Cox regression analysis was implemented to determine potential factors associated with mortality at 24 months.

RESULTS

A total of 144 patients were included in the study, of whom 37 (25.69%) died at the two-year follow-up. Survival curves were compared for different ASA groups, showing a higher proportion of survivors at two years among patients classified as ASA 1-2 at 87.50% compared to ASA 3-4 at 63.75% (p = 0.001). An ASA score of 3-4 was identified as a statistically significant factor associated with mortality, indicating a higher risk (HR: 2.71, CI95%:1.20-6.14).

CONCLUSIONS

ASA 3-4 patients may benefit from conservative management due to their higher risk of mortality at 2 years and a lower probability of disease recurrence.

Endoscopic gallbladder inside-stenting combined with aspirated lavage for calculous cholecystitis in poor surgical candidates: a prospective pilot study

Although long-term stent placement via endoscopic gallbladder stenting (EGBS) reportedly reduces cholecystitis recurrence in patients unfit to undergo cholecystectomy, it can increase the frequency of other late adverse events (AEs) such as cholangitis. This study aimed to examine the feasibility of endoscopic gallbladder inside-stenting (EGB-IS) with lavage and aspiration. This prospective, single-center, pilot study enrolled 83 patients with acute calculous cholecystitis who were poor candidates for surgery. A dedicated catheter with eight side holes was used for lavage and aspiration, and a dedicated single-pigtail stent equipped with a thread was used for EGB-IS. Outcomes such as technical success, clinical success, early AEs, recurrence of cholecystitis, and other symptomatic late AEs associated with EGB-IS with lavage and aspiration were evaluated. The technical and clinical success rates were 80.7% (67/83) and 98.5% (66/67), respectively. The rate of early AEs was 3.6% (3/83). The rate of recurrent cholecystitis was 4.5% (3/66) and that of symptomatic late AEs (besides cholecystitis) was 6.1% (4/66). Consequently, the rate of overall late AEs (cholecystitis plus other events) was 10.6% (7/66). The 1-, 2-, and 3-year cumulative incidence rates of all late AEs were 3.2%, 11.2%, and 18.9%, respectively. EGB-IS with lavage and aspiration for calculous cholecystitis showed promising results in poor surgical candidates. EGB-IS may be useful when EGBS with long-term stent placement is planned, since prevention of cholecystitis recurrence, without a rise in the incidence of other AEs, is anticipated.

Prophylactic cholecystectomy offers best outcomes following ERCP clearance of common bile duct stones: a meta-analysis

BACKGROUND

Symptomatic calculus biliary disease is common with associated morbidity and occasional mortality, further confounded when there is concomitant common bile duct (CBD) stones. Choledocholithiasis and clearance of the duct reduces recurrent cholangitis, but the question is whether after clearance of the CBD if there is a need to perform a cholecystectomy. This meta-analysis evaluated outcomes in patients undergoing ERCP with or without sphincterotomy to determine if cholecystectomy post-ERCP clearance offers optimal outcomes over a wait-and-see approach.

METHODS

A Prospero registered meta-analysis of the literature using PRISMA guidelines incorporating articles related to ERCP, choledocholithiasis, cholangitis and cholecystectomy was undertaken for papers published between 1st January 1991 and 31st May 2021. Existing research that demonstrates outcomes of ERCP with no cholecystectomy versus ERCP and cholecystectomy was reviewed to determine the related key events, complications and mortality of leaving the gallbladder in situ and removing it. Odds ratios (OR) were calculated using Review Manager Version 5.4 and meta-analyses performed using OR using fixed-effect (or random-effect) models, depending on the heterogeneity of studies.

RESULTS

13 studies (n = 2598), published between 2002 and 2019, were included in this meta-analysis, 6 retrospective, 2 propensity score-matched retrospective studies, 3 prospective studies and 2 randomised control trials from a total of 11 countries. There were 1433 in the no cholecystectomy cohort (55.2%) and 1165 in the prophylactic cholecystectomy (44.8%) cohort. Cholecystectomy resulted in a decreased risk of cholecystitis (OR = 0.15; CI 0.07-0.36; p < 0.0001), cholangitis (OR = 0.51; CI 0.26-1.00; p = 0.05) and mortality (OR = 0.38; CI 0.16-0.9; p = 0.03). In addition, prophylactic cholecystectomy resulted in a significant reduction in biliary events, biliary pain and pancreatitis.

CONCLUSIONS

In patients undergoing CBD clearance, consideration should be given to performing prophylactic cholecystectomy to optimise outcomes.

Laparoscopic cholecystectomy in super elderly (> 90 years of age): safety and outcomes

BACKGROUND

Nonagenarian patients are an age group in progressive growth. In this age group, indications for surgical procedures, including cholecystectomy, will be increasingly frequent, as biliary pathology and its complications are frequent in this population group. The main objective of this study was to analyze the safety and outcomes of laparoscopic cholecystectomy in patients older than 90 years.

METHODS

A retrospective observational cohort study was designed. This study involved 600 patients that were classified in 4 age groups for analysis (under 50 years, 50-69 years, 70-89 years, and over 90 years). Demographic, clinical, paraclinics, surgical, and outcome variables were compared according to age group. A multivariate analysis, which included variables considered clinically relevant, was performed to identify factors associated with mortality and complications classified with the Clavien-Dindo scale.

RESULTS

The patients evaluated had a median age of 65.0 (IQR 34.0) years and there was a female predominance (61.8%). A higher complication rate, conversion rate, subtotal cholecystectomy rate, and prolonged hospital stay were found in nonagenarians. The overall mortality rate was 1.6%. Mortality in the age group over 90 years was 6.8%. Regression models showed that age over 90 years (RR 4.6 CI95% 1.07-20.13), presence of cholecystitis (RR 8.2 CI95% 1.29-51.81), and time from admission to cholecystectomy (RR 1.2 CI95% 1.10-1.40) were the variables that presented statistically significant differences as risk factors for mortality.

CONCLUSION

Cholecystectomy in nonagenarian patients has a higher rate of complications, conversion rate, subtotal cholecystectomy rate, and mortality. Therefore, an adequate perioperative assessment is necessary to optimize comorbidities and improve outcomes. Also, it is important to know the greatest risk for informed consent and choose the surgical equipment and schedule of the procedure.

The influence of frailty on outcomes for older adults admitted to hospital with benign biliary disease: a single-centre, observational cohort study

INTRODUCTION

The prevalence and complications of biliary disease increase with age. Frailty has been associated with adverse outcomes in the hospital setting. We describe the prevalence of frailty in older patients hospitalised with benign biliary disease and its association with duration of hospital stay, and 90-day and 1-year mortality.

METHODS

We performed a retrospective cohort study of patients aged 75 years and over admitted with acute biliary disease between 17 September 2014 and 20 March 2017. Clinical Frailty Scale (CFS) score was recorded on admission.

RESULTS

We included 200 patients with a median age of 82 (75-99) years, 60% were female; 154 (77%) were independent for personal activities of daily living (ADLs) and 99 (49.5%) for instrumental ADLs. Cholecystitis was the most common diagnosis (43%) followed by cholangitis (36%) and pancreatitis (21%). Ninety-nine patients were non frail (NF; CFS 1-4) and 101 were frail (F; CFS 5-9). Some 104 patients received medical treatment only. Surgery was more common in NF patients (11% vs F 2%), percutaneous drainage more frequently performed in F patients (15% vs NF 5%) and endoscopic cholangiopancreatography was similar in both groups (F 32% vs NF 31%). Frailty was associated with worse clinical outcomes in F vs NF: functional deconditioning (34% vs 11%), increased care level (19% vs 3%), length of stay (12 vs 7 days), 90-day mortality (8% vs 3%) and 1-year mortality (48% vs 24%).

CONCLUSIONS

Half of patients in our cohort were frail and spent longer in hospital, were less likely to undergo surgery and were less likely to remain alive at 1 year after discharge.

Incidental gallbladder cancer: what is the prevalence and how do we perform cholecystectomy for presumably benign biliary disease?

OBJECTIVE

to determine the prevalence of incidental gallbladder cancer (IGBC) in cholecystectomies performed in a tertiary public hospital and to describe technical and epidemiological aspects of performing cholecystectomies for presumably benign disease.

METHOD

descriptive, retrospective observational study, based on analysis of medical records of patients undergoing cholecystectomy with preoperative hypothesis of benign disease between January 2018 and January 2022.

RESULTS

prevalence of gallbladder adenocarcinoma in our sample was 0.16%, similar to data in the literature. Technical aspects during cholecystectomy were also described with a frequency similar to that found in the literature.

CONCLUSION

despite a rare disease, IGBC is relevant in the routine of the General Surgeon. Its diagnosis, staging and treatment directly affect the prognosis. Technical aspects during cholecystectomy are not always remembered by surgeons and can interfere with the prognosis and subsequent treatment of the patient.

Câncer incidental de vesícula biliar: qual a prevalência e como operamos a colecistectomia por doença presumidamente benigna?

RESUMO Objetivos: determinar a prevalência de câncer incidental de vesícula biliar (CIVB) em colecistectomias realizadas em um hospital público terciário e descrever aspectos técnicos e epidemiológicos na realização de colecistectomias por doença presumidamente benigna. Método: estudo observacional descritivo, retrospectivo, a partir da análise de prontuários de pacientes submetidos à colecistectomia com hipótese pré-operatória de doença benigna entre janeiro de 2018 e janeiro de 2022. Resultados: a prevalência de adenocarcinoma de vesícula biliar na amostra avaliada foi de 0,16%, semelhante aos dados da literatura mundial. Os aspectos técnicos durante a realização da colecistectomia também foram descritos com frequência semelhante ao encontrado na literatura. Conclusão: o CIVB é uma doença rara mas de importância relevante na rotina do Cirurgião Geral. Seu diagnóstico, estadiamento e tratamento implicam diretamente no prognóstico. Aspectos técnicos durante a realização da colecistectomia nem sempre são lembrados pelos cirurgiões e podem interferir no prognóstico e tratamento subsequente do paciente.

Symptomatic Gallstones in Young Patients Under the Age of 30 Years

Introduction Gallstones are deposits of digestive fluid that is hardened into small pellets. Gallstones can be symptomatic or asymptomatic. The present study assessed the sociodemographic and clinical characteristics of patients under the age of 30 years old with symptomatic gallstones. Methodology A prospective, observational study was conducted at Surgical Unit-3, at Jinnah Postgraduate Medical Centre (JPMC), Pakistan, from July 2020 to July 2021. All patients suspected of having gallstone disease underwent ultrasonic examination. A diagnosis of gallstone disease was made if the gallbladder showed a hyperechoic mass casting a posterior acoustic shadow, with a change of position. All of the patients with gallstone disease were hospitalized. The patients were asked about their age, past history (with special emphasis on last pregnancy and years of oral contraceptive use, if any), socioeconomic status, and other demographic data. The patients were treated with a cholecystectomy, either laparoscopic or open. Postcholecystectomy complications, if any, were recorded. Results A total of 210 patients under the age of 30 years were included. The mean age of patients was 25 ± 3 years. The majority of the population were females, i.e., 170 (81%). Upon assessing the risk factors, it was found that 31.84% of the female patients had used oral contraceptives, 32.96% were pregnant at the time of presentation, 20.48% had diabetes mellitus, and 27.14% had a history of gallstones. Furthermore, it was found that about 114 (54.29%) patients were overweight with a body mass index (BMI) of 25-30 kg/m2. High triglyceride levels and high cholesterol levels were found in 108 (51.43%) and 115 (54.76%) of the patients, respectively, indicating a link between symptomatic gallstones and younger age. Conclusion Our study indicated that young people are prone to symptomatic gallstones. The rate of disease was considerably high among females and in patients with high cholesterol and triglyceride levels and abnormal body mass index. Further exploratory studies are needed to determine the cause of gallstones.

The Treatment of Gallstone Disease

BACKGROUND

Gallstone disease affects up to 20% of the European population, and cholelithiasis is the most common reason for hospitalization in gastroenterology.

METHODS

This review is based on pertinent publications retrieved by a selective search of the literature, including the German clinical practice guidelines on the diagnosis and treatment of gallstones and corresponding guidelines from abroad.

RESULTS

Regular physical activity and an appropriate diet are the most important measures for the prevention of gallstone disease. Transcutaneous ultrasonography is the paramount method of diagnosing gallstones. Endoscopic retrograde cholangiography should only be carried out as part of a planned therapeutic intervention; endosonography beforehand lessens the number of endoscopic retrograde cholangiographies that need to be performed. Cholecystectomy is indicated for patients with symptomatic gallstones or sludge. This should be performed laparoscopically with a four-trocar technique, if possible. Routine perioperative antibiotic prophylaxis is not necessary. Cholecystectomy can be performed in any trimester of pregnancy, if urgently indicated. Acute cholecystitis is an indication for early laparoscopic cholecystectomy within 24 hours of admission to hospital. After successful endoscopic clearance of the biliary pathway, patients who also have cholelithiasis should undergo laparoscopic cholecystectomy within 72 hours.

CONCLUSION

The timing of treatment for gallstone disease is an essential determinant of therapeutic success.