Outcomes of laparoscopic cholecystectomy in octogenarians

Surgical Approach and Length of Stay in Octogenarians Undergoing Pancreatic Resection for Malignancy

INTRODUCTION

Pancreatic surgery often has a lengthy recovery in the elderly. Minimally invasive surgery (MIS) can decrease length of stay (LOS), but it is unknown if this benefit applies to octogenarians (Age > 79).

METHODS

The NSQIP database was used to determine if MIS approaches were associated with reduced LOS among octogenarians undergoing pancreaticoduodenectomy (Whipple) or distal pancreatectomy (Distal). Operative approaches were classified as "Open" or "MIS" and propensity score (PS) matching was performed.

RESULTS

For the Whipple, 1665 Open and 101 MIS procedures occurred (median LOS 9, 8 days, p = 0.584). For Distal, 472 Open and 223 MIS procedures occurred (median LOS 6, 5 days, p < 0.01). After PS matching, there were 202 Whipple (101 per group) and 446 Distal (223 per group) patients. There was no difference in LOS by approach in the Whipple group (p = 0.546). The median LOS was 9 (IQR 7-15), Open and 8 (IQR 6-13), MIS. For Distal, there was a difference in LOS in the Open versus MIS approach (p < 0.01) and the median LOS was 6 (IQR 5-8) and 5 (IQR 4-6).

CONCLUSIONS

Among octogenarians the MIS approach was associated with decreased LOS in distal pancreatectomies, but not in pancreaticoduodenectomies.

Safety and Effectiveness of Large-Bore Percutaneous Cholangioscopy-Assisted Gallstone Retrieval for Inoperable Calculous Cholecystitis: A Multi-Institutional Retrospective Study

PURPOSE

To evaluate the safety and effectiveness of large-bore percutaneous biliary access techniques for cholangioscopy-assisted gallstone extraction in patients with a history of acute calculous cholecystitis who are poor surgical candidates.

MATERIALS AND METHODS

A retrospective analysis was conducted on patients who underwent percutaneous cholangioscopy for gallstone extraction using large-bore access (24 or 30 F) at 2 large academic centers from September 2020 and August 2022. Technical success, procedure duration, fluoroscopy time, immediate postprocedural symptom reduction, 3-month symptom-free outcomes, and adverse events (AEs) were assessed.

RESULTS

Thirty consecutive patients were included. Gallstone removal in a single cholangioscopy session was successful in 93.3% of cases. Large-bore access facilitated the removal of gallstones ranging from 0.5 to 4 cm in diameter, with mean procedure and fluoroscopy times of 105.4 minutes and 21.7 minutes, respectively. All patients who presented for 3-month follow-up remained symptom-free without gallstone recurrence on imaging. The overall AE rate was 6.7%, one Grade 2 and one Grade 3 based on the Society of Interventional Radiology (SIR) AE grading system, both managed successfully, leading to patient discharge home.

CONCLUSIONS

Large-bore percutaneous biliary access for cholangioscopy-assisted gallstone extraction is a safe and effective technique for managing symptomatic cholelithiasis in poor surgical candidates.

Can neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, prognostic nutrition index, and albumin be used to predict cholecystectomy morbidity in super-elderly patients?

BACKGROUND

This study aimed to evaluate the usability of neutrophil-lymphocyte ratio (NLR), platelet lymphocyte ratio (PLR), prognostic nutritional index (PNI), and serum albumin level in predicting cholecystectomy morbidity in elderly patients (85 years and older) who underwent cholecystectomy for acute cholecystitis.

METHODS

This retrospective study included super-elderly patients who underwent cholecystectomy due to acute cholecystitis at a tertiary health centre between January 2010 and January 2021. The patients were divided into two groups according to the presence of postoperative complications (morbidity). The differences between the two groups were evaluated. In addition, the role of NLR, PLR, PNI, and serum albumin level in predicting cholecystectomy morbidity for acute cholecystitis in super-elderly patients was assessed via ROC analysis.

RESULTS

Of 30 patients who met the study criteria, 22 (73.3%) were female, and the mean age of all patients was 87.43±2.66 years (range 85-94 years). 7 (23.3%) patients had at least one comorbid disease during the preoperative period. The mean value of NLR, PLR, albumin, and PNI were 8.31, 153.76, 3.45, and 48.37, respectively. The morbidity rate of the study was 23.3%. The area under the curve (AUC) for NLR was 0.466 ([95% confidence interval [CI]: 0.259-0.672]; P=0.787), and the AUC for PLR was 0.429 ([95% CI: 0.201-0.656]; P=0.573). These two factors were not suitable for predicting morbidity. The AUC for PNI was 0.780 ([95% CI: 0.568-0.991]; P=0.027), and the AUC for albumin was 0.894 ([95% CI: 0.770-1.000]; P=0.002). At the cut-off value of 3.05 g/dL, the sensitivity and specificity of albumin were 91.3% and 71.4%, respectively, while the sensitivity and specificity of PNI at the 41.70 cut-off value were 82.6% and 71.4%, respectively.

CONCLUSION

This study found that PNI and albumin can be used as predictive factors with high sensitivity and specificity for predicting cholecystectomy morbidity for acute cholecystitis in super-elderly patients. However, NLR and PLR had no significance in predicting cholecystectomy morbidity.

Similarities and Differences Between Gerontal and Young Patients with Acute Pancreatitis: Evaluation of Clinical Characteristics and Outcomes

Background:

Acute pancreatitis is an abrupt inflammatory disease of the exocrine pancreas and it can occur in different severities. It is becoming more common and more mortal in the gerontal population. The aim of our study was to explore the similarities and differences between young and gerontal patients with acute pancreatitis, with a special emphasis on patients over 80 years of age.

Methods:

Medical records of patients (n = 1150) with acute pancreatitis were analyzed retrospectively. Several scoring systems including Bedside index for severity in acute pancreatitis, Ranson’s score, Harmless acute pancreatitis score, Acute Physiology and Chronic Health Evaluation, Balthazar Grade, Glasgow score, and Japanese severity score were applied at admission. Patients were divided into 3 groups; group I, young group (n = 706), if they were aged <65 years; group II, older group (n = 338), if they were aged ≥65 years to <80 years; group III, octogenarian group (n = 106), if they were aged ≥ 0 years.

Results:

In total, 1150 patients with acute pancreatitis were analyzed. Octogenarian group (n = 42, 39.6%) showed a more severe acute pancreatitis compared to patients in group I (n = 15, 2.1%) and II (n = 50, 14.8%, P < .001). Complications were more common in patients in group III (P < .001). Mortality rate was higher in patients in group III (n = 53, 50%) compared to group I (n = 8, 1.1%) and group II (n = 53, 15.7%) (P < .001).

Conclusion:

Gerontal patients with acute pancreatitis tend to have more severe disease and systemic and local complications. Mortality rates were higher in older patients compared to younger patients.

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.

Outcome after cholecystectomy in the elderly

BACKGROUND

Cholecystectomy is considered the standard treatment for acute cholecystitis and symptomatic gallstones. An increasing number of frail elderly patients are being referred for this surgical treatment. A better understanding of surgical outcome in the elderly is needed to improve quality of care.

METHODS

A retrospective analysis of 565 patients who underwent cholecystectomy was performed. Focus of the analyses was on postoperative complications and its predictors.

RESULTS

The study population was divided in two cohorts; aged <70. More complications were found in patients aged ≥70 years. More elderly patients were admitted to the intensive care, respectively 4.0% and 14.1% (P = 0.045). Hospital mortality was 6% in patients aged ≥70 years vs 0.6% in patients <70.

CONCLUSION

In elderly patients, the complication and mortality rate following cholecystectomy is higher than previously reported. For high-risk patients aged ≥70 with cholecystitis, alternative therapies should be considered as a bridge to surgery or definite treatment.

Early surgical management of acute cholecystitis in ultra-octogenarian patients: our 5-year experience

BACKGROUND

Acute calculous cholecystitis is a leading cause for hospital admission especially in developed countries. As older age population increases, medical research should consider the efficacy of all therapeutic options, including early surgical procedure in an emergency context, for the treatment of acute cholecystitis in elderly high-risk patients.

METHODS

From 01/01/2012 to 31/12/2016, 245 patients were admitted to our Institution with diagnosis of acute cholecystitis and managed with cholecystectomy within the same hospitalization. The study population was divided into 2 subgroups: group A (patients aged more than 80 years) and group B (patients within the limit of 80 years of age); the objective of the study was to evaluate and compare the surgical outcomes of the 2 groups in terms of conversion rate, mortality rate, overall morbidity and procedure-related complication rates.

RESULTS

Statistical analysis did not show significant differences between ultra octogenarian and younger patients in terms of conversion to open procedure, iatrogenic bile duct lesions, postoperative peritoneal bleeding, bile leakage and peritoneal collection; no differences in terms of hospital stay have been demonstrated. Mortality and overall morbidity rates, even if similar to what observed in Literature and within acceptable values, were significantly higher in elderly patients, due to the presence of severe comorbidities leading to potentially fatal postoperative events.

CONCLUSIONS

Minimally invasive approach in an emergency setting for acute cholecystitis seems to be a feasible and adequate therapeutic approach for extremely aged high-risk patients.

Interventional Radiology-Operated Cholecystoscopy for the Management of Symptomatic Cholelithiasis: Approach, Technical Success, Safety, and Clinical Outcomes

OBJECTIVE

The objective of our study was to report the technique, complications, and clinical outcomes of interventional radiology-operated cholecystoscopy with stone removal for the management of symptomatic cholelithiasis.

MATERIALS AND METHODS

Ten (77%) men and three (23%) women (mean age, 65 years) with symptomatic cholelithiasis underwent cholecystostomy followed by interventional radiology-operated cholecystoscopy with stone removal. Major comorbidities precluding cholecystectomy included prior cardiac, pulmonary, or abdominal surgery; cirrhosis; sepsis with hyponatremia; seizure disorder; developmental delay; and cholecystoduodenal fistula. Cholecystostomy access, time between cholecystostomy and cholecystoscopy, endoscopic and fragmentation devices used, technical success, procedure time, fluoroscopy time, complications, length of hospital stay, time between cholecystoscopy and cholecystostomy removal, follow-up, and acute cholecystitis recurrence were recorded.

RESULTS

Eleven (85%) patients underwent transhepatic cholecystostomy, and two (15%) patients underwent transperitoneal cholecystostomy. The mean time from cholecystostomy to cholecystoscopy was 151 days. Flexible endoscopy was used in eight (62%) patients, rigid endoscopy in three (23%), and both flexible and rigid in two (15%). Electrohydraulic lithotripsy was used in eight procedures, nitinol baskets in seven, ultrasonic lithotripsy in two, and percutaneous thrombectomy devices in one. Primary technical success was achieved in 11 (85%) patients, and secondary technical success was achieved in 13 (100%) patients. The mean procedure time was 164 minutes, and the mean number of procedures required to clear all gallstones was 1. One (8%) patient developed acute pancreatitis, and one (8%) patient died of gastrointestinal hemorrhage. The median hospital length of stay after cholecystoscopy was 1 day for postoperative monitoring. The mean time between cholecystoscopy and cholecystostomy removal was 39 days. One (8%) patient developed recurrent acute cholecystitis 1095 days after cholecystoscopy.

CONCLUSION

Interventional radiology-operated cholecystoscopy may serve as an effective method for percutaneous gallstone removal in patients with multiple comorbidities precluding cholecystectomy.

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.

Cholecystectomy in octogenarians: be careful

Cholecystectomy is the standard treatment for symptomatic gallstone or acute cholecystitis, and a growing number of elderly patients are undergoing resection. The aim of this study is to evaluate the clinical outcome of cholecystectomy in elderly patients. We retrospectively reviewed the medical records of 337 patients with symptomatic gallstone or acute cholecystitis who underwent cholecystectomies between January 2011 and June 2013. Perioperative data were compared between octogenarians and younger patients. A subgroup undergoing cholecystectomy for acute cholecystitis (n = 146, 43.3 %) was further analyzed. The octogenarian group included 34 patients (10.1 %), while the younger patient group included 303 patients (89.9 %). The octogenarian group was associated with higher rates of comorbidities and acute cholecystitis. The octogenarian group had significantly low laparoscopic completed rates, high postoperative complication rates, and longer postoperative hospital stays. Among the acute cholecystitis group, 24 patients (16.4 %) were octogenarians and 122 patients (83.6 %) were younger patients. No significant difference was found in the morbidity and postoperative hospital stay between the two groups. Only one patient (0.3 %), an octogenarian, died of pneumonia. Cholecystectomy for symptomatic gallstone or acute cholecystitis can be safely performed even in octogenarians. However, care should be taken because they have comorbidities and limited functional reserves.

Role and outcomes of laparoscopic cholecystectomy in the elderly

INTRODUCTION

Laparoscopic cholecystectomy is the standard of treatment for gallstones disease and acute colecystitis. The prevalence of this disease increases with age and the population is aging in industrialized countries. So, in this study we report our experience in the treatment of gallstone disease in elderly patients, particularly analyzing the outcomes of laparoscopic approach.

METHODS

Between January 2010 and May 2014 we performed a total of 1227 cholecystectomies. In this retrospective study age group was the primary independent variable: 351 patients were 65-79 years of age and 65 were 80 years of age or older.

RESULTS

Only 65 patients (5.3%) of all population had primary open cholecystectomy, but the rate in young group was 3.7% respect the highest frequency (9.2%) in the elderly group. The conversion rate was higher (1.2%) in the older group but there was no significant difference with younger group. LC in emergency setting was performed in 10.3% of young patients and in 13.8% of elderly group.

CONCLUSION

Laparoscopic cholecystectomy is a feasible and safe procedure in elderly patients and might be performed during the same hospitalization like definitive treatment of gallstone disease. The old age and subsequent comorbidity are the fundamental predictor of surgical outcomes. Elective treatment should be recommended when repeated gallstone symptoms have occurred in the elderly patient before the development of acute cholecystitis and related complications.

Ultrasound-guided double-tract percutaneous cholecystostomy combined with a choledochoscope for performing cholecystolithotomies in high-risk surgical patients

BACKGROUND

Cholecystolithiasis is the most common disease treated by general surgery, with an incidence of about 0.15-0.22%. The most common therapies are open cholecystectomy (OC) or laparoscopic cholecystectomy (LC). However, with a greater understanding of the function of the cholecyst, more and more patients and surgeons are aware that preserving the functional cholecyst is important for young patients, as well as patients who would not tolerate anesthesia associated with either OC or LC. Based on these considerations, we have introduced a notable, minimally invasive treatment for cholecystolithotomy.

METHODS

We performed a retrospective review of patients with cholecystolithiasis who were unable to tolerate surgery or who insisted on preserving the functional cholecyst. Our particular approach can be simply described as ultrasound-guided percutaneous cholecystostomy combined with a choledochoscope for performing a cholecystolithotomy under local anesthesia.

RESULTS

Ten patients with cholecystolithiasis were treated via this approach. All except one patient had their gallbladder stones totally removed under local anesthesia, without the aggressive procedures associated with OC or LC. The maximum number of gallbladder stones removed was 16, and the maximum diameter was 13 mm without lithotripsy. After the minimally invasive surgery, the cholecyst contractile functions of all patients were normal, confirmed via ultrasound after a high-fat diet. Complications such as bile duct injury, biliary fistula, and bleeding occurred significantly less often than with OC and LC. The recurrence rates for each of 2 post-operative years were about 11.11% (1/9, excluding a failure case) with uncertainty surrounding recurrence or residue, and 22.22% (2/9, including one non-recurrence patient with follow-up time of 22 months), respectively.

CONCLUSIONS

Ultrasound-guided percutaneous cholecystostomy combined with choledochoscope is a safe, efficient, and minimally invasive cholecystolithotomy method. We recommend this technique for the management of small stones (less than 15 mm) in high-risk surgical patients.

Gallstone pancreatitis: a review

Gallstone disease is the most common cause of acute pancreatitis in the Western world. In most cases, gallstone pancreatitis is a mild and self-limiting disease, and patients may proceed without complications to cholecystectomy to prevent future recurrence. Severe disease occurs in about 20% of cases and is associated with significant mortality; meticulous management is critical. A thorough understanding of the disease process, diagnosis, severity stratification, and principles of management is essential to the appropriate care of patients presenting with this disease. This article reviews these topics with a focus on surgical management, including appropriate timing and choice of interventions.

Management of acute cholecystitis: prevalence of percutaneous cholecystostomy and delayed cholecystectomy in the elderly

BACKGROUND

Published guidelines recommend early cholecystectomy for acute cholecystitis in the elderly. Alternatively, percutaneous cholecystostomy can be used in compromised patients.

METHODS

We reviewed 806 elderly patients diagnosed with biliary disease retrospectively identified through billing and diagnosis codes. Two hundred sixty-five patients with histologically documented acute cholecystitis were selected.

RESULTS

Initially, 75 patients had percutaneous cholecystostomy (Group 1), 64 (24 % underwent interval cholecystectomy, 74 (28 %) early (Group 2), and 127 (48 %) delayed cholecystectomy (Group 3). Group 1 was more likely to have American Society of Anesthesiologists (ASA) scores of 4 when compared to those in Groups 2 and 3 (p = 0.04). No difference existed among the groups when patients with an ASA of 4 were excluded: conversion rates (11 %), biliary leak, bowel injury, need for reoperation, or 30 days mortality. Patients in Group 1 and in Group 3 were five times (p = 0.04) and four times (p = 0.06) more likely, respectively, than those in Group 2 to have recurrent episodes of pancreatitis, cholecystitis, and cholangitis.

CONCLUSION

Patients were more likely to have delayed cholecystectomy after initial antibiotic therapy or cholecystostomy without the benefit of a lower conversion rate when compared to the early group, but they had higher recurrent episodes of cholecystitis/pancreatitis or cholangitis.

Cholecystectomy in octogenarians: recent 5 years' experience

BACKGROUNDS/AIMS

Aging of population is leading to more operative treatments on elderly patients in various aspects. Growing numbers of patients are going through operations about cholecystitis in the same sense. We tried to survey them anew about remarkably increasing octogenarian patients and the outcome after operative management for cholecystitis seeking to improve treatment result.

METHODS

For 5 years, from March 2007 to Febraury 2012, 57 octogenarian patients had cholecystectomy among total 380 cases. Patients were compared between total patients and octogenarians on perioperative follow-up findings in medical records.

RESULTS

Underlying diseases were prevailing in octogenarian by more than 70% of cases. Severe acute cholecystitis was more often observed in octogenarians and procedures like endoscopic retrograde cholangiopancreaticography were more often performed preoperatively, showing more frequent conversion to open method from laparoscopic procedure. Complications such as peritonitis, sepsis, wound problem, including mortality were much more common in octogenarian cholecystectomy patients. When compared to total cholecystectomy patient group, octogenarian patients had more problems in every items significantly (p<0.05).

CONCLUSIONS

High rates of complications and mortality accompanying prolonged symptoms and examinations was inevitable for octogenarian patients after cholecystectomy. Operative treatment per se appears to be inevitable, thus it should make the patients be informed about risks with more attention to every aspect of care.