Biliary tract disorders are one of the most common reasons for surgery in older patients. Fifty percent of women and 16% of men in their 70s have been shown to have gallbladder disease.5
Laparoscopic cholecystectomy has been shown to provide a shorter hospital stay, less postoperative physiologic dysfunction, and an earlier return to daily activities than open cholecystectomy. The attainment of such goals is particularly desirable in the elderly patient.6
Advanced age is frequently associated with significant comorbidity and limited functional reserve, which may complicate a postoperative course. Preoperative assessment of cardiovascular risk factors and adequate monitoring of the patients is necessary for detection and treatment of possible complications.7
In this study, the evaluation of ASA scores showed a parallel increase with age. In the 69 or younger age group, patients with ASA 3 or higher constituted 15.9% of the group, while the percentage of these patients were 39.4% in the age 70 to 74 subgroup, 66.7% in the age 75 to 79 subgroup, and 81.8% in the age 80 and above subgroup. These differences were significant (P<0.001). Despite high ASA scores, no perioperative complications occurred in the elderly groups (patients ≥70).
In laparoscopic cholecystectomy, carbon dioxide pneumoperitoneum has potentially harmful intraoperative circulatory and ventilatory effects because of absorbed carbon dioxide and elevated intraabdominal pressure. Although not clinically significant for healthy patients, these effects are assumed to be deleterious for patients with a high risk for anesthesia (ASA 3 and 4).8,9
Therefore, all patients with an operative period >1 hour (26 patients in groups A1, A2, and A3 and 152 patients in group B) had assessment of PaCO2
and pH values in blood samples drawn at the end of the first hour of the operation. The difference between the groups was not statistically different (P>0.05). These results were consistent with the findings of Koivusola et al10
who reported that during laparoscopic cholecystectomy the pneumoperitoneum induced with 10mm Hg to 12 mm Hg pressure in patients with ASA scores 3 or 4 did not pose additional risks in elderly patients.
Previous studies have shown that the incidence of acute cholecystitits is higher in elderly patients.5,11
In our study, although the acute cholescystitis was more frequent in patients aged 70 or older compared with younger individuals, this difference was not statistically significant. On the other hand, subgroup analysis of patients older than 70 revealed that the rate of acute cholecystitis was 45.5% in patients aged 80 or older, and this was significantly higher than that in the other groups (P=0.029). We believe this finding explains the higher complication rates in patients above age 80 reported in the literature.12,13
Conversion to open surgery was 14.7% in the elderly group. This figure is concordant with the numbers reported in the literature, which range between 5% and 25%.5,14,15
The conversion rate was 8% in the younger age group. Although the conversion rates were higher in the elderly group of patients >70, this did not reach statistical significance (P=0.765). However, subgroup analysis of group A (70 or older) revealed that patients aged 80 or older had a significantly higher conversion rate than that in other subgroups (P<0.01), a finding which is also in agreement with the literature. Increased age has been noted in the literature as a preoperative risk factor for conversion, perhaps due to a longer history of gallstones and increased number of cholecystitis attacks.16,17
The most important advantage of laparoscopic cholecystectomy in elderly patients is the associated reduction in morbidity and mortality rates. The reported incidence of morbidity and mortality with open cholecystectomy in the geriatric population is approximately 23% to 28% and 1.5% to 2% respectively.18,19
In the elderly who underwent laparoscopic cholecystectomy, complication rates of 5% to 15% and an overall mortality rate of 0% to 1% have been observed.2,11,20
There was no mortality in our study. Although the complication rates were slightly higher in the group aged 70 or older compared with the younger group of patients (13.2% vs 9.7%, P=0.359), these figures are still lower than the reported complication rates for open cholecystectomy. Subgroup analysis of elderly patients showed that complication rates increase significantly in the group aged 80 or older. Another important point is the lack of pneumoperitoneum-dependent complications in the perioperative period. Higher complication rates observed in patients aged 80 or older seem to be resulting from more difficult cholecystectomies (acute cholecystitis, fibrotic gallbladder, mirizzi syndrome, and others). Therefore, we believe that patients aged 80 or older should preferentially be operated on by experienced surgical staff with good technical equipment, which will help to decrease complication rates.
To identify bile duct stones before laparoscopic cholecystectomy, we routinely evaluate the patients clinically and with ultrasonography. In case the patient has clinical, biochemical, or radiological findings suspicious of the presence of bile duct stones, we perform MRCP (Magnetic Resonance Cholangiopancreaticography), which is a noninvasive and rather sensitive method. Using our algorithm, only 0.7% (4/595) of the stones were missed in our study, all of which could be removed with ERCP after the operation, which may be due to the high sensitivity of MRCP. In the study of Charfare et al21
preoperative ERCP was performed, and postoperatively retained stones were present in 1.2% of these patients, similar to our rate. In another study by Collins et al,22
among 997 laparoscopic cholecyctectomy patients, clinically silent choledocholithiasis was present in 3.4%, one-third of which passed spontaneously within 6 weeks of the operation. Based on these previous findings and the results of Nugent et al,23
we believe that selective biliary imaging like MRCP not only represents a safe and effective tool for preoperative identification of bile stones, but also reduces the need for unnecessary ERCP and intraoperative cholangiography procedures.
Additional support for the benefit of the laparoscopic approach is demonstrated in the decreased length of stay in the hospital. In this study, although the length of hospitalization was shorter in all groups compared with that in open cholecystectomy, it was significantly longer in the elderly group compared with that in the younger patients. These results made us believe that elderly patients also benefited from the shorter hospital stay offered by the laparoscopic technique; however, due to higher complication rates and more frequent conversion to the open technique, they required longer hospitalization periods compared with younger patients.
Most studies use the ages 65 or 70 as the cut-off line for the elderly patients.1,5,20,24
In our study, patients aged 70 or older were included in the elderly group, and this group was further analyzed by separation into 3 subgroups. In the elderly patient group, it was seen that patients aged 80 or older had different characteristics compared with the remaining elderly patients, and patients in the 70 to 74 or 75 to 79 age groups had characteristics more like those of the younger group of patients.