Biliary tract disorders are one of the most common reasons for surgery in older patients. Fifty percent of women and 16% of men >70 years of age have been shown to have gallbladder disease.19,20
As the average age of the population continues to rise, the number of elderly patients with symptomatic gallstones is likely to increase.4,5
Advanced age is frequently associated with significant comorbidity and limited functional reserve, which may be related to a higher rate of complications, and longer hospital length of stay. Among elderly patients, those who are ≥80 years (usually called extremely elderly) have the worst outcomes and may be seen as a different group. Kuy et al1
have shown that patients aged ≥80 years were >3 times more likely to need blood transfusions and to require continuous mechanical ventilation and >5 times more likely to develop aspiration pneumonitis.
The incidence of choledocholithiasis rises with age, with rates as high as 43% in patients older than 80 years.7
The extremely elderly frequently present with several biliary diagnoses and complicated gallstone disease, which explains the higher rates of conversion, complications, and mortality usually seen in this group6,7,16,19–22
. A previous randomized controlled trial comparing open cholecystectomy with endoscopic management of symptomatic choledocholithiasis supported operative intervention in high-risk patients.23
In a randomized controlled trial comparing an expectant policy with LC following endoscopic clearance of bile duct stones, 47% of patients in the expectantly managed cohort developed at least one recurrent biliary event during follow-up.24
Comparative Results from Published Reports
Recent studies have confirmed the reluctance to operate on extremely elderly patients,25
probably due to a greater percentage of complicated diseases,20–22
and a greater comorbid disease burden.6,20,22
However, the implications of this conservative behavior in the management of gallstone disease in the extremely elderly may not benefit patients. Trust et al14
recently demonstrated that recurrent gallstone pancreatitis was the reason for readmission in 48% of 3689 elderly patients who did not undergo definitive therapy after an episode of mild acute gallstone pancreatitis; 33% required subsequent cholecystectomy, and most of the time surgery was performed during hospital readmission for gallstone-related complications, which was associated with a higher mortality (2.4% vs 0.9%). Moreover, because perioperative outcomes in the elderly seem to be influenced by the severity of gallbladder disease instead of chronological age, because LC after mild acute gallstone pancreatitis performed during the same hospitalization is not associated with worse outcomes, and because cholecystectomy provides the only definitive therapy, reducing the risk of recurrent gallstone pancreatitis to almost zero,26,27
our data support the idea that during the management of gallstone pancreatitis in the elderly definitive treatment during the same hospitalization must be the goal to be achieved.
Although some authors have shown respiratory complications as the most common postoperative morbidity in elderly patients undergoing LC21
and it has been reported that the use of low-pressure insufflation may further preserve respiratory function,28
we had a low rate of complications despite the fact that patients spent a long time under general anesthesia. This can be partially explained by the fact that as a teaching hospital the senior resident performed all surgeries and the absence in our service of a low-pressure pneumoperitoneum policy in high-risk patients. These results are consistent with those of previous works that did not show additional risks in high-risk patients when pneumoperitoneum was induced with 10mm Hg to 12mm Hg pressure in patients with ASA 3 or 4, and it seems to be true even for >1-hour long procedures.22,29
Our study has shown a lower conversion rate (4.8%) compared to previously published studies ()
. It may be partially explained by the fact that we did not include cholecystectomies performed for acute cholecystitis. However, as a teaching hospital, all surgeries were performed by the senior resident under supervision, and this fact seems not to have changed outcomes and corroborates what has been demonstrated by others.30
Similarly, we had a shorter postoperative length of stay for both groups (inpatient: 2.8±0.7 vs 1.9±1.1, P=.19), which can be explained by our low complication rate (16.7%) and the absence in this series of complications classified as Clavien-Dindo ≥3. Our data reinforce that the management of gallstone disease in octogenarians should not be different from current guidelines for the management of acute gallstone pancreatitis or complicated biliary disease, which means that elderly patients would benefit from definitive therapy during the same hospitalization to prevent recurrent episodes.