Management of symptomatic gallstones in the elderly

Abstract

In a study of 544 patients with symptomatic gallstones 158 subjects were aged greater than 70 years. Elderly patients had a significantly higher incidence of emergency presentation, jaundice, cholangitis, ductal stones, biliary drainage procedures, and acute complications requiring urgent or emergency surgery (P less than 0.001); they had more than twice the incidence of postoperative complications in comparison with patients aged less than 70 years. There was an increased perioperative mortality in the elderly (1.3 per cent after cholecystectomy and 2.9 per cent after bile duct exploration, P = 0.039). Conservative treatment in 11 per cent of elderly patients resulted in no mortality due to gallstones, but 3 of 17 patients had recurrent biliary symptoms. It was estimated that 38 per cent of the bile duct explorations in the elderly might have been avoided by referral for endoscopic sphincterotomy, but surgical treatment of gallstones in the district general hospital is relatively safe and specialist referral should be considered only in the relatively small number of 'high risk' cases.

Laparoscopic surgery in the elderly patient

“…Reported overall mortality rates after LC in elderly patients vary from 0% to 1.6% [9, 10, 12, 22-25, 27-29, 41]. This is substantially less than the mortality reported after open cholecystectomy (OC) in elderly patients, which varies between 0.8% and 13% [16,18,19,38]. In our series, 186 patients underwent LC, of which 3 (1.6%) died.…”

Outcomes analysis of laparoscopic cholecystectomy in the extremely elderly

“…Institutional studies of unselected elderly patients undergoing LC have reported complication rates that range from 5% to 24% (average morbidity, 15%) and an overall mortality rate of 0.7% (range, 0-2%) [1,2,9,11,17,18,22,25,29]. This contrasts with reported complication rates of 11% to 62% (average morbidity, 26%) and an overall mortality of 6% in five different studies from the 1980s involving 719 open cholecystectomies [4,[13][14][15][16]19]. Furthermore, in Lujan et al's [17] prospective trial, complications occurred in 24% of the patients undergoing open cholecystectomy, as compared with 13.5% of the patients treated laparoscopically.…”

“…Census estimates suggest that the percentage of elderly persons in the United States will rise from 12.8% in 1995 to 16.5% over the next 25 years [30]. Although they currently comprise only one-eighth of the population, the elderly already account for nearly one-third of surgical patients.…”

“…In 1990 alone, approximately 150,000 Medicare patients underwent cholecystectomy in the United States [31]. The management of gallstone disease in the elderly often is more challenging because they experience a high incidence of complicated cholelithiasis including acute cholecystitis [7,16,17,24], choledocholithiasis [7,13], and gallstone pancreatitis [18]. Many elderly patients also are at higher risk for surgery because of decreased functional reserve and more medical comorbidities.…”

Selective preoperative endoscopic retrograde cholangiography with sphincterotomy avoids bile duct exploration during laparoscopic cholecystectomy.

“…The overall morbidity for endoscopic sphincterotomy/laparoscopic cholecystectomy is proportionately less, however, than that for open duct exploration in both the young and the elderly. 23 The results of laparoscopic duct exploration in non-specialist centres are unknown. The few series reporting laparoscopic duct exploration on selected patients from specialist centres suggest a higher complication rate than that achieved in this series using ERC/laparoscopic cholecystectomy.21 24 Thirdly, there is a perceived risk of more complications from endoscopic sphincterotomy in those with normal sized bile ducts.…”