Surgical management of gallbladder disease in the very elderly

Lupinacci, Renato Micelli; Nadal, Luís Roberto Manzione; Rêgo, Ronaldo Elias Carnut; Dias, André Roncon; Marcari, Rafael S; Lupinacci, Renato Arioni; Farah, Jose F.

doi:10.1097/meg.0b013e32835b7124

Cited by 31 publications

(30 citation statements)

References 21 publications

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“…14,18,19,25-29 While elective cholecystectomy can be performed safely in older patients, limited data in this population suggest higher rates of comorbid illness, higher conversion rates, longer lengths of stay, increased need for ICU care, and more complications in this population. 18,19,30-34 In a recent study of 81 octogenarians, Lupinacci et al reported a 34% mortality rate, 51% complication rate, and an 11-day mean length of stay when cholecystectomy was performed in the acute setting (N=30); 77% of these patients required ICU care and the mean ICU stay was 9.4 days. This is in contrast to elective/non-urgent cholecystectomy (N=51), where there was no mortality, a 12-14% complication rate, and a mean length of stay under three days.…”

Section: Discussionmentioning

confidence: 99%

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The Risk Paradox: Use of Elective Cholecystectomy in Older Patients Is Independent of Their Risk of Developing Complications

Riall

Adhikari

Parmar

et al. 2015

Journal of the American College of Surgeons

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Background We recently developed and validated a prognostic model that accurately predicts the 2-year risk of emergent gallstone-related hospitalization in older patients presenting with symptomatic gallstones. Study Design We used 100% Texas Medicare data (2000-2011) to identify patients 66 and older with initial episode of symptomatic gallstones not requiring emergency hospitalization. At presentation, we calculated each patient's risk of 2-year gallstone-related emergent hospitalization using the previously validated model. Patients were placed into the following risk groups based on model estimates: <30%, 30-<60%, and ≥60%. Within each risk group, we calculated the percent of elective cholecystectomies (≤2.5 months from initial episode) performed. Results 161,568 patients had an episode of symptomatic gallstones. The mean age was 76.5±7.3 years and 59.9% were female. The risk of 2-year risk of gallstone-related hospitalizations increased from 15.9% to 41.5% to 65.2% across risk groups. For the overall cohort, 22.3% in the low-risk group, 20.9% in the moderate-risk group, and 23.2% in the high-risk group underwent elective cholecystectomy in the 2.5 months after the initial symptomatic episode. In patients with no comorbidities, elective cholecystectomy rates decreased from 34.2% in the low-risk group to 26.7% in the high-risk group. In patients who did not undergo cholecystectomy, only 9.5% were seen by a surgeon in the 2.5 months following the initial episode. Conclusions The risk of recurrent acute biliary symptoms requiring hospitalization has no influence, or even a paradoxical negative influence, on the decision to perform elective cholecystectomy after an initial symptomatic episode. Translation of the risk prediction model into clinical practice can better align treatment with risk and improve outcomes in older patients with symptomatic gallstones.

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Section: Discussionmentioning

confidence: 99%

“…15,16 Once complications occur and urgent hospitalization and/or cholecystectomy is necessary, the morbidity and mortality are significantly increased. 14,17-19 …”

Section: Introductionmentioning

confidence: 99%

The Risk Paradox: Use of Elective Cholecystectomy in Older Patients Is Independent of Their Risk of Developing Complications

Riall

Adhikari

Parmar

et al. 2015

Journal of the American College of Surgeons

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“…However, several reports show that early cholecystectomy is safe even in the severe forms of the disease [22–24] or in the elderly population [25–27]. In particular, a recent review of prospective and retrospective series (EL3) [28] did not show an increase in local postoperative complications in severe cholecystitis and confirmed that laparoscopic cholecystectomy is to be considered an acceptable indication for it, despite a demonstrated threefold conversion rate.…”

Section: Review Of Literaturementioning

confidence: 99%

Acute cholecystitis: WSES position statement

et al. 2014

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BackgroundThe management of acute calculous cholecystitis still offers room for debate in terms of diagnosis, severity scores, treatment options and timing for surgery.Material and methodsA systematic review about the treatment of acute cholecystitis has been completed. The recommendations of recent guidelines have also been examined taking into account the results of the review.ResultsThe evidence available in the literature supports the recommendation about laparoscopic cholecystectomy as treatment of choice for acute cholecystitis. Surgery should be performed as soon as possible after the diagnosis because early treatment reduces total hospital stay and does not increase complication or conversion rates. The antibiotics can play different roles and attention should be posed to the risk of emerging resistance. A surgical or percutaneous drainage of the gallbladder is advocated by some authors in the advanced forms of inflammation or patients with severe co-morbidities; however, the available evidence does not support it, and further studies are necessary to clarify its role.

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“…9,10 Once these complications occur in the elderly, mortality and morbidity increase dramatically. 11-14 The reluctance to perform elective cholecystectomy in elderly patients is likely multifactorial and includes concerns about increased morbidity, mortality, and length of hospital stay due to the comorbidities and frailty commonly seen in this population. 15,16 In addition, it is difficult for physicians to predict the risk of developing gallstone-related complications and balance this risk with operative risk at the time of decision making.…”

Section: Introductionmentioning

confidence: 99%

Trends in Follow-Up of Patients Presenting to the Emergency Department with Symptomatic Cholelithiasis

Dimou

Adhikari

Mehta

et al. 2016

Journal of the American College of Surgeons

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Background Fewer than 25% of Medicare beneficiaries presenting with symptomatic cholelithiasis undergo elective cholecystectomy. To better understand underuse of cholecystectomy, we examined physician follow-up patterns after emergency department (ED) visits for symptomatic gallstones. Study Design We used 100% Texas Medicare claims (2001-2010) to identify patients ≥66 years who presented to the ED with symptomatic cholelithiasis and were discharged home without cholecystectomy. Timing of outpatient physician visits after ED discharge and rates of emergent cholecystectomy based on physician follow-up patterns were compared. Results 11,126 patients presented to the ED with symptomatic cholelithiasis and were discharged without cholecystectomy. After discharge, 5,327 patients (47.9%) had an outpatient surgeon visit; 29.0% saw another physician and never saw a surgeon, and 23.1% never saw a physician. 68.2% of patients who saw a surgeon underwent elective cholecystectomy. 8.3% of patients who saw a surgeon, 14.6% of patients who saw other physicians and no surgeon, and 77.6% of patients who never saw any physician required emergent hospitalization (p<0.0001). For people who did not see a physician, mean time to emergent hospitalization was 7.5 days (median=2 days); 95.9% presented within 2 weeks after their initial presentation. Conclusions Fewer than half of patients were evaluated by a surgeon after an initial ED visit for symptomatic gallstones. Patients who did not have physician follow-up were most likely to require emergent cholecystectomy, suggesting inappropriate ED discharge and highlighting the need for timely follow-up. Early outpatient surgical consultation is critical in determining appropriateness for cholecystectomy and avoiding emergent cholecystectomy in older patients with symptomatic gallstones.

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Surgical management of gallbladder disease in the very elderly

Cited by 31 publications

References 21 publications

The Risk Paradox: Use of Elective Cholecystectomy in Older Patients Is Independent of Their Risk of Developing Complications

The Risk Paradox: Use of Elective Cholecystectomy in Older Patients Is Independent of Their Risk of Developing Complications

Acute cholecystitis: WSES position statement

Trends in Follow-Up of Patients Presenting to the Emergency Department with Symptomatic Cholelithiasis

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