ORIGINAL ARTICLE
Laparoscopic Cholecystectomy in Patients Aged 80 Years and Older: An Analysis of 111 Patients Yasin Peker, MD,* Haluk Recai U¨nalp, MD,w Evren Durak, MD,* Tu¨rker Karabug˘a, MD,z Yeliz Yılmaz, MD,y Hu¨dai Genc¸, MD,* and Mehmet Hacıyanlı, MD*
Introduction: The incidence of cholelithiasis increases with age. More octogenarian (Z80 y) patients are undergoing laparoscopic cholecystectomy (LC) operation throughout the world. Patients and Methods: A retrospective study was conducted on patients older than 80 years (group 1: 111 patients) and those in the 18 to 79 years age group (group 2: 185 patients), who underwent LC between July 2005 and October 2009. The variables analyzed were the presentation, demographics, comorbid illnesses, American Society of Anaesthesiology (ASA) scores, history of previous abdominal surgery, the operative time, postoperative morbidity and mortality, and the length of hospital stay. A comparison was made between the two groups. Data was evaluated by using the w2 and the Fisher exact test. P < 0.005 was considered significant. Results: The difference in both groups in the mean age and ASA scores were significant. The indication for LC was gallstone disease in 87 (78.4%) patients, acute cholecystitis in 16 (14.4%), and gallstone pancreatitis in 8 (7.2%) of group 1 patients. The conversion rate was not statistically significant. The mean operative time was 77 minutes in group 1 patients, and this was significantly longer than that of group 2 patients. The postoperative oral intake within 24 hours of surgery was significantly earlier in group 2 patients. Other parameters were not significantly different between the 2 groups. Conclusions: LC in octogenarians is a relatively safe procedure that can be performed with low morbidity and mortality rates. The comorbidities and higher ASA scale are major risk factors for postoperative complications in this age group of patients. Key Words: cholelithiasis
laparoscopic
cholecystectomy,
octogenarian,
(Surg Laparosc Endosc Percutan Tech 2014;24:173–176)
T
he introduction and rapid standardization of laparoscopic cholecystectomy (LC) has brought a new spectrum of issues such as LC in the elderly population.1–3 The incidence of cholelithiasis increases with age, and with the advancement of laparoscopic surgical techniques and postoperative care, more octogenarian (Z80 y) patients are undergoing LC operation throughout the world.1,2 The incidence of cholelithiasis has been reported to be as high as 50% in these patients.4–6
Received for publication June 23, 2012; accepted January 27, 2013. From the *Ataturk Research and Educational Hospital, I˙zmir Katip Celebi University; wMedical Faculty, Medical Park Hospital, I˙zmir University, I˙zmir; zBozkır State Hospital, Konya; and yRıze State Hospital, Rıze, Turkey. The authors declare no conflicts of interest. Reprints: Yasin Peker, MD, Basın Sıtesı Mah. 215 Sok. No: 8 D:5 35340-Karabaglar, Izmir, Turkey (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
Elderly patients frequently suffer from serious comorbidities, and their cardiopulmonary reserves are limited.7,8 The management of gallstone disease in octogenarian patients is challenging. It’s been demonstrated that LC is associated with certain morbidity and mortality in these patients.6–9 In this study, we aimed to compare whether the performance of LC in octogenarian patients has changed the outcome relative to the under 80 age group patients.
MATERIALS AND METHODS The data and patient demographics were identified form the ongoing database of IKCU Ataturk Research & Educational Hospital. Data collected between July 2005 and October 2009 included 111 patients in group 1 (Z80 y) and 185 patients in group 2 (> 18 and 45 U/L Alanine aminotransferases > 35 U/L Amylase >110 mg/dL Alkaline phosphatase Z150 mg Ultrasound Bile duct >10 mm Common bile duct stone ERCP performed
Group 1 (n = 111), n (%)
Group 2 (n = 185), n (%)
P
9 (8.1) 8 (7.2)
6 (3.2) 7 (3.8)
0.098 0.273
7 (6.3) 16 (14.4)
8 (4.3) 23 (12.4)
0.585 0.723
2 (1.8) 10 (9.0)
14 (7.4) 13 (7.0)
0.035 0.654
17 (15.3)
23 (12.4)
0.487
17 (15.3)
24 (13)
0.604
10 (9) 11 (9.9)
6 (3.2) 9 (4.9)
0.059 0.101
12 (10.8) 20 (18.0) 23 (20.7)
6 (3.2) 19 (10.2) 21 (11.4)
0.011 0.020 0.853
ERCP indicates endoscopic retrograde cholangiopancreatography.
The incidence of gallstones and gallbladder disease increases with age, with 50% of women and 15% of men aged Z80 years estimated to have gallstones.11 Gallbladder disease is the most common indication for abdominal surgery in the elderly.4,6,14 In this patient group, acute symptomatic biliary tract disease is usually associated with a 10-fold increase in the operative morbidity and TABLE 3. Perioperative Variables
Emergency surgery Conversion to open Postoperative complications* Atelectasis Pulmonary edema Acute myocardial infarct Urinary tract infection Intra-abdominal abscess Bile leak Wound infection Operating time (min) Oral intake in 24 h Adenocarcinoma of gallbladder ERCP performed Mortality Length of hospital stay (d)
Group 1 (n = 111), n (%)
Group 2 (n = 185), n (%)
P
6 (5.4) 7 (6.3) 8 (7.2)
5 (2.7) 10 (5.4) 13 (7.0)
0.341 0.799 1.000
3 (2.7) 2 (1.8) 2 (1.8)
4 (2.2) 1 (0.5) —
1 (0.9) — 1 (0.9) 2 (1.8) 77.3 ± 6.9 (55-110) 79 (71.2) 1 (0.9)
2 (1.1) 1 (0.5) 2 (1.1) 4 (2.2) 58.9 ± 8.2 (40-70) 162 (87.6) 1 (0.5)
1 (0.9) 1 (0.9) 2.1 ± 1.8 (1-14)
3 (1.6) 2 (1.1) 2.1 ± 2.4 (1-22)
0.001 0.001 1.000 1.000 1.000 0.854
*Some patients had more than 2 events. ERCP indicates endoscopic retrograde cholangiopancreatography.
r
2014 Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
Volume 24, Number 2, April 2014
mortality compared with young patients.6,11,12 The elderly are also more likely than younger patients to present with complicated cholelithiasis.1,11,15–17 Furthermore, the elderly are at an increased risk of surgery because of decreased functional reserve, associated comorbidities, more scarring around the gallbladder, choledocholithiasis, and a greater likelihood that the operation will be performed on an emergency or urgent basis.8,14,15 Open cholecystectomy in octogenarians is associated with considerable morbidity and mortality, and complication rates have been reported to be in the range of 18% to 35%, with a mortality as high as 12.7%.11,12,17 Conversion to open cholecystectomy may be required in any patient, and the risk with respect to gallstone disease patients is higher in the elderly.11,15 Therefore, the benefits of laparoscopic operations when applied to the management of symptomatic gallstone disease in the older patient population are clear.11,13 The morbidity rate in this study is consistent with the reported rates.11,13,15 The most common indication for LC in our series was gallstone disease; however, there were significantly more cases that were complicated and attributed as difficult cholecystectomies in our series. Fortunately, the need for urgent operation, the conversion rate, and postoperative complications were within reported limits. We believe that careful preoperative medical evaluation plays a crucial role in reducing postoperative complication rates in this age group of patients. Biliary diseases follow a more aggressive course in octogenarian patients.1,6,8 The incidence of common bile ducts and post-ERCP complication rates are also greater in these patients. Maxwell et al8 compared the findings of 105 octogenarian patients with gallbladder disease and reported a significantly greater number of cases with common bile duct stone passage in this age group (35% vs. 15%). We found similar results in our patients (18% vs. 10.2%), and all patients with common bile duct stones in our series underwent ERCP and stone removal before elective LC. We also believe that preoperative ERCP provides better surgical comfort for the surgeon as it reduces inflammation on the hepatoduodenal ligament significantly. The conversion rate in octogenarians ranges from 3% to 22% and is higher than in patients aged 65 to 79 years.6,11,14,17,18 The main reasons for this conversion are the following: chronic inflammation around the gallbladder; distorted anatomic features; previous abdominal surgery; an acutely inflamed gallbladder with evidence of perforation, gangrene or emphysema; bleeding; unexpected common bile duct stones; male sex, previous biliary interventions and some surgical technical problems. A higher incidence of comorbidities, more scarring around the gallbladder and choledocholithiasis are the main reasons for the poorer outcome in elderly patients.6,11,12,19,20 Brunt et al14 reported a 3.7% versus 15.7% conversion rate in patients in the
Laparoscopic Cholecystectomy in Patients Aged 80 Years and Older: An Analysis of 111 Patients Yasin Peker, MD,* Haluk Recai U¨nalp, MD,w Evren Durak, MD,* Tu¨rker Karabug˘a, MD,z Yeliz Yılmaz, MD,y Hu¨dai Genc¸, MD,* and Mehmet Hacıyanlı, MD*
Introduction: The incidence of cholelithiasis increases with age. More octogenarian (Z80 y) patients are undergoing laparoscopic cholecystectomy (LC) operation throughout the world. Patients and Methods: A retrospective study was conducted on patients older than 80 years (group 1: 111 patients) and those in the 18 to 79 years age group (group 2: 185 patients), who underwent LC between July 2005 and October 2009. The variables analyzed were the presentation, demographics, comorbid illnesses, American Society of Anaesthesiology (ASA) scores, history of previous abdominal surgery, the operative time, postoperative morbidity and mortality, and the length of hospital stay. A comparison was made between the two groups. Data was evaluated by using the w2 and the Fisher exact test. P < 0.005 was considered significant. Results: The difference in both groups in the mean age and ASA scores were significant. The indication for LC was gallstone disease in 87 (78.4%) patients, acute cholecystitis in 16 (14.4%), and gallstone pancreatitis in 8 (7.2%) of group 1 patients. The conversion rate was not statistically significant. The mean operative time was 77 minutes in group 1 patients, and this was significantly longer than that of group 2 patients. The postoperative oral intake within 24 hours of surgery was significantly earlier in group 2 patients. Other parameters were not significantly different between the 2 groups. Conclusions: LC in octogenarians is a relatively safe procedure that can be performed with low morbidity and mortality rates. The comorbidities and higher ASA scale are major risk factors for postoperative complications in this age group of patients. Key Words: cholelithiasis
laparoscopic
cholecystectomy,
octogenarian,
(Surg Laparosc Endosc Percutan Tech 2014;24:173–176)
T
he introduction and rapid standardization of laparoscopic cholecystectomy (LC) has brought a new spectrum of issues such as LC in the elderly population.1–3 The incidence of cholelithiasis increases with age, and with the advancement of laparoscopic surgical techniques and postoperative care, more octogenarian (Z80 y) patients are undergoing LC operation throughout the world.1,2 The incidence of cholelithiasis has been reported to be as high as 50% in these patients.4–6
Received for publication June 23, 2012; accepted January 27, 2013. From the *Ataturk Research and Educational Hospital, I˙zmir Katip Celebi University; wMedical Faculty, Medical Park Hospital, I˙zmir University, I˙zmir; zBozkır State Hospital, Konya; and yRıze State Hospital, Rıze, Turkey. The authors declare no conflicts of interest. Reprints: Yasin Peker, MD, Basın Sıtesı Mah. 215 Sok. No: 8 D:5 35340-Karabaglar, Izmir, Turkey (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
Elderly patients frequently suffer from serious comorbidities, and their cardiopulmonary reserves are limited.7,8 The management of gallstone disease in octogenarian patients is challenging. It’s been demonstrated that LC is associated with certain morbidity and mortality in these patients.6–9 In this study, we aimed to compare whether the performance of LC in octogenarian patients has changed the outcome relative to the under 80 age group patients.
MATERIALS AND METHODS The data and patient demographics were identified form the ongoing database of IKCU Ataturk Research & Educational Hospital. Data collected between July 2005 and October 2009 included 111 patients in group 1 (Z80 y) and 185 patients in group 2 (> 18 and 45 U/L Alanine aminotransferases > 35 U/L Amylase >110 mg/dL Alkaline phosphatase Z150 mg Ultrasound Bile duct >10 mm Common bile duct stone ERCP performed
Group 1 (n = 111), n (%)
Group 2 (n = 185), n (%)
P
9 (8.1) 8 (7.2)
6 (3.2) 7 (3.8)
0.098 0.273
7 (6.3) 16 (14.4)
8 (4.3) 23 (12.4)
0.585 0.723
2 (1.8) 10 (9.0)
14 (7.4) 13 (7.0)
0.035 0.654
17 (15.3)
23 (12.4)
0.487
17 (15.3)
24 (13)
0.604
10 (9) 11 (9.9)
6 (3.2) 9 (4.9)
0.059 0.101
12 (10.8) 20 (18.0) 23 (20.7)
6 (3.2) 19 (10.2) 21 (11.4)
0.011 0.020 0.853
ERCP indicates endoscopic retrograde cholangiopancreatography.
The incidence of gallstones and gallbladder disease increases with age, with 50% of women and 15% of men aged Z80 years estimated to have gallstones.11 Gallbladder disease is the most common indication for abdominal surgery in the elderly.4,6,14 In this patient group, acute symptomatic biliary tract disease is usually associated with a 10-fold increase in the operative morbidity and TABLE 3. Perioperative Variables
Emergency surgery Conversion to open Postoperative complications* Atelectasis Pulmonary edema Acute myocardial infarct Urinary tract infection Intra-abdominal abscess Bile leak Wound infection Operating time (min) Oral intake in 24 h Adenocarcinoma of gallbladder ERCP performed Mortality Length of hospital stay (d)
Group 1 (n = 111), n (%)
Group 2 (n = 185), n (%)
P
6 (5.4) 7 (6.3) 8 (7.2)
5 (2.7) 10 (5.4) 13 (7.0)
0.341 0.799 1.000
3 (2.7) 2 (1.8) 2 (1.8)
4 (2.2) 1 (0.5) —
1 (0.9) — 1 (0.9) 2 (1.8) 77.3 ± 6.9 (55-110) 79 (71.2) 1 (0.9)
2 (1.1) 1 (0.5) 2 (1.1) 4 (2.2) 58.9 ± 8.2 (40-70) 162 (87.6) 1 (0.5)
1 (0.9) 1 (0.9) 2.1 ± 1.8 (1-14)
3 (1.6) 2 (1.1) 2.1 ± 2.4 (1-22)
0.001 0.001 1.000 1.000 1.000 0.854
*Some patients had more than 2 events. ERCP indicates endoscopic retrograde cholangiopancreatography.
r
2014 Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
Volume 24, Number 2, April 2014
mortality compared with young patients.6,11,12 The elderly are also more likely than younger patients to present with complicated cholelithiasis.1,11,15–17 Furthermore, the elderly are at an increased risk of surgery because of decreased functional reserve, associated comorbidities, more scarring around the gallbladder, choledocholithiasis, and a greater likelihood that the operation will be performed on an emergency or urgent basis.8,14,15 Open cholecystectomy in octogenarians is associated with considerable morbidity and mortality, and complication rates have been reported to be in the range of 18% to 35%, with a mortality as high as 12.7%.11,12,17 Conversion to open cholecystectomy may be required in any patient, and the risk with respect to gallstone disease patients is higher in the elderly.11,15 Therefore, the benefits of laparoscopic operations when applied to the management of symptomatic gallstone disease in the older patient population are clear.11,13 The morbidity rate in this study is consistent with the reported rates.11,13,15 The most common indication for LC in our series was gallstone disease; however, there were significantly more cases that were complicated and attributed as difficult cholecystectomies in our series. Fortunately, the need for urgent operation, the conversion rate, and postoperative complications were within reported limits. We believe that careful preoperative medical evaluation plays a crucial role in reducing postoperative complication rates in this age group of patients. Biliary diseases follow a more aggressive course in octogenarian patients.1,6,8 The incidence of common bile ducts and post-ERCP complication rates are also greater in these patients. Maxwell et al8 compared the findings of 105 octogenarian patients with gallbladder disease and reported a significantly greater number of cases with common bile duct stone passage in this age group (35% vs. 15%). We found similar results in our patients (18% vs. 10.2%), and all patients with common bile duct stones in our series underwent ERCP and stone removal before elective LC. We also believe that preoperative ERCP provides better surgical comfort for the surgeon as it reduces inflammation on the hepatoduodenal ligament significantly. The conversion rate in octogenarians ranges from 3% to 22% and is higher than in patients aged 65 to 79 years.6,11,14,17,18 The main reasons for this conversion are the following: chronic inflammation around the gallbladder; distorted anatomic features; previous abdominal surgery; an acutely inflamed gallbladder with evidence of perforation, gangrene or emphysema; bleeding; unexpected common bile duct stones; male sex, previous biliary interventions and some surgical technical problems. A higher incidence of comorbidities, more scarring around the gallbladder and choledocholithiasis are the main reasons for the poorer outcome in elderly patients.6,11,12,19,20 Brunt et al14 reported a 3.7% versus 15.7% conversion rate in patients in the
