Laparoscopic cholecystectomy in the elderly.

OBJECTIVE: To evaluate the outcomes of laparoscopic cholecystectomy in elderly patients at a single institution.
METHODS: A retrospective chart review was conducted of all patients > or = 65 years of age who underwent laparoscopic cholecystectomy over a 5-year period (January 1995 to December 1999). Four-trocar site laparoscopic cholecystectomy using the open Hasson technique were performed in all patients. The demographic data (age, sex), associated comorbidities, American Society of Anesthesiologist's (ASA) score, postoperative morbidity, mortality, and length of stay were recorded for each patient. Statistical analysis was done using Fisher's exact test and chi-square analysis. Statistical significance was defined as P < or = 0.05.
RESULTS: The patient cohort included 46 patients with a median age of 71 years (range, 65 to 87). Seventeen (37%) patients were < or = 70 years of age, and twenty-nine (63%) patients were > or = 70 years of age. Twenty-two (48%) patients had ASA scores of > or = 3. Patients > or = 70 had significantly higher ASA scores. Eighteen patients > or = 70 years had ASA > or = 3 compared with 4 patients < or = 70 with ASA > or = 3 (P<0.05). Twenty-two patients > or = 70 and 8 patients < or = 70 required urgent surgery P<0.05). Fifteen (33%) patients presented with acute cholecystitis, and 31 (67%) patients presented with a greater number of chronic symptoms. Four (9%) patients had pancreatitis on presentation, and 6 patients underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP). Two of these 6 patients also underwent sphincterotomy. Urgent surgery was performed in 30 (65%) patients. The mean operative time was 103 +/- 37 (SD) minutes. One (2%) conversion to open cholecystectomy was required. The mean postoperative stay was 7 days (range, 1 to 46). Fourteen (30%) patients had only a 1-night postoperative stay. Patients > or = 70 had significantly longer postoperative stays. Nine patients > or = 70 and only 1 patient < or = 70 stayed in the hospital for more than 7 days. Postoperative complications were noted in 6 (13%) patients, most of which were chest infections. Five patients > or = 70 and only 1 patient < or = 70 developed postoperative complications. No mortalities occurred.
CONCLUSION: Laparoscopic cholecystectomy is safe and feasible in elderly patients. Patients > or = 70 years seem to have a longer postoperative stay and slightly more postoperative complications. Age alone should not be a contraindication to laparoscopic cholecystectomy in the elderly patient.

INTRODUCTION

Laparoscopic cholecystectomy was introduced in the United States in 1988.[1] By early 1992, more than 80% of the general surgeons in the United States had adopted the procedure. Laparoscopic cholecystectomy is currently the procedure of choice for management of gallstone disease.[2] Laparoscopic cholecystectomy is being used with increasing frequency even in the elderly population. It has been argued that laparoscopic cholecystectomy in the elderly has comparable safety and efficacy to that in younger populations.[3] The purpose of this study was to evaluate the outcome of laparoscopic cholecystectomy in the elderly population at our institution.

METHODS

This is a retrospective chart review. All patients ≥65 years of age who underwent laparoscopic cholecystectomy at our institution over a 5-year period (January 1995 to December 1999) were studied. Four-trocar laparoscopic cholecystectomies using the open Hasson technique were performed. The study comprised 2 groups of patients, one ≤70 years of age and the other ≥70 years. Statistical analysis was done using Fisher's exact test and chi-square analysis. Statistical significance was defined as P≤0.05.

RESULTS

The study comprised 46 patients with a median age of 71 years (range, 65 to 87 years). Seventeen (37%) patients were ≤70 years of age, and 29 (63%) patients were ≥70 years. There were 33(72%) female patients and 13 (28%) male patients. The male to female ratio was 1:3. Fifteen (33%) patients presented with acute cholecystitis, and 31 (67%) patients had a greater number of chronic symptoms. Four patients (9%) had pancreatitis at presentation. Six patients underwent preoperative ERCP. Two of these 6 patients also had sphincterotomy. Urgent (within 24 hrs) surgery was performed in 30 (65%) patients.

Twenty-two (48%) patients had ASA scores ≥3. Patients ≥70 had significantly higher ASA scores. Eighteen patients ≥70 had ASA ≥3 compared with 4 patients ≤70 years (P<0.05). The mean duration of surgery was 103±37 (SD) minutes. Age, sex, or ASA score did not affect the duration of surgery.

Conversion to open cholecystectomy was needed in 1 of 46 (2%) patients due to adhesions and distorted anatomy. Postoperative complications occurred in 6 (13%) patients. Four patients had chest infections, 1 patient had a myocardial infarction, and 1 had a cerebrovascular accident. None of the complications were directly related to the surgical procedure.

The mean postoperative stay was 7 days (range, 1 to 46). Fourteen (30%) patients had only a 1-night postoperative stay. The mean postoperative stay for patients ≤70 was 2.82±2.56 compared with 9.17±13.05 for patients ≥70 years (P<0.02). No deaths occurred in either group.

DISCUSSION

The incidence of gallstone disease in the geriatric population ranges from 14% to 27% according to various population-based studies.[4] Laparoscopic cholecystectomy is established as the gold standard for the surgical management of gallstone disease. The reported incidence of morbidity and mortality with elective open cholecystectomy in the geriatric population is approximately 23% to 28% and 1.5% to 2%, respectively.[5-7] Morbidity and mortality for laparoscopic cholecystectomy in the elderly ranges from 5% to 15% and 0% to 1%, respectively.[8-11] No operative mortalities occurred in our study. Six (13%) patients developed postoperative complications, which are in accordance with that reported in other studies.[9,10] Five of these 6 patients who developed postoperative complications were ≥70 years. Only 1 patient ≤70 years developed postoperative complications. Four patients had respiratory tract infections, 1 had myocardial infarction, and 1 had a cerebrovascular accident.

The majority of patients in this study underwent laparoscopic cholecystectomy for chronic symptoms. The incidence of acute cholecystitis is more common in the group ≥70 years as noted in other studies.[2]

Our mean operative time of 103±37 minutes is comparable to that in other studies.[8.12] The mean operative time between the 2 groups of patients (104 min vs 101 min) is not statistically significant. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) was done in 6 patients for clinical and laboratory suspicion of choledocholithiasis. Two of these 6 patients also underwent sphincterotomy for common bile duct stones.

One conversion (2%) from laparoscopy to open cholecystectomy was necessary. This conversion rate is lower than that previously reported,[2] which may be due to selection of cases. Twenty-two (48%) patients had ASA scores ≥3. Eighteen patients ≥70 and only 4 patients ≤70 had ASA scores of ≥3.

The postoperative stay of 7 days (range, 1 to 46) is comparable to that in other studies.[8,11,13] Fourteen (30%) patients had only a 1-night postoperative stay. The mean postoperative stay in the group ≤70 of 2.82±2.56 days is significantly lower than the stay in the group ≥70, which is 9.17±13.05 days.

CONCLUSION

Laparoscopic cholecystectomy is feasible and safe in elderly patients. The ASA scores seem to be high in extremely elderly patients with a significantly longer postoperative stay and also slightly more complications. But age alone should not be the contraindication for laparoscopic cholecystectomy.