Is cholecystectomy safe in extremely elderly patients?

Gallstone disease is the most common global indication for abdominal surgery. Especially acute cholecystitis in the elderly is frequently encountered due to an increasingly elderly population. Although cholecystectomy is the gold standard treatment for acute cholecystitis, the surgical management in the elderly presents specific challenges due to associated comorbidities, the severity of their presenting disease, and a greater likelihood of suffering postoperative complications and prolonged hospital stay. Further effort to provide firm evidence to clarify the safety and feasibility of cholecystectomy for acute cholecystitis in extremely elderly patients such as octogenarians and even nonagenarians.

The increase in the number of elderly patients due to the rise in the average life expectancy is a global trend. According to the 2015 Statistics Office in Korea, 4.51% and 0.3% of the population aged 80 to 89 years and 90 to 99 years.

Gallstone disease is one of the most common and costly of all digestive diseases. The prevalence of gallstones increases with age; the prevalence ranges from 20% to 30% in patients aged ≥60 years [1] and increases to 80% in institutionalized individuals aged ≥90 years in the United States [2].

Thus, the number of acute cholecystitis (AC) in the elderly is increasing. In young and otherwise healthy patients, early cholecystectomy including laparoscopic or open is considered as the standard treatment of AC. However, whether early cholecystectomy is desirable in elderly patients with AC remains controversial. Surgical treatment for elderly patients with AC represents a complex challenge due to the increased potential risk of perioperative morbidity and mortality. Elderly patients may have many comorbid conditions, which are associated with increased postoperative complications such as bleeding, bile leakage, cardiac and lung problem [3,4].

Thus, alternative treatments such as percutaneous transhepatic gallbladder drainage and antibiotic therapy should be performed first in patients with a high risk of cholecystitis and surgery, and they are expected to reduce postoperative complications and mortality.

Although many studies have demonstrated the advantages of perioperative outcomes of early cholecystectomy in elderly and younger patients, several of them showed no difference in postoperative morbidity or mortality [5,6]. A recent meta-analysis of systematic review has shown that careful selection of elderly patients contributes to a better perioperative outcome, but there is no uniform guidance on selection or preoperative assessment [7]. In particular, few studies have investigated laparoscopic cholecystectomy in patients older than 80 years, despite the increasing prevalence [8].

The article of Kim et al. [9] in the current issue is to assess the outcomes of cholecystectomy in octogenarians and nonagenarians with AC. The incidences of postoperative complications in the octogenarian (80–89 years, 352 patients ) and nonagenarian groups (90–99 years, 41 patients) were as follows: pneumonia, 5.7% and 7.3%; bleeding, 1.7% and 2.4%; gastrointestinal symptoms,6.0% and 2.4%; and bile leakage, 0.6% and 2.4%, respectively.

This study was a retrospective study comprised of a small sample size in study group, which may have introduced surgeon’s selection bias. Furthermore, the length of hospital stay was not measured. Despite these limitations, the study demonstrated that cholecystectomy is a safe and efficient procedure for the treatment of AC in both octogenarians and nonagenarians. However, a large-scale prospective or randomized controlled trial study are warranted for standard treatment of AC in elderly patients.