Page 8 - World Journal of Laparoscopic Surgery

Laparoscopic Cholecystectomy in Elderly Patients
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was above 70 years. Although in epidemiological studies, the incidence of bleed has been reported to be nearly 10%, irrespective
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prevalence of disease is reported to rise in conjunction with age, of the age of the patients. So this suggests that the procedure
in our study, an inverse trend in age distribution with respect to does not carry any extra risk of bleeding in elderly people. Difficulty
the number of procedures (Table 1) reflects that lesser number in extraction of gallbladder was experienced in seven (15.55%)
of laparoscopic surgeries was conducted in higher age-groups. patients. This was due to the either large number or large size of
This can be justified by reports that laparoscopic surgery in stones. Spillage of stones occurred in these patients. The procedure
elderly patients becomes more challenging due to the unique had to be converted to open in 13.33% (6 patients) and the final
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physiological demands of the procedure and also the ASA score outcome was without any complication. This figure is higher than
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(American Society of Anesthesiologists score) increases with age, a standard conversion rate of 5–10%, mentioned in literature but
increasing the risk of anesthesia. 9,10 All the patients who underwent comparable to a figure, i.e., 14.7% mentioned in another study
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laparoscopic cholecystectomy had an ASA score of I or II, including upon elderly patients. The conversion was due to multiple and
those 17 patients (37.77%) who had comorbid conditions, i.e., concomitant intraoperative difficulties, i.e., poor visualization of
hypertension and diabetes mellitus. So this suggests the patient anatomy, adhesions, intraoperative bleeding from cystic artery
selection pattern, i.e., only those patients who qualified the risk or gallbladder fossa, which has been mentioned as an important
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criteria were selected for the procedure. cause by other studies also. Operative procedure was uneventful
In a considerable number of patients, i.e., 16 (35.55%), one or in 29 patients. The mean operative time for all these patients was
multiple difficulties were encountered intraoperatively as shown in 80 minutes, which is in accordance with the mean 75 minutes in a
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the Venn diagram (Fig. 1). This has been reported in literature also similar study. This suggests that the procedure involves operative
that elderly patients suffer from repeated inflammation, resulting difficulties in a significant proportion of elderly patients due to the
in adhering to the surrounding structures, rendering laparoscopic chronicity of disease. Despite operative difficulties encountered in
surgery difficult. 11,12 We found that 13 patients (28.88%) had difficult 16 cases, in 62.5% cases operative challenges could be successfully
anatomy of Calot’s triangle and in 5 patients (11.11%) dense adhesions managed. We did not find any reporting of iatrogenic injury to
were found with omentum, colon, and duodenum. Intraoperatively visceral organ, major blood vessel, or bile duct. Therefore, more
uncontrolled bleeding occurred in 5 patients (11.11%). This occurred operative difficulties and comparatively higher conversion rate
from gallbladder fossa in two patients and cystic artery in three cannot be interpreted as a lack of procedural safety.
patients. This figure is in agreement with other series, in which the Average hospital stay was 2.5 days. In terms of morbidity and
mortality, we had a low complication rate. Postoperatively, one
Table 1: Distribution of patients according to age patient had a minor bile leak which was managed by endoscopic
Age-group (years) No. of procedures retrograde cholangiopancreatography (ERCP) and common bile
60–65 18 duct (CBD) stenting. Intraoperatively or postoperatively none of
the patients developed any cardiac or respiratory complication
66–70 19 and no mortality occurred. Although in some comparative studies
71–75 6 of elderly vs young patients a higher morbidity has been reported
75–80 2 in elderly patients, a low complication rate has been reported
17
18
Total = 45 by Marcari et al. even in octogenarians. Therefore, age is not a
contraindication for the procedure. Patient selection, considering
risk and comorbid conditions besides timely conversion of the
procedure, and weighing the intraoperative difficulties affect the
outcomes of procedure. This study being retrospective in nature,
exclusion and inclusion criteria, i.e., proper selection criteria, could
not be determined exactly, and this was the limitation of the study.
Further studies are required to determine patient selection criteria
and hence to improve the outcome of the procedure.
conclusIon
Procedure of laparoscopic cholecystectomy is safe in elderly
patients. Operative challenges can be managed by adequate
experience and timely conversion. Proper patient selection by
preoperative assessment can minimize the risk of complications.
references
1. Coelho JC, Bonilha R, Pitaki SA, et al. Prevalence of gallstones in a
Brazilian population. Int Surg 1999;84(1):25–28.
2. Festi D, Dormi A, Capodicasa S, et al. Incidence of gallstone disease in
Italy: results from a multicenter, population-based Italian study. World
J Gastroenterol 2008;14(34):5282–5289. DOI: 10.3748/wjg.14.5282.
3. Völzke H, Baumeister SE, Alte D. Independent risk factors for gallstone
formation in a region with high cholelithiasis prevalence. Digestion
2005;71(2):97–105. DOI: 10.1159/000084525.
4. Bergamaschi R, Arnaud J. Immediately recognizable benefits and
drawbacks after laparoscopic colon resection for benign disease.
Fig. 1: Intraoperative difficulties Surg Endosc 1997;11(8):802–804. DOI: 10.1007/s004649900457.

94 World Journal of Laparoscopic Surgery, Volume 12 Issue 3 (September–December 2019)