Page 23 - WJOLS - Surgery Journal

Mohend AN Alshalah
statistical), operative procedure (only universal accepted group, so stronger selection of elderly patients for surgery is
procedures were selected ) and the institution where the study needed. 19
was done (specialized institution for laparoscopic surgery). Pulmonary disease is associated with increased risk of major
18
complication. The management of acute cholecystitis in the
CONTENT extremely elderly should be considered for laparoscopic
The Incidence of Cholelithiasis approach (except contraindication) before the development of
complications. 5,16
The incidence of cholelithiasis increases with age, and among
those 80 years of age, rates as high as 38 to 53% are reported Conversion Rates
with 50% of women and 15% of men. 10,14
LC is the treatment of choice for elderly patients with The conversion rate to open cholecystectomy varies from
symptomatic cholelithiasis since the outcomes are better than 3-22% and is higher in extremely elderly patients (more than
those of OC in terms of lower morbidity rate and shorter hospital 80 years) than in younger age group (between 65-79 years
5,10,11,14
stay. 11,17 old).
Patients older than 70 years had a 2-fold increase in Conversion in complicated gall stone is 22% while 2.5% in
complicated biliary tract disease. 4 chronic cholecystitis. 4
Patient > 80 years have higher gall bladder cancer than Thus, elective surgery with acceptable morbidity and
younger age group. mortality should be the preferred choice over emergency
procedures. 10,16
Laparoscopic versus Open Cholecystectomy The main surgical reasons for this conversion in the selected

For the elderly, who are generally considered to have diminished articles are acutely inflamed gallbladder with evidence of
cardiopulmonary reserves and are therefore often less able to perforation, gangrene, chronic inflammation around the
withstand the trauma and stress of open abdominal surgery, gallbladder with fibrosis and adhesions; unclear anatomical
the advantages of a laparoscopic approach are obvious. features; previous abdominal surgery, bleeding; and unexpected
Morbidity in LC in elderly patients demonstrated from CBD stones. 10, 16, 19 But the higher incidence of co-morbidities,
5-15% ,while in OC 23 -28%. and acute cholecystitis are the main reasons for the poorer
Mortality in LC in elderly patients demonstrated from outcome in elderly patients.
0-1% while in OC 1.5-2%. 11
There was only a 14% incidence of cardiopulmonary Risk of Anesthesia
complications in those undergoing LC compared with 43% in
patients who underwent OC although both procedures were The extremely elderly patients had a significantly higher mean
completed in a similar operative time. American society of anesthesiology (ASA) class as compared
with younger age group, and a much greater percentage of
Hospital Stay extremely elderly patients were ASA class 3 or 4. 4 ,7,9,11,15
42% of elderly patients have already cardiopulmonary
The average hospital stay was 3 to 4 days. 5,10 The laparoscopic diseases. 12,19
approach was associated with a shorter hospitalization and
fewer postoperative complications than the open procedure. 16 For LC for patients with an ASA 3 and 4 risk for anesthesia,
However, elderly patients may have an increased risk for no significant adverse effects could be attributed to CO 2
10,12,13
conversion. 10, 14-17, 20 pneumoperitoneum.
Gradual abdominal insufflations to 12 mm Hg followed by
Urgent or Emergent LC 10° head up tilt associated with cardiovascular stability in elderly
ASA III patients. 2,12
In extremely elderly age group presentations with urgent or
emergent surgery more common than younger age group. 15,16 For high-risk patients, preoperative preparation and active
Emergency surgery on older patients with gallstones may perioperative monitoring are essential for safe anesthesia for
have fatal outcome due to increased co morbidities and decreased LC with or without CO PP. 13
2
functional reserve. 10,16 Regional and international variation in the practice of LC
17
Major postoperative complications may occur in emergency for acute cholecystitis. The use of LC for elderly patients with
surgery in elderly patients. acute cholecystitis in New England, US, varies widely from 30.3
6
Conversion rate 8% less than 65 years, and reach 22%in to 75.5%. Reflection of the technical difficulty of the procedure,
more than 65 years due to increased inflammation and fibrosis. concern about increased risks. The likelihood of elderly patients
In acute cholecystitis, higher rate of morbidity and mortality with acute cholecystitis receiving LC depends strongly on where
unrelated to surgical site when compared with younger age they live. 1

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