Comprehensive treatment of calculous cholecystitis associated with surgery-requiring diseases of other organs

Experience of performance of concurrent operations in 124 patients with chronic and acute calculous cholecistitis (CC) in presence of concurrent surgical diseases was summarized. Application of oblique minilaparotomic access in right subcostal region without m. rectus abdomini intersection had permitted after the cholecystectomy performance to broaden the indications for the concordant operative interventions performance using other surgical accesses. Inexpediency of doing of surgical interventions on stomach, n. vagi in CC and noncomplicated gastroduodenal ulcer disease in favor of medicinal therapy were substantiated.     

Diagnostics and treatment of postcholecystectomy biliary complications

The study concerns early postoperative bile leak and obstructive jaundice syndrome after cholecystectomy. 4865 patients were included in the study. The initial cholecystectomy was performed through the traditional laparotomy (n=2122), minilaparotomic access (n=1024) and laparoscopic access (n=1710). Early biliary complications were registered in 135 (2,8%) patients, of whom 47 had bile leak and 88 develop obstructive jaundice. The external drainage bile leak was registered in 0,68%; bile leak trough the trained common bile duct had 0,17% and bile leak into the abdominal cavity had 0,12% of these patients. In 17 cases the bile leak was caused by the cystic duct stump insufficiency, 12 cases were caused by bile leak from the gall bladder bed. 73,5% of bile leak were caused by misdiagnosed choledocholithiasis and papilla Vateri stenosis. Obstructive jaundice in early postoperative period was determined by underdiagnosed bile ductal pathology in the majority of patients (84 patients of 88). The main diagnostic method of biliary complications was the retrograde cholangiopancreaticography with the efficacy of 99,2%. Endoscopic transpapillary operations were curative in 97% of cases. Complications after endoscopic manipulations developed in 3,3%, all of them were successfully conservatively treated.     

Outcomes analysis of laparoscopic cholecystectomy in the extremely elderly

BACKGROUND: A study was conducted to determine whether extremely elderly patients, age 80 years or older, were at higher risk for adverse outcomes from laparoscopic cholecystectomy than patients younger than 80 years. METHODS: Laparoscopic cholecystectomy was attempted in 421 patients age 65 years or older from 1989 through 1999. The patients were divided into two groups: group 1 (age 65-79 years; n = 351) and group 2 (age, 80-95 years; n = 70). A prospective database was analyzed for mean +/- standard deviation and using Student's t-test and chi-square analysis. RESULTS: Advanced age (group 2) was associated with a higher mean American Society of Anesthesiology (ASA) class (2.7 vs 2.3; p < 0.001) and a greater incidence of common bile duct stones (43% vs 26%; p < 0.01), as compared with those of younger age (group 1). Mean operative times in group 2 were 106 +/- 45 min as compared with 96 +/- 38 min in group 1, a difference that is not significant. The extremely elderly (group 2) had a four-fold higher rate of conversion to open cholecystectomy (16% vs 4%) and a longer mean postoperative hospital stay (2.1 vs 1.4 days). Grades 1 and 2 complications also were more common in group 2: grade 1: group 1, 8.8% vs group 2, 17% and grade 2: group 1, 4.3% vs group 2, 7.1% (p < 0.05). One patient in group 1 had a myocardial infarction 13 days postoperatively, and two deaths occurred in the extremely elderly group within 30 days postoperatively. CONCLUSIONS: Laparoscopic cholecystectomy in the extremely elderly is associated with more complications and a higher rate of conversion to open cholecystectomy than in elderly individuals younger than 80 years. The greater chance of encountering a severely inflamed or scarred gallbladder and common bile duct stones as well as increasing comorbidities likely account for these differences in outcome.     

Laparoscopic surgery for acute cholecystitis in the elderly. Our experience

Acute cholecystitis in the elderly is a severe illness with high operative risks and mortality, which, even if less than in the past, is still too high. The surgical approach has significantly changed over the past 10 years: conservative therapy in the early 1990's was considered the only sure approach, while the laparoscopic surgical approach is recommended today for the emergency treatment of acute cholecystitis, also in the elderly. The aim of this retrospective study was to define the safety and effectiveness of early surgery for acute cholecystitis with the laparoscopic approach in the elderly. From September 2002 to September 2006, 287 patients were admitted to our unit for cholelithiasis, including 135 for acute cholecystitis. The patients with acute illness and age > 70 yrs numbered 73. After immediate monitoring of vital parameters and a brief diagnostic and therapeutic interval to restore the patient's general condition in intensive care (fasting, SNG, antibiotics, parenteral fluid therapy and analgesic drugs) all patients underwent emergency surgery within 24-96 hours. Fifty-nine (80.8%) underwent laparoscopic cholecystectomy, whereas the remaining 14 (19.2%) underwent open cholecystectomy due to their high-risk for cardiovascular, respiratory and metabolic status (ASA III-IV). In group 1 treated laparoscopically, morbidity was 11.9% versus 35.7% in group 2 treated with open cholecystectomy (p < 0.001). Mortality was 0 in group 1; and 7% (1 patient) in group 2 (p < 0.05). The median hospital stay was 3.87 (2-9) days in group 1 vs 10.5 (8-29) days in group 2 (p < 0.001). The results of our study confirm the safety and effectiveness of laparoscopic cholecystectomy in expert hands in the management of acute cholecystitis in elderly patients. This choice allowed a statistically significant reduction in morbidity and overall hospital stay. Nevertheless, open cholecystectomy remains a valuable procedure for high-risk elderly patients undergoing emergency surgery. Poor outcome is related to the almost constant presence of comorbidity in the elderly = ASA score (ASA II vs. IV: p < 0.001) and independent of the type of surgical intervention (laparoscopic cholecystectomy vs open cholecystecotmy: p = n.s.). Early cholecystectomy in case of symptomatic cholelithiasis, before infectious complications set in, could partly reduce the poor prognosis in the elderly.     

Acute gallstone cholecystitis in the elderly

BACKGROUND: The treatment of acute cholecystitis in the elderly is still a subject of debate, particularly with reference to the timing of surgery and the role of laparoscopy. PATIENTS: From January 1994 to June 2002 we observed 27 patients aged over 70 years with acute calcolous cholecystitis. The patients were submitted to ultrasonographic percutaneous cholecystostomy within 12 h of the acute attack. For two patients (7.4%) at high operative risk, we chose a conservative treatment. Twenty-five patients (92.6%) were submitted, in 15 cases (60%) within 5 days and in 10 patients (40%) within 8 days, to a laparoscopic cholecystectomy. Statistical significance was accepted when the value of p was less than 0.05. RESULTS: Ultrasonographic percutaneous cholecystostomy was performed successfully in all patients, without major morbidity or mortality, and complete resolution of clinical symptoms was obtained within 48 h. The conversion rate of laparoscopy was 20% (13.3% in patients submitted to surgery within 5 days and 30% in the group submitted within 8 days--p > 0.05). The postoperative morbidity rate was 24%; it was higher (40% versus 15%) in patients converted to laparotomy (p > 0.05); mortality was 4%. The period of hospitalization was 11 days in patients operated laparoscopically and 21 days in those converted to open cholecystectomy (p < 0.001). CONCLUSIONS: The more rational treatment of acute calcolous cholecystitis in elderly patients is represented by ultrasonographic percutaneous cholecystostomy followed, within 5 days, by laparoscopic cholecystectomy using an abdominal insufflation maximum to 12 mmHg and a limited 10-15 degrees head-up tilt.     

Laparoscopic cholecystectomy is safe but underused in the elderly

Studies confirm that laparoscopic cholecystectomy (LC) is safe and efficacious for elderly patients. The purposes of this study were to evaluate if LC is underused in the elderly and if it is a safe option in that group. Open cholecystectomy (OC) and LC were compared in nonelderly (40 to 64 years) and elderly (65 years or older) matched patient groups identified with gallbladder disease using the American College of Surgeons National Surgical Quality Improvement Program database (2005 to 2008). Length of stay (LOS), 30-day complications, and mortality were evaluated as outcomes. Using multivariate logistic regression, independent predictors of OC were identified. After case-matching, each group had 11,926 patients. A χ(2) test showed that elderly (20.1 vs 15.0%, P < 0.001) were more likely to undergo OC. Elderly patients had significantly higher comorbidities and were operated on as emergent case (all P < 0.05). OC had longer LOS and mortality (all P < 0.05). Among 10 other variables in logistic regression, elderly had a higher likelihood of receiving OC (OR, 1.299; P < 0 0.001). Significant disparity exists between elderly and nonelderly patients in use of LC surgery. LC has a lower complication rate than OC; however, elderly undergo LC less often. Awareness needs to be raised for offering earlier operative intervention and the superior results of LC in the elderly.     

Videoendoscopic surgery of cholelythiasis in elderly patients

43 patients aged 60-84 years were operated on calculous cholecystitis. Patients were divided according to the operative technique: laparoscopic and traditional. The laparoscopic cholecystectomy demonstrated good early results. The goal of the study was to define criteria of the elderly patients selection for the laparoscopic operation.     

Laparoscopic versus open cholecystectomy: a prospective comparative study in the elderly with acute cholecystitis

The aim of this prospective comparative study was to determine the feasibility and the efficacy of laparoscopic cholecystectomy for acute cholecystitis in patients older than 75 years of age and to compare the results with those of open cholecystectomy. From January 1992 to December 1999, 139 patients older than 75 years of age underwent cholecystectomy for acute cholecystitis. The two groups of patients with cholecystolithiasis included 50 patients who underwent laparoscopic cholecystectomy (group 1) and 89 patients who underwent open cholecystectomy (group 2). Group 1 consisted of 30 women and 20 men, with a mean age of 81.9 years (range, 75-98). Group 2 consisted of 51 women and 38 men, with a mean age of 81.9 years (range, 75-93). There was no difference in the American Society of Anesthesiologists classification in both groups. The length of the surgery (103.3 vs. 149.7 minutes), postoperative length of stay (7.7 vs. 12.7 days), and inpatient rehabilitation (15 vs. 42 patients) were significantly shorter in group 1 than in group 2. The postoperative morbidity rate was not different between the groups. There was no mortality in group 1, but four patients died in group 2 (P = 0.29). The conversion rate was 32% (n = 16) in group 1. In summary, laparoscopic cholecystectomy in elderly patients with acute cholecystitis is safe and effective. Laparoscopic cholecystectomy in elderly patients restores them to the best possible quality of life with the lowest cost to them physiologically.     

Acute cholecystitis: when is the best time for laparoscopic cholecystectomy?

Laparoscopic cholecystectomy is no more an elective procedure. The question is when to perform laparoscopic cholecystectomy in the face of acute cholecystitis. The last decade (1995-2004) 297 patients had a laparoscopic cholecystectomy for acute cholecystitis. One hundred forty six of them were operated in the first 24-48h after the onset of symptoms (group I), 68 were operated in less than 4 weeks time after the attack of the acute cholecystitis (group II), while the rest 83 patients had a history of acute cholecystitis at least four weeks before their elective laparoscopic cholecystectomy (group III). Analysis of the operative time, complications and hospital stay showed that laparoscopic cholecystectomy in acute cholecystitis is the recommended surgical procedure. The success of the operation depends on the degree of the inflammatory changes in the gallbladder and the expertise of the operator both in emergency and laparoscopic surgery. Timing of the operation is crucial to executing a successful procedure. The operation is easier, faster and safer when performed in first 4-5 days of the onset of symptoms.     

腹腔镜与开腹胆囊切除术对老年患者术后应激反应和疲劳综合征影响的对比研究

目的:对比分析腹腔镜与开腹胆囊切除术时老年患者术后应激反应和术后疲劳综合征的影响,为腹腔镜胆囊切除术治疗胆囊结石的老年患者是否具有优越性提供客观依据.方法:筛选符合适应证的胆囊结石患者40例,随机分为腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）组和开腹胆囊切除术(open chol...     

老年人腹腔镜胆囊切除术的特点

目的 探索老年人LC的特点及围手术期处理。方法 回顾性分析了266例老年人(≥65岁)行腹腔镜胆囊切除术(LC)的手术时间、中转剖腹手术例数、住院天、手术并发症、围手术期肺功能和血气分析变化,分别与中青年病人LC及老年病人剖腹胆囊切除术(OC)比较。结果 老年人LC平均手术时间(39分)、手术中转率(5.6％)、手术并发症(5.3％)均高于中青年LC患者,而明显低于OC的老年病人,且并发症较轻。但老年人LC后的肺功能减退(10.2％)和高碳酸血症(20.3％)明显多于OC,多数可在术后短时间内恢复。结论 老年人LC仍不失为一种损伤小、安全可靠和恢复快的理想手术方法,但要针对老年病人的特点以及LC可能引起的肺功能下降和高碳酸血症,做好术前处理、术中及术后监测和并发症的预防。     

Laparoscopic cholecystectomy after age 75]

AIM OF THE STUDY: The aim of this prospective study was to determine the feasibility, complications and benefits of laparoscopic cholecystectomy in the patients over 75 years of age. METHODS: From January 1992 to July 1998, among the 863 patients who underwent laparoscopic cholecystectomy, 102 patients over 75 years (group I) were compared to 761 younger patients (group II). RESULTS: The conversion rate was 22% in group I versus 13% in group II (P = 0.017). Mortality and morbidity rates were respectively 1% and 13.7% in elderly patients versus 0 and 6.6% in younger patients (P = 0.009). Mean length of hospital stay was higher in group I: 6.9 versus 4.5 d in group II (P < 10(-6)). CONCLUSIONS: Laparoscopic cholecystectomy is feasible in patients above 75 for the treatment of symptomatic gallstones and acute cholecystitis with a low morbidity rate.     

Combined operations for cholelithiasis]

The experience of 1560 combined operations performed in N.N.Burdenko clinic from 1974 to March 1999 for cholelithiasis is analysed. The results of 7461 cholecystectomies are analysed depending on patients' age (17.8% of patients aged 65 years and older), urgency of the operations (there were 35.6% of patients of this age group who underwent surgery under strictly urgent conditions), and complicacy of the operation (combined operations were carried out in 837 patients with cholecystitis). Last years in the clinic each 10th cholecystectomy is carried out as an additional procedure in more complicated surgery, or it is combined with less complicated one. Thus, in 389 patients with more complicated diseases than cholelithiasis (approximately in a half of them tumors of various locations were observed), cholecystectomy was performed as a combined procedure (1st group), and in 448 patients (2nd group) it was the main procedure. In the 1st group 27% of patients were aged 65 years and older, the overwhelming majority of the operations were carried out by the same approach, mortality rate being 3.3%. In the 2nd group elderly patients made up 20.7%; 68.3% of patients were operated by two approaches, lethality rate being 0.2%. Thus, lethality after 837 combined operations made up 1.7%, total mortality rate after 7461 cholecystectomies made up 0.29%.     

Early surgical treatment of acute cholecystitis. A retrospective comparative study of the laparoscopic and open approaches

The aim of this retrospective study was to compare the results of laparoscopic and open early cholecystectomy in patients with acute cholecystitis. From January 1997 to October 2000, 168 patients underwent cholecystectomy in our institution. Of the 35 patients (20.8%) with acute cholecystitis, 20 patients (57.1%) were operated on laparoscopically and the other 15 patients (42.9%) with the traditional open approach. The two groups were similar in terms of age, sex and onset of symptoms. The postoperative morbidity was 15.0% in the laparoscopic group versus 40.0% in the open group. The average postoperative hospital stay in the laparoscopic group was 5.1 days as compared to 10.5 days in the open group (P = 0.013). The conversion rate to laparotomy was 5.0% (1 case). At follow-up there has been one case of incisional hernia in the open group. Early laparoscopic cholecystectomy for acute cholecystitis was associated with a lower postoperative morbidity rate and significantly earlier patient discharge.     

Cholecystitis in the octogenarian: is laparoscopic cholecystectomy the best approach?

Management of biliary disease in the octogenarian has evolved over the last decade. Laparoscopic cholecystectomy is now more commonly performed in this patient population. Octogenarians with biliary pathology frequently present with complications of acute disease such as biliary pancreatitis, choledocholithiasis, and acute cholecystitis. As a result, laparoscopic management in this patient population can frequently be more challenging than in younger patients. We retrospectively reviewed 70 patients who were 80 years of age and older who underwent cholecystectomy at our institution for biliary tract disease. Seventeen patients presented to the Day Surgery unit for elective management of chronic biliary disease. Sixteen (94%) of these patients were attempted laparoscopically and one (6%) underwent open cholecystectomy. Two patients attempted laparoscopically were converted to open surgery (conversion rate 12.5%). Average length of hospital stay was 3.7 days for those treated laparoscopically and 11 days for patients treated with open cholecystectomy. There were three complications (19%) in this group and no deaths. The remaining 53 patients presented via the emergency room with acute complications of cholelithiasis. Laparoscopic cholecystectomy was attempted in 28 (52%) and open cholecystectomy was performed in 25 (48%) patients. Ten (37%) of the patients attempted laparoscopically were converted to an open procedure. Average length of stay in this group was 11.7 days for those treated laparoscopically and 15.7 days for patients managed with open technique. There were ten (56%) complications in the laparoscopic group and five (14%) complications in the open group. There were four deaths (22%) among those treated laparoscopically and three deaths (8.6%) in the open cholecystectomy group. Comorbid conditions were common in the patients with acute biliary pathology and those presenting for elective cholecystectomy. Laparoscopic cholecystectomy is the procedure of choice in the elective management of biliary tract disease in the octogenarian. Laparoscopic cholecystectomy has no benefit with respect to morbidity and mortality over open cholecystectomy in the management of acute biliary tract disease in this elderly population. When possible, chronic cholecystitis in the elderly should be managed with elective laparoscopic cholecystectomy rather than waiting for complications to develop.     

Standard preoperative assessment can improve outcome after cholecystectomy.

OBJECTIVE: To assess the outcome of cholecystectomy after standard preoperative handling and selection of patients, focusing on the potential of the operation to eliminate biliary colic. DESIGN: Prospective study. SETTING: University Hospital, Norway. PATIENTS: 806 patients (median age 56, range 18-91 years, male:female ratio 1:2.7), were referred to our clinic for cholecystectomy between 1992 and 1996. INTERVENTIONS: Unless there was a clear indication for cholecystectomy (frequent attacks of biliary colic/or recent complications of gallstones or both), patients were investigated in a standard way to find out what else was causing the abdominal pain. MAIN OUTCOME MEASURES: Residual pain was assessed at a clinical examination three months postoperatively, and clinical condition a median of three years later was assessed by a questionnaire. RESULTS: 465 (58%) patients were operated on primarily, and an additional 29 patients were operated on after further evaluation. Three months after cholecystectomy, 35 (7%) had persistent pain, mostly caused by other specific diseases and relieved after specific treatment. A median 3 years postoperatively, only 21 (4%) reported that they still had abdominal pain. CONCLUSION: Standard selection of patient improved the outcome of cholecystectomy. Compared with a historical control group, residual pain after three months was reduced from 20% to 7%. After three years, 96% of the patients no longer had their main clinical problem.     

CT引导下经皮经肝胆囊穿刺置管引流联合择期腹腔镜胆囊切除术治疗高龄急性重症胆囊炎效果分析

目的分析CT引导下经皮经肝胆囊穿刺置管引流(PTGBD)联合择期腹腔镜胆囊切除术(LC)治疗高龄急性重症胆囊炎(SAC)的效果。方法选取2018-01-2019-12间收治的112例高龄SAC患者,对照组行急诊LC,观察组行CT引导下PTGBD联合择期LC,每组56例。比较2组的疗效。结果观察组手术时间、术中出血量,以及术后肛门排气时间、并发症发生率和住院时间均少(短)于对照组,差异均有统计学意义(P<0.05)。结论CT引导下PTGBD联合择期LC术治疗高龄SAC,安全、有效,有利于患者术后康复。     

Management of gallstone disease in the elderly

AIM: To determine the outcome of management of symptomatic gallstone disease (GSD) in patients aged 80 years or more. PATIENTS AND METHODS: A retrospective review of the outcome of 79 patients admitted to 2 district general hospitals with symptomatic GSD over a 1-year period was undertaken. Patients were grouped according to method of management: non-operative, ERCP, and cholecystectomy. POSSUM scores for the ERCP and cholecystectomy groups were calculated and observed, and predicted outcome compared. RESULTS: Obstructive jaundice and biliary colic were the most common presenting symptoms. Each patient had been admitted at least once before the study period (median, 2; range, 1-3). Outcomes are detailed in Table 1. Non-operative management failed in 18 of 23 patients, with 17.4% mortality. ERCP was successful in 40 of 47 patients with 3 complications (0.24 of predicted) and no mortality. In all, 11 laparoscopic and 12 open cholecystectomies were performed with 6 complications and 1 mortality (0.95 and 0.83 of predicted, respectively): 4 complications and the only death occurring after emergency cholecystectomy. Table 1 Outcomes Management Number Mortality Morbidity Outcome Non-operative 23 4 9 5 OK, 13 re-admitted, 4 still symptomatic ERCP 47 0 3 1 PTC, 6 operated Operative 23 1 6 Conclusions: This study suggests that recurrent GSD in elderly patients managed non-operatively may have fatal outcome. Elective cholecystectomy has acceptable morbidity and mortality in this age group and there is often ample opportunity to avoid emergency surgery, but a prospective randomised study is required to improve clinical algorithms.     

Considerations concerning laparoscopic cholecystectomy in the extremely elderly

BACKGROUND: Since octogenarians become a growing part of the population and surgical care is possible in them, this study was conducted to evaluate the outcome of laparoscopic cholecystectomy in patients 80 years of age and over. METHODS: From June 1993 to May 2006, a total of 1263 patients underwent a laparoscopic cholecystectomy, applying the four-trocar American technique; 21 among them were >/=80 years. We retrospectively reviewed patients' age, gender, indication for surgery, comorbid conditions, American Society of Anesthesiologists (ASA) score, conversion to open procedure, postoperative complications, and length of hospital stay. RESULTS: The mean age in the >/=80 group was 82.5+/-3 and 57% were women, while in the <80 group 72% of patients were women. Recurrent biliary colic was the most frequent (62%) indication for surgery among the elderly patients. Endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy were performed preoperatively in 6 elderly patients (29%); there were 4 cases of acute calculus pancreatitis and 2 cases of acute cholangitis. A high surgical risk (ASA score of III and IV) was estimated in 11 patients (52%) from the >/=80 group versus 32% in the <80 group (P =0.047). Conversion rate was higher (19%) and hospital stay was longer (4.9 days) in the >/=80 group, compared to younger patients (P =0.01). Mortality was zero and morbidity was 14% versus 3% in the <80 group (P =0.03), including 1 case of postoperative bleeding, 1 case of wound infection, and 1 case of pulmonary atelectasis, respectively. CONCLUSIONS: Laparoscopic cholecystectomy in the extremely elderly is safe and well tolerated; however, it is associated with a higher conversion rate, increased morbidity, and a longer hospital stay.     

不同年龄患者腹腔镜胆囊切除术中肾血流量变化的比较

目的 比较不同年龄患者腹腔镜胆囊切除术中肾血流量的变化.方法 择期行腹腔镜胆囊切除术患者60例,年龄18～75岁,ASA分级Ⅰ或Ⅱ级,性别不限,体重48～78 kg,根据年龄分为2组(n=30):中青年组(18～60岁)和老年组(61 ～ 75岁).经口气管插管后置入食管超声探头,分别于气腹前、气腹1、5、10、15、20、30 min、气腹结束后1和5 min时,采用经食管超声心动图测量左肾动脉主干内径(RAD)和血流速度时间积分(VTI),计算左肾血流量(LRAF),记录最大下降时间点,计算最大下降百分比.结果 与气腹前比较,两组气腹各时点和气腹结束后1 min时RAD、VTI和LRAF降低(P＜0.05).与中青年组比较,老年组气腹前LRAF降低,最大下降时间点延迟(P＜0.05),最大下降百分比差异无统计学意义(P＞0.05).结论 中青年患者和老年患者腹腔镜胆囊手术中肾血流量均发生可逆性下降;老年患者最大下降时间延迟.