Langzeitergebnisse nach Operation eines Bauchaortenaneurysmas im Alter über 80 Jahre

Abdominal aortic aneurysm repair in patients 80 years of age and older (82.3 ± 2.0 years) was performed in 51 patients over a period of 10 years from 1985 to 1995; 34 of these patients underwent elective aneurysm repair and 17 emergency operations for rupture. Of these 51 patients, 50 cases were reviewed for long-term survival, and 44 case reports were reviewed for preoperative risk factors, postoperative complications, discharge to nursing homes and duration of hospitalisation. After 30 days, the mortality for asymptomatic or symptomatic intact aneurysm repair was 5.9%; in the case of emergency repair for rupture the mortality was 64.7%. After elective operations 9.4% of the patients were discharged to nursing homes. All patients who survived emergency operations went on to live normal lives in their previous housing areas. The survival probability was 81% for 1 year, 56% for 3 years, and 42% for 5 years. After surviving the emergency operation, life expectancy was similar to the group of elective aneurysm repair. The analysis did not show any risk factors with predictive value for long-term survival after elective surgery. The results justify elective abdominal aneurysm repair in octogenarians. Even in the case of aneurysm rupture every patient should be operated on. The mortality in elective surgery did not differ very much from that of other patients younger than 80 years old, and life expectancy after surgery was similar to the general population of 80 years of age and older.     

Final 12-year follow-up of surgery versus surveillance in the UK Small Aneurysm Trial

BACKGROUND: The aim was to determine whether early open surgical repair would benefit patients with small abdominal aortic aneurysm compared with surveillance on long-term follow-up. METHODS: The 1090 patients who were enrolled into the UK Small Aneurysm Trial between 1991 and 1995 were followed up for aneurysm repair and mortality until November 2005. RESULTS: By November 2005, 714 patients (65.5 per cent) had died, 929 (85.2 per cent) had undergone aneurysm repair, 150 (13.8 per cent) had died without aneurysm repair and 11 (1.0 per cent) remained alive without aneurysm repair. After 12 years, mortality in the surgery and surveillance groups was 63.9 and 67.3 per cent respectively, unadjusted hazard ratio 0.90 (P = 0.139). Three-quarters of the surveillance group eventually had aneurysm repair, with a 30-day elective mortality of 6.3 per cent (versus 5.0 per cent in the early surgery group, P = 0.366). Estimates suggested that the cost of treatment was 17 per cent higher in the early surgery group, with a mean difference of 1326 pounds. The death rate in these patients was about twice that in the population matched for age and sex. CONCLUSION: There was no long-term survival benefit of early elective open repair of small abdominal aortic aneurysms. Even after successful aneurysm repair, the mortality among these patients was higher than in the general population.     

Surgical treatment of abdominal aortic aneurysm in the high-risk patient.

In an attempt to define the preoperative risk factors that predictably influence mortality after aneurysmectomy, this study reviews the surgical management of abdominal aortic aneurysms in a series of 110 consecutive patients who underwent elective resection. The preoperative risks to be added to the present study included pulmonary insufficiency, renal dysfunction, advanced age of over 80 years, ischemic heart disease, and associated other diseases such as thoracic aneurysms, atherosclerosis of the limbs and malignant tumors. Forty-six patients had one of these risk factors (one-risk group), 17 had two (two-risk group), and 9 had three (three-risk group). The operative mortality rates were 4.2 per cent for the high-risk patients and 0 per cent for the patients at no risk. As the number of risk factors increased, aneurysm repair was associated with an increased operative mortality; being 2.2 per cent in the one-risk group, 5.9 per cent in the two-risk group and 11.1 per cent in the three-risk group. The common risk factor in patients who died after aneurysmectomy was pulmonary insufficiency which induced prolonged periods of assisted ventilation. Thus, the optimal management of high-risk patients, particularly those with pulmonary insufficiency, may reduce the mortality after aneurysmectomy.     

Impact of vascular surgery on community mortality from ruptured aortic aneurysms

The workload of aortic surgery in a district increased fourfold over 10 years as the incidence of aneurysm rupture rose from 7 to 17/100,000. Of 260 patients with ruptured aneurysms 101 reached hospital alive (38 per cent) of which 52 (52 per cent) survived, an overall survival rate of 19.8 per cent. Despite increasing experience, mortality after emergency surgery did not improve, suggesting outcome was largely determined by the patient's condition and age. Only 5 of 90 patients aged over 75 survived aortic rupture at home. In consequence overall community mortality did not improve in the period studied. Survival after elective surgery was 95 per cent, suggesting that efforts to improve survival should be directed towards identifying and treating the disease before rupture occurs. The commonly stated figure of 50 per cent survival for ruptured aortic aneurysms is an overestimate, due to neglect of patients dying at home.     

Endovascular treatment of thoracic aortic diseases: combined experience from the EUROSTAR and United Kingdom Thoracic Endograft registries

PURPOSE: The objective of this study was to assess the initial and 1-year outcome of endovascular treatment of thoracic aortic aneurysms and dissections collated in the European Collaborators on Stent Graft Techniques for Thoracic Aortic Aneurysm and Dissection Repair (EUROSTAR) and the United Kingdom Thoracic Endograft registries. METHODS: Four hundred forty-three patients underwent endovascular repair of thoracic aortic disease between September 1997 and August 2003 (EUROSTAR, 340 patients; UK, 103 patients). Patients represented 4 major disease groups: degenerative aneurysm (n = 249), aortic dissection (n = 131), false anastomotic aneurysm (n = 13), and traumatic aortic injury (n = 50). RESULTS: Mean age in the entire study group was 63 years. Fifty-two percent of patients were deemed at high risk for open surgery because of major comorbidity. Sixty percent of patients underwent an elective procedure, and 35% required emergency treatment. Conventional indications for treatment of aortic dissection, including aortic expansion, continuous pain, rupture, or symptoms of branch occlusion constituted the basis for endograft placement in 57% of patients, whereas in 43% of patients aortic dissections were asymptomatic. Primary technical success was obtained in 87% of patients with degenerative aneurysm and in 89% with aortic dissection. Paraplegia was a postoperative complication in 4.0% of patients with degenerative aneurysm and 0.8% of patients with aortic dissection (not significant). Thirty-day mortality in the entire study group was 9.3%, with mortality rates after elective procedures of 5.3% for degenerative aneurysms and 6.5% for aortic dissection. Mortality for degenerative aneurysm after emergency repair was higher (28%; P <.0001) then after elective procedures. For aortic dissection the emergency repair rate was 12% (not significant compared with elective repair of aortic dissection, and P = .025 compared with emergency repair of degenerative aneurysm). One-year follow-up was complete in 195 patients. The outcome at 1 year was more favorable for aortic dissection than for degenerative aneurysm with regard to aortic expansion (0% vs 15%; P = .001) and late survival (90% vs 80%; P = .048). In the groups with false anastomotic aneurysm and traumatic aortic injury, 30-day mortality rates were 8% and 6%, respectively. CONCLUSION: This multicenter experience demonstrates acceptable rates for operative mortality and paraplegia after endovascular repair of thoracic aortic disease. Outcome after 30 days and 1 year was more favorable for aortic dissection than for degenerative aneurysm. However, the durability of this technique is currently unknown, and continued use of registries should provide data from long-term follow-up.     

Surgical treatment of abdominal aortic aneurysm in the high-risk patient

In an attempt to define the preoperative risk factors that predictably influence mortality after aneurysmectomy, this study reviews the surgical management of abdominal aortic aneurysms in a series of 110 consecutive patients who underwent elective resection. The preoperative risks to be added to the present study included pulmonary insufficiency, renal dysfunction, advanced age of over 80 years, ischemic heart disease, and associated other diseases such as thoracic aneurysms, atherosclerosis of the limbs and malignant tumors. Forty-six patients had one of these risk factors (one-risk group), 17 had two (two-risk group), and 9 had three (three-risk group). The operative mortality rates were 4.2 per cent for the high-risk patients and 0 per cent for the patients at no risk. As the number of risk factors increased, aneurysm repair was associated with an increased operative mortality; being 2.2 per cent in the one-risk group, 5.9 per cent in the two-risk group and 11.1 per cent in the three-risk group. The common risk factor in patients who died after aneurysmectomy was pulmonary insufficiency which induced prolonged periods of assisted ventilation. Thus, the optimal management of high-risk patients, particularly those with pulmonary insufficiency, may reduce the mortality after aneurysmectomy. This paper was presented at the Nineteenth Annual Meeting of the Japanese Society for Cardiovascular Surgery held in Sapporo, Japan, on June 8–9, 1989     

Abdominal aortic aneurysms in Western Australia: descriptive epidemiology and patterns of rupture

All abdominal aortic aneurysms presenting to hospitals and coroners in Western Australia over an 11-year period (January 1971 to December 1981) have been reviewed. A total of 1237 abdominal aortic aneurysms were found. After age and sex standardization it was apparent that the prevalence of diagnosis of abdominal aortic aneurysms had increased from 74.8 per 100 000 to 117.2 per 100 000 for men over 55 years of age (increase of 56.7 per cent) and from 17.5 per 100 000 to 33.9 per 100 000 for women over 55 years of age (increase of 93.7 per cent) during this period. One hundred and twenty-three patients were identified by coroner's autopsy after sudden death from ruptured abdominal aortic aneurysms in whom there had been no previous diagnosis of abdominal aortic aneurysm. Between 1971 to 1981, 478 patients underwent surgery; 225 had elective resection of their aneurysm with a 4.0 per cent fatality rate, and 253 had emergency operations with a 31.2 per cent fatality rate. Seasonal variations contributing to the date of emergency presentation or death from rupture of abdominal aortic aneurysms indicated a possible influence of colder weather upon rupture. It is hoped that the information provided in this paper will be of use to surgeons and physicians involved in health care planning for similar populations.     

Risk factors for postoperative death following elective surgical repair of abdominal aortic aneurysm: results from the UK Small Aneurysm Trial. On behalf of the UK Small Aneurysm Trial participants

BACKGROUND: In regional and population studies, the mortality rate within 30 days of elective surgical repair of abdominal aortic aneurysm is approximately 8 per cent. Identification of preoperative factors associated with this mortality risk is important for informing surgical policy and may suggest suitable preoperative interventions. METHODS: In the UK Small Aneurysm Trial, 820 patients aged 60-80 years underwent elective open surgical repair of an abdominal aortic aneurysm. The relationship between 30-day mortality rate and 13 prespecified potential prognostic factors was investigated. The value of a published clinical prediction rule was also evaluated. RESULTS: The postoperative mortality rate was 5.6 per cent overall (46 deaths in 820 patients). Postoperative mortality risk was significantly associated with older age (P = 0. 03), higher serum creatinine level (P = 0.002) and lower forced expiratory volume in 1 s (FEV1) (P = 0.003) in univariate analyses. Evidence of a relationship between age and postoperative death was weakened (P = 0.08) after adjustment for creatinine level and FEV1. The predicted postoperative mortality risk ranged from 2.7 per cent in younger patients with below average creatinine levels and above average FEV1, to 7.8 per cent in older patients with above average creatinine levels and below average FEV1. The published clinical prediction rule did not validate well on these data; observed risk did not correlate with predicted risk except for a small group of high-risk patients. CONCLUSION: Poor preoperative lung and renal function was strongly associated with postoperative death. Age was less important once these two important prognostic factors had been taken into account. The potential for preoperative improvement in lung and renal function to reduce postoperative mortality rates should be addressed in future studies.     

Abdominal aortic aneurysmectomy in octogenarian patients

The authors report 56 patients. 80 years of age or older who had an abdominal aortic aneurysm (AAA): twenty seven were operated upon as emergencies, 7 with intra-peritoneal (Group I) and 20 with retro-peritoneal rupture (Group II). Twenty nine underwent elective surgery (Group III). Renal pulmonary and cardiac disease are frequent in octogenarian patients. The surgical repair consisted of 40 knitted bifurcated grafts and 16 aorto-aortic woven grafts. The overall in-hospital mortality rate is high (28.5%: 16 patients) essentially in "emergency" surgery: 71% for the seven Group I patients and 45% for the twenty Group II patients. The in-hospital mortality rate of 6.9% for the Group III of "elective" procedure is higher than the mortality rate of patients of all ages operated on for asymptomatic AAA in our institution which is 4.3%. Once a patient has been operated on successfully his life expectancy tends to parallel that of a normal population for his age group. These results can be improved with preventive measures such as elective surgery for asymptomatic AAA with a diameter of 6 cm or more. Operative contraindications are severe congestive heart failure, advanced pulmonary disease or neoplastic disease. The age "per se" is not a contraindication to aneurysmectomy. Physiologic rather than chronologic age should determine the selection for AAA in the over-80 age group. CT scans and MR are safe fast and non-invasive preoperative examinations for AAA.     

Abdominal aortic aneurysm

Between 1981 and 1986, 282 cases of abdominal aortic aneurysm were diagnosed in Waltham Forest. Rupture had occurred in 183, 15 underwent urgent operation for intact aneurysm, and 84 had elective surgery. The incidence of rupture increased from 13 to 21 per 100,000 population during the 6-year period. Operative mortality for patients with rupture was 54.7 per cent, but the mortality overall was 81.4 per cent. In 59 per cent of patients with rupture no operation was performed, and 35.0 per cent of all deaths occurred in the community. The mortality for rupture in women was significantly higher than in men, although the operative mortality was comparable. Fifty patients (27 per cent) were found to have attended hospital within 2 years of rupture and many had documented evidence of an aneurysm. One-third of all patients admitted with rupture were undiagnosed. This study complements the previous small number of community studies and suggests that the incidence of rupture is increasing nationally particularly in women, where the mortality was exceptionally high. Early elective surgery is the key to the problem and improved clinical awareness could save many patients without elaborate and expensive programmes to screen the 'at risk' population.     

Surgical treatment of abdominal aortic aneurysms of octogenarians

The purpose of this study was to determine whether elective abdominal aortic aneurysmectomy in octogenarians is justified or may even be advisable. Between January 1986 and August 1993, 30 octogenarians of mean age 83.1 (range 80–93) years underwent abdominal aortic aneurysmectomy. Patients were divided into two groups: group 1 (n = 9) underwent elective surgical repair; group 2 (n = 21) underwent emergency procedure. In 28 patients location of the abdominal aortic aneurysm was infrarenal; two patients presented with a juxtarenal aneurysm. The average aneurysm diameter was similar in both groups (group 1, 68.8 mm; group 2, 83.5 mm, P = n.s.). In group 2, two patients had free peritoneal rupture, one presented with rupture into the duodenum and one with penetration into the vena cava. Rupture was confined to the retroperitoneum in another 15 patients Two patients had an expanding aneurysm. Hospital mortality rate was zero in group 1 and 42.8% in group 2 (P = 0.011). Most early deaths were related to cardiac disease. The overall complication rate was 22% in group 1 and 62% in group 2. Mean intensive care unit time was 1.8 (range 1–3) days in group 1 and 3.6 (range 1–8) days in group 2 (P = 0.047). The 5-year survival rate was 67% in the electively managed group and 34% in the emergency group. Copyright © 1996 The International Society for Cardiovascular Surgery.     

Abdominal aortic aneurysm as an incidental finding in abdominal ultrasonography

The difference between the mortality rate from ruptured abdominal aortic aneurysm (overall mortality rate 85-95 per cent and operative mortality rate 23-63 per cent), and that for elective aneurysm repair (less than 5 per cent) is dramatic. Awareness of the existence of an abdominal aortic aneurysm is therefore essential. Of 1800 consecutive patients aged greater than or equal to 50 years referred for their first abdominal ultrasonography, 113 who had been referred specifically for suspected abdominal aortic aneurysm or vascular screening were excluded. The remaining 1687 patients (693 men and 994 women) form the study group. Apart from the symptom-directed examination, the entire abdomen of every patient was routinely studied by ultrasonography. The definition of an abdominal aortic aneurysm was a local dilatation of the aorta with an anteroposterior diameter greater than 30 mm or greater than 1.5 times the anteroposterior diameter of the proximal aorta. In 82 cases (4.9 per cent) an abdominal aortic aneurysm was disclosed; 61 were in men (8.8 per cent) and 21 were in women (2.1 per cent). The prevalence of abdominal aortic aneurysm as an incidental finding in men aged greater than or equal to 60 years was 11.4 per cent. In every patient aged greater than or equal to 50 years undergoing their first abdominal ultrasonography examination, the aorta should be screened for the presence of an aneurysm.     

Ruptured abdominal aortic aneurysm: factors influencing operative mortality

Of fifty-eight consecutive patients surgically treated for aneurysm of the abdominal aorta, twenty were emergency cases following the rupture. Associated diseases were found in 85 per cent of patients; hypertension being the most common. Fifty per cent of patients were in shock on admission. The duration between rupture and operation was three hrs to two weeks with the average of 115.5 hrs. In six patients, the diagnosis of abdominal aortic aneurysm was known for over six months. The operative mortality rate in case of ruptured abdominal aortic aneurysm was 45 per cent. The most important determinants of survival were the incidence of shock on admission, the incidence of associated disease, the known duration of the aneurysm, and the time interval from rupture to admission. The intraoperative factors most influencing survival were the type of rupture, intraoperative hypotension, and total blood loss. Comparison of the mortality rate in elective surgery of abdominal aortic aneurysms (5.3 per cent) with that in ruptured aneurysms (45.0 per cent) suggests the necessity for early elective operations whenever abdominal aortic aneurysms are diagnosed.     

Abdominal aortic aneurysms: should they all be resected?

A retrospective study has been carried out on 124 consecutive patients with abdominal aortic aneurysms admitted during the period 1960-74. The mortality rate after emergency operation was 56 per cent and after elective operation 15 per cent. As in other vascular centres during these years the mortality rate has decreased among electively operated patients. We have tried to answer two questions: which patients without signs of rupture should undergo operation and which patients with a ruptured aneurysm should not be operated upon?     

Use of mortality rate after aortic surgery as a performance indicator

BACKGROUND: Hospital episode statistics (HES) regarding death after aortic surgery were analysed to evaluate their potential value as a performance indicator. METHODS: HES data for all acute hospitals in England and Wales from 1996 to 2001 were analysed retrospectively. In-hospital mortality was calculated for all patients over 40 years of age who underwent abdominal aortic procedures or died in hospital with a primary diagnosis of aortic aneurysm. RESULTS: Some 38 319 cases were identified, of which 8.9 per cent were complex, 46.8 per cent were elective and 44.4 per cent were emergencies. The elective mortality rate was 6.4 per cent overall; that after emergency operation was 35.0 per cent, rising to 41.6 per cent if urgent procedures were excluded and 63.1 per cent if unoperated cases were included. Over the 5-year interval a median of 68 (interquartile range 30-108) elective procedures were carried out by individual hospitals. Considerable variation was identified in the proportion of elderly patients, tertiary referrals and the proportion of emergency admissions that had surgery. CONCLUSION: The use of mortality data may be misleading owing to identifiable differences in case mix and selection. Some redefinition of groups may help to provide more valid data, but ultimately only high-quality data with clinical information are likely to allow meaningful comparisons of performance.     

THE QUALITY OF SURGICAL CARE PROJECT: BENCHMARK STANDARDS OF OPEN RESECTION FOR ABDOMINAL AORTIC ANEURYSM IN WESTERN AUSTRALIA

Background: The Quality of Surgical Care Project (QSCP) was established in May 1996, to evaluate surgical outcomes and where indicated, recommend changes to improve the quality of surgical care in Western Australia (WA). The purpose of this study is to establish benchmark standards in WA for operative mortality, 5-year survival and length of stay in all patients who were surgically treated for aneurysm of the abdominal aorta (AAA) in WA. Methods: The WA Linked Database was used to link the morbidity and mortality records of all patients admitted and surgically treated for AAA in WA from 1985 to 1994. The linked chains of de-identified hospital morbidity and death records were selected using diagnostic and procedure codes pertaining to AAA. Three groups were separated for analysis: those admitted for rupture, those admitted for elective repair, and those who were admitted to hospital as an emergency without mention of rupture but who underwent repair for AAA. Independent analysis for gender and patients 80 years or more were included in the study. Patients were excluded from the study if they were less than 55 years of age. Results: A total of 1475 cases (1257 males, 218 females) were identified. The mean age in elective cases was 70.4 years in males and 72.4 years in females, and for rupture the mean ages were 71.9 and 74.8 years, respectively. Median length of stay for males was 12 days for elective cases. Admission type or age did not significantly influence length of stay. Thirty-day mortality in males was 4.4% for elective repair and 36.7% for ruptured AAA and 5-year survival was 71.7 and 47.7%, respectively. The overall case fatality rate for ruptured AAA was 79.3% which included those cases who died from rupture without being admitted to hospital. Conclusions: These community-wide data provide a realistic measure of surgical performance for open repair of AAA. The outcomes for elective and rupture repair for AAA compare favourably with standards reported by international centres of excellence. They also support the use of this procedure in patients over 80 years of age with rupture. This information can be used for ongoing audit purposes and as a benchmark for the introduction of new treatment modalities.     

Ruptured abdominal aortic aneurysm: Factors influencing operative mortality

Of fifty-eight consecutive patients surgically treated for aneurysm of the abdominal aorta, twenty were emergency cases following the rupture. Associated diseases were found in 85 per cent of patients; hypertension being the most common. Fifty per cent of patients were in shock on admission. The duration between rupture and operation was three hrs to two weeks with the average of 115.5 hrs. In six patients, the diagnosis of abdominal aortic aneurysm was known for over six months. The operative mortality rate in case of ruptured abdominal aortic aneurysm was 45 per cent. The most important determinants of survival were the incidence of shock on admission, the incidence of associated disease, the known duration of the aneurysm, and the time interval from rupture to admission. The intraoperative factors most influencing survival were the type of rupture, intraoperative hypotension, and total blood loss. Comparison of the mortality rate in elective surgery of abdominal aortic aneurysms (5.3 per cent) with that in ruptured aneurysms (45.0 per cent) suggests the necessity for early elective operations whenever abdominal aortic aneurysms are diagnosed. Presented at the Fifteenth Annual Meeting of the Japanese Association for Cardiovascular Surgery, Kanazawa, Japan, May 17–18, 1985.     

Twelve-year experience of the management of ruptured abdominal aortic aneurysm

Background The operative mortality rate for elective repair of asymptomatic abdominal aortic aneurysm (AAA) is falling but the fate of patients with ruptured AAA may have changed little over the past decade. Methods This study was an analysis of a prospectively gathered computerized database. Results In the 12 years to 31 December 1994, 1144 patients underwent (attempted) repair of AAA. In 514 patients (44·9 per cent) who had an operation for ruptured AAA there was no significant change in the mean age, male: female ratio (418:96), or operative mortality rate (35·0 per cent) over the interval of the study. Forty-seven patients died before reaching the operating theatre, giving an ‘intention to operate’ mortality rate of 405 per cent. A further 68 patients (10·8 per cent of all patients who presented with a ruptured AAA) were not offered operation because of poor medical condition (n = 34) or extreme age (n = 34); three patients refused operation. A greater proportion of patients had surgery between 1989 and 1994 (276 of 323, 85·4 per cent) than between 1983 and 1988 (238 of 309, 77·0 per cent) (P <0·01, X² test). Conclusion The proportion of aneurysms operated on for rupture in this unit remains high (almost 50 per cent). The results of surgery for ruptured AAA have not improved in the past 12 years.     

The surgical experience and a one to sixteen year follow-up of 277 abdominal aortic aneurysms

Between 1960 and 1975, 277 patients with abdominal aortic aneurysms were operated on at the West Virginia University Medical Center. One hundred ninety-three aneurysms were intact lesions and eighty-four were ruptured. Operative mortality for elective resection was 8.8 per cent and for ruptured aneurysms 66.7 per cent. Mortality associated with ruptured abdominal aortic aneurysms was best related to shock and advanced age. Ninety-nine per cent of patients underwent long-term follow-up which ranged from thirteen months to thirteen years and four months (mean, 4 years and 9 months). At present 61 per cent of patients surviving elective resection and 50 per cent of those surviving operation for ruptured aneurysm are alive.     

Urgent and early cholecystectomy for acute gallbladder disease

A retrospective study of 645 cholecystectomies performed in a surgical unit over a 10-year period is presented, of which 236 were carried out during an acute admission. Of these 236 cholecystectomies, 195 were performed for acute cholecystitis and 41 for acute gallstone pancreatitis. In the acute cholecystitis group the proportion of patients over 70 years of age was significantly higher (35 per cent) than the corresponding elective group (10.3 per cent). Of those patients presenting with complications (empyema, gangrene, perforation, and biliary peritonitis) 51 per cent were over the age of 70 years. The most valuable investigation in the diagnosis of acute cholecystitis was ultrasound carried out within the first 48 h, with positive results in 83 per cent of those examined. The mortality for elective cholecystectomy was 0.5 per cent rising to 4.7 per cent in the urgent/early cholecystectomy group. The mean age of the 11 patients who died was 76 years, 8 of these patients being over the age of 70 years. The mortality in the subgroup of patients over 70 years was 10 per cent rising to 20 per cent in the over-80 age group. There were no deaths in the acute gallstone pancreatitis group. We conclude that emergency or early cholecystectomy is a safe procedure in patients under 70 years of age. However, patients over 70 years present with more serious complications of acute gallbladder disease which necessitate urgent surgery. We therefore recommend early cholecystectomy in patients over 70 years despite the high attendant mortality.