Laparoscopic cholecystectomy in the elderly.

OBJECTIVE: To evaluate the outcomes of laparoscopic cholecystectomy in elderly patients at a single institution. METHODS: A retrospective chart review was conducted of all patients > or = 65 years of age who underwent laparoscopic cholecystectomy over a 5-year period (January 1995 to December 1999). Four-trocar site laparoscopic cholecystectomy using the open Hasson technique were performed in all patients. The demographic data (age, sex), associated comorbidities, American Society of Anesthesiologist's (ASA) score, postoperative morbidity, mortality, and length of stay were recorded for each patient. Statistical analysis was done using Fisher's exact test and chi-square analysis. Statistical significance was defined as P < or = 0.05. RESULTS: The patient cohort included 46 patients with a median age of 71 years (range, 65 to 87). Seventeen (37%) patients were < or = 70 years of age, and twenty-nine (63%) patients were > or = 70 years of age. Twenty-two (48%) patients had ASA scores of > or = 3. Patients > or = 70 had significantly higher ASA scores. Eighteen patients > or = 70 years had ASA > or = 3 compared with 4 patients < or = 70 with ASA > or = 3 (P<0.05). Twenty-two patients > or = 70 and 8 patients < or = 70 required urgent surgery P<0.05). Fifteen (33%) patients presented with acute cholecystitis, and 31 (67%) patients presented with a greater number of chronic symptoms. Four (9%) patients had pancreatitis on presentation, and 6 patients underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP). Two of these 6 patients also underwent sphincterotomy. Urgent surgery was performed in 30 (65%) patients. The mean operative time was 103 +/- 37 (SD) minutes. One (2%) conversion to open cholecystectomy was required. The mean postoperative stay was 7 days (range, 1 to 46). Fourteen (30%) patients had only a 1-night postoperative stay. Patients > or = 70 had significantly longer postoperative stays. Nine patients > or = 70 and only 1 patient < or = 70 stayed in the hospital for more than 7 days. Postoperative complications were noted in 6 (13%) patients, most of which were chest infections. Five patients > or = 70 and only 1 patient < or = 70 developed postoperative complications. No mortalities occurred. CONCLUSION: Laparoscopic cholecystectomy is safe and feasible in elderly patients. Patients > or = 70 years seem to have a longer postoperative stay and slightly more postoperative complications. Age alone should not be a contraindication to laparoscopic cholecystectomy in the elderly patient.

Laparoscopy in complicated pediatric appendicitis.

BACKGROUND: Complicated appendicitis (gangrenous or perforated) has been associated with increased risk for postoperative complications, especially intraabdominal abscess. Caution has been advised when attempting laparoscopic appendectomy for complicated appendicitis in children. The objective of our study was to assess the incidence of intraabdominal abscess formation after laparoscopic appendectomy in pediatric patients presenting with complicated appendicitis. METHODS: This is a retrospective review of 52 pediatric patients presenting with acute appendicitis at a single teaching institution who underwent laparoscopic appendectomy by a single surgeon. All laparoscopic procedures were completed without conversion. Treatment complications and outcomes were recorded for all cases. RESULTS: Five of the 52 patients (10%) had complicated appendicitis. One of the 5 patients (20%) developed intraabdominal abscess postoperatively and underwent laparoscopic drainage during the same admission. No other complications were noted. None of these patients was readmitted for wound infections or intraabdominal abscesses. The single postoperative abscess occurred early during our initial experience with laparoscopic appendectomy. CONCLUSION: Laparoscopic appendectomy seems to be a safe alternative for the treatment of complicated appendicitis in children. Caution is recommended during the initial experience of surgeons with this procedure, because the complication rate seems to be higher during the learning curve. Close postoperative follow-up and a high index of suspicion for development of complications is recommended. As surgeons' experience accumulates, the safety of the procedure seems to increase. A prospective, randomized trial is recommended to establish the role of laparoscopy in complicated appendicitis in the pediatric population.