Surgical management of gallbladder disease in the very elderly: are we operating them at the right time?

BACKGROUND: As life expectancy rises worldwide and the prevalence of gallstones increases with age, the number of very elderly patients requiring treatment for gallstone diseases is increasing. The aim of this study was to compare the results of cholecystectomy in patients 80 years or older according to different clinical presentations. METHODS: This is a retrospective study of 81 patients 80 years or older. Indications for surgery were stratified into three groups: outpatients (symptomatic chronic cholecystitis), inpatients (complicated gallstone diseases), and urgent patients (acute cholecystitis). Data analysis included age, sex, the American Society of Anesthesiologists score, indication for surgery, length of hospital stay, morbidity, and mortality. RESULTS: The mean age of the patients was 83.9 (range 80-94 years); there were 34 (42%) men. Thirty patients were operated on for acute cholecystitis. Patients in the urgency group significantly required the ICU more often, required a longer hospital stay, and had more complications, with 32% mortality. No differences were found between inpatients and outpatients, with both groups presenting low morbidity, no mortality, and the same postoperative length of stay. CONCLUSION: More than 80% of the patients were operated on because of complicated gallstone disease. Although the outcomes of patients undergoing semielective cholecystectomy were similar to those of patients treated as outpatients, patients operated with acute cholecystitis presented extremely high morbidity and mortality rates. Thus, we can only recommend that early elective cholecystectomy be performed in elderly patients as soon as they are found to have symptomatic gallstones. Also, further trials are required to elucidate the optimal management of acute cholecystitis in elderly patients.

Outcomes of laparoscopic cholecystectomy in octogenarians.

BACKGROUND AND OBJECTIVES: Extremely elderly patients usually present with complicated gallstone disease and are less likely to undergo definitive treatment. The purpose of this study was to evaluate the results of laparoscopic cholecystectomy in octogenarians, with an interest in patients presenting initially with complicated gallstone disease and pancreatitis who underwent laparoscopic cholecystectomy during the same hospitalization. METHODS: Data for 42 patients > or = 80 years who underwent an elective laparoscopic cholecystectomy between January 2007 and August 2011 were retrospectively reviewed. Indications for the procedure were stratified into 2 groups: Outpatients, who were admitted electively to undergo cholecystectomy, and Inpatients, who came to our Emergency Room due to complicated biliary diseases. Data analysis included age, sex, ASA score, conversion to open surgery, time spent under general anesthesia, and length of hospital stay. RESULTS: Mean age was 83.9 years; 19 (45.2%) were men. Thirteen patients (30.9%) were in the outpatient group, and 13 (30.9%) had a preoperative ASA of 3. Fourteen patients (33.3%) needed ICU. Two patients (4.8%) had their surgery converted. There were 7 (16.7%) postoperative complications, all of them classified as Dindo-Clavien I or II. No differences were noted between groups regarding conversion rates or complications. We had no mortalities in this series. There was no difference in hospital length of stay between the groups. CONCLUSION: Laparoscopic cholecystectomy in the extremely elderly is safe, with acceptable morbidity. Patients with complicated gallstone disease seem not to have worse postoperative outcomes once the initial diagnosis is properly treated and would benefit from definitive therapy during the same hospitalization.

Modificação técnica da coledocoduodenostomia látero-lateral - análise dos resultados / Analysis of the modified side - to - side choledochoduodenostomy

OBJETIVO: Avaliar se a oclusão do colédoco distal se mantém no decorrer do tempo, nos pacientes submetidos a coledocoduodenostomia látero lateral com oclusão do colédoco distal. MÉTODO: Foram analisados 14 doentes submetidos à coledocoduodenostomia látero-lateral modificada por Fava, para prevenir a "Síndrome do Colédoco Distal", tratados de coledocolitíase não complicada. Os doentes avaliados encontravam-se em pós-operatório que variou de três meses até dez anos após a derivação bílio-digestiva. Os doentes foram analisados do ponto de vista clínico através da classificação de Visick, submetidos à dosagem de transanimases (AST e ALT), enzimas canaliculares (gama-GT e fosfatase alcalina), bilirrubinas e ao exame de colangioressonância. Os doentes que apresentaram alguma alteração nos exames citados, foram submetidos à CPRE para avaliação definitiva da via biliar, identificação e tratamento de eventuais complicações da coledocoduodenostomia RESULTADOS: Em 11 doentes (78,6 por cento) foi identificada abertura da oclusão do colédoco distal. Quatro doentes com menos de um ano de pós-operatório; quatro, entre um e cinco anos; e três doentes com mais de cinco anos de coledocoduodenostomia. Três doentes (21,4 por cento) apresentaram "Sump Syndrome" no período de três meses, nove meses e oito anos de pós-operatório respectivamente, sendo tratados com sucesso através de papilotomia endoscópica. CONCLUSÕES: Nos doentes tratados de coledocolitíase não complicada a oclusão do colédoco distal na coledocoduodenostomia modificada por Fava et al, não se mantém patente no decorrer do tempo, não evitando o aparecimento da "Síndrome do Colédoco Distal".

BACKGROUND: To evaluate if the occlusion of distal choledochal suture will remain occluded over time, in patients submitted to a side-to-side choledochoduodenostomy with a choledochal distal occlusion, a technical modification to prevent the "Sump Syndrome" (Fava et al, 1989). METHODS: Fourteen patients with a diagnosis of choledocholithiasis have been submitted to a side-to-side choledochoduodenostomy with a choledochal distal occlusion. Follow-up varied from three months up to ten years. These patients were evaluated for their clinical aspects under the Visick criteria. Blood screening tests for serum glutamicoxalacetic transaminases, serum glutamic-pyruvic transaminases, gama-GT, alkaline phosphatase and bilirubins were obtained. All of them have been further submitted to a resonance cholangiopancreatography. Those patients whose exams showed alterations were further submitted to an endoscopic-retrograde cholangio-pancreatography with a view towards the identification and treatment of eventual problems resultant from the choledochoduodenostomy as well as for definitive evaluation of the biliar tree. RESULTS: As verified, the distal choledochal suture had opened in 11 (78.6 percent) of the patients, of which four ocurred in less than one year after the surgery, four between one and five years and the remaining three after five years. Three patients (21.4 percent) presented the "Sump Syndrome" three months, nine months and five years after the surgery respectively. They have been successfuly treated by endoscopic sphyncterotomy. CONCLUSION: We conclude that in patients treated for choledocholithiasis without complications through choledochoduodenostomy modified by Fava et al, the distal choledochal suture does not remain occluded over time thus, not avoiding the "Sump Syndrome".