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2011 SSAT POSTER PRESENTATION

Cholecystectomy in the Very Elderly—Is 90 the New 70?

Attila Dubecz & Miriam Langer & Rudolf J. Stadlhuber &

Michael Schweigert & Norbert Solymosi & Marcus Feith &

Hubert J. Stein

Received: 16 May 2011 /Accepted: 19 September 2011 /Published online: 6 December 2011# 2011 The Society for Surgery of the Alimentary Tract

AbstractBackground Nonagenarians are the fastest growing sector of population across Western Europe. Although prevalence ofgallstone disease is high, elective cholecystectomy is still controversial in this age group.Methods A retrospective chart review was conducted of cholecystectomies done in patients over 90 years of age at ourinstitution between 2004 and December 2009. During this period, a total of 3,009 cholecystectomies were performed onpatients of all ages. Data collected included demographics, patient comorbidities, indications for surgery, type of surgeryperformed, intraoperative findings, histology, perioperative morbidity and mortality.Results Twenty-two nonagenarians (18 females) underwent cholecystectomy during the study period. Of these patients, 19patients (86%) had diabetes, 16 (73%) had hypertension, and 10 (45%) had coronary artery disease. Twenty patients (91%)underwent an emergency procedure. In two patients, cholecystectomy was indicated for non-resolving pain after attemptedconservative therapy, only two patients were operated electively. Laparoscopic cholecystectomy was attempted in 13patients (59%), 3 patients needed a conversion, and 9 patients (41%) considered unfit to undergo a laparoscopic approachhad an open procedure. Mean operation time was 83 min. Histology showed gangrenous cholecystitis in six (27%)patients. The mean length of stay was 10 days (4–23 days). Two patients (8.3%) required intensive care following surgery.There were no common bile duct injuries, one patient had a cystic stump leak. One patient died in the postoperative period(4.6%). All patients with an emergency operation were classified as at least ASA III. Conversion rate, percentage of openprocedures, percentage of advanced histology, ASA score, and hospital stay were significantly higher when compared to allpatients.Conclusion Our study demonstrates that in unselected nonagenarians,cholecystectomy is safe with acceptable perioperativemorbidity and mortality even as an emergency procedure. However, our data also suggests that cholecystitis appears to be aneglected condition in this age group.

Keywords Nonagenarians . Cholecystectomy . Acutecholecystitis

Background

Nonagenarians are the fastest growing sector of society inthe western world.1 Presently, they represent a little over0.6% of the German population; but according to theGerman Bureau of Statistics, this number is to increase to3.2% by the year 2050.2 Since prevalence of gallstonedisease is over 80% in nonagenarians,3 performing surgicalprocedures in this subgroup of patients will be clinicalreality in daily practice. Additionally, while patientsbetween 65 and 80 years of age, previously described as“elderly” and “very old,” are now considered having similaroperative risks as the younger population,4–7 there are fewstudies describing the surgical results of patients over

J Gastrointest Surg (2012) 16:282–285DOI 10.1007/s11605-011-1708-2

A. Dubecz (*) :M. Langer :R. J. Stadlhuber :M. Schweigert :H. J. SteinDepartment of Surgery, Klinikum Nürnberg,Nuremberg, Germanye-mail: dubeczattila@GMAIL.COM

N. SolymosiHungarian Academy of Sciences–Corvinus University,Budapest, Hungary

M. FeithDepartment of Surgery, Technical University Munich,Munich, Germany

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90 years of age.8–11 The aim of this study was to analyzethe short-term results in a series of consecutive non-agenarians undergoing cholecystectomy in our tertiaryreferral center, providing information on optimal treatmentof these high-risk patients.

Methods

Between January 2004 and December 2009, a total of 3,009cholecystectomies were performed in our medical center.Of these, 22 patients were aged 90 years or older. Computerrecords and charts were reviewed restrospectively for thesepatients and the following variables were collected: patientdemographics, ASA classification, comorbidities, indica-tion for surgery, type of operation, conversion rates,intraoperative findings, length of hospital stay, morbidity,and mortality. Charts were reviewed if database entrieswere incomplete. Data was compared to results from allpatients under 90 years of age (n=2,987) if available.Statistical analysis was performed using the Fisher’s exacttest where appropriate and possible.

Results

Twenty-two nonagenarians underwent cholecystectomy atour institution between 2004 and 2009 (Table 1). Thecomparison of demographic and surgical parameters of thestudy population and all patients under 90 years of age isshown in Table 2. The patients were predominantly femaleand the ASA score was significantly higher in the over-90group. Only 2 of the 22 patients (9%) had previoushospitalizations for symptomatic gallstone disease. Twelvepatients over 90 years of age were classified as ASA IV orhigher. Nineteen patients (86%) had diabetes, 16 (73%) hadhypertension, and 10 (45%) had coronary artery disease.More than half of the cholecystectomies were either

converted to open approach or initiated with a laparotomy.This percentage was significantly higher than in theyounger age group. Duration of surgery was with 83 minsubstantially longer in the eldest population. Mean operat-ing time was 55 min in the laparoscopic group, 68 min inthe open group, and 109 min in patients undergoingconverted cholecystectomy. The pathologic workup of theresected specimen showed acute cholecystitis in more than75% of all patients over 90 including more than one thirdwith very advanced stages of inflammation. This value wasalso significantly lower in the control group. Nonagenarianpatients also had a longer postoperative hospital stay.Table 3 shows the surgical parameters of the studypopulation. In 20 of the 22 patients, an emergency

Table 1 Age groups of patients undergoing cholecystectomy at ourinstitution 2004–2009

Age groups (years)

Year n= <49 50–69 70–89 90<

2004 638 185 338 111 4

2005 438 134 175 124 5

2006 484 159 191 129 5

2007 405 150 142 110 3

2008 444 144 171 128 1

2009 600 181 210 205 4

Total 3,009 953 1227 807 22

Table 2 Comparison of demographic and surgical parameters

Age <90 years Age >90 years

n=(total) 2,987 22

Male (%) 1,170 (39) 4 (18)*

Mean ASA score 2.1 3.4*

% Open + converted 23 55*

Duration of surgery (min) 68 83*

% Acute cholecystitis 44 77*

% CBD injury 0.2 0a

Length of stay (days) 8.4 10.8*

*p<0.05a not significant

Table 3 Perioperative parameters of the study population (n=22)

Indications for surgery n=(%)

Emergency 20 (91)

Elective 2 (9)

Intraoperative findings

Gangrenous cholecystitis 6 (27.3)

Perforation 2 (9.1)

Chronic cholecystitis 5 (22.7)

Intraoperative cholangiography 5 (22.7)

Type of surgery

Laparoscopic 10 (45.4)

Open 9 (40.9)

Converted 3 (13.6)

ICU stay 2 (9)

Morbidity 5 (22.7)

UGI bleeding 1 (4.6)

Postoperative psychosis 1 (4.6)

Cystic stump leak 1 (4.6)

Pneumonia 2 (9)

Mortality 1 (4.6)

J Gastrointest Surg (2012) 16:282–285 283

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operation was performed. In two patients, surgical inter-vention was indicated for recurrent symptoms after conser-vative therapy. Intraoperatively, all but five patients hadacute inflammation, six patients had gangrenous cholecys-titis, and in two patients, the gallbladder was alreadyperforated. We have a selective intraoperative cholangiog-raphy policy at our institution; it was performed in less than25% of the cases. Conversion rate was comparable to therate of the under-90 group, but 40% of the operations weredone through a laparotomy. Two patients were admitted toour intensive care unit postoperatively. Postoperativemorbidity was observed in five patients (23%). Twopatients had pneumonia, one patient required endoscopictherapy for a bleeding duodenal ulcer, and one patient hadpostoperative psychosis. There were no major bile ductinjuries, but cystic stump leak was observed at one patient(9%). This patient required an ERCP postoperatively anddied on the 16th postoperative day. All patients weredischarged to their nursing homes; follow-up information of3–13 months is only available of approximately 75% (16/22) of all patients. Most of these patients (14/16) were ableto live fully/partly independently after the hospital stay.

Discussion

These data demonstrate that patients 90 years and oldertolerate the stress of open and laparoscopic cholecystecto-my fairly well. In-hospital mortality rate in our series wasonly 4.5%, which is comparable to the reported mortality inprevious studies reviewing cholecystectomies in patientover 80 years of age.12–14 Although direct comparison ofthese patient populations is not possible, it shows that theextensive surgical data of the octagenarian population couldprobably be extrapolated to the even older patient group aswell.

As expected, our study population consisted mostly offemale patients reflecting the male–female ratio in this agegroup in the general population. Also unsurprisingly, thesepatients had significanly higher morbidity and had higheroperative risk as the younger group, as more than 50% ofthe patients was in critical condition preoperatively mostlydue to the severe systemic complications of cholecystitis.

More than half of our patients underwent an openprocedure. In the published literature, laparoscopic chol-ecystecomy proved to be superior to the open procedure intreating symptomatic gallstone disease,15 but the optimaltreatment modality for acute and gangrenous cholecystitis isstill controversial.16,17 The reasons behind the unusuallyhigh rate of open cholecystectomies in our series were thehigh preoperative suspicion of advanced pathology, theconcern for a longer duration of general anesthesia inconverted cholecystectomies and the relatively lesser

importance of cosmetic factors and of length of hospitalstay in the nonagenarian population. Our patients had alonger hospital stay than the younger group mainly due togeneral nursing problems. Although a previous randomizedstudy comparing laparoscopic and open cholecystectomy inacute and gangrenous cholecystitis showed significantlyhigher postoperative morbidity in the open group, ourresults show an acceptable major complication rate.17

Furthermore, our data show that contrary to previousreports analyzing octagenarians undergoing cholecystecto-my, in patients 90 years and older, practically all cholecys-tectomies were performed in the emergency setting for veryadvanced stages of cholecystitis. This is probably caused bythe reluctance of referral for surgery and the unwillingnessof patients in this age group to undergo elective operation,although the linear progression of the untreated acutecholecystits to the gangrenous stage is not fully proven.Since previous experience shows that emergency abdomi-nal procedures have a significantly higher complication ratethan elective operations, nonagenarians with symptomaticgallstone disease should not be excluded from electivesurgery.18,19 On the other hand, due to advances inanesthesia, surgical technique and perioperative care ac-ceptable morbidity and low mortality can be achieved evenin the emergency setting.

Conclusion

Cholecystectomy in nonagenarians with symptomaticgallstone disease is safe and should be considered forelective surgery, but the present strategy of prolongedconservative treatment and emergency operation is alsojustifiable. Laparoscopic cholecystectomy is possible butprimary open operation should be considered due to thevery high rate of conversions and the longer duration ofconverted operations.

Conflict of interest statement None.

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