Laparoscopic Cholecystectomy In elderly patients Dr.Nazari,MD

Introduction Now, laparoscopic cholecystectomy (LC) has accepted as ‘gold standard’ in surgical management of symptomatic gallstone disease. Over the last decade, many expert laparoscopic surgeons prefer to do LCs in elderly and fragile patients. Although LC has become the gold standard procedure for gallstone treatment, the feasibility, safety, complications, benefits and results of laparoscopic treatment of gallstones in old patients is not well investigated.

The biliary lithiasis is the most common condition requiring intra-abdominal surgery and the incidence of gallstones increases with age. Age is one of the critical factors affecting the mortality and morbidity rates after open cholecystectomy (OC). The elderly are more prone to complications of surgery because of co-morbidity diseases. Gallstone complications are seen more frequently in the elderly.

Operation time Higher morbidity was noted in elderly patients than in younger patients. Technically challenging procedures take more operation time. A significantly higher postoperative morbidity rate was noted in patients who had a procedure longer then 2 h than in patients whose surgery required less the 2 h.

CO2 pneumoperitoneum Prolonged carbon dioxide pneumoperitoneum may decrease cardiac output (CO) and cause tachycardia, peripheral vasoconstriction, hypercarbia, and acidosis. Increasing the length of procedure may have an adverse effect on postoperative outcome, especially in elderly patients or patients with co-morbid conditions.

CO2 pneumoperitoneum 2 Healthy patients usually cope with the circulatory and respiratory alterations caused by carbon dioxide pneumoperitoneum, whereas related complications may develop in elderly and high-risk patients. Advanced age with its concomitant co-morbid conditions may be associated with increased postoperative laparoscopic complications and more frequent conversion to open surgery.

Factors influencing POHS Acute cholecystitis IHD Duration of procedure Diabetes Older age

Aims To evaluate the feasibility of laparoscopic cholecystectomies in elderly patients. To evaluate the safety aspects. To investigate retrospectively the feasibility, success rate, safety and the complications or benefits of LC in 155 consecutive, unselected patients age 60 and older.

Inclusion & Exclusion criterion The inclusion criterion was the presence of ultrasound proven gallstones. Patients were excluded from our study if there was evidence of 1CBD stones, 2abnormal liver function tests with CBD greater than 10 mm in diameter in pre-Op sonography, or 3history of pancreatitis, and/or suspicion of 4carcinoma of the gallbladder.

In the excluded group operative procedures were: laparoscopic cholecystectomies after ERCP/ES. 1)cholecystectomies +/- IOC. 2)cholecystectomies +/- exploration of CBD with/without T-tube insertion. 3)cholecystectomies with exploration of CBD and choledochodeudenostomy. 4)cholecystostomy. Open procedures

Results From November 2003 to December 2006, totally 575 patients were operated for gall stone diseases in two nonacademic hospitals by one surgeon. 476 patients operated laparoscopicly and 99 patients operated in open procedures.

60 & more Under 60 Group D O P E N LC L A P (N=45) Group C (N=54) Cholecystectomy O P E N CC+T-Tube CC+Anastoosis Cholecystostomy Group B (N=110) Group A (N=366) LC L A P LC+T-Tube Lc Converted to Open surgery 99 476 155 420 575

60 & more Under 60 20 32 O P E N 2 23 18 --- 108 348 LC L A P 10 8 456 Cholecystectomy O P E N 2 CC+T-Tube 23 18 CC+Anastoosis --- Cholecystostomy 108 348 LC L A P 10 LC+T-Tube 8 Lc Converted to Open surgery 456 110 366 476

General patients’ characteristics Male 105 (18.2%) Female 470 (81.7%) Female to male ratio 4.4 / 1 Age range (years) Female range,13-83 Male range ,24-88

Patients’ characteristics (age fewer than 60) Male 76 (13.2%) Female 344 (59.8%) Female to male ratio 4.5 / 1 Age range (years) range,13-60

Patients’ characteristics (age over 60) Male 29 (18.7%) Female 126(81.2%) Female to male ratio 4.3 / 1 Age range (years) range,60-88

Co-morbid states No. of patients <60 >60 Gastritis GERD Hypothyroidism Myasthenia gravis HPT IHD Morbid obesity G6PD Cirrhosis Pancreatitis Hemochromatosis Diabetes mellitus 137 5 3 1 29 13 2 39 -- 20 7

Previous Operations No. of patients <60 >60 CABG Stent Cardiac valve replacement Hydatid liver Splenectomy (ITP) Cessarian section BTL Hysterectomy Laparotomy Appendectomy Inguinal hernioraphy Laparoscopy Umbilical hernioraphy Abdominoplasty ERCP/ES -- 1 10 3 2 4

Concomitant Operations No. of patients < 60 > 60 Umbilical hernioraphy Appendectomy Mucocele(Appendiceal) Incisional hernioraphy Ovarian cystectomy 11 1 2 3 --

Operative time The operative time in two laparoscopic groups (A & B) had no significant difference (75 +/- 20 minutes Vs 90 +/- 20 minutes).

Intra-operative complications Among our patients, there were no complications related to peritoneal entry or introduce and establishment of the pneumoperitoneum. We had not any small bowel perforations, CBD injuries, Cystic artery laceration, or trocar site bleeding. In one case we had a big Luschka duct which controlled by clipping. Some small bleedings from liver bed was controlled easily by cautery. We had not any intra-operative mortality, myocardial infarction, or respiratory complications. Intra-operative hypertensions easily controlled by anesthesiologists.

Postoperative complications We had not any post operative mortality. Five patients from group B went to ICU or CCU for better cares. In one case from group B, who had severe headache post operatively, neurology consultation requested and brain CT scan showed brain tumor. We had not any prolonged postoperative fever without obvious reason, intra-abdominal collection, or wound infection. In one male case in group B, who complicated with RUQ pain and rise in LFT tests, sonography was done and sub-hepatic collection detected. In this case pre-operative ERCP/ES was done due to CBD stones. This case recovered after drainage of the biloma under sonography guided drain insertion. In one female case in group A, who complicated with post operative upper GI bleeding, endoscopy showed gastric cancer.

Length of postoperative hospital stay Postoperative hospital stay ranged between 24 and 72 h. The majority of patients (80%) were discharged after 24 h. There was a significant difference in hospitalization for patients whose operation was converted to open cholecystectomy with a range of 72-96 h. There were no significant difference between males and females. Among the factors with a significant influence on the postoperative hospital stay were age, LC performed for acute cholecystitis, history of ischemic heart disease, and duration of procedure.

Discussion The elderly patients may benefit most from a minimally invasive approach. A laparoscopic cholecystectomy can be used safely in an elderly population.

Discussion 2 A low rate of conversion to laparotomy, minimal perioperative morbidity, and the absence of perioperative mortality in this series indicate the safety of LC in elderly patients. The relatively high incidence of complicated gallstone disease in this age group may be decreased if surgery is offered to them at earlier stage of the disease, leading to further decrease in perioperative morbidity.