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Laparoscopic Cholecystectomy in Geriatric Patients
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Am Fam Physician. 2005 Mar 15;71(6):1193-1194.
Although laparoscopic cholecystectomy has become standard treatment for symptomatic cholecystitis, little attention has been paid to its use in geriatric patients. This procedure has a higher incidence of biliary injuries than the traditional open cholecystectomy, and most reports concerning elderly patients have focused on complications, morbidity, mortality, and rates of conversion to open procedures. The reports also concern selected patients treated at academic health centers, where various levels of residents perform the surgeries. Majeski reports on a series of 82 patients 65 years or older who underwent laparoscopic cholecystectomy for symptomatic gallbladder disease; the surgeries were performed by a single surgeon in a community surgical practice.
The patients were part of a series of 248 adults who were treated with laparoscopic cholecystectomy between 1990 and 2002. All patients were referred for surgery because of symptomatic cholecystitis or biliary colic, and all surgeries were performed using a standard technique. Of the 86 patients older than 65 years, four required conversion to open cholecystectomy. Sixty-two of the 82 geriatric patients who underwent laparoscopic cholecystectomy were women, and over one half (47 patients) were between 65 and 74 years of age. Eleven patients were older than 85 years. Elective procedures were more common in the 65- to 74-year-old patients (37 of 47 cases), whereas emergency surgeries were required in nine of the 11 patients older than 85 years. The study patients were generally healthy. Overall, 56 were in category I or II of the American Association of Anesthesiologists (ASA) physical status classification, but nine of the 11 patients older than 85 years were in category III or IV.
The rate of conversion to open cholecystectomy in geriatric patients was 3.6 percent—identical to that of the entire series. Two thirds of geriatric patients were discharged on the first postoperative day, and 24 percent on the second day. The two deaths occurred following converted procedures in patients with ASA III classifications. One death was caused by widespread carcinoma of the gallbladder, and the other occurred in a 91-year-old woman with multiple medical comorbidities and surgical complications. The rate of postoperative complications in geriatric patients was 7.2 percent (primarily wound infections). Only one patient developed postoperative pneumonia. The author polled patients and found that 90 percent would defer elective gallbladder surgeries until they could obtain a laparoscopic procedure.
The author concludes that, despite concerns about comorbidities and more challenging surgery because of fibrosis and adhesions following years of gallbladder disease, laparoscopic cholecystectomy is safe and well tolerated in geriatric patients. He recommends greater use of elective laparoscopic cholecystectomy in symptomatic geriatric patients to avoid the morbidity and mortality associated with emergency procedures.
Majeski J. Laparoscopic cholecystectomy in geriatric patients. Am J Surg. June 2004;187:747–50.
Copyright © 2005 by the American Academy of Family Physicians.
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