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Mc Geehan G, Melly C, O' Connor N, Bass G, Mohseni S, Bucholc M, Johnston A, Sugrue M. Prophylactic cholecystectomy offers best outcomes following ERCP clearance of common bile duct stones: a meta-analysis. Eur J Trauma Emerg Surg 2023; 49:2257-2267. [PMID: 36053288 PMCID: PMC10520076 DOI: 10.1007/s00068-022-02070-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 08/05/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Symptomatic calculus biliary disease is common with associated morbidity and occasional mortality, further confounded when there is concomitant common bile duct (CBD) stones. Choledocholithiasis and clearance of the duct reduces recurrent cholangitis, but the question is whether after clearance of the CBD if there is a need to perform a cholecystectomy. This meta-analysis evaluated outcomes in patients undergoing ERCP with or without sphincterotomy to determine if cholecystectomy post-ERCP clearance offers optimal outcomes over a wait-and-see approach. METHODS A Prospero registered meta-analysis of the literature using PRISMA guidelines incorporating articles related to ERCP, choledocholithiasis, cholangitis and cholecystectomy was undertaken for papers published between 1st January 1991 and 31st May 2021. Existing research that demonstrates outcomes of ERCP with no cholecystectomy versus ERCP and cholecystectomy was reviewed to determine the related key events, complications and mortality of leaving the gallbladder in situ and removing it. Odds ratios (OR) were calculated using Review Manager Version 5.4 and meta-analyses performed using OR using fixed-effect (or random-effect) models, depending on the heterogeneity of studies. RESULTS 13 studies (n = 2598), published between 2002 and 2019, were included in this meta-analysis, 6 retrospective, 2 propensity score-matched retrospective studies, 3 prospective studies and 2 randomised control trials from a total of 11 countries. There were 1433 in the no cholecystectomy cohort (55.2%) and 1165 in the prophylactic cholecystectomy (44.8%) cohort. Cholecystectomy resulted in a decreased risk of cholecystitis (OR = 0.15; CI 0.07-0.36; p < 0.0001), cholangitis (OR = 0.51; CI 0.26-1.00; p = 0.05) and mortality (OR = 0.38; CI 0.16-0.9; p = 0.03). In addition, prophylactic cholecystectomy resulted in a significant reduction in biliary events, biliary pain and pancreatitis. CONCLUSIONS In patients undergoing CBD clearance, consideration should be given to performing prophylactic cholecystectomy to optimise outcomes.
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Affiliation(s)
- Gearóid Mc Geehan
- Donegal Clinical Research Academy, Letterkenny University Hospital, Donegal, Ireland.
- School of Medicine, University of Limerick, Limerick, Ireland.
| | - Conor Melly
- Donegal Clinical Research Academy, Letterkenny University Hospital, Donegal, Ireland
- School of Medicine, University of Limerick, Limerick, Ireland
| | - Niall O' Connor
- Donegal Clinical Research Academy, Letterkenny University Hospital, Donegal, Ireland
| | - Gary Bass
- Division of Traumatology, Emergency Surgery and Surgical Critical Care, University of Pennsylvania, Philadelphia, USA
| | - Shahin Mohseni
- Department of Trauma and Emergency Surgery, Orebro University Hospital and School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Magda Bucholc
- Intelligent Systems Research Centre, School of Computing, Engineering and Intelligent Systems, Ulster University (European Union Interreg VA Funded), Magee Campus, Northern Ireland, UK
| | - Alison Johnston
- Donegal Clinical Research Academy, Letterkenny University Hospital, Donegal, Ireland
- EU INTERREG Emergency Surgery Outcome Advancement Project, Centre for Personalised Medicine, Letterkenny, Ireland
| | - Michael Sugrue
- Donegal Clinical Research Academy, Letterkenny University Hospital, Donegal, Ireland
- Department of Surgery, Letterkenny University Hospital, Letterkenny, Co Donegal, Ireland
- EU INTERREG Emergency Surgery Outcome Advancement Project, Centre for Personalised Medicine, Letterkenny, Ireland
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Mohseni S, Bass GA, Forssten MP, Casas IM, Martin M, Davis KA, Haut ER, Sugrue M, Kurihara H, Sarani B, Cao Y, Coimbra R. Common bile duct stones management: A network meta-analysis. J Trauma Acute Care Surg 2022; 93:e155-e165. [PMID: 35939370 DOI: 10.1097/ta.0000000000003755] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Timely management is critical for treating symptomatic common bile duct (CBD) stones; however, a single optimal management strategy has yet to be defined in the acute care setting. Consequently, this systematic review and network meta-analysis, comparing one-stage (CBD exploration or intraoperative endoscopic retrograde cholangiopancreatography [ERCP] with simultaneous cholecystectomy) and two-stage (precholecystectomy or postcholecystectomy ERCP) procedures, was undertaken with the main outcomes of interest being postprocedural complications and hospital length of stay (LOS). METHODS PubMed, SCOPUS, MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were methodically queried for articles from 2010 to 2021. The search terms were a combination of medical subject headings terms and the subsequent terms: gallstone; common bile duct (stone); choledocholithiasis; cholecystitis; endoscopic retrograde cholangiography/ERCP; common bile duct exploration; intraoperative, preoperative, perioperative, and postoperative endoscopic retrograde cholangiography; stone extraction; and one-stage and two-stage procedure. Studies that compared two procedures or more were included, whereas studies not recording complications (bile leak, hemorrhage, pancreatitis, perforation, intra-abdominal infections, and other infections) or LOS were excluded. A network meta-analysis was conducted to compare the four different approaches for managing CBD stones. RESULTS A total of 16 studies (8,644 participants) addressing the LOS and 41 studies (19,756 participants) addressing postprocedural complications were included in the analysis. The one-stage approaches were associated with a decrease in LOS compared with the two-stage approaches. Common bile duct exploration demonstrated a lower overall risk of complications compared with preoperative ERCP, but there were no differences in the overall risk of complications in the remaining comparisons. However, differences in specific postprocedural complications were detected between the four different approaches managing CBD stones. CONCLUSION This network meta-analysis suggests that both laparoscopic CBD exploration and intraoperative ERCP have equally good outcomes and provide a preferable single-anesthesia patient pathway with a shorter overall length of hospital stay compared with the two-stage approaches. LEVEL OF EVIDENCE Systematic Review/Meta Analysis; Level III.
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Affiliation(s)
- Shahin Mohseni
- From the Division of Trauma and Emergency Surgery, Department of Surgery (S.M., M.P.F.), Orebro University Hospital; School of Medical Sciences, Orebro University (S.M., G.A.B., M.P.F.), Orebro, Sweden; Division of Traumatology, Surgical Critical Care and Emergency Surgery (G.A.B.), Penn Presbyterian Medical Center, University of Pennsylvania, Philadelphia, Pennsylvania; Servicio de Cirugía General y Digestiva, Unidad de Cirugía de Urgencias y Trauma (I.M.C.), Hospital Universitario Virgen del Rocio, Sevilla, Andalucia, Spain; Division of Acute Care Surgery (M.M.), Los Angeles County + USC Medical Center, Uniformed Services University Health Sciences, Los Angeles, California; Division of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery (K.A.D.), Yale School of Medicine, New Haven, Connecticut; Division of Acute Care Surgery, Department of Surgery (E.R.H.), Department of Anesthesiology and Critical Care Medicine (E.R.H.), and Department of Emergency Medicine (E.R.H.), The Johns Hopkins University School of Medicine; Department of Health Policy and Management (E.R.H.), The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Letterkenny Hospital (M.S.), Galway University, Galway, Ireland; UOSD Chirurgia d'Urgenza (H.K.), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Center of Trauma and Critical Care (B.S.), George Washington University, Washington, DC; Clinical Epidemiology and Biostatistics (Y.C.), School of Medical Sciences, Orebro University, Orebro, Sweden; Department of Surgery, Riverside University Health System Medical Center (R.C.); Department of Surgery, Loma Linda University School of Medicine (R.C.), Loma Linda; and Department of Surgery, Comparative Effectiveness and Clinical Outcomes Research Center (R.C.), California
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Matsui Y, Hirooka S, Sakaguchi T, Kotsuka M, Yamaki S, Yamamoto T, Kosaka H, Satoi S, Sekimoto M. Bile Duct Stones Predict a Requirement for Cholecystectomy in Older Patients. World J Surg 2020; 44:721-729. [PMID: 31654201 DOI: 10.1007/s00268-019-05241-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The requirement for elective cholecystectomy in older patients is unclear. To determine predictors for requiring elective cholecystectomy in older patients, a prospective cohort study was performed. METHODS All patients with gallstone disease who presented to our department from 2006 to 2018 were included if they met the following criteria: (1) age 75 years or older, (2) presentation for elective cholecystectomy, and (3) preoperative diagnosis of cholecystolithiasis. Two therapeutic options, elective surgery and a wait-and-see approach, were offered at their initial visit. Enrolled patients were assigned to one arm of the study according to their choice of the therapeutic options. The primary endpoint was the incidence of gallstone-related complications. The endpoint was compared between patients who underwent cholecystectomy (CH group) and those who chose a wait-and-see approach (No-CH group). RESULTS During the study period, there were 344 patients in the CH group and 161 in the No-CH group. Among patients with a history of bile duct stones, the incidence of gallstone-related complications in the No-CH group was significantly higher (45% within 3 years, including two gallstone-related deaths) than that in the CH group (RR 2.66, 95% confidence interval 1.50-4.77, p = 0.0009). Among patients with no history of bile duct stones, the incidence of gallstone-related complications in the No-CH group reached only 10% over the 12 years. CONCLUSION Cholecystectomy is recommended for older patients with both histories of cholecystolithiasis and bile duct stones, whereas a wait-and-see approach is preferable for patients with no bile duct stone history. A history of bile duct stones is a good predictor for cholecystectomy in older patients.
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Affiliation(s)
- Yoichi Matsui
- Department of Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan.
| | - Satoshi Hirooka
- Department of Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Tatsuma Sakaguchi
- Department of Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Masaya Kotsuka
- Department of Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - So Yamaki
- Department of Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Tomohisa Yamamoto
- Department of Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Hisashi Kosaka
- Department of Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Sohei Satoi
- Department of Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Mitsugu Sekimoto
- Department of Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan
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Kamarajah SK, Karri S, Bundred JR, Evans RPT, Lin A, Kew T, Ekeozor C, Powell SL, Singh P, Griffiths EA. Perioperative outcomes after laparoscopic cholecystectomy in elderly patients: a systematic review and meta-analysis. Surg Endosc 2020; 34:4727-4740. [PMID: 32661706 PMCID: PMC7572343 DOI: 10.1007/s00464-020-07805-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 06/25/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Laparoscopic cholecystectomy is increasingly performed in an ever ageing population; however, the risks are poorly quantified. The study aims to review the current evidence to quantify further the postoperative risk of cholecystectomy in the elderly population compared to younger patients. METHOD A systematic literature search of PubMed, EMBASE and the Cochrane Library databases were conducted including studies reporting laparoscopic cholecystectomy in the elderly population. A meta-analysis was reported in accordance with the recommendations of the Cochrane Library and PRISMA guidelines. Primary outcome was overall complications and secondary outcomes were conversion to open surgery, bile leaks, postoperative mortality and length of stay. RESULTS This review identified 99 studies incorporating 326,517 patients. Increasing age was significantly associated with increased rates of overall complications (OR 2.37, CI95% 2.00-2.78), major complication (OR 1.79, CI95% 1.45-2.20), risk of conversion to open cholecystectomy (OR 2.17, CI95% 1.84-2.55), risk of bile leaks (OR 1.50, CI95% 1.07-2.10), risk of postoperative mortality (OR 7.20, CI95% 4.41-11.73) and was significantly associated with increased length of stay (MD 2.21 days, CI95% 1.24-3.18). CONCLUSION Postoperative outcomes such as overall and major complications appear to be significantly higher in all age cut-offs in this meta-analysis. This study demonstrated there is a sevenfold increase in perioperative mortality which increases by tenfold in patients > 80 years old. This study appears to confirm preconceived suspicions of higher risks in elderly patients undergoing cholecystectomy and may aid treatment planning and informed consent.
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Affiliation(s)
- Sivesh K Kamarajah
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle University NHS Foundation Trust Hospitals, Newcastle Upon Tyne, UK
- Institute of Cellular Medicine, University of Newcastle, Newcastle Upon Tyne, UK
| | - Santhosh Karri
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - James R Bundred
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Richard P T Evans
- Department of Upper Gastrointestinal Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Area 6, 7th Floor, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB, UK
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Aaron Lin
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Tania Kew
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Chinenye Ekeozor
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Susan L Powell
- Department of Geriatric Medicine, Solihull Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Pritam Singh
- Trent Oesophago-Gastric Unit, City Hospital Campus, Nottingham University Hospitals NHS Trust, Hucknall Road, Nottingham, NG5 1PB, UK
- Regional Oesophago-Gastric Unit, Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Guildford, GU2 7XX, UK
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Area 6, 7th Floor, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB, UK.
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
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Strategies for management of acute cholecystitis in octogenarians. Eur Surg 2020. [DOI: 10.1007/s10353-020-00629-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lord AC, Hicks G, Pearce B, Tanno L, Pucher P. Safety and outcomes of laparoscopic cholecystectomy in the extremely elderly: a systematic review and meta-analysis. Acta Chir Belg 2019; 119:349-356. [PMID: 31437407 DOI: 10.1080/00015458.2019.1658356] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background: Gallstones are a common cause of morbidity in the elderly. Operative treatment is often avoided due to concerns about poor outcomes but the evidence for this is unclear. We aim to consolidate available evidence assessing laparoscopic cholecystectomy outcomes in the extreme elderly (>80s) compared to younger patients. Methods: Studies comparing laparoscopic cholecystectomy in >80s with younger patients were considered. Total complications, mortality, conversion, bile duct injury, and length of stay were compared between the two groups. Results: Twelve studies including 366,522 patients were included. They were of moderate overall quality. The elderly group had more complicated gallbladder disease and also had more co-morbidities and a higher ASA grade. The risk of morbidity was lower in the younger group (RR 0.58 (95% CI 0.58-0.59)) with a slightly lower risk of conversion (RR 0.96 (0.94-0.98)) Length of stay was significantly longer for the elderly patients. Differences in mortality and bile duct injury were non-significant in all but one study. Conclusion: Laparoscopic cholecystectomy is safe and effective in the extreme elderly. Higher complication rates are predominantly related to increased co-morbidities and more complex gallbladder disease. Patients should be carefully selected, and cholecystectomy performed at an earlier stage to minimize these problems.
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Affiliation(s)
- Amy C. Lord
- Department of General Surgery, Croydon University Hospital, London, UK
| | - Georgina Hicks
- Department of General Surgery, Croydon University Hospital, London, UK
| | - Belinda Pearce
- Department of General Surgery, Royal Hampshire Hospital, Winchester, UK
| | - Lulu Tanno
- Department of General Surgery, University Hospital Southampton, Southampton, UK
| | - P.H. Pucher
- Department of Surgery, Portsmouth Hospitals NHS Trust, Portsmouth, UK
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Mesquita ARM, Iglesias AC. Risk factors for elective laparoscopic cholecystectomy morbimortality in elderly. ACTA ACUST UNITED AC 2018; 45:e1995. [PMID: 30569949 DOI: 10.1590/0100-6991e-20181995] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 10/31/2018] [Indexed: 01/31/2023]
Abstract
OBJECTIVE to identify risk factors for the occurrence of postoperative complications in laparoscopic cholecystectomies (LC) in elderly patients. METHODS an observational study with analysis of medical records of patients aged 60 years and older, submitted to elective LC at Gaffree e Guinle Universitary Hospital, from 2006 to 2018. Surgeries performed on an emergency basis or converted to the conventional technique were excluded from our study. RESULTS a total of 345 patients were included in our study, being 80% females and 62% aged 60-69 years. There were 39 cases of postoperative complications (11.3%), mostly (87%) classified as grades I or II of Clavien-Dindo surgical complication scale. There was only one death. The presence and the number of coexisting diseases and ASA II or III physical status classification of preoperative patients conferred a greater risk for the development of postoperative complications and mortality. CONCLUSION our study identified the presence of coexisting diseases, as well as their severity, according to ASA classification, as risk factors for the development of postoperative complications of LC in elderly patients. However, LC proved to be a safe technique when used in these patients with low morbidity and mortality rates.
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Affiliation(s)
- Andréa Renata Machado Mesquita
- Universidade Federal do Estado do Rio de Janeiro (UNIRIO). Hospital Universitário Gaffrée e Guinle, Serviço de Anestesiologia, Rio de Janeiro, RJ, Brasil
| | - Antonio Carlos Iglesias
- Universidade Federal do Estado do Rio de Janeiro (UNIRIO). Hospital Universitário Gaffrée e Guinle, Serviço de Cirurgia Geral e Cirurgia do Aparelho Digestivo, Rio de Janeiro, RJ, Brasil
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Walczak-Galezewska MK, Skrypnik D, Szulinska M, Skrypnik K, Bogdanski P. Conservative management of acute calculous cholecystitis complicated by pancreatitis in an elderly woman: A case report. Medicine (Baltimore) 2018; 97:e11200. [PMID: 29924043 PMCID: PMC6023843 DOI: 10.1097/md.0000000000011200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
RATIONALE Acute calculous cholecystitis is a prevalent disease whose diagnosis and management still face significant debate. Although the overall incidence of gallstone disease is 18.8% in European women aged 30 to 69 years, there is little data and experience in managing acute calculous cholecystitis in populations over 80 years old. The incidence of acute cholecystitis among the elderly is probably increasing. For the reason, we here highlight the advantages and disadvantage of various treatment and management opens based on a 96-year-old patient. PATIENT CONCERNS We present a rare case in which a 96-year-old woman suffered from abdominal pain, nausea, and lack of appetite for over a month. DIAGNOSES She was diagnosed with acute calculous cholecystitis and pancreatitis. INTERVENTIONS She was successfully treated without surgery, regaining her physical health after 5 months. OUTCOMES The question of how to manage acute calculous cholecystitis is extremely difficult in many aspects. The patient of very advanced age presented in this paper, not very well diagnosed and with a life-threating condition, survived because of careful treatment and reasonable decision-making. LESSONS The take-away from this case is that, in a high-risk senile patient, strict conservative therapy of cholecystitis may be successful, as it can avoid the complications of surgery and leave the patient with a good quality of life.
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Affiliation(s)
| | - Damian Skrypnik
- Department of Education and Obesity Treatment and Metabolic Disorders, Poznań University of Medical Sciences, ul. Szamarzewskiego
| | - Monika Szulinska
- Department of Education and Obesity Treatment and Metabolic Disorders, Poznań University of Medical Sciences, ul. Szamarzewskiego
| | - Katarzyna Skrypnik
- Institute of Human Nutrition and Dietetics, Poznań University of Life Sciences, ul. Wojska Polskiego, Poznań, Poland
| | - Pawel Bogdanski
- Department of Education and Obesity Treatment and Metabolic Disorders, Poznań University of Medical Sciences, ul. Szamarzewskiego
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Pålsson S, Saliba G, Sandblom G. Outcome after cholecystectomy in the elderly: a population-based register study. Scand J Gastroenterol 2016; 51:974-8. [PMID: 27152867 DOI: 10.3109/00365521.2016.1166517] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The decision to perform surgery in elderly is usually based on a complex consideration of benefit versus risk, which makes it difficult to perform controlled trials. The aim of this study was to assess the safety of cholecystectomy in patients aged 80 years and above. METHODS The study was based on the Swedish National Register for Gallstone Surgery and ERC (GallRiks) 2006-2011. The cohort was cross-linked with the Swedish Patient Register in order to obtain data on previous medical history and postoperative events. Date and cause of death were obtained from the Central Death Register. All events with an ICD code indicating myocardial infarct, cerebrovascular insult or pulmonary embolism within 30 days postoperatively were considered to be a cardiovascular event. Poisson regression was used to calculate the 30-day age- and sex-adjusted standardised mortality ratio (SMR). RESULTS Altogether 1961 procedures in patients aged 80 years and above were registered. A cardiovascular event within 30 days after the procedure was registered in 56 (0.20%) of the cases. Mortality within 30 days was n = 56 (0.20%). The SMR was 4.07 (CI 3.07-5.28). In univariate regression analyses, no factor was found to significantly predict a postoperative cardiovascular event. Gallstone disease without secondary complication, and open approach were associated with increased risk for death within 30 days after surgery in both univariate and multivariate regression analyse (p < 0.05). CONCLUSION Cholecystectomy seems to be a relatively safe procedure in patients aged 80 years or older. Minimally invasive techniques may reduce the risk of postoperative death.
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Affiliation(s)
- Simon Pålsson
- a Department of Surgery , Sahlgrenska University Hospital , Göteborg , Sweden
| | - Gabriel Saliba
- b Department of Surgery , Capio Sankt Göran Hospital , Stockholm , Sweden
| | - Gabriel Sandblom
- c CLINTEC, Karolinska Institutet , Stockholm , Sweden ;,d Center for Digestive Diseases , Karolinska University Hospital , Stockholm , Sweden
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PREOP-Gallstones: A Prognostic Nomogram for the Management of Symptomatic Cholelithiasis in Older Patients. Ann Surg 2016; 261:1184-90. [PMID: 25072449 DOI: 10.1097/sla.0000000000000868] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE AND BACKGROUND The decision regarding elective cholecystectomy in older patients with symptomatic cholelithiasis is complicated. We developed and validated a prognostic nomogram to guide shared decision making for these patients. METHODS We used Medicare claims (1996-2005) to identify the first episode of symptomatic cholelithiasis in patients older than 65 years who did not undergo hospitalization or elective cholecystectomy within 2.5 months of the episode. We described current patterns of care and modeled their risk of emergent gallstone-related hospitalization or cholecystectomy at 2 years. Model discrimination and calibration were assessed using a random split sample of patients. RESULTS We identified 92,436 patients who presented to the emergency department (8.3%) or physician's office (91.7%) and who were not immediately admitted. The diagnosis for the initial episode was biliary colic/dyskinesia (65.3%), acute cholecystitis (26.6%), choledocholithiasis (5.7%), or gallstone pancreatitis (2.4%). The 2-year emergent gallstone-related hospitalization rate was 11.1%, with associated in-hospital morbidity and mortality rates of 56.5% and 6.5%. Factors associated with gallstone-related acute hospitalization included male sex, increased age, fewer comorbid conditions, complicated biliary disease on initial presentation, and initial presentation to the emergency department. Our model was well calibrated and identified 51% of patients with a risk less than 10% for 2-year complications and 5.4% with a risk more than 40% (C statistic, 0.69; 95% confidence interval, 0.63-0.75). CONCLUSIONS Surgeons can use this prognostic nomogram to accurately provide patients with their 2-year risk of developing gallstone-related complications, allowing patients and physicians to make informed decisions in the context of their symptom severity and its impact on their quality of life.
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Dimou FM, Adhikari D, Mehta HB, Riall TS. Trends in Follow-Up of Patients Presenting to the Emergency Department with Symptomatic Cholelithiasis. J Am Coll Surg 2015; 222:377-84. [PMID: 26837281 DOI: 10.1016/j.jamcollsurg.2015.12.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 12/14/2015] [Indexed: 01/08/2023]
Abstract
BACKGROUND Fewer than 25% of Medicare beneficiaries presenting with symptomatic cholelithiasis undergo elective cholecystectomy. To better understand underuse of cholecystectomy, we examined physician follow-up patterns after emergency department (ED) visits for symptomatic gallstones. STUDY DESIGN We used 100% Texas Medicare claims (2001 to 2010) to identify patients 66 years of age and older who presented to the ED with symptomatic cholelithiasis and were discharged home without cholecystectomy. Timing of outpatient physician visits after ED discharge and rates of emergent cholecystectomy based on physician follow-up patterns were compared. RESULTS In total, 11,126 patients presented to the ED with symptomatic cholelithiasis and were discharged without cholecystectomy. After discharge, 5,327 patients (47.9%) had an outpatient surgeon visit, 29.0% saw another physician and never saw a surgeon, and 23.1% never saw a physician; 68.2% of patients who saw a surgeon underwent elective cholecystectomy; and 8.3% of patients who saw a surgeon, 14.6% of patients who saw other physicians and no surgeon, and 77.6% of patients who never saw any physician, required emergent hospitalization (p < 0.0001). For people who did not see a physician, mean time to emergent hospitalization was 7.5 days (median 2 days); 95.9% presented within 2 weeks after their initial presentation. CONCLUSIONS Fewer than half of patients were evaluated by a surgeon after an initial ED visit for symptomatic gallstones. Patients who did not have physician follow-up were most likely to require emergent cholecystectomy, suggesting inappropriate ED discharge and highlighting the need for timely follow-up. Early outpatient surgical consultation is critical in determining appropriateness for cholecystectomy and avoiding emergent cholecystectomy in older patients with symptomatic gallstones.
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Affiliation(s)
- Francesca M Dimou
- Department of Surgery, University of Texas Medical Branch, Galveston, TX; Department of Surgery, University of South Florida, Tampa, FL
| | - Deepak Adhikari
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | - Hemalkumar B Mehta
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | - Taylor S Riall
- Department of Surgery, University of Texas Medical Branch, Galveston, TX; Department of Surgery, University of Arizona, Tucson, AZ.
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Fuks D, Duhaut P, Mauvais F, Pocard M, Haccart V, Paquet JC, Millat B, Msika S, Sielezneff I, Scotté M, Chatelain D, Regimbeau JM. A retrospective comparison of older and younger adults undergoing early laparoscopic cholecystectomy for mild to moderate calculous cholecystitis. J Am Geriatr Soc 2015; 63:1010-6. [PMID: 25946647 DOI: 10.1111/jgs.13330] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To compare the demographic characteristics and intra- and postoperative outcomes in elderly adults (≥75) with those of younger adults undergoing early (<5 days after onset of complaints) cholecystectomy. DESIGN Retrospective analysis from May 2010 to August 2012. SETTING Randomized, multicenter, clinical trial (ABCAL Study, NCT01015417). PARTICIPANTS Individuals with mild or moderate acute calculous cholecystitis (ACC) according to the Tokyo Guidelines (N=414; n=78 aged 75-94, median 82; n=336 aged 18-74, median 49). MEASUREMENTS Demographic characteristics and pre-, intra-, and postoperative data. RESULTS The elderly group was more likely to have an American Society of Anesthesiologists score of 3 or greater (62% vs 23%, P<.001), higher serum creatinine (103 vs 74 μmol/L, P<.001), and more-severe ACC (moderate ACC (62% vs 50%, P=.05), gangrenous cholecystitis (38% vs 15%, P=.001)) on preoperative imaging and confirmed intraoperatively. Ulcerated mucosa (76% vs 61%, P=.001) was significantly more frequent in the elderly group. Operative time, postoperative mortality, and postoperative infectious (18% vs 14%, P=.35) and noninfectious (9% vs 3%, P=.80) complications were similar between the two groups. Median length of stay (7.0 vs 5.0 days, P=.54) and readmission rate (15% vs 4%, P=.07) were not significantly higher in the elderly group. No significant difference was observed for the subgroup of participants aged 80 and older. CONCLUSION In this randomized trial that included a selected sample of older adults, there was no difference in major outcomes between elderly adults and their younger counterparts after early cholecystectomy. The findings are limited because important geriatric outcomes such as delirium and functional decline were not examined.
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Affiliation(s)
- David Fuks
- Department of Digestive Surgery, Amiens University Hospital, Amiens, France.,Department of Internal Medicine, Amiens University Hospital, Amiens, France.,Inserm U1088, Faculté de Médecine, Université de Picardie Jules Verne, Amiens, France.,Réseau d'Epidémiologie Clinique International Francophone, Amiens University Hospital, Amiens, France
| | - Pierre Duhaut
- Department of Internal Medicine, Amiens University Hospital, Amiens, France.,Réseau d'Epidémiologie Clinique International Francophone, Amiens University Hospital, Amiens, France
| | - Francois Mauvais
- Department of Digestive Surgery, Beauvais Hospital, Beauvais, France
| | - Marc Pocard
- Department of Digestive Surgery, Lariboisière University Hospital, Paris, France
| | - Vincent Haccart
- Department of Digestive Surgery, Montreuil-sur-Mer Hospital, Rang-du-Fliers, France
| | | | - Bertrand Millat
- Department of Digestive Surgery, Montpellier University Hospital, Montpellier, France
| | - Simon Msika
- Department of Digestive Surgery, Louis Mourier Hospital, Colombes, France
| | - Igor Sielezneff
- Department of Digestive Surgery, La Timone University Hospital, Marseille, France
| | - Michel Scotté
- Department of Digestive Surgery, Rouen University Hospital, Rouen Cedex, France
| | - Denis Chatelain
- Department of Pathology, Amiens University Hospital, Amiens, France
| | - Jean Marc Regimbeau
- Department of Digestive Surgery, Amiens University Hospital, Amiens, France.,Inserm U1088, Faculté de Médecine, Université de Picardie Jules Verne, Amiens, France
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Bergman S, Al-Bader M, Sourial N, Vedel I, Hanna WC, Bilek AJ, Galatas C, Marek JE, Fraser SA. Recurrence of biliary disease following non-operative management in elderly patients. Surg Endosc 2015; 29:3485-90. [DOI: 10.1007/s00464-015-4098-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 01/16/2015] [Indexed: 12/16/2022]
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Riall TS, Adhikari D, Parmar AD, Linder SK, Dimou FM, Crowell W, Tamirisa NP, Townsend CM, Goodwin JS. The risk paradox: use of elective cholecystectomy in older patients is independent of their risk of developing complications. J Am Coll Surg 2014; 220:682-90. [PMID: 25660731 DOI: 10.1016/j.jamcollsurg.2014.12.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 12/09/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND We recently developed and validated a prognostic model that accurately predicts the 2-year risk of emergent gallstone-related hospitalization in older patients presenting with symptomatic gallstones. STUDY DESIGN We used 100% Texas Medicare data (2000 to 2011) to identify patients aged 66 years and older with an initial episode of symptomatic gallstones not requiring emergency hospitalization. At presentation, we calculated each patient's risk of 2-year gallstone-related emergent hospitalization using the previously validated model. Patients were placed into the following risk groups based on model estimates: <30%, 30% to <60%, and ≥ 60%. Within each risk group, we calculated the percent of elective cholecystectomies (≤ 2.5 months from initial episode) performed. RESULTS In all, 161,568 patients had an episode of symptomatic gallstones. Mean age was 76.5 ± 7.3 years and 59.9% were female. The 2-year risk of gallstone-related hospitalizations increased from 15.9% to 41.5% to 65.2% across risk groups. For the overall cohort, 22.3% in the low-risk group, 20.9% in the moderate-risk group, and 23.2% in the high-risk group underwent elective cholecystectomy in the 2.5 months after the initial symptomatic episode. In patients with no comorbidities, elective cholecystectomy rates decreased from 34.2% in the low-risk group to 26.7% in the high-risk group. Of patients who did not undergo cholecystectomy, only 9.5% were seen by a surgeon in the 2.5 months after the initial episode. CONCLUSIONS The risk of recurrent acute biliary symptoms requiring hospitalization has no influence, or even a paradoxical negative influence, on the decision to perform elective cholecystectomy after an initial symptomatic episode. Translation of the risk prediction model into clinical practice can better align treatment with risk and improve outcomes in older patients with symptomatic gallstones.
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Affiliation(s)
- Taylor S Riall
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX.
| | - Deepak Adhikari
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX
| | - Abhishek D Parmar
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX; Department of Surgery, The University of California, San Francisco-East Bay, Oakland, CA
| | - Suzanne K Linder
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX
| | - Francesca M Dimou
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX; Department of Surgery, The University of South Florida, Tampa, FL
| | - Winston Crowell
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX
| | - Nina P Tamirisa
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX; Department of Surgery, The University of California, San Francisco-East Bay, Oakland, CA
| | - Courtney M Townsend
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX
| | - James S Goodwin
- Department of Internal Medicine, The University of Texas Medical Branch, Galveston, TX
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Parmar AD, Coutin MD, Vargas GM, Tamirisa NP, Sheffield KM, Riall TS. Cost-effectiveness of elective laparoscopic cholecystectomy versus observation in older patients presenting with mild biliary disease. J Gastrointest Surg 2014; 18:1616-22. [PMID: 24919433 PMCID: PMC4140946 DOI: 10.1007/s11605-014-2570-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 06/02/2014] [Indexed: 01/31/2023]
Abstract
Our objective was to determine the probability threshold for recurrent symptoms at which elective cholecystectomy compared to observation in older patients with symptomatic cholelithiasis is the more effective and cost-effective option. We built a decision model of elective cholecystectomy versus observation in patients >65 presenting with initial episodes of symptomatic cholelithiasis that did not require initial hospitalization or cholecystectomy. Probabilities for subsequent hospitalization, emergency cholecystectomy, and perioperative complications were based on previously published probabilities from a 5 % national sample of Medicare patients. Costs were estimated from Medicare reimbursements and from the Healthcare Cost and Utilization Project. Utilities (quality-adjusted life years, QALYs) were obtained from established literature estimates. Elective cholecystectomy compared to observation in all patients was associated with lower effectiveness (-0.10 QALYs) and had an increased cost of $3,422.83 per patient at 2-year follow-up. Elective cholecystectomy became the more effective option when the likelihood for continued symptoms exceeded 45.3 %. Elective cholecystectomy was both more effective and less costly when the probability for continued symptoms exceeded 82.7 %. An individualized shared decision-making strategy based on these data can increase elective cholecystectomy rates in patients at high risk for recurrent symptoms and minimize unnecessary cholecystectomy for patients unlikely to benefit.
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Affiliation(s)
- Abhishek D. Parmar
- Departments of Surgery, The University of Texas Medical Branch, Galveston, Texas,The University of California, San Francisco-East Bay, Oakland, California
| | - Mark D. Coutin
- Departments of Surgery, The University of Texas Medical Branch, Galveston, Texas
| | - Gabriela M. Vargas
- Departments of Surgery, The University of Texas Medical Branch, Galveston, Texas
| | - Nina P. Tamirisa
- Departments of Surgery, The University of Texas Medical Branch, Galveston, Texas,The University of California, San Francisco-East Bay, Oakland, California
| | - Kristin M. Sheffield
- Departments of Surgery, The University of Texas Medical Branch, Galveston, Texas
| | - Taylor S. Riall
- Departments of Surgery, The University of Texas Medical Branch, Galveston, Texas
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Heger E, Lammert F. [Biliary diseases in the elderly]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2014; 52:447-9. [PMID: 24824910 DOI: 10.1055/s-0034-1366158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Gallstone disease is more common in the elderly. In this short review, we summarize guideline-based recommendations for the diagnosis and treatment of biliary diseases in elderly patients. Warning episodes of biliary colic represent a general indication for cholecystectomy to avoid stone-related complications. Elderly patients with mild and moderate acute cholecystitis should undergo urgent cholecystectomy. After endoscopic retrograde cholangiography and stone extraction as well as mild acute biliary pancreatitis, cholecystectomy should be performed during the same hospital admission. Since the elevated risk of gallstone carriers to develop biliary cancer increases with age, cholecystectomy also protects against cancer.
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Affiliation(s)
- E Heger
- Medizinische Klinik II, Asklepios Klinik, Langen
| | - F Lammert
- Klinik für Innere Medizin II, Universitätsklinikum des Saarlandes, Homburg
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Day LW, Lin L, Somsouk M. Adverse events in older patients undergoing ERCP: a systematic review and meta-analysis. Endosc Int Open 2014; 2:E28-36. [PMID: 26134610 PMCID: PMC4423280 DOI: 10.1055/s-0034-1365281] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 01/20/2014] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Biliary and pancreatic diseases are common in the elderly; however, few studies have addressed the occurrence of adverse events in elderly patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). Our objective was to determine the incidence rates of specific adverse events in this group and calculate incidence rate ratios (IRRs) for selected comparison groups. PATIENTS AND METHODS Bibliographical searches were conducted in Medline, EMBASE, and Cochrane library databases. The studies included documented the incidence of adverse events (perforation, pancreatitis, bleeding, cholangitis, cardiopulmonary adverse events, mortality) in patients aged ≥ 65 who underwent ERCP. Pooled incidence rates were calculated for each reported adverse event and IRRs were determined for available comparison groups. A parallel analysis was performed in patients aged ≥ 80 and ≥ 90. RESULTS Our literature search yielded 7429 articles, of which 69 studies met our inclusion criteria. Pooled incidence rates for adverse events (per 1000 ERCPs) in patients aged ≥ 65 were as follows: perforation 3.8 (95 %CI 1.8 - 7.0), pancreatitis 13.1 (95 %CI 11.0 - 15.5), bleeding 7.7 (95 %CI 5.7 - 10.1), cholangitis 16.1 (95 %CI 11.7 - 21.7), cardiopulmonary events 3.7 (95 %CI 1.5 - 7.6), and death 7.1 (95 %CI 5.2 - 9.4). Patients ≥ 65 had lower rates of pancreatitis (IRR 0.3, 95 %CI 0.3 - 0.4) compared with younger patients. Octogenarians had higher rates of death (IRR 2.4, 95 %CI 1.3 - 4.5) compared with younger patients, whereas nonagenarians had increased rates of bleeding (IRR 2.4, 95 %CI 1.1 - 5.2), cardiopulmonary events (IRR 3.7, 95 %CI 1.0 - 13.9), and death (IRR 3.8, 95 %CI 1.0 - 14.4). Conclusions ERCP appears to be safe in elderly patients, except in the very elderly who are at higher risk of some adverse events. These data on adverse event rates can help to inform clinical decision-making, the consent process, and comparative effectiveness analyses.
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Affiliation(s)
- Lukejohn W. Day
- Division of Gastroenterology, San Francisco General Hospital and Trauma Center, San Francisco, California, United States
- GI Health Outcomes, Policy and Economics (HOPE) Research Program, Department of Medicine, University of California, San Francisco, California, United States
| | - Lisa Lin
- Department of Medicine, Mount Sinai School of Medicine, New York, New York, United States
| | - Ma Somsouk
- Division of Gastroenterology, San Francisco General Hospital and Trauma Center, San Francisco, California, United States
- GI Health Outcomes, Policy and Economics (HOPE) Research Program, Department of Medicine, University of California, San Francisco, California, United States
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18
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Marcari RS, Lupinacci RM, Nadal LR, Rego RE, Coelho AM, de Matos Farah JF. Outcomes of laparoscopic cholecystectomy in octogenarians. JSLS 2013; 16:271-5. [PMID: 23477177 PMCID: PMC3481239 DOI: 10.4293/108680812x13427982376428] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Laparoscopic cholecystectomy in octogenarians appears to be safe with acceptable morbidity. 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 ≥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.
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Affiliation(s)
- Rafael S Marcari
- Department of General Surgery, Sio Paulo Estate Employees Hospital, S.o Paulo, Brazil
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Hou WY, Tung TH, Shen HJ, Chang TY, Chou P, Liu JH. Community-Based Epidemiologic Study on Gallstone Disease among Elderly Patients with Type 2 Diabetes in Kinmen, Taiwan. INT J GERONTOL 2012. [DOI: 10.1016/j.ijge.2012.01.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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20
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Bergman S, Sourial N, Vedel I, Hanna WC, Fraser SA, Newman D, Bilek AJ, Galatas C, Marek JE, Monette J. Gallstone disease in the elderly: are older patients managed differently? Surg Endosc 2010; 25:55-61. [PMID: 20512508 DOI: 10.1007/s00464-010-1128-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2010] [Accepted: 05/03/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND This study aimed to describe the differences in the management of symptomatic gallstone disease within different elderly groups and to evaluate the association between older age and surgical treatment. METHODS This single-institution retrospective chart review included all patients 65 years old and older with an initial hospital visit for symptomatic gallstone disease between 2004 and 2008. The patients were stratified into three age groups: group 1 (age, 65-74 years), group 2 (age, 75-84 years), and group 3 (age, ≥ 85 years). Patient characteristics and presentation at the initial hospital visit were described as well as the surgical and other nonoperative interventions occurring over a 1-year follow-up period. Logistic regression was performed to assess the effect of age on surgery. RESULTS Data from 397 patient charts were assessed: 182 in group 1, 160 in group 2, and 55 in group 3. Cholecystitis was the most common diagnosis in groups 1 and 2, whereas cholangitis was the most common diagnosis in group 3. Elective admissions to a surgical ward were most common in group 1, whereas urgent admissions to a medical ward were most common in group 3. Elective surgery was performed at the first visit for 50.6% of group 1, for 25.6% of group 2, and for 12.7% of group 3, with a 1-year cumulative incidence of surgery of 87.4% in group 1, 63.5% in group 2, and 22.1% in group 3. Inversely, cholecystostomy and endoscopic retrograde cholangiopancreatography (ERCP) were used more often in the older groups. Increased age (odds ratio [OR], 0.87; 95% confidence interval [CI], 0.84-0.91) and the Charlson Comorbidity Index (OR, 0.80; 95% CI, 0.69-0.94) were significantly associated with a decreased probability of undergoing surgery within 1 year after the initial visit. CONCLUSION Even in the elderly population, older patients presented more frequently with severe disease and underwent more conservative treatment strategies. Older age was independently associated with a lower likelihood of surgery.
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Affiliation(s)
- Simon Bergman
- Department of Surgery, Lady Davis Institute for Medical Research, Sir Mortimer B. Davis Jewish General Hospital, McGill University, Pavilion A-515, 3755 Côte-Sainte-Catherine, Montreal, QC, H3T 1E2, Canada.
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Kaya IO, Ozkardes A, Ozdemir F, Seker G, Tokac M, Ozmen MM. LAPAROSCOPIC CHOLECYSTECTOMY IN ELDERLY PEOPLE: DOES ADVANCED AGE PRESENT ANY RISK FOR CONVERSION? J Am Geriatr Soc 2008; 56:962-3. [DOI: 10.1111/j.1532-5415.2008.01720.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Stewart L, Grifiss JM, Jarvis GA, Way LW. Elderly patients have more severe biliary infections: influence of complement-killing and induction of TNFalpha production. Surgery 2007; 143:103-12. [PMID: 18154938 DOI: 10.1016/j.surg.2007.06.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2007] [Revised: 05/31/2007] [Accepted: 06/05/2007] [Indexed: 12/26/2022]
Abstract
BACKGROUND Biliary bacteria are more common in elderly patients and cause more serious illnesses. The reasons for this are unclear. We noted previously that bacterial serum-sensitivity and induction of TNFalpha production in sera (iTNFsera) were associated with severe biliary infections. We examined the influence of age and these factors on illness severity. METHODS Three-hundred and forty patients were studied. Gallstones and bile were cultured. Illness was staged as none (no clinical infection or inflammation), SIRS (fever, leukocytosis), severe (cholangitis, abscess, empyema), or MODS (bacteremia, hypotension, organ dysfunction/failure). Bacterial serum-sensitivity and TNFalpha induction were measured. Younger (< 70 years) and elderly (> or = 70 years) patients were compared. RESULTS Biliary bacteria were more common in elderly (64% vs 41%, P < .0001). Among patients with biliary bacteria, the elderly had more serious illnesses: none: 44% younger, 19% elderly; SIRS: 16% younger, 22% elderly; severe: 22% younger, 21% elderly; MODS 18% younger, 38% elderly (P = .003). Bacteria from elderly patients induced more TNFalpha (580 vs 310 pg/ml, P = .023). In both groups, serum-sensitive bacteria caused infectious manifestations and induced abundant TNFalpha; however, serum-resistant bacteria from elderly usually (69%) caused infectious manifestations and abundant TNFalpha, while serum-resistant bacteria from younger patients rarely (8%) caused infectious manifestations and minimal TNFalpha. Elderly patients with high iTNFsera bacteria had more severe illnesses. CONCLUSIONS Biliary bacteria were more common in elderly patients and produced more serious illnesses. Many younger patients with biliary bacteria displayed no infectious manifestations. Elderly patients harbored more virulent bacteria, and had a heightened response to high iTNFsera bacteria, as well as bacteria largely tolerated by younger patients.
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Affiliation(s)
- Lygia Stewart
- Department of Surgery, University of California, San Francisco, CA 94121, USA.
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Abstract
Evaluation of the elderly patient with acute abdominal pain is sometimes difficult. Various factors can obscure the presentation, delaying or preventing the correct diagnosis and leading to adverse patient outcomes. Clinicians must consider multiple diagnoses, especially those life-threatening conditions that require timely intervention to limit morbidity and mortality. This article reviews abdominal pain in the elderly, discusses the clinical approach, and highlights key diagnostic considerations.
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Affiliation(s)
- Ernest L Yeh
- Department of Emergency Medicine, Temple University School of Medicine, Temple University Hospital, 3401 North Broad Street, 1011, 10th Floor Jones Hall, Philadelphia, PA 19140, USA.
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Turienzo-Santos EO, Rodríguez-García JI, Trelles-Martín A, Aza-González J. Gestión integral del proceso de colecistectomía laparoscópica. Cir Esp 2006; 80:385-94. [PMID: 17192223 DOI: 10.1016/s0009-739x(06)70992-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
INTRODUCTION One of the most important objectives of public healthcare services is to guarantee integral healthcare to patients; activity is currently focussed on process management. Analysis of a "key" process could have health, social and economic effects if measures to improve the results are designed. The aim of the present study was to evaluate the process of laparoscopic cholecystectomy in our hospital in order to determine its strong and weak points. MATERIAL AND METHOD We performed a prospective observational study of the laparoscopic cholecystectomy (LC) process in the Jarrio Hospital between January 2001 and December 2002. A working group was formed and a process flowchart was designed by consensus. The different steps of the process were evaluated through the main indicators of quality: accessibility, efficiency, and effectiveness, including cost, the convalescence period, and patient satisfaction. The results were compared with the standards defined by the Andalusian Health Council, bibliographic sources, and hospital commissions. The statistical analysis was performed with 95% confidence intervals of the main results. RESULTS A series of 86 patients who underwent LC was evaluated. The results for accessibility showed wide variability in delays for specialist consultations, the waiting list for surgery, and urgent diagnostic tests, often exceeding the standards. The laparoscopic approach was more frequent than open cholecystectomy; morbidity and mortality with LC were below the reference standards and compliance with established prophylaxis protocols was close. The efficiency markers showed that the length of hospital stay for elective LC was close to the standard; however, for cholecystitis preoperative length of stay was longer than the standard. Overall patient satisfaction with medical care and non-medical services was high. CONCLUSIONS Quality analysis of a process allowed us to identify strong points such as the high rate of laparoscopic cholecystectomy -showing good effectiveness and efficiency- the quality of informed consent, and patient satisfaction. Required improvements consisted of shortening preoperative length of stay in acute cholecystitis and waiting lists, informing patients about the length of the convalesce period, eliminating routine type and screen, and admitting patients on the day of surgery.
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Costi R, DiMauro D, Mazzeo A, Boselli AS, Contini S, Violi V, Roncoroni L, Sarli L. Routine laparoscopic cholecystectomy after endoscopic sphincterotomy for choledocholithiasis in octogenarians: is it worth the risk? Surg Endosc 2006; 21:41-7. [PMID: 17111279 DOI: 10.1007/s00464-006-0169-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2006] [Accepted: 05/11/2006] [Indexed: 02/06/2023]
Abstract
BACKGROUND No unanimous consensus has been reached as to the need for routine laparoscopic cholecystectomy (LC) after endoscopic sphincterotomy (ES) for choledocholithiasis in very elderly patients, who are considered as high-risk subjects for surgery. METHODS From 1991 through 1997, 170 patients were referred to undergo preoperative ES and routine LC for common bile duct (CBD) stones. The results for 27 patients (age 80 years or older) were compared with those achieved for younger patients. Successively, in a retrospective case-control study, the results for the selected patients were compared with those for 27 very elderly patients who underwent endoscopic retrograde cholangiopancreatography (ERCP), but did not receive LC. The mean follow-up period was 126 months. RESULTS Octogenarians showed longer surgery time (79 vs 51 min) and postoperative hospital stay (2.8 vs 1.2 days), as well as more early low-grade complications (15% vs 3%), whereas there were no differences in conversion rate or serious complications. Recurrent symptoms or complications developed in 48% of octogenarians not undergoing routine LC, and 30% finally needed surgery. One patient in the control group died after emergency cholecystectomy for acute cholecystitis. The results of surgery were significantly poorer for the control group. CONCLUSIONS Although a "wait-and-see" policy allowed two-thirds of LCs to be avoided in octogenarians, biliary-related events developed for every second patient, often requiring delayed surgery, with poorer results. Sequential treatment (ES followed by elective LC) is a safe procedure for octogenarians, and should be considered as a standard, definitive treatment for cholecystocholedocholithiasis even after the age of 80 years.
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Affiliation(s)
- R Costi
- Dipartimento di Scienze Chirurgiche, Università degli Studi di Parma, Via Gramsci 14, 43100, Parma, Italy.
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Abstract
Many diseases of the biliary tract and pancreas preferentially effect the elderly. Recent innovations in the evaluation and management of these disorders have directly impacted the lives of many seniors. Improved outcomes of pancreatic surgery is a good example of a positive impact in quality of life, especially when these surgeries are performed in centers of excellence. Evaluation and treatment strategies are presented for complicated calculous biliary disease, pancreatic carcinoma, and pancreatic cystic neoplasms.
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Affiliation(s)
- R Matthew Walsh
- Department of General Surgery, The Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Costi R, Sarli L, Violi V, Roncoroni L. Expectant treatment of cholecystectomy after endoscopic retrograde cholangiopancreatography for choledocholithiasis in patients over 80 years of age. Surg Endosc 2005; 19:1513-4; author reply 1515. [PMID: 16187002 DOI: 10.1007/s00464-005-0167-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2005] [Accepted: 05/10/2005] [Indexed: 10/25/2022]
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Pring CM, Skelding-Millar L, Goodall RJR. Expectant treatment or cholecystectomy after endoscopic retrograde cholangiopancreatography for choledocholithiasis in patients over 80 years old? Surg Endosc 2005; 19:357-60. [PMID: 15645324 DOI: 10.1007/s00464-004-9089-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2004] [Accepted: 08/19/2004] [Indexed: 12/20/2022]
Abstract
BACKGROUND It is recommended that most patients between 18-80 years old, who have had an endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis, should be offered cholecystecytomy. However, we were uncertain whether this was the correct advice for patients over 80. METHOD A retrospective case note analysis was performed on 81 patients over 80, who had had an ERCP for choledocholithiasis. The primary end points were further biliary symptoms, cholecystectomy, death from biliary independent causes, and those still alive without further biliary symptoms. RESULTS The records of 81 patients (median age 87; range, 80-96 years) were analyzed. Of the patients, 11% experienced further biliary symptoms at a median time of 4.5 months [interquartile range (IQR), 2.25-8.5 months] from the ERCP; 6% received cholecystectomy; 61% were still alive with no further biliary symptoms at a median time of 17 months (IQR, 12.25-23.75 months) after ERCP; and 22% had died from biliary independent causes at a median time of 9 months after ERCP (IQR, 3-12 months). CONCLUSION Expectant treatment can be recommended in this group of patients. Those who do present with further biliary symptoms do so soon after ERCP. Therefore, we recommend follow-up for 12 months after ERCP, prior to discharge.
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Affiliation(s)
- C M Pring
- Department of Surgery, Calderdale Royal Hospital, Salterhebble, Halifax HX3 OPW, UK.
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Hong SN, Lee JK, Lee KT, Heo JS, Choi SH, Rhee PL, Paik SW, Yoo BC, Rhee JC. Usefulness of gallbladder ejection fraction estimation to predict the recurrence of biliary pain in patients with symptomatic gallstones who did not undergo cholecystectomy. Dig Dis Sci 2004; 49:820-7. [PMID: 15259504 DOI: 10.1023/b:ddas.0000030094.84619.22] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
This study was performed to evaluate any predictable factors associated with recurrence of biliary pain in symptomatic gallstone patients who did not undergo cholecystectomy because of operative risk, advanced age, and/or their refusal. The relationships among age, gender, body mass index, frequency of biliary pain before diagnosis, period between the last symptom attack and the hospital visit, size and number of gallstones, gallbladder ejection fraction (GBEF), compliance of ursodeoxycholic acid therapy, and recurrence of biliary pain were examined. The recurrence of biliary pain developed in 15 of 31 patients during the median 29-month follow-up. The cumulative 1-, 2-, and 3-year recurrence rates of biliary pain were 22.8, 40.9, and 53.0% and significantly associated with abnormal GBEF (hazard ratio, 3.12; 95% CI, 1.10-8.87; P = 0.032). In symptomatic gallstone patients with abnormal GBEF, cholecystectomy is strongly advisable because of the high risk of repeated pain attacks.
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Affiliation(s)
- Sung Noh Hong
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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