Results of laparoscopic cholecystectomy in the elderly

OBJECTIVE
to evaluate the results of laparoscopic cholecystectomy in the elderly compared with younger patients.


METHODS
we retrospectively reviewed computerized medical records of all patients who underwent laparoscopic cholecystectomy for chronic or acute cholecystitis from January 1, 2011 to March 31, 2018 at a single teaching hospital. We stratified the patients into two groups: elderly (≥60 years of age) and younger (<60 years of age).


RESULTS
of 1,645 patients subjected to laparoscopic cholecystectomy, 1,161 (70.3%) were younger and 484 (29.7%) were elderly. The rate of male was higher in the elderly (n=185; 38.2%) group than in the younger (n=355; 30.6) (p=0.003). Jaundice was more common in the elderly (p=0.004). The rate of prior abdominal operation was also higher in the elderly (p<0.001). The percentage of patients with ASA score II, III, and IV was higher in the elderly group (p<0.001 in score II and III and 0.294 in score IV). Operative time was longer in the elderly (71.68±31.27) than in the younger group (p=0.001). The following perioperative data were higher in the elderly: acute cholecystitis (p<0.001), conversion rate (p=0.028), postoperative complications (p=0.042), and mortality (p=0.026).


CONCLUSION
the operative time is longer and the rate of acute cholecystitis, conversion to open cholecystectomy and postoperative complications are higher in the elderly patients submitted to laparoscopic cholecystectomy when compared with younger individuals.


INTRODUCTION
A lthough gallstones occur in patients of any age, from newborn to the elderly, its prevalence increases markedly with age 1,2 .Cholelithiasis affects 25-40% of the population in the seventh decade of life and approximately 50% of the individuals over 80 years of age 1,3 .In 2017, the United Nations estimated the world population aged 60 years to be one billion, comprising 13% of the global population 4,5 .Globally, population aged 60 years is growing at a rate of about 3% per year, faster than all younger age groups 4,5 .
With the increasing of the population longevity, acute and chronic cholecystitis has become a frequent problem in this group.Currently, cholecystectomy for calculous cholecystitis is the most common abdominal operation in the elderly 6,7 .The natural history of symptomatic biliary lithiasis in the elderly is more severe than in younger patients and needs special considerations 6,8 .The incidence of acute cholecystitis and its complications is higher in the elderly 9,10 .In addition, the surgical risk is increased due to comorbidities and reduced physiological reserve 10,11 .Complications of surgical treatment of chronic cholecystitis and acute cholecystitis are worse in the elderly 12,13 .The aim of this study is to compare the results of laparoscopic cholecystectomy (LC) in elderly patients with those of younger individuals.
Rev Col Bras Cir 45 (5):e2020 Hospital Nossa Senhora das Graças.This institution is a private teaching hospital with surgical residency programs in General and Gastrointestinal Surgery certified by the Brazilian Ministry of Education.
The same surgeon performed or supervised all operations.Surgical residents participated in all procedures.
As recommended by the World Health Organization (WHO), we divided patients into two groups: elderly (≥60 years of age) and younger (<60 years of age) 4,5

DISCUSSION
LC has gained rapid acceptance worldwide as the gold standard treatment for symptomatic gallstones 14,15 .This procedure has several advantages when compared with open cholecystectomy, including less postoperative pain, a short recovery period, a rapid return to normal activities, and better cosmetic results 11,16 .Although LC is considered safe, the rate of morbidity and mortality may be significant in some groups of patients, such as elderly, morbidly obese and immunosuppressed patients 9,17 .LC perioperative morbidity and mortality are usually considered higher in the elderly due to low physiologic reserve and associated diseases [18][19][20][21] .In addition, the elderly present with more severe forms of gallbladder disease, such as acute cholecystitis, common bile duct stones, cholangitis and gallbladder carcinoma [22][23][24] .
The chronological age used to define an elderly or old person ranges in the medical literature from 60 to 80 years 7,9,18,25 .We used the World Health Organization (WHO) recommendation, in which the definition of elderly depends on the development stage of the countries 4,5 .In developed countries, the individual is considered elderly when over 65 years of age, and in developing countries, such as Brazil, over 60 years of age.

Similar to recent reports, our study has
shown that the rate of intraoperative morbidity in the elderly was similar to that of younger patients subjected to LC 10 .Technological advances in the laparoscopic equipment and increased surgical experience are the main reasons for reduction in the rate of intraoperative complications in laparoscopy in the last years 8,26 .Carbon dioxide pneumoperitoneum may cause important cardiovascular and ventilatory complications, mainly in old patients 8,26 .Adequate patient monitoring is pivotal to reduce intraoperative complications.Maintenance of pneumoperitoneum pressure between 10mmHg and 12mmHg avoids additional surgical risks in the elderly.
Our findings are also in agreement with previous studies, which have shown that the rate of males, jaundice, prior abdominal operations, and ASA scores II, III, and IV were higher in the elderly than in the younger group 1,8,11,26,27 .These preoperative clinical characteristics may have contributed to increment the rate of postoperative complications in this age group.
Overall, the prevalence of gallstones is two to four times higher in females than in males due to sex hormones differences 1 .However, this difference between genders decreases gradually after the sixth or seventh decade of live 1 , which may have importance in the rate of perioperative mortality in older patients.Several studies have shown that males have higher conversion rates from LC to open cholecystectomy and operative complications than females 8,15 .Males tend to be operated later and to present with more severe gallstone disease than females 8 .It has been suggested that males are more likely to delay seeking medical assistance and therefore present with a more severe disease when subjected to surgical treatment 8 .Thus, the reduction of the female/male ratio in the elderly may have contributed to increase the risk of LC in this age group.
Several other studies have also demonstrated a higher rate of prior abdominal operations in the elderly compared with younger groups 8 .Previous abdominal operations may prolong surgical time in order to divide adhesions.
In addition, adhesiolysis may increase the rate of perioperative complications, such as abdominal bleeding and intestinal perforation.
Many publications have shown higher surgical complications and laparoscopic conversion rates in patients with elevated preoperative comorbidity as determined by ASA score 8,26 .
Our study has shown that LC in the elderly is associated with longer operative time and higher rates of acute cholecystitis, conversion from laparoscopic to open cholecystectomy, and postoperative complications.These findings are consistent with the results of Kim et al. 6 and Loozen et al. 7,9 , who ) reported that these prognostic factors are mainly due to higher complicated gallbladder disease in the elderly.A longer history of cholelithiasis and an elevated number of episodes of cholecystitis increase the rate of complicated cholecystitis 8,28 .
Several studies have demonstrated that the incidences of complicated gallstone diseases, including acute cholecystitis, Mirizzi syndrome and biliary fistula, are higher in the elderly 8,10,28,29  Our postoperative morbidity and mortality rates were higher in the elderly than in the younger group.These findings are also in agreement with the medical literature and are due to various preoperative clinical characteristics and operative features that are more common in the elderly, as previously discussed 10,15,30 .
In our study, most patients of both groups were discharged on the same operative day and there was no difference in length of hospital stay between the elderly and the younger group.
Several studies have documented the safety of short hospital stay in old patients who underwent LC 15,26,27,31 .
The major limitation of our study is the retrospective data evaluation.This is minimized because all surgical procedures were coordinated and supervised by only one surgeon and the data were retrieved from electronic medical records and study protocols.
We concluded that LC is a relatively safe procedure in the elderly and it may be performed with acceptable morbidity and mortality rates.

R E S U M O
elderly patients were failure to adequately identify the biliary tract anatomy due to intense gallbladder fibrosis and adherence to adjacent structures (n=3) and intraoperative bleeding uncontrolled by laparoscopy (n=1).The single conversion in the younger group was due to a lesion of the transverse colon during insertion of the trocar in a patient with intense abdominal adhesions due to prior abdominal operation.There was no difference in the rate of intraoperative complications between the two groups (p=1.0).Intraoperative complications in the younger group were severe bronchospasm at extubation (n=2), colonic perforation (n=1), and small bowel perforation (n=1).Intense bleeding due to liver laceration (n=1) and lesion of the right hepatic artery (n=1) occurred in the elderly group.

Table 1 .
Demographic and clinical characteristics.

Table 2 .
Intraoperative and postoperative data.