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Revista do Colégio Brasileiro de Cirurgiões

Print version ISSN 0100-6991On-line version ISSN 1809-4546

Rev. Col. Bras. Cir. vol.43 no.1 Rio de Janeiro Jan./Feb. 2016

http://dx.doi.org/10.1590/0100-69912016001002 

Original Article

Comparison between open and laparoscopic elective cholecystectomy in elderly, in a teaching hospital

Cássio Padilha Rubert1 

Roberta Alves Higa1 

Fabiano Vilas Boas Farias1 

1. Hospital Regional de Mato Grosso do Sul (HRMS), MS, Brasil

ABSTRACT

Objective:

to analyze the differences in mortality rates, length of hospital stay, time of surgery and the conversion rate between elective open cholecystectomies (OC) and laparoscopic ones (LC) in elderly patients.

Methods

: we evaluated medical records of patients 65 years of age or older undergoing open or laparoscopic cholecystectomy at the Hospital Regional de Mato Grosso do Sul between January 2008 and December 2011. We excluded individuals operated in non-elective scenarios or who underwent intraoperative cholangiography.

Results

: we studied 113 patients, of whom 38.1% were submitted to the OC and 61.9%, to LC. Women accounted for 69% of patients and men, for 31%. The conversion rate was 2.9%. The mean age and duration of the procudure was 70.1 and 84 minutes, respectively, with no significant difference between OC and LC. Patients undergoing LC had shorter hospital stays (2.01 versus 2.95 days, p=0.0001). We identified operative complications in sixpatients (14%) after OC and in nine (12%) after LC, with no statistical difference.

Conclusion

: there was no difference in morbidity and mortality when comparing OC with LC. The laparoscopic approach led to shorter hospital stay. Operative time did not differ between the two access routes. The conversion rate was similar to other studies.

Key words: Cholecystectomy; Cholecystectomy, Laparoscopic; Aged; Postoperative Complications

INTRODUCTION

Life expectancy has increased over the past decades. Contributing factors for this change include improvements in primary prevention and advances in medical care, technology and pharmaceutical industries. The traditional definition of the World Health Organization (WHO) considers elderly people aged 60 or older if they live in developing countries, and 65 years of age and over in developed ones. However, in order to allow direct comparisons with other articles (which mostly are made in developing countries), we used as a cutoff age of 65 years.

In Brazil, approximately 7.3% of the population is over 65 years of age. About 50% of women and 16% men, 70 years of age, have biliary calculi1, and symptomatic or complicated cholelithiasis is the most common indication for abdominal surgery in the elederly2,3. Historically, associated diseases and the anesthetic risk have been an obstacle to perform interventions in the elderly. However, recent in anesthetic, surgical and postoperative care innovations made such patients candidates for surgery, even in the ninth and tenth decades o life4-7.

Laparoscopic cholecystectomy provides a safe alternative for symptomatic cholelithiasis or cholecystitis in elderly patients, and the benefits, lower morbidity and reduced hospital stay, were demonstrated in prospective studies and meta-analyses8-11.

In the beginning of the minimally invasive surgery era, advanced age was a relative contraindication to the laparoscopic procedure. Despite recent evidence showing that the LC is feasible in elderly patients, including over 70 or 80 years of age, there are few studies in our country on the subject.

The aim of this study was to compare the conventional cholecystectomy with the laparoscopic, electively performed in elderly patients in a teaching hospital, a reference in the state, especially in relation to morbidity, length of stay, operative time and conversion rate to open surgery.

METHODS

We searched The SAME database (Medical Records Section) of the Hospital Regional de Mato Grosso do Sul - Rosa Pedrossian (HRMS) for the medical records of patients aged over 65 years who underwent conventional and laparoscopic cholecystectomy between January 2008 and December 2011. We included all patients admitted for elective surgery, and excluded patients operated on a non-elective setting. Patients who underwent intraoperative cholangiography were also excluded.

The variables studied were age, gender, cardiovascular surgical risk, duration of surgery, accidents and intraoperative complications, postoperative complications, length of stay and conversion to open surgery.

Nominal variables were compared using the chi-square test or Fisher's exact test, as appropriate. Ordinal variables were compared using the Mann-Whitney test, with a p-value <0.05 accepted as significant.

RESULTS

Between January 1, 2008 and December 31, 2011 113 elective cholecystectomy without cholangiography were performed in patients aged over 65 years for symptomatic cholelithiasis, of which 43 (38.1%) corresponded to open cholecystectomy (OC) and 70 (61.9%), laparoscopic cholecystectomy (LC). Regarding gender, 78 (69%) patients were female and 35 (31%) were men.

The conversion from laparoscopic surgery to open one was necessary in two (2.9%) cases, one relating to the difficulty in identifying the Calot triangle structures, and the second converted at the end of the procedure, after removal of the gallbladder, to carry out an of an intestinal puncture lesion perceived at the end of the procedure.

Overall, the average age, length of stay and duration of surgery was 70.1 years (65-91), 2.3 days (1-9) and 84 minutes (30-180), respectively. When we stratified the groups by the procedure (open and laparoscopic), there was no difference in mean age (70.2 years OC versus 70 LC, p=0.873) or cardiovascular surgical risk (p=0.146). The duration of the procedure was also not different between procedures, with an average of 76±27 minutes (30-150) for OC and 88±31 minutes (40-180) for LC (p=0.582).

The length of stay was shorter in patients undergoing LC, averaging 2.01±0.9 days, while the OC group stayed for 2.95±1.5 days (p=0.0001). The distribution of hospital stay between the groups is shown in figure 1.

Figure 1 - Distribution of patients' hospital stay. 

Postoperative complications were identified in six (14%) patients after OC and in nine (12%) after LC, with no statistical difference between the two groups (p=0.8675). In LC there was one (1.4%) case of desaturation, corrected with changes in the mechanical ventilator, and one (1.4%) case of accidental damage of the small intestine, corrected during the procedure. The frequency of complications is shown in table 1 (two patients in the OC group and one of the LC group had two complications simultaneously).

Table 1 - Postoperative complications. 

Source: SAME (Medical Records Section) dadabase, Hospital Regional de Mato Grosso do Sul - Rosa Pedrossian (HRMS) - jan 2008-dec 2011.

DISCUSSION

Laparoscopic cholecystectomy (LC) causes less pain after surgery, shorter hospital stay, faster return to work activities and a lower metabolic-endocrine-immune response to trauma (REMIT)12-15. This procedure has been the gold standard for elective cholecystectomy for the general population in the last two decades16. Elderly patients with biliary tract disease have higher rates of complications, which explains their higher mortality.

LC could increase morbidity and mortality in the elderly, many of which have limited cardiopulmonary reserve. Although Behrman et al .17 have not shown a higher incidence of hypotension and hypercarbia during the procedure in their series, they still recommend that LC be performed with caution in the elderly population, with a low threshold for conversion and considering open cholecystectomy (OC) as the initial indication.

However, LC has demonstrated results superior to OC in elderly patients with symptomatic cholelithiasis in terms of morbidity and hospital stay18. There is variability in global practices for the treatment of this disease in the elderly, and social, physiological and pathological characteristics of the elderly population also differ greatly between regions. In Brazil, there are few studies on the subject19-21. When one considers the population we studied (patients from SUS - National Health System) and procedures performed in the public system teaching hospitals, researches are even scarcer.

There were complications in 13.3% of patients, without differences in morbidity rates between groups, which differs from similar studies8,22, in which LC resulted in less morbidity. We believe that this divergence is due to under-reporting of minor complications. The conversion rate to open surgery in our series was 2.9%, compared with 2.5 to 14% in LC other series studying elective for symptomatic cholelithiasis in the elderly4,17-26, being similar to the conversion rate in young patients4,27,28, unlike Qasaimeh et al .29, who reported higher conversion rates in the elderly.

Many publications have reported that LC is associated with shorter hospital stay8,22,30. We also observed this result, with average length of stay of 2.01 days for LC, versus 2.95 days for OC.

As in other studies17,18, LC did not prolong surgical time, averaging 12 minutes greater than OC, with no statistical significance. We deem this result satisfactory, since the procedures are performed mostly by resident physicians, with less experience in laparoscopy.

There were no deaths in our study, as reported by Caglià31 in his series of 50 patients.

We emphasize that possible biases related to the retrospective study and the small number of patients involved must be taken into account when interpreting the results.

In conclusion, elective laparoscopic cholecystectomy is a safe procedure in elderly patients, with no increased risk of complications compared with the open procedure. The recovery is faster and the hospital stay, shorter. It is important the correctly assess the cardiovascular surgical risk, since this group of patients have lower vital reserve, being more sensitive to surgical trauma. In the era of laparoscopic surgery, with increasing experience of surgeons and the advent of new technologies, old age is not a contraindication for LC, and there are no major complications of this surgery when electively performed.

REFERENCES

1. Pérez Lara FJ, de Luna Díaz R, Moreno Ruiz J, Suescun García R, del Rey Moreno A, Hernández Carmona J, et al. Laparoscopic cholecystectomy in patients over 70 years of age: review of 176 cases. Rev Esp Enferm Dig. 2006;98(1):42-8. [ Links ]

2. Lledó Bueno J, Serralta Serra A, Planells Roig M, Rodero Rodero D. Colecistectomía laparoscópica en el paciente anciano. Cir Esp. 2002;72(4):205-9. [ Links ]

3. Maxwell JG, Tyler BA, Maxwell BG, Brinker CC, Covington DL. Laparoscopic cholecystectomy in octogenarians. Am Surg. 1998;64(9):826-31; discussion 831-2. [ Links ]

4. Tambyraja AL, Kumar S, Nixon SJ. Outcome of laparoscopic cholecystectomy in patients 80 years and older. World J Surg. 2004;28(8):745-8. [ Links ]

5. Eldar S, Sabo E, Nash E, Abrahamson J, Matter I. Laparoscopic cholecystectomy in acute cholecystitis: prospective trial. World J Surg. 1997;21(5):540-5. [ Links ]

6. García J, Vázquez J, Pérez F, Luri P, Diego M, Calpena R, et al. Colecistectomía electiva frente a urgente en el paciente anciano. Cir Esp. 1998;63:365-7. [ Links ]

7. Hoyos SI, Cock CHR, Restrepo H. Colecistectomía laparoscópica. Seguimiento de 514 casos. Rev Colomb Cir. 1998;13(4):261-4. [ Links ]

8. Lujan JA, Parrilla P, Robles R, Marin P, Torralba JA, Garcia-Ayllon J. Laparoscopic cholecystectomy vs open cholecystectomy in the treatment of acute cholecystitis: a prospective study. Arch Surg. 1998;133(2):173-5. [ Links ]

9. Sauerland S, Agresta F, Bergamaschi R, Borzellino G, Budzynski A, Champault G, et al. Laparoscopy for abdominal emergencies: evidence-based guidelines of the European Association for Endoscopic Surgery. Surg Endosc. 2006;20(1):14-29. [ Links ]

10. Vergnaud JP, Lopera C, Penagos S. Colecistectomía laparoscópica en colecistitis aguda. Rev Colomb Cir. 2002;17(1):42-7. [ Links ]

11. Dubecz A, Langer M, Stadlhuber RJ, Schweigert M, Solymosi N, Feith M, et al. Cholecystectomy in the very elderly-is 90 the new 70? J Gastrointest Surg. 2012;16(2):282-5. [ Links ]

12. Alponat A, Kum CK, Koh BC, Rajnakova A, Goh PM. Predictive factors for conversion of laparoscopic cholecystectomy. World J Surg. 1997;21(6):629-33. [ Links ]

13. Aktan AO, Büyükgebiz O, Yegen C, Yalin R. How minimally invasive is laparoscopic surgery? Surg Laparosc Endosc. 1994;4(1):18-21. [ Links ]

14. Cho JM, LaPorta AJ, Clark JR, Schofield MJ, Hammond SL, Mallory PL 2nd. Response of serum cytokines in patients undergoing laparoscopic cholecystectomy. Surg Endosc. 1994;8(12):1380-3; discussion 1383-4. [ Links ]

15. Mealy K, Gallagher H, Barry M, Lennon F, Traynor O, Hyland J. Physiological and metabolic responses to open and laparoscopic cholecystectomy. Br J Surg. 1992;79(10):1061-4. [ Links ]

16. Dubois F, Berthelot G, Levard H. Coelioscopic cholecystectomy: experience with 2006 cases. World J Surg. 1995;19(5):748-52. [ Links ]

17. Behrman SW, Melvin WS, Babb ME, Johnson J, Ellison EC. Laparoscopic cholecystectomy in the geriatric population. Am Surg. 1996;62(5):386-90. [ Links ]

18. Lujan JA, Sanchez-Bueno F, Parrilla P, Robles R, Torralba JA, Gonzalez-Costea R. Laparoscopic vs. open cholecystectomy in patients aged 65 and older. Surg Laparosc Endosc. 1998;8(3):208-10. [ Links ]

19. Minossi JG, Picanço HC, Carvalho MA, Paulucci PRV, Vendites S. Morbimortalidade da colecistectomia em pacientes idosos, operados pelas técnicas laparotômica, minilaparotômica e videolaparoscópica. ABCD, arq bras cir dig. 2007;20(2):93-6. [ Links ]

20. Rego REC, Campos T, Moricz A, Silva RA, Pacheco Júnior AM. Tratamento cirúrgico da litíase vesicular no idoso: análise dos resultados imediatos da colecistectomia por via aberta e videolaparoscópica. Rev Assoc Med Bras. 2003;49(3):293-9. [ Links ]

21. Loureiro ER, Klein SC, Pavan CC, Almeida LDLF, Silva FHP, Paulo DNS. Colecistectomia videolaparoscópica em 960 pacientes idosos. Rev Col Bras Cir. 2011;38(3):155-60. [ Links ]

22. Leardi S, De Vita F, Pietroletti R, Simi M. Cholecystectomy for gallbladder disease in elderly aged 80 years and over. Hepatogastroenterology. 2009;56(90):303-6. [ Links ]

23. Majeski J. Laparoscopic cholecystectomy in geriatric patients. Am J Surg. 2004;187(6):747-50. [ Links ]

24. Magnuson TH, Ratner LE, Zenilman ME, Bender JS. Laparoscopic cholecystectomy: applicability in the geriatric population. Am Surg. 1997;63(1):91-6. [ Links ]

25. Pérez-Lara FJ, Luna Díaz R, Moreno Ruiz J, Suescun G, del Rey Moreno A, Hernández Carmona J. Laparoscopic cholecystectomy in patients over 70 years of age: review of 176 cases. Rev esp enferm dig. 2006;98(1):42-8. [ Links ]

26. Golden WE, Cleves MA, Johnston JC. Laparoscopic cholecystectomy in the geriatric population. J Am Geriatr Soc. 1996;44(11):1380-3. [ Links ]

27. Larson GM, Vitale GC, Casey J, Evans JS, Gilliam G, Heuser L, et al. Multipractice analysis of laparoscopic cholecystectomy in 1,983 patients. Am J Surg. 1992;163(2):221-6. [ Links ]

28. Al-Jaberi TM, Gharaibeh K, Khammash M. Empyema of the gall bladder: reappraisal in the laparoscopy era. Ann Saudi Med. 2003;23(3-4):140-2. [ Links ]

29. Qasaimeh GR, Banihani MN. Laparoscopic cholecystectomy in the elderly and young: a comparative study. Hepatogastroenterology. 2012;59(113):22-5. [ Links ]

30. Chau CH, Tang CN, Siu WT, Ha JP, Li MK. Laparoscopic cholecystectomy versus open cholecystectomy in elderly patients with acute cholecystitis: retrospective study. Hong Kong Med J. 2002;8(6):394-9. [ Links ]

31. Caglià P, Costa S, Tracia A, Veroux M, Luca S, Zappulla E, et al. Can laparoscopic cholecystectomy be safety performed in the elderly? Ann Ital Chir. 2012;83(1):21-4. [ Links ]

Source of funding: none.

Received: May 30, 2015; Accepted: October 02, 2015

Mailing address:Cassio Padilha Rubert E-mail: cassiopr85@yahoo.com.br

Conflict of interest: none.

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