Gallstone-related diseases are one of the most common worldwide pathologies, and the gold standard treatment is laparoscopic cholecystectomy. Traditionally, surgical treatment is indicated in symptomatic cases, and in asymptomatic cases associated with hemolytic diseases, gallstones bigger than 2,5cm, some patients with diabetes or travelling to countries without a good health care service.
In occidental countries population is getting older, which is creating the so called “silver tsunami”. This is increasing the mean age at which patients are seeking medical advice for gallstones-related diseases. Meaning laparoscopic cholecystectomy is being offered to older patients. Although some reports state laparoscopic cholecystectomy is safe in octagenarians, other studies concluded surgery has worse outcomes in this ageing group. Some questions arise. Are outcomes different in the “silver tsunami” era? Should we change our practice due to ageing population?
The "silver tsunami" will probably change medical practice.
Dr. Yiochi Matsui et al from Japan published in the American Journal of Surgery a retrospective study to analyse the outcomes of cholecystectomy according to age. Patients with gallstones-related diseases were treated by laparoscopic cholecystectomy. Cases of concomitant choledocholithiasis were first submitted to ERCP for stone extraction before surgery. Patients between 2006 and 2018 were included. A total of 2587 patients were studied and divided into two groups: <70yo group with 1704 patients; >70yo group with 883 patients. Results are important and not unexpected, I think.
Outcomes were worse in>70yo group for all data analyzed.
From 2006 to 2018 the mean age of the treated population increased steadily at a rate of 0,6 years per year. The >70 yo group had worse outcomes in all analyzed data and with statistical significance (p<0,0001):
Longer operative time
Higher number of open and urgent surgery
Higher rate of complications
Higher postoperative hospital death
Higher concomitant choledocholithiasis
More cases of gallbladder cancer
Higher costs
The longer operative time was due to more cases of open and urgent surgery in the older group. According to the authors the higher number of open surgeries in the >70yo group occurred because with ageing increases the probability of previous abdominal surgery. Additionally, one other factor pointed by the authors for the higher number of open surgeries is the fact that more older patients were submitted to urgent surgery. In my opinion this data has great importance because it goes against what many other authors defend about urgent surgery in cases of acute cholecystectomy. From Dr. Yiochi Matsui data we conclude that urgent cholecystectomy has higher rate of conversion to open surgery. As we all know open surgery has higher rate of postoperative complications, namely surgical site infection and incisional hernias, with longer recovery period. Think twice when deciding to operate a patient with an acute cholecystitis which has usually a benign course with medical treatment. Study, think, take your conclusions, and always question the guidelines… This is what I always do!
Postoperative complications and in-hospital postoperative mortality were also higher in the older group. In fact, mortality cases were only seen in patients >70 yo. A mortality rate of 0,9% were found in patients in their 70’s, and a mortality rate of 2,1% in their 80’s. These data are crucial and can change our practice when dealing with octagenarians. Again, think twice when proposing these patients to elective cholecystectomy. Patients must know they have a higher probability of dying. As it would be expected, medical costs were higher in the older group. According to the authors, medical costs among patients >80yo were two-fold higher. However, we cannot forget that more cases of gallbladder cancer and bile duct stones were diagnose in the older group.
Postoperative complications and mortality were higher in the >70yo group.
So… What can we do to avoid these bad outcomes? Remember that these results are also promoted by the fact older patients have a long-time gallstone disease. As the authors state “earlier recognition and intervention in patients with cholelithiasis could prevent the progression of biliary disease”. Should we change our indications? Should we indicate surgery before symptoms? Well, in my opinion this is not an option since elective surgery also has complications, and the best way to avoid them is to do not perform an unnecessary surgery. A well performed surgery for which there was no indication remains a bad operation.
Think twice during decision-making process. Risk of complications and mortality in the older group may overcome the benefits of a cholecystectomy.
What we must do is promote elective laparoscopic cholecystectomy as soon as the symptoms arise and before patient gets older. On the contrary, if a patient comes to you with more than 70yo, you must have extreme caution during decision-making process. Risk of complications and mortality in this ageing group may overcome the benefits of a cholecystectomy.
Link to PubMed:
Dr. Carlos Eduardo Costa Almeida
General Surgeon