Background
Comparing outcomes of the first Division of Abdominal Surgery of the Saint Louis Hospital of Orbassano (Turin) with the literature, regarding timing and technique of early or delayed laparoscopic cholecystectomy in the management of acute cholecystitis in elderly patients.
Materials and methods
From January 2005 to December 2009 114 laparoscopic cholecystectomy in the elderly were performed in our surgical division: 67 for gallbladder stones and 47 for acute cholecystitis.
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The diagnosis of cholecystitis and gallbladder stones was based on general condition, physical examination, laboratory, radiological findings and sepsis score. For the study we’ve also considered: total hospital stay, timing after and before the operation, kind and duration of operation, conversion to the open procedure, drain and final pathological results.
From this study 29 patients were excluded (17 for choledocolytiasis associated and 12 for hospitalisation > 20 days). We hadn’t excluded patients ASA III and ASA IV: in these patients (27.4 %, 17 ASA III and 4 ASA IV) abdominal pressure not superior of 10 mmHg was used [1].
Elderly patients included in the study were 85 (49 M, 36 F). Ordinary Cholecystectomy were peformed in 45 cases and Emergency Cholecystectomy in 40 cases. This last group was further divided into two groups [2‐4]: DEA Early, E-DLC, (31 patients operated on within 72 hours from onset of symptoms) and DEA Delayed, D-DLC, (9 patients operated on after 72 hours to 9 days from onset of symptoms).
We’ve also considered the operating team (Table 1) that performed the operation because the first operator’s experience was considered as an important factor in order to evaluate our results [5‐11].
Table 1
Definitions of equipes.
Team 1 | More than 100 laparoscopic cholecistectomy and more than 100 other laparoscopic operations. |
|---|---|
Team 2 | Less than 100 laparoscopic cholecistectomy and less than 100 other laparoscopic operations. |
Team 3 | Surgeons in learning curve progression or Resident with expert Surgeon supervisor |
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Results
The comparison between elective and emergency operations showed that drain placement and post operation hospital stay were found statistically significant in the emergency group (Table 2). There weren’t any differences regarding team evaluation (Table 3). Concerning the analysis of the E-DLC and D-DLC groups there aren’t any statistical differences (Table 4).
Table 2
Ord/DEA.
OC | DC | P Value | |
|---|---|---|---|
Operation time (min) | 75,5 (40-220) | 90 (28-200) | 0.1874 |
PO hospital stay (days) | 2 (1-10) | 3 (2-12) | 0.002313 |
Conversion rate | 6.7% | 2% | 0.3869 |
Complications | 8.5% | 2% | 0.2352 |
Drains | 16.7% | 51% | 0.0003 |
Associated operations | 13.3% | 12.8% | 0.998 |
Cancer | 3% | 0 | - |
Table 3
Equipes.
Variabile | E1-E2 | E1-E3 | E2-E3 |
|---|---|---|---|
Operation time (min) | 0.6936 | 0.6089 | 0.2759 |
PO hospital stay (days) | 0.3159 | 0.02131 | 0.09583 |
Total hospital stay | 0.9362 | 0.004337 | 0.004981 |
Conversion rate | 0.1553 | 0.6677 | 0.3896 |
Complications | 0.3823 | 0.998 | 0.998 |
Table 4
E-DLC/D-DLC.
Parameter | ELC | DLC | P Value |
|---|---|---|---|
WBC | 11.05 (3.73-28.8) | 9.05 (2.23-15.6) | 0.03264 |
PCR | 1.39 (0.04-45) | 0.66 (0.08-23.23) | 0.1672 |
Temperature | 14% | 2 (7%) | 0.5281 |
Thickened wall | 57.4% | 13 (48%) | 0.4 |
Pericholecystic fluid | 17% | 2 (7.4%) | 0.25 |
Distended gallbladder | 43.4% | 12 (44.4%) | 0.998 |
Operation time (min) | 90 (36-330) | 85 (28-195) | 0.1554 |
PO hospital stay (days) | 3 (2-15) | 3 (2-8) | 0.6551 |
Total hospital stay | 4 (2-16) | 10 (4-16) | p<0,01 |
Tasso di conversione | 5% | 0% | 0.59 |
Complications | 5% | 0% | 0.59 |
Drains | 36% | 26% | 0.3752 |
Operations associated | 8% | 15% | 0.2353 |
Cancer | 1.6% | 0% | 0.998 |
Conclusions
In contrast with other authors [12, 13], laparoscopic cholecystectomy in our elderly patients, when performed with an adequate technique, represents a safe procedure to treat all cases of acute cholecystitis in an emergency setting [14‐22]. Our technique represents a standardized surgical strategy to approach acute cholecystitis and cholelytiasis in the elderly in a safe, effective and reproducible manner.
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