Therapeutic strategy for the super-elderly with acute cholecystitis – A single center experience for ten years

Takeshi Yanagita, MD, Ken Hayashi, MD, PhD, Shigetoshi Yamada, MD, Nobuyasu Kano, MD, PhD, FACS, Hiroshi Kusanagi, MD, PhD. Kameda Medical Center

Introduction: Laparoscopic cholecystectomy (LC) has been reported to be safe and feasible even for the elderly. It is not clear, however, for what patients and under what condition, LC for the super-elderly (eighty years old or older) with acute cholecystitis (AC) can be performed the most safely and effectively. We performed retrospective review for the total number of 962 patients to determine the best management for the elderly (between 65 years old and 79) and the super-elderly.
Methods: Between January 2005 and May 2015, 962 elderly patients admitted to the Kameda Medical Center in Japan as a diagnosis of “cholecystitis”. Those patients were excluded, who didn't satisfy the diagnostic criteria of Tokyo Guidelines 2013 for AC (TG13), whose main problem was not AC (such patients as pancreatic cancer with cholecystitis) and who had additional cholecystectomy during other surgical procedures like gastrectomy. 

The total number of 522 patients was eligible for this study. Age group was the primary independent variable; 215 patients were at the age of 80 years old or older (the super-elderly group: SG), and 307 patients were 65-79 years of age (the elderly group: EG).

Each group divided into two subgroup; operative group (SG-O, EG-O) and non-operative group.

Operative group was defined as those who had surgery performed during the index admission or performed after initial non-operative management. Non-operative group was treated without surgery all through their admission.

Continuous variables were analyzed by using the Mann-Whitney U tests. Chi-square and Fisher's exact tests were used for comparisons of categorical variables.
Result: Performance Status of Eastern Cooperative Oncology Group and serum albumin level on admission were significantly different between operative group and non-operative group. 
There was significantly less complication (Clavien-Dindo classification more than 3a) in SG-O when operations were performed in 7 days from onset or more than 60 days after non-operative management. LC showed less hospital stay and less complication compared with open cholecystectomy in both SG-O and EG-O, and also cost effective.
Conclusion: Firstly, PS and serum albumin level can be a strong determinant for indication of surgery for the super-elderly.  
Secondly, early LC should be performed for TG13 grade I patients if possible. 
For TG13 grade II or III patients or those who take anticoagulants and/or antiplatelet agents, percutaneous cholecystostomy should be placed, then LC or open cholecystectomy in seven days from onset, or more than 60 days can be safely performed.

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