In elderly patients more than 70 years old with gall bladder stones, do you recommend laparoscopic or open cholecystectomy?
Or , no surgery at all except in emergency or profound complaint?
Dr.Taha,
It depends on the general condition and comorbidity of the patient. If there is no serious background, a routine procedure is indicated.
I agree with Andrey. A single answer does not exist. It must be found case by case.
Dr.Borodach,
When you said "a routine procedure is indicated" - I assume you mean laparoscopic chole. In our center, elderly patients who need cholecystectomy with mild or manageable comorbids are always treated with a laparoscopic procedure with excellent outcomes.
Indeed, these days its rare to find an elderly patient requiring surgery without comorbids !
Depending on their general status. Age per se is not a contraindication at all for the laparoscopic approach.
Dr Taha,
if if the patient is medically fit I would recommend laparoscopic cholecystectomy every time. The outcomes are excellent and the recovery is much quicker. In the case of prohibitive co-morbidities the patient might not tolerate an open procedure as well. In these cases conservative treatment, in case of small stones and CBD stones ERCP with sphincterotomy as a definitive treatment or a cholecystostomy as a bailout in the acute situation ( severe cholecystitis, gallbladder empyema) are options.
Dr Taha,
I would assume you are talking about symptomatic gallblader stones and elective surgery. In that case, I would agree with the laparoscopic approach in a medically fit patient. Acute situations are a think to discuss further.
For symptomatic patients lap chole is the default option. There is virtually no indication for planned open cholecystectomy except multiple previous incisions which might make entry difficult or impossible. The more comorbid the patient the more soon should favour lap as open surgery will increase the risks further.
Whenever options are available, one must be soft to choose best for his patient. Rigid policy in favor of one procedure may lead to complications. We decide every case on merit for open or lap chole.
Allways the laparoscopic operation if possible. Obviously you has to decide according of the performance status of the patient.
In this part of the world laparoscopic approach to a cholecystectomy is standard, resulting on the other hand in a lack of experience regarding the open procedure among younger colleagues. Their sole opportunity to perform an open procedure is a simultaneous cholecystectomy, like in pancreatoduodenectomy or major liver resections.
The only a priori indication for an open procedure here is a suspicion of malignant disease - gallbladder cancer, or major anaesthesia restrictions, mostly regarding respiratory function during capnoperitoneum.
And at the end the last word about conversions. Conversion is in our practice mandatory in a case of any anatomic difficulties or complications. A conversion does not make the operation easier, but more secure. In a case of complications and patients claim it would be not easy to find arguments in court, why in these cases the operation was not converted.
as mortality of the laparoscopic procedure is lower then this of the open procedure, even in the elderly patient, we can only accept an open procedure if laparoscopy is not feasable.
La edad en sí no es una contraindicación alguna para el abordaje laparoscópico.
My service recommends laparoschopic approach for symptomatic disease.
If symptomatic then laparoscopic approach. Age should not be a contraindication.
Laparoscopic cholecystectomy is the standard rocedure unless there are contraindications to induction of pneumoperitoneum for cardiac or respiratory failure.
Laparoscopic cholecystectomy is the procedure of choice for the management of patients with symptomatic cholelithiasis. This is independent of the patients age.
If there are no contraindications due to prior major abdominal open surgery (and this depends on type of surgery and surgical experience too) or other general conditions, chole-laparoscopy is the standard procedure.
The laparoscopic approach is better when feasible , safe and efficient for both young and elderly patients . Indeed elderly patients would benefit more of the advantages or laparoscopy in terms of less trauma to the abdominal wall and therefore , less pain, less impact on the respiratory function and quicker mobility.
Whilst young patients may have enough reserves to compensate a hypofunctioning rectus muscle, an old patient may not and hence the advantage is major in his case.
Dear Dr. Taah
Laparoscopic cholecistectomy is indicated in elderly patients; only contraindication are suspicion of malignant disease or major anesthesia restiction.
The laparoscopic approach is always preferential to an open procedure. Probably even more so in the elderly who tolerate poorly basal atelectasis, maybe over analgesiased post op, may have a higher rate of wound infection and a more prolonged length of stay
cdeg
Thre should be no controversy as to what surgical approach should be performed if it is indicated. The competent surgeon, not necessarily the brightest, should be the best judge in the operative individualization of each case. He should have been trained to be "all around" and be able to perform cholecystectomy by open and laparoscopic method in ideal conditions. He should be conversant with the technique of sedation, intercostal block and loical anesthesia in patients with co-morbidities and those can who not take general anesthesia or in the "third world". It is lamentable that many of the younger generation of surgeons are short-changed and deprived in manual craftmanship during training versus instrumentation expertise. An open incision can be only two inches in lenght with negligible morbidity from pain depending upon the anatomy or is this not taught anymore?
As long as the gallstones do not cause symptoms, there is no indication for surgery at all. If they become symptomatic (e.g. biliary colics, acute cholecystitis), laparoscopic cholecystectomy is recommended.
In case choledocholithiasis in very fragile elderly patients ERCP alone can be an option. The papilla remains open following papillotomy during ERCP for several years, severe complications of gallstones (e.g. pancreatitis, cholangitis) can therefore be prevented.
Without comorbid conditions lapròscopic and with comorbid conditions open cholecystectomy.
Well, despite patients with severe COPD especially comorbid patients can benefit from minimally invasive approach. lesser pain, quicker recovery and lesser complications.
I think that laparoscopic cholecystectomy is better for elderly because the surgery trauma is minor.Also important is the lack of major wound in the upper abdomen which impairs the proper breating after surgery because of pain. It is esspecialy important in older people because it prevents atelectasis or pneumonia
Most pts can be dealt with laparoscopically irrespective of age as long as they are relatively fit to undergo surgery. A lesser equally effective procedure such as drainage or partial cholecystectomy can be carried out laparoscopically for difficult gallbladders and there are very few reasons if any to open. Indeed in elderly pts with significant co morbidity and with 'burnt out disease' one can opt to manage medically or with simple radiological drainage.
Only laparoscopic cholecystectomy until there is no anaesthetic contraindications. I have done laparoscopic cholecystectomy with cbd exploration having 20 cbd stones in 109 years old male patient. Patient is absolutely fine.
I would ignore the age and always go for laparoscopic approach if there is no contraindication.
If there is no contraindication, the laparoscopic approach is always preferable
No question; laparoscopic as there will be less postoperative pulmonary and other complications.
I’m not sure the age cut off of 70 is relevant. If the patient is fit with a good indication for surgery and no clear contraindication for laparoscopy, then the benefits for laparoscopic approach make this first line treatment.
I absolutely agree. If there is no contraindication for laparoscopy, the laparoscopic approach is always preferable.
The biological age is more important than the chronological age. If the patient is fit to tolerate GA well, why not lap? And of course the risk: benefit ratio has to be individualized
Laparoscopic, open only with a clear contraindication agains laparoscopy. In patients more than 80 years the probably of cancer or complications are very low. In this case I will operate only symptomatic
What I see that this patient has got gallstones! Do not know how symptomatic he is. What's his LFTs? What are other comorbid status.
I would prefer not to operate on him at all unless he presents with acute complications. In such situations I would still prefer to attempt Laparoscopic but with a low threshold for conversion to open cholecystectomy.