Outcomes of Laparoscopic Cholecystectomy
Rafael S. Marcari, MD, Renato Micelli Lupinacci, MD, Luis Roberto Nadal, MD,
Ronaldo E. Rego, MD, Andrea M. Coelho, MD, Jose ´ Francisco de Matos Farah, MD, PhD
Background and Objectives: Extremely elderly patients
usually present with complicated gallstone disease and
are less likely to undergo definitive treatment. The pur-
pose of this study was to evaluate the results of laparo-
scopic cholecystectomy in octogenarians, with an interest
in patients presenting initially with complicated gallstone
disease and pancreatitis who underwent laparoscopic
cholecystectomy during the same hospitalization.
Methods: Data for 42 patients ?80 years who underwent
an elective laparoscopic cholecystectomy between Janu-
ary 2007 and August 2011 were retrospectively reviewed.
Indications for the procedure were stratified into 2 groups:
Outpatients, who were admitted electively to undergo
cholecystectomy, and Inpatients, who came to our Emer-
gency Room due to complicated biliary diseases. Data
analysis included age, sex, ASA score, conversion to open
surgery, time spent under general anesthesia, and length
of hospital stay.
Results: Mean age was 83.9 years; 19 (45.2%) were men.
Thirteen patients (30.9%) were in the outpatient group,
and 13 (30.9%) had a preoperative ASA of 3. Fourteen
patients (33.3%) needed ICU. Two patients (4.8%) had
their surgery converted. There were 7 (16.7%) postoper-
ative complications, all of them classified as Dindo-Cla-
vien I or II. No differences were noted between groups
regarding conversion rates or complications. We had no
mortalities in this series. There was no difference in hos-
pital length of stay between the groups.
Conclusion: Laparoscopic cholecystectomy in the ex-
tremely elderly is safe, with acceptable morbidity. Patients
with complicated gallstone disease seem not to have
worse postoperative outcomes once the initial diagnosis is
properly treated and would benefit from definitive ther-
apy during the same hospitalization.
Key Words: Laparoscopic cholecystectomy, Elderly, Gall-
stone disease, Octogenarians.
Gallstone disease is the most common indication for ab-
dominal surgery in the United States (US). The prevalence of
gallstones increases with age in nearly all populations and in
both sexes with related prevalence of gallstones among
older persons from 20% to 30%, reaching 80% for institution-
alized patients older than 90.1–3The population is steadily
aging in Western countries, and the most rapidly growing
segment of the US society is composed of individuals older
than 65 years of age. Census estimates suggest that the
percentage of elderly persons in the US will rise from 12.8%
in 1995 to 16.5% over the next 25 years.4Although they
currently comprise only one-eighth of the population, the
elderly already account for nearly one-third of surgical
Several studies have indicated that gallbladder disease in
elderly patients often has a high risk of acute cholecystitis,
biliary tract disease, increased mortality, and a longer
hospital stay, compared with the disease in younger pa-
The majority of studies concerning elderly patients in-
cluded individuals over 65 or 70 years of age; however,
the population at greatest risk for adverse surgical out-
comes is the extremely elderly, or those individuals age 80
years and older.8–10
It is well documented that elderly patients are less likely to
be treated than their younger counterparts. Up to 30% of
older patients do not undergo any therapeutic interven-
tion, and many surgeons tend to be more conservative
when managing older patients.11,12Adherence to current
recommendations for the management of mild gallstone
pancreatitis is low in older patients, and a recent study
suggests that more than 40% of geriatric patients who did
not undergo cholecystectomy would have benefited from
Department of General Surgery, Sa ˜o Paulo Estate Employees Hospital, Sa ˜o Paulo,
Brazil (all authors).
Address correspondence to: Renato Micelli Lupinacci, MD, Servic ¸o de Cirurgia
Geral–Hospital do Servidor Pu ´blico Estadual de Sa ˜o Paulo, Av Ibirapuera 981,
04029000, Sa ˜o Paulo, Brazil. Telephone: ?55-11-5088-8000, Fax: ?55-11-5088-
8032, E-mail: email@example.com
© 2012 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
early definitive therapy.13,14Moreover, some recent stud-
ies demonstrate age as a predictor of functional changes
but not complications,15,16although it was recently found
to be an independent predictive factor for conversion.17
The purpose of this study, therefore, was to evaluate the
results of programmed laparoscopic cholecystectomy in
octogenarians, with special interest in patients presenting
initially with complicated gallstone disease and pancreati-
tis who underwent laparoscopic cholecystectomy during
the same hospitalization.
Between January 2007 and August 2011, we performed
1138 laparoscopic cholecystectomies (LC). Forty-eight pa-
tients (4.2%) were 80 years or older. Six patients were
excluded because cholecystectomy was indicated as ur-
gent. Data from these 42 patients who underwent an
elective laparoscopic cholecystectomy were reviewed ret-
rospectively in medical charts and constitute the scope of
Indications for the procedure were stratified into 2 groups:
Outpatients, who were admitted electively to undergo LC,
and Inpatients, who came to our Emergency Room due to
complicated biliary diseases (recurrent colic and obstruc-
tive jaundice), or acute biliary pancreatitis. The second
group of patients had their initial condition properly in-
vestigated and/or treated and then underwent LC during
the same hospitalization.
The following patient data were recorded: age, sex, Amer-
ican Society of Anesthesiologists (ASA) classification, car-
diopulmonary comorbidities, and the surgical indication.
We documented the number and rates of conversions to
open surgery, length of time spent under general anes-
thesia, postoperative length of stay in an Intensive Care
Unit (ICU), and length of hospital stay. No deaths oc-
curred in this series, and postoperative complications
were classified based on Clavien and Dindo classifica-
Preoperative endoscopic retrograde cholangiopancreatogra-
phy (ERCP) was done in all patients with a diagnosis of
common bile duct stones confirmed by magnetic resonance
cholangiopancreatography. Intraoperative cholangiography
(IOC) was performed if the patient had a history of compli-
cated biliary disease, acute pancreatitis, or laboratory find-
ings suggesting common bile duct stones. LC was performed
using a standard 4-port technique by the senior resident
always under the supervision of an experienced surgeon.
Differences between groups for categorical variables were
determined by x2and Fisher’s exact tests, and ordinal vari-
ables were compared using the Student t test. Statistical
significance was considered P?.05.
Forty-two patients older than 80 years underwent LC for
all diagnoses other than acute cholecystitis. Mean age was
83.9 years (range, 80 to 90); there were 19 (45.2%) men
and 23 women. Thirteen patients (30.9%) were in the
outpatient group (Table 1). According to ASA classifica-
tion, 2 (4.8%) were ASA I, 27 (64,3%) were ASA II, and 13
(30.9%) were ASA III patients. Cardiopulmonary comor-
bidities were present in 31 (73.8%) patients. Time spent
under general anesthesia ranged from 25 minutes to 240
minutes, with a mean of 114.2 minutes. Although the
outpatient group had a shorter operating time (109?34
minutes vs. 117?23 minutes), it had no statistical differ-
ence (P?.70). IOC was performed in 24 (57.1%) patients
and was responsible for a significant increase on the
89.6?23.3 minutes, P?.01). Two patients underwent cho-
lecystectomy and another surgical procedure due to asso-
ciated pathologies. The first one was an 85-year-old
woman presenting with symptomatic alkaline gastritis due
to a previous gastrectomy with Billroth II gastrojejunal
anastomosis (operating time of 240 minutes, uneventful
postoperative period, discharged home on the fifth post-
operative day). The second patient had a large squamous
cell carcinoma of the superior lip and underwent resection
with simultaneous reparative surgery (operating time of
155 minutes, uneventful postoperative period, discharged
home on the first postoperative day).
(133?23 minutes vs.
Fourteen patients (33.3%) needed ICU, 10 of them were in
the inpatient group (P?.27). Median length of stay in the
ICU for the entire series was 1.35 days (range, 1 to 4), and
there was no difference between groups (Table 2). Two
patients (4.8%) from group 2 had their surgery converted
Recurrent Biliary Colic
Treated Biliary Acute Pancreatitis
Outcomes of Laparoscopic Cholecystectomy in Octogenarians, Marcari et al.
from LC to open procedures (P?.65). Reason for conver-
sion in both patients was the surgeon’s preference to
perform an open choledoco-duodenostomy once ICO
demonstrated multiple common bile duct stones associ-
ated with common bile duct dilatation ?1.8cm.
There were 7 (16.7%) postoperative complications, all of
them classified as Dindo-Clavien I or II. Two patients had
cardiac complications (atrial fibrillation and bradycardia),
and 1 patient presented with biliary leakage in the first
postoperative day that spontaneously closed. Other com-
plications were vomiting (2 patients), high arterial hyper-
tension needing medication, and umbilical-trocar site in-
fection. Complications were not related to indications
(P?.35) or ASA category. We had no deaths in this series
of patients during the study period. Comparative results
between inpatient and outpatient groups are summarized
in Table 2. Finally, there was no difference in hospital
length of stay between inpatients and outpatients, 2.8?0.7
vs 1.9?1.1 (P?.19).
Biliary tract disorders are one of the most common rea-
sons for surgery in older patients. Fifty percent of women
and 16% of men ?70 years of age have been shown to
have gallbladder disease.19,20As the average age of the
population continues to rise, the number of elderly pa-
tients with symptomatic gallstones is likely to increase.4,5
Advanced age is frequently associated with significant
comorbidity and limited functional reserve, which may be
related to a higher rate of complications, and longer hos-
pital length of stay. Among elderly patients, those who are
?80 years (usually called extremely elderly) have the
worst outcomes and may be seen as a different group.
Kuy et al1have shown that patients aged ?80 years were
?3 times more likely to need blood transfusions and to
require continuous mechanical ventilation and ?5 times
more likely to develop aspiration pneumonitis.
The incidence of choledocholithiasis rises with age, with
rates as high as 43% in patients older than 80 years.7The
extremely elderly frequently present with several biliary
diagnoses and complicated gallstone disease, which ex-
plains the higher rates of conversion, complications, and
mortality usually seen in this group6,7,16,19–22(Table 3). A
previous randomized controlled trial comparing open
cholecystectomy with endoscopic management of symp-
tomatic choledocholithiasis supported operative interven-
Comparison Between Inpatient and Outpatient Groups
Operating Time (minutes)
PO in Intensive Care Unit
ICU Stay (days)
Postoperative hospital stay
Postoperative complications 5 (17.2%)
10 (34. 5%) 4 (30. 8%)
Comparative Results from Published Reports
tion in high-risk patients.23In a randomized controlled
trial comparing an expectant policy with LC following
endoscopic clearance of bile duct stones, 47% of patients
in the expectantly managed cohort developed at least one
recurrent biliary event during follow-up.24
Recent studies have confirmed the reluctance to operate
on extremely elderly patients,25probably due to a greater
percentage of complicated diseases,20–22and a greater
comorbid disease burden.6,20,22However, the implications
of this conservative behavior in the management of gall-
stone disease in the extremely elderly may not benefit
patients. Trust et al14recently demonstrated that recurrent
gallstone pancreatitis was the reason for readmission in
48% of 3689 elderly patients who did not undergo defin-
itive therapy after an episode of mild acute gallstone
pancreatitis; 33% required subsequent cholecystectomy,
and most of the time surgery was performed during hos-
pital readmission for gallstone-related complications,
which was associated with a higher mortality (2.4% vs
0.9%). Moreover, because perioperative outcomes in the
elderly seem to be influenced by the severity of gallblad-
der disease instead of chronological age, because LC after
mild acute gallstone pancreatitis performed during the
same hospitalization is not associated with worse out-
comes, and because cholecystectomy provides the only
definitive therapy, reducing the risk of recurrent gallstone
pancreatitis to almost zero,26,27our data support the idea
that during the management of gallstone pancreatitis in
the elderly definitive treatment during the same hospital-
ization must be the goal to be achieved.
Although some authors have shown respiratory compli-
cations as the most common postoperative morbidity in
elderly patients undergoing LC21and it has been reported
that the use of low-pressure insufflation may further pre-
serve respiratory function,28we had a low rate of compli-
cations despite the fact that patients spent a long time
under general anesthesia. This can be partially explained
by the fact that as a teaching hospital the senior resident
performed all surgeries and the absence in our service of
a low-pressure pneumoperitoneum policy in high-risk pa-
tients. These results are consistent with those of previous
works that did not show additional risks in high-risk
patients when pneumoperitoneum was induced with
10mm Hg to 12mm Hg pressure in patients with ASA 3 or
4, and it seems to be true even for ?1-hour long proce-
Our study has shown a lower conversion rate (4.8%)
compared to previously published studies (Table 3). It
may be partially explained by the fact that we did not
include cholecystectomies performed for acute cholecys-
titis. However, as a teaching hospital, all surgeries were
performed by the senior resident under supervision, and
this fact seems not to have changed outcomes and cor-
roborates what has been demonstrated by others.30Simi-
larly, we had a shorter postoperative length of stay for
both groups (inpatient: 2.8?0.7 vs 1.9?1.1, P?.19), which
can be explained by our low complication rate (16.7%)
and the absence in this series of complications classified
as Clavien-Dindo ?3. Our data reinforce that the manage-
ment of gallstone disease in octogenarians should not be
different from current guidelines for the management of
acute gallstone pancreatitis or complicated biliary disease,
which means that elderly patients would benefit from
definitive therapy during the same hospitalization to pre-
vent recurrent episodes.
LC in the extremely elderly is safe, with acceptable mor-
bidity. Additional support for the benefit of the laparo-
scopic approach is demonstrated in the decreased length
of hospital stay. Patients with complicated gallstone dis-
ease seem not to have worse postoperative outcomes
once the initial diagnosis is properly treated would benefit
from definitive therapy during the same hospitalization.
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