**8. Elderly patients**

Age is one of the critical factors affecting the mortality and morbidity rates after open cholecystectomy for both acute and chronic cholecystitis [2, 3]. Several series of open cholecystectomy [4, 5] report death as a complication occurring almost exclusively in patients over 60 years of age [6]. Smith and Max [7] found that the morbidity-mortality rate after open cholecystectomy was 25% for patients aged 60-69 as opposed to 50% for patients over 70.

Ageing patients with symptomatic cholelithiasis frequently have associated medical disorders. They may be at higher risk of postoperative complications. Evaluation of the results of the laparoscopic approach in the aged would allow patients and surgeons to make decisions on the most appropriate treatment for symptomatic cholelithiasis.

#### **8.1 Case**

Brunt et al[22] gathered their laparoscopic data for 421 patients from 1989 to 1999 which were extremely elderly or older than 80 years to determine whether extremely elderly patients, age 80 years or older, were at higher risk for adverse outcomes from laparoscopic cholecystectomy than patients younger than 80 years. The patients were divided into two groups: group 1 (age 65-79 years; n = 351) and group 2 (age, 80-95 years; n = 70). The authors noted that the advanced age (group 2) was associated with a higher mean American Society of Anesthesiology (ASA) class and a greater incidence of common bile duct stones, as compared with those of younger age (group 1). Mean operative times in group 2 were 45- 106 minutes as compared with 38 to 96 minutes in group 1, a difference that is not significant. The authors noted that the extremely elderly group had a four times higher rate of conversion to open cholecystectomy and a longer mean postoperative hospital stay of 1.4 to 2.1 days. They also stated that Grades 1 and 2 complications were more common in group 2. They reported that one patient in group 1 had a myocardial infarction 13 days postoperatively, and two deaths occurred in the extremely elderly group within 30 days postoperatively. The authors concluded that laparoscopic cholecystectomy in the extremely elderly is associated with more complications and a higher rate of conversion to open cholecystectomy than in elderly individuals younger than 80 years. The greater chance of encountering a severely inflamed or scarred gallbladder and common bile duct stones as well as increasing comorbidities likely account for these differences in outcome.

Mayol et al[24] gathered the outcome of all their laparoscopic cholecystectomy patients between 60 and 70 years of age and patients over 70 who underwent laparoscopic cholecystectomy for symptomatic non-malignant gallbladder disease. They found out that the operative time and conversion rates were similar with both groups. They noted that the overall morbidity rate was 14.5% and there was no perioperative mortality that occurred. There was a recurrent biliary surgery done in two patients from the above 70 group. There were also postoperative endoscopic retrograde cholangiography and sphincterotomy that was done in four patients from the below 70 group. They also found out that the mean postoperative stay was longer for older patients above 70 years of age. The authors concluded that simple laparoscopic cholecystectomy is safe in the aged even for patients over 70. They stated that this procedure is associated with a short hospital stay and low rates of re-admission and recurrent biliary surgery.
