Routine laparoscopic cholecystectomy after endoscopic sphincterotomy for choledocholithiasis in octogenarians: is it...

Area of Science:

• Gastroenterology
• Surgical Oncology
• Geriatric Medicine

Background:

• Consensus is lacking on routine laparoscopic cholecystectomy (LC) post-endoscopic sphincterotomy (ES) for choledocholithiasis in very elderly, high-risk patients.
• Choledocholithiasis management in octogenarians presents unique surgical risks and challenges.

Purpose of the Study:

• To evaluate the safety and efficacy of sequential endoscopic sphincterotomy (ES) followed by routine laparoscopic cholecystectomy (LC) in octogenarian patients with common bile duct (CBD) stones.
• To compare outcomes of routine LC versus a "wait-and-see" policy in very elderly patients with CBD stones.

Main Methods:

• Retrospective comparison of 27 octogenarians (≥80 years) undergoing preoperative ES and routine LC with younger patients.
• Case-control study comparing these octogenarians with 27 very elderly patients who underwent ERCP but not LC.
• Mean follow-up period of 126 months.

Main Results:

• Octogenarians undergoing routine LC had longer surgery times and hospital stays, with more low-grade complications, but no difference in conversion or serious complications compared to younger patients.
• A "wait-and-see" policy in octogenarians led to biliary events in 48%, often requiring delayed surgery with poorer results.
• The control group (no routine LC) experienced significantly poorer surgical outcomes, including one death from acute cholecystitis.

Conclusions:

• While a "wait-and-see" approach avoids LC in two-thirds of octogenarians, nearly half experience biliary events, frequently necessitating delayed surgery with inferior outcomes.
• Sequential ES followed by elective LC is a safe and effective definitive treatment for cholecystocholedocholithiasis in patients over 80.
• This sequential approach should be considered standard care for very elderly patients with common bile duct stones.