Systematic review of cholecystostomy as a treatment option in acute cholecystitis. Conservative treatment versus endoscopic sphincterotomy in the initial management of acute cholecystitis in elderly patients at high surgical risk. Management of acute cholecystitis in the laparoscopic era: Results of a prospective, randomized clinical trial Early minilaparoscopic cholecystectomy in patients with acute cholecystitis. Acute cholecystitis in high surgical risk patients: percutaneous cholecystostomy or emergency cholecystectomy? A retrospective comparison of older and younger adults undergoing early laparoscopic cholecystectomy for mild to moderate calculous cholecystitis. Prospective Evaluation of Emergency Versus Delayed Laparoscopic Cholecystectomy for Early Cholecystitis Routine early laparoscopic cholecystectomy for acute cholecystitis after conclusion of a randomized controlled trial Percutaneous Drainage versus Emergency Cholecystectomy for the Treatment of Acute Cholecystitis in Critically Ill Patients: Does it Matter?
OBJECTIVES Percutaneous cholecystostomy ( PC ) is an established low-mortality treatment option for elderly and critically ill patients with acute cholecystitis . The primary aim of this review is to find out if there is any evidence in the literature to recommend PC rather than cholecystectomy for acute cholecystitis in the elderly population . METHODS In April 2007 , a systematic electronic data base search was performed on the subject of PC and cholecystectomy in the elderly population . After exclusions , 53 studies remained , comprising 1918 patients . Three papers described r and omized controlled trials ( RCTs ) , but none compared the outcomes of PC and cholecystectomy . A total of 19 papers on  mortality after cholecystectomy  in patients aged > 65 years were identified . RESULTS Successful intervention was seen in 85.6 % of patients with acute cholecystitis . A total of 40 % of patients treated with PC were later cholecystectomized , with a mortality rate of 1.96 % . Procedure mortality was 0.36 % , but 30-day mortality rates were 15.4 % in patients treated with PC and 4.5 % in those treated with acute cholecystectomy ( P < 0.001 ) . CONCLUSIONS There are no controlled studies evaluating the outcome of PC vs. cholecystectomy and the papers review ed are of evidence grade C. It is not possible to make definitive recommendations regarding treatment by PC or cholecystectomy in elderly or critically ill patients with acute cholecystitis . Low mortality rates after cholecystectomy in elderly patients with acute cholecystitis have been reported in recent years and therefore we believe it is time to launch an RCT to address this issue BACKGROUND AND STUDY AIMS Surgery in elderly patients with acute cholecystitis is quite a high-risk procedure . The recent finding that activated pancreatic enzyme is present in sterile bile from the acutely inflamed gallbladder suggests that obstruction at the level of the common channel is a possible precipitating factor . It was therefore hypothesized that an initial endoscopic sphincterotomy in patients with acute cholecystitis might improve the clinical course . PATIENTS AND METHODS A prospect i ve unselected series of 105 patients over 65 years of age ( 52 men , 53 women ; mean age 78 ) suffering from acute cholecystitis were initially treated on a r and om basis with either conservative methods or endoscopic sphincterotomy . Within the first 72 h after the onset of symptoms , all 52 patients in the endoscopic sphincterotomy group were managed by endoscopic retro grade cholangiopancreatography ( ERCP ) , combined with endoscopic sphincterotomy in 50 cases . The main study parameter was the need for emergency cholecystectomy  within the first week after admission . RESULTS Biliary sepsis requiring emergency surgery occurred in 15 patients in the conservatively treated group , in contrast with none of the 52 patients in the endoscopic sphincterotomy group ( P < 0.001 ) . Iatrogenic complications after endoscopic sphincterotomy  occurred in three patients , one of whom required surgery , while two were managed by conservative means . The clinical course improved , avoiding the need for emergency cholecystectomy and other interventions , in 48 patients in the endoscopic sphincterotomy group and in 36 patients in the conservatively treated group ( P < 0.01 ) . CONCLUSIONS The clinical course after endoscopic sphincterotomy  improved in the majority of elderly patients suffering from acute cholecystitis , suggesting that early relief of obstruction at the level of the common channel reduces the risk of developing biliary sepsis . The majority of these patients can undergo surgery electively or can receive further conservative treatment The aim of this prospect i ve , r and omized study was to determine whether laparoscopic cholecystectomy should be performed as an early or a delayed operation in patients with acute cholecystitis . After diagnostic workup , patients were r and omized to one of two groups : ( 1 ) early laparoscopic cholecystectomy  ( i.e. , within 7 days after onset of symptoms ) or ( 2 ) initial conservative treatment followed by delayed laparoscopic cholecystectomy 6 to 8 weeks later .  Seventy-four patients were placed in the early-operation group , and 71 patients were assigned to the delayed-operation strategy . There was no significant difference in conversion rates ( early 31 % vs. delayed 29 % ) , operating times ( early 98 [ range 30 to 355 ] minutes vs. delayed 100 [ 45 to 280 ] minutes ) , or complications . Failure with the conservative treatment strategy was noted in 26 % of these patients . The total hospital stay was significantly shorter in the early group ( 5 [ range 3 to 63 ] days ) vs. the delayed group ( 8 [ range 4 to 50 ] days ; P < 0.05 ) . Despite a high conversion rate , early laparoscopic cholecystectomy offered significant advantages in the management of acute cholecystitis compared to a conservative strategy . The greatest advantage was a reduced total hospital stay BACKGROUND Recently , techniques using fine-caliber instruments ( 2 or 3 mm in diameter ) for laparoscopic cholecystectomy , called minilaparoscopic cholecystectomy ( MLC ) , were reported to be superior to conventional LC ( CLC , using 5 mm instruments ) in postoperative course and cosmetic outcome . However , the use of MLC to date has been largely restricted to uncomplicated situations . Since CLC has been proved to be a safe and efficient technique for acute cholecystitis especially if conducted early , this study tests the feasibility and safety of MLC for acute cholecystitis . METHODS Sixty-nine consecutive patients with acute cholecystitis were prospect ively r and omized to  minilaparoscopic  ( n = 38 ) or conventional laparoscopic  ( n = 31 )  cholecystectomy  , and the operations were conducted within 2 days of admission whenever possible . Despite different operative techniques , both groups of patients received identical preoperative preparation , evaluation and postoperative care . The two groups were compared for patient characteristics , results of laboratory tests , predictive score for LC difficulties , operative time , operative complications , hospitalization days and need for meperidine injection for wound pain . RESULTS The conversion rate was 7.9 % ( 3 of 38 ) for the MLC group and 6.5 % ( 2 of 31 ) for the CLC group . Nine patients in the  MLC group and 7 in the CLC group had concomitant choledocholithiasis and underwent endoscopic stone retrieval  before operation . The age , sex , predictive score for LC difficulties , preoperative leukocyte count , length of hospital stay and requirement of intramuscular meperidine injections were similar for both groups of patients , while , the operative times were marginally longer in the MLC group ( 113.8 + /- 30.8 versus 98.2 + /- 33.2 minutes , P = 0.056 ) . No major complications occurred in either group . CONCLUSIONS The results of cholecystectomy for acute cholecystitis by MLC are as good as those of CLC if the operation is performed early , with obvious smaller incisions and minimal complications . MLC is a safe and effective procedure for patients with acute cholecystitis , and has an acceptable low conversion rate BACKGROUND Percutaneous cholecystostomy ( PC ) is an alternative treatment in  acute cholecystitis ( AC ) in high-risk or elderly patients although its advantage over emergency cholecystectomy has not yet been established . STUDY DESIGN AC prospect i ve data base analysis in high-risk patients treated by PC ( group 1 , 29 patients ) or emergency cholecystectomy ( group 2 , 32 patients ) . Surgical risk was estimated by physiological POSSUM , Charlson , Apache II , and American Society of Anesthesiologists ( ASA ) scores . RESULTS The groups showed homogeneity concerning age and surgical risk . PC allowed AC resolution in 19 patients ( 70.4 % ) , but 8 ( 29.6 % ) needed emergency cholecystectomy .  Morbidity and mortality rates were 31 % and 17.2 % , respectively . Mortality was significantly associated with ASA IV ( P = .01 ) . In group 2 , the morbidity rate was 28.1 % without mortality . There was no statistical difference in morbidity ( P = .6 ) although mortality was significantly higher in group 1 ( P = .02 ) . CONCLUSIONS PC seems of little benefit and ought to be left for those very old patients with surgical contraindication OBJECTIVES To compare the demographic characteristics and intra- and postoperative outcomes in elderly adults ( ≥75 ) with those of younger adults undergoing early ( < 5 days after onset of complaints ) cholecystectomy .  DESIGN Retrospective analysis from May 2010 to August 2012 . SETTING R and omized , multicenter , clinical trial ( ABCAL Study , NCT01015417 ) . PARTICIPANTS Individuals with mild or moderate acute calculous cholecystitis ( ACC ) according to the Tokyo Guidelines ( N=414 ; n=78 aged 75 - 94 , median 82 ; n=336 aged 18 - 74 , median 49 ) . MEASUREMENTS Demographic characteristics and pre- , intra- , and postoperative data . RESULTS The elderly group was more likely to have an American Society of Anesthesiologists score of 3 or greater ( 62 % vs 23 % , P<.001 ) , higher serum creatinine ( 103 vs 74 μmol/L , P<.001 ) , and more-severe ACC ( moderate ACC ( 62 % vs 50 % , P=.05 ) , gangrenous cholecystitis ( 38 % vs 15 % , P=.001 ) ) on preoperative imaging and confirmed intraoperatively . Ulcerated mucosa ( 76 % vs 61 % , P=.001 ) was significantly more frequent in the elderly group . Operative time , postoperative mortality , and postoperative infectious ( 18 % vs 14 % , P=.35 ) and noninfectious ( 9 % vs 3 % , P=.80 ) complications were similar between the two groups . Median length of stay ( 7.0 vs 5.0 days , P=.54 ) and readmission rate ( 15 % vs 4 % , P=.07 ) were not significantly higher in the elderly group . No significant difference was observed for the subgroup of participants aged 80 and older . CONCLUSION In this r and omized trial that included a selected sample of older adults , there was no difference in major outcomes between elderly adults and their younger counterparts after early cholecystectomy . The findings are limited because important geriatric outcomes such as delirium and functional decline were not examined Treatment of acute cholecystitis is still under debate . The aim of this study was to evaluate the efficacy of early laparoscopic cholecystectomy ( ELC ) in comparison with conservative treatment followed by delayed laparoscopic cholecystectomy ( DLC ) in the management of acute cholecystitis . This prospect i ve comparative study involved two groups of patients presenting with acute cholecystitis within 72 hours of the onset of symptoms . ELC was performed in 82 consecutive patients , whereas DLC was performed in 87 patients who previously underwent medical treatment .  Surgical variables , hospital stay , and postoperative morbidity were evaluated in both groups . Time of surgery and conversion rate were lower in the ELC group . Postoperative morbidity was similar in both groups . Overall hospital stay was shorter in the ELC group . ELC within 72 hours of the onset of acute cholecystitis is a safe procedure with better results than DLC in terms of surgical timing , conversion rate , and hospital stay The aim of this retrospective review was to assess the clinical outcomes of  laparoscopic cholecystectomy  for acute cholecystitis since the conclusion of a r and omized controlled trial in 1997 Background The aim if this study was to compare percutaneous drainage ( PD ) of the gallbladder to emergency cholecystectomy ( EC ) in a well-defined patient group with sepsis related to acute calculous/acalculous cholecystitis ( ACC/AAC ) . Methods Between 2001 and 2007 , all consecutive patients of our ICU treated by either PD or EC were retrospectively analyzed . Cases were collected from a prospect i ve data base . Percutaneous drainage was performed by a transhepatic route and EC by open or laparoscopic approach . Patients ’ general condition and organ dysfunction were assessed by two vali date d scoring systems ( SAPS II and SOFA , respectively ) . Morbidity , mortality , and long-term outcome were systematic ally review ed and analyzed in both groups . Results Forty-two patients [ median age = 65.5 years ( range = 32–94 ) ] were included ; 45 % underwent EC  ( ten laparoscopic , nine open ) and 55 % PD ( n = 23 ) . Both patient groups had similar preoperative characteristics .  Percutaneous drainage and EC  were successful in 91 and 100 % of patients , respectively . Organ dysfunctions were similarly improved by the third postoperative/postdrainage days . Despite undergoing PD , two patients required EC due to gangrenous cholecystitis . The conversion rate after laparoscopy was 20 % . Overall morbidity was 8.7 % after PD and 47 % after EC ( P = 0.011 ) . Major morbidity was 0 % after PD and 21 % after EC ( P = 0.034 ) . The mortality rate was not different ( 13 % after PD and 16 % after EC , P = 1.0 ) and the deaths were all related to the patients ’ preexisting disease . Hospital and ICU stays were not different . Recurrent symptoms ( 17 % ) occurred only after ACC in the PD group . Conclusions In high-risk patients , PD and EC are both efficient in the resolution of acute cholecystitis sepsis . However , EC is associated with a higher procedure-related morbidity and the laparoscopic approach is not always possible . Percutaneous drainage represents a valuable intervention , but secondary cholecystectomy is m and atory in cases of acute calculous cholecystitis
Conclusion : Early cholecystectomy seems to be a feasible treatment in elderly patients with acute cholecystitis .
Background : In the era of advanced surgical techniques and improved perioperative care , the willingness to perform emergency operations in elderly patients continues to increase .
This systematic review aim ed at assessing the clinical outcomes of early cholecystectomy in elderly patients with acute cholecystitis .