Management of gallstone disease in elderly: WSES Guidelines

The World Society of Emergency Surgery (WSES) and the Italian Society of Geriatric Surgery (SICG) have released guideline on acute calculous cholecystitis (ACC) in the elderly. The guideline is published in the World Journal of Emergency Surgery.

Gallstone disease is very common afflicting 20 million people in the USA. The frequency of gallstones related disease increases by age. The elderly population is increasing worldwide.

Cholecystitis is inflammation of the gallbladder that occurs most commonly because of an obstruction of the cystic duct by gallstones arising from the gallbladder (cholelithiasis). Uncomplicated cholecystitis has an excellent prognosis; the development of complications such as perforation or gangrene renders the prognosis less favorable.

It includes recommendations on the diagnostic tests that the elderly should undergo, managing the right balance between pro and cons for surgery in elderly patients with acute calculous cholecystitis, most appropriate timing and the most appropriate surgical technique for elderly, alternative treatments in case of reduced benefit from surgery in elderly, management of associated biliary tree stones, and antibiotic schedule for treatment. The recommendations are described below:

Diagnosis

• There is no single investigation with sufficient diagnostic power to establish or exclude acute cholecystitis without further testing even in elderly people. Combination of symptoms, signs, and laboratory tests results may have better diagnostic accuracy in confirming the diagnosis of ACC.


• Abdominal ultrasound is the preferred initial imaging technique for elderly patients who are clinically suspected of having acute cholecystitis, in terms of lower costs, better availability, lack of invasiveness, and good accuracy for stones.


• Even in elderly patients, evidence on the diagnostic accuracy of CT are scarce and remain elusive while diagnostic accuracy of MRI might be comparable to that of abdominal ultrasound, but no sufficient data are provided to support this hypothesis. HIDA-scan has the highest sensitivity and specificity for acute cholecystitis than other imaging modalities although its scarce availability, long time of execution and exposure to ionizing radiations limit its use.


• Even in elderly patients, combining clinical, laboratory, and imaging investigations should be recommended, although the best combination is not yet known.


• No high-quality studies on specific diagnostic findings of acute cholecystitis in the elderly have been found; therefore, the stated recommendations of the WSES guidelines previously reported remain unchanged.

Pro and Cons for Surgery

• Old age (> 65 years), by itself, does not represent a contraindication to cholecystectomy for ACC.


• Cholecystectomy is the preferred treatment for ACC even in elderly patients.


• The evaluation of the risk for the elderly patient with ACC should include:
  
  
  
  • The mortality rate for conservative and surgical therapeutic options
  
  
  • Rate of gallstone-related disease relapse and the time to relapse
  
  
  • Age-related life expectancy
  
  
  • Consider patient frailty evaluation by the use of frailty scores
  
  
  • Consider the estimation of specific risk (patient/type of surgery) by the use of surgical clinical scores
  
  
  
  

Appropriate Timing and Surgical Technique

• In elderly patients with acute cholecystitis, the laparoscopic approach should always be attempted at first except in the case of absolute anesthetic contraindications and septic shock.


• In elderly patients, laparoscopic cholecystectomy for acute cholecystitis is safe, feasible, with a low complication rate and associated with a shortened hospital stay.


• In elderly patients, laparoscopic or open subtotal cholecystectomy is a valid option for advanced inflammation, gangrenous gallbladder, and “difficult gallbladder” where anatomy is difficult to be recognized and main bile duct injuries are highly probable.


• In elderly patients, conversion to open surgery may be predicted by fever, leucocytosis, elevated serum bilirubin, and extensive upper abdominal surgery.


• Even in elderly patients, early laparoscopic cholecystectomy should be performed as soon as possible but can be performed up to 10 days of onset of symptoms.

Role for Percutaneous Cholecystostomy in Case of Reduced Benefit from Surgery

• Percutaneous cholecystostomy can be considered in the treatment of ACC patients (older than 65, with ASA III/IV, performance status 3 to 4, or septic shock) who are deemed unfit for surgery.


• If medical therapy failed, percutaneous cholecystostomy should be considered as a bridge to cholecystectomy in acutely ill (high-risk) elderly patients deemed unfit for surgery, in order to convert them in a moderate risk patient, more suitable for surgery.


• As in the general population, even in elderly patients, percutaneous transhepatic cholecystostomy is the preferred method to perform percutaneous cholecystostomy.


• As in the general population, even in elderly patients, percutaneous cholecystostomy catheter should be removed between 4 and 6 weeks after placement, if a cholangiogram performed 2–3 weeks after percutaneous cholecystostomy demonstrated biliary tree patency.

Management of Biliary Tree Stones

• Even in elderly patients, the elevation of liver biochemical enzymes and/or bilirubin levels is not sufficient to identify ACC patients with choledocholithiasis and further diagnostic tests are needed.


• Even in elderly patients, the visualization of common bile duct stones on abdominal ultrasound is a very strong predictor of choledocholithiasis.


• Liver biochemical tests, including ALT, AST, bilirubin, ALP, GGT, and abdominal ultrasound should be performed in all patients with ACC to assess the risk for common bile duct stones.


• Even in elderly patients with moderate risk for choledocholithiasis preoperative magnetic resonance cholangiopancreatography (MRCP), endoscopic US, intraoperative cholangiography, or laparoscopic ultrasound should be performElderly patients with high risk for choledocholithiasis should undergo preoperative ERCP, intraoperative cholangiography, or laparoscopic ultrasound, depending on the local expertise and the availability of the technique. ed depending on the local expertise and availability.


• Even in elderly patients, common bile duct stones could be removed preoperatively, intraoperatively, or postoperatively according to the local expertise and the availability of the technique.

Antibiotic Regime for Treatment?

• Elderly patients with uncomplicated cholecystitis can be treated without postoperative antibiotics when the focus of infection is controlled by cholecystectomy.


• In elderly patients with complicated acute cholecystitis, antibiotic regimens with the broad spectrum are recommended as adequate empiric therapy significantly affects outcomes in critical elderly patients.


• The results of the microbiological analysis are helpful in designing targeted therapeutic strategies for individual patients with healthcare infections to customize antibiotic treatments and ensure adequate antimicrobial coverage.

For detailed guideline follow the link: https://doi.org/10.1186/s13017-019-0224-7