Management of Acute Calculous Cholecystitis in the Elderly: WSES/SICG Clinical Practice Guidelines

In collaboration with the Italian Society of Geriatric Surgery (SICG), the World Society of Emergency Surgery (WSES) has released guidelines for the management of acute calculous cholecystitis (ACC) in the elderly people. The Guidelines have been published in World Journal of Emergency Surgery.

Gallstone disease is very common afflicting 20 million people in the USA. In Europe, the overall incidence of gallstone disease is 18.8% in women and 9.5% in men. The frequency of gallstones related disease increases by age. Biliary colic is the most common acute presentation of gallstone disease occurring from 1 to 4% annually

A)Which test for elderlies?

1. There is no single investigation with sufficient diagnostic power to establish or exclude acute cholecystitis without further testing even in elderly people


2. In elderly patients, no single investigation is capable of establishing or excluding ACC without further testing.


3. 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


4. 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. Hence, There is no specific data available on the elderly on this topic.


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


6. 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

B)How to establish the right balance between pro and cons for surgery in elderly patients with acute calculus cholecystitis?

Old age (>65 years), by itself, is not a contraindication for cholecystectomy to treat ACC.

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

Evaluation of risk for elderly ACC patients should include the following:

• Mortality for conservative and surgical therapeutic options


• Rate of gallstone-related disease relapse and time to relapse


• Age-related life expectancy


• Patient frailty; consider the use of frailty scores for assessment


• Specific risk (for an individual patient or particular procedure); consider the use of surgical clinical scores

C)Most appropriate timing and technique

1. 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.


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


3. 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.


4. In elderly patients, conversion to open surgery may be predicted by fever, leucocytosis, elevated serum bilirubin, and extensive upper abdominal surgery. In case of local severe inflammation, adhesions, bleeding in the Calot's triangle, and suspect bile duct injury, conversion to open surgery should be considered.


5. 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. However, it should be noted that earlier surgery is associated with shorter hospital stay and fewer complications

D) alternative treatments in case of reduced benefit from surgery in elderly

1. 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.


2. 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


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


4. 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

E)Associated biliary tree stones: when to suspect, how to investigate when a high index of suspicion is available for treatment, and what treatment?

1. 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.


2. Even in elderly patients, the visualization of common bile duct stones on abdominal ultrasound is a very strong predictor of choledocholithiasis (LoE 5 GoR D). Even in elderly patients, indirect signs of stone presence such as the increased diameter of the common bile duct are not sufficient to identify ACC patients with choledocholithiasis and further diagnostic tests are needed.


3. 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. (LoE 3 GoR C). Even in elderly patients, common bile duct stone risk should be stratified according to the proposed classification, modified from the American Society of Gastrointestinal Endoscopy and the Society of American Gastrointestinal Endoscopic Surgeon Guidelines


4. Elderly 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.


5. 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.

F) Antibiotics: which treatment schedule?

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


2. 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 principles of empiric antibiotic therapy should be guided by most frequently isolated bacteria taking into consideration antibiotic resistance and the clinical condition of the patient


3. 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.

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doi: 10.1186/s13017-019-0224-7