Endoscopy 2006; 38(8): 773-778
DOI: 10.1055/s-2006-925448
Original article
© Georg Thieme Verlag KG Stuttgart · New York

Conservative treatment versus endoscopic sphincterotomy in the initial management of acute cholecystitis in elderly patients at high surgical risk

J.  Vracko1 , S.  Markovic1 , K.-L.  Wiechel2
  • 1Dept. of Gastroenterological Surgery, University Medical Center, Ljubljana, Slovenia
  • 2Karolinska Institute, Stockholm, Sweden
Further Information

Publication History

Submitted 22 July 2005

Accepted after revision 6 April 2006

Publication Date:
28 August 2006 (online)

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 prospective 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 random 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 retrograde 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.

References

  • 1 Stefanidis D, Bingener J, Richards M. et al . Gangrenous cholecystitis in the decade before and after the introduction of laparoscopic cholecystectomy.  JSLS. 2005;  9 169-173
  • 2 Kauvar D S, Brown B D, Braswell A W. et al . Laparoscopic cholecystectomy in the elderly: increased operative complications and conversions to laparotomy.  J Laparoendosc Adv Surg Tech A. 2005;  15 379-382
  • 3 Napolitano L, Waku M, Di Bartolomeo N. et al . Clinical study on laparoscopic approach to cholelithiasis in the elderly; in Italian.  G Chir. 2004;  25 301-303
  • 4 Pessaux P, Regenet N, Tuech J J. et al . Laparoscopic versus open cholecystectomy: a prospective comparative study in the elderly with acute cholecystitis.  Surg Laparosc Endosc Percutan Tech. 2001;  11 252-255
  • 5 Coenye K E, Jourdin S, Mendes da Costa P. Laparoscopic cholecystectomy for acute cholecystitis in the elderly: a retrospective study.  Hepatogastroenterology. 2005;  52 17-21
  • 6 Benfatto G, Catania G, Licari V. et al . Acute cholecystitis in patients over 80 years of age: indications for immediate surgical treatment; in Italian.  G Chir. 2001;  22 15-17
  • 7 Kolla S B, Aggarwal S, Kumar A. et al . Early versus delayed laparoscopic cholecystectomy for acute cholecystitis: a prospective randomized trial.  Surg Endosc. 2004;  18 1323-1327
  • 8 Leardi S, Delmonaco S, Maira E. et al . Acute cholecystitis in patients over 70 years old; in Italian.  Minerva Chir. 2001;  56 501-506
  • 9 Uecker J, Adams M, Skipper K, Dunn E. Cholecystitis in the octogenarian: is laparoscopic cholecystectomy the best approach?.  Am Surg. 2001;  67 637-640
  • 10 Vracko J, Wiechel K L. Increased gallbladder trypsin in acute cholecystitis indicates functional disorder in the sphincter of Oddi and could make EPT a logical procedure.  Surg Laparosc Endosc Percutan Tech. 2003;  13 308-313
  • 11 Vracko J, Zemva Z, Pegan V. et al . Sphincter of Oddi function studied by radioimmunoassay of biliary trypsin in patients with bile duct stones and in controls.  Surg Endosc. 1994;  8 389-392
  • 12 Vracko J, Wiechel K L. The laparoscopic finding of pericholedochitis at cholecystectomy predicts the presence of unsuspected bile duct stones.  Surg Laparosc Endosc Percutan Tech. 2000;  10 120-126
  • 13 Vracko J, Wiechel K L. Trypsin level in gallbladder bile and ductitis and width of the cystic duct.  Hepatogastroenterology. 2000;  47 115-120
  • 14 Makela J T, Kiviniemi H, Laitinen S. Acute cholecystitis in the elderly.  Hepatogastroenterology. 2005;  52 999-1004
  • 15 Wiechel K L. Cholecystostomy by simple percutaneous puncture. In: Blumgart LH, (editor) Proceedings of the International Biliary Association. Barcelona; Graficas Esteve 1983: 39
  • 16 Spira R M, Nissan A, Zamir O. et al . Percutaneous transhepatic cholecystostomy and delayed laparoscopic cholecystectomy in critically ill patients with acute calculous cholecystitis.  Am J Surg. 2002;  183 62-66
  • 17 Berman M, Nudelman I L, Fuko Z. et al . Percutaneous transhepatic cholecystostomy: effective treatment of acute cholecystitis in high risk patients.  Isr Med Assoc J. 2002;  4 331-333
  • 18 Tambyraja A L, Kumar S, Nixon S J. Outcome of laparoscopic cholecystectomy in patients 80 years and older.  World J Surg. 2004;  28 745-748
  • 19 Boytchev I, Pelletier G, Prat F. et al . Late biliary complications after endoscopic sphincterotomy for common bile duct stones in patients older than 65 years of age with gallbladder in situ; in French.  Gastroenterol Clin Biol. 2000;  24 995-1000

Prof. J. Vracko, M D, Ph D 

Department of Gastroenterologic Surgery, University Mediak Centre ·

Vodnikova 62 · Sl-1000 Ljubljana · Slovenia

Email: jozef.vracko@kclj.sl