ORIGINAL ARTICLE
Laparoscopic Common Bile Duct Exploration in Elderly Patients: Is There Still a Difference? Pablo Parra-Membrives, PhD,*w Darı´o Martı´nez-Baena, MD,w Jose Manuel Lorente-Herce, MD,w and Javier Jime´nez-Vega, MDw
Purpose: Although surgery is frequently not the first treatment option in elderly patients diagnosed with common bile duct stones (CBDS) because of the fear of high morbidity and mortality rates, there are few data about the safety and efficacy of laparoscopic common bile duct exploration (LCBDE) in the elderly. Methods: From February 2004 to January 2012, 94 patients underwent LCBDE at our center. Data about sex, age, comorbidity, American Society of Anesthesiologists (ASA) score, conversion to open surgery and bile duct clearance rate, postoperative complications, need for reoperation, and mortality were analyzed comparing patients of age 70 or older (group A, n = 38) with patients aged under 70 (group B, n = 56). Results: Elderly patients had significantly more preoperative risk factors. Stone extraction was equally successful in both groups (89.5% in group A vs. 96.4% in group B, P = 0.176). Six patients developed medical complications (7.9% in group A vs. 5.4% in group B, P = 0.621). Surgical morbidity was equivalent for both groups (13.2% in group A vs. 10.7% in group B, P = 0.718). Four patients in each group experienced some grade of bile leakage. Three patients were reoperated (1 patient in group A because of a biliary peritonitis and 2 in group B after an intra-abdominal hemorrhage). There were no mortality cases directly related to surgery. Conclusions: This study reveals that LCBDE is safe in the elderly patients and results are not different from those described in the general population. Patients with choledocholithiasis should be offered to undergo an LCBDE irrespective of their age at diagnosis. Key Words: laparoscopic surgery, common bile duct stones, elderly patients
(Surg Laparosc Endosc Percutan Tech 2014;24:e118–e122)
E
lderly patients are traditionally classified as fragile patients. In addition, increasing age is correlated with a more morbid status. As a result of their underlying diseases, they frequently receive anticoagulant therapy, or have a poor pulmonary or heart condition to affront a safe surgical procedure. Conversely, this issue is frequently advocated to justify a less aggressive approach and even to support a wait-and-see policy for different health problems. Choledocholithiasis, which is common among elderly patients, is one of those diseases in which different management
Received for publication October 27, 2012; accepted December 10, 2012. From the *Department of Surgery, University of Seville; and wHepatobilio-pancreatic Surgery Unit, General and Digestive Surgery Department, Valme University Hospital, Sevilla, Spain. The authors declare no conflicts of interest. Reprints: Pablo Parra-Membrives, PhD, C/Rubi 35, 41927 Mairena del Aljarafe, Sevilla, Spain (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
e118 | www.surgical-laparoscopy.com
options have been proposed in order to relieve surgery as a secondary treatment option because of its potential risk in elderly patients.1–4 The state-of-the-art treatment of common bile duct stones (CBDS) in the general population is not well defined. The literature has well documented that either the 2-stage strategy with endoscopic bile duct clearance and subsequent laparoscopic cholecystectomy (LC) or the surgery alone approach performing a laparoscopic common bile duct exploration (LCBDE) are both equivalent in terms of efficacy in bile duct clearance and associated morbidity.5–12 However, the management of CBDS in elderly patients usually includes the endoscopic approach as the first choice achieving a success rate of >80%4,13–16 relieving surgery for emergency treatment of septic patients with suppurative cholangitis, or as a second line option after endoscopic bile duct clearance failure. Despite this, since minimal invasive surgery has replaced open surgery, the elderly population has been reconsidered for surgical management of their gallstone disease. LC has revealed to be safe in elderly patients though increased conversion rate and morbidity have been reported.17,18 However, there are few data about the safety and efficacy of LCBDE in these patients. The aim of this study is to analyze the value of the laparoscopic approach of choledocholithiasis in terms of bile duct clearance and postoperative morbidity rates in elderly patients.
MATERIALS AND METHODS From February 2004 to January 2012, 94 patients underwent LCBDE at our center. The management policy of our institution for CBDS includes LCBDE for all patients that are diagnosed with choledocholithiasis and are fit for surgery. Only patients without a dilated common bile duct (CBD; 0.05). The elderly patients group had significantly more preoperative risk factors (Table 1). Pulmonary diseases, arterial hypertension, diabetes mellitus, previous abdominal surgery, and antiaggregant therapy was more frequent in group A. The preoperative calculated anesthetic risk (ASA score) was also significantly increased in the elderly. Patients presented with similar symptoms in both groups (Table 2). Only incidence of pain was more frequent in the aging patients group. Conversion rate was not different in both groups (10.5% in group A vs. 8.9% in group B, P = 0.796). There was only a single case of transcystic approach in each group. All other patients underwent a choledochotomy for CBDS removal. There was no difference in average number of extracted CBDS (2.4 ± 2.1 in group A vs. 3.5 ± 7.2 in group B, P = 0.764). Both groups had a similar low incidence of ampullaryimpacted stones (5.3% in group A vs. 8.9% in group B, P = 0.506) and of intrahepatic stones (5.3% in group A vs. 7.1% in group B, P = 0.714). LCBDE was successful in r
2014 Lippincott Williams & Wilkins
Laparoscopic Common Bile Duct Exploration in the Elderly
TABLE 1. Preoperative Risk Factors
Variables
Elderly Patients (n = 38)
General Population (n = 56)
P
7 7 30 5 12 6 12 0 12
9 3 14 6 4 9 7 1 8
0.157 0.044 > 0.0005 0.718 0.002 0.971 0.016 0.408 0.044
0 18 18 2
15 27 13 2
Heart diseases Pulmonary diseases Arterial hypertension Liver diseases Diabetes mellitus Obesity Antiaggregant therapy Anticoagulant therapy Previous abdominal surgery ASA risk score ASA 1 ASA 2 ASA 3 ASA 4
0.002
ASA indicates American Society of Anesthesiologists.
both groups with a high bile duct clearance rate (89.5% in the elderly patients vs. 96.4% in the general population, P = 0.176). Most of the patients received a T-tube insertion for bile duct closure in both groups (23 patients in group A and 34 patients in group B). Further 14 patients in group A and 20 in group B underwent antegrade stenting before choledochotomy was closed. A choledochoduodenostomy was performed in a patient who was converted to open surgery in group B. The incidence of patients affected with complications after surgery was not different in both groups. Only few patients developed medical complications (7.9% in group A vs. 5.4% in group B). Among surgical complications, 4 patients in each group experienced some grade of bile leakage from the bile duct closure. There were 2 patients in the general population group who suffered an intra-abdominal hemorrhage and had to be reoperated. A further patient in group A underwent a reintervention because of a biliary peritonitis. Two patients of the younger patients group received a percutaneous drainage because of an intra-abdominal abscess. There was a patient in the
TABLE 2. Clinical Presentation
Variables Jaundice Pain Pancreatitis Fever Dyspepsia Intraoperative diagnosis of CBDS Asymptomatic Cholecystitis
Elderly Patients (n = 38), n (%)
General Population (n = 56), n (%)
20 36 7 11 5 5
32 44 7 15 5 4
(52.6) (94.7) (18.4) (28.9) (13.2) (13.2)
1 (2.6) 8 (21.1)
P
(57.1) (78.6) (12.5) (26.8) (8.9) (7.1)
0.66 0.031 0.429 0.818 0.514 0.454
5 (8.9) 9 (16.1)
0.233 0.591
CBDS indicates common bile duct stones.
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Parra-Membrives et al
elderly group who was readmitted to the hospital because of a pancreatitis caused by a stent migration obstructing the pancreatic duct. Biliary complications after tube removal in the patients that had a T-tube inserted for bile duct closure (Table 3) were also not different when both groups were compared. There were no mortality cases directly related to surgery, but 1 patient with a remnant stone in group B who underwent an ERCP developed a severe pancreatitis that finally caused her decease.
DISCUSSION Life expectancy has been prolonged and there is a general increase of elderly population that is frequently charged with serious comorbid diseases. Therefore, the physicians have to frequently deal not only with the present clinical problem itself, but also with all the associated diseases and a decline in physical activity that makes taking clinical decisions more challenging and hazardous. Elderly patients are considered to be particularly prone to morbidity and mortality; consequently, the role of surgery in the management of CBDS in this group of patients has been a matter of debate. Although biliary surgery was considered in the past the commonest abdominal operation performed in aging patients14,31,32 since the onset of endoscopic explorations, ERCP with ES has been increasingly
TABLE 3. Postoperative Morbidity
Variables Patients with complications (overall)* Patients with medical complications* Arrhythmia Pleural effusion Respiratory failure Deep vein thrombosis Acute renal failure Upper gastrointestinal bleeding Patients with surgical complications* Bile leakage Biloma Biliary peritonitis Intra-abdominal hemorrhage Pancreatitis Intra-abdominal abscess Reintervention Patients with T-tube removal–related complications* Bile leakage Biloma Biliary peritonitis
Elderly Patients (n = 38), n (%)
General Population (n = 56), n (%)
P
8 (21.1)
11 (19.6)
0.867
3 (7.9)
3 (5.4)
0.621
1 (2.6) 0 1 (2.6) 1 (2.6) 0 1 (2.6)
0 1 1 (1.8) 0 1 0
0.222 0.408 0.780 0.222 0.408 0.222
5 (13.2)
6 (10.7)
0.718
3 (7.9) 0 1 (2.6) 0
3 (5.4) 1 (1.8) 0 2 (3.6)
0.147 0.408 0.222 0.239
1 (2.6) 0
0 3
0.222 0.147
1 (2.6) 3 (7.9)
2 (3.6) 4 (7.1)
0.799 0.371
1 (2.6) 0 1 (2.6)
1 (1.8) 2 (3.6) 2 (3.6)
0.780 0.239 0.799
*Number of patients affected with complications. Incidence of each complication type is listed. More than 1 complication type present in some patients.
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Volume 24, Number 4, August 2014
indicated for CBDS extraction.3,4,14 Endoscopic management has been regarded as less invasive than surgery and is considered at present as the treatment of choice for choledocholithiasis in elderly patients. After CBDS removal, it has been even suggested not to perform an LC in aging patients in order to diminish potential morbidity.33 However, although the wait-and-see policy avoids two thirds of all LC after ERCP in the elderly population, the remaining patients may need surgery for gallbladder removal to treat biliary-related events with poorer results when compared with the sequential approach (ES followed by elective LC). Conversely, cholecystectomy after endoscopic extraction of CBDS should be strongly recommended even in elderly patients.34,35 Given that LC has proven to be safe in the elderly population,36,37 the next question is if LCBDE should be offered to aging patients with CBDS as a 1-stage approach. Although several studies have shown that ERCP and ES before, during, or after LC and the laparoscopic surgery 1-stage approach have both similar efficacy in terms of bile duct clearance and associated morbidity,5,10,12,38 whether both strategies are equivalent in the elderly population has not been proven. Our study reveals that a high bile duct clearance rate with acceptable morbidity, not different from the success rate in the general population, is possible in aging patients. Therefore, LCBDE should be offered also to elderly patients as a primary treatment option for CBDS and not only as a therapy of last resort when other treatment modalities have failed. Though expert endoscopy centers may report a very high success rate, many institutions achieve a bile duct clearance rate of slightly above 80%,10,13,38–41 which leaves nearly 15% to 20% of patients that will need further treatment options. In addition, recurrence of symptomatic CBDS after endoscopic therapy is more frequent in the elderly and counts for 20% of all successfully treated patients, whereas only 4% of the general population is charged with recurrent CBDS.42 Different therapeutic strategies have been proposed to deal with CBD that are not suitable for endoscopic removal or that remain in the biliary tree after sphincterotomy. The use of bile duct stenting with or without the addition of choleretic agents, endoscopic papillary balloon dilatation, or even intraductal lithotripsy has been reported with a high success rate.1–3,43–45 However, these strategies have not been generalized and surgery may be necessary for failed endoscopic extraction of CBDS and has proven to be safe in elderly patients in the case of the open surgery approach.32 Our study shows that LCBDE may be carried out in safe conditions as well. In addition, our clearance rate is similar or even higher to those reported for the endoscopic approach in the elderly or in the general population.2,46–49 A recent large retrospective review revealed that repeated biliary interventions within 90 days of the first procedure were significantly higher after an endoscopic clearance attempt than after LCBDE and that biliary reinterventions within this period were charged with a 14-fold increased risk of death.48 Thus, given that it is of paramount importance that the first treatment choice allows to achieve CBDS extraction successfully without the need for further procedures, that the clearance rates of LCBDE are as good as endoscopic ones or even better, considering that there is an important rate of CBDS recurrence in elderly patients after endoscopic treatment and, at last, taking into account that LC after bile duct clearance is strongly recommended even in the elderly as stated above, only safety of LCBDE may r
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be questioned before it can be declared that the laparoscopic approach could be the treatment of choice for CBDS even in aging people. Hence, our study reveals that the procedure is safe and that the morbidity rates are not different from those described in the general population. We suggest that only a poor performance status should preclude LCBDE in elderly patients. Centers with experience with the laparoscopic approach should offer aging patients with CBDS to undergo an LCBDE at the same manner they usually offer it to younger patients, as excluding elderly patients with CBDS for surgery should not be a dogma anymore.
CONCLUSIONS Our study reveals that LCBDE is safe in the elderly patients and results are not different from those described in the general population. Patients with choledocholithiasis should be offered to undergo an LCBDE irrespective of their age at diagnosis. REFERENCES 1. Lee TH, Han JH, Kim HJ, et al. Is the addition of choleretic agents in multiple double-pigtail biliary stents effective for difficult common bile duct stones in elderly patients? A prospective, multicenter study. Gastrointest Endosc. 2011; 74:96–102. 2. Swahn F, Edlund G, Enochsson L, et al. Ten years of Swedish experience with intraductal electrohydraulic lithotripsy and laser lithotripsy for the treatment of difficult bile duct stones: an effective and safe option for octogenarians. Surg Endosc. 2010;24:1011–1016. 3. Ito Y, Tsujino T, Togawa O, et al. Endoscopic papillary balloon dilation for the management of bile duct stones in patients 85 years of age and older. Gastrointest Endosc. 2008; 68:477–482. 4. Ashton CE, McNabb WR, Wilkinson ML, et al. Endoscopic retrograde cholangiopancreatography in elderly patients. Age Ageing. 1998;27:683–688. 5. Tranter SE, Thompson MH. Comparison of endoscopic sphincterotomy and laparoscopic exploration of the common bile duct. Br J Surg. 2002;89:1495–1504. 6. >Heili MJ, Wintz NK, Fowler DL. Choledocholithiasis: endoscopic versus laparoscopic management. Am Surg. 1999; 65:135–138. 7. Rogers SJ, Cello JP, Horn JK, et al. Prospective randomized trial of LC + LCBDE versus ERCP/S + LC for common bile duct stone disease. Arch Surg. 2010;145:28–33. 8. Williams EJ, Green J, Beckingham I, et al. Guidelines on the management of common bile duct stones (CBDS). Gut. 2008;57:1004–1021. 9. Parra-Membrives P, Diaz-Gomez D, Vilegas-Portero R, et al. Appropriate management of common bile duct stones: a RAND Corporation/UCLA Appropriateness Method statistical analysis. Surg Endosc. 2010;24:1187–1194. 10. Martin DJ, Vernon DR, Toouli J. Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev. 2006;2:CD003327. 11. Noble H, Tranter S, Chesworth T, et al. A randomized, clinical trial to compare endoscopic sphincterotomy and subsequent laparoscopic cholecystectomy with primary laparoscopic bile duct exploration during cholecystectomy in higher risk patients with choledocholithiasis. J Laparoendosc Adv Surg Tech A. 2009;19:713–720. 12. Clayton ES, Connor S, Alexakis N, et al. Meta-analysis of endoscopy and surgery versus surgery alone for common bile duct stones with the gallbladder in situ. Br J Surg. 2006;93: 1185–1191. r
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13. Carr-Locke DL. Therapeutic role of ERCP in the management of suspected common bile duct stones. Gastrointest Endosc. 2002;56(6, suppl):S170–S174. 14. Mee AS, Vallon AG, Croker JR, et al. Non-operative removal of bile duct stones by duodenoscopic sphincterotomy in the elderly. Br Med J (Clin Res Ed). 1981;283:521–523. 15. Mitchell RM, O’Connor F, Dickey W. Endoscopic retrograde cholangiopancreatography is safe and effective in patients 90 years of age and older. J Clin Gastroenterol. 2003;36: 72–74. 16. Deenitchin GP, Konomi H, Kimura H, et al. Reappraisal of safety of endoscopic sphincterotomy for common bile duct stones in the elderly. Am J Surg. 1995;170:51–54. 17. Qasaimeh GR, Banihani MN. Laparoscopic cholecystectomy in the elderly and young: a comparative study. Hepatogastroenterology. 2012;59:22–25. 18. Kauvar DS, Brown BD, Braswell AW, et al. Laparoscopic cholecystectomy in the elderly: increased operative complications and conversions to laparotomy. J Laparoendosc Adv Surg Tech A. 2005;15:379–382. 19. Gurusamy KS, Samraj K. Primary closure versus T-tube drainage after open common bile duct exploration. Cochrane Database Syst Rev. 2007;1:CD005640. 20. Ambreen M, Shaikh AR, Jamal A, et al. Primary closure versus T-tube drainage after open choledochotomy. Asian J Surg. 2009;32:21–25. 21. Lygidakis NJ. Choledochotomy for biliary lithiasis: T-tube drainage or primary closure. Effects on postoperative bacteremia and T-tube bile infection. Am J Surg. 1983; 146:254–256. 22. Marwah S, Singh I, Godara R, et al. Evaluation of primary duct closure versus T-tube drainage following choledochotomy. Indian J Gastroenterol. 2004;23:227–228. 23. Payne RA, Woods WG. Primary suture or T-tube drainage after choledochotomy. Ann R Coll Surg Engl. 1986;68: 196–198. 24. Williams JA, Treacy PJ, Sidey P, et al. Primary duct closure versus T-tube drainage following exploration of the common bile duct. Aust N Z J Surg. 1994;64:823–826. 25. Martin IJ, Bailey IS, Rhodes M, et al. Towards T-tube free laparoscopic bile duct exploration: a methodologic evolution during 300 consecutive procedures. Ann Surg. 1998;228:29–34. 26. Jameel M, Darmas B, Baker AL. Trend towards primary closure following laparoscopic exploration of the common bile duct. Ann R Coll Surg Engl. 2008;90:29–35. 27. Zhang WJ, Xu GF, Wu GZ, et al. Laparoscopic exploration of common bile duct with primary closure versus T-tube drainage: a randomized clinical trial. J Surg Res. 2009;157:e1–e5. 28. Zhu QD, Tao CL, Zhou MT, et al. Primary closure versus T-tube drainage after common bile duct exploration for choledocholithiasis. Langenbecks Arch Surg. 2011;396:53–62. 29. Kanamaru T, Sakata K, Nakamura Y, et al. Laparoscopic choledochotomy in management of choledocholithiasis. Surg Laparosc Endosc Percutan Tech. 2007;17:262–266. 30. Paganini AM, Feliciotti F, Guerrieri M, et al. Laparoscopic cholecystectomy and common bile duct exploration are safe for older patients. Surg Endosc. 2002;16:1302–1308. 31. Strohl EL, Diffenbaugh WG, Anderson RE. Biliary tract surgery in the aged patient. Geriatrics. 1964;19:275–279. 32. Davidson BR, Lauri A, Horton R, et al. Outcome of surgery for failed endoscopic extraction of common bile duct stones in elderly patients. Ann R Coll Surg Engl. 1994;76:320–323. 33. Ingoldby CJ, el-Saadi J, Hall RI, et al. Late results of endoscopic sphincterotomy for bile duct stones in elderly patients with gall bladders in situ. Gut. 1989;30:1129–1131. 34. Costi R, DiMauro D, Mazzeo A, et al. Routine laparoscopic cholecystectomy after endoscopic sphincterotomy for choledocholithiasis in octogenarians: is it worth the risk? Surg Endosc. 2007;21:41–47. 35. McAlister VC, Davenport E, Renouf E. Cholecystectomy deferral in patients with endoscopic sphincterotomy. Cochrane Database Syst Rev. 2007;4:CD006233.
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36. Weber DM. Laparoscopic surgery: an excellent approach in elderly patients. Arch Surg. 2003;138:1083–1088. 37. Bingener J, Richards ML, Schwesinger WH, et al. Laparoscopic cholecystectomy for elderly patients: gold standard for golden years? Arch Surg. 2003;138:531–535; discussion 535-6. 38. Cuschieri A, Lezoche E, Morino M, et al. E.A.E.S. multicenter prospective randomized trial comparing two-stage versus single-stage management of patients with gallstone disease and ductal calculi. Surg Endosc. 1999;13:952–957. 39. Rhodes M, Sussman L, Cohen L, et al. Randomised trial of laparoscopic exploration of common bile duct versus postoperative endoscopic retrograde cholangiography for common bile duct stones. Lancet. 1998;351:159–161. 40. Sgourakis G, Karaliotas K. Laparoscopic common bile duct exploration and cholecystectomy versus endoscopic stone extraction and laparoscopic cholecystectomy for choledocholithiasis. A prospective randomized study. Minerva Chir. 2002;57:467–474. 41. Weinberg BM, Shindy W, Lo S. Endoscopic balloon sphincter dilation (sphincteroplasty) versus sphincterotomy for common bile duct stones. Cochrane Database Syst Rev. 2006;4:CD004890. 42. Keizman D, Ish Shalom M, Konikoff FM. Recurrent symptomatic common bile duct stones after endoscopic stone extraction in elderly patients. Gastrointest Endosc. 2006;64:60–65.
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43. Maxton DG, Tweedle DE, Martin DF. Retained common bile duct stones after endoscopic sphincterotomy: temporary and longterm treatment with biliary stenting. Gut. 1995;36:446–449. 44. Han J, Moon JH, Koo HC, et al. Effect of biliary stenting combined with ursodeoxycholic acid and terpene treatment on retained common bile duct stones in elderly patients: a multicenter study. Am J Gastroenterol. 2009;104:2418–2421. 45. Lauri A, Davidson BR, Horton R, et al. Longterm follow-up of biliary stents for retained common bile duct stones in elderly patients. J R Coll Surg Edinb. 1995;40:42–45. 46. Gronroos JM. Clinical success of ERCP procedures in nonagenarian patients with bile duct stones. Minim Invasive Ther Allied Technol. 2011;20:146–149. 47. Glomsaker T, Soreide K, Hoff G, et al. Contemporary use of endoscopic retrograde cholangiopancreatography (ERCP): a Norwegian prospective, multicenter study. Scand J Gastroenterol. 2011;46:1144–1151. 48. Stromberg C, Nilsson M. Nationwide study of the treatment of common bile duct stones in Sweden between 1965 and 2009. Br J Surg. 2011;98:1766–1774. 49. Jafri SM, Monkemuller K, Lukens FJ. Endoscopy in the elderly: a review of the efficacy and safety of colonoscopy, esophagogastroduodenoscopy, and endoscopic retrograde cholangiopancreatography. J Clin Gastroenterol. 2010; 44:161–166.
r
2014 Lippincott Williams & Wilkins
Laparoscopic Common Bile Duct Exploration in Elderly Patients: Is There Still a Difference? Pablo Parra-Membrives, PhD,*w Darı´o Martı´nez-Baena, MD,w Jose Manuel Lorente-Herce, MD,w and Javier Jime´nez-Vega, MDw
Purpose: Although surgery is frequently not the first treatment option in elderly patients diagnosed with common bile duct stones (CBDS) because of the fear of high morbidity and mortality rates, there are few data about the safety and efficacy of laparoscopic common bile duct exploration (LCBDE) in the elderly. Methods: From February 2004 to January 2012, 94 patients underwent LCBDE at our center. Data about sex, age, comorbidity, American Society of Anesthesiologists (ASA) score, conversion to open surgery and bile duct clearance rate, postoperative complications, need for reoperation, and mortality were analyzed comparing patients of age 70 or older (group A, n = 38) with patients aged under 70 (group B, n = 56). Results: Elderly patients had significantly more preoperative risk factors. Stone extraction was equally successful in both groups (89.5% in group A vs. 96.4% in group B, P = 0.176). Six patients developed medical complications (7.9% in group A vs. 5.4% in group B, P = 0.621). Surgical morbidity was equivalent for both groups (13.2% in group A vs. 10.7% in group B, P = 0.718). Four patients in each group experienced some grade of bile leakage. Three patients were reoperated (1 patient in group A because of a biliary peritonitis and 2 in group B after an intra-abdominal hemorrhage). There were no mortality cases directly related to surgery. Conclusions: This study reveals that LCBDE is safe in the elderly patients and results are not different from those described in the general population. Patients with choledocholithiasis should be offered to undergo an LCBDE irrespective of their age at diagnosis. Key Words: laparoscopic surgery, common bile duct stones, elderly patients
(Surg Laparosc Endosc Percutan Tech 2014;24:e118–e122)
E
lderly patients are traditionally classified as fragile patients. In addition, increasing age is correlated with a more morbid status. As a result of their underlying diseases, they frequently receive anticoagulant therapy, or have a poor pulmonary or heart condition to affront a safe surgical procedure. Conversely, this issue is frequently advocated to justify a less aggressive approach and even to support a wait-and-see policy for different health problems. Choledocholithiasis, which is common among elderly patients, is one of those diseases in which different management
Received for publication October 27, 2012; accepted December 10, 2012. From the *Department of Surgery, University of Seville; and wHepatobilio-pancreatic Surgery Unit, General and Digestive Surgery Department, Valme University Hospital, Sevilla, Spain. The authors declare no conflicts of interest. Reprints: Pablo Parra-Membrives, PhD, C/Rubi 35, 41927 Mairena del Aljarafe, Sevilla, Spain (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
e118 | www.surgical-laparoscopy.com
options have been proposed in order to relieve surgery as a secondary treatment option because of its potential risk in elderly patients.1–4 The state-of-the-art treatment of common bile duct stones (CBDS) in the general population is not well defined. The literature has well documented that either the 2-stage strategy with endoscopic bile duct clearance and subsequent laparoscopic cholecystectomy (LC) or the surgery alone approach performing a laparoscopic common bile duct exploration (LCBDE) are both equivalent in terms of efficacy in bile duct clearance and associated morbidity.5–12 However, the management of CBDS in elderly patients usually includes the endoscopic approach as the first choice achieving a success rate of >80%4,13–16 relieving surgery for emergency treatment of septic patients with suppurative cholangitis, or as a second line option after endoscopic bile duct clearance failure. Despite this, since minimal invasive surgery has replaced open surgery, the elderly population has been reconsidered for surgical management of their gallstone disease. LC has revealed to be safe in elderly patients though increased conversion rate and morbidity have been reported.17,18 However, there are few data about the safety and efficacy of LCBDE in these patients. The aim of this study is to analyze the value of the laparoscopic approach of choledocholithiasis in terms of bile duct clearance and postoperative morbidity rates in elderly patients.
MATERIALS AND METHODS From February 2004 to January 2012, 94 patients underwent LCBDE at our center. The management policy of our institution for CBDS includes LCBDE for all patients that are diagnosed with choledocholithiasis and are fit for surgery. Only patients without a dilated common bile duct (CBD; 0.05). The elderly patients group had significantly more preoperative risk factors (Table 1). Pulmonary diseases, arterial hypertension, diabetes mellitus, previous abdominal surgery, and antiaggregant therapy was more frequent in group A. The preoperative calculated anesthetic risk (ASA score) was also significantly increased in the elderly. Patients presented with similar symptoms in both groups (Table 2). Only incidence of pain was more frequent in the aging patients group. Conversion rate was not different in both groups (10.5% in group A vs. 8.9% in group B, P = 0.796). There was only a single case of transcystic approach in each group. All other patients underwent a choledochotomy for CBDS removal. There was no difference in average number of extracted CBDS (2.4 ± 2.1 in group A vs. 3.5 ± 7.2 in group B, P = 0.764). Both groups had a similar low incidence of ampullaryimpacted stones (5.3% in group A vs. 8.9% in group B, P = 0.506) and of intrahepatic stones (5.3% in group A vs. 7.1% in group B, P = 0.714). LCBDE was successful in r
2014 Lippincott Williams & Wilkins
Laparoscopic Common Bile Duct Exploration in the Elderly
TABLE 1. Preoperative Risk Factors
Variables
Elderly Patients (n = 38)
General Population (n = 56)
P
7 7 30 5 12 6 12 0 12
9 3 14 6 4 9 7 1 8
0.157 0.044 > 0.0005 0.718 0.002 0.971 0.016 0.408 0.044
0 18 18 2
15 27 13 2
Heart diseases Pulmonary diseases Arterial hypertension Liver diseases Diabetes mellitus Obesity Antiaggregant therapy Anticoagulant therapy Previous abdominal surgery ASA risk score ASA 1 ASA 2 ASA 3 ASA 4
0.002
ASA indicates American Society of Anesthesiologists.
both groups with a high bile duct clearance rate (89.5% in the elderly patients vs. 96.4% in the general population, P = 0.176). Most of the patients received a T-tube insertion for bile duct closure in both groups (23 patients in group A and 34 patients in group B). Further 14 patients in group A and 20 in group B underwent antegrade stenting before choledochotomy was closed. A choledochoduodenostomy was performed in a patient who was converted to open surgery in group B. The incidence of patients affected with complications after surgery was not different in both groups. Only few patients developed medical complications (7.9% in group A vs. 5.4% in group B). Among surgical complications, 4 patients in each group experienced some grade of bile leakage from the bile duct closure. There were 2 patients in the general population group who suffered an intra-abdominal hemorrhage and had to be reoperated. A further patient in group A underwent a reintervention because of a biliary peritonitis. Two patients of the younger patients group received a percutaneous drainage because of an intra-abdominal abscess. There was a patient in the
TABLE 2. Clinical Presentation
Variables Jaundice Pain Pancreatitis Fever Dyspepsia Intraoperative diagnosis of CBDS Asymptomatic Cholecystitis
Elderly Patients (n = 38), n (%)
General Population (n = 56), n (%)
20 36 7 11 5 5
32 44 7 15 5 4
(52.6) (94.7) (18.4) (28.9) (13.2) (13.2)
1 (2.6) 8 (21.1)
P
(57.1) (78.6) (12.5) (26.8) (8.9) (7.1)
0.66 0.031 0.429 0.818 0.514 0.454
5 (8.9) 9 (16.1)
0.233 0.591
CBDS indicates common bile duct stones.
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elderly group who was readmitted to the hospital because of a pancreatitis caused by a stent migration obstructing the pancreatic duct. Biliary complications after tube removal in the patients that had a T-tube inserted for bile duct closure (Table 3) were also not different when both groups were compared. There were no mortality cases directly related to surgery, but 1 patient with a remnant stone in group B who underwent an ERCP developed a severe pancreatitis that finally caused her decease.
DISCUSSION Life expectancy has been prolonged and there is a general increase of elderly population that is frequently charged with serious comorbid diseases. Therefore, the physicians have to frequently deal not only with the present clinical problem itself, but also with all the associated diseases and a decline in physical activity that makes taking clinical decisions more challenging and hazardous. Elderly patients are considered to be particularly prone to morbidity and mortality; consequently, the role of surgery in the management of CBDS in this group of patients has been a matter of debate. Although biliary surgery was considered in the past the commonest abdominal operation performed in aging patients14,31,32 since the onset of endoscopic explorations, ERCP with ES has been increasingly
TABLE 3. Postoperative Morbidity
Variables Patients with complications (overall)* Patients with medical complications* Arrhythmia Pleural effusion Respiratory failure Deep vein thrombosis Acute renal failure Upper gastrointestinal bleeding Patients with surgical complications* Bile leakage Biloma Biliary peritonitis Intra-abdominal hemorrhage Pancreatitis Intra-abdominal abscess Reintervention Patients with T-tube removal–related complications* Bile leakage Biloma Biliary peritonitis
Elderly Patients (n = 38), n (%)
General Population (n = 56), n (%)
P
8 (21.1)
11 (19.6)
0.867
3 (7.9)
3 (5.4)
0.621
1 (2.6) 0 1 (2.6) 1 (2.6) 0 1 (2.6)
0 1 1 (1.8) 0 1 0
0.222 0.408 0.780 0.222 0.408 0.222
5 (13.2)
6 (10.7)
0.718
3 (7.9) 0 1 (2.6) 0
3 (5.4) 1 (1.8) 0 2 (3.6)
0.147 0.408 0.222 0.239
1 (2.6) 0
0 3
0.222 0.147
1 (2.6) 3 (7.9)
2 (3.6) 4 (7.1)
0.799 0.371
1 (2.6) 0 1 (2.6)
1 (1.8) 2 (3.6) 2 (3.6)
0.780 0.239 0.799
*Number of patients affected with complications. Incidence of each complication type is listed. More than 1 complication type present in some patients.
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indicated for CBDS extraction.3,4,14 Endoscopic management has been regarded as less invasive than surgery and is considered at present as the treatment of choice for choledocholithiasis in elderly patients. After CBDS removal, it has been even suggested not to perform an LC in aging patients in order to diminish potential morbidity.33 However, although the wait-and-see policy avoids two thirds of all LC after ERCP in the elderly population, the remaining patients may need surgery for gallbladder removal to treat biliary-related events with poorer results when compared with the sequential approach (ES followed by elective LC). Conversely, cholecystectomy after endoscopic extraction of CBDS should be strongly recommended even in elderly patients.34,35 Given that LC has proven to be safe in the elderly population,36,37 the next question is if LCBDE should be offered to aging patients with CBDS as a 1-stage approach. Although several studies have shown that ERCP and ES before, during, or after LC and the laparoscopic surgery 1-stage approach have both similar efficacy in terms of bile duct clearance and associated morbidity,5,10,12,38 whether both strategies are equivalent in the elderly population has not been proven. Our study reveals that a high bile duct clearance rate with acceptable morbidity, not different from the success rate in the general population, is possible in aging patients. Therefore, LCBDE should be offered also to elderly patients as a primary treatment option for CBDS and not only as a therapy of last resort when other treatment modalities have failed. Though expert endoscopy centers may report a very high success rate, many institutions achieve a bile duct clearance rate of slightly above 80%,10,13,38–41 which leaves nearly 15% to 20% of patients that will need further treatment options. In addition, recurrence of symptomatic CBDS after endoscopic therapy is more frequent in the elderly and counts for 20% of all successfully treated patients, whereas only 4% of the general population is charged with recurrent CBDS.42 Different therapeutic strategies have been proposed to deal with CBD that are not suitable for endoscopic removal or that remain in the biliary tree after sphincterotomy. The use of bile duct stenting with or without the addition of choleretic agents, endoscopic papillary balloon dilatation, or even intraductal lithotripsy has been reported with a high success rate.1–3,43–45 However, these strategies have not been generalized and surgery may be necessary for failed endoscopic extraction of CBDS and has proven to be safe in elderly patients in the case of the open surgery approach.32 Our study shows that LCBDE may be carried out in safe conditions as well. In addition, our clearance rate is similar or even higher to those reported for the endoscopic approach in the elderly or in the general population.2,46–49 A recent large retrospective review revealed that repeated biliary interventions within 90 days of the first procedure were significantly higher after an endoscopic clearance attempt than after LCBDE and that biliary reinterventions within this period were charged with a 14-fold increased risk of death.48 Thus, given that it is of paramount importance that the first treatment choice allows to achieve CBDS extraction successfully without the need for further procedures, that the clearance rates of LCBDE are as good as endoscopic ones or even better, considering that there is an important rate of CBDS recurrence in elderly patients after endoscopic treatment and, at last, taking into account that LC after bile duct clearance is strongly recommended even in the elderly as stated above, only safety of LCBDE may r
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be questioned before it can be declared that the laparoscopic approach could be the treatment of choice for CBDS even in aging people. Hence, our study reveals that the procedure is safe and that the morbidity rates are not different from those described in the general population. We suggest that only a poor performance status should preclude LCBDE in elderly patients. Centers with experience with the laparoscopic approach should offer aging patients with CBDS to undergo an LCBDE at the same manner they usually offer it to younger patients, as excluding elderly patients with CBDS for surgery should not be a dogma anymore.
CONCLUSIONS Our study reveals that LCBDE is safe in the elderly patients and results are not different from those described in the general population. Patients with choledocholithiasis should be offered to undergo an LCBDE irrespective of their age at diagnosis. REFERENCES 1. Lee TH, Han JH, Kim HJ, et al. Is the addition of choleretic agents in multiple double-pigtail biliary stents effective for difficult common bile duct stones in elderly patients? A prospective, multicenter study. Gastrointest Endosc. 2011; 74:96–102. 2. Swahn F, Edlund G, Enochsson L, et al. Ten years of Swedish experience with intraductal electrohydraulic lithotripsy and laser lithotripsy for the treatment of difficult bile duct stones: an effective and safe option for octogenarians. Surg Endosc. 2010;24:1011–1016. 3. Ito Y, Tsujino T, Togawa O, et al. Endoscopic papillary balloon dilation for the management of bile duct stones in patients 85 years of age and older. Gastrointest Endosc. 2008; 68:477–482. 4. Ashton CE, McNabb WR, Wilkinson ML, et al. Endoscopic retrograde cholangiopancreatography in elderly patients. Age Ageing. 1998;27:683–688. 5. Tranter SE, Thompson MH. Comparison of endoscopic sphincterotomy and laparoscopic exploration of the common bile duct. Br J Surg. 2002;89:1495–1504. 6. >Heili MJ, Wintz NK, Fowler DL. Choledocholithiasis: endoscopic versus laparoscopic management. Am Surg. 1999; 65:135–138. 7. Rogers SJ, Cello JP, Horn JK, et al. Prospective randomized trial of LC + LCBDE versus ERCP/S + LC for common bile duct stone disease. Arch Surg. 2010;145:28–33. 8. Williams EJ, Green J, Beckingham I, et al. Guidelines on the management of common bile duct stones (CBDS). Gut. 2008;57:1004–1021. 9. Parra-Membrives P, Diaz-Gomez D, Vilegas-Portero R, et al. Appropriate management of common bile duct stones: a RAND Corporation/UCLA Appropriateness Method statistical analysis. Surg Endosc. 2010;24:1187–1194. 10. Martin DJ, Vernon DR, Toouli J. Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev. 2006;2:CD003327. 11. Noble H, Tranter S, Chesworth T, et al. A randomized, clinical trial to compare endoscopic sphincterotomy and subsequent laparoscopic cholecystectomy with primary laparoscopic bile duct exploration during cholecystectomy in higher risk patients with choledocholithiasis. J Laparoendosc Adv Surg Tech A. 2009;19:713–720. 12. Clayton ES, Connor S, Alexakis N, et al. Meta-analysis of endoscopy and surgery versus surgery alone for common bile duct stones with the gallbladder in situ. Br J Surg. 2006;93: 1185–1191. r
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43. Maxton DG, Tweedle DE, Martin DF. Retained common bile duct stones after endoscopic sphincterotomy: temporary and longterm treatment with biliary stenting. Gut. 1995;36:446–449. 44. Han J, Moon JH, Koo HC, et al. Effect of biliary stenting combined with ursodeoxycholic acid and terpene treatment on retained common bile duct stones in elderly patients: a multicenter study. Am J Gastroenterol. 2009;104:2418–2421. 45. Lauri A, Davidson BR, Horton R, et al. Longterm follow-up of biliary stents for retained common bile duct stones in elderly patients. J R Coll Surg Edinb. 1995;40:42–45. 46. Gronroos JM. Clinical success of ERCP procedures in nonagenarian patients with bile duct stones. Minim Invasive Ther Allied Technol. 2011;20:146–149. 47. Glomsaker T, Soreide K, Hoff G, et al. Contemporary use of endoscopic retrograde cholangiopancreatography (ERCP): a Norwegian prospective, multicenter study. Scand J Gastroenterol. 2011;46:1144–1151. 48. Stromberg C, Nilsson M. Nationwide study of the treatment of common bile duct stones in Sweden between 1965 and 2009. Br J Surg. 2011;98:1766–1774. 49. Jafri SM, Monkemuller K, Lukens FJ. Endoscopy in the elderly: a review of the efficacy and safety of colonoscopy, esophagogastroduodenoscopy, and endoscopic retrograde cholangiopancreatography. J Clin Gastroenterol. 2010; 44:161–166.
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