Nonoperative management of inflamed gallbladder may be best for elderly

By Sarah Guy, medwireNews Reporter

Medical rather than surgical management of acute cholecystitis (AC) - or inflamed gallbladder - may be the most appropriate option for elderly patients who may be unsuitable for surgery, report researchers.

Their study results show that despite selecting the healthiest elderly patients to be treated with a cholecystectomy, postoperative morbidity rates over 9 years at their institution were high.

By contrast, over half of the AC patients who were managed medically with antibiotic therapy or antibiotics with percutaneous cholecystostomy were free from recurrence of AC or other biliary tract complications during follow up.

"The increased medical comorbidities and decreased physiological reserve in the elderly necessitate careful patient selection for a potentially morbid procedure," say Kevin Schuster, from Yale University School of Medicine in New Haven, Connecticut, USA, and co-investigators.

"This finding suggests that antibiotic therapy (with or without cholecystostomy) may be not only necessary but sufficient for the treatment of AC in patients who are poor candidates for general anesthesia," they add.

A total of 475 patients with AC who fitted the study criteria presented at Yale New Haven hospital between 2000 and 2009, of whom 290 (61.1%) underwent cholecystectomy and 185 (38.9%) underwent nonoperative treatment.

The mean age of surgical patients was 76.9 years, which was not significantly different from the mean 80.0 years in the nonoperative group. However, patients in the latter group were more likely to be nonambulatory at presentation, be nursing home residents, and have dementia than their peers treated with surgery.

Among the surgically treated patients, 58 (20%) experienced 98 complications including acute respiratory failure and pneumonia, surgical-site infection, and retained stones.

Among patients treated nonoperatively, 67 underwent percutaneous cholecystostomy, with catheters remaining in place for a mean of 47 days, and 44 patients went on to have a planned cholecystectomy. None of these elective procedures were due to recurrent AC, and of the remaining 126 patients from this group, 91 (59% of all nonoperative patients) were followed up for a mean 30 months with no evidence of recurrence.

"Based on the present data, surgeons are probably selecting the healthiest possible cohort of elderly patients for surgical management," write Schuster et al in the British Journal of Surgery.

Despite this, "the complication rate is significant" and patients initially managed without surgery "may not suffer from the morbidity of recurrent AC," they add, suggesting that prospective randomized studies comparing operative and ongoing expectant management are justified.

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