Diagnostic Testing
In elderly patients, no single investigation is capable of establishing or excluding ACC without further testing. A combination of symptoms, signs, and laboratory tests results may have better diagnostic accuracy.
Abdominal ultrasonography (US) is the preferred initial imaging technique for elderly patients clinically suspected of having acute cholecystitis.
Data on the diagnostic accuracy of computed tomography (CT) are scarce. The accuracy of magnetic resonance imaging (MRI) may be comparable to that of abdominal US, but the data are insufficient to support this view. Hepatobiliary iminodiacetic acid (HIDA) scanning has the highest sensitivity and specificity, but scarce availability, long execution time, and radiation exposure limit its use.
Combining clinical, laboratory, and imaging investigations should be recommended, though the best combination is not yet known.
No high-quality studies on specific diagnostic findings of ACC in the elderly are available.
Pros vs Cons of Surgical Treatment
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 use of frailty scores for assessment
Specific risk (for individual patient or particular procedure); consider use of surgical clinical scores
Optimal Timing and Choice of Surgical Technique
A laparoscopic approach should always be attempted first, except in the case of absolute anesthetic contraindications or septic shock.
Laparoscopic cholecystectomy is safe and feasible in elderly patients, associated with a low complication rate and a shorter hospital stay.
Laparoscopic or open subtotal cholecystectomy is a valid option for advanced inflammation, gangrenous gallbladder, and "difficult gallbladder."
Conversion to open surgery may be predicted by fever, leukocytosis, elevated serum bilirubin, and extensive upper abdominal surgery. It should be considered in the setting of local severe inflammation, adhesions, bleeding in the Calot triangle, or suspected bile duct injury.
Laparoscopic cholecystectomy should be performed as soon as possible but can be performed up to 10 days after the onset of symptoms.
Percutaneous Cholecystostomy in Patients Unsuitable for Surgery
Percutaneous cholecystostomy can be considered in the treatment of ACC patients deemed unfit for surgery (>65 years, American Society of Anesthesiologists [ASA] class 3 or 4, performance status 3 to 4, septic shock).
When medical therapy has failed, percutaneous cholecystostomy should be considered as a bridge to cholecystectomy in acutely ill (high-risk) elderly patients deemed unfit for surgery to render them more suitable for surgery.
Percutaneous transhepatic cholecystostomy is the preferred method of performing percutaneous cholecystostomy.
The percutaneous cholecystostomy catheter should be removed 4-6 weeks after placement if a cholangiogram performed 2-3 weeks after cholecystostomy demonstrated biliary tree patency.
Management of Associated Biliary Tree Stones
Elevation of liver biochemical enzymes and/or bilirubin levels is not sufficient to identify patients with choledocholithiasis; further diagnostic tests are needed.
Visualization of common bile duct (CBD) stones on abdominal US is a very strong predictor of choledocholithiasis. Indirect signs of stone presence (eg, increased CBD diameter) are not sufficient to identify patients with choledocholithiasis; further diagnostic tests are needed.
Liver biochemical tests and abdominal US should be performed in all patients to assess the risk for CBD stones. CBD stone risk should be stratified according to a classification modified from American Society of Gastrointestinal Endoscopy (ASGE) and Society of American Gastrointestinal Endoscopic Surgeons (SAGES) guidelines.
Elderly patients at moderate risk for choledocholithiasis should be evaluated with preoperative magnetic resonance cholangiopancreatography (MRCP), endoscopic US, intraoperative cholangiography, or laparoscopic US, depending on local expertise and availability.
Elderly patients at high risk for choledocholithiasis should undergo preoperative endoscopic retrograde cholangiopancreatography (ERCP), intraoperative cholangiography, or laparoscopic US, depending on local expertise and availability.
CBD stones may be removed preoperatively, intraoperatively, or postoperatively in accordance with local expertise and availability.
Choice of Antibiotic Regimen
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, broad-spectrum antibiotic regimens are recommended; adequate empiric therapy significantly affects outcomes in critical elderly patients.
Microbiologic analysis is helpful for designing targeted therapeutic strategies for individual patients.
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