Abstract

Background: Acute cholecystitis is a serious surgical emergency for elderly patients. strophe and dittensbaugh (1953) observed that all gall stones were found twice as often in the age group of over 70 years as compared to all groups. Several studies have also found that laparoscopic cholecystectomy (LC) is a safe and efficient treatment approach for acute cholecystitis compared with open cholecystectomy (OC). The role of LC in acute cholecystitis in elderly patients has yet to be defined. Advanced age with concomitant medical conditions may be associated with increased postoperative complications and more frequent conversion to OC.

But with improvement in preoperative care for ageing population the safety and feasibility of laparoscopic cholecystectomy in elderly patients with acute cholecystitis and its associated morbidity and mortality with respect to open cholecystectomy can be assessed which is the main goal of this prospective randomized study.

Aims: This prospective randomized study has been devised to evaluate complications of laparoscopic and open cholecystectomy in elderly patients with acute cholecystitis in terms of-

• Duration of procedure.
• Blood loss during surgery.
• Postoperative discomfort or pain.
• Requirements of antibiotics, analgesics and antiemetics.
• Complications encountered (intra and postoperative)
• Duration of hospitalization and rehabilitation.
• Conversion to open method.
• Patient satisfaction.

Materials and Methods: It is a prospective randomized study, total 50 patients (over 65 years with acute cholecystitis) underwent cholecystectomy from November 2015 to October 2017 in the department of general and laparoscopic surgery of V.S.S. medical college and hospital, Burla, Sambalpur, Odisha with best possible available resources. 25 cases underwent laparoscopic cholecystectomy and rest 25 had open cholecystectomy. Most of the cases were operated within 72 hours of attack of acute cholecystitis. patients written valid informed consent for the particular procedure was taken and the procedure were explained in details to the patient. this study was done after due clearance of ethical committee.

Result: Duration of surgery in laparoscopic group was bit more than open method (Mean= 1hr 53 minutes in LC vs mean = 1hr 50 minutes in OC). Blood loss was considerably high in open cholecystectomy group of patients.

Intravenous antibiotics coverage was given for more duration in open method (Mean= 7.2 days) than in laparoscopy group (Mean= 3.8 days). Postoperative pain in laparoscopy group was considerably less than open cholecystectomy as measured by visual analogue score. So days of analgesics required was also less in LC group (Mean = 1.44 days) than OC (Mean= 4 days). Antiemetics requirement was same in both the groups.

Resumption to enteral nutrition was early in laparoscopic method (Mean=2.6 days) than open method (Mean=5 days). Postoperative hospital stay was more in OC group (Mean=7.84 days) than LC group of patients (mean=4.48 days). Resumption to routine physical activities of the patients was also significantly early in laparoscopic method (Mean=7.8 days) than in open method (Mean=12.88 days).

Complications like CBD injury and bile leak were more in laparoscopic method whereas bleeding, Wound infection deterioration of pulmonary function were more in open method. But these complications as a whole are not significantly different in both the procedures, rather pulmonary dysfunction and wound infection increased the morbidity in old age.

Conversion rate from laparoscopy to open method was found to be 8% in our study, which was due to either large stone, empyema or with morbid adhesion of gallbladder to adjacent organs.

Cosmesis was considerably the best in laparoscopy group of patients than open group. Cost factors involved with both the procedures were at par with each other. There was no mortality in any group.

Conclusion: hSo laparoscopic cholecystectomy is better than open cholecystectomy in terms of blood loss during surgery, postoperative pain, requirement of antibiotics, analgesics, duration of hospitalization and rehabilitation and patient satisfaction. with all these advantages and a liberal attitude towards conversion to open method in proper time and proper patients considered as the gold standard for elderly patient with acute cholecystitis. however, open cholecystectomy is preferred method for surgeons in the beginning of their career and in case of difficult cholecystectomy.

Keywords: cholelithiasis, minimally invasive surgery, laparocopic cholecystectomy (LC), open cholecystectmy (OC), bile duct injuiry.