Risk Factors in Surgical Treatment of Cholelithiasis in Elderly Patients

The research is dedicated to the analysis of risk factors and the improvement of surgical treatment outcomes for cholelithiasis and chronic calculous cholecystitis in patients of elderly (60-74 years) and senile (75-90 years) age. A comprehensive analysis of clinical data from patients treated at City Clinical Hospital No. 60 over the period from 1997 to 2006 was conducted. Special attention is given to the clinical features of cholelithiasis course in elderly and senile patients, assessment of local and general operative-anesthetic risk factors, and immunomorphological changes in the gallbladder wall and peripheral blood. Methods of preoperative preparation and postoperative management were developed that include correction of functional disorders and the application of lymphotropic therapy, which allows for the reduction of postoperative complication rates.

Surgical treatment of patients with cholelithiasis and calculous cholecystitis in elderly and senile age remains an urgent problem to this day (Savelyev V.S., 1999; Prudkov M.I., 2000; Galperin E.I., 2004; Shulutko A.M., 2004; Briskin B.S., 2006; Kiviluato I. et al., 1998; Lujani A., 1998).

According to various authors, 10-15% of the world's population suffer from cholelithiasis. More than 1 million cholecystectomies are performed worldwide annually. In Russia, up to 1 million people are diagnosed with this disease each year, and more than 110,000 cholecystectomies are performed. Both in our country and abroad, this operation remains the most frequently performed surgical intervention. Thus, the number of patients suffering from cholelithiasis and calculous cholecystitis remains quite large, especially in elderly and senile age (Pikovsky D.L., 1988; Danilov M.V., 1990; Ermolov A.S., 1996; Lazebnik L.B., 1999; Vetchev P.S. et al., 2003; Yarema I.V. et al., 2006; Adams A.K., 1987).

Patients of elderly (60-74 years) and senile (75-90 years) age constitute the largest portion of the total number of people seeking medical care from physicians of various specialties. Among most elderly and senile individuals, in addition to surgical conditions, there are also concomitant diseases of the cardiovascular, respiratory, digestive, endocrine, and other systems, which increase the risk of surgical intervention and anesthesia, as well as aggravate the condition of patients in the immediate postoperative period. All this increases the likelihood of unfavorable surgical outcomes by 2-3 times (Damir E.A. et al., 1966; Chadayev A.P. et al., 1989; Rudin E.P. et al., 1999).

Complicated course of cholelithiasis in elderly and senile age is observed in 30-40% of patients. Acute destructive cholecystitis is the most frequent complication (15-20%). Choledocholithiasis is detected in 15-33% of patients and often leads to such complications as mechanical jaundice (58.2-85%), cholangitis (23.6-50.6%), acute pancreatitis (7.6-8%), and papillary stenosis (3-5%). Treatment of complicated cholelithiasis is associated with a large number of postoperative complications and high mortality reaching 14-34%. (Korolev B.L. et al., 1983; Yarema I.V. et al., 2000; Dhadwani S.A., 2000; Briskin B.S., 2002; Shulutko A.M., 2002; Yakovenko I.Yu., 2003; Schafer M. et al., 1998)

The introduction of minimally invasive technologies in the treatment of cholelithiasis has largely contributed to favorable surgical outcomes. However, advanced age, severe concomitant diseases with the syndrome of "mutual aggravation," make surgical intervention poorly tolerated for these patients. This is evidenced by high rates of postoperative complications (5-30%) and mortality (3-10%). The level of postoperative mortality among patients over 70 years of age reaches 16%, which is several times higher than in any other age group (Struchkov V.I. et al., 1976; Dederer Yu.G., 1983; Kuzin M.I., 1988; Lutshevich O.E., 1995; Galperin E.I., 2000; Shimanko A.I., 2001; Oleynikov P.N., 2003; Dibirov M.D., 2004; Kulliffas S. et al., 1998).

Among patients of elderly and senile age, in more than half of cases, unfavorable outcomes are associated with changes in the cardiovascular, pulmonary, immune, and endocrine systems, which significantly increase the risk of surgery. Hidden insufficiency of the cardiovascular and other systems is a characteristic feature of patients of the older age group. With age, changes occur in coronary and cerebral blood flow, decreased myocardial contractility and cardiac output, which substantially limits the adaptive and reserve capabilities of patients. These disorders require special correction in the preoperative and postoperative periods.

Thus, the above dictates the necessity of searching for new approaches to improve the results of surgical treatment of patients of elderly and senile age.

The goal of the research is to improve the results of surgical treatment of cholelithiasis and chronic calculous cholecystitis in patients of elderly and senile age.

The tasks of the research:

1. To analyze the results of surgical treatment of patients with cholelithiasis and chronic calculous cholecystitis who were treated at City Clinical Hospital No. 60 over the period from 1997 to 2006.

2. To study the features of the clinical course of cholelithiasis and chronic calculous cholecystitis in patients of elderly and senile age.

3. To provide a systematic assessment of risk factors in surgical treatment of patients with cholelithiasis based on data on the clinical course of the disease, clinical-instrumental examination, and results of surgical treatment.

4. To study changes in local and general immunity in patients of elderly and senile age with cholelithiasis, based on data from immunomorphological examination of operative specimens of the gallbladder and immunological examination of blood.

5. To develop rational methods of preoperative preparation and postoperative management of patients of elderly and senile age, providing for the reduction of postoperative complications in surgical treatment of cholelithiasis.

The scientific novelty of the research lies in the fact that for the first time:

1. The features of the clinical picture and immune status of patients with cholelithiasis and chronic calculous cholecystitis in elderly and senile age were clarified.

2. The ASA (American Society of Anesthesiologists) severity classification was supplemented with an assessment of local and general operative risk factors in surgical treatment of cholelithiasis.

3. Age-related changes in diffuse lymphoid tissue and the structure of the lymphatic system of the gallbladder in patients with cholelithiasis and chronic calculous cholecystitis in elderly and senile age were studied.

4. A system of preparation and postoperative management of patients of elderly and senile age, taking into account the degree of functional disorders, was developed for planned surgical treatment of cholelithiasis.

Practical significance:

1. Criteria for preparation and selection of patients of elderly and senile age with cholelithiasis and chronic calculous cholecystitis for surgical treatment were summarized using the supplemented ASA classification.

2. A statistically reliable assessment of local and general risk factors in surgical treatment of cholelithiasis was provided based on clinical data.

3. The rationale for postoperative regional lymphotropic antibacterial therapy and general lymphotropic immunocorrective therapy in patients with cholelithiasis of elderly and senile age was demonstrated.

4. A method of intraoperative punctural catheterization of the round ligament of the liver during videolaparoscopic operations was developed.

Basic propositions to be defended:

1. In most patients of elderly and senile age, cholelithiasis manifests with a masked clinical picture and is characterized by a prolonged course (10 years or more), with the development of pronounced pathological changes of the gallbladder, surrounding tissues, and neighboring organs (empyema of the gallbladder, perivesical adhesive process, infiltration of the gallbladder, perivesical abscess, choledocholithiasis, Mirizzi syndrome, bilioenteric fistulas, stricture of the common bile duct).

2. In patients of elderly and senile age, against the background of a long-standing inflammatory process in cholelithiasis, destruction and obliteration of the structure of the lymphatic network of all layers of the gallbladder wall, destruction of diffuse lymphoid tissue and its surrounding framework, leading to impairment of immune competent cell function and phenomena of secondary local immunodeficiency, are observed.

3. In patients of elderly and senile age, against the background of involutional changes, the inflammatory process in cholelithiasis proceeds more aggressively than in younger patients. The combination of involutional and inflammatory changes leads to the development of pronounced general immunodeficiency.

4. Complications of cholelithiasis and chronic calculous cholecystitis, along with concomitant diseases manifesting as impairment of organ and system functions, are the main factors of operative-anesthetic risk directly affecting the outcome of surgical treatment.

5. A complex of measures including thorough patient examination, preoperative preparation, and postoperative regional lymphotropic antibacterial therapy combined with general lymphotropic immunocorrective therapy allows improvement of the results of surgical treatment of patients with cholelithiasis, reducing postoperative complications by more than two times.

Work presentation

The main provisions of the dissertation were reported at the X and XI annual international scientific-practical conferences "Elderly Patient. Quality of Life," Moscow, 2005, 2006; at the sixth and seventh annual scientific-practical conferences of polyclinic surgeons of Moscow and the Moscow Region "Problems of Ambulatory Surgery," Moscow, 2005, 2006; at the joint scientific conference of the Department of Hospital Surgery of MGMSU, the Department of Polyclinic Surgery and Rehabilitation of RMAPO, and the Scientific Department of Operative Surgery and Clinical Lymphology of RMAPO (2007).

Publications

7 scientific works on the topic of the dissertation have been published, including 3 articles in VAK-recommended medical journals.

Implementation of research results

The results of the dissertation work have been implemented in clinical practice in the treatment of patients with cholelithiasis and chronic calculous cholecystitis in surgical departments of City Clinical Hospital No. 60 of Moscow.

Volume and structure of the dissertation

The dissertation is presented in 149 pages of typed text. It consists of an introduction, 4 chapters, discussion, conclusion, findings, practical recommendations, and a list of references. Bibliographic data contain 160 domestic and 54 foreign sources of literature. The work is illustrated with 29 tables, 3 diagrams, and 10 figures.