Scientific letter
Recurrence of gallstone disease following non-surgical treatment of acute cholecystitis in the elderly population
Recurrencia de enfermedad biliar tras el tratamiento conservador de la colecistitis aguda en la población geriátrica
Ismael Mora-Guzmán
, Marcello Di Martino, Elena Martín-Pérez
Corresponding author
Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de La Princesa, Madrid, Spain
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The incidence of symptomatic cholelithiasis is close to 30% in the geriatric population, and it constitutes the main cause of abdominal pain at this age. A higher risk has been estimated for the development of complications related to biliary disease in this population, with a subsequent increase in morbidity with each new episode.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a> The aim of the present study was to analyse the results after the conservative treatment of acute cholecystitis (AC) in the elderly patient, and to determine the percentage of recurrence of biliary disease after the initial episode.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The study population consisted of all patients over 65 years of age with an initial AC episode with no history of previous symptomatic cholelithiasis who were admitted with conservative treatment after diagnosis in the Emergency Department. Patients admitted between January 2010 and June 2014, with a minimum follow-up of 2 years for possible recurrence of biliary disease (biliary colic, AC, choledocholithiasis, cholangitis, biliary pancreatitis) were included. Patients who were operated on or who died on the first admission were excluded. Epidemiological, clinical, therapeutic and progression variables were analysed.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Of the 177 patients admitted for a first AC episode in the study period, 45 cases were excluded: 35 for cholecystectomy during admission and 10 for death. The mean age was 81.8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>7.5 years, predominantly women (55.3%). Regarding comorbidity, 53.8% had a high Elixhauser index, with at least 3 or more associated diseases. Only 75% had antibiotic treatment and a percutaneous cholecystostomy was performed in 33 cases. Endoscopic retrograde cholangiopancreatography (ERCP) was associated in 16 patients (12.1%) with suspected choledocholithiasis.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Recurrence of disease was detected during follow-up in 29.5% (39) of patients. The median time to recurrence was 40.5 days (11.5–308.2), with 79.5% occurring within the first year. During the follow-up period, 66.7% had one episode of recurrence, 20.5%, 2 episodes, and 12.8%, 3 episodes or more. After recurrence, there was a cholecystectomy rate of 41%, 44% being emergency cases.</p><p id="par0025" class="elsevierStylePara elsevierViewall">When comparing patients according to the existence or not of recurrence, no significant differences were found according to sex, age or comorbidity index. Regarding the treatment of the first episode, no differences were found depending on the use or not of percutaneous cholecystectomy. There were significant differences in ERCP in cases with suspected choledocholithiasis, with recurrence in 32.7% (38) of patients without ERCP and in 6.2% (1) of those with ERCP (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.038).</p><p id="par0030" class="elsevierStylePara elsevierViewall">Laparoscopic cholecystectomy is the treatment of choice according to current guidelines for the treatment of mild or moderate AC during the first admission, ideally within the first 72<span class="elsevierStyleHsp" style=""></span>h of progression.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> In the era of minimally invasive surgery, it is possible to treat the disease more quickly and with less morbidity, especially in the elderly population. Although the safety and efficacy of surgery have been widely described,<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">4,5</span></a> a significant number of these patients are still following a conservative treatment. There is a 29% recurrence rate in our series, with 70% in the first 6 months. These figures agree with the rest of the series, which describe a recurrence rate slightly over 30% after the initial non-surgical treatment.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a> These recurrences will be associated with repeated visits to the Emergency Department and hospitalisation, with associated increases in morbidity and mortality rates and health costs.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> In selected cases of severity or non-intervention, percutaneous cholecystostomy may be useful, and the intervention can be performed on a scheduled basis weeks after the initial admission.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> In our series, the post-recurrence cholecystectomy ratio was 41%.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In conclusion, the conservative treatment of the first episode of AC in the elderly will have a significant percentage of recurrence, and laparoscopic cholecystectomy is recommended despite advanced age if the indication is present.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Mora-Guzmán I, Di Martino M, Martín-Pérez E. Recurrencia de enfermedad biliar tras el tratamiento conservador de la colecistitis aguda en la población geriátrica. Med Clin (Barc). 2017;148:570–571.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A population-based analysis of the clinical course of 10,304 patients with acute cholecystitis, discharged without cholecystectomy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "C. De Mestral" 1 => "O.D. Rotstein" 2 => "A. Laupacis" 3 => "J.S. Hoch" 4 => "B. Zagorski" 5 => "A.B. 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