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2010 Annual Meeting Abstracts

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Acute Cholecystitis in the Elderly. Is Cholecystectomy Necessary?
*Edward A McGillicuddy, *Kevin M Schuster, Kimberly A Davis, Walter E Longo
Yale University School of Medicine, New Haven, CT

Objective: Cholecystectomy is standard for acute cholecystitis (AC), but morbidity in the elderly may be high. We sought to characterize the management of AC in the elderly to define the outcomes of operative and long-term non-operative management.
Design: Retrospective data collection and analysis.
Setting: Urban, tertiary care center.
Patients: 475 patients over age 64 with AC, admitted from 1/2000-1/2010.
Interventions: None.
Main Outcome Measures: Demographics, presenting characteristics, and complications; univariate and multivariate analysis with logistic regression.
Results: 290 patients underwent cholecystectomy during the index admission. 59 of 290 (20.3%) required conversion to an open operation. In the operative group 58 patients experienced a total of 98 complications, including acute respiratory failure (N=27), myocardial infarction (N=18), pneumonia (N=16), and sepsis (N=15). ICU admission, clopidogrel use, new renal dysfunction, and peritonitis predicted complications. 185 patients were treated non-operatively with 67 undergoing percutaneous cholecystostomy. Multivariate predictors of non-operative management included admission to a medical service (p<0.001 OR 4.25 CI 2.66-6.80), ICU admission (p=0.048 OR 2.35 CI 1.01-5.47), non-ambulatory status (p=0.01 OR 2.57 CI 1.25-5.26), dementia (p=0.017 OR 2.46 CI 1.17-5.17), and elevated alkaline phosphatase (p=0.01 OR 1.86 CI 1.16-2.99). 35 non-operative patients underwent cholecystectomy during a subsequent admission, none for recurrent AC. Although the rate of conversion to an open operation (21% vs. 0%) was lower in the delayed surgery group, complications were similar (20% vs. 23%). There were no re-admissions for biliary tract symptoms in the remaining 150 non-operative patients.
Conclusions: Despite apparent selection of the best elderly candidates for cholecystectomy, post-operative morbidity is significant. Medical management, with interval cholecystectomy only for recurrent AC, may be appropriate therapy in selected patients.

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