Original Paper

Received: October 22, 2010

Accepted after revision: January 17, 2011
Published online: May 4, 2011

Dig Surg 2011;28:205209

DOI: 10.1159/000324445

Elective Laparoscopic Cholecystectomy:

The Effect of Age on Conversions,
Complications and Long-Term Results
SvenLill a ArtoRantala a TeroVahlberg b JuhaM.Grnroos a,c

Departments of a Surgery, b Biostatistics and c Emergency, University of Turku, Turku, Finland

Key Words
Age Elderly Elective surgery Gallstones
Laparoscopic cholecystectomy

years, 83% 6574 years, 80% 675 years). Conclusion: Elective laparoscopic cholecystectomy is also a safe and feasible
operation with good long-term results in the elderly.
Copyright 2011 S. Karger AG, Basel

Abstract
Background/Aims: The purpose of the present study was to
analyze the appropriateness and long-term results of elective laparoscopic cholecystectomy in the treatment of gallstone disease in the elderly. Methods: We studied all elderly
(675 years) patients (n = 80) who underwent laparoscopic
cholecystectomy at our institution during the years 1992
2001. Two control groups (6574 years and !65 years) included the same amount of patients. For determining the longterm results, we asked the patients to specify their overall
satisfaction with the results of the procedure (very satisfied,
satisfied, no effect, worse). Results: There were no statistically significant differences in mean operative time (61, 65,
72 min) or conversions to open surgery (6, 11, 16%) between
the age groups (!65, 6574, 675 years). The mean hospitalization time (2.1, 3.3, 4.4 days) and complications (0, 11, 13%)
increased with the age of the patients. Neither severe complications nor mortality were encountered. The vast majority
of the patients were very satisfied or satisfied with the longterm results of the procedure in all age groups (97% !65

2011 S. Karger AG, Basel

02534886/11/02830205$38.00/0
Fax +41 61 306 12 34
E-Mail karger@karger.ch
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Introduction

Since gallstone disease is the most common cause of

acute abdomen in the elderly, the appropriate treatment
modality of gallstones is of utmost importance in this patient population and remains perhaps the most common
clinical problem in geriatric gastrointestinal surgery. In
addition, as our population ages, the challenge for expedient surgical intervention in older age groups will become more and more significant, particularly in common diseases such as gallstone disease [1, 2] and acute
appendicitis [3]. According to the web pages of Statistics
Finland, the proportion of elderly in the Finnish population will grow twofold during the next quarter century [4].
In general, laparoscopic cholecystectomy is at present
the treatment of choice for symptomatic uncomplicated
gallstone disease, supported by a huge number of publications in the literature. How is it with the elderly, though?
Dr. Juha M. Grnroos
Department of Surgery
University of Turku, PB 52
FI20521 Turku (Finland)
Tel. +358 2 2313 0247, E-Mail juha.gronroos@tyks.fi

Table 1. Characteristics of the three age groups of patients (n = 80 in each group) scheduled to undergo laparoscopic cholecystectomy

Females/males, n (%)
Mean BMI 8 SD
Operated earlier, n (%)
Upper abdomen
Lower abdomen
Comorbidity, n (%)
Main preoperative symptom, n (%)
Biliary colic
Unspecific
Complicated disease

<65 years

6574 years

75 years

67 (84)/13 (16)
25.983.4
43 (54)
0
43
25 (31)

67 (84)/13 (16)
26.384.5
50 (63)
3
47
50 (63)

67 (84)/13 (16)
25.684.5
37 (47)
2
35
62 (78)

33 (41)
39 (49)
8 (10)

In the literature, there are only case series published on

laparoscopic cholecystectomy performed in the elderly,
but no true comparative studies can be found of the effect
of age on the feasibility and safety of laparoscopic cholecystectomy. Similarly, we found no earlier studies on the
long-term results of laparoscopic cholecystectomy in the
elderly.
The purpose of the present study was to analyze the
appropriateness of elective laparoscopic cholecystectomy
in the treatment of gallstone disease in elderly patients by
determining the effect of age on the treatment results. In
addition to examining the effect of age on the feasibility
and safety, i.e. conversions and complications, of laparoscopic cholecystectomy, we conducted this study to clarify the long-term results of this procedure in the elderly
when compared to younger patients.

Methods
We studied all elective laparoscopic cholecystectomies performed in the Turku City Hospital for Surgery during the first 10
years (19922001) after the adoption of the laparoscopic method
of cholecystectomy at our hospital. A total of 1,101 patients (mean
age: 53 years, range: 1589 years, 876 females and 227 males) were
operated during the study period. In all cases, the diagnosis of
gallbladder stones had been made by ultrasonography.
The present study population comprised all patients aged 675
years (n = 80) at the time of the operation. For controls, we used
80 operated patients aged 6574 years and 80 operated patients
!65 years. As our study period began with the first laparoscopic
cholecystectomies at our institution and the team of surgeons remained relatively constant during the study period, the patients
could be matched for the learning curve of the surgeons by picking up corresponding controls whose operations were close in
time to the operations of the patients in the study group. The patient groups are characterized in table1. There was no significant
difference in the number of earlier operations between the three

206

Dig Surg 2011;28:205209

27 (34)
37 (46)
16 (20)

Overall p value
0.810
0.139
<0.001
0.018

21 (26)
34 (43)
25 (31)

age groups of patients, but the prevalence of comorbidities was

higher in the patients belonging to the older age groups. The most
usual symptoms which led to surgery were biliary colic and unspecific abdominal pain, both in less than half of the cases in all
groups. Patients with a history of cholecystitis, jaundice, cholangitis or biliary pancreatitis were included in the subgroup of patients with complicated disease.
Operative and hospitalization times, conversions to open surgery, intraoperative and postoperative complications, reoperations, rehospitalizations, mortalities, and long-term results of the
procedure were analyzed from patient records and by sending a
questionnaire to all patients in the three age groups a median of
7 years (range: 311) postoperatively. The patient records of all
patients were available, and the percentages of patients who returned the questionnaire were 84, 80 and 56% in the groups aged
!65 years, 6574 years and 675 years, respectively. For determining the long-term results, we asked the patients to specify their
overall satisfaction with the results of the procedure (very satisfied, satisfied, no effect, worse).
Statistical Analysis
All differences measured in the current study were overall differences comprising all three age groups. A Kruskal-Wallis test
was used to compare the differences in continuous variables between the age groups (!65, 6574, 675 years). Categorical variables were analyzed with a 2 or Fishers exact test. p ! 0.05 was
considered statistically significant. Statistical analyses were done
using SAS System for Windows, release 9.1.3 (SAS Institute Inc.,
Cary, N.C., USA).

Results

The data on operative and hospitalization times, conversions, intraoperative and postoperative complications,
reoperations, rehospitalizations and mortalities in the age
groups are presented in table2. There were no statistically
significant differences in mean duration of operations (61,
65, 72 min) or conversion rate to open surgery (6, 11, 16%)
Lill /Rantala /Vahlberg /Grnroos

Table 2. Operative and hospitalization times, conversions to open surgery, intra- and postoperative complica-

tions, reoperations, rehospitalizations and mortality in the three age groups of patients (n = 80 in each group)
who underwent laparoscopic cholecystectomy

Mean operative time 8 SD, min

Mean hospitalization 8 SD, days
Conversions, n (%), due to
Anatomy
Bleeding
Bile duct stone
Malignancy
Insufflation failure
Biliary fistula
Complications, n (%)
Infections
Bleeding
Pulmonary embolism
Bile duct injury
Reoperation, n (%)
Rehospitalization, n (%)
Mortality, n

<65 years

6574 years

75 years

61823
2.181.4
5 (6)
4
0
1
0
0
0
0 (0)
0
0
0
0
0
0
0

65823
3.382.4
9 (11)
4
3
0
1
1
0
9 (11)
7
1
1
0
0
3 (4)
0

72835
4.483.4
13 (16)
11
1
0
0
0
1
10 (13)
6
4
0
0
2 (3)
3 (4)
0

Overall p value
0.139
<0.001
0.135

0.006

0.331
0.252

between the age groups. Unclear anatomy was the most

common reason leading to conversion in all age groups.
The hospitalization time (2.1, 3.3, 4.4 days) and complication rate (0, 11, 13%) increased with patient age. No
complications occurred in patients !65 years. In older
patients, infectious complications were the most common complications encountered. There were neither severe complications, such as bile duct injuries, nor mortality in any of the age groups, and only a small minority of
the patients, including the elderly, had to be reoperated or
rehospitalized afterwards.
The long-term results of laparoscopic cholecystectomy
were good in all three age groups (table3). In the group
of patients !65 years, 97% of the patients were very satisfied or satisfied with the long-term results of the procedure. Even though the vast majority (83 and 80%) of the
patients in the two groups of older patients were very satisfied or satisfied with the long-term results of the procedure, the satisfaction of the patients decreased slightly
with increased age. The recurrence of the preoperative
symptoms occurred in 28, 32 and 28% of the patients in
the age groups !65 years, 6574 years and 675 years,
respectively. In the same age groups, an endoscopic retrograde cholangiopancreatography procedure or a magnetic resonance cholangiopancreatography was performed postoperatively in 3, 6 and 12%, and common bile
duct stones were found in 0, 5 and 6% of the patients.

Table 3. Long-term results of laparoscopic cholecystectomy in the

three age groups of patients

Elective Laparoscopic Cholecystectomy

and Age

Dig Surg 2011;28:205209

Years
<65

6574

75

50 (75)
15 (22)
1 (1)
1 (1)

36 (56)
17 (27)
9 (14)
2 (3)

25 (56)
11 (24)
7 (16)
2 (4)

Overall
p value
0.037

Very satisfied, n (%)

Satisfied, n (%)
No effect, n (%)
Worse, n (%)

67 out of 80 patients aged <65 years, 64/80 patients aged 6574

years and 45/80 patients aged 75 years returned the questionnaire.

Discussion

The purpose of the present study was to analyze the

feasibility, safety and long-term results of elective laparoscopic cholecystectomy in the treatment of gallstone disease in elderly patients. We found that although complications were more frequent in elderly patients undergoing
laparoscopic cholecystectomy than in younger patients,
all complications were mild and the recovery uneventful.
In addition, there was no mortality, and the vast majority
207

of the elderly patients were satisfied with the long-term

results of the procedure. Therefore, in elderly patients
suffering from symptomatic gallstone disease, elective
laparoscopic cholecystectomy is a safe and feasible operation with good long-term results.
Understanding and filling in long and sophisticated
questionnaires can be difficult for aged patients. In order
to get a higher response rate, we decided to use a simple
4-grade scale (very satisfied, satisfied, no effect, worse) to
study the overall satisfaction of the patients with the results of the procedure. Even though there are weaknesses
in such kinds of simplified methods of evaluating the
long-term results of laparoscopic cholecystectomy, we
find that the information obtained in the current study is
reliable.
A meta-analysis has been published on the feasibility
of laparoscopic procedures in the elderly [1]. It was concluded that despite underlying comorbidities, individuals
165 years tolerate laparoscopic procedures extremely
well and complications and hospitalization are lower
than in open procedures. Bingener et al. [2] studied elderly patients scheduled for laparoscopic cholecystectomy and concluded that laparoscopic cholecystectomy is
the gold standard in gallstone disease for people in their
golden years, although patients older than 70 years had a
twofold increase in conversion rate, and the mortality
rate was 2%. Conversion rates of 4, 7 and 12% [57], complication rates of 18 and 19% [68], and mortality rates of
2, 0 and 0% [57] have also been reported in elderly patients scheduled for laparoscopic cholecystectomy because of symptomatic gallstone disease. These figures are
fairly well in accordance with the results of the current
study. The rates of postoperative infectious complications
without routine antibiotic prophylaxis (ABP) were 9 and
7% in the two older age groups and 0% among the younger controls in our study. In several meta-analyses, it has
been shown that routine ABP is not warranted in low-risk
patients in elective laparoscopic cholecystectomy [911],
but so far there have been no randomized controlled
studies to assess the role of ABP in high-risk patients (age
160 years, acute cholecystitis, recent history of acute cholecystitis, bile duct stones, jaundice, immune suppression, prosthetic implants, obesity). The results of the current study seem to support the view of routine ABP in
elderly patients in elective laparoscopic cholecystectomy.
The vast majority of our patients, including the elderly, were very satisfied or satisfied with the long-term results of laparoscopic cholecystectomy. In the literature,
we found no earlier studies on the long-term results of
laparoscopic cholecystectomy in the elderly. Further208

Dig Surg 2011;28:205209

more, the number of elderly patients undergoing elective

laparoscopic cholecystectomy has been relatively low in
the earlier studies (n = 49 patients [2], 35 patients [5], 29
patients [6], 16 patients [7] and 17 patients [8]) when compared with the current study (80 patients). Moreover, in
two of the earlier studies [6, 7], no control groups were
included, and in the remaining three studies [2, 5, 8], the
controls were matched neither for the sex of the patients
nor for the learning curve of the surgeons, indicating that
the former studies have mainly been case series, and not
true comparative studies, by their nature.
The role of the laparoscopic method of cholecystectomy in elderly patients with acute cholecystitis is controversial. In a prospective randomized study from France
[12], laparoscopic cholecystectomy was better than open
cholecystectomy, based on lower mortality and hospitalization. Similar results on the superiority of the laparoscopic method in acute cholecystitis in the elderly were
reported in a retrospective comparative study from Hong
Kong, based on lower morbidity and hospitalization [13].
On the contrary, the results of a retrospective comparative study from The United States [7] suggested that laparoscopic cholecystectomy has no benefit over open cholecystectomy in acute cholecystitis in the elderly population. Instead, the morbidity and mortality were even
higher after laparoscopic cholecystectomy than after
open procedure. Our current study did not contain patients with acute cholecystitis.
In the present study, the operative time and conversion
rate to open surgery had a tendency although the difference was not statistically significant to increase in
concert with the increase in the age of the patients, which
may be due to the larger amount of complicated disease
such as chronic cholecystitis in the elderly [2, 6, 14], making the dissection of the triangle of Calot and layers in
and around the gallbladder more difficult. Therefore,
early surgical intervention is warranted in gallstone disease.
Neither mortality nor severe complications such as
bile duct injuries were encountered in the present study,
not even in the elderly. According to most reports, the
rate of iatrogenic bile duct injuries sustained during laparoscopic cholecystectomy remains as high as 1% if cystic
stump leakages are included in the numbers [1517]. Female gender has been reported to be a risk factor for severe bile duct injuries during laparoscopic cholecystectomy [18, 19]. In the present study population involving
elderly patients and their sex-matched controls, female
gender was overcrowded (201 females out of 240 patients)
since the majority of the elderly and patients with gallLill /Rantala /Vahlberg /Grnroos

stones are females. Recently, we analyzed the incidence

and treatment of the iatrogenic bile duct injuries sustained during laparoscopic cholecystectomy in our catchment area, which covers one tenth of all Finns [17]. We
found that the overall rate for injuries, including all minor injuries (cystic duct leaks and bile duct strictures),
was 0.9%; for major injuries alone the incidence was 0.4%.
In general, since its introduction in the late 1980s, laparoscopic cholecystectomy has become the treatment of
choice for gallstone disease. The present study indicates
that elective laparoscopic cholecystectomy is also a safe
and feasible operation with good long-term results in elderly patients. We believe that our current results are of
clinical importance since gallstone disease is the most
common cause of acute abdomen in the elderly. Our results support the view that, as a rule, the treatment of
symptomatic uncomplicated gallstone disease should be
active in the elderly as well, similarly as is the case in el-

derly with malignant diseases such as rectal cancer [20].

The patients should be scheduled for early laparoscopic
cholecystectomy to avoid complications of the disease. It
should be kept in mind, particularly as our population
ages, that the life expectancy at 75 years of age is still 12
years in women and 10 years in men, for example, in Finland [4].
In conclusion, elective laparoscopic cholecystectomy
is a safe and feasible operation with good long-term results in elderly patients. Surgeons need to inform primary care physicians and geriatricians of these findings to
encourage early referrals.

Disclosure Statement
The authors declare no conflicts of interest and that this research received no external funding.

References
1 Weber DM: Laparoscopic surgery: an excellent approach in elderly patients. Arch Surg
2003;138:10831088.
2 Bingener J, Richards ML, Schwesinger WH,
Strodel WE, Sirinek KR: Laparoscopic cholecystectomy for elderly patients: gold standard for golden years? Arch Surg 2003; 138:
531535.
3 Grnroos JM: Is there a role for leukocyte
and CRP measurements in the diagnosis of
acute appendicitis in the elderly? Maturitas
1999;31:255258.
4 Statistics Finland. www.stat.fi. 2009.
5 Majeski J: Laparoscopic cholecystectomy in
geriatric patients. Am J Surg 2004; 187: 747
750.
6 Hazzan D, Geron N, Golijanin D, Reissman
P, Shiloni E: Laparoscopic cholecystectomy
in octogenarians. Surg Endosc 2003;17:773
776.
7 Uecker J, Adams M, Skipper K, Dunn E:
Cholecystitis in the octogenarian: is laparoscopic cholecystectomy the best approach?
Am Surg 2001;67:637640.
8 Chang WT, Yu FJ, Hsieh MY, Huang MC,
Lee KT, Chen JS, Kuo KK, Chuang SC, Wang
SR, Ker CG: Laparoscopic cholecystectomy
in aged patients. Hepatogastroenterology
2009;56:950955.

Elective Laparoscopic Cholecystectomy

and Age

9 Al-Ghnaniem R, Benjamin IS, Patel AG: Meta-analysis suggests antibiotic prophylaxis is

not warranted in low-risk patients undergoing laparoscopic cholecystectomy. Br J Surg
2003;90:365366.
10 Choudhary A, Bechtold ML, Puli SR, Othman MO, Roy PK: Role of prophylactic antibiotics in laparoscopic cholecystectomy: a
meta-analysis. J Gastrointest Surg 2008; 12:
18471853.
11 Zhou H, Zhang J, Wang Q, Hu Z: Meta-analysis: antibiotic prophylaxis in elective laparoscopic cholecystectomy. Aliment Pharmacol Ther 2009;29:10861095.
12 Pessaux P, Regenet N, Tuech JJ, Rouge C,
Bergamaschi R, Arnaud JP: Laparoscopic
versus open cholecystectomy: a prospective
comparative study in the elderly with acute
cholecystitis. Surg Laparosc Endosc Percutan Tech 2001;11:252255.
13 Chau CH, Tang CN, Siu WT, Ha JP, Li
MK: Laparoscopic cholecystectomy versus
open cholecystectomy in elderly patients
with acute cholecystitis: retrospective study.
Hong Kong Med J 2002;8:394399.
14 Grnroos JM, Salminen P, Laine S, Gullichsen R: Feasibility of ERCP procedures in patients 90 years of age and older. J Clin Gastroenterol 2010;44:227228.

15 Adamsen S, Hansen OH, Funch-Jensen P,

Schulze S, Stage JG, Wara P: Bile duct injury
during laparoscopic cholecystectomy: a prospective nationwide series. J Am Coll Surg
1997;184:571578.
16 Krhenbuhl L, Sclabas G, Wente MN,
Schfer M, Schlumpf R, Buchler M: Incidence, risk factors, and prevention of biliary
tract injuries during laparoscopic cholecystectomy in Switzerland. World J Surg 2001;
25:13251330.
17 Karvonen J, Gullichsen R, Laine S, Salminen
P, Grnroos JM: Bile duct injuries during
laparoscopic cholecystectomy primary and
long-term results from a single institution.
Surg Endosc 2007; 21:10691073.
18 Grnroos JM, Hmlinen MT, Karvonen J,
Gullichsen R, Laine S: Is male gender a risk
factor for bile duct injury during laparoscopic cholecystectomy? Langenbecks Arch Surg
2003;388:261264.
19 Grnroos JM, Laine S, Salminen P, Karvonen J, Lavonius M, Gullichsen R: Female
gender may give rise to difficulties in endoscopic and laparoscopic biliary surgery. Surg
Endosc 2008; 22:27612762.
20 Varpe P, Huhtinen H, Rantala A, Grnroos J:
Age of the patient should not play a key role
in clinical decision making on the surgical
treatment of rectal cancer. Aging Clin Exp
Res 2010;22:4246.

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