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294
S. de Franciscis and R. Serra
For the subgroup of patients with acute iliofemoral DVT and recently formed
thrombus (<10–14days), endovascular treatment options may also be considered
such as catheter-directed thrombolysis (CDT), pharmacomechanical catheterdirected thrombolysis (PCDT), percutaneous aspiration thrombectomy (PAT), vena
cava lter protection, venous balloon dilatation, and venous stent implantation.
Current practice shows strong clinical tendency for the use of PCDT with or without
other endovascular methods and an individualized approach for each DVT patient.
PCDT seems also to be the most promising interventional modality for prevention
of PTS.PCDT aims to improve early mechanical thrombus removal and promote
lysis of remaining clot.
Current guidelines from the American College of Chest Physicians suggest that
directed thrombolysis should be used in those with life expectancy >1year, good
functional status, extensive iliofemoral thrombosis, and presenting soon after the
onset of symptoms (fewer than 14days) (level 2B evidence) [20–25].
Acknowledgments The authors have no conict of interests to declare.
This chapter received no funding.
Authors’ Contribution
They both conceived the chapter, participated in its design, drafted, and revised it critically.
SdF and RS contributed equally to this work.
References
1. Serra R, Grande R, Butrico L, Fugetto F, de Franciscis S.Epidemiology, diagnosis and treat-
ment of chronic venous disease: a systematic review. Chirurgia. 2016;29(2):34–45.
2. Serra R, Buffone G, de Franciscis A, Mastrangelo D, Molinari V, Montemurro R, etal. A
genetic study of chronic venous insufciency. Ann Vasc Surg. 2012;26:636–42.
3. Robertson L, Evans C, Fowkes FG. Epidemiology of chronic venous disease. Phlebology.
2008;23:103–11.
4. Beebe-Dimmer JL, Pfeifer JR, Engle JS, Schottenfeld D.The epidemiology of chronic venous
insufciency and varicose veins. Ann Epidemiol. 2005;15:175–84.
5. Eklöf B, Rutherford RB, Bergan JJ, Carpentier PH, Gloviczki P, Kistner RL, etal. Revision
of the CEAP classication for chronic venous disorders: consensus statement. J Vasc Surg.
2004;40:1248–52.
6. Serra R, Andreucci M, De Caridi G, Massara M, Mastroroberto P, de Franciscis S.Functional
chronic venous disease: a systematic review. Phlebology. 2017;1:268355516686451. https://
doi.org/10.1177/0268355516686451. [Epub ahead of print].
7. O’Hare JL, Earnshaw JJ.Practical advice for the treatment of venous disease in the elderly.
Phlebology. 2008;23(3):101–2.
8. Etufugh CN, Phillips TJ.Venous ulcers. Clin Dermatol. 2007;25(1):121–30.
9. Canonico S, Campitiello F, Pacico F, Sepe D, Lauletta V.Day care surgery of varicose veins
in elderly patients. Vasc Surg. 1996;30(5):387–92.
10. de Franciscis S, Gasbarro V, Amato B, Buffone G, Grande R, Serra R.Hemodynamic surgery
versus conventional surgery in chronic venous disease: a multicenter retrospective study. Acta
Phlebologica. 2013;14:109–14.
11. Serra R, Gasbarro V, Barbetta A, De Caridi G, Massara M, Perri P, Ciranni S, Torcia G,
Abatucci G, Andreucci M, Buffone G, de Franciscis S.Endovenous radiofrequency ablation
of tributary veins reux. Acta Phlebologica. 2016;17:61–3.
12. Müller R. Traitement des varices par la phlebéctomie ambulatoire. Bull Soc Fr Phléb.
1966;19:277–9.
19 Venous Disorders oftheLeg
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
295
13. Francheschi C.Thèorie et pratique de la cure conservatrice de l’insusance veineuse en ambu-
latoire. Précy-sous- Thil: Editions de l’Armancon; 1988.
14. Solis JV, Ribè L, Portero JL, Rio J.Stripping saphenectomy, CHIVA and laser ablation for the
treatment of the saphenous vein insufciency. Ambul Surg. 2009;15:11–4.
15. Onida S, Davies AH. CHIVA, ASVAL and related techniques—concepts and evidence.
Phlebology. 2015;30(2 Suppl):42–5.
16. Jaworucka-Kaczorowska A, Oszkinis G, Huber J, Wiertel-Krawczuk A, Gabor E, Kaczorowski
P. Saphenous vein stripping surgical technique and frequency of saphenous nerve injury.
Phlebology. 2015;30(3):210–6.
17. Lam H, Chao L.Endovascular ablation therapies for varicose veins in elderly patients. Int J
Gerontol. 2014;8:219–22.
18. Serra R, Rizzuto A, Rossi A, Perri P, Barbetta A, Abdalla K, Caroleo S, Longo C, Amantea B,
Sammarco G, de Franciscis S.Skin grafting for the treatment of chronic leg ulcers– a systematic review in evidence-based medicine. Int Wound J. 2017;14:149–57.
19. Carpentier PH, Becker F, Thiney G, Poensin D, Satger B.Acceptability and practicability of
elastic compression stockings in the elderly: a randomized controlled evaluation. Phlebology.
2011;26(3):107–13.
20. Silverstein RL, Bauer KA, Cushman M, Esmon CT, Ershler WB, Tracy RP.Venous thrombosis
in the elderly: more questions than answers. Blood. 2007;110(9):3097–101.
21. Prandoni P.Treatment of patients with acute deep vein thrombosis and/or pulmonary embo-
lism: efcacy and safety of non-VKA oral anticoagulants in selected populations. Thromb
Res. 2014;134(2):227–33.
22. Rabinovich A, Kahn SR. The postthrombotic syndrome: current evidence and future chal-
lenges. J Thromb Haemost. 2017;15(2):230–41. https://doi.org/10.1111/jth.13569. [Epub
ahead of print].
23. Goktay AY, Senturk C.Endovascular treatment of thrombosis and embolism. Adv Exp Med
Biol. 2017;906:195–213.
24. Kuo TT, Huang CY, Hsu CP, Lee CY.Catheter-directed thrombolysis and pharmacomechani-
cal thrombectomy improve midterm outcome in acute iliofemoral deep vein thrombosis. J
Chin Med Assoc. 2017;80(2):72–9.
25. Patterson BO, Hinchliffe R, Loftus IM, Thompson MM, Holt PJ.Indications for catheter-
directed thrombolysis in the management of acute proximal deep venous thrombosis.
Arterioscler Thromb Vasc Biol. 2010;30(4):669–74.
Part V
Hepato-Biliary System
Cholecystectomy inElderly: Challenge
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andCritical Analysis ofAvailable
20
Evidence
AlessandroPuzziello, DomenicoLandi,
FernandoVicinanza, GiuliaPacella, GiulioOrlando,
andIleana MariaLuppino
20.1 Introduction
The incidence of gallstone disease in the elderly population ranges from 14 to 27%.
The prevalence of gallstones increases with age. It ranges from 20 to 30% in patients
aged ≥60 years [1, 2], and according to several potentially high severity studies,
especially with patients presenting with complications, the prevalence increases to
80% in institutionalized individuals aged ≥90years [3]. One such complication is
acute cholecystitis, which is a frequent reason for an emergency presentation to
hospital. Surgery for cholelithiasis is more common in elderly patients since the
incidence of gallstones increases with age (13–50%). It is the higher frequency of
associated pathologies in patients older than 60years of age that can inuence the
type and effectiveness of treatment. In elderly patients, the optimal treatment of
acute cholecystitis remains controversial. Laparoscopic cholecystectomy (LC) is
the gold standard for the treatment of gallbladder stone disease. Even though laparoscopic cholecystectomy has become the gold standard for the treatment of gallbladder stones, its safety in elderly patients is still questioned [4–6]. In comparison
with the open approach, the advantages of this procedure include better cosmetic
results, less postoperative pain, shorter operative time, less intraoperative and postoperative complications and shorter postoperative hospital stay both in younger and
older people.
A. Puzziello (*) • D. Landi • F. Vicinanza • G. Pacella
General and Day Surgery Unit, AOU San Giovanni di Dio e Ruggi d’Aragona, Department of
Medicine Surgery and Dentistry, University of Salerno, Salerno, Italy
e-mail: apuzziello@unisa.it
G. Orlando
University Magna Graecia of Catanzaro, Catanzaro, Italy
I.M. Luppino
Gastroenterology and Endoscopy Unit, AO Annunziata, Cosenza, Italy
© Springer International Publishing AG, part of Springer Nature 2018
A. Crucitti (ed.), Surgical Management of Elderly Patients,
https://doi.org/10.1007/978-3-319-60861-7_20
299
300
This chapter considers the question of whether to recommend laparoscopic or
open cholecystectomy in elderly patients of over 70years of age. The most important points of the discussion are addressed.
A. Puzziello et al.
20.2 Discussion Points
The literature contains many criteria, none of which have led to the dening of an
agreed single cutoff age. The National Institute on Aging and the National Institute
of Health identify three age classes: “young old” (65–74years), “older (middle)
old” (75–85years) and “oldest old” (>85years). Census predictions indicate that
from 1995 to 2020, the percentage of the population aged 65years or older will
increase from 12.8 to 15%, those aged 75years or older will increase from 5.6 to
6.8% and those aged 85 years or older will increase from 1.4 to 2% [7].
Cholecystectomy is a common operation in ageing patients, due to the increasing
prevalence of gallstones in an increasingly older population [8, 9].
The laparoscopic approach to a cholecystectomy is standard. Their only opportunity to perform an open procedure is a simultaneous cholecystectomy, such as in
a total gastrectomy, a pancreatoduodenectomy, or major liver resections.
The only a priori indications for an open procedure are in the case of a suspected
malignant disease, gallbladder cancer or major anaesthesia restrictions, mostly
related to respiratory function during pneumoperitoneum.
20.3 Biliary Lithiasis
Biliary tract disorders are amongst the most common reasons for surgery in older
patients. Fifty percent of women and 16% of men in young old have been shown to
have gallbladder disease [10]. When bile duct stones are suspected, an MRCP (magnetic resonance cholangiopancreatography) is performed, which is a sensitive noninvasive and rather sensitive method. Once the biliary stones have been identied, the
use of Endoscopic Retrograde Cholangio Pancreatography (ERCP) allows the clearance of the principal bile duct. In the study carried out by Charfare etal., a preoperative ERCP was performed, and postoperatively retained stones were present in 1.2%
of these patients [11]. In another study by Collins etal. amongst 997 laparoscopic
cholecystectomy patients, clinically silent choledocholithiasis was present in 3.4%,
one-third of which were passed spontaneously within 6weeks of the operation [12].
The extremely elderly frequently present with several biliary diagnoses and complicated gallstone disease, which explains the higher rate of complications and mortality
usually seen in this age group [11–15].
The incidence of choledocholithiasis ranges from 5 to 10% in patients undergoing laparoscopic cholecystectomy for symptomatic cholelithiasis and from 18
to 33% of patients with acute biliary pancreatitis. The clinical presentation of
choledocholithiasis may vary widely, as up to half the cases of common bile duct
stones (CBDS) may be asymptomatic or associated with various symptoms and
conditions [16].
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301
Over the last 30years, the diagnosis and management of CBDS have radically
changed following the dramatic diffusion of imaging, including endoscopic ultrasound (EUS) and magnetic resonance cholangiography (MRC), endoscopy and laparoscopy. During the 2000s, a critical appraisal of management options [17, 18] and the
diffusion of new diagnostic examinations led to a more cautious, patient- tailored preoperative workup, based on patient risk of carrying CBDS, and management based on
the perception that CBDS [19, 20] may be treated in a multidisciplinary way.
The 2006 European Society for Endoscopic Surgery (EAES) guideline update justied an expectant attitude in elderly patients [21]. In 2008, the British Society of
Gastroenterology guidelines [22] recommended that whenever patients have symptoms and investigations suggest ductal stones, possible extraction should be performed;
the American Society for Gastrointestinal Endoscopy (ASGE) guidelines [23] incorporated those recommendations and proposes a stratication of patients according to the
risk for choledocholithiasis, thus inuencing subsequent management [23].
According to ASGE guidelines, cholangitis, total bilirubin >4mg/dL and common bile duct stone (CBDS) on US were considered very strong predictors. Total
bilirubin 1.8–4mg/dL and dilated CBD on US were considered strong predictors.
Abnormal liver biochemical tests, patients aged >55years and gallstone pancreatitis
were considered moderate predictors (Fig.20.1) [23].
A retrospective study conrms that the combination of choledocolithiasis predictors may improve risk estimation of choledocholithiasis and should be considered to
optimize patient selection for ERCP. However, even in the “high-risk group”, the
specicity was low (56.2%), meaning that a signicant proportion of patients will
still have an unnecessary ERCP [24].
There are two main approaches for patients with an intermediate to high risk of
carrying CBDS: on one hand, the “laparoscopy-rst” approach and on the other
hand, the “endoscopy-rst” approach [25].
Since no consensus has been achieved, CBDS diagnosis and management seem
to be more conditioned by availability of instrumentation, personnel and skills than
cost-effectiveness [
19, 23].
The optimal timing for therapeutic ERC in the management of choledocholithiasis is variable and depends on the specic clinical scenario. In elderly patients, it is
better to bring forward the therapeutic time to prevent cascades of pathological
events linked to associated pathologies [25].
The ageing population of Western countries together with the increasingly less
invasive nature of CBDS management is rekindling the debate concerning the most
appropriate treatment not only for the “young old” and “older old” but also for oldest old, where procedure-related complications may become severe or fatal [25].
Operative ERCP is proposed for CBDS retrieval in the very elderly [16, 26]. In oldest old patients and those with serious comorbidities, where other endoscopic or
surgical procedures may confer unacceptably high risks, endoscopic biliary stenting
is a useful alternative [27, 28].
In general, although results of mini-invasive CBDS management in very elderly
patients seem to be worse than in younger patients, they mostly consist of longer
operating times and hospital stays. Since clinical impact and morbidity appear lower
than those of traditional surgery, age should not contraindicate per se CBDS
302
Predictors of choledocholithiasis
“Very strong”
CBD stone on transabdominal US
Clinical ascending cholangitis
Bilirubin > 4 mg/dL
“strong”
Dilated CBD on US (> 6 mm with gallbladder in situ)
Bilirubin level 1.8-4 mg/dL
“Moderate”
Abnormal liver biochemical test other than bilirubin
Age older than 55 years
Clinical gallstone pancreatitis
Assigning a likelihood of choledcholithiasis based on clinical predictors
Presence of any very strong predictor
Presence of both strong predictors
No predictors Present
All other patients
A. Puzziello et al.
High
High
Low
Intermediate
Fig. 20.1 Taken from Maple JT, Ikenberry SO, Anderson MA, Appalaneni V, Decker GA, etal.
The role of endoscopy in the management of choledocholithiasis. Gastrointest Endosc. 2011; 74:
731–744
management. Biliary stent placement is a possible alternative in elderly patients but
is likely to put the patients at risk for cholangitis as a result of stent clogging. To
avoid this adverse event, a periodic (e.g. every 3months) exchange of biliary stents
is needed [24]. An emerging dilemma is whether to proceed with cholecystectomy
after successful CBD clearance in patients of 80years or over [25, 29].
The goal of treatment for the elderly is to provide them with the best possible
quality of life with the lowest physiological cost.
20.4 Postoperative Course: Hospital Stay
Laparoscopic cholecystectomy has been shown to provide a shorter hospital stay,
less postoperative physiological dysfunction and an earlier return to daily activities
than open cholecystectomy. The attainment of such goals is particularly desirable in
the elderly patient [30]. Advanced age is frequently associated with signicant
20 Cholecystectomy inElderly: Challenge andCritical Analysis ofAvailable Evidence
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303
comorbidity and limited functional reserve, which may complicate a postoperative
course. Preoperative assessment of cardiovascular risk factors and adequate monitoring of the patient is necessary for detection and treatment of possible complications [31]. In the Yetkin et al. study [32], the length of hospitalization was
signicantly longer in the elderly group compared with that in the younger group.
These results indicated that elderly patients also beneted from the shorter hospital
stay offered by the laparoscopic technique.
20.5 Morbidity andMortality
The reported incidence of morbidity and mortality with open cholecystectomy in the
geriatric population is approximately 23–28% and 1.5–2% respectively [33, 34]. In the
elderly who underwent laparoscopic cholecystectomy, complication rates of 5–15%
and an overall mortality rate of 0–1% have been observed [4, 13, 14]. Higher complica-
tion rates observed in oldest old patients seem to result from more difcult cholecystectomies. The best surrogate markers of biological age are the functional reserves of
the organism. The functional reserves represent the difference between basal and maximum function of the organ/system and are a measure of the capability of the organism
to cope with conditions of increased stress or disease [58].
Kuy etal. [36] have shown that the oldest old are ≥3 times more likely to need
blood transfusions and to require continuous mechanical ventilation and ≥5 times
more likely to develop aspiration pneumonitis. Other studies have proven that
age>65years, male gender, acute cholecystitis, thickened gallbladder wall, diabetes
mellitus, ASA 3 and previous upper abdominal surgery were signicantly associated
with an increased risk of conversion to the open technique [37, 38]. In oldest old
patients, the rates of acute cholecystitis, conversion to open surgery and postoperative complications were signicantly higher than in other groups (Tables 20.1 and
20.2) [32]. On the other hand, the enhanced recovery offered by laparoscopy, with
reduced postoperative pain, improved mobilization, a shorter length of hospital stay
and fewer complications may be most advantageous in this group with a prevalent
comorbidity and reduced physiologic reserve [
quently present with complicated gallstone disease, which explains the higher rate of
31, 39]. The extremely elderly fre-
Table 20.1 Signicantly higher incidence of postoperative complications compared to their t
counterparts
Postoperative complication
OR (95% CI) PPresent N (%) Absent N (%)
CGA assessment
Fit 2 (15.4) 23 (52.3) 1.0 0.026
Frail 11 (84.6) 21 (47.7) 6.0 (1.2–30.4)
Age
<75 8 (61.5) 28 (65.1) 1.0 1.000
≥75
ASA
<3 3 (23.1) 2 (4.5) 1.0 0.072
≥3
5 (38.5) 15 (34.9) 1.2 (0.3–4.2)
10 (76.9) 42 (95.5) 6.3 (0.9–42.8)
304
Functional abilities
Table 20.2 Post-operative stay as outcome in elderly group
Postoperative stay
OR (95% CI) P≤2 days N (%) >2 days N (%)
CGA assessment
Fit 13 (65.0) 11 (30.6) 1.0 0.023
Frail 7 (35.0) 25 (69.4) 4.2 (1.3–13.5)
Age
<75 14 (70.0) 22 (61.1) 1.0 0.571
≥75
ASA score
<3 0 (0) 5 (13.9) 1.0 0.148
≥3
Taken from Lasithiotakis K, Petrakis J, Venianaki M, Georgiades G, Koutsomanolis D, Andreou A,
Zoras O, Chalkiadakis G.Frailty predicts outcome of elective laparoscopic cholecystectomy in
geriatric patients. Surg Endosc. 2013;27(4):1144–50
6 (30.0) 14 (38.9) 0.7 (0.2–2.2)
20 (100) 31 (86.1) 5.6 (0.8–35.8)
Minor illness (eg, urinary tract infection)
Independent
A. Puzziello et al.
Fig. 20.2 Vulnerability of frail elderly people to a sudden change in health status after a minor
illness. The green line represents a t elderly individual who after a minor stressor event has a
small deterioration in function and then returns to homeostasis. The red line represents a frail
elderly individual who after a similar stressor event undergoes a larger deterioration and does not
return to baseline homeostasis. Taken from Clegg A. Frailty in elderly people. Lancet. 2013;
381:752–62
complications and mortality usually seen in this group [5, 30]. It is estimated that the
30% residue of the functional reserve may represent the minimum threshold for the
functionality of the system itself. Therefore, it is possible to lose 70% of a function
without any symptomatic manifestation, especially if such reduction occurs over
time (Fig.20.2) [58].
Dependent
20 Cholecystectomy inElderly: Challenge andCritical Analysis ofAvailable Evidence
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305
20.6 Pneumoperitoneum
In laparoscopic cholecystectomy, CO2 pneumoperitoneum has potentially harmful
intraoperative circulatory and ventilatory effects because of absorbed carbon dioxide and elevated intraabdominal pressure. Pneumoperitoneum decreases functional
residual capacity, lung compliance and peak airway pressures, and absorbed intraperitoneal CO2 causes hypercarbia and acidemia. Both increased intra-abdominal
pressure and reduced cardiac function and renal and hepatic hypoperfusion resulting in oliguria and transient hepatocellular injury [40, 41, 57]. Cardiac output
decreases by up to 30% during laparoscopic surgery, due to a decrease in stroke
volume. Pneumoperitoneum also causes an increase in systemic vascular resistance [42, 43]. Findings from the Koivusola etal. [15] report show that during laparoscopic cholecystectomy, the pneumoperitoneum induced with 10–12 mm Hg
pressure in patients with ASA scores 3 or 4 did not pose additional risks in elderly
patients.
20.7 Acute Cholecystitis
Applying strict criteria to select patients who might benet from early cholecystectomy as treatment for acute cholecystitis (AC) may contribute to a better
perioperative outcome. Fuks etal. [44] assessed the perioperative outcome of
early cholecystectomy in elderly patients. It included only patients with grades
I and II acute cholecystitis based on the severity assessment criteria from the
Tokyo Guidelines [45]. To reduce the risk of perioperative morbidity and mortality, a severity assessment of pre-existing comorbid conditions should be performed. This review showed that patients who died had been suffering from
severe pre-existent comorbidities or a poor clinical preoperative condition [44,
46, 47].
Previous studies have shown that the incidence of acute cholecystitis is higher
in elderly patients [10, 13]. The Yetkin study in older old patients revealed that
the rate of acute cholecystitis was 45.5%, and in oldest old patients, it was signicantly higher than that of other groups (P 0.029) [32]. This nding seems to
explain the higher complication rate in oldest old patients [39, 48]. Even though
elderly patients are more likely to present with several comorbidities in advanced
stages, early laparoscopic cholecystectomy for elderly patients with acute gallbladder disease proved to be safe and effective. It should be regarded as the
standard of care in conjunction with an appropriate selection of cases [13, 49].
Loozen demonstrated that early cholecystectomy for acute cholecystitis in
patients aged ≥70years is associated with a perioperative morbidity of 24% and
a mortality of 3.5% [50].
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