What is the treatment for Cholelithiasis (Gallstones) in the elderly?

From the Guidelines

Laparoscopic cholecystectomy is the preferred treatment for cholelithiasis in elderly patients, as it is safe, feasible, and associated with a low complication rate and shortened hospital stay, as supported by the 2020 World Society of Emergency Surgery guidelines 1.

Key Considerations

• The treatment approach should be individualized based on the patient's overall health, comorbidities, and risk factors.
• Careful preoperative assessment is crucial to identify potential risks and optimize the patient's condition before surgery.
• Alternative treatments, such as endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous cholecystostomy, may be considered for patients who are poor surgical candidates.

Management Strategies

• Pain management with NSAIDs or opioids, along with antiemetics, may be necessary to control symptoms.
• Medical dissolution therapy with ursodeoxycholic acid may be considered for small, non-calcified cholesterol stones, although its efficacy is limited.
• The evaluation of the risk for elderly patients with cholelithiasis should include mortality rate, rate of gallstone-related disease relapse, age-related life expectancy, and patient frailty evaluation using frailty scores, as recommended by the 2017 WSES and SICG guidelines 1.

Surgical Approach

• Laparoscopic cholecystectomy should be attempted first, except in cases of absolute anesthetic contraindications and septic shock, as stated in the 2017 WSES and SICG guidelines 1.
• The timing of surgery should be as soon as possible, but can be performed up to 10 days after the onset of symptoms, with earlier surgery associated with shorter hospital stay and fewer complications, as supported by the 2017 WSES and SICG guidelines 1.

From the FDA Drug Label

Watchful waiting has the advantage that no therapy may ever be required. For patients with silent or minimally symptomatic stones, the rate of development of moderate-to-severe symptoms or gallstone complications is estimated to be between 2% and 6% per year, leading to a cumulative rate of 7% to 27% in 5 years Cholecystectomy For patients with symptomatic gallstones, surgery offers the advantage of immediate and permanent stone removal, but carries a high risk in some patients. The spectrum of surgical risk varies as a function of age and the presence of disease other than cholelithiasis. Mortality Rates for Cholecystectomy in the U. S. (National Halothane Study, JAMA 1966; 197:775-8) Women 0-49 50-69 0.54 2.80 Men 0-49 50-69 1. 04 5.41

The treatment for Cholelithiasis in the elderly can be either watchful waiting or cholecystectomy. However, cholecystectomy carries a high risk in some patients, especially with increasing age and presence of other diseases. The mortality rates for cholecystectomy are higher in older patients, with rates rising with each decade of life 2.

• Watchful waiting may be considered for patients with silent or minimally symptomatic stones.
• Cholecystectomy may be considered for patients with symptomatic gallstones, but the decision should be made cautiously due to the high risk of surgery in older patients. Ursodeoxycholic acid may be used for gallstone dissolution, but the dosage and administration are not specifically addressed for the elderly population in the provided drug labels 2.

From the Research

Treatment Options for Cholelithiasis in the Elderly

• Laparoscopic cholecystectomy is a recommended treatment for symptomatic cholelithiasis in elderly patients due to its low morbidity and mortality rates 3, 4, 5
• The conversion rate to open cholecystectomy is higher in elderly patients, but laparoscopic cholecystectomy is still considered a safe and feasible procedure in this age group 4, 5
• Elective treatment is recommended for elderly patients with repeated gallstone symptoms before the development of acute cholecystitis and related complications 5

Considerations for Elderly Patients

• Age and comorbidity are significant predictors of surgical outcomes in elderly patients 5
• The presence of inflammation is an independent risk factor for conversion to open cholecystectomy and complications in elderly patients 4
• Laparoscopic cholecystectomy can be performed during the same hospitalization as definitive treatment for gallstone disease in elderly patients 5

Management of Choledocholithiasis

• There is no consensus on the ideal management strategy for choledocholithiasis, but therapeutic approaches can be performed in one or two sessions 6
• ERCP is a common treatment for choledocholithiasis, but cholecystectomy after ERCP can prevent the occurrence of new biliary events in elderly patients 7
• Cholecystectomy after ERCP resulted in a non-statistically significant difference in mortality in elderly patients 7