García-Alonso Francisco Javier, de Lucas Gallego María, Bonillo Cambrodón Daniel, Algaba Alicia, de la Poza Gema, Martín-Mateos Rosa María, Bermejo Fernando
Servicio de Aparato Digestivo, Hospital Universitario de Fuenlabrada, Camino del Molino 2, 28942, Fuenlabrada, Madrid, Spain,
Dig Dis Sci. 2015 Jun;60(6):1770-7. doi: 10.1007/s10620-014-3497-4. Epub 2015 Jan 11.
Elderly patients are frequently affected by gallstone-related disease. Current guidelines support cholecystectomy after a first acute biliary complication. In the aging, these recommendations are irregularly followed.
We analyzed data from patients 65 or older admitted between June 30, 2004 and June 30, 2013 with a diagnosis of acute pancreatitis, cholangitis, or cholecystitis. Diagnosis and severity assessment were defined according to current guidelines. Harms, mortality, and cholecystectomy rates were evaluated. Baseline factors independently predicting cholecystectomy were identified.
A total of 491 patients were included. The median age was 78.8 years, and 51.7 % were women. Acute cholecystitis was present in 51.7 %, acute pancreatitis in 36.5 %, and acute cholangitis in 11.8 %. Cholecystectomy was performed in 47.1 %. Age, myocardial infarct, dementia, diabetes, nonmetastatic tumor, and severe liver disease were risk factors for not undergoing surgery. Complications related to hospital stay appeared in 33 % of patients. Surgery, cholecystostomy, and ERCP presented harms in 21-25 %. Overall mortality rate was 5.4 %: 10.4 % in acute cholangitis, 6.8 % in acute cholecystitis, and 2.2 % in acute pancreatitis. Mild cases presented a 1.3 % mortality, while 28.6 % of severe cases died. After discharge, 24.7 % of patients presented a new biliary complication, 9.7 % of them severe. Relapse was more frequent in patients managed without invasive procedures, 42.3 % than in cholecystectomy patients, 9.9 % (p < 0.001) and than in ERCP patients, 19.4 % (p = 0.01).
Cholecystectomy should be recommended to elderly patients after a first acute biliary complication. If not previously performed, ERCP should be offered as an alternative when surgery is contraindicated or refused.
老年患者常受胆结石相关疾病影响。当前指南支持在首次急性胆道并发症发生后行胆囊切除术。在老年人群中，这些建议并未得到规范遵循。
我们分析了2004年6月30日至2013年6月30日期间收治的65岁及以上诊断为急性胰腺炎、胆管炎或胆囊炎患者的数据。根据当前指南进行诊断和严重程度评估。评估不良事件、死亡率和胆囊切除率。确定独立预测胆囊切除术的基线因素。
共纳入491例患者。中位年龄为78.8岁，51.7%为女性。急性胆囊炎占51.7%，急性胰腺炎占36.5%，急性胆管炎占11.8%。47.1%的患者接受了胆囊切除术。年龄、心肌梗死、痴呆、糖尿病、非转移性肿瘤和严重肝病是未接受手术的危险因素。33%的患者出现与住院相关的并发症。手术、胆囊造瘘术和内镜逆行胰胆管造影术（ERCP）的不良事件发生率为21%-25%。总死亡率为5.4%：急性胆管炎为10.4%，急性胆囊炎为6.8%，急性胰腺炎为2.2%。轻症患者死亡率为1.3%，而重症患者死亡率为28.6%。出院后，24.7%的患者出现新的胆道并发症，其中9.7%为重症。未接受侵入性治疗的患者复发更频繁，为42.3%，高于胆囊切除术后患者的9.9%（p<0.001），也高于ERCP术后患者的19.4%（p=0.01）。
老年患者首次发生急性胆道并发症后应建议行胆囊切除术。如果之前未进行手术，当手术禁忌或被拒绝时，应提供ERCP作为替代方案。
