*4.1. Comparative Characterization of the Age-Related Subgroups*

The comparative statistical analysis of the four subgroups defined according to age showed that each of them behaves differently and presents specific challenges and outcomes.

Group A, of young patients (<50 years), is a group without significant comorbidities and without significant anesthetic-surgical risk, which generally presents with mild and moderate forms resolvable in a proportion of 97.5% laparoscopically, with a short postoperative stay and without significant complications. In the presence of a septic factor, they can still develop severe cardiovascular acute events and even death. Fluid and electrolyte rebalancing and supportive care were important as an adjuvant to combat septic shock.

Group B (50–64 years) did not differ statistically significantly from group A in terms of anesthetic-surgical risk and CCI score. The severity of the forms of acute cholecystitis was not significantly increased, but there were patients with longer biliary distress with local fibro-inflammatory remodeling, which explains the intraoperative technical difficulties, with an increased conversion rate (7.2% vs. 1.6% in group A) and the classic approach by open cholecystectomy (3.6% vs. 0.8%). During the early postoperative period, these patients were at risk of major cardiovascular complications, especially when diabetes or chronic renal disease are associated.

Group C (65–79 years) was characterized by a statistically significant increase in both the anesthetic-surgical risk (ASA-PS and CCI) compared to group A, but also a significant increase in severe cases according to TG13/TG18 criteria (12.1% vs. 2.5%, *p* = 0.001). Recall that severe forms of acute cholecystitis mean the association of significant local and general inflammation with systemic or organ dysfunction. This result therefore correlated with significant increases in biological markers of inflammation (leukocytosis, fibrinogen) compared to group A. Additionally, the presence of increased CCI and associated comorbidities, especially cardiovascular disease and diabetes, explained the evolution of cholecystitis from moderate to severe, with functional decompensation. In the therapeutic management of these patients, careful preoperative rebalancing was particularly important to prevent major systemic complications and reduce perioperative mortality.

Group D (>80 years) presented the same clinical-therapeutic challenges as group C, but the differences from group A were more marked: late presentation, higher frequency of severe forms of TG 13/18, anesthetic-surgical risk increased by the presence of comorbidities, having as outcomes an increased rate of conversions and major postoperative systemic complications. Thus, the conversion rate increased from 1.6% in group A to 17.6% in group D, and open surgery from 0.8% to 5.9%. However, there were no statistically significant differences in terms of preoperative evaluation and surgery approach and postoperative outcomes between group C (65–79 years) and group D (≥80 years).

Consequently, patients over 50 years of age in the presence of cardiovascular comorbidities or diabetes should be closely monitored in the postoperative period to avoid cardiovascular ischemic incidents and cardiovascular decompensation.

The utility of drain insertion in laparoscopic cholecystectomy is still a subject of debate. In a recent systematic review, Cirrochi et al. [39] found that the incidences of wound infection and abdominal collections are significantly higher in the drain group vs. the no-drain group, while the postoperative recovery and hospital days are shorter in cases without drain. In our clinic, drain insertion was not a routine procedure after laparoscopic cholecystectomy. However, it is still used in cases with severe inflammation, difficult dissection or bleeding in order to prevent intra-abdominal collections in the early postoperative period. An increased incidence of drain insertion with age was well correlated with the severity of acute cholecystitis in the elderly. This could also be an explanation for the increased incidence of postoperative septic complications, such as wound infection and intra-abdominal collections, described by other authors [40–42].
