*4.2. Safety of Laparoscopic Cholecystectomy in the Elderly*

Although laparoscopic cholecystectomy is currently considered to be a routine abdominal procedure with minor risks, a deep understanding of the physiological reserve of elderly patients is also mandatory in surgery, as it can be used to assess the vulnerability of patients with frailty syndrome to complications [1–3,20].

Acute cholecystitis has clinical particularities in aged patients: statistically significant increases in severe forms, as well as the presence of associated comorbidities, with an increased rate of conversion and a higher percentage of postoperative complications. These findings were also encountered in other studies [19–21,24,43–45]. In a crossectional analysis on cholecystectomy in the elderly, Kuy et al. found that older people have more complex forms of disease and that a longer time from admission to surgery is a predictor for poor outcome [43].

In a meta-analysis on 99 studies between 1995 and 2018, Kamarajah et al. [44] found a tenfold increase in mortality in patients aged over 80. One of the major drawbacks they remarked on in their research was that the studies evaluated did not take into account the associated comorbidities and their impact on the final outcomes. In a meta-analysis on 11 studies published between 1993 and 2011, on 101,559 patients aged 65 or older (48,195 treated laparoscopically and 53,364 by open cholecystectomy), Antoniou et al. found that mortality was 1.0% for the laparoscopic approach and 4.4% for the open approach [24].

In the present study, there were 100 patients aged over 65, and 77% of them successfully underwent laparoscopic cholecystectomy, with 0% mortality. In the 23 cases in which laparoscopy could not be performed (direct open surgery and conversion groups), there was only one death (4.34%). In our study, despite an increased conversion and complications rate, there were no deaths in group D (aged over 80). There were no significant differences regarding cardiovascular complications between the four age-groups. Similar findings are also encountered by Shin et al. [38]. With the pre-operative optimization of comorbidities and medications and addressing frailty in a multi-disciplinary team, an experienced surgical staff with good technical equipment are effective in improving postoperative outcomes [16,38]. Moreover, the multivariate analysis showed that severe inflammation (gangrenous cholecystitis) and comorbidities such as diabetes, previous stroke and chronic renal and pulmonary disease, but not age itself, are risk factors for postoperative morbidity. This finding is also communicated by Kim et al. [46,47]. Moreover, Agrusa et al. recommended elective laparoscopic surgery in elderly people with symptomatic gallstone disease before the development of acute cholecystitis and related complications [48].

When comparing open to laparoscopic surgery, most of the studies found better outcomes in terms of mortality and morbidity associated with laparoscopic procedures [15,24,49], while a limited number of studies founded similar results for both methods [22]. These findings confirmed that laparoscopic cholecystectomy is a safe procedure and should be used in the elderly. On the other hand, a proper comparison cannot be performed between the open and laparoscopic approach due to the fact that the open approach does not represent a first line option in our surgical department, regardless of the patient's age. Open surgery (and conversion) was used only in cases in which laparoscopic surgery could not be performed. The severity of the inflammatory process and sepsis might also be associated with increased mortality in the open surgery group.

Laparoscopy is associated with a limited response in serum Il-6 and no change in gut mucosa Il-6 [50]. There is strong evidence that laparoscopy provides a decreased inflammatory response at the peritoneal and intestinal level, with a faster intestinal transit recovery. The reduced inflammatory systemic response associated with laparoscopic surgery may also be important, especially in the elderly, in preventing pulmonary related complications [50].
