Tratamento cirúrgico da litíase biliar em idosos experiência em hospital de ensino

Bromberg, Sanson Henrique; Waisberg, Jaques; Gonçalves, José Eduardo; Zanoto, Arnaldo; Godoy, Antônio Cláudio de; Goffi, Fábio Schmidt

doi:10.1590/S0100-69911998000300003

Resumos

O receio de graves complicações pós-operatórias tem inibido muitas das indicações cirúrgicas da litíase biliar no paciente idoso sintomático. A finalidade principal deste trabalho foi averiguar a extensão real desse problema no Serviço de Gastroenterologia Cirúrgica do HSPE-FMO. Foram estudados 185 idosos portadores de litíase biliar com idade média de 73,0 ± 6,2 anos, no período de seis anos (1990-1995). Os pacientes foram divididos em dois grupos de acordo com a idade: I - com 118 (63,8%) pacientes de 60 a 74 anos e o II - com 67 (36,2%) pacientes entre 75 e 90 anos. O número de doentes do sexo masculino foi proporcionalmente maior no grupo II (p<0,02). Os sintomas foram similares nos dois grupos de enfermos. A maioria dos doentes foi submetida à operação eletiva-163 (88,1 %) sendo 22 (11,9%) operados de urgência por colecistite aguda. Maior número de cirurgias de urgência incidiu no grupo 11 (19,4% contra 7,6%). A colecistectomia foi realizada em todos os doentes. Cirurgia complementar indicada pela presença de coledocolitíase (15,1 %) e estenose papilar (2,7%) foi necessária em 38 (20,5%) deles, sendo maior no grupo II. A coledocolitotomia foi realizada em 28 (15,1%) doentes, a anastomose biliodigestiva em sete (3,8%) e a papilotomia em cinco (2,7%) doentes, não diferindo entre os dois grupos. Complicações pós-operatórias ocorreram em 37 (20%) doentes e foram as mesmas nos dois grupos. Não houve óbitos. Nossos resultados demonstram que a colecistectomia eletiva pode ser realizada com baixa morbidade e sem mortalidade em idosos, quando se impede a demora da indicação operatória em pacientes sintomáticos.

Colelitíase; Colecistectomia; Paciente idoso; Tratamento cirúrgico

Due to high incidence of postoperative complications in elderly people there is some degree of reluctance in the surgical management of the biliar lithiasis in these patients. The main purpose of this study was to verify the real extension of these problem in the Department of Gastroenterologic Surgery of the HSPE-FMO. Over a 6-year period (1990-1995) 185 elderly patients with biliary lithiasis and mean age of 73.0 ± 6,2 years were evaluated. The patients were divided into two groups according to the age: I-118 (63.8%) patients with 60-74 and II- 67 (36.2%) patients with 75-90 years. The number of mate patients was significantly higher at the group II. Symptoms were similar into two groups of patients. The most part of patients was submitted to elective procedures - (163) 88.1% while (22) 1.9% underwent emergency surgery (acute cholecystitis). The number of emergency cases was more than twice in the group II (19.4% versus 7.6%). Cholecystectomy was performed in all patients. Operative cholangiography was performed in 157 (84,8%) patients. Complementary surgery was necessary for 38 (21.6%)patients (choledocholithiasis in 15.1% and papillar stricture in 2.7%) and was higher in the group II. Choledocholithotomy as a component of the primary biliary operation was performed in 28 (15.1%) patients, biliar enteric anastomosis in seven (3.8%) and papillotomy in five (2.7%) patients. Complications occurred in 37 (20%) patients and were similar in both groups. There was no mortality. Retained stones of the common duct was found in 15 (8.1%) patients. Endoscopic sphincterotomy was performed upon all patients, with success. The results of the present study support the use of elective cholecystectomy with low morbidity and without mortality in geriatric patients.

Cholelithiasis; Cholecystectomy; Elderly; Surgical treatment

Tratamento cirúrgico da litíase biliar em idosos experiência em hospital de ensino

Surgical management of biliary tract in the elderly experience in an teaching hospital

Sanson Henrique Bromberg, ACBC-SP^I; Jaques Waisberg, TCBC-SP^I; José Eduardo Gonçalves, TCBC-SP^I; Arnaldo Zanoto^II; Antônio Cláudio de Godoy^III; Fábio Schmidt Goffi, ECBC-SP^IV

^IVice-Coordenador da Pós-Graduação em Gastroenterologia Cirúrgica do HSPE-FMO

^IIProf. Assistente de Técnica Cirúrgica, da Faculdade de Medicina da Universidade de S.Paulo

^IIIDiretor do Serviço de Gastroenterologia Cirúrgica do HSPE-FMO

^IVCoordenador da Pós-Graduação em Gastroenterologia Cirúrgica do HSPE-FMO

^{Endereço para correspondência} Endereço para correspondência: Dr. Sansom Henrique Bromberg Av. Angélica, 589/81 01227-000 - São Paulo - SP

RESUMO

O receio de graves complicações pós-operatórias tem inibido muitas das indicações cirúrgicas da litíase biliar no paciente idoso sintomático. A finalidade principal deste trabalho foi averiguar a extensão real desse problema no Serviço de Gastroenterologia Cirúrgica do HSPE-FMO. Foram estudados 185 idosos portadores de litíase biliar com idade média de 73,0 ± 6,2 anos, no período de seis anos (1990-1995). Os pacientes foram divididos em dois grupos de acordo com a idade: I - com 118 (63,8%) pacientes de 60 a 74 anos e o II - com 67 (36,2%) pacientes entre 75 e 90 anos. O número de doentes do sexo masculino foi proporcionalmente maior no grupo II (p<0,02). Os sintomas foram similares nos dois grupos de enfermos. A maioria dos doentes foi submetida à operação eletiva-163 (88,1 %) sendo 22 (11,9%) operados de urgência por colecistite aguda. Maior número de cirurgias de urgência incidiu no grupo 11 (19,4% contra 7,6%). A colecistectomia foi realizada em todos os doentes. Cirurgia complementar indicada pela presença de coledocolitíase (15,1 %) e estenose papilar (2,7%) foi necessária em 38 (20,5%) deles, sendo maior no grupo II. A coledocolitotomia foi realizada em 28 (15,1%) doentes, a anastomose biliodigestiva em sete (3,8%) e a papilotomia em cinco (2,7%) doentes, não diferindo entre os dois grupos. Complicações pós-operatórias ocorreram em 37 (20%) doentes e foram as mesmas nos dois grupos. Não houve óbitos. Nossos resultados demonstram que a colecistectomia eletiva pode ser realizada com baixa morbidade e sem mortalidade em idosos, quando se impede a demora da indicação operatória em pacientes sintomáticos.

Unitermos: Colelitíase; Colecistectomia; Paciente idoso; Tratamento cirúrgico.

ABSTRACT

Due to high incidence of postoperative complications in elderly people there is some degree of reluctance in the surgical management of the biliar lithiasis in these patients. The main purpose of this study was to verify the real extension of these problem in the Department of Gastroenterologic Surgery of the HSPE-FMO. Over a 6-year period (1990-1995) 185 elderly patients with biliary lithiasis and mean age of 73.0 ± 6,2 years were evaluated. The patients were divided into two groups according to the age: I-118 (63.8%) patients with 60-74 and II- 67 (36.2%) patients with 75-90 years. The number of mate patients was significantly higher at the group II. Symptoms were similar into two groups of patients. The most part of patients was submitted to elective procedures - (163) 88.1% while (22) 1.9% underwent emergency surgery (acute cholecystitis). The number of emergency cases was more than twice in the group II (19.4% versus 7.6%). Cholecystectomy was performed in all patients. Operative cholangiography was performed in 157 (84,8%) patients. Complementary surgery was necessary for 38 (21.6%)patients (choledocholithiasis in 15.1% and papillar stricture in 2.7%) and was higher in the group II. Choledocholithotomy as a component of the primary biliary operation was performed in 28 (15.1%) patients, biliar enteric anastomosis in seven (3.8%) and papillotomy in five (2.7%) patients. Complications occurred in 37 (20%) patients and were similar in both groups. There was no mortality. Retained stones of the common duct was found in 15 (8.1%) patients. Endoscopic sphincterotomy was performed upon all patients, with success. The results of the present study support the use of elective cholecystectomy with low morbidity and without mortality in geriatric patients.

Key words: Cholelithiasis; Cholecystectomy; Elderly; Surgical treatment.

Texto completo disponível apenas em PDF.

Full text available only in PDF format.

Recebido em 27/6/97

Aceito para publicação em 26/1/98

Trabalho realizado no Serviço de Gastroenterologia do Hospital do Servidor Público Estadual Francisco Morato de Oliveira - HSPE-FMO.

1. Sullivan DM, Hood TR, Griffen Jr WO. Biliary tract surgery in the elderly. Am J Surg 1982;143:218-20.
2. Huber DF, Martin EW, Cooperman M. Cholecystectomy in elderly patients. Am J Surg 1983;146:719-22.
3. Harness IK, Strodel WE, Talsma SE. Symptomatic biliary disease in the elderly patient. Am Surg 1986; 52:442-5.
4. McSherry CK. Open cholecystectomy. Am J Surg 1993;165:435-9.
⁵
Goffi FS, Goffi Jr PS. "Operações sobre as vias biliares extra- hepáticas". In Coelho JCU (ed). Aparelho digestivo. Clínica e Cirurgia, 1ª edição, Rio de Janeiro:1990, pp 1104-13.
6. Gilliland TM, Traverso LW. Modern standards for comparison of cholecystectomy with alternative treatments for symptomatic cholelithiasis with emphasis on long term relief of symptoms. Surg Gynecol Obstet 1990; 170:39-44.
7. Clavien PA, Sanabria IR, Mentha G, et al. Recent results of eletive open cholecystectomy in a North American and a European center. Ann Surg 1992;216:618-26.
8. Strasberg SM, Clavien PA. Overview of therapeutic modalities for the treatment of gallstone diseases. Am J Surg 1993;165:420-6.
9. Margiotta Jr SI, Willis IH, Wallack MK. Cholecystectomy in the elderly. Am Surg 1989;54:34-9.
10. Targarona EM, Ayuso RMP, Bordas IM. Randomised trial of endoscopic sphincterotomy with gallbladder left in situ versus open surgery for common bile duct calculi in high-risk patients. Lancet 1996;347: :926-9.
11. Coelho JCU, Moraes LM, Barbara MS, et al. Colecistectomia no paciente idoso. Rev Ass Med Brasil 1988;34:89-92.
12. Pickleman I, Gonzalez RP. The improving results of cholecystectomy. Arch Surg 1986;121:930-4.
13. Bartolomucci AC, Ungari Filho O, Berthoud AD. Laparotomia transversa versus vertical como via de acesso na cirurgia da litíase biliar. Um estudo prospectivo. Rev Col Bras Cir 1991;18:125-31.
14. Houghton PWJ, Jenkinson LR, Donaldson LA. Cholecystectomy in the elderly: a prospective study. Br J Surg 1985;72:220-2.
15. Casaroli AA, Bevilacqua RG, Rasslan S. Análise multivariada de risco no tratamento cirúrgico da colecistite aguda no idoso. Rev Col Bras Cir 1996; 23:1-7.
16. Ganey JB, Johnson Jr PA, Prillaman PE, et al. Cholecystectomy: clinical experience with a large series. Am J Surg 1986; 151 :352-7.
17. Pitt HA. Role of open choledochotomy in the treatment of choledocholithiasis. Am J Surg 1993;165:483-6.
18. Morgenstem L, Wong L, Berci G. Twelve hundred open cholecystectomies before the laparoscopic era. A standard for comparison. Arch Surg 1992;127: 400-3, 1992.
19. Schwab G, Pointner R, Wetscher G, et al. Treatment of calculi of the common bile duct. Surg Gynecol Obstet 1992;175:115-20.
20. Lygidakis NJ. Operative risk factors of cholecystectomy-choledochotomy in the elderly. Surg Gynecol Obstet 1983;157:15-9.
21. Neoptolemos JP, Carr-Locke DL, Fosgard DP. Prospective randomised study of preoperative endoscopic sphinterotomy versus surgery alone for common bile duct stones. Br Med J 1987; 294:470-4.
22. Campos ACL, Alves MB, Massignan LL, et al. Causas de insucesso no tratamento cirúrgico da coledocolitíase. Rev Col Bras Cir 1993; 20:6-14.
23. Neoptolemos JP, Davidson BR, Shaw DE, et al. Study of common bile duct exploration and endoscopic sphinterectomy in a consecutive series of 438 patients. Br J Surg 1987;74:916-21.
24. Truedson H, Elmros T, Holm S. The incidence of bacteria in gallbladder bile at acute and elective cholecystectomy. Acta Chir Scand 1983; 149:307-13.
25. Grande M, Torquati A, Farinon AM. Wound infection after cholecystectomy. Eur J Surg 1992; 158:109-12.
26. Machado RJC, Goffi FS. Bacteriologia da bile em colecistopatias. Associaçăo radiológica. Arq Gastroent S Paulo 1983; 20:48-52.
27. Pacheco Jr AM, Silva RA, Kowes I, et al. Tratamento cirúrgico da coledocolitíase: análise de 145 casos. Rev Paul Med 1988; 106: 215-9.
28. Traverso LW. Carl Langenbuch and the first cholecystectomy. Am J Surg 1976;132:81-2.

Endereço para correspondência:

Dr. Sansom Henrique Bromberg

Av. Angélica, 589/81

01227-000 - São Paulo - SP

Datas de Publicação

Publicação nesta coleção
28 Jul 2010
Data do Fascículo
Jun 1998

Histórico

Aceito
26 Jan 1998
Recebido
27 Jun 1997

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. Sullivan DM, Hood TR, Griffen Jr WO. Biliary tract surgery in the elderly. Am J Surg 1982;143:218-20.

[2] 2. Huber DF, Martin EW, Cooperman M. Cholecystectomy in elderly patients. Am J Surg 1983;146:719-22.

[3] 3. Harness IK, Strodel WE, Talsma SE. Symptomatic biliary disease in the elderly patient. Am Surg 1986; 52:442-5.

[4] 4. McSherry CK. Open cholecystectomy. Am J Surg 1993;165:435-9.

[5] ⁵
Goffi FS, Goffi Jr PS. "Operações sobre as vias biliares extra- hepáticas". In Coelho JCU (ed). Aparelho digestivo. Clínica e Cirurgia, 1ª edição, Rio de Janeiro:1990, pp 1104-13.

[6] 6. Gilliland TM, Traverso LW. Modern standards for comparison of cholecystectomy with alternative treatments for symptomatic cholelithiasis with emphasis on long term relief of symptoms. Surg Gynecol Obstet 1990; 170:39-44.

[7] 7. Clavien PA, Sanabria IR, Mentha G, et al. Recent results of eletive open cholecystectomy in a North American and a European center. Ann Surg 1992;216:618-26.

[8] 8. Strasberg SM, Clavien PA. Overview of therapeutic modalities for the treatment of gallstone diseases. Am J Surg 1993;165:420-6.

[9] 9. Margiotta Jr SI, Willis IH, Wallack MK. Cholecystectomy in the elderly. Am Surg 1989;54:34-9.

[10] 10. Targarona EM, Ayuso RMP, Bordas IM. Randomised trial of endoscopic sphincterotomy with gallbladder left in situ versus open surgery for common bile duct calculi in high-risk patients. Lancet 1996;347: :926-9.

[11] 11. Coelho JCU, Moraes LM, Barbara MS, et al. Colecistectomia no paciente idoso. Rev Ass Med Brasil 1988;34:89-92.

[12] 12. Pickleman I, Gonzalez RP. The improving results of cholecystectomy. Arch Surg 1986;121:930-4.

[13] 13. Bartolomucci AC, Ungari Filho O, Berthoud AD. Laparotomia transversa versus vertical como via de acesso na cirurgia da litíase biliar. Um estudo prospectivo. Rev Col Bras Cir 1991;18:125-31.

[14] 14. Houghton PWJ, Jenkinson LR, Donaldson LA. Cholecystectomy in the elderly: a prospective study. Br J Surg 1985;72:220-2.

[15] 15. Casaroli AA, Bevilacqua RG, Rasslan S. Análise multivariada de risco no tratamento cirúrgico da colecistite aguda no idoso. Rev Col Bras Cir 1996; 23:1-7.

[16] 16. Ganey JB, Johnson Jr PA, Prillaman PE, et al. Cholecystectomy: clinical experience with a large series. Am J Surg 1986; 151 :352-7.

[17] 17. Pitt HA. Role of open choledochotomy in the treatment of choledocholithiasis. Am J Surg 1993;165:483-6.

[18] 18. Morgenstem L, Wong L, Berci G. Twelve hundred open cholecystectomies before the laparoscopic era. A standard for comparison. Arch Surg 1992;127: 400-3, 1992.

[19] 19. Schwab G, Pointner R, Wetscher G, et al. Treatment of calculi of the common bile duct. Surg Gynecol Obstet 1992;175:115-20.

[20] 20. Lygidakis NJ. Operative risk factors of cholecystectomy-choledochotomy in the elderly. Surg Gynecol Obstet 1983;157:15-9.

[21] 21. Neoptolemos JP, Carr-Locke DL, Fosgard DP. Prospective randomised study of preoperative endoscopic sphinterotomy versus surgery alone for common bile duct stones. Br Med J 1987; 294:470-4.

[22] 22. Campos ACL, Alves MB, Massignan LL, et al. Causas de insucesso no tratamento cirúrgico da coledocolitíase. Rev Col Bras Cir 1993; 20:6-14.

[23] 23. Neoptolemos JP, Davidson BR, Shaw DE, et al. Study of common bile duct exploration and endoscopic sphinterectomy in a consecutive series of 438 patients. Br J Surg 1987;74:916-21.

[24] 24. Truedson H, Elmros T, Holm S. The incidence of bacteria in gallbladder bile at acute and elective cholecystectomy. Acta Chir Scand 1983; 149:307-13.

[25] 25. Grande M, Torquati A, Farinon AM. Wound infection after cholecystectomy. Eur J Surg 1992; 158:109-12.

[26] 26. Machado RJC, Goffi FS. Bacteriologia da bile em colecistopatias. Associaçăo radiológica. Arq Gastroent S Paulo 1983; 20:48-52.

[27] 27. Pacheco Jr AM, Silva RA, Kowes I, et al. Tratamento cirúrgico da coledocolitíase: análise de 145 casos. Rev Paul Med 1988; 106: 215-9.

[28] 28. Traverso LW. Carl Langenbuch and the first cholecystectomy. Am J Surg 1976;132:81-2.

Brasil