1.Clinical data
1.1 General information
1.2 Perioperative management
1.2.1 Preoperative management
Check the vital indications after admission, and if smooth, routinely perform imaging examinations such as ultrasound and CT examination. If combined with shock, actively resuscitate the shock and perform imaging examination after the shock is stabilized. If combined with acute heart attack, perform thrombolysis and stent treatment, and perform bedside ultrasound examination. Combined with acute cerebral hemorrhage, perform stent treatment.
1.2.2 Surgical methods
163 cases of laparoscopic cholecystectomy were performed, and there were no cases of intermediate open abdomen. Among them, 9 cases were treated with preoperative antibiotics for more than 7 days, and most of the gallbladder was resected because of heavy inflammation of the gallbladder, unclear demarcation of the peri-bladder tissue, and more bleeding from the separation of the gallbladder bed. 15 patients underwent cholecystocentesis under ultrasound guidance, among which 11 cases were combined with acute heart infarction and 4 cases were combined with acute cerebral hemorrhage. 2 cases refused surgical treatment and were discharged in remission after applying antibiotics.
1.2.3 Postoperative complication management
Those with preoperative combined hypertension, diabetes mellitus and intrapulmonary infection were actively controlled according to their condition after surgery. Newly emerged postoperative complications should be closely observed and dealt with at any time. The most common postoperative complications: right-sided pleural effusion combined with right-sided pulmonary atelectasis, the reason; heavy inflammation of gallbladder and reactive effusion in the chest cavity. Treatment: puncture drainage can be performed under ultrasound guidance, while performing nebulized inhalation, patting back to drain sputum and other comprehensive treatment; gastrointestinal emptying disorder, vomiting, stopping defecation and exhaustion, causes: poor gastrointestinal peristalsis in the elderly, postoperative incisional pain, poor rest, and phytodysfunction.
Treatment: feasible gastrointestinal decompression, laxative enema, while performing catheterization, physiotherapy and other treatments; postoperative diarrhea, cause: bile enters the intestine too quickly after gallbladder removal, stimulating intestinal peristalsis too quickly, causing diarrhea. Application of broad-spectrum antibiotics for too long, fungal infection causing diarrhea. Treatment: Apply drugs such as biliary amines for bilious diarrhea. Application of antifungal drugs combined with drugs such as gold shuangqi; arrhythmia, causes: postoperative fever, abdominal distension, pain, insomnia, electrolyte disorders, etc. can lead to arrhythmia.
Treatment: according to the type of arrhythmia; postoperative depression, causes: postoperative pain, insomnia, no family companion, economy, etc. Treatment: postoperative sedation, analgesic treatment, more communication with patients, and application of antidepressants at the same time.
1.3 Results
There were 25 cases of postoperative combined right pleural effusion, 39 cases of gastrointestinal emptying disorder, 43 cases of diarrhea, 18 cases of heart rate disorders, and 12 cases of depression, all of which were cured by conventional treatment. The average hospital stay was 7 days. There were no fatal cases.
2. Discussion
Clinical characteristics of geriatric acute cholecystitis: rapid onset, rapid changes, high perioperative mortality if not handled timely, and many postoperative complications. Moreover, most of the combined medical diseases and a history of recurrent attacks are very difficult to handle [4].
2.1 Preoperative examination and evaluation
Acute cholecystitis in the elderly, due to the characteristics of rapid onset and rapid changes. There is often no time for comprehensive examination and evaluation before surgery, which causes many problems and even medical disputes for clinicians. Therefore, it is a great test for clinicians to assess whether a patient needs surgical treatment and what kind of surgical procedure to choose based on the shortest time and the least amount of examination.
2.1.1 Assessment of vital indications
One of the reasons why some elderly patients may die suddenly in the examination room of ultrasound and CT is that the young physicians do not make an adequate assessment of the vital indications and let the family members take the patient to an imaging department which is far away from the clinical department. If the vital signs were monitored on admission, patients with unstable vital signs were identified in a timely manner, and managed promptly, patient death might have been prevented.
2.1.2 Assessment of cardiopulmonary function
Elderly patients often have cardiopulmonary dysfunction, and preoperative pulmonary function, cardiac ultrasound, and electrocardiogram should be routinely performed, but often there is no time to be able to fully examine them before surgery, and only basic pulmonary function can be judged by breath-hold test, and intrapulmonary infection by chest X-ray or CT. Cardiac function is judged by asking patients about their daily activities.
2.1.3 Assessment of liver and kidney function
The routine laboratory can make the assessment of renal function in an emergency, but cannot make the assessment of liver function, and the patient’s combined severe liver dysfunction can lead to postoperative death.
2.1.4 Conventional biochemical assessment
Acute cholecystitis in the elderly is often combined with nausea and vomiting, which may last for several days. Upon admission, patients may be combined with severe electrolyte disturbances, especially hypokalemia, which can lead to sudden death. Severe infection can also lead to prolonged clotting time and thrombocytopenia affecting surgical operations.
2.2 Surgical approach and intraoperative considerations
2.2.1 Laparoscopic cholecystectomy
The increasing maturity of laparoscopic technology is the original contraindication to surgery becomes possible. Most of the acute cholecystitis in the elderly can be done laparoscopically. If there is no contraindication to surgery in the preoperative evaluation, basically laparoscopic cholecystectomy can be accomplished. As most elderly patients have recurrent cholecystitis or are readmitted after several days of antibiotic therapy. Intraoperatively, heavy adhesions around the gallbladder will be found, and the gallbladder triangle is difficult to reveal.
In separating the gallbladder triangle it should be blunt combined with sharp separation to identify the position of the common bile duct before ligating the cholecystic artery and the cholecystic duct. If there is more bleeding during the separation of the gallbladder bed and the inflammation is too severe, most of the gallbladder can be considered for resection or cholecystostomy.
2.2.2 Ultrasound-guided gallbladder puncture and drainage
Patients with severe combined cardiac, cerebral, pulmonary and other medical disorders, whose general state is not suitable for surgical operation and combined with right upper abdominal peritonitis, fever and other symptoms, can be considered for ultrasound-guided puncture treatment. Ultrasound puncture can be done under local anesthesia, without monitoring, and is quick to perform. Because the bacteriological results of bile can be obtained by puncture, drugs can be targeted to alleviate the condition.
2.3 Management of postoperative complications
2.3.1 Right-sided pleural effusion combined with pulmonary atelectasis
Right-sided pleural effusion is often due to excessive inflammation of the gallbladder and surrounding inflammatory exudate irritating the diaphragm to produce pleural fluid. Pleural effusion combined with pulmonary atelectasis can lead to decreased partial pressure of oxygen, oxygen saturation, acidosis, and death of the patient. Postoperative ultrasonography is routinely performed to detect pleural effusion early by puncture and drainage.
2.3.2 Gastrointestinal dysfunction
Postoperative electrolyte disturbance, pain, poor sleep, and vegetative nerve dysfunction can all lead to gastrointestinal dysfunction. Patients experience nausea, vomiting, abdominal distension, and cessation of defecation and exhaustion. Abdominal distension can elevate the diaphragm and affect breathing. Timely application of gastrointestinal decompression, enema, catheterization, and physical therapy. Promote gastrointestinal emptying and ease breathing. Postoperative diet should be low-fat and easy to digest diet.
2.3.3 Postoperative diarrhea
After gallbladder removal, bile loses the concentrating effect of the gallbladder and enters the intestine too quickly, stimulating enhanced intestinal peristalsis and causing bilious diarrhea. The application of broad-spectrum antibiotics in elderly patients tends to cause gastrointestinal flora dysbiosis, which causes pseudomembranous enteritis and diarrhea. Cholestatic diarrhea can be relieved by drug therapy such as cholestyramine and restricting a high-fat diet in the near future. In pseudomembranous enteritis, elderly patients need to apply antibiotics along with drugs that regulate the intestinal flora, such as gold sunchokes, etc. If a fungal infection has been identified, oral treatment with drugs such as Daflucan can be administered. Also pay attention to the regulation of electrolyte disorders.
2.3.4 Postoperative depression
Postoperative pain, insomnia, and adverse stimulation of the ICU surroundings can all lead to the manifestation of postoperative depression in elderly patients. Patients show mental loss of control and non-cooperation with treatment. Therefore, for postoperative analgesia in elderly patients, it is important to ensure good sleep, and also to strengthen communication with patients during the perioperative period, so that once there is a change in mood should be detected early and given the appropriate treatment.
The disease characteristics of elderly patients in the perioperative period of acute cholecystitis are rapid onset, rapid changes and many complications, which should be detected early and treated promptly.