Are They Too Old for Surgery? Safety of Cholecystectomy in Superelderly Patients (≥ Age 90)


Busayo Irojah, MD; Ted Bell, MS; Rodney Grim, PhD; Jennifer Martin, PhD; Vanita Ahuja, MD, FACS

Perm J 2017;21:16-013 [Full Citation]
E-pub: 04/14/2017


Context: Cholecystectomy is the most common general surgery procedure in patients older than age 65 years. By 2050, it is estimated that 2.0% of the population will be older than age 90 years.
Objective: To assess the mortality of cholecystectomy in superelderly patients (≥ age 90 years).
Design: Using the American College of Surgeons National Surgical Quality Improvement Program database, a retrospective analysis was performed of superelderly patients who underwent laparoscopic and open cholecystectomy between 2005 and 2012.
Main Outcome Measures: Thirty-day mortality.
Results: A total of 1007 cholecystectomies were performed in superelderly patients between 2005 and 2012. Of these surgical procedures, 807 (80%) were nonemergent and 200 (20%) were performed emergently. Two hundred sixteen procedures (21.4%) were open and 791 (78.6%) were laparoscopic. Mortality did not decrease significantly during the study period. The overall mortality was 5.5%, significantly less for the laparoscopic group (3.7% vs 12%, p < 0.001) and for the nonemergent group (4.5% vs 9.5%, p < 0.005). The median length of stay for open cholecystectomy was 9 days compared with 5 days for laparoscopic (p < 0.001); for nonemergent cholecystectomy it was 5 days compared with 7 days for emergent cholecystectomy (p < 0.001).
Conclusion: The mortality after cholecystectomy in superelderly patients did not change significantly during the study period. The mortality and morbidity for laparoscopic and elective procedures were significantly lower than for open procedures and for emergent procedures, respectively.


Elderly individuals are the fastest growing segment of the US population.1 It is projected that by 2050, individuals aged 90 years and older, designated “superelderly,” will represent 2% of the population.

The incidence of gallstones rises with age because of increasing lithogenicity of bile and gallbladder dysfunction.2 By age 90 years, greater than 24% of men and 35% of women have gallstones.3 Complications secondary to gallstones such as cholecystitis, cholangitis, and pancreatitis also increase with age.4 Although cholecystectomy is accepted as the standard treatment of gallstone complications, the likelihood of a patient undergoing a cholecystectomy after presenting with symptomatic gallstone disease reduces with age.5 Elderly patients who do not undergo cholecystectomy after their initial presentation with symptomatic gallstones are at risk of presenting again in the emergent setting with gallstone complications. This leads to increased morbidity, mortality, and cost.6 Those who undergo surgery have a higher likelihood of undergoing open procedures than do younger patients.5

Despite the reluctance of some surgeons to perform cholecystectomy in elderly patients,5 cholecystectomy remains the most common general surgery procedure in the elderly.7 Increasing age has been identified as an independent risk factor for mortality after surgery8; however, few studies have addressed the outcomes of superelderly patients after cholecystectomy. The purpose of our study was to assess the mortality and morbidity of superelderly (≥ age 90 years) patients after laparoscopic and open cholecystectomy.


The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) is a national, validated program for measuring risk-adjusted surgical outcomes. Surgical clinical reviewers collect data from before the operation through 30 days postoperatively. The data collected are entered securely into a Web-based platform and are used to create a Participant Use Data File. The data in the Participant Use Data File are available for researchers to perform studies to advance patient care.9,10

Using data from the ACS NSQIP database, we performed a retrospective analysis of all patients age 90 years and older who underwent cholecystectomy as the primary hospital procedure between 2005 and 2012. Current Procedural Terminology codes were as follows: 47562 (laparoscopic cholecystectomy), 47563 (laparoscopic cholecystectomy with intraoperative cholangiogram, 47600 (open cholecystectomy), and 47605 (open cholecystectomy with intraoperative cholangiogram). Data before 2005 were not included, because 2005 was the first year the NSQIP database documented whether a procedure was emergent. Cases with malignant neoplasm of the gallbladder and extrahepatic bile ducts (International Classification of Diseases, Ninth Revision Code 156) were excluded from analysis.

Patient variables examined include sex, race, inpatient or outpatient status, year of the operation, level of resident supervision, diabetes, smoking, alcohol use (> 2 drinks a day 2 weeks before surgery), do-not-resuscitate status, functional health before surgery, history of severe chronic obstructive pulmonary disease, current pneumonia, hypertension requiring medication, congestive heart failure within 30 days of surgery, history of myocardial infarction 6 months before surgery, open wound or infection, emergency case, open or laparoscopic procedure, American Society of Anesthesiologists class, and mortality (Table 1).

Laparoscopic converted to open procedures were identified as cases that had open cholecystectomy as their primary procedure but laparoscopic cholecystectomy as their secondary procedure. Because the difference in outcomes between the open cholecystectomy group and the laparoscopic converted to open group was small, they were combined to form an “open cholecystectomy” group for our regression.

The primary outcome evaluated was 30-day mortality. Our secondary outcomes were: postoperative length of stay, superficial surgical site infection, deep incisional infection, organ space infections, pneumonia, pulmonary embolism, ventilator dependence longer than 48 hours, acute kidney injury, urinary tract infection, cardiac arrest requiring cardiopulmonary resuscitation, bleeding requiring blood transfusions, sepsis, and septic shock. Descriptions of these variables can be found in the ACS NSQIP participant user guide.11

Incidences of primary and secondary outcomes were determined, as were their association with patient variables. Patient variables that were associated with a statistically significant increase in mortality and postoperative complications were entered into a logistic regression to determine which were predictive.

Scale variables were reported as the median secondary to skewness.

16 013a


We identified 1007 (64.6% women and 35.1% men) superelderly patients who underwent cholecystectomy as their primary hospital procedure between 2005 and 2012. Of the 1007 cholecystectomies, 791 (78.6%) were laparoscopic and 216 (21.4%) were open procedures. Of the open procedures, 41 started out as laparoscopic but subsequently converted to open procedures. Ten (24%) of these laparoscopic converted to open procedures were emergent. Eight hundred seven (80%) of the cholecystectomies were nonemergent and 200 (20%) were performed emergently. The rate of cholecystectomies captured over the study period rose by 2.26 per 10,000: from 1.64 per 10,000 in 2005 to 3.9 per 10,000 in 2012. Using rate calculations takes into consideration increases in patient volume and hospital participation over the study period. Figure 1 shows the number of cholecystectomies captured per year by the NSQIP database.

Thirty-Day Mortality

The overall mortality was 5.5%. The mortality for open cholecystectomy was 12% compared with 3.7% for laparoscopic cholecystectomy (p < 0.001). For laparoscopic converted to open procedures, the mortality was 12.2% (p < 0.001). During the study period, the mortality for open cholecystectomy decreased from 20% to 10.3% (p = 0.874). The mortality for laparoscopic cholecystectomy decreased from 5% to 2.7% during the study period (p = 0.322, Figure 2). The mortality for nonemergent cholecystectomy was 4.5% and for emergent cholecystectomy was 9.5% (p = 0.005). There was no statistically significant difference in the overall mortality of women and men (6.1% and 4.2%, respectively).

Predictors of Mortality

Table 2 shows patient variables associated with a statistically significant increase in mortality. When all of these variables were entered into a logistic regression model, totally dependent functional status before surgery (odds ratio [OR] = 19.3, p < 0.001), impaired sensorium (OR = 6.1, p = 0.013), postoperative myocardial infarction (OR = 31.3, p = 0.008), septic shock (OR = 8.9, p = 0.009), and open cholecystectomy (OR = 5.4, p < 0.001) were predictive of mortality (Table 3).


Overall, 17.1% of patients had at least 1 postoperative complication. Of those who underwent open cholecystectomy as their primary procedure, 32% had at least 1 complication compared with 13.1% in those who underwent laparoscopic cholecystectomy (p < 0.001). In the laparoscopic converted to open cholecystectomy group, 26.8% of patients had at least 1 complication (p < 0.001). Bleeding requiring blood transfusion was the most common postoperative complication, with an incidence of 3.6%. There was no statistically significant difference in international normalized ratio between those who had a bleeding complication necessitating blood transfusion and those who did not. Pneumonia (3.3%), urinary tract infection (2.7%), ventilator dependence longer than 48 hours (2.7%), and unplanned reintubation (2.6%) were the next most common complications.

Predictors of Complications

Table 4 shows patient variables associated with a statistically significant increase in postoperative complications. When these variables were entered into a logistic regression, Hispanic race (OR = 4.89, p = 0.007), smoking (OR = 4.87, p = 0.019), totally dependent functional status (OR = 3.49, p = 0.001), preoperative acute renal failure (OR = 7.64, p = 0.018), corticosteroid use for chronic condition (OR = 4.05, p = 0.001), sepsis (OR = 2.54, p < 0.001), systemic inflammatory response syndrome (OR = 2.32, p = 0.001), and open cholecystectomy (OR = 2.19, p = 0.001) were predictive of postoperative complications (Table 5).

Length of Stay and Duration of Procedure

The median length of stay for open cholecystectomy was 9 days compared with 5 days for laparoscopic (p < 0.001). For nonemergent cholecystectomy it was 5 days compared with 7 days for emergent procedures (p < 0.001). The median length of stay for cases with 1 or more complications was 10 days compared with 5 days for cases with no complications (p < 0.001). The median operative time for laparoscopic cholecystectomy was 64 minutes compared with 85 minutes for open cholecystectomy (p < 0.001). Operative time for emergent procedures was 76 minutes vs 66 minutes for nonemergent cholecystectomy, respectively (p = 0.004).

Transfer Status and Discharge Destination

Eighty-five percent of the patients were transferred from home, 9.3% from a skilled nursing facility, 4.5% from other hospitals, and 1.2% had unknown transfer status. Most of the discharge destinations were unknown (63.1%); 22.4% were discharged to home, 9.4% discharged to a skilled care facility which was not their home, 2.0% were discharged to a facility which was their home, 1.5% were discharged to rehab, 0.4% were discharged to an acute care facility and 0.1% were discharged to an unskilled facility. The discharge destination of 0.8% of patients was documented as “Died.”

16 013


Elderly individuals are the fastest growing segment of the population and are projected to constitute 2% of the US population by 2050.1 Cholecystectomy is the most common general surgery procedure performed in elderly patients because the incidence of gallstones and gallstone complications increases with age.2,4 Unfortunately, elderly patients with gallstone complications are less likely to undergo cholecystectomy than are younger patients.5 Riall et al12 showed less than 25% of elderly patients who met criteria for elective cholecystectomy underwent cholecystectomy. In their study, failure by primary care physicians and Emergency Department physicians to refer patients to surgeons played a role in the low rates of surgical therapy.12 Bergman et al5 also found increasing age to be a negative predictor of undergoing cholecystectomy after an admission for gallstone complications.

Our analysis showed that the mortality for superelderly patients after laparoscopic and open cholecystectomy was 3.7% and 12% respectively, significantly higher than the mortality rate of 0.3% and 3.8% for laparoscopic and open cholecystectomy, respectively, in the general population.13 The mortality of laparoscopic converted to open cholecystectomy was similar to that of open procedures, at 12.2%. The increased mortality in superelderly individuals is expected because age has been shown to be an independent predictor of mortality.8,14 Our overall mortality of 5.5% was similar to that observed by Dubecz et al15 but remarkably lower than the mortality rate of 10.5% observed by Lee16 in a study of patients age 80 years and older.

Hispanic race was predictive of postoperative complications. In their study based on the Veterans Affairs NSQIP database, Ibrahim et al17 also found that Hispanic race was predictive of postoperative complications after knee arthroplasty. Minority patients are more likely than white patients to be underinsured, and this may result in delayed presentation and poorer outcomes.18 Unfortunately, the exact reason for the racial disparity remains unexplained and needs further investigation.

The cholecystectomy rate captured during the study period increased by 2.26 per 10,000, reflecting an increase in the number of superelderly patients in the population as well as an increase in NSQIP participation.19,20 The number of superelderly patients tripled between 1980 and 2010.21 In 2004, there were 18 participating hospitals in NSQIP, but by 2016 the number of participating hospitals had grown to 743.22,23

Emergent procedures carried a higher risk of death than did nonemergent procedures (9.5% vs 4.5%, p < 0.001). In addition, postoperative length of stay was longer after emergent cholecystectomy. This finding is consistent with prior studies24-27 and is likely secondary to an inability to perform medical optimization preoperatively. Early identification of symptomatic cholelithiasis and subsequent nonemergent cholecystectomy may reduce the number of emergent procedures required.

Laparoscopic cholecystectomies were associated with a lower mortality, morbidity, and length of stay than were open cholecystectomies. Consistent with results of other studies,5,28-30 open cholecystectomy was also predictive of mortality and postoperative complications. Given the data supporting the advantages of laparoscopic cholecystectomy, it is interesting that 216 (21.4%) of the patients in our study underwent open cholecystectomy; however, this finding is consistent with existing data that show rates of open cholecystectomy are higher in elderly patients.5,16 This is presumed to be secondary to increased severity of gallbladder disease in this patient population as well as a lower threshold for conversion to open surgery by surgeons.5 Given the high mortality and morbidity associated with open cholecystectomy in this age group, we recommend a laparoscopic approach when possible and a high threshold for conversion to open cholecystectomy. Subtotal laparoscopic cholecystectomy should also be considered as an alternative to open cholecystectomy in especially difficult cases because the mortality associated with laparoscopic subtotal cholecystectomy is lower than that of open cholecystectomy.31,32 Bile leaks are the most frequent complication after subtotal laparoscopic cholecystectomy, but these usually resolve spontaneously or can easily be managed with postoperative endoscopic retrograde cholangiopancreatography.31-33

Poor preoperative functional status was predictive of postoperative mortality and complications in the present study. Multiple studies have shown that poor functional status is predictive of postoperative morbidity and mortality; however, the exact etiology remains unclear.34,35 Attempts should be made to improve these patients’ functional status before considering surgery. In those who present with acute cholecystitis whose functional status cannot be improved on, nonoperative intervention with a percutaneous cholecystostomy tube should be considered. Cholecystostomy tubes have been shown to be effective in the treatment of cholecystitis in high-risk patients, with overall lower mortality than for emergent cholecystectomy.36,37 Howard et al38 demonstrated the use of cholecystostomy tubes in 3 high-risk patients older than age 85 years. Wang et al,39 in a retrospective study that included 184 patients, showed only a 9.2% recurrence rate of cholecystitis after initial treatment with cholecystostomy tubes. Their study, as well as others, demonstrate the use of cholecystostomy tubes as a definitive treatment of cholecystitis and as a bridge to elective cholecystectomy.36-39

Consistent with results of prior studies, postoperative myocardial infarction increased the risk of death after surgery.40-42 Sepsis, systemic inflammatory response syndrome, smoking, and corticosteroid use were predictive of postoperative complications, congruent with the existing literature.43-46 Smoking cessation at least 4 weeks before elective procedures will reduce postoperative pulmonary and wound complications.45

Preoperative acute delirium and septic shock were predictive of mortality. Delirium in this population was likely a sign of organ failure secondary to sepsis. Interestingly, preoperative comorbidities were not predictive of morbidity or mortality. This was an unexpected finding but is consistent with results of previous studies.8,47,48

The most common complication was bleeding requiring a blood transfusion, followed closely in frequency by pneumonia. Similarly, Donkervoort et al49 found bleeding and pneumonia to be the leading complications of laparoscopic cholecystectomy in elderly patients (age > 65 years). Increasing age is an independent risk factor for postoperative pulmonary complications secondary to age-related reduction in pulmonary compliance, reduced responsiveness to hypoxia and hypercapnia, and diminished oropharyngeal protective reflexes.50-53 The reason for the high rate of bleeding necessitating blood transfusion may be lower hemoglobin concentration at admission in this age group because anemia is more prevalent in elderly patients.54 Advanced age is not associated with major alterations in the coagulation cascade, and consequently age alone does not increase the risk of bleeding.55 There was no statistically significant difference in the international normalized ratio of those with postoperative bleeding necessitating blood transfusion compared with those without this complication.

In patients with good preoperative functional status, the risk of cholecystectomy must be balanced against the risk of recurrent gallstone complications, which is estimated to be between 25% and 47.7%.4,56,57 The preoperative gallstone nomogram developed by Parmar et al57 is a useful tool for predicting risk of recurrent gallstone complications and can help surgeons weigh the risk of nonoperative intervention against the risk of recurrence.

Our study has a number of limitations. The incidence of bile duct injury, an important complication after cholecystectomy, is not captured in the ACS NSQIP database. Also, ACS NSQIP collects data exclusively from participating hospitals; consequently, our results may not be applicable to nonparticipating hospitals. Additionally, the ACS NSQIP database collects data only up to 30 days postoperatively; subsequently, our outcomes were limited to this period, and the results of our study may have been different if patients were followed for a longer time. The confidence intervals for the predictors of mortality and complications were wide because of low contribution of the predictor owing to very low numbers. This was particularly evident for corticosteroid use and myocardial infarction; however, all results were statistically significant. Given the low number of superelderly patients in the population, low “N” values were unavoidable. A larger study is needed to obtain narrower intervals but may be difficult given the small proportion of superelderly patients compared with the rest of the population. We were unable show the impact of surgery on the loss of dependence as indicated by discharge to a skilled nursing facility because the discharge destination of most of the patients was unknown. Last, given the retrospective nature of our study the potential for bias exists.


An increasing number of superelderly patients (age 90 years or older) present with symptomatic gallstones, and surgeons are frequently faced with the question, “Are they too old for surgery?” Our results show that cholecystectomy in superelderly patients has a mortality rate of 5.5% and a complication rate of 17.2%. The mortality and morbidity rates for laparoscopic and elective procedures were significantly lower than those for open and emergent procedures. Superelderly patients with poor functional status are at increased risk of death and complications after cholecystectomy, and nonoperative management with cholecystectomy tubes should be considered for these patients.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.


Kathleen Louden, ELS, of Louden Health Communications provided editorial assistance.

How to Cite this Article

Irojah B, Bell T, Grim R, Martin J, Ahuja V. Are they too old for surgery? safety of cholecystectomy in superelderly patients (≥ age 90). Perm J 2017;21:16-013. DOI:

1.    Ortman JM, Velkoff VA, Hogan H. An aging nation: The older population in the United States. Current population reports. P25-1140 [Internet]. Washington, DC: United States Census Bureau; 2014 May [cited 2016 Sep 12]. Available from:
    2.    Siegel JH, Kasmin FE. Biliary tract diseases in the elderly: Management and outcomes. Gut 1997 Oct;41(4):433-5. DOI:
    3.    Khang KU, Wargo JA. Gallstone disease in the elderly. In: Rosenthal RA, Zenilman ME, Katlic MR, editors. Principles and practice of geriatric surgery. 1st ed. New York, NY: Springer-Verlag New York, Inc; 2001. p 690-710.
    4.    Riall TS, Zhang D, Townsend CM Jr, Kuo YF, Goodwin JS. Failure to perform cholecystectomy for acute cholecystitis in elderly patients is associated with increased morbidity, mortality, and cost. J Am Coll Surg 2010 May;210(5):668-77. DOI:
    5.    Bergman S, Sourial N, Vedel I, et al. Gallstone disease in the elderly: Are older patients managed differently? Surg Endosc 2011 Jan;25(1):55-61. DOI:
    6.    García-Alonso FJ, de Lucas Gallego M, Bonillo Cambrodón D, et al. Gallstone-related disease in the elderly: Is there room for improvement? Dig Dis Sci 2015 Jun;60(6):
1770-7. DOI:
    7.    Wargo JA, Kahng KU. Benign disease of the gallbladder and pancreas. In: Rosenthal RA, Zenilman ME, Katlic MR, editors. Principles and practice of geriatric surgery. 2nd ed. New York, NY: Springer Science + Business Media LLC; 2011. p 957.
    8.    Turrentine FE, Wang H, Simpson VB, Jones RS. Surgical risk factors, morbidity,
and mortality in elderly patients. J Am Coll Surg 2006 Dec;203(6):865-77. DOI:
    9.    About ACS NSQIP [Internet]. Chicago, IL: American College of Surgeons; c1996-2016 [cited 2015 Jul 27]. Available from:
    10.    ACS NSQIP participant use data file [Internet]. Chicago, IL: American College of Surgeons; c1996-2016 [cited 2016 Aug 24]. Available from:
    11.    American College of Surgeons National Surgical Quality Improvement Program. User guide for the 2011 participant use data file [Internet]. Chicago, IL: American College of Surgeons; 2012 Oct [cited 2015 Oct 11]. Available from:
    12.    Riall TS, Adhikari D, Parmar AD, et al. The risk paradox: Use of elective cholecystectomy in older patients is independent of their risk of developing complications. J Am Coll Surg 2015 Apr;220(4):682-90. DOI:
    13.    Ingraham AM, Cohen ME, Ko CY, Hall BL. A current profile and assessment of North American cholecystectomy: Results from the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg 2010 Aug;211(2):176-86. DOI:
    14.    Cook TM, Day CJ. Hospital mortality after urgent and emergency laparotomy in patients aged 65 yr and over. Risk and prediction of risk using multiple logistic regression analysis. Br J Anaesth 1998 Jun;80(6):776-81. DOI:
    15.    Dubecz A, Langer M, Stadlhuber RJ, et al. Cholecystectomy in the very elderly—is 90 the new 70? J Gastrointest Surg 2012 Feb;16(2):282-5. DOI:
    16.    Lee W. Cholecystectomy in octogenarians: Recent 5 years’ experience. Korean J Hepatobiliary Pancreat Surg 2013 Nov;17(4):162-5. DOI:
    17.    Ibrahim SA, Stone RA, Han X, et al. Racial/ethnic differences in surgical outcomes in veterans following knee or hip arthroplasty. Arthritis Rheum 2005 Oct;52(10):3143-51. DOI:
    18.    Pourat N, Rice T, Kominski G, Snyder RE. Socioeconomic differences in Medicare supplemental coverage. Health Aff (Millwood) 2000 Sep-Oct;19(5):186-96. DOI:
    19.    Werner CA. The older population: 2010. 2010 census briefs [Internet]. Washington, DC: United States Census Bureau; 2011 Nov [cited 2016 May 1]. Available from:
    20.    Irani JL. Participation in quality measurement nationwide. Clin Colon Rectal Surg 2014 Mar;27(1):14-8. DOI:
    21.    Census bureau releases comprehensive analysis of fast-growing 90-and-older population [Internet]. Washington, DC: United States Census Bureau; 2011 Nov 17 [cited 2016 Aug 24]. Available from:
    22.    Hall BL, Hamilton BH, Richards K, Bilimoria KY, Cohen ME, Ko CY. Does surgical quality improve in the American College of Surgeons National Surgical Quality Improvement Program: An evaluation of all participating hospitals. Ann Surg 2009 Sep;250(3):363-76. DOI:
    23.    ACS NSQIP: Participants [Internet]. Chicago, IL: American College of Surgeons; c1996-2016 [cited 2016 May 23]. Available from:
    24.    Fukuda N, Wada J, Niki M, Sugiyama Y, Mushiake H. Factors predicting mortality in emergency abdominal surgery in the elderly. World J Emerg Surg 2012 May 11;7(1):12. DOI:
    25.    Keller SM, Markovitz LJ, Wilder JR, Aufses AH Jr. Emergency and elective surgery in patients over age 70. Am Surg 1987 Nov;53(11):636-40.
    26.    Abbas S, Booth M. Major abdominal surgery in octogenarians. N Z Med J 2003 Apr 17;116(1172):U402.
    27.    Blansfield JA, Clark SC, Hofmann MT, Morris JB. Alimentary tract surgery in the nonagenarian: Elective vs emergent operations. J Gastrointest Surg 2004 Jul-Aug;8(5):539-42. DOI:
    28.    Sandblom G, Videhult P, Crona Guterstam Y, Svenner A, Sadr-Azodi O. Mortality after a cholecystectomy: A population-based study. HPB (Oxford) 2015 Mar;17(3):239-43. DOI:
    29.    Zacks SL, Sandler RS, Rutledge R, Brown RS Jr. A population-based cohort study comparing laparoscopic cholecystectomy and open cholecystectomy. Am J Gastroenterol 2002 Feb;97(2):334-40. DOI:
    30.    Dua A, Aziz A, Desai SS, McMaster J, Kuy S. National trends in the adoption of laparoscopic cholecystectomy over 7 years in the United States and impact of laparoscopic approaches stratified by age. Minim Invasive Surg 2014;2014:635461. DOI: https://doi/org/10.1155/2014/635461.
    31.    Shingu Y, Komatsu S, Norimizu S, Taguchi Y, Sakamoto E. Laparoscopic subtotal cholecystectomy for severe cholecystitis. Surg Endosc 2016 Feb;30(2):526-31. DOI:
    32.    Harilingam MR, Shrestha AK, Basu S. Laparoscopic modified subtotal cholecystectomy for difficult gall bladders: A single-centre experience. J Minim Access Surg 2016 Oct-Dec;12(4):325-9. DOI:
    33.    Elshaer M, Gravante G, Thomas K, Sorge R, Al-Hamali S, Ebdewi H. Subtotal cholecystectomy for “difficult gallbladders”: Systematic review and meta-analysis. JAMA Surg 2015 Feb;150(2):159-68. DOI:
    34.    Malani PN. Functional status assessment in the preoperative evaluation of older adults. JAMA 2009 Oct 14;302(14):1582-3. DOI:
    35.    Bettelli G. Preoperative evaluation in geriatric surgery: Comorbidity, functional status and pharmacological history. Minerva Anestesiol 2011 Jun;77(6):637-46.
    36.    Li JC, Lee DW, Lai CW, Li AC, Chu DW, Chan AC. Percutaneous cholecystostomy for the treatment of acute cholecystitis in the critically ill and elderly. Hong Kong Med J 2004 Dec;10(6):389-93.
    37.    Yun SS, Hwang DW, Kim SW, et al. Better treatment strategies for patients with acute cholecystitis and American Society of Anesthesiologists classification 3 or greater. Yonsei Med J 2010 Jul;51(4):540-5. DOI:
    38.    Howard JM, Hanly AM, Keogan M, Ryan M, Reynolds JV. Percutaneous cholecystostomy—a safe option in the management of acute biliary sepsis in the elderly. Int J Surg 2009 Apr;7(2):94-9. DOI:
    39.    Wang CH, Wu CY, Yang JC, et al. Long-term outcomes of patients with acute cholecystitis after successful percutaneous cholecystostomy treatment and the risk factors for recurrence: A decade experience at a single center. PLoS One 2016 Jan 28;11(1):e0148017. DOI:
    40.    Manjarrez EC, Mauck KF, Cohn SL. Postoperative cardiac complications. In: Jaffer AK, Grant PJ, editors. Perioperative medicine: Medical consultation and co-management. Hoboken, NJ: John Wiley & Sons, Inc; 2012. p 407-24. DOI:
    41.    Devereaux PJ, Goldman L, Cook DJ, Gilbert K, Leslie K, Guyatt GH. Perioperative cardiac events in patients undergoing noncardiac surgery: A review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk. CMAJ 2005 Sep 13;173(6):627-34. DOI:
    42.    Larsen KD, Rubinfeld IS. Changing risk of perioperative myocardial infarction. Perm J 2012 Fall;16(4):4-9. DOI:
    43.    Moore LJ, Moore FA, Todd SR, Jones SL, Turner KL, Bass BL. Sepsis in general surgery: The 2005-2007 National Surgical Quality Improvement Program perspective. Arch Surg 2010 Jul;145(7):695-700. DOI:
    44.    Grønkjær M1, Eliasen M, Skov-Ettrup LS, et al. Preoperative smoking status and postoperative complications: A systematic review and meta-analysis. Ann Surg 2014 Jan;259(1):52-71. DOI:
    45.    Myers K, Hajek P, Hinds C, McRobbie H. Stopping smoking shortly before surgery and postoperative complications: A systematic review and meta-analysis. Arch Intern Med 2011 Jun 13;171(11):983-9. DOI:
    46.    Ismael H, Horst M, Farooq M, Jordon J, Patton JH, Rubinfeld IS. Adverse effects of preoperative steroid use on surgical outcomes. Am J Surg 2011 Mar;201(3):305-9. DOI:
    47.    Merani S, Payne J, Padwal RS, Hudson D, Widder SL, Khadaroo RG. Predictors of in-hospital mortality and complications in very elderly patients undergoing emergency surgery. World J Emerg Surg 2014 Jul 7;9:43. DOI:
    48.    Leong QM, Aung MO, Ho CK, Sim R. Emergency colorectal resections in Asian octogenarians: Factors impacting surgical outcome. Surg Today 2009;39(7):575-9. DOI:
    49.    Donkervoort SC, Kortram K, Dijksman LM, Boermeester MA, van Ramshorst B, Boerma D. Anticipation of complications after laparoscopic cholecystectomy: Prediction of individual outcome. Surg Endosc 2016 Dec;30(12):5388-940. DOI:
    50.    Smetana GW. Postoperative pulmonary complications: An update on risk assessment and reduction. Cleve Clin J Med 2009 Nov;76 Suppl 4:S60-5. DOI:
    51.    Smetana GW, Conde MV. Preoperative pulmonary update. Clin Geriatr Med 2008 Nov;24(4):607-24. DOI:
    52.    Qaseem A, Snow V, Fitterman N, et al; Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery: A guideline from the American College of Physicians. Ann Intern Med 2006 Apr 18;144(8):575-80. DOI:
    53.    Sprung J, Gajic O, Warner DO. Review article: Age related alterations in respiratory function—anesthetic considerations. Can J Anaesth 2006 Dec;53(12):1244-57. DOI:
    54.    Beghé C, Wilson A, Ershler WB. Prevalence and outcomes of anemia in geriatrics: A systematic review of the literature. Am J Med 2004 Apr 5;116 Suppl 7A:3S-10S. DOI:
    55.    Copplestone JA. Bleeding and coagulation disorders in the elderly. Baillieres Clin Haematol 1987 Jun;1(2):559-80. DOI:
    56.    Trust MD, Sheffield KM, Boyd CA, et al. Gallstone pancreatitis in older patients: Are we operating enough? Surgery 2011 Sep;150(3):515-25. DOI:
    57.    Parmar AD, Sheffield KM, Adhikari D, et al. PREOP-gallstones: A prognostic nomogram for the management of symptomatic cholelithiasis in older patients. Ann Surg 2015 Jun;261(6):1184-90. DOI:


Click here to join the eTOC list or text ETOC to 22828. You will receive an email notice with the Table of Contents of The Permanente Journal.


2 million page views of TPJ articles in PubMed from a broad international readership.


Indexed in MEDLINE, PubMed Central, EMBASE, EBSCO Academic Search Complete, and CrossRef.




ISSN 1552-5775 Copyright © 2021

All Rights Reserved