Heterogeneity of proliferative markers in pancreatic ß-cells of patients with severe hypoglycemia following Roux-en-Y gastric bypass.

AIMS: Severe postprandial hypoglycemia with neuroglycopenia is an increasingly recognized, debilitating complication of Roux-en-Y gastric bypass (RYGB) surgery. Increased secretion of insulin and incretin hormones is implicated in its pathogenesis. Histopathologic examination of pancreas has demonstrated increased islet size and/or nuclear diameter in post-RYGB patients who underwent pancreatectomy for severe refractory hypoglycemia with neuroglycopenia (RYGB + NG). We aimed to determine whether ß-cell proliferation or apoptosis is altered in RYGB + NG. METHODS: We performed an observational study to analyze markers of proliferation, apoptosis, cell cycle, and transcription factor expression in pancreatic tissue from affected RYGB + NG patients (n = 12), normoglycemic patients undergoing pancreatic surgery for benign lesions (controls, n = 6), and individuals with hypoglycemia due to insulinoma (n = 52). RESULTS: Proliferative cell nuclear antigen (PCNA) expression was increased in insulin-positive cells in RYGB + NG patients (4.5-fold increase, p < 0.001 vs. controls) and correlated with ß-cell mass. Ki-67 immunoreactivity was low in both RYGB + NG and controls, but did not differ between groups. Phospho-histone H3 levels did not differ between RYGB + NG and controls. PCNA and Ki-67 were both significantly lower in both controls and RYGB + NG than insulinomas. Markers of apoptosis and cell cycle (M30, p27, and p21) did not differ between groups. PDX1 and menin exhibited similar expression patterns, while FOXO1 appeared to be more cytosolic in RYGB + NG. CONCLUSIONS: Markers of proliferation are heterogeneous in patients with severe post-RYGB hypoglycemia. Increased ß-cell proliferation in some individuals may contribute to increased ß-cell mass observed in severely affected patients.

Who Will Be Able to Perform Open Biliary Surgery in 2025?

BACKGROUND: Although laparoscopic cholecystectomy (LC) is the gold standard, some patients still require an open cholecystectomy (OC). This study evaluates the mean number of OCs performed by each graduating general surgery resident during each of 3 decades. STUDY DESIGN: Data were obtained from all patients undergoing a cholecystectomy during 3 decades: prelaparoscopic era (1981 to 1990), first decade of LC (1991 to 2001), and recent decade of LC (2004 to 2013). Data were prospectively collected and retrospectively reviewed and analyzed by chi-square or Fisher's exact test. RESULTS: Compared with the prelaparoscopic decade, the number of patients undergoing an OC decreased considerably, by 67%, during the first decade of LC, and by 92% during the most recent decade at the 2 core teaching hospitals. Mean number of OCs performed per graduating chief general surgery resident decreased significantly for both laparoscopic decades compared with the prelaparoscopic decade (70.4, 22.4, and 3.6, respectively). In the last decade at the core institutions, 683 (8.8%) patients also underwent an intraoperative cholangiogram (IOC) and 36 (0.5%) underwent common bile duct exploration (CBDE). When biliary cases done at affiliated institutions during the last decade were included, the mean number of OCs (from 3.6 to 10.2), IOCs (from 683 to 2,098), and CBDEs (from 36 to 116) all increased (p < 0.001) per graduating chief general surgery resident. CONCLUSIONS: There has been a considerable decline in the number of OCs, IOCs, and CBDEs available to our trainees during the past 30 years. New training paradigms should include renewed focus on performing an IOC and/or CBDE as clinically indicated during LC; high-quality simulation programs for OC, IOC, and CBDE; and the availability of an advanced video library depicting complicated open biliary procedures.

Has intraoperative cholangiography during laparoscopic cholecystectomy become obsolete in the era of preoperative endoscopic retrograde and magnetic resonance cholangiopancreatography?

BACKGROUND: Preoperative ERCP, magnetic resonance cholangiopancreatography (MRCP), and intraoperative cholangiography (IOC) are standard procedures in evaluating patients with suspected choledocholithiasis. This study evaluates the changing practice patterns over time of these 3 procedures in a large cohort of patients undergoing laparoscopic cholecystectomy (LC) at a single tertiary care center. STUDY DESIGN: Data from all patients undergoing an LC with or without preoperative ERCP, MRCP, or an IOC from January 1, 2004 to December 31, 2013 were retrospectively reviewed from billing data obtained by CPT code and analyzed by chi-square testing. RESULTS: During 10 years, 7,427 patients underwent successful LC. The number of patients undergoing successful IOC (11.9% to 7.6%) or preoperative ERCP (7.2% to 1.5%) decreased significantly during that time interval (p < 0.01). In the last 6 years, 4,506 patients underwent successful LC. The number of patients from this group undergoing a preoperative MRCP (0.9% to 8.6%) or MRCP and ERCP (0.4% to 3.6%) increased significantly (p < 0.001). CONCLUSIONS: Despite a shift from IOC and preoperative ERCP to preoperative MRCP alone or with ERCP, a significant percentage (7.6%) of patients still underwent IOC in 2013. Use of IOC during LC has decreased but is not considered obsolete, rather, it remains a valuable tool for the evaluation of bile duct anatomy, bile duct injury, or suspected choledocholithiasis. Intraoperative cholangiography during uncomplicated LC should be emphasized in teaching programs to insure general surgery resident competency with the procedure.

Contributing factors to postoperative length of stay in laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy for gallbladder disease is a common surgical procedure performed in hospitals throughout the world. This study evaluates the major factors that contribute to postoperative length of stay for patients undergoing laparoscopic cholecystectomy. METHODS: We analyzed data for patients undergoing laparoscopic cholecystectomy in a 5-hospital community health system from December 1, 2008 to January 31, 2009. The natural logarithm of postoperative length of stay was modeled to evaluate significant factors and contributions. RESULTS: Included in the analysis were 232 patients. Three preoperative patient factors were significant contributors: body mass index was associated with decreased postoperative length of stay, while white blood cell count and the presence of biliary pancreatitis were associated with increased postoperative length of stay. The operative factors of fluids administered and ASA class were significant contributors to increased postoperative length of stay, with an increasing contribution with a higher ASA class. The utilization factor of nonelective status was a significant contributor to increased postoperative length of stay. CONCLUSION: Several factors were major contributors to postoperative length of stay, with ASA class and nonelective status having the most significant increased contribution. Efforts to optimize efficient elective care delivery for patients with symptomatic gallbladder disease may demonstrate a benefit of decreased hospital utilization.

Randomized study of natural orifice transluminal endoscopic surgery and endoscopy shows similar hemodynamic impact in a porcine model.

BACKGROUND: A previous porcine study showed a significant difference in heart rate and diastolic blood pressure (DBP) between natural orifice transluminal endoscopic surgery (NOTES) and laparoscopy. This study evaluated the hemodynamics during endoscopy, laparoscopy, and transluminal access. METHODS: For this study, 37 female swine were randomized and invasively monitored in terms of blood and abdominal pressure, heart rate, and arterial blood gas (ABG) during 90-min procedures. Group 1 (n = 11) underwent NOTES peritoneoscopy; group 2 (n = 14) underwent 45-min diagnostic endoscopy, a 10-min washout period, and 35-min laparoscopy with mesh placement; and group 3 (n = 12) NOTES had transgastric mesh placement. The groups were compared using a mixed model and a Spearman trend test. This study was approved by Institutional Animal Care and Use Committee (IACUC). RESULTS: No difference in the systolic blood pressure (SBP) was noted. During the initial 30 min, DBP increased significantly from baseline in groups 1 (p < 0.001) and 2 (p = 0.01), but not in group 3 (p = 0.08). The mean DBP did not differ between the groups. During laparoscopy, the average end-tidal carbon dioxide (CO(2)) level was 6.6 mmHg higher in group 2 than in group 1 (p = 0.01). The heart rate and ABG values did not differ between the groups (p ≥ 0.10). CONCLUSION: Heart rate and DBP were similar for NOTES and endoscopy. The differences seen in a previous trial comparing NOTES and laparoscopy were not duplicated. The initial DBP increased for the endoscopy and diagnostic NOTES animals. Differences in end-tidal CO(2) were encountered again during the shortened laparoscopy segment.

Music experience influences laparoscopic skills performance.

BACKGROUND: Music education affects the mathematical and visuo-spatial skills of school-age children. Visuo-spatial abilities have a significant effect on laparoscopic suturing performance. We hypothesize that prior music experience influences the performance of laparoscopic suturing tasks. METHODS: Thirty novices observed a laparoscopic suturing task video. Each performed 3 timed suturing task trials. Demographics were recorded. A repeated measures linear mixed model was used to examine the effects of prior music experience on suturing task time. RESULTS: Twelve women and 18 men completed the tasks. When adjusted for video game experience, participants who currently played an instrument performed significantly faster than those who did not (P<0.001). The model showed a significant sex by instrument interaction. Men who had never played an instrument or were currently playing an instrument performed better than women in the same group (P=0.002 and P<0.001). There was no sex difference in the performance of participants who had played an instrument in the past (P=0.29). CONCLUSION: This study attempted to investigate the effect of music experience on the laparoscopic suturing abilities of surgical novices. The visuo-spatial abilities used in laparoscopic suturing may be enhanced in those involved in playing an instrument.

Can gastric irrigation prevent infection during NOTES mesh placement?

BACKGROUND: Natural orifice transluminal endoscopic surgery (NOTES) ventral hernia repair could avoid abdominal wall incisions. The infectious risk for mesh placement is of concern. We compared NOTES with laparoscopic mesh placement. METHODS: Thirty-seven swine were randomized to abdominal wall polypropylene mesh placement via NOTES or laparoscopy or NOTES control. All animals received antibiotics and gastric irrigation; the laparoscopy group also received preoperative acid suppression. In the NOTES mesh group, the 2-cm(2) polypropylene mesh was placed using a transgastric transportation device and clipped to the anterior abdominal wall. The control animals underwent endoscopy (no gastrotomy) followed by laparoscopic mesh placement or NOTES only without mesh placement. Necropsy was performed at 14 days. RESULTS: One NOTES mesh placement was incomplete (endoscope failure). All mesh animals survived to 14 days. At necropsy, significantly more mesh infections were noted in the NOTES mesh versus laparoscopy group (4:11 vs 0:14; p = 0.03). Gastric irrigation reduced the bacterial load significantly in all groups (p < 0.001). Infection was independent of gastric bacterial load. No difference between acid suppressed and non-suppressed animals was seen. CONCLUSION: The mesh placement via NOTES is technically feasible but has a high infection rate despite irrigation. Sterile conduits are needed to enable NOTES-type hernia repair with mesh.

Randomized blinded trial shows relative thrombocytopenia in natural orifice translumenal endoscopic surgery compared with standard laparoscopy in a porcine survival model.

BACKGROUND: Anecdotal reports of natural orifice translumenal endoscopic surgery (NOTES) procedures in patients are emerging. Whether the new procedure truly is less invasive is not known. Perioperative hematologic parameters during NOTES was compared with those during standard laparoscopy. METHODS: For this study, 12 swine were randomized to transgastric peritoneoscopy with air or diagnostic laparoscopy using carbon dioxide. Arterial and venous catheters provided cardiopulmonary parameters and blood draws at baseline and up to 7 days postoperatively. The animals survived for 14 days. Data were analyzed by an investigator blinded to the procedure performed. Treatments were contrasted in terms of the mean outcome using a repeated measures linear model. RESULTS: All experiments were successfully completed. No gastric leak or peritonitis resulted. One NOTES animal died of hemorrhagic gastritis on postoperative day 3 due to bleeding distant from the gastrotomy site. Two animals in the laparoscopy group and one animal in the endoscopy group experienced respiratory compromise requiring disinflation. A widening pulse pressure and lower bladder pressure were observed in the NOTES group compared with the laparoscopy group (p < 0.001). Pre- and postoperative laboratory results showed an increase in the white blood cell count (1,000/ml) from 16.83 +/- 1.94 in the laparoscopy group and 15.17 +/- 0.41 in the NOTES group at baseline to 24.17 +/- 3.25 and 23.33 +/- 3.88, respectively, on postoperative day 7, but no difference between the groups (p = 0.6). The platelet count (1,000/ml) showed a difference between the two groups, changing from 422.5 +/- 97.49 to 446.33 +/- 89.86 in the laparoscopy group and from 368 +/- 105 to 299.5 +/- 161.9 in the NOTES group (p = 0.03). CONCLUSION: Significant differences in measured but not clinically apparent parameters were encountered. A potentially significant thrombocytopenia clinically was encountered in the NOTES group. The physiologic impact of NOTES procedures beyond the absence of abdominal incisions should be investigated further.

Randomized blinded trial comparing the cardiopulmonary effects of NOTES with standard laparoscopy in a porcine survival model.

BACKGROUND: Anecdotal reports of natural orifice translumenal endoscopic surgery (NOTES) procedures in patients are emerging. Whether the new procedure is truly less invasive is not known. We compared perioperative cardiopulmonary parameters during NOTES with standard laparoscopy. METHODS: Twelve swine were randomized to transgastric peritoneoscopy with air or diagnostic laparoscopy with CO(2). Cardiopulmonary parameters were invasively monitored. Animals were survived for 14 days. Data were analyzed by an investigator blinded to the procedure performed. Treatments were contrasted on the mean outcome using a repeated measures linear model. RESULTS: All experiments were successfully completed. No gastric leak or peritonitis resulted. Two hundred and fifty cubic centimeters of saline irrigation was adequate to decrease gastric contamination. Respiratory compromise requiring desufflation resulted in two laparoscopy and one endoscopy animal. Mean arterial oxygen saturation remained at baseline for the NOTES group and decreased by 1.5 +/- 1.5% in the laparoscopic group (p < 0.001). Mean arterial pH dropped significantly lower in the laparoscopy versus the NOTES group (-0.09 +/- 0.06 versus -0.05 +/- 0.05, p = 0.01). Mean systolic blood pressure (Sbp) in both groups remained unchanged from the respective baseline (p = 0.45). Mean diastolic blood pressure (Dbp) showed a mean difference of 19 +/- 1.5 mmHg between the groups (p < 0.001), increasing from baseline for the laparoscopy group and decreasing significantly from baseline in the NOTES group (+2.4 +/- 12.5 versus -6.1 +/- 7.0 mmHg, p < 0.001). Mean heart rate increased significantly from baseline in the laparoscopy group compared to the NOTES group (15.0 +/- 23.4 versus 3.8 +/- 19.0 bpm, p = 0.004). A widening pulse pressure resulted in the NOTES group compared to the laparoscopy group (p < 0.001). The mean bladder pressure was 14.6 +/- 8.0 cmH(2)O in the laparoscopy group compared to 7.1 +/- 7.1 cm H(2)O the NOTES group (p < 0.001). CONCLUSION: Significant differences in measured but not clinically apparent cardiopulmonary parameters were encountered. The difference in insufflation gas, different vagal or catecholamine response may be contributing to these findings.

The Mirizzi syndrome: multidisciplinary management promotes optimal outcomes.

The Mirizzi syndrome (MS) is a rare cause of obstructive jaundice produced by the impaction of a gallstone either in the cystic duct or in the gallbladder, resulting in stenosis of the extrahepatic bile duct and, in severe cases, direct cholecystocholedochal fistula formation. Sixteen patients were treated for MS in our center over the 12-year period 1993--2005 for a prevalence of 0.35% of all cholecystectomies performed. One patient was diagnosed only at the time of cholecystectomy. The other 15 patients presented with laboratory and imaging findings consistent with choledocholithiasis and underwent preoperative endoscopic retrograde cholangiopancreatography, which established the diagnosis in all but one patient. All patients underwent cholecystectomy. An initial laparoscopic approach was attempted in 14 patients, of whom 11 were converted to open procedures. MS was recognized operatively in 15 patients with definitive stone extraction and relief of obstruction in 13 patients. T-tubes were placed in 10 patients and 1 patient required a choledochoduodenostomy. Two patients required postoperative laser lithotripsy via a T-tube tract to clear their stones; and in another patient, MS was detected and treated via postoperative endoscopic retrograde cholangiopancreatography (ERCP). MS remains a serious diagnostic and therapeutic challenge for endoscopists and biliary surgeons.

Randomized double-blinded trial investigating the impact of a curriculum focused on error recognition on laparoscopic suturing training.

BACKGROUND: Error recognition predicts technical skill. A curriculum including error recognition may improve laparoscopic suturing performance. METHODS: Thirty novices were randomized into 2 groups. Each viewed an instruction videotape and underwent timed objective structured assessments of technical skills. Group A practiced the task, group B viewed an error-instruction video, practiced, followed by re-assessment. Participants counted errors on a videotape. Data were analyzed with the Fisher exact text, the Wilcoxon test, and the Kendall tau test. RESULTS: The improvement in task time was greater in group A than in group B (P < .001). The objective structured assessments of technical skills scores improved for both groups, but did not reveal differences between the groups. Group B recognized significantly more errors than group A (P < 0.001). CONCLUSIONS: The additional error instruction showed a negative impact on performance speed, but improved cognitive error recognition. Whether visual memory overload influenced the outcome requires further examination.

Imaging in bariatric surgery: a guide to postsurgical anatomy and common complications.

OBJECTIVE: This article reviews the various bariatric surgical techniques and the associated imaging findings of normal postoperative anatomy and of common complications. CONCLUSION: Bariatric surgery is increasingly performed to control morbid obesity secondary to failed medical approaches. As a result, imaging plays an important role in postoperative evaluation and management. Practical knowledge of postsurgical anatomy allows accurate interpretation of imaging findings related to normal postsurgical anatomy and common postsurgical complications.

Long-term outcomes in laparoscopic vs open ventral hernia repair.

OBJECTIVE: To investigate whether there was a difference in morbidity, recurrence rate, and length of hospital stay between patients undergoing open or laparoscopic incisional hernia repair. DESIGN AND SETTING: Single-institution cohort study. We compared prospectively collected patient cohorts undergoing laparoscopic or open intraperitoneal onlay mesh repair. Statistical analysis was performed by Fisher exact test and analysis of variance. PATIENTS: Between October 1995 and December 2005, data from 360 consecutive patients who had undergone open or laparoscopic intraperitoneal onlay mesh repair of a ventral hernia were prospectively collected in a database and were supplemented by record review. MAIN OUTCOME MEASURES: Morbidity, hernia recurrence, and length of hospital stay. Postoperative complications of Clavien grade II or greater were considered major complications. RESULTS: Intraperitoneal onlay mesh repair was performed in 233 patients by the open approach and in 127 patients using the laparoscopic approach. The groups were similar for sex and body mass index (calculated as the weight in kilograms divided by the height in meters squared); the mean age of the laparoscopic group was 3 years younger; and the mesh was larger in the laparoscopic group. Mean follow-up was 30 and 36 months for the laparoscopic and open groups, respectively; the conversion rate was 4%. Major morbidities were 15% in the open group vs 7% in the laparoscopic group (P = .01). Recurrence rates were 9% in the open group vs 12% in the laparoscopic group (P = .36). Postoperative inpatient admission was more frequent after the open procedure than after the laparoscopic procedure (28% vs 16%, respectively; P<.05). CONCLUSIONS: Outcomes did not differ with respect to recurrence rates after long-term follow-up; however, the lower rate of major morbidity and increased outpatient-based procedure rates favor laparoscopic repair in this study.

Metabolic aspects of bariatric surgery.

Insulin resistance is a nearly universal finding in morbid obesity. It may be compensated and latent or uncompensated with single or multiple clinical abnormalities. Although lifestyle interventions and medical measures alone may control most metabolic problems in the short term, the ultimate benefits of such an approach are usually limited by the complexity of available therapeutic regimens and the difficulty of maintaining full patient compliance. Many studies now document that bariatric surgery can effectively and safely control these complications in the short term and long term or even prevent their occurrence. Further investigations are needed to understand better the mechanisms involved and to define more clearly the appropriate indications and contraindications of the treatments proposed.

Non-developed external oblique aponeurosis in inguinal hernia repair: a case report and discussion of the literature.

Open inguinal hernia repair is one of the most commonly performed operations in the world. It relies heavily on the presence of an inguinal canal formed by the external oblique aponeurosis and conjoint tendon. Variations of the anatomy of this region are rarely described. We describe a patient with bilateral inguinal hernias and missing external oblique aponeurosis. The patient underwent open repair secondary to previous abdominal surgery and the inability to obtain laparoscopic access. A medline search was performed and we provide a synopsis of the literature. At operation, no clear external oblique aponeurosis could be identified and large defects of the transversalis fascia were corrected. CT images of the anatomic variations are provided. To the best of our knowledge, combined abnormalities of the external oblique aponeurosis and transversalis fascia have not been described before.

Gangrenous cholecystitis in the decade before and after the introduction of laparoscopic cholecystectomy.

BACKGROUND: Gangrenous cholecystitis is a severe form of acute cholecystitis with high morbidity. This study investigate the outcomes for patients undergoing cholecystectomy for gangrenous cholecystitis in the decade before and after the introduction of laparoscopic technology at our institution. METHODS: From 1982 to 2002, all patients undergoing cholecystectomy for gangrenous cholecystitis were prospectively entered into a database. Demographic data, method of surgery, and outcome variables were assessed and compared over time. RESULTS: Cholecystectomy was performed to treat gangrenous cholecystitis in 238 patients (mean age, 54 years). From 1982 to 1992, 98 patients underwent cholecystectomy for gangrenous cholecystitis, and from 1992 to 2002, 140 patients underwent the procedure. Ninety-seven patients underwent laparoscopic cholecystectomy, and 33 patients (34%) required conversion. The open and laparoscopic cholecystectomy group differed in the number of intensive care unit admissions (13% vs. 5%, P < 0.05), overall length of hospital stay (10 vs. 5.7 days, P < 0.001) and rate of intraabdominal abscesses (8% vs. 0.7%). CONCLUSION: Gangrenous cholecystitis remains a disease with high morbidity. Laparoscopic cholecystectomy shortened hospital stay and can be offered without increasing morbidity. Methods to decrease intraabdominal abscess formation in patients undergoing laparoscopic cholecystectomy for gangrenous cholecystitis are needed.

Does the correlation of acute cholecystitis on ultrasound and at surgery reflect a mirror image?

BACKGROUND: It remains unclear if sonography accurately describes the severity of gallstone disease. METHODS: Patients were prospectively enrolled if urgent cholecystectomy was indicated. Two radiologists, blinded to operative findings, evaluated the patients' ultrasound imagings. Laparoscopic cholecystectomy was performed within 48 hours. The operative findings regarding gallbladder wall thickness and inflammation were compared to ultrasound results and histology. RESULTS: Fifty-five patients completed the study. Ultrasound studies exhibited a sensitivity of 60% for the diagnosis of acute cholecystitis compared to the findings at operation and 52% relative to the histologic findings. Specificity for acute cholecystitis diagnosed on ultrasound examination was 77% compared to findings at operation and 71% relative to histologic findings. The correlation coefficient of the wall thickness at ultrasound and surgery was 0.18: 0.24 for ultrasound and histology and 0.5 for surgery and histology. CONCLUSIONS: Ultrasound's ability to predict acute cholecystitis in patients with clinical symptoms appears limited.

Adhesion formation after laparoscopic ventral incisional hernia repair with polypropylene mesh: a study using abdominal ultrasound.

OBJECTIVE: Laparoscopic repair of ventral incisional hernias is feasible and safe. Polypropylene mesh is often preferred because of its ease of handling and lower cost. Complications like adhesion and fistula formation can occur. The goal of this study was to determine whether bowel adhesions and their attendant complications could be prevented by interposition of omentum. METHODS: Thirty patients underwent laparoscopic ventral incisional hernias repair with polypropylene mesh. Omentum was always positioned over the loops of bowel for protection. At a mean follow-up of 14 months, 20 patients underwent ultrasonic examination using the previously described visceral slide technique to detect adhesions. RESULTS: The mean size of the hernias in the study was 50.3 cm2, and the mean size of the mesh applied was 275 cm2. Thirteen patents (65%) had no sonographically detectable adhesions. Five patients demonstrated adhesions between the mesh and omentum, 1 patient developed adhesions between the left lobe of the liver and the mesh, and only 1 case of bowel adhesion to the edge of the mesh was found. CONCLUSION: Laparoscopic ventral incisional hernias repair with polypropylene mesh and omental interposition is not associated with visceral adhesions in the majority of patients. Polypropylene mesh can be used safely when adequate omental coverage is available.

Laparoscopic cholecystectomy for elderly patients: gold standard for golden years?

HYPOTHESIS: Laparoscopic cholecystectomy (LC) has known physiological benefits and positive socioeconomic effects over the open procedure. Although recent studies have questioned the technique's efficacy in elderly patients (>65 years), we hypothesize that LC is safe and efficacious in that patient group. METHODS: Five thousand eight hundred eighty-four consecutive patients (mean age, 40 years; 26% male) underwent an attempted LC (conversion rate, 5.2%) from 1991 to 2001 at a teaching institution. Of these, 395 patients (6.7%) were older than 65 years. Analysis included patient age, sex, American Society of Anesthesiologists classification, conversion rate, morbidity, mortality, and assessment of results over time. RESULTS: Elderly patients were predominantly male (64%). Septuagenarians had a 40% incidence of complicated gallstone disease, such as acute cholecystitis, choledocholithiasis, or biliary pancreatitis, and octogenarians had a 55% incidence. Overall mortality was 1.4%. The conversion rate was 17% for the first 5 years of the study period and 7% for the second half. The conversion rate was 22% for patients with complicated disease and 2.5% for patients with chronic cholecystitis. Average hospital stay decreased from 10.2 days to 4.6 days during the first and second half of the study period, respectively. CONCLUSIONS: The results of LC in patients aged 65 to 69 years are comparable with those previously reported in younger patients. Patients older than 70 years had a 2-fold increase in complicated biliary tract disease and conversion rates, but a low mortality rate (2%) compared with results of other authors (12%), despite an increase in American Society of Anesthesiologists classification. Increased technical experience with LC favorably affected outcomes over time. Early diagnosis and treatment prior to onset of complications are necessary for further improvement in the outcomes of elderly patients undergoing LC.