Gallbladder Surgery at 95: A Case of Acute Necrotising Cholecystitis

Madam A, a 95-year-old patient with a history of high cholesterol and asthma, was admitted to a private hospital under a gastroenterologist following a sudden onset of severe upper abdominal pain. She had experienced the pain earlier that day and had a longstanding history of intermittent bloating and indigestion after meals, symptoms she had never investigated. Prior to admission, she was largely independent, managing daily activities and mobilising at home without assistance.

On admission, a CT scan revealed a grossly distended gallbladder with large stones and significant inflammatory changes. Shortly after the scan, Madam A developed an acute asthmatic attack requiring inhaler and nebuliser treatment.

CT scan images of gallbladder

Madam A was referred to Dr Lee Chin Li late that evening. On assessment, her abdomen was distended and markedly tender on applying gentle pressure over the upper abdomen. She had also spiked a fever of 38.7°C. Together, these findings pointed clearly to an active infection.

Dr Lee discussed the treatment options with Madam A and her family. Two approaches were considered: a gallbladder drainage procedure followed by surgery approximately one month later (interval cholecystectomy), or proceeding directly with gallbladder removal (laparoscopic cholecystectomy).

The drainage-first approach is intended to stabilise the patient and allow the infection to settle before surgery. However, it carries its own risks: the procedure can trigger a bacterial shower that worsens the patient's condition, and if the gallbladder wall has already become necrotic (dead tissue), drainage may not be effective and perforation remains a concern.

Operating on an elderly patient who is not sufficiently stable also carries significant risk. After a joint assessment with the anaesthetist, it was determined that Madam A's breathlessness had improved with medication and that she was in reasonable health for her age. Dr Lee recommended proceeding with surgery.

Intraoperative findings confirmed a necrotic, infected gallbladder containing large stones, with pus present and gangrenous changes to the wall. The cholecystectomy was completed laparoscopically using a keyhole approach.

Intraoperative surgical images

Following surgery, Madam A was monitored in the high dependency unit for one day before being transferred to the general ward, where she remained for a further three days. Given her age, several medical issues required concurrent management, including poorly controlled blood pressure and asthma, and she was co-managed alongside other physicians throughout her stay. She also underwent intensive physiotherapy in the ward to support her recovery.

Madam A recovered well and was discharged without complications. Post-operative histology of the gallbladder returned a diagnosis of acute necrotising cholecystitis alongside an incidental but significant finding: an intrapapillary neoplasm with high-grade dysplasia (a pre-cancerous tumour with a high risk of malignant transformation). Had this gone undetected and untreated, it carried a high likelihood of progressing to aggressive gallbladder cancer. The surgery addressed both conditions and Madam A was considered cured.

Madam A's case reflects the value of a multidisciplinary approach when managing elderly patients with acute presentations. It also underscores that surgical suitability is not determined by age alone. Overall health, functional status and careful pre-operative assessment are far more meaningful indicators of how a patient will tolerate and recover from surgery.

Laparoscopic cholecystectomy, while not considered a major procedure, carries risk like any surgery. Thorough assessment and optimisation of patient’s medical conditions, in this case conducted in collaboration with the anaesthetist and supporting physicians, allow that risk to be minimised and the best possible outcome to be achieved.

Gallbladder cancer is an aggressive and largely silent disease, rarely presenting with obvious symptoms until it has reached an advanced stage. In Madam A's case, the pre-cancerous tumour discovered on histology carried a high likelihood of malignant transformation. Without surgical intervention, she would have faced serious and potentially untreatable cancer. Early action, in this instance, was not just the right clinical decision, it may well have been lifesaving.