老年及高龄胆囊结石诊疗困境与策略思考

Challenges and strategic considerations in the diagnosis and treatment of gallstones in elderly and advanced-age patients

摘要:

随着我国人口老龄化加剧，老年及高龄人群胆囊结石发病率持续升高，严重影响患者预期寿命及生活质量。老年患者常存在生理储备下降、多病共存及临床表现与病理损伤程度不匹配等特点，显著增加胆囊结石诊治难度。近年来，精准个体化医疗理念强调通过多学科综合评估，对老年患者实施“筛查—诊断—评估”的全流程管理，早期识别高危人群并开展干预。对已确诊患者应在积极干预与手术风险之间取得平衡，制定个体化诊疗策略并把握最佳手术时机。腹腔镜胆囊切除术仍为首选治疗方式，但需遵循损伤控制原则。对于高危患者，可采用经皮肝胆囊穿刺引流术作为“两步法”桥接策略以降低围手术期风险。术中可借助吲哚菁绿荧光或术中超声辅助辨识解剖结构，必要时行胆囊次全切除或及时中转开腹。围手术期精细化管理是促进老年患者快速康复的重要环节。未来可依托大数据与人工智能构建适用于中国高龄人群的风险预测模型，推动区域性胆道疾病中心建设，实现从社区筛查到全流程管理的闭环诊疗模式。

Abstract:

With the acceleration of population aging in China, the incidence of gallstones among elderly and advanced-age individuals has continued to rise, seriously affecting patients' life expectancy and quality of life. Elderly patients often present with reduced physiological reserve, multimorbidity, and a mismatch between clinical manifestations and the severity of pathological injury, which markedly increases the difficulty of diagnosis and treatment. In recent years, the concept of precision individualized medicine has emphasized multidisciplinary comprehensive assessment and the implementation of a full-process management model of "screening-diagnosis-evaluation" for elderly patients, enabling early identification of high-risk populations and timely intervention. For patients with confirmed gallstones, it is essential to balance active intervention with surgical risk, formulate individualized treatment strategies, and determine the optimal timing for surgery. Laparoscopic cholecystectomy remains the treatment of choice, but the principles of damage control should be strictly followed. For high-risk patients, percutaneous transhepatic gallbladder drainage can be adopted as a bridging strategy in a "two-step" approach to reduce perioperative risk. Intraoperatively, indocyanine green fluorescence imaging or intraoperative ultrasound may assist in identifying anatomical structures; if necessary, subtotal cholecystectomy or timely conversion to open surgery should be performed to ensure safety. Refined perioperative management is a key component in promoting rapid recovery in elderly patients. In the future, big data and artificial intelligence may help establish risk prediction models tailored to the elderly population in China, facilitate the development of regional biliary disease centers, and ultimately achieve a closed-loop management model ranging from community screening to whole-process care.