Differential Management Strategies and Outcomes in Patients over 65 years with Acute Calculous Biliary Disease—Results and Insights from the ESTES Complicated Biliary Calculous Disease Snapshot Audit

Abstract

Background: Acute complicated calculous biliary disease (ACCBD) may pose challenges in an ageing population. Frailty and comorbidities increase the potential risks of surgery; thus, surgeons may opt to offer operative treatments less often to their older patients. We set out to capture the incidence and treatment algorithms used across Europe to treat older patients presenting with ACCBD.Methods: Analysis of the European Society of Trauma and Emergency Surgery (ESTES) 2018 Acute Complicated Calculous Biliary Disease audit was performed. Patients undergoing emergency hospital admission with ACCBD between 1 October 2018 and 31 October 2018 were included. The primary outcome measure was operative intervention in patients over and under 65 years of age. Mortalities, post-operative morbidity, time to operative intervention, post-acute disposition and length of hospital stay were measured as secondary outcomes.Results: The median age of the 338 patients admitted to the snapshot was 67 years; 185 patients (54.7%) were over 65 years at time of admission. Significantly fewer patients over 65 underwent definitive surgical treatment, compared with those under 65 (37.8% vs. 64.7%, p <0.001). Surgical complications were seen more frequently in the over 65 cohort. Post-operative mortality was seen in 2.2% of over 65s versus 0.7% under 65(p=0.253). Mean post-operative length of stay was significantly longer in the elderly cohort. In patients surviving to discharge, post-acute convalescence or rehabilitation was required in 13.3% in the elderly cohort versus 1.9% of those under 65 (p=0.002).Conclusions: Elderly patients commonly present with ACCBD. Increased frailty and incidence of comorbid disease in this population increases the potential surgical risk. In our snapshot, elderly patients represented the majority, but far fewer were offered definitive surgical treatment. Post-operative mortality, morbidity, length of post-operative in-hospital stay and the requirement for post-discharge convalescence were higher in this group.

Patients over 65 years with Acute Complicated Calculous Biliary Disease are Treated Differently—Results and Insights from the ESTES Snapshot Audit

“…Of those, 25 centers completed the local ethics approval process and enrolled patients in the study. These centers came from 9 countries: Austria, Italy, Ireland, Romania, Spain, Sweden, Portugal, the United Kingdom, and the USA [18].…”

“…All participating centers provided local institutional review board approval or equivalent as a requirement of registration. Center and patient eligibility, as well as data capture, have been reported in previous publication [18].…”

“…In particular, elderly patients appear to accrue excess morbidity and mortality following gallbladder surgery [16]. Acknowledging acute complicated calculous biliary disease (ACCBD) as a common set of clinical problems presented to general surgeons, the Cohort Studies Group of the European Society for Trauma and Emergency Surgery (ESTES) set out to capture real‐world data on the epidemiology, and contemporary management of these patients [17, 18]. Traditional medical school teaching identifies the 6Fs (fair, fat, fertile, female, forty, and family history) as phenotypic predictors of symptomatic gallstone disease [19].…”

“…Traditional medical school teaching identifies the 6Fs (fair, fat, fertile, female, forty, and family history) as phenotypic predictors of symptomatic gallstone disease [19]. Notably, however, the cohort presenting to European emergency departments with acute complicated biliary calculous conditions were older than this teaching suggests, with a median age of 67 years [17, 18].…”

“…Despite consensus in several guidelines, surgical practice patterns regarding older patients with ACCBD appear to vary between centers and even between individual surgeons [17, 18]. This prospective non‐randomized observational cohort study aims to provide granular real‐world data contrasting outcomes in patients over and under 65 years of age and comparing outcomes following operative and non‐operative treatment strategies in patients over 65.…”