Geriatric Surgery: Impact of Age on the Operative Decision in Gallstone Disease

Introduction: Elderly patients with gallstone disease often present and are treated differently than their younger counterparts. We hypothesize that these differences also exist within age subgroups of elderly patients. The purpose of this study is to evaluate the relationship between age and disease severity and management of gallstone disease, and to identify the predictors of performing a cholecystectomy.

Methods: This is a single institution retrospective chart review of hospital visits for patients ≥65 with biliary colic, cholecystitis, choledocholithiasis, cholangitis, or biliary pancreatitis, between April 2004 and April 2008. All prior visits for these patients were also reviewed. Disease severity outcomes were diagnosis (colic vs. complicated) at first visit, visit type (emergency department (ED) visit only vs. urgent admission vs. elective admission) and clinical severity score (calculated upon presentation to ED and based on temperature, pulse, BP, WBC, and symptom duration). Management outcomes were occurrence of cholecystectomy, occurrence of cholecystostomy tube, and admitting ward at first visit. Stratified age groups (Group 1: 65-75, Group 2: 75-85, and Group 3: ≥85) were compared using Mantel-Haenszel for proportions. Multivariable logistic regression was used to identify predictors of undergoing cholecystectomy.

Results: 433 patients over 622 hospital visits were included in the analysis. Mean Charlson Comorbidity Index (CCI) for Group 1 (n=203), Group 2 (n=169), and Group 3 (n=61) were 1.5±1.8, 2.2±2.1, and 2.3±1.9, respectively. Disease severity: At first visit, diagnosis was complicated disease in 34.0%, 63.1%, and 70.5% of patients (p<0.0001). 33.5% of group 1 visits represented urgent admissions, increasing to 63.7% and 75.4% in groups 2 and 3. The clinical severity score was 1.1±1.0, 1.4±1.1, and 1.6±1.2 for Groups 1, 2, and 3. Management: Over all visits, cholecystectomy was performed in 90.9% in Group 1, 65.4% in Group 2, and 24.7% in Group 3 (p<0.0001) with equivalent proportions of conversion to open (11.5%, 9.4%, 7.1%). Despite multiple visits, the cumulative incidence of operative management reached early plateaus in the older age groups (figure). Cholecystostomy tubes were used in 3.9%, 12.4%, and 16.4% of Group 1, 2, and 3 patients, respectively. The admitting ward was medical for 7.9% of patients in Group 1, 25.6% in Group 2 and 45.9% in Group 3. Patients who were older (OR=0.18, CI=0.11-0.30), with a complicated diagnosis (OR=0.12, CI=0.07-0.19), and higher CCI (OR=0.75, CI=0.67-0.85) were less likely to have a cholecystectomy.

Conclusion: Older age was associated with more severe gallstone disease and a higher likelihood of non-operative management. Age and diagnosis severity were strongly associated with the decision to perform a cholecystectomy. Comorbidity was also predictive, but to a lesser degree. Whether such different treatment strategies are justified for this population should be questioned by comparing the outcomes of operative and non-operative management.

Session: Podium Presentation

Program Number: S019

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