Following an open call for participation by ESTES in May 2018, 38 centers expressed interest in participating. 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 .
Patient demographics and clinical characteristics
Three-hundred and thirty-eight individual patients admitted between October 1 and October 31 2018 were enrolled in the study and followed up until 120 days following admission.
Over half (54.7%) of the study cohort were age 65 years or older. The mean age in the ≥65 years group was 79 ± 8 years compared to 47 ± 12 years in the < 65 years group (p = 0.001). There was no statistically significant difference in sex between the groups (59.5% vs. 49.2%, p = 0.075). As depicted in Table 1, patients in the ≥ 65 years group had more comorbidities measured by their Charlson Comorbidity Index (CCI), were less fit for surgery based on their ASA score, were significantly more likely to have a history of ischemic heart disease, congestive heart failure, cerebrovascular disease, insulin-dependent diabetes mellitus, and chronic renal disease compared to patients under 65. Previous abdominal surgical history did not differ between patients under and ≥65 years (37% vs. 34%, p = 0.487) (Table 1).
Cholecystitis was the most common (45.6%) diagnosis in the study cohort, followed by gallstone pancreatitis (21%), common bile duct stone (18%), and cholangitis (13.9%). Five patients (1.5%) had Mirizzi syndrome or bilioenteric fistula. There was no statistical difference in main admitting diagnosis between those under and ≥ 65 years (p = 0.065) (Table 1). The incidence of cholecystitis AAST grade III and V was higher in the ≥ 65 compared to the < 65 years group, 17.4% vs. 5.9% and 2.3% vs. 0% (p = 0.048), respectively. AAST grade IV cholecystitis was more common in the < 65 years group (8.8% vs. 3.5%, p = 0.048) (Table 1). There was no difference in the severity of pancreatitis between the groups based on the AAST grading (Table1).
Of the 338 patients enrolled in the study, 50% underwent surgical intervention, while 50% had not received operative treatment by the end of the 120-day follow-up period. Patients younger than 65 were more likely to undergo index admission cholecystectomy than those ≥ 65 years (64.7% vs. 37.8%, p = 0.001). Cholecystectomy alone was performed in 99.3% of cases . The use of laparoscopy did not differ between age groups (86.9% vs. 80.0%, p = 0.153). Conversion occurred in 14 (8.2%) cases, 5 in patients under 65 (5%) and 9 (12.9%) in those ≥ 65 years of age (p = 0.070). A further thirteen (7.6%) cholecystectomies were performed as open from the beginning of the procedure—eight in patients under 65 years and five in patients ≥ 65 (p = 0.909). Subtotal cholecystectomy was performed in 3 patients ≥ 65 and 1 in under 65 years (p = 0.180). It was not possible to ascertain the reasons for conversion, subtotal cholecystectomy, or primary open cholecystectomy. There was a trend towards shorter time to surgery from admission in the ≥ 65 group [days median (IQR): 1.0 (0.0–3.5) vs. 2.0 (1.0–6.2), p = 0.057] (Table 2).
Patients in the ≥ 65 group underwent endoscopic evaluation and management of the common bile duct more frequently than younger patients, (34.1% versus 22.9%, p = 0.024). Endoscopic Retrograde Cholangiopancreatography (ERCP) with duct clearance and sphincterotomy was the most commonly performed procedure (77.6%), followed by ERCP and stent placement (19.4%), and diagnostic EUS alone (3.1%). Of those patients undergoing ERCP, nine (9.2%) patients experienced complications, namely post-ERCP pancreatitis in six (6.1%) and bleeding in three (3.1%). No procedure was complicated by perforation. Time from admission to endoscopy was significantly longer in patients over the age of 65 years compared with patients under 65 [days Median (IQR): 6.5 (2.2–11.0) vs. 4 (2.0–5.0), p = 0.009] (Table 2).
Interventional radiologic management
Interventional radiologic management of the gallbladder or common bile duct was undertaken in 26 (7.7%) of patients—11 patients under the age of 65 years and 15 patients ≥ 65 (p = 0.752). Cholecystostomy was performed in 23 (88.5%) of these cases, percutaneous radiologic drainage of a collection or abscess was performed in one (3.8%) patient, and percutaneous transhepatic cholangiography was performed in two (7.7%). No complication was recorded for patients undergoing interventional radiologic procedures. Time from admission to intervention radiology intervention did not differ between patients over the age of 65 years compared with patients under 65 [days median (IQR): 2.5 (1.2–9.2) vs. 2 (0.0–6.0), p = 0.358] (Table 2).
Nineteen patients (5.6%) were admitted to ICU for organ failure during their hospital stay—10 (6.5%) patients under 65 and 9 (4.8%) ≥ 65 (p = 0.506). Both postoperative [days median (IQR): 5.0 (3.8–9.2) vs. 3.0 (2.0–6.0), p = 0.002] and total hospital length of stay [days median (IQR): 7.5 (5.0–14.0) vs. 7.0 (4.0–9.0), p = 0.039] (irrespective of diagnosis) was longer for patients ≥ 65 years (Table 2). Conversion to open cholecystectomy doubled the median (IQR) postoperative length of stay from 4.0 (2.0–6.0) to 8.0 (4.0–12.0) days (p = 0.006).
Five deaths were recorded (1.4%) in the total cohort– one (1.4%) patient in those suffering from gallstone pancreatitis, two (4.2%) in patients with cholangitis, and two (1.2%) patients with acute cholecystitis, both of which had an AAST Grade IV cholecystitis. One (0.58%) postoperative death occurred following cholecystectomy for AAST Grade IV cholecystitis. Four deaths occurred in patients ≥65 (2.2%), compared with one (0.7%) under 65 years (p = 0.253). Those patients who died had a significantly higher comorbidity burden, with a median (IQR) age-adjusted CCI (aaCCI) of 12.0 (11.0–12.0) versus 6.0 (3.0–8.0) in surviving patients (p < 0.001). Of the 333 patients surviving to discharge, significantly more patients ≥ 65 years had ongoing morbidity requiring post-acute convalescence or rehabilitation (13.0%), compared with 2% under the age of 65 (p < 0.001). Postoperative complications were reported more frequently in patients over 65 compared with younger patients without statistical significance (18.6% vs. 10.1%, p = 0.114) (Table 3).