Management of acute cholecystitis in healthy octogenarians – caution or ageism?

Author(s):
Andrea Spota; Amir Hassanpour; Eran Shlomovitz; David Gomez; Eisar Al-Sukhni

Background:

Patients with a surgical illness are increasingly elderly. Despite often coexisting, comorbidity, old age, and frailty do not necessarily confer the same risks or merit the same management. Tokyo guidelines suggest early cholecystectomy for healthy patients with mild/moderate acute cholecystitis (AC).

Hypothesis:

Many healthy octogenarians undergo non-operative management (NOM) instead of recommended cholecystectomy.

Methods:

This was a retrospective cohort study at a Canadian tertiary care center with hepatobiliary surgery coverage. Octogenarian patients with AC from 2018-2023 were identified and their management described. AC severity was graded following Tokyo 2018 guidelines (ie mild, moderate or severe). Comorbidities were reported as Charlson Comorbidity Index (CCI). Frailty was defined using the 5-item modified Frailty Index (5mFI). 30 day follow-up was available from routine clinic visit notes after discharge.

Results:

We identified 116 octogenarian patients (55% male). 45% of patients were functionally independent and 51% were non-frail (5mFI<2). Median CCI was 5 (IQR 4-6).

AC was mild, moderate or severe in 52%, 39% and 9%, respectively. 27% of patients had SIRS, 11% sepsis and 4% septic shock, while 58% had none of these conditions. Management included only antibiotics (41%), percutaneous cholecystostomy (PC) (43%), or cholecystectomy (16%). Compared with patients undergoing NOM (antibiotics +/- PC), patients undergoing surgery were younger (83 vs 87 years, p=0.002), more functionally independent (100% vs 47%, p<0.001), and less frail (5mFI ≥2 21% vs 55%, p=0.011); however, there was no difference in AC severity, CCI, or degree of sepsis. At 30 days, complication rates of NOM and cholecystectomy were 14% and 32%, while death rates were 9% and 0%, respectively. Among 43 healthy octogenarians (CCI=4) with mild/moderate AC, 9 (21%) underwent cholecystectomy and the rest NOM. 65% of NOM patients were functionally independent and 74% were non-frail. There was a trend for lower 30 day complications (3.4% vs 22.2%, p=0.134) and longer LOS (5 vs 3 days, p=0.112) among NOM versus surgery patients. There were no deaths in either group at 30 days. Treatment rationale was not documented for any patients.

Conclusions:

Few healthy octogenarians with mild/moderate AC at our specialized center were treated with surgery, despite guidelines. More research is needed to clarify whether these results reflect patient preference, suboptimal assessment, or surgeon caution.