Effect of Frailty on the Management of Suspected Choledocholithiasis

Abstract

Introduction The American Society for Gastrointestinal Endoscopy and The Society of American Gastrointestinal and Endoscopic Surgeons (ASGE-SAGES) guidelines for managing choledocholithiasis (CDL) omit patient-specific factors like frailty. We evaluated how frail patients with CDL undergoing same-admission cholecystectomy were managed within ASGE-SAGES guidelines. Methods We analyzed patients undergoing same-admission cholecystectomy for CDL and/or acute biliary pancreatitis (ABP) from 2016 to 2019 at 12 US academic medical centers. Patients were grouped by Charlson comorbidity index into non-frail (NF), moderately frail (MF), and severely frail (SF). ASGE-SAGES guidelines stratified likelihood of CDL and were used to compare actual to suggested management. Rate of guideline deviation was our primary outcome. Secondary outcomes included rates of surgical site infections (SSIs), biliary leaks, and 30-day surgical readmissions. Rates are presented as NF, MF, and SF. Results Among 844 patients, 43.3% (n = 365) were NF, 25.4% (n = 214) were MF, and 31.4% (n = 265) were SF. Frail patients were older (33y vs 56.7y vs 73.5y, P < .0001) and more likely to have ABP (32.6% vs 47.7% vs 43.8%, P = .0005). As frailty increased, guideline deviation increased (41.1% vs 43.5% vs 53.6%, P < .006). Severe frailty was predictive of guideline deviation compared to MF (aOR 1.47, 95% CI 1.02-2.12, P = .04) and NF (aOR 1.46, 95% CI 1.01-2.12, P = .04). There was no difference in SSIs ( P = .2), biliary leaks ( P = .7), or 30-day surgical readmission ( P = .7). Conclusion Frail patients with common bile duct stones had more management deviating from guidelines yet no difference in complications. Future guidelines should consider including frailty to optimize detection and management of CDL in this population.

Association between cholelithiasis and frailty index in US adults: a population-based epidemiological study

“…It involves physiological changes in the neuromuscular, metabolic, immune, and other systems [40]. Frail patients with common bile duct stones may receive non-guideline-concordant management, but preliminary studies suggest that this does not result in any difference in complications [17]. Furthermore, stable cell cycle arrest is associated with macromolecular alterations and the secretion of proin ammatory cytokines and molecules [41].…”

“…Therefore, while dietary therapy, drug therapy, and surgical intervention might be recommended, treating cholelithiasis remains a fundamental challenge [13][14][15][16]. Furthermore, Bergush has identi ed the need for updated guidelines for managing cholelithiasis, taking into account individual patient factors such as frailty [17]. And A substantial body of literature con rms that frailty index is a signi cant risk factor for liver diseases like cirrhosis in patients with frailty [18,19].…”