Frailty Predicts Morbidity and Mortality After Laparoscopic Cholecystectomy for Acute Cholecystitis: An ACS-NSQIP Cohort Analysis

Outcomes after cholecystectomy in patients aged ≥80 years: A National Surgical Quality Improvement Program analysis evaluating safety and risk factors for elderly patients

BACKGROUND

Geriatric patients may be at an increased risk of complications after cholecystectomy; however, quantification of this risk is not defined. We aimed to evaluate outcomes after cholecystectomy in octogenarians and factors independently associated with complications in these patients.

METHODS

This is a retrospective study of 2017 to 2021 National Surgical Quality Improvement Program data evaluating patients undergoing cholecystectomy, comparing patients aged ≥80 years with those aged <80 years. We compared demographics and outcomes with multivariable logistic regression modeling to evaluate factors independently associated with serious complications and mortality or serious complications.

RESULTS

Overall, 288,705 patients were included with 4.9% being octogenarian. Octogenarians were more likely to have comorbidities, functional dependence, and lower body mass index. Octogenarians were more likely to receive open cholecystectomies (7.2% vs 2.8%; P <.001), and they had longer operative time (76.6 vs 70.2 min; P <.001) and hospital stay (4.1 vs 1.6 days; P <.001). They were also more likely to undergo reoperation (1.7% vs 0.9%; P <.001) or have serious complications (9.7% vs 2.9%; P <.001). Multivariable logistic regression demonstrated that being an octogenarian was an independent factor of increased risk of mortality (odds ratio [OR], 3.29; P <.001) and serious complications (OR, 1.54; P <.001). Specific to octogenarians, minimally invasive surgical approach was significantly protective against serious complications (OR, 0.30; P <.001) and mortality (OR, 0.29; P <.001), whereas functional dependence increased likelihood of morbidity (OR, 4.42; P <.001) and serious complications (OR, 2.08; P =.002).

CONCLUSION

Octogenarians have an increased risk of morbidity after cholecystectomy. Minimally invasive surgery seems protective for these patients. Assessment of the octogenarians' functional dependence would provide insight preoperatively into their markedly increased perioperative risk.

A Comparison of Preoperative Frailty Indices Correlation with Perioperative Risk for Patients Undergoing Sacrocolpopexy

OBJECTIVE

To assess whether frailty as defined by the NSQIP mFI-5 or the RAI-rev indices is correlated with 30-day postoperative outcomes for patients undergoing SCP, and whether one index is more closely correlated than the other.

METHODS

SCPs performed between 2006-2020 were identified in   the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database. Frailty was calculated using two indices: the NSQIP modified frailty index (mFI-5), and the revised surgical Risk Analysis Index (RAI-rev). mFI-5 scores and RAI-rev scores were analyzed as continuous variables. Binary logistic regression and t-test analyses were performed to apply mFI-5 and RAI-rev as predictors of surgical complications, 30-day readmissions, 30-day mortality, and hospital length of stay (LOS).

RESULTS

We identified 9,082 SCPs between 2006-2020. Minor complications were experienced by 5.2% of patients, and 3.9% of patients experienced major complications. The 30-day readmission and mortality rates were 2.8% and 0.02%, respectively. The mFI-5 was significantly associated with increased odds of major complications overall, failure to wean ventilator, myocardial infarction, septic shock, and 30-day readmission. The RAI-rev, on the other hand, was associated with increased odds of individual complications such as pneumonia, failure to wean ventilator, renal failure, CVA, cardiac arrest, myocardial infarction, and septic shock.

CONCLUSIONS

Frailty may be a useful predictor of complications after SCP, depending on which frailty index is used. The mFI-5 is significantly associated with increased odds of major complications and 30-day readmission, and may help in the decision making and risk counseling for patients with POP considering SCP.

Outcome prediction after emergency cholecystectomy: performance evaluation of the ACS-NSQIP surgical risk calculator and the 5-item modified frailty index

Pre-operative risk assessment tools and frailty scores are increasingly common due to the growing number of elderly, comorbid and frail patients. This study aims to assess the performance of the ACS-NSQIP-SRC (American College of Surgeons- National Surgical Quality Improvement Program- Surgical Risk Calculator) and the 5mFI (5-items modified Frailty Index) in predicting clinical outcomes after emergency cholecystectomy. This is a retrospective cohort study of patients with acute calculous cholecystitis admitted at our tertiary care center from 2018 to 2023. We evaluated discrimination, calibration, and accuracy of the ACS-NSQIP-SRC and 5mFI in predicting any complication, mortality, length of hospital stay (LOS), need for readmission and supported discharge (30-day follow-up). Among 365/642 patients who underwent surgery, the 5mFI showed poor discrimination for all outcomes but good overall accuracy in the prediction of a supported discharge. In 198 operated patients with available data for the ACS-NSQIP-SRC, it underestimated complications and need for readmission while overestimated the need for supported discharge. There was no concordance between predicted and observed LOS. Among 277/642 patients undergoing non-operative management, 2/3 were frail or mild frail and had a predicted rate of any unfavorable outcome after surgery between 0 and 20%, being 95% above the average risk of each outcome. Mortality couldn't be studied because no death was reported. ACS-NSQIP-SRC and 5mFI performance in predicting outcomes after emergency cholecystectomy for acute cholecystitis was poor. In the emergency cholecystectomy setting, the ACS-NSQIP-SRC may be less informative, and the 5mFI may be excessively simplistic by neglecting the multidimensional nature of frailty.

Sacrocolpopexy in urology versus gynecology: a contemporary analysis of outcomes and patient profiles

INTRODUCTION

With the aging population, more females will suffer from pelvic organ prolapse. Both urologists and gynecologists perform sacrocolpopexy, but there is no comparative study analyzing differences in provision of care, outcomes, or patient population. We aimed to elucidate potential differences in demographics, outcomes, and minimally invasive surgery utilization for SCP performed by urology and gynecology.

METHODS

In our retrospective analysis, sacrocolpopexies were identified using the American College of Surgeons National Surgical Quality Improvement Project database from 2006-2020. Pearson's chi-square test was performed to test trends in the utilization of MIS in five-year blocks. Frailty was calculated using the NSQIP modified frailty index and the revised surgical Risk Analysis Index. Univariate analysis was performed using Student's t-test and Pearson's chi-square to compare operative parameters, frailty, demographics, and outcomes.

RESULTS

We identified 8944 sacrocolpopexies. Gynecology performed 81% of cases while urology performed the remaining 19% (p < 0.001). Between the specialties, there were no significant differences in outcomes, minor or major complications, or 30-day reoperations/hospital readmissions/mortality. However, urologists tended to care for patients who were older (65 vs. 61 years, p < 0.001) and frailer by both frailty indices (p < 0.001).

CONCLUSION

Case distributions have remained stable, with gynecologists four-fold more sacrocolpopexies, in keeping with the larger number of practicing gynecologists vs. urologists. There was no difference in 30-day outcomes between both specialties. However, urologists operated on older, more frail patients.

Gallbladder Cryoablation for Calculous Cholecystitis Initially Treated with Percutaneous Drainage: A Prospective Trial in High-Risk Patients

PURPOSE

To prospectively evaluate the safety and effectiveness of gallbladder cryoablation in patients with calculous cholecystitis initially treated with percutaneous drainage.

MATERIALS AND METHODS

High-operative risk patients with calculous cholecystitis treated with cholecystostomy tube drainage underwent gallbladder cryoablation. The primary end points were safety, defined as the absence of procedure-related adverse events during the follow-up period, and clinical success, defined as the absence of symptoms after cholecystostomy tube removal. The secondary end point was imaging success, defined as gallbladder involution on computed tomography (CT) or magnetic resonance (MR) imaging.

RESULTS

Ten patients underwent gallbladder cryoablation. Mean age was 71 years (SD ± 10; range, 53-90 years). Mean American Society of Anesthesiologists score was 3 (SD ± 1; range, 2-4), and mean modified Frailty Index was 4 (SD ± 2; range, 1-6). Cholecystostomy tubes were in situ for a mean of 60 days (SD ± 26; range, 18-94 days) prior to cryoablation. Mean duration of clinical follow-up was 563 days (SD ± 152; range, 326-799 days) and of imaging follow-up was 368 days (SD ± 235; range, 66-792 days). One infection and 1 mortality occurred, both in patients with gallstones >20 mm in size, prior pseudomonas infection, and iceball volumes >150 cm3. Institutional review board (IRB) review concluded that the cause of the mortality was a medication allergy. Clinical and imaging success was achieved in 9 of 10 patients.

CONCLUSIONS

Gallbladder cryoablation may be an effective treatment for high-operative risk patients with calculous cholecystitis initially treated with percutaneous drainage, with 90% clinical and imaging success. Optimization of patient selection is indicated, with particular reference to gallstone size and bacterial colonization.

Frailty as a predictor of mortality and morbidity after cholecystectomy: A systematic review and meta-analysis of cohort studies

BACKGROUND

Although cholecystectomy is a common surgery, it carries higher risks of postoperative complications and mortality for older adults. Age alone is not a reliable predictor of postoperative outcomes, whereas frailty may provide a more accurate assessment of a patient's health and functional status. Frailty, characterized by physical deterioration and reduced resilience, has been shown to predict mortality, prolonged recovery, and morbidity after various surgeries, including cholecystectomy. Thus, incorporating frailty evaluations into preoperative assessments can improve patient outcomes by individualizing treatment strategies. This systematic review and meta-analysis aims to evaluate how well frailty predicts postoperative outcomes following cholecystectomy.

METHODS

In accordance with PRISMA guidelines, we searched PubMed, Embase, and Web of Science on August 14th, 2024, without restrictions on publication year or language. The quality of the studies was assessed using the Newcastle-Ottawa scale, and meta-analysis was conducted using odds ratios with 95% confidence intervals as the effect size, employing a random-effects model.

RESULTS

Nine cohort studies comprising a total of 128,421 participants were included. The pooled results showed significantly higher odds of short-term mortality (OR: 5.54, 95% CI: 1.65-18.60, p = 0.006), postoperative morbidity (OR: 2.65, 95% CI: 1.51-4.64, p = 0.001), major morbidity (OR: 3.61, 95% CI: 1.52-8.59), and respiratory failure (OR: 3.85, 95% CI: 1.08-13.79) among frail patients. Additionally, frail patients had longer hospital stays (mean difference: 2.98 days, 95% CI: 1.91-4.04) and significantly higher odds of postoperative infection and sepsis. However, no association was evident with reoperation rates.

CONCLUSION

This study highlights the value of utilizing frailty assessment tools in preoperative settings for predicting outcomes after cholecystectomy. These tools could improve decision-making in both emergency and elective situations, aiding in the choice between surgical and medical management, as well as between open and laparoscopic procedures tailored to each patient.

Evaluation of the surgical management strategy for acute cholecystitis in patients over 75years old

INTRODUCTION

Acute cholecystitis occurs frequently in the elderly. According to the current recommendations specific to the characteristics of each case, these patients are most often treated by delayed cholecystectomy after medical treatment. Our study aimed to compare the success rate of this strategy in patients over and under 75years of age.

PATIENTS AND METHODS

This was a retrospective single-center analytic observational study that included patients who were hospitalized for acute cholecystitis in a geriatric postoperative unit (unité postopératoire gériatrique [UPOG]) and gastrointestinal surgery unit between 2021 and 2022. The main endpoint was the failure rate of deferred cholecystectomy. Secondary endpoints included: respect for the recommended operative delay, loss of the patient's functional independence during hospitalization, and the reason for surgical abstention.

RESULTS

In total, 290 patients were included. The strategy of delayed elective cholecystectomy was not achieved in 31 (44%) patients 75years old or older vs. eight (18%) patients younger than 75years old (P=0.005). The main reason was the decision not to operate after medical treatment. In both groups, the recommended operative interval was equitably respected and the loss of autonomy during hospitalization was minor. More than one-third of the elderly patients scheduled for elective surgery finally refused to undergo surgery.

CONCLUSION

The strategy of routine elective cholecystectomy should not be strict in the elderly with acute cholecystitis; the indication for this procedure should take into account the wishes as well as the physiological status of the patient.

Effectiveness and Safety of Cholecystectomy Versus Percutaneous Cholecystostomy for Acute Cholecystitis in Older and High-Risk Surgical Patients: A Systematic Review

Acute cholecystitis (AC) is a prevalent surgical emergency, particularly among elderly individuals who present with high perioperative risks. While early cholecystectomy (CCY) is the standard treatment, percutaneous cholecystostomy (PC) is proposed as an alternative for high-risk patients. This systematic review aims to evaluate the comparative safety and efficacy of CCY versus PC in managing AC among elderly and high-risk surgical patients. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search was conducted across multiple electronic databases, including PubMed/Medline, Cochrane Central Register of Controlled Trials (CENTRAL), ScienceDirect, Europe PMC, ClinicalTrials.gov, and EBSCO Open Dissertations, from July 1 to 15, 2024. Studies published from January 2019 to July 15, 2024, were included if they focused on patients aged 65 and older or those classified as high-risk surgical candidates. The review encompassed 72,366 participants across 22 studies, predominantly observational. Key outcomes assessed included postoperative complications, readmission rates, recurrence of cholecystitis, and mortality rates. This study highlights the need for individualized treatment strategies for managing AC in elderly populations. While CCY remains the preferred approach when feasible, PC offers a critical alternative for high-risk patients. Future research is necessary to optimize outcomes for this vulnerable population.

Interhospital variation in the nonoperative management of acute cholecystitis

BACKGROUND

Cholecystectomy remains the standard management for acute cholecystitis. Given that rates of nonoperative management have increased, we hypothesize the existence of significant hospital-level variability in operative rates. Thus, we characterized patients who were managed nonoperatively at normal and lower operative hospitals (>90th percentile).

METHODS

All adult admissions for acute cholecystitis were queried using the 2016-2019 Nationwide Readmissions Database. Centers were ranked by nonoperative rate using multi-level, mixed effects modeling. Hospitals in the top decile of nonoperative rate (>9.4%) were classified as Low Operative Hospitals (LOH; others:nLOH). Separate regression models were created to determine factors associated with nonoperative management at LOH and nLOH.

RESULTS

Of an estimated 418,545 patients, 9.9% were managed at 880 LOH. Multilevel modeling demonstrated that 20.6% of the variability was due to hospital factors alone. After adjustment, older age (Adjusted Odds Ratio [AOR] 1.02/year, 95% Confidence Interval [CI] 1.01-1.02) and public insurance (Medicare AOR 1.31, CI 1.21-1.43 and Medicaid AOR 1.43, CI 1.31-1.57; reference: Private Insurance) were associated with nonoperative management at LOH. These were similar at nLOH. At LOH, SNH status (AOR 1.17, CI 1.07-1.28) and small institution size (AOR 1.20, CI 1.09-1.34) were associated with increased odds of nonoperative management.

CONCLUSION

We noted a significant variability in the interhospital variation of the nonoperative management of acute cholecystitis. Nevertheless, comparable clinical and socioeconomic factors contribute to nonoperative management at both LOH and non-LOH. Directed strategies to address persistent non-clinical disparities are necessary to minimize deviation from standard protocol and ensure equitable care.

Role of mFI-5 in predicting geriatric outcomes in laparoscopic cholecystectomy

BACKGROUND

Frailty is the age-related decline contributing to adverse outcome vulnerability. This study assesses the modified 5-factor frailty index's (mFI-5) ability to predict geriatric cholecystectomy outcomes.

METHODS

Laparoscopic cholecystectomy patients ages ≥65 were identified from the American College of Surgeons' National Surgical Quality Improvement Program database (2018-2020). MFI-5 variables include hypertension, congestive heart failure, chronic obstructive pulmonary disease, diabetes, and functional status. Groups were stratified according to the number of comorbidities: mFI ​= ​0, mFI ​= ​1, mFI≥2.

RESULTS

32,481 cases included 27.6% mFI ​= ​0, 46.4% mFI ​= ​1, 26.0% mFI≥2. Highest frailty correlated with increased discharges to not home (OR 1.88, p ​< ​0.01). Non-independent functional status was associated with mortality (OR 7.32), prolonged length of stay (LOS) (5.69), pneumonia (4.90), sepsis (3.78), readmission (2.60) (p ​< ​0.01). AUCs were calculated for prolonged LOS (0.89), discharges to not home (0.85), mortality (0.83), pneumonia (0.76), sepsis (0.76).

CONCLUSIONS

Healthcare teams can use mFI-5 to target at-risk cholecystectomy patients and proactively intervene to avoid complications.

Emergency Colon Resection in the Geriatric Population: the Modified Frailty Index as a Risk Factor of Early Mortality

BACKGROUND

Surgical interventions in the elderly are becoming more frequent given the aging of the population. Due to their increased vulnerability in an emergent context, we aimed to evaluate various risk factors associated with an early mortality and an unfavorable postoperative trajectory.

METHODS

We performed a retrospective, single-center cohort study including patients over the age of 75 who underwent emergency colon resection between January 2016 and December 2020.

RESULTS

Among 299 patients included, the type of resection most frequently encountered was right hemicolectomy (34%). Large bowel obstruction was the surgical indication for 61% of patients (n = 182). The mortality rate within 30 days of primary surgery was 14% (n = 42). The main factors having a significant impact on early mortality were the modified Frailty Index (mFI) (26% vs 4%; p < 0.001), Charlson comorbidity index (CCI) (20 vs 0%; p = 0.03) and surgical indication (36% vs 11%; p = 0.03). No statistically significant difference was observed according to the age of the patients. Patients with a higher mFI ([Formula: see text] 3) had an increased risk of early mortality with an odds ratio (OR) of 11.94 (95%CI: 2.38-59.88; p < 0.001) in multivariate analysis. This association was also observed for the secondary outcomes, as patients with a higher mFI were less likely to return home (59% vs 32%; p = 0.009) and have their stoma closured at the end of the follow-up period (94% vs 33%; p < 0.001).

CONCLUSION

In the geriatric population, the use of mFI is a good predictor of early mortality following an emergency colon resection. This accessible tool could be used to guide the surgical decision-making.

Frailty assessment as independent prognostic factor for patients ≥65 years undergoing urgent cholecystectomy for acute cholecystitis

BACKGROUND

To evaluate, in a prospective observational cohort study of adults ≥65 years old, the frailty status at the emergency department (ED) admission for the in-hospital death risk stratification of patients needing urgent cholecystectomy.

METHODS

Clinical variables and frailty status assessed in the ED were evaluated for the association with major complications and the need for open surgery. The parameters evaluated were frailty, comorbidities, physiological parameters, surgical approach, and laboratory values at admission. Logistic regression analysis was used to identify independent risk factors for poor outcomes.

RESULTS

The study enrolled 358 patients aged ≥65 years [median age 74 years]; 190 males (53.1%)]. Overall, 259 patients (72.4%) were classified as non-frail, and 99 (27.6%) as frail. The covariate-adjusted analysis revealed that frailty (P< 0.001), and open surgery (P = 0.015) were independent predictors of major complications. Frailty, peritonitis, constipation at ED admission, and Charlson Comorbidity Index ≥ 4 were associated with higher odds of open surgical approach (2.06 [1.23 - 3.45], 2.49 [1.13 - 5.48], 11.59 [2.26 - 59.55], 2.45 [1.49 - 4.02]; respectively).

DISCUSSION

In patients aged ≥65 years undergoing urgent cholecystectomy, the evaluation of functional status in the ED could predict the risk of open surgical approach and major complications. Frail patients have an increased risk both for major complications and need for "open" surgical approach.

Prediction of morbidity and mortality after early cholecystectomy for acute calculous cholecystitis: results of the S.P.Ri.M.A.C.C. study

Background

Less invasive alternatives than early cholecystectomy (EC) for acute calculous cholecystitis (ACC) treatment have been spreading in recent years. We still lack a reliable tool to select high-risk patients who could benefit from these alternatives. Our study aimed to prospectively validate the Chole-risk score in predicting postoperative complications in patients undergoing EC for ACC compared with other preoperative risk prediction models.

Method

The S.P.Ri.M.A.C.C. study is a World Society of Emergency Surgery prospective multicenter observational study. From 1st September 2021 to 1st September 2022, 1253 consecutive patients admitted in 79 centers were included. The inclusion criteria were a diagnosis of ACC and to be a candidate for EC. A Cochran-Armitage test of the trend was run to determine whether a linear correlation existed between the Chole-risk score and a complicated postoperative course. To assess the accuracy of the analyzed prediction models—POSSUM Physiological Score (PS), modified Frailty Index, Charlson Comorbidity Index, American Society of Anesthesiologist score (ASA), APACHE II score, and ACC severity grade—receiver operating characteristic (ROC) curves were generated. The area under the ROC curve (AUC) was used to compare the diagnostic abilities.

Results

A 30-day major morbidity of 6.6% and 30-day mortality of 1.1% were found. Chole-risk was validated, but POSSUM PS was the best risk prediction model for a complicated course after EC for ACC (in-hospital mortality: AUC 0.94, p < 0.001; 30-day mortality: AUC 0.94, p < 0.001; in-hospital major morbidity: AUC 0.73, p < 0.001; 30-day major morbidity: AUC 0.70, p < 0.001). POSSUM PS with a cutoff of 25 (defined in our study as a ‘Chole-POSSUM’ score) was then validated in a separate cohort of patients. It showed a 100% sensitivity and a 100% negative predictive value for mortality and a 96–97% negative predictive value for major complications.

Conclusions

The Chole-risk score was externally validated, but the CHOLE-POSSUM stands as a more accurate prediction model. CHOLE-POSSUM is a reliable tool to stratify patients with ACC into a low-risk group that may represent a safe EC candidate, and a high-risk group, where new minimally invasive endoscopic techniques may find the most useful field of action.

Trial Registration: ClinicalTrial.gov NCT04995380.

Risk factors for complications in acute calculous cholecystitis. Deconstruction of the Tokyo Guidelines

OBJECTIVE

To challenge the risk factors described in Tokyo Guidelines in Acute Calculous Cholecystitis.

METHODS

Retrospective single center cohort study with 963 patients with Acute Cholecystitis during a period of 5 years. Some 725 patients with a "pure" Acute Calculous Cholecystitis were selected. The analysis included 166 variables encompassing all risk factors described in Tokyo Guidelines. The Propensity Score Matching method selected two subgroups of patients with equal comorbidities, to compare the severe complications rate according to the initial treatment (Surgical vs Non-Surgical). We analyzed the Failure-to-rescue as a quality indicator in the treatment of Acute Calculous Cholecystitis.

RESULTS

the median age was 69 years (IQR 53-80). 85.1% of the patients were ASA II or III. The grade of the Acute Calculous Cholecystitis was mild in a 21%, moderate in 39% and severe in 40% of the patients. Cholecystectomy was performed in 95% of the patients. The overall complications rate was 43% and the mortality was 3.6%. The Logistic Regression model isolated 3 risk factor for severe complication: ASA > II, cancer without metastases and moderate to severe renal disease. The Failure-to-Rescue (8%) was higher in patients with non-surgical treatment (32% vs. 7%; P = 0.002). After Propensity Score Matching, the number of severe complications was similar between Surgical and Non-Surgical treatment groups (48.5% vs 62.5%; P = 0.21).

CONCLUSIONS

the recommended treatment for Acute Calculous Cholecystitis is the Laparoscopic Cholecystectomy. Only three risk factors from the Tokyo Guidelines list appeared as independent predictors of severe complications. The failure-to-rescue is higher in non-surgically treated patients.

Wait-and-see strategy is justified after ERCP and endoscopic sphincterotomy in elderly patients with common biliary duct stones

BACKGROUND

Older patients with simultaneous main bile duct and gallbladder stones, especially those with high-surgical risks, create a common clinical dilemma. After successful endoscopic removal of main bile duct stones, should these patients undergo laparoscopic cholecystectomy to reduce risk of recurrent biliary events? In this population-based cohort study, we report long-term outcomes of a wait-and-see strategy after successful endoscopic extraction of main bile duct stones.

METHODS

Consecutive patients 75 years or older undergoing endoscopic stone extraction without subsequent cholecystectomy in two tertiary academic centers between January 2010 and December 2018 were included. Primary outcome measure was recurrence of biliary events. Secondary outcome measures were operation-related morbidity and mortality.

RESULTS

A total of 450 patients (median age, 85 years; 61% female) were included, with a median follow-up time of 36 months (0-120 months). Recurrent biliary events occurred in 51 patients (11%), with a median time from index hospital admission to recurrence of 307 days (12-1993 days). The most common biliary event was acute cholecystitis (7.1%). Twelve patients had cholangitis (2.7%) and two biliary pancreatitis (0.4%). Only one patient (0.4%) underwent surgery due to later gallstone-related symptoms. Eighteen patients (4.0%) required endoscopic intervention and 16 (3.5%) underwent surgery. There were no operation-associated deaths or morbidity among those undergoing later surgical or endoscopic interventions.

CONCLUSION

In elderly patients, it is relatively safe to leave gallbladder in situ after successful sphincterotomy and endoscopic common bile duct stone removal. In elderly and frail patients, a wait-and-see strategy without routine cholecystectomy rarely leads to clinically significant consequences.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Management of Incidentally Detected Gallbladder Polyps: Society of Radiologists in Ultrasound Consensus Conference Recommendations

Gallbladder polyps (also known as polypoid lesions of the gallbladder) are a common incidental finding. The vast majority of gallbladder polyps smaller than 10 mm are not true neoplastic polyps but are benign cholesterol polyps with no inherent risk of malignancy. In addition, recent studies have shown that the overall risk of gallbladder cancer is not increased in patients with small gallbladder polyps, calling into question the rationale for frequent and prolonged follow-up of these common lesions. In 2021, a Society of Radiologists in Ultrasound, or SRU, consensus conference was convened to provide recommendations for the management of incidentally detected gallbladder polyps at US. See also the editorial by Sidhu and Rafailidis in this issue.

Clinical-pathological features and treatment of acute appendicitis in the very elderly: an interim analysis of the FRAILESEL Italian multicentre prospective study

BACKGROUND

Emergency abdominal surgery in the elderly represents a global issue. Diagnosis of AA in old patients is often more difficult. Appendectomy remains the gold standard of treatment and, even though it is performed almost exclusively with a minimally invasive technique, it can still represent a great risk for the elderly patient, especially above 80 years of age. A careful selection of elderly patients to be directed to surgery is, therefore, fundamental. The primary aim was to critically appraise and compare the clinical-pathological characteristics and the outcomes between oldest old (≥ 80 years) and elderly (65-79 years) patients with Acute Appendicitis (AA).

METHODS

The FRAILESEL is a large, nationwide, multicentre, prospective study investigating the perioperative outcomes of patients aged ≥ 65 years who underwent emergency abdominal surgery. Particular focus has been directed to the clinical and biochemical presentation as well as to the need for operative procedures, type of surgical approach, morbidity and mortality, and in-hospital length of stay. Two multivariate logistic regression analyses were performed to assess perioperative risk factors for morbidity and mortality.

RESULTS

182 patients fulfilled the inclusion criteria. Mean age, ileocecal resection, OAD and ASA score ≥ 3 were related with both overall and major complication. The multivariate analysis showed that MPI and complicated appendicitis were independent factors associated with overall complications. OAD and ASA scores ≥ 3 were independent factors for both overall and major complications.

CONCLUSIONS

Age ≥ 80 years is not an independent risk factor for morbidities. POCUS is safe and effective for the diagnosis; however, a CECT is often needed. Having the oldest old a smaller functional organ reserve, an earlier intervention should be considered especially because they often show a delay in presentation and frequently exhibit a complicated appendicitis.

Predicting Outcomes in Thyroidectomy and Parathyroidectomy: The Modified Five-Point Frailty Index Versus American Society of Anesthesiologists Classification

INTRODUCTION

Thyroidectomy and parathyroidectomy are relatively safe procedures, with overall morbidity rates of 2%-5%. The increasing age is associated with higher likelihood of poor outcomes. The modified five-point frailty index (mFI-5) is associated with complications, but many surgeons are unfamiliar with mFI-5. We assessed the accuracy of the mFI-5 versus the commonly-used American Society of Anesthesiologists (ASA) classification to predict complications following thyroidectomy and parathyroidectomy.

METHODS

Patients undergoing thyroidectomy or parathyroidectomy in 2015-2018 NSQIP datasets were identified. The mFI-5 scores were calculated by adding the number of the following comorbidities: congestive heart failure, hypertension requiring medication, chronic obstructive pulmonary disease, diabetes, and nonindependent functional status. Receiver operating characteristics curves were plotted for 30-d mortality and serious morbidity (defined as deep surgical site infection, dehiscence, unplanned intubation, failure to wean from the ventilator 48-h postoperatively, acute renal failure, pneumonia, pulmonary embolism, myocardial infarction, cardiac arrest requiring cardiopulmonary resuscitation, sepsis, septic shock, cerebrovascular accident, or reoperation) using mFI-5 and ASA classification. Areas under these curves (AUC) were compared.

RESULTS

Ninety-two thousand, six hundred and ninety-one patients were studied. The mFI-5 and ASA were fair predictors of 30-d mortality (AUC 0.75 and 0.82, respectively) and good predictors of serious morbidity (AUC 0.61 and 0.64). After stratification by age, ASA was superior to mFI-5 in predicting mortality for patients aged 65, 70, 80 y, and older, for the entire population and for thyroidectomy and parathyroidectomy separately.

CONCLUSIONS

The ASA classification is a better predictor of mortality and serious morbidity than mFI-5 among patients undergoing thyroidectomy or parathyroidectomy and may be a better prognostic indicator to use when counseling patients before low-risk neck surgery.

Using the Modified Frailty Index to Predict Complications in Breast Reduction: A National Surgical Quality Improvement Program Study of 14,160 Cases

BACKGROUND

Breast reduction is a generally well-tolerated procedure with high patient satisfaction and low risk of surgical site infection and other complications. While age, obesity and comorbidities have historically been used as surgical risk proxies, recent literature suggests 'frailty' measures, such as the modified 5-item frailty index (mFI-5), may be a superior predictor.

OBJECTIVES

To investigate if mFI-5 can predict the likelihood and magnitude of 30-day complications resulting from breast reductions.

METHODS

A retrospective review was performed using the National Surgical Quality Improvement Program (NSQIP) database of patients who underwent breast reduction without other concurrent procedures, from 2013 to 2019. mFI-5 scores were calculated for each patient, and complication data were gathered. Age, BMI, number of major comorbidities, ASA class, smoking status, diabetes, steroid use and mFI-5 score were compared as predictors of all-cause 30-day complications, 30-day surgical site complications of any kind, length of stay, and aggregate Clavien-Dindo complication severity score. Univariate logistic, linear regressions and multivariate logistic regression analyses were performed to evaluate predictive value. Statistical significance was set at p < 0.05.

RESULTS

A total of 14,160 patients were analyzed. The overall complication rate was 5.6%. The mFI-5 score significantly predicted overall 30-day complications, surgical site complications, complication severity, overnight stay and likelihood of readmission (all p < 0.0001).

CONCLUSIONS

The mFI-5 is a statistically significant predictor for adverse outcomes in breast reduction surgery. The mFI-5 is a simple and reliable tool that can be efficiently used to conduct a preoperative evaluation of patients requesting breast reductions.

The impact of frailty on the postoperative outcomes of patients undergoing cholecystectomy: propensity score matched analysis of 2011-2017 US hospitals

BACKGROUND

Frailty is an aggregate variable that encompasses debilitating geriatric conditions, which potentially affects postoperative outcomes. In this study, we evaluate the relationship between clinical frailty and post-cholecystectomy outcomes using a national registry of hospitalized patients.

METHODS

2011-2017 National Inpatient Sample database was used to identify patients who underwent cholecystectomy. Patients were stratified using the Johns Hopkins ACG frailty definition into binary (frailty and no-frailty) and tripartite frailty (frailty, prefrailty, no-frailty) indicators. The controls were matched to study cohort using 1:1 propensity score-matching and postoperative outcomes were compared.

RESULTS

Post-match, using the binary term, frail patients (n = 40,067) had higher rates of mortality (OR 2.07 95%CI 1.90-2.25), length of stay, costs, and complications. In multivariate, frailty was associated with higher mortality (aOR 2.06 95%CI 1.89-2.24). When using tripartite frailty term, prefrail (n = 35,595) and frail (n = 4472) patients had higher mortality (prefrailty: OR 2.04 95%CI 1.86-2.23; frailty: OR 2.49 95%CI 1.99-3.13), length of stay, costs, and complications. In multivariate, prefrailty and frailty were associated with higher mortality (prefrailty: aOR 2.02 95%CI 1.84-2.21; frailty: aOR 2.54 95%CI 2.02-3.19).

CONCLUSION

This study shows the presence of frailty (and prefrailty) is an independent risk factor of adverse postoperative outcomes in patients undergoing cholecystectomy.

Frailty in elderly patients with acute appendicitis

PURPOSE

Acute appendicitis in the elderly is becoming increasingly recognized for its often severe course. For various elective and urgent operations in older patients, frailty is a risk factor for poor outcomes. However, there is a lack of data on frailty in elderly patients with acute appendicitis.

METHODS

Patients over 65 years old who underwent surgery for acute appendicitis in three hospitals between January 2015 and September 2020 were assessed with the Hospital Frailty Risk Score (HFRS) and the modified Frailty Index (mFI). Outcomes of interest, including morbidity, mortality, and length of stay, were recorded.

RESULTS

While frailty can be measured with both tests, the mFI has better applicability and takes significantly less time to implement compared to the HFRS (21.6 s vs. 80.3 s, p < 0.0001) while providing the same information value. Patients who exhibited frailty according to either assessment had a significantly higher rate of milder (OR 5.85/2.87, p < 0.0001/0.009) and serious (OR 4.92/3.61, p < 0.011/0.029) complications, more admissions to the intensive care unit (OR 5.16/7.36, p < 0.0001), and an almost doubled length of stay (12.7 days vs. 6.6 days, p < 0.005). Up to 31% of these patients required institutional care after discharge, which is significantly more than those without frailty (p < 0.0001). Furthermore, the mortality rate in frail patients was significantly elevated to 17%, compared to less than 1% in non-frail patients (p = 0.018).

CONCLUSION

In elderly patients, frailty is a significant risk factor for negative outcomes. Frailty can be assessed more quickly and reliably with the mFI compared to the HFRS.

Minimally Invasive Management of Acute Cholecystitis and Frailty Assessment in Geriatric Patients

The aim was to compare laparoscopic cholecystectomy (LC) with the percutaneous cholecystostomy (PC) for the management of acute lithiasic cholecystitis in geriatric patients and investigate the decision-making using frailty assessment. A retrospective analysis was performed in all patients aged over 65 years who were treated for acute cholecystitis at our hospital in a period of 5 years. Patients were divided in LC and PC groups. In total, 111 (54.1%) patients were subjected to LC and 94 (45.9%) to PC. The American Society of Anesthesiologists (ASA) and the Clinical Frailty Score were lower for the LC group. However, for patients over 85 years of age, frailty scores between groups were not statistically different. Morbidity and mortality between groups were not statistically different. Both LC and PC are safe and efficient in geriatric patients. Frailty score may better drive the selection of patients to be managed laparoscopically.

The Correlation Between Case Total Work Relative Value Unit, Operative Stress, and Patient Frailty: Retrospective Cohort Study

OBJECTIVE

Assess the relationships between case total work relative value units (wRVU), patient frailty, and the physiologic stress of surgical interventions.

SUMMARY OF BACKGROUND DATA

Surgeon reimbursement is frequently apportioned by wRVU. These subjective, procedure-specific valuations generated by physician survey estimate the intensity and time for typical patient care services. We hypothesized wRVU would not adequately account for patient-specific factors, such as frailty, that modify the required physician work, regardless of procedural complexity.

METHODS

Using National and Veterans Affairs Surgical Quality Improvement Programs (2015-2018), we evaluated the correlation between case total wRVU, patient frailty (risk analysis index) and physiologic surgical stress (operative stress score).

RESULTS

Of 4,111,371 (86%) cases, the correlation between total wRVU and operative stress was moderate [ρs = 0.587 (95% confidence interval, 0.586-0.587)], but negligible with frailty ρ = 0.177 (95% confidence interval, 0.176-0.178)]. Very high operative stress procedures [n = 34,047 (1%)] generated a mean total wRVU of 55.1 (standard deviation, 12.9), comprising 7%, 2%, and 1% of thoracic, vascular, and general surgical cases, respectively. Very frail patients [n = 152,535 (4%)] accounted for 9% of thoracic, 9% of vascular, 4% of general, 5% of urologic, and 4% of neurologic surgical cases, generating 21.0 (standard deviation, 12.4) mean total wRVU. Some nonfrail patients undergoing low operative stress procedures [n = 60,128 (2%)] nonetheless generated the highest quintile wRVU; these comprised >15% of plastic, gynecologic, and urologic surgical cases.

CONCLUSIONS

Surgeon reimbursement correlates with operative stress but not patient frailty. The total wRVU does not adequately reflect patient-specific factors that increase the physician workload required to render optimal care to complex patients.

Modified Frailty Index (mFI) predicts 30-day complications after microsurgical breast reconstruction

Frailty lacks a universal definition. The modified Frailty Index (mFI) using patient comorbidities can be used to measure frailty. We hypothesized that mFI predicts 30-day complications after microsurgical breast reconstruction. American College of Surgeons' (ACS) National Surgical Quality Improvement Project (NSQIP) was investigated to identify patients undergoing microsurgical breast reconstruction between 2005-2014 using Current Procedure Terminology (CPT) code, 19364. We used mFI as a measure of frailty. The patients were assigned a frailty score based on the number of preoperative comorbid conditions as defined by the mFI. Other risk indices used include age, BMI, wound class, ASA class. Stratification was performed in ascending order for each. The outcome measure was aggregate 30-day complications. Regression analysis was performed followed by Receptor Operating Characteristic (ROC) curve to determine the accuracy of each risk index in predicting 30-day complications. Of the 3237 patients 24% experienced complications. Univariate logistic regression analysis found odds ratio of complications for frailty score 1 = 22.1 (CI = 17.9-27.3, p < 0.01), and 2 = 28 (CI = 18.3-43, p < 0.01) compared to frailty score = 0. ROC curve demonstrated mFI with the highest concordance score (c-score = 0.816). Multivariable logistic regression found frailty as the strongest independent predictor of 30-day aggregate complications adjusted OR = 22.24, CI = 17.77-27.82, p < 0.01 when compared to other risk indices. The modified Frailty Index is a simple, reliable, and objective tool that can be used to predict postoperative complications after microsurgical breast reconstruction. The application of this tool can help microsurgeons preoperatively identify patients who are at high risk.Abbreviations: ACS: American College of Surgeons; ASA: American Society of Anesthesiologists; BMI: body mass index; CHF: congestive heart failure; CPT: current procedural terminology; COPD: chronic obstructive pulmonary disease; CVA: cerebrovascular accident; DM: diabetes mellitus; IRB: institutional review board; mfi: modified frailty index; MI: myocardial infarction; NSQIP: national surgical quality improvement program; PVD: peripheral vascular disease; ROC: receptor operating characteristic; TIA: transient ischemic attach.

Mortality risk estimation in acute calculous cholecystitis: beyond the Tokyo Guidelines

BACKGROUND

Acute calculous cholecystitis (ACC) is the second most frequent surgical condition in emergency departments. The recommended treatment is the early laparoscopic cholecystectomy; however, the Tokyo Guidelines (TG) advocate for different initial treatments in some subgroups of patients without a strong evidence that all patients will benefit from them. There is no clear consensus in the literature about who is the unfit patient for surgical treatment. The primary aim of the study is to identify the risk factors for mortality in ACC and compare them with Tokyo Guidelines (TG) classification.

METHODS

Retrospective unicentric cohort study of patients emergently admitted with and ACC during 1 January 2011 to 31 December 2016. The study comprised 963 patients. Primary outcome was the mortality after the diagnosis. A propensity score method was used to avoid confounding factors comparing surgical treatment and non-surgical treatment.

RESULTS

The overall mortality was 3.6%. Mortality was associated with older age (68 + IQR 27 vs. 83 + IQR 5.5; P = 0.001) and higher Charlson Comorbidity Index (3.5 + 5.3 vs. 0+2; P = 0.001). A logistic regression model isolated four mortality risk factors (ACME): chronic obstructive pulmonary disease (OR 4.66 95% CI 1.7-12.8 P = 0.001), dementia (OR 4.12; 95% CI 1.34-12.7, P = 0.001), age > 80 years (OR 1.12: 95% CI 1.02-1.21, P = 0.001) and the need of preoperative vasoactive amines (OR 9.9: 95% CI 3.5-28.3, P = 0.001) which predicted the mortality in a 92% of the patients. The receiver operating characteristic curve yielded an area of 88% significantly higher that 68% (P = 0.003) from the TG classification. When comparing subgroups selected using propensity score matching with the same morbidity and severity of ACC, mortality was higher in the non-surgical treatment group. (26.2% vs. 10.5%).

CONCLUSIONS

Mortality was higher in ACC patients treated with non-surgical treatment. ACME identifies high-risk patients. The validation to ACME with a prospective multicenter study population could allow us to create a new alternative guideline to TG for treating ACC.

TRIAL REGISTRATION

Retrospectively registered and recorded in Clinical Trials. NCT04744441.

The obesity paradox: Underweight patients are at the greatest risk of mortality after cholecystectomy

BACKGROUND

Elevated body mass index is a risk factor for gallstone disease and cholecystectomy, but outcomes for low body mass index patients remain uncharacterized. We examined the association of body mass index with morbidity, mortality, and resource use after cholecystectomy.

METHODS

The 2005 to 2016 American College of Surgeons National Surgical Quality Improvement Program was retrospectively analyzed for adult patients undergoing laparoscopic and open cholecystectomy. Patients were stratified into 5 groups: body mass index <18.5 (underweight), body mass index 18.5 to 24.9 (normal weight), body mass index 25 to 29.9 (overweight), body mass index 30 to 34.9 (class I obesity), body mass index 35 to 39.9 (class II obesity), and body mass index ≥40 (class III obesity). Multivariable regressions identified independent associations of covariates with 30-day mortality, complications, and resource use.

RESULTS

Of 327,473 cholecystectomy patients, 1.0% were underweight, 19.5% normal weight, 30.3% overweight, 24.0% class I obesity, 13.5% class II obesity, and 11.7% class III obesity. After multivariable analysis, underweight patients had a higher risk of mortality (adjusted odds ratio = 1.53; P = .029) and postoperative bleeding (adjusted odds ratio = 1.45; P = .011) relative to normal weight patients. Conversely, class III obesity patients had lower mortality (adjusted odds ratio = 0.66; P = .005) but increased operative time (β = 10.2 minutes; P < .001), wound infection (adjusted odds ratio = 1.38; P < .001), and wound dehiscence (adjusted odds ratio = 2.20; P < .001). Hospital duration of stay and readmission rates were highest for underweight patients.

CONCLUSION

Underweight patients experience increased risk of mortality and readmission, while class III obesity patients have higher rates of wound infection and dehiscence as well as prolonged operative time. These findings may guide choice of intervention.

Peri-operative Mortality Following Cholecystectomy in Australia: Potential Preventability of Adverse Events

BACKGROUND

Cholecystectomy is a commonly performed procedure; however, it is not without risks. It is crucial to constantly audit surgical outcomes in order to improve quality of care. The aim of this retrospective population-based cohort study is to identify preventable issues of clinical management associated with adverse occurrences in order to reduce mortality of cholecystectomy patients.

METHODS

Data were obtained from the Australian and New Zealand Audit of Surgical Mortality (ANZASM). It encompasses peer-reviewed first and second line assessments of management of cholecystectomy patients who died from 2005 to 2015 in Australia. Clinical Management Issues (CMIs) were identified from text in assessments and grouped into communication failures, pre-operative, intra-operative and post-operative categories. These were further classified into subthemes using thematic analysis with a data-driven approach.

RESULTS

There were 359 deaths in the study period. CMIs were present in 71 cases, with a reported total of 124 concerns or adverse events. Post-operative CMIs were the most prevalent issue [50% (62/124)], with the most common theme being delay to recognise complications (19/124). Pre-operative concerns were the second most common (n = 34). Decision to operate was questioned in 14 cases, and delay to surgery was reported in 12 cases.

CONCLUSION

ANZASM analysis has allowed us to identify modifiable adverse occurrences. This audit shows that delay to recognise complications is the most common assessment recorded. Preventive measures should be taken to improve outcomes and reduce peri-operative mortality, with an emphasis on post-operative management and enhancing communication between members of the multidisciplinary team.

Strategies to Promote ResiliencY (SPRY): a randomised embedded multifactorial adaptative platform (REMAP) clinical trial protocol to study interventions to improve recovery after surgery in high-risk patients

INTRODUCTION

As the population ages, there is interest in strategies to promote resiliency, especially for frail patients at risk of its complications. The physiological stress of surgery in high-risk individuals has been proposed both as an important cause of accelerated age-related decline in health and as a model testing the effectiveness of strategies to improve resiliency to age-related health decline. We describe a randomised, embedded, multifactorial, adaptative platform (REMAP) trial to investigate multiple perioperative interventions, the first of which is metformin and selected for its anti-inflammatory and anti-ageing properties beyond its traditional blood glucose control features.

METHODS AND ANALYSIS

Within a multihospital, single healthcare system, the Core Protocol for Strategies to Promote ResiliencY (SPRY) will be embedded within both the electronic health record (EHR) and the healthcare culture generating a continuously self-learning healthcare system. Embedding reduces the administrative burden of a traditional trial while accessing and rapidly analysing routine patient care EHR data. SPRY-Metformin is a placebo-controlled trial and is the first SPRY domain evaluating the effectiveness of three metformin dosages across three preoperative durations within a heterogeneous set of major surgical procedures. The primary outcome is 90-day hospital-free days. Bayesian posterior probabilities guide interim decision-making with predefined rules to determine stopping for futility or superior dosing selection. Using response adaptative randomisation, a maximum of 2500 patients allows 77%-92% power, detecting >15% primary outcome improvement. Secondary outcomes include mortality, readmission and postoperative complications. A subset of patients will be selected for substudies evaluating the microbiome, cognition, postoperative delirium and strength.

ETHICS AND DISSEMINATION

The Core Protocol of SPRY REMAP and associated SPRY-Metformin Domain-Specific Appendix have been ethically approved by the Institutional Review Board and are publicly registered. Results will be publicly available to healthcare providers, patients and trial participants following achieving predetermined platform conclusions.

TRIAL REGISTRATION NUMBER

NCT03861767.