Patients over 65 years with acute complicated calculous biliary disease are treated differently-Results and insights from the ESTES snapshot audit

ORIGINAL SCIENTIFIC REPORT Patients over 65 years with Acute Complicated Calculous Biliary Disease are Treated Differently—Results and Insights from the ESTES Snapshot Audit Gary A. Bass 1,2,3 •Amy E. Gillis 3 •Yang Cao 4 •Shahin Mohseni 2,5 •for the European Society for Trauma and Emergency Surgery (ESTES) Cohort Studies Group Accepted: 12 February 2021 / Published online: 3 April 2021 ÓThe Author(s) 2021 Abstract Background Accrued comorbidities are perceived to increase operative risk. Surgeons may offer operative treatments less often to their older patients with acute complicated calculous biliary disease (ACCBD). We set out to capture ACCBD incidence in older patients across Europe and the currently used treatment algorithms. Methods The European Society of Trauma and Emergency Surgery (ESTES) undertook a snapshot audit of patients undergoing emergency hospital admission for ACCBD between October 1 and 31 2018, comparing patients under and C65 years. Mortality, postoperative complications, time to operative intervention, post-acute disposition, and length of hospital stay (LOS) were compared between groups. Within the C65 cohort, comorbidity burden, mortality, LOS, and disposition outcomes were further compared between patients undergoing operative and nonoperative management. Results The median age of the 338 admitted patients was 67 years; 185 patients (54.7%) of these were the age of 65 or over. Significantly fewer patients C65 underwent surgical treatment (37.8% vs. 64.7%, p\0.001). Surgical complications were more frequent in the C65 cohort than younger patients, and the mean postoperative LOS was significantly longer. Postoperative mortality was seen in 2.2% of patients C65 (vs. 0.7%, p= 0.253). However, operated elderly patients did not differ from non-operated in terms of comorbidity burden, mortality, LOS, or postdischarge rehabilitation need. Conclusions Few elderly patients receive surgical treatment for ACCBD. Expectedly, postoperative morbidity, LOS, and the requirement for post-discharge rehabilitation are higher in the elderly than younger patients but do not differ from elderly patients managed non-operatively. With multidisciplinary perioperative optimization, elderly patients may be safely offered optimal treatment. Trial Registration ClinicalTrials.gov (Trial # NCT03610308). Study Collaborators listed in Appendix 1. Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/s00268- 021-06052-0. &Shahin Mohseni [email protected]; [email protected] Gary A. Bass [email protected] Amy E. Gillis [email protected] Yang Cao [email protected] 1 Division of Traumatology, Emergency Surgery & Surgical Critical Care, Penn Presbyterian Medical Center, University of Pennsylvania, Philadelphia, PA 19104, USA 123 World J Surg (2021) 45:2046–2055 https://doi.org/10.1007/s00268-021-06052-0 Abbreviations AAST American Association for the Surgery of Trauma aaCCI Age-adjusted Charlson comorbidity index ACCBD Acute Complicated Calculous Biliary Disease CHSA Canadian Study of Health and Aging Frailty Index ERCP Endoscopic Retrograde Cholangiopancreatography ESTES European Society of Trauma and Emergency Surgery ICU Intensive Care Unit IQR Interquartile range p-POSSUM Portsmouth Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity Introduction The number of older people undergoing emergency noncardiac surgical procedures over the last 25 years has exceeded the rate of population aging. This increase is likely due to changing patient expectations, as well as advances in perioperative care. However, patients, age and pre-existing comorbidities remain significant predictors of adverse postoperative outcome [1–16]. In particular, elderly patients appear to accrue excess morbidity and mortality following gallbladder surgery [16]. Acknowledging acute complicated calculous biliary disease (ACCBD) as a common set of clinical problems presented to general surgeons, the Cohort Studies Group of the European Society for Trauma and Emergency Surgery (ESTES) set out to capture real-world data on the epidemiology, and contemporary management of these patients [17,18]. Traditional medical school teaching identifies the 6Fs (fair, fat, fertile, female, forty, and family history) as phenotypic predictors of symptomatic gallstone disease [19]. Notably, however, the cohort presenting to European emergency departments with acute complicated biliary calculous conditions were older than this teaching suggests, with a median age of 67 years [17,18]. Despite consensus in several guidelines, surgical practice patterns regarding older patients with ACCBD appear to vary between centers and even between individual surgeons [17,18]. This prospective non-randomized observational cohort study aims to provide granular real-world data contrasting outcomes in patients over and under 65 years of age and comparing outcomes following operative and non-operative treatment strategies in patients over 65. Learnings from these data are presented as hypothesis-generating to stimulate further work investigating why definitive surgical therapy is not routinely offered to older patients and to create a context for practice management guidelines. Methods Study centers and patients This study was an exploratory subgroup analysis from an international, multicenter, prospective non-randomized observational cohort study, conducted according to a previously published protocol (protocol registered at ClinicalTrials.gov, #NCT03610308). All participating centers provided local institutional review board approval or equivalent as a requirement of registration. Center and patient eligibility, as well as data capture, have been reported in previous publication [18]. The study included adult patients (over 18 years of age) presenting with acute complicated calculous biliary disease defined as one of the following diagnoses: American Association of Trauma (AAST) Severity Grade II or above acute calculous cholecystitis, choledocholithiasis, cholangitis, or biliary pancreatitis; subjected to any interventions ranging from conservative management to surgical or radiological interventions. The study excluded patients with uncomplicated biliary colic, biliary dyskinesia, or uncomplicated acute calculous cholecystitis (AAST Grade I). Statistical analysis Descriptive and inferential statistical analyses were performed using Stata 15.1 (StataCorp LLC, College Station, TX, USA) and the jamovi project (www.jamovi.com, 2019) utilizing the R language for statistical computing. Effect estimates are presented as odds ratios (OR) with 95% confidence intervals and two-tailed Pvalues. An alpha significance level of 0.05 was used throughout. Measures of central tendency were presented as mean [±standard deviation (SD); median, interquartile range (IQR)]. 2 School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden 3 Department of Surgery, Tallaght University Hospital, Dublin 24, Ireland 4 Clinical Epidemiology and Biostatistics, School of Medical Sciences, Orebro University, 701 82 Orebro, Sweden 5 Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, 701 85 Orebro, Sweden World J Surg (2021) 45:2046–2055 2047 123 Outcome measure Outcomes were compared between patients aged under and C65 years and, within the C65 group, between patients who underwent operative or non-operative management. The primary outcome measure was index admission surgical treatment by cholecystectomy. Secondary outcome measures included the total LOS, the postoperative LOS (in whole days), postoperative and 30-day mortality rates, and a post-discharge rehabilitation requirement. Results Participating centers 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 [18]. 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 C65 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 C65 years group had more comorbidities measured by their Charlson Comorbidity Index (CCI), were less fit for Table 1 Patient Demographics, comparing those under and over 65 years \65 years C65 years Total pvalue Included patients n(%) 153 (45.3) 185 (54.7) 338 (100) Age, years, mean (SD) 47 (12) 79 (8.0) 65 (18) \0.001 Sex, Female n(%) 91 (59.5) 91 (49.2) 182 (53.8) 0.075 Charlson Comorbidity Index, median (IQR) 1.0 (0.0–2.0) 4.0 (4.0–6.0) 3.0 (1.0–5.0) \0.001 Age-adjusted Charlson Comorbidity Index, median (IQR) 3.0 (1.0–4.0) 9.0 (7.0–11.0) 6.0 (3.0–9.0) \0.001 BMI (kg/m2), mean (SD) 29.6 (7.2) 27.3 (6.2) 28.3 (6.8) 0.002 ASA, n (%) \0.001 1 53 (35.1) 9 (4.9) 62 (18.6) 2 74 (49.0) 75 (41.2) 149 (44.7) 3 18 (11.9) 77 (42.3) 95 (28.5) 4 6 (4.0) 21 (11.5) 27 (8.1) Diagnosis, n (%) 0.065 Cholecystitis 68 (44.4) 86 (46.5) 154 (45.6) Gallstone pancreatitis 40 (26.1) 31 (16.8) 71 (21.0) CBD stone 25 (16.3) 36 (19.5) 61 (18.0) Cholangitis 16 (10.5) 31 (16.8) 47 (13.9) Mirizzi syndrome or bilioenteric fistula 4 (2.6) 1 (0.5) 5 (1.5) AAST Cholecystitis Grade, n (%) 0.048 1 0 (0.0%) 0 (0.0%) 0 (0.0%) 2 58 (85.3%) 66 (76.7%) 124 (80.5%) 3 4 (5.9%) 15 (17.4%) 19 (12.3%) 4 6 (8.8%) 3 (3.5%) 9 (5.8%) 5 0 (0.0%) 2 (2.3%) 2 (1.3%) Grade 3 or higher 10.0 (14.7%) 20.0 (23.3%) 30.0 (19.5%) 0.183 1 AAST Pancreatitis Grade, n (%) 0.542 1 31 (81.6) 26 (83.9) 57 (82.6) 2 6 (15.8) 4 (12.9) 10 (14.5) 3 0 (0.0) 1 (3.2) 1 (1.4) 4 1 (2.6) 0 (0.0) 1 (1.4) 2048 World J Surg (2021) 45:2046–2055 123 surgery based on their ASA score, were significantly more likely to have a history of ischemic heart disease, congestive heart failure, cerebrovascular disease, insulin-de- pendent diabetes mellitus, and chronic renal disease compared to patients under 65. Previous abdominal surgical history did not differ between patients under and C65 years (37% vs. 34%, p= 0.487) (Table 1). Diagnosis 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 C65 years (p= 0.065) (Table 1). The incidence of cholecystitis AAST grade III and V was higher in the C65 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). Surgical intervention 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 C65 years (64.7% vs. 37.8%, p= 0.001). Cholecystectomy alone was performed in 99.3% of cases [18]. 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 C65 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 C65 (p= 0.909). Subtotal cholecystectomy was performed in 3 patients C65 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 C65 group [days median (IQR): 1.0 (0.0–3.5) vs. 2.0 (1.0–6.2), p= 0.057] (Table 2). Endoscopic management Patients in the C65 group underwent endoscopic evaluation and management of the common bile duct more Table 2 Surgical, endoscopic and radiologic intervention and outcomes, comparing those under and over 65 years \65 years C65 years Total p value Surgical Intervention, n (%) 99 (64.7) 70 (37.8) 169 (50.0) \0.001 Surgical Approach, n (%) Laparoscopic 86 (86.9) 56 (80.0) 142 (84.0) 0.153 1 Laparoscopic converted to open 5 (5.0) 9 (12.9) 14 (8.2) 0.070 1 Open 8 (8.1) 5 (7.1) 13 (7.6) 0.909 1 Type of surgery, n (%) Cholecystectomy 98 (98.9) 67 (95.7) 165 (97.6) 0.399 1 Subtotal cholecystectomy 1 (1.1) 3 (4.3) 5 (2.9) 0.180 1 Admission to Surgery (days), median (IQR) 2.0 (1.0–6.2) 1.0 (0.0–3.5) 2.0 (0.0–5.5) 0.057 Endoscopy Intervention, n (%) 35 (22.9) 63 (34.1) 98 (29) 0.024 Admission to Endoscopy (days), median (IQR) 4.0 (2.0–5.0) 6.5 (2.2–11.0) 5.0 (2.0–8.0) 0.009 IR Intervention, n (%) 11 (7.2) 15 (8.1) 26 (7.7) 0.752 Admission to IR (days), median (IQR) 2.0 (0.0–6.0) 2.5 (1.2–9.2) 2.0 (0.5–7.0) 0.358 Postoperative LOS (days), median (IQR) 3.0 (2.0–6.0) 5.0 (3.8–9.2) 4.0 (3.0–7.0) 0.002 Total LOS (days), median (IQR) 7.0 (4.0–9.0) 7.5 (5.0–14.0) 7.0 (4.0–10.0) 0.039 Disposition, n (%) Home 149 (97.4) 157 (84.9) 306 (90.5) \0.001 Mortality 1 (0.7) 4 (2.2) 5 (1.5) 0.253 Convalescence 3 (2.0) 24 (13.0) 27 (8.0) \0.001 World J Surg (2021) 45:2046–2055 2049 123 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 C65 (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). Outcomes 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%) C65 (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 C65 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 C65 (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) ageadjusted 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 C65 years had ongoing morbidity requiring postacute 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). Demographics, management, and outcomes of the elderly subgroup Patient demographic and clinical characteristics in patients over 65 years of age, dichotomized into surgical or nonoperative management, are captured in Table 4. Patients who underwent cholecystectomy were younger (75 ±7 vs. 81 ±8 years, p\0.001), male (64.3% vs. 42.6%, p= 0.004), and with fewer comorbidities [CCI median (IQR): 4.0 (3.0–5.0) vs. 5.0 (4.0–2.6), p= 0.031]. There was no difference in their fitness for surgery based on their preoperative ASA score assessment (p= 0.197) (Table 4). Acute cholecystitis was the most common diagnosis in the cholecystectomy group (74.3% vs. 29.6%, p\0.001), while most non-operated patients presented with gallstone pancreatitis, common bile duct stone, or cholangitis (69.5% vs. 25.7%, p\0.001). There was no difference in intervention radiology (p= 0.437) or endoscopy interventions (p= 0.813) between the cohorts (Table 5). No statistical differences in the total hospital length of stay or disposition after discharge was measured between the groups (Table 5). Discussion There has been a disproportionate increase in the number of older adults within the world population over the last 50 years, with the global population aged 60 years or older projected to treble to nearly 2 billion people within the first half of this century [20]. In Europe alone, almost 30% of the population is predicted to be aged 65 or over by 2050 [20]. Geriatric patients frequently undergo emergency general surgery and accrue more postoperative complications and fatal outcomes than the general population [5,13,16]. It is thus highly relevant to develop and guide evidence-based patient-centered decision-making around emergency surgical care [21]. ACCBD is a relatively frequent diagnosis in patients over 65 years, and while some consensus guidance exists, age is not considered to be a contraindication to operative management [26]. 2050 World J Surg (2021) 45:2046–2055 123 Table 4 Demographics, treatment metrics and outcomes in patients over the age of 65 years, comparing those who underwent surgical intervention or not Not operated (N= 115) Operated (N= 70) Total (N= 185) pvalue Age, years, mean (SD) 81 (8) 75 (7) 79 (8.0) \0.001 Sex, Female n(%) 66 (57.4%) 25 (35.7%) 91 (49.2%) 0.004 Charlson Comorbidity Index, median (IQR) 5.0 (4.0–6.2) 4.0 (3.0–5.0) 4.0 (4.0–6.0) 0.031 Age-adjusted Charlson Comorbidity Index, median (IQR) 8.0 (7.0–10.0) 8.0 (6.0–9.0) 8.0 (7.0–10.0) 0.024 BMI (kg/m 2 ), mean (SD) 27.0 (5.6) 28.6 (5.3) 27.6 (5.5) 0.049 1 ASA, n(%) 0.197 2 1 1 (3.1%) 4 (7.7%) 5 (6.0%) 2 8 (25.0%) 23 (44.2%) 31 (36.9%) 3 17 (53.1%) 19 (36.5%) 36 (42.9%) 4 6 (18.8%) 6 (11.5%) 12 (14.3%) Diagnosis, n(%) \0.001 1 Cholecystitis 34 (29.6%) 52 (74.3%) 86 (46.5%) Gallstone pancreatitis 27 (23.5%) 4 (5.7%) 31 (16.8%) Cholangitis 26 (22.6%) 5 (7.1%) 31 (16.8%) CBD stone 27 (23.5%) 9 (12.9%) 36 (19.5%) Mirizzi syndrome or bilioenteric fistula 1 (0.9%) 0 (0.0%) 1 (0.5%) AAST Cholecystitis Grade, n(%) 0.642 1 1 0 (0%) 0 (0%) 0 (0%) 2 26 (76.5%) 40 (76.9%) 66 (76.7%) 3 7 (20.6%) 8 (15.4%) 15 (17.4%) 4 1 (2.9%) 2 (3.8%) 3 (3.5%) 5 0 (0.0%) 2 (3.8%) 2 (2.3%) Grade 3 or higher 8.0 (23.5%) 12.0 (23.1%) 20.0 (23.3%) 0.961 1 AAST Pancreatitis Grade, n(%) 0.700 1 1 23 (85.2%) 3 (75.0%) 26 (83.9%) 2 3 (11.1%) 1 (25.0%) 4 (12.9%) 3 1 (3.7%) 0 (0.0%) 1 (3.2%) 4 0 (0%) 0 (0%) 0 (0%) 1 Linear Model ANOVA 2 Trend test for ordinal variables Table 3 Operative and postoperative complications in patients under and over 65 years undergoing surgical intervention \65 years C65 years Total pvalue Strasberg Classification of CBD Complication, n (%) 0.183 1 Cystic duct leak 2 (1.3) 5 (2.7) 7 (2.1) Lateral injury to CBD/CHD (Strasberg D) 1 (0.7) 0 (0.0) 1 (0.3) CBD/CHD division (Strasberg E1) 0 (0.0) 1 (0.5) 1 (0.3) Postoperative, n (%) 0.114 1 No complication 89 (89.9%) 57 (81.4%) 146 (86.4%) Abscess 3 (3.0%) 4 (5.7%) 7 (4.1%) Bile duct complications 3 (3.0%) 6 (8.6%) 9 (5.3%) Hemorrhage 0 (0.0%) 1 (1.4%) 1 (0.6%) Wound infection 3 (3.0%) 2 (2.9%) 5 (3.0%) Enterotomy 1 (1.0%) 0 (0.0%) 1 (0.6%) Total 10 (10.1%) 13 (18.6%) 23 (13.6%) 1 Pearson’s Chi-squared test World J Surg (2021) 45:2046–2055 2051 123 As evidenced by a significantly higher CCI and ageadjusted CCI in the current study cohort, pre-existing cardiovascular, endocrine, and renal comorbidities are more frequent in older than younger patients [9–11]. While a direct correlation has yet to be studied between aaCCI and morbidity and mortality following emergency cholecystectomy, strong evidence exists supporting aaCCI as a robust predictor of poor outcomes following elective gynecologic, oncologic gastrointestinal, and emergency orthopedic surgery [22–25]. Indeed, the observed case fatality rate in our study was 2.2% in patients over 65 years, a postoperative complication occurred in 18.6%, and aaCCI was positively correlated with higher mortality and complication rates. International guidelines, which advocate for index admission cholecystectomy, make no specific recommendations for older patients [2]. In the current cohort of patients admitted for acute complicated biliary calculus disease, index admission cholecystectomy was achieved only in 37.8% cases in patients 65 years of age and older. Subgroup analysis of the over 65 years cohort detected no difference in fitness for surgery by anesthesia assessment (as measured by ASA classification score) or difference in severe cholecystitis incidence (AAST Grade 3–5). However, the non-operative group was found to be older. This finding is of particular importance since other gallstone complications (e.g., gallstone pancreatitis, common bile duct stone with or without concomitant cholangitis) were managed by percutaneous cholecystostomy or ERCP alone. Several studies have shown better outcomes in those who received early cholecystectomy following duct clearance for gallstone pancreatitis, and the Tokyo Guidelines (2018) advise index admission cholecystectomy in this instance [26,27]. A recent comparison of one-stage ERCP and cholecystectomy versus index admission ERCP with planned interval elective day-case cholecystectomy demonstrated a readmission rate over 20% in the latter group, due to complications relating to the retained gallbladder as a stone reservoir [28]. Regrettably, our current data did not report readmission rate, but given the overlap in patient populations, we would expect similar rates of disease recidivism in the non-operated cohort. However, there was no difference in postintervention complications between the cohorts. These are important factors to Table 5 Surgical, endoscopic and radiologic intervention and outcomes in patients over 65 years of age, comparing those who underwent surgical intervention or not Not operated (N = 115) Operated (N = 70) Total (N = 185) pvalue Admission to IR (days) 0.437 1 IR, n (%) 9 (7.8%) 7 (10.0%) 18 Mean (SD) 5.7 (11.5) 9.9 (9.2) 7.3 (10.6) Admission to Endoscopy (days) 0.813 1 Endoscopy, n (%) 45 (39.1%) 19 (27%) 62 Mean (SD) 9.0 (10.8) 9.8 (12.4) 9.3 (11.2) Surgical Approach, n (%) Laparoscopic 55 (78.6%) Laparoscopic converted to open 9 (12.9%) Open 6 (8.6%) Type of surgery, n (%) Cholecystectomy 66 (94.3%) Subtotal cholecystectomy 4 (5.7%) Admission to ICU (days) ICU admission, n (%) 1 (0.9%) 8 (11.4%) 9 (4.9%) 0.004 Median (IQR) 4.0 (4.0 to 4.0) 3.0 (1.8 to 8.0) 3 (2 to 8) 0.695 1 Total Length of Stay (days) 0.538 1 Mean (SD) 9.3 (7.6) 10.0 (9.3) 9.6 (8.3) Median (IQR) 7.0 (5.0 to 12.0) 7.0 (5.0 to 12.0) 7.0 (5.0 to 12.0) Disposition, n (%) Home 94 (81.7%) 63 (90.0%) 157 (84.9%) 0.128 1 Mortality 3 (2.6%) 1 (1.4%) 4 (2.2%) 0.592 1 Convalescence 18 (15.7%) 6 (8.6%) 24 (13.0%) 0.165 1 1 Linear Model ANOVA 2052 World J Surg (2021) 45:2046–2055 123 consider when deferring cholecystectomy in the elderly frail patient since another physiologic hit from recurrent disease could be devastating. Further, as a temporary measure of source control compared to cholecystectomy, percutaneous cholecystostomy has been shown to be associated with more complication and mortality in the elderly population [29]. Such interventions should be reserved for patients that fulfill the criteria for absolute contraindication for anesthesia or surgery [30]. Notably, recovery following acute illness and mainly surgical intervention may be prolonged in the elderly population, as a consequence of a loss of strength, mobility, and functional capacity [31–34]. However, there was no difference hospital length of stay, and post-discharge disposition comparing those patients over 65 years of age subjected to cholecystectomy versus their counterparts. Thus, it appears that underlying frailty, not surgical stress, might be the principal factor predicting recovery from acute illness. The growing elderly patient population poses challenges to physicians and healthcare systems worldwide. While some risk factors, such as age and comorbidities, cannot be modified, other components of care such as multidisciplinary management in close collaboration with gerontology colleagues, time to the operating room and early physiologic optimization have been shown to improve outcomes. To that end, The American College of Surgeons has launched a geriatric verification program for hospitals and the American Geriatrics Society and the American College of Surgeons have issued joint guidelines on optimal care of the geriatric surgical patient based on analysis of retrospective administrative NSQIP data [35,36]. Finally, with the linkage between higher hospital and surgeon volume of emergency surgical cases and improved outcome, especially in geriatrics, designated centers or indeed acute surgical service reorganization at a local level should be considered for this patient population in the future [37–39]. Conclusion Although this study is limited by its intention and design as a descriptive study, granular ‘real world’ data illustrate the challenges faced by elderly patients with AACBD. Excess morbidity, mortality, length of postoperative hospitalization, and a greater need for rehabilitation are seen in these patients. Guidelines considering age and comorbidities, routine use of prognostic tools and frailty indices in mitigating risk or pre-rehabilitation, and anticipating the requirement for enhanced supports in this patient cohort is warranted. Acknowledgements The authors would like to thank the European Society for Trauma and Emergency Surgery for facilitating this collaborative effort. In particular, thanks are due to Dr Jorge Pereira, Mr Michael Sugrue and Prof. Andreas Shamiyeh of the Emergency Surgery Committee of ESTES. Authors’ contributions GAB, AEG, YC and SM conceived the study, analyzed the data and wrote the manuscript. All study collaborators sought local ethics approval, provided the anonymous patient-level data and per protocol are listed as PubMed-indexed authors. Funding Open access funding provided by O ¨rebro University. Data availability The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. This prospective, observational, multicenter audit was conducted in line with a pre-specified protocol which was registered with ClinicalTrials.gov (Trial # NCT03610308). Declaration Conflict of interest The authors declare no conflicts of interest. Ethical approval All 25 participating centers (see Supplemental Table of Collaborators) provided local institutional review board approval or equivalent as a requirement of registration. No patient consent was sought since the current study was purely observational and did not change the medical course of any patient. 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Appendix 1 Collaborating Group Membership Country Center name Authors Austria Kepler University Clinic Andreas Shamiyeh, Lena Rosetti, Gu ¨nter Klimbacher, Bettina Klugsberger Ireland Beaumont Hospital Dublin Paul Healy, Conor Moriarty, Colm Power, Nauar Knightly, Arnold DK Hill World J Surg (2021) 45:2046–2055 2053 123 Country Center name Authors Ireland SVUH Institute for Clinical Outcomes Research and Education, Dublin Desmond C Winter, Michael E Kelly, Ben E Creavin, E ´anna J Ryan, Caoimhe C Duffy Ireland Letterkenny University Hospital Michael Sugrue, Michael Hugh Moore, Louise Flanagan Ireland Mayo University Hospital, Castlebar, Mayo Jessica Ryan, Conor Keady, Brian Fahey, Kevin L McKevitt, Kevin Barry Ireland Saint Vincent’s University Hospital, Dublin Kevin C Conlon, Keno Mentor, Andrea Kazemi- Nava, Barbara Julies Ireland Tallaght University Hospital, Dublin Paul F Ridgway, Dara O Kavanagh, Mark Donnelly, Cathleen McCarrick, Umair Muhammad, Tara M Connelly, Paul C Neary Italy Fondazione Policlinico Universitario ‘‘A. Gemelli’’ IRCCS Sabina Magalina, Valerio Cozza, Antonio LaGreca, Daniele Gui Italy Policlinico San Pietro, Bergamo, Milano Alessia Malagnino, Mauro Zago, Mauro Montuori Italy Clinica Chirurgica, Trieste University Hospital, Trieste, Italy Alan Biloslavo, Natasa Samardzic, Stefano Fracon, Davide Cosola, Nicolo `de Manzini Portugal Centro Hospitalar de Tra ´sos-montes e Alto Douro Ura ˆnia Fernandes, Paulo Avelar, Rita Marques, Ana Sofia Esteves, Andre ´ Marc¸al, Carina Gomes Portugal Centro Hospitalar Cova de Biera, Covilha Daniela Machado, Tobias Teles, Sofia Neves, Miguel Semiao, Rui Cunha Portugal Centro Hospitalar Tondela Viseu Jorge Pereira, Ju ´lio Constantino, Milene Sa ´, Carlos Casimiro Romania St. Spiridon Emergency Universitary Hospital, Iasi Lidia Ionescu, Roxana Livadariu, Ludmila Stirbu, Radu Danila, Daniel Timofte, Bogdan Astefaniei Spain Hospital Urduliz Aitor Landaluce Olavarria, Begon ˜a Estraviz Mateos, Jaime Gonzalez Taranco, David Gomez, Jon Barrutia, Julio Zeballos Spain University Hospital ‘‘Marques de Valdecilla’’ Dieter Morales Garcia, Ana Lozano Najera, Erik Gonzalez Tolaretxipi Spain Hospital Virgen del Rocı ´o Luis Tallon-Aguilar, Jose ´ Pintor-Tortolero, Alejandro Sanchez- Arteaga, Virginia Duran- Mun ˜o ´z Cruzado, Violeta Camacho-Marente, Jose ´ Tinoco-Gonzalez Country Center name Authors Sweden Jo ¨nko ¨ping Medical Center Anna A ¨lverdal Sweden Linko ¨ping University Hospital Stefan Redeen Sweden O ¨rebro University Hospital Shahin Mohseni, Ahmad Mohammad Ismail, Rebecka Ahl UK Stoke Mandeville Hospital Spyros Marinos, Naomi Warner, Rikhil Patel, Tania Magro, Romeshan Sunthareswaran UK Tameside General Hospital Andrei Mihailescu, Goran Pokusewski, Alexandru Leopold Bubuianu UK Wrightington, Wigan and Leigh NHS Foundation Trust Corneliu Dimitriu, Marius Paraoan UK Worthing Hospital Arjun Desai, Katie Jones, Makhosini Mlotshwa, Kenny Ross, Simon Lambracos, Yegor Tryliskyy USA Marshfield Clinic Daniel C. 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