Geriatric Assessment as a qualification element for elective and emergency cholecystectomy in older patients
Kenig et al. World Journal of Emergency Surgery
Geriatric Assessment as a qualification element for elective and emergency cholecystectomy in older patients
Jakub Kenig 0
Piotr Wałęga 0
Urszula Olszewska 0
Aleksander Konturek 0
Wojciech Nowak 0
0 3rd Department of General Surgery, Jagiellonian University Medical College , Pradnicka str. 35-37, 31-202 Kraków , Poland
Background: Older patients experience a higher incidence of postoperative complications after cholecystectomy compared with younger patients. However, most studies have not considered patient frailty, particularly regarding emergency cholecystectomy. The aim of this prospective study was to evaluate outcomes in frail older patients eligible for elective and emergency cholecystectomy. Methods: Preoperative Geriatric Assessment (GA) was performed in consecutive patients aged 65+ years, operated for biliary disease. The GA evaluated the functional, cognitive, comorbidity, depressive, nutritional, and polypharmacy status and patients with two or more abnormal domains were considered frail. Outcomes of interest were 30-day postoperative mortality, morbidity, and length of hospital stay (LOS). Results: A total of 126 patients (median age 74; range 65-93 years) were included. There was no difference between elective frail and non-frail patients regarding postoperative mortality (0 %) and morbidity (6 % vs. 5 %; p = 0.76). LOS was not significantly longer in the frail group (5.6 vs. 4 days; p = 0.22). In the emergency-admitted patients, almost all complications occurred in the frail population (mortality 5 % vs. 0 %; morbidity 36.7 % vs. 3.3 %, compared with nonfrail patients, respectively; p < 0.01) and LOS was significantly longer (10.3 (frail) vs. 6 days (non-frail);p = 0.03). Frail status was a significant independent predictive factor for postoperative complications in the emergency population, only (odds ratio: 3.4 (1.2-9.7); p = 0.02). Conclusions: Elective laparoscopic cholecystectomy is a safe and effective surgical technique also for older frail patients. In emergency settings, frail patients have significantly more complications and a longer LOS. However, the role of severity of frailty and the most reliable GA tools require further study. Trial registration: ISRCTN14976998 (retrospectively registered)
Geriatric assessment; Frailty; Surgery in older patients; Cholecystectomy
Several studies, concerning surgical treatment of biliary
disease, have shown that older patients more often have
complicated gallstone disease, more emergency and
open operations, higher postoperative morbidity and
mortality rates, and a longer postoperative hospital stay
compared with younger patients [
]. However, most
studies have not considered the larger heterogeneity of
co-morbidity and physical strength in this group of
patients, which further contributes to the complexity of
treatment. This relates especially to frail patients who
have reduced physiologic reserve associated with
increased susceptibility to disability because of age-related
loss of physical, cognitive, social, and physiological
functioning . In these patients, standard preoperative
medical history, physical examination, biochemistry, and
imaging tests often do not provide the information
needed for optimal and tailored treatment, leading to
both under- and overtreatment [
]. On the other hand, a
Geriatric Assessment (GA), can provide a
comprehensive health appraisal to guide targeted geriatric
interventions and appropriate treatment selection [
systemic approach was mostly investigated in surgical,
oncologic patients  but not among patients with
biliary diseases apart from one study by Lasithiotakis et al.
]. Furthermore, the appropriate assessment can be
even more complex in case of patients with acute
cholecystitis. At present, such “patient-related” treatment
guidelines do not exist, taking into consideration local
pathological changes, patient clinical status and the
subsequent treatment decisions [
]. Therefore, the aim of
this prospective study was to evaluate postoperative
outcomes in frail older patients eligible for elective and
emergency cholecystectomy. To our knowledge, this is
the first prospective study to assess the outcome of frail
older patients undergoing emergency cholecystectomy.
Between June 2014 and December 2015, we prospectively
enrolled consecutive patients over 65 years of age with
symptomatic gallstone disease, acute cholecystitis
requiring elective or emergency surgery, respectively. The study
was conducted at a tertiary referral hospital. The ethics
committee approved this study and informed consent was
obtained from all patients or their caregivers.
Inclusion criteria for the elective patients were
symptomatic and sonographically detected cholelithiasis.
Inclusion criteria for the emergency patients were acute
cholecystitis according to the 2013 Tokyo Guidelines
]. Patients with pancreatitis at the time of surgery
were excluded. Three patients who were unable to give
consent or answer the GA questions were excluded and
two additional patients were excluded because of
All patients were assessed using the GA, which was
performed on the day of admission by trained physicians or,
for emergency patients, by trained physicians or nurses.
The GA comprised the validated instruments presented
in the Table 1, with the range and the literature-based
cut-off scores [
The results of each test were recorded and each test
was also scored on a dichotomous scale, based on
whether an impairment in any of the parameters was
All operations were performed by residents under the
direct supervision of a consultant (who also served as
the first assistant) or by the consultants themselves.
Laparoscopic cholecystectomy was performed using a
standard three- or four-port technique and all emergency
patients were treated surgically within 24 h after
admission. Severity grading for the acute cholecystitis patients
was according to the 2013 Tokyo Guidelines [
A cumulative deficit model of frailty was used. The
equally weighted deficits, as a measure of accumulated
vulnerability, included ADL/IADL, Geriatric Depression
Score, BOMC/CDT, the Mini-Nutritional Assessment,
CCS, and the Polypharmacy Assessment. The functional
(ADL/IADL) and cognitive domains (BOMC/CDT) were
considered abnormal if one of the assessment tools
showed literature-based impairment. The detection of
deficits in two or more GA domains indicated an
increased risk of disability or death and was used as the
cut-off score for the GA set and also as the definition of
The primary outcome, complications, was defined as any
event occurring within 30 days of surgery that required
treatment not routinely applied in the post-operative
period. The severity of predefined complications was
classified according to the Clavien–Dindo scale [
]. Grade I
and II complications were classified as minor morbidity,
and Grade III and IV complications as major morbidity.
Postoperative mortality was defined as death within
30 days after surgery. LOS was calculated as the period
from the admission day until discharge from hospital.
ADL Activities of daily living, IADL Instrumental Activities of Daily Living, BOMC Blessed Orientation-Memory-Concentration Test, CDT Clock Drawing Test, CCS
Charlson Comorbidity Scale, GDS Geriatric Depression Scale, MNA Mini Nutritional Assessment
The data were analyzed using Statistica 10.0 software
(StatSoft, Krakow, Poland). Categorical variables are
described as percentages of the total population, while
continuous variables are reported as the median and
range. Pearson’s chi-square or Fisher’s exact test was
used to compare categorical variables and the unpaired
Student’s t-test was used for comparisons.
Univariate and multivariate analysis was conducted to
investigate the association between the GA set and
30day postoperative morbidity (including a comparison of
“any” with “no” complications and “major” with “no/
minor” complications), adjusted for age and sex. Because
of the small number of fatal events, postoperative
mortality was not analyzed separately but as part of the
“major morbidity” category. Statistical significance was
defined as two-sided p ≤ 0.05.
The study sample comprised 66 elective patients (48
female and 18 male) and 60 emergency-admitted patients
(34 female and 26 male). The median age was
significantly lower among elective patients: 71 vs. 76 years of
age; p < 0.01. Patients’ baseline characteristics are shown
in Table 2.
Laparoscopic cholecystectomy was successfully
performed in 57 (86 %) elective and 42 (70 %) emergency
patients. The conversion to open cholecystectomy was
performed in two patients (3 %) in the elective group
and in five patients (8.3 %) in the emergency group.
Seven (10.6 %) and 13 (21.7 %) patients had primary
open cholecystectomy in the elective and emergency
group, respectively, due to severe pulmonary and/or
cardiac comorbidities after consultation with the
anesthesiologists, numerous laparotomies in the upper abdomen.
The mean operation time was 79 min (range, 30–
180 min). Emergency frail patients had a
nonsignificantly longer operation time compared with
emergency fit patients (85 vs. 71 min; p = 0.14). There was no
difference between frail and fit patients operated
electively (77 vs. 76 min; p = 0.87).
The severity of acute cholecystitis in emergency
admitted patients according to the revised 2013 Tokyo
Guidelines was as follows: Grade I: two patients
(3.3 %); Grade II: 39 patients (65 %); and Grade III:
19 patients (31.7 %).
Descriptive analysis of the GA components and frailty frequency
The Table 3 presents the results of the GA instruments
with literature-based cut-off scores and the proportion
of patients who had abnormal results in the test.
Table 4 shows the results of the cumulative deficit
model of the GA. The frequency of frailty was significantly
higher among emergency patients compared with elective
patients (34 vs. 46 patients, respectively; p < 0.01). The
cumulative number of abnormal domains among frail
patients was between two and five (elective patients) and
between two and six (emergency patients). Additionally,
significantly more frail emergency patients had Grade III
(severe) acute cholecystitis according to the 2013 Tokyo
Guidelines (17 vs. three patients, (frail emergency patients
vs. fit emergency patients, respectively); p < 0.01).
The discharge status was to home in all elective cases
and to skilled nursing facilities in 8.3 % (n = 5) of
emergency patients. There were no readmissions and there
was no mortality among the elective patients. In the
emergency group, the 30-day mortality was 5 % (n = 3)
with patients dying on the 1st, 3rd, and 10th
postoperative day because of progressive circulatory insufficiency.
The 30-day morbidity was 10.6 % (including 6.1 % major
morbidities) and 36.7 % (including 10 % major
morbidities), in the elective vs. the emergency group of patients,
respectively. Comparing the incidence of both 30-day
postoperative overall and major complications between
frail and non-frail patients, there was no statistically
significant difference (6 % vs. 5 %, p = 0.76) in the elective
group. All four occurrences of major complications
(postoperative bleeding, bile leakage, abscess formation)
in the elective group were observed among patients with
chronic severe inflammatory processes and were
connected to the surgical technique. In comparison, in the
emergency group, almost all mortality and major
complications were observed in the frail populations (36.7 vs.
3.3 %; p < 0.01) - Table 5.
Comparing the LOS of frail and non-frail patients,
the frail group had non-significantly longer mean
hospital stay (5.6 vs. 4 days; p = 0.22) in the elective
group. In the emergency group, the LOS was
significantly longer among frail patients (10.3 vs. 6 days,
frail emergency patients vs. non-frail emergency
patients, respectively; p = 0.03).
Cumulative effect of GA in determining surgical outcome
The results of the univariate and multivariate logistic
regression analysis showed that age and sex did not
increase the surgical risk either in the elective or the
emergency group. The frailty status was not predictive
of all and major postoperative complications in the
elective group. In turn, frailty was an independent risk
factor for all complications in the emergency group. It
ADL/IADL + MNA + BOMC/CDT + CCS +
GDS + Polypharmacy (>5 drugs/day)
34 (51.5 %) 46 (76.7 %)
ADL Activities of daily living, IADL Instrumental Activities of Daily Living, MNA
Mini Nutritional Assessment, BOMC Blessed
Orientation-MemoryConcentration, Test, CDT Clock Drawing Test, CCS Charlson Comorbidity Scale,
GDS Geriatric Depression Scale
was not possible to build a model for the major
complications in the emergency group because of an
insufficient number of patients in this subgroup (major
complications were observed only among frail patients).
The results of the multivariate logistic regression are
presented in Table 6.
In this study, almost half of the elective and two thirds
of the emergency older patients were frail. However, the
procedure was performed safely with no 30-day
postoperative mortality and a low number of major
complications, for both frail and non-frail elective patients. In
contrast, we encountered poorer outcomes in emergency
operated patients. All of the cases of mortality and major
comorbidity occurred in frail emergency patients, which
was confirmed by regression analysis. Frail status was
not a risk factor for overall and major postoperative
complications in the elective group but was a significant
independent predictive factor for postoperative
complications in the emergency population. Similarly, the LOS
was not significantly longer in the elective frail group of
patients and was significantly longer in the emergency
Published studies show that elective laparoscopic
cholecystectomy is a feasible and safe procedure in older
patients, including in a group of octogenarians. The
authors report no or single cases of mortality and usually a
higher, but acceptable, rate of postoperative
complications when compared with a younger population [
]. However, the authors of a meta-analysis of
laparoscopic versus open cholecystectomy in older patients,
including studies up to June 2013, concluded that
further high-quality evidence is necessary to draw
definitive conclusions, although the best available evidence
supports the selective use of laparoscopy . Older
patients with acute cholecystitis have more frequent
primary open cholecystectomies, a higher conversion rate
and, in most studies, a worse postoperative outcome
]. We obtained similar results with no mortality
in the elective population, a low postoperative
complication rate, and most of the procedures were performed
using minimally invasive techniques. Similar to other
studies, older patients with acute cholecystitis had a
higher rate of mortality, morbidity, primary open
cholecystectomies, and conversions in our study. However,
the frailty factor was not considered in these studies and
advanced age alone is not necessarily synonymous with
vulnerability to adverse health outcomes.
Another problem with the frailty concept is the choice
of the best assessment model, which is still debatable.
Three of them are most frequently cited in the current
literature: the multi-domain GA, the cumulative deficit
score (CDS), and the frailty phenotype model [
trials evaluating the multi-domain GA in surgical
patients have analyzed the relationship between individual
elements of the GA and the outcomes, showing a
statistically significant predictive possibility of postoperative
]. In our study, domains as a single
risk factor were not relevant in the elective patients,
both in the univariate and multivariate regression
analysis. In turn, in the emergency group some domains
(I-ADL, CDT, CCI, Polypharmacy) turned out to be the
risk factor of postoperative outcome, however, only in
the univariate analysis (data not included in the paper).
Robinson et al. and Kim KI et al. showed that a
cumulative deficit frailty score was independently associated
with postoperative mortality [
]. Similarly, in our
previous study, this model turned out to be also
predictive of 30-day postoperative morbidity in oncologic
patients with solid cancer eligible for abdominal surgery.
However, the number of incorporated GA domains had
a great influence on the prevalence of frailty and on
adequate surgical risk assessment [
]. Another problem is
the cut-off of two abnormal domains, which was used as
a frailty definition in our study. We extrapolated the
guidelines of Geriatric Assessment used by the SIOG in
the older oncologic patients [
]. However, there is still
no “golden standard” regarding the number of impaired
domains that should be considered as a frailty marker.
Kristjansson et al., Kwang-il et al., Tan et al., and
Makary et al. used a frailty phenotype model and observed
that impairments were also independently associated
with adverse in-hospital events, prolonged LOS, and
post-discharge institutionalization [
However, none of these studies analyzed exclusively
patients eligible for cholecystectomy. Lasithiotakis et al.
performed the only study including a frailty assessment
in 57 older patients eligible for elective laparoscopic
cholecystectomy. In contrast to our results, they
observed that the GA might predict 30-day postoperative
complications and a prolonged stay. This and our study
have common features: similar median age, a cumulative
model used to assess frailty (with five out of six similar
domains and the same cut-offs), almost the same
number of patients identified as frail (56.1 vs. 51.5 %), and a
similar method of reporting outcomes [
our study has a few important differences. The study by
Lasithiotakis et al. included only patients with
uncomplicated biliary disease whereas our study included
consecutive patients also presenting with severe chronic
cholecystitis (intraoperative finding in patients admitted
electively) and these patients experienced the major
postoperative complications. Unfortunately, our study
period included the highest number of bile leakages ever
experienced in our institution, in both the fit and frail
groups. Moreover, our study included also the Geriatric
Depression Scale in the frailty assessment, which is a
proven predictor of postoperative adverse outcome [
Although, we are in favor of the use of the cumulative
deficit model, it still remains unclear which measure of
frailty should be used in surgical patients. All of the
frailty models evaluate the same concept but from a
different perspective and further research is needed to
determine the best approach.
It is also important to note the severity of acute
cholecystitis in our case series. Previous studies have shown
that perioperative outcomes are influenced by the severity
of gallbladder disease rather than chronological age [
In our emergency population, only 3 % of patients had a
Grade I score and more than one third had Grade III
acute cholecystitis according to the 2013 Tokyo
Guidelines, which is one of the highest reported results.
Moreover, the timing of the surgery plays an important role
] but this factor was not significant in regression and
correlation analysis (data not presented) in our study.
ADL/IADL + MNA + BOMC/CDT + CCS
+ GDS + Polypharmacy (>5 drugs/day)
ELECTIVE PATIENTS OR (95 % CI)
1.2 (0.5-2.7) p = 0.63 0.89 (0.3-2.6) p = 0.84
EMERGENCY PATIENTS OR (95 % CI)
3.4 (1.2-9.7) p = 0.02 -a
All variables were considered dichotomous; OR odds ratio, 95% CI 95% confidence interval, The statistically significant values appear in bold font; aThere were no
cases of major complications in the non-frail group. ADL Activities of Daily Living, IADL Instrumental Activities of Daily Living, MNA Mini Nutritional Assessment,
BOMC Blessed Orientation-Memory-Concentration ,Test, CDT Clock Drawing Test, CCS Charlson Comorbidity Scale, GDS Geriatric Depression Scale
We believe that the severity of the surgical insult is of
great importance in frail patients. In our study, in
patients eligible for elective cholecystectomy, this factor
did not appear to be strong enough to influence the
reduced physiologic reserve and outcomes in frail patients
and this could be a result of further heterogeneity within
this population. The identification of frailty alone
appears to be insufficient in patients undergoing surgery
and it should be supported by its magnitude. The
number of abnormal deficits in the cumulative model of
frailty could be one such factor. Additionally, meticulous
surgical technique in experienced hands is of paramount
importance for this particular group. Therefore, the
influence of the surgeon, the surgical technique, and the
reaction of the patient’s body to the stress connected
with the operative procedure in the context of frailty
require further study.
Elective laparoscopic cholecystectomy is a safe and
effective surgical technique also for older frail patients. In
emergency settings, frail patients have significantly more
complications and a longer LOS compared with the fit
population. However, the role of severity of frailty and
the most reliable GA tools require further study.
ADL, activities of daily living; ASA score, the American Society of
Anesthesiologist’s score; BOMC, the blessed orientation-memory-concentration
test; CCS, the charlson comorbidity scale; CDS, the cumulative deficit score;
CDT, the clock drawing test (CDT); ECOG-PS, the performance status eastern
cooperative oncology group performance status; GA, geriatric assessment; GDS,
the geriatric depression scale; IADL, instrumental activities of daily living; LOS,
length of hospital stay; MNA, the mini nutritional assessment
We thank all of the nurses in the Surgical Department for their help during
the study period.
This research received no specific grant from any funding agency,
commercial or not-for-profit sectors.
Availability of data and materials
The data and materials are not available because consent for such an action
was not taken from the participants.
JK - Study conception and design, Acquisition of data, Analysis and
interpretation of data. Drafting of manuscript; PW - Acquisition of data,
Drafting of manuscript; UO - Acquisition of data, Drafting of manuscript; AK
Acquisition of data, Drafting of manuscript; WN - Drafting of manuscript,
Critical revision of manuscript All authors read and approved the final
The authors declare that they have no competing interests.
Consent for publication
The authors assert this manuscript does not contain any individual person’s
data in any form.
Ethics approval and consent to participate
The ethics committee of the Jagiellonian University Medical College
approved this study and the informed consent was obtained from all
patients or their caregivers.
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