Effect of Frailty on the Management of Suspected Choledocholithiasis

Area of Science:

• Gastroenterology
• Surgical Management
• Patient Frailty Assessment

Background:

• Current ASGE-SAGES guidelines for choledocholithiasis (CDL) management do not account for patient-specific factors like frailty.
• This study investigates the management of frail patients with CDL undergoing same-admission cholecystectomy within existing guidelines.

Purpose of the Study:

• To evaluate adherence to ASGE-SAGES guidelines for CDL management in frail versus non-frail patients.
• To determine if frailty influences the rate of guideline deviation in patients undergoing cholecystectomy for CDL.

Main Methods:

• Analysis of 844 patients with CDL and/or acute biliary pancreatitis (ABP) undergoing same-admission cholecystectomy across 12 US academic medical centers (2016-2019).
• Patients were stratified into non-frail (NF), moderately frail (MF), and severely frail (SF) groups using the Charlson comorbidity index.
• Comparison of actual management against ASGE-SAGES guideline recommendations, with guideline deviation rate as the primary outcome.

Main Results:

• Frail patients were older and more likely to present with ABP.
• Guideline deviation rates increased with frailty severity (41.1% NF, 43.5% MF, 53.6% SF; P < .006).
• Severe frailty independently predicted guideline deviation (aOR 1.47 vs MF, aOR 1.46 vs NF; P = .04 for both), with no significant differences in surgical site infections, biliary leaks, or 30-day readmissions.

Conclusions:

• Frail patients with CDL experience higher rates of guideline deviation during same-admission cholecystectomy.
• Despite increased deviation, frailty did not correlate with higher rates of surgical complications or readmissions.
• Incorporating frailty assessment into future guidelines is recommended for optimizing CDL management in vulnerable patient populations.