22 - MANAGEMENT OF SUSPECTED CHOLEDOCHOLITHIASIS IN PATIENTS WITH FRAILTY

Objectives: The American Society for Gastrointestinal Endoscopy provides guidelines for managing choledocholithiasis (CDL) yet does not account for patient-specific factors like frailty. We sought to evaluate how frail patients with common bile duct (CBD) stones undergoing same-admission cholecystectomy were managed within the purview of these guidelines.

Methods: We performed a post-hoc analysis of prospectively collected patients undergoing same-admission cholecystectomy for CDL and/or acute biliary pancreatitis (ABP) from 2016-2019 at 12 US academic medical centers. Patients with cholangitis were excluded. Patients were grouped by Charlson comorbidity index: 0 [non-frail], 1-2 [moderately frail], ≥3 [severely frail]. Using the guidelines, each patient’s likelihood of CDL (low, intermediate, high) was determined. The actual management was then compared to the suggested management (Figure 1). Our primary outcome was the rate of deviating from guidelines between groups. Secondary outcomes included rates of CDL detection, surgical site infections (SSIs), biliary leaks, and 30-day surgical readmissions between groups. Rates are presented in order of non-frail, moderately frail, severely frail.

Results: 844 patients were included in our analysis. 43.3% (n=365) were non-frail, 25.4% (n=214) were moderately frail, and 31.4% (n=265) were severely frail. There was no difference in rates of concomitant cholecystitis (12.9% vs 16.8% vs 19.3%, p=0.09) between groups. Frail patients were older (33 y vs 56.7 y vs 73.5 y, p<.0001), more likely to have ABP (32.6% vs 47.7% vs 43.8%, p=0.0005), and less likely to have abnormal LFTs (90.7% vs 82.7% vs 84.5%, p=0.01). There was no difference in the likelihood of CDL (p=0.6), management of CDL (p=0.1), or rates of CDL detection (58.5% vs 51% vs 58%, p=0.2) between groups. As frailty increased, guideline deviation increased significantly (41.1% vs 43.5% vs 53.6%, p<.006). Deviation among non-frail and moderately frail patients was not associated with a difference in rates of CDL detection; however, severely frail patients with deviation had higher rates of CDL detection compared to patients managed according to guidelines. There was no difference in SSIs (2% vs 4.2% vs 2%, p=0.2), biliary leaks (0.5% vs 1% vs 1.1%, p=0.7), or 30-day surgical readmission (4.1% vs 2.8% vs 3.8%, p=0.7) between groups.

Conclusion: Frail patients with CBD stones were more likely to have management that deviated from guidelines yet had higher rates of CDL detection and no difference in rates of adverse outcomes. Future guidelines should consider including frailty to optimize detection of CDL in this population.