Recurrence of biliary disease following non-operative management in elderly patients

Introduction: The purpose of this study was to determine the proportion of symptomatic recurrence following initial non-operative management of gallstone disease in the elderly and to test possible predictors. Methods: This is a single institution retrospective chart review of patients 65 years and older with an initial hospital visit (V1) for symptomatic gallstone disease, over a 4-year period. Patients with initial “non-operative” management were defined as those without surgery at V1 and without elective surgery at visit 2 (V2). Baseline characteristics included age, sex, Charlson comorbidity index (CCI), diagnosis, and interventions (ERCP or cholecystostomy) at V1. Outcomes assessed over 1 year were as follows: recurrence (any ER/admission visit following V1), surgery, complications, and mortality. A survival analysis using a Cox proportional hazards model was performed to assess predictors of recurrence. Results: There were 195 patients initially treated non-operatively at V1. Mean age was 78.3 ± 7.8 years, 45.6 % were male, and the mean CCI was 2.1 ± 1.9. At V1, 54.4 % had a diagnosis of biliary colic or cholecystitis, while 45.6 % had a diagnosis of cholangitis, pancreatitis, or choledocholithiasis. 39.5 % underwent ERCP or cholecystostomy. Excluding 10 patients who died at V1, 31.3 % of patients had a recurrence over the study period. Among these, 43.5 % had emergency surgery, 34.8 % had complications, and 4.3 % died. Median time to first recurrence was 2 months (range 6 days–4.8 months). Intervention at V1 was associated with a lower probability of recurrence (HR 0.3, CI [0.14–0.65]). Conclusion: One-third of elderly patients will develop a recurrence following non-operative management of symptomatic biliary disease. These recurrences are associated with significant rates of emergency surgery and morbidity. Percutaneous or endoscopic therapies may decrease the risk of recurrence.