EP539 - Association Of Patient Frailty And Concurrent Cholecystectomy With Postoperative Outcomes In Patients With Gallstone Ileus

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Purpose/Background: Gallstone ileus is a rare, but potentially life-threatening complication of gallstone disease where cholecysto-enteric fistulization can lead to mechanical bowel obstruction from a gallstone. Conventionally, patients undergo surgical management of the obstruction with delayed cholecystectomy, but there is an approximate 10% chance of recurrence. This study investigates the association between concurrent cholecystectomy (CC) during the index surgical procedure and patient frailty, measured by the 5-factor modified frailty index (mFI-5), with major postoperative complications and discharge destination.

Methods/Interventions: This is a retrospective review of the American College of Surgeons National surgical Quality Improvement Program (ACS-NSQIP) database from 2006 to 2021. Patients who received either enterolithotomy or enteric resection for a diagnosis of gallstone ileus based on ICD9/10 codes were included. CC was used as a covariate in the downstream analysis. Patient frailty was determined based on mFI-5 score which was calculated based on the presence of five conditions: diabetes, congestive heart failure, hypertension, chronic obstructive pulmonary disease, and dependent functional status. Patients were stratified by mFI-5 scores with mFI-5 = 0 being nonfrail, mFI-5 = 1 being mildly frail, and mFI-5 ≥ 2 being frail/very frail. Primary outcomes of interest were major complications (Clavien-Dindo ≥ 3) and non-home discharge destination. Univariate and multivariate analyses were performed to assess the association between primary outcomes with surgery performed and patient frailty.

Results/Outcomes: A total of 670 patients were analyzed with a median age of 75 [65-83] years with 71% female. Most patients were classified as mildly frail or frail/very frail with an mFI-5 of 1 (39%) or ≥ 2 (30%), respectively. While the majority underwent enterolithotomy (73%) compared to enteric resection (27%), only 6% received CC for management of gallstone ileus. There was no significant difference in whether CC was performed based on mFI-5 score subgroups (4% vs 7% vs 6%, respectively, p = 0.39). CC was associated with prolonged hospitalization (8 vs 12 days, p < 0.001) and operative time (64 vs 147 minutes, p < 0.001). On multivariable analysis, enteric resection, CC, and frailty were not associated with major complications (all p > 0.05). mFI ≥ 2 was associated with non-home discharge (OR 1.97, p < 0.02), while CC (OR 1.26, p = 0.56) was not (Table 1).

Conclusion/Discussion: Performing a CC was not associated with either major complications or non-home discharge in this patient population. Performing CC may be a viable option in management of gallstone ileus especially in non-frail patients. The mFI-5 may serve as a tool to determine patients at risk for non-home discharge but was not associated with major complications after surgical management of gallstone ileus.