The influence of frailty on outcomes for older adults admitted to hospital with benign biliary disease: a single-centre, observational cohort study

INTRODUCTION

The prevalence and complications of biliary disease increase with age. Frailty has been associated with adverse outcomes in the hospital setting. We describe the prevalence of frailty in older patients hospitalised with benign biliary disease and its association with duration of hospital stay, and 90-day and 1-year mortality.

METHODS

We performed a retrospective cohort study of patients aged 75 years and over admitted with acute biliary disease between 17 September 2014 and 20 March 2017. Clinical Frailty Scale (CFS) score was recorded on admission.

RESULTS

We included 200 patients with a median age of 82 (75-99) years, 60% were female; 154 (77%) were independent for personal activities of daily living (ADLs) and 99 (49.5%) for instrumental ADLs. Cholecystitis was the most common diagnosis (43%) followed by cholangitis (36%) and pancreatitis (21%). Ninety-nine patients were non frail (NF; CFS 1-4) and 101 were frail (F; CFS 5-9). Some 104 patients received medical treatment only. Surgery was more common in NF patients (11% vs F 2%), percutaneous drainage more frequently performed in F patients (15% vs NF 5%) and endoscopic cholangiopancreatography was similar in both groups (F 32% vs NF 31%). Frailty was associated with worse clinical outcomes in F vs NF: functional deconditioning (34% vs 11%), increased care level (19% vs 3%), length of stay (12 vs 7 days), 90-day mortality (8% vs 3%) and 1-year mortality (48% vs 24%).

CONCLUSIONS

Half of patients in our cohort were frail and spent longer in hospital, were less likely to undergo surgery and were less likely to remain alive at 1 year after discharge.

Amputation neuroma derived from a remnant cystic duct 30 years after cholecystectomy: A case report

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Amputation neuroma (AN) arising from a remnant cystic duct after cholecystectomy is rare.

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It is difficult to distinguish AN and malignant tumor because radiological findings of ANs mimic findings of malignancy.

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Intraoperative diagnosis is necessary to select an appropriate surgical procedure.

Introduction

Amputation neuroma is difficult to diagnose preoperatively. Amputation neuroma arising from a remnant cystic duct after cholecystectomy is rare. Herein, we present a case of amputation neuroma derived from a remnant cystic duct along with a review of the literature.

Presentaion of the case

A 60-year-old woman visited our hospital due to a tumor located in the hepatoduodenal ligament. A gallbladder adenoma was resected by open cholecystectomy 30 years prior. Endoscopic ultrasonography demonstrated branched intraductal papillary mucinous neoplasm of the pancreas and a tumor with a low-echoic pattern in the extrahepatic biliary system. Enhanced computed tomography revealed a 6-mm tumor in the artery phase. Surrounding lymph nodes were not swollen. Magnetic resonance cholangiopancreatography showed that the tumor presented with slightly high intensity on T2 weighted imaging. Operative findings revealed that the whitish nodule was moderately attached to surrounding tissues. The remnant cystic duct and the tumor could not be separated; however, no direct invasion toward common bile duct was observed. Rapid intraoperative pathological examination demonstrated that the tumor was a neuroma. The peration time was 251 min and blood loss was 80 ml. The patient was discharged nine days after surgery with no postoperative complications.

Conclusion

It is difficult to distinguish amputation neuroma from malignant tumors because radiological findings of a neuroma mimic findings of malignancy. Intraoperative diagnosis is necessary to select an appropriate surgical procedure due to the difficulty of preoperative diagnosis.

Liver pathology in patients undergoing surgical treatment for biliary calculus or inflammation: Analysis of 57 cases

AIM: To discuss the cause and effect relationship between biliary calculus or inflammation and liver damage in the patients undergoing surgery for benign biliary system diseases.

METHODS: A total of 1479 patients underwent surgery for calculus of the bile duct, cholangitis, gallstones or cholecystitis from June 1, 2012 to May 31, 2013 at our hospital, of whom 120 underwent surgical liver pathology analysis, because their liver morphology was found to be abnormal by preoperative ultrasound, CT or MRI. There were 57 cases of liver injury for unknown reasons after excluding hepatitis B virus, hepatitis C virus, alcoholic liver disease, drug-induced liver disease, autoimmune liver disease, liver hydatid, hepatic cyst, hepatic hemangioma, hepatoma and biliary tract cancer. We analyzed and discussed the possible pathogenesis of these 57 cases.

RESULTS: Most of the patients undergoing biliary tract surgery had pathological liver injury (71.93%). Liver fibrosis was observed in 50.88% of cases. In comparison with calculus of the bile duct and cholangitis, gallstones and cholecystitis were more easily accompanied by steatosis (47.1% vs 17.5%, P < 0.05, RR = 2.689, 95%CI: 0.05-6.234; OR = 4.190, 95%CI: 1.196-14.683). Steatosis was more easily accompanied by inflammatory necrosis (26.7% vs 7.1%, P < 0.05, RR = 3.733, 95%CI: 0.05-14.780; OR = 4.727, 95%CI: 0.917-24.362). Diabetes was easily accompanied by inflammatory necrosis (42.9% vs 8.0%, P < 0.05, RR = 5.357, 95%CI: 0.05-19.094; OR = 8.625, 95%CI: 1.408-52.828).

CONCLUSION: In patients undergoing surgical resection for biliary tract diseases, quite a number of them have the clinical symptoms of non-alcoholic fatty liver disease. Therefore, it is necessary to strengthen the assessment of metabolic liver disease, especially non-alcoholic fatty liver disease, before deciding whether to manage biliary calculus or inflammation by surgical methods.