Operative Versus Non-Operative Treatment of Acute Cholecystitis in Older Adults with Multiple Comorbidities–Advocating for Definitive Care
Clinical question: In patients 65 years and older, with multimorbidity, and presenting with acute cholecystitis, is operative treatment more efficacious than non-operative treatment?
Background: Approximately one-third of elderly patients and those who are medically complex receive initial non-operative treatment for acute cholecystitis, given the perceived increased risks of operative treatment. Although some guidelines advocate for up-front laparoscopic cholecystectomy, these recommendations are not based on large comparative studies and are inconsistently applied in practice.
Study design: Retrospective, comparative effectiveness, cohort study
Setting: U.S. Medicare inpatient database of beneficiaries 65.5 years and older, admitted through the emergency department (ED) with a primary diagnosis of cholecystitis, identified using ICD-10 codes, from 2016 to 2018.
Synopsis: The cohort included 32,527 patients. The mean age was 78, and patients were predominantly white. Comorbid conditions selected were associated with higher rates of surgical morbidity and mortality. Patients with gallstone pancreatitis were excluded. Among all patients, 67% received operative treatment (90% laparoscopic cholecystectomy) and 33% received non-operative treatment. Of the non-operative subset, only 32% underwent percutaneous cholecystostomy tube placement; the rest received antibiotics or supportive care. The primary outcomes included 30- and 90-day mortality. Readmissions, ED visits, and overall cost were also tracked. In the propensity-weighted analysis, the authors concluded that patients in the operative group compared to those in the non-operative group had statistically significantly lower 30- and 90-day mortality (risk difference 3% and 4%, respectively), readmissions (risk difference 12% and 18%, respectively), and cost at 180 days (savings of $1,460). The authors applied a novel method of analysis called the instrumental variable model, which is meant to represent patients in clinical equipoise, and the findings were directionally consistent, though mortality differences failed to meet statistical significance at 30 and 90 days.
Bottom line: In this elderly, traditionally high-risk group of patients, those treated with operative management had similar or improved mortality rates with fewer readmissions, less ED utilization, and lower cost. There will always be patients in whom the surgical risk outweighs the benefit, but these data support consideration of definitive surgical management, even in medically complex patients.
Citation: Acker RC, et al. Operative vs nonoperative treatment of acute cholecystitis in older adults with multimorbidity. JAMA Surg. 2025;160(6):656-664. doi:10.1001/jamasurg.2025.0729.Â
Dr. Badawy is an academic hospitalist at UT Health San Antonio and an associate clinical professor in the division of internal medicine at Joe R. & Teresa Lozano Long School of Medicine in San Antonio.