MANagement of Gallstone disease in the Older patient (MANGO): Clinical and Quality of Life Outcomes from a Prospective Multicentre Cohort Study

MANagement of Gallstone disease in the Older patient (MANGO): Clinical and Quality of Life Outcomes from a Prospective Multicentre Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article MANagement of Gallstone disease in the Older patient (MANGO): Clinical and Quality of Life Outcomes from a Prospective Multicentre Cohort Study Anna Fairclough, Ana Gavrila, Charlotte Cossins, Simon Toh, Alexander Darbyshire, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8970129/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 15 You are reading this latest preprint version Abstract Background: Gallstones commonly cause emergency surgical admission in older adults and are frequently associated with complications. Although cholecystectomy is recommended in the general population, decision-making is complicated by increased comorbidity and frailty in older patients. Methods: Trainee-led prospective multicentre cohort across nine NHS hospitals. Consecutive emergency admissions in patients aged ≥70 years with radiologically confirmed gallstone disease were recruited (November 2022–March 2024). Data were collected at baseline, 30-days and 1-year, including Gastrointestinal Quality of Life Index (GIQLI) scores. Results: Of 194 patients , 158 (81.4%) were managed non-operatively and 36 (18.6%) underwent emergency cholecystectomy. The non-operative group had greater comorbidity burden and frailty. All emergency operations were started laparoscopically (one conversion) with no major complications; median length of stay was similar (7 vs 5 days, p=0.105). Gallstone-related readmission at 1-year was higher after non-operative management (23.0% vs 2.9%, p=0.024); non-biliary readmissions were similar. One-year mortality was 12.4% vs 0% (p=0.06). Forty-three patients underwent interval cholecystectomy by 1-year. Baseline GIQLI was similar. At 30-days, emergency cholecystectomy was associated with higher GIQLI across domains (p≤0.007). At 1-year, GIQLI remained higher after emergency cholecystectomy (123.8 vs 115.6, p=0.039) but was comparable when interval cholecystectomy patients were included. Conclusion: Emergency cholecystectomy in older patients deemed suitable for surgery is associated with improved QoL scores and reduced gallstone-related re-admissions at 1-year. Interval surgery achieved comparable QoL outcomes. These findings support consideration of surgery in appropriately selected older patients. Aged Aged 80 and over Cholecystectomy Cholecystitis Gallstones Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Complications of gallstone disease are a common emergency surgical presentation. Management with early or interval laparoscopic cholecystectomy (LC) is the recommended treatment for symptomatic gallstone disease, and it is well proven in the general population that LC is safe, reduces hospital stay and improves quality of life (QoL) ( 1 , 2 ). Despite this, the decision to proceed to surgery is not always straightforward; the potential benefits of surgery must be weighed against the age, comorbidities and frailty of the individual patient ( 3 , 4 ). As our population ages, we are seeing increasing numbers of symptomatic gallstone disease in older patients, for whom surgery is not without significant risk ( 3 , 5 , 6 ). This leads to higher rates of conservative management in older patients, but may result in increased complications, recurrent symptoms and poor QoL ( 6 – 10 ). The current evidence base to support clinical decision making for older patients with gallstone diseases comprises only limited, retrospective studies with heterogeneous age thresholds to define ‘elderly’. While limited, it is increasingly supportive of intervention in this age group, including emergency/early LC and laparoscopic common bile duct (CBD) exploration ( 3 , 7 , 11 – 13 )​. Despite this, in practice we continue to see high rates of conservative management. The impact of disease and intervention on QoL is crucial to guide decision making in higher risk surgical groups. Currently, there is limited evidence evaluating QoL for gallstone disease in older patients and the resultant cost-benefit of treatments. Some studies present subgroup analysis for QoL by age and have shown benefit of LC in older patients, but generally with a smaller difference than in younger patients, due mostly to a lower baseline QoL ( 14 ). A cost-utility analysis of LC, however, demonstrated a greater benefit of early intervention in older patients, with a larger cost-saving compared to younger groups ( 15 ). Overall, the optimal management of gallstones in the elderly population is still unclear. This study aims to prospectively investigate the management of gallstone diseases in older patients, defined as over 70, and evaluate outcomes of those who undergo emergency or interval LC and those who receive non-operative management. Methods This study was designed and led by the Wessex Research Collaborative and sponsored by Portsmouth Hospitals University NHS Trust. The protocol for this research project has been approved by the Health Research Authority (REC reference: 22/NS/0026) and registered (ISRCTN: 12668840). Funding was provided by The Rosetrees Trust and Wessex Clinical Research Network. This study is reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement ​( 16 ). Written informed consent was obtained from all participants. Study design and setting MANGO was a prospective multicentre cohort study investigating patients, aged 70 years or older, admitted as an emergency with symptomatic gallstone disease during 25th November 2022 to 31st March 2024. The study recruited patients from nine NHS hospitals in the southwest of England. The study collected QoL and readmission data at 30-days and 1-year. Follow-up is ongoing with outcomes planned for collection again at 3-years. Inclusion criteria All patients aged 70 years or older, admitted as an emergency with symptoms due to gallstone disease, were potentially eligible. To be included in the study patients must have radiological evidence of gallstones on imaging and a confirmed diagnosis, made by a senior clinician, of a gallstone related condition. The eligible diagnoses included were biliary colic, cholecystitis, bile duct stones, cholangitis and acute pancreatitis. Exclusion criteria were patients with prior cholecystectomy or those unable to give informed consent. Data source Patients were recruited prospectively by clinical and research teams and baseline data recorded on the index admission. 30-day and 1-year follow-up was performed by telephone, or in person if the patient remained an inpatient. All data were entered prospectively using the secure online database REDCap. Data items collected were patient age, sex, co-morbidities, ASA 1 grade, clinical frailty score ( 17 )​, diagnosis, radiology findings, factors affecting management decisions and treatment received. Quality of life was assessed using the Gastro-intestinal Quality of Life Index (GIQLI), a 36-item questionnaire which derives an overall score from several domains: core symptoms, physical, emotional and social dysfunction ​( 18 )​. A higher score denotes a better QoL. It has been validated as an effective tool in assessing QoL in gallstone disease ​​( 19 ). Sample size and bias The study was powered to detect a difference in readmission rates between the surgery and non-surgery groups at 1-year. We estimated a minimum approximate readmission rate of 30% in patients who do not have surgery compared to 5% in those who do, and that approximately 10% of patients over 70 will have surgery, therefore the enrolment ratio was estimated to be 1:9. Using an alpha of 0.05 and a power of 0.9 the number of patients required was calculated to be 260. We aimed to recruit a minimum of 290 patients to account for a maximum of 10% lost to follow-up. Statistical analysis The study population was divided into those who underwent emergency cholecystectomy and those managed non-operatively. Continuous variables were summarised as mean (SD) or median (IQR) as appropriate, and categorical variables as counts (%). Group comparisons were performed using the chi-squared test for categorical variables and the Kruskal–Wallis test for continuous variables as appropriate. A two-sided p value < 0.05 was considered statistically significant. Analyses were performed using R (version 4.3.2; R Foundation for Statistical Computing, Vienna, Austria) Results A total of 194 patients were recruited from 9 hospitals. The rate of recruitment varied between centres (median 14 [IQR 14–30]) and is displayed in Fig. 1 . At 1-year, only 3 patients (1.5%) were lost to follow-up for clinical results. For QoL results, 2 patients did not complete the GIQLI questionnaire at baseline, and loss to follow-up was 40 (20.6%) at 30-days and 44 (22.6%) at 1-year (see Fig. 2 ). Clinical Results The majority received non-operative management of their gallstone disease at index admission (81.4%), with 36 patients undergoing emergency cholecystectomy (18.6%). Baseline demographic data analysis is displayed in Table 1 , with no difference in patient age or sex observed between groups. Patient ASA grade, clinical frailty score and burden of major comorbidities were higher in the non-operative group, although these differences did not reach statistical significance. These baseline differences could introduce potential confounding by indication between groups. Higher rates of cholecystitis were seen in the emergency cholecystectomy group, with biliary colic and bile duct stones more common in the non-operative group. Table 1 Patient demographic and diagnostic data based on initial management. Data is presented as either counts (%) or median (IQR). Total Emergency Cholecystectomy Non-operative Management p value 36 (18.6) 158 (81.4) Age in years 77.0 (73.0 to 81.0) 78.0 (74.0 to 83.0) 0.13 Female Sex 18 (50.0) 85 (53.8) 0.82 ASA grade 2.0 (2.0 to 3.0) 3.0 (2.0 to 3.0) 0.05 Clinical frailty score None 30 (88.2) 100 (69.9) 0.08 Mild to Moderate 4 (11.8) 38 (26.6) Severe 0 (0.0) 5 (3.5) Place of residence Home - independent 35 (97.2) 139 (88.0) 0.01 Residential home 1 (2.8) 0 (0.0) Home - with carers 0 (0.0) 19 (12.0) Number of major comorbidities 0.0 (0.0 to 1.0) 1.0 (0.0 to 1.0) 0.10 Co-morbidities Heart failure 5 (13.9) 30 (19.0) 0.60 COPD 4 (11.1) 19 (12.0) 1.00 Diabetes mellitus 5 (13.9) 31 (19.6) 0.58 Stroke/TIA 1 (2.8) 24 (15.2) 0.08 Renal failure 4 (11.1) 19 (12.0) 1.00 Active malignancy 0 (0.0) 9 (5.7) 0.30 Duration of symptoms (hours) 10.0 (7.0 to 15.0) 7.0 (2.0 to 14.0) 0.21 Diagnosis Biliary colic 1 (2.8) 14 (8.9) 0.38 Simple acute cholecystitis 17 (47.2) 68 (43.0) 0.79 Complicated cholecystitis 9 (25.0) 21 (13.3) 0.13 Acute pancreatitis 7 (19.4) 33 (20.9) 1.00 CBD stones with obstructive jaundice 4 (11.1) 26 (16.5) 0.59 CBD stones with cholangitis 1 (2.8) 21 (13.3) 0.13 Figure 3 shows the reasons given for selecting non-operative management, with the most common being patient co-morbidity. Within the non-operative group, the majority received antibiotics, with 38 (24.1%) needing an ERCP and 9 (5.7%) treated with IR guided drain (see Fig. 4 ). Of the 36 patients who underwent emergency cholecystectomy, all were started laparoscopically, with 1 case converted to open and 1 sub-total cholecystectomy performed. On table cholangiogram was performed in 13 cases (36%) and intra-operative ultrasound in 1 case. Intra-operative bile duct exploration was performed in 4 cases, 1 of which using robotic assisted surgery. Early minor complications occurred in 9 patients. There were 2 reports of post-operative bleeding, 1 respiratory, 3 cardiac problems and 3 acute kidney injuries. There were no major complications, including return to theatre, bile leak, bile duct injury or admission to intensive care. Patients undergoing emergency cholecystectomy had a slightly longer median length of stay than non-operative management (7 vs 5 days), though this was not statistically significant (see Table 2 ). Most patients were discharged to their own home without the need for additional support, regardless of the treatment received. At 30-days, there had been 10 unplanned hospital readmissions with gallstone-related disease in the non-operative group, compared to 1 readmission in the operative group (6.3% vs 2.8%) though this did not achieve statistical significance. By 1-year follow-up, there had been 34 emergency readmissions in the non-operative, compared to 1 in the operative group (23% vs 2.9%). Readmission rates due to other health conditions were not significantly different between groups at 30-day and 1-year follow-up (Table 2 ). 30-day mortality was low, with 3 deaths in the non-operative group, one related to biliary disease, and none in the operative group. However, 1-year mortality was higher in the non-operative group (12.4% vs 0%), although this did not quite reach statistical significance at the 5% level (p = 0.06). By 30-day follow-up 14 participants in the non-operative group had undergone an interval cholecystectomy, with a total of 43 interval cholecystectomies at 1-year. Table 2 Initial, 30-day & 1-year outcomes based on initial management. Emergency Cholecystectomy Non-operative management p value Initial Admission Total (%) 36 (18.6) 158 (81.4) Length of stay (days) 7.0 (4.8 to 9.0) 5.0 (3.0 to 9.0) 0.10 Discharge destination Patient’s own home 35 (97.2) 147 (95.5) 0.78 Patient’s own home with new need for carers 1 (2.8) 5 (3.2) Rehabilitation hospital 0 (0.0) 2 (1.3) 30-day outcomes Total (%) 36 (18.6) 158 (81.4) Emergency readmission with gallstone related disease 1 (2.8) 10 (6.5) 0.65 Emergency readmission with other health condition 5 (13.9) 20 (13.2) 1.00 30-day mortality 0 (0.0) 3 (1.9) 0.93 1-year outcomes Total (%) 35 (18.3) 156 (81.7) Emergency readmission with gallstone related disease 1 (2.9) 34 (23.0) 0.02 Emergency readmission with other health condition 7 (20.6) 32 (23.2) 0.92 1-year mortality 0 (0.0) 19 (12.4) 0.06 Quality of Life Results At baseline, no difference was observed in QoL scores between patient groups. At 30-day follow-up, participants who had undergone an emergency cholecystectomy had significantly higher QoL scores compared to those who received non-operative management. This was also the case when patients who had undergone interval cholecystectomy were included in the operative group. At 1-year, patient QoL in the emergency cholecystectomy group remained significantly improved compared to the non-operative group. However, by 1-year this difference was no longer apparent when patients who had undergone interval cholecystectomy were included in the operative group (Table 3 ). Table 3 Quality of life scores for baseline, 30-day and 1-year follow up. Data presented as counts (%) or mean (SD). Baseline Emergency cholecystectomy Non-operative management p value Total N (%) 35 (18.2) 157 (81.8) Symptoms score 53.4 (11.4) 51.1 (10.8) 0.26 Emotional score 11.1 (4.8) 10.7 (4.9) 0.63 Physical score 12.7 (6.3) 11.6 (5.8) 0.32 Social score 13.2 (4.4) 13.1 (3.9) 0.93 Total score 90.4 (21.4) 86.5 (20.9) 0.32 30-day follow up Emergency cholecystectomy Non-operative (inc. interval cholecystectomy) p value Total N (%) 30 (19.5) 124 (80.5) Symptoms score 67.2 (7.1) 61.0 (9.9) 0.001 Emotional score 17.5 (2.4) 13.8 (4.7) 0.001 Physical score 19.8 (4.9) 16.5 (6.2) 0.007 Social score 16.8 (3.0) 14.3 (4.0) 0.002 Total score 121.3 (13.1) 105.5 (20.0) 0.001 30-day follow up Emergency and interval cholecystectomy Non-operative management p value Total N (%) 41 (26.6) 113 (73.4) Symptoms score 65.3 (8.3) 61.1 (10.0) 0.018 Emotional score 16.6 (3.4) 13.8 (4.8) 0.001 Physical score 19.2 (5.1) 16.3 (6.2) 0.009 Social score 16.4 (3.3) 14.1 (4.0) 0.001 Total score 117.5 (16.1) 105.4 (20.1) 0.001 1-year follow up Emergency cholecystectomy Non-operative (inc. interval cholecystectomy) p value Total N (%) 32 (21.3) 118 (78.7) Symptoms score 67.5 (7.5) 63.8 (10.8) 0.08 Emotional score 17.6 (3.1) 16.3 (4.2) 0.11 Physical score 20.6 (5.0) 18.4 (5.9) 0.05 Social score 18.2 (2.4) 17.6 (3.0) 0.24 Total score 123.8 (14.4) 115.6 (21.1) 0.04 1-year follow up Emergency and interval cholecystectomy Non-operative management p value Total N (%) 71 (47.3) 79 (52.7) Symptoms score 65.7 (9.6) 63.6 (10.8) 0.21 Emotional score 16.8 (4.1) 16.3 (3.9) 0.42 Physical score 19.7 (5.5) 18.0 (5.9) 0.07 Social score 17.9 (3.2) 17.6 (2.7) 0.53 Total score 119.9 (19.5) 115.1 (20.5) 0.14 Discussion This prospective cohort study presents the 30-day and 1-year outcomes of emergency admissions due to gallstone disease in patients over 70. Reflective of current practice, fewer patients underwent emergency surgery during their index presentation of gallstone disease. For those who received emergency surgery, there were fewer readmissions for gallstone disease and an improved QoL both at 30-days and 1-year, consistent with other studies ( 3 , 6 , 9 , 10 , 20 ). The significant difference in QoL between the two groups is an important finding, pivotal for management decisions. Our data also suggest that interval cholecystectomy may achieve comparable longer-term QoL to emergency surgery; another important finding to be considered, supporting existing evidence. ( 21 , 22 ). Overall, our findings support emerging evidence that in appropriately selected older patients, emergency surgery may be associated with better outcomes than non-operative management. One-year mortality was higher in the non-operative group (12.4% vs 0%), although this did not reach statistical significance (p = 0.06), which may reflect limited power and/or baseline differences between groups. This difference may be due to confounding by indication, as patients managed non-operatively had greater comorbidity and frailty and were therefore less likely to be selected for surgery. Given the observational design, we cannot infer a causal relationship between treatment strategy and mortality in this cohort. Gallstone-related readmission at 1 year was 23% in the non-operative group, suggesting that conservative and endoscopic strategies are effective for many patients but are associated with a substantial burden of recurrent biliary events. This is consistent with existing evidence showing benefit of early laparoscopic cholecystectomy where feasible, while recognising the role of non-operative strategies in patients who are not suitable for surgery. In gallstone pancreatitis, ERCP with sphincterotomy reduces recurrence but remains inferior to cholecystectomy, with recurrence rates reported at 11% in older cohorts ( 20 , 22 , 23 ). Several limitations of our study must be acknowledged. As an observational study, our findings are subject to confounding by indication and selection bias, particularly given baseline differences in frailty and comorbidity between groups. Study recruitment did not meet protocol targets due to slower than expected recruitment and was powered to detect a difference in readmission rates at 1-year rather than QoL. This reflects the real-world challenges of conducting multicentre studies without dedicated research infrastructure. The sample size restricts our ability to draw conclusions on rare but critical outcomes, such as bile leak, bile duct injury and return to theatre. Our cohort also under-represents patients with cognitive impairment or advanced frailty. This is because those who did not have capacity or were otherwise unable to provide written consent to the study were excluded from recruitment, despite these individuals often presenting with gallstone-related emergencies. This reflects the difficulties in recruiting from this group due to consent and ethical challenges. Although informative, our results do not definitively identify the optimal management strategy for emergency presentations of gallstone disease in the elderly. Rather, it highlights that older patients who are deemed suitable for emergency or early laparoscopic cholecystectomy may be associated with better outcomes. These findings support the need for larger, stratified prospective studies in this population. Conclusions In this prospective multicentre cohort, approximately half of older patients had undergone cholecystectomy by 1-year follow-up, suggesting that operative management is feasible in selected individuals. Older patients undergoing emergency or interval cholecystectomy demonstrated improved quality-of-life outcomes compared with those managed non-operatively. Patients receiving non-operative management experienced higher rates of gallstone-related readmission and more limited QoL improvement at 30 days and 1 year. The higher mortality observed in the non-operative group likely reflects underlying comorbidity and frailty rather than treatment effect. Overall, these findings add to the growing evidence that cholecystectomy, when appropriately selected, appears safe and may offer meaningful clinical and quality-of-life benefits in older patients. Further large-scale, risk-stratified prospective studies are warranted to better define optimal management pathways in this population. Abbreviations ASA American Society of Anesthesiologists (ASA) Physical Status Classification System CBD common bile duct ERCP Endoscopic Retrograde Cholangiopancreatography GIQLI Gastrointestinal Quality of Life Index IQR Interquartile range IR Interventional Radiology LC laparoscopic cholecystectomy QoL Quality of Life SD Standard deviation Declarations Ethics approval and consent to participate Informed consent was obtained from all participants. The protocol for this research project was approved by the Health Research Authority (REC reference: 22/NS/0026) and registered (ISRCTN: 12668840 – equivalent to clinical trials number). Ethics approvals: Approved 22/06/2022, HRA and Health and Care Research Wales (HCRW, [email protected] , [email protected] ), ref: 22/NS/0026 Approved 01/03/2022, North of Scotland Research Ethics Service (Summerfield House, 2 Eday Road, Aberdeen, AB15 6RE, +44(0)1224 558458; [email protected] ), ref: 22/NS/0026 Availability of data and materials The datasets generated and analysed for this study are not publicly available due to participant confidentiality and institutional data governance policies. Data can be made available from the corresponding author on reasonable request. Data are stored in a secure REDCap (Research Electronic Data Capture) database hosted by the study institution. Competing Interests Authors declare no Conflict of Interests for this article. Funding Funding was provided by the Rosetrees Trust and Wessex Clinical Research Network. Authors' contributions A.F lead author for manuscript text and joint for data collection and analysis. C.C & A.G contributed to data collection, analysis and manuscript text. S.T principle investigator. A.D & A.L senior authors for study protocol creation, registration and project supervision, and contributed to data collection, data analysis and manuscript text. Acknowledgements Portsmouth Hospitals University NHS Trust: Mr Ayman Darwich, Ms Louise Finch, Mr Atilla Emin, Ms Charlotte Parfitt. University Hospitals Southampton: Mr Malcolm West, Prof John Primrose, Mr Charles West, Mr Oliver Pickering, Mr Vikash Dodhia, Ms Charlotte Parfitt, Dr Raymond Chaorui Li, Dr Alison Ferguson, Dr Noha Al-Makadma, Dr Samuel McKoy, Dr Orla Busby, Dr Phoebe Carter, Dr Michael Woyton. Dorset County Hospital NHS Foundation Trust: Mr Nathan Curtis, Mrs Madeleine Taylor, Mr Manish Gupta, Mr Ulysses Hechanova, Dr Thomas Knowles, Mr Aseem Shah, Dr Sarita Agte, Mrs Georgina Belt, Mrs Stephanie Hannabus. Yeovil District Hospital NHS Foundation Trust: Mr Godwin Dennison, Mr Vimal Mahendran, Mr Nigel Beer, Ms Lucy Pippard, Ms Kate Beesley, Ms Linda Howard, Ms Alison Lewis, Ms Jess Perry. Basingstoke and North Hampshire Hospital: Ms Fenella Welsh, Mr Mark Sidhom, Mr Rikhilroy Patel, Ms Rosin Kelly, Ms Joanne McClintock, Mr Joseph Doyle. Royal Hampshire County Hospital: Mr Christian Wakefield, Mr Bhavik Patel, Ms Simran Chhugani, Mr Nathan Grundy, Ms Arpita Devashetty, Ms Joanne McClintock. Royal Bournemouth Hospital: Mr Luca Bonomo, Ms Claire Osey, Ms Chloe Bascombe, Ms Cheryl Lindsay, Dr Javen Ramsami, Ms Suzanne Roffe, Ms Lindsay Rogers. Poole General Hospital: Mr Luca Bonomo, Ms Karen O'Toole, Mr Matthew Bayliss, Ms Charlotte Humphrey, Ms Natasha Tamjidi. Salisbury District Hospital: Mr Damian Mayo, Mr Alpha Anthony, Mr Luke Bennett, Ms Holly Morgan, Ms Kate Seymour, Ms Fiona Trim. References Guidance NC. 2018 surveillance of gallstone disease: diagnosis and management (NICE clinical guidance CG188). 2018 surveillance of gallstone disease: diagnosis and management (NICE clinical guidance CG188) [Internet]. 2018. Available from: https://www.ncbi.nlm.nih.gov/books/NBK550940/ Lammert F, Acalovschi M, Ercolani G, van Erpecum KJ, Gurusamy KS, van Laarhoven CJ, et al. EASL Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones. J Hepatol. 2016;65(1):146–81. 10.1016/J.JHEP.2016.03.005/ASSET/96D6CFC5-25B9-44A3-89C8-18B68B5EF67E/MAIN.ASSETS/FX49_LRG.JPG . Lodha M, Chauhan AS, Puranik A, Meena SP, Badkur M, Chaudhary R, et al. Clinical Profile and Evaluation of Outcomes of Symptomatic Gallstone Disease in the Senior Citizen Population. Cureus. 2022;14(8). 10.7759/CUREUS.28492 . Chhoda A, Mukewar SS, Mahadev SH. Managing Gallstone Disease in the Elderly. Clin Geriatr Med. 2021;37(1):43–69. 10.1016/J.CGER.2020.08.005 . Velamazán R, López-Guillén P, Martínez-Domínguez SJ, Abad Baroja D, Oyón D, Arnau A, et al. Symptomatic gallstone disease: Recurrence patterns and risk factors for relapse after first admission, the RELAPSTONE study. United Eur Gastroenterol J. 2024;12(3):286–98. 10.1002/UEG2.12544 . Bhaskaran P, Swaminathan C, Krasicka D, Gilbert JA, Bhaskaran IP, Khan M. A Systematic Review and Meta-Analysis of the Management of Gallstone Cholecystitis and Common Biliary Duct Stones to Reduce the Incidence of Complications in Elderly Patients. Cureus. 2024;16(6). 10.7759/CUREUS.63115 . Escartín A, González M, Cuello E, Pinillos A, Muriel P, Merichal M, et al. Acute Cholecystitis in Very Elderly Patients: Disease Management, Outcomes, and Risk Factors for Complications. Surg Res Pract. 2019;2019:9709242. 10.1155/2019/9709242 . Markopoulos G, Mulita F, Kehagias D, Tsochatzis S, Lampropoulos C, Kehagias I. Outcomes of percutaneous cholecystostomy in elderly patients: a systematic review and meta-analysis. Prz Gastroenterol. 2021;16(3):188–95. 10.5114/pg.2020.100658 . Blundell JD, Gandy RC, Close J, Harvey L. Cholecystectomy for people aged 50 years or more with mild gallstone pancreatitis: predictors and outcomes of index and interval procedures. Med J Aust. 2022;217(5):246–52. 10.5694/mja2.51492 . Blundell JD, Gandy RC, Close JCT, Harvey LA. Time to interval cholecystectomy and associated outcomes in a population aged 50 and above with mild gallstone pancreatitis. Langenbecks Arch Surg. 2023;408(1):380. 10.1007/s00423-023-03098-7 . Platt TE, Smith K, Sinha S, Nixon M, Srinivas G, Johnson N, et al. Laparoscopic common bile duct exploration; a preferential pathway for elderly patients. Ann Med Surg (Lond). 2018;30:13–7. 10.1016/J.AMSU.2018.03.044 . Asmar S, Bible L, Obaid O, Anand T, Chehab M, Ditillo M, et al. Frail geriatric patients with acute calculous cholecystitis: Operative versus nonoperative management? J Trauma Acute Care Surg. 2021;91(1):219–25. 10.1097/TA.0000000000003115 . Wiggins T, Markar SR, Mackenzie H, Jamel S, Askari A, Faiz O, et al. Evolution in the management of acute cholecystitis in the elderly: population-based cohort study. Surg Endosc. 2018;32(10):4078–86. 10.1007/s00464-018-6092-5 . Sutherland JM, Albanese CM, Crump T, Liu G, Karimuddin A. The minimally important difference of the Gastrointestinal Quality of Life Index for symptomatic gallstone surgery. Surg Endosc. 2021;35(12):6938. 10.1007/S00464-020- . 08205-Z PubMed PMID: 33398564. Karimuddin A, Albanese CM, Crump T, Liu G, Sutherland JM. Measuring the impact of delayed access to elective cholecystectomy through patient’s cost-utility: an observational cohort study. Int J Qual Health Care. 2021;33(1). 10.1093. /INTQHC/MZAB018 PubMed PMID: 33493262. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61(4):344–9. .2007.11.008 PubMed PMID: 18313558. Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005;173(5):489–95. 10. 1503/CMAJ.050051 PubMed PMID: 16129869. Eypasch E, Williams JI, Wood-Dauphinee S, Ure BM, Schmulling C, Neugebauer E, et al. Gastrointestinal Quality of Life Index: development, validation and application of a new instrument. Br J Surg. 1995;82(2):216–22. 10. 1002/BJS.1800820229 PubMed PMID: 7749697. Sandblom G, Videhult P, Karlson BM, Wollert S, Ljungdahl M, Darkahi B, et al. Validation of Gastrointestinal Quality of Life Index in Swedish for assessing the impact of gallstones on health-related quality of life. Value Health. 2009;12(1):181–4. 00396.X PubMed PMID: 19911447. Stefanova I, Kyle E, Wilson I, Tobbal M, Veeramootoo D, De’Ath HD. Laparoscopic Cholecystectomy vs Endoscopic Retrograde Cholangiopancreatography With Sphincterotomy in Elderly Patients With Acute Gallstone Pancreatitis. Am Surg. 2024. 10.1177/00031348241248564 . Haltmeier T, Benjamin E, Inaba K, Lam L, Demetriades D. Early versus delayed same-admission laparoscopic cholecystectomy for acute cholecystitis in elderly patients with comorbidities. J Trauma Acute Care Surg. 2015;78(4):801–7. 10.1097/TA.0000000000000577 . Xu R, Xu Y, Xu R. Effect of timing of laparoscopic cholecystectomy on postoperative efficacy and rehabilitation of elderly patients with acute cholecystitis. Am J Transl Res. 2022;14(2):1107–13. Kivivuori A, Mattila L, Siiki A, Laukkarinen J, Rantanen T, Ukkonen M. Wait-and-see strategy is justified after ERCP and endoscopic sphincterotomy in elderly patients with common biliary duct stones. J Trauma Acute Care Surg. 2023;94(3):443–7. 10.1097/TA.0000000000003852 . ​. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 23 Mar, 2026 Reviews received at journal 12 Mar, 2026 Reviewers agreed at journal 10 Mar, 2026 Reviews received at journal 09 Mar, 2026 Reviews received at journal 08 Mar, 2026 Reviewers agreed at journal 06 Mar, 2026 Reviewers agreed at journal 06 Mar, 2026 Reviewers agreed at journal 06 Mar, 2026 Reviewers agreed at journal 06 Mar, 2026 Reviewers agreed at journal 04 Mar, 2026 Reviewers invited by journal 04 Mar, 2026 Editor assigned by journal 04 Mar, 2026 Editor invited by journal 02 Mar, 2026 Submission checks completed at journal 27 Feb, 2026 First submitted to journal 27 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8970129","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":602661122,"identity":"06a40192-a569-4c0a-8e11-02633b0c5d42","order_by":0,"name":"Anna Fairclough","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABA0lEQVRIiWNgGAWjYNACGwYeBgbmBiDrgByDBFFa0kBaGMFajKFaDAhqYYBpSWwgpIV/du/BDwwJdjLm7QcbH/P8upO+Xbr9AXNBxR+cWiTunEuWYEhI5pE5k9hszNv3LHfnnDMGzDPO4HHYjRwDCcYfzDwSEoxt0rw9h3M33MhhYOZtw61F/kaO8Q+GhHq4lnSDG+kPmHn/4dZicCPHDOiwwxAtPD8OJxjcSDBg5m3ArcUQqMUiIeE4jwRPYrPh3IbDhkCHGRzmOWaMU4sc0GE3PiRU20uwHz744M2fw/JAhz18zFMjh9v7IJAAYzC2QegD+NWjANyxMQpGwSgYBSMYAAAtPFNBWBXXmgAAAABJRU5ErkJggg==","orcid":"","institution":"University Hospital Southampton NHS Foundation Trust","correspondingAuthor":true,"prefix":"","firstName":"Anna","middleName":"","lastName":"Fairclough","suffix":""},{"id":602661123,"identity":"e1d381f9-bd4b-4fb1-a58f-37586feb390b","order_by":1,"name":"Ana Gavrila","email":"","orcid":"","institution":"Dorset County Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ana","middleName":"","lastName":"Gavrila","suffix":""},{"id":602661124,"identity":"02749282-b632-44b4-8ef1-f97dbbbaa865","order_by":2,"name":"Charlotte Cossins","email":"","orcid":"","institution":"Stoke Mandeville Hospital","correspondingAuthor":false,"prefix":"","firstName":"Charlotte","middleName":"","lastName":"Cossins","suffix":""},{"id":602661125,"identity":"b1db295d-a90f-4f9d-8435-6b61a6bc0c72","order_by":3,"name":"Simon Toh","email":"","orcid":"","institution":"Portsmouth Hospitals University NHS Trust","correspondingAuthor":false,"prefix":"","firstName":"Simon","middleName":"","lastName":"Toh","suffix":""},{"id":602661126,"identity":"faf82ef5-d333-4a3e-b9d2-d8c8320b3ba4","order_by":4,"name":"Alexander Darbyshire","email":"","orcid":"","institution":"Portsmouth Hospitals University NHS Trust","correspondingAuthor":false,"prefix":"","firstName":"Alexander","middleName":"","lastName":"Darbyshire","suffix":""},{"id":602661127,"identity":"37a238e4-f0f6-4045-a3ca-e4f78e8aa9a7","order_by":5,"name":"Amy Lord","email":"","orcid":"","institution":"Basingstoke and North Hampshire Hospital","correspondingAuthor":false,"prefix":"","firstName":"Amy","middleName":"","lastName":"Lord","suffix":""}],"badges":[],"createdAt":"2026-02-25 17:09:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8970129/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8970129/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104321201,"identity":"69ccf42c-cba3-423c-9883-1d426c3e8191","added_by":"auto","created_at":"2026-03-10 13:18:06","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":351518,"visible":true,"origin":"","legend":"\u003cp\u003eInpatient management strategy by study site (count)\u003c/p\u003e","description":"","filename":"Figure1Inpatientmanagmentcount.png","url":"https://assets-eu.researchsquare.com/files/rs-8970129/v1/656b84fe895e6a4fed562830.png"},{"id":104405375,"identity":"ef5039b8-6fe5-4020-b764-596c8e0271bc","added_by":"auto","created_at":"2026-03-11 12:22:43","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1771622,"visible":true,"origin":"","legend":"\u003cp\u003eFlow-chart of patient management and loss to follow-up\u003c/p\u003e","description":"","filename":"Figure2Patientflowchart.png","url":"https://assets-eu.researchsquare.com/files/rs-8970129/v1/4c2680df726231382f230b42.png"},{"id":104405967,"identity":"e668e404-cbab-4944-936a-6583ddda0ab2","added_by":"auto","created_at":"2026-03-11 12:24:20","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":496974,"visible":true,"origin":"","legend":"\u003cp\u003eReasons given for non-operative management (count)\u003c/p\u003e","description":"","filename":"Figure3Reasonsfornonoperativemanagement.png","url":"https://assets-eu.researchsquare.com/files/rs-8970129/v1/b2ca0d793c9537d1de0e8497.png"},{"id":104405467,"identity":"19f58eaa-7a93-4628-8d09-f9e44010d460","added_by":"auto","created_at":"2026-03-11 12:23:01","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":243032,"visible":true,"origin":"","legend":"\u003cp\u003eNon-operative management strategy (count)\u003c/p\u003e","description":"","filename":"Figure4Choiceofnonoperativemanagement.png","url":"https://assets-eu.researchsquare.com/files/rs-8970129/v1/43fad3a8dc2eb668ae8abe90.png"},{"id":104409505,"identity":"78cbb6e6-c47a-4c18-8a9a-f78478925602","added_by":"auto","created_at":"2026-03-11 12:45:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5206997,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8970129/v1/f56b004c-4ef3-489f-b6ba-a014c0f3541e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"MANagement of Gallstone disease in the Older patient (MANGO): Clinical and Quality of Life Outcomes from a Prospective Multicentre Cohort Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eComplications of gallstone disease are a common emergency surgical presentation. Management with early or interval laparoscopic cholecystectomy (LC) is the recommended treatment for symptomatic gallstone disease, and it is well proven in the general population that LC is safe, reduces hospital stay and improves quality of life (QoL) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Despite this, the decision to proceed to surgery is not always straightforward; the potential benefits of surgery must be weighed against the age, comorbidities and frailty of the individual patient (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAs our population ages, we are seeing increasing numbers of symptomatic gallstone disease in older patients, for whom surgery is not without significant risk (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). This leads to higher rates of conservative management in older patients, but may result in increased complications, recurrent symptoms and poor QoL (\u003cspan additionalcitationids=\"CR7 CR8 CR9\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The current evidence base to support clinical decision making for older patients with gallstone diseases comprises only limited, retrospective studies with heterogeneous age thresholds to define \u0026lsquo;elderly\u0026rsquo;. While limited, it is increasingly supportive of intervention in this age group, including emergency/early LC and laparoscopic common bile duct (CBD) exploration (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)​. Despite this, in practice we continue to see high rates of conservative management.\u003c/p\u003e \u003cp\u003eThe impact of disease and intervention on QoL is crucial to guide decision making in higher risk surgical groups. Currently, there is limited evidence evaluating QoL for gallstone disease in older patients and the resultant cost-benefit of treatments. Some studies present subgroup analysis for QoL by age and have shown benefit of LC in older patients, but generally with a smaller difference than in younger patients, due mostly to a lower baseline QoL (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). A cost-utility analysis of LC, however, demonstrated a greater benefit of early intervention in older patients, with a larger cost-saving compared to younger groups (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOverall, the optimal management of gallstones in the elderly population is still unclear. This study aims to prospectively investigate the management of gallstone diseases in older patients, defined as over 70, and evaluate outcomes of those who undergo emergency or interval LC and those who receive non-operative management.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study was designed and led by the Wessex Research Collaborative and sponsored by Portsmouth Hospitals University NHS Trust. The protocol for this research project has been approved by the Health Research Authority (REC reference: 22/NS/0026) and registered (ISRCTN: 12668840). Funding was provided by The Rosetrees Trust and Wessex Clinical Research Network. This study is reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement ​(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Written informed consent was obtained from all participants.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003eMANGO was a prospective multicentre cohort study investigating patients, aged 70 years or older, admitted as an emergency with symptomatic gallstone disease during 25th November 2022 to 31st March 2024. The study recruited patients from nine NHS hospitals in the southwest of England. The study collected QoL and readmission data at 30-days and 1-year. Follow-up is ongoing with outcomes planned for collection again at 3-years.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInclusion criteria\u003c/h3\u003e\n\u003cp\u003eAll patients aged 70 years or older, admitted as an emergency with symptoms due to gallstone disease, were potentially eligible. To be included in the study patients must have radiological evidence of gallstones on imaging and a confirmed diagnosis, made by a senior clinician, of a gallstone related condition. The eligible diagnoses included were biliary colic, cholecystitis, bile duct stones, cholangitis and acute pancreatitis. Exclusion criteria were patients with prior cholecystectomy or those unable to give informed consent.\u003c/p\u003e\n\u003ch3\u003eData source\u003c/h3\u003e\n\u003cp\u003ePatients were recruited prospectively by clinical and research teams and baseline data recorded on the index admission. 30-day and 1-year follow-up was performed by telephone, or in person if the patient remained an inpatient. All data were entered prospectively using the secure online database REDCap. Data items collected were patient age, sex, co-morbidities, ASA\u003csup\u003e1\u003c/sup\u003e grade, clinical frailty score (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)​, diagnosis, radiology findings, factors affecting management decisions and treatment received.\u003c/p\u003e \u003cp\u003eQuality of life was assessed using the Gastro-intestinal Quality of Life Index (GIQLI), a 36-item questionnaire which derives an overall score from several domains: core symptoms, physical, emotional and social dysfunction ​(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)​. A higher score denotes a better QoL. It has been validated as an effective tool in assessing QoL in gallstone disease ​​(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eSample size and bias\u003c/h3\u003e\n\u003cp\u003eThe study was powered to detect a difference in readmission rates between the surgery and non-surgery groups at 1-year. We estimated a minimum approximate readmission rate of 30% in patients who do not have surgery compared to 5% in those who do, and that approximately 10% of patients over 70 will have surgery, therefore the enrolment ratio was estimated to be 1:9. Using an alpha of 0.05 and a power of 0.9 the number of patients required was calculated to be 260. We aimed to recruit a minimum of 290 patients to account for a maximum of 10% lost to follow-up.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe study population was divided into those who underwent emergency cholecystectomy and those managed non-operatively. Continuous variables were summarised as mean (SD) or median (IQR) as appropriate, and categorical variables as counts (%). Group comparisons were performed using the chi-squared test for categorical variables and the Kruskal\u0026ndash;Wallis test for continuous variables as appropriate. A two-sided p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. Analyses were performed using R (version 4.3.2; R Foundation for Statistical Computing, Vienna, Austria)\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 194 patients were recruited from 9 hospitals. The rate of recruitment varied between centres (median 14 [IQR 14\u0026ndash;30]) and is displayed in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAt 1-year, only 3 patients (1.5%) were lost to follow-up for clinical results. For QoL results, 2 patients did not complete the GIQLI questionnaire at baseline, and loss to follow-up was 40 (20.6%) at 30-days and 44 (22.6%) at 1-year (see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eClinical Results\u003c/h3\u003e\n\u003cp\u003eThe majority received non-operative management of their gallstone disease at index admission (81.4%), with 36 patients undergoing emergency cholecystectomy (18.6%). Baseline demographic data analysis is displayed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, with no difference in patient age or sex observed between groups. Patient ASA grade, clinical frailty score and burden of major comorbidities were higher in the non-operative group, although these differences did not reach statistical significance. These baseline differences could introduce potential confounding by indication between groups. Higher rates of cholecystitis were seen in the emergency cholecystectomy group, with biliary colic and bile duct stones more common in the non-operative group.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient demographic and diagnostic data based on initial management. Data is presented as either counts (%) or median (IQR).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmergency Cholecystectomy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-operative Management\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (18.6)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e158 (81.4)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge in years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77.0 (73.0 to 81.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78.0 (74.0 to 83.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFemale Sex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85 (53.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eASA grade\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.0 (2.0 to 3.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.0 (2.0 to 3.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClinical frailty score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNone\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (88.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100 (69.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMild to Moderate\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (11.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (26.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSevere\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (3.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePlace of residence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHome - independent\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (97.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e139 (88.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eResidential home\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHome - with carers\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (12.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of major comorbidities\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.0 (0.0 to 1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.0 (0.0 to 1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCo-morbidities\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHeart failure\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (13.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (19.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCOPD\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (12.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eDiabetes mellitus\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (13.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (19.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eStroke/TIA\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (15.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eRenal failure\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (12.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eActive malignancy\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (5.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDuration of symptoms (hours)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.0 (7.0 to 15.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.0 (2.0 to 14.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiagnosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eBiliary colic\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (8.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSimple acute cholecystitis\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (47.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68 (43.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.79\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eComplicated cholecystitis\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAcute pancreatitis\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (19.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (20.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCBD stones with obstructive jaundice\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (16.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCBD stones with cholangitis\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the reasons given for selecting non-operative management, with the most common being patient co-morbidity. Within the non-operative group, the majority received antibiotics, with 38 (24.1%) needing an ERCP and 9 (5.7%) treated with IR guided drain (see Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOf the 36 patients who underwent emergency cholecystectomy, all were started laparoscopically, with 1 case converted to open and 1 sub-total cholecystectomy performed. On table cholangiogram was performed in 13 cases (36%) and intra-operative ultrasound in 1 case. Intra-operative bile duct exploration was performed in 4 cases, 1 of which using robotic assisted surgery. Early minor complications occurred in 9 patients. There were 2 reports of post-operative bleeding, 1 respiratory, 3 cardiac problems and 3 acute kidney injuries. There were no major complications, including return to theatre, bile leak, bile duct injury or admission to intensive care.\u003c/p\u003e \u003cp\u003ePatients undergoing emergency cholecystectomy had a slightly longer median length of stay than non-operative management (7 vs 5 days), though this was not statistically significant (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Most patients were discharged to their own home without the need for additional support, regardless of the treatment received. At 30-days, there had been 10 unplanned hospital readmissions with gallstone-related disease in the non-operative group, compared to 1 readmission in the operative group (6.3% vs 2.8%) though this did not achieve statistical significance. By 1-year follow-up, there had been 34 emergency readmissions in the non-operative, compared to 1 in the operative group (23% vs 2.9%). Readmission rates due to other health conditions were not significantly different between groups at 30-day and 1-year follow-up (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). 30-day mortality was low, with 3 deaths in the non-operative group, one related to biliary disease, and none in the operative group. However, 1-year mortality was higher in the non-operative group (12.4% vs 0%), although this did not quite reach statistical significance at the 5% level (p\u0026thinsp;=\u0026thinsp;0.06).\u003c/p\u003e \u003cp\u003eBy 30-day follow-up 14 participants in the non-operative group had undergone an interval cholecystectomy, with a total of 43 interval cholecystectomies at 1-year.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInitial, 30-day \u0026amp; 1-year outcomes based on initial management.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmergency Cholecystectomy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-operative management\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eInitial Admission\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (18.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e158 (81.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLength of stay (days)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.0 (4.8 to 9.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.0 (3.0 to 9.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDischarge destination\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePatient\u0026rsquo;s own home\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (97.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e147 (95.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePatient\u0026rsquo;s own home with new need for carers\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eRehabilitation hospital\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003e30-day outcomes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (18.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e158 (81.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmergency readmission with gallstone related disease\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (6.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmergency readmission with other health condition\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (13.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (13.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e30-day mortality\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1-year outcomes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (18.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e156 (81.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmergency readmission with gallstone related disease\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (23.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.02\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmergency readmission with other health condition\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (20.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (23.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1-year mortality\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (12.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.06\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eQuality of Life Results\u003c/h3\u003e\n\u003cp\u003eAt baseline, no difference was observed in QoL scores between patient groups. At 30-day follow-up, participants who had undergone an emergency cholecystectomy had significantly higher QoL scores compared to those who received non-operative management. This was also the case when patients who had undergone interval cholecystectomy were included in the operative group. At 1-year, patient QoL in the emergency cholecystectomy group remained significantly improved compared to the non-operative group. However, by 1-year this difference was no longer apparent when patients who had undergone interval cholecystectomy were included in the operative group (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eQuality of life scores for baseline, 30-day and 1-year follow up. Data presented as counts (%) or mean (SD).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmergency cholecystectomy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-operative management\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (18.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e157 (81.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSymptoms score\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e53.4 (11.4)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e51.1 (10.8)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.26\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEmotional score\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e11.1 (4.8)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e10.7 (4.9)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.63\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePhysical score\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e12.7 (6.3)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e11.6 (5.8)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.32\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSocial score\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e13.2 (4.4)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e13.1 (3.9)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.93\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90.4 (21.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86.5 (20.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e30-day follow up\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eEmergency cholecystectomy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eNon-operative (inc. interval cholecystectomy)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003ep value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (19.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e124 (80.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSymptoms score\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e67.2 (7.1)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e61.0 (9.9)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEmotional score\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e17.5 (2.4)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e13.8 (4.7)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePhysical score\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e19.8 (4.9)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e16.5 (6.2)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.007\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSocial score\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e16.8 (3.0)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e14.3 (4.0)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e121.3 (13.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e105.5 (20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e30-day follow up\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eEmergency and interval cholecystectomy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eNon-operative management\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003ep value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (26.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e113 (73.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSymptoms score\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e65.3 (8.3)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e61.1 (10.0)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.018\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEmotional score\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e16.6 (3.4)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e13.8 (4.8)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePhysical score\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e19.2 (5.1)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e16.3 (6.2)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.009\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSocial score\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e16.4 (3.3)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e14.1 (4.0)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e117.5 (16.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e105.4 (20.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1-year follow up\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eEmergency cholecystectomy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eNon-operative (inc. interval cholecystectomy)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003ep value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (21.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e118 (78.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSymptoms score\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e67.5 (7.5)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e63.8 (10.8)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.08\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEmotional score\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e17.6 (3.1)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e16.3 (4.2)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.11\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePhysical score\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e20.6 (5.0)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e18.4 (5.9)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.05\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSocial score\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e18.2 (2.4)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e17.6 (3.0)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.24\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e123.8 (14.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e115.6 (21.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.04\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1-year follow up\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eEmergency and interval cholecystectomy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eNon-operative management\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003ep value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71 (47.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79 (52.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSymptoms score\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e65.7 (9.6)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e63.6 (10.8)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.21\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEmotional score\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e16.8 (4.1)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e16.3 (3.9)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.42\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePhysical score\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e19.7 (5.5)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e18.0 (5.9)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.07\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSocial score\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e17.9 (3.2)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e17.6 (2.7)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.53\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e119.9 (19.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e115.1 (20.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis prospective cohort study presents the 30-day and 1-year outcomes of emergency admissions due to gallstone disease in patients over 70. Reflective of current practice, fewer patients underwent emergency surgery during their index presentation of gallstone disease. For those who received emergency surgery, there were fewer readmissions for gallstone disease and an improved QoL both at 30-days and 1-year, consistent with other studies (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The significant difference in QoL between the two groups is an important finding, pivotal for management decisions. Our data also suggest that interval cholecystectomy may achieve comparable longer-term QoL to emergency surgery; another important finding to be considered, supporting existing evidence. (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Overall, our findings support emerging evidence that in appropriately selected older patients, emergency surgery may be associated with better outcomes than non-operative management.\u003c/p\u003e \u003cp\u003eOne-year mortality was higher in the non-operative group (12.4% vs 0%), although this did not reach statistical significance (p\u0026thinsp;=\u0026thinsp;0.06), which may reflect limited power and/or baseline differences between groups. This difference may be due to confounding by indication, as patients managed non-operatively had greater comorbidity and frailty and were therefore less likely to be selected for surgery. Given the observational design, we cannot infer a causal relationship between treatment strategy and mortality in this cohort. Gallstone-related readmission at 1 year was 23% in the non-operative group, suggesting that conservative and endoscopic strategies are effective for many patients but are associated with a substantial burden of recurrent biliary events. This is consistent with existing evidence showing benefit of early laparoscopic cholecystectomy where feasible, while recognising the role of non-operative strategies in patients who are not suitable for surgery. In gallstone pancreatitis, ERCP with sphincterotomy reduces recurrence but remains inferior to cholecystectomy, with recurrence rates reported at 11% in older cohorts (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSeveral limitations of our study must be acknowledged. As an observational study, our findings are subject to confounding by indication and selection bias, particularly given baseline differences in frailty and comorbidity between groups. Study recruitment did not meet protocol targets due to slower than expected recruitment and was powered to detect a difference in readmission rates at 1-year rather than QoL. This reflects the real-world challenges of conducting multicentre studies without dedicated research infrastructure. The sample size restricts our ability to draw conclusions on rare but critical outcomes, such as bile leak, bile duct injury and return to theatre. Our cohort also under-represents patients with cognitive impairment or advanced frailty. This is because those who did not have capacity or were otherwise unable to provide written consent to the study were excluded from recruitment, despite these individuals often presenting with gallstone-related emergencies. This reflects the difficulties in recruiting from this group due to consent and ethical challenges. Although informative, our results do not definitively identify the optimal management strategy for emergency presentations of gallstone disease in the elderly. Rather, it highlights that older patients who are deemed suitable for emergency or early laparoscopic cholecystectomy may be associated with better outcomes. These findings support the need for larger, stratified prospective studies in this population.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn this prospective multicentre cohort, approximately half of older patients had undergone cholecystectomy by 1-year follow-up, suggesting that operative management is feasible in selected individuals. Older patients undergoing emergency or interval cholecystectomy demonstrated improved quality-of-life outcomes compared with those managed non-operatively. Patients receiving non-operative management experienced higher rates of gallstone-related readmission and more limited QoL improvement at 30 days and 1 year. The higher mortality observed in the non-operative group likely reflects underlying comorbidity and frailty rather than treatment effect. Overall, these findings add to the growing evidence that cholecystectomy, when appropriately selected, appears safe and may offer meaningful clinical and quality-of-life benefits in older patients. Further large-scale, risk-stratified prospective studies are warranted to better define optimal management pathways in this population.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eASA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAmerican Society of Anesthesiologists (ASA) Physical Status Classification System\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCBD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecommon bile duct\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eERCP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEndoscopic Retrograde Cholangiopancreatography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGIQLI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGastrointestinal Quality of Life Index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIQR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInterquartile range\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInterventional Radiology\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003elaparoscopic cholecystectomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eQoL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eQuality of Life\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStandard deviation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eInformed consent was obtained from all participants. The protocol for this research project was approved by the Health Research Authority (REC reference: 22/NS/0026) and registered (ISRCTN: 12668840 – equivalent to clinical trials number). Ethics approvals:\u0026nbsp;\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eApproved 22/06/2022, HRA and Health and Care Research Wales (HCRW, [email protected], [email protected]), ref: 22/NS/0026\u003c/li\u003e\n \u003cli\u003eApproved 01/03/2022, North of Scotland Research Ethics Service (Summerfield House, 2 Eday Road, Aberdeen, AB15 6RE, +44(0)1224 558458; [email protected]), ref: 22/NS/0026\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe datasets generated and analysed for this study are not publicly available due to participant confidentiality and institutional data governance policies. Data can be made available from the corresponding author on reasonable request. Data are stored in a secure REDCap (Research Electronic Data Capture) database hosted by the study institution.\u003c/p\u003e\n\u003ch2\u003eCompeting Interests\u003c/h2\u003e\n\u003cp\u003eAuthors declare no Conflict of Interests for this article.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eFunding was provided by the Rosetrees Trust and Wessex Clinical Research Network.\u003c/p\u003e\n\u003ch2\u003eAuthors' contributions\u003c/h2\u003e\n\u003cp\u003eA.F lead author for manuscript text and joint for data collection and analysis. C.C \u0026amp; A.G contributed to data collection, analysis and manuscript text. S.T principle investigator. A.D \u0026amp; A.L senior authors for study protocol creation, registration and project supervision, and contributed to data collection, data analysis and manuscript text.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003ePortsmouth Hospitals University NHS Trust: Mr Ayman Darwich, Ms Louise Finch, Mr Atilla Emin, Ms Charlotte Parfitt. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUniversity Hospitals Southampton: Mr Malcolm West, Prof John Primrose, Mr Charles West, Mr Oliver Pickering, Mr Vikash Dodhia, Ms Charlotte Parfitt, Dr Raymond Chaorui Li, Dr Alison Ferguson, Dr Noha Al-Makadma, Dr Samuel McKoy, Dr Orla Busby, Dr Phoebe Carter, Dr Michael Woyton. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDorset County Hospital NHS Foundation Trust: Mr Nathan Curtis, Mrs Madeleine Taylor, Mr Manish Gupta, Mr Ulysses Hechanova, Dr Thomas Knowles, Mr Aseem Shah, Dr Sarita Agte, Mrs Georgina Belt, Mrs Stephanie Hannabus.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eYeovil District Hospital NHS Foundation Trust: Mr Godwin Dennison, Mr Vimal Mahendran, Mr Nigel Beer, Ms Lucy Pippard, Ms Kate Beesley, Ms Linda Howard, Ms Alison Lewis, Ms Jess Perry. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBasingstoke and North Hampshire Hospital: Ms Fenella Welsh, Mr Mark Sidhom, Mr Rikhilroy Patel, Ms Rosin Kelly, Ms Joanne McClintock, Mr Joseph Doyle. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRoyal Hampshire County Hospital: Mr Christian Wakefield, Mr Bhavik Patel, Ms Simran Chhugani, Mr Nathan Grundy, Ms Arpita Devashetty, Ms Joanne McClintock. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRoyal Bournemouth Hospital: Mr Luca Bonomo, Ms Claire Osey, Ms Chloe Bascombe, Ms Cheryl Lindsay, Dr Javen Ramsami, Ms Suzanne Roffe, Ms Lindsay Rogers. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePoole General Hospital: Mr Luca Bonomo, Ms Karen O'Toole, Mr Matthew Bayliss, Ms Charlotte Humphrey, Ms Natasha Tamjidi.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSalisbury District Hospital: Mr Damian Mayo, Mr Alpha Anthony, Mr Luke Bennett, Ms Holly Morgan, Ms Kate Seymour, Ms Fiona Trim. \u0026nbsp;\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGuidance NC. 2018 surveillance of gallstone disease: diagnosis and management (NICE clinical guidance CG188). 2018 surveillance of gallstone disease: diagnosis and management (NICE clinical guidance CG188) [Internet]. 2018. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/books/NBK550940/\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/books/NBK550940/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLammert F, Acalovschi M, Ercolani G, van Erpecum KJ, Gurusamy KS, van Laarhoven CJ, et al. EASL Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones. J Hepatol. 2016;65(1):146\u0026ndash;81. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/J.JHEP.2016.03.005/ASSET/96D6CFC5-25B9-44A3-89C8-18B68B5EF67E/MAIN.ASSETS/FX49_LRG.JPG\u003c/span\u003e\u003cspan address=\"10.1016/J.JHEP.2016.03.005/ASSET/96D6CFC5-25B9-44A3-89C8-18B68B5EF67E/MAIN.ASSETS/FX49_LRG.JPG\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLodha M, Chauhan AS, Puranik A, Meena SP, Badkur M, Chaudhary R, et al. Clinical Profile and Evaluation of Outcomes of Symptomatic Gallstone Disease in the Senior Citizen Population. Cureus. 2022;14(8). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7759/CUREUS.28492\u003c/span\u003e\u003cspan address=\"10.7759/CUREUS.28492\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChhoda A, Mukewar SS, Mahadev SH. Managing Gallstone Disease in the Elderly. Clin Geriatr Med. 2021;37(1):43\u0026ndash;69. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/J.CGER.2020.08.005\u003c/span\u003e\u003cspan address=\"10.1016/J.CGER.2020.08.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVelamaz\u0026aacute;n R, L\u0026oacute;pez-Guill\u0026eacute;n P, Mart\u0026iacute;nez-Dom\u0026iacute;nguez SJ, Abad Baroja D, Oy\u0026oacute;n D, Arnau A, et al. Symptomatic gallstone disease: Recurrence patterns and risk factors for relapse after first admission, the RELAPSTONE study. United Eur Gastroenterol J. 2024;12(3):286\u0026ndash;98. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/UEG2.12544\u003c/span\u003e\u003cspan address=\"10.1002/UEG2.12544\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhaskaran P, Swaminathan C, Krasicka D, Gilbert JA, Bhaskaran IP, Khan M. A Systematic Review and Meta-Analysis of the Management of Gallstone Cholecystitis and Common Biliary Duct Stones to Reduce the Incidence of Complications in Elderly Patients. Cureus. 2024;16(6). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7759/CUREUS.63115\u003c/span\u003e\u003cspan address=\"10.7759/CUREUS.63115\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEscart\u0026iacute;n A, Gonz\u0026aacute;lez M, Cuello E, Pinillos A, Muriel P, Merichal M, et al. Acute Cholecystitis in Very Elderly Patients: Disease Management, Outcomes, and Risk Factors for Complications. Surg Res Pract. 2019;2019:9709242. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1155/2019/9709242\u003c/span\u003e\u003cspan address=\"10.1155/2019/9709242\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarkopoulos G, Mulita F, Kehagias D, Tsochatzis S, Lampropoulos C, Kehagias I. Outcomes of percutaneous cholecystostomy in elderly patients: a systematic review and meta-analysis. Prz Gastroenterol. 2021;16(3):188\u0026ndash;95. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5114/pg.2020.100658\u003c/span\u003e\u003cspan address=\"10.5114/pg.2020.100658\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlundell JD, Gandy RC, Close J, Harvey L. Cholecystectomy for people aged 50 years or more with mild gallstone pancreatitis: predictors and outcomes of index and interval procedures. Med J Aust. 2022;217(5):246\u0026ndash;52. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5694/mja2.51492\u003c/span\u003e\u003cspan address=\"10.5694/mja2.51492\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlundell JD, Gandy RC, Close JCT, Harvey LA. Time to interval cholecystectomy and associated outcomes in a population aged 50 and above with mild gallstone pancreatitis. Langenbecks Arch Surg. 2023;408(1):380. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00423-023-03098-7\u003c/span\u003e\u003cspan address=\"10.1007/s00423-023-03098-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePlatt TE, Smith K, Sinha S, Nixon M, Srinivas G, Johnson N, et al. Laparoscopic common bile duct exploration; a preferential pathway for elderly patients. Ann Med Surg (Lond). 2018;30:13\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/J.AMSU.2018.03.044\u003c/span\u003e\u003cspan address=\"10.1016/J.AMSU.2018.03.044\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAsmar S, Bible L, Obaid O, Anand T, Chehab M, Ditillo M, et al. Frail geriatric patients with acute calculous cholecystitis: Operative versus nonoperative management? J Trauma Acute Care Surg. 2021;91(1):219\u0026ndash;25. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/TA.0000000000003115\u003c/span\u003e\u003cspan address=\"10.1097/TA.0000000000003115\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWiggins T, Markar SR, Mackenzie H, Jamel S, Askari A, Faiz O, et al. Evolution in the management of acute cholecystitis in the elderly: population-based cohort study. Surg Endosc. 2018;32(10):4078\u0026ndash;86. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00464-018-6092-5\u003c/span\u003e\u003cspan address=\"10.1007/s00464-018-6092-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSutherland JM, Albanese CM, Crump T, Liu G, Karimuddin A. The minimally important difference of the Gastrointestinal Quality of Life Index for symptomatic gallstone surgery. Surg Endosc. 2021;35(12):6938. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/S00464-020-\u003c/span\u003e\u003cspan address=\"10.1007/S00464-020-\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. 08205-Z PubMed PMID: 33398564.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKarimuddin A, Albanese CM, Crump T, Liu G, Sutherland JM. Measuring the impact of delayed access to elective cholecystectomy through patient\u0026rsquo;s cost-utility: an observational cohort study. Int J Qual Health Care. 2021;33(1). 10.1093. /INTQHC/MZAB018 PubMed PMID: 33493262.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evon Elm E, Altman DG, Egger M, Pocock SJ, G\u0026oslash;tzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61(4):344\u0026ndash;9. .2007.11.008 PubMed PMID: 18313558.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005;173(5):489\u0026ndash;95. 10. 1503/CMAJ.050051 PubMed PMID: 16129869.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEypasch E, Williams JI, Wood-Dauphinee S, Ure BM, Schmulling C, Neugebauer E, et al. Gastrointestinal Quality of Life Index: development, validation and application of a new instrument. Br J Surg. 1995;82(2):216\u0026ndash;22. 10. 1002/BJS.1800820229 PubMed PMID: 7749697.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSandblom G, Videhult P, Karlson BM, Wollert S, Ljungdahl M, Darkahi B, et al. Validation of Gastrointestinal Quality of Life Index in Swedish for assessing the impact of gallstones on health-related quality of life. Value Health. 2009;12(1):181\u0026ndash;4. 00396.X PubMed PMID: 19911447.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStefanova I, Kyle E, Wilson I, Tobbal M, Veeramootoo D, De\u0026rsquo;Ath HD. Laparoscopic Cholecystectomy vs Endoscopic Retrograde Cholangiopancreatography With Sphincterotomy in Elderly Patients With Acute Gallstone Pancreatitis. Am Surg. 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/00031348241248564\u003c/span\u003e\u003cspan address=\"10.1177/00031348241248564\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaltmeier T, Benjamin E, Inaba K, Lam L, Demetriades D. Early versus delayed same-admission laparoscopic cholecystectomy for acute cholecystitis in elderly patients with comorbidities. J Trauma Acute Care Surg. 2015;78(4):801\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/TA.0000000000000577\u003c/span\u003e\u003cspan address=\"10.1097/TA.0000000000000577\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXu R, Xu Y, Xu R. Effect of timing of laparoscopic cholecystectomy on postoperative efficacy and rehabilitation of elderly patients with acute cholecystitis. Am J Transl Res. 2022;14(2):1107\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKivivuori A, Mattila L, Siiki A, Laukkarinen J, Rantanen T, Ukkonen M. Wait-and-see strategy is justified after ERCP and endoscopic sphincterotomy in elderly patients with common biliary duct stones. J Trauma Acute Care Surg. 2023;94(3):443\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/TA.0000000000003852\u003c/span\u003e\u003cspan address=\"10.1097/TA.0000000000003852\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u0026amp;#8203.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Aged, Aged 80 and over, Cholecystectomy, Cholecystitis, Gallstones","lastPublishedDoi":"10.21203/rs.3.rs-8970129/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8970129/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eGallstones commonly cause emergency surgical admission in older adults and are frequently associated with complications. Although cholecystectomy is recommended in the general population, decision-making is complicated by increased comorbidity and frailty in older patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eTrainee-led prospective multicentre cohort across nine NHS hospitals. Consecutive emergency admissions in patients aged ≥70 years with radiologically confirmed gallstone disease were recruited (November 2022–March 2024). Data were collected at baseline, 30-days and 1-year, including Gastrointestinal Quality of Life Index (GIQLI) scores.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eOf 194 patients\u003cstrong\u003e, \u003c/strong\u003e158 (81.4%) were managed non-operatively and 36 (18.6%) underwent emergency cholecystectomy. The non-operative group had greater comorbidity burden and frailty. All emergency operations were started laparoscopically (one conversion) with no major complications; median length of stay was similar (7 vs 5 days, p=0.105).\u003c/p\u003e\n\u003cp\u003eGallstone-related readmission at 1-year was higher after non-operative management (23.0% vs 2.9%, p=0.024); non-biliary readmissions were similar. One-year mortality was 12.4% vs 0% (p=0.06). Forty-three patients underwent interval cholecystectomy by 1-year. Baseline GIQLI was similar. At 30-days, emergency cholecystectomy was associated with higher GIQLI across domains (p≤0.007). At 1-year, GIQLI remained higher after emergency cholecystectomy (123.8 vs 115.6, p=0.039) but was comparable when interval cholecystectomy patients were included.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eEmergency cholecystectomy in older patients deemed suitable for surgery is associated with improved QoL scores and reduced gallstone-related re-admissions at 1-year. Interval surgery achieved comparable QoL outcomes. These findings support consideration of surgery in appropriately selected older patients.\u003c/p\u003e","manuscriptTitle":"MANagement of Gallstone disease in the Older patient (MANGO): Clinical and Quality of Life Outcomes from a Prospective Multicentre Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-10 13:17:50","doi":"10.21203/rs.3.rs-8970129/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-23T07:53:25+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-12T10:17:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"146484762059463466611959147771775403910","date":"2026-03-10T08:12:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-09T16:35:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-08T17:45:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"66859010443711251107688256483364134034","date":"2026-03-07T01:47:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"255776448935078954649588727931640190227","date":"2026-03-06T18:25:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"75743811777216588888950957641835993306","date":"2026-03-06T17:37:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"92421072710714226210948779942422336640","date":"2026-03-06T10:02:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"305363241500355737654481669650726094037","date":"2026-03-04T10:19:55+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-04T09:17:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-04T09:02:43+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-02T10:45:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-27T19:51:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2026-02-27T12:59:48+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e47678f5-9330-46cd-bacf-aa8d33be3f8c","owner":[],"postedDate":"March 10th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-18T08:23:10+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-10 13:17:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8970129","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8970129","identity":"rs-8970129","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}