Researchers at Showa General Hospital, a regional tertiary care center, reviewed the records of nearly 2,700 patients admitted for acute abdominal disease between January 2016 and 2024. From that pool they identified 247 patients aged 85 and older who underwent emergency surgery, 220 of them within 48 hours of presentation and 27 after unplanned deterioration during conservative treatment. The cohort, published in Annals of Gastroenterological Surgery, was strikingly vulnerable: 44.9 percent had an American Society of Anesthesiologists physical status of 3 or worse, 35.6 percent were on anticoagulant therapy, and more than a third lived with dementia. The most common condition was strangulated bowel obstruction, followed by acute cholecystitis and mechanical bowel obstruction.

The headline result is a paradox that reframes surgical decision-making at the extremes of age. Overall postoperative complications occurred in 44.1 percent of patients, and major complications—graded 3 or higher on the Clavien–Dindo scale—affected 19.4 percent. Yet 72.1 percent of the cohort was discharged directly home. In other words, despite a complication rate that would alarm any surgical audience, the majority of these very old patients returned to their own lives rather than to nursing facilities or rehabilitation hospitals. The median postoperative stay was 11 days, with a range stretching from 1 to 76 days.

What determined who did badly was not birthday count but physiology. In multivariable analyses, a higher ASA physical status score and longer operative time were the dominant independent risk factors for both overall and major complications. Each additional point of ASA status roughly tripled the odds of a major complication, with an odds ratio of 3.52, and each additional hour in the operating room increased those odds by a factor of 2.10. Disease category mattered as well: conditions the researchers grouped as high-mortality—strangulated bowel obstruction, gastrointestinal perforation, and intestinal ischemia or bleeding—doubled the odds of any complication. By contrast, age per se did not predict complications at all.

Age did, however, shape what happened after recovery. The significant predictors of failure to return home were chronological age, dementia, and the occurrence of a major complication, with odds ratios of 1.17 per year of age, 2.34 for dementia, and 2.87 for a major complication. This divergence—complications driven by physiological reserve and operative invasiveness, discharge destination driven by age and cognition—suggests that the two central questions of emergency surgery in the very old, whether to operate and where the patient will go afterward, are governed by partly different factors and should be evaluated separately.

The study also dissects the money. All patients were treated under Japan’s Diagnosis Procedure Combination system, which bundles payment into a fixed per-diem component plus fee-for-service items such as rehabilitation, imaging, and additional procedures. Patients who suffered major complications stayed roughly twice as long, accumulated about 2.4 times the total inpatient claim points, and generated more than three times the fee-for-service costs of those who avoided major complications. Subgroup analyses revealed a grim linear gradient: cases requiring bowel resection with stoma creation fared worse and cost more than resection with anastomosis, which in turn fared worse than cases needing no resection. Contaminated infectious conditions produced longer operations, more blood loss, more major complications, and higher bills than ischemic events.

The most provocative finding lies in the patients who did not develop major complications. Using linear regression, the team modeled expected costs as a function of postoperative length of stay and calculated residuals—the gap between what each patient actually cost and what the model predicted. Among the 199 complication-free patients, a distinct subset clustered in the upper quartile of cost residuals, consuming disproportionate resources that were not explained by clinical severity or operative complexity. Critically, the excess showed up almost entirely in the fee-for-service component rather than in surgical procedure points or operating room consumables, pointing the finger at postoperative management: delayed resumption of oral intake, insufficient rehabilitation, and delayed discharge planning in patients who were otherwise clinically stable.

When the researchers ran the numbers on who landed in that excess-cost quartile, age and preoperative care dependency were conspicuously absent. Instead, higher ASA status, higher systemic inflammatory response syndrome scores, high-mortality disease categories, and longer operative times predicted inflated total costs, while greater blood loss predicted inflated fee-for-service costs. Splitting the cohort at the median stay of 10 days revealed another asymmetry: in short-stay patients, costs tracked ASA status, inflammatory burden, and operative time, whereas in long-stay patients only operative time mattered. Prolonged hospitalization without major complications, the authors argue, is a distinct clinical state—one driven less by initial severity than by the pace of postoperative recovery, where a failure to mobilize and eat early can cascade into prolonged stays and further functional decline.

The implications cut in two directions at once. On the clinical side, the study strengthens the case against using chronological age as a gatekeeper: surgical indication at this hospital was based on comorbidities, functional status, and anesthetic tolerance rather than age, and the results support that philosophy, particularly when paired with Enhanced Recovery After Surgery protocols emphasizing early mobilization, early feeding, swallowing rehabilitation, multimodal analgesia, and prompt catheter removal. On the economic side, the findings identify a realistic target for value-based reform. Costs tied to major complications should be accepted as the unavoidable price of treating fragile patients with life-threatening disease, but costs accumulated by stable patients lingering on the ward are potentially modifiable through intensified rehabilitation, nutritional support, and earlier discharge planning.

The authors are candid about the limits. The design was retrospective, so the super-elderly surgical cohort could not be compared with younger patients or with non-operated peers, and detailed geriatric frailty measures were unavailable. The claim data, while comprehensively audited, reflect reimbursement points rather than true hospital costs, and because the DPC system is unique to Japan, the cost findings may not transfer directly to other health systems. The cohort represents only those selected for surgery, not the full population of octogenarians with acute abdomens, so the true benefit of an aggressive approach remains to be tested prospectively. Even so, for a population that demographers expect to grow dramatically in Japan and beyond, the message is clear: well-selected patients over 85 can survive emergency abdominal surgery and go home, and the biggest opportunity to improve their care may lie not in the operating room but in the days that follow it.

Subject of Research: Short-term outcomes and cost drivers of emergency abdominal surgery in patients aged 85 and older

Article Title: Short‐Term Outcomes and Cost Drivers of Emergency Surgery for Acute Abdominal Disease in Super‐Elderly Patients: A Study in the Japanese Tertiary Care Hospital

Article References: Kobayashi, Y., Oikawa, R., Shibuya, Y., Tatsuno, M., Kamiyama, A., Ozawa, T., Hara, K., Hata, S., & Yamaguchi, H. (2026). Short‐Term Outcomes and Cost Drivers of Emergency Surgery for Acute Abdominal Disease in Super‐Elderly Patients: A Study in the Japanese Tertiary Care Hospital. Annals of Gastroenterological Surgery, 10(5), 1486-1495. https://doi.org/10.1002/ags3.70222

Image Credits: AI Generated

DOI: 10.1002/ags3.70222

Keywords: emergency surgery, super-elderly, acute abdominal disease, Clavien-Dindo classification, DPC reimbursement, ERAS protocol, length of stay, healthcare costs, geriatric surgery, tertiary care hospital, Japan, risk factors