ERCP in patients 90 years of age and older

Comparison of ERCP Outcomes and Complication Risk between Elderly and Younger Patients: A Large Single-Center Study

Objectives: The current study compared potential risks, complications, and the impact on clinical outcomes among elderly and younger patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). Methods: Procedure-related complications, risk factors, and clinical outcomes following complications in elderly patients (aged ≥75 years) and younger who underwent biliary ERCP were evaluated. Results: Median age of 63 (48-74) of 1164 patients who underwent biliary ERCP for the first time, and 266 (22.8%) were elderly. Comorbidities were statistically significant (81 [30.5%] versus 78 [8.7%], p < 0.001), and periampullary diverticulum (PAD) was detected more commonly in the elderly group (79 [29.7%] vs. 103 [11.5%], p < 0.001). There was no statistical difference in cannulation technique, cannulation time, and cannulation success in both groups, while the total ERCP procedure time was higher in the elderly group (22 [16-29] vs. 20 [14-29], p = 0.030). Regarding the procedure-related complications, there was no statistically significant difference between the two groups (26 [9.8%] vs. 71 [7.9%], p = 0.292). In the case of complications, the length of hospitalization stay was statistically longer in the elderly group. Moreover, the elderly had a longer length of hospitalization, experiencing pancreatitis and a higher probability of developing moderate/severe pancreatitis. In multivariate and univariate analysis, prolonged cannulation time was found to be an independent risk factor in patients ≥75 years of age. Conclusions: This study showed that while ERCP-related complication rates in elderly patients are comparable to younger patients, it can be associated with worse outcomes following the complication and prolonged length of hospitalization.

Urgent Endoscopic Retrograde Cholangiopancreatography Treatment Useful for Acute Cholangitis Caused by Bile Duct Stones in Patients Aged 90 Years and Older

BACKGROUND

Recently, the incidence of acute obstructive cholangitis caused by bile duct stones in patients aged 90 years and older (super-old) has been increasing, for which urgent endoscopic retrograde cholangiopancreatography (ERCP) treatment may be required. The aim of this study was to evaluate the efficacy and safety of urgent ERCP in super-old patients with acute cholangitis caused by bile duct stones.

METHODS

A total 147 consecutive patients aged between 75 and 99 years who underwent urgent ERCP for acute cholangitis caused by bile duct stones were analyzed in a retrospective manner. They were divided into the old (age 75-89 years, control) and super-old (age 90-99 years) groups. Urgent ERCP efficacy and safety, including general status, ERCP-related findings and outcomes, cardiopulmonary monitoring during ERCP, and mortality, were compared between the groups.

RESULTS

The physical status of the super-old group was worse than that of the old group. The success rates for biliary drainage and complete clearance of bile duct stones at the first attempt in the super-old group were lower as compared to the old group, while those after two attempts increased in the super-old group and were nearly the same as in the old group. No fatal cardiopulmonary complications during ERCP were observed in either group. Mortality rate within 2 months was higher in the super-old group, though recovered to the same level as in the old group after 2 months.

CONCLUSIONS

Efficacy and safety of urgent ERCP treatment in super-old patients were comparable to those seen in old patients, though the overall trend indicated greater difficulty. Urgent ERCP treatment can be useful for acute cholangitis caused by bile duct stones in super-old patients.

ERCP for common bile duct stones in the elderly: refining the procedure to improve outcomes

Removal of common bile duct stones in patients with a previous cholecystectomy was one of the first indications for ERCP with biliary sphincterotomy. Thanks to a minimally invasive procedure, patients were prevented from having a new operation. Subsequently, as the technique proved to be successful, ERCP was extended to all patients with choledocholithiasis, regardless of whether or not they had gallbladder. Also contributing was the fact that, at least in the beginnings, surgical interventions on the bile duct with laparoscopic cholecystectomy were more difficult. Nowadays, many surgeons prefer to perform cholecystectomy with a bile duct clean of stones. In this issue of the Spanish Journal of Gastroenterology, Gardenyes et al. present a study on ERCP for common bile duct stones in elderly patients. The novelty of this study is not only to analyze the ERCP procedure, which we already knew has similar success and complication rates to younger patients, but also to focus on the long-term outcome, considering the frailty that frequently accompanies aging. The study concludes that older patients may benefit from enhanced care protocols to reduce medical adverse events and improve outcomes. For us gastroenterologists and endoscopists, another conclusion that can be drawn from this study is that we should not be satisfied that ERCP in older patients has the same success and complication rates as in younger patients, but rather we should strive to ensure that the results are even better.

Endoscopic removal of common bile duct stones in nonagenarians: a tertiary centre experience

BACKGROUND/AIMS

There are few studies assessed the efficacy and mortality of endoscopic retrograde cholangiopancreatography (ERCP) for the removal of common bile duct (CBD) stones in the elderly aged ≥90 years. We aimed to assess the safety and efficacy of endoscopic removal of CBD stones in nonagenarians.

METHODS

We retrospectively reviewed ERCP reports for CBD stone removal. The endoscopic and therapeutic outcomes were collected. The length of stay (LOS), the total number of adverse events, and mortality rate were compared between groups.

RESULTS

A total of 125 nonagenarians were compared with 1,370 controls (65-89 years old individuals). The mean LOS for nonagenarians was significantly higher than in controls (13.6 days vs. 6.5 days). Completed intended treatment was similar in the nonagenarians and controls (89.8% and 89.5%, respectively). The overall complication rate did not differ between the groups. However, nonagenarians had a higher incidence of post-ERCP pneumonia (3.9%). None of the nonagenarians were readmitted to the hospital within 7 days. Four nonagenarians (3.2%) and 25 (1.8%) controls died within 30 days.

CONCLUSION

Advanced age alone did not affect the decision to perform the procedure. However, prompt diagnosis and treatment of post-ERCP pneumonia in nonagenarians could improve the outcomes and reduce mortality.

Safety and Efficacy of Endoscopic Retrograde Cholangiopancreatography in Nonagenarians: A Systematic Review and Meta-Analysis

BACKGROUND

Recent advances in modern medicine have translated into increase in life expectancy in the USA and with that, a rise in the demand for invasive procedures in elderly patients. Endoscopic retrograde cholangiopancreatography (ERCP) is the procedure of choice for managing various benign and malignant pancreatobiliary conditions and can be associated with various adverse events.

AIM

We performed a systematic review and meta-analysis to evaluate outcomes of ERCP in nonagenarians.

METHODS

A comprehensive literature search was performed in Embase, MEDLINE, Web of Science, and Cochrane Review library until July 2020. Our primary outcomes were the rate of technical success and adverse events in nonagenarians. Secondary outcomes were comparison of technical success and adverse events compared with younger patients.

RESULTS

The initial search revealed 4933 studies, of which 24 studies with 5521 patients met our inclusion criteria. Pooled technical success rate of ERCP in nonagenarians was 92%, and pooled adverse event rate was 7.8%. There was no significant difference in technical success rate and overall rate of adverse events comparing ERCP outcomes in nonagenarians with a relatively younger population. The risk of post-ERCP bleeding was significantly higher in nonagenarians compared to younger patients with OR = 1.986 [1.113-3.544], I2 = 0. ERCP-related mortality was also significantly higher in nonagenarians compared to younger patients with OR = 4.720 [1.368-16.289], I2 = 0.

CONCLUSION

There was no significant difference in technical success rate and risk of adverse events related to ERCP in nonagenarians compared to younger patients. However, the risk of bleeding and procedure-related mortality was significantly higher.

A 25 mg rectal dose of diclofenac for prevention of post-ERCP pancreatitis in elderly patients

A 50-100 mg rectal dose of diclofenac or indomethacin is recommended for prophylaxis of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP); however, limited data are available regarding the appropriate dose to prevent PEP in elderly patients. We aimed to evaluate the efficacy and safety of 25 mg diclofenac in preventing PEP in elderly patients. Material and methods: Overall, 276 patients with naive papilla, aged over 75 years, were included in the present study between April 2013 and March 2020. We retrospectively evaluated the risk of PEP in patients over 75 years, administered with or without 25 mg diclofenac 30 min before ERCP using inverse probability of treatment weighting (IPTW) analysis. Results: Patients were categorized into the diclofenac group (83 patients) or non-diclofenac group (193 patients). The incidence rate of PEP in the diclofenac group was significantly lower than that in the non-diclofenac group (4% vs. 14%, p = .01). Multivariate analysis revealed that 25 mg diclofenac was an independent protective factor against PEP in elderly patients aged over 75 years (odds ratio [OR] = 0.17; 95% confidence interval [CI] = 0.04-0.67; p = 0.01). This protective effect of diclofenac against PEP remained robust after IPTW analysis (OR = 0.11; 95% CI = 0.03-0.40; p = .001). No adverse events related to diclofenac were observed. Conclusion: Diclofenac (25 mg) was considered effective and safe for preventing PEP in elderly patients. Our results may provide a new strategy for preventing PEP in elderly patients.

Prognosis and risk factors of ERCP pancreatitis in elderly

Post Endoscopic Retrograde Cholangiopancreatography (ERCP) pancreatitis is one of the most serious complications of ERCP. Our study aims to investigate the risk, predisposing factors and prognosis of pancreatitis after ERCP in elderly patients. Patients referred to the ERCP unit between April 2008 and 2012 and admitted to the hospital at least 1 day after the ERCP procedure were included to the study. Information including patient’s demographics, diagnosis, imaging findings, biochemical analysis, details of the ERCP procedure and complications were recorded. The severity of post ERCP pancreatitis (PEP) was determined by revised Atlanta Criteria as well as APACHE II and Ranson scores. A total of 2902 ERCP patients were evaluated and 988 were included to the study. Patients were divided into two groups as ≥ 65 years old (494 patients, 259 F, 235 M) and < 65 years old (494 patients, 274 F, 220 M). PEP was diagnosed in 4.3% of patients aged 65 years and older. The female gender was risk factors in elderly for PEP. The Sphincter Oddi Dysfunction (SOD) and Juxta papillary diverticula (JPD) were higher in elderly patients with PEP. Age did not increase the risk of PEP development. The most important post ERCP pancreatitis risk factor in the elderly is the female gender, while the risk is enhanced slightly by SOD and JPD.

Prolonged endoscopic retrograde cholangiopancreatography results in higher rates of pancreatitis and unplanned hospitalisation

BACKGROUND AND AIM

Although complications from endoscopic retrograde cholangiopancreatography (ERCP) are well described, procedure duration has received scant attention. The relationship between ERCP duration and patient demographics, indications, results and complications were examined.

METHODS

A contemporaneously recorded database of 2572 consecutive ERCPs performed between 2008 and 2018 by a single endoscopist was analysed. Those taking under 40 min were compared with those taking over 40 min.

RESULTS

Of 2572 cases, 2213 took under 40 min and 359 took over 40 min. Emergency cases (relative risk 2.10), older age (66.6 vs 61.6 years p value < 0.01) and no previous sphincterotomy (relative risk 1.94) were factors which resulted in prolonged procedures. The indication of change or removal of stent for benign conditions resulted in fewer prolonged procedures (relative risk 0.37). Indications of pancreatitis, cholangitis and positive intraoperative cholangiogram were not associated with procedure length. Findings of biliary stricture(s) (relative risk 2.02) and failure to cannulate desired duct (relative risk 3.69) were associated with prolonged procedures. Choledocholithiasis (relative risk 0.62), dilated bile duct without stricture/stone (relative risk 0.46) and normal ductal anatomy (relative risk 0.50) resulted in fewer prolonged procedures. Procedures taking over 40 min had increased risks of complications resulting in unplanned or prolongation of hospitalisation (relative risk 1.41) and pancreatitis (relative risk 1.74).

CONCLUSIONS

Prolonged procedures had increased rates of pancreatitis and unplanned/prolonged hospitalisation. Failed access to desired duct, advanced age, biliary strictures, no previous sphincterotomy and unplanned emergency cases were associated with prolonged procedures.

Does Endoscopic Retrograde Cholangiopancreatography Carry Higher Risk for Patients 90 Years and Older? A Single-Institution Retrospective Study

BACKGROUND Endoscopic retrograde cholangiography (ERCP) for patients aged ≥90 years is often required. The safety of ERCP for super-elderly patients is a major concern for gastrointestinal endoscopists. We retrospectively examined the safety of ERCP for super-elderly patients by comparison with patients in their 70s. MATERIAL AND METHODS We reviewed 66 patients aged ≥90 years (Group A) and 43 patients in their 70s (Group B) who underwent ERCP in our institution from January 2012 to October 2019. Data were collected on patients' backgrounds, corresponding procedures, and clinical outcomes, including adverse events. RESULTS Patients in Group A (mean age: 92.3±2.1 years) had significantly poorer performance status (median: 3 vs. 0; P<0.001) and American Society of Anesthesiologists classification (median: III vs. II; P<0.001) when compared to Group B (mean age: 75.1±2.7 years). Underlying cardiovascular, cerebrovascular, renal, and orthopedic comorbidity occurrence was significantly higher in Group A than in Group B (87.88% vs. 67.44%; P=0.0094). Group A comprised more patients with benign disease than Group B (90.91% vs. 76.74%; P=0.040). Group B comprised more patients with malignant disease (31.82% vs. 53.54%; P=0.041). Emergency ERCP was higher in Group A than in Group B (71.70% vs. 29.73%; P<0.0001). No significant between-group differences in adverse events (15.15% vs. 11.63%; P=0.602) and mortality rate (1.52% vs. 2.33%; P=0.758) were noted. CONCLUSIONS Indications for ERCP should not be determined simply based on the super-elderly age of patients. ERCP may not necessarily carry higher risks if endoscopists practice maximal caution against gastrointestinal perforation.

Two-stage versus single-stage procedure for the management of cholecystocholedocholithiasis in elderly patients: a retrospectively cohort study

BACKGROUND

there is an increasing incidence rate of cholecysto-choledocholithiasis associated with the increasing proportion of senile individuals.

METHODS

a total of 100 elderly patients (over 80 years of age) suffering both from cholelithiasis and choledocholithiasis were retrospectively studied from January 2010 to December 2016. Patients were scheduled for either a single-stage or two-stage procedure. The LCBDE group (n = 54) included cases that underwent a single stage procedure of laparoscopic exploration of the common bile duct combined with cholecystectomy. The ERCP/EST group (n = 46) included cases that underwent a two stage procedure of preoperative endoscopic retrograde cholangiopancreaticography with endoscopic sphincterotomy followed by cholecystectomy. Comorbidity conditions, presenting symptoms, bile duct clearance, length of hospital stay and the frequency of procedural, postoperative and long-term complications were recorded.

RESULTS

the LCBDE group had a higher stones clearance rate than the ERCP/EST group (100.0% vs 89.1%, p < 0.05). Postoperative complications and hospitalization length were comparable in the two groups (p > 0.05). There were more procedural complications in the ERCP/EST group than in the LCBDE group (10.8% vs 0%, p < 0.05). Furthermore, a patient in the ERCP/EST group died due to duodenal perforation. More patients in the ERCP/EST group experienced long-term complications than those in the LCBDE group (23.9% vs 3.7%, p < 0.05) during a mean follow-up period of 28.4 months.

CONCLUSIONS

the single-stage procedure is a safe and effective technique for elderly patients with cholecysto-choledocholithiasis. LCBDE provides a good stone clearance rate with few long term complications.

Risk factors of adverse events in endoscopic retrograde cholangiopancreatography for patients aged ≥85 years

AIM

Little is known about the factors that contribute to the occurrence of adverse events in endoscopic retrograde cholangiopancreatography (ERCP) for people aged ≥85 years and safety for the super-old. Therefore, we decided to identify these factors and to examine whether ERCP is safe in the super-old.

METHODS

This was a single-center retrospective study. A total of 137 patients aged ≥85 years who underwent therapeutic ERCP at Chiba University Hospital from January 2012 to March 2017 were retrospectively reviewed.

RESULTS

Four cases of Billroth II reconstruction and two cases of gastrectomy with Roux-en-Y reconstruction were excluded, and 131cases in total were examined in the present study. A total of 10 and 121 cases with and without adverse events, respectively, were present. Using univariate analysis, factors significantly contributing to the occurrence of adverse events in therapeutic ERCP were identified as aged ≥90 years (P = 0.0096), duodenal papilla cancer (P = 0.0012), gallbladder carcinoma (P = 0.023), and biliary metal stenting (P = 0.040). In multivariate analysis, only ≥90 years-of-age was a significant factor (P = 0.049). In addition, comparison between 25 cases of the super-old and 106 cases aged 85-89 years was carried out. In the super-old group, the average value of the American Society of Anesthesiologists physical status classification and Charlson's Comorbidity Index were significantly better than those in 85-89-year-olds (P = 0.0035 and P < 0.0001, respectively).

CONCLUSIONS

Although the super-old group had fewer comorbid diseases, they had significantly increased adverse events compared with patients aged 85-89 years. Geriatr Gerontol Int 2018; 18: 1038-1045.

Endoscopic retrograde cholangiopancreatography in the elderly: results of a retrospective study and a geriatricians' point of view

Background

The incidence of biliary tract pathology is growing with an age-related trend, and progresses as the population ages. Endoscopic Retrograde Cholangiopancreatography (ERCP) represents the gold standard for treatment in these cases, but evidence about its safety in the elderly is still debated.

Methods

We retrospectively analyzed the clinical records of all patients aged ≥65 undergoing ERCP between July 2013 and July 2015. Of 387 ERCP cases, 363 (~ 94%) were completed entirely. The mean age of the study population (n = 363) was 79.9 years old (range 70–95), with 190 subjects aged 70–79 and 173 older than 80. We recorded demographics, Charlson Comorbidity index (CCI), American Society of Anesthesiologists (ASA) physical status classification score, indication for the use of the ERCP procedure, and clinical outcomes. Then, we tested all variables to identify the potential risk factors for complications associated with the procedure.

Results

The older group (those ≥80 years old) showed significantly more patients with ASA Classes III-IV than the younger one (those ≤79 years old). Interestingly, the CCI was higher in the younger group (p = 0.009). The overall complication rate was 17.3% without inter-group differences. Older age, sex, CCI and intra-ERCP procedures were not related to a higher risk of complications, and the multivariate regression did not identify any of the considered variables to be an independent risk factor for complications.

Conclusion

ERCP appears as safe in the patients aged 80 years and older, as it is in those aged 70–79 years old in our study, however, a selection bias may affect these findings. A study including a comprehensive geriatric assessment will contribute to shedding light on this issue.

The impact of age on the incidence and severity of post-endoscopic retrograde cholangiopancreatography pancreatitis

Background:

With advancing age there is progressive pancreatic atrophy and fibrosis, leading to tissue destruction and chronic pancreatitis that has been found to be protective against post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). However, there are no reports regarding the potential effect of the aging pancreatic changes on the incidence and severity of PEP. Therefore, the aim of the present study was to investigate the impact of senile changes in the pancreas on the incidence and severity of PEP.

Methods:

A total of 2688 patients who underwent the first therapeutic ERCP at a single center were included in the final analysis of the study. Patients were classified into two groups: 1644 patients aged ≤75 years (mean age 61.56+1.26 years), group A; and 1044 patients aged >75 years (mean age 81.97+4.29 years), group B. Patients’ files were identified using a retrospective database linked to the endoscopy reporting system. Patients’ characteristic, endoscopic findings, details of intervention and rate and severity of PEP were evaluated.

Results:

No significant differences between the two groups were observed with regard to ERCP indication, patient- and technique-related risk factors for PEP, presence of periampullary diverticulum, and type of therapeutic intervention. The incidence of PEP was 5.2% in group A and 4% in group B (P=NS) with comparable grades of severity. All episodes of pancreatitis had full recovery with conventional treatment. One death occurred from respiratory arrest in each group of patients.

Conclusion:

This study shows that the pancreatic changes associated with aging do not influence the incidence and severity of PEP.

Endoscopic Retrograde Cholangiopancreatography in Nonagenarian Patients: Is It Really Safe?

Background/Aims

Literature on the safety of endoscopic retrograde cholangiopancreatography (ERCP) in elderly patients is divided. Based on this we decided to examine the safety of ERCP in nonagenarian patients.

Methods

A total of 1,389 patients, with a mean age of 63.94±19.62 years, underwent ERCP during the study period. There were 74 patients aged 90 years or older with a mean age of 92.07±1.8. Logistic regression showed that nonagenarian patients had a significantly increased odds of in-patient mortality (adjusted odds ratio [AOR]=9.6; 95% confidence interval [CI]=4, 23; p≤0.001). Charlson Comorbidity Index (CCI) ≥2 was also an independent predictor of in-patient mortality (AOR=2.4; 95% CI=1.2, 5.2; p=0.021). Age ≥90 was not associated with increased adverse events; however emergency procedures (AOR=2.4; 95% CI=1.5, 4; p<0.001) and CCI ≥2 (AOR=2.6; 95% CI=1.7, 4.0; p<0.001) were more likely to have adverse events.

Conclusions

Age ≥90 and CCI ≥2 are independently associated with increased odds of in-patient mortality in patients undergoing ERCP, whereas emergency procedures and CCI ≥2 are associated with an increased adverse event rate. Caution must be exercised when considering ERCP in patients aged ≥90 years and those with a CCI ≥2.

Safety and Efficacy of Acute Endoscopic Retrograde Cholangiopancreatography in the Elderly

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is a frequent procedure in elderly patients.

AIMS

We aimed to determine the safety and efficacy of acute ERCP in older patients.

METHODS

A prospectively managed, hospital-based registry containing all ERCP procedures and complications at a tertiary referral center was used to form the study population, which consisted of consecutive elderly (≥65 years) patients undergoing acute ERCP during the 5-year study period. Indications, details, outcome, and complications of the procedure were analyzed in relation to patient age, gender, and co-morbidities.

RESULTS

A total of 480 elderly patients (median age 78; range 65-97; 48 % men) underwent 531 ERCPs during the study period. The most common indications were bile duct stones (56.1 %) and biliary obstruction caused by malignancy (33.7 %). Successful stone extraction was achieved in 72.8 %, and with an additional, planned ERCP in 96.6 % of the patients. Post-ERCP complications developed in 3.4 % of the patients. These included pancreatitis in 1.7 %, hemorrhage in 0.6 %, and duodenal perforation in 0.2 % of the patients. One of these (0.2 %) was considered severe as this patient required invasive treatments and prolonged hospital stay. The risk of complications was associated with chronic obstructive pulmonary disease and difficult cannulation. Procedure-related mortality was zero, but overall 30-day mortality was 10 %, being 24 % in the patients with malignancy.

CONCLUSIONS

ERCP can be safely and efficaciously performed on elderly patients. The high mortality should be taken into consideration when selecting therapeutic options.

Efficacy and safety of emergency endoscopic retrograde cholangiopancreatography for acute cholangitis in the elderly

AIM

To investigate the efficacy and safety of emergency endoscopic retrograde cholangiopancreatography (ERCP) in elderly patients with acute cholangitis.

METHODS

From June 2008 to May 2016, emergency ERCPs were performed in 207 cases of acute cholangitis at our institution. Patients were classified as elderly if they were aged 80 years and older (n = 102); controls were under the age of 80 years (n = 105). The patients’ medical records were retrospectively reviewed for comorbidities, laboratory data, etiology of cholangitis (presence of biliary stones, biliary stricture and malignancy), details of the ERCP (therapeutic approaches, technical success rates, procedure duration), ERCP-related complications and mortality.

RESULTS

The frequency of comorbidities was higher in the elderly group than the control group (91.2% vs 67.6%). Periampullary diverticulum was observed in the elderly group at a higher frequency than the control group (24.5% vs 13.3%). Between the groups, there was no significant difference in the technical success rates (95.1% vs 95.2%) or endoscopic procedure durations. With regard to the frequency of ERCP-related complications, there was no significant difference between the two groups (6.9% vs 6.7%), except for a lower rate of post-ERCP pancreatitis in the elderly group than in the control group (1.0% vs 3.8%). Neither angiographic nor surgical intervention was required in any of the cases with ERCP-related complications. There was no mortality during the observational periods.

CONCLUSION

Emergency ERCP for acute cholangitis can be performed safely even in elderly patients aged 80 years and older.

Is ERCP both effective and safe for common bile duct stones removal in octogenarians? A comparative study

BACKGROUND

Some studies have investigated the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) for octogenarians, but more and larger comparative studies are still needed.

METHODS

From January 2008 to June 2011, patients who underwent ERCP for common bile duct stone removal were included and divided into three groups, based upon their age. Basic information, medical records, and ERCP operation notes were retrospectively reviewed.

RESULTS

868 patients were included, with 474 patients in Group 1 (<65 years old), 281 patients in Group 2 (≥65 years old and <80 years old), and 113 patients in Group 3 (≥80 years old). No difference was observed regarding the rate of complete stone removal and hospital stay among the three groups. Pancreatitis occurred more frequently in Group 1 than Group 3, and the incidence of pancreatitis in Group 2 had no statistical difference when compared with Group 1 or Group 3. The occurrence of biliary infection, hemorrhage, perforation, and other complications was not statistically different among the three groups. The mortality directly related to the ERCP procedure was zero (0).

CONCLUSIONS

ERCP is an effective and safe therapeutic method for stone removal in octogenarians, and age per se should not be a contraindication to endoscopic intervention.

Efficacy and Safety of Therapeutic Endoscopic Retrograde Cholangiopancreatography in the Elderly Over 80 Years

BACKGROUND/AIMS

Concern regarding the safety and efficacy of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in elderly patients is increasing as a result of the aging society. However, there are limited data, especially in the super-aged elderly. This study aimed to evaluate the efficacy and safety of therapeutic ERCP in patients ≥80 years of age.

METHODS

Patients 80 years of age or older (n = 312) and younger than 65 years (n = 312) who underwent therapeutic ERCP from June 2006 to April 2014 were randomly selected and analyzed retrospectively. The main outcome measurements were therapeutic ERCP-related complications and clinical outcomes in the two groups.

RESULTS

Choledocholithiasis combined with gallbladder stone was the most common indication for ERCP in both groups. Comorbid diseases (70.5 and 29.8 %, p < 0.001) and the use of anti-thrombotic drugs (18.6 and 1.6 %, p < 0.001) were more frequent in the super-aged group. The mean procedure time was longer, and the frequency of second ERCP was more common in the super-aged group. However, the technical success rate (94.9 and 97.4 %, p = 0.096) and the procedure-related complication rate (4.8 and 5.8 %, p = 0.592) were not different between the two groups. Post-ERCP pancreatitis occurred in 1.3 % of the super-aged group and in 2.9 % of the control group (p = 0.262). Cardiopulmonary complications occurred in 1.9 % of patients in each group (p = 1.0).

CONCLUSIONS

Therapeutic ERCP is comparable in terms of efficacy and safety between patients ≥80 years and those <65 years of age, although the elderly group had a higher rate of comorbid diseases and used anti-thrombotic drugs more frequently.

Efficacy and Safety of Endoscopic Papillary Large Balloon Dilation for Removal of Large Bile Duct Stones in Advanced Age

Objective. Bile duct stone-related adverse events can be detrimental in the elderly. However, little is known about clinical outcomes and adverse events following endoscopic papillary large balloon dilation (EPLBD) in the elderly. The aim of this study was to evaluate the safety and feasibility of EPLBD for the removal of CBD stones in patients aged ≥ 80 years. Methods. A total of 204 patients who underwent EPLBD from 2006 to 2012 were retrospectively reviewed. Patients were classified into two groups (148 patients < 80 years old, Group A; 56 patients ≥ 80 years old, Group B). Endoscopic findings, clinical outcomes, and adverse events in two groups were compared. Results. The number of underlying chronic diseases in Group B was significantly higher than in Group A (P = 0.032). The rates of overall stone clearance were similar between two groups (P = 0.145). No significant difference with regard to post-ERCP pancreatitis between two groups was observed (P = 0.687). All episodes of pancreatitis had full recovery with conservative treatment. One major hemorrhage in Group A was successfully controlled endoscopically and one death caused by retroperitoneal perforation occurred in Group A. Conclusions. EPLBD appear to be safe and effective for CBD stone removal in patients aged ≥ 80 years.

ERCP in elderly patients: increased risk of sedation adverse events but low frequency of post-ERCP pancreatitis

BACKGROUND AND AIMS

The continually increasing life expectancy in man comes along with an increasing number of endoscopic interventions performed in patients with advanced or even very advanced age. Data on the feasibility and safety of ERCP in elderly patients are relatively scarce.

METHODS

By a systematic query of the University Hospital Frankfurt clinical database, patients undergoing their first ERCP procedure at our center were retrospectively identified. Patients were grouped according to age at the day of the intervention (>80 years, 61-80 years, 40-60 years, and <40 years). Demographic data, indication, outcome, and risk factors were compared among the indicated groups.

RESULTS

A total of 758 patients who underwent ERCP procedures at our center were identified and included in the study. Main indications for ERCP were intraductal gallstones in 345 patients (45%) and tumor obstruction of the bile ducts (distal common bile duct: n = 126 [16.5%], hilar cholangiocarcinoma: n = 89 [11.7%], tumor of papilla of Vater: n = 16 [2.1%]). Gallstones were the most common cause for ERCP in patients aged >80 years (53.8%), and normal findings indicating exclusion of relevant disease were more frequent in patients <80 years (13.4%) compared with older patients (4.3%) (P < .01). Sedation adverse events were significantly more common in individuals aged >80 years compared with younger patients (3.4% vs 0.5%; P < .01). However, post-ERCP pancreatitis was significantly less frequent in the older patients (>80 years) (0.9% vs 5.3%; P < .05). Other adverse events were equally distributed in all age groups. The ERCP success rate (>80%) was not different among age groups.

CONCLUSIONS

ERCP is safe and efficient in patients aged 80 years or older. However, conscious sedation must be carefully monitored in older patients because risk of sedation adverse events is increased. The incidence of post-ERCP pancreatitis is lower in older patients compared with younger ones.

Endoscopic papillary large balloon dilation for bile duct stones in elderly patients

AIM: To investigate whether endoscopic papillary large balloon dilation (EPLBD) can be safety and effectively performed in patients aged ≥ 80 years.

METHODS: Lithotomy by EPLBD was conducted in 106 patients with bile duct stones ≥ 13 mm in size or with three or more bile duct stones ≥ 10 mm. The patients were divided into group A (< 80 years) and group B (≥ 80 years). Procedure success rate, number of endoscopic retrograde cholangiopancreatographies (ERCP), and incidence of complications were examined in both groups.

RESULTS: Group B tended to include significantly more patients with peripapillary diverticulum, hypertension, hyperlipemia, cerebrovascular disease/dementia, respiratory disease/cardiac disease, and patients administered an anticoagulant or antiplatelet agent (P < 0.05). The success rate of the initial lithotomy was 88.7 (94/106)%. The final lithotomy rate was 100 (106/106)%. Complications due to treatment procedure occurred in 4.72 (5/106)% of the patients. There was no significant difference in procedure success rate, number of ERCP, or incidence of complications between group A and group B.

CONCLUSION: EPLBD can be safely performed in elderly patients, the same as in younger patients.

Assessment of safety of non-anesthesiologist-assisted endoscopic retrograde cholangiopancreatography based on performance status in elderly patients

BACKGROUND AND AIM

Endoscopic retrograde cholangiopancreatography (ERCP) has been increasingly performed in the elderly patients, yet little is known concerning objective criteria of safety. This study aimed to determine the potential predictors for the procedure-related outcomes.

METHODS

Two hundred eighty-one patients older than 70 years who were indicated for ERCP (group A [n = 195], 70-79 years of age; group B [n = 86], ≥ 80 years of age) were prospectively enrolled and analyzed for the development of serious adverse events related to ERCP.

RESULTS

ERCP was not performed in six patients at high risk for the procedure. There were significant differences between group A and B in Duke Activity Status Index (DASI) (23.1 vs 14.9, P < 0.01) and Eastern Cooperative Oncology Group performance status (3 and 4, 49/195 vs 33/86, P < 0.05). Major ERCP-related complications (hypotension, severe bradycardia, hypoxia, myocardial infarction, cerebral infarction) occurred in five patients from group B and three from group A. Post-ERCP pancreatitis occurred in one patient from group A and bleeding in one from group B. In univariate analysis, old age (≥ 80 years), American Society of Anesthesiologists score ≥ 3, and DASI < 10 were statistically significant predictors for overall serious events related to ERCP. In the multivariate analysis, DASI < 10 (only manage to ambulate) was independent predictor for overall serious events related to ERCP.

CONCLUSION

DASI score is useful predictor for the feasibility assessment of safe ERCP in the elderly patients.

Safety of endoscopic retrograde cholangiopancreatography in patients 80 years of age and older

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is used in the diagnosis and therapy of biliary tract diseases. The ERCP is an invasive procedure that does not increase complications in the elderly. Few studies have assessed the safety of ERCP in the elderly. Life expectancy is rising, which causes an increasing demand for ERCP in the elderly.

Aim

To show that therapeutic ERCP is safe and we compared the level of complications among the elderly (> 80 years of age) and the level among a younger group (< 65 years of age).

Material and methods

The study was designed retrospectively. The details of all patients 80 years of age and older undergoing ERCP were analysed. One hundred and fifty patients were included in each of the groups: > 80 years of age, older group A; and < 65 years of age, younger group B.

Results

In group A, 4 cases (2.7%) of bleeding (all mild) was observed, and perforation was not observed. The ERCP-related mild pancreatitis was observed in 7 patients (4.6%). There were no cases of mortality during procedures of ERCP in group A. In group B 6 bleeding cases (4%) (all mild) were observed. Perforation was not observed in group B. ERCP-related mild pancreatitis occurred in 11 patients (7.3%). There were no cases of mortality during procedures of ERCP in group B. Our study showed that ERCP is a safe and effective procedure in elderly patients.

Conclusions

Outcomes of ERCP for diagnostic and therapeutic success, and complication rates, are similar to those in younger patients. The ERCP is effective and safe in the elderly.

Long-term follow-up of therapeutic ERCP in 78 patients aged 90 years or older

This study aimed to determine the performance and long-term outcomes of therapeutic ERCP in very old patients. Patients aged or over 90 (Group A, n = 78) and consecutive sex-matched controls (Group B, n = 312) under 65 selected were compared. More patients in Group A had chronic concomitant diseases, but the success and complication rates were comparable. The follow-up of 61 patients (78.2%) in Group A were done, with a mean period of 27.5 (3–54) months. Seven patients survived; the main causes of death for the other patients were concomitant diseases (n = 43) and primary diseases (n = 11). In patients with choledocholithiasis, cases with complete extractions of stones in bile ducts survived longer than those without (30 vs. 24 months, P < 0.001). Therapeutic ERCP in patients aged 90 years or older is effective and safe. In patients with choledocholithiasis, complete clearance of stones is associated with longer survival time.

Adverse events in older patients undergoing ERCP: a systematic review and meta-analysis

BACKGROUND AND STUDY AIMS

Biliary and pancreatic diseases are common in the elderly; however, few studies have addressed the occurrence of adverse events in elderly patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). Our objective was to determine the incidence rates of specific adverse events in this group and calculate incidence rate ratios (IRRs) for selected comparison groups.

PATIENTS AND METHODS

Bibliographical searches were conducted in Medline, EMBASE, and Cochrane library databases. The studies included documented the incidence of adverse events (perforation, pancreatitis, bleeding, cholangitis, cardiopulmonary adverse events, mortality) in patients aged ≥ 65 who underwent ERCP. Pooled incidence rates were calculated for each reported adverse event and IRRs were determined for available comparison groups. A parallel analysis was performed in patients aged ≥ 80 and ≥ 90.

RESULTS

Our literature search yielded 7429 articles, of which 69 studies met our inclusion criteria. Pooled incidence rates for adverse events (per 1000 ERCPs) in patients aged ≥ 65 were as follows: perforation 3.8 (95 %CI 1.8 - 7.0), pancreatitis 13.1 (95 %CI 11.0 - 15.5), bleeding 7.7 (95 %CI 5.7 - 10.1), cholangitis 16.1 (95 %CI 11.7 - 21.7), cardiopulmonary events 3.7 (95 %CI 1.5 - 7.6), and death 7.1 (95 %CI 5.2 - 9.4). Patients ≥ 65 had lower rates of pancreatitis (IRR 0.3, 95 %CI 0.3 - 0.4) compared with younger patients. Octogenarians had higher rates of death (IRR 2.4, 95 %CI 1.3 - 4.5) compared with younger patients, whereas nonagenarians had increased rates of bleeding (IRR 2.4, 95 %CI 1.1 - 5.2), cardiopulmonary events (IRR 3.7, 95 %CI 1.0 - 13.9), and death (IRR 3.8, 95 %CI 1.0 - 14.4). Conclusions ERCP appears to be safe in elderly patients, except in the very elderly who are at higher risk of some adverse events. These data on adverse event rates can help to inform clinical decision-making, the consent process, and comparative effectiveness analyses.

Is endoscopic retrograde cholangiopancreatography safe in patients 90 years of age and older?

Background/Aims

This case-control study evaluated the safety and efficacy of endoscopic retrograde cholangiopancreatography (ERCP) in patients 90 years of age and older.

Methods

From January 2005 to August 2011, 5,070 cases of ERCP were performed at our institution. Of these, 43 cases involved patients 90 years of age and older (mean age, 91.7±1.9 years). A control group of 129 cases (mean age, 65.7±14.8 years) was matched by the patient sex, sphincterotomy, and presence of choledocholithiasis using a propensity score. The patients’ medical records were retrospectively reviewed for comorbidity, periampullary diverticulum, urgent procedure, conscious sedation, technical success, procedure duration, ERCP-related complication, and death.

Results

Between the case and control groups, there was no significant difference with regard to comorbidity, periampullary diverticulum, and urgent procedure. Conscious sedation was performed significantly less in the patient group versus the control group (28 [65%] vs 119 [92%], respectively; p=0.000). There was no significant difference in the technical success, procedure duration, or ERCP-related complications. In both groups, there was no major bleeding or perforation related to ERCP. Post-ERCP pancreatitis occurred significantly less in the patient group compared to the control group (0 vs 13 [10%], respectively; p=0.004). One death occurred from respiratory arrest in the case group.

Conclusions

ERCP can be performed safely and successfully in patients aged 90 years and older without any significant increase in complications.

Combined ERCP and EUS in one session is safe in elderly patients when compared to non-elderly patients: outcomes in 206 combined procedures

AIMS

Combined ERCP/EUS is becoming common. Combined procedures are frequently performed in elderly patients. We hypothesized that combined ERCP/EUS is equally safe in elderly patients when compared to non-elderly patients.

METHODS

This was a retrospective single-center study comparing outcomes in elderly and non-elderly patients undergoing combined ERCP/EUS.

RESULTS

A total of 206 patients were included. Mean age was 65 years (M:F 113:93); 99 were <65 years and 107 were >65. Indications included: jaundice (51%), abnormal imaging (17%), pancreatic tumor (11%), abdominal pain (5%), stent placement/change (5%), acute or chronic pancreatitis (5%), other (6%). Fine needle aspiration was performed in 134 (65%) procedures. Malignancy was identified in 142/206 (69%) patients. Mean Charlson Comorbidity Index (CCI) was 7.5 (range 0-22). Among patients <65 years old there were no immediate adverse events. Long-term adverse events in patients <65 (within 30 days) included cholangitis (1), increasing abdominal pain (4), post-ERCP pancreatitis (3), nausea/vomiting (1), increasing fatigue (1), and increasing jaundice (1). A subgroup analysis among geriatric patients (>65) was performed. Mean CCI was 8.2 (range 0-22). There was one immediate adverse event of non-sustained ventricular tachycardia in a 76-year old. Long-term adverse events included increasing fatigue (1), nausea/vomiting (2), increasing abdominal pain (2), urosepsis (1), fever (2) and dehydration (1). There were no statistically significant differences in outcomes in elderly compared to non-elderly patients. Elderly patients had higher CCI scores (p = 0.04).

CONCLUSION

Combined ERCP/EUS in one session is safe in the general population and elderly patients, with no more adverse events than in non-elderly patients.

Anesthesiologist assistance in endoscopic retrograde cholangiopancreatography procedures in the elderly: is it worthwhile?

BACKGROUND

Anesthesiologists provide sedation of the patients for mini-invasive procedures such as endoscopic retrograde cholangiopancreatography (ERCP) at many institutions at present, particularly for the elderly. The purpose of the present study was to define the safety of sedation and the tolerance of ERCP procedures in the extremely elderly patients at our institution, in which sedation is provided and controlled by endo team only.

METHODS

Forty-one ERCP procedures were performed in patients aged 90 years or older. All patients had chronic concomitant diseases, and 88% of the patients belonged to American Society of Anesthesiologists group IV. The patients were sedated with midazolam, and 7 out of 41 patients received fentanyl.

RESULTS

All ERCP procedures except one could be successfully completed, indicating good tolerance in 98% of the patients. There were neither sedation-related complications nor procedural mortality. In none of the cases, anesthesiologist assistance was needed.

CONCLUSIONS

Routine anesthesiological assistance in ERCP procedures in the elderly seems unnecessary.

Complications of endoscopic and radiologic investigation of biliary tract disorders

The investigation and treatment of disorders of the human biliary tree depend considerably on invasive endoscopic and radiologic procedures. These are associated with a significant risk of complications, some of which can be fatal. This review looks at these complications through the lens of 40 years of publications in the medical literature, and identifies the strengths and weaknesses of their current classification, diagnosis, and treatment.

Analysis of plastic stents in the treatment of large common bile duct stones in 45 patients

BACKGROUND

Although endoscopic plastic biliary stenting is a clinical procedure routinely carried out in patients with common bile duct stones, the effects of stenting on the sizes or fragmentation of large common bile duct stones have not been formally established and the mechanism of this condition is controversial. We compared the stone sizes of common bile duct stones after biliary stenting in order to develop the mechanism.

PATIENTS AND METHODS

Endoscopic plastic biliary stenting was performed in 45 patients with large common bile duct stones or those difficult to extract with conventional endoscopic therapy, including mechanical lithotripsy. The stone diameter was ≥16mm in all patients. Bile duct drainage and endoscopic placement of 7-8.5 Fr plastic biliary stents were established in all patients. Differences of stone sizes and fragmentations after biliary stenting were compared. The complete stone clearance rate after treatment was obtained.

RESULTS

After biliary stenting for 3-6months, the bile stones disappeared or changed to sludge in 10 (10/45) patients, and fragmentation of the stones or decreased stone sizes were seen in 33 patients, whose stone median size was significantly decreased from 23.1mm to 15.4mm in 33 patients (P<0.05). The stones were removed successfully with basket, balloon, mechanical lithotripsy or a combination in 43 (43/45) patients. The remaining two patients (2/45) demonstrated no significant changes in stone sizes.

CONCLUSION

  Plastic biliary stenting may fragment common bile duct stones and decrease stone sizes. This is an effective and feasible method to clear large or difficult common bile duct stones.

Clinical success of ERCP procedures in nonagenarian patients with bile duct stones

In the general population, endoscopic retrograde cholangiopancreatography (ERCP) procedures are the gold standard in the treatment of bile duct stones. However, repeat endoscopic procedures and sometimes even open surgery are needed in difficult cases with retaining bile duct stones. The aim of the present study was to determine the clinical success of ERCP procedures in the treatment of bile duct stones in extremely old patients. A retrospective data review comprising prospective data collection and double-entry bookkeeping of 23 therapeutic ERCPs in 20 nonagenarians with bile duct stones was conducted between 1997 and 2007. The primary ERCP procedure was the definitive treatment in 17 out of 20 patients with bile duct stones, giving a clinical success rate of 85 % for the first endoscopic procedure. In the remaining three patients, a repeat ERCP procedure had to be done in the follow-up. After these three repeat procedures with successful outcome, the clinical success of endoscopic treatment was 100%. There was no further recurrent biliary obstruction in any of the patients prior to death which occurred after a mean of 38 months (two patients are still alive), and no open surgery had to be performed in these patients. To be concluded, endoscopic treatment modality seems to be excellent in extremely elderly patients with bile duct stones.

EUS and ERCP complication rates are not increased in elderly patients

BACKGROUND

Further studies evaluating the safety of advanced endoscopic procedures in elderly patients are needed.

AIM

To evaluate the safety of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) in the elderly.

METHODS

The study population, consisting of 1,000 patients who underwent ERCP or EUS, was divided into two cohorts. The elderly cohort consisted of patients ≥ 75 years old. The nonelderly cohort consisted of patients <75 years old. The data collected included demographic information, type of procedure completed, procedure medication used, and endoscopic intervention performed. Complications included any event which occurred during the procedure or up to 1 month post procedure.

RESULTS

A total of 600 ERCPs and 400 EUS were included. The mean age of the elderly cohort was 80 years (range 75-95 years, n = 184) versus 54 years (range 13-74 years, n = 816) for the nonelderly cohort. The ERCP complication rate was 10.0% in the elderly versus 10.6% (P = 1.0) for the nonelderly. The EUS complication rate was 4.8% in the elderly versus 3.1% in the nonelderly (P = 0.49). The overall complication rates were identical at 7.6% (P = 1.0). Sedation doses were lower for the elderly cohort (P < 0.001). There was a higher rate of procedure bleeding in the elderly cohort (P = 0.016).

CONCLUSION

Advanced age is not a contraindication for advanced endoscopic procedures. There is no significant increase in the rate of overall procedure-related complications seen with either ERCP or EUS in elderly patients; however, elderly patients have a higher risk of bleeding. Less procedure-related sedation medication is required for elderly patients.

Endoscopic palliation of malignant obstructive jaundice in extremely elderly patients: plastic stent is enough

Although the price of biliary metal stents is manyfold higher when compared to plastic stents, the lower frequency of recurrent obstructions makes metal stents superior to plastic stents for endoscopic palliation of malignant biliary stricture in most patients. Is this the case in extremely elderly patients as well? A retrospective data review comprising prospective data collection and double-entry bookkeeping of therapeutic endoscopic retrograde cholangiopancreatographies (ERCP) with biliary strictures referring to malignancy in 14 patients aged 90 years or older at our institution in 1997-2007. Plastic stents were successfully inserted in 11 out of 14 patients, yielding a technical success rate of 79 %. In the remaining three patients, high biliary obstruction was relieved percutaneously in two cases while the general condition of one patient was so poor that terminal care decision was made in that case. There was no recurrent biliary obstruction in any of the patients with plastic stents prior to death which occurred after a mean of 2.8 months, giving a clinical success rate of 100 %. To be concluded, in extremely elderly patients with malignant obstructive jaundice, palliation with plastic stent is effective enough.

Findings and risk factors of early mortality of endoscopic retrograde cholangiopancreatography in different cohorts of elderly patients

OBJECTIVES

To analyze experience of endoscopic retrograde cholangiopancreatography (ERCP) in patients with of different age cohorts and discuss the risk factors of early mortality after ERCP.

DESIGN

Retrospective study.

SETTING

Tertiary care medical center.

PARTICIPANTS

Two hundred sixty-four patients with pancreatobiliary diseases divided into cohorts according to decades as young-old (YO, 65-74, n=143), old-old (OO, 75-84, n=88), and very-old (VO, >or=85, n=33).

MEASUREMENTS

The indications, results, and complications of ERCP in these three groups were demonstrated and compared.

RESULTS

Three hundred three ERCP procedures were performed. The leading indication for ERCP was common bile duct (CBD) obstruction or dilation. Diabetes mellitus was significantly more prevalent in the YO group (39.2%) than in the other two groups (OO, 15.9%; VO, 24.2%; P=.001). The most common finding of ERCP was CBD dilatation. There was no difference in incidence of malignant diseases between the three groups. Acute pancreatitis was the most frequently identified post-ERCP complication. There was no significant difference in early mortality between the three cohorts. Patients with malignancy had higher early mortality than those with benign disease (71.4% vs 11.2%; P=.001).

CONCLUSION

The findings and incidences of complication of ERCP in different elderly cohorts were similar. Underlying malignancy seemed to bear some relation to early mortality after the ERCP procedure.

ERCP is safe and effective in patients 80 years of age and older compared with younger patients

BACKGROUND

Biliary disease frequently occurs in the elderly, but there are limited data on ERCP in the elderly population.

PATIENTS

A total of 502 patients (group A, 97; group B, 405) underwent 724 ERCP procedures.

MAIN OUTCOME MEASUREMENTS

All consecutive ERCPs performed between 2000 and 2002 at a single center were retrospectively reviewed for patients >/=80 years old (group A) and patients <80 years old (group B) to evaluate endoscopic findings, interventions, complications, and mortality related to complications.

RESULTS

The number of important chronic concomitant diseases was significantly higher in the older group (average per patient 1.08 vs 0.57, P < .001). Successful cannulation was achieved in 88% in group A versus 86% in group B, and endoscopic sphincterotomy was performed in 63.2% versus 51.4%. Periampullary diverticulum was found significantly more often in patients of group A (39.2%) than of group B (14.1%, P < .001). Stents were used in 24.1% of ERCP procedures in group A and in 22.9% in group B. There was no significant difference in the complication rate between group A (6.8%) and group B (5.1%) and in early mortality (1.03% vs 0.25%), respectively.

CONCLUSION

ERCP is a safe and effective intervention in the elderly because complication and early mortality rates are comparable to those of younger patients, although comorbidity is significantly higher.

Cardiopulmonary complications of ERCP in older patients

BACKGROUND

Biochemical markers of ERCP-related myocardial injury have not previously been investigated.

OBJECTIVE

To evaluate ERCP-related cardiac troponin I (cTnI) release, myocardial ischemia, hemodynamic changes, and arterial hypoxemia in a series of consecutive patients according to age and to determine their relationship to preexisting cardiovascular risk factors (RF) and the development of post-ERCP pancreatitis.

DESIGN

Prospective cohort study.

SETTING

Tertiary teaching hospital, Canberra, Australia.

PATIENTS

Data were collected on 130 consecutive ERCPs performed on 100 unselected patients (aged 18-93 years) by one endoscopist. Patients were divided into two groups: 65 years of age and older (group 1, n = 53; 27 women) and less than 65 years of age (group 2, n = 47; 33 women).

INTERVENTIONS

ERCP.

MAIN OUTCOME MEASUREMENTS

Cardiovascular RFs were identified, and electrocardiogram (ECG), cTnI, creatine kinase (CK), amylase, and lipase were measured before and 24 hours after ERCP. Oxygen saturation (SpO(2)), heart rate (HR), blood pressure (BP), and ECG were monitored continuously during each procedure.

RESULTS

New ECG changes (ischemia, arrhythmias) occurred in 24% of procedures in group 1 and in 9.3% in group 2 (p = 0.168), and episodic arterial hypoxemia (SpO(2) < 90%) in 16.2% (group 1) and 21.4% (group 2) (p = 0.596). A post-ERCP rise in cTnI levels was documented in 6 patients in the older group. Two of these patients died: one from acute myocardial infarction and one from undiagnosed ascending aortic aneurysm. A cTnI rise was not related to any comorbid conditions, total number of RFs, hemodynamic or ECG changes, or arterial desaturation. In patients with a new cTnI rise, the duration of ERCP was significantly longer (59.5 vs. 26.4 minutes, p = 0.026), being 30 minutes or longer in 5 of 6 patients. Post-ERCP pancreatitis was associated with desaturation (relative risk [RR] = 5.9; 95% confidence interval [CI] [1.2, 32.0], p = 0.027) and myocardial ischemia/injury (RR = 4.4; 95% CI [1.4, 7.8]; p = 0.009).

CONCLUSIONS

Although the majority of older patients tolerated ERCP well, in 8% of procedures, most of which were prolonged (>30 minutes), myocardial injury, as defined by the release of cTnI, occurred. Desaturation and myocardial ischemia/injury were associated with post-ERCP pancreatitis.

Efficacy and safety of therapeutic ERCP in patients 90 years of age and older

BACKGROUND

Therapeutic ERCP has an established role in the treatment of pancreatobiliary diseases, but little information is available on the outcomes of this procedure in patients 90 years of age and older.

OBJECTIVE

To evaluate the efficacy and the safety of therapeutic ERCP in an extremely elderly cohort.

DESIGN

Retrospective study.

SETTING

Two Greek cohorts of patients > or =90 and 70 to 89 years of age who underwent therapeutic ERCPs.

PATIENTS

Sixty-three patients aged 90 years and older (group A) and 350 patients 70 to 89 years of age (group B).

INTERVENTIONS

A retrospective review of therapeutic ERCPs was performed between 1994 and 2000 on both groups, identified by using a database linked to the endoscopy reporting system in our department.

MAIN OUTCOME MEASUREMENTS

Efficacy and safety of therapeutic ERCPs. Concomitant diseases, complications, and outcome were also evaluated.

RESULTS

Group A patients had a higher incidence of concomitant diseases than group B patients (100% vs 72.8%, respectively). The rate of post-ERCP early complications was low in both groups: 6.3% in group A and 8.4% in group B. The frequency of ERCP-related mortality was 1.6% (1 patient) in group A and 0.6% (2 patients) in group B. Group A required endoscopic sessions for stone clearance and mechanical lithotripsy more frequently than group B (20.6% vs 11.4% and 17.5% vs 10.3%, respectively). No patient in either group experienced subjective deterioration in mental status, and the 3 patients who died required ventilatory support before death. Late complications occurred in 2.3% of patients in group B.

CONCLUSIONS

Therapeutic ERCP is safe and effective for the treatment of pancreatobiliary diseases in extremely elderly patients, and advanced age per se should not impinge on decisions relating to its use.

[Complications of endoscopic retrograde cholangiopancreatography in patients aged more than 90 years old]

INTRODUCTION

To evaluate the effectiveness of endoscopic retrograde cholangiopancreatography (ERCP) and the complication rates of this procedure in patients aged 90 years and older.

PATIENTS AND METHOD

A descriptive, prospective study including 42 endoscopic procedures performed from first January 2001 until first June 2004 in 36 patients (7 males and 29 females) was performed. The mean age was 91 years (range 90-96 years). All patients underwent the following: a) clinical evaluation before and after endoscopic exploration; b) evaluation of the success or failure of the endoscopic procedure and c) assessment of complications (perforation, hemorrhage, pancreatitis and infection). Concurrent associated illnesses, as well as the existence of anatomical alterations in Vaters papilla (duodenal diverticula), were also evaluated.

RESULTS

ERCP was successful in 85.7% of all explorations performed. Twenty-three patients (63.8%) had one or more major associated diseases. In 15 patients (33.3%) Vaters papilla was associated with duodenal diverticula. The complication rates were as follows: 1) acute pancreatitis in 2 explorations (4.7%), one mild (2.35%) and the other moderate (2.35%); 2) hemorrhage after endoscopic sphincterotomy in 2.8% of patients (1/35); 3) bacteriemia in one patient (2.3%) and cholangitis in one patient (2.3%), with no cases of secondary cholecystitis; 4) hypoxemia in one patient. There were no perforations or deaths related to the procedure.

CONCLUSION

ERCP is a safe and effective technique with a low complication rate in patients aged 90 years or older.

Endoscopic retrograde cholangiopancreatography in the elderly: a prospective and comparative study

OBJECTIVE

In this study we aimed to compare the utility and safety of endoscopic retrograde cholangiopancreatography (ERCP) in elderly and younger groups of people.

METHODS

The study involved 299 patients who underwent ERCP for the first time between March 2002 and January 2003. Group A consisted of 202 patients who were 69 years of age or younger and group B involved 97 patients who were 70 years of age or older. The patients were prospectively identified and data were gathered on them prospectively. Clinical and biochemical features, ERCP procedures, ERCP diagnosis, complications and length of hospital stay were compared between the two groups.

RESULTS

Group B patients presented with more specific symptoms compared with group A. Laboratory findings were similar in both groups other than mean bilirubin levels, which were higher in the elderly group. Selective biliary cannulation was technically successful in 99% of both groups. Pre-cut papillotomy was performed in 49.5% of group A patients and 56.7% of group B patients. Choledocholithiasis was the most frequent diagnosis in both groups. Benign biliary stenosis was more frequent in group A and malignant biliary stenosis in group B. Among the malignant aetiologies, pancreatic carcinoma was the most common cancer in both groups. Post-procedural complications developed in 27 (9%) patients. There were 16 (7.9%) complications (six bleeding, five pancreatitis, three perforation and two cholangitis) in the 202 patients aged under 70 years. In comparison, 11 (11.3%) of the 97 patients aged over 70 years developed a complication (bleeding in six, pancreatitis in one, perforation in one, cholangitis in two and ileus in one). Twelve (nine group A and three group B) patients died within 5-30 days of the procedure. Length of hospital stay was comparable for both groups (15.53+/-12.43 days in group A and 14.84+/-11.56 days in group B).

CONCLUSIONS

Diagnostic and therapeutic ERCP has similar outcomes in both elderly and younger patients. ERCP is effective and safe in elderly patients with naive papilla. The more invasive procedures like pre-cut papillotomy may be performed safely in the elderly.