Efficacy and Safety of Therapeutic ERCP in the Elderly: A Single Center Experience. Surg Laparosc Endosc Percutan Tech. 2018;28:e44-e48. [PMID: 29252934 DOI: 10.1097/sle.0000000000000499]

Impact of frailty on endoscopic retrograde cholangiopancreatography outcomes in nonagenarians: A United States national experience

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is an essential therapeutic tool for biliary and pancreatic diseases. Frail and elderly patients, especially those aged ≥ 90 years are generally considered a higher-risk population for ERCP-related complications.

AIM

To investigate outcomes of ERCP in the Non-agenarian population (≥ 90 years) concerning Frailty.

METHODS

This is a cohort study using the 2018-2020 National Readmission Database. Patients aged ≥ 90 were identified who underwent ERCP, using the international classification of diseases-10 code with clinical modification. Johns Hopkins’s adjusted clinical groups frailty indicator was used to classify patients as frail and non-frail. The primary outcome was mortality, and the secondary outcomes were morbidity and the 30 d readmission rate related to ERCP. We used univariate and multivariate regression models for analysis.

RESULTS

A total of 9448 patients were admitted for any indications of ERCP. Frail and non-frail patients were 3445 (36.46%) and 6003 (63.53%) respectively. Indications for ERCP were Choledocholithiasis (74.84%), Biliary pancreatitis (9.19%), Pancreatico-biliary cancer (7.6%), Biliary stricture (4.84%), and Cholangitis (1.51%). Mortality rates were higher in frail group [adjusted odds ratio (aOR) = 1.68, P = 0.02]. The Intra-procedural complications were insignificant between the two groups which included bleeding (aOR = 0.72, P = 0.67), accidental punctures/lacerations (aOR = 0.77, P = 0.5), and mechanical ventilation rates (aOR = 1.19, P = 0.6). Post-ERCP complication rate was similar for bleeding (aOR = 0.72, P = 0.41) and post-ERCP pancreatitis (aOR = 1.4, P = 0.44). Frail patients had a longer length of stay (6.7 d vs 5.5 d) and higher mean total charges of hospitalization ($78807 vs $71392) compared to controls (P < 0.001). The 30 d all-cause readmission rates between frail and non-frail patients were similar (P = 0.96).

CONCLUSION

There was a significantly higher mortality risk and healthcare burden amongst nonagenarian frail patients undergoing ERCP compared to non-frail. Larger studies are warranted to investigate and mitigate modifiable risk factors.

Ultrasound-Guided Percutaneous Transhepatic Cholangioscopic Lithotripsy for the Treatment of Common Bile Duct Stones and Analysis of Risk Factors for Recurrence

BACKGROUND

As a minimally invasive treatment for common bile duct (CBD) stones, ultrasound-guided percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) is gaining attention and recognition from the medical community.

METHODS

A retrospective analysis was conducted on patients with CBD stones treated in our hospital from January 2016 to April 2022. Patients were divided into three groups: 77 treated with PTCSL, 93 with endoscopic retrograde cholangiopancreatography (ERCP), and 103 with laparoscopic common bile duct exploration (LCBDE). Their clinical data, perioperative indicators, and complications were analyzed comparatively. Then, risk factors for the post-PTCSL recurrence of CBD stones were analyzed by logistic regressions. Finally, the receiver operating characteristic curve was drawn.

RESULTS

All perioperative indicators of the PTCSL group were better than the LCBDE group (P < 0.001). The incidences of cholangitis, hemobilia, and incisional infection after surgery were lower in the PTCSL group than in the LCBDE group (P < 0.05). Pancreatitis, reflux esophagitis, and papillary stenosis occurred less frequently in the PTCSL group than in the ERCP group (P < 0.05). Logistic regression analysis indicated that gallstones and family history were independent risk factors. The AUC for recurrent CBD stones predicted by multi-indicators was 0.895 (95% CI 0.792-0.999, P < 0.001) with a sensitivity of 96.7% and specificity of 68.8%.

CONCLUSIONS

Ultrasound-guided PTCSL is a safe and effective treatment for CBD stones. Patients recovered quickly with fewer postoperative complications. It can be a first-line treatment for CBD stones. Gallstones and family history are independent risk factors for recurrent CBD stones, which provide a reference for clinicians in identifying the high-risk population needing close follow-up.

Efficacy and Safety of Electrohydraulic Lithotripsy Using Peroral Cholangioscopy under Endoscopic Retrograde Cholangiopancreatography Guidance in Older Adults: A Single-Center Retrospective Study

Background and objectives: The safety of electrohydraulic lithotripsy (EHL) in older adults remains unclear. We aimed to investigate the efficacy and safety of EHL using peroral cholangioscopy (POCS) under endoscopic retrograde cholangiopancreatography (ERCP) guidance in older adults aged ≥80 years. Materials and Methods: This retrospective clinical study was conducted at a single center. Fifty patients with common bile duct stones who underwent EHL using POCS under ERCP guidance at our institution, between April 2017 and September 2022, were enrolled in this study. The eligible patients were divided into an elderly group (n = 21, age ≥80 years) and a non-elderly group (n = 29, age ≤79 years), and were analyzed. Results: A total of 33 and 40 EHL procedures were performed in the elderly and non-elderly groups, respectively. After excluding cases in which stone removal was performed at other institutions, complete removal of common bile duct stones was confirmed in 93.8% and 100% of the elderly and non-elderly groups, respectively (p = 0.20). The mean number of ERCPs required for complete removal of bile duct stones was 2.9 and 4.3 in the elderly and non-elderly groups, respectively (p = 0.17). In the EHL session, the overall occurrence of adverse events was eight and seven in the elderly (24.2%) and non-elderly (17.5%) groups, respectively; however, the difference was insignificant (p = 0.48). Conclusions: EHL using POCS under ERCP guidance is effective in patients aged ≥80 years and there was no significant increase in adverse event rates compared to those aged ≤79 years.

Safety of Nonagenarians Receiving Therapeutic ERCP, Single Center Experience

(1) Background: The complication rates for nonagenarians receiving therapeutic endoscopic retrograde cholangiopancreatography (ERCP) remain poorly understood. We aimed to determine whether nonagenarians were at an increased risk of ERCP-related complications. (2) Methods: We performed a retrospective study on therapeutic ERCP in nonagenarians from 2011 to 2016 at Taichung Veterans General Hospital. A control group comprising patients aged 65 to 89 years was used to compare demographic data and the outcomes of therapeutic ERCP with the nonagenarians. The risk factors for complications were determined by logistic regression model. (3) Results: There were 35 nonagenarians and 111 patients in the control group. Overall, complication rates were not statistically different between the two groups. However, advanced age was an independent predictor of complications in the multivariate analysis (odds ratio [OR] = 1.06; 95% confidence interval [CI] = 1.01-1.12; p = 0.049). End stage renal disease (ESRD) was another independent predictor of complications (OR = 4.87; 95% CI = 1.11-21.36; p = 0.036). Post-ERCP pancreatitis and bleeding were more common in ESRD patients than patients without ESRD. (4) Conclusions: Although nonagenarians receiving ERCP did not have more complications compared to elderly patients younger than 90 years, advanced age and comorbidity still affect the outcome of therapeutic ERCP in the elderly patients.

Sequential endoscopist-driven phone calls improve the capture rate of adverse events after ERCP: a prospective study

BACKGROUND AND AIMS

ERCP is a high-risk endoscopic procedure, yet reports of ERCP-related adverse events are largely limited to early adverse events based on immediate postprocedure assessment. We hypothesize that immediate/1-day follow-up underestimates the true adverse event rate, and later follow-up calls may enable a more accurate assessment of adverse events, leading to enhanced postprocedural patient care.

METHODS

Consecutive patients undergoing ERCP at our tertiary care academic medical center from 2018 to 2019 were analyzed. Patients were encouraged to contact us with postprocedure symptoms, and they received phone calls at 1, 7, 14, and 30 days after the procedure using a standardized script to assess for delayed adverse events and unplanned health care encounters.

RESULTS

This study is notable for a high rate of successful patient follow-up at day 1 (94%) and day 7 (93%). The overall adverse event rate was 1.9% immediately postprocedure, 3.3% on day 1, and 9.8% on day 7. Increased detection of adverse events was accomplished by the day 7 call relative to the day 1 call (pancreatitis 2% vs 0.5%; bleeding 0.5% vs 0.2%; infection 0.9% vs 0.5%). Follow-up calls at 14 and 30 days were lower yield for detection of post-ERCP adverse events.

CONCLUSIONS

Initial postprocedure assessment and day 1 follow-up calls underestimate adverse event rates/unplanned health care encounters related to ERCP, due to delayed evolution of some adverse events. The day 7 call is optimal in that it resulted in a >3-fold higher rate of detection of adverse events and successful direction of over 10% of symptomatic patients to appropriate assessment and follow-up health care.

Difficult biliary stones in the elderly: Endoscopic retrograde cholangiography - A single surgical tertiary centre experience with follow-up

Background

Pancreaticobiliary diseases and choledocholithiasis are common in elderly patients. Endoscopic treatment of biliary stones represents a well-established mini-invasive technique. However, limited data are available regarding the treatment of 'difficult' biliary stones, especially in the elderly population. The aim of our study is to evaluate the efficacy and safety of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in patients ≥85 years of age with complex biliary stones.

Materials and Methods

From January 2015 to January 2017, data from ERCP procedures performed for complex biliary stones were retrospectively collected. The patients were divided into two groups based on their age: Group A - aged 85 years or older (n = 110) and Group B - aged 65 years or younger (n = 62). Demographic data, success, complications and recurrence rates for both groups were reported.

Results

Chronic comorbidities (86.3% vs. 24.2%; P < 0.001) and use of antithrombotic drugs (48.2% vs. 19.3%; P < 0.001) were more frequent in the elderly. The technical success rate (95.4% vs. 96.7%; P > 0.6) and complication rate (8.2% vs. 13%; P > 0.2) were not statistically different among the two groups. Periampullary diverticula (PAD) were observed more frequently in Group A (38.1% vs. 17.7%; P < 0.006). More patients from Group B underwent cholecystectomy during the same admission (8.2% vs. 42.3%; P < 0.001). The recurrence rate was not different among the groups (7.6% vs. 5%; P > 0.5). PAD was identified as the risk factor for recurrence (P < 0.02).

Conclusion

ERCP in the elderly was found to be a safe procedure, carrying a high degree of success for the treatment of difficult biliary stones.

Endoscopic retrograde cholangiopancreatography in elderly patients: Difficult cannulation and adverse events

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is a valuable therapeutic technique for pancreatobiliary diseases, and its application in the elderly is no longer limited. However, a higher incidence of procedure difficulty and periprocedural adverse events might be expected in elderly patients due to the presence of other medical disorders and the poor general condition of this population.

AIM

To evaluate the incidence, causes, and management of difficult biliary cannulation during ERCP in elderly patients and the role of difficult cannulation as a risk factor for adverse events.

METHODS

A total of 614 patients who underwent ERCP during the study period were prospectively studied and divided into two groups based on their age. One hundred and forty-six patients were aged 80 years or older and 468 patients were aged less than 80 years. The primary outcome measurements were cannulation difficulty, cannulation success rate, ERCP procedure time, and related adverse events.

RESULTS

There was no difference in the incidence of difficult cannulation among the two groups (32.9% vs 34.4%, P = 0.765), as well as in the cannulation success rate (96.6% vs 96.8%, P = 0.54). The cannulation techniques were shown to be safe and efficient in achieving successful cannulation. Logistic regression analysis showed that patients aged 80 years or older were not associated with increased adverse events; however, difficult cannulation cases [adjusted odds ratio (AOR) = 3.478; 95% confidence interval (CI): 1.877-6.442; P < 0.001] and patients with Charlson Comorbidity Index ≥ 2 (AOR = 1.824; 95%CI: 0.993-3.349; P = 0.045) were more likely to develop adverse events. In contrast, other factors including age ≤ 65 (AOR = 3.460; 95%CI: 1.511-7.922; P = 0.003), female gender (AOR = 2.362; 95%CI=1.089-5.124; P = 0.030), difficult cannulation (AOR = 4.527; 95%CI: 2.078-9.860; P < 0.001), and patients with cholangitis (AOR = 3.261; 95%CI: 1.204-8.832; P = 0.020) were strongly associated with a higher rate of post-ERCP pancreatitis.

CONCLUSION

Advanced age has not been proved to be a risk factor for difficult cannulation, and secondary cannulation techniques can be safely and efficaciously utilized in this group. Patients with a Charlson Comorbidity Index ≥ 2 and difficult cannulation are associated with an increased overall adverse events rate, while age ≥ 80 years is not.

Cholecystectomy after Endoscopic Papillotomy for Choledocholithiasis in the Elderly—Is It Necessary?

Although elective laparoscopic cholecystectomy is the accepted strategy after endoscopic retrograde cholangiopancreatography (ERCP), papillotomy, and common bile duct (CBD) clearance, the decision to perform a cholecystectomy in high-risk elderly comorbid patients remains subjective and is controversial. The aim of this study was to examine the outcome of elderly patients with cholecystectomy deferral after successful initial endoscopic removal of CBD stones. The study examined a retrospective patient database, which included all patients aged >60 years who underwent an ERCP for CBD stones at the Chaim Sheba Medical Center. The study cohort was divided according to whether a subsequent cholecystectomy was performed and also by age 60 to 80 or >80 years. All biliary-related complications were recorded. The primary outcome measures were biliary complications, perioperative and periprocedural mortality, CBD stone recurrence, and the need for future surgical intervention. There were 111 patients (mean age 79.4 ± 9.1 years) who underwent ERCP with follow-up. After excluding 11 patients, 100 patients were left for analysis, 46 of whom underwent a cholecystectomy and 54 were observed without operation. There were significant longer term biliary complications in five of the operated patients (10.9%) and in four of the unoperated cases (7.4%). All biliary-related complications were managed successfully by conservative means except for one fatality in the nonoperated group. Biliary-related complications after successful ERCP for CBD stones were unaffected by surgery but were more commonly observed in older cases. A watch and wait policy may be justified in elderly comorbid patients.