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

Abstract

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.

Is Cholecystectomy a cause of difficult biliary cannulation in endoscopic retrograde cholangiopancreatography?

“…In another study conducted on difficult cannulation, 42.1% of the maneuvers used were pancreatic guidewire and 26.8% were pancreatic stents. The frequency rates of using these maneuvers are similar to the data obtained in our study (22). The frequency of maneuvers used in difficult biliary cannulation cases was similar in both patient groups.…”

Elderly patients (≥ 80 years) with acute calculous cholangitis have similar outcomes as non-elderly patients (< 80 years): Propensity score-matched analysis

“…However, there is evidence that age itself is not the determinant of inferior outcomes in elective and emergency biliary diseases[ 10 , 11 ]. Endoscopic retrograde cholangiopancreatography (ERCP) have been demonstrated to be safe with good outcomes in elderly patients[ 11 , 12 ].…”

“…However, there is evidence that age itself is not the determinant of inferior outcomes in elective and emergency biliary diseases[ 10 , 11 ]. Endoscopic retrograde cholangiopancreatography (ERCP) have been demonstrated to be safe with good outcomes in elderly patients[ 11 , 12 ]. In a study including 149 acute cholecystitis patients treated with emergency laparoscopic cholecystectomy (LC), Amirthalingam et al [ 13 ] showed that patient comorbidities and not age determine outcomes.…”

Propensity score-matched analysis for comparing transpancreatic sphincterotomy and needle-knife precut in difficult biliary cannulation

“…Most studies showed that the PEP rate of TPS is similar to other advanced cannulation methods; even NKP could be better to avoid PEP 17 , 19 , 20 . However, limited studies have prospectively compared PEP rate in TPS and NKP, in addition to a lack of information on using uniform PEP preventive methods, which could make the PEP rate with TPS even lower 5 , 17 .…”