Risk factors for complications in elderly patients aged 85 years and over undergoing endoscopic biliary stone removal

Abstract

Background and aimThe number of elderly patients with biliary stones is increasing. Endoscopic retrograde cholangiography (ERCP) is considered to be an effective treatment for biliary stones. Having a sound knowledge of the risk factors can help reduce the incidence and severity of complications for ERCP. Furthermore, limited research has been published on patients aged over 85 years undergoing endoscopic biliary stone removal. This study aims to determine the risk factors that lead to complications of ERCP in patients over 85 years of age.MethodsThis was a single-center retrospective study. We analyzed 156 patients aged ≥ 85 years with biliary stones who underwent their first ERCP at Chinese PLA General Hospital from February 2002 to March 2021. Logistic regression models were employed to identify the independent risk factors for complications.ResultsA total of 13 patients (8.3%) had complications. Thereinto, pancreatitis, cholangitis, bleeding, and other complications occurred in 4 cases (2.6%), 1 cases (0.6%), 4 cases (2.6%), and 4 cases (2.6%), respectively. There was no perforation or death related to ERCP. Independent risk factors for complications were acute biliary pancreatitis (ABP) (P = 0.017) and Charlson Comorbidity Index (CCI) (P = 0.019). Significantly, reasons for incomplete stone removal at once were large stone (>10 mm) (P < 0.001) and higher acute physiology and chronic health evaluation scoring system (APACHE-II) (P = 0.005).ConclusionsERCP was recommended with caution in patients ≥ 85 years of age with ABP or higher CCI undergoing endoscopic biliary stone removal. In patients with ABP without cholangitis or biliary obstruction we recommend against urgent (within 48 h) ERCP. Patients with higher CCI who can tolerate ERCP can undergo rapid ERCP biliary stenting or nasobiliary implantation with later treatment of stones, and patients who cannot tolerate ERCP are treated promptly with PTCD and aggressive conservative treatment.

Commentary: Risk factors for complications in elderly patients aged 85 years and over undergoing endoscopic biliary stone removal

“…We interpreted our findings considering a possible selection bias, i.e., the lack of a standardized comprehensive geriatric assessment (CGA) for elderly subjects accessing endoscopy service. Although the CCI is a validated and user-friendly index, we agree with Zhang et al (1) that it cannot be the only tool considered because it cannot capture alone the clinical complexity of geriatric patients. In fact, although they may possess the criteria to undergo ERCP, elderly patients might be erroneously excluded from this procedure because of their comorbidity burden.…”

“…The authors define him as "frail," but this judgment is based on clinical conditions and comorbidities rather than on specific frailty assessment. We think that Zhang et al (1) significantly contributed to enlighten the potential risk factors of ERCP-related complications in the over 85 population, paving the path for further research in an age group characterized by complex health needs and a high burden of comorbidity. Nevertheless, we suggest including the assessment of frailty in the preoperative evaluation because of its prognostic significance in the geriatric population.…”