Published online Apr 16, 2022. doi: 10.4253/wjge.v14.i4.215
Peer-review started: November 17, 2021
First decision: January 12, 2022
Revised: January 22, 2022
Accepted: March 16, 2022
Article in press: March 16, 2022
Published online: April 16, 2022
Processing time: 142 Days and 5.8 Hours
In parallel with the growing aging population worldwide, endoscopic retrograde cholangiopancreatography (ERCP) is being increasingly used in the treatment of common bile duct stones (CBDS) in patients with a poor performance status (PS). Therefore, determining the safety and efficacy of ERCP for CBDS in patients with a PS score of 3 or 4 is essential.
PS is an important tool to elucidate the indications and strategies of ERCP for CBDS in elderly patients. However, few studies examined the safety and efficacy of ERCP for CBDS in patients with a poor PS.
To examine the safety and efficacy of ERCP for CBDS in patients with poor PS, which is defined as a PS score of 3 or 4.
We reviewed the medical records of three institutions in Japan from April 2012 to February 2020. The exclusion criteria were (1) failure to detect CBDS during ERCP; (2) history of therapeutic ERCP; and (3) and an already surgically altered gastrointestinal tract including Billroth II or Roux-en-Y reconstruction. Finally, we identified 1343 patients with choledocholithiasis who met the inclusion criteria for the study, and 1113 and 230 patients had PS scores of 0-2 and 3 or 4, respectively. One-to-one propensity score matching was performed to compare the safety and efficacy of ERCP for CBDS between patients with PS scores of 0-2 and 3 or 4.
The overall ERCP-related complication rates in all patients with PS scores of 0-2 and 3 or 4 were 9.0% (100/1113) and 7.0% (16/230; P = 0.37), respectively. In the propensity score-matched group, the overall ERCP-related complication rates were 4.6% (9/196) and 6.6% (13/196; P = 0.51) among patients with PS scores of 0-2 and PS 3-4, respectively, and complications were significantly more severe in the group with a PS score of 3-4 than in the groups with a PS score of 0-2 (P = 0.042). In multivariate analysis, risk factors for ERCP-related complications were indication of ERCP and absence of antibiotics (P < 0.001 and P = 0.034, respectively). Particularly, absence of acute cholangitis including asymptomatic CBDS, was associated with increased risk of ERCP-related complications. Therapeutic success rates, including complete CBDS removal and permanent biliary stent placement, in propensity score-matched patients with PS scores of 0-2 and 3 or 4 were 97.4% (191/196) and 97.4% (191/196), respectively (P = 1.0).
ERCP for CBDS can be performed effectively in patients with a PS score of 3 or 4. The rates of ERCP-related complications were similar between the patients with PS scores of 0-2 and 3 or 4; however, their severity was higher in the group with a PS score of 3 or 4 than in the group with a PS score of 0-2. The indication of ERCP for CBDS, particularly in patients with asymptomatic CBDS, requires careful consideration, and antibiotics should be administrated before ERCP in patients with a PS score of 3 or 4.
The retrospective study design that included specialized centers in Japan was an important limitation of this study. Future multicenter studies including large patient cohorts from institutions with different ERCP experiences are warranted to confirm our findings.