Observational Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Jul 26, 2020; 8(14): 2988-2999
Published online Jul 26, 2020. doi: 10.12998/wjcc.v8.i14.2988
Endoscopic retrograde cholangiopancreatography in elderly patients: Difficult cannulation and adverse events
Fatema Tabak, Hui-Shan Wang, Quan-Peng Li, Xian-Xiu Ge, Fei Wang, Guo-Zhong Ji, Lin Miao
Fatema Tabak, Hui-Shan Wang, Quan-Peng Li, Xian-Xiu Ge, Fei Wang, Guo-Zhong Ji, Lin Miao, Institute of Digestive Endoscopy and Medical Centre for Digestive Disease, Second Affiliated Hospital of Nanjing Medical University, Nanjing 210011, Jiangsu Province, China
Author contributions: Tabak F and Li QP designed the study; Tabak F, Wang HS, Ge XX, and Wang F recorded and analyzed the data; Tabak F and Miao L drafted the initial manuscript; Tabak F, Ji GZ and Miao L revised the article critically for important intellectual content.
Institutional review board statement: This study was reviewed and approved by the Ethics Committee of the Second Affiliated Hospital of Nanjing Medical University.
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: There are no conflicts of interest to report.
Data sharing statement: The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Lin Miao, MD, PhD, Chief Doctor, Professor, Institute of Digestive Endoscopy and Medical Center for Digestive Disease, Second Affiliated Hospital of Nanjing Medical University, No. 121, Jiangjiayuan Road, Nanjing 210011, Jiangsu Province, China. linmiao@njmu.edu.cn
Received: March 6, 2020
Peer-review started: March 6, 2020
First decision: April 12, 2020
Revised: May 26, 2020
Accepted: June 19, 2020
Article in press: June 19, 2020
Published online: July 26, 2020
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.

Keywords: Endoscopic retrograde cholangiopancreatography, Difficult cannulation, Cannulation techniques, Elderly, Adverse events, Post- endoscopic retrograde cholangiopancreatography pancreatitis

Core tip: As life expectancy has increased, the application of endoscopic retrograde cholangiopancreatography in the elderly population is no longer limited. This increase may come with more difficulty in biliary cannulation or more related adverse events in senior patients. Little is known about cannulation difficulty grading in the elderly and its relationship with adverse events. Therefore, we aimed to evaluate the risk factors for adverse events in elderly patients with difficult bile duct access.