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

Table 1 Summary of patient characteristics in the older and younger groups

Parameter	Overall (n = 614)	Age ≥ 80 (n = 146)		Age < 80 (n = 468)	P value
Age [median (IQR)] (yr)	68 (54-79)	83 (81-86)		62 (50-71)
Charlson score [median (IQR)]	0 (0-1)	1 (0-2)		0 (0-1)	0.001a
Charlson score ≥ 2	21% (129)	29.5% (43)		18.4% (86)	0.005b
ERCP procedure time [median (IQR)] (min)	30 (23-45)	30 (23-45)		30 (24-45)	0.711a
Cannulation time [median (IQR)] (min)	3.6 (0.8-11.8)	3.4 (0.8-11.2)		3.7 (0.8-12)	0.292a
Male	53.2% (327)	51.4% (75)		53.8% (252)	0.636b
Cannulation success rate	96.7% (595)	96.6% (141)		96.8% (454)	0.547b
Indications
Biliary stones	82.4% (506)	82.9% (121)		82.3% (385)	0.468b
Benign strictures	12.7% (78)	11% (16)		13.2% (62)	0.287b
Cholangiocarcinoma	4.2% (26)	4.8% (7)		4.1% (19)	0.424b
Cholangitis	9.1% (56)	6.8% (10)		9.8% (46)	0.180b
Biliary pancreatitis	5.9% (36)	4.8% (7)		6.2% (29)	0.346b
Chronic pancreatitis	1.3% (8)	0% (0)		1.7% (8)	0.113b
Ampullary carcinoma	3.3% (20)	5.5% (8)		2.6% (12)	0.076b
Pancreatic cancer	3.6% (22)	2.7% (4)		3.8% (18)	0.371b
Comorbidities
Hypertension	29.5% (181)	38.4% (56)		26.7% (125)	0.009b
Cardiac diseases	7.5% (46)	15.1% (22)		5.1% (24)	< 0.001b
Diabetes mellitus	11.7% (72)	13% (19)		11.3% (53)	0.558b
Neurological diseases	12.5% (77)	21.9% (32)		9.6% (45)	< 0.001b
Hepatic diseases	7.8% (48)	5.5% (8)		8.5% (40)	0.290b
Malignancy	9.3% (57)	11% (16)		8.8% (41)	0.256b
Others	9.9% (61)	14.4% (21)		8.5% (40)	0.031b
Periampullary diverticulum	19.7% (121)	29.5% (43)		16.7% (78)	0.001b
Cannulation grade of difficulty
Easy cannulation	66% (405)		67.1% (98)	65.6% (307)	0.621b
Moderate cannulation	11.7% (72)		10.3% (15)	12.2% (57)	0.658b
Difficult cannulation	22.3% (137)		22.6% (33)	22.2% (104)	0.910b
Second ERCP	20.4% (125)		20.5% (30)	20.3% (95)	0.512b
Adverse events	9.8% (60)		13% (19)	8.8% (41)	0.089b
PEP	5.2% (32)		2.7% (4)	6% (28)	0.088b
Perforation	0.5% (3)		0.7% (1)	0.4% (2)	0.557b
Bleeding	1.9% (12)		4.1% (6)	1.3% (6)	0.111b
Cholangitis	0.6% (4)		0.7% (1)	0.6% (3)	0.663b
Cardiopulmonary	0.6% (4)		0.7% (1)	0.6% (3)	0.443b
Duration of hospitalization [median (IQR)] (d)	9 (6-13)		9 (7-13)	9 (6-13)	0.208a
Pancreatic stent	10.4% (64)		7.5% (11)	11.3% (53)	0.124b
Anti-thrombotic drug	5.5% (34)		7.5% (11)	4.9% (23)	< 0.001b

^aIndependent sample Mann-Whitney U-test.

^bFisher’s exact test. IQR: Interquartile range; ERCP: Endoscopic retrograde cholangiopancreatography.

Table 2 Summary of causes, cannulation techniques, and adverse events of difficult cannulation patients in the older and younger groups

	Overall (n = 209), %	Age ≥ 80 (n = 49),%	Age < 80 (n = 160), %	P value1
Causes of difficulty
Papillary anatomy	31.1 (65)	18.4 (9)	35 (56)	0.029
Distal stricture or impacted stone	32.5 (68)	22.4 (11)	35.6 (57)	0.108
Diverticulum	18.2 (38)	26.5 (13)	15.6 (25)	0.047
Ampullary carcinoma	4.8 (10)	14.3 (7)	1.9 (3)	0.001
Altered anatomy	8.6 (18)	10.2 (5)	8.1 (13)	0.326
Cannulation failure	5.7 (12)	8.3 (4)	5 (8)	0.286
Cannulation techniques
Guidewire assisted	42.1 (88)	40.8 (20)	42.5 (68)	0.868
NKP	37.7 (79)	42.8 (21)	36.2 (58)	0.239
TPS	20.1 (42)	16.7 (8)	21.2 (34)	0.546
Pancreatic stent	26.8 (56)	22.9 (11)	28.1 (45)	0.489
Adverse events
PEP	10 (21)	4.2 (2)	11.8 (19)	0.096
Perforation	1 (2)	2.1 (1)	0.6 (1)	0.407
Bleeding	1.9 (4)	4.2 (2)	1.2 (2)	0.227
Cholangitis	1.9 (4)	2.1 (1)	1.9 (3)	0.651
Cardiopulmonary	1 (2)	- (0)	1.2 (2)	0.593

¹Fisher’s exact test.

IQR: Interquartile range; ERCP: Endoscopic retrograde cholangiopancreatography; PEP: Post-endoscopic retrograde cholangiopancreatography; TPS: Transpancreatic sphincterotomy; NKP: Needle knife precut.

Table 3 The incidence of adverse events in difficult cannulation cases in the elderly group after repeated guidewire-assisted cannulation, needle knife precut, and transpancreatic sphincterotomy

	Guidewire	NKP	TPS	P value1
Adverse events	n = 20	n = 21	n = 8
PEP	10% (2)	- (0)	- (0)	0.203
Overall adverse events	15% (3)	14.3% (3)	- (0)	0.129

¹Fisher’s exact test.

PEP: Post-endoscopic retrograde cholangiopancreatography; TPS: Transpancreatic sphincterotomy; NKP: Needle knife precut.

Table 4 Multivariate analysis of risk factors for adverse events considering age ≥ 80, Charlson Comorbidity Index ≥ 2, difficult cannulation, ampullary carcinoma, and needle knife precut

	Adjusted odds ratio	95% Confidence interval		P value
		Lower	Upper
Adverse events
Age ≥ 80	1.568	0.861	2.854	0.141
CCI ≥ 2	1.824	0.993	3.349	0.045
Difficult cannulation	3.478	1.877	6.442	< 0.001
Ampullary carcinoma	0.551	0.116	2.610	0.453
NKP	0.506	0.229	1.121	0.093

CCI: Charlson Comorbidity Index; NKP: Needle knife precut.

Table 5 Multivariate analysis of risk factors for post-endoscopic retrograde cholangiopancreatography considering difficult cannulation, age ≤ 65, female gender, cholangitis, and Charlson Comorbidity Index ≥ 2

	Adjusted odds ratio	95% Confidence interval		P value
		Lower	Upper
PEP
Difficult cannulation	4.527	2.078	9.860	< 0.001
Age ≤ 65 yr	3.460	1.511	7.922	0.003
Female	2.362	1.089	5.124	0.030
Cholangitis	3.261	1.204	8.832	0.020
CCI ≥ 2	2.253	0.923	5.497	0.074

PEP: Post-endoscopic retrograde cholangiopancreatography; CCI: Charlson Comorbidity Index.