Clin Endosc > Volume 51(4); 2018 > Article
Lee and Kim: Age is Important, but Patient Status is also Important in Endoscopic Retrograde Cholangiopancreatography
See “Endoscopic Retrograde Cholangiopancreatography in Nonagenarian Patients: Is It Really Safe?” by Zain A Sobani, Daria Yunina, Anna Abbasi, et al., on page 375-380.
According to a recent study by the World Health Organization, projections by the United Nations Department of Economic and Social Affairs predict that the total world population aged >100 years will increase from 310,000 in 2011 to 3,200,000 in 2050. With the aging society, the incidence of pancreatobiliary disease and cases of endoscopic retrograde cholangiopancreatography (ERCP) in elderly patients increased [1]. With development of radiological technology, the role of ERCP has consistently been increasing, not only in pathological confirmation, but also for therapeutic purposes such as the resolution of obstructive jaundice [2]. ERCP is merely “less invasive” than surgery, but is not a “noninvasive” procedure. Therefore, precautions must be taken against ERCP-related complications, and more caution is required for elderly patients in whom complications can have more dangerous and severe consequences [3].
In this regard, many studies have evaluated whether ERCP in elderly patients is safe [4-6]. Recently, Sobani et al. published a study on the safety of ERCP in 74 patients aged ≥90 years [7]. In this study, unlike previous studies, the control group included a large number of patients aged <90 years. Moreover, this study reported that age of >90 years alone does not determine the safety or risk of ERCP but rather indicates that the risk may vary according to the patient’s comorbidity assessed with the Charlson Comorbidity Index (CCI). In other words, the investigators of this study hypothesized that in patients aged >90 years, higher CCI is associated with increased risk of ERCP-related complications and mortality. After its proposal in 1987 by Charlson et al., CCI has been widely used as a predictive marker of mortality in various diseases [8-10].
However, most studies analyzed the relationship between comorbidity and prognosis by categorizing CCI according to points (i.e., 0 points, 1 or 2 points, and ≥3 points) [11,12]. Unlike previous studies, Sobani et al. analyzed whether the risk of ERCP-related complication increases with a CCI of ≥2 points as compared with 0 or 1 point, but did not clearly indicate the reason behind choosing 2 points as the reference value [7]. For example, if a patient aged >90 years has uncomplicated diabetes and mild fatty liver, his or her CCI score will be 2 points, and the two comorbidities are not considered to pose a high risk of ERCP-related complication even if they coexist. Therefore, different results may be obtained if investigators base their analyses on more finely divided subcategories of CCI.
Periampullary diverticulum is known to increase in size and frequency with old age [13]. In addition, selective cannulation during ERCP is known to be difficult despite the increased incidence of bile duct stone and cholangitis due to diverticulum [14]. This study also found that the frequency of periampullary diverticulum was higher in patients aged >90 years. However, the fact that the average procedure time was similar between the two groups was not mentioned in the study. As some reports stated no significant difference in the success rate of ERCP as long as it is performed by a skilled operator [15], the success rate or duration of the procedure may not be significantly different regardless of the presence of periampullary diverticulum, on the basis of the procedural expertise of the investigators, including the authors. However, to remove doubt, the proportion of ERCP performed on a naive major papilla must be indicated. In old age, recurrent common bile duct stone or cholangitis is more likely, and endoscopic sphincterotomy would be required more often, which would make subsequent cannulation for ERCP easier and reduce the duration of the procedure. Therefore, the history of ERCP must be investigated to clarify the causality that underlies the fact that the duration of the procedure is similar in patients aged >90 years despite the more frequently observed periampullary diverticulum.
In addition, the results of the multivariate analysis showed that patients with accompanying cholangitis had a lower risk of adverse events after ERCP. However, this result is controversial, as no literature review has been conducted on the reasoning behind such a conclusion. The increased all-cause mortality after ERCP in patients aged >90 years is similar to the results of previous studies [16,17]. The interpretation of this result requires caution because patient comorbidity, rather than ERCP itself, is closely associated with mortality.
Furthermore, the risk of septic shock with acute cholangitis is higher in older patients owing to their poor general condition. Therefore, the proportions of patients aged 90 years who presented with cholangitis and progressed to septic shock, underwent ERCP after resuscitation, and converted to percutaneous biliary drainage instead of ERCP because of failed response to resuscitation must be investigated. This is because the patients included in this study may have been in good enough general condition to undergo ERCP despite their age.
With the aging society, ERCP in elderly patients will increase in proportion, and these patients are likely to have at least one comorbidity. Therefore, this study is meaningful in that it identified patient comorbidities and predicted the risk of adverse events after ERCP. However, as all-cause mortality in elderly patients can increase after ERCP, it is important to remember that not only the treatment of diseases that require ERCP, such as biliary stone disease or cholangitis, but also the management of comorbidities is important for improving patient prognosis.

NOTES

Conflicts of Interest:The authors have no financial conflicts of interest.

REFERENCES

1. Harness JK, Strodel WE, Talsma SE. Symptomatic biliary tract disease in the elderly patient. Am Surg 1986;52:442–445.
pmid
2. Farrell RJ, Mahmud N, Noonan N, Kelleher D, Keeling PW. Diagnostic and therapeutic ERCP: a large single centre’s experience. Ir J Med Sci 2001;170:176–180.
crossref pmid pdf
3. Yun DY, Han J, Oh JS, Park KW, Shin IH, Kim HG. Is endoscopic retrograde cholangiopancreatography safe in patients 90 years of age and older? Gut Liver 2014;8:552–556.
crossref pmid pmc pdf
4. Sugiyama M, Atomi Y. Endoscopic sphincterotomy for bile duct stones in patients 90 years of age and older. Gastrointest Endosc 2000;52:187–191.
crossref pmid
5. Katsinelos P, Paroutoglou G, Kountouras J, Zavos C, Beltsis A, Tzovaras G. Efficacy and safety of therapeutic ERCP in patients 90 years of age and older. Gastrointest Endosc 2006;63:417–423.
crossref pmid
6. Hu L, Sun X, Hao J, et al. Long-term follow-up of therapeutic ERCP in 78 patients aged 90 years or older. Sci Rep 2014;4:4918.
crossref pmid pmc pdf
7. Sobani ZA, Yunina D, Abbasi A, et al. Endoscopic retrograde cholangiopancreatography in nonagenarian patients: is it really safe? Clin Endosc 2018;51:375–380.
crossref pmid pmc pdf
8. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373–383.
crossref pmid
9. Sarfati D, Tan L, Blakely T, Pearce N. Comorbidity among patients with colon cancer in New Zealand. N Z Med J 2011;124:76–88.

10. Mnatzaganian G, Ryan P, Norman PE, Hiller JE. Accuracy of hospital morbidity data and the performance of comorbidity scores as predictors of mortality. J Clin Epidemiol 2012;65:107–115.
crossref pmid
11. West DW, Satariano WA, Ragland DR, Hiatt RA. Comorbidity and breast cancer survival: a comparison between black and white women. Ann Epidemiol 1996;6:413–419.
crossref pmid
12. de Groot V, Beckerman H, Lankhorst GJ, Bouter LM. How to measure comorbidity: a critical review of available methods. J Clin Epidemiol 2003;56:221–229.
crossref pmid
13. Chen YY, Yen HH, Soon MS. Impact of endoscopy in the management of duodenal diverticular bleeding: experience of a single medical center and a review of recent literature. Gastrointest Endosc 2007;66:831–835.
crossref pmid
14. Afridi SA, Fichtenbaum CJ, Taubin H. Review of duodenal diverticula. Am J Gastroenterol 1991;86:935–938.
pmid
15. Boix J, Lorenzo-Zúñig V, Añaños F, Domènech E, Morillas RM, Gassull MA. Impact of periampullary duodenal diverticula at endoscopic retrograde cholangiopancreatography: a proposed classification of periampullary duodenal diverticula. Surg Laparosc Endosc Percutan Tech 2006;16:208–211.
crossref pmid
16. Grönroos JM, Salminen P, Laine S, Gullichsen R. Feasibility of ERCP procedures in patients 90 years of age and older. J Clin Gastroenterol 2010;44:227–228.
crossref pmid
17. Mitchell RM, O’Connor F, Dickey W. Endoscopic retrograde cholangiopancreatography is safe and effective in patients 90 years of age and older. J Clin Gastroenterol 2003;36:72–74.
crossref pmid
TOOLS
PDF Links  PDF Links
PubReader  PubReader
ePub Link  ePub Link
XML Download  XML Download
Full text via DOI  Full text via DOI
Download Citation  Download Citation
  Print
Share:      
METRICS
1
Web of Science
2
Crossref
1
Scopus
4,545
View
90
Download
Related articles
Black esophagus: a life-threatening adverse event associated with endoscopic retrograde cholangiopancreatography  
Preventive effect of tacrolimus on patients with post-endoscopic retrograde cholangiopancreatography pancreatitis  2022 September;55(5)
An unwonted complication of endoscopic retrograde cholangiopancreatography  2022 May;55(3)
Portal cavernography during endoscopic retrograde cholangiopancreatography: from bilhemia to hemobilia  2023 July;56(4)
Factors Predicting Difficult Biliary Cannulation during Endoscopic Retrograde Cholangiopancreatography for Common Bile Duct Stones  2022 March;55(2)
Editorial Office
Korean Society of Gastrointestinal Endoscopy
#817, 156 Yanghwa-ro (LG Palace, Donggyo-dong), Mapo-gu, Seoul, 04050, Korea
TEL: +82-2-335-1552   FAX: +82-2-335-2690    E-mail: CE@gie.or.kr
Copyright © Korean Society of Gastrointestinal Endoscopy.                 Developed in M2PI
Close layer