Anesthesiologist Assistance in Endoscopic Retrograde Cholangiopancreatography Procedures in the Elderly: Is it Worthwhile?

Introduction

The role of endoscopic retrograde cholangiopancreatography (ERCP) procedures as mini-invasive treatment modalities has proved pivotal in the treatment of pancreato-biliary diseases during the last two decades. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy recently prepared the guidelines on sedation and anesthesia in gastrointestinal endoscopy including ERCP procedures. ¹ The guidelines specify that anesthesiologist assistance should be considered in ERCP procedures if one or more sedation-related risk factors such as extremes of age or the American Society of Anesthesiologists (ASA) score greater than III are present or if therapeutic procedures are performed. Accordingly, anesthesiologists provide sedation and analgesia of the patients in ERCP at many institutions at present, particularly in the elderly patients who are considered to be more prone to sedation-related complications. However, is using anesthesiologist assistance really worthwhile when ERCP procedures are performed in the elderly?

In the literature, there are only three studies on very old patients undergoing ERCP,^2–4 of which two surveys^3,4 face the issue from the endoscopical point of view and only one of them ² touches upon the tolerance of procedures. In none of the surveys, the presence/absence of anesthesiological assistance was reported. The purpose of the present study was to analyze the sedatives and analgesics used, the safety of sedation and analgesia, and the tolerance of procedures in the extremely elderly patients undergoing ERCP at our institution, in which sedation and analgesia are provided and controlled by endo team only.

Patients and Methods

During the years 1997–2007, a total of 3676 ERCPs were performed at our institution, Turku University Hospital, which is a 850-bed tertiary teaching hospital serving an area of 450,000 inhabitants in southwestern Finland. The number of people living in our area of responsibility is the second largest in Finland, and we serve one-tenth of all Finns. Our hospital is the only hospital in this area with ERCP facilities. All the ERCPs were performed (or supervised, one younger surgeon receiving ERCP training) by three surgeons with substantial ERCP experience for >10 years.

Of the total of 3676 ERCPs, 41 (1.1%) procedures were performed in patients aged 90 years or older [mean age, 93 years (range 90–99)]. There were six repeat procedures, and one of the patients had earlier undergone ERCP before the age of 90 years. The demographic data of the patients is shown in Table 1. All these patients had chronic concomitant diseases, and 88% of the patients belonged to ASA group IV.

Cholangiogram indicated bile duct stones or strictures in the majority of patients. Thirty-eight out of 41 patients underwent at least one endoscopical procedure and more than three quarters of the patients underwent multiple procedures. As for procedural details, we have recently published the indications, techniques, results, and complications of ERCP procedures performed at our institution.^5–7

The patients were positioned on the left side for the ERCP. All medications, including sedatives, were provided and controlled by endo team only. During the procedure, additional oxygen was given to patients, and heart rate, blood pressure, and oxygen saturation were documented. After the procedure, all patients were followed up at the endoscopy unit for 1 hour. The mean hospital stay of the patients was long, 5 days (range 1–16 days), due to the poor general condition of many of the patients.

Data on medication used for ERCP procedures, tolerance of procedures, sedation-related complications, the need of anesthesiological assistance, and procedural, and 30-day mortality were collected both from the hospital records and database and from a manual accounting book created for ERCP procedures in our endoscopy unit. Thus, every piece of ERCP data, including medication used, ERCP indication, findings and procedures, the course of the procedures, and possible complications, is written down by the endoscopist in addition to completing normal hospital records; that is, ERCP procedure records are done by double-entry bookkeeping in our unit. At our institution, anesthesiological assistance is indicated at ERCP if the general condition of the patient deteriorates during the procedure, as indicated by the decrease in oxygen saturation below 90%, decrease in systolic blood pressure below 90 mmHg, bradycardia of <40 beats per minute, or tachycardia of >130 beats per minute.

The tolerance of ERCP procedures was determined as described earlier. ² Accordingly, three levels of tolerance were defined: good (procedure performed with no difficulty), deficient (ERCP suspended before desired result attained), and poor (procedure could not be performed).

The review of the medical records and data of the patients was approved by the committee on clinical research of our hospital.

Results

Premedication, given 1 hour before ERCP, included pethidine [50 mg s.c. (25–100 mg); median (range)], atropine [0.6 mg s.c. (0.4–0.7 mg)], and cefuroxime (1.5 g i.v. infusion). The patients were given topical pharyngeal spray with 10% lidocaine. Immediately before the procedure, all patients were sedated with midazolam [3 mg i.v. (1.5–5 mg)], and 7 out of 41 patients received fentanyl [75 μg i.v. (25–150 μg)]. Duodenal relaxation was induced with glucagon [0.5 mg i.v. (0.5–1.0 mg)] in all patients, and three patients required additional hyoscine butylbromide (20 mg i.v.) during the procedure. After the procedure, 6 out of 41 patients received flumazenil [0.3 mg i.v. (0.2–0.5 mg)] for reversal of sedation.

The tolerance for ERCP procedures in the current patient population is shown in Table 2. All ERCP procedures except one could be successfully completed, indicating good tolerance in 98% of the patients. In the case with failure, due to the restlessness of the patient only pancreatogram could be achieved at the first ERCP. However, after 1 week the repeat attempt of bile duct cannulation in this patient was successful, and the ERCP procedures could be completed successfully in this case as well. In the current series of patients, there was no need for rendezvous procedures^8,9 or open surgery.

Neither sedation-related complications nor procedural mortality was encountered in the present patient population. In none of the cases, anesthesiologist assistance was needed. The 30-day mortality was 10% (four cases), all related to advanced malignancy.

Discussion

The purpose of the present study was to analyze the sedatives and analgesics used, the safety of sedation and analgesia, and the tolerance of procedures in the extremely elderly patients undergoing ERCP at our institution, in which sedation and analgesia are provided and controlled by endo team only. We found that although elderly patients are often considered to be prone to sedation-related complications, the safety of midazolam sedation and fentanyl analgesia and the tolerance of ERCP procedures are excellent also in the extremely elderly patients, even when sedation and analgesia are provided and controlled by endo team only.

All patients in the current study had chronic concomitant diseases, and 88% of the patients belonged to ASA group IV. Thirty-eight out of 41 patients underwent at least one endoscopical procedure, and more than three quarters of the patients underwent multiple procedures. These figures emphasize that we do not hesitate to perform ERCP procedures even in the very elderly patients with poor general condition. This is also indicated by the proportion of the patients aged 90 years or older of the total number of patients undergoing ERCP at our institution (1.1%), markedly exceeding the proportion of the elderly aged 90 years or older of the Finnish adult population (0.3%). In earlier studies, chronic concomitant diseases were present in 42% ² and 100% ⁴ of the very elderly patients. Mitchell et al. ³ reported that in 23 patients aged 90 years or older a median of two concurrent serious medical conditions were encountered and the patients had a median of three medications. The corresponding findings in our 41 patients were a median of three concomitant diseases and a median of four medications.

The success rate of bile duct cannulation in patients with unhindered access to the papilla was very high, 98%, in the present study involving very old patients, and after one repeat ERCP all bile ducts could be cannulated. Therefore, the high tolerance of ERCP procedures found in the present study may be associated with the substantial ERCP experience for >10 years of all ERCP endoscopists at our institution. The present success rate of bile duct cannulation in very old patients is well in accordance with the success rate of bile duct cannulation of 97% in all patients undergoing ERCP at our institution. ⁵ The needle-knife fistulotomy technique was employed in 20% of the cases in the present study, exceeding the percentage of needle-knife assisted ERCP (10%) of all ERCP cases at our institution, ⁵ suggesting that the cannulation procedure may have been more troublesome in elderly patients. In earlier studies on patients aged 90 years or older, the success rates of bile duct cannulation in patients with unhindered access to the papilla were 92%, ² 91%, ³ and 98%. ⁴ The needle-knife technique was employed in 13% of the patients in the study with 98% success rate of bile duct cannulation, ⁴ whereas the use of needle-knife was not reported in the remaining two studies with lower success rates of bile duct cannulation. In the recent large-scale prospective survey of ERCP practice in the UK, the overall deep cannulation was achieved in only 2684 of 3210 (84%) patients undergoing their first ever ERCP, supporting the view that ERCP procedures should be centralized in high-volume centers, since high success rates of bile duct cannulation can be reached only in high-volume centers in which needle-knife-assisted ERCP is a routine practice in difficult cases. ¹⁰ The total success rate of biliary cannulation was as high as 99% (497 out of 501 patients) in a recent study in which needle-knife precut papillotomy was performed in 16% of the cases. ¹¹ Thus, the tolerance of ERCP procedures and the need of anesthesiologist assistance in ERCPs definitely are associated also with the experience of the local ERCP endoscopists.

There were neither sedation-related complications nor procedural mortality in the present study. Also in earlier studies, the procedural mortality has been low, 1%, ² 0%, ³ and 0%. ⁴

To be concluded, the safety of midazolam sedation and fentanyl analgesia and the tolerance of ERCP procedures are excellent also in the extremely elderly patients, even when sedation and analgesia are provided and controlled by endo team only. We find that at least in experienced ERCP centers the routine assistance of an anesthesiologist in ERCP procedures is cost prohibitive and unnecessary, even in the extremely elderly patients.