Endoscopic retrograde cholangiopancreatography in Ayrshire,Scotland: a comparison of two age cohorts

Abstract

Background and aims

There is an increased trend in prevalence of pancreato-biliary disease in the elderly population. Consequently there is an increasing demand for endoscopic retrograde cholangiopancreatography (ERCP). The aims of this study were to compare ERCP outcomes in patients over 80 with those aged between 60 and 79 years and with the published literature.

Methods and results

Data were collected from a prospectively maintained database. All patients over the age of 60 years who underwent ERCP from May 2010 to May 2012 were identified. Two cohorts were formed, group A: 60–79 years (n = 66) and group B: > 80 years old (n = 49). Data on indications for ERCP, outcome, complications and repeat procedures were collected. One hundred and fifteen patients between the age of 60 and 92 years were identified. Group A had a total of 89 ERCPs and group B 69. Cannulation, overall procedure success, complication and mortality rates were comparable between both groups. Group B contained two cases of perforation with one associated mortality (1.4%) which did not reach statistical significance.

Conclusions

ERCP in octogenarians is safe and effective when compared to patients aged 60–79.

Keywords

Endoscopic retrograde pancreatography (ERCP)octogenarians elderly pancreatitis gallstones

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is an established therapeutic procedure often employed in the management of biliary tract diseases. Since its introduction as a diagnostic test over 40 years, it has matured to a predominantly therapeutic procedure.^1,2 As in the case of other minimally invasive techniques, improved operator expertise has reduced morbidity and mortality whilst availability has expanded.³

Biliary tract pathology has a higher incidence in the elderly. This ranges from benign conditions such as choledocholithiasis to malignancy.^4,5 A reflection of this is the larger number of elderly patients attending health services with a first presentation of biliary disease and/or its complications.⁶ The incidence and severity of co-morbidities in the elderly increases the morbidity and mortality from invasive interventional procedures. With the ever increasing rise in life expectancy it is important that the safety and feasibility of ERCP particularly in the elderly population are established.

Previous studies have shown that ERCP is well tolerated in octogenarians and is associated with low morbidity from post-ERCP pancreatitis as well as other procedural complications.^7–12 However, published data are limited and outcomes are often compared with significantly younger age groups.

The primary aim of this study was to compare the outcomes of ERCP in patients over 80 with those aged between 60 and 79 years. The secondary aim was to make comparisons between outcomes in Ayrshire, Scotland and the published literature.

Methods

A prospectively maintained electronic database was reviewed to identify all patients over the age of 60 who had an ERCP at our institution (University Hospital Ayr) between May 2010 and May 2012. This NHS trust serves a mixed rural/urban population of approximately 370,000.¹³ A regular ERCP service is provided at both university hospitals in the region, University Hospital Ayr and University Hospital Crosshouse.

The patients included in the analysis were divided into two age groups; group A: 60–79 years old and group B: ≥ 80 years. Demographic details, indication for ERCP, hepatobiliary radiology reports, pre- and post-procedure blood tests were recorded. The database was then used to retrieve the procedure details including: routine / urgent procedure, pre-medications, bile duct cannulation, findings, therapeutic or diagnostic intervention, outcome and immediate complications. Procedural complications were recorded and categorised as follows: minor bleeding (settled spontaneously, controlled endoscopically at the time of ERCP), major bleeding (requiring further procedure / operation or blood transfusion), pancreatitis and perforation. Mortalities associated with ERCP were noted.

Non-emergency cases were admitted to hospital for a minimum of 24 h. An ERCP scope (Olympus, USA) was used in all procedures. Endoscopic sphincterotomy was performed to facilitate cannulation or stone retrieval. The number of attempts made at cannulating the common bile duct (CBD) varied between individual operators with the procedure being abandoned if 10 attempts had failed. Stone retrieval was performed using a balloon catheter or a basket. A 7 cm biliary stent (Boston Scientific, USA, 7-8 Fr) was placed in cases where a definitive relief of obstruction could not be achieved (partial stone removal, tumours).

Coagulation profile was checked and corrected in all patients before procedure. Continuous monitoring of oxygen saturation, blood pressure and heart rate was maintained throughout. All patients received midazolam 3–5 mg, pethidine 25–50 mg and a single dose of gentamicin titrated to their renal function.

Amylase levels were measured 24 h post procedure in all patients. This was considered significant if it was three times greater than the upper limit of normal.¹⁴ For the purposes of this study, transient hyperamylasemia and pancreatitis were used as interchangeable terms, since abdominal examination had not been captured in the database.

Failure of the procedure was categorised into two groups: inability to cannulate the papilla and anatomical variations (e.g. post upper gastrointestinal surgery).

The primary outcomes of this study were: success of the procedure, cannulation rate and complications. Secondary outcomes were indications of ERCP and causes of repeat ERCP in the two groups.

Data were tabulated on a Microsoft® Excel spreadsheet (Excel for Windows®; Microsoft Corporation, Redmond, Washington, USA). Calculation of statistical significance, confidence intervals and tests of heterogeneity across estimates from previous published studies in a meta-analytic framework were performed in Stata/SE 11.0.

Results

We identified 115 patients over the age of 60 who had a total of 158 ERCPs over the two year period (Table 1). There were 49 octogenarians (15 men and 33 women) and 66 non-octogenarians (24 men and 42 women) undergoing 69 and 89 procedures, respectively. The mean age in the octogenarian group was 84.3 years (SD = 3.65, range 80–92 years) and 70.8 years (SD = 5.81, range 60–79 years) in the non-octogenarian group. Six patients (12.2%) were over 90 years old. The procedures were performed by three consultant surgeons at University Hospital Ayr.

Table 1.

Group details.

	<80	≥80
Number of patients	66	49
Age range (years)	60–79	80–92
Mean age (years)	70.80	84.33
Median age (years)	70	84
Male:Female	24:42	15:33
Total number of ERCPs	89	69
Urgent:Routine ERCPs	33:56	27:42
Number ERCPs male:female	29:60	23:46
Successful CBD cannulation	81	64
Overall procedure success	68	58

Procedure indications, as recorded on an electronic endoscopy reporting tool (Unisoft Medical Systems, Middlesex, UK) are summarised in Table 2. In some cases multiple indications were recorded (e.g. CBD stones and acute pancreatitis). The most common indication in both groups was pre-procedure radiological confirmation of extrahepatic bile duct stone.

Table 2.

Indications for ERCP on endoscopy reporting tool.^a

	<80	≥80
	N	N
Jaundice with no cause identified	0	3
Acute pancreatitis	1	5
Cholangitis	3	4
Blocked biliary stent	5	5
CBD stricture	15	3
Dilated bile ducts (intra or extra hepatic)	17	9
Extrahepatic bile duct stone	49	44

Some patients had more than one indication.

In both groups the most common endoscopic finding was presence of CBD stones (35 and 32). Stones were successfully removed in 51.4% of cases in the younger group and 46.9% in the over 80s. Stent insertion for incomplete stone extractions was required in 14 (40%) procedures in the younger group and 8 (25%) in the octogenarians. Table 3 summarises the findings at ERCP as recorded on the endoscopy reporting tool.

Table 3.

Findings and further procedures performed during ERCP.

Group A (<80)				Group B (≥80)
Findings	n=	Procedure	n=	Findings	n=	Procedure	n=
CBD stones	35	Removed	18	CBD stones	32	Removed	15
		Partial extraction & stent insertion	14			Partial extraction & stent insertion	8
		No extraction & stent insertion	3			No extraction & stent insertion	9
CBD stricture	17	Biopsy & stent	10	CBD stricture	6	Biopsy & stent	3
		Biopsy & further work-up	7			Biopsy & further work-up	2
		Referred for PTC	0			Referred for PTC	1
Blocked stent	6	Stent replaced	5	Blocked stent	5	Stent replaced	4
Blocked stent	6	Stent & stones removed	1	Blocked stent	5	Stent & stones removed	1
Failed ERCP	13	Difficult anatomy	7	Failed ERCP	8	Difficult anatomy	2
Failed ERCP	13	Failed cannulation	6	•	8	Failed cannulation	6
Normal ERCP	9	No further intervention	9	Normal ERCP	9	No further intervention	9
Dilated CBD, no obvious cause	3	No further intervention	3	Dilated CBD, no obvious cause	2	No further intervention	2
Pus in the CBD	0	N/A	0	Pus in the CBD	2	No intervention, no stones seen	2
Post cholecystectomy bile leak	1	No leak, CBD stone removed	1	Post cholecystectomy bile leak	0	N/A	0

The rate for successful CBD cannulation was high in both groups, 93% in the non-octogenarian group and 91% in the octogenarian group; Pearson χ² p value = 0.69. Overall procedure success, defined as reaching a pre-procedure goal, was 76.4% in the control group and 84.1% in the over 80s; Pearson χ² p value = 0.24.

The most common complication in both groups was post-ERCP pancreatitis (12.4% vs. 8.7% in octogenarians; Pearson χ² p value = 0.46). The overall complication rate was 14.61% in non-octogenarians versus 15.94% in octogenarians; p value = 0.92. There were two cases of perforation in the octogenarian group (one gastric and one pharyngeal) and one mortality (1.4%) as a consequence. The younger cohort contained one case of minor bleeding and one case of major bleeding that required surgical intervention. There were two cases of minor bleeding in the older cohort. None of the observed differences between the two groups were statistically significant with respect to each type of complication. A summary of all complications is given in Table 4.

Table 4.

Complications.

	<80	≥80
Acute pancreatitis	11	6
Minor bleeding	1	2
Major bleeding	1	0
Gastric perforation	0	1
Pharyngeal pouch perforation	0	1
ERCP related mortality	0	1
Total number	13	11
Frequency of total procedures	14.61%	15.94%
95% CI binomial exact	(8.01%, 23.7%)	(8.14%, 26.74%)

The rate of repeat procedures was 27.3 per 100 patients (18 of 66) in the younger group and 22.4 per 100 patients (11 of 49) in the older group (risk ratio 1.21; 95% confidence intervals: 0.54, 2.85). The reasons for repeated ERCP procedures are shown in Table 5.

Table 5.

Causes of repeat ERCP.

	<80	≥80
Partial CBD stone extraction	7	6
Stent replacement	6	10
Unsuccessful ERCP	6	3
MRCP mis-reported CBD stones	2	1
Deranged LFTs despite normal imaging	1	0
Possible malignancy	0	1
Post cholecystectomy CBD stone extraction	1	0

Discussion

The precise meaning of an older or elderly patient is a contentious subject. Chronological definitions vary between continents, countries and international institutions.¹⁵ Furthermore, the definition has changed over time and will likely continue to change as average human life expectancy continues to rise.¹⁶ As a result, studies categorising patients into elderly for statistical and research purposes can be quite heterogeneous making direct comparisons difficult.

We chose to categorise our patients into two age groups: 60–79 and ≥80 years. In an effort to promote international compatibility, the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD10) has recommended a general purpose age classification, where 80 years of age is not a group boundary.¹⁷ Despite this, in our study we used a cut off at 80 years to facilitate comparisons with other studies, as most of the published literature on ERCPs uses this milestone (see Table 6). However, the same literature uses an even more heterogeneous age range for the control group with some studies including all patients under 79. We used 60–79 years in an attempt to make direct comparisons with a closer age group.

Table 6.

Summary of recent literature comparing ERCP outcomes in patients of different age groups.

Study	This study 2013	Mohammad et al.²⁰	Han et al.²¹	Ali et al.⁷	Obana et al.²²	Talar et al.²³	Aftab et al.¹¹	Lukens et al.⁹	Riphaus et al.²⁴	Christoforidis et al.¹⁹	García-Cano et al.¹⁸	Fritz et al.¹²
Country	Scotland	Iran	Korea	Canada	Japan	Poland	Ireland	USA	Germany	Greece	Spain	Austria	Inverse variance pooled RR (95%CI) older vs. younger	p value of test for heterogeneity I² (% attributable to heterogeneity)
Ages	≥80 60–79	≥70 <70	>90 65–89	>80 16–79	>80 <80	>80 16–79	>80 <55	>80 4–79	>80 17–80	>90 75–89	>75 <75	>80 <80
No of Procedures	69 89	222 558	43 129	102 391	164 260	96 725	485 391	728 3195	195 1765	33 272	178 159	133 591
Cannulation Rate	91% 93%	81.9% 89.0%	86% 91%	96.1% 95.1%	99.2% 99.5%	N/A N/A	91.8% 92.5%	N/A N/A	N/A N/A	N/A N/A	N/A N/A	88% 86%	0.99 (0.94, 1.05)	p = 0.998 I² = 0.0%
Total Success Rate	84.1% 76.4%	N/A N/A	N/A N/A	N/A N/A	92.4% 99%	N/A N/A	N/A N/A	96.6% 98.3%	N/A N/A	24.2%^a 90.8%	97.7% 98.7%	88% 86%	0.99 (0.94,1.04)	p = 0.158 I² = 37.3%
Normal ERCP	13.0% 10.1%	5.0% 13.4%	N/A N/A	N/A N/A	N/A N/A	N/A N/A	7.8% 25.9%	N/A N/A	N/A N/A	N/A N/A	N/A N/A	N/A N/A	0.42 (0.31, 0.56)	P = 0.03 I² = 71.3%
Total Complications	8.6% 12.3%	2.3% 4.8%	12% 22%	0.98% 5.9%	5.5% 6.6%	4.2% 6.2%	1.6% 2.0%	1.65% 3.45%	6.3% 8.4%	12% 7%	11.8% 14.4%	6.8% 5.1%	0.75 (0.60,0.94)	p = 0.513 I² = 0.0%
Pancreatitis	6.7% 12.3%	1.5% 3.6%	0 10%	0.98% 4.9%	N/A N/A	2.1% 4.4%	0.002% 0	0.14% 1.16%	4.2% 4.1%	3% 1.5%	4.7% 4.8%	2.3% 2.5%	0.67 (0.45, 0.98)	p = 0.394 I² = 5.1%
Mortality	1 (1.4%) 0	0 0	1 (2.3%) 0	0 1 (0.2%)	N/A N/A	0 0	0 0	1 (0.13%) 0	N/A N/A	0 1 (0.3%)	2 (1.1%) 1 (0.6%)	1 (1.03%) 1 (0.25%)

Notes: The upper row in each column shows results in older patient group and lower row shows results in younger age patients,

unlike other studies, Christoforidis et al. defined procedure success as complete bile duct clearance of stones.

We have shown that within the two studied groups, indications for ERCP were grossly similar: CBD stones being the most common indication. Cannulation rates were not statistically different between the two age groups. Similarly, there was no statistical difference in success of overall procedure or complication rates.

The results of this study were also compared to the published international literature. A PubMed literature search identified 11 similar studies for suitable comparison. These provided a sample from both developed and developing countries.

Overall procedure success rates were difficult to compare between studies, due to varying definitions of the term. For example, some studies defined this as complete biliary drainage¹⁸ others as complete CBD stone extraction.¹⁹ In order to provide an indicative comparison across studies, a pooled risk ratio was calculated using a meta-analytic approach for each study outcome (with the exception of mortality where numbers were too low). The pooled estimate across studies was not the main objective, it was employed to provide an estimate of the degree of heterogeneity across studies. All study outcomes, with the exception of a normal ERCP, showed no evidence of heterogeneity (see Table 6).

Conclusion

In summary, our study provides further evidence that ERCP is a well tolerated procedure in octogenarians with similar success rates to the younger population. Complication rates are comparable between groups with no significant difference. Furthermore, these figures suggest that procedure outcomes in Ayrshire, Scotland are similar to similar studies reported in the published literature.

Footnotes

Author contributions

SP manuscript drafting, data analysis, NM data analysis, LIS manuscript drafting, MAK concept, data collection, critical review, AM concept, data collection, AA concept, critical review, oversee project. All authors revised and approved the final manuscript.

Declaration of conflicting interests

None declared.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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