Adverse events in older patients undergoing ERCP: a systematic review and meta-analysis

Abstract

Background and study aims: Biliary and pancreatic diseases are common in the elderly; however, few studies have addressed the occurrence of adverse events in elderly patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). Our objective was to determine the incidence rates of specific adverse events in this group and calculate incidence rate ratios (IRRs) for selected comparison groups. Patients and methods: Bibliographical searches were conducted in Medline, EMBASE, and Cochrane library databases. The studies included documented the incidence of adverse events (perforation, pancreatitis, bleeding, cholangitis, cardiopulmonary adverse events, mortality) in patients aged ≥ 65 who underwent ERCP. Pooled incidence rates were calculated for each reported adverse event and IRRs were determined for available comparison groups. A parallel analysis was performed in patients aged ≥ 80 and ≥ 90. Results: Our literature search yielded 7429 articles, of which 69 studies met our inclusion criteria. Pooled incidence rates for adverse events (per 1000 ERCPs) in patients aged ≥ 65 were as follows: perforation 3.8 (95 %CI 1.8 – 7.0), pancreatitis 13.1 (95 %CI 11.0 – 15.5), bleeding 7.7 (95 %CI 5.7 – 10.1), cholangitis 16.1 (95 %CI 11.7 – 21.7), cardiopulmonary events 3.7 (95 %CI 1.5 – 7.6), and death 7.1 (95 %CI 5.2 – 9.4). Patients ≥ 65 had lower rates of pancreatitis (IRR 0.3, 95 %CI 0.3 – 0.4) compared with younger patients. Octogenarians had higher rates of death (IRR 2.4, 95 %CI 1.3 – 4.5) compared with younger patients, whereas nonagenarians had increased rates of bleeding (IRR 2.4, 95 %CI 1.1 – 5.2), cardiopulmonary events (IRR 3.7, 95 %CI 1.0 – 13.9), and death (IRR 3.8, 95 %CI 1.0 – 14.4). Conclusions ERCP appears to be safe in elderly patients, except in the very elderly who are at higher risk of some adverse events. These data on adverse event rates can help to inform clinical decision-making, the consent process, and comparative effectiveness analyses.

Managing Risks Related to ERCP in Elderly Patients with Difficult Bile Duct Stones

“…The lower bleeding rate in elderly patients compared with that reported by Day et al [3] may be related to the reduced ES size and the more homogeneous comparative groups in this study (both groups had similar stone characteristics). The absence of cardiopulmonary events may be explained by the lower need for mechanical lithotripsy [8,9] and the reduced mean procedure time [10] required for EPLBD.…”

“…A recent systematic review [3] reported adverse events in older patients undergoing ERCP, concluding that the incidence and risk of developing specific adverse events vary by age. Elderly patients more frequently have morbid underlying diseases, periampullary diverticula, and large multiple common bile duct stones, all of which increase procedure complexity and risk.…”

“…Elderly patients more frequently have morbid underlying diseases, periampullary diverticula, and large multiple common bile duct stones, all of which increase procedure complexity and risk. While most studies describe post-ERCP pancreatitis as the most frequent adverse event after ES, Day et al [3] report that patients aged[65 were 70 % less likely to have an episode of post-ERCP pancreatitis compared with younger patients. Yet, bleeding and cardiopulmonary events dominated, with a twofold increase in mortality in octogenarians and nearly a fourfold increase in nonagenarians.…”

ERCP in elderly patients: increased risk of sedation adverse events but low frequency of post-ERCP pancreatitis

“…Furthermore, the risk seems to decrease with age, confirming the findings of others. 7,12,21,[23][24][25][26] The pathophysiology behind that observance remains unclear. One explanation could be reduced levels of pancreatic enzyme secretion or more advanced atrophy of the pancreas in older patients.…”

“…20,21,30,[36][37][38] Post-ERCP pancreatitis was defined as the onset of typical abdominal pain with an at least 3-fold elevation of serum lipase levels within 48 hours after the procedure. Perforation was defined as retroperitoneal or bowel-wall perforation identified during the procedure macroscopically or by radiologic imaging after the procedure.…”