Introduction
The increase in life expectancy has led to a more frequent performance of invasive procedures in older patients, including endoscopic retrograde cholangiopancreatography (ERCP). Elderly patients often present with multiple comorbidities and technical challenges, which may lead to the rejection of the procedure due to concerns about morbidity and mortality, as well as the potential futility of treatment. Few series address the safety and efficacy of ERCP in patients aged ≥95 years.
Aims & Methods
To compare the clinical characteristics, techniques, complications, and short- and long-term outcomes of super-elderly (≥95 years) and elderly (65-70 years) patients undergoing ERCP at La Paz University Hospital. A retrospective study was conducted, including all ERCP performed in super-elderly patients between 2018 and 2024. For the elderly group, an equal number of procedures performed during the same period were randomly selected and matched by sex. Data on demographics, comorbidities, indications, technical characteristics, complications, technical success rates and mortality at 30 days, 6 months and 12 months were collected and compared.
Results
A total of 92 procedures were included in each group, with 78.3% women in both groups. Super-elderly patients had a higher frequency of comorbidities, such as hypertension, heart failure, atrial fibrillation, chronic kidney disease and dementia (p<0.01). In terms of frailty, they had a significantly lower Barthel index compared to the elderly (p<0.001). ERCP indications were predominantly urgent in the super-elderly (cholangitis and biliary colic), while the elderly had a higher proportion of elective procedures such as planned choledocholithiasis and tumor-related causes (p<0.01). Most procedures in the super-elderly were performed in a hospital setting, while in the elderly, outpatient procedures predominated (p<0.001). Although no differences were observed in average hospital stay (p=0.59), the elderly had a higher proportion of procedures with 24-hour observation (p<0.001). In terms of techniques performed, the elderly group underwent more complex procedures such as cholangioscopy and radiofrequency ablation than the super-elderly. Technical success and procedure completion rates were similar (95.65% in the elderly and 96.74% in the super-elderly, p>0.05). Globally, immediate complications were slightly more frequent in the super-elderly (32.6%), although without significant differences compared to the elderly (25%, p=0.33); similarly for late complications. Regarding technique-related complications, despite the rates being comparable, the types of complications varied between the groups. In the elderly, mild pancreatitis predominated, whereas the super-elderly experienced a broader range of complications, including moderate pancreatitis, severe cholangitis and perforations, with a tendency towards greater severity, suggesting higher fragility in this group. Despite this, no statistically significant differences were observed in short- or long-term mortality. In the elderly, most deaths at 6 and 12 months were due to biliary causes (77.8% and 70%, respectively), primarily due to tumor-related processes. In the super-elderly, only 26.3% of deaths at 6 months and none at 12 months were due to biliary causes, reflecting the influence of additional comorbidities in this group.
| Characteristics | 65-70 years | ≥95 years
| p-value |
|---|
Barthel index score 100 (%) | 97.83 | 6.52 | <0.001 |
Cholangitis indication (%) | 16.3 | 46.7 | <0.001 |
Outpatient procedure setting (%) | 35.87 | 10.87 | <0.001 |
One-day hospitalization (%) | 27.17 | 5.43 | <0.001 |
Post-ERCP bleeding (%) | 2.17 | 3.26 | 1 |
Post-ERCP perforation (%) | 0 | 2.17 | 0.49 |
Post-ERCP pancreatitis (%) | 8.69 | 7.61 | 11 |
Post-ERCP cholangitis (%) | 3.26 | 2.17 | 1 |
Survival rate at 30 days; 6 months; 12 months (%) | 94.56; 89.41; 85.51 | 92.39; 79.35; 71.74 | 0.76; 0.79; 0.25 |
Conclusion
Although super-elderly patients have a higher burden of comorbidities and frailty, the technical success and procedure completion rates are similar to those of 65-70-years-old. The indications and therapeutic approaches vary significantly between the two groups, with a higher proportion of urgent procedures in the super-elderly and a greater frequency of advanced techniques in the elderly. Despite differences in clinical characteristics, no significant differences in short- and long-term mortality were observed, suggesting that ERCP is safe and effective in both age groups, highlighting the importance of not rejecting the indication solely due to advanced age.
References
Dumonceau JM, Kapral C, Aabakken L, Papanikolaou IS, Tringali A, Vanbiervliet G, Beyna T, Dinis-Ribeiro M, Hritz I, Mariani A, Paspatis G, Radaelli F, Lakhtakia S, Veitch AM, van Hooft JE. ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2020 Feb;52(2):127-149. doi: 10.1055/a-1075-4080. Epub 2019 Dec 20. PMID: 31863440.
