Retrospective Cohort Study
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Apr 16, 2022; 14(4): 215-225
Published online Apr 16, 2022. doi: 10.4253/wjge.v14.i4.215
Endoscopic retrograde cholangiopancreatography for bile duct stones in patients with a performance status score of 3 or 4
Hirokazu Saito, Yoshihiro Kadono, Takashi Shono, Kentaro Kamikawa, Atsushi Urata, Jiro Nasu, Haruo Imamura, Ikuo Matsushita, Tatsuyuki Kakuma, Shuji Tada
Hirokazu Saito, Shuji Tada, Department of Gastroenterology, Kumamoto City Hospital, Kumamoto City 862-8505, Japan
Yoshihiro Kadono, Department of Gastroenterology, Tsuruta Hospital, Kumamoto City 862-0925, Japan
Takashi Shono, Ikuo Matsushita, Department of Gastroenterology, Kumamoto Chuo Hospital, Kumamoto City 862-0965, Japan
Kentaro Kamikawa, Atsushi Urata, Haruo Imamura, Department of Gastroenterology, Saiseikai Kumamoto Hospital, Kumamoto City 861-4193, Japan
Jiro Nasu, Department of Gastroenterological Surgery, Kumamoto Chuo Hospital, Kumamoto City 862-0965, Japan
Tatsuyuki Kakuma, Department of Biostatics, Kurume University, Kurume City 8300011, Japan
Author contributions: Saito H, Kadono Y, Shono T, Kamikawa K, Urata A, Nasu J, Imamura H, Matsushita I, and Tada S have been equally involved and have read and approved the final manuscript; Saito H, Kadono Y, Shono T, Kamikawa K, Urata A, Nasu J, Imamura H, Matsushita I, and Tada S meet the criteria for authorship established by the International Committee of Medical Journal Editors and verify the validity of the reported results.
Institutional review board statement: The institutional review boards of the participating institutions approved this study.
Informed consent statement: All study participants or their legal guardian provided informed written consent about personal and medical data collection prior to study enrolment.
Conflict-of-interest statement: The authors declare that there are no conflicts of interest in relation to this article.
Data sharing statement: No additional data are available.
STROBE statement: All the authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Hirokazu Saito, MD, Doctor, Department of Gastroenterology, Kumamoto City Hospital, 4-1-60, Higashimachi, Higashi-ku, Kumamoto City 862-8505, Japan. arnestwest@yahoo.co.jp
Received: November 17, 2021
Peer-review started: November 17, 2021
First decision: January 12, 2022
Revised: January 22, 2022
Accepted: March 16, 2022
Article in press: March 16, 2022
Published online: April 16, 2022
ARTICLE HIGHLIGHTS
Research background

In parallel with the growing aging population worldwide, endoscopic retrograde cholangiopancreatography (ERCP) is being increasingly used in the treatment of common bile duct stones (CBDS) in patients with a poor performance status (PS). Therefore, determining the safety and efficacy of ERCP for CBDS in patients with a PS score of 3 or 4 is essential.

Research motivation

PS is an important tool to elucidate the indications and strategies of ERCP for CBDS in elderly patients. However, few studies examined the safety and efficacy of ERCP for CBDS in patients with a poor PS.

Research objectives

To examine the safety and efficacy of ERCP for CBDS in patients with poor PS, which is defined as a PS score of 3 or 4.

Research methods

We reviewed the medical records of three institutions in Japan from April 2012 to February 2020. The exclusion criteria were (1) failure to detect CBDS during ERCP; (2) history of therapeutic ERCP; and (3) and an already surgically altered gastrointestinal tract including Billroth II or Roux-en-Y reconstruction. Finally, we identified 1343 patients with choledocholithiasis who met the inclusion criteria for the study, and 1113 and 230 patients had PS scores of 0-2 and 3 or 4, respectively. One-to-one propensity score matching was performed to compare the safety and efficacy of ERCP for CBDS between patients with PS scores of 0-2 and 3 or 4.

Research results

The overall ERCP-related complication rates in all patients with PS scores of 0-2 and 3 or 4 were 9.0% (100/1113) and 7.0% (16/230; P = 0.37), respectively. In the propensity score-matched group, the overall ERCP-related complication rates were 4.6% (9/196) and 6.6% (13/196; P = 0.51) among patients with PS scores of 0-2 and PS 3-4, respectively, and complications were significantly more severe in the group with a PS score of 3-4 than in the groups with a PS score of 0-2 (P = 0.042). In multivariate analysis, risk factors for ERCP-related complications were indication of ERCP and absence of antibiotics (P < 0.001 and P = 0.034, respectively). Particularly, absence of acute cholangitis including asymptomatic CBDS, was associated with increased risk of ERCP-related complications. Therapeutic success rates, including complete CBDS removal and permanent biliary stent placement, in propensity score-matched patients with PS scores of 0-2 and 3 or 4 were 97.4% (191/196) and 97.4% (191/196), respectively (P = 1.0).

Research conclusions

ERCP for CBDS can be performed effectively in patients with a PS score of 3 or 4. The rates of ERCP-related complications were similar between the patients with PS scores of 0-2 and 3 or 4; however, their severity was higher in the group with a PS score of 3 or 4 than in the group with a PS score of 0-2. The indication of ERCP for CBDS, particularly in patients with asymptomatic CBDS, requires careful consideration, and antibiotics should be administrated before ERCP in patients with a PS score of 3 or 4.

Research perspectives

The retrospective study design that included specialized centers in Japan was an important limitation of this study. Future multicenter studies including large patient cohorts from institutions with different ERCP experiences are warranted to confirm our findings.