Is endoscopic retrograde cholangiopancreatography safe for centenarians?

Abstract

This letter aims to discuss the article, published in the recent issue of the World Journal of Gastrointestinal Endoscopy 2025. Endoscopic retrograde cholangiopancreatography (ERCP) is widely acknowledged as an effective procedure for managing biliary obstruction. However, its use in very elderly patients, particularly centenarians, presents unique challenges related to both safety and efficacy. In this report, we share our experience with three centenarian patients who underwent ERCP for biliary obstruction in our unit. Remarkably, all patients had favorable outcomes, and no significant adverse events were observed.

Key Words: Endoscopic retrograde cholangiopancreatography; Choledocholithiasis; Centenarians; Nonagenarians; Safety; Complications

Core Tip: Endoscopic retrograde cholangiopancreatography (ERCP) is a well-established and generally safe procedure for managing biliary obstruction. However, the use of ERCP in very elderly populations raises distinct concerns regarding both safety and efficacy. Here, we present the cases of three centenarian patients who underwent ERCP for biliary obstruction, all of whom experienced favorable outcomes with no significant adverse events.

TO THE EDITOR

We were particularly interested in the retrospective study conducted by Wang et al[1], which found no significant difference in the success or complication rates of endoscopic retrograde cholangiopancreatography (ERCP) procedures between patients aged 65-89 years and those in the older cohort (90-94 years). ERCP is a well-established procedure for managing biliary obstruction and is generally considered safe. However, it carries a higher risk of complications compared to other endoscopic interventions. Despite the implementation of various preventive strategies, careful attention to patients is crucial to minimize these risks[2]. For this reason, its use in very elderly populations presents unique concerns regarding both safety and efficacy[3,4]. Procedure-related mortality rates for ERCP are reported to be between 0.3% and 0.5%, with adverse event rates ranging from 5% to 10%[3-5]. These statistics underscore the necessity for careful patient selection and thorough pre-procedure assessments in this age group. Notably, there is a lack of literature specifically addressing the outcomes of ERCP in patients aged 100 years and older. We present a series of three centenarian patients who underwent ERCP for biliary obstruction at our unit between September 2022 and July 2024.

CASE REPORT

Case 1

A 106-year-old female with a history of cholecystectomy, hypertension, and chronic kidney failure was admitted with symptomatic choledocholithiasis. She had presented to the emergency department with epigastric pain and nausea. Laboratory tests revealed elevated transaminases and gamma-glutamyl transferase levels. Abdominal ultrasound confirmed the presence of two stones in the common bile duct.

Case 2

A 100-year-old male with chronic ischemic heart disease and chronic obstructive pulmonary disease was referred for evaluation of acute cholangitis. He presented with fever and right upper quadrant abdominal pain. Abdominal ultrasound revealed dilated biliary ducts and a 1-cm stone in the common bile duct, along with gallbladder calculi. Laboratory tests showed mild jaundice and elevated inflammatory markers.

Case 3

A 101-year-old male with a medical history of chronic cerebral ischemia, hypertension, and diabetes mellitus presented with fever, chills, jaundice, and right upper quadrant abdominal pain, which had progressively worsened over the past two days. Laboratory tests revealed mild leukocytosis and elevated liver function markers, including total bilirubin, alkaline phosphatase, and gamma-glutamyl transferase. C-reactive protein was elevated, indicating an ongoing inflammatory response.

Abdominal ultrasound showed moderate dilation of the common bile duct and a 1.2 cm stone in the distal segment. The gallbladder was distended and contained multiple calculi. A contrast-enhanced computed tomography scan confirmed these findings, revealing marked dilation of the biliary ducts and an impacted stone in the common bile duct.

All three patients underwent ERCP under conscious sedation, with assistance from an anesthesiologist. Sedation was achieved using a combination of propofol, fentanyl, and midazolam. Vital signs were continuously monitored before, during, and after the procedure. Each patient received supplemental oxygen (2 L/minute) via nasal cannula throughout the procedure. Duodenal relaxation was facilitated by intravenous administration of hyoscine butylbromide. ERCP were performed by a single highly experienced endoscopist, who has completed over 1000 procedures. In all cases, a wire-guided cannulation technique was successfully employed, and sphincterotomy was performed. Both Dormia baskets and balloon catheters were used to fully extract stones from the common bile duct.

Only one patient (case 2) developed a small, asymptomatic hepatic biloma, which was successfully managed conservatively within 14 days. The other two patients did not experience any early or late adverse events, including bleeding, post-ERCP pancreatitis, or complications related to sedation.

The follow-up duration ranged from a minimum of 6 months to a maximum of 12 months. All three patients remained in stable condition throughout the follow-up period.

CONCLUSION

The outcomes from these cases suggest that ERCP can be safely performed in centenarian patients when appropriate precautions are taken. While one patient did encounter a manageable complication, the absence of significant adverse events in the others indicates that, with careful patient selection and technique, ERCP can be a viable option for treating biliary conditions in this fragile population. Further research and case studies are essential to develop a more comprehensive understanding of the risks and benefits associated with ERCP in centenarians, potentially guiding future clinical practices.