Endoscopic retrograde cholangiopancreatography as a single-modality 'gold-standard' treatment for common bile duct stones in the elderly.

Abstract

There are more octogenarians presenting with gallstone disease each year. Many are not suitable for surgical intervention. An alternative treatment option for common bile duct stones in the elderly is endoscopic retrograde cholangiopancreatography (ERCP) with or without stent insertion. We conducted a retrospective study using a prospectively collected database, analysing the outcomes of consecutive patients >80 years old who underwent an ERCP in a single centre for the treatment of common bile duct stones. In total, 156 patients, with a median age of 91 years, underwent an ERCP for choledocholithiasis over a 3-year period. ERCP was successful in 90% of patients but a proportion required repeat intervention. Forty-six (29%) patients had a concurrently inserted stent due to incomplete stone extraction. Six (4%) patients required a post-ERCP cholecystectomy due to ongoing symptoms. The overall ERCP complication rate was 7% (4% Clavien-Dindo 1 and 3% Clavien-Dindo 2), with no cases of post-ERCP pancreatitis or death. Patients were followed up over 5 years following index ERCP. There was a 60% 3-year survival and 30% 5-year survival rate following index ERCP. Importantly, of those who did not survive, only four patients (2.6%) had a death attributable to a biliary cause and none were fit for definitive surgery. ERCP can be considered as a possible definitive management option for treating common bile duct stones in the elderly, particularly in the comorbid population. Concurrent stenting is an effective temporizing strategy and mitigator of biliary-related readmission, but routine stent changes should be considered. Key messages What is already known on this topic Current guidelines advocate for laparoscopic cholecystectomy and common bile duct exploration in patients with choledocholithiasis. What this study adds Endoscopic retrograde cholangiopancreatography with or without stent insertion is a safe, alternative single-treatment modality for choledocholithiasis in the elderly comorbid population. How this study might affect research, practice, or policy Studies and guidelines evaluating treatment options for choledocholithiasis may be altered to accommodate patient-specific factors, including age and comorbid status, and the concurrent use of stenting as a either a temporizing or longer-term measure for complex stone disease.