ERCP Is a Safe Procedure in Nonagenarian Patients Regardless of Frailty: A Nationwide Analysis

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is an essential therapeutic tool for biliary and pancreatic diseases. Frail and elderly patients, especially those aged ≥90 years are generally considered a high-risk population for ERCP related complications. We aimed to investigate the outcomes of ERCP in elderly (≥90 years) population. Methods: This is a cohort study using 2019 National readmission database. Patients aged ≥90 were identified using ICD-10 code with clinical modification who underwent ERCP. Johns Hopkin’s adjusted clinical groups frailty indicator was used to classify patients as frail or non-frail. Readmission is defined as hospitalization due to non-trauma related diagnosis within 30 days from index admission. The primary outcome was morbidity. The secondary outcomes were mortality and 30-days readmission rate related to ERCP. We used univariate and multivariate regression models for statistical analysis. Results: A total 3,322 patients, 65% female underwent ERCP were included in the analysis. Frail and non-frail patients were 1205 (36.27%) and 2,117 (63.72%) respectively. The indications of ERCP were choledocholithiasis (74.82%), biliary pancreatitis (9.81%), pancreaticobiliary cancer (7.52%), biliary stricture (3.83%), pancreatitis of unspecified etiology (2.24%), cholangitis (1.55%), abnormal LFTs (0.13%), and pancreatic pseudocyst (0.05%). The overall intra-procedural complications were non-significant between frail and non-frail patients. These include bleeding (0.31% vs 0.12%, P=0.29), accidental punctures/lacerations (0.81% vs 0.82%, P=0.98) and need for mechanical ventilation rates (2.69% vs 1.69%, P=0.14). Post ERCP complications rate were similar for bleeding (1.15% vs 0.63%, P=0.11), shock (0.09% vs 0.11%, P=0.93), and post-ERCP pancreatitis (3.5% vs 4.2%, P=0.83). Frail had a longer length of stay compared to non-frail patients (7 days vs 5 days, P< 0.001). The mortality rates of frail and non-frail patients were 2.09% vs 1.53%, P=0.59). The most common cause of 30-days readmission in both groups were sepsis (33.7%), pneumonia (14.87%), heart diseases (14.54%), and UTI (13.34%). There was no readmission due to ERCP related complications in both groups. All-cause 30-day readmission rates were identical between the 2 groups (Table 1). Conclusion: ERCP is safe in elderly (≥90 years) population with a comparable morbidity, readmission and mortality rates in frail and non-frail patients. Larger, prospective studies are warranted to validate these results. Table 1. - Outcomes of ERCP in Frail elderly patients compared to Non-Frail patients Variables Frail (n= 1,240) Non-frail (n= 2,116) P-value Stent placement 0.92% 1.51% 0.3 Adjusted OR1=0.61 0.29 Sphincterotomy 4.5% 5.35% 0.45 Intraprocedural complications Bleeding 0.31% 0.12% 0.29 Adjusted OR1=2.44 0.32 Accidental puncture/laceration 0.81% 0.82 Adjusted OR1=0.93 0.98 Mechanical Ventilation 2.69% 1.69% 0.14 Adjusted OR1=0.82 0.75 Post-procedural complications Bleeding 1.15% 0.63% 0.11 Adjusted OR1=1.73 0.28 Shock 0.09% 0.11% 0.93 Adjusted OR1=0.88 0.94 Post ERCP Pancreatitis 3.5% 4.2% 0.83 Adjusted OR1=0.71 0.7 Mortality rate 2.09% 1.53% 0.38 Adjusted OR1=1.2 0.59 Length of Stay (days) 6.57 5.06 < 0.001 Mean change in length of stay1 = 1.34 < 0.001 30-day all cause readmission rate 9.27% 8.42% 0.55 Adjusted OR1=1.07 0.7 1Adjusted for sex, insurance status, income quartile, and Elixhauser co-morbidity index.