ERCP for biliary stones in the elderly: should we stop ducking the cholecystectomy?

Since endoscopic retrograde cholangiopancreatography (ERCP) was first described in 1968, the procedure has become indispensable in management of biliary tract stones [1]. Endoscopic biliary sphincterotomy, with or without papillary balloon dilation (EPBD), is considered to be highly effective for the removal of all but the most challenging stones. Even in cases where a more complex intervention is required, ERCP provides the platform for directed stone remediation via mechanical, laser, or electrohydraulic lithotripsy [2]. In spite of its undeniable efficacy and central role in management of choledocholithiasis, ERCP carries a well-recognized profile of inherent risks which may occur in up to 10% of patients who undergo the procedure [3]. In view of that, considerable effort has been expended in identifying and stratifying patients and situations that contribute to increased risk. Particular attention is frequently given to short-term problems such as post-ERCP pancreatitis (PEP) [4]. As the life expectancy and proportion of elderly patients increases throughout much of the developedworld [5], we can reasonably expect that the number of octogenarians and nonagenarians who undergo ERCP will increase accordingly. Indeed, an intramural survey of ERCP volume at our institution over the last 12 months demonstrated that out of well over 1000 total cases, more than 40% of the procedures were performed on patients over age 65 and nearly 10% were done on individuals in their 80s and 90s. Given the reasonable expectation that ERCP in the elderly will become a more common exercise among interventional gastroenterologists, a comprehensive understanding of the risks and challenges of this patient population is critical. In this issue of Endoscopy International Open, Kenamori et al [6] present a large, single-center cohort study examining both the shortand longterm outcomes of patients who underwent therapeutic ERCP for choledocholithiasis between 1982 and 2011.Patients included in the study were stratified by age and were classified as either young (960 patients<80 years) or old (250 patients≥80 years) for subsequent analysis. While it has been previously asserted that the shortterm risks of ERCP in older adults are generally acceptable [7], there is a growing body of evidence regarding specific differences in this patient population. A systematic review published in the current journal by Day et al [8] suggested that patients over age 65 have a nearly 70% overall reduction in post-ERCP pancreatitis when compared to younger cohorts. This is consistent with the experience reported by Kenamori et al, and when taken together with contemporary work, seems to support the notion of a “dose-dependent” protective effect of advancing age on PEP [9–11]. Kenamori et al also suggest similar outcomes between age groups when it comes to other short-term complications such as bleeding, periprocedural infection (cholecystitis or cholangitis) and perforation. Despite the overall congruence, older patients did carry an increased risk of cardiopulmonary complications. While consistent with Day et al [8], this observation may have more to do with the medical comorbidities carried by elderly patients rather thanwith age alone [12,13]. While most studies to date have focused on the short-term complications of ERCP in the elderly, there is relatively little published data examining long-term outcomes in these patients. What data we do have suggest that complete treatment of biliary lithiasis may affect the overall survival of the elderly who require ERCP [14]. While the authors of Kenamori et al acknowledge that the broad time course of their study may have introduced unintended bias, it also permitted extended follow-up (a mean of 1278 days in the older cohort) in a fairly large number of patients. Perhaps the most interesting observation made by the authors is the increased likelihood (20.4% v.