With improving access to healthcare, there has been a global increase in the average age. It is predicted that by 2050, 2 billion people will be above the age of 60 years and 434 million above 80 years, as compared to 900 million and 125 million, respectively, in 2015, and that 80% will live in low- and middle-income countries.¹ The elderly population has been sub-classified as the oldest old (> 80 years), centenarians (100+), and super-centenarians (110+).² Two points are important to note. Firstly, the elderly population has a higher prevalence of comorbidities requiring medication and may prefer outpatient procedures in view of their poor ambulation and dependency on family and social support. Secondly, there is a high incidence of disorders in octogenarians warranting endoscopic retrograde cholangiopancreatography (ERCP) or endoscopic ultrasound (EUS).³ ERCP is complicated by pancreatitis, perforations, gastrointestinal bleeding, and cholangitis. Although the currently available literature shows that ERCP is safe in the elderly population, the presence of concomitant frailty, multiple co-morbidities, and poor cognition has led endoscopists to consider avoiding interventions unless the indication is life-saving.⁴ Furthermore, while studies have established the safety of ERCP/EUS on an outpatient basis,^5,6 data are lacking on outpatient therapeutic ERCP/EUS in patients aged 80 years and older from India. The current retrospective study was done to establish the safety of outpatient therapeutic ERCP/EUS in patients aged 80 years or older.

The existing medical records for all ERCP/EUS procedures were screened for patients aged more than 80 years who had undergone ERCP/EUS on a day-care basis (observed for 6 hours in the endoscopy recovery room to monitor them for any complications and discharged on the same day). As per the protocol in our hospital, a careful pre-anesthetic check-up (PAC) was carried out for all patients, and were given an appropriate American Society of Anesthesiologists (ASA) classification. During procedure, all patients were pre-medicated with fentanyl (1 μg/kg and titrated further according to the effect, with a maximum of 2 μg/kg) and ondansetron (4 mg), intravenously. All patients were given total intravenous anesthesia (intravenous propofol at 5 μg/kg and intravenous ketamine at 1 mg/kg, titrated to effect) and were monitored for any anesthesia-related complications during and after the procedure.

Pancreatitis was defined as new-onset abdominal pain with at least a three-fold elevation of serum amylase or lipase levels that required more than 1 night of hospitalization. Perforation was defined as retroperitoneal or bowel-wall perforation, as evidenced by any imaging technique. Bleeding adverse events were defined as clinically evident hemorrhage, with a decrease in hemoglobin of at least 2 g/dL or the need for endo-therapy or transfusion. Cholangitis was defined as a temperature of more than 38°C for 24–48 hours occurring after the procedure that was thought to have a biliary cause, without evidence of other concomitant infections. Cardio-pulmonary adverse events included myocardial infarction, cerebrovascular accident, congestive heart failure, cardiac/respiratory arrest, arrhythmia including bradycardia (heart rate < 60 beats/minute), tachycardia (heart rate > 110 beats/minute), or vasovagal response. Hypoxemia was defined as oxygen saturation < 90% by pulse oximetry and hypotension was defined as a systolic blood pressure < 90 mmHg.

Patients were advised to report back in case of fever, abdominal pain, vomiting, or any other complication. After discharge, we followed our patients telephonically on a daily basis for 7 days and reviewed them at the outpatient department after 7 days to evaluate the efficacy of the procedure or to address any complications.

Results

We collected retrospective data on patients undergoing EUS/ERCP from endoscopy records from January 2019 through December 2019 at Department of Gastroenterology at Army Hospital (Referral and Research) and screened patients who were above 80 years. A total of 534 patients underwent ERCP/EUS in the study period, of whom 48 were more than 80 years of age.

Thirty patients underwent day-care procedures and were enrolled in the study. During the PAC, 70.0% (n = 21) patients were classified as ASA III due to their geriatric age and multiple comorbidities. The rest of the patients (30.0%, n = 9) were ASA II.

The mean age of the patients was 86.7 years. The majority of patients were male (n = 24, 80.0%), while 20% were female. ERCP was done in 27 (90.0%) patients, and 73.3% (n = 22) patients had a naïve papilla, while 5 patients had undergone ERCP before. The most common indication for ERCP was choledocholithiasis (46.6%, n = 14) followed by malignant biliary obstruction (30.0%, n = 9) and benign stricture (20.0%, n = 6) (Table 1). At least one comorbidity was present in 73.3% (n = 22) patients, of whom 33.3% had hypertension, 26.6% had diabetes, and 16.6% had hypothyroidism.

Table 1 . Characteristics of the Oldest Old Undergoing Day-Care ERCP/EUS.

Characteristic	Number (%)
Age distribution
80–89 yr	25 (83.3)
90–99 yr	4 (13.3)
100 yr and above	1 (3.3)
Sex distribution
Male	24 (80.0)
Female	6 (20.0)
Indication
Choledocholithiasis	14 (46.6)
Benign biliary strictures	6 (20.0)
Malignant stenosis	9 (30.0)
Pancreatic pseudocyst	1 (3.3)
Comorbidity
Diabetes	8 (26.6)
Hypertension	10 (33.3)
Coronary artery disease	1 (3.3)
Hypothyroidism	5 (16.6)
Complete heart block	2 (6.6)
Rheumatoid arthritis	2 (6.6)
No comorbidities	8 (26.6)
Procedure
Sphincterotomy	23 (76.6)
Sphincteroplasty	12 (40.0)
Stent placement	26 (86.6)
EUS-guided cysto-gastrostomy	1 (3.3)
EUS-guided rendezvous ERCP	1 (3.3)
EUS-guided choledochoduodenostomy	1 (3.3)
Incomplete procedure	1 (3.3)
Complication
Desaturation	2 (6.66)
Cardiopulmonary complications	1 (3.3)
Hypotension	8 (26.6)
Bleeding	None
Perforation	None
Pancreatitis	None
Death	None

ERCP, endoscopic retrograde cholangiopancreatography; EUS, endoscopic ultrasound..

During ERCP, 76.6% (n = 23) patients underwent sphincterotomy, 40.0% (n = 12) underwent balloon sphincteroplasty (controlled radial expansion balloon, 12 to 18 mm), and 86.6% (n = 26) patients had stent placement. Three patients had failed cannulation. Out of these three patients, two patients needed EUS-guided interventions (EUS-guided rendezvous procedure, and EUS-guided choledochoduodenostomy). In one patient, cannulation could not be performed due to a duodenal obstruction.

Therapeutic EUS was performed in 10.0% (n = 3) patients. Of these patients, one underwent EUS-guided cysto-gastrostomy (n = 1) for a pancreatic pseudo-cyst, one had an EUS-guided rendezvous procedure for difficult common bile duct (CBD) cannulation (n = 1), and one underwent EUS guided choledochoduodenostomy due to difficult CBD access (n = 1).

Transient complications such as desaturation during the procedure (6.6%, n = 2) and intra- procedural hypotension (26.6%, n = 8) were noted. No bleeding, perforation, or pancreatitis was observed. No patient required admission after the procedure (Table 1).

ERCP is the procedure of choice for the treatment of choledocholithiasis and is used frequently as a drainage procedure for extrahepatic biliary obstruction, both of which have a higher incidence in the elderly population. ERCP is technically demanding compared to colonoscopy and esophago-gastroduodenoscopy and is associated with complications such as pancreatitis, bleeding, and perforation, in addition to anesthesia-related complications.⁷ Therefore, the safety and success of ERCP and EUS in elderly patients should be assessed and ensured.

Outpatient ERCP is now gaining acceptance worldwide, and its safety has been established in various studies.⁸ As elderly patients have a high prevalence of associated comorbid conditions (mainly cardiopulmonary), which predispose them to increased procedural and anesthesia-related adverse effects, most centers prefer to perform these procedures on an inpatient basis. Hui et al⁵ reported that 85% of all complications developed within 6 hours after the procedure. The authors also found that all cases of post-ERCP pancreatitis or nonspecific abdominal pain occurred within 6 hours. Similarly, Freeman et al⁹ concluded that 79% of complications were reported within 6 hours after ERCP. However, in studies where patients were observed for 1 to 4 hours, 4% of the outpatients subsequently developed post-ERCP pancreatitis, requiring readmission to the hospital.^6,10 These results indicate that while complications may be more common in the elderly, they, like complications in younger patients, tend to manifest within the first 6 hours. The fact that our outpatient ERCP protocol involved a minimum observation period of 6 hours mitigates this risk and indicates that the procedure could be safe. This study presents our experiences of ERCP/EUS as a day-care procedure in the elderly.

In our patients, delayed post-endoscopic sphincterotomy bleeding, pancreatitis, perforation, and cholangitis were not observed in any patients. Jeurnink et al¹¹ observed that cholangitis and hemorrhage requiring re-admission each occurred in 1% of patients who underwent ERCP as outpatient treatment.

The oldest old patients have higher chances of sedation-related adverse effects. Finkelmeier et al¹² reported that adverse events related to sedation occurred significantly more commonly in elderly patients (> 80 years) than in younger patients (3.4% vs. 0.5%; P < 0.01). In our study, almost all the complications were anesthesia-related and were reversible within an hour. No patient required admission. Studies have shown that the combination of propofol and ketamine in low doses can be used to maintain hemodynamic stability and to avoid side effects related to individual agents when administered in large doses.¹³ We used a combination of ketamine and propofol at lower dosages to minimize the adverse effects. Early detection of complications is the key to success of therapeutic procedures. Hence, close monitoring of patients after the ERCP or therapeutic EUS procedure with frequent direct contact with the physician/team who performed the procedure is essential.

In the present era with rising healthcare costs, the feasibility of performing ERCP/EUS safely in the day-care/outpatient setting has become of paramount importance. Avenues to reduce high costs rely on more efficient medical care. Because of the expected risk of complications in the elderly, overnight observation after ERCP is common. This policy, albeit useful, causes unnecessarily high health costs and inefficient use of medical resources. A possible solution is shifting from inpatient to outpatient treatments and to reserve admission only for patients with complications or with a high risk of complications; however, careful selection of patients eligible for ERCP on an outpatient basis is required. Patients with relatively good health status who are not at risk for post-ERCP complications may be considered for outpatient or day-care procedures if they have normal coagulation tests and metabolic profile and are staying near the hospital.

The strengths of this case series are consecutive patient selection from a single tertiary care center and close follow-up of patients during the observational period by the endoscopy and anesthesia team with more than 15 years of experience in ERCP. Its limitations include the retrospective nature of data collection.

In conclusion, this study demonstrated that therapeutic outpatient ERCP/EUS can be done by experienced endoscopy and anesthetic teams even in the oldest old patients with associated comorbid diseases, and are acceptable and safe, avoiding unnecessary hospital admissions.

None.

No potential conflict of interest relevant to this article was reported.