Comparison of the efficacy and safety between palliative biliary stent placement and duct clearance among elderly patients with choledocholithiasis: a propensity score-matched analysis

Abstract

Objectives: This study aimed to evaluate and compare the outcomes of palliative endoscopic biliary stenting (EBS) and complete stone removal among elderly patients with choledocholithiasis using propensity score matching.

Methods: From April 2012 to October 2017, 161 patients aged 75 years and older with choledocholithiasis underwent endoscopic retrograde cholangiopancreatography at our institution. Among them, 136 (84.5%) had complete stone removal, and 25 (15.5%) underwent palliative EBS without further intervention until symptom occurrence. The median age of the EBS group was significantly higher than that of the complete stone removal group. The proportion of patients with dementia, cerebral infarction, preserved gallbladder with gallstones, and surgically altered anatomy was higher in the EBS group than in the complete stone removal group. Propensity score matching was used to adjust for different factors. In total, 50 matched patients (n = 25 in each group) were analyzed.

Results: The median duration of cholangitis-free periods was significantly shorter in the EBS group (596 days) than in the complete stone removal group. About half of patients in the EBS group required retreatment and rehospitalization for cholangitis during the observation period. Cholangitis was mainly caused by stent migration. There was no significant difference in terms of mortality rate and procedure-related adverse events between the two groups. Death was commonly attributed to underlying diseases. However, one patient in the EBS group died due to severe cholangitis.

Conclusions: Palliative EBS should be indicated only to patients with choledocholithiasis who have a poor prognosis.

Keywords: Aged; Choledocholithiasis; Endoscopic retrograde cholangiopancreatography; Lithotripsy; Stents.

Fig. 1

Flowchart of patient selection. Flowchart of patient selection into matched palliative EBS and complete stone removal groups (ERCP, endoscopic retrograde cholangiopancreatography; EBS, endoscopic biliary stenting)

Fig. 2

Duration of cholangitis-free periods. Kaplan–Meier graph showing the duration of cholangitis-free periods. The duration of EBS was significantly shorter than that of complete stone removal (p < 0.01, log-rank test; EBS, endoscopic biliary stenting; NA, not applicable)

Fig. 3

Stent–stone complex. One patient in the palliative EBS group had stent–stone complex. He developed cholangitis 3 years after the initial ERCP stent placement. ERCP was performed again, and the stent ruptured upon removal (EBS, endoscopic biliary stenting; ERCP, endoscopic retrograde cholangiopancreatography)