ERCP Outcomes in Elderly Patients (Age >65) With Biliary Strictures Following Orthotopic Liver Transplantation

Introduction: The proportion of adults aged 65 and older in the United States is increasing and is projected to reach approximately 21% of the population by 2030. Consequently, the demand for orthotopic liver transplantation (OLT) among the elderly has risen, with non-alcoholic steatohepatitis emerging as the most common etiology. Biliary strictures (anastomotic and non-anastomotic) are a common complication following OLT, with an overall incidence of 10 to 15%. The current standard of treatment is ERCP with balloon dilation and serial stent placement, with a 97% stricture resolution rate. Studies on biliary strictures in elderly OLT patients are lacking. We aimed to assess the long-term safety and efficacy of ERCP in patients > 65, with post-OLT biliary strictures, including resolution rates, recurrence rates, and adverse events. Methods: A single center, retrospective case series of all consecutive patients >65 years of age at the time of OLT, from January 1st, 2012, to December 31st, 2021, was conducted. Biliary strictures were identified on either imaging or during ERCP, and procedure outcomes and complications were extracted from the electronic health record. Results were summarized using descriptive statistics. Results: Out of the 215 elderly patients who underwent OLT over a 10-year period, 62 (29%) developed a biliary stricture, with 84% of them being anastomotic. Of those who underwent ERCP, 84% (43 out of 51) achieved stricture resolution with a mean of 3.49 (+/- 1.64) procedures. However, 11.3% (n=7) experienced stricture recurrence, with a median time to recurrence of 16 weeks. Among those with biliary strictures, 9.7% (n=6) required surgical revision due to a recalcitrant stricture. Complications from ERCP were observed in 8 patients (12.9%). For complete results, please refer to Table 1. Conclusion: Our study findings indicate a higher incidence of biliary strictures (29%) in elderly patients compared to reported rates in post-OLT patients of all age groups. While most strictures were managed effectively with ERCP, the resolution rate was below that reported in the literature. In addition, there was a high rate of surgical revisions. Post-ERCP adverse events range from 3% to 13% in OLT recipients, and we found a comparable rate of complications in our patients. Overall, our findings suggest that elderly post-OLT patients may have an increased risk of stricture formation, lower resolution rate with comparable post-ERCP adverse event rate when compared to the overall post-OLT population (see Figure 1).Figure 1.: Flowchart of patient outcomes: development of stricture and subsequent ERCP success. Table 1. - Characteristics and outcomes of ERCP for post-transplant anastomotic strictures in patients older than 65 years OLT in patients > 65 yrs of age (n) 215 Mean age at transplant 68.1 Patients with post transplant strictures n(%) 62 (28.8%) Type of Stricture Anastomotic n(%) 52 (83.9%) Non-anastomotic n(%) 7 (11.3%) Not available n(%) 3 (4.8%) Patients with stricture undergoing ERCP n(%) 43 (84%) Mean number of ERCPs performed (SD) 3.49 (+/- 1.64) ERCP interventions Sphincterotomy n(%) 46 (74.2%) Balloon dilation n(%) 43 (69.4%) ERCP Complications n(%) 8 (12.9%) Pancreatitis n(%) 3 (4.8%) Abdominal pain n(%) 2 (3.2%) Billiary leak n(%) 1 (1.6%) Bleeding n(%) 1 (1.6%) Cholangitis n(%) 1 (1.6%) Other ERCP findings Sludge n(%) 32 (51.6%) Stones n(%) 25 (40.3%) Median number of cumulative stents placed (range) 3 (0-9) Stent type on final ERCP Plastic n(%) 35 (56.5%) Metal n(%) 11 (17.7%) Not available n(%) 16 (28.5%) ERCP outcome Stricture resolution 43 (69.4%) Stricture recurrence 7 (11.3%) Median time in weeks to stricture recurrence (range) 16 (8-166) Patients requiring surgical revision 6 (9.7%)