Incomplete Procedure Reports on Endoscopic Retrograde Cholangiopancreatography May Delay Exchange/Removal of Plastic Biliary Stents

Abstract

The occlusion rate of plastic biliary stents is known to rise precipitously 3 months after placement. Thus, it is critical that they be exchanged or removed within the appropriate timeframe. After encountering an index case of acute cholangitis due to occlusion of a plastic biliary stent placed more than a year prior, a gastrointestinal fellow–initiated quality improvement project (QI) was initiated. We hypothesized that incomplete endoscopic retrograde cholangiopancreatography (ERCP) reporting may lead to delayed plastic stent exchange or removal in our open ERCP system. The aims of our QI project were to quantify the frequency of incomplete ERCP reporting and determine whether an incomplete ERCP report is associated with delayed plastic biliary stent exchange/removal and cholangitis. We retrospectively evaluated ERCP procedures with plastic biliary stent placement at our tertiary referral center from January to April 2015. ERCP procedures with metal biliary stent or plastic pancreatic stent placement were excluded. An incomplete ERCP report was defined as an ERCP report that did not specify time interval for stent exchange/removal. Delayed repeat ERCP was defined as repeat ERCP for plastic stent exchange or removal occurring later than the recommended time interval plus a 4-week grace period to account for scheduling delays. For ERCP report without a recommended time interval for stent exchange/removal, we used 12 weeks (including grace period) as a cutoff because the median recommended time for the group with complete ERCP report was 8 weeks. Of 193 ERCP procedures with biliary plastic stent placement, 32 (16.5%) were incomplete ERCP reports. Of 193 cases, 159 had repeat ERCP procedures (Figure 1). The incomplete ERCP report group had a higher rate of delayed repeat ERCP (30.0% vs 7.2%; P = .007), but comparable rate of cholangitis at the time of repeat ERCP (20.0% vs 13.0%; P = .48) (Table 1). Importantly, we found one potentially preventable case of acute cholangitis with septicemia from an occluded plastic stent that was placed 9 months prior. This case was in the incomplete ERCP report group and the patient was admitted to hospital for 6 days. In patients who underwent ERCP procedures with plastic biliary stent placement requiring repeat ERCP for stent exchange or removal, 16.5% of ERCP reports were found to be incomplete with respect to specifying the required interval for stent exchange/removal. The incomplete ERCP reports were significantly associated with delayed repeat ERCP procedures. The intervention phase of our QI project has been initiated to decrease the rate of incomplete ERCP reports by sharing these data monthly among therapeutic endoscopists to increase their awareness.Table 1Individuals Who Had a Repeat Endoscopic Retrograde Cholangiopancreatography Stratified Into Those With Incomplete vs Complete Endoscopic Retrograde Cholangiopancreatography ReportVariableAll ERCP report (n = 159)Incomplete ERCP report (n = 20 [12.6%])Complete ERCP report (n = 139 [87.4%])P valueDuration between index and repeat ERCP, wk, median (IQR)7.3 (4.4–10.9)8.5 (1.4–37.4)7.0 (0.6–39.6).16Delayed repeat ERCP, n (%)aFor incomplete ERCP report, we used 8 weeks as the recommended time because the median recommended time for the group with complete ERCP report was 8 wk. We also allowed a 4-wk grace period for all repeat ERCP for scheduling reason.16 (10.1)6 (30.0)10 (7.2).007Cholangitis at the time of subsequent ERCP, n (%)22 (13.8)4 (20.0)18 (13.0).48IQR, interquartile range.a For incomplete ERCP report, we used 8 weeks as the recommended time because the median recommended time for the group with complete ERCP report was 8 wk. We also allowed a 4-wk grace period for all repeat ERCP for scheduling reason. Open table in a new tab