Abstract
BackgroundSuccess in deep biliary cannulation via native ampullae of Vater is an accepted measure of competence in ERCP training and practice, yet prior studies focused on predicting adverse events alone, rather than success. Our aim is to determine factors associated with deep biliary cannulation success, with/ without precut sphincterotomy.MethodsThe ERCP Quality Network is a unique prospective database of over 10,000 procedures by over 80 endoscopists over several countries. After data cleaning, and eliminating previously stented or cut papillae, two multilevel fixed effect multivariate models were used to control for clustering within physicians, to predict biliary cannulation success, with and without allowing “precut” to assist an initially failed cannulation.Results13018 ERCPs were performed by 85 endoscopists (March 2007 - May 2011). Conventional (without precut) and overall cannulation rates were 89.8% and 95.6%, respectively. Precut was performed in 876 (6.7%). Conventional success was more likely in outpatients (OR 1.21), but less likely in complex contexts (OR 0.59), sicker patients (ASA grade (II, III/V: OR 0.81, 0.77)), teaching cases (OR 0.53), and certain indications (strictures, active pancreatitis). Overall cannulation success (some precut-assisted) was more likely with higher volume endoscopists (> 239/year: OR 2.79), more efficient fluoroscopy practices (OR 1.72), and lower with moderate (versus deeper) sedation (OR 0.67).ConclusionBiliary cannulation success appears influenced by both patient and practitioner factors. Patient- and case-specific factors have greater impact on conventional (precut-free) cannulation success, but volume influences ultimate success; both may be used to select appropriate cases and can help guide credentialing policies.
Highlights
Success in deep biliary cannulation via native ampullae of Vater is an accepted measure of competence in Endoscopic retrograde cholangiopancreatography (ERCP) training and practice, yet prior studies focused on predicting adverse events alone, rather than success
In the Network, 13,018 ERCPs in native papillae were performed by 85 endoscopists
Further multivariate analyses suggest that only case-specific factors are significantly associated with conventional native papilla biliary cannulation success, and that endoscopist- and institution-level factors may not be as important
Summary
Success in deep biliary cannulation via native ampullae of Vater is an accepted measure of competence in ERCP training and practice, yet prior studies focused on predicting adverse events alone, rather than success. Our aim is to determine factors associated with deep biliary cannulation success, with/ without precut sphincterotomy. Minimum standards of 80-90% have been proposed internationally [9,10], yet wide practice variations (54%-98%) exist. This rate variation can only be partly explained by variable exclusions of precut sphincterotomy, and cut/ stented papillae [11,12,13,14]. It would seem preferable to exclude previously stented/cut papillae
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