The Impact of Introduction of a New Endoscopic Ultrasound (EUS) Service on the Volume, Success, and Complexity of Endoscopic Retrograde Cholangiopancreatography (ERCP) Performed in a Tertiary Referral Center

Abstract

Introduction: Endoscopic ultrasound (EUS) can aid in biliary duct cannulation where conventional ERCP techniques fail, improving the success rate in complex ERCPs. The introduction of EUS service may change the pattern of ERCPs, which has never been systematically studied in the past. The aim is to assess the impact of introducing EUS service on the volume, outcome, and complexity of ERCP in a tertiary referral medical center. Methods: A retrospective data review of all ERCP procedures was performed during 1.5-year time periods, before and after the introduction of EUS service (before EUS and after EUS) from January 2010 to January 2013. Patients’ demographics, ERCP indications, types of sedation, therapeutic interventions, outcomes, and complexity of ERCP (following the ASGE complexity grade) were collected. The categorical and continuous variables between the 2 time periods were compared using Fisher’s exact test and unpaired t-test, respectively. Multivariable logistic regression analysis was used to compare ERCP outcomes after adjusting the complexity grade. Results: A total of 945 ERCPs (411, 43.4% before the introduction of EUS; 534, 56.5% after introduction of EUS) were included. There was a 30% relative increase in the volume of ERCPs after the introduction of EUS. Five hundred sixty-seven (60%) patients in our study were females with a mean age of 51.5 years. The 2 most common indications of ERCP were jaundice (before EUS 37%; after EUS 34%) and choledocholithiasis (before EUS 25.6%; after EUS 26%). There was an increase in the frequency of precut sphincterotomy (0.97% vs. 5.43%; p=0.0002), metal stent placement (1.95% vs. 5.43%; p=0.0062), pancreatic stent placement (5.6% vs. 10.11%; p=0.0119), and EUS-guided biliary cannulation “rendezvous” (0% vs. 1.5%; p=0.0127) after the introduction of EUS. The complexity of ERCP was increased after the introduction of EUS. The odds ratio (OR) of grade 4 ERCP was 4.44 (95% CI 1.92-10.24; p=0.0005) after EUS introduction (Table 1). ERCP success rate was higher after the introduction of EUS even after adjusting the complexity grade (OR 4.54; 95% CI 1.85-11.14; p=0.001). The complication rate was 4.6 times higher in the after EUS period when compared to the before EUS period (OR 4.63; 95% CI 1.90-11.3; p=0.0007).Table 1: Comparison of ERCP Complexity Grade and ERCP Outcome (Success) Between the Two Time Periods (“After EUS” and “Before EUS”)Conclusion: The introduction of a new EUS service in our tertiary referral university medical center was associated with an increase in volume, success, and complexity of ERCP procedures. EUS expertise is valuable for better ERCP outcomes.