Endoscopic Retrograde Cholangiopancreatography Practice Research Articles

A high-volume ERCP service led by surgeons is associated with good outcomes and meets national key performance indicators: results from a British district general hospital.

Endoscopic retrograde cholangiopancreatography (ERCP) is a common, but technically challenging procedure used in the management of hepatopancreaticobiliary (HPB) disease. It is traditionally performed by medical gastroenterologists. In 2014, the British Society of Gastroenterology (BSG) proposed key performance indicators to evaluate and set standards of ERCP practice. This study aimed to compare our ERCP outcomes against these targets, in a centre where ERCP is exclusively performed by surgeons. A retrospective analysis of all ERCPs undertaken over a 38months in a District General Hospital in the United Kingdom (UK), by three Upper Gastrointestinal Surgeons. Study outcomes were based upon, and compared against, BSG key performance indicators, including number of ERCPs per annum, proportion of successful cannulations of bile duct and stone clearance, ERCP-specific complications and mortality. The unit's caseload over this period was 1324, equating to approximately 418 per annum (BSG minimum 200 per unit). Management of bile duct stones was the commonest indication for ERCP. Overall, 95% (1253/1324) of bile ducts were cannulated and 92% (645/698) for those undergoing their first ERCP. Bile duct clearance was achieved in 80% of patients (BSG recommend > 75%) and the successful stenting of extra-hepatic strictures in 94% (BSG recommend > 80%). The overall complication rate was 4.3% (BSG standard < 6%). Procedure-specific mortality was 0.3% (4/1324) where death was either caused by pancreatitis or sepsis. A high-volume ERCP service led and performed exclusively by surgeons meets all BSG performance indicators, with good procedural and patient outcomes. Formal training pathways should be developed to encourage more surgical centres to provide an ERCP service and deal with what are common surgical pathologies.

UK Joint Advisory Group consensus statements for training and certification in endoscopic retrograde cholangiopancreatography.

Background and study aims Despite the high-risk nature of endoscopic retrograde cholangiopancreatography (ERCP), a robust and standardized credentialing process to ensure competency before independent practice is lacking worldwide. On behalf of the Joint Advisory Group (JAG), we aimed to develop evidence-based recommendations to form the framework of ERCP training and certification in the UK. Methods Under the oversight of the JAG, a modified Delphi process was conducted with stakeholder representation from the British Society of Gastroenterology, Association of Upper Gastrointestinal Surgeons, trainees and trainers. Recommendations on ERCP training and certification were formulated after formal literature review and appraised using the GRADE tool. These were subjected to electronic voting to achieve consensus. Accepted statements were peer-reviewed by JAG and relevant Specialist Advisory Committees before incorporation into the ERCP certification pathway. Results In total, 27 recommendation statements were generated for the following domains: definition of competence (9 statements), acquisition of competence (8 statements), assessment of competence (6 statements) and post-certification support (4 statements). The consensus process led to the following criteria for ERCP certification: 1) performing ≥ 300 hands-on procedures; 2) attending a JAG-accredited ERCP skills course; 3) in modified Schutz 1–2 procedures: achieving native papilla cannulation rate ≥80%, complete bile duct clearance ≥ 70 %, successful stenting of distal biliary strictures ≥ 75 %, physically unassisted in ≥ 80 % of cases; 4) 30-day post-ERCP pancreatitis rates ≤5 %; and 5) satisfactory performance in formative and summative direct observation of procedural skills (DOPS) assessments. Conclusions JAG certification in ERCP has been developed following evidence-based consensus to quality assure training and to ultimately improve future standards of ERCP practice.

Risk evaluation of duodenoscope-associated infections in the Netherlands calls for a heightened awareness of device-related infections: a systematic review.

The risk of exogenous infections from endoscopic procedures is often cited as almost negligible (1 infection in 1.8 million procedures); however, this risk is based on older literature and does not seem to match the number of infectious outbreaks due to contaminated duodenoscopes reported after endoscopic retrograde cholangiopancreatography (ERCP). Using Dutch data, we aimed to estimate the minimum risk of duodenoscope-associated infection (DAI) and colonization (DAC) in patients undergoing ERCP. A systematic literature search identified all DAI outbreaks in the Netherlands reported between 2008 and 2019. Included cases were confirmed by molecular matching of patient and duodenoscope cultures. Risk ratios were calculated based on the total number of ERCPs performed during the study period. Three outbreaks were reported and published between 2008 and 2018, including 21 confirmed DAI cases and 52 confirmed DAC cases. The estimated number of ERCPs performed during the same period was 181 209-227 006. The calculated minimum estimated DAI risk was approximately 0.01 % and the minimum estimated DAC risk was 0.023 %-0.029 %. The estimated risk of DAI in Dutch ERCP practice was at least 180 times higher than previously published risk estimates. The actual risk is likely to be (much) higher due to underreporting of infections caused by multidrug-resistant organisms and sensitive bacteria. Greater awareness by healthcare personnel involved in endoscopy and endoscope cleaning is required, as well as innovative technical solutions to contain and ultimately eliminate DAIs.

Current ERCP practice in Belgium: the BSGIE survey.

Data on procedural outcome and quality of endoscopic retrograde cholangiopancreatography (ERCP) in Belgian practice are scarce. The aim of this study is to assess current status of ERCP-performance in Belgium. National multi-institutional survey (online questionnaire) among members of the Belgian Society of Gastrointestinal Endoscopy (BSGIE), conducted in the period June-August 2018. The RIZIV/INAMI provided real-life data on the total number of ERCPs performed in Belgium. Forty-five responders completed the survey (for 43 centers performing ERCP), providing information for 8368 ERCPs performed in 45% (43/95) of institutions performing ERCP in Belgium. Fifty-eight percent of centers performed > 100 ERCPs/year and 7% of centers (n=3) performed < 50 ERCPs/year. According to the RIZIV/INAMI data, low case-volume centers are underrepresented in this survey. The most common ERCPindication was stone extraction (52%). 74% of endoscopists had more than 10 years of experience in performing ERCP. The majority of centers had their own written protocol (84%) for microbiological duodenoscope surveillance. Monitoring of cannulation rate and post-ERCP pancreatitis (PEP) was only performed in a minority of centers (30%). The majority of centers (76%) provided verbal informed consent relating to the ERCP-procedure ; a minority also requested a written informed consent (23%). 65% of centers systematically use NSAIDs for PEP prophylaxis. This is the first survey of ERCP performance in Belgium. There were wide variations in practice. Adherence to key performance measures and measurement and evaluation of ERCP performance in daily practice at center and endoscopist level are not uniformly widespread.

Issue Highlights

Issue Highlights

15 Utilization Patterns of Prophylactic Pancreatic Stents for the Prevention of Post-ERCP Pancreatitis: A 2018 National Survey Study

INTRODUCTION: Post ERCP Pancreatitis (PEP) is the most frequent complication of endoscopic retrograde cholangiopancreatography (ERCP). Prophylactic pancreatic stents (PPS) and rectal indomethacin (IND) prevent PEP, decrease severity in PEP and are endorsed by GI societies. It is unclear the extent to which these interventions are practiced throughout the United States (US). The impact of such factors as training, experience and practice setting on the use of PPS for PEP prophylaxis is unclear. The aims of our study are to describe utilization patterns and identify factors that impact physician decisions to use PPS for PEP prophylaxis. METHODS: A 27-question electronic survey was distributed using a cloud based program (Qualtrics). Questions assessed ERCP training, practice setting, experience, practice patterns and perceptions for PEP prophylaxis interventions. Endoscopists with practices based in the US, listed in the American Society for Gastrointestinal Endoscopy (ASGE) member directory received a survey invitation via e-mail. The invitation outlined the study and contained a link with instructions to complete the voluntary survey if they had an active ERCP practice. Data was de-identified for the purposes of analysis. RESULTS: Of survey respondents (n = 319/6276), 46% reported therapeutic endoscopy fellowship training and 37% practiced in teaching programs (Table 1). Annualized ERCP volume of &gt;100 cases per year were reported by 47%, with pancreatic ERCP comprising ≤5% of procedures in the majority of respondents (61%). The majority of respondents utilized PPS and 54% reported frequent use (Table 2). The most common indications for PPS were: difficult cannulation, to assist biliary access and multiple pancreatic duct injections. The majority of respondents reported frequent use of IND (89%). Of physicians that do not use PPS, use of IND was the most common reason (80%). Variables associated with frequent use of PPS were therapeutic fellowship training (P = &lt;0.001), practice at a teaching program (P = &lt;0.001), &lt;10 yrs in practice (P = 0.005), higher procedure volume (P = &lt;0.001), higher proportion of pancreatic cases (P = &lt;0.001), and selective use of IND (P = 0.002) (Table 3). CONCLUSION: Physicians with higher volume, teaching hospital based ERCP practices and regularly perform pancreatic ERCP are more likely to use PPS. Therapeutic fellowship training and recent entry into practice also associate with PPS utilization. Indomethacin use was prevalent and the most cited reason for electing not to use PPS.

Outcomes and timing of endoscopic retrograde cholangiopancreatography for acute biliary pancreatitis

BackgroundIndication of endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis (ABP) is challenging. AimsIn this retrospective study, we analyzed real-world data to understand the ERCP practice in ABP in Hungarian centers. MethodsClinical data on ABP patients (2013–2015) were extracted from our large multicentric database. Outcomes, quality indicators and the role of early timing of ERCP (<24 h from admission) were analyzed. ResultsThere were 356 patients with ABP. ERCP was performed in 267 (75%). Performance indicators of ERCP proved to be suboptimal with a biliary cannulation rate of 84%. Successful vs unsuccessful cannulation of naïve papilla resulted in lower rates of local [22.9% vs 40.9%, (P = 0.012)] and systemic [4.9% vs 13.6%, (P = 0.042)] complications. Successful vs unsuccessful clearance resulted in lower rates of local complications [22.5% vs 40.8%, (P = 0.008)]. Successful cannulation and drainage correlated with less severe course of ABP [3.6% vs 15.9%, (P = 0.001) and 4.1% vs 12.2%, (P = 0.033)] respectively. A tendency of an increased rate of local complications was observed if ERCP was performed later [<24 h: 21.1% (35/166); between 24–48 h: 23.4% (11/47); >48h: 37.2% (16/43) (P = 0.088)]. ConclusionOptimization of ERCP indication in ABP patients is critical as suboptimal ERCP practices in ABP without definitive stone detection are associated with poorer clinical outcomes.

Prospective evaluation of ERCP performance in an Italian regional database study

BackgroundProspective studies about endoscopic retrograde cholangio-pancreatography (ERCP) in a community setting are rare. AimTo assess success and complication rates of routinely-performed ERCP in a regional setting, and the priority quality indicators for ERCP practice. MethodsProspective region wide observational study on consecutive patients undergoing ERCP during a 6-month period. A centralized online ERCP questionnaire was built and used for data storage. Primary quality indicators provided by the American Society of Gastrointestinal Endoscopy (ASGE) were considered. Results38 endoscopists from 18 centers performed a total of 2388 ERCP. The most common indication for ERCP was choledocholitiasis (54.8%) followed by malignant jaundice (22.6%). Cannulation of the desired duct was obtained in 2293 cases (96%) and ERCP was successful in 2176 cases (91.1%). Success and ERCP difficulty were significantly related to the experience of the operator (p = 0.001 and p < 0.001, respectively). ERCP difficulty was also significantly related to volume centers (p < 0.01). The overall complication rate was 8.4%: post-ERCP pancreatitis (PEP) occurred in 4.1% of procedures, bleeding in 2.9%, infection in 0.8%, perforation in 0.4%. Mortality rate was 0.4%. All the ASGE priority quality indicators for ERCP were confirmed. ConclusionsThe procedural questionnaire proved to be an important tool to assess and verify the quality of routinely-performed ERCP performance in a community setting.

A modern approach to ERCP: maintaining efficacy while optimising safety.

Endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging and complications such as post-ERCP pancreatitis (PEP) remain a concern. Modern ERCP techniques aim to maintain efficacy and improve safety. There are limited data regarding efficacy and safety of ERCP carried out by a newly qualified practitioner using modern techniques. The aim of the present study was to conduct an ERCP practice audit and compare it with an Australian national survey in order to review the evidence base underlying modern ERCP practice. All ERCP carried out by a newly qualified practitioner, using prospectively collected data, from September 2011 to May 2015, were audited. Outcomes were compared to an Australia-wide survey of ERCP practice. A literature review was carried out regarding recent developments in ERCP practice. Audit results correlated well with national data. All 478 ERCP were therapeutic and had pre-procedure imaging. Wire-guided biliary cannulation was used. Success rate was 97%. Overall adverse-event rate was 0.8%. Choledocholithiasis was the predominant indication (72%). Biliary cannulation was successful in 338 of 348 naiive papillae. Of these, there were 53 (16%) difficult cannulations but the needle-knife sphincterotomy (NKS) rate was low compared to national data (13% vs 33%). Rate of dual-wire cannulation technique was higher (87% vs 30%). Pancreatic duct stenting (done in 32 cases [70% of dual-wire cannulation cases]) and rectal indomethacin (25%) were used to reduce PEP risk. A newly qualified ERCP proceduralist achieved high success rates with minimal adverse events using modern techniques. Practice was consistent with national data, although dual-wire cannulation technique was preferred to NKS. Evidence base for modern ERCP techniques was reviewed. ERCP efficacy and safety should be monitored by practice audit.

A prospective audit of local ERCP practice: Single centre experience

Aims: Endoscopic retrograde cholangio-pancreatography (ERCP) procedure is carried out for both diagnostic and therapeutic purposes. On average approximately 54,000 ERCP procedures are carried out in the UK each year. The Joint Advisory Group for GI endoscopy in conjunction with the British Society of Gastroenterology (BSG) has released quality and safety guidelines for ERCP procedure. We aimed to compare our local ERCP practice to the national guidelines for quality assurance and practice improvement. Methods: A one year data on all ERCP related procedures maintained prospectively from a single endoscopy unit was collected and analysed against a standard audit proforma. The audit proforma was devised locally based on a range of procedure related parameters as suggested in the BSG guidelines. Results: A total of n = 162 ERCPs were undertaken. The male to female ratio in the study cohort was 1:1.8 with a mean age of 71 and 66 years respectively. Of the total procedures, 79.6% (129/162) were therapeutic and 20.4% (33/162) diagnostic; 92% (n = 149) had successful biliary cannulation rate; 9.9% (16/162) were re-admitted with abdominal pain and 6.2% (10/162) had post-procedure pancreatitis. From the study cohort, the success rate of combined therapeutic and diagnostic procedures was recorded at 92% (149/162). None of the patients from the study cohort suffered from bowel perforation, bleeding or death. The structure and staffing levels of the unit were found to be adequate and complied with the recommended standards. A variance was noted in the prophylactic antibiotics usage between the endoscopists in the unit. Conclusions: Findings from the audit showed that our local ERCP practice complied with most of the national standards. However, a few areas of improvement included strategies to reduce post-ERCP pancreatitis, standarisation of antibiotic prophylaxsis use and reduction of ERCP for diagnostic purposes. Corrective measures were suggested based on the audit findings.

Advances in endoscopic retrograde cholangiopancreatography for the treatment of cholangiocarcinoma.

Cholangiocarcinoma (CCA) is a malignancy of the bile ducts that carries high morbidity and mortality. Patients with CCA typically present with obstructive jaundice, and associated complications of CCA include cholangitis and biliary sepsis. Endoscopic retrograde cholangiopancreatography (ERCP) is a valuable treatment modality for patients with CCA, as it enables internal drainage of blocked bile ducts and hepatic segments by using plastic or metal stents. While there remains debate as to if bilateral (or multi-segmental) hepatic drainage is required and/or superior to unilateral drainage, the underlying tenant of draining any persistently opacified bile ducts is paramount to good ERCP practice and good clinical outcomes. Endoscopic therapy for malignant biliary strictures from CCA has advanced to include ablative therapies via ERCP-directed photodynamic therapy (PDT) or radiofrequency ablation (RFA). While ERCP techniques cannot cure CCA, advancements in the field of ERCP have enabled us to improve upon the quality of life of patients with inoperable and incurable disease. ERCP-directed PDT has been used in lieu of brachytherapy to provide neoadjuvant local tumor control in patients with CCA who are awaiting liver transplantation. Lastly, mounting evidence suggests that palliative ERCP-directed PDT, and probably ERCP-directed RFA as well, offer a survival advantage to patients with this difficult-to-treat malignancy.

Predicting native papilla biliary cannulation success using a multinational Endoscopic Retrograde Cholangiopancreatography (ERCP) Quality Network

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.

Prophecy about post-endoscopic retrograde cholangiopancreatography pancreatitis: From divination to science

One unresolved issue of endoscopic retrograde cholangiopancreatography (ERCP) is post-ERCP pancreatitis (PEP), which occurs in up to 40% of patients. Identification of risk factors for PEP is especially important in the field of ERCP practice because it may assist physicians in taking protective measures in situations with high risk. A decade ago, Freeman et al meticulously evaluated a large number of potentially relevant risk factors for PEP, which can be divided into patient-related and procedure-related issues. In this commentary, we summarize this classic article and reevaluate the risk factors for PEP from the current point of view. This is followed by assessment of strategies for prevention of PEP that can be divided into mechanical and pharmacologic methods.

The ERCP Quality Network

There is increasing interest in the quality of endoscopic practice and in documenting it. Endoscopic retrograde cholangiopancreatography (ERCP) is the most complex and risky procedure performed regularly by gastroenterologists. The goal was to test the acceptability and functioning of a voluntary system for individual endoscopists to report details of their ERCP cases and to compare them with unidentified peers. Participants were compared by site of practice, procedure complexity, volumes, durations, and selected technical success rates. There was no independent audit. A total of 63 endoscopists in the United States entered data on 18 182 procedures over 3 years. Results in academic and community practices were similar, but there were significant and expected differences in the complexity of practice and key quality metrics between endoscopists performing more than and fewer than 100 cases per year. The study provided useful data on variations in ERCP practice in the United States and will assist in planning the development of national projects in this field.

The ERCP quality network benchmarking project: a preliminary comparison of practice in UK and USA

ObjectiveThe Endoscopic retrograde cholangiopancreatography (ERCP) Quality Network is a voluntary system for submission of data to generate individual report cards and benchmarking. The aim of this study was to compare...

HEAD-TO-HEAD COMPARISON OF PRACTICE WITH ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY COMPUTER AND MECHANICAL SIMULATORS BY EXPERIENCED ENDOSCOPISTS AND TRAINEES

The endoscopic retrograde cholangiopancreatography (ERCP) mechanical simulator (EMS) and computer simulator (ECS) are described herein. No direct hands-on comparison has been reported to reflect the perception of trainers and trainees regarding the efficacy of each model for trainee ERCP education. We compared the trainers' and trainees' assessments of the EMS and ECS for trainee education. Eighteen gastrointestinal trainees and 16 trainers with varying ERCP experience completed a questionnaire survey before and after practice with each simulator at hands-on ERCP practice workshops. They carried out scope insertion, selective bile duct cannulation, guidewire negotiation of a bile duct stricture, biliary papillotomy and insertion of a single biliary stent using both simulators. Main outcome measurement was respondents' assessments of comparative efficacy of EMS and ECS practice for trainee education. Compared to pre-practice evaluation, both EMS and ECS received higher scores after hands-on practice. Both trainers and trainees showed significantly greater increases in scores for EMS when compared with ECS in facilitating understanding of ERCP procedure, enhancing confidence in carrying out ERCP and the simulator as a credible option for supplementing clinical ERCP training (P < 0.05). Participants also scored EMS significantly higher in realism and usefulness as an instructional tool. Both computer and mechanical simulators are accepted modalities for ERCP training. The current data (based on a head-to-head comparison of hands-on practice experience) indicate EMS practice is rated higher than ECS practice in supplementing clinical ERCP training. EMS offers the additional advantage of coordinated practice with real equipment and accessories.

Endoscopic retrograde cholangio-pancreatography practice in district general hospitals in North East England: a Northern Regional Endoscopy Group (NREG) study

Endoscopic retrograde cholangio-pancreatography (ERCP) is an important tool for the management of pancreato-biliary disease. The aim of this study was to compare the current practice of ERCP in North East England against the key 2004 National Confidential Enquiry Report into Patient Outcome and Death (NCEPOD) recommendations and the standards set by the Joint Advisory Group on Gastrointestinal Endoscopy (JAG). This was a prospective multicentre study involving all hospitals in North East England, coordinated through the Northern Regional Endoscopy Group (NREG). Fourteen endoscopy units submitted data for 481 ERCPs. Mean dose of midazolam was 3.24 mg (standard deviation 1.35; range 1-8 mg). Coagulation profile results were available on 469 patients (97%). Radiological investigations were documented in 96% of the procedures (463 of 481) prior to ERCP. The most common indication for ERCP was related to choledocholithiasis and its complications. All procedures were performed with a therapeutic intent. A total of 84% of all patients were either American Society of Anesthesiologists grade I or II. The selective biliary cannulation rate was 87.3%. The total completion rate of all procedures was 80.2% (381 of 475) and completion of therapy was 89.5% (425 of 475). The 30-day mortality rate was 2% (ten patients) and procedure-related complications occurred in 5% of patients. There were no deaths directly as a result of ERCP; all deaths were related to underlying medical conditions. The practice of ERCP in North East England adheres to the key recommendations of the NCEPOD and the standards set by JAG. The rates of complications compare favourably with those reported internationally.

The substitution of endoscopic ultrasound for endoscopic retrograde cholangio-pancreatography: implications for service development and training.

Choledocholithiasis and other benign conditions of the biliary tree are difficult to define clinically. Endoscopic retrograde cholangio-pancreatography (ERCP) is increasingly being replaced as the investigation of choice by other imaging modalities. The aim of this study was to measure the impact of substituting endoscopic ultrasound (EUS) for ERCP in terms of case throughput and the proportion of therapeutic ERCPs performed. Over a 12-month period, cases with a low/medium likelihood for biliary pathology were triaged to EUS rather than ERCP. Data were collected on the proportion of ERCPs performed with diagnostic or therapeutic intent and compared with data from the preceding 12-month period. In the 12 months to April 2001, 518 cases were referred for ERCP; 140 underwent EUS and 378 underwent ERCP. The proportions of diagnostic and therapeutic ERCP were 14% and 86%, respectively. Benign biliary disease represented 33% of all referrals for EUS, and calculi were identified in 6% of these cases. During the preceding year, 637 ERCPs were performed. The proportion of diagnostic (33%) and therapeutic (67%) cases differed from the index year (P < 0.001). The substitution of EUS for ERCP results in significant quantitative and qualitative change to ERCP practice, which has direct consequences for training and service development.