Endoscopic Retrograde Cholangiopancreatography Quality Research Articles

Development and Usability of an Endoscopist Report Card Assessing ERCP Quality

Audit and feedback (A&F) for endoscopic retrograde cholangiopancreatography (ERCP) is relatively understudied despite the demonstrated effectiveness of A&F for endoscopic procedures such as colonoscopy. Endoscopist 'report cards' are one A&F tool. We aimed to develop an ERCP report card and assess its appropriateness, acceptability and feasibility through usability testing. A prototype report card was designed using a combination of published quality indicators and established predictors of adverse events (AE). Exploratory analyses from a prospective multi-center registry were performed to further identify novel and/or understudied parameters for possible inclusion. Semi-structured interviews with ERCP endoscopists were conducted and framework analysis performed. Validated post-interview usability instruments were administered. Feedback was incorporated to create a final report card. The report card included domains of technical parameters, AE rates/prevention, and patient-reported experience measures (PREMs). Qualitative feedback was positive, with respondents agreeing with inclusion of relevant content in most domains. Post-interview instruments revealed adequate appropriateness and acceptability. PREMs were felt by respondents to be poorly actionable and were replaced with appropriateness of indication and fluoroscopy usage parameters in the final report card. Concerns were raised regarding the feasibility of implementation due to reliance on difficult-to-obtain granular intraprocedural data. We designed and tested an ERCP report card that has potential to be an effective A&F intervention for endoscopists in clinical practice. Though feasibility of data capture and implementation are currently limitations, advances in video recording and artificial intelligence technologies could accelerate widespread adoption of such a tool.

Quality Indicators of Endoscopic Retrograde Cholangiopancreatography in Korea

Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that requires abundant clinical experience and endoscopic skills, and can lead to various complications, some of which may progress to life-threatening conditions. With expanding indications and technological advancements, ERCP is widely utilized, enhancing procedural accessibility. However, without proper quality management, the procedure can pose significant risks. Quality management in ERCP is essential to ensure safe and successful procedures and meet societal demands for improved healthcare competitiveness. To address these concerns, the Korean Society of Pancreatobiliary Endoscopy has developed a Korean-specific ERCP quality indicator reflecting domestic medical environments and realities. Initially, based on a review of foreign ERCP quality indicators and related literatures, key questions were formulated for five pre-procedural items, three intra-procedural items, and four post-procedural items. Descriptions and recommendations for each item were selected through peer evaluation. The developed Korean-specific ERCP quality indicator was reviewed by external experts based on the latest evidence and consensus in this fields. This Korean-specific indicator is expected to significantly contribute to improving ERCP quality in Korea, as it is tailored to local needs.

Quality Indicators of Endoscopic Retrograde Cholangiopancreatography in Korea.

Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that requires significant experiences and skills and has various procedure-related complications, some of which can be severe and even result in the death of patients. Expanding ERCP availability has the advantage of increasing accessibility for patients. However, ERCP poses a substantial risk if performed without proper quality management. ERCP quality management is essential for both ensuring safe and successful procedures and meeting the social demands for enhanced healthcare competitiveness and quality assurance. To address these concerns, the Korean Pancreatobiliary Association established a task force to develop ERCP quality indicators (QIs) tailored to the Korean medical environment. Key questions for five pre-procedure, three intra-procedure, and four post-procedure measures were formulated based on a literature search related to ERCP QIs and a comprehensive clinical review conducted by experts. The statements and recommendations regarding each QI item were selected through peer review. The developed ERCP QIs were reviewed by external experts based on the latest available evidence at the time of development. These domestically tailored ERCP QIs are expected to contribute considerably to improving ERCP quality in Korea.

Development of an Automated Endoscopic Retrograde Cholangiopancreatography Quality Report Card Using an Integrated Analytics Suite

BACKGROUND AND AIMSQuality indicators (QIs) are essential for evaluating the safety and effectiveness of endoscopy but are difficult to measure accurately for endoscopic retrograde cholangiopancreatography (ERCP). We developed a fully automated, real-time endoscopy analytics tool using Health Level-7 standards that collects ERCP QIs from an endoscopy reporting system to generate an ERCP quality report card in a third-party analytics suite. METHODSERCP report data were collected between June 2021 and December 2022 from 4 referral centers. Discrete data elements from endoscopy reports generated in the EndoPro reporting platform were imported into the Qlik analytics suite, and QI data were aggregated into a report card. The collected data were manually validated to confirm accuracy. RESULTSPooled data were successfully used to generate a comprehensive institutional ERCP quality report card comprising a total of 2146 ERCPs performed by 12 endoscopists. Manual review confirmed high accuracy (96.5%-100%) of automatic extraction of ERCP QIs from endoscopy reports. Multiple procedural data elements were successfully extracted, including cannulation difficulty, success rate, and administration of post-ERCP pancreatitis prophylaxis for procedures with biliary and pancreatic indication. Generation of the report card required minimal additional work on the part of the performing endoscopist and was updated in real time. CONCLUSIONWe developed an automated ERCP analytics tool that accurately and automatically extracts QI data into a succinct ERCP quality report card without the need for manual data extraction or natural language processing. The use of the Health Level-7 standard provides a framework for the creation of similar tools in other electronic health records. This tool allows for accurate ERCP quality and performance data evaluation at individual and institutional levels.

Limited exposure to pancreatic ERCP during advanced endoscopy training impacts competence and performance in independent practice

Background/ObjectivesThe impact of competency-based training programs on pancreatic endoscopic retrograde cholangiopancreatography (ERCP) performance remains unclear. This study aimed to describe the learning curves of pancreatic ERCP and subsequent performance during independent practice. MethodsThis was a multicenter prospective cohort study involving advanced endoscopy trainees (AETs). In the 1st phase, trainees were assessed on every 5th ERCP using the ERCP and EUS Skills Assessment Tool (TEESAT). Cumulative sum (CUSUM) analysis of pancreatic ERCP evaluations was used to establish learning curves. During the 2nd phase (1st year of independent practice), now-graduated participants documented their performance on key ERCP quality indicators. ResultsA total of 24 AETs (20 training programs) received sufficient evaluations for CUSUM analysis. Pancreatic ERCP accounted for 14.6 % (196/1339) of all ERCPs evaluated with 45 % of pancreatic ERCPs carrying a Grade 3 level of complexity. A minority of AETs (16.7 %) performed enough pancreatic ERCPs to generate meaningful learning curves with no AETs achieving competence in pancreatic cannulation, sphincterotomy, or stone clearance during Phase 1. In Phase 2, a total of 3620 ERCPs were performed, of which 281 (7.8 %) were pancreatic ERCPs. While the overall pancreatic duct cannulation rate was 92.2 %, the native papilla pancreatic duct cannulation rate was 85.7 %, which was below the recommended 90 % threshold. ConclusionsAdvanced endoscopy training offers a low level of exposure to pancreatic ERCP, which is mirrored in independent practice, highlighting the inadequate training in pancreatic ERCP. Given the complexity of pancreatic ERCP, novel strategies are warranted to improve training in pancreatic ERCP.

The impact of transpancreatic precut sphincterotomy on the quality of ERCP in a low-volume setting

Background and aimsAlthough quality improvement is crucial for endoscopic retrograde cholangiopancreatography (ERCP), a low practice volume can pose challenges to achieving high-quality bile duct cannulation. Transpancreatic precut sphincterotomy (TPS) has been proven effective for advanced cannulation. However, existing data mainly come from skilled endoscopists in large medical centers. The impact of TPS on ERCP quality in a lower-volume setting deserves investigation. MethodsOur hospital performs approximately 200 ERCPs annually, with one expert performing approximately half of them and three nonexpert endoscopists sharing the remaining cases. TPS was started and became our predominant advanced cannulation technique in April 2016. We retrospectively reviewed ERCP cases three years before and after the introduction of TPS. The primary endpoints of the study were the differences in two ERCP quality indicators, the bile duct cannulation rate and the incidence of post-ERCP pancreatitis (PEP). ResultsA total of 701 ERCP cases with naïve papilla were analyzed, with 350 patients treated before the introduction of TPS and 351 patients treated afterward. The successful cannulation rate was significantly improved (before: 87.4%, after: 92.3%, P=0.032), while the incidence of PEP decreased, but not significantly (before: 4.0%, after: 2.8%, P=0.402). All endoscopists benefited from utilizing TPS, with nonexperts demonstrating a significantly higher improvement in the cannulation rate (before: 85.5%, after: 93.1%, P=0.019). ConclusionsTPS can effectively enhance the quality of ERCP irrespective of practice volume.

A prospective study on quality in endoscopic retrograde cholangiopancreatography (ERCP): trend in Italy from the REQUEST study.

Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) is a complex procedure with a relatively high rate of adverse events. Data on training of operators and fulfillment of quality indicators in Italy are scarce. The goal of this study was to assess the overall quality of ERCP in Italy compared to international standards. Patients and methods This was a prospective, observational study from different Italian centers performing ERCP. Operators answered a questionnaire, then recorded data on ERCPs over a 1-to 3-month period. Results Nineteen Italian centers participated in the study. The most common concern of operators about training was the lack of structured programs. Seven/19 centers routinely used conscious sedation for ERCP. Forty-one experienced operators and 21 trainees performed 766 ERCPs: a successful deep biliary cannulation in native-papilla patients was achieved in 95.1 % of cases; the post-ERCP pancreatitis (PEP) rate was 5.4 % in native-papilla patients; cholangitis rate was 1.0 %; bleeding and perforation occurred in 2.7 % and 0.4 % of the patients, respectively. Conclusions This study revealed that, overall, ERCP is performed in the participating Italian centers meeting good quality standards, but structured training and sedation practice are still subpar. The bleeding and perforation rate slightly exceeded the American Society of Gastrointestinal Endoscopy indicator targets but they are comparable to the reported rates from other international surveys.

Implementation of mandatory ERCP registration in The Netherlands and compliance with European Society of Gastrointestinal Endoscopy performance measures: a multicenter database study.

In 2018, the European Society of Gastrointestinal Endoscopy (ESGE) and United European Gastroenterology (UEG) published quality performance measures for endoscopic retrograde cholangiopancreatography (ERCP). Since January 2016, all endoscopists in the Netherlands have been required to register all ERCP procedures in a nationwide quality registry. This study aimed to evaluate the procedural success rates of ERCP after the implementation of mandatory national registration and to compare these with the ESGE quality performance measures. This study was conducted with data from a multicenter endoscopy database. Data from 2019 and 2020 were analyzed. The primary outcome was ERCP procedural outcome. ESGE performance measures that could be evaluated were the percentage of successful bile duct cannulations in patients with virgin papillary anatomy; successful stent placement for a biliary obstruction located below the liver hilum; and complete removal of bile duct stones (< 10 mm). In total, 5295 ERCPs performed in 11 centers were included for analysis. The overall procedural success rate was 89.1 %. Successful biliary cannulation in patients with a virgin papilla was 90.3 % in nonacademic and 92.4 % in academic centers. The rates of successful stent placement in patients with a biliary obstruction located below the liver hilum were 97.0 % in nonacademic and 98.2 % in academic centers, and of successful bile duct stone extraction were 97.9 % in both nonacademic and academic centers. The quality of ERCPs performed met five of the six evaluated ESGE performance measures. The 95 % target for successful biliary cannulation in patients with virgin papillary anatomy in academic centers was not met. Mandatory registration provides valuable insight into ERCP performance rates.

Artificial intelligence-assisted analysis of endoscopic retrograde cholangiopancreatography image for identifying ampulla and difficulty of selective cannulation

The advancement of artificial intelligence (AI) has facilitated its application in medical fields. However, there has been little research for AI-assisted endoscopy, despite the clinical significance of the efficiency and safety of cannulation in the endoscopic retrograde cholangiopancreatography (ERCP). In this study, we aim to assist endoscopists performing ERCP through automatic detection of the ampulla and the identification of cannulation difficulty. We developed a novel AI-assisted system based on convolutional neural networks that predict the location of the ampulla and the difficulty of cannulation to the ampulla. ERCP data of 531 and 451 patients were utilized in the evaluation of our model for each task. Our model detected the ampulla with mean intersection-over-union 64.1%, precision 76.2%, recall 78.4%, and centroid distance 0.021. In classifying the cannulation difficulty, it achieved the recall of 71.9% for the class of easy cases and that of 61.1% for that of difficult cases. Remarkably, our model accurately detected AOV with varying morphological shape, size, and texture on par with the level of a human expert and showed promising results for recognizing cannulation difficulty. It demonstrated its potential to improve the quality of ERCP by assisting endoscopists.

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.

Quality in Endoscopic Retrograde Cholangiopancreatography—Incidence and Predictive Factors of Adverse Events

Background and AimsIncidence of endoscopic retrograde cholangiopancreatography (ERCP)-related adverse events varies between endoscopy units. We aimed to identify factors related to successful bile duct (BD) cannulation and to determine the incidence and predictive factors of post-ERCP adverse events. MethodsAbout 1103 ERCPs were evaluated from a prospective database over a 4-year period and 57 were excluded: age <18 years; incomplete procedure; surgically altered small bowel anatomy and refusal of informed consent. Factors associated with successful BD cannulation and predictive of post-ERCP adverse events were evaluated. ResultsOut of 1046 ERCPs analyzed, successful cannulation rate of native papilla of Vater was 91.3% (n = 639). Guidewire-assisted BD cannulation and choledocholithiasis were associated with higher native papilla cannulation rates (P = 0.02 and P < 0.001). Malignant biliary stricture and acute gallstone pancreatitis were associated with lower native papilla cannulation rates (P < 0.001 and P = 0.024). The incidence of post-ERCP adverse events was: Pancreatitis (PEP) 2.7% (n = 28), bleeding 0.8% (n = 8), cholangitis 0.7% (n = 7) and perforation 0.5% (n = 5). PEP risk was significantly higher in patients with native papilla compared with non-native papilla (rate of 3.6% and 0.6%, respectively, P = 0.005). In patients with native papilla, ≥2 unintentional pancreatic duct cannulations was the only independent predictive factor associated with PEP (odds ratio 2.371, 95% confidence interval: 1.003-5.605, P = 0.049). ConclusionCholedocholithiasis is associated with a higher cannulation rate while malignant biliary stricture and acute gallstone pancreatitis are associated with a lower BD cannulation rate. Patients with native papilla have a significantly higher risk of PEP with the only factor associated with PEP being 2 or more unintentional pancreatic duct cannulations.

Tu1160 “HARD STOPS” TO CAPTURE ERCP QUALITY METRICS.

A multi-society task force on endoscopic quality published a list of evidence-based quality indicators to measure endoscopic retrograde cholangiopancreatography (ERCP) outcomes in 2015. There are five high priority indicators, of which three measure intraprocedural outcomes in patients with native, non-surgically altered biliary anatomy. These include (1) frequency of native papilla cannulation; (2) Frequency of extraction of common bile duct stones <1 cm; (3) Frequency of stent placement for biliary obstruction below the bifurcation. The performance targets for each are recommended to be greater than 90%. Methods to increase compliance in capturing and documenting these measures would enable outcomes analyses and allow healthcare systems to monitor ERCP quality. We developed a method to universally capture these three intraprocedural quality indicators. In our health system, three hospitals perform the majority of ERCPs, and all share the same endoscopy reporting software (ProVationMD, ProVation Medical, Minneapolis, MN). We created “hard stops” in this software that requires the endoscopist to record an outcome of either success, failure, or not applicable (N/A) for each measure before the report can be finalized. These data can be exported to a spreadsheet for analysis. We analyzed intraprocedural ERCP quality metrics since instituting these “hard stops” at each hospital, and compared outcomes by (a) annual hospital volume- low (<100) vs high (>200), and (b) annual endoscopist volume- low (<50) vs high (>200). A total of 3395, 800, and 112 ERCPs were performed at three hospitals (2 high volume; 1 low volume) in our health system over 46, 41, and 39-month periods respectively. These procedures were performed by 12 different endoscopists (5 high volume; 7 low volume). Documentation of success, failure, or N/A for each quality indicator was captured in all ERCPs (100%). The average cannulation success rate at all sites was 95%. Cannulation success was higher for the high volume endoscopists (97% vs 90%; p=0.0001), and at high volume centers (97% vs 91%; p=0.009). Success for extracting biliary stones <1 cm was 97%, with higher success for high volume endoscopists (97% vs 93%; p=0.0441), and at high volume centers (97% vs 90%; p=0.0047). Success for stenting strictures was 98%, with higher success for high volume endoscopists (99% vs 81%; p=0.001), and at high volume centers (98% vs 76%; p=0.002). The metrics measuring stent placement were below recommended targets for low volume endoscopists and at low volume centers. Endoscopy documentation software can be formatted to force “hard stops” to prospectively capture intraprocedural quality indicators for ERCP. Implementing such methods allows for 100% collection of these outcomes, and can be used to analyze ERCP quality metrics in a health care system.

889 Enhancing Radiation Safety During Fluoroscopy Procedures in Endoscopy Units

INTRODUCTION: Fluoroscopy is an imaging technique often used in gastroenterology for endoscopic retrograde cholangiopancreatography (ERCP) procedures, subjecting the endoscopist and staff to radiation. Many studies have proposed best practices around behavior, choices, and equipment that attenuate radiation exposure. Gastrointestinal society guidelines also recommend measuring and documenting fluoroscopy time as an important quality metric for ERCP. Our goal was to ensure adequate safety precautions and reporting are adhered to by gastroenterology (GI) staff during fluoroscopy. METHODS: We performed baseline assessments of adherence to radiation safety protocols for fluoroscopy, interviewed interventional radiologists, and reviewed the medical literature to guide development of our intervention. We created an educational presentation on radiation safety and equipment handling with survey administration before and after. The first 4 questions used a Likert scale (1 = poor, 5 = excellent) to assess knowledge of and adherence to various aspects of radiation safety, while the latter 4 were multiple-choice questions regarding content. Second, we designated a radiation safety officer (RSO) to assess yearly reports. Lastly, we created a template with fluoroscopy time and dose recording. All interventions were delivered from 10/1/18 – 10/11/18. We reviewed post-ERCP notes to assess adherence. RESULTS: 17 individuals responded to pre- and post-intervention surveys (Table 1). Before the intervention, the first four questions had an average rating of 4.1 (SD of 0.70) and last four questions had an average correct response of 48% (SD of 20%); after the intervention, the average increased to 4.6 (SD of 0.17) and 93% (SD of 11%). We reviewed post-ERCP notes from 8/1/18 – 9/30/18 (n = 11) and found recording of the fluoroscopy time and radiation dose at baseline was 3%. After intervention, review of all post-ERCP notes from 10/1/18 – 5/31/19 (n = 94) showed recording to range from 86% - 100%. CONCLUSION: Initial audits showed a lack in radiation safety knowledge resulting in poor adherence to radiation safety protocols and documentation among GI staff at our tertiary care center. Interventions on education and facilitating documentation with templates can improve the quality of ERCPs and safe radiation practices dramatically.

Preprocedural Administration of Simethicone and Otilonium Bromide Improves the Quality of Endoscopic Retrograde Cholangiopancreatography: A Prospective Randomized Trial.

Endoscopic retrograde cholangiopancreaticography (ERCP) is performed for diagnostic and therapeutic purposes in patients with pancreaticobiliary diseases. We investigated the role of simethicone and concomitant otilonium bromide during ERCP. This prospective randomized study included 120 patients who underwent ERCP (study and control group=60 patients each). The study group received otilonium bromide and simethicone. The control group received no medication. The quantity of duodenal foam and bubbles in the study group was significantly lesser than that in the control group. The duodenal motility score was 2.1±0.7 and 4.3±0.9 in the study and the control groups, respectively. Endoscopist satisfaction was good in 82%, moderate in 15%, and poor in 3% of ERCPs in the study group and good in 15%, moderate in 65%, and poor in 25% of ERCPs in the control group. The study group showed a shorter ERCP duration than the control group. Simethicone and otilonium bromide administered concomitantly reduce duodenal motility and foam/bubble formation, which facilitates papilla of Vater catheterization to reduce procedure time.

How to measure quality in endoscopic retrograde cholangiopancreatography (ERCP).

Endoscopic retrograde cholangiopancreatography (ERCP) is invasive therapeutic procedure demanding specific individual approach for learning and mastering. It is associated with greater morbidity and mortality than any other procedure in gastroenterology. The risk for complications and harm for patient inevitably require strict guidelines to be followed regarding training, certification and proficiency. In an attempt to reduce the risk of complications, various endoscopic societies worldwide have established so called "Quality measures" which proved to be the back bone for safety and quality in ERCP. Recently developed ERCP quality network allowing data comparison between endoscopist is the key of reducing complications and creating a state of the art teaching program for beginner endoscopist. Further research is required regarding quality measures improvement and information exchange in the global ERCP quality network.

24 Measuring the value of endoscopic retrograde cholangiopancreatography (ERCP) activity: an opportunity to stratify endoscopists based on their value

Background The value in healthcare can be defined as patient health outcomes achieved per monetary unit spent. Aim To characterise the value of ERCP performance of four gastroenterologists. Method Medical records of patients undergoing ERCP between September 2014 and September 2016 in an academic medical centre were reviewed; all procedures were performed by one of four experienced gastroenterologists, all of whom have performed at least 1000 ERCPs. Procedure value was defined as the quality of procedure (Q) divided by the duration of procedure (T) adjusted for complexity level (C), that is, Q/(T/C). In those patients undergoing multiple ERCPs during the study period, only the index procedure was considered for analysis. ERCP quality and complexity were both graded on a 1 to 4 Likert scale based on American Society for Gastrointestinal Endoscopy (ASGE) criteria; time was recorded (in minutes) from intubation to extubation. Although individual components of procedure cost (eg, ERCP accessories, patient sedation, etc.) were not itemised, the procedure duration (ie, the cost of endoscopist’s time) was considered to be a reliable surrogate estimate of overall procedure cost. Results In total, index procedures on 465 patients were performed over 24 months; mean of 116 index ERCPs per endoscopist. Mean quality varied from 2.25 to 2.53 while adjusted mean duration (T/C) varied from 22.13 to 28.66 min per procedure. Value measurements varied from 8.1 to 10.7. Conclusions There was a 32% variation in the value of endoscopist activity. As healthcare costs are scrutinised more closely, such value measurements are likely to become more relevant.

Perfect or Failed ERCP: What Makes the Difference?

Endoscopic retrograde cholangiopancreatography (ERCP) has become an effective and safe therapeutic method, providing clinical success in more than 80% of cases. As ERCP has evolved from a diagnostic to a therapeutic procedure, technical demands have risen. Furthermore, it is an invasive procedure that can be potentially harmful when administered improperly. Quality of ERCP and procedural outcome are dependent on various factors that are related to the patient, procedure, and endoscopist. These factors are reviewed in detail and their contribution to ERCP quality is presented and discussed. Preventive therapies through procedural techniques and medical management to avoid complications are available. Proper and organised training and ERCP outcome reporting are essential for further quality improvement.

Sa1401 How Well Are WE Doing? Results of a Nationwide ERCP Quality Registry

Endoscopic retrograde cholangio- pancreatography (ERCP) is a complex procedure with high risk of complications. Despite significant interest by health authorities, patient organizations and insurance companies, data on procedural outcome and quality of ERCP in general and academic practice are sparse. The aim of this study was to assess procedural outcome of ERCP within a large prospective registry in the Netherlands and to evaluate associations between endoscopist-related factors and procedural outcome.

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.

Recording ERCP Fluoroscopy Metrics Using a Multinational Quality Network: Establishing Benchmarks and Examining Time-Related Improvements

We aimed to establish benchmarks for fluoroscopy time (FT) in endoscopic retrograde cholangiopancreatography (ERCP) and assess the effect of physician practice networking on time trends. Data from the ERCP Quality Network were used to assess practice variability in FT and establish case- and provider-level benchmarks of the first 200 cases for providers entering more than 100 cases. Trends in FT and high FT, by 50-patient groupings, were assessed by multilevel multivariate linear and logistic regression models. Median FT was 2.9 minutes, averaging 16% of procedure time. Ninetieth percentiles for the 57 eligible providers were 10 minutes and 22% (n = 9, 185 ERCP). Every 50 cases entered was associated with lower FT. In multivariate analysis, more cases entered, higher lifetime and annual volumes, lower difficulty grade, and manometry had lower FTs; academics, trainee involvement, various therapeutics, and failed cannulation had higher FTs. FT is highly variable, and many provider and case factors predict FT. FT benchmarks are now available. Self-review of one's case FT might decrease FT.