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Vedantam S, Amin S, Maher B, Ahmad S, Kadir S, Niaz SK, Wright M, Tehami N. Increased ERCP volume improves cholangiogram interpretation: a new performance measure for ERCP training? Clin Endosc 2022; 55:426-433. [PMID: 35114744 PMCID: PMC9178142 DOI: 10.5946/ce.2021.239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/26/2021] [Accepted: 11/08/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND/AIMS Cholangiogram interpretation is not used as a key performance indicator (KPI) of endoscopic retrograde cholangiopancreatography (ERCP) training, and national societies recommend different minimum numbers per annum to maintain competence. This study aimed to determine the relationship between correct ERCP cholangiogram interpretation and experience. METHODS One hundred fifty ERCPists were surveyed to appropriately interpret ERCP cholangiographic findings. There were three groups of 50 participants each: "Trainees," "Consultants group 1" (performed >75 ERCPs per year), and "Consultants group 2" (performed >100 ERCPs per year). RESULTS Trainees was inferior to Consultants groups 1 and 2 in identifying all findings except choledocholithiasis outside the intrahepatic duct on the initial or completion/occlusion cholangiogram. Consultants group 1 was inferior to Consultants group 2 in identifying Strasberg type A bile leaks (odds ratio [OR], 0.86; 95% confidence interval [CI], 0.77-0.96), Strasberg type B (OR, 0.84; 95% CI, 0.74-0.95), and Bismuth type 2 hilar strictures (OR, 0.81; 95% CI, 0.69-0.95). CONCLUSION This investigation supports the notion that cholangiogram interpretation improves with increased annual ERCP case volumes. Thus, a higher annual volume of procedures performed may improve the ability to correctly interpret particularly difficult findings. Cholangiogram interpretation, in addition to bile duct cannulation, could be considered as another KPI of ERCP training.
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Affiliation(s)
- Shyam Vedantam
- Department of Medicine, University of Miami, Miami, FL, USA
| | - Sunil Amin
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami, Miami, FL, USA
| | - Ben Maher
- Department of Interventional Radiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Southampton Interventional Endoscopy Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Saqib Ahmad
- Department of Gastroenterology, Sherwood Forest Hospitals NHS Foundation Trust, Sutton in Ashfield, UK
| | - Shanil Kadir
- Department of Gastroenterology, Liaquat National Hospital and Medical College, Karachi, Pakistan
| | - Saad Khalid Niaz
- Interventional Endoscopy Unit, Surgical Unit 4, Dow University of Health Sciences, Karachi, Pakistan
| | - Mark Wright
- Southampton Interventional Endoscopy Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Nadeem Tehami
- Southampton Interventional Endoscopy Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Hindman NM, Arif-Tiwari H, Kamel IR, Al-Refaie WB, Bartel TB, Cash BD, Chernyak V, Goldstein A, Grajo JR, Horowitz JM, Kamaya A, McNamara MM, Porter KK, Srivastava PK, Zaheer A, Carucci LR. ACR Appropriateness Criteria ® Jaundice. J Am Coll Radiol 2020; 16:S126-S140. [PMID: 31054739 DOI: 10.1016/j.jacr.2019.02.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/08/2019] [Indexed: 02/07/2023]
Abstract
Jaundice is the end result of myriad causes, which makes the role of imaging in this setting particularly challenging. In the United States, the most common causes of all types of jaundice fall into four categories including hepatitis, alcoholic liver disease, blockage of the common bile duct by a gallstone or tumor, and toxic reaction to a drug or medicinal herb. Clinically, differentiating between the various potential etiologies of jaundice requires a detailed history, targeted physical examination, and pertinent laboratory studies, the results of which allow the physician to categorize the type of jaundice into mechanical or nonmechanical causes. Imaging modalities used to evaluate the jaundiced patient (all etiologies) include abdominal ultrasound (US), CT, MR cholangiopancreatography, endoscopic retrograde cholangiopancreatography and endoscopic US. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | | | - Hina Arif-Tiwari
- University of Arizona, Banner University Medical Center, Tucson, Arizona
| | - Ihab R Kamel
- Panel Chair, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Waddah B Al-Refaie
- Georgetown University Hospital, Washington, District of Columbia; American College of Surgeons
| | | | - Brooks D Cash
- University of Texas McGovern Medical School, Houston, Texas; American Gastroenterological Association
| | | | | | - Joseph R Grajo
- University of Florida College of Medicine, Gainesville, Florida
| | | | - Aya Kamaya
- Stanford University Medical Center, Stanford, California
| | | | | | - Pavan K Srivastava
- University of Illinois College of Medicine, Chicago, Illinois; American College of Physicians
| | | | - Laura R Carucci
- Specialty Chair, Virginia Commonwealth University Medical Center, Richmond, Virginia
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Merei F, Shapiro G, Abu Shakra I, Bickel A, Ganam S, Bez M, Kakiashvili E. A unusual case of multifocal pyogenic abscess formation following ERCP procedure. BMC Surg 2020; 20:92. [PMID: 32375832 PMCID: PMC7203808 DOI: 10.1186/s12893-020-00759-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 04/28/2020] [Indexed: 11/30/2022] Open
Abstract
Background Endoscopic retrograde cholangiopancreatography (ERCP) is essential for managing biliary and pancreatic disorders. Infection is the most morbid complication of ERCP and among the most common causes of ERCP-related death. Case presentation A 69-year-old man presented with right upper quadrant abdominal pain, obstructive jaundice and abnormal liver function tests. Ultrasound revealed cholelithiasis without bile duct dilation. After receiving intravenous antibiotics for acute cholecystitis, the patient was discharged. Two weeks later, an endoscopic ultrasound demonstrated gallstones and CBD dilation of up to 6.4 mm with 2 filling defects. An ERCP was performed with a papillotomy and stone extraction. Twenty-four hours post-ERCP the patient developed a fever, chills, bilirubinemia and elevated liver function tests. Ascending cholangitis was empirically treated using Ceftriaxone and Metronidazole. However, the patient remained febrile, with a diffusely tender abdomen and elevated inflammatory markers. A CT revealed a very small hypodense lesion in the seventh liver segment. Extended-spectrum beta-lactamase positive Klebsiella Pneumonia and Enterococcus Hirae were identified, and the antibiotics were switched to Imipenem and Cilastatin. The hypodense lesion in the liver increased to 1.85 cm and a new hypodense lesion was seen in the right psoas. At day 10 post-ERCP, the patient started having low back pain and difficulty walking. MRI revealed L4-L5 discitis with a large epidural abscess, spanning L1-S1 and compressing the spinal cord. Decompressive laminectomy of L5 was done and Klebsiella pneumonia was identified. Due to continued drainage from the wound, high fever, we performed a total body CT which revealed increased liver and iliopsoas abscess. Decompressive laminectomy was expanded to include L2-L4 and multiple irrigations were done. Gentamycin and Vancomycin containing polymethylmethacrylate beads were implanted locally and drainage catheters were placed before wound closure. Multidisciplinary panel discussion was performed, and it was decided to continue with a non invasive approach . Conclusions Early recognition of complications and individualized therapy by a multi-disciplined team is important for managing post-ERCP septic complications. Particular attention should be given to adequate coverage by empiric antibiotics.
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Affiliation(s)
- Fahed Merei
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel
| | | | | | - Amitai Bickel
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel.,Faculty of Medicine in the Galilee, Bar-Ilan University, Safad, Israel
| | - Samer Ganam
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel
| | - Maxim Bez
- Medical Corps, Israel Defense Forces, Ramat Gan, Israel
| | - Eli Kakiashvili
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel. .,Faculty of Medicine in the Galilee, Bar-Ilan University, Safad, Israel.
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López-Picazo J, Alberca de Las Parras F, Sánchez Del Río A, Pérez Romero S, León Molina J, Júdez FJ. Quality indicators in digestive endoscopy: introduction to structure, process, and outcome common indicators. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 109:435-450. [PMID: 28553719 DOI: 10.17235/reed.2017.5035/2017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The general goal of the project wherein this paper is framed is the proposal of useful quality and safety procedures and indicators to facilitate quality improvement in digestive endoscopy units. This initial offspring sets forth procedures and indicators common to all digestive endoscopy procedures. First, a diagram of pre- and post-digestive endoscopy steps was developed. A group of health care quality and/or endoscopy experts under the auspices of the Sociedad Española de Patología Digestiva (Spanish Society of Digestive Diseases) carried out a qualitative review of the literature regarding the search for quality indicators in endoscopic procedures. Then, a paired analysis was used for the selection of literature references and their subsequent review. Twenty indicators were identified, including seven for structure, eleven for process (five pre-procedure, three intra-procedure, three post-procedure), and two for outcome. Quality of evidence was analyzed for each indicator using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) classification.
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Affiliation(s)
- Julio López-Picazo
- Servicio de Calidad Asistencial, Hospital Clínico Universitario Virgen de la Arrixaca
| | | | | | - Shirley Pérez Romero
- Servicio de Calidad Asistencial, Hospital Clínico Universitario Virgen de la Arrixaca
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Vashisht K, Nady SL, Engler RD, Kelsch BK, Lynk SN, Cape BR, Hoffmann G, Meseck EK, Johnson RC. Extraparenchymal Bile/Pancreatic Ducts and Duodenal Papillae: Pathologic Evaluation in Nonclinical Species--A Brief Review. Toxicol Pathol 2015; 43:651-61. [PMID: 25633421 DOI: 10.1177/0192623314560612] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This review focuses on the anatomy, histologic preparation, and pathologic evaluation of extraparenchymal bile and pancreatic ducts (BPDs) and their openings at the duodenal papillae in the cynomolgus macaque (Macaca fascicularis), the Beagle dog (Canis familiaris), the Wistar Hanover rat (Rattus norvegicus), and the CD1 mouse (Mus musculus). In nonclinical safety assessment, intraparenchymal BPDs (with sections of liver and pancreas, respectively) are evaluated routinely. However, detailed evaluation of the extraparenchymal BPDs or the duodenal papillae is not included. In the context of nonclinical safety assessment studies, this review describes situations in which evaluation of extraparenchymal ductal structures and duodenal papillae may be useful in characterizing test article-related changes; elucidates anatomic similarities between human, macaque, and dog and notable differences in rats and mice; and consolidates the information required for the histopathologic evaluation of these tissues.
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Affiliation(s)
- Kapil Vashisht
- Novartis Institutes for BioMedical Research, East Hanover, New Jersey, USA
| | - Sherry L Nady
- Novartis Institutes for BioMedical Research, East Hanover, New Jersey, USA
| | - Rita D Engler
- Novartis Institutes for BioMedical Research, East Hanover, New Jersey, USA
| | - Brian K Kelsch
- Novartis Institutes for BioMedical Research, East Hanover, New Jersey, USA
| | | | | | | | - Emily K Meseck
- Novartis Institutes for BioMedical Research, East Hanover, New Jersey, USA
| | - Robert C Johnson
- Novartis Institutes for BioMedical Research, East Hanover, New Jersey, USA
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Glomsaker TB, Hoff G, Kvaløy JT, Søreide K, Aabakken L, Søreide JA. Patient-reported outcome measures after endoscopic retrograde cholangiopancreatography: a prospective, multicentre study. Scand J Gastroenterol 2013; 48:868-76. [PMID: 23721162 DOI: 10.3109/00365521.2013.794470] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE While patient-reported outcome measures (PROMs) in ERCP are scarce, these reports are important for making improvements in quality of care. This study sought to document patient satisfaction and specifically pain related to endoscopic retrograde cholangiopancreatography (ERCP) procedures and to identify predictors for these experiences. METHODS From 2007 through 2009, prospective data from consecutive ERCP procedures at 11 hospitals during normal daily practice were recorded. Information regarding undesirable events that occurred during a 30-day follow-up period was also reported. The patient-reported pain, discomfort and general satisfaction with the ERCP were recorded. RESULTS Data from 2808 ERCP procedures were included in this study. Patient questionnaires were returned for 52.6% of the procedures. Moderate or severe pain was experienced in 15.5% and 14.0% of the procedures during the ERCP and in 10.8% and 7.7% of the procedures after the ERCP, respectively. In addition, female gender, endoscopic sphincterotomy (EST), and longer procedure times served as independent predictors of increased pain during the ERCP. The performing hospitals and sedation regimens were independent predictors of the procedural pain experience. In 90.9% of the procedures, the patients were satisfied with the information overall, and in 98.3% of the procedures, the patients were satisfied with the treatment provided. Independent predictors of dissatisfaction with the treatment included the occurrence of specific complications after ERCP and pain during or after the procedure. CONCLUSIONS Female gender, the performance of EST and longer procedure times were independent predictors for increased procedure-related pain. The individual hospital and sedation regimen predicts the patient's pain experience.
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Affiliation(s)
- Tom B Glomsaker
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
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Lalani T, Couto CA, Rosen MP, Baker ME, Blake MA, Cash BD, Fidler JL, Greene FL, Hindman NM, Katz DS, Kaur H, Miller FH, Qayyum A, Small WC, Sudakoff GS, Yaghmai V, Yarmish GM, Yee J. ACR Appropriateness Criteria Jaundice. J Am Coll Radiol 2013; 10:402-9. [DOI: 10.1016/j.jacr.2013.02.020] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Accepted: 02/26/2013] [Indexed: 01/20/2023]
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