ERCP development in the largest developing country: a national survey from China in 2013

Development and status quo of digestive endoscopy in China: An analysis based on the national census in 2013 and 2020

Background and Objectives

Technique and practice of digestive endoscopy are undergoing speedy development all over the world. This study aimed to evaluate its status quo and development in China.

Methods

All hospitals performing digestive endoscopy in mainland China participated in the national census in 2013 and 2020. Retrospective data of hospitals, endoscopists, volumes, and qualities were collected via an online structured questionnaire, and its accuracy and rationality were verified by logical tests and manual reviews. Data from other countries were used to compare with that of China.

Results

From 2012 to 2019, the number of hospitals performing digestive endoscopy increased from 6,128 to 7,470 (1.22-fold), in which primary healthcare played a minor role. The median hospitals per 100,000 inhabitants per provincial region increased from 0.49 (IQR, 0.39-0.57) to 0.55 (IQR, 0.49-0.63). The endoscopists increased from 26,203 to 39,638 (1.51-fold), but their average workload even expanded. Overall volume increased from 28.8 million to 44.5 million (1.55-fold), and most types of endoscopic procedures recorded a high growth rate. Contrastingly, the specific utilization rates were low and paled in comparison with some developed countries. Nationwide, regional utilization rates showed a significant correlation with GDP per capita (P <0.001). Overall qualities of digestive endoscopy were excellent, but certain results of quality indicators posed a huge challenge, such as the detection rates of adenoma and early cancers.

Conclusions

Impressive progress has been made in digestive endoscopy with rapidly expanding economy in China. However, primary healthcare, utilization rates, and income-related inequality of regional services were needed to be improved to promote public health better.

Development, quality, and influencing factors of colonoscopy in China: results from the national census in 2013 and 2020

Background and Aim

With the increasing burden of colorectal cancer (CRC), the practice of colonoscopy is gaining attention worldwide. However, it exhibits distinct trends between developing and developed countries. This study aims to explore its development and identify influencing factors in China.

Methods

The Chinese Digestive Endoscopy Censuses were conducted twice in mainland China under the supervision of health authorities. Information regarding the practice of colonoscopy was collected through a structured online questionnaire. The authenticity of the data was evaluated through logical tests, and a random selection of endoscopic reports underwent manual validation by Quality Control Centers. Potential factors associated with colonoscopy were analyzed using real-world information.

Results

From 2012 to 2019, the number of hospitals that performed colonoscopy increased from 3,210 to 6,325 (1.97-fold), and the volume increased from 5.83 to 12.92 million (2.21-fold). The utilization rate rose from 436.0 to 914.8 per 100,000 inhabitants (2.10-fold). However, there was an exacerbation of regional inequality in the adequacy of colonoscopy. Regions with higher incidence of CRC, higher gross domestic product per capita, more average numbers of endoscopists and tertiary hospitals tended to provide more accessible colonoscopy (P<0.001). Nationwide, the cecal intubation rate improved from 83.9% to 94.4% and the unadjusted adenoma detection rate (ADR) improved from 16.3% to 18.1%. Overall, hospital grading, educational background of endoscopists, economic income, and colonoscopy volume were observed as the significantly positive factors affecting ADR (P<0.05), but not the incidence of CRC or the number of endoscopists.

Conclusions

Tremendous progress in colonoscopy has been made in China, but some issues needed timely reflection. Our findings provide timely evidence for better colonoscopy strategies and measures, such as quality control and medical education of endoscopists.

Impact of center and endoscopist ERCP volume on ERCP outcomes: a systematic review and meta-analysis

BACKGROUND AND AIMS

Endoscopist experience and center volume might be associated with ERCP outcomes, as in other fields of endoscopy and in surgery. An effort to assess this relationship is important to improve practice. This systematic review and meta-analysis aimed to evaluate these comparative data and to assess the impact of endoscopist and center volume on ERCP procedure outcomes.

METHODS

We performed a literature search in PubMed, Web of Science, and Scopus through March 2022. Volume classification included high- and low-volume (HV and LV) endoscopists and centers. The primary outcome was the impact of endoscopist and center volume on ERCP success. Secondary outcomes were the overall adverse event (AE) rate and the specific AE rate. The quality of the studies was assessed using the Newcastle-Ottawa scale. Data synthesis was obtained by direct meta-analyses using a random-effects model; results are presented as odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

Of 6833 relevant publications, 31 studies met the inclusion criteria. Procedure success was higher among HV endoscopists (OR, 1.81; 95% CI, 1.59-2.06; I2 = 57%) and in HV centers (OR, 1.77; 95% CI, 1.22-2.57; I2 = 67%). The overall AE rate was lower for procedures performed by HV endoscopists (OR, .71; 95% CI, .61-.82; I2 = 38%) and in HV centers (OR, .70; 95% CI, .51-.97; I2 = 92%). Bleeding was less frequent in procedures performed by HV endoscopists (OR, .67; 95% CI, .48-.95; I2 = 37%) but did not differ based on center volume (OR, .68; 95% CI, .24-1.90; I2 = 89%). No statistical differences were detected concerning pancreatitis, cholangitis, and perforation rates.

CONCLUSIONS

HV endoscopists and centers provide higher ERCP success rates with fewer overall AEs, especially bleeding, compared with respective LV comparators.

Machine-Learning Model for the Prediction of Hypoxaemia during Endoscopic Retrograde Cholangiopancreatography under Monitored Anaesthesia Care

PURPOSE

Hypoxaemia is a significant adverse event during endoscopic retrograde cholangiopancreatography (ERCP) under monitored anaesthesia care (MAC); however, no model has been developed to predict hypoxaemia. We aimed to develop and compare logistic regression (LR) and machine learning (ML) models to predict hypoxaemia during ERCP under MAC.

MATERIALS AND METHODS

We collected patient data from our institutional ERCP database. The study population was randomly divided into training and test sets (7:3). Models were fit to training data and evaluated on unseen test data. The training set was further split into k-fold (k=5) for tuning hyperparameters, such as feature selection and early stopping. Models were trained over k loops; the i-th fold was set aside as a validation set in the i-th loop. Model performance was measured using area under the curve (AUC).

RESULTS

We identified 6114 cases of ERCP under MAC, with a total hypoxaemia rate of 5.9%. The LR model was established by combining eight variables and had a test AUC of 0.693. The ML and LR models were evaluated on 30 independent data splits. The average test AUC for LR was 0.7230, which improved to 0.7336 by adding eight more variables with an l₁ regularisation-based selection technique and ensembling the LRs and gradient boosting algorithm (GBM). The high-risk group was discriminated using the GBM ensemble model, with a sensitivity and specificity of 63.6% and 72.2%, respectively.

CONCLUSION

We established GBM ensemble model and LR model for risk prediction, which demonstrated good potential for preventing hypoxaemia during ERCP under MAC.

International cross-sectional survey on endoscopic retrograde cholangiopancreatography training by the World Endoscopy Organization

OBJECTIVES

Endoscopic retrograde cholangiopancreatography (ERCP) has revolutionized the treatment of many pancreaticobiliary conditions. However, little is known about the global practices, training programs, and credentialing of the procedure. The aim of the current study is to address the above questions.

METHODS

This was an international cross-sectional survey conducted between October 2020 and May 2021. Participating countries were requested to complete an online survey on ERCP services and training.

RESULTS

Eighty-nine countries responded to the survey. There were significant increases in the proportion of ERCP services provided by the government (P < 0.0001), number of endoscopists per million of population (P < 0.0001), and number of institutions per million of population (P < 0.0001) from low to high human development index (HDI). Eighteen percent of the countries offer the procedure as part of a standard training program, 68.5% do not follow a standardized training curriculum. Risk factors for higher incidence and mortality from pancreatic cancers include higher HDI category, smaller population, a larger number of endoscopists proficient in ERCP, and lower number of institutions providing ERCP training. Countries with very high HDI have four times higher incidence and mortality from pancreatic cancers as compared to those with low HDI.

CONCLUSIONS

There is still an ongoing need for improving ERCP training in low to very high HDI countries. A structured training program is still lacking in many parts of the world. With increasing incidence and mortality of pancreatic cancers, particularly in high HDI countries, there is a need for further increasing facilities for ERCP training.

EUS development in China: Results from national surveys in 2013 and 2020

Background and Objectives

EUS has recently gained attraction in mainland China. This study aimed to evaluate the development of EUS from results of two national surveys.

Methods

EUS-related information, including infrastructure, personnel, volume, and quality indicator, was extracted from the Chinese Digestive Endoscopy Census. Data from 2012 and 2019 were compared, and differences among various hospitals and regions were analyzed. The EUS rates (EUS annual volume per 100,000 inhabitants) between China and developed countries were also compared.

Results

The number of hospitals performing EUS in mainland China increased from 531 to 1236 (2.33-fold), and 4025 endoscopists performed EUS in 2019. The volumes of all EUS and interventional EUS increased from 207,166 to 464,182 (2.24-fold) and 10,737 to 15,334 (1.43-fold), respectively. The EUS rate in China was lower than that in developed countries but showed a higher growth rate. EUS rate varied substantially among different provincial regions (in 2019: 4.9-152.0 per 100,000 inhabitants) and showed significant positive association with gross domestic product per capita (in 2019: r = 0.559, P = 0.001). The EUS-FNA-positive rate in 2019 was comparable between hospitals in terms of annual volume (≥50 or < 50: 79.9% vs. 71.6%, P = 0.704) and practice duration (starting EUS-FNA before or after 2012: 78.7% vs. 72.6%, P = 0.565).

Conclusion

EUS has developed considerably in China in recent years but still needs substantial improvement. More resources are in demand for hospitals in less-developed regions and with low EUS volume.

Racial disparities in endoscopic retrograde cholangiopancreatography (ERCP) utilization in the United States: are we getting better?

BACKGROUND

We identified trends of inpatient therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in the United States (US), focusing on outcomes related to specific patient demographics.

METHODS

The National Inpatient Sample was utilized to identify all adult inpatient ERCP in the US between 2007-2018. Trends of utilization and adverse outcomes were highlighted. P-values ≤ 0.05 were considered statistically significant.

RESULTS

We noted a rising trend for total inpatient ERCP in the US from 126,921 in 2007 to 165,555 in 2018 (p = 0.0004), with a significant increase in utilization for Blacks, Hispanics, and Asians. Despite an increasing comorbidity burden [Charlson Comorbidity Index (CCI) score ≥ 2], the overall inpatient mortality declined from 1.56% [2007] to 1.46% [2018] without a statistically significant trend (p = 0.14). Moreover, there was a rising trend of inpatient mortality for Black and Hispanic populations, while a decline was noted for Asians. After a comparative analysis, we noted higher rates of inpatient mortality for Blacks (2.4% vs 1.82%, p = 0.0112) and Hispanics (1.17% vs 0.83%, p = 0.0052) at urban teaching hospitals between July toand September compared to the October to June study period; however, we did not find a statistically significant difference for the Asian cohort (1.9% vs 2.10%, p = 0.56). The mean length of stay (LOS) decreased from 7 days in 2007 to 6 days in 2018 (p < 0.0001), while the mean total hospital charge (THC) increased from $48,883 in 2007 to $85,909 in 2018 (p < 0.0001) for inpatient ERCPs. Compared to the 2015-2018 study period, we noted higher rates of post-ERCP pancreatitis (27.76% vs 17.25%, p < 0.0001) from 2007-2014.

CONCLUSION

Therapeutic ERCP utilization and inpatient mortality were on the rise for a subset of the American minority population, including Black and Hispanics.

Changhai advanced endoscopy courses for ERCP (CHANCE) training program: A short-term training model in China

BACKGROUND

There is huge shortage of ERCP practitioners (ERCPists) in China, and ERCP training is urgently needed. ChangHai Advanced eNdoscopy Courses for ERCP (CHANCE) is a 4-month program for ERCP training since 2004. This study evaluated the efficiency of this short-term training model, and reported on the ERCP careers of the trainees following completion of the CHANCE program.

METHODS

This study was a retrospective investigation included all the CHANCE trainees from Jan 2004 to Dec 2014. Questionnaires were sent to all trainees. The career competence percentage, ERCP careers and predictive factors of career competence were investigated and analyzed.

RESULTS

A total of 413 trainees participated in the CHANCE program over 11 years covered by the survey and 258 questionnaires were valid for the study. The mean (SD) age of the trainees was 35.36 (4.17), and the male to female ratio was 4.4:1. The average follow-up time was 7.77 (3.44) years. A total of 173 (67.1%) trainees had achieved career competence. In terms of ERCP careers, the mean annual ERCP volume was 120.60 (96.67), with a complication percentage of 8.2%. Hospital qualification, compliance with follow-up learning guidance, participating academic activity, and practitioner type were identified predictive factors of career competence.

CONCLUSIONS

As a short-term training program, the CHANCE achieved an acceptable career competence percentage, providing endoscopists more chances to learn ERCP and giving them appropriate training guidance for career competence. This training mode is worth promoting in developing countries with shortage of ERCPists.

Utilization and quality assessment of digestive endoscopy in China: results from 5-year consecutive nationwide surveys

BACKGROUND

Worldwide, the volume and availability of digestive endoscopy have undergone dramatic development in recent years, with increasing attention on quality assurance. We investigated the utilization and quality of digestive endoscopy in China from 2015 to 2019 and developed a quantitative quality evaluation tool for medical institutions.

METHODS

We invited all tertiary/secondary hospitals in Chinese mainland to participate in the survey annually. The questionnaires included the personnel, annual volume, and quality indicators of endoscopy. An endoscopy quality index (EQI) was developed based on recorded quality indicators using principal component analysis to determine the relative weight.

RESULTS

From 2015 to 2019, 806, 1412, 2644, 2468, and 2541 hospitals were respectively enrolled in this study. The average annual volume of endoscopy increased from 12,445 to 16,206 (1.30-fold) and from 2938 to 4255 (1.45-fold) in tertiary and secondary hospitals, respectively. The most obvious growth was observed in diagnostic colonoscopy (1.44-fold for all hospitals after standardization). The proportion of early cancer among all esophageal and gastric cancers during diagnostic esophagogastroduodenoscopy increased from 12.3% (55,210/448,861) to 17.7% (85,429/482,647) and from 11.4% (69,411/608,866) to 16.9% (107,192/634,235), respectively. The adenoma detection rate of diagnostic colonoscopy increased from 14.9% (2,118,123/14,215,592) to 19.3% (3,943,203/20,431,104). The EQI model included 12 quality indicators, incorporating 64.9% (7.792/12) of the total variance into one comprehensive index. According to the EQI measurements, the quality of endoscopy was higher in tertiary hospitals and hospitals in developed areas with higher volume or more endoscopists than that in other hospitals.

CONCLUSIONS

Digestive endoscopy in China has developed considerably in recent years in terms of both volume and quality. The EQI is a promising tool to quantify the quality of endoscopy at different hospitals.

Procedural analgesic interventions in China: a national survey of 2198 hospitals

Background

Humane treatment requires the provision of appropriate sedation and analgesia during medical diagnosis and treatment. However, limited information is available about the status of procedural analgesic interventions in Chinese hospitals. Therefore, a nationwide survey was established to identify challenges and propose potential improvement strategies.

Methods

Forty-three members of the Pain Group of Chinese Society of Anesthesiology established and reviewed the questionnaire, which included (1) general information on the hospitals, (2) the sedation/analgesia rate in gastrointestinal endoscopy, labor, flexible bronchoscopy, hysteroscopy in China, (3) staff assignments, (4) drug use for procedural analgesic interventions, and (5) difficulties in procedural analgesic interventions. The data were obtained using an online questionnaire sent to the chief anesthesiologists of Chinese hospitals above Grade II or members of the Pain Group of Chinese Society of Anesthesiology.

Results

Valid and complete questionnaires were received from 2198 (44.0%) hospitals, of which 64.5% were Grade III. The overall sedation/analgesia rates were as follows: gastroscopy (50.6%), colonoscopy (53.7%), ERCP (65.9%), induced abortion (67.5%), labor (42.3%), hysteroscopy (67.0%) and fiber bronchoscopy (52.6%). Compared with Grade II hospitals, Grade III hospitals had a higher proportion of procedural analgesic interventions services except for induced abortion. On average (median [IQR]), each anesthesiologist performed 5.7 [2.3—11.4] cases per day, with 7.3 [3.2—13.6] performed in Grade III hospitals and 3.4 [1.8—6.8] performed in Grade II hospitals (z = -7.065, p < 0.001).

Conclusions

Chinese anesthesiologists have made great efforts to achieve procedural analgesic interventions, as evidenced by the increased rate. The uneven health care provided by hospitals at different levels and in different regions and the lack of anesthesiologists are the main barriers to optimal procedural analgesic interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01783-6.

Global trends of ERCP research in the last 25 years: A bibliometrics study

PURPOSE

Endoscopic retrograde cholangiopancreatography (ERCP) has been used in clinical practice for over 50 years. This study aims to investigate the current state of research in the field of ERCP.

METHODS

Web of Science database was searched using the term "ERCP" for articles published between 1994 and 2018. The total number of articles from the top 20 countries with the most published articles was determined. The top 5 countries were compared in terms of output per capita, number of articles published in top journals, cumulative impact factor (IF), and average IF. All annual data were subjected to time-trend analysis. The frequently used terms in the titles and abstracts of all articles were retrieved to conduct co-occurrence analysis to determine the research focus of ERCP.

RESULTS

A total of 9960 articles on ERCP were published between 1994 and 2018, of which 8778 articles were from the top 20 producing countries. There was a significant positive correlation between the output and GDP of each country (R = 0.870, P = .001). The United States of America (USA), Japan, Germany, Italy, and China were the top 5 producing countries with 3190 (32.0%), 868 (8.7%), 658 (6.6%), 512 (5.1%) and 488 (4.9%) articles published, respectively. The USA, Japan, Italy, and China were trending upwards in the total outputs and outputs per capita, while Germany were trending downwards. For average IF, Germany had a downwards trend, while the other 4 countries remained stable. Overall, the USA had the highest output per capita (97.5/10 million) and the highest average IF (6.454). China had the lowest output per capita (3.5/10 million) and average IF (3.125). The ERCP procedures for sphincter of Oddi dysfunction, the combination of ERCP, and laparoscopic cholecystectomy have been the research focus of ERCP.

CONCLUSIONS

Except for Germany, research on ERCP will continue to increase in the top-producing countries. The outputs per capita and quality of articles from developed countries are higher than those from developing countries.

Safety and efficacy of therapeutic endoscopic retrograde cholangiopancreatography in elderly patients with a native papilla

BACKGROUND

The diagnosis and treatment of biliary and pancreatic diseases in elderly patients are a challenge for clinicians, while population ageing is becoming a prominent social issue. However, there are few clinical studies on therapeutic endoscopic retrograde cholangiopancreatography in elderly patients.

AIM

To evaluate the safety, efficacy, clinical characteristics, and influencing factors related to therapeutic ERCP in patients aged above 80 years.

METHODS

Data of 446 elderly patients (aged above 80 years) with a native papilla who underwent therapeutic ERCP form July 2011 to December 2020 were retrospectively analyzed. Their clinical characteristics, procedures of ERCP, and complications after ERCP were evaluated.

RESULTS

Mean age of included patients was (83.2 ± 3.3) years old. Significant comorbidities were found in 308 cases. One hundred and twenty-four cases had biliary, pancreatic, or papillary carcinomas. There was no significant difference in post-ERCP complications with regard to comorbidities or timing of ERCP. Overall complications were comparable between patients undergoing difficult and non-difficult cannulation. The incidence of complications in the malignant disease group was higher than that in the benign disease group (15.32% vs 7.86%, P < 0.05). The rate of biliary infection was higher in patients with malignant diseases than in those with benign diseases (6.45% vs 1.57%, P < 0.01). However, the rate of bleeding was higher in patients undergoing urgent ERCP than in those undergoing selective operation (8.33% vs 1.52%, P < 0.05).

CONCLUSION

The current study showed that therapeutic ERCP for patients aged 80 years or above is safe and effective. To avoid post-ERCP complications in elderly patients with high risk, detailed peri-ERCP evaluation may be necessary.

National survey on sedation for gastrointestinal endoscopy in 2758 Chinese hospitals

BACKGROUND

Although sedation during gastrointestinal endoscopy is widely used in China, the characteristics of sedation use, including regional distribution, personnel composition, equipment used, and drug selection, remain unclear. The present study aimed to provide insights into the current practice and regional distribution of sedation for gastrointestinal endoscopy in China.

METHODS

A questionnaire consisting of 19 items was distributed to directors of anaesthesiology departments and anaesthesiologists in charge of endoscopic sedation units in mainland China through WeChat.

RESULTS

The results from 2758 participating hospitals (36.7% of the total) showed that 9 808 182 gastroscopies (69.3%) and 4 353 950 colonoscopies (30.7%), with a gastroscopy-to-colonoscopy ratio of 2.3, were conducted from January to December 2016. Sedation was used with 4 696 648 gastroscopies (47.9%) and 2 148 316 colonoscopies (49.3%), for a ratio of 2.2. The most commonly used sedative was propofol (61.0% for gastroscopies and 60.4% for colonoscopies). Haemoglobin oxygen saturation (SpO₂) was monitored in most patients (96.1%). Supplemental oxygen was routinely administered, but the availability of other equipment was variable (anaesthesia machine in 64.9%, physiological monitor in 84.4%, suction device in 72.3%, airway equipment in 75.5%, defibrillator in 32.7%, emergency kit in 57.0%, and difficult airway kit in 20.8% of centres responding).

CONCLUSIONS

The sedation rate for gastrointestinal endoscopy is much lower in China than in the USA and in Europe. The most commonly used combination of sedatives was propofol plus an opioid (either fentanyl or sufentanil). Emergency support devices, such as difficult airway devices and defibrillators, were not usually available.

Recent 5-Year Trend of Endoscopic Retrograde Cholangiography in Korea Using National Health Insurance Review and Assessment Service Open Data

Background/Aims

The utilization of endoscopic retrograde cholangiopancreatography (ERCP) is variable and largely dependent on a patient’s age, sex, and region. Herein we analyzed the publicly available Health Insurance Review and Assessment (HIRA) database with the aim of understanding the current status and trend of ERCP use in Korea.

Methods

Between 2013 and 2017, information regarding ERCP was acquired from the HIRA database using the procedural codes of the Korean Standard Classification of Disease. We analyzed the annual number of patients according to age in 10-year increments, sex, type of medical institution, and administrative division.

Results

The total number of patients and number of patients undergoing ERCP per 100,000 people increased from 40,516 and 78.6 in 2013 to 47,027 and 91.3 in 2017, respectively those aged 70 years accounted for the highest number, and the increase was the most prominent in those aged 80 years or older. Men underwent more ERCPs than women, except in younger patients (<40 years). Most ERCPs were performed at tertiary and general hospitals; however, the ratios between the two types of institutions were different according to the procedure. There were different patterns of patients associated with each procedure according to the administrative division. Therapeutic ERCP was performed more frequently than diagnostic ERCP.

Conclusions

Most procedures in Korea were therapeutic, and the increase in patients was most prominent in those aged 80 years or older. The utilization of ERCP increased markedly and varied depending on age, sex, type of medical institution, and region.

Epidemiological profile, referral routes and diagnostic accuracy of cases of acute cholangitis among individuals with obstructive jaundice admitted to a tertiary-level university hospital: a cross-sectional study

BACKGROUND

Obstructive jaundice may lead to ominous complications and requires complex diagnostic evaluations and therapies that are not widely available.

OBJECTIVE

To analyze the epidemiological profile, referral routes and diagnostic accuracy at admittance of cases of acute cholangitis among patients with obstructive jaundice treated at a referral unit.

DESIGN AND SETTING

Cross-sectional study at a tertiary-level university hospital.

METHODS

Patients with obstructive jaundice who were treated by means of endoscopic retrograde cholangiopancreatography, resection and/or surgical biliary drainage were evaluated. The main variables analyzed were epidemiological data, referral route, bilirubin levels and time elapsed between symptom onset and admittance and diagnosing of acute cholangitis at the referral unit. The accuracy of the clinical diagnosis of acute cholangitis was compared with a retrospective analysis on the medical records in accordance with the Tokyo criteria.

RESULTS

Female patients predominated (58%), with an average age of 56 years. Acute cholangitis was detected in 9.9% of the individuals; application of the Tokyo criteria showed that the real prevalence was approximately 43%. The main referral route was direct contact (31.8%) and emergency care (29.7%); routing via official referral through the public healthcare system accounted for 17.6%, and internal referral from other specialties, 20%. The direct route with unofficial referral was the most important route for cases of neoplastic etiology (P < 0.01) and was the fastest route (P < 0.01).

CONCLUSIONS

There is a deficiency in the official referral routes for patients with obstructive jaundice. The accuracy of the clinical diagnosis of acute cholangitis was poor. Wider dissemination of the Tokyo criteria is essential.

ERCP practice beyond the training period - bridging the gap between guidelines and real-life practice: a single operator experience of 679 procedures

BACKGROUND

Endoscopic retrograde cholangiopancreatography has evolved significantly in recent years. The increase in complexity and range of applications has not been adequately reflected in an improvement of training methods for ERCP, with many endoscopists failing to meet required performance standards during their training period and limited available data on their performance immediately after completing training. We aimed to analyze the performance of an independent operator from a developing country after the completion of formal training with regard to procedure and patient-related outcomes.

METHODS

We conducted an observational study of ERCPs performed by a young endoscopist from a referral center. Data about the procedure, cannulation technique (including use of precut), trainee involvement and procedure-related outcomes was retrieved and analyzed from a prospectively maintained database on quality in ERCP (the QUASIE initiative).

RESULTS

Data from 679 consecutive ERCPs conducted or supervised by one endoscopist with < 200 independent procedures prior to the study period were included in the final analysis. Cannulation rates significantly improved over time, from 90% to 96% (p = 0.016). Use of precut techniques changed significantly over time, with an initial increase followed by a subsequent decrease as overall cannulation rates improved. Trainee involvement was significantly associated with prolonged cannulation times (p = 0.003) and use of precut (p = 0.001), but did not impact on technical success or patient safety.

CONCLUSIONS

Independent practice of ERCP after the training period is characterized by ongoing changes in technique, especially with regard to cannulation and use of precut, showing significant improvements in performance over time.

Establishing a model to measure and predict the quality of gastrointestinal endoscopy

BACKGROUND

Tens of millions of gastrointestinal endoscopic procedures are performed every year in China, but the quality varies significantly and related factors are complex. Individual endoscopist- and endoscopy division-related factors may be useful to establish a model to measure and predict the quality of endoscopy.

AIM

To establish a model to measure and predict the quality of gastrointestinal endoscopic procedures in mainland China.

METHODS

Selected data on endoscopy experience, equipment, facility, qualification of endoscopists, and other relevant variables were collected from the National Database of Digestive Endoscopy of China. The multivariable logistic regression analysis was used to identify the potential predictive variables for occurrence of medical malpractice and patient disturbance. Linear and nonlinear regressions were used to establish models to predict incidence of endoscopic complications.

RESULTS

In 2012, gastroscopy/colonoscopy-related complications in mainland China included bleeding in 4,359 cases (0.02%) and perforation in 914 (0.003%). Endoscopic-retrograde-cholangiopancreatography-related complications included severe acute pancreatitis in 593 cases (0.3%), bleeding in 2,151 (1.10%), perforation in 257 (0.13%) and biliary infection in 4,125 (2.11%). Moreover, 1,313 (5.0%) endoscopists encountered with medical malpractice, and 5,243 (20.0%) encountered with the disturbance from patients. The length of endoscopy experience, weekly working hours, weekly night shifts, annual vacation days and job satisfaction were predictors for the occurrence of medical malpractice and patient disturbance. However, the length of endoscopy experience and the ratio of endoscopists to nurses were not adequate to establish an effective predictive model for endoscopy complications.

CONCLUSION

The workload and job satisfaction of endoscopists are valuable predictors for medical malpractice or patient disturbance. More comprehensive data are needed to establish quality-predictive models for endoscopic complications.

Extracorporeal Shock Wave Lithotripsy for Chronic Pancreatitis Patients With Stones After Pancreatic Surgery

OBJECTIVES

The objective of this study was to evaluate the safety and efficacy of pancreatic extracorporeal shock wave lithotripsy (P-ESWL) in chronic pancreatitis (CP) patients with pancreatic stones after previous pancreatic surgery.

METHODS

This is a single-center study prospectively conducted in pained CP patients undergoing P-ESWL. Patients with a pancreatic surgery history (PSH) were included in the PSH group, and patients without a PSH during the same period were assigned to the control group. The primary outcomes included complications associated with P-ESWL and pain relief. Secondary outcomes included stone clearance and improved quality-of-life scores.

RESULTS

From March 2011 to October 2014, P-ESWLs were performed on 1017 patients (50 in the PSH group, 967 in the control group). No significant difference was observed in the frequency of occurrence of P-ESWL complications between the PSH group and control group (14.0% vs 13.2%, P = 0.877). At follow-up (2.6 years; range, 1.0-4.5 years), pain relief was achieved in 36 patients (75.0%), and 37 patients (77.1%) experienced complete stone clearance. No significant differences were observed between these patients and the matched controls.

CONCLUSIONS

For CP patients who develop painful stones after pancreatic surgery, P-ESWL safely achieves significant pain relief and stone clearance, preventing the need for a repeat surgery.

Post-ERCP infection and its epidemiological and clinical characteristics in a large Chinese tertiary hospital: a 4-year surveillance study

Background

Endoscopic retrograde cholangiopancreatography (ERCP) is widely performed as a treatment for biliary and pancreatic illness in China; however, there are few data available regarding post-ERCP infections. This study aimed to describe the overall incidence of post-ERCP infections and the epidemiological characteristics of infected patients in a large tertiary-care hospital in China.

Methods

Real-time surveillance was performed from 2012 through 2015 to identify all healthcare-associated infections (HAIs) that occurred after ERCP, using an automatic system. All HAIs (e.g., cholangtitis, bacteremia) were identified by infection control practitioners and doctors. Inpatient data were automatically collected by the surveillance system.

Results

A total of 1743 ERCP operations were included in the study, among these, 132 (7.57%) HAIs were identified. ERCP postoperative infections occurred following different surgical procedures, with infection rates ranging from 3.58 to 13.51%. The most prevalent HAI was biliary tract infection (4.02%), followed by transient bacteremia (1.14%). Overall, 62 cases of bacteremia occurred following ERCP surgery and 34 (54.84%) cases occurred on the day of the operation or 1-day post-surgery. The most prevalent isolates detected during bacteremia were Enterococcus faecium (12/58) and Escherichia coli (11/58). A large proportion (72.73%) of the E. coli isolates and all of the E. faecium isolates were resistant to ciprofloxacin. In addition, only 37.50% of the E. coli isolates were susceptible to ceftriaxone.

Conclusions

The high incidence of post-ERCP infection and the prevalence of drug resistance suggests that employing second generation cephalosporin or ceftriaxone as the antibiotic of choice for prophylaxis before ERCP, as recommended by the Chinese clinical application of antibacterial drugs guidelines, may not be effective.