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

Adverse Events Associated With Endoscopic Retrograde Cholangiopancreatography: Systematic Review and Meta-Analysis

BACKGROUND & AIMS

Endoscopic retrograde cholangiopancreatography (ERCP)-related adverse events (AEs) are associated with morbidity, mortality, and health care expenditure. We aimed to assess incidences and comparisons of ERCP AEs.

METHODS

We included studies performed after 2000 reporting on ERCP AEs from database inception through March 12, 2024. Outcomes included pancreatitis, bleeding, cholangitis, cholecystitis, perforation, and death. DerSimonian and Laird random effects meta-analyses were performed to calculate incidences of AEs. Subgroup and pairwise meta-analyses were performed. Meta-regression was performed on median recruitment year to assess temporal trends in pancreatitis incidence.

RESULTS

A total of 380 studies were included. The incidence of death attributable to ERCP was 0.2% (95% confidence interval [CI], 0.1%-0.3%; I2, 44%; n = 47,258) in all-comers. The overall incidence of pancreatitis was 4.6% (95% CI, 4.0%-5.1%; I2, 96%; n = 293,378) among all-comers and 6.5% (95% CI, 5.9%-7.1%, I2, 89%; n = 88,809) among first-time patients. Pancreatitis incidence remained stable between 2000 and 2023 (average annual percent change 0.06, 95% CI, -0.27 to 0.39). The overall incidences of the following AEs for all-comers were: bleeding (1.5%; 95% CI, 1.2%-1.7%; I2, 93%; n = 229,655), cholangitis (2.5%; 95% CI, 1.9%-3.3%; I2, 96%; n = 121,619), cholecystitis (0.8%; 95% CI, 0.5%-1.2%; I2, 39%; n = 7799), and perforation (0.5%; 95% CI, 0.4%-0.6%; I2, 90%; n = 306,378).

CONCLUSIONS

ERCP-associated AEs remain common. Incidence of post-ERCP pancreatitis remained static despite improvements in techniques, prevention, and recognition. These results are important to patients, endoscopists, and policy makers to inform consent and to encourage implementation of available risk mitigation strategies.

Updates in Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis

Although endoscopic retrograde cholangiopancreatography (ERCP) has been shown to be a safe and effective approach in treating these diseases while carrying lower morbidity than traditional surgical treatments, ERCP has associated risks, with post-ERCP pancreatitis (PEP) being the most common serious adverse event and carries significant morbidity and health care cost. PEP results from multifactorial factors involving trauma to the pancreatic duct and papilla, leading to subsequent obstruction and impairment of pancreatic drainage. Important risk factors for PEP include history of prior PEP, suspected sphincter of Oddi dysfunction, difficult cannulation, pancreatic duct contrast injections, and pancreatic sphincterotomy.

Risks and use of ERCP during the diagnostic workup in a national cohort of biliary cancer

BACKGROUND

In biliary cancer, the indication of endoscopic intervention might be diagnostic as well as therapeutic, in the latter situation with the aim to relieve biliary obstruction e.g. by stenting. Our aim was to investigate the use of endoscopic biliary interventions during the diagnostic workup of biliary cancers in a national cohort, and to evaluate their complications, especially cholangitis and pancreatitis.

METHODS

This is a registry-based study of national cohort of patients with biliary cancers in Sweden 2010-2020. The use of endoscopic retrograde cholangiopancreatography (ERCP) during the diagnostic work up period before treatment onset, and risk of complications were evaluated in patients with gallbladder cancer, intrahepatic-, perihilar- and distal cholangiocarcinoma. The risk of complications was compared depending on age, sex, comorbidity, in relation to stage and curative intent, endoscopy unit size, and with relation to survival.

RESULTS

Forty percent of the patients with biliary cancer underwent ERCP during the diagnostic workup, with variations depending on diagnosis. There was a 20% overall risk of periprocedural complications, a 9% risk of post-ERCP-pancreatitis (PEP), and a 6% risk of cholangitis. Increasing tumor stage did not increase risk, nor did comorbidity. The complication rates were slightly higher for younger patients and those undergoing curative treatment. For perihilar cholangiocarcinoma (pCCA) treated with curative intention, the risk of periprocedural complications was as high as 30.7%. No association between post-ERCP complications and survival was found.

CONCLUSION

Irrespective of type of biliary cancer, ERCP is frequently used during diagnostic workup. The complication risk indicates that primary biliary cancers are complication prone, regardless of stage. Notably the risk of complications was the highest for younger patients with low comorbidity scores, as well as for patients undergoing curatively aiming treatment.

Outcomes of bile duct cannulation using a novel contrast-enhanced catheter: A single-center, retrospective cohort study

BACKGROUND

Endoscopic retrograde cholangiopancreatography is a challenging procedure involving bile duct cannulation. Despite the development of several cannulation devices, none have effectively facilitated the procedure.

AIM

To evaluate the efficacy of a recently developed catheter for bile duct cannulation.

METHODS

We retrospectively examined 342 patients who underwent initial cholangiopancreatography. We compared the success rate of bile duct cannulation and the incidence of complications between the groups using existing and novel catheters.

RESULTS

The overall success rates of bile duct cannulation were 98.3% and 99.1% in the existing and novel catheter groups, respectively (P = 0.47). The bile duct cannulation rate using the standard technique was 73.0% and 82.1% in the existing and novel catheter groups, respectively (P = 0.042). Furthermore, when catheterization was performed by expert physicians, the bile duct cannulation rate was significantly higher in the novel catheter group (81.3%) than in the existing catheter group (65.2%) (P = 0.017). The incidence of difficult cannulation was also significantly lower in the novel catheter group (17.4%) than in the existing catheter group (33.0%) (P = 0.019).

CONCLUSION

The novel catheter improved the bile duct cannulation rate using the standard technique and reduced the frequency of difficult cannulation cases, valuable tool in endoscopic retrograde cholangiopancreatography procedures performed by experts.

Assessment of heterogeneity according to hospital or medical experience factors in outcomes of chemotherapy for advanced biliary tract cancer: a post-hoc analysis of JCOG1113

BACKGROUND

JCOG1113 is a randomized phase III trial that showed non-inferiority of gemcitabine plus S-1 to gemcitabine plus cisplatin in patients with advanced biliary tract cancer. Assessment of inter-institutional heterogeneity in chemotherapy contributes to confirm generalizability and reliability of the study itself. However, there have been no studies conducted to assess the heterogeneity among participating centers in randomized phase III trials for biliary tract cancer.

METHODS

The objective of this post-hoc analysis was to assess the inter-institutional heterogeneity in the overall survival and progression-free survival of patients with advanced biliary tract cancer treated with first-line chemotherapy in the JCOG1113 trial. The heterogeneity in the overall survival and progression-free survival was assessed according to three factors: hospital volume, experience in medical oncology and experience in biliary intervention. A total of 300 advanced biliary tract cancer patients were analyzed. There were no statistically significant trends observed between hospital volume, experience in medical oncology, or experience in biliary intervention and overall survival (hospital volume: adjusted trend P value = 0.6796; experience in medical oncology: adjusted trend P value = 0.4092; experience in biliary intervention: adjusted trend P value = 0.6112). Similarly, no statistically significant trends were observed between these factors and progression-free survival (hospital volume: adjusted trend P value = 0.3000; experience in medical oncology: adjusted trend P value = 0.1108; experience in biliary intervention: adjusted trend P value = 0.2898).

CONCLUSIONS

This study revealed no inter-institutional heterogeneity in the overall survival and progression-free survival in the JCOG1113 study population of advanced biliary tract cancer patients.

Outcomes of endoscopic retrograde cholangiopancreatography performed in the AM versus PM: does procedural timing matter?

Background

ERCP is a technically demanding procedure that carries a high cumulative adverse event (AE) rate of >10%. Identifying risk factors for adverse events is paramount. Procedure timing, as a surrogate for endoscopist fatigue, has been shown to influence key quality metrics in colonoscopy, but data on this relationship in ERCP is sparse.

Methods

We conducted a retrospective cohort study of ERCP procedures performed by 5 experienced staff endoscopists, with or without advanced endoscopy fellow (AEF) involvement, from January 1, 2010 to December 1, 2020 at St Michael's Hospital, Toronto, Ontario, a regional referral center for therapeutic endoscopy. The primary outcome was the difference in rate of selective deep, duct canulation between AM and PM procedures.

Results

A total of 5672 ERCP procedures were eligible for inclusion. 2793 (49.2%) procedures were performed in the AM and 2879 procedures (50.8%) were performed in the PM. We found no significant difference in the rate of selective ductal cannulation between AM and PM procedures in the unadjusted (82.8% AM vs. 83.1% P-value = .79) or adjusted (OR = 0.98, 95% CI, 0.85-1.12, P-value = .72) analyses. We found no significant difference in the mean procedural duration or rate of perforation between AM and PM procedures. The rate of immediate bleeding was slightly higher in the AM cohort.

Conclusion

In our single-center retrospective study, ERCP quality, including selective cannulation rates and immediate adverse events were not significantly different in procedures performed in the morning compared to those performed in the afternoon.

Provider Specialization in Inflammatory Bowel Diseases: Quality of Care and Outcomes

BACKGROUND & AIMS

Management of inflammatory bowel diseases (IBD) is complex and variation in care has been well-documented. However, the drivers of practice variation remain unexplored. We examined variation based on the treating gastroenterologist's IBD focus (proportion of outpatient visits for IBD).

METHODS

We conducted a retrospective cohort of newly diagnosed patients with IBD using data from Optum's deidentified Clinformatics Data Mart Database (2000-2020). The exposure variable was whether the treating gastroenterologist had an IBD focus (>90th percentile of IBD visits/total outpatient visits). We used adjusted regression models to evaluate associations between provider IBD focus and process measures (use of mesalamine, corticosteroid, biologic, and narcotic medications and endoscopic or radiographic imaging) and clinical outcomes (time to IBD-related hospitalization and bowel resection surgery). We tested for change in treatment patterns over time by including an interaction term for study era (2004-2012 vs 2013-2020).

RESULTS

The study included 772 children treated by 493 providers and 2864 adults treated by 2076 providers. In children, none of the associations between provider focus and process or outcome measures were significant. In adults, care from an IBD-focused provider was associated with more use of biologics, combination therapy, and imaging and endoscopy, and less mesalamine use for Crohn's disease (P < .05 for all comparisons) but not with other process measures. Biologics were prescribed more frequently and narcotics less frequently during the later era (P < .05 for both). Hospitalization and surgery rates were not associated with IBD focus or era.

CONCLUSIONS

IBD care for adults varies by provider specialization. Given the evolving complexity, novel methods may be needed to standardize care.

Endoscopic retrograde cholangiopancreatography training conditions, results from a pan-European survey: Between vision and reality

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) still has a relatively high complication rate, underscoring the importance of high-quality training. Despite existing guidelines, real-world data on training conditions remain limited. This pan-European survey aims to systematically explore the perceptions surrounding ERCP training.

METHODS

A survey was distributed through the friends of United European Gastroenterology (UEG) Young Talent Group network to physicians working in a UEG member or associated states who regularly performed ERCPs.

RESULTS

Of 1035 respondents from 35 countries, 649 were eligible for analysis: 228 trainees, 225 trainers, and 196 individuals who regularly performed ERCP but were neither trainees nor trainers. The mean age was 43 years, with 72.1% identifying as male, 27.6% as female, and 0.3% as non-binary. The majority (80.1%) agreed that a structured training regimen is desirable. However, only 13.7% of trainees and 28.4% of trainers reported having such a structured program in their institutions. Most respondents (79.7%) supported the concept of concentrating training in centers meeting specific quality metrics, with 64.1% suggesting a threshold of 200 annual ERCPs as a prerequisite. This threshold revealed that 36.4% of trainees pursued training in lower-volume centers performing <200 ERCPs annually. As many as 70.1% of trainees performed <50 annual ERCPs, whereas only 5.0% of trainers performed <50 ERCPs annually. A low individual trainee caseload (<50 ERCPs annually) was more common in lower-volume centers than in higher-volume centers (82.9% vs. 63.4%).

CONCLUSIONS

The first pan-European survey investigating ERCP training conditions reveals strong support for structured training and the concentration of training efforts within centers meeting specific quality metrics. Furthermore, this survey exposes the low availability of structured training programs with many trainees practicing at lower-volume centers and 71% of all trainees having little hands-on exposure. These data should motivate to standardize ERCP training conditions further and ultimately improve patient care throughout Europe.

Development and usability of an endoscopist report card assessing ERCP quality

BACKGROUND AND AIMS

Audit and feedback (A&F) for ERCP is relatively understudied despite the demonstrated effectiveness of A&F for endoscopic procedures such as colonoscopy. Endoscopist "report cards" are one such A&F tool. We aimed to develop an ERCP report card and assess its appropriateness, acceptability, and feasibility through usability testing.

METHODS

A prototype report card was designed using a combination of published quality indicators and established predictors of adverse events (AEs). Exploratory analyses from a prospective multicenter registry were performed to further identify novel and/or understudied parameters for possible inclusion. Semistructured interviews with ERCP endoscopists were conducted and framework analysis performed. Validated postinterview usability instruments were administered. Feedback was incorporated to create a final report card.

RESULTS

The report card included domains of technical parameters, AE rates and prevention, and patient-reported experience measures (PREMs). Qualitative feedback was positive, with respondents agreeing with inclusion of relevant content in most domains. Postinterview instruments revealed adequate appropriateness and acceptability. PREMs were believed 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 because of reliance on difficult-to-obtain granular intraprocedural data.

CONCLUSIONS

We designed and tested an ERCP report card that has the potential to be an effective A&F intervention for endoscopists in clinical practice. Although 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.

Examining the Impact of a GI Hospitalist Model on the Outcomes of Double-Balloon Enteroscopy: A Single-Center Retrospective Study

BACKGROUND

A GI hospitalist (GIH) is a physician who practices in the inpatient setting performing consultations and endoscopic procedures. Obscure small bowel bleeding is a common inpatient diagnosis that is difficult to manage and associated with longer hospitalizations. Having an onsite GIH physician with expertise in video capsule endoscopy (VCE) and double-balloon enteroscopy (DBE) has the potential to improve patient outcomes.

AIMS

This study will be the first to explore how implementing a GIH model and providing a GIH with training in DBE can affect the outcomes of patients with small bowel pathology.

METHODS

We performed a retrospective study of patients who received an inpatient DBE at an academic medical center before and after initiation of a GIH model and credentialing of a GIH in DBE. We compared outcomes, including procedure volumes, diagnostic and therapeutic yields, procedure duration, time to procedure, and length of stay.

RESULTS

There was a 46.5% increase in the number of DBEs performed by the GIH. The diagnostic yield increased from 56.3 to 74.0% (OR 2.2, 95% CI 1.2-4.2), and the proportion of DBEs with a therapeutic intervention increased from 38.0 to 65.4% (OR 3.1, 95% CI 1.4-7.0). The total procedure time increased from 77.8 to 96.4 min (p < 0.05) with a GIH.

CONCLUSION

Having a GIH perform inpatient DBEs was associated with an increased number of procedures, duration of procedures, diagnostic yield, and therapeutic interventions. The onsite presence of a GIH with competency in DBE improves the care of hospitalized patients with small bowel pathology.

[Influence of specialization on primary success and complication rate in ERCP. Proposal to improve the quality of ERCP]

Endoscopic retrograde cholangiopancreatography [ERCP] is a complex procedure with a flat learning curve. It is associated with the risk of serious complications such as pancreatitis, bleeding, cholangitis and perforation. Endosonography should therefore also be offered for the precise indication of the higher-risk ERCP. Numerous factors influence the success of ERCP. In addition to structured training for the initial acquisition of skills and a minimum number of ERCPs of varying degrees of difficulty, maintaining a good quality of ERCP also requires a regular minimum number of examinations performed per year. There is extensive evidence that shows a significant correlation between ERCP volumes and primary success rates, lower lengths of hospital stay, fewer unwanted readmissions and fewer complications. The cut-offs for differentiating between high-volume and low-volume centers were chosen inconsistently in the studies, with the highest evidence for a cut-off value of 200 ERCPs/year. The question of specialization in ERCP has been given a relevance by the current developments in german hospital reform. Here, a minimum number of ERCPs should be defined for groups of different specialization. However, a minimum number alone will not be able to achieve good treatment quality. In terms of high-quality patient care, it is necessary to offer ERCPs in specialized gastroenterology center, which, in addition to a sufficient number of ERCPs for training and to maintain competence, offer an on-call service and complementary procedures such as EUS and which are embedded in appropriately accessible clinics that have the necessary resources for complication management.

Assessing the impact of center volume on the cost-effectiveness of centralizing ERCP

BACKGROUND AND AIMS

ERCP is a complex endoscopic procedure in which the center's procedure volume influences outcomes. With the increasing healthcare expenses and limited resources, promoting cost-effective care becomes essential for healthcare provision. This study was a cost-effectiveness analysis to evaluate the hypothesis that high-volume (HV) centers perform ERCP with higher quality at lower costs than low-volume (LV) centers.

METHODS

A baseline case compared the current distribution of ERCPs among HV and LV centers with a hypothetical scenario in which all ERCPs are performed at HV centers. A cost-effectiveness analysis was constructed, followed by 1- and 2-way sensitivity analyses, and probabilistic sensitivity analysis using Monte Carlo simulations.

RESULTS

In the baseline case, the incremental cost-effectiveness ratio was -$151,270 per year, due to the hypothetical scenario's lower costs and slightly higher quality-adjusted life years. The model was most sensitive to changes in transportation costs (109.34%), probability of significant adverse events (AEs) after successful ERCP at LV centers (42.12%), utility after ERCP with significant AEs (30.10%), and probability of significant AEs after successful ERCP at HV centers (23.53%); only transportation costs above $3655 changed the study outcome, however. The current ERCP distribution would only be cost-effective if LV centers achieved higher success (≥92.4% vs 89.3%), with much lower significant AEs (≤.5% vs 6.7%). The study's main findings remained unchanged while combining all model parameters in the probabilistic sensitivity analysis.

CONCLUSIONS

Our findings show that HV centers have high-performance rates at lower costs, raising the need to consider the principle of centralization of ERCPs into HV centers to improve the quality of care.

ERCP for common bile duct stones in the elderly: refining the procedure to improve outcomes

Removal of common bile duct stones in patients with a previous cholecystectomy was one of the first indications for ERCP with biliary sphincterotomy. Thanks to a minimally invasive procedure, patients were prevented from having a new operation. Subsequently, as the technique proved to be successful, ERCP was extended to all patients with choledocholithiasis, regardless of whether or not they had gallbladder. Also contributing was the fact that, at least in the beginnings, surgical interventions on the bile duct with laparoscopic cholecystectomy were more difficult. Nowadays, many surgeons prefer to perform cholecystectomy with a bile duct clean of stones. In this issue of the Spanish Journal of Gastroenterology, Gardenyes et al. present a study on ERCP for common bile duct stones in elderly patients. The novelty of this study is not only to analyze the ERCP procedure, which we already knew has similar success and complication rates to younger patients, but also to focus on the long-term outcome, considering the frailty that frequently accompanies aging. The study concludes that older patients may benefit from enhanced care protocols to reduce medical adverse events and improve outcomes. For us gastroenterologists and endoscopists, another conclusion that can be drawn from this study is that we should not be satisfied that ERCP in older patients has the same success and complication rates as in younger patients, but rather we should strive to ensure that the results are even better.

Patient Radiation Exposure during Enteroscopy-Assisted Endoscopic Retrograde Cholangiopancreatography in Surgically Altered Anatomy (with Video)

BACKGROUND

Fluoroscopy must be used cautiously during endoscopic retrograde cholangiopancreatography (ERCP). Radiation exposure data in patients with surgically altered anatomy undergoing enteroscopy-assisted ERCP (EA-ERCP) are scarce.

METHODS

34 consecutive EA-ERCP procedures were compared with 68 conventional ERCP (C-ERCP) procedures. Patient and procedure characteristics and radiation data were collected.

RESULTS

Surgical reconstructions were gastrojejunostomy, Roux-en-Y hepaticojejunostomy, Roux-en-Y total gastrectomy, Roux-en-Y gastric bypass and Whipple's duodenopancreatectomy. Procedures were restricted to biliary indications. Mean fluoroscopy time was comparable in both groups (370 ± 30 s EA-ERCP vs. 393 ± 40 s C-ERCP, p = 0.7074), whereas total mean radiation dose was lower in EA-ERCP (83 ± 6 mGy) compared to C-ERCP (110 ± 11 mGy, p = 0.0491) and dose area product (DAP) was higher in EA-ERCP (2216 ± 173 µGy*m2) compared to C-ERCP (1600 ± 117 µGy*m2, p = 0.0038), as was total procedure time (77 ± 5 min vs. 39 ± 3 min, p < 0.0001). Enteroscope insertion to reach the bile duct during EA-ERCP took 28 ± 4 min, ranging from 4 to 90 min. These results indicate that C-ERCP procedures are generally more complex, needing magnified fluoroscopy, whereas EA-ERCP procedures take more time for enteroscope insertion under wide field fluoroscopic guidance (increased DAP) with less complex ERCP manipulation (lower total radiation dose).

CONCLUSIONS

Radiation exposure during EA-ERCP in surgically altered anatomy is different as compared to C-ERCP. EA-ERCP takes longer with a higher DAP because of the enteroscope insertion, but with lower total radiation dose because these ERCP procedures are usually less complex.

Face and content validity of a biological papilla designed for the Boškoski-Costamagna ERCP simulator

BACKGROUND AND AIMS

A biological papilla made of chicken heart tissue, incorporated into the Boškoski-Costamagna ERCP Trainer simulator, was recently designed to allow training in sphincterotomy. This study aimed to evaluate the face and content validity of this tool.

METHOD

Participants from 2 groups (nonexperienced and experienced [<600 or >600 lifetime ERCPs, respectively]) were invited to perform standardized assignments on the model: sphincterotomy and precut for both groups and papillectomy for the experienced group. Following these assignments, all participants filled out a questionnaire to rate their appreciation of the realism of the model, and experienced endoscopists were also asked to evaluate its didactic value using a 5-point Likert scale.

RESULTS

A total of 19 participants were included (nonexperienced, n = 10; experienced, n = 9). Parameters regarding the realism of the tool in terms of general appearance, sphincterotomy, precut, and papillectomy were overall considered realistic (4 of 5), with good agreement rates in terms of overall realism between groups. Experienced operators reported the highest realism for "positioning the scope and needle-knife in the field of view" and "during precut," "cutting in small increments during precut," and "controlling the scope during papillectomy," and they highly agreed that this papilla should be included for training novice and intermediate trainees in sphincterotomy, precut, and papillectomy.

CONCLUSIONS

Our results show good face validity and excellent content validity of this biological papilla combined with the Boškoski-Costamagna ERCP Trainer. This new tool provides a useful, inexpensive, versatile, and easy tool for training regarding sphincterotomy, precut, and papillectomy. Future studies should explore whether including this model in real-life training improves the learning curve of endoscopy trainees.

ERCP-related adverse events: incidence, mechanisms, risk factors, prevention, and management

INTRODUCTION

Endoscopic retrograde cholangiopancreatography (ERCP) is a commonly performed procedure for pancreaticobiliary disease. While ERCP is highly effective, it is also associated with the highest adverse event (AE) rates of all commonly performed endoscopic procedures. Thus, it is critical that endoscopists and caregivers of patients undergoing ERCP have clear understandings of ERCP-related AEs.

AREAS COVERED

This narrative review provides a comprehensive overview of the available evidence on ERCP-related AEs. For the purposes of this review, we subdivide the presentation of each ERCP-related AE according to the following clinically relevant domains: definitions and incidence, proposed mechanisms, risk factors, prevention, and recognition and management. The evidence informing this review was derived in part from a search of the electronic databases PubMed, Embase, and Cochrane, performed on 1 May 20231 May 2023.

EXPERT OPINION

Knowledge of ERCP-related AEs is critical not only given potential improvements in peri-procedural quality and related care that can ensue but also given the importance of reviewing these considerations with patients during informed consent. The ERCP community and researchers should aim to apply standardized definitions of AEs. Evidence-based knowledge of ERCP risk factors should inform patient care decisions during training and beyond.