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Loganathan P, Mohan B, Baraka A, Gajendran M, Saligram S, Aloysius M, Echavarria J, Goyal H. Trainee Involvement and ERCP Complications: A Systematic Review and Meta-Analysis. Dig Dis Sci 2024; 69:2363-2369. [PMID: 38713275 DOI: 10.1007/s10620-024-08452-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 04/15/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND Therapeutic endoscopy and gastroenterology fellows often participate in endoscopic retrograde cholangiopancreatography (ERCP) during their training period. However, it is generally feared that trainee involvement may increase ERCP-related complications, mainly because of the side-viewing nature of the endoscope and the higher risk of pancreatic duct cannulation. There is no concrete evidence to support this notion. This systematic review and meta-analysis aims to investigate the resultsof trainee participation on adverse events related to ERCP. METHODS PubMed, EMBASE, Google Scholar, SCOPUS, and Web of Science databases were searched from inception to 31 May 2023 for studies evaluating the ERCP outcomes defined as success rates, procedure time, failed attempts, and adverse events with and without trainee participation. A random effect model was used to perform the meta-analysis, and heterogeneity was assessed using the I2 statistics. RESULTS Seven studies were included in the final analysis, including 17,088 ERCPs. The pooled odds ratio (pOR) of success rate, incomplete/failed attempts in the trainee and no trainee groups were 0.466 (95% CI 0.13 to 1.66, I2 = 97.8%, p = 0.239) and 3.2 (95% CI 0.70 to 14.55), I2 = 98.5%, p = 0.134), respectively. The pOR of post-ERCP pancreatitis and bleeding in the trainee vs. no trainee groups was 0.97 (95% CI 0.76 to 1.23, I2 = 0%, p = 0.78) and 1.3 (95% CI 0.59 to 2.83, I2 = 49%, p = 0.54). The pOR of all adverse events in both groups was 1.028 (95% CI 0.917 to 1.152, I2 = 0%, p = 0.636). Surprisingly, the pooled std mean difference for the procedure time was 0.217 (95% - 0.093 to 0.05, I2 = 98.5%, p = 0.17). CONCLUSION This meta-analysis comprising of 17,088 ERCPs in seven studies demonstrated comparable ERCP outcomes related to trainee participation regarding success rates, procedure time, and adverse events. Trainees' involvement in ERCP within a proper teaching setting appears safe and does not compromise the overall procedure's success.
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Affiliation(s)
- Priyadarshini Loganathan
- Internal Medicine, University Medical Associates, UT Health San Antonio, 302 West Rector, San Antonio, TX, 78216, USA.
| | - Babu Mohan
- Gastroenterology & Hepatology, Orlando Gastroenterology PA, Orlando, FL, USA
| | - Abakar Baraka
- Long School of Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Mahesh Gajendran
- Gastroenterology & Hepatology Division, UT Health San Antonio, San Antonio, TX, USA
| | - Shreyas Saligram
- Gastroenterology & Hepatology Division, UT Health San Antonio, San Antonio, TX, USA
| | - Mark Aloysius
- Gastroenterology & Hepatology, Upstate University Hospital, Syracuse, NY, USA
| | - Juan Echavarria
- Gastroenterology & Hepatology Division, UT Health San Antonio, San Antonio, TX, USA
| | - Hemant Goyal
- Therapeutic Endoscopist at Boreland Groover Downtown, Jacksonville, FL, USA
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2
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Gupta R, Khalaf RT, Morrison J, Amankwah E, Ruan W, Fishman DS, Barth BA, Liu QY, Giefer M, Kim KM, Martinez M, Dall'oglio L, Torroni F, De Angelis P, Faraci S, Bitton S, Dua K, Werlin S, Gugig R, Huang C, Mamula P, Quiros JA, Zheng Y, Piester T, Grover A, Fox VL, Wilsey M, Troendle DM. Impact of Trainee Involvement on Pediatric ERCP Procedures: Results From the Pediatric ERCP Initiative. J Pediatr Gastroenterol Nutr 2023; 77:126-130. [PMID: 36976177 DOI: 10.1097/mpg.0000000000003782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
This study examines the role of trainee involvement with pediatric endoscopic retrograde cholangiopancreatography (ERCP) and whether it affects the procedure's success, post-procedural adverse outcomes, and duration. A secondary analysis of the Pediatric ERCP Database Initiative, an international database, was performed. Consecutive ERCPs on children <19 years of age from 18 centers were entered prospectively into the database. In total 1124 ERCPs were entered into the database, of which 320 (28%) were performed by trainees. The results showed that the presence of trainees did not impact technical success ( P = 0.65) or adverse events rates ( P = 0.43). Rates of post-ERCP pancreatitis, pain, and bleeding were similar between groups ( P > 0.05). Fewer cases involving trainees were in the top quartile (>58 minutes) of procedural time (19% vs 26%; P = 0.02). Overall, our findings indicate trainee involvement in pediatric ERCP is safe.
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Affiliation(s)
- Rekha Gupta
- From the Department of Pediatrics, Johns Hopkins All Children's Hospital, Saint Petersburg, FL
| | - Racha T Khalaf
- the Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of South Florida Morsani College of Medicine, Tampa, FL
| | - John Morrison
- Johns Hopkins All Children's Hospital, Saint Petersburg, FL
| | | | - Wenly Ruan
- Baylor College of Medicine Texas Children's Hospital, Houston, TX
| | - Douglas S Fishman
- From the Department of Pediatrics, Johns Hopkins All Children's Hospital, Saint Petersburg, FL
| | - Bradley A Barth
- the UT Southwestern Medical Center; Children's Health, Children's Medical Center, Dallas, TX
| | - Quin Y Liu
- the Cedars-Sinai Medical Center, Los Angeles, CA
| | - Matthew Giefer
- The University of Queensland, AU-Oschsner Health, New Orleans, LA
| | - Kyung Mo Kim
- University of Ulsan College of Medicine; Asan Medical Center Children's Hospital, Seoul, Republic of Korea
| | - Mercedes Martinez
- Columbia University New York Presbyterian Morgan Stanley Children's Hospital of New York, New York, NY
| | | | | | | | | | - Sam Bitton
- From the Department of Pediatrics, Johns Hopkins All Children's Hospital, Saint Petersburg, FL
| | - Kulwinder Dua
- Medical College of Wisconsin; Children's Wisconsin, Milwaukee, WI
| | - Steven Werlin
- Medical College of Wisconsin; Children's Wisconsin, Milwaukee, WI
| | - Roberto Gugig
- Stanford Children's Health; Lucile Packard Children's Hospital Stanford, Palo Alto, CA
| | | | - Petar Mamula
- Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Yuhua Zheng
- University of Southern California; Children's Hospital of Los Angeles, Los Angeles, CA
| | - Travis Piester
- University of Southern California; Children's Hospital of Los Angeles, Los Angeles, CA
| | - Amit Grover
- From the Department of Pediatrics, Johns Hopkins All Children's Hospital, Saint Petersburg, FL
| | - Victor L Fox
- From the Department of Pediatrics, Johns Hopkins All Children's Hospital, Saint Petersburg, FL
| | - Michael Wilsey
- Johns Hopkins All Children's Hospital, Saint Petersburg, FL
| | - David M Troendle
- the UT Southwestern Medical Center; Children's Health, Children's Medical Center, Dallas, TX
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3
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Ben Abdallah K, Hamzaoui L, Mahmoudi M, Cherif I, Ben Mohamed A, Yakoubi M, Khsiba A, Medhioub M, Azouz M. Predictive factors of difficult biliary cannulation: An experience of a tunisian tertiary center. Heliyon 2022; 8:e12526. [PMID: 36619425 PMCID: PMC9812703 DOI: 10.1016/j.heliyon.2022.e12526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 12/03/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction Selective biliary cannulation is a prerequisite for a successful endoscopic retrograde cholangiopancreatography (ERCP). However, conventional biliary access can be difficult. The aims of our study were to determine the prevalence of difficult biliary cannulation (DBC) and its associated factors and to describe the efficiency and safety of used standard and advanced cannulation techniques. Methods We conducted a single-center retrospective study including all patients with naïve papilla who had an ERCP procedure in Gastroenterology department of Mohamed Taher Maamouri Hospital from June 2019 to December 2021. Efficiency was defined as successful selective deep biliary cannulation. DBC was defined based on the presence of one or more of the European Society of Gastrointestinal Endoscopy (ESGE) criteria (5-5-1): more than five cannulation attempts, more than 5 min before cannulation and more than one accidental passage in the wirsung. Prevalence was measured using ESGE 5-5-1 cutoffs and chinese set cutoffs 15-10-2. Predictors of DBC were sought by univariate and multivariate analysis (SPSS software, p significant if < 0.05). Results We included 664 patients (mean age 62 years and sex ratio M/W = 0.8). Main indication for ERCP was choledocholithiasis (67%, n = 442) followed by malignant biliary stenosis (21%, n = 138). Based on ESGE criteria, prevalence of DBC was 42.62% (n = 283). Prevalence was 21.15% when 15-10-2 cutoffs are applied in trainee-involved procedure. Cumulative biliary success rate was 96.46%. Standard cannulation method achieved access in 98.2% while advanced methods permitted success in 92.2% in fistulotomy, 94.1% in papillotomy and 77.3% in transpancreatic sphincterotomy. Independent predictive factors of DBC in multivariate analysis were: Trainee presence OR 1.80 [1.24-2.65], SOD OR 4.71 [1.11-19.88], biliary stenosis found on imaging examinations (OR 2.53 [1.63-3.92], small papilla OR 4.09 [1.82-9.17] and difficult orientation of the papilla OR 14.90 [3.28-67.62]. Conclusion DBC is a frequent endoscopic situation. Predictors of DBC can be related to trainee involvement in the procedure, anatomical and clinical factors. A thorough understanding of these factors can actively contribute to ERCP management plans.
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Affiliation(s)
- K. Ben Abdallah
- Gastroenterology Department, Mohamed Taher Maamouri University Hospital, Nabeul, Tunisia,Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia,Corresponding author.
| | - L. Hamzaoui
- Gastroenterology Department, Mohamed Taher Maamouri University Hospital, Nabeul, Tunisia,Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - M. Mahmoudi
- Gastroenterology Department, Mohamed Taher Maamouri University Hospital, Nabeul, Tunisia,Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - I. Cherif
- Laboratory of Medical Epidemiology, Institut Pasteur de Tunis, Tunisia,Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - A. Ben Mohamed
- Gastroenterology Department, Mohamed Taher Maamouri University Hospital, Nabeul, Tunisia,Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - M. Yakoubi
- Gastroenterology Department, Mohamed Taher Maamouri University Hospital, Nabeul, Tunisia,Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - A. Khsiba
- Gastroenterology Department, Mohamed Taher Maamouri University Hospital, Nabeul, Tunisia,Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - M. Medhioub
- Gastroenterology Department, Mohamed Taher Maamouri University Hospital, Nabeul, Tunisia,Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - M.M. Azouz
- Gastroenterology Department, Mohamed Taher Maamouri University Hospital, Nabeul, Tunisia,Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
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4
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Saito H, Kadono Y, Shono T, Kamikawa K, Urata A, Nasu J, Imamura H, Matsushita I, Kakuma T, Tada S. Factors Predicting Difficult Biliary Cannulation during Endoscopic Retrograde Cholangiopancreatography for Common Bile Duct Stones. Clin Endosc 2021; 55:263-269. [PMID: 34763384 PMCID: PMC8995991 DOI: 10.5946/ce.2021.153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 07/02/2021] [Indexed: 11/21/2022] Open
Abstract
Background/Aims Difficult biliary cannulation is an important risk factor for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). Therefore, this study aimed to identify the factors that predict difficult cannulation for common bile duct stones (CBDS) to reduce the risk for PEP.
Methods This multicenter retrospective study included 1,406 consecutive patients with native papillae who underwent ERCP for CBDS. Factors predicting difficult cannulation for CBDS were identified using univariate and multivariate analyses.
Results Univariate analysis showed that six factors significantly predicted difficult cannulation: ERCP performed by non-expert endoscopists, low-volume center, absence of acute cholangitis, normal serum bilirubin, intradiverticular papilla, and type of major duodenal papilla. Multivariate analysis identified ERCP performed by non-expert endoscopists (odds ratio [OR], 2.5; p<0.001), low-volume center (OR, 1.6; p<0.001), intradiverticular papilla (OR, 1.3; p=0.007), normal serum bilirubin (OR, 1.3; p=0.038), and absence of acute cholangitis (OR, 1.3; p=0.049) as factors significantly predicting difficult cannulation for CBDS.
Conclusions Initial cannulation by an experienced endoscopist, early rescue cannulation, or early takeover by an experienced endoscopist should be considered when performing ERCP for CBDS in the presence of factors predicting difficult cannulation.
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Affiliation(s)
- Hirokazu Saito
- Department of Gastroenterology, Kumamoto City Hospital, Kumamoto, Japan
| | - Yoshihiro Kadono
- Department of Gastroenterology, Tsuruta Hospital, Kumamoto, Japan
| | - Takashi Shono
- Department of Gastroenterology, Kumamoto Chuo Hospital, Kumamoto, Japan
| | - Kentaro Kamikawa
- Department of Gastroenterology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Atsushi Urata
- Department of Gastroenterology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Jiro Nasu
- Department of Gastroenterological Surgery, Kumamoto Chuo Hospital, Kumamoto, Japan
| | - Haruo Imamura
- Department of Gastroenterology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Ikuo Matsushita
- Department of Gastroenterology, Kumamoto Chuo Hospital, Kumamoto, Japan
| | - Tatsuyuki Kakuma
- Department of Biostatics Center, Medical School, Kurume University, Fukuoka, Japan
| | - Shuji Tada
- Department of Gastroenterology, Kumamoto City Hospital, Kumamoto, Japan
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5
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Fernandes J, Canena J, Alexandrino G, Figueiredo L, Rafael M, Moreira M, Araújo T, Lourenço L, Horta D, Familiari P, Dinis-Ribeiro M, Lopes L. Outcomes of single-endoscopist-performed needle-knife fistulotomy for selective biliary access in 842 consecutive patients: learning curve and changes over a 14-year period in a retrospective study. Scand J Gastroenterol 2021; 56:1363-1370. [PMID: 34355615 DOI: 10.1080/00365521.2021.1958369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Needle-knife fistulotomy (NKF) has emerged as the preferred precut technique. From a late strategy, NKF has shifted to an early rescue technique and has been used recently as a primary method for biliary access. It is unknown how these changes have affected NKF outcomes. We analyzed the outcomes of NKF over time in a large cohort of patients. METHODS Multicenter retrospective cohort study of 842 patients who underwent NKF for biliary access between 2006 and 2019. Patients were divided into four study periods according to a late or early cannulation strategy and to the use of post-ERCP pancreatitis prophylaxis (Period 1-Period 4). We assessed outcomes of NKF, learning curves and shifts over time. RESULTS Bile duct access was obtained in 88.0% of the patients. The initial cannulation rate increased significantly from 77.5% in P1 to 92.0% in P4 (p < .001). An endoscopist can obtain 80% success rate after performing 100 NKF procedures (95% CI: 0.79-0.86) and a 95% success rate after 830 procedures (95% CI: 0.92-0.98). Adverse events and pancreatitis were observed in 6.5% and 4.9% of patients respectively. The rate of pancreatitis was not significantly different during the 4 periods (p = .190). A decline in the pancreatitis rate was observed from 2006 until 2016 (no trainees) and then an increase until 2019 (trainees involved). The presence of trainees increased the rate of pancreatitis in the last period by 9.9%. CONCLUSIONS The success of NKF has increased significantly over the years, initially in a rapid manner and then more slowly. It is associated with a low rate of complications, which tend to decrease with experience. The involvement of trainees is associated with an increased rate of pancreatitis.
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Affiliation(s)
- João Fernandes
- Department of Gastroenterology, Santa Luzia Hospital, Unidade Local de Saúde Alto Minho, Viana do Castelo, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Jorge Canena
- Department of Gastroenterology, Professor Doutor Fernando Fonseca Hospital, Amadora, Portugal.,Department of Gastroenterology, Nova Medical School/Faculty of Medical Sciences, Lisbon, Portugal.,Cintesis, Center for Health Technology and Services Research, Porto, Portugal
| | - Gonçalo Alexandrino
- Department of Gastroenterology, Professor Doutor Fernando Fonseca Hospital, Amadora, Portugal
| | - Luísa Figueiredo
- Department of Gastroenterology, Professor Doutor Fernando Fonseca Hospital, Amadora, Portugal
| | - Maria Rafael
- Department of Gastroenterology, Professor Doutor Fernando Fonseca Hospital, Amadora, Portugal
| | - Marta Moreira
- Department of Gastroenterology, Santa Luzia Hospital, Unidade Local de Saúde Alto Minho, Viana do Castelo, Portugal
| | - Tarcísio Araújo
- Department of Gastroenterology, Santa Luzia Hospital, Unidade Local de Saúde Alto Minho, Viana do Castelo, Portugal
| | - Luís Lourenço
- Department of Gastroenterology, Professor Doutor Fernando Fonseca Hospital, Amadora, Portugal
| | - David Horta
- Department of Gastroenterology, Professor Doutor Fernando Fonseca Hospital, Amadora, Portugal.,Department of Gastroenterology, Nova Medical School/Faculty of Medical Sciences, Lisbon, Portugal
| | - Pietro Familiari
- Digestive Endoscopy Unit, Agostino Gemelli University Hospital, Rome, Italy
| | - Mário Dinis-Ribeiro
- Digestive Endoscopy Unit, Agostino Gemelli University Hospital, Rome, Italy.,Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal
| | - Luís Lopes
- Department of Gastroenterology, Santa Luzia Hospital, Unidade Local de Saúde Alto Minho, Viana do Castelo, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
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6
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Uchida D, Tsutsumi K, Kato H, Matsumi A, Saragai Y, Tomoda T, Matsumoto K, Horiguchi S, Okada H. Potential Factors Affecting Results of Short-Type Double-Balloon Endoscope-Assisted Endoscopic Retrograde Cholangiopancreatography. Dig Dis Sci 2020; 65:1460-1470. [PMID: 31562611 DOI: 10.1007/s10620-019-05857-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 09/18/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Short-type double-balloon endoscope (DBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) has been developed as an alternative approach for cases with a surgically altered gastrointestinal anatomy. However, this technique is sometimes technically challenging and carries a risk of severe adverse events. AIMS To evaluate the factors affecting the technical success rate and adverse events of DBE-ERCP. METHODS A total of 319 patients (805 procedures) with a surgically altered gastrointestinal anatomy underwent short DBE-ERCP. The factors affecting the technical success rate and adverse events, and the learning curve of the trainees were retrospectively evaluated. RESULTS The technical success rate of all procedures was 90.7%. Adverse events occurred in 44 (5.5%) procedures. A multivariate analysis indicated that Roux-en-Y reconstruction and first-time short DBE-ERCP were factors affecting the technical failure and adverse event rates, while the modified Child method after subtotal stomach-preserving pancreaticoduodenectomy reconstruction was a non-risk factor for adverse events. The trainee caseload did not affect the technical success or adverse event rates significantly; however, trainees tended to perform cases involving the modified Child method after subtotal stomach-preserving pancreaticoduodenectomy reconstruction. The success rate of scope insertion increased according to experience; however, the overall success rate did not differ to a statistically significant extent. CONCLUSION Short DBE-ERCP was useful and safe for managing cases with a surgically altered anatomy; however, trainees should concentrate on accumulating experience with easy cases, such as those with the modified Child method after subtotal stomach-preserving pancreaticoduodenectomy reconstruction or a history of DBE-ERCP.
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Affiliation(s)
- Daisuke Uchida
- Department of Gastroenterology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan.
- Center for Innovative Clinical Medicine, Okayama University Hospital, Okayama, Japan.
| | - Koichiro Tsutsumi
- Department of Gastroenterology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Hironari Kato
- Department of Gastroenterology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Akihiro Matsumi
- Department of Gastroenterology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Yosuke Saragai
- Department of Gastroenterology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Takeshi Tomoda
- Department of Gastroenterology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Kazuyuki Matsumoto
- Department of Gastroenterology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Shigeru Horiguchi
- Department of General Medicine, Okayama University Hospital, Okayama, Japan
| | - Hiroyuki Okada
- Department of Gastroenterology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
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7
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Haraldsson E, Kylänpää L, Grönroos J, Saarela A, Toth E, Qvigstad G, Hult M, Lindström O, Laine S, Karjula H, Hauge T, Sadik R, Arnelo U. Macroscopic appearance of the major duodenal papilla influences bile duct cannulation: a prospective multicenter study by the Scandinavian Association for Digestive Endoscopy Study Group for ERCP. Gastrointest Endosc 2019; 90:957-963. [PMID: 31326385 DOI: 10.1016/j.gie.2019.07.014] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 07/10/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Certain appearances of the major duodenal papilla have been claimed to make cannulation more difficult during ERCP. This study uses a validated classification of the endoscopic appearance of the major duodenal papilla to determine if certain types of papilla predispose to difficult cannulation. METHODS Patients with a naïve papilla scheduled for ERCP were included. The papilla was classified into 1 of 4 papilla types before cannulation started. Time to successful bile duct cannulation, attempts, and number of pancreatic duct passages were recorded. Difficult cannulation was defined as after 5 minutes, 5 attempts, or 2 pancreatic guidewire passages. RESULTS A total of 1401 patients were included from 9 different centers in the Nordic countries. The overall frequency of difficult cannulation was 42% (95% confidence interval [CI], 39%-44%). Type 2 small papilla (52%; 95% CI, 45%-59%) and type 3 protruding or pendulous papilla (48%; 95% CI, 42%-53%) were more frequently difficult to cannulate compared with type 1 regular papilla (36%; 95% CI, 33%-40%; both P < .001). If an inexperienced endoscopist started cannulation, the frequency of failed cannulation increased from 1.9% to 6.3% (P < .0001), even though they were replaced by a senior endoscopist after 5 minutes. CONCLUSIONS The endoscopic appearance of the major duodenal papilla influences bile duct cannulation. Small type 2 and protruding or pendulous type 3 papillae are more frequently difficult to cannulate. In addition, cannulation might even fail more frequently if a beginner starts cannulation. These findings should be taken into consideration when performing studies regarding bile duct cannulation and in training future generations of endoscopists.
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Affiliation(s)
- Erik Haraldsson
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Skaraborg Hospital, Skövde, Sweden
| | - Leena Kylänpää
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Juha Grönroos
- Department of Surgery, University of Turku, and Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | - Arto Saarela
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Ervin Toth
- Department of Gastroenterology, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Gunnar Qvigstad
- Department of Gastroenterology and Hepatology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Mari Hult
- Department of Medicine, Solna, Unit of Clinical Epidemiology, Karolinska Institutet, Stockholm, Sweden; Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Outi Lindström
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Simo Laine
- Department of Surgery, University of Turku, and Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | - Heikki Karjula
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Truls Hauge
- Department of Gastroenterology, Oslo University Hospital and Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Riadh Sadik
- Department of Gastroenterology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Urban Arnelo
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
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8
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ERCP practice beyond the training period - bridging the gap between guidelines and real-life practice: a single operator experience of 679 procedures. ACTA ACUST UNITED AC 2019; 57:151-158. [PMID: 30517080 DOI: 10.2478/rjim-2018-0038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Indexed: 11/21/2022]
Abstract
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.
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Desai R, Patel U, Doshi S, Zalavadia D, Siddiq W, Dave H, Bilal M, Khullar V, Goyal H, Desai M, Shah N. A Nationwide Assessment of the "July Effect" and Predictors of Post-Endoscopic Retrograde Cholangiopancreatography Sepsis at Urban Teaching Hospitals in the United States. Clin Endosc 2019; 52:486-496. [PMID: 31129956 PMCID: PMC6785412 DOI: 10.5946/ce.2018.190] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 02/27/2019] [Indexed: 12/23/2022] Open
Abstract
Background/Aims To analyze the incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) sepsis in the early (July to September) and later (October to June) academic months to assess the “July effect”.
Methods The National Inpatient Sample (2010–2014) was used to identify ERCP-related adult hospitalizations at urban teaching hospitals by applying relevant procedure codes from the International Classification of Diseases, 9th revision, Clinical Modification. Post-ERCP outcomes were compared between the early and later academic months. A multivariate analysis was performed to evaluate the odds of post-ERCP sepsis and its predictors.
Results Of 481,193 ERCP procedures carried out at urban teaching hospitals, 124,934 were performed during the early academic months. The demographics were comparable for ERCP procedures performed during the early and later academic months. A higher incidence (9.4% vs. 8.8%, p<0.001) and odds (odds ratio [OR], 1.07) of post-ERCP sepsis were observed in ERCP performed during the early academic months. The in-hospital mortality rate (7% vs. 7.5%, p=0.072), length of stay, and total hospital charges in patients with post-ERCP sepsis were also equivalent between the 2 time points. Pre-ERCP cholangitis (OR, 3.20) and post-ERCP complications such as cholangitis (OR, 6.27), perforation (OR, 3.93), and hemorrhage (OR, 1.42) were significant predictors of higher post-ERCP sepsis in procedures performed during the early academic months.
Conclusions The July effect was present in the incidence of post-ERCP sepsis, and academic programs should take into consideration the predictors of post-ERCP sepsis to lower health-care burden.
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Affiliation(s)
| | - Upenkumar Patel
- Department of Internal Medicine, Nassau University Medical Center, East Meadow, NY, USA
| | - Shreyans Doshi
- Department of Internal Medicine, College of Medicine/Hospital Corporation of America Graduate Medicine Education Consortium, University of Central Florida, Gainesville, FL, USA
| | - Dipen Zalavadia
- Department of Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, PA, USA
| | - Wardah Siddiq
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Hitanshu Dave
- Department of Internal Medicine, Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Mohammad Bilal
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Vikas Khullar
- Division of Gastroenterology, Department of Internal Medicine, University of Florida, Gainesville, FL, USA
| | - Hemant Goyal
- Department of Internal Medicine, Mercer University School of Medicine, Macon, GA, USA
| | - Madhav Desai
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, MO, USA
| | - Nihar Shah
- Division of Gastroenterology, Department of Internal Medicine, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA
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Voiosu T, Bălănescu P, Voiosu A, Benguş A, Preda C, Umans DS, Bogdan Mateescu R, van Hooft JE. Measuring trainee competence in performing endoscopic retrograde cholangiopancreatography: A systematic review of the literature. United European Gastroenterol J 2019; 7:239-249. [PMID: 31080609 PMCID: PMC6498806 DOI: 10.1177/2050640618817110] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 11/09/2018] [Indexed: 12/13/2022] Open
Abstract
Background Current recommendations on training in endoscopic retrograde cholangiopancreatography are predicated on a performance-centred approach designed to ensure that trainees achieve appropriate skills. We aimed to analyse how competence in endoscopic retrograde cholangiopancreatography is defined in the literature and what proportion of trainees actually reach this threshold. Methods We conducted a systematic MEDLINE search for studies reporting on endoscopic retrograde cholangiopancreatography training programmes in a clinical setting. The main outcome measure was threshold for achieving competence in endoscopic retrograde cholangiopancreatography; the secondary outcome measure was assessment of trainee performance. Quality was assessed using the Cochrane Risk of Bias tool and the Methodological Index for Non-Randomized Studies criteria. Results Of 522 initially identified articles, 20 were included in the analysis; most studies showed a high risk of bias. Cannulation rate of the desired duct was the main marker of competence in all studies; however, only 8/20 studies reported on the performance of individual trainees, who achieved their respective standard of competence in only 25.6% of reported cases. Conclusions Current literature identifies cannulation rate of a native papilla to be the most appropriate measure of endoscopic retrograde cholangiopancreatography competence; however, most trainees do not reach predefined competence thresholds. Furthermore, due to the limitations of available studies, the most appropriate competence measure remains subject for debate.
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Affiliation(s)
- Theodor Voiosu
- Carol Davila School of Medicine, Bucharest, Romania
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
| | | | - Andrei Voiosu
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
| | - Andreea Benguş
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
| | - Carmen Preda
- Carol Davila School of Medicine, Bucharest, Romania
- Gastroenterology Department, Fundeni Clinical Institute, Bucharest, Romania
| | - Devica S Umans
- Department of Gastroenterology and Hepatology, University of Amsterdam, Amsterdam, the Netherlands
| | - Radu Bogdan Mateescu
- Carol Davila School of Medicine, Bucharest, Romania
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, University of Amsterdam, Amsterdam, the Netherlands
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Affiliation(s)
- James H. Tabibian
- Division of Gastroenterology, Department of Medicine Olive View-UCLA Medical Center, Sylmar, CA, United States,Corresponding author Dr. James H. Tabibian Department of Medicine14445 Olive View Dr., 2B-182Sylmar, CA 91203+1-747-210-4573
| | - Joseph W. Leung
- Division of Gastroenterology and Hepatology, UC Davis Medical Center, Sacramento, CA, United States
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Wu DX, Chen YD, Liu P. Advances in management of difficult biliary access. Shijie Huaren Xiaohua Zazhi 2017; 25:3149-3154. [DOI: 10.11569/wcjd.v25.i35.3149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Since the first report of endoscopic retrograde cholangio-pancreatography (ERCP) in 1986 for the diagnosis of biliary-pancreatic disease, ERCP has become an important means for the diagnosis and treatment of biliary-pancreatic disease. At present, although the success rate of endoscopic selective biliary cannulation is more than 90%, there are still 5%-10% of cases with failed cannulation, for which assistive technology is needed as a supplementary to achieve successful cannulation. Repeated attempts correlate with a higher success rate of cannulation, but also extend the operating time and increase the incidence of complications. In recent years, the concept of difficult biliary cannulation has been put forward and gradually accepted by endoscopic physicians. In the cases of difficult biliary cannulation, endoscopic physicians can adjust the cannulation strategy in time to improve the success rate and reduce the complication rate. This paper summarizes the literature published recently to make a systematic review of the advances in the management of difficult biliary cannulation.
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Affiliation(s)
- Dong-Xia Wu
- Department of Gastroenterology, the First Affiliated Hospital of Hunan Normal University, Changsha 410000, Hunan Province, China
| | - Ya-Dong Chen
- Department of Gastroenterology, the First Affiliated Hospital of Hunan Normal University, Changsha 410000, Hunan Province, China
| | - Peng Liu
- Department of Gastroenterology, the First Affiliated Hospital of Hunan Normal University, Changsha 410000, Hunan Province, China
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