Consenting patients for endoscopic retrograde cholangiopancreatography: results of a survey of 182 UK endoscopists and 2059 of their patients

The evolution of informed consent in gastroenterology

With medical litigation on the rise, physicians require a nuanced understanding of the legalities of consenting patients to reduce their liability while practising evidence-based medicine. This study aims to a) clarify the legal duties of gastroenterologists in the UK and USA when gaining informed consent and b) provide recommendations at the international and physician level to improve the consent process and reduce liability.A bibliometric analysis of the Web of Science database with the MeSH terms "gastroenterology" and "informed consent" yielded 383 articles, of which 228 were excluded due to not meeting the inclusion criteria. Of the top 50 articles, 48% were from American institutions and 16% were from the UK. Thematic analysis showed 72% of the articles discussed informed consent in relation to diagnostic procedures, 14% regarding treatment, and 14% regarding research participation.Both the USA and the UK have progressed from previously paternalistic Natanson case (1960) and Bolam test (1957), respectively, where physicians were held to the standard of a "reasonable and prudent medical doctor". The American Canterbury case (1972) and the British Montgomery case (2015) radically shifted the standard of disclosure during the consent process by requiring physicians to explain all information pertinent to a "reasonable patient".It is our recommendation that a two-pronged approach be taken; a) creation of international guidelines for consenting patients for invasive procedures in gastroenterology, and b) development of internationally standardised endoscopy consent forms containing all the details pertinent to a "reasonable patient".

Video education can improve awareness of risks for patients undergoing endoscopic retrograde cholangiopancreatography: A randomized trial

OBJECTIVE

We conducted a randomized trial aiming at improving patients' informed consent for undergoing endoscopic retrograde cholangiopancreatography (ERCP) in clinical care by comparing the efficacy of an additional educational video to written informed consent with that of written informed consent alone.

METHODS

This was a single-center, randomized controlled trial. Consecutive patients undergoing ERCP were randomized to a video education or a control group. An educational video detailing ERCP procedure plus standard written informed consent was administered to the video education group, while the control group reviewed standard written informed consent only. The primary outcome was the patients' perception of the risk or possibility of ERCP complications. Their perception of the benefits of ERCP, alternative treatments and overall satisfaction with the process of informed consent were also compared.

RESULTS

In total 205 patients were included in the study (104 in the control group and 101 in the video education group). Patients' comprehension of ERCP-related complications in the video education group was significantly increased (P < 0.001), and these patients were more likely to correctly identify the incidence of such complications. Significantly more patients in the video education group were very satisfied with informed consent process (87.1% vs 76.0%, P = 0.040) and fewer patients needed additional explanations (31.7% vs 47.1%, P = 0.024).

CONCLUSIONS

A supplementary educational video could greatly improve patient's understanding of ERCP procedure, in particular, its potential risks and complications, as well as their overall satisfaction with the process of informed consent (ClinicalTrials.gov no. NCT02810379).

Issues on informed consent for endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) is an endoscopic operation with potential therapeutic risks. With the development of endoscopic techniques, the rate of performing ERCP is more and more higher and as a result, the rate of complications is increasing. Unfortunately, quite a few patients have little comprehension about the process of ERCP and its complications. This paper gives a brief overview of some issues on informed consent for ERCP.

Distal bile duct cancers complicated with cholangiobronchopleural fistula after ERCP: A case report

Distal (lower) bile duct cancers arise in the lower half of the biliary tree closer to the small intestine. Biliary disease complicated with cholangiobronchopleural fistula, which may occur in cases of multiple hepatobiliary stones or biliary ascariasis-associated severe infection, has rarely been reported in the literature, particularly following endoscopic retrograde cholangiopancreatography (ERCP). The present study describes the case of a 60-year-old female with distal cholangiocarcinoma complicated with cholangiobronchopleural fistula after ERCP for this rare disease. This complication was likely due to the inability to control retrograde infection following ERCP and, thus, the infection was disseminated. This resulted in mixed infection involving the diaphragm and pleura, and further penetrating the bronchus. The patient was managed with pancreatoduodenectomy and has since remained in good health.

All-cause mortality after first ERCP in England: clinically guided analysis of hospital episode statistics with linkage to registry of death

BACKGROUND

All-cause death within 30 days of ERCP is a candidate indicator of care, but institutional-level statistics require careful interpretation. National-scale, population-based outcome studies of unselected patients undergoing ERCP are needed to define expected levels of real-world mortality risk and the case-mix factors that predict poor outcome.

OBJECTIVE

To develop methods for analyzing administrative data for English hospitals with linkage to death registration to study all-cause mortality after first ERCPs and explore predictors of death and institutional variation.

DESIGN

Hospital episode statistics for 2006 to 2007 and 2007 to 2008 were linked to the statutory death register. First ERCP episodes were extracted and analyzed for demographic characteristics, admission method, diagnoses, and comorbidities. Additional linkages identified the last-coded diagnosis before death. Factors associated with 30-day death were identified by univariate and multiple logistic analyses. Pilot data and a survey were sent to clinicians at each institution. Crude and case-mix adjusted mortality were analyzed at the institutional level.

MAIN OUTCOME MEASUREMENTS

Death within 30 days of the first ERCP procedure.

RESULTS

We analyzed 20,246 first ERCPs from 2006 to 2007 and 20,422 from 2007 to 2008. Diagnostic profile: gallstone related 57.3%; cancer 12.6%; gallstone and cancer 2%; others 28.1%. All-cause 30-day death was 5.3% (2.4% in non-cancer cases). Predictors of 30-day death (adjusted odds ratio [OR]) were as follows: age (OR 6.2, for ≥85 years vs <55 years), male sex (OR 1.2 vs female), emergency admission (OR 2.0 vs elective), cancer (OR 8.6 vs no cancer), and non-cancer comorbidity (OR 1.5 vs none). A mortality risk estimator (look-up table) based on pooled data for >40,000 first ERCPs is provided. Specific procedural complication codes were identified in 1.2% of deaths (0.06% of ERCPs). At the institutional level, analysis of mortality rates was within expected statistical funnel limits, and we found no correlation with ERCP volume (Pearson r = -0.05; P > .05).

LIMITATIONS

The completeness and accuracy of coding may vary between different hospitals. Routine coding does not capture information about procedural complexity or severity of illness.

CONCLUSION

Linkage analysis of hospital episode statistics data for England provides a powerful tool for studying mortality risk after ERCP on an unselected and truly nationwide scale. Institutional-level statistics suggest that the mortality risk for patients requiring ERCP was comparable across English hospitals.