A national audit of temporal trends in endoscopic retrograde cholangiopancreatography in Norway

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.

Single-use duodenoscope for ERCP performed by endoscopists with a range of experience in procedures of variable complexity

BACKGROUND AND AIMS

Expert endoscopists previously reported ERCP outcomes for the first commercialized single-use duodenoscope. We aimed to document usability of this device by endoscopists with different levels of ERCP experience.

METHODS

Fourteen "expert" (>2000 lifetime ERCPs) and 5 "less-expert" endoscopists performed consecutive ERCPs in patients without altered pancreaticobiliary anatomy. Outcomes included ERCP completion for the intended indication, rate of crossover to another endoscope, device performance ratings, and serious adverse events.

RESULTS

Two hundred ERCPs including 81 (40.5%) with high complexity (American Society for Gastrointestinal Endoscopy grades 3-4) were performed. Crossover rate (11.3% vs 2.5%, P = .131), ERCP completion rate (regardless of crossovers) (96.3% vs 97.5%, P = .999), median ERCP completion time (25.0 vs 28.5 minutes, P = .130), mean cannulation attempts (2.8 vs 2.8, P = .954), and median overall satisfaction with the single-use duodenoscope (8.0 vs 8.0 [range, 1.0-10.0], P = .840) were similar for expert versus less-expert endoscopists, respectively. The same metrics were similar by procedural complexity except for shorter median completion time for grades 1 to 2 versus grades 3 to 4 (P < .001). Serious adverse events were reported in 13 patients (6.5%).

CONCLUSIONS

In consecutive ERCPs including high complexity procedures, endoscopists with varying ERCP experience had good procedural success and reported high device performance ratings. (Clinical trial registration number: NCT04223830.).

Long-Term Survivors after Upfront Resection for Pancreatic Ductal Adenocarcinoma: An Actual 5-Year Analysis of Disease-Specific and Post-Recurrence Survival

BACKGROUND

Data on long-term actual survival in patients with surgically resected pancreatic ductal adenocarcinoma (PDAC) are limited. The aim of this study was to evaluate the actual 5-year disease-specific survival (DSS) and post-recurrence survival (PRS) in patients who underwent pancreatectomy for PDAC.

METHODS

Data from patients who underwent upfront surgical resection for PDAC between 2009 and 2014 were analyzed. Exclusion criteria included PDAC arising in the background of an intraductal papillary mucinous neoplasm and patients undergoing neoadjuvant therapy. All alive patients had a minimum follow-up of 60 months. Independent predictors of PRS, DSS, and survival > 5 years were searched.

RESULTS

Of the 176 patients included in this study, 48 (27%) were alive at 5 years, but only 20 (11%) had no recurrence. Median PRS was 12 months. In the 154 patients after disease recurrence, independent predictors of shorter PRS were total pancreatectomy, G3 tumors, early recurrence (< 12 months from surgery), and no treatment at recurrence. Median DSS was 36 months. Independent predictors of DSS were CA19-9 at diagnosis > 200 U/mL, total pancreatectomy, N + status, G3 tumors and perineural invasion. Only the absence of perineural invasion was a favorable independent predictor of survival > 5 years.

CONCLUSION

More than one-quarter of patients who underwent upfront surgery for PDAC were alive after 5 years, although only 11% of the initial cohort were cancer-free. Long-term survival can also be achieved in tumors with more favorable biology in an upfront setting followed by adjuvant chemotherapy.

Device profile of the EXALT Model D single-use duodenoscope for endoscopic retrograde cholangiopancreatography: overview of its safety and efficacy

Introduction: The management of pancreaticobiliary disorders relies heavily on endoscopic retrograde cholangiopancreatography, which is performed with a duodenoscope. Bacterial colonization of reusable duodenoscopes leading to subsequent infectious outbreaks is well recognized and remains an issue despite efforts to optimize best practices in high-level disinfection. The EXALT Model D duodenoscope (EXALT) (Boston Scientific Corporation, Marlborough, MA) is a single-use device, designed to achieve technical equivalency with reusable devices while eliminating the potential for device-related outbreaks.Areas covered: This review covers the challenges associated with reprocessing duodenoscopes and the development of duodenoscope-related infections, with an emphasis on the use of single-use duodenoscopes as a potential solution to this issue.Expert Opinion: Duodenoscope-related infections are an increasingly recognized problem. Infectious outbreaks harm patients, significantly affect providers and medical centers, and can erode patient trust in the health-care system. Single-use duodenoscopes eliminate both the risk of device-related infection transmission and the need for burdensome duodenoscope reprocessing. In clinical evaluations, the EXALT device has demonstrated an equivalent technical performance and provider satisfaction compared to reusable duodenoscopes. Increasing use of this device will clarify how it compares to reusable duodenoscopes in a variety of clinical settings among endoscopists of varying skills levels.

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.

Clinical Evaluation of a Single-Use Duodenoscope for Endoscopic Retrograde Cholangiopancreatography

BACKGROUND & AIMS

Disposable, single-use duodenoscopes might reduce outbreaks of infections associated with endoscope reuse. We tested the feasibility, preliminary safety, and performance of a new single-use duodenoscope in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

We conducted a case-series study of the outcomes of ERCP with a single-use duodenoscope from April through May 2019 at 6 academic medical centers. We screened consecutive patients (18 years and older) without alterations in pancreaticobiliary anatomy and enrolled 73 patients into the study. Seven expert endoscopists performed roll-in maneuvers (duodenoscope navigation and visualization of duodenal papilla only) in 13 patients and then ERCPs in the 60 other patients. Outcomes analyzed included completion of ERCP for the intended clinical indication, crossover from a single-use duodenoscope to a reusable duodenoscope, endoscopist performance ratings of the device, and serious adverse events (assessed at 72 hours and 7 days).

RESULTS

Thirteen (100%) roll-in maneuver cases were completed using the single-use duodenoscope. ERCPs were of American Society for Gastrointestinal Endoscopy procedural complexity grade 1 (least complex; 7 patients [11.7%]), grade 2 (26 patients [43.3%]), grade 3 (26 patients [43.3%]), and grade 4 (most complex; 1 patient [1.7%]). Fifty-eight ERCPs (96.7%) were completed using the single-use duodenoscope only and 2 ERCPs (3.3%) were completed using the single-use duodenoscope followed by crossover to a reusable duodenoscope. Median overall satisfaction was 9 out of 10. Three patients developed post-ERCP pancreatitis, 1 patient had post-sphincterotomy bleeding, and 1 patient had worsening of a preexisting infection and required rehospitalization.

CONCLUSIONS

In a case-series study, we found that expert endoscopists can complete ERCPs of a wide range of complexity using a single-use duodenoscope for nearly all cases. This alternative might decrease ERCP-related risk of infection. Clinicaltrials.gov no: NCT03701958.

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

BACKGROUND AND AIMS

The ERCP volume in developed countries has decreased recently, whereas the ERCP trend is unknown in developing countries. This study aimed to evaluate the ERCP development in China between 2006 and 2012.

METHODS

All hospitals performing ERCP in mainland China in 2012 participated in an online survey. Data on ERCP infrastructure, volume, indication, and adverse events were collected and compared with those in a previous national survey and in developed countries.

RESULTS

From 2006 to 2012 the number of hospitals performing ERCP in China increased from 470 to 1156. The total ERCP volume increased from 63,787 to 195,643, of which >95% were therapeutic. The ERCP rate in China (14.4 per 100,000 inhabitants) in 2012 was still much lower than that in developed countries. There was significant imbalance between different regions (1.3-99.1 per 100,000 inhabitants). The median ERCP volume per hospital decreased from 80 (interquartile range [IQR], 31-150) in 2006 to 52 (IQR, 20-146) in 2012. The median volume of the 686 hospitals that started ERCP after 2006 was 31.5 (IQR, 11-82). The post-ERCP adverse event rate in 2012 was comparable between hospitals in terms of volume (≥500 or <500 per year: 5.8% vs 5.6%) and practice durations (starting ERCP before or after 2006: 5.5% vs 5.6%).

CONCLUSIONS

ERCP has developed considerably in China in recent years. Despite low annual volume, the hospitals starting ERCP after 2006 have acceptable adverse event rates and will be promising and important sources of ERCP development in China.

Post-endoscopic retrograde cholangiopancreatography pancreatitis

Acute pancreatitis remains the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). It is reported to occur in 2–10% of unselected patient samples and up to 40% of high-risk patients. The purpose of this article is to review the evidence behind the known risk factors for post-ERCP pancreatitis, as well as the technical and medical approaches developed to prevent it. There have been many advances in identifying the causes of this condition. Based on this knowledge, a variety of preventive strategies have been developed and studied. The approach to prevention begins with careful patient selection and performing ERCP for specific indications, while considering alternative diagnostic modalities when appropriate. Patients should also be classified by high-risk factors such as young age, female sex, suspected sphincter of Oddi dysfunction, a history of post-ERCP pancreatitis, and normal serum bilirubin, all of which have been identified in numerous research studies. The pathways of injury that are believed to cause post-ERCP pancreatitis eventually lead to the common endpoint of inflammation, and these individual steps can be targeted for preventive therapies through procedural techniques and medical management. This includes the use of a guide wire for cannulation, minimizing the number of cannulation attempts, avoiding contrast injections or trauma to the pancreatic duct, and placement of a temporary pancreatic duct stent in high-risk patients. Administration of rectal non-steroidal anti-inflammatory agents (NSAIDs) in high-risk patients is the proven pharmacological measure for prevention of post-ERCP pancreatitis. The evidence for or against numerous other attempted therapies is still unclear, and ongoing investigation is required.

Patient-reported outcome measures after endoscopic retrograde cholangiopancreatography: a prospective, multicentre study

OBJECTIVE

While patient-reported outcome measures (PROMs) in ERCP are scarce, these reports are important for making improvements in quality of care. This study sought to document patient satisfaction and specifically pain related to endoscopic retrograde cholangiopancreatography (ERCP) procedures and to identify predictors for these experiences.

METHODS

From 2007 through 2009, prospective data from consecutive ERCP procedures at 11 hospitals during normal daily practice were recorded. Information regarding undesirable events that occurred during a 30-day follow-up period was also reported. The patient-reported pain, discomfort and general satisfaction with the ERCP were recorded.

RESULTS

Data from 2808 ERCP procedures were included in this study. Patient questionnaires were returned for 52.6% of the procedures. Moderate or severe pain was experienced in 15.5% and 14.0% of the procedures during the ERCP and in 10.8% and 7.7% of the procedures after the ERCP, respectively. In addition, female gender, endoscopic sphincterotomy (EST), and longer procedure times served as independent predictors of increased pain during the ERCP. The performing hospitals and sedation regimens were independent predictors of the procedural pain experience. In 90.9% of the procedures, the patients were satisfied with the information overall, and in 98.3% of the procedures, the patients were satisfied with the treatment provided. Independent predictors of dissatisfaction with the treatment included the occurrence of specific complications after ERCP and pain during or after the procedure.

CONCLUSIONS

Female gender, the performance of EST and longer procedure times were independent predictors for increased procedure-related pain. The individual hospital and sedation regimen predicts the patient's pain experience.

ERCP service in China: results from a national survey

BACKGROUND

ERCP had been performed throughout China for decades.

OBJECTIVE

To determine the status of ERCP service in China.

DESIGN

A national survey.

SETTING

All of the hospitals performing ERCP in mainland China in 2006.

PATIENTS

All of the patients undergoing ERCP in mainland China in 2006.

MAIN OUTCOME MEASUREMENTS

The questionnaire included the (1) type of hospitals involved; (2) ownership of the endoscopy unit; (3) ERCP infrastructure; (4) volume, indication, setting, and anesthesia methods; and (5) training and research. The correlation between economic development and ERCP status in different regions was investigated, and the ERCP rates in China and developed countries were compared.

RESULTS

Completed questionnaires were returned by 449 (95.5%) of the 470 hospitals providing ERCP service. Among the 449 hospitals, 186 (41.4%) did not have separate ERCP suites, 379 (84.4%) shared fluoroscopy with their radiology departments, and the average number of duodenoscopes was 1.58. A total of 63,787 ERCP procedures were performed in mainland China in 2006, with an estimated annual ERCP rate of 4.87 per 100,000 inhabitants, much lower than that of developed countries. Ninety-six percent of patients were admitted to undergo ERCP, and 94.4% of hospitals used pharyngeal local anesthesia and conscious sedation, whereas 5.6% used general anesthesia. There was a significant correlation between the ERCP rate and gross domestic product per capita (r = 0.871, P < .001).

LIMITATIONS

The survey was retrospective and descriptive.

CONCLUSIONS

There is an enormous gap in ERCP service between China and developed countries. The imbalance of ERCP status between different regions is significant, which correlates with economic development. Great effort is needed to develop the technique nationwide.

Patterns and predictive factors of complications after endoscopic retrograde cholangiopancreatography

BACKGROUND

With an increased use of magnetic resonance imaging, the indications for endoscopic retrograde cholangiopancreatography (ERCP) have changed. Consequently, the patterns and factors predictive of complications after ERCP performed during current routine clinical practice are not well known.

METHODS

A prospective multicentre cohort study was undertaken in 11 Norwegian hospitals. Complications and mortality within 30 days after ERCP were analysed by univariable and multivariable regression analysis.

RESULTS

There were 2808 ERCP procedures, of which 2573 (91·6 per cent) were therapeutic. More than half of the patients were aged 70 years or more. Common bile duct cannulation was achieved in 2557 procedures (91·1 per cent). Complications occurred in 327 (11·6 per cent) of the procedures, including cholangitis in 100 (3·6 per cent), pancreatitis in 88 (3·1 per cent), bleeding in 66 (2·4 per cent), perforation in 25 (0·9 per cent) and cardiovascular-respiratory events in 32 (1·1 per cent). In the multivariable regression analysis, older age, increasing American Society of Anesthesiologists fitness score, centre ERCP volumes of more than 150 procedures annually and precut sphincterotomy were predictive factors for severe complications. The overall 30-day mortality rate was 2·2 per cent (63 patients), with a procedure-related mortality rate of 1·4 per cent (39 patients). Malignancy was diagnosed in 46 (73 per cent) of the patients who died.

CONCLUSION

ERCP is a procedure with considerable risk for complications. Morbidity and mortality are related to patient age and co-morbidity, as well as hospital volume of ERCP procedures and the type of intervention.

Contemporary use of endoscopic retrograde cholangiopancreatography (ERCP): a Norwegian prospective, multicenter study

OBJECTIVE

Novel imaging modalities have supplanted endoscopic retrograde cholangiopancreatography (ERCP) for the diagnosis of hepatobiliary pancreatic diseases, but the use of ERCP as a diagnostic and therapeutic tool in current clinical practice is not well known. The main objective of this study was to describe and evaluate contemporary use of ERCP in Norway.

MATERIAL AND METHODS

Prospective and consecutive data were collected between January 2007 and December 2009 from voluntary institutional reports of ERCP activity at participating hospitals in the Gastronet database.

RESULTS

A total of 3840 procedures at 14 hospitals were registered during the study period. Data from 3809 procedures (53% females) were available for evaluation. Patients were ≥60 years of age in 2567 (67%) procedures. High co-morbidity (ASA score ≥3) was present in 32% of patients. The main indication for ERCP was evaluation and therapy of bile duct-related disorders. Successful bile duct cannulation was achieved in 93%. Pre-cut sphincterotomy was performed in 5% of procedures, and a guide wire to facilitate duct access was employed in 63%. Sphincterotomy, treatment for common bile duct stones (CBDS), and an insertion or change of bile duct stents were the most commonly employed procedures. Complications occurred in 10% of the patients, with a procedure-related mortality of 1%.

CONCLUSIONS

In Norway, ERCP is predominantly performed for CBDS and biliary strictures in elderly patients with associated co-morbidity. Patient selection, indications, and procedures are in concert with international guidelines and recommendations. Disease patterns in Norway differ slightly from those observed in central Europe and North America.