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Fukushi K, Imaoka H, Ikeda M, Mizusawa J, Morizane C, Okusaka T, Kobayashi S, Sasahira N, Shimizu S, Yamazaki K, Okano N, Miwa H, Hara K, Satoi S, Sano K, Sakai K, Sugimoto R, Nakamura K, Terashima T, Ozaka M, Ueno M. 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. Jpn J Clin Oncol 2025; 55:355-361. [PMID: 39775866 PMCID: PMC11973634 DOI: 10.1093/jjco/hyae188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2024] [Accepted: 12/21/2024] [Indexed: 01/11/2025] Open
Abstract
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.
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Affiliation(s)
- Koh Fukushi
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Hiroshi Imaoka
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Masafumi Ikeda
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Junki Mizusawa
- Japan Clinical Oncology Group Data Center, Clinical Research Support Office, National Cancer Center Hospital, Tokyo
| | - Chigusa Morizane
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Takuji Okusaka
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Satoshi Kobayashi
- Department of Gastroenterology, Kanagawa Cancer Center, Yokohama, Japan
| | - Naoki Sasahira
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Satoshi Shimizu
- Department of Gastroenterology, Saitama Cancer Center, Saitama, Japan
| | - Kentaro Yamazaki
- Division of Gastrointestinal Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Naohiro Okano
- Department of Medical Oncology, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Haruo Miwa
- Gastroenterological Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Kazuo Hara
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Sohei Satoi
- Department of Pancreatobiliary Surgery, Kansai Medical University, Hirakata, Japan
| | - Keiji Sano
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Kenji Sakai
- Department of Gastroenterology and Hepatology, NHO Osaka National Hospital, Osaka, Japan
| | - Rie Sugimoto
- Department of Hepato-Biliary-Pancreatology, NHO Kyushu Cancer Center, Fukuoka, Japan
| | | | - Takeshi Terashima
- Department of Gastroenterology, Kanazawa University Hospital, Kanazawa, Japan
| | - Masato Ozaka
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Makoto Ueno
- Department of Gastroenterology, Kanagawa Cancer Center, Yokohama, Japan
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Kato H, Tomoda T, Matsumi A, Matsumoto K. Current status and issues for prediction and prevention of postendoscopic retrograde cholangiopancreatography pancreatitis. Dig Endosc 2025; 37:362-372. [PMID: 39633248 DOI: 10.1111/den.14966] [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: 07/14/2024] [Accepted: 11/10/2024] [Indexed: 12/07/2024]
Abstract
Acute pancreatitis, which sometimes results in mortality, is a significant complication of endoscopic retrograde cholangiopancreatography (ERCP). Many studies have been conducted to predict and prevent post-ERCP pancreatitis (PEP), and meta-analyses have been reported that summarized these studies. However, many issues remain unresolved. Many risk factors for PEP have been reported, and it is rare for patients undergoing ERCP to have only one risk factor. The use of artificial intelligence may be important for analyzing complex and diverse risk factors. It is desirable to develop an alternative test for pancreatic enzymes that can predict the onset of PEP within 1 h after ERCP. The effectiveness of low-dose nonsteroidal anti-inflammatory drugs (NSAIDs) are controversial. Nitrate and tacrolimus are considered medications that have additional effects on NSAIDs and may be used for the prevention of PEP. Pancreatic stent placement with deliberate placement of the guidewire into the pancreatic duct may be more effective in preventing PEP. A comparison between transpancreatic sphincterotomy with deliberate guidewire placement into the pancreatic duct and needle-knife precut sphincterotomy is necessary. Early precutting is thought to be effective for the prevention of PEP, and the effectiveness of primary precut has been reported. However, the optimal timing of precut for the prevention of PEP has not been sufficiently discussed. Further research on prediction and prevention must be conducted to eliminate the mortality caused by PEP.
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Affiliation(s)
- Hironari Kato
- Department of Gastroenterology, Okayama City Hospital, Okayama, Japan
| | - Takeshi Tomoda
- Department of Gastroenterology, Okayama City Hospital, Okayama, Japan
| | - Akihiro Matsumi
- Department of Gastroenterology, Okayama University Hospital, Okayama, Japan
| | - Kazuyuki Matsumoto
- Department of Gastroenterology, Okayama University Hospital, Okayama, Japan
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Tavakkoli A, Kapinos KA, Elmunzer BJ, Kwon RS, Troendle DM, Zhang S, Singal AG. Burden and cost of post-endoscopic retrograde cholangiopancreatography pancreatitis among commercially insured people undergoing endoscopic retrograde cholangiopancreatography. Gastrointest Endosc 2025:S0016-5107(25)00808-9. [PMID: 40120865 DOI: 10.1016/j.gie.2025.03.639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2025] [Revised: 03/04/2025] [Accepted: 03/05/2025] [Indexed: 03/25/2025]
Abstract
BACKGROUND AND AIMS ERCP is the primary therapeutic procedure for pancreaticobiliary diseases. Post-ERCP pancreatitis can occur in up to 10% to 15% of cases; however, very little data describe the incidence and financial burden of post-ERCP pancreatitis in a nationally representative sample in the United States. In this study, we characterized the 30-day incidence of post-ERCP pancreatitis, identified patient- and procedure-related factors associated with post-ERCP pancreatitis, and described 30-day direct and out-of-pocket (OOP) costs among patients with post-ERCP pancreatitis. METHODS We used the Merative MarketScan commercial claims data to identify inpatient and outpatient ERCPs occurring from 2019 to 2021. The primary outcome was the development of post-ERCP pancreatitis within 30 days of an ERCP. The main measure of financial burden was the total direct and OOP costs of the index ERCP and all encounters within 30 days after the index ERCP. We used multivariable regression to identify factors and estimate adjusted costs of post-ERCP pancreatitis. RESULTS Among 27,482 patients who underwent 42,212 ERCPs during the study period, post-ERCP pancreatitis was observed in 5.7% of patients. In multivariable analysis, the highest odds of post-ERCP pancreatitis was observed among the youngest age group (≤17 years) undergoing ERCP (odds ratio, 1.53; 95% CI, 1.06-2.21). The 30-day adjusted mean direct costs among persons with and without post-ERCP pancreatitis were $38,569 and $30,103, respectively (difference, $8483). The population-level cost of post-ERCP pancreatitis ranged from $85,833,757 to $432,648,810 across a range of reported estimates for post-ERCP pancreatitis and annual ERCP volume in the United States. CONCLUSIONS Post-ERCP pancreatitis is relatively uncommon, occurring in 5% to 6% of individuals, but results in substantial financial burden.
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Affiliation(s)
- Anna Tavakkoli
- Division of Digestive & Liver Diseases, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
| | | | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Richard S Kwon
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - David M Troendle
- Division of Pediatric Gastroenterology, University of Texas Southwestern Medical Center, Children's Health, Dallas, Texas, USA
| | - Song Zhang
- O'Donnell School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Amit G Singal
- Division of Digestive & Liver Diseases, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Barakat M, Saumoy M, Forbes N, Elmunzer BJ. Complications of Endoscopic Retrograde Cholangiopancreatography. Gastroenterology 2025:S0016-5085(25)00527-X. [PMID: 40120770 DOI: 10.1053/j.gastro.2025.03.009] [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] [Received: 10/06/2024] [Revised: 03/13/2025] [Accepted: 03/15/2025] [Indexed: 03/25/2025]
Abstract
Up to 1 in 6 patients will experience an unplanned hospitalization after endoscopic retrograde cholangiopancreatography (ERCP), largely for the evaluation and management of adverse events. Therefore, a commitment to the prevention, early recognition, and effective rescue of complications related to ERCP is critical toward improving outcomes. ERCP is most often complicated by acute pancreatitis, bleeding, infection, or perforation, although myriad other adverse events may occur. The prevention of post-ERCP pancreatitis has been the area of greatest interest and progress in the last decade, but the application of evidence-based prophylactic measures remains inconsistent. Innovations in stent, hemostasis, and perforation closure technology now allow effective and efficient endoscopic management of several important nonpancreatitis complications. Overall, our ability to prevent and treat ERCP-related adverse events has improved substantially, amplifying the importance of a high level of suspicion for and a thorough understanding of these events.
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Affiliation(s)
- Monique Barakat
- Divisions of Pediatric and Adult Gastroenterology & Hepatology, Departments of Pediatrics and Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Monica Saumoy
- Center for Digestive Health, Penn Medicine Princeton Health, Princeton, New Jersey
| | - Nauzer Forbes
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina.
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Forslund A, Haraldsson E, Holmberg E, Naredi P, Rizell M. Risks and use of ERCP during the diagnostic workup in a national cohort of biliary cancer. Surg Endosc 2025; 39:991-1001. [PMID: 39672987 PMCID: PMC11794412 DOI: 10.1007/s00464-024-11449-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2024] [Accepted: 11/23/2024] [Indexed: 12/15/2024]
Abstract
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.
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Affiliation(s)
- Anna Forslund
- Transplant Institute, Sahlgrenska University Hospital, 41345, Gothenburg, Sweden.
| | - Erik Haraldsson
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Surgery, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Erik Holmberg
- Department of Oncology, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Peter Naredi
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Surgery, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Magnus Rizell
- Transplant Institute, Sahlgrenska University Hospital, 41345, Gothenburg, Sweden
- Department of Surgery, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
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6
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Jin H, Fu C, Sun X, Fan C, Chen J, Zhou H, Liu K, Xu H. The assessment of postoperative cholangitis in malignant biliary obstruction: a real-world study of nasobiliary drainage after endoscopic placement of self-expandable metal stent. Front Oncol 2024; 14:1440131. [PMID: 39610922 PMCID: PMC11602394 DOI: 10.3389/fonc.2024.1440131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Accepted: 10/29/2024] [Indexed: 11/30/2024] Open
Abstract
Objectives Endoscopic retrograde cholangiopancreatography(ERCP) with endoscopic metallic biliary endoprosthesis(EMBE) serves as a crucial palliative treatment for advanced malignant biliary obstruction(MBO). While endoscopic nasobiliary drainage(ENBD) effectively reduces post-ERCP cholangitis (PEC) incidence, its impact on PEC in MBO patients is unclear. This study evaluates ENBD's effects on PEC in patients undergoing EMBE and identifies risk factors. Methods This retrospective cohort study at the First Hospital of Jilin University involved MBO patients who underwent EMBE from September 2011 to September 2022. Propensity score matching (PSM) was applied to minimize selection bias. Primary and secondary outcomes included the incidence and recovery rate/time of PEC, biliary drainage success, and hospitalization duration. Univariate, multivariate, and Lasso regression analyses identified independent risk factors. Results In this study of 1,008 patients, 730 were analyzed after PSM(365 each in the EMBE+ENBD and EMBE groups). No significant differences were observed in PEC incidence(10.7% vs 11.2%, p=0.9057) or recovery rates(48.7% vs 31.7%, p=0.1855). However, PEC recovery time was shorter in the EMBE+ENBD group(4.0 days [3.0, 6.0] vs 5.0 days [4.0, 7.5], p=0.0240), as was hospitalization duration(6.0 days [4.0, 8.0] vs 7.0 days [5.0, 10.0], p=0.0146), and a higher success rate of biliary drainage(54.0% vs 43.3%, p=0.0049). Tumor location(HR 1.10, 95% CI 1.00-1.20) and preoperative total bilirubin(HR 2.13, 95% CI 1.66-2.73) were identified as independent risk factors. Conclusion In this large-scale PSM study, ENBD did not reduce PEC incidence but expedited recovery and shortened hospital stays. Patients with hilar MBO of Bismuth III-IV or high preoperative bilirubin were more prone to PEC.
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Affiliation(s)
- Hengwei Jin
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Chang Fu
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Xu Sun
- Clinical Medical College, Changchun University of Traditional Chinese Medicine, Changchun, Jilin, China
| | - Changqing Fan
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Junhong Chen
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Hao Zhou
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Kai Liu
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Hongji Xu
- Department of Abdominal Surgery, Guiqian International General Hospital, Guiyang, Guizhou, China
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Elmunzer BJ, Anderson MA, Mishra G, Rex DK, Yadlapati R, Shaheen NJ. Quality indicators common to all GI endoscopic procedures. Gastrointest Endosc 2024; 100:382-394. [PMID: 38935015 DOI: 10.1016/j.gie.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Accepted: 05/01/2024] [Indexed: 06/28/2024]
Affiliation(s)
- B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Michelle A Anderson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Girish Mishra
- Section of Gastroenterology and Hepatology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Douglas K Rex
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Rena Yadlapati
- Division of Gastroenterology & Digestive Health, University of California San Diego, San Diego, California, USA
| | - Nicholas J Shaheen
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Elmunzer BJ, Anderson MA, Mishra G, Rex DK, Yadlapati R, Shaheen NJ. Quality Indicators Common to All Gastrointestinal Endoscopic Procedures. Am J Gastroenterol 2024:00000434-990000000-01295. [PMID: 39167096 DOI: 10.14309/ajg.0000000000002988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 01/16/2024] [Indexed: 08/23/2024]
Affiliation(s)
- B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Michelle A Anderson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Girish Mishra
- Section of Gastroenterology and Hepatology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Douglas K Rex
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Rena Yadlapati
- Division of Gastroenterology & Digestive Health, University of California San Diego, San Diego, California, USA
| | - Nicholas J Shaheen
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Leifeld L, Jakobs R, Frieling T, Denzer U, Faiss S, Lenzen H, Lynen P, Mayerle J, Ockenga J, Tappe U, Terjung B, Wedemeyer H, Albert J. [Influence of specialization on primary success and complication rate in ERCP. Proposal to improve the quality of ERCP]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:1224-1228. [PMID: 39111334 DOI: 10.1055/a-2350-1930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2024]
Abstract
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.
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Affiliation(s)
- Ludger Leifeld
- Medizinische Klinik 3 - Allgemeine Innere Medizin und Gastroenterologie, St Bernward Krankenhaus, Hildesheim, Deutschland
| | - Ralf Jakobs
- Medizinische Klinik C mit Schwerpunkt Gastroenterologie, Klinikum Ludwigshafen, Deutschland
| | - Thomas Frieling
- Medizinische Klinik II, HELIOS Klinikum Krefeld, Krefeld, Deutschland
| | - Ulrike Denzer
- Klinik und Poliklinik für Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg - Standort Marburg, Marburg, Deutschland
| | - Siegbert Faiss
- Gastroenterologie, Sana Klinikum Lichtenberg, Berlin, Deutschland
| | - Henrike Lenzen
- Klinik für Gastroenterologie, Hepatologie, Infektiologie und Endokrinologie, Medizinische Hochschule Hannover, Deutschland
| | - Petra Lynen
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS), Berlin, Deutschland
| | - Julia Mayerle
- Klinik für Innere Medizin II, LMU Klinikum, LMU München, Deutschland
| | - Johann Ockenga
- Medizinische Klinik II, Gesundheit Nord, Klinikverbund Bremen, Deutschland
| | - Ulrich Tappe
- Gastropraxis an der St. Barbara Klinik, Hamm, Deutschland
| | - Birgit Terjung
- Klinik für Innere Medizin und Gastroenterologie, GFO Kliniken Bonn, Deutschland
| | - Heiner Wedemeyer
- Klinik für Gastroenterologie, Hepatologie, Infektiologie und Endokrinologie, Medizinische Hochschule Hannover, Deutschland
| | - Jörg Albert
- Klinik für Gastroenterologie, gastroenterologische Onkologie, Hepatologie, Infektiologie und Pneumologie, Klinikum der Landeshauptstadt Stuttgart gemeinnützige Kommunalanstalt öffentlichen Rechts (gKAöR), Stuttgart, Deutschland
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10
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Tavakkoli A, Beauchamp A, Prasad T, Zhu H, Singal AG, Elmunzer BJ, Kubiliun NM, Kwon RS, Hughes AE, Pruitt SL. Accessibility to ERCP-performing hospitals among patients with pancreatic cancer living in SEER regions. Cancer Med 2024; 13:e7020. [PMID: 38400670 PMCID: PMC10891451 DOI: 10.1002/cam4.7020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 01/15/2024] [Accepted: 02/02/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND AND AIMS The two most common interventions used to treat painless jaundice from pancreatic cancer are endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD). Our study aimed to characterize the geographic distribution of ERCP-performing hospitals among patients with pancreatic cancer in the United States and the association between geographic accessibility to ERCP-performing hospitals and biliary interventions patients receive. METHODS This is a retrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database for pancreatic cancer from 2005 to 2013. Multilevel models were used to examine the association between accessibility to ERCP hospitals within a 30- and 45-min drive from the patient's residential ZIP Code and the receipt of ERCP treatment. A two-step floating catchment area model was used to calculate the measure of accessibility based on the distribution across SEER regions. RESULTS 7464 and 782 patients underwent ERCP and PTBD, respectively, over the study period. There were 808 hospitals in which 8246 patients diagnosed with pancreatic cancer in SEER regions from 2005 to 2013 received a procedure. Patients with high accessibility within both 30- and 45-min drive to an ERCP-performing hospital were more likely to receive an ERCP (30-min adjusted odds ratio [aOR]: 1.53, 95% confidence interval [CI]: 1.17-2.01; 45-min aOR: 1.31, 95% CI: 1.01-1.70). Furthermore, in the adjusted model, Black patients (vs. White) and patients with stage IV disease were less likely to receive ERCP than PTBD. CONCLUSIONS Patients with pancreatic cancer and high accessibility to an ERCP-performing hospital were more likely to receive ERCP. Disparities in the receipt of ERCP persisted for Black patients regardless of their access to ERCP-performing hospitals.
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Affiliation(s)
- Anna Tavakkoli
- Division of Gastroenterology & Liver Diseases, Department of MedicineUniversity of Texas Southwestern Medical CenterDallasTexasUSA
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical CenterDallasTexasUSA
| | - Alaina Beauchamp
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical CenterDallasTexasUSA
| | - Tanushree Prasad
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical CenterDallasTexasUSA
| | - Hong Zhu
- Department of Public Health SciencesUniversity of Virginia School of MedicineCharlottesvilleVirginiaUSA
| | - Amit G. Singal
- Division of Gastroenterology & Liver Diseases, Department of MedicineUniversity of Texas Southwestern Medical CenterDallasTexasUSA
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical CenterDallasTexasUSA
| | - B. Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Department of MedicineMedical University of South CarolinaCharlestonSouth CarolinaUSA
| | - Nisa M. Kubiliun
- Division of Gastroenterology & Liver Diseases, Department of MedicineUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Richard S. Kwon
- Division of Gastroenterology, Department of Internal MedicineUniversity of MichiganAnn ArborMichiganUSA
| | - Amy E. Hughes
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical CenterDallasTexasUSA
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical CenterDallasTexasUSA
| | - Sandi L. Pruitt
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical CenterDallasTexasUSA
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical CenterDallasTexasUSA
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Ahmed W, Joshi D, Huggett MT, Everett SM, James M, Menon S, Oppong KW, On W, Paranandi B, Trivedi P, Webster G, Hegade VS. Update on the optimisation of endoscopic retrograde cholangiography (ERC) in patients with primary sclerosing cholangitis. Frontline Gastroenterol 2024; 15:74-83. [PMID: 38487565 PMCID: PMC10935540 DOI: 10.1136/flgastro-2023-102491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 08/28/2023] [Indexed: 03/17/2024] Open
Affiliation(s)
- Wafaa Ahmed
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Deepak Joshi
- Gastroenterology, King's College Hospital Liver Unit, London, UK
| | - Matthew T Huggett
- Gastroenterology, St James's University Hospital, The Leeds Teaching Hospitals NHS Foundation Trust, Leeds, UK
| | - Simon M Everett
- Gastroenterology, St James's University Hospital NHS Trust, Leeds, UK
| | - Martin James
- Gastroenterology, Nottingham University, Nottingham, UK
| | - Shyam Menon
- Department of Hepatology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Wei On
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Bharat Paranandi
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Palak Trivedi
- National Institute for Health Research, Centre for Liver Research, University Hospitals Birmingham, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - George Webster
- Department of Gastroenterology, University College London Hospital NHS Foundation Trust, London, UK
| | - Vinod S Hegade
- Leeds Liver Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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12
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Aloysius M, Goyal H, Nikumbh T, Shah NJ, Hammoud GM, Mutha P, Joseph-Talreja M, John S, Aswath G, Wadhwa V, Thosani N. Endoscopic retrograde cholangiopancreatography-related early perforations: A study of effects of procedure duration, complexity, and endoscopist experience. World J Gastrointest Endosc 2023; 15:641-648. [DOI: 10.4253/wjge.v15.i11.641] [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: 04/28/2023] [Revised: 08/06/2023] [Accepted: 09/27/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Perforations (Perf) during endoscopic retrograde cholangiopancreatography (ERCP) are rare (< 1%) but potentially fatal events (up to 20% mortality). Given its rarity, most data is through case series studies from centers or analysis of large databases. Although a meta-analysis has shown fewer adverse events as a composite (bleeding, pancreatitis, Perf) during ERCP performed at high-volume centers, there is very little real-world data on endoscopist and center procedural volumes, ERCP duration and complexity on the occurrence of Perf.
AIM To study the profile of Perf related to ERCP by center and endoscopist procedure volume, ERCP time, and complexity from a national endoscopic repository.
METHODS Patients from clinical outcomes research initiative-national endoscopic database (2000-2012) who underwent ERCP were stratified based on the endoscopist and center volume (quartiles), and total procedure duration and complexity grade of the ERCP based on procedure details. The effects of these variables on the Perf that occurred were studied. Continuous variables were compared between Perf and no perforations (NoPerf) using the Mann-Whitney U test as the data demonstrated significant skewness and kurtosis.
RESULTS A total of 14153 ERCPs were performed by 258 endoscopists, with 20 reported Perf (0.14%) among 16 endoscopists. Mean patient age in years 61.6 ± 14.8 vs 58.1 ± 18.8 (Perf vs. NoPerf, P = NS). The cannulation rate was 100% and 91.5% for Perf and NoPerf groups, respectively. 13/20 (65%) of endoscopists were high-volume performers in the 4th quartile, and 11/20 (55%) of Perf occurred in centers with the highest volumes (4th quartile). Total procedure duration in minutes was 60.1 ± 29.9 vs 40.33 ± 23.5 (Perf vs NoPerf, P < 0.001). Fluoroscopy duration in minutes was 3.3 ± 2.3 vs 3.3 ± 2.6 (Perf vs NoPerf P = NS). 50% of the procedures were complex and greater than grade 1 difficulty. 3/20 (15%) patients had prior biliary surgery. 13/20 (65%) had sphincterotomies performed with stent insertion. Peritonitis occurred in only 1/20 (0.5%).
CONCLUSION Overall adverse events as a composite during ERCP are known to occur at a lower rate with higher volume endoscopists and centers. However, Perf studied from the national database show prolonged and more complex procedures performed by high-volume endoscopists at high-volume centers contribute to Perf.
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Affiliation(s)
- Mark Aloysius
- Division of Gastroenterology, Department of Internal Medicine, SUNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Hemant Goyal
- Department of Surgery, The University of Texas Health Science Center, Houston, TX 77030, United States
| | - Tejas Nikumbh
- Department of Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, PA 18510, United States
| | - Niraj James Shah
- Department of Medicine, Division of Digestive Diseases, The University of Missouri at Columbia, Columbia, MO 65211, United States
| | - Ghassan M Hammoud
- Department of Medicine, Division of Digestive Diseases, The University of Missouri at Columbia, Columbia, MO 65211, United States
| | - Pritesh Mutha
- Department of Surgery, The University of Texas Health Science Center, Houston, TX 77030, United States
| | - Mairin Joseph-Talreja
- Department of Surgery, The University of Texas Health Science Center, Houston, TX 77030, United States
| | - Savio John
- Division of Gastroenterology, Department of Internal Medicine, SUNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Ganesh Aswath
- Division of Gastroenterology, Department of Internal Medicine, SUNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Vaibhav Wadhwa
- Department of Surgery, The University of Texas Health Science Center, Houston, TX 77030, United States
| | - Nirav Thosani
- Department of Surgery, The University of Texas Health Science Center, Houston, TX 77030, United States
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13
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Ketwaroo GA, Protiva P. Endoscopic drainage of pancreatic fluid collections: Does hospital volume impact outcomes? Gastrointest Endosc 2023; 98:607-608. [PMID: 37734815 DOI: 10.1016/j.gie.2023.06.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 06/18/2023] [Indexed: 09/23/2023]
Affiliation(s)
- Gyanprakash A Ketwaroo
- Department of Internal Medicine, Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA; Division of Gastroenterology, Department of Medicine, Veterans Administration Connecticut Health Care System, West Haven, Connecticut, USA
| | - Petr Protiva
- Department of Internal Medicine, Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA; Division of Gastroenterology, Department of Medicine, Veterans Administration Connecticut Health Care System, West Haven, Connecticut, USA
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14
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Ramai D, Heaton J, Ofosu A, Gkolfakis P, Chandan S, Tringali A, Barakat MT, Hassan C, Repici A, Facciorusso A. Influence of Frailty in Patients Undergoing Endoscopic Retrograde Cholangiopancreatography for Biliary Stone Disease: A Nationwide Study. Dig Dis Sci 2023; 68:3605-3613. [DOI: 10.1007/s10620-023-08013-0 pmid: 37368202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 06/14/2023] [Indexed: 05/16/2025]
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Voiosu TA, Benguș A, Bronswijk M, Lyutakov I, Klarin I, Voiosu B, Bălănescu P, Diaconu C, Busuioc B, Boskoski I, Voiosu AM, Mateescu RB, Wani S. A simple clinical score to stratify the risk of procedure-related adverse events in ERCP procedures with trainee involvement. Endoscopy 2023; 55:804-811. [PMID: 36828031 DOI: 10.1055/a-2042-6288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
BACKGROUND : Optimal training strategies in endoscopic retrograde cholangiopancreatography (ERCP) remain controversial despite the shift toward competence-based training models, with limited data available on patient safety during training. We aimed to assess whether pre-procedural clinical predictors could identify patients at low risk of developing procedure-related adverse-events (AEs) in a training environment. METHODS : We performed a prospective, multicenter, cohort study in five training centers. A data collection system documenting indication, clinical data, trainee performance (assessed using a validated competence assessment tool), technical outcomes, and AEs over a 30-day follow-up was utilized. We developed a clinical risk score (Trainee Involvement in ERCP Risk Score [TIERS]) for patients undergoing ERCP and compared the rate of AEs in a training environment between low-risk and high-risk groups. The association between trainee performance and AE rate was also evaluated. RESULTS : 1283 ERCPs (409 [31.9 %, 95 %CI 29.3 %-34.4 %] with trainee involvement) performed by 11 trainers and 10 trainees were analyzed. AEs were more frequent in the high-risk compared with the low-risk group: 26.7 % (95 %CI 20.5 %-34.7 %) vs. 17.1 % (95 %CI 12.8 %-22.2 %). TIERS demonstrated a high negative predictive value for AEs (82.9 %, 95 %CI 79.4 %-85.8 %) and was the only predictor of AEs on multivariable analysis (odds ratio 1.38, 95 %CI 1.09-1.75). Suboptimal trainee performance was associated with an increase in AE rates. CONCLUSION : Simple, clinical-based predictive tools could improve ERCP training by selecting the most appropriate cases for hands-on training, with the aim of increasing patient safety.
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Affiliation(s)
- Theodor A Voiosu
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
- Department of Internal Medicine, Carol Davila University of Medicine, Bucharest, Romania
| | - Andreea Benguș
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
| | - Michiel Bronswijk
- Department of Gastroenterology and Hepatology, Imelda Hospital, Bonheiden, Belgium
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Imelda GI Research Center, Bonheiden, Belgium
| | - Ivan Lyutakov
- Department of Gastroenterology, University Hospital "Tsaritsa Yoanna - ISUL", Sofia, Bulgaria
- Department of Gastroenterology, Medical University Sofia, Sofia, Bulgaria
| | - Ivo Klarin
- Department of Health Studies, University of Zadar, Zadar, Croatia
- Gastroenterology Department, General Hospital Zadar, Zadar, Croatia
| | - Bianca Voiosu
- Gastroenterology Department, Cantacuzino Hospital, Bucharest, Romania
| | - Paul Bălănescu
- Internal Medicine Department, Carol Davila School of Medicine, Bucharest, Romania
- Clinical Immunology Department, Colentina Clinical Hospital, Bucharest, Romania
| | - Claudia Diaconu
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
| | - Bogdan Busuioc
- Gastroenterology Department, Cantacuzino Hospital, Bucharest, Romania
| | - Ivo Boskoski
- Gastroenterology, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy
- Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrei M Voiosu
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
- Department of Internal Medicine, Carol Davila University of Medicine, Bucharest, Romania
| | - Radu B Mateescu
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
- Department of Internal Medicine, Carol Davila University of Medicine, Bucharest, Romania
| | - Sachin Wani
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
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Ramai D, Heaton J, Ofosu A, Gkolfakis P, Chandan S, Tringali A, Barakat MT, Hassan C, Repici A, Facciorusso A. Influence of Frailty in Patients Undergoing Endoscopic Retrograde Cholangiopancreatography for Biliary Stone Disease: A Nationwide Study. Dig Dis Sci 2023; 68:3605-3613. [PMID: 37368202 DOI: 10.1007/s10620-023-08013-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 06/14/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND AND AIMS Pancreaticobiliary diseases are common in the elderly. To this end, frailty represents a state of vulnerability that should be considered when assessing the risks and benefits of therapeutic endoscopic procedures. We aim to determine the rate of readmissions and clinical outcomes using the validated Hospital Frailty Risk Score in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). METHODS Using the National Readmissions Database, we identified patients with an admission diagnosis of cholangitis with obstructive stone from 2016 to 2019. Patients were determined to be of low frailty risk with a score of < 5, while patients of medium to high frailty risk had a score of > 5. RESULTS During the study period, 5751 patients were identified with acute cholangitis with obstructing stone. Mean age of index admissions was 69.4 years and 51.8% were female. From the total cohort, 5119 (89.2%) patients underwent therapeutic ERCP, 38.0% (n = 1947) of whom were regarded as frail (risk score > 5). Following ERCP, frail patients had a less but statistically insignificant readmission rate compared to non-frail patients (2.76% vs 4.05%, p = 0.450). However, compared to non-frail patients, frail patients experienced higher post-ERCP complications (6.20% vs 14.63%, p < 0.001). Frail patients were more likely to have longer lengths of stay, higher hospital cost, and mortality risk. CONCLUSION ERCP is not a risk factor for readmission among frail patients. However, frail patients are at higher risk for procedure-related complications, healthcare utilization, and mortality.
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Affiliation(s)
- Daryl Ramai
- Division of Gastroenterology and Hepatology, University of Utah Health, Salt Lake City, UT, USA.
| | - Joseph Heaton
- Department of Medicine, Jersey Shore University Medical Center, Neptune City, NJ, USA
| | - Andrew Ofosu
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH, USA
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Saurabh Chandan
- Division of Gastroenterology & Hepatology, CHI Health Creighton University Medical Center, Omaha, NE, USA
| | | | - Monique T Barakat
- Division of Gastroenterology, Stanford University, Stanford, CA, USA
| | - Cesare Hassan
- Endoscopic Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Alessandro Repici
- Endoscopic Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Antonio Facciorusso
- Section of Gastroenterology, Department of Medical Sciences, University of Foggia, 71122, Foggia, Italy
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Teles de Campos S, Papaefthymiou A, Florou T, Facciorusso A, Arvanitakis M, Devière J, Gkolfakis P. Impact of center and endoscopist ERCP volume on ERCP outcomes: a systematic review and meta-analysis. Gastrointest Endosc 2023; 98:306-315.e14. [PMID: 37201726 DOI: 10.1016/j.gie.2023.05.045] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/08/2023] [Accepted: 05/06/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND AND AIMS Endoscopist experience and center volume might be associated with ERCP outcomes, as in other fields of endoscopy and in surgery. An effort to assess this relationship is important to improve practice. This systematic review and meta-analysis aimed to evaluate these comparative data and to assess the impact of endoscopist and center volume on ERCP procedure outcomes. METHODS We performed a literature search in PubMed, Web of Science, and Scopus through March 2022. Volume classification included high- and low-volume (HV and LV) endoscopists and centers. The primary outcome was the impact of endoscopist and center volume on ERCP success. Secondary outcomes were the overall adverse event (AE) rate and the specific AE rate. The quality of the studies was assessed using the Newcastle-Ottawa scale. Data synthesis was obtained by direct meta-analyses using a random-effects model; results are presented as odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS Of 6833 relevant publications, 31 studies met the inclusion criteria. Procedure success was higher among HV endoscopists (OR, 1.81; 95% CI, 1.59-2.06; I2 = 57%) and in HV centers (OR, 1.77; 95% CI, 1.22-2.57; I2 = 67%). The overall AE rate was lower for procedures performed by HV endoscopists (OR, .71; 95% CI, .61-.82; I2 = 38%) and in HV centers (OR, .70; 95% CI, .51-.97; I2 = 92%). Bleeding was less frequent in procedures performed by HV endoscopists (OR, .67; 95% CI, .48-.95; I2 = 37%) but did not differ based on center volume (OR, .68; 95% CI, .24-1.90; I2 = 89%). No statistical differences were detected concerning pancreatitis, cholangitis, and perforation rates. CONCLUSIONS HV endoscopists and centers provide higher ERCP success rates with fewer overall AEs, especially bleeding, compared with respective LV comparators.
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Affiliation(s)
- Sara Teles de Campos
- Gastroenterology Department, Digestive Unit, Champalimaud Foundation, Lisbon, Portugal; Université Libre Bruxelles, Brussels, Belgium.
| | - Apostolis Papaefthymiou
- Pancreaticobiliary Medicine Unit, University College London Hospitals (UCLH) NHS Foundation Trust, London, United Kingdom; Department of Gastroenterology, University Hospital of Larissa, Thessaly, Greece
| | - Theodosia Florou
- Department of Gastroenterology, University Hospital of Larissa, Thessaly, Greece
| | - Antonio Facciorusso
- Section of Gastroenterology, Department of Medical Sciences, University of Foggia, Foggia, Italy
| | - Marianna Arvanitakis
- Université Libre Bruxelles, Brussels, Belgium; Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Brussels, Belgium
| | - Jacques Devière
- Gastroenterology Department, Digestive Unit, Champalimaud Foundation, Lisbon, Portugal; Université Libre Bruxelles, Brussels, Belgium; Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Brussels, Belgium
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Brussels, Belgium; Konstantopoulio-Patision General Hospital of Athens, Athens, Greece
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18
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Vila JJ, Arrubla Gamboa A, Jusué V, Estremera-Arévalo F, González de la Higuerra B, Carrascosa Gil J, Rodríguez Mendiluce I, Hervás N, Prieto C, Gómez Alonso M, Fernández-Urién I, Ibáñez Beroiz B. The volume of ERCP per endoscopist is associated with a higher technical success and a lower post-ERCP pancreatitis rate. A prospective analysis. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2023; 115:368-373. [PMID: 36043537 DOI: 10.17235/reed.2022.9056/2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
INTRODUCTION conflicting results have been reported regarding the influence of the annual volume of endoscopic retrograde cholangiopancreatography (ERCP) on outcome. OBJECTIVE to evaluate the influence of case volume on ERCP outcomes. PATIENTS AND METHODS an analysis of a prospective database was performed, comparing the outcomes of ERCP in three consecutive periods defined by the number of endoscopists performing ERCP: five endoscopists in period I (P1), four in period II (P2) and three in period III (P3). Only patients with biliary ERCP in accessible and naïve papilla were included. Primary variables were cannulation rates and adverse effects (AE). The American Society of Gastrointestinal Endoscopy (ASGE) complexity grades III and IV were considered as highly complex procedures. RESULTS a total of 2,561 patients were included: 727 (P1), 972 (P2) and 862 (P3). There were no differences in age and sex between groups (p > 0.05). The cannulation rate was significantly higher in P2 and P3: 92.4 % vs 93.3 % vs 93 % (p = 0.037). The AE rate was 13.8 %, 12.6 % and 10.3 % (p > 0.05), respectively. The rate of post-ERCP pancreatitis was significantly lower in P3: 8.5 %, 7.3 % and 5 % (p = 0.01). The rate of complex procedures was 12 %, 14.8 % and 27 % (p < 0.0001), respectively. Two endoscopists participated in all periods and only one had significantly improved outcomes. Cannulation and post-ERCP pancreatitis rates remained significantly better in P3 after adjusting for sex, complexity and endoscopist. CONCLUSION a higher annual volume of ERCP per endoscopist was associated with a higher rate of cannulation and a lower rate of post-ERCP pancreatitis, despite the greater complexity of the procedures. These beneficial effects seem to differ between endoscopists.
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Affiliation(s)
- Juan J Vila
- Digestivo A, Hospital Universitario de Navarra, España
| | - Amaia Arrubla Gamboa
- Endoscopia. Servicio de Aparato Digestivo, Hospital Universitario de Navarra, España
| | - Vanesa Jusué
- Endoscopia. Servicio de Aparato Digestivo, Hospital Universitario de Navarra
| | | | | | - Juan Carrascosa Gil
- Endoscopia. Servicio de Aparato Digestivo, Hospital Universitario de Navarra
| | | | - Nerea Hervás
- Endoscopia. Servicio de Aparato Digestivo, Hospital Universitario de Navarra
| | - Carlos Prieto
- Endoscopia. Servicio de Aparato Digestivo, Hospital Universitario de Navarra
| | - Marta Gómez Alonso
- Endoscopia. Servicio de Aparato Digestivo, Hospital Universitario de Navarra
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Frolov PA, Korotkevich AG, Pavlenko VV, Pachgin IV, Krasnov KA. Prevention of acute post-manipulation pancreatitis. EXPERIMENTAL AND CLINICAL GASTROENTEROLOGY 2023:114-121. [DOI: 10.31146/1682-8658-ecg-213-5-114-121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2025]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most informative and often in-demand methods for the detection and treatment of pathology of the biliary tract, its diagnostic value is 79-98%. A significant disadvantage of the method are side effects and various complications (acute pancreatitis, bleeding, retroduodenal perforation, cholangitis, acute cholecystitis, etc.). Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is a common and severe complication of intraluminal endoscopic operations on the large duodenal papilla, its etiology is multifactorial, and the pathophysiology has not yet been fully studied. According to many randomized, controlled studies, the incidence of PEP ranges from 2.7 to 37%. Despite all the possibilities of modern medicine and the introduction of new methods, mortality with the development of PEP remains at a very high level: it reaches 7-15%, and with the development of destructive forms - 40-70%. The problems of prevention of PEP are still the subject of discussions and numerous studies by leading clinics around the world. In this paper, we conducted a review of the literature over the past decade using the sources of major medical libraries Medline, eLibrary, PubMed. The article discusses current modern pathogenetic mechanisms and the main risk factors for the development of PEP, related to both the characteristics of the patient and the procedure being performed, technical options for performing ERCP. The article also presents currently used and recommended by most authors methods of drug prevention of PEP and various technical solutions related to this complication. Thus, the not entirely satisfactory results of the proposed methods of prevention of PEP force the authors to search for safer and more effective solutions to this urgent problem at the present time.
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Affiliation(s)
- P. A. Frolov
- Kuzbass Clinical Hospital of Emergency Medical Care named after M. A. Podgorbunsky
| | - A. G. Korotkevich
- Novokuznetsk State Institute of Advanced Training of Doctors; Novokuznetsk City Clinical Hospital No. 29 named after A. A. Lutsik
| | - V. V. Pavlenko
- Kuzbass Clinical Hospital of Emergency Medical Care named after M. A. Podgorbunsky; Kemerovo State Medical University
| | - I. V. Pachgin
- Kuzbass Clinical Hospital of Emergency Medical Care named after M. A. Podgorbunsky
| | - K. A. Krasnov
- Kuzbass Clinical Hospital of Emergency Medical Care named after M. A. Podgorbunsky; Kemerovo State Medical University
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Parveen S, Shah AH, Gulzar GM, Sodhi JS, Khan MA, Tiwari A, Mir TA, Sharma A, Ahmad SN, Dar NA. ERCP practice at a tertiary care hospital in Kashmir, North India: a large single-center cross-sectional study with focus on quality indicators, success rate, and indications. Ann Med Surg (Lond) 2023; 85:1705-1711. [PMID: 37228934 PMCID: PMC10205241 DOI: 10.1097/ms9.0000000000000613] [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: 12/16/2022] [Accepted: 03/25/2023] [Indexed: 05/27/2023] Open
Abstract
UNLABELLED Endoscopic retrograde cholangiopancreatography (ERCP) is the most technically demanding endoscopic procedure with significant adverse events that mandate appropriate training, competence and careful decision-making. The American Society for Gastrointestinal Endoscopy (ASGE) and the European Society of Gastrointestinal Endoscopy (ESGE) updated a list of quality indicators and performance measures for pancreatobiliary endoscopy. Nevertheless, real-life data are scarce, especially from developing countries. The study aimed to assess overall quality, procedural success, and indications of ERCP at our center. METHODS An audit of our endoscopy center at the start of the study for quality and performance indicators and a retrospective analysis of the 4 years of the prospectively maintained data of patients who underwent ERCP regarding procedural success and indications was done. RESULTS The study showed that ERCP is performed by meeting good quality standards, but structured training, sedation practice, and microbiological surveillance are subpar. A total of 3544 procedures were carried out with successful cannulation of the naive papilla in 93%, with 60% of procedures carried out on females, 80.5% of procedures done for benign diseases, and 19.5% on suspected or proven malignancy (47% men and 53% women) with perihilar obstruction being commonest in both sexes (32-33%) followed by carcinoma gallbladder in women (21%) and distal cholangiocarcinoma in men (27%). Among benign diseases (2711), 12% had benign pancreatic diseases, and 64.8% had common bile duct (CBD) stones, with 31% of CBD stones requiring more than one session for clearance. CONCLUSION ERCP at our center is performed by meeting quality standards and by competent endoscopists with good procedural success. Improving sedation strategies, microbiological surveillance, and training programs remains an unmet need.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Syed N. Ahmad
- Department of Medical Oncology, Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
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Shah-Khan SM, Zhao E, Tyberg A, Sarkar S, Shahid HM, Duarte-Chavez R, Gaidhane M, Kahaleh M. Endoscopic Ultrasound-Directed Transgastric ERCP (EDGE) Utilization of Trends Among Interventional Endoscopists. Dig Dis Sci 2023; 68:1167-1177. [PMID: 35947304 DOI: 10.1007/s10620-022-07650-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 07/29/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Endoscopic ultrasound-directed transgastric ERCP (EDGE) has become standard-of-care therapy at many centers for pancreaticobiliary disease in patients with Roux-en-Y Gastric Bypass. In this study, we aimed to evaluate the opinions and practices of endoscopists who perform EDGE. METHODS A 22-question utilization of EDGE survey was sent to 36 advanced endoscopists at tertiary care centers in the United States. The two-section survey included questions regarding advanced endoscopy volume and training at the respective facilities, and questions on specific details of EDGE utilization. RESULTS Among 36 interventional endoscopists (IE) surveyed, 14 (39%) reported performing > 1000 ERCPs annually. Thirty (83%) offered EDGE as an option for Roux-en-Y gastric bypass patients with previous cholecystectomy. Other options offered included: 19 (53%) offered Laparoscopy-assisted ERCP (LA-ERCP), 7 (19%) offered Single-Balloon ERCP (SBE), and 10 (28%) offered percutaneous drainage (PTC). Twenty (56%) IE performed 10 or less EDGE procedures, while 16 (44%) performed 11 or more. Single-session EDGE was performed by 7 (19%) IE, while 15 (42%) performed dual session, and 13 (36%) performed both. 19 (53%) actively closed fistulas while 17 (47%) let them close spontaneously. Thirty one (86%) reported a technical success rate of 91% to 100%. The most frequently reported immediate adverse event post-procedurally was abdominal pain, reported by 17 IE (47%). Weight gain was reported by 2 IE (6%). CONCLUSION EDGE continues to gain in popularity as an option for Roux-en-Y gastric bypass patients requiring pancreaticobiliary interventions, with 24/36 IE (67%) believing that it should be the new standard. In addition, most report a low frequency of post-procedural weight gain. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT05041608.
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Affiliation(s)
- Sardar M Shah-Khan
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, New Brunswick, NJ, 08901, USA
| | - Eric Zhao
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, New Brunswick, NJ, 08901, USA
| | - Amy Tyberg
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, New Brunswick, NJ, 08901, USA
| | - Sardar Sarkar
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, New Brunswick, NJ, 08901, USA
| | - Haroon M Shahid
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, New Brunswick, NJ, 08901, USA
| | - Rodrigo Duarte-Chavez
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, New Brunswick, NJ, 08901, USA
| | - Monica Gaidhane
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, New Brunswick, NJ, 08901, USA
| | - Michel Kahaleh
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, New Brunswick, NJ, 08901, USA.
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22
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Who will excel in advanced endoscopy? A study assessing the criteria and perceptions of experts with regard to selection of ERCP and EUS trainees. Endosc Int Open 2023; 11:E268-E275. [PMID: 36968977 PMCID: PMC10036202 DOI: 10.1055/a-2017-3827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 11/17/2022] [Indexed: 03/25/2023] Open
Abstract
Background and study aims
Training program directors (TPDs) and experts play a crucial role in selecting ERCP/EUS trainees and determining the workforce in endoscopy. Additionally, prospective trainees should know what TPDs/experts expect from them. Nonetheless, the criteria and perceptions used in this selection have not been clarified. The aim of this study was to identify TPD/expert values/beliefs regarding personal attributes needed for selecting trainees that can excel and those which may lead to disqualification; compare perspectives between TPDs/experts and trainees regarding the selection process and critical trainee characteristics; and investigate the general approach and satisfaction regarding current application process for ERCP/EUS training.
Methods
We conducted a web-based survey to collect general opinion and data regarding the application process and trainee selection and disqualification from training. European TPDs/experts and trainees were invited to participate.
Results
Thirty-six TPDs/experts and 25 trainees from 18 countries responded. The application process is mainly driven by individual request (86.1 %). Almost half of TPDs/experts felt only moderately (38.9 %) to slightly (8.3 %) satisfied with the current application process. TPDs/experts value a diversity of trainee characteristics, but mainly traits such as “honesty,” “being a team player,” and “self-awareness” (72.2 % each). Technical skills ranked seventh as considered “extremely important.” “Disregard for patient welfare” and “lack of work ethic” were the most common reasons for disqualification. TPDs/experts and trainees agreed in most questions.
Conclusions
This survey outlines trainee selection criteria for ERCP/EUS training. Non-technical skills are the most valued by TPDs/experts. While knowledge and technical expertise are clearly important, understanding that professional attitudes are highly regarded may help direct the application process more effectively.
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Watanabe J, Miki A, Sasanuma H, Kotani K, Sata N. Metal vs plastic stents for preoperative biliary drainage in patients with periampullary cancer: An updated systematic review and meta-analysis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2023; 30:6-20. [PMID: 35466557 DOI: 10.1002/jhbp.1162] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/10/2022] [Accepted: 03/27/2022] [Indexed: 01/17/2023]
Abstract
BACKGROUND/PURPOSE Metal stents (MS) are recommended for preoperative biliary drainage (PBD) in patients with periampullary cancer, but whether MS are superior in terms of re-intervention and direct cost is debatable. This study aimed to compare the effects of MS and PS on the outcomes of patients with periampullary cancer. METHODS For this random-effects meta-analysis, electronic databases were screened for randomized controlled trials (RCTs) published until January 2022. Subgroup analyses were performed basis on the center type and presence of NAC. RESULTS In this meta-analysis, seven RCTs (440 participants) were included. MS reduced re-interventions (risk ratio [RR] = 0.42, 95% confidence interval [CI] = 0.25-0.72) and direct costs (mean difference = -474 USD, 95% CI = -656 to -292). PBD-related complications (RR = 0.74, 95% CI = 0.32-1.71) and postoperative complications (RR = 0.73, 95% CI = 0.45-1.17) did not differ between MS and PS. Compared PS, MS reduced postoperative complications in high-volume centers (RR = 0.64, 95% CI = 0.49-0.84) and PBD-related complications in patients receiving NAC (RR = 0.29, 95% CI = 0.08-1.08). CONCLUSIONS Metal stents likely reduces re-interventions and direct costs. Further studies are needed to confirm the effects of MS on the outcomes.
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Affiliation(s)
- Jun Watanabe
- Division of Gastroenterological, General and Transplant Surgery, Department of Surgery, Jichi Medical University, Shimotsuke-City, Tochigi, Japan
- Division of Community and Family Medicine, Jichi Medical University, Shimotsuke-City, Tochigi, Japan
| | - Atsushi Miki
- Division of Gastroenterological, General and Transplant Surgery, Department of Surgery, Jichi Medical University, Shimotsuke-City, Tochigi, Japan
| | - Hideki Sasanuma
- Division of Gastroenterological, General and Transplant Surgery, Department of Surgery, Jichi Medical University, Shimotsuke-City, Tochigi, Japan
| | - Kazuhiko Kotani
- Division of Community and Family Medicine, Jichi Medical University, Shimotsuke-City, Tochigi, Japan
| | - Naohiro Sata
- Division of Gastroenterological, General and Transplant Surgery, Department of Surgery, Jichi Medical University, Shimotsuke-City, Tochigi, Japan
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24
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AbiMansour JP, Garimella V, Petersen BT, Law RJ, Storm AC, Martin JA, Levy MJ, Abu Dayyeh BK, Chandrasekhara V. Risk of post-sphincterotomy bleeding in patients with thrombocytopenia. Ther Adv Gastrointest Endosc 2023; 16:26317745231200971. [PMID: 37767287 PMCID: PMC10521278 DOI: 10.1177/26317745231200971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/26/2023] [Indexed: 09/29/2023] Open
Abstract
Background Reports suggest that the rate of adverse events (AEs) post-endoscopic sphincterotomy (ES) to be as high as 10%, with gastrointestinal bleeding being most common after post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Objective The aim of this study was to characterize the incidence of bleeding in patients with thrombocytopenia following ES. Design Retrospective observational cohort study. Methods Patients with thrombocytopenia (defined as <150,000 platelets/μL) who underwent ES between May 2017 and December 2020 were identified at a tertiary care medical center. The incidence of immediate (intraprocedural oozing >5 min or requiring intervention) or delayed (clinical bleeding with associated hemoglobin drop within 14 days) post-ES bleeding was determined via manual chart review. Results A total of 221 patients with a mean platelet count of 108,000 ± 13,000 platelets/μL underwent ERCP with ES. Immediate bleeding occurred in 11 (5%) patients with no significant drop in hemoglobin or transfusion requirement. Two patients (0.9%), both of whom were noted to have immediate bleeding, also developed delayed bleeding. Presence of malignancy was associated with an increased risk of bleeding (36.4% versus 11.4%, p = 0.037) while platelet count was not. Conclusion In a cohort of patients with thrombocytopenia, rates of immediate and delayed bleeding are similar to previously reported AE rates of ES in the general patient population. Careful attention should be given to patients with a history of active malignancy as well as those who develop immediate bleeding as they appear to be at increased risk for bleeding complications.
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Affiliation(s)
- Jad P. AbiMansour
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Vishal Garimella
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Bret T. Petersen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Ryan J. Law
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Andrew C. Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - John A. Martin
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Michael J. Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Vinay Chandrasekhara
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
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25
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Miao YS, Li YY, Cheng BW, Zhan YF, Zeng S, Zhou XJ, Chen YX, Lv NH, Li GH. Clinical analysis of 45 cases of perforation were identified during endoscopic retrograde cholangiopancreatography procedure. Front Med (Lausanne) 2022; 9:1039954. [PMID: 36507518 PMCID: PMC9729696 DOI: 10.3389/fmed.2022.1039954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 11/02/2022] [Indexed: 11/25/2022] Open
Abstract
Background Endoscopic retrograde cholangiopancreatography (ERCP) has become an important method to diagnose and treat biliary-pancreatic diseases. Perforations are infrequent but serious complications can occur during ERCPs. However, it is unclear which patients are suitable for surgery and when these patients should receive surgery. Aim To analyze the outcome of 45 patients with endoscopic retrograde cholangiopancreatography (ERCP) related perforation. Materials and methods We retrospectively reviewed all 45 patients with ERCP-related perforation between January 2003 and December 2017, and observed the location and causes of perforation, treatment strategies, and mortality. Results Twenty thousand four hundred and seventy-nine patients received ERCP procedures from January 2003 to December 2017 in our digestive endoscopy center. Forty-five patients suffered from ERCP-related perforations. The incidence rate of ERCP-related perforations was 0.22%. Twenty-six patients suffered from periampullary perforations, 15 patients suffered from duodenal wall perforations, 1 patient suffered from a fundus perforation, 1 patient suffered from a residual gallbladder duct perforation, 1 patient suffered from a papillary diverticulum perforation, and 1 patient suffered from an intrahepatic bile duct perforation. Six patients with duodenal perforations underwent surgery, and the other patients received conservative treatment. One patient with a duodenal perforation and ERCP-related pancreatitis died of heart failure, and all the other patients recovered. The mortality rate was 2.2%. Conclusion Endoscopic closure is seen as the first method for treating Stapfer type I perforations in the early phase, and surgery is seen as a remedial method when local treatment was failed. The Stapfer type II to type IV perforations can recover by conservative treatment.
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Affiliation(s)
- Yin-Shui Miao
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China,School of Medicine, Nanchang University, Nanchang, Jiangxi, China
| | - Yuan-Yuan Li
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Bo-Wen Cheng
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China,School of Medicine, Nanchang University, Nanchang, Jiangxi, China
| | - Yan-Fang Zhan
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China,School of Medicine, Nanchang University, Nanchang, Jiangxi, China
| | - Sheng Zeng
- Department of Record Room, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xiao-Jiang Zhou
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - You-Xiang Chen
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Nong-Hua Lv
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Guo-Hua Li
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China,*Correspondence: Guo-Hua Li,
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Farooqu W, Penninga L, Burgdorf SK, Krohn PS, Storkholm JH, Hansen CP. Relieving the bile ducts prior to pancreatoduodenectomy – A retrospective cohort study. Ann Med Surg (Lond) 2022; 84:104894. [DOI: 10.1016/j.amsu.2022.104894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 10/08/2022] [Accepted: 11/06/2022] [Indexed: 11/14/2022] Open
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27
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Canakis A, Kahaleh M. Endoscopic palliation of malignant biliary obstruction. World J Gastrointest Endosc 2022; 14:581-596. [PMID: 36303806 PMCID: PMC9593514 DOI: 10.4253/wjge.v14.i10.581] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 08/20/2022] [Accepted: 10/05/2022] [Indexed: 02/05/2023] Open
Abstract
Malignant biliary obstruction often presents with challenges requiring the endoscopist to assess the location of the lesion, the staging of the disease, the eventual resectability and patient preferences in term of biliary decompression. This review will focus on the different modalities available in order to offer the most appropriate palliation, such as conventional endoscopic retrograde cholangiopancreatography, endoscopic ultrasound guided biliary drainage as well as ablative therapies including photodynamic therapy or radiofrequency ablation.
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Affiliation(s)
- Andrew Canakis
- Department of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD 21201, United States
| | - Michel Kahaleh
- Department of Gastroenterology and Hepatology, Robert Wood Johnson Medical Center, New Brunswick, NJ 08901, United States
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28
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Finn CB, Tong JK, Alexander HE, Wirtalla C, Wachtel H, Guerra CE, Mehta SJ, Wender R, Kelz RR. How Referring Providers Choose Specialists for Their Patients: a Systematic Review. J Gen Intern Med 2022; 37:3444-3452. [PMID: 35441300 PMCID: PMC9550909 DOI: 10.1007/s11606-022-07574-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 03/31/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Physician referrals are a critical step in directing patients to high-quality specialists. Despite efforts to encourage referrals to high-volume hospitals, many patients receive treatment at low-volume centers with worse outcomes. We aimed to determine the most important factors considered by referring providers when selecting specialists for their patients through a systematic review of medical and surgical literature. METHODS PubMed and Embase were searched from January 2000 to July 2021 using terms related to referrals, specialty, surgery, primary care, and decision-making. We included survey and interview studies reporting the factors considered by healthcare providers as they refer patients to specialists in the USA. Studies were screened by two independent reviewers. Quality was assessed using the CASP Checklist. A qualitative thematic analysis was performed to synthesize common decision factors across studies. RESULTS We screened 1,972 abstracts and identified 7 studies for inclusion, reporting on 1,575 providers. Thematic analysis showed that referring providers consider factors related to the specialist's clinical expertise (skill, training, outcomes, and assessments), interactions between the patient and specialist (prior experience, rapport, location, scheduling, preference, and insurance), and interactions between the referring physician and specialist (personal relationships, communication, reputation, reciprocity, and practice or system affiliation). Notably, studies did not describe how providers assess clinical or technical skills. CONCLUSIONS Referring providers rely on subjective factors and assessments to evaluate quality when selecting a specialist. There may be a role for guidelines and objective measures of quality to inform the choice of specialist by referring providers.
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Affiliation(s)
- Caitlin B Finn
- NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, NY, USA.
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Jason K Tong
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Hannah E Alexander
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Chris Wirtalla
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Heather Wachtel
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Carmen E Guerra
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Shivan J Mehta
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Richard Wender
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Family Medicine and Community Health, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Rachel R Kelz
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
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Post-ERCP Pancreatitis: Prevention, Diagnosis and Management. Medicina (B Aires) 2022; 58:medicina58091261. [PMID: 36143938 PMCID: PMC9502657 DOI: 10.3390/medicina58091261] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/21/2022] [Accepted: 08/26/2022] [Indexed: 11/17/2022] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) carries a post-ERCP pancreatitis (PEP) rate of 2–10%, which could be as high as 30–50% in high-risk cases. PEP is severe in up to 5% of cases, with potential for life-threatening complications, including multi-organ failure, peripancreatic fluid collections, and death in up to 1% of cases. The risk of PEP is potentially predictable and may be modified with pharmacological measures and endoscopist technique. This review covers the definition, epidemiology and risk factors for PEP, with a focus on the latest evidence-based medical and endoscopic strategies to prevent and manage PEP.
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30
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Zhou F, Zhan X, Song C, Li G, Hong J, Chen Y, Zhou X. The assessment of the ASGE-grading system of ERCP: a large-sample retrospective study. Surg Endosc 2022; 36:6480-6487. [PMID: 34997345 DOI: 10.1007/s00464-021-09000-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/31/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND AIMS The American Society for Gastrointestinal Endoscopy (ASGE) has developed a complexity-grading system for endoscopic retrograde cholangiopancreatography (ERCP) to predict technical success and adverse events. This study aimed to assess the association between the degree of difficulty for ERCP and the rates of success and adverse event, in turn demonstrating the validity and practicality of this system. METHODS ERCP procedures performed in the First Affiliated Hospital of Nanchang University from January 2011 to December 2020 were retrospectively reviewed. Procedural success and adverse events were recorded based on difficulty level according to the ASGE-grading system. RESULTS A total of 20,652 ERCP procedures performed during the study period were analyzed, including 1908 procedures considered grade 1(9.2%), 10,170 procedures considered grade 2 (49.2%), 7764 procedures considered grade 3 (37.6%), 810 procedures considered grade 4 (3.9%). The overall success rate increased from 92.8% in 2011-2015 to 94.0% in 2016-2020, while the distribution of procedures and the incidence of complications showed little variation. The success rate revealed a significantly decreasing trend with increasing difficulty (ranging from 55.6 to 98.6%), mainly for biliary diseases. In addition, the difficulty scale was not associated with any differences in the rate of adverse event, except for the pancreatitis for grade 1 procedures, which had a low incidence. CONCLUSIONS The ASGE-grading system can help predict the success rate of ERCP procedures but showed poor performance in predicting adverse events. Further exploration may be required to improve the grading system by adjusting or including certain clinical parameters, and to validate the system for extrapolation to other endoscopy units.
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Affiliation(s)
- Feng Zhou
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, No. 17 Yongwaizheng Street, Nanchang, 330000, Jiangxi Province, China
| | - Xiaoyun Zhan
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, No. 17 Yongwaizheng Street, Nanchang, 330000, Jiangxi Province, China
| | - Conghua Song
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, No. 17 Yongwaizheng Street, Nanchang, 330000, Jiangxi Province, China
| | - Guohua Li
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, No. 17 Yongwaizheng Street, Nanchang, 330000, Jiangxi Province, China
| | - Junbo Hong
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, No. 17 Yongwaizheng Street, Nanchang, 330000, Jiangxi Province, China
| | - Youxiang Chen
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, No. 17 Yongwaizheng Street, Nanchang, 330000, Jiangxi Province, China
| | - Xiaojiang Zhou
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, No. 17 Yongwaizheng Street, Nanchang, 330000, Jiangxi Province, China.
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31
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Lee TH, Moon JH, Stuart S. Role of ERCP in Malignant Hilar Biliary Obstruction. Gastrointest Endosc Clin N Am 2022; 32:427-453. [PMID: 35691690 DOI: 10.1016/j.giec.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Malignant hilar biliary obstruction (MHO), an aggressive perihilar biliary obstruction caused by cholangiocarcinoma, gallbladder cancer, or other metastatic malignancies, has a poor prognosis. Surgical resection is the only curative treatment method for biliary malignancies. However, most of the patients with MHO cannot undergo surgeries on presentation because of an advanced inoperable state or a poor performance state due to old age or comorbid diseases. Therefore, palliative biliary drainage is mandatory to improve symptomatic jaundice and quality of life. Among drainage methods, endoscopic biliary drainage is the current standard for the palliation of unresectable advanced MHO. The development of stents and various accessories and advances in endoscopic techniques including endoscopic ultrasonography have facilitated primary endoscopic intervention in difficult high-grade hilar strictures. However, some issues are still under debate, such as palliation methods, appropriate stents, the number of stents, deployment methods, and additional local ablation therapies. Therefore, this review presents currently optimal endoscopic palliation methods for advanced MHO based on the reported literature.
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Affiliation(s)
- Tae Hoon Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, SoonChunHyang University Cheonan Hospital, SoonChunHyang University School of Medicine, Cheonan, 31, Sooncheonhyang 6-gil, Dongnam-gu, Cheonan-si, Chungcheongnam-do, 31151, Republic of Korea
| | - Jong Ho Moon
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, SoonChunHyang University Bucheon Hospital, SoonChunHyang University School of Medicine, 170 Jomaru-Ro, Bucheon 14584, Republic of Korea.
| | - Sherman Stuart
- Department of Medicine, Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indiana University Health-University Hospital, 550 North University Boulevard, Suite 1634, Indianapolis, IN 46202, USA
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Fugazza A, Troncone E, Amato A, Tarantino I, Iannone A, Donato G, D'Amico F, Mogavero G, Amata M, Fabbri C, Radaelli F, Occhipinti P, Repici A, Anderloni A. Difficult biliary cannulation in patients with distal malignant biliary obstruction: An underestimated problem? Dig Liver Dis 2022; 54:529-536. [PMID: 34362708 DOI: 10.1016/j.dld.2021.07.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 07/13/2021] [Accepted: 07/14/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Failed biliary cannulation still poses a major challenge in patients undergoing Endoscopic Retrograde Cholangiopancreatography (ERCP). To date, there is a lack of data on rates of Difficult Biliary Cannulation (DBC) in patients with distal malignant biliary obstruction (DMBO). MATERIALS This was a retrospective study (09/2015 to 02/2019) of consecutive patients with DMBO that underwent ERCP in four Italian centers. The primary outcome was to evaluate the rate of DBC. Secondary outcomes were: cannulation failure, rate of adverse events (AEs), the predictive factors for DBC as well as for AEs. RESULTS A total of 622 patients with DMBO, were included in the study, with 351(56,4%) matching the definition of DBC. One-hundred and two ERCP-related AEs occurred in 97 of 622 patients (15,6%). Subjects with DBC showed a higher risk for AEs (p = 0.02). The lack of pancreatitis prophylaxis (p = 0.03), diagnosis of cholangiocarcinoma (p = 0.02), the use of papillotomy (OR=1.98; 95%CI = 1.14-3.45) and the combination of two or more techniques for cannulation (OR = 2.88; 95%CI = 1.04-7.97) were associated with the occurrence of AEs. CONCLUSIONS According to the results of this study, patients with DMBO carries a higher rate of DBC thus requiring alternative techniques for biliary drainage. Furthermore, DBC carries a high risk for AEs. Further prospective multicentric studies are needed to confirm these data in this specific subgroup of patients.
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Affiliation(s)
- Alessandro Fugazza
- Digestive Endoscopy Unit, Departement of Gastroenterology, Humanitas Research Hospital-IRCCS, Rozzano, Italy.
| | - Edoardo Troncone
- Department of Systems Medicine, University of Rome ``Tor Vergata'', Rome 00133, Italy
| | - Arnaldo Amato
- Division of Digestive Endoscopy and Gastroenterology, Valduce Hospital, Como, Italy
| | - Ilaria Tarantino
- Digestive Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
| | - Andrea Iannone
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Giulio Donato
- Azienda Ospedaliero Universitaria "Maggiore della Carità", Novara, Italy
| | - Ferdinando D'Amico
- Digestive Endoscopy Unit, Departement of Gastroenterology, Humanitas Research Hospital-IRCCS, Rozzano, Italy
| | - Giuseppe Mogavero
- Division of Digestive Endoscopy and Gastroenterology, Valduce Hospital, Como, Italy
| | - Michele Amata
- Digestive Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Medical Department, Forlì-Cesena Hospitals, AUSL Romagna
| | - Franco Radaelli
- Division of Digestive Endoscopy and Gastroenterology, Valduce Hospital, Como, Italy
| | - Pietro Occhipinti
- Azienda Ospedaliero Universitaria "Maggiore della Carità", Novara, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Departement of Gastroenterology, Humanitas Research Hospital-IRCCS, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Departement of Gastroenterology, Humanitas Research Hospital-IRCCS, Rozzano, Italy
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Naringrekar HV, Shahid H, Varghese C, Schlachterman A, Deshmukh SP, Roth CG. Extrapancreatic Advanced Endoscopic Interventions. Radiographics 2022; 42:379-396. [PMID: 35089818 DOI: 10.1148/rg.210087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
As the field of interventional endoscopy advances, conditions that were once treated with surgery are increasingly being treated with advanced endoscopy. Endoscopy is now used for treatment of achalasia, bariatric procedures for obesity; resection of early-stage malignancies in the gastrointestinal tract; and placement of lumen-apposing metal stents in the treatment of biliary obstruction, gastric outlet obstruction, cholecystitis, and drainage of nonpancreatic-related fluid collections or abscesses. Knowledge of the novel terminology, procedural details, expected postintervention imaging findings, and potential complications is vital for radiologists because these procedures are rapidly becoming more mainstream in daily practice. These procedures include peroral endoscopic myotomy for the treatment of achalasia and other esophageal motility disorders; endoscopic sleeve gastroplasty and placement of an intragastric balloon for weight loss; endoscopic submucosal dissection in the resection of tumors of the gastrointestinal tract; and therapeutic endoscopic-guided procedures for the treatment of biliary obstruction, gastric outlet obstruction, acute cholecystitis, and drainage of nonpancreatically related fluid collections. Patients benefit from these minimally invasive procedures, with potential improvement in morbidity and mortality rates, decreased length of hospital stay, and decreased health care costs when compared with the surgical alternative. Complications of these procedures include leaks or perforations, infections or abscesses, fistulas, and occlusion and migration of stents. An invited commentary by Pisipati and Pannala is available online. ©RSNA, 2022.
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Affiliation(s)
- Haresh Vijay Naringrekar
- From the Department of Radiology (H.V.N., S.P.D., C.G.R.) and Department of Gastroenterology and Hepatology (A.S.), Thomas Jefferson University Hospital, 132 S 10th St, Philadelphia, PA 19123; Division of Gastroenterology and Hepatology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ (H.S.); and Department of Radiology, Westchester Medical Center, Valhalla, NY (C.V.)
| | - Haroon Shahid
- From the Department of Radiology (H.V.N., S.P.D., C.G.R.) and Department of Gastroenterology and Hepatology (A.S.), Thomas Jefferson University Hospital, 132 S 10th St, Philadelphia, PA 19123; Division of Gastroenterology and Hepatology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ (H.S.); and Department of Radiology, Westchester Medical Center, Valhalla, NY (C.V.)
| | - Cyril Varghese
- From the Department of Radiology (H.V.N., S.P.D., C.G.R.) and Department of Gastroenterology and Hepatology (A.S.), Thomas Jefferson University Hospital, 132 S 10th St, Philadelphia, PA 19123; Division of Gastroenterology and Hepatology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ (H.S.); and Department of Radiology, Westchester Medical Center, Valhalla, NY (C.V.)
| | - Alex Schlachterman
- From the Department of Radiology (H.V.N., S.P.D., C.G.R.) and Department of Gastroenterology and Hepatology (A.S.), Thomas Jefferson University Hospital, 132 S 10th St, Philadelphia, PA 19123; Division of Gastroenterology and Hepatology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ (H.S.); and Department of Radiology, Westchester Medical Center, Valhalla, NY (C.V.)
| | - Sandeep P Deshmukh
- From the Department of Radiology (H.V.N., S.P.D., C.G.R.) and Department of Gastroenterology and Hepatology (A.S.), Thomas Jefferson University Hospital, 132 S 10th St, Philadelphia, PA 19123; Division of Gastroenterology and Hepatology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ (H.S.); and Department of Radiology, Westchester Medical Center, Valhalla, NY (C.V.)
| | - Christopher G Roth
- From the Department of Radiology (H.V.N., S.P.D., C.G.R.) and Department of Gastroenterology and Hepatology (A.S.), Thomas Jefferson University Hospital, 132 S 10th St, Philadelphia, PA 19123; Division of Gastroenterology and Hepatology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ (H.S.); and Department of Radiology, Westchester Medical Center, Valhalla, NY (C.V.)
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De'Ath HD, Nagendram S, Smith E, Ramadan M, Veeramootoo D, Singh S. A high-volume ERCP service led by surgeons is associated with good outcomes and meets national key performance indicators: results from a British district general hospital. Surg Endosc 2022; 36:6016-6023. [PMID: 35020059 DOI: 10.1007/s00464-021-08978-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 12/31/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is a common, but technically challenging procedure used in the management of hepatopancreaticobiliary (HPB) disease. It is traditionally performed by medical gastroenterologists. In 2014, the British Society of Gastroenterology (BSG) proposed key performance indicators to evaluate and set standards of ERCP practice. This study aimed to compare our ERCP outcomes against these targets, in a centre where ERCP is exclusively performed by surgeons. METHODS A retrospective analysis of all ERCPs undertaken over a 38 months in a District General Hospital in the United Kingdom (UK), by three Upper Gastrointestinal Surgeons. Study outcomes were based upon, and compared against, BSG key performance indicators, including number of ERCPs per annum, proportion of successful cannulations of bile duct and stone clearance, ERCP-specific complications and mortality. RESULTS The unit's caseload over this period was 1324, equating to approximately 418 per annum (BSG minimum 200 per unit). Management of bile duct stones was the commonest indication for ERCP. Overall, 95% (1253/1324) of bile ducts were cannulated and 92% (645/698) for those undergoing their first ERCP. Bile duct clearance was achieved in 80% of patients (BSG recommend > 75%) and the successful stenting of extra-hepatic strictures in 94% (BSG recommend > 80%). The overall complication rate was 4.3% (BSG standard < 6%). Procedure-specific mortality was 0.3% (4/1324) where death was either caused by pancreatitis or sepsis. CONCLUSION A high-volume ERCP service led and performed exclusively by surgeons meets all BSG performance indicators, with good procedural and patient outcomes. Formal training pathways should be developed to encourage more surgical centres to provide an ERCP service and deal with what are common surgical pathologies.
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Affiliation(s)
- Henry D De'Ath
- Department of Upper Gastrointestinal Surgery, Frimley Park Hospital, Portsmouth Road, Camberley, Surrey, GU16 7UJ, England, UK.
| | - Sathyan Nagendram
- Department of Upper Gastrointestinal Surgery, Frimley Park Hospital, Portsmouth Road, Camberley, Surrey, GU16 7UJ, England, UK
| | - Eleanor Smith
- Department of Upper Gastrointestinal Surgery, Frimley Park Hospital, Portsmouth Road, Camberley, Surrey, GU16 7UJ, England, UK
| | - Mohamed Ramadan
- Department of Upper Gastrointestinal Surgery, Frimley Park Hospital, Portsmouth Road, Camberley, Surrey, GU16 7UJ, England, UK
| | - Darmarajah Veeramootoo
- Department of Upper Gastrointestinal Surgery, Frimley Park Hospital, Portsmouth Road, Camberley, Surrey, GU16 7UJ, England, UK
| | - Sukhpal Singh
- Department of Upper Gastrointestinal Surgery, Frimley Park Hospital, Portsmouth Road, Camberley, Surrey, GU16 7UJ, England, UK
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Syrén EL, Sandblom G, Enochsson L, Eklund A, Isaksson B, Österberg J, Eriksson S. Outcome of ERCP related to case-volume. Surg Endosc 2022; 36:5339-5347. [PMID: 34981237 PMCID: PMC9160106 DOI: 10.1007/s00464-021-08915-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 11/21/2021] [Indexed: 11/30/2022]
Abstract
Background and aims In some studies, high endoscopic retrograde cholangiopancreatography (ERCP) case-volume has been shown to correlate to high success rate in terms of successful cannulation and fewer adverse events. The aim of this study was to analyze the association between ERCP success and complications, and endoscopist and centre case-volumes. Methods Data were obtained from the Swedish National Register for Gallstone Surgery and ERCP (GallRiks) on all ERCPs performed for Common Bile Duct Stone (CBDS) (n = 17,873) and suspected or confirmed malignancy (n = 6152) between 2009 and 2018. Successful cannulation rate, procedure time, intra- and postoperative complication rates and post-ERCP pancreatitis (PEP) rate, were compared with endoscopist and centre ERCP case-volumes during the year preceding the procedure as predictor. Results In multivariable analyses of the CBDS group adjusting for age, gender and year, a high endoscopist case-volume was associated with higher successful cannulation rate, lower complication and PEP rates, and shorter procedure time (p < 0.05). Centres with a high annual case-volume were associated with high successful cannulation rate and shorter procedure time (p < 0.05), but not lower complication and PEP rates. When indication for ERCP was malignancy, a high endoscopist case-volume was associated with high successful cannulation rate and low PEP rates (p < 0.05), but not shorter procedure time or low complication rate. Centres with high case-volume were associated with high successful cannulation rate and low complication and PEP rates (p < 0.05), but not shorter procedure time. Conclusions The results suggest that higher endoscopist and centre case-volumes are associated with safer ERCP and successful outcome.
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Affiliation(s)
- Eva-Lena Syrén
- Department of Surgical Sciences, Uppsala University, 751 35, Uppsala, Sweden. .,Centre for Clinical Research, Uppsala University, Region Västmanland, Uppsala, Sweden. .,Department of Surgery, Akademiska Hospital, Uppsala, Sweden.
| | - Gabriel Sandblom
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institute, Stockholm, Sweden.,Department of Surgery, Södersjukhuset, Stockholm, Sweden
| | - Lars Enochsson
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Arne Eklund
- Centre for Clinical Research, Uppsala University, Region Västmanland, Uppsala, Sweden.,Department of Surgery, Hospital of Västmanland, Västerås, Sweden
| | - Bengt Isaksson
- Department of Surgical Sciences, Uppsala University, 751 35, Uppsala, Sweden.,Department of Surgery, Akademiska Hospital, Uppsala, Sweden
| | - Johanna Österberg
- Department of Surgery, Mora Hospital, Mora, Sweden.,Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden
| | - Staffan Eriksson
- Centre for Clinical Research, Uppsala University, Region Västmanland, Uppsala, Sweden.,Department of Surgery, Hospital of Västmanland, Västerås, Sweden
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Aminoff H, Meijer S, Groth K, Arnelo U. User Experience in Remote Surgical Consultation: Survey Study of User Acceptance and Satisfaction in Real-Time Use of a Telemedicine Service. JMIR Hum Factors 2021; 8:e30867. [PMID: 34851302 PMCID: PMC8672288 DOI: 10.2196/30867] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/16/2021] [Accepted: 07/23/2021] [Indexed: 01/19/2023] Open
Abstract
Background Teleguidance, a promising telemedicine service for intraoperative surgical consultation, was planned to scale up at a major academic hospital in partnership with 5 other hospitals. If the service was adopted and used over time, it was expected to provide educational benefits and improve clinical outcomes during endoscopic retrograde cholangiopancreatography (ERCP), which is a technically advanced procedure for biliary and pancreatic disease. However, it is known that seemingly successful innovations can play out differently in new settings, which might cause variability in clinical outcomes. In addition, few telemedicine services survive long enough to deliver system-level outcomes, the causes of which are not well understood. Objective We were interested in factors related to usability and user experience of the telemedicine service, which might affect adoption. Therefore, we investigated perceptions and responses to the use and anticipated use of a system. Technology acceptance, a construct referring to how users perceive a technology’s usefulness, is commonly considered to indicate whether a new technology will actually be used in a real-life setting. Satisfaction measures were used to investigate whether user expectations and needs have been met through the use of technology. In this study, we asked surgeons to rate the perceived usefulness of teleguidance, and their satisfaction with the telemedicine service in direct conjunction with real-time use during clinical procedures. Methods We designed domain-specific measures for perceived usefulness and satisfaction, based on performance and outcome measures for the clinical procedure. Surgeons were asked to rate their user experience with the telemedicine service in direct conjunction with real-time use during clinical procedures. Results In total, 142 remote intraoperative consultations were conducted during ERCP procedures at 5 hospitals. The demand for teleguidance was more pronounced in cases with higher complexity. Operating surgeons rated teleguidance to have contributed to performance and outcomes to a moderate or large extent in 111 of 140 (79.3%) cases. Specific examples were that teleguidance was rated as having contributed to intervention success and avoiding a repeated ERCP in 23 cases, avoiding 3 PTC, and 11 referrals, and in 11 cases, combinations of these outcomes. Preprocedure beliefs about the usefulness of teleguidance were generally lower than postprocedure satisfaction ratings. The usefulness of teleguidance was mainly experienced through practical advice from the consulting specialist (119/140, 85%) and support with assessment and decision-making (122/140, 87%). Conclusions Users’ satisfaction with teleguidance surpassed their initial expectations, mainly through contribution to nontechnical aspects of performance, and through help with general assessment. Teleguidance shows the potential to improve performance and outcomes during ERCP. However, it takes hands-on experience for practitioners to understand how the new telemedicine service contributes to performance and outcomes.
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Affiliation(s)
- Hedvig Aminoff
- Department of Biomedical Engineering and Health Systems, School of Engineering Sciences in Chemistry, Biotechnology and Health, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Sebastiaan Meijer
- Department of Biomedical Engineering and Health Systems, School of Engineering Sciences in Chemistry, Biotechnology and Health, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Kristina Groth
- The Center for Innovation, Karolinska University Hospital, Stockholm, Sweden
| | - Urban Arnelo
- CLINTEC Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.,Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
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Kokas B, Szijártó A, Farkas N, Ujváry M, Móri S, Kalocsai A, Szücs Á. Percutaneous transhepatic drainage is safe and effective in biliary obstruction-A single-center experience of 599 patients. PLoS One 2021; 16:e0260223. [PMID: 34793565 PMCID: PMC8601527 DOI: 10.1371/journal.pone.0260223] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 11/04/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Historically, surgical bilioenteric bypass was the only treatment option for extrahepatic bile duct obstruction, but with technological advancements, percutaneous transhepatic drainage (PTD) and endoscopic solutions were introduced as a less invasive alternative. Endoscopic methods may lead to a decreasing indication of PTD in the future, but today it is still the standard treatment method, especially in hilar obstructions. METHODS In our retrospective data analysis, we assessed technical success rate, reintervention rate, morbidity, mortality, and the learning curve of patients treated with PTD over 12 years in a tertiary referral center. RESULTS 599 patients were treated with 615 percutaneous interventions. 94.5% (566/599) technical success rate; 2.7% (16/599) reintervention rate were achieved. 111 minor and 22 major complications occurred including 1 case of death. In perihilar obstruction, cholangitis were significantly more frequent in cases where endoscopic retrograde cholangiopancreatography had also been performed prior to PTD compared to PTD alone, with 39 (18.2%) and 15 (10.5%) occurrences, respectively. DISCUSSION The results and especially the excellent success rates demonstrate that PTD is safe and effective, and it is appropriate for first choice in the treatment algorithm of perihilar stenosis. Ultimately, we concluded that PTD should be performed in experienced centers to achieve low mortality, morbidity, and high success rates.
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Affiliation(s)
- Bálint Kokas
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Attila Szijártó
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Nelli Farkas
- Institute of Bioanalysis, University of Pécs, Pécs, Hungary
| | - Miklós Ujváry
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Szabolcs Móri
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Adél Kalocsai
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Ákos Szücs
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
- * E-mail:
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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: 7] [Impact Index Per Article: 1.8] [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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Kylänpää L, Koskensalo V, Saarela A, Ejstrud P, Udd M, Lindström O, Rainio M, Tenca A, Halttunen J, Qvigstad G, Arnelo U, Fagerström N, Hauge T, Aabakken L, Grönroos J. Transpancreatic biliary sphincterotomy versus double guidewire in difficult biliary cannulation: a randomized controlled trial. Endoscopy 2021; 53:1011-1019. [PMID: 33440441 DOI: 10.1055/a-1327-2025] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Difficult biliary cannulation in endoscopic retrograde cholangiopancreatography (ERCP) increases the risk of post-ERCP pancreatitis (PEP). The purpose of this prospective, randomized, multicenter study was to compare two advanced rescue methods, transpancreatic biliary sphincterotomy (TPBS) and a double-guidewire (DGW) technique, in difficult common bile duct (CBD) cannulation. METHODS Patients with native papilla and planned CBD cannulation were recruited at eight Scandinavian hospitals. An experienced endoscopist attempted CBD cannulation with wire-guided cannulation. If the procedure fulfilled the definition of difficult cannulation and a guidewire entered the pancreatic duct, randomization to either TPBS or to DGW was performed. If the randomized method failed, any method available was performed. The primary end point was the frequency of PEP and the secondary end points included successful cannulation with the randomized method. RESULTS In total, 1190 patients were recruited and 203 (17.1 %) were randomized according to the study protocol (TPBS 104 and DGW 99). PEP developed in 14/104 patients (13.5 %) in the TPBS group and 16/99 patients (16.2 %) in the DGW group (P = 0.69). No difference existed in PEP severity between the groups. The rate of successful deep biliary cannulation was significantly higher with TPBS (84.6 % [88/104]) than with DGW (69.7 % [69/99]; P = 0.01). CONCLUSIONS In difficult biliary cannulation, there was no difference in PEP rate between TPBS and DGW techniques. TPBS is a good alternative in cases of difficult cannulation when the guidewire is in the pancreatic duct.
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Affiliation(s)
- Leena Kylänpää
- Abdominal Center, Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Vilja Koskensalo
- Abdominal Center, Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Arto Saarela
- Department of Gastrointestinal Surgery, Oulu University Hospital, Oulu, Finland
| | - Per Ejstrud
- Department of Gastrointestinal Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Marianne Udd
- Abdominal Center, Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Outi Lindström
- Abdominal Center, Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Mia Rainio
- Abdominal Center, Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Andrea Tenca
- Abdominal Center, Gastroenterology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Jorma Halttunen
- Abdominal Center, Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Gunnar Qvigstad
- Department of Gastroenterology and Hepatology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Urban Arnelo
- Department of Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Niklas Fagerström
- Department of Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Truls Hauge
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
| | - Lars Aabakken
- Department of Medical Gastroenterology, Rikshospitalet University Hospital, Oslo, Norway
| | - Juha Grönroos
- Division of Digestive Surgery and Urology, Turku University Hospital and University of Turku, Turku, Finland
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Donato G, Occhipinti P, Correale L, Spadaccini M, Repici A, Anderloni A, Fugazza A, Mosca P, Tringali A, Costamagna G, Bulajic M, de Pretis G, Gabbrielli A, Di Matteo FM, Faggiani R, Ayoubi M, De Luca L, Cantù P, Blois M, Dell’Amico I, Maurano A, Savarese MF, Manes G, Ferraro R, Barberis M, Hassan C, The REQUEST Group . A prospective study on quality in endoscopic retrograde cholangiopancreatography (ERCP): trend in Italy from the REQUEST study. Endosc Int Open 2021; 9:E1563-E1571. [PMID: 34540552 PMCID: PMC8445684 DOI: 10.1055/a-1531-4691] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 06/07/2021] [Indexed: 12/28/2022] Open
Abstract
Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) is a complex procedure with a relatively high rate of adverse events. Data on training of operators and fulfillment of quality indicators in Italy are scarce. The goal of this study was to assess the overall quality of ERCP in Italy compared to international standards. Patients and methods This was a prospective, observational study from different Italian centers performing ERCP. Operators answered a questionnaire, then recorded data on ERCPs over a 1-to 3-month period. Results Nineteen Italian centers participated in the study. The most common concern of operators about training was the lack of structured programs. Seven/19 centers routinely used conscious sedation for ERCP. Forty-one experienced operators and 21 trainees performed 766 ERCPs: a successful deep biliary cannulation in native-papilla patients was achieved in 95.1 % of cases; the post-ERCP pancreatitis (PEP) rate was 5.4 % in native-papilla patients; cholangitis rate was 1.0 %; bleeding and perforation occurred in 2.7 % and 0.4 % of the patients, respectively. Conclusions This study revealed that, overall, ERCP is performed in the participating Italian centers meeting good quality standards, but structured training and sedation practice are still subpar. The bleeding and perforation rate slightly exceeded the American Society of Gastrointestinal Endoscopy indicator targets but they are comparable to the reported rates from other international surveys.
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Affiliation(s)
- Giulio Donato
- Gastroenterology Unit, Department of Oncological and Specialty Medicine, Ospedale “Maggiore della Carità”, Novara, Italy
| | - Pietro Occhipinti
- Gastroenterology Unit, Department of Oncological and Specialty Medicine, Ospedale “Maggiore della Carità”, Novara, Italy
| | - Loredana Correale
- Gastroenterology Unit, Department of Oncological and Specialty Medicine, Ospedale “Maggiore della Carità”, Novara, Italy
| | - Marco Spadaccini
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Hospital-IRCCS, Rozzano (MI), Italy,Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Hospital-IRCCS, Rozzano (MI), Italy; Department of Biomedical Sciences, Pieve Emanuele, Milano, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Hospital-IRCCS, Rozzano (MI), Italy,Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Hospital-IRCCS, Rozzano (MI), Italy; Department of Biomedical Sciences, Pieve Emanuele, Milano, Italy
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Hospital-IRCCS, Rozzano (MI), Italy
| | - Alessandro Fugazza
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Hospital-IRCCS, Rozzano (MI), Italy
| | - Piergiorgio Mosca
- Division of Gastroenterology, Department of Gastroenterology & Transplantation, AOU Ospedali Riuniti, Ancona, Italy
| | - Andrea Tringali
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy,Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Roma, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy,Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Roma, Italy
| | - Milutin Bulajic
- Gastroenterology and GI Endoscopy Unit, University Hospital of Udine, Udine, Italy,Mater Olbia Hospital-Qatar Foundation Endowment & Gemelli Foundation, Gastroenterology and GI Endoscopy Unit, Olbia (OT), Italy
| | - Giovanni de Pretis
- Gastroenterology and Digestive Endoscopy Unit, Ospedale S. Chiara, Trento, Italy
| | | | | | - Roberto Faggiani
- Gastroenterology and Endoscopy Unit, Department of Oncological and Specialty Medicine, S. Camillo Forlanini Hospital, Rome, Italy
| | - Mohammad Ayoubi
- Gastroenterology and Endoscopy Unit, Gradenigo-Humanitas, Torino, Italy
| | - Luca De Luca
- Gastroenterology and Digestive Endoscopy Unit, A.O. Ospedale Riuniti Marche Nord, Pesaro, Italy
| | - Paolo Cantù
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Matteo Blois
- Interventional Endoscopy Unit, Azienda USL Toscana Nord-Ovest, Livorno, Italy
| | | | - Attilio Maurano
- Operative Endoscopy Unit, Azienda Ospedaliera Universitaria di Salerno, Italy
| | - Maria Flavia Savarese
- Gastroenterology and Gastrointestinal Endoscopy, General Hospital, Sanremo (IM), Italy
| | - Giampiero Manes
- Department of Gastroenterology and Digestive Endoscopy, ASST Rhodense Garbagnate Milanese, Milano, Italy
| | - Raffaella Ferraro
- Gastroenterology and Digestive Endoscopy Unit, Ospedale S. Andrea, ASL VC, Vercelli, Italy
| | - Mauro Barberis
- Gastroenterology Unit, Policlinico di Monza, Monza (MB), Italy
| | - Cesare Hassan
- Department of Gastroenterology, Nuovo Regina Margherita Hospital, Roma, Italy
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Khoury T, Mari A, Sbeit W. Endoscopic retrograde cholangiopancreatography related perforations: is there plenty to discover? Minerva Gastroenterol (Torino) 2021; 67:273-275. [PMID: 32623874 DOI: 10.23736/s2724-5985.20.02736-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Tawfik Khoury
- Department of Gastroenterology, Galilee Medical Center, Nahariya, Israel
- Faculty of Medicine, Bar-Ilan University, Safed, Israel
- Unit of Gastroenterology and Endoscopy, EMMS The Nazareth Hospital, Nazareth, Israel
| | - Amir Mari
- Faculty of Medicine, Bar-Ilan University, Safed, Israel -
- Unit of Gastroenterology and Endoscopy, EMMS The Nazareth Hospital, Nazareth, Israel
| | - Wisam Sbeit
- Department of Gastroenterology, Galilee Medical Center, Nahariya, Israel
- Faculty of Medicine, Bar-Ilan University, Safed, Israel
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Bass GD, Zhao FS, Schweickert WD, Manaker S. A Retrospective Analysis of Malpractice-Related Procedure Rates for Internal Medicine Specialists at an Academic Medical Center. Jt Comm J Qual Patient Saf 2021; 47:704-710. [PMID: 34456152 DOI: 10.1016/j.jcjq.2021.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 08/01/2021] [Accepted: 08/02/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although malpractice litigation is common in the United States, the risk of a malpractice claim for procedures performed by internal medical practitioners is unknown. This study determined the frequency of malpractice claims related to procedures in a large department of medicine at an academic medical center over a five-year period. METHODS Researchers retrospectively reviewed all malpractice claims and procedures performed by internal medicine practitioners of all specialties between July 1, 2014, and June 30, 2019, in a department of medicine at a large academic medical center. A list of all procedures and Current Procedural Terminology codes performed by internal medicine practitioners was compiled. Active procedure-related malpractice claims and the total number of procedures performed during the study period were counted. RESULTS During the study period, 353,661 procedures were performed by internal medicine practitioners. During the same period, 76 active malpractice claims were identified, of which only 13 (17.1%) were procedure-related. For 2 different malpractice claims, a single patient had 2 procedures; thus 13 total claims related to the performance of 15 procedures. The proportion of procedure-related claims per total number of procedures performed was 0.37 claims/10,000 cases. The frequency of procedure-related malpractice claims per number of procedures performed ranged from 1 in 38 for pulmonary artery thrombolytic therapy to 1 in 137,325 for colonoscopy. CONCLUSION Procedure-related malpractice claims against internal medicine practitioners at a large academic medical center over a five-year period were infrequent despite significant procedural volume. Contextualizing procedure-related malpractice claims in terms of procedure-specific volume reframes the reporting of malpractice risk.
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Forbes N, Chau M, Koury HF, Lethebe BC, Smith ZL, Wani S, Keswani RN, Elmunzer BJ, Anderson JT, Heitman SJ, Hilsden RJ. Development and validation of a patient-reported scale for tolerability of endoscopic procedures using conscious sedation. Gastrointest Endosc 2021; 94:103-110.e2. [PMID: 33385464 PMCID: PMC8761529 DOI: 10.1016/j.gie.2020.12.038] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/18/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Patient-reported experience measures (PREMs) assessing the tolerability of endoscopic procedures are scarce. In this study, we designed and validated a PREM to assess tolerability of endoscopy using conscious sedation. METHODS The patient-reported scale for tolerability of endoscopic procedures (PRO-STEP) consists of questions within 2 domains and is administered to outpatients at discharge from the endoscopy unit. Domain 1 (intraprocedural) consists of 2 questions regarding discomfort/pain and awareness, whereas domain 2 (postprocedural) consists of 4 questions on pain, nausea, distention, and either throat or anal pain. All questions are scored on a Likert scale from 0 to 10. Cronbach's alpha was used to measure internal consistency of the questions. Multivariable logistic regression was performed to assess predictors of higher scores, reported using adjusted odds ratios and confidence intervals. RESULTS Two hundred fifty-five patients (91 colonoscopy, 73 gastroscopy, and 91 ERCP) were included. Colonoscopy was the least tolerable procedure by recall, with mean intraprocedural awareness and discomfort scores of 5.1 ± 3.8, and 2.6 ± 2.7, respectively. Consistency between intraprocedural awareness and discomfort/pain yielded an acceptable Cronbach's alpha of .71 (95% confidence interval, .62-.78). Higher use of midazolam during colonoscopy was inversely associated with an intraprocedural awareness score of 7 or higher (per additional mg: adjusted odds ratio, .23; 95% confidence interval, .09-.54). CONCLUSIONS PRO-STEP is a simple PREM that can be administered after multiple endoscopic procedures using conscious sedation. Future work should focus on its performance characteristics in adverse event prediction.
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Affiliation(s)
- Nauzer Forbes
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Millie Chau
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Hannah F. Koury
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - B. Cord Lethebe
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Zachary L. Smith
- Department of Medicine, Division of Gastroenterology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Denver, Colorado, USA
| | - Rajesh N. Keswani
- Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - B. Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - John T. Anderson
- Department of Gastroenterology, Gloucestershire Hospitals NHSFT, Gloucester, UK
| | - Steven J. Heitman
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Robert J. Hilsden
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Huang RJ, Barakat MT, Park W, Banerjee S. Quality metrics in the performance of EUS: a population-based observational cohort of the United States. Gastrointest Endosc 2021; 94:68-74.e3. [PMID: 33476611 DOI: 10.1016/j.gie.2020.12.055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 12/31/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS There are few data on the quality of EUS in the community setting. We characterized EUS performance at the individual facility level in 3 large American states, using need for repeat biopsy (NRB) as a metric for procedural failure, and the rate of unplanned hospital encounters (UHEs) as a metric for adverse events. METHODS We collected data on 76,614 EUS procedures performed at 166 facilities in California, Florida, and New York (2009-2014). The endpoints for the study were 7-day rate of UHEs after EUS, and 30-day rate of NRB after EUS with fine-needle aspiration. Facility-level factors analyzed included annual procedure volume, urban/rural location, and free-standing status (facilities not attached to a larger hospital). Predictors for UHE and NRB were analyzed in both multivariable regression and nonparametric local regression. RESULTS Facility volume did not predict risk for UHEs. However, high facility volume protected against NRB (P trend <.001) even after adjustment for other facility-level factors. When regressing facility volume against risk for NRB in local regression, a join point (inflection point) was identified at 97 procedures per annum. Once facilities reached this threshold volume, there appeared little additional protective effect of higher volume. Rural facility location (odds ratio, 1.81; 95% confidence interval, 1.36-2.40) and free-standing status (odds ratio, 1.57; 95% confidence interval, 1.16-2.13) were also associated with NRB. CONCLUSION Facility volume does not predict risk for adverse events after EUS. However, high facility volume is associated with decreased rates of technical failure (as assessed by NRB). These data provide one of the first descriptions of EUS practice in community settings and highlight opportunities to improve endoscopic quality nationally.
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Affiliation(s)
- Robert J Huang
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, California, USA
| | - Monique T Barakat
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, California, USA
| | - Walter Park
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, California, USA
| | - Subhas Banerjee
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, California, USA
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Pokala SK, Jones B, Wani S. Improving quality in EUS: a call for a national benchmarking registry. Gastrointest Endosc 2021; 94:75-77. [PMID: 33975714 DOI: 10.1016/j.gie.2021.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 03/06/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Sridevi K Pokala
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Blake Jones
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Improving the Standard of Care for All-A Practical Guide to Developing a Center of Excellence. Healthcare (Basel) 2021; 9:healthcare9060777. [PMID: 34205635 PMCID: PMC8235374 DOI: 10.3390/healthcare9060777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 06/04/2021] [Accepted: 06/15/2021] [Indexed: 11/17/2022] Open
Abstract
Pancreatic surgery is one of the more challenging procedures performed by surgeons. The operations are technically complex and have historically been accompanied by a substantial risk for mortality and postoperative complications. Other pancreatic pathologies require advanced therapeutic procedures that are highly endoscopist-dependent, requiring specific, knowledge-based training for optimal outcomes. An increase in diagnosed pancreatic pathologies every year reinforces a critical need for experienced surgeons, gastroenterologists/endoscopists, hospitals, and support personnel in the management of complex pancreatic cases and thus, well-designed Centers of Excellence (CoE). In this paper, we outline the framework for a Pancreas CoE across three developmental domains: (1) establishing the foundation; (2) formalizing the program; (3) solidifying the CoE status. This framework can likely be translated to any disease or procedure-specific service-line and facilitate the development of a successful CoE.
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Elmunzer BJ, Walsh CM, Guiton G, Serrano J, Chak A, Edmundowicz S, Kwon RS, Mullady D, Papachristou GI, Elta G, Baron TH, Yachimski P, Fogel E, Draganov PV, Taylor J, Scheiman J, Singh V, Varadarajulu S, Willingham FF, Cote G, Cotton PB, Simon V, Spitzer R, Keswani R, Wani S. Development and initial validation of an instrument for video-based assessment of technical skill in ERCP. Gastrointest Endosc 2021; 93:914-923. [PMID: 32739484 PMCID: PMC8961206 DOI: 10.1016/j.gie.2020.07.055] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 07/24/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The accurate measurement of technical skill in ERCP is essential for endoscopic training, quality assurance, and coaching of this procedure. Hypothesizing that technical skill can be measured by analysis of ERCP videos, we aimed to develop and validate a video-based ERCP skill assessment tool. METHODS Based on review of procedural videos, the task of ERCP was deconstructed into its basic components by an expert panel that developed an initial version of the Bethesda ERCP Skill Assessment Tool (BESAT). Subsequently, 2 modified Delphi panels and 3 validation exercises were conducted with the goal of iteratively refining the tool. Fully crossed generalizability studies investigated the contributions of assessors, ERCP performance, and technical elements to reliability. RESULTS Twenty-nine technical elements were initially generated from task deconstruction. Ultimately, after iterative refinement, the tool comprised 6 technical elements and 11 subelements. The developmental process achieved consistent improvements in the performance characteristics of the tool with every iteration. For the most recent version of the tool, BESAT-v4, the generalizability coefficient (a reliability index) was .67. Most variance in BESAT scores (43.55%) was attributed to differences in endoscopists' skill, indicating that the tool can reliably differentiate between endoscopists based on video analysis. CONCLUSIONS Video-based assessment of ERCP skill appears to be feasible with a novel instrument that demonstrates favorable validity evidence. Future steps include determining whether the tool can discriminate between endoscopists of varying experience levels and predict important outcomes in clinical practice.
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Affiliation(s)
- B. Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC, USA
| | - Catharine M Walsh
- Division of Gastroenterology, Hepatology, and Nutrition, Learning Institute and Research Institute, Hospital for Sick Children, Toronto, Canada
| | - Gretchen Guiton
- Department of Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jose Serrano
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Amitabh Chak
- Division of Gastroenterology and Liver Disease, Case Western Reserve University, Cleveland, OH, USA
| | - Steven Edmundowicz
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Richard S. Kwon
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Daniel Mullady
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Georgios I. Papachristou
- Division of Gastroenterology, Hepatology, and Nutrition, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Grace Elta
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Todd H. Baron
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
| | - Patrick Yachimski
- Division of Gastroenterology, Vanderbilt University, Nashville, TN, USA
| | - Evan Fogel
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | - Peter V. Draganov
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, FL, USA
| | - Jason Taylor
- Division of Gastroenterology and Hepatology, Saint Louis University, Saint Louis, MO, USA
| | - James Scheiman
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
| | - Vikesh Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | | | | | - Gregory Cote
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC, USA
| | - Peter B. Cotton
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC, USA
| | - Violette Simon
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Rebecca Spitzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC, USA
| | - Rajesh Keswani
- Division of Gastroenterology, Northwestern University, Chicago, IL, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Forbes N, Koury HF, Bass S, Cole M, Mohamed R, Turbide C, Gonzalez-Moreno E, Kayal A, Chau M, Lethebe BC, Hilsden RJ, Heitman SJ. Characteristics and Outcomes of ERCP at a Canadian Tertiary Centre: Initial Results from a Prospective High-Fidelity Biliary Endoscopy Registry. J Can Assoc Gastroenterol 2021; 4:78-83. [PMID: 33855265 PMCID: PMC8023809 DOI: 10.1093/jcag/gwaa007] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 02/06/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is an essential procedure in the management of pancreatic and biliary disease. While its role is firmly established, further well-designed prospective ERCP research is required, as a large portion of previous work has employed retrospective or administrative methodologies, both prone to potential biases. The aim of the Calgary Registry for Advanced and Therapeutic Endoscopy (CReATE) is to be a high-fidelity prospective multicentre registry. METHODS The study population consisted of consecutive adult ERCP patients from September 2018 to September 2019. Informed consent was acquired for each patient. All relevant preprocedural, procedural, peri-procedural and postprocedural data were captured in real time by a full-time third-party research assistant directly observing procedures. Outcomes were ascertained by comprehensive medical record review and patient phone interview 30 days after the index procedure. RESULTS Five endoscopists performed 895 ERCP procedures, 90.1% of which were deemed successful. Suspected choledocholithiasis was the most common indication for ERCP, followed by suspected or confirmed stricture(s), at 61.0% and 29.5%, respectively. 61.0% of procedures were performed on ERCP-naive patients. Post-ERCP pancreatitis occurred following 4.9% of procedures, with clinically significant bleeding or perforation occurring following 1.8% and 0.1% of procedures, respectively. DISCUSSION Through 12 months, CReATE captured 895 procedures prospectively, with each entry containing over 300 data fields. Active expansion to additional tertiary centres is underway, and this will enhance the existing data pool. CReATE has the potential to improve multiple facets of ERCP, including training, optimal procedural techniques, mitigation of adverse events and personalized patient care.
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Affiliation(s)
- Nauzer Forbes
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Hannah F Koury
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sydney Bass
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Martin Cole
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Rachid Mohamed
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Christian Turbide
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Emmanuel Gonzalez-Moreno
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Ahmed Kayal
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Millie Chau
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - B Cord Lethebe
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robert J Hilsden
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Steven J Heitman
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Mutneja HR, Vohra I, Go A, Bhurwal A, Katiyar V, Palomera Tejeda E, Thapa Chhetri K, Baig MA, Arora S, Attar B. Temporal trends and mortality of post-ERCP pancreatitis in the United States: a nationwide analysis. Endoscopy 2021; 53:357-366. [PMID: 32668463 DOI: 10.1055/a-1220-2242] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND : Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is the most common and most serious complication of ERCP. Our aim was to estimate the nationwide incidence, temporal trends, and mortality of PEP in the United States and to establish risk factors associated with PEP development. METHODS : This was a retrospective cohort study analyzing Nationwide Inpatient Sample data from 2011 to 2017 using International Classification of Diseases codes. The primary outcomes were trends in PEP incidence and predictors of PEP development. Secondary outcomes were in-hospital mortality, length of hospital stay, and admission to the intensive care unit. RESULTS : Of 1 222 467 adult patients who underwent inpatient ERCP during the study period, 55 225 (4.5 %) developed PEP. The hospital admission rate of PEP increased by 15.3 %, from 7735 in 2011 to 8920 in 2017 (odds ratio [OR] 1.23, 95 % confidence interval [CI] 1.04 - 1.46; P = 0.02). The overall rate of mortality increased from 2.8 % of PEP cases in 2011 to 4.4 % in 2017 (OR 1.62, 95 %CI 1.10 - 2.38; P = 0.01). Multiple patient-related (alcohol use, cocaine use, obesity, chronic kidney disease, heart failure), procedure-related (therapeutic ERCP, sphincterotomy, pancreatic duct stent placement, sphincter of Oddi dysfunction), and hospital-related (teaching hospitals, hospitals located in the West and Midwest) factors that impact the occurrence of PEP were identified. CONCLUSIONS : Our study showed rising hospital admission and mortality rates associated with PEP in the United States. This calls for a greater recognition of this life-threatening complication and amelioration of its risk factors, whenever possible.
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Affiliation(s)
- Hemant Raj Mutneja
- Gastroenterology, Cook County Health and Hospitals System, Chicago, Illinois, United States
| | - Ishaan Vohra
- Gastroenterology, Cook County Health and Hospitals System, Chicago, Illinois, United States
| | - Andrew Go
- Medicine, Loyola University Medical Center, Chicago, Illinois, United States
| | - Abhishek Bhurwal
- Gastroenterology, Robert Wood Johnson University Hospital, Chicago, Illinois, United States
| | - Vatsala Katiyar
- Medicine, John H. Stroger Hospital of Cook County, Chicago, Illinois, United States
| | | | - Kapil Thapa Chhetri
- Medicine, John H. Stroger Hospital of Cook County, Chicago, Illinois, United States
| | - Muhammad Arslan Baig
- Gastroenterology, University of Illinois College of Medicine, Peoria, Illinois, United States
| | - Shilpa Arora
- Medicine, Rush University Medical Center, Chicago, Illinois, United States
| | - Bashar Attar
- Gastroenterology and Hepatology, John H. Stroger Hospital of Cook County, Chicago, Illinois, United States
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50
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Bill JG, Ryou M, Hathorn KE, Cortes P, Maple JT, Al-Shahrani A, Lang G, Mullady DK, Das K, Cosgrove N, Salameh H, Kumta NA, DiMaio CJ, Zia H, Orr J, Yachimski P, Kushnir VM. Endoscopic ultrasound-guided biliary drainage in benign biliary pathology with normal foregut anatomy: a multicenter study. Surg Endosc 2021; 36:1362-1368. [PMID: 33712939 DOI: 10.1007/s00464-021-08418-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 02/23/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND AIMS Biliary drainage using endoscopic ultrasound (EUS-BD) has been developed as a novel technique to obtain biliary access and drainage when ERCP fails. Numerous studies have demonstrated its safety and efficacy specifically pertaining to those with malignant distal biliary obstruction or altered foregut anatomy. The aim of this study is to evaluate the safety and efficacy of EUS-BD in benign indications in patients with normal foregut anatomy. METHODS We performed a retrospective comparative study from 5 academic medical centers (2008-2018) involving patients with benign biliary obstruction and native foregut anatomy who had an initial failed ERCP with subsequent attempt at biliary decompression via EUS-BD or by repeating ERCP. RESULTS 36 patients (mean age 61.6 ± 2.2, 38.9% female) who underwent attempted EUS-BD following initial failed ERCP were compared to 50 patients (mean age 62.7 ± 2.3, 73.5% female) who underwent repeat ERCP following an initial failed cannulation. EUS-BD was technically successful in 28 (77.8%) patients with rendezvous being the most common approach (86.1%). A higher level of pre-procedural bilirubin was found to be associated with technical success of EUS-BD (3.65 ± 0.63 versus 1.1 ± 0.4, p value 0.04). Success of repeat ERCP following failed cannulation was 86%. Adverse events were significantly more frequent in the EUS-BD cohort when compared to the repeat ERCP (10 (27.8%) versus 4 (8.0%), p = 0.02, OR 4.32. CONCLUSIONS EUS-BD remains a viable therapeutic option in the setting of benign biliary disease, with success rates of 77.8%. Adverse events were significantly more common with EUS-BD vs. repeat ERCP, emphasizing the need to perform in expert centers with appropriate multidisciplinary support and to strongly consider the urgency of biliary decompression before considering same session EUS-BD after failed initial biliary access.
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Affiliation(s)
- Jason G Bill
- Division of Gastroenterology, Washington University in Saint Louis, Saint Louis, USA.
- University of Illinois College of Medicine - Peoria, 5105 North Glen Park Place, Peoria, IL, 61614, USA.
| | - Marvin Ryou
- Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Kelly E Hathorn
- Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Pedro Cortes
- Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | | | - Abdullah Al-Shahrani
- Division of Gastroenterology, Washington University in Saint Louis, Saint Louis, USA
| | - Gabriel Lang
- Division of Gastroenterology, Washington University in Saint Louis, Saint Louis, USA
| | - Daniel K Mullady
- Division of Gastroenterology, Washington University in Saint Louis, Saint Louis, USA
| | - Koushik Das
- Division of Gastroenterology, Washington University in Saint Louis, Saint Louis, USA
| | - Natalie Cosgrove
- Division of Gastroenterology, Washington University in Saint Louis, Saint Louis, USA
| | | | | | | | | | | | | | - Vladimir M Kushnir
- Division of Gastroenterology, Washington University in Saint Louis, Saint Louis, USA
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