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Rashtak S, Goyal H, Chandran A, Dedania B, Patil P, Wadhwa V, Guha S, Davee T, Ramireddy S, Thosani N. Practice patterns and adherence to society guidelines for suspected choledocholithiasis: A comparison of academic and community settings from a large US healthcare system. Front Med (Lausanne) 2022; 9:1000368. [DOI: 10.3389/fmed.2022.1000368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 10/05/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThe American Society of Gastrointestinal Endoscopy (ASGE) has proposed practice guidelines for evaluating patients with suspected choledocholithiasis. This study aims to assess and compare practice patterns for following ASGE guidelines for choledocholithiasis in a large academic vs. community hospital setting.MethodsA total of one thousand ER indicated for choledocholithiasis were randomly selected. Patients’ demographics, total bilirubin, imaging studies including magnetic resonance cholangiopancreatography (MRCP), intraoperative cholangiogram (IOC), endoscopic ultrasound (EUS), and ERCP results were retrospectively collected. Patients with prior sphincterotomy were excluded. We examined the following practice deviations from the current ASGE guidelines; (1) ERCP was potentially delayed in high probability cases while awaiting additional imaging studies, (2) ERCP was performed without additional imaging studies in cases of low/intermediate-risk, or (3) ERCP was performed in low/intermediate-risk cases when additional imaging studies were negative.ResultsA total of 640 patients with native papilla who underwent ERCP were included in the final analysis. Overall, the management of 43% (275) of patients was deviated from the applicable ASGE guidelines. Academic and community provider rates of non-adherence were 32 vs. 45%, respectively (p-value: < 0.01). Of 381 high-risk cases, 54.1% had additional imaging before ERCP. (Academic vs. community; 11.7 vs. 88.3%, p-value: < 0.01). In 26.7% (69/258) of low/intermediate risk cases, ERCP was performed without additional studies; academic (14.5%) vs. community (85.5%) (p-value: < 0.01). Finally, in 11.2% (19/170) of patients, ERCP was performed despite intermediate/low probability and negative imaging; academic (26.3%) vs. community (73.7%) (p-value: 0.02).ConclusionOur study results show that providers do not adhere to ASGE practice guidelines in 43% of suspected choledocholithiasis cases. The rate of non-adherence was significantly higher in community settings. It could be due to various reasons, including lack/delays for alternate studies (i.e., MRCP, EUS), concern regarding the length of stay, patient preference, or lack of awareness/understanding of the guidelines. Increased availability of alternate imaging and educational strategies may be needed to increase the adoption of practice guidelines across academic and community settings to improve patient outcomes and save healthcare dollars.
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Dietrich CF, Bekkali NL, Burmeister S, Dong Y, Everett SM, Hocke M, Ignee A, On W, Hebbar S, Oppong K, Sun S, Jenssen C, Braden B. Controversies in ERCP: Indications and preparation. Endosc Ultrasound 2021; 11:186-200. [PMID: 34677145 PMCID: PMC9258020 DOI: 10.4103/eus-d-21-00106] [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] [Indexed: 11/29/2022] Open
Abstract
The aim of the series of papers on controversies of biliopancreatic drainage procedures is to discuss the pros and cons of the varying clinical practices and techniques in ERCP and EUS for drainage of biliary and pancreatic ducts. The first part focuses on indications, clinical and imaging prerequisites before ERCP, sedation options, post-ERCP pancreatitis (PEP) prophylaxis, and other related technical topics. In the second part, specific procedural ERCP-techniques including precut techniques and its timing as well as management algorithms are discussed. In addition, controversies in EUS-guided bile duct and pancreatic drainage procedures are under preparation.
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Affiliation(s)
- Christoph F Dietrich
- Department of Ultrasound, The First Affiliated Hospital of Zhengzhou University, China; Johann Wolfgang Goethe University, Frankfurt/Main, Germany; Department of Allgemeine Innere Medizin, Kliniken Hirslanden Beau Site, Salem und Permanence, Bern, Switzerland
| | - Noor L Bekkali
- Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Sean Burmeister
- Surgical Gastroenterology Unit, Groote Schuur Hospital, Cape Town, South Africa
| | - Yi Dong
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | | | - Michael Hocke
- Medical Department, Helios Klinikum Meiningen, Meiningen, Germany
| | - Andre Ignee
- Medical Department 2, Caritas-Krankenhaus, Uhlandstr 7, D-97980 Bad Mergentheim, Germany
| | - Wei On
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Srisha Hebbar
- University Hospitals of North Midlands, North Midlands, United Kingdom
| | - Kofi Oppong
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Siyu Sun
- Endoscopy Center, Sheng Jing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Christian Jenssen
- Department of Internal Medicine, Krankenhaus Markisch-Oderland, Strausberg; Brandenburg Institute for Clinical Ultrasound at Medical University Brandenburg, Neuruppin, Germany
| | - Barbara Braden
- Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom; Johann Wolfgang Goethe University, Frankfurt/Main, Germany
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Kourounis G, Gall LS, McArthur D, Gibson S, Glen P. Choledocholithiasis: Long-term follow-up in patients without stone clearance at first endoscopic retrograde cholangiopancreatography. J Dig Dis 2021; 22:551-556. [PMID: 34405551 DOI: 10.1111/1751-2980.13043] [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: 03/02/2021] [Revised: 06/20/2021] [Accepted: 08/15/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Complete clearance during endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis is not always successful and biliary stenting is commonplace. Strategies vary between temporary stent placement (TSP) with interval ERCP or permanent stent placement (PSP) and watchful waiting for recurrent biliary obstruction (RBO). This study aimed to describe outcomes in these two groups and stent patency rates in PSP. METHODS Patients with incomplete clearance at first ERCP for choledocholithiasis between May 2015 and December 2018 were identified. Clinical outcomes were obtained by retrospective interrogation of the case notes. Median follow-up duration was 41 months (interquartile range 29-51 mo). RESULTS Of 1263 index ERCP, 199 (15.8%) had no stone clearance, with 53.3% receiving PSP and 46.7% undergoing TSP. The TSP group had repeat ERCP after a median of 8 weeks; 75.3% had clearance on a repeat ERCP. The PSP group was elder than the TSP group (82 y vs 72 y, P < 0.001). The rates of RBO (32.1% vs 16.1%) and emergency readmissions (32.1% vs 19.4%) were higher in the PSP group (both P < 0.05). More patients died without further biliary disease in the PSP group (39.6% vs 12.9%, P = 0.001). PSP stent patency rates at 6, 12, 24, 36, and 61 months were 87.7%, 82.1%, 75.5%, 69.8% and 67.9%, respectively. CONCLUSIONS Though PSP had higher RBO and emergency readmissions, two-thirds of patients either died or survived without recurrent biliary disease. Stent patency decreased fastest in the first 12 months. Criteria to guide decision-making for biliary stenting remain unclear.
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Affiliation(s)
- Georgios Kourounis
- Department of General Surgery, Queen Elizabeth University Hospital, Glasgow, UK.,Faculty of Medicine, University of Glasgow, Glasgow, UK
| | - Lewis S Gall
- Department of General Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Donald McArthur
- Department of General Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Simon Gibson
- Department of General Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Paul Glen
- Department of General Surgery, Queen Elizabeth University Hospital, Glasgow, UK.,Faculty of Medicine, University of Glasgow, Glasgow, UK
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Jayakody H, Knight M. Implementation assessment in confidential enquiry programmes: A scoping review. Paediatr Perinat Epidemiol 2020; 34:399-407. [PMID: 31846103 PMCID: PMC7383863 DOI: 10.1111/ppe.12604] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 09/08/2019] [Accepted: 09/17/2019] [Indexed: 01/30/2023]
Abstract
BACKGROUND Response should be a key part of maternal death surveillance and response (MDSR) programmes, which include confidential enquiries into maternal deaths. The programmes investigate avoidable factors in maternal deaths and make recommendations for improving maternity care. There is a gap in information on how these recommendations are transformed into practice. OBJECTIVE To explore the methods used to assess the implementation status of recommendations made in confidential enquiries into maternal deaths and other health outcomes. DATA SOURCES We searched PubMed, Web of Science, CINAHL, and Google Scholar databases and general web for grey literature using the "Arksey and O'Malley framework" in all major scientific databases and search engines. STUDY SELECTION AND DATA EXTRACTION An initial screening was followed by extraction of information using a data chart. Variables in the chart were based on the response component of maternal death and surveillance systems. SYNTHESIS Information collected was summarised using content analysis method. RESULTS We reviewed 13 confidential enquiry systems into maternal deaths. Many confidential enquiries into maternal deaths published reports with their recommendations and dissemination often involved national-level scientific presentations. Only five reports provided strategies for implementing the recommendations. Follow-up of previous recommendations was routinely published in only two reports. However, impact assessment of recommendations on other health outcomes was found only in the UK. CONCLUSION There is a gap in monitoring the response generated by confidential enquiries into maternal deaths. Actions to develop this are therefore needed.
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Affiliation(s)
- Hemali Jayakody
- National Perinatal Epidemiology UnitUniversity of OxfordOxfordUK
| | - Marian Knight
- National Perinatal Epidemiology UnitUniversity of OxfordOxfordUK
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Tarikci Kilic E, Kahraman R, Ozdil K. Evaluation of Safety and Outcomes of Endoscopic Retrograde Cholangiopancreatography in 1337 Patients at a Single Center. Medeni Med J 2019; 34:290-296. [PMID: 32821451 PMCID: PMC7433733 DOI: 10.5222/mmj.2019.58265] [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: 04/04/2019] [Accepted: 06/15/2019] [Indexed: 11/16/2022] Open
Abstract
Objective: Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard treatment for pancreaticobiliary diseases. The aim of this study was to evaluate the safety and review the outcomes of our experience of ERCP over the past 4 years. Method: The clinical records of patients aged 18-104 years who underwent ERCP at our gastroenterology clinic between 2014 and 2018 were included in the study. Data were acquired from the hospital archive system. Results: A total of 1337 patients with a mean age of 60.58±17.96 years. including 775 female, and 562 male cases were included in the study. The patients were in the age groups of 18-30 (n=39), 30-65 (n=694), 65-75 (n=274), 75-85 (n=258), and > 85 (n=72) years. Among them, 28.27% were rated as ASA III-IV on the American Society of Anesthesiologists scale. Although biliary cannulation with standard sphincterotomy was successful in 1303 (97.45%), patients it could not be performed in 34 (2.55%). patients Precut papillotomy was performed in 27 (79.41%) of 34 patients. Furthermore, no complication was observed in 1207 patients (90.27%), whereas 96 patients (7.18%) had minor and major procedure-related and anesthesia-related complications. The 30-day mortality rate was 1.64% (n=22). Conclusion: We concluded that ERCP, which is currently performed entirely for therapeutic purposes, is safe and lifesaving, with high clinical success rates.
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Affiliation(s)
- Ebru Tarikci Kilic
- Health Sciences University Ümraniye Training and Research Hospital, Department of Anesthesiology and Reanimation, Istanbul, Turkey
| | - Resul Kahraman
- Health Sciences University Ümraniye Training and Research Hospital, Department of Gastroenterology, Istanbul, Turkey
| | - Kamil Ozdil
- Health Sciences University Ümraniye Training and Research Hospital, Department of Gastroenterology, Istanbul, Turkey
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Siau K, Green JT, Hawkes ND, Broughton R, Feeney M, Dunckley P, Barton JR, Stebbing J, Thomas-Gibson S. Impact of the Joint Advisory Group on Gastrointestinal Endoscopy (JAG) on endoscopy services in the UK and beyond. Frontline Gastroenterol 2019; 10:93-106. [PMID: 31210174 PMCID: PMC6540274 DOI: 10.1136/flgastro-2018-100969] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 09/18/2018] [Accepted: 09/24/2018] [Indexed: 02/04/2023] Open
Abstract
The Joint Advisory Group on Gastrointestinal Endoscopy (JAG) was initially established in 1994 to standardise endoscopy training across specialties. Over the last two decades, the position of JAG has evolved to meet its current role of quality assuring all aspects of endoscopy in the UK to provide the highest quality, patient-centred care. Drivers such as changes to healthcare agenda, national audits, advances in research and technology and the advent of population-based cancer screening have underpinned this shift in priority. Over this period, JAG has spearheaded various quality assurance initiatives with support from national stakeholders. These have led to the achievement of notable milestones in endoscopy quality assurance, particularly in the three major areas of: (1) endoscopy training, (2) accreditation of endoscopy services (including the Global Rating Scale), and (3) accreditation of screening endoscopists. These developments have changed the landscape of UK practice, serving as a model to promote excellence in endoscopy. This review provides a summary of JAG initiatives and assesses the impact of JAG on training and endoscopy services within the UK and beyond.
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Affiliation(s)
- Keith Siau
- Endoscopy Unit, Dudley Group NHS Foundation Trust, Dudley, UK
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - John T Green
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Department of Gastroenterology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Neil D Hawkes
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Department of Gastroenterology, Cwm Taf University Health Board, Llantrisant, UK
| | - Raphael Broughton
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
| | - Mark Feeney
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Department of Gastroenterology, South Devon Healthcare NHS Foundation Trust, Torquay, UK
| | - Paul Dunckley
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Department of Gastroenterology, Gloucestershire Royal Hospital, Gloucester, UK
| | - John Roger Barton
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Newcastle University Medicine Malaysia, Nusajaya, Johor, Malaysia
| | - John Stebbing
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Department of GI Surgery, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Siwan Thomas-Gibson
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Wolfson Unit for Endoscopy, St Marks Hospital, Harrow, UK
- Imperial College London, London, UK
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Martin JA. Incisionless stone extraction 2.0: clever, but costly. Gastrointest Endosc 2015; 82:724-7. [PMID: 26385280 DOI: 10.1016/j.gie.2015.06.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 06/17/2015] [Indexed: 12/11/2022]
Affiliation(s)
- John A Martin
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Sheppard DP, Craddock SJ, Warner BD, Wilkinson ML. ERCP cannulation success benchmarking: implications for certification and validation. Frontline Gastroenterol 2015; 6:141-146. [PMID: 28839801 PMCID: PMC5369611 DOI: 10.1136/flgastro-2014-100473] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 08/22/2014] [Accepted: 08/27/2014] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Investigate success rates of cannulating a 'virgin' papilla during endoscopic retrograde cholangiopancreatography (ERCP) at a tertiary referral centre; determine reasons for failure and propose learnings for consideration in future revision of success benchmarking. DESIGN Review of all ERCPs recorded on Endosoft database from 2006 to 2012 (n=1862). Specifically, 'virgin' papillae, defined as those with no evidence of prior surgical intervention, stents in situ or sphincterotomy (n=947). Virgin papillae present the most challenging target for endoscopists. SETTING Gastroenterology department, St Thomas' Hospital, London. PATIENTS All patients who underwent an ERCP recorded on Endosoft from 2006 to 2012 (n=1134). A proportion of these patients underwent repeat procedures, all considered virgin provided the aforementioned criteria were met. INTERVENTIONS None, retrospective audit and benchmarking exercise. MAIN OUTCOME MEASURES Determine criteria for successful cannulation of a virgin papilla. RESULTS Overall success of cannulation of a virgin papilla at ERCP was 79.5%, 753 out of a total of 947 virgin papillae cases. Per patient with a virgin papilla, the success rate was 79.7%, 693 out of 869. Eliminating cases with features complicating cannulation increased success rates to 86% and 87%, respectively. Chronic pancreatitis was the single Indication associated with a failed cannulation (OR=3.9, CI 2.1 to 7.1), while biliary stones were significantly associated with a successful cannulation (OR=0.3, CI 0.2 to 0.4). Reasons for failure included patient agitation (OR=27.1, CI 7.9 to 92.7), duodenal stricturing (OR=12.5, CI 5.5 to 28.5), previous anatomy-changing surgery (OR=12.2, CI 3.3 to 45.4), tumour impingement (OR=9.5, CI 4.1 to 22.3) and equipment failure (OR=7.9, CI 1.4=43.5). CONCLUSIONS The Joint Advisory Group's 80% success rate for completion of therapeutic intent must be viewed in light of published difficulty rating scales, if fair comparisons and standards are to be met. This highlights the need for standardised success criterion for ERCP training and accreditation.
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Affiliation(s)
- D P Sheppard
- King's College London Medical School, London, UK
| | - S J Craddock
- King's College London Medical School, London, UK
| | - B D Warner
- Department of Gastroenterology, Guy's and St Thomas’ NHS Foundation Trust, London, UK
| | - M L Wilkinson
- Department of Gastroenterology, Guy's and St Thomas’ NHS Foundation Trust, London, UK,King's College London, London, UK
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Steed H, Lau K, Glass R, Durkin D, Deakin M, Green JRB. Biliary boulders. Frontline Gastroenterol 2014; 5:161-166. [PMID: 28839765 PMCID: PMC5369731 DOI: 10.1136/flgastro-2013-100391] [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: 09/18/2013] [Revised: 11/22/2013] [Accepted: 12/10/2013] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To examine the outcome of endoscopic retrograde cholangiopancreatography (ERCP) in the management of common bile duct (CBD) stones. DESIGN A retrospective review of 100 consecutive ERCPs performed for CBD stones. RESULTS 100 ERCPs were performed on 84 patients with a median cohort age of 77. Completion in this cohort, as defined by duct clearance, was achieved in 65% of cases. Completion rates fell rapidly after two ERCPs. 33% of the cohort had small stones <10 mm, and 67% had stones >10 mm. Size, but not number of stones, affected the completion rate and frequency of complications (16%). Presence of periampullary diverticulum did not affect completion or complication rates. MR cholangiopancreatography (MRCP) had a 90% sensitivity for detecting CBD stones compared with 56% for CT. DISCUSSION AND CONCLUSIONS ERCP remains a high-risk procedure with a significant complication rate when performed to deal with CBD stones. MRCP should be the second choice of investigation for CBD stones. This cohort had an unusually high number of larger stones at ERCP of 67% compared with other published UK cohorts of 8%, and this was reflected in the completion and complication rate.
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Affiliation(s)
- H Steed
- Department of Gastroenterology, University Hospital North Staffordshire, Stoke-on-Trent, Staffordshire, UK
| | - K Lau
- Department of Gastroenterology, University Hospital North Staffordshire, Stoke-on-Trent, Staffordshire, UK
| | - R Glass
- Department of Gastroenterology, University Hospital North Staffordshire, Stoke-on-Trent, Staffordshire, UK
| | - D Durkin
- Department of Hepatobiliary Surgery, University Hospital North Staffordshire, Stoke-on-Trent, Staffordshire, UK
| | - M Deakin
- Department of Hepatobiliary Surgery, University Hospital North Staffordshire, Stoke-on-Trent, Staffordshire, UK
| | - J R B Green
- Department of Gastroenterology, University Hospital North Staffordshire, Stoke-on-Trent, Staffordshire, UK
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Rajasekhar P, Rees C, Rutter M, Hungin P. Developing a clinical research network: the Northern Region Endoscopy Group experience. Clin Med (Lond) 2014; 14:107-12. [PMID: 24715118 PMCID: PMC4953278 DOI: 10.7861/clinmedicine.14-2-107] [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] [Indexed: 11/27/2022]
Abstract
Research is central to the National Health Service. Clinical trial recruitment has been aided by the National Institute for Health Research's Comprehensive Research Network but these networks do not support development of research. The Northern Region Endoscopy Group (NREG) was founded in 2007, encompasses 17 endoscopy units and has become a highly successful collaborative research network. The network is now a major contributor to UK trials, has published over 20 papers (>60 abstracts) and holds grants totalling more than £1.5 million. The NREG provides an exemplar model of how collaborative working can contribute significantly to biomedical research.
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Affiliation(s)
- Praveen Rajasekhar
- Gastroenterology, South Tyneside District Hospital, South Tyneside NHS Foundation Trust, Tyne and Wear, UK, The Northern Region Endoscopy Group, South Shields, UK and School of Medicine, Pharmacy and Health, Durham University, Stockton-on-Tees, UK
| | - Colin Rees
- Gastroenterology, South Tyneside District Hospital, South Tyneside NHS Foundation Trust, Tyne and Wear, UK and The Northern Region Endoscopy Group, South Shields, UK and School of Medicine, Pharmacy and Health, Durham University, Stockton-on-Tees, UK
| | - Matthew Rutter
- Gastroenterology, University Hospital North Tees, Stockton-on-Tees, UK, The Northern Region Endoscopy Group, South Shields, UK and School of Medicine, Pharmacy and Health, Durham University, Stockton-on-Tees, UK
| | - Pali Hungin
- School of Medicine, Pharmacy and Health, Durham University, Stockton-on-Tees, UK and The Northern Region Endoscopy Group, South Shields, UK
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DeBenedet AT, Elmunzer BJ, McCarthy ST, Elta GH, Schoenfeld PS. Intraprocedural quality in endoscopic retrograde cholangiopancreatography: a meta-analysis. Am J Gastroenterol 2013; 108:1696-704; quiz 1705. [PMID: 23877349 PMCID: PMC3840532 DOI: 10.1038/ajg.2013.217] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Accepted: 06/10/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVES In 2006, the American College of Gastroenterology (ACG)/the American Society for Gastrointestinal Endoscopy (ASGE) Taskforce on Quality in Endoscopy published quality indicators for the major gastrointestinal procedures. Our primary aim was to use the published literature to assess current endoscopic retrograde cholangiopancreatography (ERCP) intraprocedural performance and compare it to the targets set by the ACG/ASGE taskforce. Our secondary aim was to determine whether performance varies across different health-care settings (academic and community), study designs (prospective and retrospective), and trainee participation. METHODS A PubMed and EMBASE literature search from 1/1/2006 to 2/1/2013 was conducted. Articles were selected based on title, abstract, full text, and reporting of success rates for the intraprocedural quality indicators. Success rates, represented as numerical proportions, were collected from each study. For each success rate, a standard error and a 95% confidence interval (CI) was calculated. A random-effects meta-analysis model was used to weight each study, and a cumulative, weighted success rate (or effect size) for each indicator was determined. Random-effects meta-regression was then used to examine the impact of study setting, design, and trainee involvement on each quality indicator. RESULTS A total of 8,005 articles were initially retrieved. Following the application of predefined criteria, 52 articles remained. The cumulative, weighted bile duct cannulation success rate was 89.3% (95% CI 0.866-0.919); pancreatic duct cannulation was 85.0% (95% CI 0.813-0.886); precut utilization rate was 10.5% (95% CI 0.087-0.123); common bile duct stone extraction rate was 88.3% (95% CI 0.825-0.941); and the rate of successful biliary stenting below the common bile duct bifurcation was 97.5% (95% CI 0.967-0.984). Subgroup analysis with meta-regression showed no statistically significant differences between academic and community settings, prospective and retrospective study designs, and trainee participation on success across bile duct cannulation, precut utilization, and common bile duct stone extraction (insufficient observations/variance for pancreatic duct cannulation and biliary stent placement). CONCLUSIONS ERCP intraprocedural quality is in good standing. On the basis of this analysis, the two targets that could be potentially revised are precut utilization and biliary stenting. This analysis was confined to the published literature and therefore, in general, reflects the ERCP performance of institutions, primarily academic, that are conducting clinical research. Thus, it is difficult to generalize this performance assessment to the broader ERCP community as a whole.
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Affiliation(s)
- Anthony T. DeBenedet
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - B. Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Sean T. McCarthy
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Grace H. Elta
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Philip S. Schoenfeld
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
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Muller AF. Endoscopic retrograde cholangiopancreatography: is the centre better? The case against centralisation of ERCP services. Frontline Gastroenterol 2013; 4:210-212. [PMID: 23795285 PMCID: PMC3686311 DOI: 10.1136/flgastro-2012-100182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2012] [Revised: 09/27/2012] [Accepted: 10/23/2012] [Indexed: 02/04/2023] Open
Abstract
More than 48 000 endoscopic retrograde cholangiopancreatographies (ERCP) are performed in the UK per annum; the majority within district general hospitals. The proposal for centralisation of ERCP services is based on evidence that technical success, length of stay and complication rates are related to the numbers of procedures performed. Local units wishing to continue their ERCP practice, must demonstrate that they are performing sufficient numbers of procedures in a safe, timely and competent fashion.
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Slattery E, Kale V, Anwar W, Courtney G, Aftab AR. Role of long-term biliary stenting in choledocholithiasis. Dig Endosc 2013; 25:440-3. [PMID: 23808949 DOI: 10.1111/j.1443-1661.2012.01399.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Accepted: 09/11/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Endoscopic retrograde cholangiopancreatography (ERCP) is the treatment of choice for the management of choledocholithiasis. Biliary stenting facilitates repeated attempts at stone extraction. The aim of the present paper was to assess long-term outcomes of patients where biliary stenting was used as the primary treatment for the management of choledocholithiasis. METHODS We undertook a review of a prospectively maintained database of all ERCP carried out at a single institution. All patients had stones not amenable to endoscopic retrieval. RESULTS Between January 1998 and December 2008, 3655 ERCP were carried out in our unit. Of these, 201 (120 female) patients met our inclusion criteria. All patients underwent ERCP and sphincterotomy, followed by insertion of a double pigtail 7-Fr plastic stent. Repeat ERCP was not scheduled routinely. Stent change was only carried out in patients when clinical suspicion of stent blockage occurred. Median stent patency was 59.6 months (interquartile range 47.7-71.2). At 6 months, stent patency was 93.5%, and at 24 months, it was 81.9%. Serious adverse outcomes with blocked stents were uncommon, and tended to occur early. Cholangitis was seen in only 7.4% (6) of patients (median stent patency 11.8 months) and jaundice was seen in 18.5% (15 patients, median stent patency 7.2 months). CONCLUSION Our data demonstrate median stent patency of almost 5 years. The low incidence of significant complications with blocked stents and excellent stent patency rates suggest that long-term biliary stenting is an acceptable alternative in elderly, frail patients with stones that are not endoscopically retrievable.
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Affiliation(s)
- Eoin Slattery
- Department of Gastroenterology, St Luke's Hospital, Kilkenny, Ireland.
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Epelboym I, Winner M, Allendorf JD. MRCP is not a cost-effective strategy in the management of silent common bile duct stones. J Gastrointest Surg 2013; 17:863-71. [PMID: 23515912 DOI: 10.1007/s11605-013-2179-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Accepted: 03/01/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Few formal cost-effectiveness analyses simultaneously evaluate radiographic, endoscopic, and surgical approaches to the management of choledocholithiasis. STUDY DESIGN Using the decision analytic software TreeAge, we modeled the initial clinical management of a patient presenting with symptomatic cholelithiasis without overt signs of choledocholithiasis. In this base case, we assumed a 10 % probability of concurrent asymptomatic choledocholithiasis. Our model evaluated four diagnostic/therapeutic strategies: universal magnetic resonance cholangiopancreatography (MRCP), universal endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic cholecystectomy (LC), or laparoscopic cholecystectomy with universal intraoperative cholangiogram (LCIOC). All probabilities were estimated from a review of published literature. Procedure and intervention costs were equated with Medicare reimbursements. Costs of hospitalizations were derived from median hospitalization reimbursement for New York State using diagnosis-related groups (DRG). Sensitivity analyses were performed on all cost and probability variables. RESULTS The most cost-effective strategy in the diagnosis and management of symptomatic cholelithiasis with a 10 % risk of asymptomatic choledocholithiasis was LCIOC. This was followed by LC alone, MRCP, and ERCP. LC was preferred only when the probability that a retained CBD stone would eventually become symptomatic fell below 15 % or if the probability of technical success of an intraoperative cholangiogram (IOC) was less than 35 %. Universal MRCP and ERCP were both more costly and less effective than surgical strategies, even at a high probability of asymptomatic choledocholithiasis. Within the tested range for both procedural and hospitalization-related costs for any of the surgical or endoscopic interventions, LCIOC and LC were always more cost-effective than universal MRCP or ERCP, irrespective of the presence or absence of complications. Varying the cost, sensitivity, and specificity of MRCP had no effect on this outcome. CONCLUSIONS LC with routine IOC is the preferred strategy in a cost-effectiveness analysis of the management of symptomatic cholelithiasis with asymptomatic choledocholithiasis. MRCP was both more costly and less effective under all tested scenarios.
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Affiliation(s)
- Irene Epelboym
- Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, NY, USA.
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