Patients and Methods
The 2006 ASGE/ACG Task Force on Quality in Endoscopy proposed 11 research questions, with five of the questions specifically directed at ERCP in the community setting. In 2002, the ASGE Committee on Outcomes Research published eight ERCP-specific quality indicators designed to provide a more complete description of quality in ERCP. The aim of this prospective study was to determine ERCP quality outcomes, including complications, in a community practice using these quality indicators.
The study was performed from December 1, 2005, through July 31, 2006, at eight community hospitals in Minneapolis, St. Paul and surrounding suburbs in Minnesota. Diagnositic and therapeutic ERCP procedures in both inpatients and outpatients were included. A total of 805 ERCP procedures were performed in 696 patients with a mean age of 61.1 years. Technical success was broken down into three categories: cannulation (insertion of a catheter or wire into the preferred bile or pancreas duct), stone removal and drainage. Each physician completed pre-procedure and post-procedure forms that included patient information, physician intent, findings, grade of difficulty, and technical aspects of the procedure.
Results
ERCP was performed because of known or suspected bile duct stones in over 50 percent of the procedures. A therapeutic intervention (e.g., stone removal, stent placement) was performed in 78 percent of the ERCPs. The overall complication rate following ERCP was five percent, with pancreatitis (post-ERCP pain due to temporary inflammation of the pancreas) being the most common complication at a rate of 3.2 percent. Hemorrhage (bleeding) occurred in less than one percent of procedures.
The ASGE/ACG Task Force has recommended competence levels for cannulation of the bile duct (90 percent), bile duct stone removal (85 percent), and bile duct drainage of a blocked duct (90 percent). This group of gastroenterologists performing ERCP in a community, non-academic setting met or exceeded these levels of success. Cannulation was successful in 94 percent, stone removal in 87 percent and drainage in 90 percent of the cases.
Researchers noted that these results may not be applicable to all community practices. The study center, Minnesota Gastroenterology PA, is a very large private practice composed of approximately 50 gastroenterologists allowing for a degree of specialization within the practice. The select group of physicians performing ERCP had a mean of 16.6 years of ERCP experience. Although this study did not find any relationship between years of experience and complication rates, several previous studies demonstrated a relationship. Further, the observation in previous studies that more complex cases tend to be handled at academic centers while “routine” cases are managed at community centers diminishes the ability to compare outcomes and complication rates between the two venues.
The study authors conclude that their results address issues that have not previously been well-studied and, when taken together with data from academic departments, provide a more complete picture of ERCP quality indices.
Source: American Society for Gastrointestinal Endoscopy
