Clinical Endoscopy

The Korean Society of Gastrointestinal Endoscopy (대한소화기내시경학회)
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Increased ERCP volume improves cholangiogram interpretation: a new performance measure for ERCP training?

  • Shyam Vedantam (Department of Medicine, University of Miami) ;
  • Sunil Amin (Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami) ;
  • Ben Maher (Department of Interventional Radiology, University Hospital Southampton NHS Foundation Trust) ;
  • Saqib Ahmad (Department of Gastroenterology, Sherwood Forest Hospitals NHS Foundation Trust) ;
  • Shanil Kadir (Department of Gastroenterology, Liaquat National Hospital and Medical College) ;
  • Saad Khalid Niaz (Interventional Endoscopy Unit, Surgical Unit 4, Dow University of Health Sciences) ;
  • Mark Wright (Southampton Interventional Endoscopy Unit, University Hospital Southampton NHS Foundation Trust) ;
  • Nadeem Tehami (Southampton Interventional Endoscopy Unit, University Hospital Southampton NHS Foundation Trust)
  • Received : 2021.09.23
  • Accepted : 2021.11.08
  • Published : 2022.05.30
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Abstract

Background/Aims: Cholangiogram interpretation is not used as a key performance indicator (KPI) of endoscopic retrograde cholangiopancreatography (ERCP) training, and national societies recommend different minimum numbers per annum to maintain competence. This study aimed to determine the relationship between correct ERCP cholangiogram interpretation and experience. Methods: One hundred fifty ERCPists were surveyed to appropriately interpret ERCP cholangiographic findings. There were three groups of 50 participants each: "Trainees," "Consultants group 1" (performed >75 ERCPs per year), and "Consultants group 2" (performed >100 ERCPs per year). Results: Trainees was inferior to Consultants groups 1 and 2 in identifying all findings except choledocholithiasis outside the intrahepatic duct on the initial or completion/occlusion cholangiogram. Consultants group 1 was inferior to Consultants group 2 in identifying Strasberg type A bile leaks (odds ratio [OR], 0.86; 95% confidence interval [CI], 0.77-0.96), Strasberg type B (OR, 0.84; 95% CI, 0.74-0.95), and Bismuth type 2 hilar strictures (OR, 0.81; 95% CI, 0.69-0.95). Conclusions: This investigation supports the notion that cholangiogram interpretation improves with increased annual ERCP case volumes. Thus, a higher annual volume of procedures performed may improve the ability to correctly interpret particularly difficult findings. Cholangiogram interpretation, in addition to bile duct cannulation, could be considered as another KPI of ERCP training.

Keywords

Acknowledgement

This was an international survey project that would not have been possible without the help of colleagues around the world. Their participation in this project is appreciated.

References

  1. Costamagna G, Familiari P, Marchese M, et al. Endoscopic biliopancreatic investigations and therapy. Best Pract Res Clin Gastroenterol 2008;22:865-881.  https://doi.org/10.1016/j.bpg.2008.05.004
  2. Kapral C, Muhlberger A, Wewalka F, et al. Quality assessment of endoscopic retrograde cholangiopancreatography: results of a running nationwide Austrian benchmarking project after 5 years of implementation. Eur J Gastroenterol Hepatol 2012;24:1447-1454.  https://doi.org/10.1097/MEG.0b013e3283583c6f
  3. Elta GH, Jorgensen J, Coyle WJ. Training in interventional endoscopy: current and future state. Gastroenterology 2015;148:488-490.  https://doi.org/10.1053/j.gastro.2015.01.001
  4. Wani S, Keswani RN, Han S, et al. Competence in endoscopic ultrasound and endoscopic retrograde cholangiopancreatography, from training through independent practice. Gastroenterology 2018;155:1483-1494.e7.  https://doi.org/10.1053/j.gastro.2018.07.024
  5. Shahidi N, Ou G, Telford J, et al. When trainees reach competency in performing ERCP: a systematic review. Gastrointest Endosc 2015;81:1337-1342.  https://doi.org/10.1016/j.gie.2014.12.054
  6. Voiosu T, Balanescu P, Voiosu A, et al. Measuring trainee competence in performing endoscopic retrograde cholangiopancreatography: a systematic review of the literature. United European Gastroenterol J 2019;7:239-249.  https://doi.org/10.1177/2050640618817110
  7. Cappell MS, Friedel DM. Stricter national standards are required for credentialing of endoscopic-retrograde-cholangiopancreatography in the United States. World J Gastroenterol 2019;25:3468-3483.  https://doi.org/10.3748/wjg.v25.i27.3468
  8. ASGE Training Committee, Jorgensen J, Kubiliun N, et al. Endoscopic retrograde cholangiopancreatography (ERCP): core curriculum. Gastrointest Endosc 2016;83:279-289.  https://doi.org/10.1016/j.gie.2015.11.006
  9. The British Society of Gastroenterology (BSG). ERCP: the way forward, a standards framework [Internet]. London: BSG; 2013 [cited 2021 Dec 9]. Available from: https://www.bsg.org.uk/wp-content/uploads/2019/12/ERCP-%E2%80%93-The-Way-Forward-A-Standards-Framework-1.pdf 
  10. Adler DG, Lieb JG, Cohen J, et al. Quality indicators for ERCP. Gastrointest Endosc 2015;81:54-66.  https://doi.org/10.1016/j.gie.2014.07.056
  11. Domagk D, Oppong KW, Aabakken L, et al. Performance measures for ERCP and endoscopic ultrasound: a European Society of Gastrointestinal Endoscopy (ESGE) quality improvement initiative. Endoscopy 2018;50:1116-1127.  https://doi.org/10.1055/a-0749-8767
  12. Sanjay P, Tagolao S, Dirkzwager I, et al. A survey of the accuracy of interpretation of intraoperative cholangiograms. HPB (Oxford) 2012;14:673-676.  https://doi.org/10.1111/j.1477-2574.2012.00501.x
  13. Caglar E, Atasoy D, Tozlu M, et al. Experience of the endoscopists matters in endoscopic retrograde cholangiopancreatography in Billroth II gastrectomy patients. Clin Endosc 2020;53:82-89.  https://doi.org/10.5946/ce.2019.073
  14. Cotton PB. Are low-volume ERCPists a problem in the United States? A plea to examine and improve ERCP practice-NOW. Gastrointest Endosc 2011;74:161-166.  https://doi.org/10.1016/j.gie.2011.03.1233
  15. Barkun AN, Rezieg M, Mehta SN, et al. Postcholecystectomy biliary leaks in the laparoscopic era: risk factors, presentation, and management. McGill Gallstone Treatment Group. Gastrointest Endosc 1997;45:277-282.  https://doi.org/10.1016/S0016-5107(97)70270-0
  16. Davids PH, Tanka AK, Rauws EA, et al. Benign biliary strictures. Surgery or endoscopy? Ann Surg 1993;217:237-243.  https://doi.org/10.1097/00000658-199303000-00004
  17. Bergman JJ, van den Brink GR, Rauws EA, et al. Treatment of bile duct lesions after laparoscopic cholecystectomy. Gut 1996;38:141-147.  https://doi.org/10.1136/gut.38.1.141
  18. Loperfido S, Angelini G, Benedetti G, et al. Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study. Gastrointest Endosc 1998;48:1-10.  https://doi.org/10.1016/S0016-5107(98)70121-X
  19. Tanner AR. ERCP: present practice in a single region. Suggested standards for monitoring performance. Eur J Gastroenterol Hepatol 1996;8:145-148.  https://doi.org/10.1097/00042737-199602000-00010
  20. Masci E, Toti G, Mariani A, et al. Complications of diagnostic and therapeutic ERCP: a prospective multicenter study. Am J Gastroenterol 2001;96:417-423.  https://doi.org/10.1111/j.1572-0241.2001.03594.x
  21. Andriulli A, Loperfido S, Napolitano G, et al. Incidence rates of post-ERCP complications: a systematic survey of prospective studies. Am J Gastroenterol 2007;102:1781-1788.  https://doi.org/10.1111/j.1572-0241.2007.01279.x
  22. Chan CK, Pace RF. Misdiagnosis using endoscopic retrograde cholangiopancreatography in a patient with postcholecystectomy pain. Surg Endosc 1987;1:179-180.  https://doi.org/10.1007/BF00590928
  23. Trap R, Adamsen S, Hart-Hansen O, et al. Severe and fatal complications after diagnostic and therapeutic ERCP: a prospective series of claims to insurance covering public hospitals. Endoscopy 1999;31:125-130.  https://doi.org/10.1055/s-1999-13659
  24. Siau K, Webster G, Wright M, et al. Attitudes to radiation safety and cholangiogram interpretation in endoscopic retrograde cholangiopancreatography (ERCP): a UK survey. Frontline Gastroenterol 2020;12:550-556.  https://doi.org/10.1136/flgastro-2020-101521
  25. Perneger TV. What's wrong with Bonferroni adjustments. BMJ 1998;316:1236-1238.  https://doi.org/10.1136/bmj.316.7139.1236
  26. Nakagawa S. A farewell to Bonferroni: the problems of low statistical power and publication bias. Behavioral Ecology 2004;15:1044-1045.  https://doi.org/10.1093/beheco/arh107
  27. Desai R, Patel U, Doshi S, et al. A nationwide assessment of the "July Effect" and predictors of post-endoscopic retrograde cholangiopancreatography sepsis at urban teaching hospitals in the United States. Clin Endosc 2019;52:486-496.  https://doi.org/10.5946/ce.2018.190
  28. Lee TY, Nakai Y. Is the July effect real in patients undergoing endoscopic retrograde cholangiopancreatography? Clin Endosc 2019;52:399-400. https://doi.org/10.5946/ce.2019.132