An interesting study and accompanying editorial (RN Keswani et al. Clin Gastroenterol Hepatol 2017; 15: 1866-75, & P Cotton Clin Gastroenterol Hepatol 2017; 15:1855-57) point out that ERCP is more successful in high volume centers and with high volume (HV) endoscopists.
The study was a systematic review and meta-analysis. The threshold for low volume for endoscopist was < 27 case/year and for centers of <156 cases/year. However, this data is not widely available.
- In this study with 59,437 ERCPs, HV endoscopists had OR of 1.6 for success compared to LV endoscopist.
- Similarly HV centers had OR of 2.0 for successful ERCP.
- Post-ERCP adverse risks were lower for HV endoscopists with OR of 0.7
In addition, the level of complexity for the cases matters a lot. Dr. Cotton breaks down the complexity of procedures:
- Standard complexity includes cannulation of bile duct, biliary stent removal/exchange, biliary stone removal <10 mm, treating bile leaks, treating benign and malignant strictures, and placing prophylactic stents..
- Advanced procedure complexity includes any of the above procedures after Billroth II, minor papilla cannulaiton, removing biliary stents that have migrated internally, fine needle aspiration, treating pancreatic strictures, removing small (< 5 mm), mobile pancreatic stones, treating biliary strictures at hilum or more proximal
- Highly technical complexity (“advanced tertiary”) includes removal of internally migrated pancreatic stents, intraductal image-guided therapy (eg. PDT EHL), pancreatic stones impacted or >5 mm, intrahepatic stones, pseudocyst drainage, ampullectomy, ERCP after Whipple or roux-en-Y bariatric surgery
My take: The ultimate goal is high success rates and lower complication rates. Highly proficient endoscopists and high volume centers achieve these goals more consistently, particularly for more complicated ERCP procedures.