How Good Is Your ERCPist?

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.

Grand Canyon near Phantom Ranch