Predicting native papilla biliary cannulation success using a multinational Endoscopic Retrograde Cholangiopancreatography (ERCP) Quality Network

Abstract

BackgroundSuccess in deep biliary cannulation via native ampullae of Vater is an accepted measure of competence in ERCP training and practice, yet prior studies focused on predicting adverse events alone, rather than success. Our aim is to determine factors associated with deep biliary cannulation success, with/ without precut sphincterotomy.MethodsThe ERCP Quality Network is a unique prospective database of over 10,000 procedures by over 80 endoscopists over several countries. After data cleaning, and eliminating previously stented or cut papillae, two multilevel fixed effect multivariate models were used to control for clustering within physicians, to predict biliary cannulation success, with and without allowing “precut” to assist an initially failed cannulation.Results13018 ERCPs were performed by 85 endoscopists (March 2007 - May 2011). Conventional (without precut) and overall cannulation rates were 89.8% and 95.6%, respectively. Precut was performed in 876 (6.7%). Conventional success was more likely in outpatients (OR 1.21), but less likely in complex contexts (OR 0.59), sicker patients (ASA grade (II, III/V: OR 0.81, 0.77)), teaching cases (OR 0.53), and certain indications (strictures, active pancreatitis). Overall cannulation success (some precut-assisted) was more likely with higher volume endoscopists (> 239/year: OR 2.79), more efficient fluoroscopy practices (OR 1.72), and lower with moderate (versus deeper) sedation (OR 0.67).ConclusionBiliary cannulation success appears influenced by both patient and practitioner factors. Patient- and case-specific factors have greater impact on conventional (precut-free) cannulation success, but volume influences ultimate success; both may be used to select appropriate cases and can help guide credentialing policies.

Biliary drainage: role of EUS guidance

“…Biliary cannulation is an essential procedural step, which fails in 4% to 16% of ERCPs. [1][2][3][4] Cannulation failure may be a result of patient and disease factors, such as altered papillary structure (eg, ampullary adenoma or cancer, duodenal diverticulum) or inability to reach the papilla (eg, duodenal stricture or gastric outlet obstruction, postsurgical anatomy). Biliary access and drainage after failed ERCP has historically been treated by using two main approaches: percutaneous transhepatic biliary drainage (PTBD) or surgery.…”

Minimizing Radiation Exposure During ERCP by Avoiding Live or Continuous Fluoroscopy

“…2 In accordance with the "as low as reasonably achievable" (ALARA) principle put forth by the American College of Radiology, all efforts should be made to limit FT to minimize radiation exposure. 1,3,4,8,9 Pulsed fluoroscopy, a setting by which the x-ray beam turns on and off repeatedly at a set rate (eg, 4, 8, 15 "pulses" per second) while pressing the paddle, is a technology utilized by modern fluoroscopy machines to limit the FT. This technique is commonly used in conjunction with "last image hold," a feature that saves the last image visible during pulse fluoroscopy to a film-screen system.…”

Risk assessment and reduction

“…However, this recommendation is based on a reduction in perioperative mortality in major abdominal, orthopedic, and vascular surgery, and not in endoscopy [65]. In addition, a larger meta-analysis of variable surgery types did not agree with the reduction in risk [66].…”

“…In addition, endoscopists, units, or patient groups with higher failure rates generally have higher rates of other AEs because of cannulation difficulties. Recently, we used a subset of the multicenter ERCP quality network, comprising over 10,000 ERCPs performed by over 80 endoscopists, to assess for associations with cannulation failure [65]. Conventional (without precut assistance) success was more likely in outpatients (OR 1.21), but less likely in complex contexts (OR 0.59), sicker patients (ASA grade (II, III/V: OR 0.81, 0.77)), teaching cases (OR 0.53), and certain indications (strictures, active pancreatitis).…”