Retrospective Cohort Study
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Nov 16, 2023; 15(11): 641-648
Published online Nov 16, 2023. doi: 10.4253/wjge.v15.i11.641
Endoscopic retrograde cholangiopancreatography-related early perforations: A study of effects of procedure duration, complexity, and endoscopist experience
Mark Aloysius, Hemant Goyal, Tejas Nikumbh, Niraj James Shah, Ghassan M Hammoud, Pritesh Mutha, Mairin Joseph-Talreja, Savio John, Ganesh Aswath, Vaibhav Wadhwa, Nirav Thosani
Mark Aloysius, Savio John, Ganesh Aswath, Division of Gastroenterology, Department of Internal Medicine, SUNY Upstate Medical University, Syracuse, NY 13210, United States
Hemant Goyal, Pritesh Mutha, Mairin Joseph-Talreja, Vaibhav Wadhwa, Nirav Thosani, Department of Surgery, The University of Texas Health Science Center, Houston, TX 77030, United States
Tejas Nikumbh, Department of Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, PA 18510, United States
Niraj James Shah, Ghassan M Hammoud, Department of Medicine, Division of Digestive Diseases, The University of Missouri at Columbia, Columbia, MO 65211, United States
Author contributions: Aloysius M and Goyal H designed the study, performed the statistical analysis, generated the figures, and edited the manuscript; Nikumbh T performed the literature review and drafted the initial version of the manuscript and revised manuscript; Shah NJ, Hammoud GM, Mutha P, and Joseph-Talreja M edited the manuscript; John S, Aswath G, Wadhwa V and Thosani N critically reviewed manuscript.
Institutional review board statement: The Institutional review board approval was not needed for this study originating from a publicly available database.
Informed consent statement: As the study used anonymous and pre-existing data, the requirement for the informed consent from patients was waived.
Conflict-of-interest statement: All the Authors have no conflict of interest related to the manuscript.
Data sharing statement: The original anonymous dataset is available on request from the corresponding author at doc.hemant@yahoo.com.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Hemant Goyal, MD, Instructor, Department of Surgery, The University of Texas Health Science Center, No. 6431 Fannin, MSB 4.152, Houston, TX 77030, United States. doc.hemant@yahoo.com
Received: April 28, 2023
Peer-review started: April 28, 2023
First decision: July 4, 2023
Revised: August 6, 2023
Accepted: September 27, 2023
Article in press: September 27, 2023
Published online: November 16, 2023
Processing time: 195 Days and 23.8 Hours
Abstract
BACKGROUND

Perforations (Perf) during endoscopic retrograde cholangiopancreatography (ERCP) are rare (< 1%) but potentially fatal events (up to 20% mortality). Given its rarity, most data is through case series studies from centers or analysis of large databases. Although a meta-analysis has shown fewer adverse events as a composite (bleeding, pancreatitis, Perf) during ERCP performed at high-volume centers, there is very little real-world data on endoscopist and center procedural volumes, ERCP duration and complexity on the occurrence of Perf.

AIM

To study the profile of Perf related to ERCP by center and endoscopist procedure volume, ERCP time, and complexity from a national endoscopic repository.

METHODS

Patients from clinical outcomes research initiative-national endoscopic database (2000-2012) who underwent ERCP were stratified based on the endoscopist and center volume (quartiles), and total procedure duration and complexity grade of the ERCP based on procedure details. The effects of these variables on the Perf that occurred were studied. Continuous variables were compared between Perf and no perforations (NoPerf) using the Mann-Whitney U test as the data demonstrated significant skewness and kurtosis.

RESULTS

A total of 14153 ERCPs were performed by 258 endoscopists, with 20 reported Perf (0.14%) among 16 endoscopists. Mean patient age in years 61.6 ± 14.8 vs 58.1 ± 18.8 (Perf vs. NoPerf, P = NS). The cannulation rate was 100% and 91.5% for Perf and NoPerf groups, respectively. 13/20 (65%) of endoscopists were high-volume performers in the 4th quartile, and 11/20 (55%) of Perf occurred in centers with the highest volumes (4th quartile). Total procedure duration in minutes was 60.1 ± 29.9 vs 40.33 ± 23.5 (Perf vs NoPerf, P < 0.001). Fluoroscopy duration in minutes was 3.3 ± 2.3 vs 3.3 ± 2.6 (Perf vs NoPerf P = NS). 50% of the procedures were complex and greater than grade 1 difficulty. 3/20 (15%) patients had prior biliary surgery. 13/20 (65%) had sphincterotomies performed with stent insertion. Peritonitis occurred in only 1/20 (0.5%).

CONCLUSION

Overall adverse events as a composite during ERCP are known to occur at a lower rate with higher volume endoscopists and centers. However, Perf studied from the national database show prolonged and more complex procedures performed by high-volume endoscopists at high-volume centers contribute to Perf.

Keywords: Endoscopic retrograde cholangiopancreatography, Endoscopy complications, Perforations

Core Tip: We analyzed the profile of perforations (Perf) related to endoscopic retrograde cholangiopancreatography (ERCP) from the clinical outcomes research initiative-national endoscopic database over 12 years. The retrospective analysis of 14153 ERCPs done by 258 endoscopists reported a Perf rate of 0.14% (20 Perf) among 16 endoscopists. The cannulation rate was 100% for Perf and 91.5% for no Perf groups. 65% of endoscopists were high-volume performers, and 55% of Perf occurred in centers with the highest volumes (4th quartile). Higher volume endoscopists and centres are known to have less ERCP-related adverse events. However, this national database study on Perf has shown prolonged and complex procedures performed by high-volume endoscopists at high-volume centers contributed to Perf.