Are we meeting the standards set for endoscopy? Results of a large-scale prospective survey of endoscopic retrograde cholangio-pancreatograph practice

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Published Online First: 4 December 2006. doi:10.1136/gut.2006.097543Gut 2007;56:821-829Copyright © 2007 BMJ Publishing Group Ltd & British Society of Gastroenterology

PANCREAS AND BILIARY TRACT

Are we meeting the standards set for endoscopy? Results of a large-scale prospective survey of endoscopic retrograde cholangio-pancreatograph practiceEarl J 1, Steve 2, Fairclough3, Hamlyn4, F Logan5, Derrick 6,1, Stuart A Riley7, Veitch8,2, Mark Wilkinson9, a J on2, Lombard1 on behalf of participating units, BSG Audit of ERCP

1 Department of Gastroenterology, Royal Liverpool University Hospital, Liverpool, UK2 Centre for Medical Statistics and Health Evaluation, School of Health Sciences, University of Liverpool, Liverpool, UK3 Department of Gastroenterology, Barts and The London NHS Trust, London, UK4 Department of Gastroenterology, ’s Hall Hospital, Dudley, West Midlands, UK5 Division of Epidemiology and Public Health, Queen’s Medical Centre, Nottingham, UK6 Department of Radiology, Wythenshawe Hospital, Manchester, UK7 Department of Gastroenterology, Northern General Hospital, Sheffield, UK8 Department of Surgery, Royal Free Hospital, London, UK9 Department of Gastroenterology, Guy’s & St ’ NHS Foundation Trust, London, UK

Correspondence to: Dr M Lombard Audit Steering Group, Department of Gastroenterology, 5z Link, Royal Liverpool University Hospital, Prescot St, Liverpool L7 8XP, UK; martin.lombard@...

ABSTRACTObjective: To examine endoscopic retrograde cholangio-pancreatography (ERCP) services and training in the UK.

Design: Prospective multicentre survey.

Setting: Five regions of England.

Participants: Hospitals with an ERCP unit.

Outcome measures: Adherence to published guidelines, technical success rates, complications and mortality.

Results: Organisation questionnaires were returned by 76 of 81 (94%) units. Personal questionnaires were returned by 190 of 213 (89%) ERCP endoscopists and 74 of 91 (81%) ERCP trainees, of whom 45 (61%) reported participation in <50 ERCPs per annum. In all, 66 of 81 (81%) units collected prospective data on 5264 ERCPs, over a mean period of 195 days. Oximetry was used by all units, blood pressure monitoring by 47 of 66 (71%) and ECG monitoring by 37 of 66 (56%) units; 1484 of 4521 (33%) patients were given >5 mg of midalozam. Prothrombin time was recorded in 4539 of 5264 (86%) procedures. Antibiotics were given in 1021 of 1412 (72%) cases, where indicated. Patients’ American Society of Anesthesiology (ASA) scores were 3–5 in 670 of 5264 (12.7%) ERCPs, and 4932 of 5264 (94%) ERCPs were scheduled with therapeutic intent. In total, 140 of 182 (77%) trained endoscopists demonstrated a cannulation rate 80%. The recorded cannulation rate among senior trainees (with an experience of >200 ERCPs) was 222/338 (66%). Completion of intended treatment was done in 3707 of 5264 (70.4%) ERCPs; 268 of 5264 (5.1%) procedures resulted in a complication. Procedure-related mortality was 21/5264 (0.4%). Mortality correlated with ASA score.

Conclusion: Most ERCPs in the UK are performed on low-risk patients with therapeutic intent. Complication rates compare favourably with those reported internationally. However, quality suffers because there are too many trainees in too many low-volume ERCP centres.

Abbreviations: ASA, American Society of Anesthesiology; BSG, British Society of Gastroenterology; ERCP, endoscopic retrograde cholangio-pancreatography; NCEPOD, National Confidential Enquiry into Patient Outcome and Death