1. An audit of ERCP service provision in Nobles Hospital
Marina Yiasemidou, MBBS, MSc – CT1 Surgery
Audit lead: Mr Simon Stock

2. Introduction 2004 NCEPOD Report “Scoping our Practice”
“68% of the ERCPs undertaken were futile”
Place of ERCP in diagnosis
EUS
MRCP
Insufficient case load experience
ERCP optional in Joint Advisory Group (JAG) endoscopy curriculum

3. Recommendations AUDIT - Current ERCP Service BSG ERCP Audit
STANDARDS –
Clear standards for service as well as training
STRATEGY –
Clear strategy for future of service and training
BSG ERCP Audit
BSG Endoscopy Committee Quality and Safety Standards in ERCP– adopted by the JAG
BSG Endoscopy Committee ERCP ‘Stakeholder’ Group-Aimed to represent all performing ERCPs

4. The future of ERCP – Service provision
BSG Audit
48,000 ERCPs are performed each year in the UK.
Vast majority of ERCPs are therapeutic
Increasingly, but patchily, pre- ERCP investigation includes EUS
Future: Continuous increase in ERCP numbers annually in the UK

5. Skills – Setting standards for competency
> 80% successful completion of the intended procedure
Post-ERCP complication rate of < 5.
Assessment of skills will be by:-
formative DOPS records of at least 100 cases during training
summative DOPS assessment as per JAG criteria
evidence of continued practice

6. JAG QUALITY AND SAFETY STANDARDS FOR ERCP – August 2007
Quality standards
>90% of ERCPs intended as therapeutic
Completion of the intended therapeutic procedure (eg decompression of dilated and/or obstructed biliary system) at initial ERCP in at least 80% of cases
Following failed initial ERCP, decompression of obstructed biliary systems within 5 working days in a stable patient, or within 24hr in an unstable patient (e.g. severe cholangitis)
Sphincterotomy bleeding requiring transfusion < 2%
Perforation rate <2%
Clinically symptomatic pancreatitis < 5%
Procedure related mortality <1%
Continued appropriate antibiotic treatment when obstruction unrelieved by ERCP in 100% of cases

7. JAG QUALITY AND SAFETY STANDARDS FOR ERCP – August 2007
Auditable outcomes
Number of procedures performed by each operator
Success in cannulating desired duct and in performance of intended therapeutic procedure
Frequency of post-procedure clinical pancreatitis
Please refer back to “General quality and safety indicators”

8. ERCP service provision outside the UK
QUALITY OUTCOMES AND COMPLICATION RATES FOR ERCP IN A COMMUNITY HOSPITAL SETTING COMPARE FAVORABLY WITH ACADEMIC CENTERS -
American Society for Gastrointestinal Endoscopy (ASGE)/American College of Gastroenterology (ACG) Task Force.

9. ASGE – Minnesota trial
Aim: Outcomes and complications of ERCP in a community practice
ASGE/ACG Task Force recommended competence levels:
Cannulation of the bile duct: 90%
Bile duct stone removal: 85%
Bile duct drainage of a blocked duct: 90%
Prospective study

10. Minnesota trial - Methods
December 1, 2005, through July 31, 2006
8 community hospitals in Minneapolis, St. Paul and surrounding suburbs in Minnesota.
Diagnostic and therapeutic ERCP procedures
Both inpatients and outpatients were included.
805 ERCP procedures 696 patients with a mean age of 61.1 years.
Technical success was broken down into three categories: cannulation (insertion of a catheter or wire into the preferred bile or pancreas duct), stone removal and drainage

11. Minnesota trial - Results
Cannulation was successful in 94 percent, stone removal in 87 percent and drainage in 90 percent of the cases
Success rates met or exceeded the recommended rates reported by the ASGE/ACG Task Force

12. Nobles Audit

13. Aim Assess Nobles success rates compare to UK and US guidelines
Can a small volume unit provide a satisfactory ERCP service?

14. Methods Between December 2010 and January 2012
42 ERCPs were performed on 36 patients
F:M 24:12, Mean age: 69.8
Retrospective inspection of ERCP results
Single consultant
SPSS 14 software
Chi-square test was used to compare success ratios between Nobles Hospital and ASGE/ACG Task Force recommended competency levels

15. Results - Indications Indication Number of patients
Jaundice - Stones identified in pre-procedure imaging 22
Jaundice - Dilated ducts in pre procedural imaging–no cause identified 10
Jaundice - Dilated ducts and space occupying lesions in pre procedural imaging 6
Jaundice - ?CBD injury post lap chole 1
Jaundice - ?Stent occlusion in pre procedural imaging 3

16. Results - Procedures Procedure Number of patients Stone extraction 3
Stone extraction and Sphincterotomy 17
Stent +/- Biopsies 12
Stent replacement post occlusion

17. Indications – ASGE categorisation
Number of patients
Diagnostic
Jaundice-stones identified in biliary ducts on pre procedural imaging 21
Jaundice-causes besides stones were identified in pre procedural imaging

18. Results – Success rates
42 ERCP
35 Successful
83.3%
7 Unsuccessful
16.7%

19. Breakdown of unsuccessful procedures – 7 procedures
Large hiatus hernia – Unable to intubate
Partial extraction of stones
Surgical clips blocked CBD – Unable to pass guidewire
Respiratory problems during procedure
Too uncooperative
Unable to intubate due to pharyngeal pouch
Extravasation of contrast to necrotic tumour cavity – Unable to obtain biopsies

20. Comparison of success rates to JAG quality and safety standards for ERCP
JAG: Recommended overall success rates – 80%
Nobles Success Rates – 83.3%

21. Comparison of success rates to ASGE/ACG Task Force.
Value
ASGE/ACG Task Force
Nobles
P-value (Chi-square test)
Successful cannulation 38
90.48% 37
88.1%
0.72
Stone removal 18
85.7% 17
80.95%
0.68
Drainage of blocked duct 19
0.63

22. Conclusion Success rates – Good practice identified
ERCP success rates in Nobles Hospital are equivalent to the ASGE/ACG Task Force recommended competency levels and exceed JAG recommended success rates.
This study provides evidence that ERCP can be successfully performed in a non-specialised environment

23. Recommendations
Annual audit of success and complication rates to maintain good practice
Introduction of protocol for prophylactic antibiotics and antibiotic treatment between repeated procedures

24. Thank you