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

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

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

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

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

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  

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”

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.

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

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

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

Nobles Audit

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

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

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

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

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

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

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

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

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

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

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

Thank you