ASGE Endoscopy Course at ACG: Everyday Endoscopy: Expertise Meets Evidence

8_Keswani Quality in ERCP

Pdf Summary

The document outlines Dr. Rajesh N. Keswani's discussion on enhancing the quality of Endoscopic Retrograde Cholangiopancreatography (ERCP) procedures, which are crucial in gastrointestinal endoscopy. It highlights the importance of measuring outcomes in gastrointestinal endoscopy, as variations in ERCP success rates directly influence patient mortality and other significant outcomes.<br /><br />Dr. Keswani emphasizes the lack of a mandatory registry in the United States, which hampers the comprehensive tracking and improvement of ERCP outcomes. Comparisons with international practices show overall procedure success rates of around 86-89%. The document also details a meta-analysis linking higher ERCP provider volumes with better patient outcomes, suggesting that consolidating procedures to high-volume providers might improve quality.<br /><br />Several strategies to enhance ERCP quality are discussed, including performing ERCP for appropriate indications to avoid unnecessary procedures. The document criticizes performing ERCP for marginal reasons, such as unverified biliary pain or primary sclerosing cholangitis diagnosis without other indicators.<br /><br />Technically, improving cannulation success is crucial. Practices like prone positioning, deep sedation, and advanced cannulation techniques, particularly by high-volume endoscopists, are associated with improved success rates. The document acknowledges a lack of robust, evidence-based interventions to ensure appropriate indications and enhance success rates.<br /><br />To prevent post-ERCP pancreatitis, the document underscores the effectiveness of rectal indomethacin and the potential benefits of aggressive intravenous hydration. However, the optimal use of these interventions needs improvement.<br /><br />In summary, the document calls for reducing unnecessary ERCPs, improving technical competencies to enhance cannulation success, and minimizing adverse events to refine overall ERCP quality and safety. These improvements are intended to reduce the variability in ERCP performance and consequently enhance patient outcomes.

Keywords

ERCP quality

gastrointestinal endoscopy

outcome measurement

patient mortality

procedure success rates

high-volume providers

cannulation success

post-ERCP pancreatitis

rectal indomethacin

intravenous hydration