Are we meeting the standards set for endoscopy? Results of a large scale prospective survey of ERCP practice

Earl Jon Williams ^1*, Steve Taylor ², Peter Fairclough ³, Adrian Hamlyn ⁴, Richard F Logan ⁵, Derrick Martin ⁶, Stuart A Riley ⁷, Peter Veitch ⁸, Mark Wilkinson ⁹, Paula R Williamson ² and Martin Lombard ¹

¹ Royal Liverpool University Hospital, United Kingdom
² University of Liverpool, United Kingdom
³ Barts and The London NHS Trust, London, United Kingdom
⁴ Russell's Hall Hospital, Dudley, United Kingdom
⁵ Queen's Medical Centre, Nottingham, United Kingdom
⁶ Wythenshawe Hospital, Manchester, United Kingdom
⁷ Northern General Hospital, Sheffield, United Kingdom
⁸ Royal Free Hospital, London, United Kingdom
⁹ Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom

^* To whom correspondence should be addressed. E-mail: earljwilliams{at}hotmail.com.

Accepted 17 October 2006

Abstract

Objectives. To examine UK ERCP services and training. Design. Prospective multi-centre survey. Setting. Five regions of England. Participants. Hospitals with an ERCP unit.

Outcome Measures. Adherence to published guidelines; technical success rates; complications; mortality.

Results. Organisation questionnaires were returned by 76/81 (94%) of units. Personal questionnaires were returned by 190/213 (89%) of ERCP endoscopists and 74/91 (81%) of ERCP trainees, of whom 45/74 (61%) reported participation in <50 ERCPs per annum. In total 66/81 (81%) of units collected prospective data on 5264 ERCPs, over a mean period of 195 days. Oximetry was used by all units, BP monitoring by 47/66 (71%) and ECG monitoring by 37/66 (56%); 1484/4521 (33%) of patients receiving midazolam were given >5mg. Prothrombin time was recorded in 4539/5264 (86%) of procedures. Antibiotics were given in 1021/1412 (72%) of cases where indicated. Patients' ASA scores were 3-5 during 670/5264 (12.7%) of ERCPs and 4932/5264 (94%) of ERCPs were scheduled with therapeutic intent. In total 140/182 (77%) of trained endoscopists demonstrated a cannulation rate >= 80%. Recorded cannulation rate among senior trainees (with experience of >200 ERCPs) was 222/338 (66%). Completion of intended therapy occurred in 3707/5264 (70.4%) of ERCPs; 268/5264 (5.1%) of 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.

Keywords: ERCP, endoscopy, pancreatobiliary disease

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