Introduction Cholangiocarcinoma (CC) is a rare and challenging cancer with poor prognosis and low operative rate. Early successful biliary drainage is a key determinant of outcome and ERCP is the primary modality. It is unclear whether current care organisation for CC is optimal. We report a national study aimed at describing outcomes for all patients undergoing ERCP for CC in English hospitals and volumes at cancer networks and institutions.
Methods We built on linkage methods applied to overall ERCP mortality1 to develop new techniques to map the entire pathway of hospital care for incident cases of CC. 2 years of Hospital Episode Statistics (HES) data were merged (2006–2008) and admissions screened for CC diagnosis. To identify a 1-year incident cohort of CC, we selected only patients with first cancer coding in middle year (October–September), then extracted all admissions within 6 months (before and after) of first cancer coding, ordered chronologically, screened for ERCP, radiological intervention (PTC) and major surgery codes. Identified first and subsequent procedure dates, admission diagnoses and co-morbidity. Linkage to death registry for death date. Cases allocated to cancer networks using provider codes.
Results Nationally, 1211 CC patients underwent ERCP with mean age (SD) of 72 (12) years and 623 male (51.4%). First ERCP was performed during an acute (emergency) hospitalisation in 690 cases (57%). ERCP case volumes for CC ranged from 7 to 79 patients per Cancer Network and 1–57 patients per Trust (n=146 institutions). Outcomes (post-first ERCP): Mortality: 7 day [40 (3.3%)]; 30 day: 172 (14.2%); 365 day: 781 (64.5%). Emergency readmission: 7 day: 110 (9.1%); 30 day: 252 (20.8%). Additional PTC: 213 (17.6%) with poorer 365 d survival in those needing both (ERCP alone: 64.5% vs ERCP+PTC: 73%, p=0.013, non-surgical cases only). Patients requiring first ERCP during an acute hospitalisation had poorer prognosis than those on elective pathway (Log rank, p<0.001). 365 day mortality for surgical 42.4% vs non-surgical 66.2% (p<0.001).
Conclusion First endoscopic intervention for this rare form of cancer is undertaken in most English hospitals, often during acute hospitalisation. There is wide variation in institutional case load. These data provide a potential tool for exploring variation in relation to local or network service provision and organisation.
Competing interests None declared.
Reference 1. Bodger K, Bowering K, Sarkar S, et al. All-cause mortality after first ERCP in England: clinically guided analysis of hospital episode statistics with linkage to registry of death. Gastrointest Endosc 2011;74:825–33.