In this article, we review all ERCP procedures recorded on the Endosoft reporting software between 20 at St Thomas’ and analyse whether particular indications or intraprocedural factors were implicated in cannulation failure. For the purpose of this study, the use of needle knife ‘pre-cut’ sphincterotomy is defined as an aid to a successful virgin cannulation if this is achieved at the same sitting however, if cannulation is only achieved at a second procedure, when any oedema and/or bleeding from the pre-cut have subsided, the first procedure is defined as a failure, and the second as a successful non-virgin cannulation. Therefore, a patient’s second ERCP attempt may again be counted among the virgin cases, provided that the ampulla has not been irreversibly altered at the first attempt. Virgin papillae have been defined as those unaltered by prior surgery, endoscopic sphincterotomy or stent insertion. In most proposed systems of assessment, a key differentiator is not accounted for, namely whether the papillae were virgin or otherwise prior to commencement. The alternative approach of dealing with all cases on an intention-to-treat basis, and ignoring case mix, is undoubtedly simpler, but less precise. Once cannulated, the therapeutic intent will be realised partially or fully, but separating the two elements of the procedure, as far as benchmarking is concerned, allows a clearer understanding of exactly what is occurring at each ERCP centre. The intent of this paper is to define a straightforward and readily reproducible measure of successful cannulation of a virgin papilla, an interpretation of JAG's definition of ‘initial attempt’, where subsequent therapeutic or diagnostic success is treated as a separate category. These guidelines echo the statement made in their previous endoscopy guidelines of 2007, 2 which advise that completion of the intended therapeutic procedure should be achieved in at least 80% of cases.ĭue to caseload differences between endoscopy units, direct comparison of success rates requires standardising, with a wide variation nationally and internationally in both grading systems and success rates. The Joint Advisory Group (JAG) on Gastrointestinal Endoscopy published guidelines for the use of a Global Rating Scale in 2009, 1 which promotes the frequent audit of quality and safety of each mode of endoscopy. The caseload is shared between three consultants, one of whom works for another Trust where he also performs ERCP. St Thomas’ Hospital was the first centre performing ERCP in the UK in the early 1970s and now serves as a tertiary referral centre performing a moderately high volume of procedures per year. Measuring success of the procedure against an agreed benchmark is an evolving and debated topic, and one which is essential in providing a basis for assessing performance of both trainees and established practitioners. Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most challenging endoscopic techniques indicated in a range of pancreatic and biliary diseases.
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