From the Journals

VIDEO: High-volume endoscopists, centers produced better ERCP outcomes


Key clinical point: High endoscopic retrograde cholangiopancreatography (ERCP) volume predicted procedure success.

Major finding: High-volume endoscopists were significantly more likely to achieve success with ERCP than were low-volume endoscopists (odds ratio, 1.6; 95% confidence interval, 1.2 to 2.1). High-volume centers also had greater odds of successful ERCP than did low-volume centers (OR, 2; 95% CI, 1.6 to 2.5).

Data source: A systematic review and meta-analysis of 13 studies comprising 59,437 procedures and patients.

Disclosures: One coinvestigator acknowledged support from the University of Colorado Department of Medicine Outstanding Early Career Faculty Program. The researchers reported having no conflicts of interest.

With the increasing proportion of complex therapeutic ERCPs, the field is shifting toward performance of these procedures by those who have had advanced training and who make them the focus of their clinical practice. Consistent with this, the meta-analysis by Keswani et al. highlights benefits of higher-volume centers and endoscopists - improved ERCP success rate (at the provider and practice level) and reduced adverse events (provider level only). It is unclear, however, if higher-volume endoscopists received additional training that translated into better outcomes. Other variables, including case complexity and provider experience, could not be fully assessed in this study.

Dr. Gyanprakash A. Ketwaroo

Practically speaking, consolidating performance of ERCPs at fewer high-volume centers presents its own obstacles, including potentially limiting access to care. Additionally, as the authors point out, lower volume is not necessarily the cause of worse outcomes. Indeed, it is not known if lower-volume endoscopists would do better at higher-volume centers - i.e., is it the infrastructure, including technicians and equipment as well as the consistent performance of ERCPs, that are the main drivers of improved outcomes?

Overall, however, this large, well-performed meta-analysis adds to the growing chorus that endoscopists and endoscopic centers will have better results if the endoscopists are specially trained and routinely perform these procedures. Future studies are needed to more accurately define procedure success (significant variation in the meta-analysis) and assess other variables that affect outcomes for which volume may only be a proxy. In an era of reporting and demonstrating value in endoscopic care, quality metrics for ERCP performance may not be fully appreciated but eventually may become the driving force in consolidation of these procedures to particular centers or providers, regardless of volume.

Avinash Ketwaroo, MD, MSc, is assistant professor in the division of gastroenterology and hepatology at Baylor College of Medicine, Houston, and an associate editor of GI & Hepatology News. He has no relevant conflicts of interest.



Endoscopists who performed endoscopic retrograde cholangiopancreatography (ERCP) at high-volume centers had a 60% greater odds of procedure success compared with those at low-volume centers, according to the results of a systematic review and meta-analysis.

Diagnostic ERCP has fallen sevenfold in the past 30 years while therapeutic use has increased 30-fold, the researchers noted. Therapeutic use spans several complex pancreaticobiliary conditions, including chronic pancreatitis, malignant jaundice, and complications of liver transplantation. This shift from diagnostic to therapeutic has naturally increased the complexity of ERCP, the need for expert endoscopy, and the potential risk of adverse events. “As health care continues to shift toward rewarding value rather than volume, it will be increasingly important to deliver care that is effective and efficient,” the reviewers wrote. “Thus, understanding factors associated with unsuccessful interventions, such as a failed ERCP, will be of critical importance to payers and patients (Clin Gastroenterol Hepatol. 2017 Jun 7;218:237-45).

Therefore, they searched MEDLINE, EMBASE, and the Cochrane register of controlled trials for prospective and retrospective studies published through January 2017. In all, the researchers identified 13 studies that stratified outcomes by volume per endoscopist or center. These studies comprised 59,437 procedures and patients. Definitions of low volume varied by study, ranging from less than 25 to less than 156 annual ERCPs per endoscopist and from less than 87 to less than 200 annual ERCPs per center. Endoscopists who achieved this threshold were significantly more likely to perform successful ERCPs than were low-volume endoscopists (OR, 1.6; 95% CI, 1.2 to 2.1), and were significantly less likely to have patients develop pancreatitis, perforation, or bleeding after ERCP (OR, 0.7; 95% CI, 0.5 to 0.8).

One reviewer acknowledged support from the University of Colorado Department of Medicine Outstanding Early Career Faculty Program. The reviewers reported having no conflicts of interest.

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