Endoscopic retrograde cholangiopancreatography-related early perforations: A study of effects of procedure duration, complexity, and endoscopist experience

Abstract

Introduction Perforations during ERCP are rare (<1%) but potentially fatal events (up to 20% mortality). Given its rarity, most data is through case series studies from centers or analysis of large databases. Although a meta-analysis has shown fewer adverse events as a composite (bleeding, pancreatitis, perforation) during ERCP performed at high-volume centers, there is very little real-world data on endoscopist and center procedural volumes, ERCP duration and complexity on the occurrence of perforation. Methods Patients from Clinical Outcome Research Initiative National Endoscopic Database CORI-NED (2000-2012) who underwent ERCP were stratified based on the endoscopist and center volume (quartiles), and total procedure duration and complexity grade of the ERCP based on procedure details. The effects of these variables on the perforations that occurred were studied. Continuous variables were compared between perforations (Perf) and no perforations (NoPerf) using the Mann-Whitney U Test as the data demonstrated significant skewness and Kurtosis. Results A total of 14,153 ERCPs were performed by 258 endoscopists, with 20 reported perforations (0.14%) among 16 endoscopists. Mean patient age in years (?SD) 61.6? 14.8 vs 58.1?18.8 (Perf vs. NoPerf, p=NS). The cannulation rate was 100% and 91.5% for Perf and NoPerf groups, respectively. 13/20 (65%) of endoscopists were high-volume performers in the 4th quartile, and 11/20 (55%) of perforations occurred in centers with the highest volumes (4th quartile). Total procedure duration in minutes was 60.1? 29.9 vs. 40.33 ? 23.5 (Perf vs. NoPerf, p?0.001). Fluoroscopy duration in minutes was 3.3 ? 2.3 vs. 3.3? 2.6 (Perf vs. NoPerf p=NS). 50% of the procedures were complex and greater than grade 1 difficulty. 3/20 (15%) patients had prior biliary surgery. 13/20 (65%) had sphincterotomies performed with stent insertion. Peritonitis occurred in only 1/20 (0.5%). Discussion Overall adverse events as a composite during ERCP are known to occur at a lower rate with higher volume endoscopists and centers. However, perforations studied from the national database have shown prolonged and more complex procedures performed by high-volume endoscopists at high-volume centers contributing to perforations. This is likely a result of high-risk procedures undertaken in patients with complex pathology at tertiary and quaternary centers.