Author(s): Toufic A Kachaamy 1 , Douglas O Faigel [*] 2
endoscopic retrograde cholangiopancreatography; endoscopic sphincterotomy; hemorrhage; infection; indomethacin; intestinal perforation; pancreatitis; radiation; sedation; stent
Proper indication & avoiding diagnostic endoscopic retrograde cholangiopancreatography
Probably the most important principle in decreasing complications of endoscopic retrograde cholangiopancreatography (ERCP) is making sure there is a proper indication for the procedure. It is optimal to see the patient in consult when possible prior to an ERCP. In addition to providing the opportunity to review the indication ahead of time, this allows the endoscopist to discuss at length the indication, risks, benefit and alternative options with the patient and caregivers. One of the best ways to decrease complications is avoiding diagnostic ERCPs when the information needed can be obtained by another less invasive method. This is why ERCP has become almost exclusively a therapeutic modality. Often the information needed can be obtained by a good quality MRCP or an endoscopic ultrasound. Occasionally, diagnostic ERCP is needed as for example when tissue needs to be obtained by brushing or biopsy of a stricture. In most cases, however, when the information can be obtained with less invasive means, the risk of the diagnostic ERCP will outweigh the benefit. In fact, lack of a good indication for an ERCP continues to be a significant cause of litigation in gastroenterology [1,2] .
Center volume & endoscopist volume, training & experience
ERCP is best performed by a team that is well set up to perform the task needed. This requires an endoscopist who has the needed expertise in addition to a supportive environment in terms of nursing staff, technicians and equipment needed. The best way for endoscopists to acquire ERCP skills is through formal training in a therapeutic endoscopy program. The American Society for Gastrointestinal Endoscopy (ASGE) has organized a Match process for therapeutic endoscopy fellowships in the USA. The information is available on the ASGE website (ASGE.org). The issue of maintaining expertise after training can be a challenge especially with the increase in the number of endoscopists performing ERCP without a concomitant increase in the need for ERCP. It is not known how many ERCPs are needed to be performed annually to maintain good skills. Parameters for classification of ERCP practices into low versus high volume are not fully agreed on. Studies have used different parameters including number of ERCPs performed per year by the endoscopist, number performed by the center and number of sphincterotomies performed per week. While it is widely believed that a higher volume of ERCP translates into lower complication rate, studies on this issue have not been consistent. For example, a study from Austria found that low-volume endoscopist (less than 50 ERCPs per year) had a higher rate of overall and severe complications  . A US multicenter study reported that performing less than one sphincterotomy per week was associated with a higher complication rate  . On the other hand, a recent study from Norway showed that over 150 ERCPs performed per year in a specific center...