Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
Division of Gastroenterology and Hepatology, Archbold Medical Group, Florida State University, Thomasville, Georgia.
Clin Gastroenterol Hepatol. 2017 Dec;15(12):1866-1875.e3. doi: 10.1016/j.cgh.2017.06.002. Epub 2017 Jun 10.
BACKGROUND & AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) has become a predominantly therapeutic intervention with a resultant increase in complexity. The relationship between ERCP volume and outcomes is unclear. We aimed to conduct a systematic review and meta-analysis assessing the relationship between endoscopist and center ERCP volume with ERCP success and adverse event (AE) rates.
A comprehensive search of MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials was conducted from inception to January 2017. Studies providing outcomes stratified by endoscopist and/or center volume were included in the final analysis. Endoscopist/center volume was stratified as low volume (LV) and high volume (HV). The definition of ERCP success varied between studies. The overall AE rate was a composite rate including pancreatitis, perforation, and bleeding.
A literature search resulted in 1264 citations. Of those, 13 articles (n = 59,437 ERCPs) met inclusion criteria. LV endoscopist (<25 to <156 annual ERCPs) and center (<87 to <200 annual ERCPs) definitions varied between studies. HV endoscopists were significantly more likely to achieve ERCP success compared with LV endoscopists (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.2-2.1). HV centers were significantly more likely to achieve ERCP success (OR, 2; 95% CI, 1.6-2.5). The post-ERCP AE risk was lower for HV endoscopists (OR, 0.7; 95% CI, 0.5-0.8) but not HV centers (OR, 0.7; 95% CI, 0.3-1.5).
This study identifies a significant relationship between increasing endoscopist and center ERCP volume with overall procedure success. Increasing endoscopist volume also was associated with a decreased AE rate. Given these compelling findings, we propose that providers and payers consider consolidating ERCP to HV endoscopists to improve ERCP outcomes and value.
经内镜逆行胰胆管造影术（ERCP）已成为一种主要的治疗性介入手段，其复杂性也随之增加。ERCP 量与结局之间的关系尚不清楚。本研究旨在进行系统评价和荟萃分析，评估内镜医师和中心 ERCP 量与 ERCP 成功率和不良事件（AE）发生率之间的关系。
从建库到 2017 年 1 月，对 MEDLINE、EMBASE 和 Cochrane 对照试验中心注册库进行了全面检索。最终分析纳入了根据内镜医师和/或中心量对结局进行分层的研究。将内镜医师/中心量分为低量（LV）和高量（HV）。ERCP 成功率的定义在不同研究之间有所不同。总体 AE 发生率是包括胰腺炎、穿孔和出血在内的复合率。
文献检索得到 1264 条引文。其中，13 篇文章（n=59437 例 ERCP）符合纳入标准。LV 内镜医师（<25 例至<156 例/年）和中心（<87 例至<200 例/年）的定义在不同的研究中有所不同。HV 内镜医师行 ERCP 成功率明显高于 LV 内镜医师（比值比[OR]，1.6；95%置信区间[CI]，1.2-2.1）。HV 中心行 ERCP 成功率明显高于 LV 中心（OR，2.0；95%CI，1.6-2.5）。HV 内镜医师的 post-ERCP AE 风险较低（OR，0.7；95%CI，0.5-0.8），但 HV 中心的风险无差异（OR，0.7；95%CI，0.3-1.5）。
本研究确定了内镜医师和中心 ERCP 量与整体手术成功率之间存在显著关系。内镜医师量的增加也与 AE 发生率的降低相关。鉴于这些有说服力的发现，我们建议提供者和支付者考虑将 ERCP 集中到 HV 内镜医师，以改善 ERCP 结局和价值。
