Rashtak Shahrooz, Goyal Hemant, Chandran Aswathi, Dedania Bhavtosh, Patil Prithvi, Wadhwa Vaibhav, Guha Sushovan, Davee Tomas, Ramireddy Srinivas, Thosani Nirav
Center for Interventional Gastroenterology at UTHealth (iGUT), McGovern Medical School, University of Texas Health Science Center, Houston, TX, United States.
Front Med (Lausanne). 2022 Oct 20;9:1000368. doi: 10.3389/fmed.2022.1000368. eCollection 2022.
The American Society of Gastrointestinal Endoscopy (ASGE) has proposed practice guidelines for evaluating patients with suspected choledocholithiasis. This study aims to assess and compare practice patterns for following ASGE guidelines for choledocholithiasis in a large academic vs. community hospital setting.
A total of one thousand ER indicated for choledocholithiasis were randomly selected. Patients' demographics, total bilirubin, imaging studies including magnetic resonance cholangiopancreatography (MRCP), intraoperative cholangiogram (IOC), endoscopic ultrasound (EUS), and ERCP results were retrospectively collected. Patients with prior sphincterotomy were excluded. We examined the following practice deviations from the current ASGE guidelines; (1) ERCP was potentially delayed in high probability cases while awaiting additional imaging studies, (2) ERCP was performed without additional imaging studies in cases of low/intermediate-risk, or (3) ERCP was performed in low/intermediate-risk cases when additional imaging studies were negative.
A total of 640 patients with native papilla who underwent ERCP were included in the final analysis. Overall, the management of 43% (275) of patients was deviated from the applicable ASGE guidelines. Academic and community provider rates of non-adherence were 32 vs. 45%, respectively (-value: < 0.01). Of 381 high-risk cases, 54.1% had additional imaging before ERCP. (Academic vs. community; 11.7 vs. 88.3%, -value: < 0.01). In 26.7% (69/258) of low/intermediate risk cases, ERCP was performed without additional studies; academic (14.5%) vs. community (85.5%) (-value: < 0.01). Finally, in 11.2% (19/170) of patients, ERCP was performed despite intermediate/low probability and negative imaging; academic (26.3%) vs. community (73.7%) (-value: 0.02).
Our study results show that providers do not adhere to ASGE practice guidelines in 43% of suspected choledocholithiasis cases. The rate of non-adherence was significantly higher in community settings. It could be due to various reasons, including lack/delays for alternate studies (i.e., MRCP, EUS), concern regarding the length of stay, patient preference, or lack of awareness/understanding of the guidelines. Increased availability of alternate imaging and educational strategies may be needed to increase the adoption of practice guidelines across academic and community settings to improve patient outcomes and save healthcare dollars.
美国胃肠内镜学会(ASGE)已提出评估疑似胆总管结石患者的实践指南。本研究旨在评估和比较大型学术医院与社区医院环境中遵循ASGE胆总管结石指南的实践模式。
总共随机选择了1000例因胆总管结石而进行内镜逆行胰胆管造影(ERCP)的患者。回顾性收集患者的人口统计学资料、总胆红素、包括磁共振胰胆管造影(MRCP)、术中胆管造影(IOC)、内镜超声(EUS)在内的影像学检查以及ERCP结果。排除既往有括约肌切开术的患者。我们检查了以下与当前ASGE指南的实践偏差;(1)在高概率病例中,在等待额外影像学检查时ERCP可能被延迟,(2)在低/中度风险病例中,未进行额外影像学检查就进行了ERCP,或者(3)在额外影像学检查为阴性的低/中度风险病例中进行了ERCP。
最终分析纳入了总共640例接受ERCP的有天然乳头的患者。总体而言,43%(275例)患者的管理偏离了适用的ASGE指南。学术机构和社区医疗机构的不依从率分别为32%和45%(P值:<0.01)。在381例高风险病例中,54.1%在ERCP前进行了额外的影像学检查。(学术机构与社区;11.7%与88.3%,P值:<0.01)。在26.7%(69/258)的低/中度风险病例中,未进行额外检查就进行了ERCP;学术机构(14.5%)与社区(85.5%)(P值:<0.01)。最后,在11.2%(19/170)的患者中,尽管可能性为中/低且影像学检查为阴性,但仍进行了ERCP;学术机构(26.3%)与社区(73.7%)(P值:0.02)。
我们的研究结果表明,在43%的疑似胆总管结石病例中,医疗人员未遵循ASGE实践指南。社区环境中的不依从率显著更高。这可能是由于各种原因,包括替代检查(即MRCP、EUS)的缺乏/延迟、对住院时间的担忧、患者偏好或对指南的缺乏认识/理解。可能需要增加替代影像学检查的可及性和教育策略,以提高学术机构和社区环境中实践指南的采用率,从而改善患者预后并节省医疗费用。