Korean J Gastroenterol.  2024 Sep;84(3):111-122. 10.4166/kjg.2024.067.

Quality Indicators of Endoscopic Retrograde Cholangiopancreatography in Korea

• Kim KH
• Chon HK
• Song TJ
• Ahn DW
• Lee ES
• Lee YN
• Lee YS
• Jeon TJ
• Park CH
• Cho KB
• Lee DW
• Park JS
• Yoon SB
• Chung KH
• Lee J
• Choi M

• KMID: 2559844
• DOI: http://doi.org/10.4166/kjg.2024.067

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that requires abundant clinical experience and endoscopic skills, and can lead to various complications, some of which may progress to life-threatening conditions. With expanding indications and technological advancements, ERCP is widely utilized, enhancing procedural accessibility. However, without proper quality management, the procedure can pose significant risks. Quality management in ERCP is essential to ensure safe and successful procedures and meet societal demands for improved healthcare competitiveness. To address these concerns, the Korean Society of Pancreatobiliary Endoscopy has developed a Korean-specific ERCP quality indicator reflecting domestic medical environments and realities. Initially, based on a review of foreign ERCP quality indicators and related literatures, key questions were formulated for five pre-procedural items, three intra-procedural items, and four post-procedural items. Descriptions and recommendations for each item were selected through peer evaluation. The developed Korean-specific ERCP quality indicator was reviewed by external experts based on the latest evidence and consensus in this fields. This Korean-specific indicator is expected to significantly contribute to improving ERCP quality in Korea, as it is tailored to local needs.

Keyword

ERCP; Quality indicators; Korean

Figure

• 

  Fig. 1 The results of the modified e-Delphi process involving a panel of 32 experts regarding the statements. ERCP, endoscopic retrograde cholangiopancreatography; KPBA, Korean Pancreatobiliary Association; PEP, post-ERCP pancreatitis.

Reference

1. Tarar ZI, Farooq U, Gandhi M, Saleem S, Daglilar E. 2023; Safety of endoscopic retrograde cholangiopancreatography (ERCP) in cirrhosis compared to non-cirrhosis and effect of Child-Pugh score on post-ERCP complications: a systematic review and meta-analysis. Clin Endosc. 56:578–589. DOI: 10.5946/ce.2023.027. PMID: 37157959. PMCID: PMC10565436.

2. Chon HK, Kim TH. 2017; Endoclip therapy of post-sphincterotomy bleeding using a transparent cap-fitted forward-viewing gastroscope. Surg Endosc. 31:2783–2788. DOI: 10.1007/s00464-016-5287-x. PMID: 27761747.

3. Akshintala VS, Kanthasamy K, Bhullar FA, et al. 2023; Incidence, severity, and mortality of post-ERCP pancreatitis: an updated systematic review and meta-analysis of 145 randomized controlled trials. Gastrointest Endosc. 98:1–6.e12. DOI: 10.1016/j.gie.2023.03.023. PMID: 37004815.

4. Adler DG, Lieb JG 2nd, Cohen J, et al. 2015; Quality indicators for ERCP. Gastrointest Endosc. 81:54–66. DOI: 10.1016/j.gie.2014.07.056. PMID: 25480099.

5. Domagk D, Oppong KW, Aabakken L, et al. 2018; Performance measures for ERCP and endoscopic ultrasound: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy. 50:1116–1127. DOI: 10.1055/a-0749-8767. PMID: 30340220.

6. Alberca de Las Parras F, López-Picazo J, Pérez Romero S, Sánchez Del Río A, Júdez Gutiérrez J, León Molina J. 2018; Quality indicators for endoscopic retrograde cholangiopancreatography. The procedure of endoscopic retrograde cholangiopancreatography. Rev Esp Enferm Dig. 110:658–666. DOI: 10.17235/reed.2018.5652/2018. PMID: 30071737.

7. Jorgensen J, Kubiliun N, Law JK, et al. 2016; Endoscopic retrograde cholangiopancreatography (ERCP): core curriculum. Gastrointest Endosc. 83:279–289. DOI: 10.1016/j.gie.2015.11.006. PMID: 26708081.

8. Isaacs P. 2011; Endoscopic retrograde cholangiopancreatography training in the United Kingdom: A critical review. World J Gastrointest Endosc. 3:30–33. DOI: 10.4253/wjge.v3.i2.30. PMID: 21403814. PMCID: PMC3055941.

9. Raveesh BN, Nayak RB, Kumbar SF. 2016; Preventing medico-legal issues in clinical practice. Ann Indian Acad Neurol. 19(Suppl 1):S15–S20. DOI: 10.4103/0972-2327.192886. PMID: 27891020. PMCID: PMC5109754.

10. O'Sullivan S, Crippen C, Ponich T. 2002; Are patients informed when they consent to ERCP? Can J Gastroenterol. 16:154–158. DOI: 10.1155/2002/573627. PMID: 11930192.

11. Schutz SM, Abbott RM. 2000; Grading ERCPs by degree of difficulty: a new concept to produce more meaningful outcome data. Gastrointest Endosc. 51:535–539. DOI: 10.1016/S0016-5107(00)70285-9. PMID: 10805837.

12. Ragunath K, Thomas LA, Cheung WY, Duane PD, Richards DG. 2003; Objective evaluation of ERCP procedures: a simple grading scale for evaluating technical difficulty. Postgrad Med J. 79:467–470. DOI: 10.1136/pmj.79.934.467. PMID: 12954961. PMCID: PMC1742772.

13. Cotton PB, Eisen G, Romagnuolo J, et al. 2011; Grading the complexity of endoscopic procedures: results of an ASGE working party. Gastrointest Endosc. 73:868–874. DOI: 10.1016/j.gie.2010.12.036. PMID: 21377673.

14. Olsson G, Arnelo U, Swahn F, Törnqvist B, Lundell L, Enochsson L. 2017; The H.O.U.S.E. classification: a novel endoscopic retrograde cholangiopancreatography (ERCP) complexity grading scale. BMC Gastroenterol. 17:38. DOI: 10.1186/s12876-017-0583-z. PMID: 28274206. PMCID: PMC5343382.

15. Williams EJ, Ogollah R, Thomas P, et al. 2012; What predicts failed cannulation and therapy at ERCP? Results of a large-scale multicenter analysis. Endoscopy. 44:674–683. DOI: 10.1055/s-0032-1309345. PMID: 22696192.

16. Ekkelenkamp VE, de Man RA, Ter Borg F, et al. 2015; Prospective evaluation of ERCP performance: results of a nationwide quality registry. Endoscopy. 47:503–507. DOI: 10.1055/s-0034-1391231. PMID: 25590180.

17. Sahar N, La Selva D, Gluck M, et al. 2019; The ASGE grading system for ERCP can predict success and complication rates in a tertiary referral hospital. Surg Endosc. 33:448–453. DOI: 10.1007/s00464-018-6317-7. PMID: 29987568.

18. Dumonceau JM, Kapral C, Aabakken L, et al. 2020; ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 52:127–149. DOI: 10.1055/a-1075-4080. PMID: 31863440.

19. Niederau C, Pohlmann U, Lübke H, Thomas L. 1994; Prophylactic antibiotic treatment in therapeutic or complicated diagnostic ERCP: results of a randomized controlled clinical study. Gastrointest Endosc. 40:533–537. DOI: 10.1016/S0016-5107(94)70247-0. PMID: 7988813.

20. Sauter G, Grabein B, Huber G, Mannes GA, Ruckdeschel G, Sauerbruch T. 1990; Antibiotic prophylaxis of infectious complications with endoscopic retrograde cholangiopancreatography. A randomized controlled study. Endoscopy. 22:164–167. DOI: 10.1055/s-2007-1012830. PMID: 2209498.

21. Harris A, Chan AC, Torres-Viera C, Hammett R, Carr-Locke D. 1999; Meta-analysis of antibiotic prophylaxis in endoscopic retrograde cholangiopancreatography (ERCP). Endoscopy. 31:718–724. DOI: 10.1055/s-1999-153. PMID: 10604613.

22. Bai Y, Gao F, Gao J, Zou DW, Li ZS. 2009; Prophylactic antibiotics cannot prevent endoscopic retrograde cholangiopancreatography-induced cholangitis: a meta-analysis. Pancreas. 38:126–130. DOI: 10.1097/MPA.0b013e318189fl6d. PMID: 19238021.

23. Brand M, Bizos D, O'Farrell P Jr. Antibiotic prophylaxis for patients undergoing elective endoscopic retrograde cholangiopancreatography. Cochrane Database Syst Rev. 2010; (10):CD007345. DOI: 10.1002/14651858.CD007345.pub2. PMID: 20927758.

24. Motte S, Deviere J, Dumonceau JM, Serruys E, Thys JP, Cremer M. 1991; Risk factors for septicemia following endoscopic biliary stenting. Gastroenterology. 101:1374–1381. DOI: 10.1016/0016-5085(91)90091-X. PMID: 1936809.

25. Cotton PB, Connor P, Rawls E, Romagnuolo J. 2008; Infection after ERCP, and antibiotic prophylaxis: a sequential quality-improvement approach over 11 years. Gastrointest Endosc. 67:471–475. DOI: 10.1016/j.gie.2007.06.065. PMID: 18294510.

26. De Palma GD, Galloro G, Siciliano S, Iovino P, Catanzano C. 2001; Unilateral versus bilateral endoscopic hepatic duct drainage in patients with malignant hilar biliary obstruction: results of a prospective, randomized, and controlled study. Gastrointest Endosc. 53:547–553. DOI: 10.1067/mge.2001.113381. PMID: 11323577.

27. Bangarulingam SY, Gossard AA, Petersen BT, Ott BJ, Lindor KD. 2009; Complications of endoscopic retrograde cholangiopancreatography in primary sclerosing cholangitis. Am J Gastroenterol. 104:855–860. DOI: 10.1038/ajg.2008.161. PMID: 19259076.

28. Byl B, Devière J, Struelens MJ, et al. 1995; Antibiotic prophylaxis for infectious complications after therapeutic endoscopic retrograde cholangiopancreatography: a randomized, double-blind, placebo-controlled study. Clin Infect Dis. 20:1236–1240. DOI: 10.1093/clinids/20.5.1236. PMID: 7620004.

29. Navaneethan U, Jegadeesan R, Nayak S, et al. 2015; ERCP-related adverse events in patients with primary sclerosing cholangitis. Gastrointest Endosc. 81:410–419. DOI: 10.1016/j.gie.2014.06.030. PMID: 25085336.

30. Sethi A, Chen YK, Austin GL, et al. 2011; ERCP with cholangiopancreatoscopy may be associated with higher rates of complications than ERCP alone: a single-center experience. Gastrointest Endosc. 73:251–256. DOI: 10.1016/j.gie.2010.08.058. PMID: 21106195.

31. Thosani N, Zubarik RS, Kochar R, et al. 2016; Prospective evaluation of bacteremia rates and infectious complications among patients undergoing single-operator choledochoscopy during ERCP. Endoscopy. 48:424–431. DOI: 10.1055/s-0042-101407. PMID: 26919263.

32. Othman MO, Guerrero R, Elhanafi S, et al. 2016; A prospective study of the risk of bacteremia in directed cholangioscopic examination of the common bile duct. Gastrointest Endosc. 83:151–157. DOI: 10.1016/j.gie.2015.05.018. PMID: 26116469.

33. Bianco JA, Pepe MS, Higano C, Applebaum FR, McDonald GB, Singer JW. 1990; Prevalence of clinically relevant bacteremia after upper gastrointestinal endoscopy in bone marrow transplant recipients. Am J Med. 89:134–136. DOI: 10.1016/0002-9343(90)90289-P. PMID: 2382662.

34. Olsson G, Arnelo U, Lundell L, Persson G, Törnqvist B, Enochsson L. 2015; The role of antibiotic prophylaxis in routine endoscopic retrograde cholangiopancreatography investigations as assessed prospectively in a nationwide study cohort. Scand J Gastroenterol. 50:924–931. DOI: 10.3109/00365521.2014.990504. PMID: 25769041.

35. Domagk D, Oppong KW, Aabakken L, et al. 2018; Performance measures for endoscopic retrograde cholangiopancreatography and endoscopic ultrasound: A European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. United European Gastroenterol J. 6:1448–1460. DOI: 10.1177/2050640618808157. PMID: 30574315. PMCID: PMC6297928.

36. Udd M, Kylänpää L, Halttunen J. 2010; Management of difficult bile duct cannulation in ERCP. World J Gastrointest Endosc. 2:97–103. DOI: 10.4253/wjge.v2.i3.97. PMID: 21160709. PMCID: PMC2999064.

37. Testoni PA, Mariani A, Aabakken L, et al. 2016; Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 48:657–683. DOI: 10.1055/s-0042-108641. PMID: 27299638.

38. Saito H, Kadono Y, Shono T, et al. 2022; Factors predicting difficult biliary cannulation during endoscopic retrograde cholangiopancreatography for common bile duct stones. Clin Endosc. 55:263–269. DOI: 10.5946/ce.2021.153. PMID: 34763384. PMCID: PMC8995991.

39. DeBenedet AT, Elmunzer BJ, McCarthy ST, Elta GH, Schoenfeld PS. 2013; Intraprocedural quality in endoscopic retrograde cholangiopancreatography: a meta-analysis. Am J Gastroenterol. 108:1696–1704. quiz 1705DOI: 10.1038/ajg.2013.217. PMID: 23877349. PMCID: PMC3840532.

40. Buxbaum JL, Abbas Fehmi SM, Sultan S, et al. 2019; ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis. Gastrointest Endosc. 89:1075–1105. e15. DOI: 10.1016/j.gie.2018.10.001. PMID: 30979521. PMCID: PMC8594622.

41. Andriulli A, Loperfido S, Napolitano G, et al. 2007; Incidence rates of post-ERCP complications: a systematic survey of prospective studies. Am J Gastroenterol. 102:1781–1788. DOI: 10.1111/j.1572-0241.2007.01279.x. PMID: 17509029.

42. Carr-Locke DL. 2002; Therapeutic role of ERCP in the management of suspected common bile duct stones. Gastrointest Endosc. 56(6 Suppl):S170–S174. DOI: 10.1067/mge.2002.129024. PMID: 12447262.

43. Lauri A, Horton RC, Davidson BR, Burroughs AK, Dooley JS. 1993; Endoscopic extraction of bile duct stones: management related to stone size. Gut. 34:1718–1721. DOI: 10.1136/gut.34.12.1718. PMID: 8282260. PMCID: PMC1374470.

44. Wilkinson M. ERCP Working Party. 2014. June. ERCP - The Way Forward, A Standards Framework. [Internet]. British Society of Gastroenterology;Available from: https://www.bsg.org.uk/getattachment/74bb58bd-a04d-4a53-bf8c-8975106dafd5/ERCP-%e2%80%93-The-Way-Forward-A-Standards-Framework-1.pdf?lang=en-US. cited 2024 Apr 15.

45. Kim J, Park ET, Son BK, et al. 2017; ERCP educational guidelines for fellows. Korean J Pancreas Biliary Tract. 22:1–13. DOI: 10.15279/kpba.2017.22.1.1.

46. Ekkelenkamp VE, Koch AD, Haringsma J, et al. 2014; Quality evaluation through self-assessment: a novel method to gain insight into ERCP performance. Frontline Gastroenterol. 5:10–16. DOI: 10.1136/flgastro-2013-100334. PMID: 24416502. PMCID: PMC3880906.

47. Kochar B, Akshintala VS, Afghani E, et al. 2015; Incidence, severity, and mortality of post-ERCP pancreatitis: a systematic review by using randomized, controlled trials. Gastrointest Endosc. 81:143–149.e9. DOI: 10.1016/j.gie.2014.06.045. PMID: 25088919.

48. Anderson MA, Fisher L, Jain R, et al. 2012; Complications of ERCP. Gastrointest Endosc. 75:467–473. DOI: 10.1016/j.gie.2011.07.010. PMID: 22341094.

49. Lee HJ, Cho CM, Heo J, et al. 2020; Impact of hospital volume and the experience of endoscopist on adverse events related to endoscopic retrograde cholangiopancreatography: A prospective observational study. Gut Liver. 14:257–264. DOI: 10.5009/gnl18537. PMID: 31060119. PMCID: PMC7096235.

50. Cheng CL, Sherman S, Watkins JL, et al. 2006; Risk factors for post-ERCP pancreatitis: a prospective multicenter study. Am J Gastroenterol. 101:139–147. DOI: 10.1111/j.1572-0241.2006.00380.x. PMID: 16405547.

51. Ding X, Zhang F, Wang Y. 2015; Risk factors for post-ERCP pancreatitis: A systematic review and meta-analysis. Surgeon. 13:218–229. DOI: 10.1016/j.surge.2014.11.005. PMID: 25547802.

52. Cotton PB, Lehman G, Vennes J, et al. 1991; Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc. 37:383–393. DOI: 10.1016/S0016-5107(91)70740-2. PMID: 2070995.

53. Freeman ML, DiSario JA, Nelson DB, et al. 2001; Risk factors for post-ERCP pancreatitis: a prospective, multicenter study. Gastrointest Endosc. 54:425–434. DOI: 10.1067/mge.2001.117550. PMID: 11577302.

54. Hou YC, Hu Q, Huang J, Fang JY, Xiong H. 2017; Efficacy and safety of rectal nonsteroidal anti-inflammatory drugs for prophylaxis against post-ERCP pancreatitis: a systematic review and meta-analysis. Sci Rep. 7:46650. DOI: 10.1038/srep46650. PMID: 28440297. PMCID: PMC5404221.

55. Fan JH, Qian JB, Wang YM, Shi RH, Zhao CJ. 2015; Updated meta-analysis of pancreatic stent placement in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis. World J Gastroenterol. 21:7577–7583. DOI: 10.3748/wjg.v21.i24.7577. PMID: 33244208. PMCID: PMC7656216.

56. Buxbaum J, Yan A, Yeh K, Lane C, Nguyen N, Laine L. 2014; Aggressive hydration with lactated Ringer's solution reduces pancreatitis after endoscopic retrograde cholangiopancreatography. Clin Gastroenterol Hepatol. 12:303–307.e1. DOI: 10.1016/j.cgh.2013.07.026. PMID: 23920031. PMCID: PMC3879172.

57. Bae SS, Lee DW, Han J, Kim HG. 2019; Risk factor of bleeding after endoscopic sphincterotomy in average risk patients. Surg Endosc. 33:3334–3340. DOI: 10.1007/s00464-018-06623-8. PMID: 30604265.

58. Freeman ML. 1997; Complications of endoscopic biliary sphincterotomy: a review. Endoscopy. 29:288–297. DOI: 10.1055/s-2007-1004193. PMID: 9255535.

59. Anderson MA, Ben-Menachem T, Gan SI, et al. 2009; Management of antithrombotic agents for endoscopic procedures. Gastrointest Endosc. 70:1060–1070. DOI: 10.1016/j.gie.2009.09.040. PMID: 19889407.

60. Veitch AM, Radaelli F, Alikhan R, et al. 2021; Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update. Gut. 70:1611–1628. DOI: 10.1136/gutjnl-2021-325184. PMID: 34362780. PMCID: PMC8355884.

61. Paspatis GA, Arvanitakis M, Dumonceau JM, et al. 2020; Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement-Update 2020. Endoscopy. 52:792–810. DOI: 10.1055/a-1222-3191. PMID: 32781470.

62. Masci E, Toti G, Mariani A, et al. 2001; Complications of diagnostic and therapeutic ERCP: a prospective multicenter study. Am J Gastroenterol. 96:417–423. DOI: 10.1111/j.1572-0241.2001.03594.x. PMID: 11232684.

63. Stapfer M, Selby RR, Stain SC, et al. 2000; Management of duodenal perforation after endoscopic retrograde cholangiopancreatography and sphincterotomy. Ann Surg. 232:191–198. DOI: 10.1097/00000658-200008000-00007. PMID: 10903596. PMCID: PMC1421129.

64. Chandrasekhara V, Khashab MA, Muthusamy VR, et al. 2017; Adverse events associated with ERCP. Gastrointest Endosc. 85:32–47. DOI: 10.1016/j.gie.2016.06.051. PMID: 27546389.

65. Enns R, Eloubeidi MA, Mergener K, et al. 2002; ERCP-related perforations: risk factors and management. Endoscopy. 34:293–298. DOI: 10.1055/s-2002-23650. PMID: 11932784.

66. Cotton PB, Garrow DA, Gallagher J, Romagnuolo J. 2009; Risk factors for complications after ERCP: a multivariate analysis of 11,497 procedures over 12 years. Gastrointest Endosc. 70:80–88. DOI: 10.1016/j.gie.2008.10.039. PMID: 19286178.

67. Miller R, Zbar A, Klein Y, et al. 2013; Perforations following endoscopic retrograde cholangiopancreatography: a single institution experience and surgical recommendations. Am J Surg. 206:180–186. DOI: 10.1016/j.amjsurg.2012.07.050. PMID: 23870391.

68. Kim J, Lee SH, Paik WH, et al. 2012; Clinical outcomes of patients who experienced perforation associated with endoscopic retrograde cholangiopancreatography. Surg Endosc. 26:3293–3300. DOI: 10.1007/s00464-012-2343-z. PMID: 22648110.

69. Byun JW, Kim JW, Sung SY, et al. 2012; Usefulness of forward-viewing endoscope for endoscopic retrograde cholangiopancreatography in patients with Billroth II gastrectomy. Clin Endosc. 45:397–403. DOI: 10.5946/ce.2012.45.4.397. PMID: 23251888. PMCID: PMC3521942.

70. Park TY, Kang JS, Song TJ, et al. 2016; Outcomes of ERCP in Billroth II gastrectomy patients. Gastrointest Endosc. 83:1193–1201. DOI: 10.1016/j.gie.2015.10.036. PMID: 26546981.

71. Kurzynske FC, Romagnuolo J, Brock AS. 2015; Success of single-balloon enteroscopy in patients with surgically altered anatomy. Gastrointest Endosc. 82:319–324. DOI: 10.1016/j.gie.2015.01.017. PMID: 25841583.