Endoscopic retrograde cholangiopancreatography in pediatric and adult populations: 17-year experience from Pakistan with trends, complications, and global comparison

Table 1 Proposed quality indicators for endoscopic retrograde cholangiopancreatography

Quality indicators	Grade of recommendation	Measure type	Performance target, %	Target achieved
Pre-procedure
Frequency with which ERCP is performed for an indication that is included in a published standard list of appropriate indications, and the indication is documented (priority indicator)	1C+	Process	> 90.0	Yes
Frequency with which informed consent is obtained, including specific discussions of risks associated with ERCP, and fully documented medical consent is obtained and fully documented	1C	Process	> 98.0	Yes
Frequency with which appropriate antibiotics for ERCP are administered for settings in which they are indicated	2B	Process	> 98.0	Yes
Frequency with which ERCP is performed by an endoscopist who is fully trained and credentialed to perform ERCP	3	Process	> 98.0	Yes
Frequency with which the volume of ERCP procedures performed per year is recorded per endoscopist	1C	Process	> 98.0	Yes
Procedure
Frequency with which deep cannulation of the ducts of interest is documented	1C	Process	> 98.0	Yes
Frequency with which deep cannulation of the ducts of interest in patients with native papillae without surgically altered anatomy is achieved and documented (priority indicator)	1C	Process	> 90.0	Yes
Frequency with which fluoroscopy time and radiation dose are measured and documented	2C	Process	> 98.0	No
Frequency with which CBD stones (1 cm) in patients with normal bile duct anatomy are extracted successfully and documented (priority indicator)	1C	Outcome	> 90.0	Yes
Frequency with which stent placement for biliary obstruction in patients with normal anatomy, whose obstruction is below the bifurcation, is successfully achieved and documented (priority indicator)	1C	Outcome	> 90.0	Yes
Post-procedure
Frequency with which a complete ERCP report that details the specific techniques performed, particular accessories used, and all intended outcomes is prepared	3	Process	> 98.0	Yes
Frequency with which acute adverse events and hospital transfers are documented	3	Process	> 98.0	Yes
Rate of post-ERCP pancreatitis (priority indicator)	1C	Outcome	N/A	Yes
Rate and type of perforation	2C	Outcome	< 0.2	Yes
Rate of clinically significant hemorrhage after sphincterotomy or sphincteroplasty in patients undergoing ERCP	1C	Outcome	< 1.0	Yes
Frequency with which patients are contacted at 14 days or greater to detect and record the occurrence of delayed adverse events after ERCP	3	Process	> 90.0	Yes

CBD: Common bile duct; ERCP: Endoscopic retrograde cholangiopancreatography; N/A: Not available.

Table 2 Demographics and procedural parameters of the included endoscopic retrograde cholangiopancreatography procedures

Characteristics	n (%)/mean ± SD
Sex
Male	5392 (40.8)
Female	7823 (59.2)
Age in years
< 18 (pediatric)	533 (4.0)
0-3 (toddlers)	6
4-11 (childhood)	126
12-18 (adolescence)	401
> 18 (adult)	12682 (96.0)
Mean age, years	46.50 ± 16.03
Clinical symptoms
Jaundice	6308 (47.7)
Abdominal pain	5911 (44.7)
Other	996 (7.6)
Laboratory parameters
Increased total bilirubin	8515 (64.4)
Mean total bilirubin in mg/dL	9.50 ± 48.86
Increased ALP	10256 (77.6)
Mean ALP in IU/L	605.6 ± 1218.4
Post-ERCP pancreatitis	356 (2.7)
Mild pancreatitis	164 (1.2)
Moderate pancreatitis	136 (1.0)
Severe pancreatitis	56 (0.4)
Clinically significant bleeding after EST/EPLBD	230 (1.7)
Hemostasis with balloon tamponade	35 (0.2)
Hemostasis with adrenaline spray	195 (1.5)
Cardio pulmonary adverse effects	31 (0.2)
Perforation	26 (0.2)
Death	5 (0.0)

ALP: Alkaline phosphatase; ERCP: Endoscopic retrograde cholangiopancreatography; EST: Endoscopic sphincterotomy; EPLBD: Endoscopic papillary large balloon dilation.

Table 3 Endoscopic retrograde cholangiopancreatography cases

Type	n	%
Biliary cases	12298	100.0
Native	9196	74.8
Follow-up	3102	25.2
Pancreatic cases	567	100.0
Native1	346	61.0
Follow-up	221	38.9

¹Inadvertent pancreatic duct cannulation was reported in 202 cases, they were not included as pancreatic cases.

Table 4 Imaging findings in native cases (indications)

Types	n	%
Benign biliary cases
Choledocholithiasis	3682	40.0
Bile leak	466	5.1
Choledochal cyst	22	0.2
CBD worms	21	0.2
Unspecified jaundice1	3046	33.1
Malignant cases
Pancreatic mass	389	4.2
Perihilar	145	1.6
Periampullary mass	1307	14.2
Gallbladder mass	118	1.3
Pancreatic cases
Chronic pancreatitis	201	58.1
Other	145	41.9

¹Unspecified obstructive jaundice was defined as increased total bilirubin (> 1.3 mg/dL) and alkaline phosphatase (> 125 U/L) along with evidence of biliary dilatation on imaging.

CBD: Common bile duct.

Table 5 Endoscopic retrograde cholangiopancreatography findings of native biliary and pancreatic cases

ERCP findings	n	%
Benign cases
CBD stones	4901	53.2
Mirizzi syndrome	53	0.6
Normal CBD	1545	16.8
Bile leak	740	8.0
Post-laparoscopic cholecystectomy stricture	55	0.6
CBD worms	28	0.3
Choledochal cyst	61	0.7
Cannulation successful in benign biliary cases	6955	94.2
Cannulation unsuccessful in benign biliary cases	428	5.8
Malignant strictures
Periampullary cancer	477	5.2
Gallbladder mass	66	0.7
Perihilar stricture	329	3.6
Pancreatic mass	262	2.9
Indeterminate stricture	679	7.4
Total malignant strictures	1813	19.7
Gastric outlet obstruction, ampulla not accessed	350
Cannulation successful in malignant strictures	1681	92.7
Cannulation unsuccessful in malignant stricture cases	132	7.3
Pancreatic cases
Normal PD	27	7.8
Dilated PD	160	46.2
DPDS	22	6.4
PD stones	83	24.0
PD stricture	80	23.1
Pancreatic divisum	75	21.7

CBD: Common bile duct; PD: Pancreatic duct; DPDS: Disconnected pancreatic duct syndrome.

Table 6 Characteristics of cases with common bile duct stones that underwent endoscopic retrograde cholangiopancreatography

CBD stones	n (%)
Biliary stones	6323 (52.3)
Duct clearance
Index duct cleared	4901 (77.5)
Follow-up duct clearance	1422 (22.5)
Interventions
Sphincterotomy	4883 (39.7)
Sphincteroplasty	965 (7.8)
Basket	418 (3.4)
Spyglass EHL	201 (1.6)
Maneuvers
Biliary sphincterotomy	8347 (67.8)
Balloon sphincteroplasty	1024 (8.3)
Needle-knife papillotomy	714 (5.8)
Cholangioscopy and EHL	214 (1.7)
Trapezoid basket	432 (3.5)
Soehendra dilator	94 (0.8)
Biliary stenting	5381 (43.8)
CBD cleared in one session	1683 (13.7)

All the percentages were calculated from the total biliary cases. CBD: Common bile duct; EHL: Electrohydraulic lithotripsy.

Table 7 Number of endoscopic retrograde cholangiopancreatography procedures per patient

Number of procedures	n	%
18	1	0.007
17	1	0.007
16	1	0.007
15	1	0.007
14	1	0.007
13	1	0.007
12	2	0.015
11	3	0.022
10	5	0.037
9	9	0.068
8	20	0.151
7	61	0.461
6	109	0.824
5	255	1.929
4	631	4.774
3	2116	16.01
2	2116	16.01
1	7882	59.64
Total	13215	100