Should Specialist Endoscopists Perform All Complicated Endoscopies?

Dear Sir,
We have read with great interest the paper by Dafnis et al. [1] regarding the impact of endoscopist experience and learning curves on colonoscopy completion rates. The authors analyzed the completion and complication rates of 5494 colonoscopies in a Swedish county with a population of 258 000 over a period of 17 years. Although the overall completion rate was 75 %, the authors confirmed the importance of experience and intensity of workload in achieving a better completion rate.

We recently performed a retrospective outcomes study for endoscopic retrograde cholangiopancreatography (ERCP) at our endoscopy unit, which is in a district hospital with a moderate ERCP workload (about four per week). From September 1998 to April 2000, a total of 341 ERCPs were performed. Of these, 181 procedures (group 1) were performed by “nonspecialist endoscopists” and 160 procedures (group 2) were done by “specialist endoscopists.” A specialist endoscopist was arbitrarily defined as one who had undergone a structured training program in gastrointestinal endoscopy, had performed more than 300 ERCPs, and held a specialist qualification in gastrointestinal medicine or surgery. Those who did not fulfil all three criteria were assigned to the nonspecialist group. Outcome measures included numbers of failed procedures, successful diagnostic procedures (defined as selective cannulation of desired duct), and therapeutic procedures (defined as sphincterotomy and/or stone removal, nasobiliary drainage, stent insertion). Other outcome measures included complications (according to Cotton et al. [2]); length of hospital stay; and 30-day mortality.

The median patient ages were 69 (interquartile range [IQR] 28 - 97) and 70.5 (IQR 23 - 93) in groups 1 and 2, respectively. There was no difference in the indications for ERCP between the groups. Although there was no difference in co-morbidity between the two groups, more patients in group 2 presented with hypotension (systolic pressure < 90 mmHg) before ERCP (group 1, 5 %; group 2, 11 %; P = 0.03). In group 1, there were significantly more failed procedures and fewer therapeutic procedures compared with group 2 (group 1, failed 50 [28 %], diagnostic 62 [34 %], therapeutic 69 [38 %]; group 2, failed 18 [11 %], diagnostic 37 [23 %], therapeutic 105 [66 %]; P < 0.01). In group 1 there were 13 instances of complications (7 %), i. e. pancreatitis 6, cholangitis 2, hemorrhage 1, and perforation 4; in group 2 there were four (2.5 %), i. e. pancreatitis 3 and perforation 1 (P = 0.047). The median hospital stays were 7 and 8 days (P = 0.13), and the overall mortalities were 1.7 % and 0.6 % (P = 0.63), in groups 1 and 2, respectively. We concluded that specialist endoscopists had performed a higher percentage successful therapeutic ERCPs with a lower complication rate, and therefore all ERCPs should be performed by specialist endoscopists.

Our study and that of Dafnis et al. [1] have demonstrated an obvious yet important point, that complicated endoscopic procedures such as colonoscopy and ERCP should be performed by experienced and competent endoscopists in order to achieve a higher success rate with possibly lesser complications. Freeman et al. [3] and Loperfido et al. [4] have also previously demonstrated that a higher intensity of workload was associated with lower complication rates in therapeutic ERCPs. From these studies, it is prudent to assume that the experience and the volume of work needed to maintain the proficiency of the individual endoscopist are equally important in determining the outcomes in complicated endsocopies. In a low-volume endoscopy unit, where competent endoscopists may not be available, referral to a tertiary center should be recommended for complicated endoscopies, in order to achieve a higher standard of care.

References

• 1 Dafnis G, Granath F, Pahlman L. et al . The impact of endoscopists' experience and learning curves and interendoscopist variation on colonoscopy completion rates.  Endoscopy. 2001;  33 511-517
• 2 Cotton P B, Lehman G, Vennes J. et al . Endoscopic sphincterotomy complications and their management: an attempt at consensus.  Gastrointest Endosc. 1991;  37 383-393
• 3 Freeman M L, Nelson D B, Sherman S. et al . Complications of endoscopic biliary sphincterotomy.  N Engl J Med. 1996;  335 909-918
• 4 Loperfido S, Angelini G, Benedetti G. et al . Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study.  Gastrointest Endosc. 1998;  48 1-10