Time Trend of the Radiation Exposure Dose in Endoscopic Retrograde Cholangiopancreatography Over an 8-Year Period: A Single-Center Retrospective Study.

INTRODUCTION: The global needs for a reduction in radiation exposure (RE) are increasing. Endoscopic retrograde cholangiopancreatography (ERCP) is a significant fluoroscopic procedure in the gastrointestinal field. However, the actual RE in ERCP and its annual trend are still unclear. Therefore, we examined the yearly trend of RE in ERCP. METHODS: This retrospective, single-center cohort study included consecutive cases of ERCP from September 2012 to June 2019. We measured the air kerma (AK, mGy), dose area product (DAP, Gycm2), and fluoroscopy time (FT, min). We also evaluated the annual trend of the RE before and after the fluoroscopy device update. RESULTS: In total, 2,174 patients receiving ERCP were enrolled. Among these, the mean age was 74.3 years, and 913 patients were women (42.0%). The median/third quartile values of AK (mGy), DAP (Gycm2), and FT (min) were 109/234 mGy, 13.3/25.8 Gycm2, and 18.2/27.7 minutes. The annual AK, DAP, and FT from 2012 to 2019 were 138, 207, 173, 177, 106, 71.0, 45.0, and 33.3 mGy; 23, 21.4, 19, 18.3, 11.9, 9.0, 6.8, and 6.4 Gycm2; and 12.5, 12.1, 9.7, 9.8, 8.2, 10.8, 9.4, and 10.3 minutes, respectively. The corresponding values before and after the update in July 2016 were 177 and 52 mGy (P < 0.0001), 19.2 and 7.6 Gycm2 (P < 0.0001), and 10.2, and 9.9 minutes (P = 0.05), respectively. DISCUSSION: The RE from ERCP tended to decrease every year, especially after fluoroscopy device updates.

Nationwide Evolution of Pediatric Endoscopic Retrograde Cholangiopancreatography Indications, Utilization, and Readmissions over Time.

OBJECTIVES: To analyze outcome and utilization trends over time of pediatric endoscopic retrograde cholangiopancreatography (ERCP) in an all-capture US population-level study. STUDY DESIGN: Using the National Inpatient Sample (2005-2014) and National Readmission Database (2010-2014), we identified pediatric (age <20 years) hospitalizations during which ERCP was performed and assessed ERCP-associated readmissions. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify hospitalization diagnoses, comorbidities, and patient/hospital characteristics. Multivariate logistic regression analyses were performed to determine significant predictors (P < .05) of 30-day readmission. RESULTS: A total of 11 060 hospitalized pediatric patients underwent ERCP between 2005 and 2014. Most were female (n = 8859; 81%), aged 14-20 years (n = 9342; 84%), and white (n = 4230; 45%). Most (85%) of ERCPs were therapeutic, and leading indications were biliary (n = 5350; 48%) and pancreatitis (n = 3218; 29%). Thirteen pecent of patients were readmitted post-ERCP. Odds for 30-day readmission were highest for patients with a history of liver transplantation, age 0-4 years, male sex, and obesity (P < .001 for each). Patients in both urban teaching and urban hospitals had much lower odds than those in rural hospitals for prolonged length of stay associated with ERCP. CONCLUSIONS: These data represent a comprehensive study of nationwide trends in age-specific volumes and outcomes following ERCP in the pediatric population and provide important insights into trends in pediatric pancreaticobiliary disease management, as well as practice setting, patient characteristics, and patient comorbidities associated with pediatric post-ERCP outcomes, including readmission and length of stay.

Use of an Ultra-slim Gastroscope to Accomplish Endoscopist-Facilitated Rescue Intubation During ERCP: A Novel Approach to Enhance Patient and Staff Safety.

BACKGROUND: ERCP is often performed under monitored anesthesia care (MAC) rather than general anesthesia (GA), with patients positioned semi-prone on the fluoroscopy table. Rarely, a MAC ERCP must be converted to GA due to hypoxia or retained food in the stomach. In these circumstances, standard intubation is associated with a significant delay and potential for patient/staff injury during repositioning. We report a novel endoscopist-driven approach to intubation during ERCP using an ultra-slim, flexible gastroscope with an endotracheal tube backloaded onto it. MATERIALS AND METHODS: We identified patients who underwent ERCP from 2014 to 2019, and MAC to GA conversion events. Mode of intubation (standard vs. endoscopist-facilitated) and patient/procedure characteristics were evaluated. All endoscopist-facilitated intubations were performed under anesthesiologist supervision. RESULTS: A total of 3409 patients underwent ERCP; 1568 (46%) GA and 1841 (54%) MAC. Of these, 42 (2.3%) required intubation during ERCP and 16 underwent endoscopist-facilitated intubation due to retained food in the stomach and/or hypoxia. In 3 patients, aspirated material was suctioned from the trachea and bronchi using the ultra-slim gastroscope. Immediate post-procedure extubation was successful in all endoscopist-facilitated intubation patients and none exhibited radiographic evidence of aspiration pneumonia. CONCLUSIONS: Endoscopist-facilitated intubation using an ultra-slim flexible gastroscope is feasible and expeditious for MAC to GA conversion during ERCP. This technique is readily accomplished in the semi-prone position, while standard intubation requires patient transfer from fluoroscopy table to gurney, with associated delay/risks. These data suggest that further study of this approach is warranted, and this may be the most favorable approach for intubation during ERCP.

Trends in same-admission cholecystectomy and endoscopic retrograde cholangiopancreatography for acute gallstone pancreatitis: A nationwide analysis across a decade.

BACKGROUND/OBJECTIVES: Gallstones are the leading cause of acute pancreatitis in developed countries. National and international guidelines recommend that a cholecystectomy should be performed during the index hospitalization for acute gallstone pancreatitis. We aimed to delineate the national trends for same-admission cholecystectomy and ERCP for acute gallstone pancreatitis over the last ten years. METHODS: We used the 2004, 2009 and 2014 National Inpatient Sample database including patients with a principal diagnosis of acute pancreatitis and a secondary diagnosis of choledocholithiasis or cholelithiasis. Exclusion criteria were age <18 years and elective admission. Primary outcome was the trend in incidence rate of same admission cholecystectomy from 2004 to 2014. The secondary outcomes were: 10-year trend in 1) Incidence of gallstone pancreatitis, 2) proportion of gallstone pancreatitis compared to all other etiologies of acute pancreatitis, 3) incidence rate of same-admission ERCP, 4) length of hospital stay, and 5) total hospitalization costs and charges. RESULTS: The proportion of admissions during which a same-admission cholecystectomy was performed decreased from 48.7% in 2004 to 46.9% in 2009 to 45% in 2014 (trend p < 0.01). During the same time interval, the percentage of admissions during which an ERCP was performed decreased from 25.1% to 18.7% (Trend p < 0.01). CONCLUSIONS: Adherence to the guidelines for same-admission cholecystectomy for patients admitted with acute gallstone pancreatitis have been declining over the past decade. On the other hand, decline in rate of ERCP in patients with acute gallstone pancreatitis and no signs of cholangitis demonstrates adherence to guidelines in this regard.

National trends of endoscopic retrograde cholangiopancreatography utilization and outcomes in decompensated cirrhosis.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) can be challenging in patients with decompensated cirrhosis (DC) due to increased risk of adverse events related to liver dysfunction. Limited data exist regarding its national utilization in patients with DC. We aim to determine the trends in utilization and outcomes of ERCP among patients with DC in US hospitalizations. METHODS: We identified hospitalizations undergoing ERCP (diagnostic and therapeutic) between 2000 and 2013 from the National Inpatient Sample (NIS) database and used validated ICD9-CM codes to identify DC hospitalizations. We utilized Cochrane-Armitage test to identify changes in trends and multivariable survey regression modeling for adjusted odds ratios (aOR) for adverse outcomes and mortality predictors. RESULTS: There were 43782 cases of ERCPs performed in DC patients during the study period. Absolute number of ERCPs performed in this population from 2000 to 2013 showed an upward trend; however, the proportion of DC patients undergoing ERCP remained stable. We noted significant decrease in utilization of diagnostic ERCP and an increase of therapeutic ERCPs (P < 0.01). There was a significant decrease in the mean length of stay for DC patients undergoing ERCP from 8.2 days in 2000 to 7.2 days in 2013 (P < 0.01) with an increase in the mean cost of hospitalization from $17053 to $19825 (P < 0.001). Mortality rates showed a downward trend from 2000 to 2013 from 13.6 to 9.6% (P < 0.01). Increasing age, Hispanic race, diagnosis of hypertension and diabetes mellitus, and private insurance were related to adverse discharges(P < 0.01). Increasing age, presence of hepatic encephalopathy, and sepsis were associated with higher mortality (P < 0.01). CONCLUSIONS: There is an increasing trend in therapeutic ERCP utilization in DC hospitalizations nationally. There is an overall decrease in mortality in DC hospitalizations undergoing ERCP. This improvement in mortality suggests improvement in both procedural technique and peri-procedural care as well as overall decreasing mortality in cirrhosis.

Periampullary Diverticula and ERCP Outcomes: A Systematic Review and Meta-Analysis.

INTRODUCTION: Periampullary diverticulum (PAD) is most often asymptomatically found in elderly population. ERCP in the presence of PAD is technically challenging since the location and orientation of the ampulla could be altered. Various studies have reported differing results on the technical success and safety outcomes of ERCP in the presence of PAD. We aimed at a meta-analysis of such studies to assess the technical success and the occurrence of complications during ERCP in patients with PAD. METHODS: We conducted a comprehensive search of several databases and conference proceedings including PubMed, EMBASE, and Web of Science databases (earliest inception to October 2017). The search was done in accordance with PRISMA guidelines to identify studies. Studies that reported on the ERCP outcomes based on the presence of PAD were included. Both prospective and retrospective studies, manuscripts and abstracts were included. Only articles in English literature were included. The primary analysis focused on the overall technical success of ERCP in the presence of PAD, and the secondary analysis was to estimate the risk of occurrence of complications. RESULTS: Our search resulted in 16 studies that were included for final analysis. These 16 studies reported on 2794 patients, who had PAD, and the control group included 13,032 patients, who did not have a PAD during ERCP. Our meta-analysis of this data showed an Odd's ratio estimate of having a successful ERCP procedure in patients with PAD to be 0.51 [95% C.I. (0.35-0.72)] when compared to patients without it. This was statistically significant, with a p value 0.00. Considerable heterogeneity was noted among the studies. The heterogeneity proportion was quantified at 74.6% based on I2 statistic. The secondary outcomes measured were complications. We analyzed the pooled Post-ERCP Pancreatitis (PEP), cholangitis, perforation, and bleeding. Only those studies that had the data for these complications in both the study and the control groups were selected. PEP: The pooled Odd's estimate of having PEP was 1.28, [95% C.I (0.88-1.87)] from 12 studies reporting on 1863 patients with PAD in comparison with 7803 patients without it. The risk of PEP occurrence tended to be more in the group without PAD, though it was not statistically significant, with a p value 0.20. There was some heterogeneity observed between the studies, with the quantification I2 statistic being 28.6%. Our analysis shows that having PAD does not put a patient at increased risk for PEP. Bleeding: The pooled Odds estimate was 1.69, 95% C.I. 0.88-3.25 from nine studies reporting on 1816 patients with PAD in comparison with 5327 patients without it. This was not statistically significant, p value 0.11. Considerable heterogeneity was noted, with I2 being 55.7%. The risk of having a bleed was noted to be more in control group, and having PAD did not put patients at increased risk for bleeding during an ERCP procedure. Perforation: Patients with PAD undergoing ERCP were not at increased risk for perforation. Seven studies reported on this complication. This was noted in seven patients out of 1245 in study group, and 19 patients out of 4912 in control group. The pooled Odd's estimate was 1.24, 95% C.I. 0.54-2.87. There was no statistical significance, p value 0.61. No heterogeneity was noted among the studies included in this analysis. Cholangitis: Only four studies reported on this complication. In a total of 778 patients in study group, four had cholangitis and eight had this complication out of 3886 patients in the control group. The pooled Odd's was 2.12, 95% C.I. 0.61-7.33. There was no statistical significance, p value 0.24. No heterogeneity was noted. CONCLUSION: ERCP is technically feasible and increasingly successful when performed by experts in the presence of PAD. The risk of complications such as PEP, bleeding, perforation and cholangitis does not differ between ERCP done in patients with and without PAD.

Trends in the timing of inpatient ERCP relative to cholecystectomy: a nationwide database studied longitudinally.

BACKGROUND AND AIMS: ERCP has largely replaced common bile duct exploration for therapy of common bile duct pathology, yet its use as a purely diagnostic test has declined. Among inpatients, we hypothesized that timing between ERCP and cholecystectomy (CCY) has changed. The objectives were to measure temporal trends in the timing between inpatient ERCP and CCY and to examine factors associated with delays. METHODS: We used the National Inpatient Sample between 1998 and 2013 to classify admissions for gallstone-related diagnoses undergoing inpatient CCY and ERCP by timing relative to CCY: within (±) 1 day, ≥2 days before, and ≥2 days after. Logistic regression and Poisson regression were used to determine pattern utilization and association of ERCP timing on hospital length of stay. RESULTS: Between 1998 and 2013, the proportion of admissions for CCY associated with same-stay ERCP increased (14.5% in 1998 to 17.3% in 2013, P < .001), and approximately two-thirds of ERCPs were performed within 1 day of CCY. After adjusting for covariates, the mean adjusted length of stay remained significantly shorter for patients who underwent CCY within 1 day of ERCP (5.13 vs 7.48 days for ERCP ≥2 days before and vs 7.41 days for ERCP ≥2 days after, P < .001). CONCLUSIONS: Use of inpatient ERCP in conjunction with CCY has increased minimally between 1998 and 2013, whereas length of stay has decreased. ERCPs performed within 1 day of CCY were associated with shorter hospital length of stay, suggesting delays between inpatient procedures should be minimized unless medical comorbidities preclude it.

Temporal trends in utilization and outcomes of endoscopic retrograde cholangiopancreatography in acute cholangitis due to choledocholithiasis from 1998 to 2012.

BACKGROUND AND AIMS: Expeditious endoscopic retrograde cholangiopancreatography (ERCP) in acute cholangitis with biliary decompression is associated with better outcomes. In this study, we evaluated the temporal trends of ERCP utilization and healthcare outcomes among patients hospitalized with acute cholangitis due to choledocholithiasis (CDC) from 1998 to 2012. METHODS: We identified patients with a combined diagnosis of cholangitis and choledocholithiasis from the national inpatient sample database. The temporal trends of ERCP usage and outcomes were analyzed. Based on timing of the procedure, we arbitrarily divided ERCPs into urgent (<24 h), early(24-48 h), and delayed ERCP(>48 h) groups. In addition, trends in length of stay (LOS), hospital charges, and in-hospital mortality rates were evaluated. RESULTS: In-patient admissions for CDC increased by 105.7%. Overall ERCP rate also increased significantly from 66.5 ± 2.3% in 1998 to 80.3 ± 0.93% in 2012, particularly after 2006-2007. There was a significant increase in proportion of urgent and early ERCPs. In the early ERCP group, there was a significant decrease in LOS (6.4 ± 0.43 days in 1998 to 5.8 ± 0.24 days in 2012) and mortality rate (2.4 ± 1.4% in 1998 to 0.33 ± 0.33% in 2012). Hospital charges increased in all ERCP groups, but most significantly in delayed ERCP group ($20,448 ± 1611 in 1998 to $90,566 ± 6122 in 2012). CONCLUSION: In-patient admissions for CDC and ERCP rates have increased significantly, particularly evident after 2006-2007. This may be attributed to increasing incidence of gallstones and wider implementation of Tokyo guidelines for the management of acute cholangitis. In-hospital morality and LOS reduced significantly in early ERCP group, whereas hospital charges increased most significantly in delayed ERCP group.

Safety and Efficacy of Endoscopic Retrograde Cholangiopancreatography for Choledocholithiasis in Long-Term Dialysis: A Propensity Score Analysis.

BACKGROUND AND AIM: Previous studies evaluating the safety of endoscopic retrograde cholangiopancreatography (ERCP) in patients with end-stage renal disease (ESRD) undergoing hemodialysis reported an increased risk of post-procedural bleeding. We investigated the safety and efficacy of ERCP for the treatment of choledocholithiasis in patients with ESRD undergoing long-term dialysis. METHODS: A total of 3466 patients who underwent ERCP due to choledocholithiasis between January 2000 and Feb 2018 were reviewed and analyzed retrospectively. Patients were divided into dialysis and non-dialysis group, and propensity score matching was used to minimize selection bias. RESULTS: Patients of dialysis group (n = 39) and non-dialysis group (n = 78) were compared after propensity score matching. Among 39 patients of dialysis group, hemodialysis was used in 28 (71.8%) patients for renal replacement therapy, while 11 (28.2%) patients received peritoneal dialysis. The median duration of dialysis was 8 years (range 1-24 years). Overall success rate of ERCP was not different between two groups. The overall prevalence of post-procedural complications in dialysis group and non-dialysis group was 28.2 and 15.4%, respectively (p = 0.100). Post-procedural bleeding occurred more frequently in dialysis group than non-dialysis group (23.1 vs 5.1%, p = 0.004). All procedure-related bleeding episodes were successfully controlled using endoscopic management. Prevalence of post-ERCP pancreatitis, infection, and perforation were not significantly different between two groups (p > 0.05). CONCLUSIONS: Overall success rate of complete ductal clearance was not different between dialysis and non-dialysis groups. The risk of post-procedural bleeding seems to be increased in patients with ESRD undergoing long-term dialysis.

Evolution in the utilization of biliary interventions in the United States: results of a nationwide longitudinal study from 1998 to 2013.

BACKGROUND AND AIMS: Bile duct surgery (BDS), percutaneous transhepatic cholangiography (PTC), and ERCP are alternative interventions used to treat biliary disease. Our aim was to describe trends in ERCP, BDS, and PTC on a nationwide level in the United States. METHODS: We used the National Inpatient Sample to estimate age-standardized utilization trends of inpatient diagnostic ERCP, therapeutic ERCP, BDS, and PTC between 1998 and 2013. We calculated average case fatality, length of stay, patient demographic profile (age, gender, payer), and hospital characteristics (hospital size and metropolitan status) for these procedures. RESULTS: Total biliary interventions decreased over the study period from 119.8 to 100.1 per 100,000. Diagnostic ERCP utilization decreased by 76%, and therapeutic ERCP utilization increased by 35%. BDS rates decreased by 78% and PTC rates by 24%. ERCP has almost completely supplanted surgery for the management of choledocholithiasis. Fatality from ERCP, BDS, and PTC have all decreased, whereas mean length of stay has remained stable. The proportion of Medicare-insured, Medicaid-insured, and uninsured patients undergoing biliary procedures has increased over time. Most of the increase in therapeutic ERCP and decrease in BDS occurred in large, metropolitan hospitals. CONCLUSIONS: Although therapeutic ERCP utilization has increased over time, the total volume of biliary interventions has decreased. BDS utilization has experienced the most dramatic decrease, possibly a consequence of the increased therapeutic capacity and safety of ERCP. ERCPs are now predominantly therapeutic in nature. Large urban hospitals are leading the shift from surgical to endoscopic therapy of the biliary system.

ERCP development in the largest developing country: a national survey from China in 2013.

BACKGROUND AND AIMS: The ERCP volume in developed countries has decreased recently, whereas the ERCP trend is unknown in developing countries. This study aimed to evaluate the ERCP development in China between 2006 and 2012. METHODS: All hospitals performing ERCP in mainland China in 2012 participated in an online survey. Data on ERCP infrastructure, volume, indication, and adverse events were collected and compared with those in a previous national survey and in developed countries. RESULTS: From 2006 to 2012 the number of hospitals performing ERCP in China increased from 470 to 1156. The total ERCP volume increased from 63,787 to 195,643, of which >95% were therapeutic. The ERCP rate in China (14.4 per 100,000 inhabitants) in 2012 was still much lower than that in developed countries. There was significant imbalance between different regions (1.3-99.1 per 100,000 inhabitants). The median ERCP volume per hospital decreased from 80 (interquartile range [IQR], 31-150) in 2006 to 52 (IQR, 20-146) in 2012. The median volume of the 686 hospitals that started ERCP after 2006 was 31.5 (IQR, 11-82). The post-ERCP adverse event rate in 2012 was comparable between hospitals in terms of volume (≥500 or <500 per year: 5.8% vs 5.6%) and practice durations (starting ERCP before or after 2006: 5.5% vs 5.6%). CONCLUSIONS: ERCP has developed considerably in China in recent years. Despite low annual volume, the hospitals starting ERCP after 2006 have acceptable adverse event rates and will be promising and important sources of ERCP development in China.

Trends in the Use of Endoscopic Retrograde Cholangiopancreatography for the Management of Chronic Pancreatitis in the United States.

GOALS: The aim of this study was to characterize current trends in the use of endoscopic retrograde cholangiopancreatography (ERCP) in the United States for patients hospitalized with chronic pancreatitis. BACKGROUND: Historically, ERCP was the primary tool for diagnostic and therapeutic management of chronic pancreatitis. With increased availability of magnetic resonance imaging and endoscopic ultrasound, indications for ERCP are being redefined. STUDY: We performed a retrospective cohort study using the Nationwide Inpatient Sample from 1998 to 2010. We identified patients with a primary discharge diagnosis of chronic pancreatitis who underwent ERCP. We excluded patients diagnosed with biliary, gallbladder, or pancreatic neoplasm and patients who underwent gallbladder or pancreatic operation during the same admission. We analyzed patient and hospital characteristics, length of stay, and in-hospital mortality, and adjusted for weighted sample schema. RESULTS: During the study period, 29,318 patients with chronic pancreatitis (mean age 52 y, 57.2% female) underwent ERCP during their hospitalization. The majority of patients were white (56.1%). The majority of procedures were performed at large (72.4%), urban (95.2%), and academic (69.0%) hospitals. Mean hospital charges were $32,929 (SE= $1605). Mean length of stay was 6 days (SE=0.3), with in-hospital mortality of 0.76%. Over the study period, the number of procedures has decreased significantly (P<0.001). CONCLUSIONS: In the United States, ERCP has been an important diagnostic and therapeutic tool for chronic pancreatitis. Over the last decade, ERCP has become an uncommon inpatient procedure for chronic pancreatitis.

A survey of European-African surgeons' management of common bile duct stones.

BACKGROUND: Common bile duct (CBD) stones can be managed by either endoscopic retrograde cholangiopancreatography (ERCP) or laparoscopic common bile duct exploration (LCBDE). The aim of this survey was to document the management of CBD stones by European-African HPB Association (E-AHPBA) members. METHODS: All 331 members of the E-AHPBA were invited by personal email to participate to an online survey. RESULTS: Ninety-three (28%) surgeons replied within 2 months. Responding surgeons were attending surgeons (84%), working as HPB surgeons (75%) in academic hospitals (73%). In patients with clinically suspected CBD stones, MRCP was the preferred diagnostic test for 61% of respondents. LCBDE was the preferred therapeutic strategy for 11 (12%) respondents only. Previous gastric surgery was an absolute contraindication to ERCP for 47% of respondents. Absence of CBD dilation was considered an absolute contraindication for LCBDE in 24% of respondents. Yearly caseload exceeded 10 patients for only 30% of 56 centers performing LCBDE. The transcystic approach was preferred by 39% of surgeons performing LCBDE. There was considerable variation amongst respondents with regard to type and duration of drainage, bile duct closure technique and follow-up after LCBDE. CONCLUSION: Indications for single-stage LCBDE are not standardized and do not appear well established across E-AHPBA members.

Trends in utilization of diagnostic and therapeutic ERCP and cholecystectomy over the past 25 years: a population-based study.

BACKGROUND: Comprehensive, population-based data on ERCP use over the last 30 years in North America are lacking. OBJECTIVE: To establish crude and age-adjusted population-based rates of ERCP, evaluate for changing indications for ERCP, and evaluate for interactions between cholecystectomy technique and ERCP use from 1984 to 2009. DESIGN: Retrospective, comprehensive, population-based study. SETTING: All inpatient and outpatient ERCPs and cholecystectomies in Manitoba, Canada from 1984 to 2009. PATIENTS: All residents of Manitoba, Canada with a history of ERCP and/or cholecystectomy. INTERVENTION: None. MAIN OUTCOME MEASUREMENTS: Yearly crude and age-adjusted rates of ERCP (diagnostic and therapeutic) and cholecystectomy (open, laparoscopic, and with open bile duct exploration), and patient and/or procedure demographics. RESULTS: The rate of ERCP/10,000 people increased from 7.70 (1984) to 13.86/10,000 (2009) (P = .001). Diagnostic ERCP declined from 7.28/10,000 (1984) to 1.11/10,000 (2009), and therapeutic ERCP increased from 0.42/10,000 (1984) to 12.75/10,000 (2009) (P < .001). ERCPs were more common in women (62%) and in older populations (60-79 years, >80 years), with rates of therapeutic ERCP reaching 62.58/10,000 in the elderly. The primary indication for ERCP has changed over time, with biliary indications increasing from 50.3% to 67.3% and pancreatic indications decreasing from 18.3% to 8.1% (P < .05). The rate of therapeutic ERCP increased during the transition from open to laparoscopic cholecystectomy (1991-1994), whereas open bile duct exploration (OBDE) decreased from 2.0 to 0.18/10,000 (P < .001). LIMITATIONS: Retrospective analysis, administrative data. CONCLUSION: ERCP use increased steadily from 1984 to 2009, and changed from a diagnostic modality to a therapeutic one. Changes in cholecystectomy technique may have influenced therapeutic ERCP use and likewise, the availability of therapeutic ERCP has decreased the need for OBDE.

Trends in endoscopic retrograde cholangiopancreatography in children within the United States, 2000-2009.

We investigated the volume of endoscopic retrograde cholangiopancreatographies (ERCPs) performed in hospitalized children in the United States using a nationwide healthcare administrative database for the years 2000 to 2009. A total of 22,153 cases of ERCP were identified: 6372 diagnostic and 17,314 therapeutic (1533 cases were recorded as undergoing both types during a single hospitalization). The number of ERCPs increased from 5337 to 6733 per year; diagnostic ERCPs decreased 43% and therapeutic increased 69% (significant decreasing trends for diagnostic and increasing for therapeutic ERCPs, P<0.001 for each analysis). Our results define a recent increase in the use of therapeutic ERCPs in hospitalized children.

ERCP service in China: results from a national survey.

BACKGROUND: ERCP had been performed throughout China for decades. OBJECTIVE: To determine the status of ERCP service in China. DESIGN: A national survey. SETTING: All of the hospitals performing ERCP in mainland China in 2006. PATIENTS: All of the patients undergoing ERCP in mainland China in 2006. MAIN OUTCOME MEASUREMENTS: The questionnaire included the (1) type of hospitals involved; (2) ownership of the endoscopy unit; (3) ERCP infrastructure; (4) volume, indication, setting, and anesthesia methods; and (5) training and research. The correlation between economic development and ERCP status in different regions was investigated, and the ERCP rates in China and developed countries were compared. RESULTS: Completed questionnaires were returned by 449 (95.5%) of the 470 hospitals providing ERCP service. Among the 449 hospitals, 186 (41.4%) did not have separate ERCP suites, 379 (84.4%) shared fluoroscopy with their radiology departments, and the average number of duodenoscopes was 1.58. A total of 63,787 ERCP procedures were performed in mainland China in 2006, with an estimated annual ERCP rate of 4.87 per 100,000 inhabitants, much lower than that of developed countries. Ninety-six percent of patients were admitted to undergo ERCP, and 94.4% of hospitals used pharyngeal local anesthesia and conscious sedation, whereas 5.6% used general anesthesia. There was a significant correlation between the ERCP rate and gross domestic product per capita (r = 0.871, P < .001). LIMITATIONS: The survey was retrospective and descriptive. CONCLUSIONS: There is an enormous gap in ERCP service between China and developed countries. The imbalance of ERCP status between different regions is significant, which correlates with economic development. Great effort is needed to develop the technique nationwide.