title: Telemedicine: an important aid to perform high-quality endoscopic retrograde cholangiopancreatography in low-volume centers.
abstract: OBJECTIVE
  The aim of this study was to investigate whether telemedicine can help to ensure high-quality endoscopic retrograde cholangiopancreatography (ERCP) in patients living in rural areas. The study was conducted by investigators from two centers: the Karolinska University Hospital, a high-volume center which provided the teleguided support, and the Visby District Hospital, a low-volume center.
  
  
  METHODS
  From September 2010 to August 2011, 26 ERCP procedures performed at a district hospital were teleguided by an experienced endoscopist at the Karolinska University Hospital. To ensure patient data protection, all communication went through a network (Sjunet) that was separate from the Internet and open only to accredited users. The indications for ERCP were common bile duct stones (n = 12), malignant strictures (n = 12), and benign biliary strictures (n = 2). In 15 cases, this was the patient's first ERCP procedure.
  
  
  RESULTS
  The common bile duct was successfully cannulated in all 26 teleguided procedures. The local endoscopist scored the teleguided support as crucial for the successful outcome in 8 /26 cases, as an important factor in 8, and as being of less importance in the remaining 10. In the eight cases where the teleguided support was judged to be crucial, six subsequent percutaneous transhepatic cholangiography procedures and two repeat ERCPs were avoided. The overall cannulation rate at the district hospital improved from 85 % to 99 % after teleguided support was introduced. No procedure-related complications occurred.
  
  
  CONCLUSIONS
  Distant guidance of advanced ERCP procedures in a low-volume center, through teleguided support from a high-volume center, has the potential to improve the quality of care, as reflected in high cannulation rates and the ability to complete the scheduled interventions.
authors.affiliation: Karolinska Institutet, CLINTEC, Stockholm, Sweden. hans-ivar.pahlsson@gotland.se
authors.forename: H I
authors.initials: HI
authors.lastname: Påhlsson
authors.forename: K
authors.initials: K
authors.lastname: Groth
authors.forename: J
authors.initials: J
authors.lastname: Permert
authors.forename: F
authors.initials: F
authors.lastname: Swahn
authors.forename: M
authors.initials: M
authors.lastname: Löhr
authors.forename: L
authors.initials: L
authors.lastname: Enochsson
authors.forename: L
authors.initials: L
authors.lastname: Lundell
authors.forename: U
authors.initials: U
authors.lastname: Arnelo
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D014670:Ampulla of Vater; D001291:Attitude of Health Personnel; D001660:Biliary Tract Diseases / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D002404:Catheterization; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000592:standards*; D002779:Cholestasis / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery; D003251:Constriction, Pathologic / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery; D004067:Digestive System Neoplasms / Q000150:complications*; D005260:Female; D042882:Gallstones / Q000000981:diagnostic imaging / Q000601:surgery; D061846:Hospitals, Low-Volume / Q000592:standards*; D006801:Humans; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D019035:Rural Health Services / Q000592:standards*; D017216:Telemedicine