title: Intraprocedural quality in endoscopic retrograde cholangiopancreatography: a meta-analysis.
abstract: OBJECTIVE
  In 2006, the American College of Gastroenterology (ACG)/the American Society for Gastrointestinal Endoscopy (ASGE) Taskforce on Quality in Endoscopy published quality indicators for the major gastrointestinal procedures. Our primary aim was to use the published literature to assess current endoscopic retrograde cholangiopancreatography (ERCP) intraprocedural performance and compare it to the targets set by the ACG/ASGE taskforce. Our secondary aim was to determine whether performance varies across different health-care settings (academic and community), study designs (prospective and retrospective), and trainee participation.
  
  
  METHODS
  A PubMed and EMBASE literature search from 1/1/2006 to 2/1/2013 was conducted. Articles were selected based on title, abstract, full text, and reporting of success rates for the intraprocedural quality indicators. Success rates, represented as numerical proportions, were collected from each study. For each success rate, a standard error and a 95% confidence interval (CI) was calculated. A random-effects meta-analysis model was used to weight each study, and a cumulative, weighted success rate (or effect size) for each indicator was determined. Random-effects meta-regression was then used to examine the impact of study setting, design, and trainee involvement on each quality indicator.
  
  
  RESULTS
  A total of 8,005 articles were initially retrieved. Following the application of predefined criteria, 52 articles remained. The cumulative, weighted bile duct cannulation success rate was 89.3% (95% CI 0.866-0.919); pancreatic duct cannulation was 85.0% (95% CI 0.813-0.886); precut utilization rate was 10.5% (95% CI 0.087-0.123); common bile duct stone extraction rate was 88.3% (95% CI 0.825-0.941); and the rate of successful biliary stenting below the common bile duct bifurcation was 97.5% (95% CI 0.967-0.984). Subgroup analysis with meta-regression showed no statistically significant differences between academic and community settings, prospective and retrospective study designs, and trainee participation on success across bile duct cannulation, precut utilization, and common bile duct stone extraction (insufficient observations/variance for pancreatic duct cannulation and biliary stent placement).
  
  
  CONCLUSIONS
  ERCP intraprocedural quality is in good standing. On the basis of this analysis, the two targets that could be potentially revised are precut utilization and biliary stenting. This analysis was confined to the published literature and therefore, in general, reflects the ERCP performance of institutions, primarily academic, that are conducting clinical research. Thus, it is difficult to generalize this performance assessment to the broader ERCP community as a whole.
authors.affiliation: Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA.
authors.forename: Anthony T
authors.initials: AT
authors.lastname: DeBenedet
authors.forename: B Joseph
authors.initials: BJ
authors.lastname: Elmunzer
authors.forename: Sean T
authors.initials: ST
authors.lastname: McCarthy
authors.forename: Grace H
authors.initials: GH
authors.lastname: Elta
authors.forename: Philip S
authors.initials: PS
authors.lastname: Schoenfeld
mesh_terms: D001652:Bile Ducts / Q000601:surgery*; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000592:standards*; D006801:Humans; D010183:Pancreatic Ducts / Q000601:surgery*; D019984:Quality Indicators, Health Care; D011787:Quality of Health Care; D016896:Treatment Outcome